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  • Question 1 - A 60-year-old woman comes in with severe left eye pain and loss of...

    Correct

    • A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. She has experienced vomiting multiple times. During the examination, there is noticeable left-sided circumcorneal erythema, and the left pupil is mid-dilated and unresponsive to light.

      What would be the most suitable initial investigation in this case?

      Your Answer: Applanation tonometry

      Explanation:

      This patient has presented with acute closed-angle glaucoma, which is a serious eye condition requiring immediate medical attention. It occurs when the iris pushes forward and blocks the fluid access to the trabecular meshwork, leading to increased pressure within the eye and damage to the optic nerve.

      The main symptoms of acute closed-angle glaucoma include severe eye pain, decreased vision, redness around the cornea, swelling of the cornea, a fixed semi-dilated pupil, nausea, vomiting, and episodes of blurred vision or seeing haloes.

      To confirm the diagnosis, tonometry is performed to measure the intraocular pressure. Normal pressure ranges from 10 to 21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.

      Management of acute closed-angle glaucoma involves providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous acetazolamide is administered to reduce intraocular pressure. Additionally, a topical miotic medication like pilocarpine is started about an hour after initiating other treatments to help constrict the pupil, as it may initially be paralyzed and unresponsive.

      Overall, acute closed-angle glaucoma is a medical emergency that requires prompt intervention to alleviate symptoms and prevent further damage to the eye.

    • This question is part of the following fields:

      • Ophthalmology
      20.1
      Seconds
  • Question 2 - You evaluate a 50-year-old woman with recent-onset carpal tunnel syndrome after injuring her...

    Correct

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

      Your Answer: Abductor digiti minimi

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
      23.7
      Seconds
  • Question 3 - The nurse contacts you to promptly assess a 21-year-old male experiencing respiratory distress...

    Correct

    • The nurse contacts you to promptly assess a 21-year-old male experiencing respiratory distress and suspected anaphylaxis. The nurse has initiated high-flow oxygen. What would be your immediate priority in terms of drug treatment?

      Your Answer: Adrenaline 500 mcg 1:1000 IM

      Explanation:

      Adrenaline is the most crucial drug in treating anaphylaxis. It is essential to be aware of the appropriate dosage and administration method for all age groups. Additionally, high flow oxygen should be administered, as mentioned in the question stem. While there are other drugs that should be given, they are considered less important than adrenaline. These include IV fluid challenge, slow administration of chlorpheniramine (either IM or IV), slow administration of hydrocortisone (particularly in individuals with asthma), and the consideration of nebulized salbutamol or ipratropium for wheezing individuals (especially those with known asthma).

      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
      12.7
      Seconds
  • Question 4 - A 57-year-old man comes in with bothersome swelling in both ankles. This has...

    Correct

    • A 57-year-old man comes in with bothersome swelling in both ankles. This has developed since he began taking a new medication for high blood pressure a couple of weeks ago.
      Which medication is the MOST likely culprit for this side effect?

      Your Answer: Amlodipine

      Explanation:

      Amlodipine is a medication that belongs to the class of calcium-channel blockers and is often prescribed for the management of high blood pressure. One of the most frequently observed side effects of calcium-channel blockers is the swelling of the ankles. Additionally, individuals taking these medications may also experience other common side effects such as nausea, flushing, dizziness, sleep disturbances, headaches, fatigue, abdominal pain, and palpitations.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      9.7
      Seconds
  • Question 5 - A 4-week-old baby girl is brought in by her parents with projectile vomiting....

    Correct

    • A 4-week-old baby girl is brought in by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen.

      What is the first test to be done in this case?

      Your Answer: Abdominal ultrasound scan

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neonatal Emergencies
      9
      Seconds
  • Question 6 - You evaluate a teenager with tetralogy of Fallot in a pediatric cardiology clinic.
    Which...

    Correct

    • You evaluate a teenager with tetralogy of Fallot in a pediatric cardiology clinic.
      Which of the following is NOT a characteristic of tetralogy of Fallot?

      Your Answer: Left ventricular hypertrophy

      Explanation:

      Tetralogy of Fallot (TOF) is the most prevalent cause of cyanotic congenital heart disease. It is characterized by four distinct features: pulmonary infundibular stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. TOF is often associated with various congenital syndromes, including DiGeorge syndrome (22q11 microdeletion syndrome), Trisomy 21, Foetal alcohol syndrome, and Maternal phenylketonuria.

      Nowadays, many cases of TOF are identified during antenatal screening or early postnatal assessment due to the presence of a heart murmur. Initially, severe cyanosis is uncommon shortly after birth because the patent ductus arteriosus provides additional blood flow to the lungs. However, once the ductus arteriosus closes, typically a few days after birth, cyanosis can develop.

      In cases where TOF goes undetected, the clinical manifestations may include severe cyanosis, poor feeding, breathlessness, dyspnea on exertion (such as prolonged crying), hypercyanotic spells triggered by activity, agitation, developmental delay, and failure to thrive. A cardiac examination may reveal a loud, long ejection systolic murmur caused by pulmonary stenosis, a systolic thrill at the lower left sternal edge, an aortic ejection click, and digital clubbing. Radiologically, a characteristic finding in TOF is a ‘boot-shaped’ heart (Coeur en sabot).

      Treatment for TOF often involves two stages. Initially, a palliative procedure is performed to alleviate symptoms, followed by a total repair at a later stage.

    • This question is part of the following fields:

      • Neonatal Emergencies
      8.5
      Seconds
  • Question 7 - A patient is experiencing upper gastrointestinal bleeding after receiving heparin. You determine that...

    Correct

    • A patient is experiencing upper gastrointestinal bleeding after receiving heparin. You determine that protamine sulfate should be used to reverse the anticoagulation. How much protamine sulfate is needed to neutralize 200 IU of heparin?

      Your Answer: 2 mg

      Explanation:

      Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex renders heparin inactive, making protamine sulphate a useful tool for neutralizing the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.

      It is important to note that protamine sulphate also possesses its own weak intrinsic anticoagulant effect. This effect is believed to stem from its ability to inhibit the formation and activity of thromboplastin.

      When administering protamine sulphate, it is typically done through slow intravenous injection. The dosage should be adjusted based on the amount of heparin that needs to be neutralized, the time that has passed since heparin administration, and the aPTT (activated partial thromboplastin time). As a general guideline, 1 mg of protamine can neutralize 100 IU of heparin. However, it is crucial to adhere to a maximum adult dose of 50 mg within a 10-minute period.

      It is worth mentioning that protamine sulphate can have some adverse effects. It acts as a myocardial depressant, potentially leading to bradycardia (slow heart rate) and hypotension (low blood pressure). These effects may arise due to complement activation and leukotriene release.

    • This question is part of the following fields:

      • Haematology
      7.9
      Seconds
  • Question 8 - You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
    Which tuning...

    Correct

    • You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
      Which tuning fork should be utilized to conduct a Rinne's test on this individual?

      Your Answer: 512 Hz

      Explanation:

      A 512 Hz tuning fork is commonly used for both the Rinne’s and Weber’s tests. However, a lower-pitched fork, such as a 128 Hz tuning fork, is typically used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for either test, it is considered less reliable for both.

      To perform a Rinne’s test, the 512 Hz tuning fork is first made to vibrate and then placed on the mastoid process until the sound is no longer heard. The top of the tuning fork is then positioned 2 cm away from the external auditory meatus, and the patient is asked to indicate where they hear the sound loudest.

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

      In cases of conductive hearing loss, the patient will no longer hear the tuning fork once it is no longer appreciated on the mastoid. This suggests that their bone conduction is greater than their air conduction, indicating an obstruction in the passage of sound waves through the ear canal into the cochlea. This is considered a true negative result.

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      3.6
      Seconds
  • Question 9 - A 68 year old man is brought to the emergency department due to...

    Correct

    • A 68 year old man is brought to the emergency department due to sudden difficulty breathing. Bedside echocardiography reveals significant mitral regurgitation. What is a common clinical characteristic of mitral regurgitation?

      Your Answer: A 3rd heart sound

      Explanation:

      Mitral regurgitation is characterized by several clinical features. One of the main signs is a pansystolic murmur that can be heard throughout the entire systolic phase of the cardiac cycle. This murmur often radiates to the left axilla. Another notable feature is a soft S1 heart sound, which is the first heart sound heard during the cardiac cycle. Additionally, a 3rd heart sound, also known as an added sound, can be detected in patients with mitral regurgitation. As the condition progresses to moderate to severe levels, signs such as a laterally displaced apex beat with a heave may become apparent.

      Further Reading:

      Mitral Stenosis:
      – Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
      – Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
      – Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
      – Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valve

      Mitral Regurgitation:
      – Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
      – Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
      – Signs of acute MR: Decompensated congestive heart failure symptoms
      – Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
      – Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR.

    • This question is part of the following fields:

      • Cardiology
      23.8
      Seconds
  • Question 10 - A 30-year-old woman who is being treated for a urinary tract infection comes...

    Correct

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

      Your Answer: Fosfomycin

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Urology
      25.6
      Seconds
  • Question 11 - A 45-year-old man is brought into the Emergency Department by his wife after...

    Correct

    • A 45-year-old man is brought into the Emergency Department by his wife after taking an overdose of paracetamol. The patient claims that he wants to end it all and refuses to stay in the hospital for treatment. His wife insists that he must be treated because he is not thinking clearly.

      Which medication is the primary treatment for paracetamol overdose in an inpatient setting?

      Your Answer: Acetylcysteine

      Explanation:

      Paracetamol overdose is the most common overdose in the U.K. and is also the leading cause of acute liver failure. The liver damage occurs due to a metabolite of paracetamol called N-acetyl-p-benzoquinoneimine (NAPQI), which depletes the liver’s glutathione stores and directly harms liver cells. Severe liver damage and even death can result from an overdose of more than 12 g or > 150 mg/kg body weight.

      The clinical manifestations of paracetamol overdose can be divided into four stages:

      Stage 1 (0-24 hours): Patients may not show any symptoms, but common signs include nausea, vomiting, and abdominal discomfort.

      Stage 2 (24-48 hours): Right upper quadrant pain and tenderness develop, along with the possibility of hypoglycemia and reduced consciousness.

      Stage 3 (48-96 hours): Hepatic failure begins, characterized by jaundice, coagulopathy, and encephalopathy. Loin pain, haematuria, and proteinuria may indicate early renal failure.

      Stage 4 (> 96 hours): Hepatic failure worsens progressively, leading to cerebral edema, disseminated intravascular coagulation (DIC), and ultimately death.

      The earliest and most sensitive indicator of liver damage is a prolonged INR, which starts to rise approximately 24 hours after the overdose. Liver function tests (LFTs) typically remain normal until 18 hours after the overdose. However, AST and ALT levels then sharply increase and can exceed 10,000 units/L by 72-96 hours. Bilirubin levels rise more slowly and peak around 5 days.

      The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is a highly effective antidote, but its efficacy diminishes rapidly if administered more than 8 hours after a significant ingestion. Ingestions exceeding 75 mg/kg are considered significant.

      Acetylcysteine should be given based on a 4-hour level or administered empirically if the presentation occurs more than 8 hours after a significant overdose. If the overdose is staggered or the timing is uncertain, empirical treatment is also recommended. The treatment regimen is as follows:

      – First dose: 150 mg/kg in 200 mL 5% glucose over 1 hour
      – Second dose 50 mg/kg in 500 mL 5% glucose over 4 hours
      – Third dose 100 mg/kg in 1000 mL 5% glucose over 16 hours

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.7
      Seconds
  • Question 12 - You review a middle-aged man on the Clinical Decision Unit (CDU) who is...

    Correct

    • You review a middle-aged man on the Clinical Decision Unit (CDU) who is known to have Parkinson’s disease. Currently, he takes a combination of levodopa and selegiline, and his symptoms are reasonably well controlled. He has recently been diagnosed with a different condition, and he wonders if this could be related to his Parkinson’s disease.

      Which of the following conditions is most likely to be associated with Parkinson’s disease?

      Your Answer: Depression

      Explanation:

      Parkinson’s disease is often accompanied by two prevalent diseases, namely dementia and depression. Dementia is observed in approximately 20 to 40% of individuals diagnosed with Parkinson’s disease. On the other hand, depression is experienced by around 45% of patients with Parkinson’s disease.

    • This question is part of the following fields:

      • Neurology
      9
      Seconds
  • Question 13 - A 60-year-old woman presents with recent weight loss, difficulty breathing, and chest pain....

    Correct

    • A 60-year-old woman presents with recent weight loss, difficulty breathing, and chest pain. She has a long history of smoking and has been diagnosed with COPD. A chest X-ray reveals a large mass in the left lung consistent with cancer. You recommend that she be referred to a specialist for further evaluation and treatment, but she refuses and does not want her family to know about her condition. She also states that she does not want to hear any negative news. After assessing her mental capacity and determining that she is competent and has capacity, which of the following statements is true regarding her ongoing care?

      Your Answer: You should document that the patient has declined information

      Explanation:

      There is no indication for an independent psychiatric evaluation of this patient. However, it is important to clearly document in his medical records that you have assessed his mental capacity and determined that he is capable of making decisions. It would not be appropriate in this case to refer him to a specialist against his wishes or to breach confidentiality by discussing his illness with his family or next of kin. According to the guidelines set by the General Medical Council (GMC), it is necessary to document the fact that the patient has declined relevant information. It is also important to avoid pressuring the patient to change their mind in these circumstances.

      For further information, please refer to the GMC guidelines on treatment and care towards the end of life: good practice in decision making.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      36.7
      Seconds
  • Question 14 - A 45 year old female visits the emergency department complaining of abdominal cramps...

    Correct

    • A 45 year old female visits the emergency department complaining of abdominal cramps and bloating that are alleviated by defecation. Blood tests and an abdominal X-ray are conducted, all of which come back normal. It is observed that the patient has visited the hospital twice in the past 4 months with similar symptoms and has also consulted her primary care physician regarding these recurring issues. The suspicion is that the patient may be suffering from irritable bowel syndrome (IBS). What diagnostic criteria would be most suitable for diagnosing IBS?

      Your Answer: ROME IV

      Explanation:

      The ROME IV criteria are utilized in secondary care to diagnose IBS, as recommended by NICE. The DSM-5 criteria are employed in diagnosing various mental health disorders. Coeliac disease diagnosis involves the use of modified marsh typing. Gastro-oesophageal reflux disease diagnosis relies on the Lyon Consensus.

      Further Reading:

      Irritable bowel syndrome (IBS) is a chronic disorder that affects the interaction between the gut and the brain. The exact cause of IBS is not fully understood, but factors such as genetics, drug use, enteric infections, diet, and psychosocial factors are believed to play a role. The main symptoms of IBS include abdominal pain, changes in stool form and/or frequency, and bloating. IBS can be classified into subtypes based on the predominant stool type, including diarrhea-predominant, constipation-predominant, mixed, and unclassified.

      Diagnosing IBS involves using the Rome IV criteria, which includes recurrent abdominal pain associated with changes in stool frequency and form. It is important to rule out other more serious conditions that may mimic IBS through a thorough history, physical examination, and appropriate investigations. Treatment for IBS primarily involves diet and lifestyle modifications. Patients are advised to eat regular meals with a healthy, balanced diet and adjust their fiber intake based on symptoms. A low FODMAP diet may be trialed, and a dietician may be consulted for guidance. Regular physical activity and weight management are also recommended.

      Psychosocial factors, such as stress, anxiety, and depression, should be addressed and managed appropriately. If constipation is a predominant symptom, soluble fiber supplements or foods high in soluble fiber may be recommended. Laxatives can be considered if constipation persists, and linaclotide may be tried if optimal doses of previous laxatives have not been effective. Antimotility drugs like loperamide can be used for diarrhea, and antispasmodic drugs or low-dose tricyclic antidepressants may be prescribed for abdominal pain. If symptoms persist or are refractory to treatment, alternative diagnoses should be considered, and referral to a specialist may be necessary.

      Overall, the management of IBS should be individualized based on the patient’s symptoms and psychosocial situation. Clear explanation of the condition and providing resources for patient education, such as the NHS patient information leaflet and support from organizations like The IBS Network, can also be beneficial.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      3.9
      Seconds
  • Question 15 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Correct

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

      What is the most probable diagnosis in this case?

      Your Answer: Superior vena cava syndrome

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Oncological Emergencies
      15.8
      Seconds
  • Question 16 - A 30-year-old woman presents with a persistent sore throat that has been bothering...

    Correct

    • A 30-year-old woman presents with a persistent sore throat that has been bothering her for five days. She has also been experiencing symptoms of a cold for the past few days and has a bothersome dry cough. Upon examination, she does not have a fever and there are no swollen lymph nodes in her neck. Her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.
      Using the FeverPAIN Score to evaluate her sore throat, what would be the most appropriate course of action for her at this point?

      Your Answer: No treatment is required, and she should be reassured

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      60.7
      Seconds
  • Question 17 - A 35-year-old businessman has returned from a trip to the U.S.A. this morning...

    Correct

    • A 35-year-old businessman has returned from a trip to the U.S.A. this morning with ear pain and ringing in his ears. He reports experiencing significant pain in his right ear while the plane was descending. He also feels slightly dizzy. Upon examination, there is fluid buildup behind his eardrum and Weber's test shows lateralization to the right side.

      What is the MOST SUITABLE next step in managing this patient?

      Your Answer: Give patient advice and reassurance

      Explanation:

      This patient has experienced otic barotrauma, which is most commonly seen during aircraft descent but can also occur in divers. Otic barotrauma occurs when the eustachian tube fails to equalize the pressure between the middle ear and the atmosphere, resulting in a pressure difference. This is more likely to happen in patients with eustachian tube dysfunction, such as those with acute otitis media or glue ear.

      Patients with otic barotrauma often complain of severe ear pain, conductive hearing loss, ringing in the ears (tinnitus), and dizziness (vertigo). Upon examination, fluid can be observed behind the eardrum, and in more severe cases, the eardrum may even rupture.

      In most instances, the symptoms of otic barotrauma resolve within a few days without any treatment. However, in more severe cases, it may take 2-3 weeks for the symptoms to subside. Nasal decongestants can be beneficial before and during a flight, but their effectiveness is limited once symptoms have already developed. Nasal steroids have no role in the management of otic barotrauma, and antibiotics should only be used if an infection develops.

      The most appropriate course of action in this case would be to provide the patient with an explanation of what has occurred and reassure them that their symptoms should improve soon.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      31.6
      Seconds
  • Question 18 - A 60-year-old man who has recently undergone treatment for lymphoma presents with retrosternal...

    Correct

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Oesophageal candidiasis

      Explanation:

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

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

      The recommended treatment for oesophageal candidiasis is as follows:

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

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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      10.1
      Seconds
  • Question 19 - You are called into the emergency room to assist with multiple trauma patients...

    Correct

    • You are called into the emergency room to assist with multiple trauma patients after a car accident. The patient you are assigned to has significant bruising on their chest, muffled heart sounds, and low blood pressure despite receiving fluids. During an ultrasound scan, a large buildup of fluid around the heart is observed. Due to the high number of injured individuals, the cardiac surgery team is unable to immediately take the patient to the operating room. You are given the task of performing a pericardiocentesis. Which of the following changes in the patient's electrocardiogram (ECG) would indicate that the needle has been successfully inserted into the ventricle?

      Your Answer: ST elevation

      Explanation:

      ST elevation and ventricular ectopics indicate that the needle has made contact with the ventricle. In such cases, it is recommended to retract the needle until the ECG pattern returns to its normal baseline.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      9.6
      Seconds
  • Question 20 - You are reviewing a middle-aged woman who came into the department with abdominal...

    Incorrect

    • You are reviewing a middle-aged woman who came into the department with abdominal pain. A diagnosis of a simple urinary tract infection has been made, and she will continue with a course of antibiotics at home. She lives at home by herself and has a neighbor who checks on her occasionally. She has mild anxiety, but has capacity and is keen to go back home. Her daughter stops you in the corridor and tells you that she doesn't want her mother to go home, but would like her to go to a rehabilitation center that specializes in mental health.

      What is the most appropriate initial response? Select ONE option only.

      Your Answer: The patient has capacity and therefore their interests and wishes must be prioritised

      Correct Answer:

      Explanation:

      This question delves into the challenges of managing chronic illnesses and promoting patient self-care, while also considering concerns regarding confidentiality. The patient in question is mentally capable and already has caregivers at home. It is both the patient’s preference and the most clinically sensible decision to discharge them back home. It is important to address any family concerns, ensuring that the family members have the patient’s best interests at heart rather than personal or financial motives. It is not appropriate to delegate this conversation to a nurse, as it is your responsibility as the healthcare provider. It is crucial to communicate with the patient’s general practitioner, but it is important to involve the patient in any decision regarding a referral to a nursing home.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      39.7
      Seconds
  • Question 21 - A 35-year-old woman is given a medication for a medical condition during her...

    Incorrect

    • A 35-year-old woman is given a medication for a medical condition during her pregnancy. As a result, the newborn experiences multiple significant birth defects, such as neural tube, craniofacial, and limb abnormalities.

      Which of the following medications is the most probable culprit for these anomalies?

      Your Answer: Trimethoprim

      Correct Answer: Sodium valproate

      Explanation:

      Sodium valproate is considered the most high-risk anti-epileptic drug during pregnancy. A recent review found that up to 40% of children born to women who took sodium valproate while pregnant experienced some form of adverse effect. These effects include a 1.5% risk of neural tube defects and an increased risk of cardiac, craniofacial, and limb defects. Additionally, there is a significant risk of neurodevelopmental problems in childhood.

      Here is a list outlining the commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.

      Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose a significant risk.

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimester, they can lead to fetal growth retardation.

      Carbamazepine: This drug can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can result in gray baby syndrome.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.

      Danazol: If given in the first trimester, this drug can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol: If given in the first trimester, this drug may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Maternal bleeding and thrombocytopenia are potential adverse outcomes.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.8
      Seconds
  • Question 22 - A 35-year-old diving instructor complains of pain and discharge in his right ear....

    Incorrect

    • A 35-year-old diving instructor complains of pain and discharge in his right ear. Upon examination, you observe redness in the ear canal along with a significant amount of pus and debris.
      What is the SINGLE most probable organism responsible for this condition?

      Your Answer: Streptococcus pneumoniae

      Correct Answer: Pseudomonas aeruginosa

      Explanation:

      Otitis externa, also known as swimmer’s ear, is a condition characterized by infection and inflammation of the ear canal. Common symptoms include pain, itching, and discharge from the ear. Upon examination with an otoscope, the ear canal will appear red and there may be pus and debris present.

      There are several factors that can increase the risk of developing otitis externa, including skin conditions like psoriasis and eczema. Additionally, individuals who regularly expose their ears to water, such as swimmers, are more prone to this condition.

      The most common organisms that cause otitis externa are Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), Gram-negative bacteria like E.coli (12%), and fungal species like Aspergillus and Candida (12%).

      Treatment for otitis externa typically involves the use of topical antibiotic and corticosteroid combinations, such as Betnesol-N or Sofradex. In some cases, when the condition persists, referral to an ear, nose, and throat specialist may be necessary for auditory cleaning and the placement of an antibiotic-soaked wick.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      18
      Seconds
  • Question 23 - A 45-year-old combat veteran, Sarah, has been diagnosed with post-traumatic stress disorder (PTSD).
    What...

    Correct

    • A 45-year-old combat veteran, Sarah, has been diagnosed with post-traumatic stress disorder (PTSD).
      What is the most suitable treatment for her?

      Your Answer: Eye Movement Desensitisation and Reprocessing

      Explanation:

      Eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive-behavioral therapy (CBT) are the primary treatment options for post-traumatic stress disorder (PTSD). These therapies should be provided to individuals of all ages, including children, adolescents, and adults, regardless of the time that has passed since the traumatic event. The recommended number of sessions is typically 8-12, although additional sessions may be necessary in cases involving multiple traumas, chronic disability, comorbidities, or social difficulties.

    • This question is part of the following fields:

      • Mental Health
      6.8
      Seconds
  • Question 24 - A 5 year old boy is brought into the emergency department by worried...

    Correct

    • A 5 year old boy is brought into the emergency department by worried parents. The child's parents inform you that the patient has had a cough and a runny nose for about 2-3 days, but in the past 24 hours, he has developed a fever and started coughing up large quantities of green mucus. You suspect bacterial tracheitis. What is the most probable causative agent?

      Your Answer: Staphylococcus aureus

      Explanation:

      Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

      The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

      In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

      Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

      When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

    • This question is part of the following fields:

      • Paediatric Emergencies
      6.3
      Seconds
  • Question 25 - A 15 year old female is brought to the emergency department by a...

    Correct

    • A 15 year old female is brought to the emergency department by a family member after collapsing at home. The triage nurse asks you to evaluate the patient after obtaining vital signs and a capillary glucose. The results are as follows:

      Blood pressure: 88/58 mmHg
      Pulse rate: 118 bpm
      Respiration rate: 38 bpm
      Temperature: 37.5ºC
      Oxygen saturation: 97% on room air
      Glucose level: 28 mmol/l

      Further tests confirm a diagnosis of diabetic ketoacidosis. What would be the most appropriate initial treatment in this case?

      Your Answer: Administer 500ml of 0.9% sodium chloride solution over 10-15 minutes

      Explanation:

      It is recommended to administer sodium chloride solution gradually over a period of 10-15 minutes. If the systolic does not respond adequately, the bolus dose may need to be repeated. It is important to note that patients with DKA often have a fluid deficit of more than 5 liters, which should be taken into consideration.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      25.8
      Seconds
  • Question 26 - A 45-year-old man presents with a sudden onset of severe asthma symptoms. You...

    Correct

    • A 45-year-old man presents with a sudden onset of severe asthma symptoms. You begin treatment for the patient, following the most recent BTS guidelines.

      According to the BTS guidelines, what is the appropriate course of action for management?

      Your Answer: Steroids should be given in all cases of acute asthma attack

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      18.9
      Seconds
  • Question 27 - A 35-year-old woman that has been involved in a car accident is estimated...

    Correct

    • A 35-year-old woman that has been involved in a car accident is estimated to have suffered a class II haemorrhage according to the Advanced Trauma Life Support (ATLS) haemorrhagic shock classification. The patient weighs approximately 60 kg.
      Which of the following physiological parameters is consistent with a diagnosis of class II haemorrhage?

      Your Answer: Heart rate of 110 bpm

      Explanation:

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

      The ATLS classification for hemorrhagic shock is as follows:

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      12.1
      Seconds
  • Question 28 - A 45-year-old man is brought to the resuscitation area of your Emergency Department...

    Correct

    • A 45-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few days with vomiting and diarrhea. His wife tells you that he was started on a medication by his GP six months ago for pain and stiffness around his shoulders, upper arms, and hips. She describes this medication as being '6 small blue tablets.' He has been unable to take these tablets for the past few days. On examination, he is pale and sweaty and appears confused. His observations are as follows: temperature 36.9°C, HR 140 bpm, BP 83/42, RR 24, SaO2 98% on 2 L oxygen, GCS 14. He has intravenous access in situ, and his BM stick glucose is 2.1.
      Which rheumatological condition is it most likely that his GP is treating?

      Your Answer: Polymyalgia rheumatica

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      19.6
      Seconds
  • Question 29 - A 35-year-old man with a history of bipolar affective disorder presents with symptoms...

    Incorrect

    • A 35-year-old man with a history of bipolar affective disorder presents with symptoms suggestive of lithium toxicity.
      Which of the following symptoms is MOST likely to be present?

      Your Answer: Reduced muscle tone

      Correct Answer: Clonus

      Explanation:

      Lithium toxicity presents with various symptoms, including nausea and vomiting, diarrhea, tremor, ataxia, confusion, increased muscle tone, clonus, nephrogenic diabetes insipidus, convulsions, coma, and renal failure. One notable symptom associated with digoxin toxicity is xanthopsia.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      20.9
      Seconds
  • Question 30 - A 65-year-old woman with a history of Alzheimer's disease is brought to the...

    Correct

    • A 65-year-old woman with a history of Alzheimer's disease is brought to the Emergency Department with a nosebleed. She currently lives alone and receives a care package once a week. The nosebleed stops with minimal treatment, and all other tests and observations are normal. Just as you are finishing up her paperwork, her daughter brings up a few concerns that she wants to address before her mother is discharged home.
      What would be the most appropriate step to take?

      Your Answer: Talk to the patient about their daughter's concerns and get their perspective

      Explanation:

      This situation is potentially complicated and involves another family member. The patient currently lives alone and based on the given history, it seems to be a mild episode of epistaxis. Without any additional information, it would be reasonable to assume that the patient can continue living in his current conditions.

      It is crucial to listen to the family’s concerns. However, it is important to keep the patient as the main focus. Out of the options provided, the most sensible approach would be to have a conversation with the patient regarding his son’s concerns and understand his perspective on those concerns.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      31.7
      Seconds
  • Question 31 - A 2-year-old girl is brought in by her father with a reported high...

    Correct

    • A 2-year-old girl is brought in by her father with a reported high temperature at home. The triage nurse measures her temperature again as part of her initial assessment.
      Which of the following is suggested by NICE as being an acceptable method of measuring body temperature in this age group?

      Your Answer: Infra-red tympanic thermometer

      Explanation:

      In infants who are less than 4 weeks old, it is recommended to measure their body temperature using an electronic thermometer placed in the armpit.

      For children between the ages of 4 weeks and 5 years, there are several methods that can be used to measure body temperature. These include using an electronic thermometer in the armpit, a chemical dot thermometer in the armpit, or an infra-red tympanic thermometer.

      It is important to note that measuring temperature orally or rectally should be avoided in this age group. Additionally, forehead chemical thermometers are not reliable and should not be used.

    • This question is part of the following fields:

      • Infectious Diseases
      20.7
      Seconds
  • Question 32 - A 32-year-old woman with chronic anemia secondary to a diagnosis of sickle cell...

    Correct

    • A 32-year-old woman with chronic anemia secondary to a diagnosis of sickle cell disease receives a blood transfusion. A few minutes after the blood transfusion has started, she experiences wheezing, chest discomfort, nausea, and widespread itching with a rash. Her blood pressure drops to 76/40 mmHg.

      What is the most suitable course of treatment for this patient?

      Your Answer: Stop the transfusion and administer adrenaline

      Explanation:

      Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, immune dilution, and transfusion errors. While there have been improvements in safety procedures and efforts to minimize the use of transfusion, errors and serious adverse reactions still occur and often go unreported.

      One rare complication of blood transfusion is transfusion-associated graft-vs-host disease (TA-GVHD). This condition typically presents with fever, rash, and diarrhea 1-4 weeks after the transfusion. Laboratory findings may show pancytopenia and abnormalities in liver function. Unlike GVHD after marrow transplantation, TA-GVHD leads to severe marrow aplasia with a mortality rate exceeding 90%. Unfortunately, there are currently no effective treatments available for this condition, and survival is rare, with death usually occurring within 1-3 weeks of the first symptoms.

      During a blood transfusion, viable T lymphocytes from the donor are transfused into the recipient’s body. In TA-GVHD, these lymphocytes engraft and react against the recipient’s tissues. However, the recipient is unable to reject the donor lymphocytes due to factors such as immunodeficiency, severe immunosuppression, or shared HLA antigens. Supportive management is the only option for TA-GVHD.

      The following summarizes the main complications and reactions that can occur during a blood transfusion:

      Complication Features Management
      Febrile transfusion reaction
      – Presents with a 1-degree rise in temperature from baseline, along with chills and malaise.
      – Most common reaction, occurring in 1 out of 8 transfusions.
      – Usually caused by cytokines from leukocytes in transfused red cell or platelet components.
      – Supportive management, with the use of paracetamol for symptom relief.

      Acute haemolytic reaction
      – Symptoms include fever, chills, pain at the transfusion site, nausea, vomiting, and dark urine.
      – Often accompanied by a feeling of ‘impending doom’.
      – Most serious type of reaction, often due to ABO incompatibility caused by administration errors.
      – Immediate action required: stop the transfusion, administer IV fluids, and consider diuretics if necessary.

      Delayed haemolytic reaction
      – Typically occurs 4-8 days after a blood transfusion.
      – Symptoms include fever, anemia and/or hyperbilirubinemia

    • This question is part of the following fields:

      • Haematology
      31.4
      Seconds
  • Question 33 - A middle-aged woman presents with symptoms that can be associated with sexually transmitted...

    Correct

    • A middle-aged woman presents with symptoms that can be associated with sexually transmitted infection (STI). Following her investigations, she is diagnosed with the most common cause of STI in the UK.

      Which of the following is the SINGLE most likely diagnosis?

      Your Answer: Chlamydia

      Explanation:

      Chlamydia trachomatis is a type of Gram-negative bacteria that is responsible for causing the sexually transmitted infection known as chlamydia. This bacterium is typically either coccoid or rod-shaped in its appearance.

      There are various serological variants of C. trachomatis, and each variant is associated with different patterns of disease. Specifically, types D-K are responsible for causing genitourinary infections.

      In the United Kingdom, chlamydia is the most commonly diagnosed sexually transmitted infection (STI). It is also the leading preventable cause of infertility worldwide. Interestingly, around 50% of men infected with chlamydia do not experience any symptoms, while at least 70% of infected women are asymptomatic.

      If left untreated, chlamydia can lead to various complications. In women, these complications may include pelvic inflammatory disease (PID), ectopic pregnancy, and tubal infertility. Men, on the other hand, may experience complications such as proctitis, epididymitis, and epididymo-orchitis.

    • This question is part of the following fields:

      • Sexual Health
      8.2
      Seconds
  • Question 34 - A 45-year-old man presents with a history of feeling generally unwell and having...

    Correct

    • A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently receiving radiation therapy. His observations are as follows: HR 92 bpm, BP 130/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
      According to the current NICE guidelines what is the cut off point for the neutrophil count for a diagnosis of neutropenic sepsis to be made?

      Your Answer: 0.5 x 109 per litre or lower

      Explanation:

      Neutropenic sepsis is a serious complication that can arise when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is commonly seen in individuals undergoing treatments such as cytotoxic chemotherapy or taking immunosuppressive drugs. Other causes of neutropenia include infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, as well as nutritional deficiencies.

      To diagnose neutropenic sepsis, doctors look for specific criteria in patients receiving anticancer treatment. These criteria include having a neutrophil count of 0.5 x 109 per liter or lower, along with either a body temperature higher than 38°C or other signs and symptoms that indicate a clinically significant sepsis.

    • This question is part of the following fields:

      • Oncological Emergencies
      5.4
      Seconds
  • Question 35 - A 35-year-old man who resides in a Traveller community comes in with a...

    Incorrect

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

      Your Answer: Azithromycin

      Correct Answer: Erythromycin

      Explanation:

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

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

    • This question is part of the following fields:

      • Respiratory
      16.8
      Seconds
  • Question 36 - A 45-year-old woman is about to begin taking warfarin for the treatment of...

    Correct

    • A 45-year-old woman is about to begin taking warfarin for the treatment of her atrial fibrillation. She is currently on multiple other medications.
      Which ONE medication will counteract the effects of warfarin?

      Your Answer: Phenytoin

      Explanation:

      Cytochrome p450 enzyme inducers have the ability to hinder the effects of warfarin, leading to a decrease in INR levels. To remember the commonly encountered cytochrome p450 enzyme inducers, the mnemonic PC BRASS can be utilized. Each letter in the mnemonic represents a specific inducer: P for Phenytoin, C for Carbamazepine, B for Barbiturates, R for Rifampicin, A for Alcohol (chronic ingestion), S for Sulphonylureas, and S for Smoking. These inducers can have an impact on the effectiveness of warfarin and should be taken into consideration when prescribing or using this medication.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24
      Seconds
  • Question 37 - A 40-year-old man has a confirmed diagnosis of von Willebrand disease.
    Which of the...

    Correct

    • A 40-year-old man has a confirmed diagnosis of von Willebrand disease.
      Which of the following abnormalities is MOST likely to appear on his clotting profile?

      Your Answer: Prolonged APTT

      Explanation:

      Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects approximately 1 in 100 individuals. It occurs due to a deficiency in Von Willebrand factor (vWF), which plays a crucial role in blood clotting. vWF not only binds to factor VIII to protect it from rapid breakdown, but it is also necessary for proper platelet adhesion. When vWF is lacking, both factor VIII levels and platelet function are affected, leading to prolonged APTT and bleeding time. However, the platelet count and thrombin time remain unaffected.

      While some individuals with vWD may not experience any symptoms and are diagnosed incidentally during a clotting profile check, others may present with easy bruising, nosebleeds (epistaxis), and heavy menstrual bleeding (menorrhagia). In severe cases, more significant bleeding and joint bleeding (haemarthrosis) can occur.

      For mild cases of von Willebrand disease, bleeding can be managed with desmopressin. This medication works by stimulating the release of vWF stored in the Weibel-Palade bodies, which are storage granules found in the endothelial cells lining the blood vessels and heart. By increasing the patient’s own levels of vWF, desmopressin helps improve clotting. In more severe cases, replacement therapy is necessary. This involves infusing cryoprecipitate or Factor VIII concentrate to provide the missing vWF. Replacement therapy is particularly recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

    • This question is part of the following fields:

      • Haematology
      6.8
      Seconds
  • Question 38 - A 65-year-old woman is brought in by ambulance to the resuscitation area of...

    Incorrect

    • A 65-year-old woman is brought in by ambulance to the resuscitation area of your Emergency Department. She developed sudden onset chest pain and then collapsed while exercising at home. On examination, she is pale and sweaty, and you can palpate a pulsatile mass in her abdomen. You suspect that she has a ruptured abdominal aortic aneurysm (AAA).
      What is the most suitable initial imaging technique for evaluating this patient?

      Your Answer: CT scan of abdomen with contrast

      Correct Answer: Bedside ultrasound scan

      Explanation:

      An abdominal aortic aneurysm (AAA) is a localized or diffuse enlargement of the abdominal aorta, reaching 1.5 times its normal diameter. The majority of AAAs are found between the diaphragm and the aortic bifurcation. They can be classified as suprarenal, pararenal, or infrarenal, depending on which arteries are involved. About 85% of AAAs are infrarenal, with a normal diameter of 1.7 cm in men and 1.5 cm in women over 50 years old. An infrarenal aorta larger than 3 cm is considered an aneurysm. Risk factors for AAA development include age (most common in those over 65), male gender, smoking, hypertension, history of peripheral vascular disease, positive family history, and connective tissue disorders.

      Most AAAs are asymptomatic, but an expanding aneurysm can cause pain or pulsatile sensations in the abdomen. Symptomatic aneurysms have a high risk of rupture. In the UK, elective surgery for AAAs is recommended if the aneurysm is larger than 5.5 cm or larger than 4.5 cm with a growth of more than 0.5 cm in the past six months.

      Imaging modalities used to assess AAAs include ultrasound (best for unstable patients), CT scan with contrast (best for uncertain diagnosis), and MRI scan (suitable for stable patients in an elective setting). The most significant complication of AAA is rupture, which can result in sudden death. Only around 50% of patients with a ruptured AAA survive long enough to receive treatment. Common clinical features of a ruptured AAA include acute severe abdominal pain, flank pain (with pararenal AAAs), back pain (with more distal AAAs), unexplained syncope, and a pulsatile abdominal mass. Other less common complications include aortic branch involvement causing ischemia, distal embolization, rhabdomyolysis, and bacterial infection.

    • This question is part of the following fields:

      • Vascular
      14.8
      Seconds
  • Question 39 - A 7 year old girl is brought into the emergency department with a...

    Incorrect

    • A 7 year old girl is brought into the emergency department with a 24 hour history of vomiting and becoming increasingly tired. A capillary blood glucose is taken and the result is shown as 25 mmol/l. You suspect diabetic ketoacidosis (DKA). Which of the following is included in the diagnostic criteria for DKA?

      Your Answer: Blood pH <7.3 or bicarbonate <15 mmol/L

      Correct Answer:

      Explanation:

      To diagnose diabetic ketoacidosis (DKA), all three of the following criteria must be present: ketonaemia (≥3 mmol/L) or ketonuria (> 2+ on urine dipstick), blood glucose > 11 mmol/L or known diabetes mellitus, and blood pH <7.3 or bicarbonate < 15 mmol/L. It is important to note that plasma osmolality and anion gap, although typically elevated in DKA, are not included in the diagnostic criteria. Further Reading: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia. The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis. DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain. The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels. Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L. Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.

    • This question is part of the following fields:

      • Endocrinology
      9.8
      Seconds
  • Question 40 - In the aftermath of a suspected CBRN (chemical, biological, radiological, and nuclear) incident,...

    Correct

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

      Your Answer: The wearing of adequate personal protective equipment

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      11.5
      Seconds
  • Question 41 - A 28-year-old woman is given an antibiotic while pregnant. As a result, the...

    Correct

    • A 28-year-old woman is given an antibiotic while pregnant. As a result, the newborn is born with deafness in both ears.
      Which antibiotic is most likely responsible for these abnormalities?

      Your Answer: Gentamicin

      Explanation:

      Aminoglycosides have the ability to pass through the placenta and can lead to damage to the 8th cranial nerve in the fetus, resulting in permanent bilateral deafness.

      ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the 2nd and 3rd trimesters.

      Aminoglycosides, like gentamicin, can cause ototoxicity and deafness in the fetus.

      High doses of aspirin can lead to 1st trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines, including diazepam, when administered late in pregnancy, can result in respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers, if given in the 1st trimester, can cause phalangeal abnormalities. If given in the 2nd and 3rd trimesters, they can lead to fetal growth retardation.

      Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol is associated with grey baby syndrome.

      Corticosteroids, if given in the 1st trimester, may cause orofacial clefts.

      Danazol, if given in the 1st trimester, can cause masculinization of the female fetuses genitals.

      Finasteride should not be handled by pregnant women as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol, if given in the 1st trimester, may cause limb malformations. If given in the 3rd trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin can lead to maternal bleeding and thrombocytopenia.

      Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate.

      Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.

      Lithium, if given in the 1st trimester, poses a risk of fetal cardiac malformations.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.4
      Seconds
  • Question 42 - A 5 year old girl is brought into the emergency department with a...

    Correct

    • A 5 year old girl is brought into the emergency department with a two day history of sudden onset loose watery stools accompanied by abdominal cramps and vomiting. Your consultant inquires about any indications of hypernatraemic dehydration.

      Which of the following signs or symptoms are linked to hypernatraemia?

      Your Answer: Jittery movements

      Explanation:

      If a child with gastroenteritis shows signs of jittery movements, increased muscle tone, hyper-reflexia, or convulsions, hypernatraemic dehydration should be considered. Additional signs of hypernatraemic dehydration include drowsiness or coma.

      Further Reading:

      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:

      • Gastroenterology & Hepatology
      6.9
      Seconds
  • Question 43 - A 45-year-old woman presents with a severe, widespread, bright red rash covering her...

    Correct

    • A 45-year-old woman presents with a severe, widespread, bright red rash covering her entire torso, face, arms and upper legs. The skin is scaling and peeling in places and feels hot to touch. She was recently prescribed a new medication by her doctor a few days ago and is concerned that this might be the cause.

      What is the SINGLE most likely diagnosis?

      Your Answer: Exfoliative erythroderma

      Explanation:

      Erythroderma is a condition characterized by widespread redness affecting more than 90% of the body surface. It is also known as exfoliative erythroderma due to the presence of skin exfoliation. Another term used to describe this condition is the red man syndrome.

      The clinical features of exfoliative erythroderma include the rapid spread of redness to cover more than 90% of the body surface. Scaling of the skin occurs between days 2 and 6, leading to thickening of the skin. Despite the skin feeling hot, patients often experience a sensation of coldness. Keratoderma, which is the thickening of the skin on the palms and soles, may develop. Over time, erythema and scaling of the scalp can result in hair loss. The nails may become thickened, ridged, and even lost. Lymphadenopathy, or enlarged lymph nodes, is a common finding. In some cases, the patient’s overall health may be compromised.

      Exfoliative erythroderma can be caused by various factors, including eczema (with atopic dermatitis being the most common underlying cause), psoriasis, lymphoma and leukemia (with cutaneous T-cell lymphoma and Hodgkin lymphoma being the most common malignant causes), certain drugs (more than 60 drugs have been implicated, with sulphonamides, isoniazid, penicillin, antimalarials, phenytoin, captopril, and cimetidine being the most commonly associated), idiopathic (unknown cause), and rare conditions such as pityriasis rubra pilaris and pemphigus foliaceus. Withdrawal of corticosteroids, underlying infections, hypocalcemia, and the use of strong coal tar preparations can also precipitate exfoliative erythroderma.

      Potential complications of exfoliative erythroderma include dehydration, hypothermia, cardiac failure, overwhelming secondary infection, protein loss and edema, anemia (due to loss of iron, B12, and folate), and lymphadenopathy.

      Management of exfoliative erythroderma should involve referring the patient to the medical on-call team and dermatology for admission. It is important to keep the patient warm and start intravenous fluids, such as warmed 0.9% saline. Applying generous amounts of emollients and wet dressings can help alleviate

    • This question is part of the following fields:

      • Dermatology
      24.4
      Seconds
  • Question 44 - A 35 year old male presents to the emergency department with complaints of...

    Correct

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

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

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

      Your Answer: Vagal manoeuvres

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      18.9
      Seconds
  • Question 45 - You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
    Which...

    Incorrect

    • You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
      Which of the following is NOT a recognized complication of Mycoplasma pneumoniae infection?

      Your Answer: Pancreatitis

      Correct Answer: Infective endocarditis

      Explanation:

      Mycoplasma pneumoniae infection does not have a connection with infective endocarditis. However, it is associated with various extra-pulmonary complications. These include skin conditions such as erythema multiforme and Stevens-Johnson syndrome. In the central nervous system, it can lead to Guillain-Barre syndrome, meningitis, encephalitis, optic neuritis, cerebellar ataxia, and cranial nerve palsies. Gastrointestinal symptoms may include anorexia, nausea, diarrhea, hepatitis, and pancreatitis. Hematological complications can manifest as cold agglutinins, hemolytic anemia, thrombocytopenia, and disseminated intravascular coagulation. Mycoplasma pneumoniae infection can also cause pericarditis and myocarditis. Rheumatic symptoms such as arthralgia and arthritides may occur, and acute glomerulonephritis can affect the kidneys.

    • This question is part of the following fields:

      • Respiratory
      20.2
      Seconds
  • Question 46 - A 6-year-old girl presents with a history of a persistent cough that has...

    Correct

    • A 6-year-old girl presents with a history of a persistent cough that has been present for the past four weeks. The cough occurs in quick bursts with a deep breath in followed by a series of forceful coughs. She occasionally vomits after coughing. Her mother reports that the cough is more severe at night.

      During the examination, her chest sounds clear, but you observe two small subconjunctival hemorrhages and some tiny red spots on her face.

      What is the MOST suitable test to perform in this case?

      Your Answer: Serology for anti-pertussis toxin IgG antibody levels

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually not as severe as in the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may also experience vomiting and develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) has specific recommendations for testing for whooping cough based on the age of the patient, the time since onset of illness, and the severity of the presentation.

      For infants under 12 months of age, hospitalized patients should be tested using PCR testing. Non-hospitalized patients within two weeks of onset should be investigated with culture of a nasopharyngeal swab or aspirate. Non-hospitalized patients presenting over two weeks after onset should be tested using serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

    • This question is part of the following fields:

      • Respiratory
      28
      Seconds
  • Question 47 - A 32-year-old man with a known history of diabetes presents with fatigue, frequent...

    Correct

    • A 32-year-old man with a known history of diabetes presents with fatigue, frequent urination, and blurred vision. His blood glucose levels are significantly elevated. He currently takes insulin injections and metformin for his diabetes. You organize for a urine sample to be taken and find that his ketone levels are markedly elevated, and he also has electrolyte abnormalities evident.
      Which of the following electrolyte abnormalities is most likely to be present?

      Your Answer: Hypokalaemia

      Explanation:

      The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      55.5
      Seconds
  • Question 48 - A 42-year-old man has been brought into the Emergency Department (ED) experiencing seizures...

    Correct

    • A 42-year-old man has been brought into the Emergency Department (ED) experiencing seizures that have lasted for 40 minutes before his arrival. On arrival, he is still having a tonic-clonic seizure. He is a known epileptic and is currently taking phenobarbital for seizure prevention. He has received a single dose of rectal diazepam by the paramedics on the way to the hospital approximately 15 minutes ago. Upon arrival in the ED, intravenous access is established, and a dose of IV lorazepam is administered. After an additional 15 minutes, a fosphenytoin infusion is started. Another 25 minutes have passed, and he has not responded to the previous treatment.

      Which of the following medications would be most appropriate to administer next?

      Your Answer: Thiopental sodium bolus

      Explanation:

      Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In this case, the patient has already received two doses of benzodiazepine and is currently on a phenytoin infusion. However, despite these treatments, the seizures persist, and it has been 20 minutes since the infusion started. At this point, the preferred treatment option is to induce general anesthesia. The induction agents that can be considered include thiopental sodium, propofol, and midazolam. There is no need to administer intravenous thiamine in this situation.

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

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

      2nd stage (0-30 minutes):
      – Implement regular monitoring
      – Consider the possibility of non-epileptic status
      – Initiate emergency antiepileptic drug (AED) therapy
      – Perform emergency investigations
      – Administer glucose or intravenous thiamine if alcohol abuse or impaired nutrition is suspected
      – Treat severe acidosis if present

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

      4th stage (30-90 minutes):
      – Transfer the patient to the intensive care unit
      – Establish intensive care and EEG monitoring
      – Initiate long-term maintenance AED therapy
      – Perform further investigations as needed, such as brain imaging or lumbar puncture

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

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

    • This question is part of the following fields:

      • Neurology
      26.9
      Seconds
  • Question 49 - A student nurse on a clinical rotation in the Emergency Department experiences a...

    Correct

    • A student nurse on a clinical rotation in the Emergency Department experiences a needlestick injury from a patient with a history of chronic hepatitis B.
      Which ONE statement about hepatitis B prophylaxis is accurate?

      Your Answer: An accelerated regime is available for post-exposure prophylaxis

      Explanation:

      Hepatitis B vaccination is included in the routine childhood immunisation schedule to provide long-term protection against hepatitis for children under 1 year of age. For these children, the vaccination consists of a primary course that includes the diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis, and Haemophilus influenza type B vaccine. This primary course is given at 4 weekly intervals.

      The Hepatitis B vaccine is a conjugate vaccine that contains a surface antigen of the hepatitis virus (HBsAg) and is combined with an aluminium adjuvant to enhance its effectiveness. It is produced using a recombinant DNA technique.

      When administering the vaccine to adults and older children, the preferred injection site is the deltoid muscle. However, in younger children, the anterolateral thigh is the preferred site. It is not recommended to inject the vaccine in the gluteal area as it has been found to have reduced efficacy.

      The standard vaccination regime for Hepatitis B consists of three primary doses. The initial dose is followed by further doses at one and six months later. A booster dose is recommended at five years if the individual is still at risk.

      In cases of post-exposure prophylaxis, an accelerated vaccination regime is used. This involves administering a vaccination at the time of exposure, followed by repeat doses at one and two months later.

      In high-risk situations, Hepatitis B immunoglobulin can be given up to 7 days after exposure. Ideally, it should be administered within 12 hours, but according to the BNF, it can still be effective if given within 7 days after exposure.

    • This question is part of the following fields:

      • Infectious Diseases
      16.3
      Seconds
  • Question 50 - A 35-year-old woman with a background of mental health issues is behaving strangely...

    Correct

    • A 35-year-old woman with a background of mental health issues is behaving strangely and making threats to harm herself and those nearby in the shopping district. The authorities are contacted and determine the necessity to relocate the woman to a secure location.
      Which section of the 2007 Mental Health Act (MHA) permits a police officer to transfer an individual displaying signs of a mental health disorder to a place of safety?

      Your Answer: Section 136

      Explanation:

      Section 136 of the Mental Health Act (MHA) grants authority to a police officer to relocate an individual who seems to be experiencing a mental health disorder to a secure location. This provision permits detention for a period of 72 hours, during which time the patient can undergo evaluation by a medical professional.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      11.6
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  • Question 51 - A 30 year old male with a history of hereditary angioedema (HAE) presents...

    Correct

    • A 30 year old male with a history of hereditary angioedema (HAE) presents to the emergency department with sudden facial swelling. What is the most suitable management for an acute exacerbation of hereditary angioedema?

      Your Answer: Icatibant acetate

      Explanation:

      In the UK, the most commonly used treatment for acute exacerbations of hereditary angioedema (HAE) in emergency departments is C1-Esterase inhibitor. However, there are alternative options available. Icatibant acetate, sold under the brand name Firazyr®, is a bradykinin receptor antagonist that is licensed in the UK and Europe and can be used as an alternative treatment. Another alternative is the transfusion of fresh frozen plasma.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Dermatology
      10.6
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  • Question 52 - A 62-year-old woman presents with severe otalgia in her right ear that has...

    Correct

    • A 62-year-old woman presents with severe otalgia in her right ear that has been gradually worsening over the past few weeks. She describes the pain as ‘constant’, and she has been unable to sleep for several nights. Her family have noticed that the right side of her face appears to be ‘drooping’. Her past medical history includes poorly controlled type 2 diabetes mellitus. She was diagnosed with otitis externa by a colleague a few weeks earlier, but the pain has failed to settle despite two separate courses of antibiotic drops. On examination, she has a right-sided lower motor neuron facial nerve palsy. Her right ear canal is very swollen and purulent exudate is visible. You are unable to clearly view her tympanic membrane. A swab of the ear taken last week has cultured Pseudomonas aeruginosa.
      What is the SINGLE most likely diagnosis?

      Your Answer: Malignant otitis externa

      Explanation:

      Malignant otitis externa (MOE), also known as necrotising otitis externa, is a rare type of ear infection that primarily affects older individuals with diabetes, particularly if their diabetes is poorly managed.

      MOE initially starts as an infection in the ear canal and gradually spreads to the surrounding bone and soft tissues. In about 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

      Typically, MOE presents with intense ear pain and persistent inflammation of the ear canal that does not respond well to topical antibiotics. The pain is often described as constant and tends to worsen at night. Even after the swelling of the ear canal subsides with the use of topical antibiotics, the pain may persist. Other symptoms that may be present include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may also be affected.

      If left untreated, MOE can be life-threatening, and serious complications may arise, such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

      To diagnose MOE, technetium scanning and contrast-enhanced CT scanning are typically performed. Treatment usually involves long-term administration of intravenous antibiotics.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      32.1
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  • Question 53 - A 65-year-old patient who was diagnosed with Parkinson's disease five years ago has...

    Incorrect

    • A 65-year-old patient who was diagnosed with Parkinson's disease five years ago has experienced a sudden and severe deterioration in her functioning and is now reliant on a wheelchair. Her motor symptoms affect both sides of her body, and she does not exhibit any noticeable tremors. Additionally, she experiences significant fluctuations in blood pressure, urinary incontinence, and has a high-pitched voice.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Progressive Supranuclear Palsy

      Correct Answer: Multiple System Atrophy

      Explanation:

      The Parkinson-plus syndromes are a group of neurodegenerative disorders that share similar features with Parkinson’s disease but also have additional clinical characteristics that set them apart from idiopathic Parkinson’s disease (iPD). These syndromes include Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Corticobasal degeneration (CBD), and Dementia with Lewy Bodies (DLB).

      Multiple System Atrophy (MSA) is a less common condition than iPD and PSP. It is characterized by the loss of cells in multiple areas of the nervous system. MSA progresses rapidly, often leading to wheelchair dependence within 3-4 years of diagnosis. Some distinguishing features of MSA include autonomic dysfunction, bladder control problems, erectile dysfunction, blood pressure changes, early-onset balance problems, neck or facial dystonia, and a high-pitched voice.

      To summarize the distinguishing features of the Parkinson-plus syndromes compared to iPD, the following table provides a comparison:

      iPD:
      – Symptom onset: One side of the body affected more than the other
      – Tremor: Typically starts at rest on one side of the body
      – Levodopa response: Excellent response
      – Mental changes: Depression
      – Balance/falls: Late in the disease
      – Common eye abnormalities: Dry eyes, trouble focusing

      MSA:
      – Symptom onset: Both sides equally affected
      – Tremor: Not common but may occur
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Depression
      – Balance/falls: Within 1-3 years
      – Common eye abnormalities: Dry eyes, trouble focusing

      PSP:
      – Symptom onset: Both sides equally affected
      – Tremor: Less common, if present affects both sides
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Personality changes, depression
      – Balance/falls: Within 1 year
      – Common eye abnormalities: Dry eyes, difficulty in looking downwards

      CBD:
      – Symptom onset: One side of the body affected more than the other
      – Tremor: Not common but may occur
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Depression
      – Balance/falls: Within 1-3 years
      – Common eye abnormalities: Dry eyes, trouble focusing

    • This question is part of the following fields:

      • Neurology
      24.5
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  • Question 54 - A 65-year-old man presents with a 10-week history of loose stools and occasional...

    Correct

    • A 65-year-old man presents with a 10-week history of loose stools and occasional blood in his stool. He has experienced a weight loss of 5 kg over the past eight months. During the examination, you detect a mass in his lower right quadrant.

      What is the SINGLE most probable diagnosis?

      Your Answer: Colorectal cancer

      Explanation:

      In patients of this age who have experienced a change in bowel habit, rectal bleeding, and weight loss, the most probable diagnosis is colorectal carcinoma. Considering the patient’s history and examination findings, the other options in this question are significantly less likely. It is crucial to refer this patient promptly to a specialized team that focuses on the treatment of lower gastrointestinal cancer.

    • This question is part of the following fields:

      • Surgical Emergencies
      12.3
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  • Question 55 - A toddler is brought in with a rash and a high fever. You...

    Correct

    • A toddler is brought in with a rash and a high fever. You suspect a potential diagnosis of bacterial meningitis.
      Based on the current NICE guidelines, which of the following features is LEAST indicative of this condition?

      Your Answer: Focal seizures

      Explanation:

      NICE has emphasized that certain indications and manifestations may indicate specific diseases as the underlying cause of fever. For instance, symptoms such as neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus are suggestive of bacterial meningitis. On the other hand, NICE has identified focal seizures and focal neurological signs as the most indicative of herpes simplex encephalitis. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Neurology
      12.8
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  • Question 56 - A 72-year-old man comes in with increasing shortness of breath. During the examination,...

    Correct

    • A 72-year-old man comes in with increasing shortness of breath. During the examination, it is noted that he has reduced chest movement on the right side. Dullness to percussion and decreased breath sounds are also observed over the right lower lobe. A chest X-ray confirms the presence of a significant pleural effusion. You plan to perform a percutaneous needle aspiration.

      Which ONE statement about percutaneous needle aspiration is accurate?

      Your Answer: The needle should be inserted just above the upper border of the chosen rib

      Explanation:

      A pleural effusion refers to the accumulation of excess fluid in the pleural cavity, which is the fluid-filled space between the parietal and visceral pleura. Normally, this cavity contains about 5-10 ml of lubricating fluid that allows the pleurae to slide over each other and helps the lungs fill with air as the thorax expands. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons: to investigate pleural effusion and to provide relief from breathlessness caused by pleural effusion. According to the guidelines from the British Thoracic Society (BTS), pleural aspiration should be reserved for the investigation of unilateral exudative pleural effusions. It should not be done if unilateral or bilateral transudative effusion is suspected, unless there are atypical features or a lack of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

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

    • This question is part of the following fields:

      • Respiratory
      35.4
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  • Question 57 - A 35-year-old woman is involved in a car crash and sustains severe facial...

    Correct

    • A 35-year-old woman is involved in a car crash and sustains severe facial injuries. Facial X-rays and CT scans show the presence of a Le Fort I fracture.
      What is the most probable cause of this injury?

      Your Answer: A force directed in a downward direction against the upper teeth

      Explanation:

      Le Fort fractures are intricate fractures of the midface, which involve the maxillary bone and the surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the separation of the pterygomaxillary due to trauma. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening situations and disfigurement.

      The causes of Le Fort fractures vary depending on the type of fracture. Common mechanisms include motor vehicle accidents, sports injuries, assaults, and falls from significant heights. Patients with Le Fort fractures often have concurrent head and cervical spine injuries. Additionally, they frequently experience other facial fractures, as well as neuromuscular injuries and dental avulsions.

      The specific type of fracture sustained is determined by the direction of the force applied to the face. Le Fort type I fractures typically occur when a force is directed downward against the upper teeth. Le Fort type II fractures are usually the result of a force applied to the lower or mid maxilla. Lastly, Le Fort type III fractures are typically caused by a force applied to the nasal bridge and upper part of the maxilla.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      10.8
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  • Question 58 - You review a middle-aged man who has a non-operable brain tumor and is...

    Correct

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

      Your Answer: Cyclizine

      Explanation:

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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
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  • Question 59 - A 32-year-old woman presents with a diagnosis of cluster headache.
    Which SINGLE clinical feature...

    Correct

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

      Your Answer: Ipsilateral mydriasis

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Neurology
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  • Question 60 - A 62 year old male presents to the emergency department due to worsening...

    Correct

    • A 62 year old male presents to the emergency department due to worsening abdominal distension over the past few weeks. You note the patient has a history of heavy alcohol use and continues to drink 50-100 units per week. On clinical assessment the patient's abdomen is visibly distended, nontender to palpation with shifting dullness on percussion. The patient's observations are shown below:

      Blood pressure 118/78 mmHg
      Pulse 86 bpm
      Respiration rate 16 bpm
      Temperature 36.6ºC

      Which of the following medications would be most appropriate to use first line to treat this patient's condition?

      Your Answer: Spironolactone

      Explanation:

      Spironolactone, a potassium sparing diuretic, is the preferred initial treatment for ascites. Ascites triggers the renin-angiotensin-aldosterone system (RAAS), causing sodium retention (Hypernatraemia) and potassium excretion (Hypokalaemia). By blocking aldosterone, spironolactone helps to counteract these effects. Other diuretics can worsen potassium deficiency, so close monitoring of electrolyte levels is necessary if they are used instead.

      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
      32.4
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  • Question 61 - A 25-year-old pregnant woman comes in with dysuria, high body temperature, chills, and...

    Correct

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

      Your Answer: Cefuroxime

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Urology
      12.9
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  • Question 62 - You assess a patient who has a confirmed diagnosis of Parkinson's disease. She...

    Correct

    • You assess a patient who has a confirmed diagnosis of Parkinson's disease. She has been living with the disease for several years and is currently in the advanced stages of the condition.
      Which of the following clinical manifestations is typically observed only in the later stages of Parkinson's disease?

      Your Answer: Cognitive impairment

      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
      15.5
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  • Question 63 - You are evaluating a 42-year-old woman in the ER after a fall. During...

    Correct

    • You are evaluating a 42-year-old woman in the ER after a fall. During the examination, you observe multiple clinical manifestations consistent with Cushing syndrome. What is the most probable underlying cause of Cushing syndrome in this case?

      Your Answer: Pituitary adenoma

      Explanation:

      Cushing syndrome is most commonly caused by the use of external glucocorticoids. However, when it comes to endogenous causes, pituitary adenoma, also known as Cushing’s disease, is the leading culprit.

      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
      13.2
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  • Question 64 - You assess a 16 year old with an open fracture dislocation of the...

    Correct

    • You assess a 16 year old with an open fracture dislocation of the ankle after a motorcycle accident. The patient has been given nitrous oxide during transportation in the ambulance. The orthopedic surgeon on call is currently in the emergency department and recommends that the injury be promptly treated in the operating room. Which of the following statements about nitrous oxide is correct?

      Your Answer: Nitrous oxide administration increases the fractional content of inhaled anaesthetic gases

      Explanation:

      The administration of nitrous oxide increases the amount of inhaled anaesthetic gases in the body through a phenomenon called the ‘second gas effect’. Nitrous oxide is much more soluble than nitrogen, with a solubility that is 20 to 30 times higher. When nitrous oxide is given, it causes a decrease in the volume of air in the alveoli. Additionally, nitrous oxide can enhance the absorption of other inhaled anaesthetic agents through the second gas effect. However, it is important to note that nitrous oxide alone cannot be used as the sole maintenance agent in anaesthesia.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      18.5
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  • Question 65 - A 42-year-old woman with a lengthy background of depression arrives at the hospital...

    Correct

    • A 42-year-old woman with a lengthy background of depression arrives at the hospital after intentionally overdosing on the medication she takes for her heart condition. She informs you that the medication she takes for this condition is verapamil immediate-release 240 mg. She ingested the tablets approximately half an hour ago but was promptly discovered by her husband, who quickly brought her to the Emergency Department.

      What is one of the effects of verapamil?

      Your Answer: Negative dromotropy

      Explanation:

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

      The toxic effects of calcium-channel blockers can be summarized as follows:

      Cardiac effects:
      – Excessive negative inotropy: causing myocardial depression
      – Negative chronotropy: leading to sinus bradycardia
      – Negative dromotropy: resulting in atrioventricular node blockade

      Vascular smooth muscle tone effects:
      – Decreased afterload: causing systemic hypotension
      – Coronary vasodilation: leading to widened blood vessels in the heart

      Metabolic effects:
      – Hypoinsulinaemia: insulin release depends on calcium influx through L-type calcium channels in islet beta-cells
      – Calcium channel blocker-induced insulin resistance: causing reduced responsiveness to insulin.

      It is important to be aware of these effects and take appropriate action in cases of calcium-channel blocker overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      26.7
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  • Question 66 - A 32-year-old woman has been brought into the Emergency Department, experiencing seizures that...

    Correct

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

      Your Answer: Intravenous thiamine

      Explanation:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      29.1
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  • Question 67 - A 35-year-old woman comes to the clinic complaining of difficulty swallowing for the...

    Correct

    • A 35-year-old woman comes to the clinic complaining of difficulty swallowing for the past 6 months. Her dysphagia affects both solids and liquids and has been getting worse over time. Additionally, she has noticed that her fingers turn purple when exposed to cold temperatures. On examination, her fingers appear swollen and the skin over them is thickened. There are also visible telangiectasias.
      Which of the following autoantibodies is most specific for the underlying condition in this case?

      Your Answer: Anti-centromere

      Explanation:

      Scleroderma disorders are a group of connective tissue disorders that affect multiple systems in the body. These disorders are characterized by damage to endothelial cells, oxidative stress, inflammation around blood vessels, and the activation of fibroblasts leading to fibrosis. Autoantibodies also play a significant role in the development of these conditions.

      Scleroderma, which refers to thickened skin, can also involve internal organs, resulting in a condition called systemic sclerosis. Systemic sclerosis can be further classified into two types: limited cutaneous involvement and diffuse involvement.

      The cardinal features of limited cutaneous involvement, such as in CREST syndrome, include subcutaneous calcifications (calcinosis), Raynaud’s phenomenon leading to ischemia in the fingers or organs, difficulty swallowing (dysphagia) or painful swallowing (odynophagia) due to oesophageal dysmotility, localized thickening and tightness of the skin in the fingers and toes (sclerodactyly), and abnormal dilatation of small blood vessels (telangiectasia).

      In the case of the patient mentioned in this question, they present with progressive dysphagia and Raynaud’s phenomenon. Physical examination reveals sclerodactyly and telangiectasia. These findings strongly suggest a diagnosis of systemic sclerosis with limited cutaneous involvement. The most specific autoantibody associated with this condition is anti-centromere.

      It is important to note that anti-dsDNA and anti-Smith antibodies are typically seen in systemic lupus erythematosus, while anti-Jo1 is associated with polymyositis and dermatomyositis. Anti-SS-B (also known as anti-La antibody) is commonly found in Sjogren’s syndrome.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      12.1
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  • Question 68 - You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you...

    Correct

    • You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you observe a loud first heart sound and a mid-diastolic murmur at the apex. Upon examination, you observe that he has plum-red discoloration of his cheeks.
      What is the SINGLE most probable diagnosis?

      Your Answer: Mitral stenosis

      Explanation:

      The clinical symptoms of mitral stenosis include shortness of breath, which tends to worsen during exercise and when lying flat. Tiredness, palpitations, ankle swelling, cough, and haemoptysis are also common symptoms. Chest discomfort is rarely reported.

      The clinical signs of mitral stenosis can include a malar flush, an irregular pulse if atrial fibrillation is present, a tapping apex beat that can be felt as the first heart sound, and a left parasternal heave if there is pulmonary hypertension. The first heart sound is often loud, and a mid-diastolic murmur can be heard.

      The mid-diastolic murmur of mitral stenosis is a rumbling sound that is best heard at the apex, in the left lateral position during expiration, using the bell of the stethoscope.

      Mitral stenosis is typically caused by rheumatic heart disease, and it is more common in females, with about two-thirds of patients being female.

    • This question is part of the following fields:

      • Cardiology
      27.6
      Seconds
  • Question 69 - You review a patient with a history of renal failure that has presented...

    Correct

    • You review a patient with a history of renal failure that has presented with nausea, fatigue, and sleepiness. Upon reviewing her blood results today, you note that her glomerular filtration rate has recently fallen significantly. She has no other medical history of note.

      At what level should patients generally begin dialysis when their glomerular filtration rate (GFR) reaches?

      Your Answer: 10 ml/minute

      Explanation:

      Patients typically initiate dialysis when their glomerular filtration rate (GFR) drops to 10 ml/min. However, if the patient has diabetes, dialysis may be recommended when their GFR reaches 15 ml/min. The GFR is a measure of kidney function and indicates how well the kidneys are able to filter waste products from the blood. Dialysis is a medical procedure that helps perform the function of the kidneys by removing waste and excess fluid from the body.

    • This question is part of the following fields:

      • Nephrology
      7.1
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  • Question 70 - A 35-year-old man with a history of anxiety and panic disorder has ingested...

    Correct

    • A 35-year-old man with a history of anxiety and panic disorder has ingested an excessive amount of diazepam.
      Which of the following antidotes is appropriate for cases of benzodiazepine poisoning?

      Your Answer: Flumazenil

      Explanation:

      There are various specific remedies available for different types of poisons and overdoses. The following list provides an outline of some of these antidotes:

      Poison: Benzodiazepines
      Antidote: Flumazenil

      Poison: Beta-blockers
      Antidotes: Atropine, Glucagon, Insulin

      Poison: Carbon monoxide
      Antidote: Oxygen

      Poison: Cyanide
      Antidotes: Hydroxocobalamin, Sodium nitrite, Sodium thiosulphate

      Poison: Ethylene glycol
      Antidotes: Ethanol, Fomepizole

      Poison: Heparin
      Antidote: Protamine sulphate

      Poison: Iron salts
      Antidote: Desferrioxamine

      Poison: Isoniazid
      Antidote: Pyridoxine

      Poison: Methanol
      Antidotes: Ethanol, Fomepizole

      Poison: Opioids
      Antidote: Naloxone

      Poison: Organophosphates
      Antidotes: Atropine, Pralidoxime

      Poison: Paracetamol
      Antidotes: Acetylcysteine, Methionine

      Poison: Sulphonylureas
      Antidotes: Glucose, Octreotide

      Poison: Thallium
      Antidote: Prussian blue

      Poison: Warfarin
      Antidote: Vitamin K, Fresh frozen plasma (FFP)

      By utilizing these specific antidotes, medical professionals can effectively counteract the harmful effects of various poisons and overdoses.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      5.6
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  • Question 71 - You are treating a 35-year-old with limb injuries resulting from a rock climbing...

    Correct

    • You are treating a 35-year-old with limb injuries resulting from a rock climbing incident. Your responsibility is to insert a central venous line. The attending physician requests you to place the central venous line in the internal jugular vein. What is the ideal patient positioning for this procedure?

      Your Answer: Trendelenburg position

      Explanation:

      To insert an IJV line, the patient should be positioned in the Trendelenburg position. This means that the patient should lie on their back with their head tilted down by at least 15 degrees. Additionally, the patient’s head should be turned away or laterally rotated from the side where the cannulation will take place. This positioning helps to distend the neck veins, making it easier to access them for the procedure.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      7.1
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  • Question 72 - A 40-year-old woman comes in with bitemporal hemianopia resulting from a meningioma.
    Where...

    Correct

    • A 40-year-old woman comes in with bitemporal hemianopia resulting from a meningioma.
      Where in the visual pathway has this lesion occurred?

      Your Answer: Optic chiasm

      Explanation:

      The optic chiasm is situated just below the hypothalamus and is in close proximity to the pituitary gland. When the pituitary gland enlarges, it can impact the functioning of the optic nerve at this location. Specifically, the fibres from the nasal half of the retina cross over at the optic chiasm to form the optic tracts. Compression at the optic chiasm primarily affects these fibres, resulting in a visual defect that affects peripheral vision in both eyes, known as bitemporal hemianopia. There are several causes of optic chiasm lesions, with the most common being a pituitary tumor. Other causes include craniopharyngioma, meningioma, optic glioma, and internal carotid artery aneurysm. The diagram below provides a summary of the different visual field defects that can occur at various points in the visual pathway.

    • This question is part of the following fields:

      • Ophthalmology
      12.6
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  • Question 73 - 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
      57.4
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  • Question 74 - You are part of the resus team treating a 42-year-old female patient with...

    Correct

    • You are part of the resus team treating a 42-year-old female patient with a severe head injury after falling from a ladder. As the patient's GCS continues to decline, your consultant instructs you to prepare for rapid sequence induction. You gather the necessary supplies and prepare etomidate as the induction agent. Upon reviewing the patient's details, you observe that she weighs 65kg. What would be the appropriate dose of etomidate for this patient during RSI?

      Your Answer: 21mg

      Explanation:

      The recommended dose of etomidate for rapid sequence intubation (RSI) is typically 0.3mg per kilogram of body weight. For example, a patient weighing 70 kilograms would receive a dose of 21mg (70 x 0.3 = 21mg). This dosage falls within the accepted range of 0.15-0.3 mg/kg as suggested by the British National Formulary (BNF). Therefore, the only option within this range is the fourth option.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      24.9
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  • Question 75 - A 28 year old male presents to the emergency department after experiencing 4...

    Correct

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

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

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

      Your Answer: 4 hours

      Explanation:

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

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      17.9
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  • Question 76 - A 45-year-old executive presents with a painful, swollen right calf after a recent...

    Incorrect

    • A 45-year-old executive presents with a painful, swollen right calf after a recent flight from New York. You evaluate him for a potential deep vein thrombosis (DVT). As part of your evaluation, you compute a two-level Wells score, which is two points.

      What would be the most suitable next course of action in his treatment?

      Your Answer: Distal leg vein ultrasound scan

      Correct Answer: Proximal leg vein ultrasound scan

      Explanation:

      The NICE guidelines for suspected DVT state that if a person scores two points or more on the DVT Wells score, they are likely to have DVT. On the other hand, if a person scores one point or less, it is unlikely that they have DVT.

      For individuals who are likely to have DVT, it is recommended to offer a proximal leg vein ultrasound scan with the results available within 4 hours if possible. However, if the ultrasound scan cannot be done within 4 hours, the following steps should be taken: a D-dimer test should be offered, followed by interim therapeutic anticoagulation. It is preferable to choose an anticoagulant that can be continued if DVT is confirmed. Additionally, a proximal leg vein ultrasound scan should be conducted with the results available within 24 hours.

      For individuals who are unlikely to have DVT, it is advised to offer a D-dimer test with the results available within 4 hours. If obtaining the results within 4 hours is not possible, interim therapeutic anticoagulation should be provided while awaiting the result. If feasible, an anticoagulant that can be continued if DVT is confirmed should be chosen.

      For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.

    • This question is part of the following fields:

      • Vascular
      39.6
      Seconds
  • Question 77 - A 30-year-old woman with a history of schizophrenia is brought to the Emergency...

    Correct

    • A 30-year-old woman with a history of schizophrenia is brought to the Emergency Department. She is exhibiting signs of acute psychosis.
      Which ONE of the following statements is TRUE regarding schizophrenia?

      Your Answer: 10% of patients go on to commit suicide

      Explanation:

      The occurrence of schizophrenia is consistent across all social classes. It affects individuals from all walks of life without discrimination. The likelihood of developing schizophrenia over one’s lifetime is 1%, and this probability remains the same for both men and women. However, it is worth noting that men tend to experience the onset of symptoms at a younger age compared to women, with the average age of onset falling between 15 and 45 years.

      There is a recognized genetic predisposition for schizophrenia, meaning that certain individuals may have a higher likelihood of developing the condition due to their genetic makeup. The risk of schizophrenia affecting first-degree relatives, such as siblings or parents, is approximately 10%. Furthermore, the risk of children being affected by schizophrenia increases to 40%.

      When considering the impact of genetics on schizophrenia, it is interesting to note that monozygotic twins, who share identical genetic material, have a concordance rate of around 50%. This suggests that genetic factors play a significant role in the development of the condition.

      Tragically, approximately 10% of individuals suffering from schizophrenia ultimately die by suicide, particularly during the early stages of the illness. This highlights the importance of providing appropriate support and intervention to individuals with schizophrenia to prevent such devastating outcomes.

    • This question is part of the following fields:

      • Mental Health
      16.5
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  • Question 78 - A 42-year-old patient arrives at the emergency department with a nosebleed that has...

    Correct

    • A 42-year-old patient arrives at the emergency department with a nosebleed that has been ongoing for 1 hour. The patient has been sitting down and applying continuous pressure to the soft part of the nose since being seen by the triage nurse 15 minutes ago. When asked to release the pressure for examination, an active bleeding point is observed in the anterior nasal septum of the right nostril.

      What is the most suitable approach to managing this patient?

      Your Answer: Perform cautery of the bleeding point with a silver nitrate stick

      Explanation:

      Nasal cautery is a suitable option for patients who are experiencing epistaxis (nosebleeds) and have not responded to initial measures. It is particularly effective when a specific bleeding point in the anterior nasal septum (known as Little’s area) has been identified. This procedure is recommended for adult patients who have already undergone an appropriate period of nasal pressure application (10-15 minutes). It is important to note that naseptin or mupirocin should not be used to control active bleeding, but rather after the bleeding has been successfully managed. Nasal packing, on the other hand, is a more invasive procedure that requires hospital admission and is typically reserved for cases where the bleeding point cannot be visualized or when cautery has been unsuccessful.

      Further Reading:

      Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

      The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

      If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

      Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

      In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      16.2
      Seconds
  • Question 79 - A 32-year-old woman with a known history of asthma presents with a headache,...

    Correct

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

      Your Answer: Ciprofloxacin

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      19.8
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  • Question 80 - A child develops a palsy of their right arm following a traumatic birth....

    Incorrect

    • A child develops a palsy of their right arm following a traumatic birth. During the examination, there is a deformity known as 'claw hand' and sensory loss on the ulnar side of the forearm and hand.
      What is the SINGLE most probable diagnosis?

      Your Answer: Radial nerve palsy

      Correct Answer: Klumpke’s palsy

      Explanation:

      Klumpke’s palsy, also known as Dejerine-Klumpke palsy, is a condition where the arm becomes paralyzed due to an injury to the lower roots of the brachial plexus. The most commonly affected root is C8, but T1 can also be involved. The main cause of Klumpke’s palsy is when the arm is pulled forcefully in an outward position during a difficult childbirth. It can also occur in adults with apical lung carcinoma (Pancoast’s syndrome).

      Clinically, Klumpke’s palsy is characterized by a deformity known as ‘claw hand’, which is caused by the paralysis of the intrinsic hand muscles. There is also a loss of sensation along the ulnar side of the forearm and hand. In some cases where T1 is affected, a condition called Horner’s syndrome may also be present.

      Klumpke’s palsy can be distinguished from Erb’s palsy, which affects the upper roots of the brachial plexus (C5 and sometimes C6). In Erb’s palsy, the arm hangs by the side with the elbow extended and the forearm turned inward (known as the ‘waiter’s tip sign’). Additionally, there is a loss of shoulder abduction, external rotation, and elbow flexion.

    • This question is part of the following fields:

      • Neurology
      27.2
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  • Question 81 - You assess a patient with a past medical history of ulcerative colitis. She...

    Incorrect

    • You assess a patient with a past medical history of ulcerative colitis. She expresses significant worry about the potential risk of developing colon cancer due to her condition.
      Which ONE statement accurately addresses this concern?

      Your Answer: There is no associated risk with colon cancer

      Correct Answer: The longer that the patient has ulcerative colitis the greater the risk of colon cancer

      Explanation:

      Patients diagnosed with ulcerative colitis face a significantly heightened risk of developing colon cancer. It is crucial for these individuals, especially those with severe or extensive disease, to undergo regular monitoring to detect any potential signs of colon cancer. The risk of developing colon cancer increases as the duration of ulcerative colitis progresses. After 10 years, the risk stands at 1 in 50. After 20 years, the risk increases to 1 in 12. And after 30 years, the risk further rises to 1 in 6. While Crohn’s disease also carries a risk of colonic carcinoma, it is comparatively smaller than that associated with ulcerative colitis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      19.4
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  • Question 82 - You are asked to evaluate a 7-year-old girl who is feeling unwell in...

    Incorrect

    • You are asked to evaluate a 7-year-old girl who is feeling unwell in the Pediatric Emergency Department. Upon reviewing her urea & electrolytes, you observe that her potassium level is elevated at 6.7 mmol/l. An ECG is conducted, which reveals normal sinus rhythm. A nebulizer treatment with salbutamol is administered, and shortly after, an arterial blood gas is performed. The child's pH is 7.41, but her potassium level remains unchanged.
      As per the APLS guidelines, which medication should be utilized next?

      Your Answer: Calcium resonium

      Correct Answer: Insulin and glucose infusion

      Explanation:

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

      Calcium is used to counteract the harmful effects of hyperkalaemia on the heart by stabilizing the cardiac cell membrane and preventing abnormal depolarization. It works quickly, usually within 15 minutes, but its effects are not long-lasting. Calcium is considered a first-line treatment for arrhythmias and significant ECG abnormalities caused by hyperkalaemia, such as widening of the QRS interval, loss of the P wave, and cardiac arrhythmias. However, arrhythmias are rare at potassium levels below 7.5 mmol/l.

      It’s important to note that calcium does not lower the serum potassium level. Therefore, it should be used in conjunction with other therapies that actually help reduce potassium levels, such as insulin and salbutamol. If the pH is measured to be above 7.35 and the potassium level remains high despite nebulized salbutamol, the APLS guidelines recommend the administration of an insulin and glucose infusion.

    • This question is part of the following fields:

      • Nephrology
      51.1
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  • Question 83 - You evaluate a 60-year-old patient with hepatomegaly. He was recently diagnosed with type...

    Incorrect

    • You evaluate a 60-year-old patient with hepatomegaly. He was recently diagnosed with type 2 diabetes mellitus and is currently taking metformin 500 mg twice daily. He consumes approximately 25 units of alcohol per week and has a BMI of 30. His liver function tests are as follows:
      - Bilirubin: 18 mmol (3-20)
      - ALT: 320 IU/L (5-40)
      - AST: 85 IU/L (5-40)
      - ALP: 110 IU/L (20-40)
      - GGT: 120 (5-40)
      - ANA: positive

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Chronic hepatitis B

      Correct Answer: Non-alcoholic steatohepatitis

      Explanation:

      The diagnosis in this case is non-alcoholic steatohepatitis (NASH), which is characterized by fatty infiltration of the liver and is commonly associated with obesity. It is the most frequent cause of persistently elevated ALT levels in patients without risk factors for chronic liver disease.

      Risk factors for developing NASH include obesity, particularly truncal obesity, diabetes mellitus, and hypercholesterolemia.

      The clinical features of NASH can vary, with many patients being completely asymptomatic. However, some may experience right upper quadrant pain, nausea and vomiting, and hepatomegaly (enlarged liver).

      The typical biochemical profile seen in NASH includes elevated transaminases, with an AST:ALT ratio of less than 1. Often, there is an isolated elevation of ALT, and gamma-GT levels may be mildly elevated. In about one-third of patients, non-organ specific autoantibodies may be present. The presence of antinuclear antibodies (ANA) is associated with insulin resistance and indicates a higher risk of rapid progression to advanced liver disease.

      If the AST level is significantly elevated or if the gamma-GT level is markedly elevated, further investigation for other potential causes should be considered. A markedly elevated gamma-GT level may suggest alcohol abuse, although it can also be elevated in NASH alone.

      Diagnosis of NASH is confirmed through a liver biopsy, which will reveal increased fat deposition and a necro-inflammatory response within the hepatocytes.

      Currently, there is no specific treatment for NASH. However, weight loss and medications that improve insulin resistance, such as metformin, may help slow down the progression of the disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      47.3
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  • Question 84 - A 35-year-old patient is worried because she has observed blood in her urine...

    Incorrect

    • A 35-year-old patient is worried because she has observed blood in her urine for the past few days. She is not currently experiencing her menstrual cycle, and there is no possibility of pregnancy. She has not had any recent fevers but has noticed some discomfort in her lower abdomen. Additionally, she has been urinating more frequently than usual. She is not taking any medications. During the examination, her abdomen is soft, with slight tenderness in the suprapubic region. There is no guarding or rebound tenderness, and she does not experience any renal angle tenderness. Her urine appears pinkish in color and tests positive for leukocytes, protein, and blood on the dipstick.

      What is the SINGLE most likely diagnosis?

      Your Answer: Bladder cancer

      Correct Answer: Urinary tract infection

      Explanation:

      This is a classical history for a simple urinary tract infection. The other possible causes mentioned can also result in frank haematuria, but they would be less likely based on the given history.

      Bladder cancer typically presents with additional symptoms such as an abdominal mass, weight loss, and fatigue. Nephritis is more likely to cause renal angle tenderness and some systemic upset. It is often preceded by another infection.

      Tuberculosis may also have more systemic involvement, although it can present on its own. Renal stones commonly cause severe pain from the loin to the groin and renal angle tenderness.

    • This question is part of the following fields:

      • Urology
      22.1
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  • Question 85 - A 68-year-old patient with advanced metastatic lung cancer is observed by his family...

    Incorrect

    • A 68-year-old patient with advanced metastatic lung cancer is observed by his family to have a parched mouth and chapped lips. He confesses that he hasn't been consuming fluids regularly in the past few days. He is mentally clear and attentive and is presently at ease and free from pain. He has been informed that he has only a few days left to live.
      What is the most suitable course of action at this point?

      Your Answer: Force the patient to drink one glass of water hourly

      Correct Answer: Encourage frequent sips of fluids

      Explanation:

      When dealing with a terminally ill patient who is still lucid and alert and able to drink oral fluids, it is sensible to encourage them to take frequent sips of fluids to maintain hydration and alleviate symptoms of a dry mouth. According to NICE guidelines, it is important to support the dying person in their desire to drink if they are capable and willing. However, it is crucial to assess any difficulties they may have with swallowing or the risk of aspiration. It is recommended to have a discussion with the dying person and those involved in their care to weigh the risks and benefits of continuing to drink.

      In addition, it is essential to provide regular care for the dying person’s mouth and lips, including managing dry mouth if necessary. This can involve assisting with teeth or denture cleaning if desired, as well as offering frequent sips of fluid. It is also encouraged to involve important individuals in the dying person’s life in providing mouth and lip care or giving drinks, if they are willing. Necessary aids should be provided, and guidance on safe drink administration should be given.

      The hydration status of the dying person should be assessed on a daily basis, and the potential need for clinically assisted hydration should be reviewed while respecting the person’s wishes and preferences. It is important to discuss the risks and benefits of clinically assisted hydration with the dying person and their loved ones. It should be noted that while clinically assisted hydration may relieve distressing symptoms related to dehydration, it may also cause other problems. The impact on life extension or the dying process is uncertain whether hydration is provided or not.

      Before initiating clinically assisted hydration, any concerns raised by the dying person or their loved ones should be addressed. An individualized approach should be taken into account, considering factors such as the person’s expressed preferences, cultural or religious beliefs, level of consciousness, swallowing difficulties, thirst level, risk of pulmonary edema, and the possibility of temporary recovery.

      If the person exhibits distressing symptoms or signs associated with dehydration, such as thirst or delirium, and oral hydration is insufficient, a therapeutic trial of clinically assisted hydration may be considered. Monitoring for changes in symptoms or signs of dehydration, as well as any evidence of benefit or harm, should be conducted at least every 12 hours for those receiving clinically assisted hydration. If there are signs of clinical benefit, the hydration should be continued. However, if there are indications of potential harm, such as fluid overload, or if the person no longer desires it, the clinically assisted hydration should be stopped.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      5.3
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  • Question 86 - You finish evaluating a 32-year-old individual who has been brought to the emergency...

    Incorrect

    • You finish evaluating a 32-year-old individual who has been brought to the emergency department after being involved in a physical altercation. You suspect that the patient may have a fractured mandible. What would be the most suitable examination to confirm the suspected diagnosis?

      Your Answer: Occipitomental 30º facial X-ray

      Correct Answer: Orthopantomogram

      Explanation:

      The OPG is the recommended first-line imaging test for diagnosing TMJ dislocation and mandibular fractures.

      Further Reading:

      Mandibular fractures are a common type of facial fracture that often present to the emergency department. The mandible, or lower jaw, is formed by the fusion of two hemimandibles and articulates with the temporomandibular joints. Fractures of the mandible are typically caused by direct lateral force and often involve multiple fracture sites, including the body, condylar head and neck, and ramus.

      When assessing for mandibular fractures, clinicians should use a look, feel, move method similar to musculoskeletal examination. However, it is important to note that TMJ effusion, muscle spasm, and pain can make moving the mandible difficult. Key signs of mandibular fracture include malocclusion, trismus (limited mouth opening), pain with the mouth closed, broken teeth, step deformity, hematoma in the sublingual space, lacerations to the gum mucosa, and bleeding from the ear.

      The Manchester Mandibular Fracture Decision Rule uses the absence of five exam findings (malocclusion, trismus, broken teeth, pain with closed mouth, and step deformity) to exclude mandibular fracture. This rule has been found to be 100% sensitive and 39% specific in detecting mandibular fractures. Imaging is an important tool in diagnosing mandibular fractures, with an OPG X-ray considered the best initial imaging for TMJ dislocation and mandibular fracture. CT may be used if the OPG is technically difficult or if a CT is being performed for other reasons, such as a head injury.

      It is important to note that head injury often accompanies mandibular fractures, so a thorough head injury assessment should be performed. Additionally, about a quarter of patients with mandibular fractures will also have a fracture of at least one other facial bone.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      11.9
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  • Question 87 - A 7-year-old girl is brought to the Emergency Department by her father after...

    Incorrect

    • A 7-year-old girl is brought to the Emergency Department by her father after falling at a park. Her ankle appears to be deformed, and it is suspected that she has a fracture in her distal fibula. Her pain is evaluated using a numerical rating scale, and the triage nurse informs you that she is experiencing moderate pain.
      According to the RCEM guidance, which of the following analgesics is recommended for managing moderate pain in a child of this age?

      Your Answer: Oral paracetamol 5 mg/kg

      Correct Answer: Rectal diclofenac 1 mg/kg

      Explanation:

      A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.

      To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.

      The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.

      To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.

    • This question is part of the following fields:

      • Pain & Sedation
      18.3
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  • Question 88 - A 40-year-old man comes in with abdominal cramps and severe bloody diarrhoea due...

    Incorrect

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

      Your Answer: Giardia lamblia

      Correct Answer: Entamoeba histolytica

      Explanation:

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      15.1
      Seconds
  • Question 89 - A 30-year-old woman comes in with intense pain in her right flank and...

    Incorrect

    • A 30-year-old woman comes in with intense pain in her right flank and microscopic blood in her urine. After evaluation, you diagnose her with renal colic.
      What is the ONE medication that has been proven to improve the passage of kidney stones in cases of renal colic?

      Your Answer: Diclofenac

      Correct Answer: Tamsulosin

      Explanation:

      NSAIDs are known to have a relaxing effect on the ureter, but a randomized controlled trial found no difference between NSAIDs and a placebo in terms of this effect. Currently, only two classes of drugs, calcium channel blockers and alpha-blockers, are considered effective as medical expulsive therapy (MET). Calcium channel blockers work by blocking the active calcium channel pump that the smooth muscle of the ureter uses to contract, resulting in relaxation of the muscle and improved stone passage. Alpha-blockers, on the other hand, are commonly used as the first-line treatment to enhance stone passage. They reduce the basal tone of the ureter smooth muscle, decrease the frequency of peristaltic waves, and lower ureteric contraction. This leads to a decrease in intraureteric pressure below the stone, increasing the chances of stone passage. Patients treated with calcium channel blockers or alpha-blockers have been shown to have a 65% higher likelihood of spontaneous stone passage compared to those not given these medications.

    • This question is part of the following fields:

      • Urology
      15.5
      Seconds
  • Question 90 - A 65 year old male is brought to the emergency department by a...

    Incorrect

    • A 65 year old male is brought to the emergency department by a family member. The family member informs you that the patient experiences episodes of cognitive decline that last for a few days. During these episodes, the patient struggles to remember the names of friends or family members and often forgets what he is doing. The family member also mentions that the patient seems to have hallucinations, frequently asking about animals in the house and people in the garden who are not actually there. Upon examination, you observe muscle rigidity and a tremor. What is the most likely diagnosis?

      Your Answer: Normal pressure hydrocephalus

      Correct Answer: Dementia with Lewy bodies

      Explanation:

      Dementia with Lewy bodies (DLB) is characterized by several key features, including spontaneous fluctuations in cognitive abilities, visual hallucinations, and Parkinsonism. Visual hallucinations are particularly prevalent in DLB and Parkinson’s disease dementia, which are considered to be part of the same spectrum. While visual hallucinations can occur in other forms of dementia, they are less frequently observed.

      Further Reading:

      Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

      To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

      The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

      There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

      Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

      Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

      Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

      In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

    • This question is part of the following fields:

      • Neurology
      17.8
      Seconds
  • Question 91 - You are conducting a research project and audit based on patients who presented...

    Incorrect

    • You are conducting a research project and audit based on patients who presented to the emergency department with back pain and were subsequently diagnosed with a ruptured aortic aneurysm. As part of the audit, you need to collect the ages of all patients in the study. What steps would you take before starting the research to ensure the appropriate use and protection of patient data throughout the course of the project?

      Your Answer: Register with the information commissioner's office (ICO) and submit a data storage & processing plan

      Correct Answer: Submit a Caldicott request

      Explanation:

      If you are conducting research or an audit that involves using patient identifiable information, you must submit a Caldicott request to the designated Caldicott guardian for the trust.

      Further Reading:

      Principles of Medical Ethics:

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

      Confidentiality:

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

      Obtaining Patient’s Consent for Disclosure:

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

      Situations Where Patient Consent is Not Required for Disclosure:

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

      Confidentiality Following a Patient’s Death:

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

      The Law & Caldicott Guardians:

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

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      12.8
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  • Question 92 - A 21-year-old college student comes to the clinic complaining of a sore throat,...

    Incorrect

    • A 21-year-old college student comes to the clinic complaining of a sore throat, low-grade fever, and feeling generally unwell for the past week. She mentions that she had a faint rash all over her body that disappeared quickly about a week ago. During the examination, you observe mild enlargement of the spleen. The heterophile antibody test comes back positive, confirming a diagnosis of infectious mononucleosis.
      What is the most distinguishing feature of infectious mononucleosis?

      Your Answer: Massive hepatomegaly

      Correct Answer: Atypical lymphocytes

      Explanation:

      Infectious mononucleosis is typically a self-limiting infection that is primarily caused by the Epstein-Barr virus (EBV), a member of the human herpesvirus family. About 10% of cases are caused by cytomegalovirus (CMV) infection.

      This clinical infection is most commonly observed in populations with a large number of young adults, such as university students and active-duty military personnel.

      The main clinical features of infectious mononucleosis include a low-grade fever, fatigue, prolonged malaise, sore throat (often accompanied by tonsillar enlargement and exudate), a transient, fine, non-itchy rash, lymphadenopathy (most commonly in the cervical region), arthralgia and myalgia, mild enlargement of the liver and spleen, and jaundice (which is less common in young adults but more prevalent in the elderly).

      To diagnose EBV infectious mononucleosis, a variety of unrelated non-EBV heterophile antibodies and specific EBV antibodies can be used.

      1. Heterophile antibodies:
      Around 70-90% of patients with EBV infectious mononucleosis produce heterophile antibodies, which are antibodies that react against antigens from other species. False positives can occur with hepatitis, malaria, toxoplasmosis, rubella, systemic lupus erythematosus (SLE), lymphoma, and leukemia. Two main screening tests can detect these antibodies and provide rapid results within a day:
      – Paul-Bunnell test: Sheep red blood cells agglutinate in the presence of heterophile antibodies.
      – Monospot test: Horse red blood cells agglutinate in the presence of heterophile antibodies.

      2. EBV-specific antibodies:
      Patients who remain heterophile-negative after six weeks are considered heterophile-negative and should be tested for EBV-specific antibodies. These antibodies are also useful in cases where a false positive heterophile antibody test is suspected.

      Other useful investigations include a full blood count, which often shows a raised white cell count with lymphocytosis and atypical lymphocytes in more than 20% of cases, an elevated erythrocyte sedimentation rate (ESR) in most patients, liver function tests (LFTs) that may show mild elevation of serum transaminases, throat swabs to rule out group A streptococci pharyngitis as a differential diagnosis, and abdominal ultrasound if splenomegaly is present.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      8.8
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  • Question 93 - A 25-year-old patient comes in with a painful and red left eye. Upon...

    Incorrect

    • A 25-year-old patient comes in with a painful and red left eye. Upon examination, you observe conjunctival erythema and the presence of mucopurulent discharge and lid crusting. Based on these findings, you diagnose the patient with bacterial conjunctivitis. However, the patient cannot use the first-line treatment due to a previous reaction. According to the current NICE guidance, what is the recommended second-line antibiotic for managing bacterial conjunctivitis?

      Your Answer: Ciprofloxacin 0.3% drops

      Correct Answer: Fusidic acid 1% drops

      Explanation:

      When it comes to managing bacterial conjunctivitis, NICE provides some helpful guidance. It is important to inform the patient that most cases of bacterial conjunctivitis will resolve on their own within 5-7 days without any treatment. However, in severe cases or situations where a quick resolution is necessary, topical antibiotics may be necessary. In some cases, it may be appropriate to delay treatment and advise the patient to start using topical antibiotics if their symptoms have not improved within 3 days.

      There are a few options for topical antibiotics that can be used. One option is Chloramphenicol 0.5% drops, which should be applied every 2 hours for 2 days and then 4 times daily for 5 days. Another option is Chloramphenicol 1% ointment, which should be applied four times daily for 2 days and then twice daily for 5 days. Fusidic acid 1% eye drops can also be used as a second-line treatment and should be applied twice daily for 7 days.

      By following these guidelines, healthcare professionals can effectively manage bacterial conjunctivitis and provide appropriate treatment options for their patients.

    • This question is part of the following fields:

      • Ophthalmology
      15.2
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  • Question 94 - A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As...

    Correct

    • A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As a result of this medication, the newborn develops a defect.
      What is the most probable defect that will occur as a result of using this drug during pregnancy?

      Your Answer: Haemorrhagic disease of the newborn

      Explanation:

      There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.

      Below is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.

      Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.

      Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.

      Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.

      Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      36.5
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  • Question 95 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Correct

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with central chest discomfort. Her ECG showed ST depression in the inferior leads, but her discomfort subsides, and ECG returns to normal after receiving GTN spray and IV morphine. She was also given 300 mg of aspirin in the ambulance en route to the hospital. Her vital signs are as follows: SaO2 99% on room air, HR 89 bpm, and BP 139/82 mmHg. A troponin test has been scheduled and she is scheduled for an urgent coronary angiography.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Unfractionated heparin

      Explanation:

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

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

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

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

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

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.

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

    • This question is part of the following fields:

      • Cardiology
      73.2
      Seconds
  • Question 96 - An older woman arrives at the Emergency Department in the afternoon, reporting chest...

    Incorrect

    • An older woman arrives at the Emergency Department in the afternoon, reporting chest discomfort. She has visited the hospital four times within the past two weeks with similar symptoms, and each time her examination and all tests came back normal. She lives alone but has family members living nearby. Her cat passed away recently. During today's examination, she appears to be in a slightly low mood. All systems examinations, ECG, and tests conducted today show no abnormalities.
      What is the best course of action for managing this patient? Choose ONE option.

      Your Answer: Discuss her low mood, reassure her and discharge her home

      Correct Answer: Send a discharge summary to the GP outlining your findings and suggest that she may benefit from some social support

      Explanation:

      When it comes to decision making and utilizing the wider medical team, it is crucial to always consider the possibility of new medical issues, even if the symptoms have occurred multiple times before. In the case of chest pain in elderly individuals, it is important to conduct further investigations, even if the presentation is similar to previous instances.

      In addition, this patient appears to be displaying signs of depression. The loss of a pet can intensify feelings of loneliness. To address this, it would be wise to send a discharge summary to the patient’s general practitioner, outlining the findings and suggesting the potential benefits of providing social support for the patient.

      By rephrasing and organizing the information with paragraph spacing, the explanation becomes clearer and easier to read.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      4.8
      Seconds
  • Question 97 - A 32 year old male is brought into the emergency department with wheezing...

    Incorrect

    • A 32 year old male is brought into the emergency department with wheezing and swelling of the lips. The patient's friend informs you that he has a nut allergy. Anaphylaxis is suspected. What is the underlying pathophysiology of anaphylaxis?

      Your Answer: IgM mediated immediate reaction

      Correct Answer: IgE mediated immediate reaction

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Allergy
      12.4
      Seconds
  • Question 98 - A 25-year-old engineering student returns from a hiking trip in South America with...

    Incorrect

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

      Which of the following statements about Plasmodium falciparum malaria is correct?

      Your Answer: It is transmitted by the female Aedes mosquito

      Correct Answer: There may be a continuous fever

      Explanation:

      Plasmodium falciparum malaria is transmitted by female mosquitoes of the Anopheles genus. The Aedes genus, on the other hand, is responsible for spreading diseases like dengue fever and yellow fever. The parasite enters hepatocytes and undergoes asexual reproduction, resulting in the release of merozoites into the bloodstream. These merozoites then invade the red blood cells of the host. The incubation period for Plasmodium falciparum malaria ranges from 7 to 14 days.

      The main symptom of malaria is known as the malarial paroxysm, which consists of a cyclical pattern of cold chills, followed by a stage of intense heat, and finally a period of profuse sweating as the fever subsides. However, some individuals may experience a continuous fever instead.

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

      If artemisinin combination therapy is not available, oral quinine or atovaquone with proguanil hydrochloride can be used as an alternative. However, quinine is not well-tolerated for prolonged treatment and should be combined with another drug, typically oral doxycycline (or clindamycin for pregnant women and young children).

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

    • This question is part of the following fields:

      • Infectious Diseases
      13.5
      Seconds
  • Question 99 - A 45 year old female with a history of alcohol-related visits to the...

    Incorrect

    • A 45 year old female with a history of alcohol-related visits to the emergency department is currently in the emergency department after tripping while intoxicated. She has a 7 cm laceration on the frontal area of the scalp. You examine the wound using local anesthesia. What tissue layer lies directly beneath the scalp skin?

      Your Answer: Areolar connective tissue

      Correct Answer: Dense connective tissue

      Explanation:

      The scalp is composed of five layers, starting from the outermost layer, which is the skin, and moving towards the deepest layer, which is the periosteum of the skull. These layers can be remembered using the mnemonic: SCALP – Skin, Connective tissue, Aponeurosis, Loose areolar connective tissue, and Periosteum.

      Further Reading:

      The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.

      The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.

      The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.

      In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.

    • This question is part of the following fields:

      • Dermatology
      49.8
      Seconds
  • Question 100 - You are present for the unexpected delivery of a baby in one of...

    Incorrect

    • You are present for the unexpected delivery of a baby in one of the cubicles in the Emergency Department. Your consultant evaluates the newborn one minute after birth and informs you that:
      The hands and feet appear bluish in color
      The heart rate is 110 beats per minute
      There is no response to stimulation
      There is slight bending of the limbs
      The cry is feeble, and the baby is gasping for breath
      What is the Apgar score of the newborn at one minute?

      Your Answer:

      Correct Answer: 5

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Ophthalmology (3/3) 100%
Neurology (8/9) 89%
Allergy (2/2) 100%
Pharmacology & Poisoning (8/11) 73%
Neonatal Emergencies (3/3) 100%
Haematology (3/3) 100%
Ear, Nose & Throat (6/7) 86%
Cardiology (4/4) 100%
Urology (3/4) 75%
Palliative & End Of Life Care (4/4) 100%
Gastroenterology & Hepatology (7/9) 78%
Oncological Emergencies (2/2) 100%
Resus (2/2) 100%
Safeguarding & Psychosocial Emergencies (4/5) 80%
Mental Health (2/2) 100%
Paediatric Emergencies (2/2) 100%
Endocrinology (2/3) 67%
Respiratory (3/5) 60%
Trauma (1/1) 100%
Infectious Diseases (3/3) 100%