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  • Question 1 - Following a postnatal home visit, the community midwife refers a newborn baby with...

    Correct

    • Following a postnatal home visit, the community midwife refers a newborn baby with jaundice. The pediatric team conducts an assessment and investigations, revealing unconjugated hyperbilirubinemia. The suspected underlying cause is extrinsic hemolysis. Which of the following is the most likely diagnosis?

      Your Answer: Haemolytic disease of the newborn

      Explanation:

      Neonatal jaundice is a complex subject, and it is crucial for candidates to have knowledge about the different causes, presentations, and management of conditions that lead to jaundice in newborns. Neonatal jaundice can be divided into two groups: unconjugated hyperbilirubinemia, which can be either physiological or pathological, and conjugated hyperbilirubinemia, which is always pathological.

      The causes of neonatal jaundice can be categorized as follows:

      Haemolytic unconjugated hyperbilirubinemia:
      – Intrinsic causes of haemolysis include hereditary spherocytosis, G6PD deficiency, sickle-cell disease, and pyruvate kinase deficiency.
      – Extrinsic causes of haemolysis include haemolytic disease of the newborn and Rhesus disease.

      Non-haemolytic unconjugated hyperbilirubinemia:
      – Breastmilk jaundice, cephalhaematoma, polycythemia, infection (particularly urinary tract infections), Gilbert syndrome.

      Hepatic conjugated hyperbilirubinemia:
      – Hepatitis A and B, TORCH infections, galactosaemia, alpha 1-antitrypsin deficiency, drugs.

      Post-hepatic conjugated hyperbilirubinemia:
      – Biliary atresia, bile duct obstruction, choledochal cysts.

      By understanding these different categories and their respective examples, candidates will be better equipped to handle neonatal jaundice cases.

    • This question is part of the following fields:

      • Neonatal Emergencies
      14.7
      Seconds
  • Question 2 - You evaluate a 72-year-old in the emergency department who has come in with...

    Correct

    • You evaluate a 72-year-old in the emergency department who has come in with complaints of back pain. After conducting a thorough assessment, you observe that the patient possesses several risk factors for osteoporosis. You recommend that the patient undergo a formal evaluation to determine their risk of osteoporotic fractures. Which tool is considered the gold standard for this assessment?

      Your Answer: Qfracture

      Explanation:

      QFracture is a highly regarded tool used to predict the risk of osteoporotic fractures and determine if a DXA bone assessment is necessary. It is considered the preferred and gold standard tool by NICE and SIGN. FRAX is another fracture risk assessment tool that is also used to determine the need for a DXA bone assessment. The Rockwood score and electronic frailty Index (eFI) are both frailty scores. The informant questionnaire on cognitive decline in the elderly is a tool used to assess cognitive decline in older individuals.

      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.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      7.3
      Seconds
  • Question 3 - A 62 year old male with a history of alcohol dependence is brought...

    Correct

    • A 62 year old male with a history of alcohol dependence is brought into the emergency department by a social worker who is concerned that the patient appears to be growing more confused and drowsy in recent days. The social worker informs you that the patient had been behaving normally but had mentioned intending to visit his primary care physician regarding obtaining medication for his constipation. You suspect hepatic encephalopathy. Which of the following medications would be the most suitable to administer?

      Your Answer: Rifaximin

      Explanation:

      Hepatic encephalopathy is a condition caused by the accumulation of nitrogenous waste products in the body due to impaired liver function. These waste products cross the blood brain barrier and contribute to the production of glutamine, leading to changes in astrocyte osmotic pressure, brain edema, and neurotransmitter dysfunction.

      To address hepatic encephalopathy, the first-line drugs used are Rifaximin and lactulose. Rifaximin is an oral antibiotic that helps reduce the presence of ammonia-producing bacteria in the intestines. Lactulose, on the other hand, converts soluble ammonia into insoluble ammonium and aids in relieving constipation.

      It is important to note that Chlordiazepoxide, a benzodiazepine, may be used to treat alcohol withdrawal but should be avoided in cases of hepatic encephalopathy as it can worsen the condition.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      10.2
      Seconds
  • Question 4 - A 52-year-old woman comes in with postmenopausal bleeding. Her medical records indicate that...

    Correct

    • A 52-year-old woman comes in with postmenopausal bleeding. Her medical records indicate that she recently underwent a transvaginal ultrasound, which revealed an endometrial thickness of 6.5 mm. What is the MOST suitable next step in investigating her condition?

      Your Answer: Endometrial biopsy

      Explanation:

      postmenopausal bleeding should always be treated as a potential malignancy until proven otherwise. The first-line investigation for this condition is transvaginal ultrasound (TVUS). This method effectively assesses the risk of endometrial cancer by measuring the thickness of the endometrium.

      In postmenopausal women, the average endometrial thickness is much thinner compared to premenopausal women. The likelihood of endometrial cancer increases as the endometrium becomes thicker. Currently, in the UK, an endometrial thickness of 5 mm is considered the threshold.

      If the endometrial thickness is greater than 5 mm, there is a 7.3% chance of endometrial cancer. However, if a woman with postmenopausal bleeding has a uniform endometrial thickness of less than 5 mm, the likelihood of endometrial cancer is less than 1%.

      In cases where there is a high clinical risk, hysteroscopy and endometrial biopsy should also be performed. The definitive diagnosis is made through histological examination. If the endometrial thickness is greater than 5 mm, an endometrial biopsy is recommended.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      5.2
      Seconds
  • Question 5 - A 45 year old male comes to the emergency department complaining of fatigue...

    Incorrect

    • A 45 year old male comes to the emergency department complaining of fatigue and a headache. The medical team records his vital signs and takes blood samples. The results are as follows:

      Blood pressure: 192/98 mmHg
      Pulse: 84 bpm
      Respiration rate: 17 bpm
      Temperature: 36.9ºC

      Sodium (Na+): 149 mmol/l
      Potassium (K+): 3.0 mmol/l
      Urea: 3.8 mmol/l
      Creatinine: 81 µmol/l

      What is the most likely diagnosis?

      Your Answer: SIADH

      Correct Answer: Primary hyperaldosteronism

      Explanation:

      Primary hyperaldosteronism is the leading endocrine cause of secondary hypertension, commonly affecting individuals between the ages of 30 and 50. It is characterized by metabolic alkalosis and often presents with hypernatraemia, although normal sodium levels can also be observed. When compared to pheochromocytoma, primary hyperaldosteronism is more frequently encountered. The diagnostic test of choice is the plasma aldosterone-to-renin ratio.

      Further Reading:

      Hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal glands. It can be classified into primary and secondary hyperaldosteronism. Primary hyperaldosteronism, also known as Conn’s syndrome, is typically caused by adrenal hyperplasia or adrenal tumors. Secondary hyperaldosteronism, on the other hand, is a result of high renin levels in response to reduced blood flow across the juxtaglomerular apparatus.

      Aldosterone is the main mineralocorticoid steroid hormone produced by the adrenal cortex. It acts on the distal renal tubule and collecting duct of the nephron, promoting the reabsorption of sodium ions and water while secreting potassium ions.

      The causes of hyperaldosteronism vary depending on whether it is primary or secondary. Primary hyperaldosteronism can be caused by adrenal adenoma, adrenal hyperplasia, adrenal carcinoma, or familial hyperaldosteronism. Secondary hyperaldosteronism can be caused by renal artery stenosis, reninoma, renal tubular acidosis, nutcracker syndrome, ectopic tumors, massive ascites, left ventricular failure, or cor pulmonale.

      Clinical features of hyperaldosteronism include hypertension, hypokalemia, metabolic alkalosis, hypernatremia, polyuria, polydipsia, headaches, lethargy, muscle weakness and spasms, and numbness. It is estimated that hyperaldosteronism is present in 5-10% of patients with hypertension, and hypertension in primary hyperaldosteronism is often resistant to drug treatment.

      Diagnosis of hyperaldosteronism involves various investigations, including U&Es to assess electrolyte disturbances, aldosterone-to-renin plasma ratio (ARR) as the gold standard diagnostic test, ECG to detect arrhythmia, CT/MRI scans to locate adenoma, fludrocortisone suppression test or oral salt testing to confirm primary hyperaldosteronism, genetic testing to identify familial hyperaldosteronism, and adrenal venous sampling to determine lateralization prior to surgery.

      Treatment of primary hyperaldosteronism typically involves surgical adrenalectomy for patients with unilateral primary aldosteronism. Diet modification with sodium restriction and potassium supplementation may also be recommended.

    • This question is part of the following fields:

      • Endocrinology
      16.4
      Seconds
  • Question 6 - A 25 year old female is treated for anaphylaxis and responds well to...

    Correct

    • A 25 year old female is treated for anaphylaxis and responds well to treatment. You inform the patient that she will need to remain under observation. What is the minimum duration an adult patient should be observed following an episode of anaphylaxis?

      Your Answer: 6-12 hours

      Explanation:

      According to NICE guidelines, it is recommended that adults and young people aged 16 years or older who receive emergency treatment for suspected anaphylaxis should be observed for a minimum of 6-12 hours from the time symptoms first appear. There are certain situations where a longer observation period of 12 hours is advised. These include cases where the allergen is still being absorbed slowly, the patient required more than 2 doses of adrenaline, there is severe asthma or respiratory compromise, or if the presentation occurs at night or there is difficulty in accessing emergency care.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Allergy
      4.7
      Seconds
  • Question 7 - You have recently conducted rapid sequence induction utilizing ketamine and rocuronium and successfully...

    Correct

    • You have recently conducted rapid sequence induction utilizing ketamine and rocuronium and successfully inserted an endotracheal tube under the guidance of a consultant. What should have been the available reversal agent to counteract the effects of Rocuronium if necessary?

      Your Answer: Sugammadex

      Explanation:

      Sugammadex is a medication used to quickly reverse the effects of muscle relaxation caused by drugs like rocuronium bromide or vecuronium bromide. The 2020 guidelines for sedation and anesthesia outside of the operating room recommend having a complete set of emergency drugs, including specific reversal agents like naloxone, sugammadex, and flumazenil, readily accessible. Sugammadex is a modified form of gamma cyclodextrin that is effective in rapidly reversing the neuromuscular blockade caused by these specific drugs.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.2
      Seconds
  • Question 8 - A 35 year old male is brought into the emergency department with burns...

    Incorrect

    • A 35 year old male is brought into the emergency department with burns to the face and neck. It is decided to insert a central line into the femoral vein.

      What is the positioning of the femoral vein in relation to the femoral artery?

      Your Answer: The femoral vein lies immediately lateral to the femoral artery

      Correct Answer: The femoral vein lies immediately medial to the femoral artery

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      17.8
      Seconds
  • Question 9 - A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
    Which of the following statements...

    Correct

    • A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
      Which of the following statements is accurate regarding subarachnoid hemorrhage?

      Your Answer: SAH is associated with polycystic kidneys

      Explanation:

      A subarachnoid haemorrhage (SAH) occurs when there is spontaneous bleeding into the subarachnoid space and is often a catastrophic event. The incidence of SAH is 9 cases per 100,000 people per year, and it typically affects individuals between the ages of 35 and 65.

      The majority of SAH cases (80%) are caused by the rupture of berry (saccular) aneurysms, while 15% are caused by arteriovenous malformations (AVM). In less than 5% of cases, no specific cause can be found. Berry aneurysms are associated with polycystic kidneys, Ehlers-Danlos Syndrome, and coarctation of the aorta.

      There are several risk factors for SAH, including smoking, hypertension, bleeding disorders, alcohol misuse, mycotic aneurysm, and a family history of the condition.

      Patients with SAH typically experience a sudden and severe occipital headache, often described as the worst headache of my life. This may be accompanied by vomiting, collapse, seizures, and coma. Clinical signs of SAH include neck stiffness, a positive Kernig’s sign, and focal neurological abnormalities. Fundoscopy may reveal subhyaloid retinal haemorrhages in approximately 25% of patients.

      Re-bleeding occurs in 30-40% of patients who survive the initial episode, with the highest risk occurring between 7 and 14 days after the initial event.

      Untreated SAH has a mortality rate of nearly 50% within the first eight weeks following presentation. Prolonged coma is associated with a 100% mortality rate.

      The first-line investigation for SAH is a CT head scan, which can detect over 95% of cases if performed within the first 24 hours. The sensitivity of the CT scan increases to nearly 100% if performed within 6 hours of symptom onset. If the CT scan is negative and there are no contraindications, a lumbar puncture (LP) should be performed at least 12 hours after the onset of headache to diagnose SAH. Approximately 3% of patients with a negative CT scan will be confirmed to have had an SAH following an LP.

    • This question is part of the following fields:

      • Neurology
      9.6
      Seconds
  • Question 10 - A 35-year-old man comes in with intense tooth pain that has developed 3...

    Incorrect

    • A 35-year-old man comes in with intense tooth pain that has developed 3 days after having a tooth pulled.
      What is the MOST LIKELY diagnosis?

      Your Answer: Pulpitis

      Correct Answer: Acute alveolar osteitis

      Explanation:

      This patient is experiencing a condition called acute alveolar osteitis, commonly known as ‘dry socket’. It occurs when the blood clot covering the socket gets dislodged, leaving the bone and nerve exposed. This can result in infection and intense pain.

      There are several risk factors associated with the development of a dry socket. These include smoking, inadequate dental hygiene, extraction of wisdom teeth, use of oral contraceptive pills, and a previous history of dry socket.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      11.5
      Seconds
  • Question 11 - A 25-year-old woman arrives at the emergency department with complaints of palpitations and...

    Correct

    • A 25-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During triage, the patient reveals that she was previously diagnosed with narrow complex tachycardia a couple of years ago after experiencing palpitations during a night out. You order an ECG. What are the specific criteria used to define narrow complex tachycardia?

      Your Answer: Pulse rate greater than 100 beats per minute and QRS duration less than 0.12 seconds

      Explanation:

      Narrow QRS complex tachycardia is a term used to describe a fast heart rhythm with a pulse rate over 100 bpm and a QRS duration shorter than 120 ms.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

    • This question is part of the following fields:

      • Cardiology
      12.2
      Seconds
  • Question 12 - A 45 year old male presents to the emergency department complaining of worsening...

    Incorrect

    • 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: Plasma metanephrines

      Correct Answer: 24-hour urinary free cortisol

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      8.3
      Seconds
  • Question 13 - A 35-year-old woman was diagnosed two years ago with multiple sclerosis (MS). She...

    Incorrect

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

      Your Answer: Relapsing and remitting MS

      Correct Answer: Primary progressive MS

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      12.3
      Seconds
  • Question 14 - A middle-aged patient experiences a stroke that leads to impairment in Broca's area....

    Correct

    • A middle-aged patient experiences a stroke that leads to impairment in Broca's area. What will be the consequences of the damage to Broca's area?

      Your Answer: Expressive aphasia

      Explanation:

      Broca’s area is situated in the frontal lobe of the dominant cerebral hemisphere. Specifically, it can be located in the posterior section of the inferior frontal gyrus, and it comprises of the pars opercularis and the pars triangularis.

      Broca’s area is responsible for regulating the motor functions involved in speech production. It facilitates the creation of words through its connections with neighboring motor areas, which stimulate the muscles of the larynx, mouth, tongue, and soft palate.

      If there is damage to Broca’s area, it will lead to speech paralysis and expressive aphasia, commonly referred to as Broca’s aphasia.

    • This question is part of the following fields:

      • Neurology
      4.6
      Seconds
  • Question 15 - You evaluate a 78-year-old woman who has come in after a fall. She...

    Incorrect

    • You evaluate a 78-year-old woman who has come in after a fall. She is frail and exhibits signs of recent memory loss. You administer an abbreviated mental test score (AMTS) and record the findings in her medical records.
      Which ONE of the following is NOT included in the abbreviated mental test score (AMTS)?

      Your Answer: Recognition of two people

      Correct Answer: Repeating back a phrase

      Explanation:

      The 30-point Folstein mini-mental state examination (MMSE) includes a task where the examiner asks the individual to repeat back a phrase. However, this task is not included in the AMTS. The AMTS consists of ten questions that assess different aspects of cognitive function. These questions cover topics such as age, time, year, location, recognition of people, date of birth, historical events, present monarch or prime minister, counting backwards, and recall of an address. The AMTS is a useful tool for evaluating memory loss and is referenced in the RCEM syllabus.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      12.6
      Seconds
  • Question 16 - A 6-year-old child experiences an anaphylactic reaction after being stung by a bee....

    Incorrect

    • 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
      6.2
      Seconds
  • Question 17 - A 4-year-old girl is brought to the Emergency Department by her parents. She...

    Correct

    • A 4-year-old girl is brought to the Emergency Department by her parents. She is typically healthy but has been experiencing abdominal pain for the past two days. She has vomited once, but there have been no loose stools. Her temperature has been elevated throughout the day. She has been producing urine with a strong odor. Upon examination, her abdomen is soft and nontender. Bowel sounds are normal. Urine dipstick reveals the presence of leukocytes and is positive for nitrites.

      What is the SINGLE most likely diagnosis?

      Your Answer: Urinary tract infection

      Explanation:

      This presentation strongly indicates the presence of a urinary tract infection (UTI). According to the recommendations from the National Institute for Health and Care Excellence (NICE), certain clinical features are indicative of a UTI in children of this age group. These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information, please refer to the NICE guidelines on the assessment and management of feverish illness in children under the age of 5.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      10.3
      Seconds
  • Question 18 - A 65-year-old woman with a history of Parkinson's disease and depression has experienced...

    Correct

    • 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.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      10.8
      Seconds
  • Question 19 - A 5-year-old girl is brought to the Emergency Department by her parents. For...

    Correct

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

      Your Answer: 10%

      Explanation:

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

      The clinical features of dehydration and shock are summarized below:

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

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

    • This question is part of the following fields:

      • Nephrology
      4.3
      Seconds
  • Question 20 - A 25 year old college student is brought into the ER after being...

    Correct

    • A 25 year old college student is brought into the ER after being discovered in a collapsed state with decreased consciousness in the early morning hours. You have concerns about the patient's airway and opt to insert an oropharyngeal airway. How would you determine the appropriate size for an oropharyngeal airway?

      Your Answer: Distance between the patient's incisors and the angle of their mandible

      Explanation:

      The size of an oropharyngeal airway (OPA or Guedel) can be determined by measuring the distance between the patient’s incisors and the angle of their mandible. To ensure proper fit, the OPA should be approximately the same length as this measurement. Please refer to the image in the notes for visual guidance.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      6.2
      Seconds
  • Question 21 - Your supervisor requests you to arrange a training session for the new medical...

    Correct

    • Your supervisor requests you to arrange a training session for the new medical interns on diabetes mellitus and hypoglycemia. Which of the following statements is accurate?

      Your Answer: Glucose levels should be checked 10-15 minutes after administering glucagon

      Explanation:

      After administering any treatment for hypoglycemia, it is important to re-check glucose levels within 10-15 minutes. This allows for a reassessment of the effectiveness of the treatment and the possibility of administering additional treatment if needed. Obesity is a significant risk factor for developing type 2 diabetes, while most individuals with type 1 diabetes have a body mass index (BMI) below 25 kg/m2. It is crucial to provide carbohydrates promptly after treating hypoglycemia. The correct dose of glucagon for treating hypoglycemia in adults is 1 mg, and the same dose can be used for children aged 9 and above who weigh more than 25kg. HbA1c results between 42 and 47 indicate pre-diabetes.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      9.5
      Seconds
  • Question 22 - A 42-year-old woman is noted to have 'Auer rods' on her peripheral blood...

    Correct

    • A 42-year-old woman is noted to have 'Auer rods' on her peripheral blood smear.
      What is the MOST probable diagnosis?

      Your Answer: Acute myeloid leukaemia

      Explanation:

      Auer rods are small, needle-shaped structures that can be found within the cytoplasm of blast cells. These structures have a distinct eosinophilic appearance. While they are most frequently observed in cases of acute myeloid leukemia, they can also be present in high-grade myelodysplastic syndromes and myeloproliferative disorders.

    • This question is part of the following fields:

      • Haematology
      9.9
      Seconds
  • Question 23 - A 68-year-old patient with advanced metastatic lung cancer is experiencing significant shortness of...

    Correct

    • A 68-year-old patient with advanced metastatic lung cancer is experiencing significant shortness of breath and appears to be in distress. The patient is alert and currently not experiencing any pain. They have been informed that they have only a few days left to live. Their oxygen saturation levels are currently at 95% on room air, and there are no specific signs of chest abnormalities.
      What is the most suitable course of action to address the patient's breathlessness in this situation?

      Your Answer: Diazepam

      Explanation:

      Here are some recommendations from NICE on how to manage breathlessness in the final days of life:

      1. First, it is important to identify and treat any reversible causes of breathlessness in the person who is dying. This could include conditions like pulmonary edema or pleural effusion.

      2. Non-pharmacological methods can also be considered for managing breathlessness in these individuals. It is not necessary to automatically start oxygen therapy for breathlessness. Oxygen should only be offered to those who are known or suspected to have low oxygen levels causing symptoms.

      3. Breathlessness can be managed using medications such as opioids or benzodiazepines. These can be used individually or in combination, depending on the needs of the person.

      For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      14.1
      Seconds
  • Question 24 - A 32 year old male is brought into the emergency department following a...

    Correct

    • A 32 year old male is brought into the emergency department following a car accident. You evaluate the patient's risk of cervical spine injury using the Canadian C-spine rule. What is included in the assessment for the Canadian C-spine rule?

      Your Answer: Ask patient to rotate their neck 45 degrees to the left and right

      Explanation:

      The Canadian C-spine assessment includes evaluating for tenderness along the midline of the spine, checking for any abnormal sensations in the limbs, and assessing the ability to rotate the neck 45 degrees to the left and right. While a significant portion of the assessment relies on gathering information from the patient’s history, there are also physical examination components involved. These include testing for tenderness along the midline of the cervical spine, asking the patient to perform neck rotations, ensuring they are comfortable in a sitting position, and assessing for any sensory deficits in the limbs. It is important to note that any reported paraesthesia in the upper or lower limbs can also be taken into consideration during the assessment.

      Further Reading:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

    • This question is part of the following fields:

      • Trauma
      4.4
      Seconds
  • Question 25 - You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would...

    Correct

    • You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would like to ask you some questions about her diagnosis.
      Which ONE statement about this condition is accurate?

      Your Answer: Diabetes insipidus may occur

      Explanation:

      Sheehan’s syndrome is a condition where the pituitary gland becomes damaged due to insufficient blood flow and shock during and after childbirth, leading to hypopituitarism. The risk of developing this syndrome is higher in pregnancies with conditions that increase the chances of bleeding, such as placenta praevia and multiple pregnancies. However, Sheehan’s syndrome is quite rare, affecting only 1 in 10,000 pregnancies.

      During pregnancy, the anterior pituitary gland undergoes hypertrophy, making it more vulnerable to ischaemia in the later stages. While the posterior pituitary gland is usually not affected due to its own direct blood supply, there have been rare cases where it is involved. In these instances, central diabetes insipidus, a form of posterior pituitary dysfunction, can occur as a complication of Sheehan’s syndrome.

      The clinical features of Sheehan’s syndrome include the absence or infrequency of menstrual periods, the inability to produce milk and breastfeed (galactorrhoea), decreased libido, fatigue and tiredness, loss of pubic and axillary hair, and the potential development of secondary hypothyroidism and adrenal insufficiency. Serum prolactin levels are typically low (less than 5ng/ml). An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.

      Treatment for Sheehan’s syndrome involves hormone replacement therapy. With appropriate management, the prognosis for this condition is excellent.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      10.5
      Seconds
  • Question 26 - A 2 year old male is brought to the emergency department by concerned...

    Correct

    • 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.

    • This question is part of the following fields:

      • Paediatric Emergencies
      15
      Seconds
  • Question 27 - A 28 year old female is brought into the emergency department after a...

    Correct

    • A 28 year old female is brought into the emergency department after a jet skiing accident at a local lake. The patient fell off the jet ski but her leg got caught in the handlebars and she was submerged for 2-3 minutes before being freed. The patient's friends started rescue breaths and chest compressions as the patient was unconscious but were stopped after approximately 30 seconds by an off duty lifeguard who assessed the patient and determined she was breathing spontaneously and had a pulse. On examination, the patient is breathing spontaneously with intermittent coughing, oxygen saturation levels are 97% on room air, a few crackling sounds are heard in the lower parts of the lungs, and the patient's Glasgow Coma Scale score is 13 out of 15.

      Which of the following should be included in the initial management of this patient?

      Your Answer: Obtain an arterial blood gas sample for evidence of hypoxia

      Explanation:

      It is recommended to obtain an arterial blood gas (ABG) sample from all patients who have experienced submersion (drowning) as even individuals without symptoms may have a surprising level of hypoxia. Draining the lungs is not effective and not recommended. There is no strong evidence to support the routine use of antibiotics as a preventive measure. Steroids have not been proven to be effective in treating drowning. All drowning patients, except those with normal oxygen levels, normal saturations, and normal lung sounds, should receive supplemental oxygen as significant hypoxia can occur without causing difficulty in breathing.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      13.9
      Seconds
  • Question 28 - A 35-year-old woman with a history of sickle cell disease undergoes a blood...

    Correct

    • A 35-year-old woman with a history of sickle cell disease undergoes a blood transfusion. After one week, she experiences a slight fever and notices dark urine. Blood tests are ordered, revealing elevated bilirubin and LDH levels, as well as a positive Direct Antiglobulin Test (DAT).
      Which of the following transfusion reactions is the most probable cause of these symptoms?

      Your Answer: Delayed haemolytic reaction

      Explanation:

      Blood transfusion is a crucial treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur.

      Delayed haemolytic transfusion reactions (DHTRs) typically occur 4-8 days after a blood transfusion, but can sometimes manifest up to a month later. The symptoms are similar to acute haemolytic transfusion reactions but are usually less severe. Patients may experience fever, inadequate rise in haemoglobin, jaundice, reticulocytosis, positive antibody screen, and positive Direct Antiglobulin Test (Coombs test). DHTRs are more common in patients with sickle cell disease who have received frequent transfusions.

      These reactions are caused by the presence of a low titre antibody that is too weak to be detected during cross-match and unable to cause lysis at the time of transfusion. The severity of DHTRs depends on the immunogenicity or dose of the antigen. Blood group antibodies associated with DHTRs include those of the Kidd, Duffy, Kell, and MNS systems. Most DHTRs have a benign course and do not require treatment. However, severe haemolysis with anaemia and renal failure can occur, so monitoring of haemoglobin levels and renal function is necessary. If an antibody is detected, antigen-negative blood can be requested for future transfusions.

      Here is a summary of the main transfusion reactions and complications:

      1. Febrile transfusion reaction: Presents with a 1-degree rise in temperature from baseline, along with chills and malaise. It is the most common reaction and is usually caused by cytokines from leukocytes in transfused red cell or platelet components. Supportive treatment with paracetamol is helpful.

      2. Acute haemolytic reaction: Symptoms include fever, chills, pain at the transfusion site, nausea, vomiting, and dark urine. It is the most serious type of reaction and often occurs due to ABO incompatibility from administration errors. The transfusion should be stopped, and IV fluids should be administered. Diuretics may be required.

      3. Delayed haemolytic reaction: This reaction typically occurs 4-8 days after a blood transfusion and presents with fever, anaemia, jaundice and haemoglobuinuria. Direct antiglobulin (Coombs) test positive. Due to low titre antibody too weak to detect in cross-match and unable to cause lysis at time of transfusion. Most delayed haemolytic reactions have a benign course and require no treatment. Monitor anaemia and renal function and treat as required.

    • This question is part of the following fields:

      • Haematology
      5.9
      Seconds
  • Question 29 - A 25 year old third year medical student is brought into the emergency...

    Correct

    • A 25 year old third year medical student is brought into the emergency department for a check up after fainting while observing a prolonged delivery that required an emergency C-section. The patient complains of feeling warm and sweaty for a couple of minutes before becoming lightheaded and losing consciousness. There were no reports of loss of bladder or bowel control, and no tongue biting was observed. Physical examination reveals no focal neurological deficits and a normal cardiovascular examination. Blood pressure is 122/74 mmHg when lying down and 120/72 mmHg when standing.

      What is the probable cause of the fainting episode?

      Your Answer: Vasovagal syncope

      Explanation:

      The most likely cause of the fainting episode in this 25-year-old third year medical student is vasovagal syncope. Vasovagal syncope is a common type of fainting that occurs in response to certain triggers, such as emotional stress, pain, or seeing blood. In this case, the prolonged delivery and emergency C-section likely triggered the patient’s vasovagal response.

      The patient’s symptoms of feeling warm and sweaty before fainting are consistent with vasovagal syncope. During a vasovagal episode, there is a sudden drop in blood pressure and heart rate, leading to a temporary loss of consciousness. The absence of loss of bladder or bowel control and tongue biting further support this diagnosis.

      The physical examination findings of no focal neurological deficits and a normal cardiovascular examination also align with vasovagal syncope. Additionally, the blood pressure measurements of 122/74 mmHg when lying down and 120/72 mmHg when standing suggest orthostatic hypotension, which is commonly seen in vasovagal syncope.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

    • This question is part of the following fields:

      • Neurology
      4.7
      Seconds
  • Question 30 - A 65-year-old woman presents having experienced a minor fall while shopping with her...

    Correct

    • A 65-year-old woman presents having experienced a minor fall while shopping with her husband. He has observed that she has been forgetful for quite some time and that her condition has been gradually deteriorating over the past few years. She frequently forgets the names of people and places and struggles to find words for things. Lately, she has also been experiencing increased confusion. She has no significant medical history of note.

      What is the SINGLE most probable diagnosis?

      Your Answer: Alzheimer’s disease

      Explanation:

      Alzheimer’s disease is the leading cause of dementia, accounting for approximately half of all cases. It involves the gradual degeneration of the cerebral cortex, resulting in cortical atrophy, the formation of neurofibrillary tangles and amyloid plaques, and a decrease in acetylcholine production from affected neurons. The exact cause of this disease is still not fully understood.

      The onset of Alzheimer’s disease is typically slow and subtle, progressing over a span of 7 to 10 years. The symptoms experienced by individuals vary depending on the stage of the disease. In the early stages, family and friends may notice that the patient becomes forgetful, experiencing lapses in memory. They may struggle to recall the names of people and places, as well as have difficulty finding the right words for objects. Recent events and appointments are easily forgotten. As the disease advances, language skills deteriorate, and problems with planning and decision-making arise. The patient may also exhibit apraxia and become more noticeably confused.

      In the later stages of Alzheimer’s disease, symptoms become more severe. The patient may wander aimlessly, become disoriented, and display apathy. Psychiatric symptoms, such as depression, are common during this stage. Hallucinations and delusions may also occur. Behavioral issues, including disinhibition, aggression, and agitation, can be distressing for the patient’s family.

      Considering the absence of a history of transient ischemic attacks (TIAs) or cardiovascular disease, vascular dementia is less likely. Unlike Alzheimer’s disease, vascular dementia typically has a more sudden onset and exhibits stepwise increases in symptom severity.

      Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative disorder closely associated with Parkinson’s disease. It can be distinguished from Alzheimer’s disease by the presence of mild Parkinsonism features, fluctuations in cognition and attention, episodes of transient loss of consciousness, and early occurrence of visual hallucinations and complex delusions.

      Frontotemporal dementia is a progressive form of dementia that primarily affects the frontal and/or temporal lobes. It typically occurs at a younger age than Alzheimer’s disease, usually between 40 and 60 years old. Personality changes often precede memory loss in this condition.

      Pseudodementia, also known as depression-related cognitive dysfunction, is a condition characterized by a temporary decline in cognitive function alongside a functional psychiatric disorder. While depression is the most common cause.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      5.7
      Seconds
  • Question 31 - A 45-year-old man presents with rigidity and slowness of movement. Following a referral...

    Incorrect

    • A 45-year-old man presents with rigidity and slowness of movement. Following a referral to a specialist, a diagnosis of Parkinson’s disease is made. The patient is in the early stages of the disease at present.

      Which of the following clinical features is most likely to also be present?

      Your Answer: Bilateral rest tremor

      Correct Answer: Hypokinesia

      Explanation:

      Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:

      – Hypokinesia (reduced movement)
      – Bradykinesia (slow movement)
      – Rest tremor (usually occurring at a rate of 4-6 cycles per second)
      – Rigidity (increased muscle tone and ‘cogwheel rigidity’)

      Other commonly observed clinical features include:

      – Gait disturbance (characterized by a shuffling gait and loss of arm swing)
      – Loss of facial expression
      – Monotonous, slurred speech
      – Micrographia (small, cramped handwriting)
      – Increased salivation and dribbling
      – Difficulty with fine movements

      Initially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:

      – Postural instability
      – Cognitive impairment
      – Orthostatic hypotension

      Although PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.

    • This question is part of the following fields:

      • Neurology
      5.2
      Seconds
  • Question 32 - A 25-year-old woman is stabbed in the chest during a fight outside a...

    Incorrect

    • A 25-year-old woman is stabbed in the chest during a fight outside a bar. A FAST scan is conducted, revealing the presence of free fluid in the chest cavity.

      Which of the following organs is most likely to be damaged in this scenario?

      Your Answer: Diaphragm

      Correct Answer: Liver

      Explanation:

      Stab wounds to the abdomen result in tissue damage through laceration and cutting. When patients experience penetrating abdominal trauma due to stab wounds, the organs that are most commonly affected include the liver (40% of cases), small bowel (30% of cases), diaphragm (20% of cases), and colon (15% of cases). These statistics are derived from the latest edition of the ATLS manual.

    • This question is part of the following fields:

      • Trauma
      17.3
      Seconds
  • Question 33 - You conduct a cardiovascular examination on a 62-year-old man who complains of palpitations....

    Incorrect

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

      Your Answer: Pulmonary hypertension

      Correct Answer: Pulmonary stenosis

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      19.8
      Seconds
  • Question 34 - A 2-year-old girl is brought in by her father. She is experiencing pain...

    Correct

    • A 2-year-old girl is brought in by her father. She is experiencing pain in her left ear and has symptoms of a cold. Upon examination, her left eardrum appears red. She does not have a fever and is otherwise healthy. You diagnose her with acute otitis media.
      What would be a valid reason to prescribe antibiotics for this child?

      Your Answer: Age less than 2 years

      Explanation:

      According to a Cochrane review conducted in 2008, it was discovered that approximately 80% of children experiencing acute otitis media were able to recover within a span of two days. However, the use of antibiotics only resulted in a reduction of pain for about 7% of children after the same two-day period. Furthermore, the administration of antibiotics did not show any significant impact on the rates of hearing loss, recurrence, or perforation. In cases where antibiotics are deemed necessary for children with otitis media, some indications include being under the age of two, experiencing discharge from the ear (otorrhoea), and having bilateral acute otitis media.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      8.9
      Seconds
  • Question 35 - A 68-year-old individual experiences a stroke. The primary symptoms include weakness in the...

    Incorrect

    • A 68-year-old individual experiences a stroke. The primary symptoms include weakness in the limbs on the right side, particularly affecting the right leg and right shoulder, as well as dysarthria.

      Which blood vessel is most likely to be impacted in this case?

      Your Answer: Middle cerebral artery

      Correct Answer: Anterior cerebral artery

      Explanation:

      The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:

      Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.

      Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.

      Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.

      It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.

    • This question is part of the following fields:

      • Neurology
      20.1
      Seconds
  • Question 36 - A 65-year-old male patient is brought into the emergency department with suspected sepsis....

    Incorrect

    • A 65-year-old male patient is brought into the emergency department with suspected sepsis. It is decided to intubate the patient pending transfer to the intensive care unit (ICU). Your consultant requests you to prepare propofol and suxamethonium for rapid sequence intubation. What is the mechanism of action of suxamethonium?

      Your Answer: Competitive agonist of acetylcholine receptors at the neuromuscular junction

      Correct Answer: Non-competitive agonist of acetylcholine receptors at the neuromuscular junction

      Explanation:

      Suxamethonium, also called succinylcholine, is a type of drug used to block neuromuscular transmission. It acts as an agonist by binding to acetylcholine receptors at the neuromuscular junction. Unlike acetylcholine, suxamethonium is not broken down by acetylcholinesterase, which means it stays bound to the receptors for a longer time, leading to prolonged inhibition of neuromuscular transmission. Eventually, suxamethonium is metabolized by plasma cholinesterase.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      14.1
      Seconds
  • Question 37 - A 21 year old male is brought to the emergency department by his...

    Incorrect

    • A 21 year old male is brought to the emergency department by his parents and admits to ingesting 48 paracetamol tablets. What are the criteria for administering activated charcoal in this case?

      Your Answer: Patient presents within 4 hours of ingesting paracetamol and paracetamol blood levels are in excess of 150 mg/kg

      Correct Answer: Patient presents within 1 hour of ingesting paracetamol and stated dose is in excess of 150 mg/kg

      Explanation:

      Activated charcoal should be given to patients who have ingested paracetamol and meet two criteria: they must present within one hour of ingestion, and they must have taken a dose of paracetamol that is equal to or greater than 150 mg/kg. The recommended dose of activated charcoal is 50g, which is typically administered as 300ml. It is important to note that the dose criteria of 150 mg/kg is based on the amount of paracetamol reported by the patient, not on paracetamol levels, which should not be assessed until at least four hours after ingestion.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.8
      Seconds
  • Question 38 - You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician...

    Correct

    • You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician requests you to insert a femoral central venous line. How should the patient be positioned for this procedure?

      Your Answer: Patient supine with slight abduction and external rotation of thigh/hip

      Explanation:

      To insert a femoral line, the patient should be lying on their back with a pillow placed under their buttocks to elevate the groin area. The thigh should be slightly moved away from the body and rotated outward.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      8.4
      Seconds
  • Question 39 - A 65-year-old patient with advanced metastatic lung cancer is experiencing severe pain in...

    Incorrect

    • A 65-year-old patient with advanced metastatic lung cancer is experiencing severe pain in his limbs and chest. Despite taking the maximum dose of paracetamol, codeine phosphate, and ibuprofen regularly, his symptoms are no longer being adequately controlled. You decide to discontinue the use of codeine phosphate and initiate stronger opioids.
      What is the most suitable course of action at this point?

      Your Answer: Subcutaneous morphine

      Correct Answer: Sustained-release oral morphine

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      1.3
      Seconds
  • Question 40 - A 65-year-old man comes in with a 2-hour history of left-sided weakness and...

    Correct

    • A 65-year-old man comes in with a 2-hour history of left-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage, and he is being prepared for thrombolysis. According to the current NICE guidelines, which thrombolytic agent is recommended for the treatment of acute ischemic stroke?

      Your Answer: Alteplase

      Explanation:

      According to the current guidelines from NICE, alteplase is recommended as a thrombolysis treatment for acute ischaemic stroke. For more information, you can refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over the age of 16.

    • This question is part of the following fields:

      • Neurology
      7
      Seconds
  • Question 41 - A father brings his 6-year-old daughter to the emergency department with a 6...

    Correct

    • A father brings his 6-year-old daughter to the emergency department with a 6 cm laceration to the right thigh. The wound requires suturing. Your consultant suggests you suture the child under ketamine sedation as the child is upset by the wound. You are confident there are no contraindications and proceed to obtain parental consent. Which of the following risks should be specifically listed on the consent form and discussed with the parent giving consent?

      Your Answer: Rash

      Explanation:

      Ketamine sedation in children should only be performed by a trained and competent clinician who is capable of managing complications, especially those related to the airway. The clinician should have completed the necessary training and have the appropriate skills for procedural sedation. It is important for the clinician to consider the length of the procedure before deciding to use ketamine sedation, as lengthy procedures may be more suitable for general anesthesia.

      Examples of procedures where ketamine may be used in children include suturing, fracture reduction/manipulation, joint reduction, burn management, incision and drainage of abscess, tube thoracostomy placement, foreign body removal, and wound exploration/irrigation.

      During the ketamine sedation procedure, a minimum of three staff members should be present: a doctor to manage the sedation and airway, a clinician to perform the procedure, and an experienced nurse to monitor and support the patient, family, and clinical staff. The child should be sedated and managed in a high dependency or resuscitation area with immediate access to resuscitation facilities. Monitoring should include sedation level, pain, ECG, blood pressure, respiration, pulse oximetry, and capnography, with observations taken and recorded every 5 minutes.

      Prior to the procedure, consent should be obtained from the parent or guardian after discussing the proposed procedure and use of ketamine sedation. The risks and potential complications should be explained, including mild or moderate/severe agitation, rash, vomiting, transient clonic movements, and airway problems. The parent should also be informed that certain common side effects, such as nystagmus, random purposeless movements, muscle twitching, rash, and vocalizations, are of no clinical significance.

      Topical anesthesia may be considered to reduce the pain of intravenous cannulation, but this step may not be advisable if the procedure is urgent. The clinician should also ensure that key resuscitation drugs are readily available and doses are calculated for the patient in case they are needed.

      Before administering ketamine, the child should be prepared by encouraging the parents or guardians to talk to them about happy thoughts and topics to minimize unpleasant emergence phenomena. The dose of ketamine is typically 1.0 mg/kg by slow intravenous injection over at least one minute, with additional doses of 0.5 mg/kg administered as required after 5-10 minutes to achieve the desired dissociative state.

    • This question is part of the following fields:

      • Paediatric Emergencies
      8.4
      Seconds
  • Question 42 - You are requested to deliver a teaching session on delirium for the incoming...

    Correct

    • You are requested to deliver a teaching session on delirium for the incoming medical interns rotating to the emergency department. What is a commonly acknowledged characteristic of delirium?

      Your Answer: Lucid intervals usually occur during the day

      Explanation:

      Delirium is characterized by fluctuating symptoms of disturbed consciousness that typically develop over hours to days. During the day, lucid intervals may occur, while the worst disturbances are often experienced at night. In contrast, dementia has a gradual onset and does not involve fluctuations in mental state. Stroke, on the other hand, is associated with focal neurological deficits.

      Further Reading:

      Delirium is an acute syndrome that causes disturbances in consciousness, attention, cognition, and perception. It is also known as an acute confusional state. The DSM-IV criteria for diagnosing delirium include recent onset of fluctuating awareness, impairment of memory and attention, and disorganized thinking. Delirium typically develops over hours to days and may be accompanied by behavioral changes, personality changes, and psychotic features. It often occurs in individuals with predisposing factors, such as advanced age or multiple comorbidities, when exposed to new precipitating factors, such as medications or infection. Symptoms of delirium fluctuate throughout the day, with lucid intervals occurring during the day and worse disturbances at night. Falling and loss of appetite are often warning signs of delirium.

      Delirium can be classified into three subtypes based on the person’s symptoms. Hyperactive delirium is characterized by inappropriate behavior, hallucinations, and agitation. Restlessness and wandering are common in this subtype. Hypoactive delirium is characterized by lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn. Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.

      The exact pathophysiology of delirium is not fully understood, but it is believed to involve multiple mechanisms, including cholinergic deficiency, dopaminergic excess, and inflammation. The cause of delirium is usually multifactorial, with predisposing factors and precipitating factors playing a role. Predisposing factors include older age, cognitive impairment, frailty, significant injuries, and iatrogenic events. Precipitating factors include infection, metabolic or electrolyte disturbances, cardiovascular disorders, respiratory disorders, neurological disorders, endocrine disorders, urological disorders, gastrointestinal disorders, severe uncontrolled pain, alcohol intoxication or withdrawal, medication use, and psychosocial factors.

      Delirium is highly prevalent in hospital settings, affecting up to 50% of inpatients aged over 65 and occurring in 30% of people aged over 65 presenting to the emergency department. Complications of delirium include increased risk of death, high in-hospital mortality rates, higher mortality rates following hospital discharge, increased length of stay in hospital, nosocomial infections, increased risk of admission to long-term care or re-admission to hospital, increased incidence of dementia, increased risk of falls and associated injuries, pressure sores.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      9.6
      Seconds
  • Question 43 - A 3-year-old girl comes in with stridor and a barking cough. Her mother...

    Correct

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

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

      Your Answer: Nebulised budesonide

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Respiratory
      13
      Seconds
  • Question 44 - There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological and...

    Correct

    • There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological and nuclear) incident, with indications pointing towards sarin gas as the responsible agent. In the management of this situation, certain casualties are administered atropine as an antidote.
      What is the mode of action of atropine?

      Your Answer: Muscarinic acetylcholine receptor antagonist

      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.

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      10.4
      Seconds
  • Question 45 - A 65 year old male presents to the emergency department with a 3...

    Correct

    • A 65 year old male presents to the emergency department with a 3 hour history of severe chest pain that radiates to his left arm and neck. On examination, his chest is clear and his heart sounds are normal with a regular rhythm. No carotid bruits are heard. The following observations are noted:

      Blood pressure: 150/90 mmHg
      Pulse rate: 88 bpm
      Respiration rate: 18 rpm
      Oxygen saturation: 97% on room air
      Temperature: 37.2ºC

      An ECG reveals normal sinus rhythm and a chest X-ray shows no abnormalities. The patient's pain subsides after receiving buccal GTN (glyceryl trinitrate). Cardiac enzyme tests are pending. What is the most appropriate course of action for this patient?

      Your Answer: Administer 300 mg oral aspirin

      Explanation:

      For patients suspected of having acute coronary syndromes (ACS), it is recommended that they receive 300 mg of aspirin and pain relief in the form of glyceryl trinitrate (GTN) with the option of intravenous opioids such as morphine. However, if the patient is pain-free after taking GTN, there is no need to administer morphine. The next steps in medical management or intervention will be determined once the diagnosis is confirmed.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      10.6
      Seconds
  • Question 46 - A 45 year old male is brought into the emergency department following a...

    Correct

    • A 45 year old male is brought into the emergency department following a car crash. There is significant bruising on the right side of the chest. You suspect the patient has a haemothorax. What are the two main objectives in managing this condition?

      Your Answer: Replace lost circulating blood volume and decompression of the pleural space

      Explanation:

      The main objectives in managing haemothorax are to restore the lost blood volume and relieve pressure in the pleural space. These actions are crucial for improving the patient’s oxygen levels.

      Further Reading:

      Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.

      The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.

      In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.

    • This question is part of the following fields:

      • Trauma
      8.9
      Seconds
  • Question 47 - A 25-year-old male is brought to the emergency department after intentionally ingesting 70...

    Correct

    • A 25-year-old male is brought to the emergency department after intentionally ingesting 70 amitriptyline tablets. You administer activated charcoal to the patient. Which other medication, listed as an antidote on the RCEM/NPIS, can be used to treat tricyclic overdose?

      Your Answer: Sodium bicarbonate

      Explanation:

      In the latest guideline published in 2021 by RCEM and NPIS regarding antidote availability for emergency departments, it is emphasized that immediate access to sodium bicarbonate is essential for treating TCA overdose. It is worth noting that previous versions of the guideline included glucagon as a recommended treatment for TCA overdose, but this reference has been omitted in the latest edition.

      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.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.2
      Seconds
  • Question 48 - A 14 year old female is brought to the emergency department by her...

    Correct

    • A 14 year old female is brought to the emergency department by her parents approximately 90 minutes after taking an overdose. The patient tells you she was at her friend's house and they got into an argument which ended with her friend telling her she was ending their friendship. The patient grabbed a bottle of pills from the bathroom and swallowed all of them before leaving. She didn't tell her friend she had taken the pills and wanted her to feel guilty but now regrets her actions. The patient tells you she didn't read the name on the bottle and threw the bottle away as she walked home. The patient also tells you she didn't see how many pills were in the bottle but thinks there were 20-30 of them. Several attempts to contact the patient's friend to try and clarify the identity of the pills are unsuccessful. The patient advises you she feels nauseated and has ringing in her ears. You also note the patient is hyperventilating. A blood gas sample is taken and is shown below:

      Parameter Result
      pH 7.49
      pO2 14.3 KPa
      pCO2 3.4 KPa
      HCO3- 25 mmol/L
      BE -1

      What is the likely causative agent?

      Your Answer: Aspirin

      Explanation:

      Tinnitus is often seen as an early indication of salicylate toxicity, which occurs when there is an excessive use of salicylate. Another common symptom is feeling nauseous and/or vomiting. In the initial stages of a salicylate overdose, individuals may experience respiratory alkalosis, which is caused by the direct stimulation of the respiratory centers in the medulla by salicylate. This leads to hyperventilation and the elimination of carbon dioxide, resulting in alkalosis. As the body metabolizes salicylate, a metabolic acidosis may develop.

      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.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      6.4
      Seconds
  • Question 49 - A 32-year-old woman is brought to the Emergency Department by ambulance due to...

    Incorrect

    • A 32-year-old woman is brought to the Emergency Department by ambulance due to 'severe palpitations.' Her heart rate is 180 bpm, and her rhythm strip is suggestive of supraventricular tachycardia. You plan to administer adenosine.
      Which of the following is NOT a contraindication to the use of adenosine?

      Your Answer: Decompensated heart failure

      Correct Answer: History of heart transplant

      Explanation:

      Adenosine is a type of purine nucleoside that is primarily utilized in the diagnosis and treatment of paroxysmal supraventricular tachycardia. Its main mechanism of action involves stimulating A1-adenosine receptors and opening acetylcholine-sensitive potassium channels. This leads to hyperpolarization of the cell membrane in the atrioventricular (AV) node and slows down conduction in the AV node by inhibiting calcium channels.

      When administering adenosine, it is given rapidly through an intravenous bolus, followed by a saline flush. The initial dose for adults is 6 mg, and if necessary, additional doses of 12 mg or 18 mg can be given at 1-2 minute intervals until the desired effect is observed. It is important to note that the latest ALS guidelines recommend 18 mg for the third dose, while the BNF/NICE guidelines suggest 12 mg.

      One of the advantages of adenosine is its very short half-life, which is less than 10 seconds. This means that its effects are rapid, typically occurring within 10 seconds. However, the duration of action is also short, lasting only 10-20 seconds. Due to its short half-life, any side effects experienced are usually brief. These side effects may include a sense of impending doom, facial flushing, dyspnea, chest discomfort, and a metallic taste.

      There are certain contraindications to the use of adenosine. These include 2nd or 3rd degree AV block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure, chronic obstructive lung disease, and asthma. It is important to exercise caution when administering adenosine to patients with a heart transplant, as they are particularly sensitive to its effects. In these cases, a reduced initial dose of 3 mg is recommended, followed by 6 mg and then 12 mg.

      It is worth noting that the effects of adenosine can be potentiated by dipyridamole, a medication commonly used in combination with adenosine. Therefore, the dose of adenosine should be adjusted and reduced in patients who are also taking dipyridamole.

    • This question is part of the following fields:

      • Cardiology
      10.2
      Seconds
  • Question 50 - A 12-year-old girl presents with her father. She is very active and enjoys...

    Incorrect

    • A 12-year-old girl presents with her father. She is very active and enjoys participating in various sports at a high level. Lately, she has been worried about experiencing pain in her right ankle. There is no history of injury, instability, or swelling. She is in good overall health. She can walk and run without discomfort, and the pain does not worsen after prolonged periods of rest. During the examination of her ankle, you observe tenderness and slight swelling around the lateral malleolus.

      What is the SINGLE most likely diagnosis?

      Your Answer: Still’s disease

      Correct Answer: Osgood-Schlatter disease

      Explanation:

      Osgood-Schlatter disease is commonly observed in active teenagers and is characterized by pain and tenderness in the tibial tuberosity. Rest is typically recommended as part of the treatment plan, and the diagnosis is made based on clinical evaluation.

      Chondromalacia patella is most prevalent in teenage girls and is often accompanied by knee pain while going up and downstairs. Discomfort tends to worsen after prolonged periods of sitting. Treatment options include pain relief medication and physiotherapy.

      Prepatellar bursitis, also known as housemaid’s knee, is linked to excessive kneeling.

      Pseudogout is an inflammatory arthritis caused by the accumulation of pyrophosphate crystals. While the knees are frequently affected, it is unlikely to occur in this age group.

      Still’s disease accounts for approximately 10% of cases of juvenile chronic arthritis. It typically involves multiple systems in the body and is often characterized by fever, rash, swollen lymph nodes, and joint pain.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      26.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Neonatal Emergencies (1/1) 100%
Elderly Care / Frailty (4/5) 80%
Gastroenterology & Hepatology (2/2) 100%
Obstetrics & Gynaecology (2/2) 100%
Endocrinology (1/3) 33%
Allergy (1/2) 50%
Basic Anaesthetics (2/3) 67%
Resus (1/2) 50%
Neurology (4/7) 57%
Maxillofacial & Dental (0/1) 0%
Cardiology (2/4) 50%
Nephrology (1/1) 100%
Haematology (2/2) 100%
Palliative & End Of Life Care (1/2) 50%
Trauma (3/4) 75%
Paediatric Emergencies (2/2) 100%
Ear, Nose & Throat (1/1) 100%
Pharmacology & Poisoning (2/3) 67%
Respiratory (1/1) 100%
Major Incident Management & PHEM (1/1) 100%
Musculoskeletal (non-traumatic) (0/1) 0%
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