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  • Question 1 - A 42 year old male is brought into the ED resuscitation room. The...

    Incorrect

    • A 42 year old male is brought into the ED resuscitation room. The paramedics report the patient was discovered outdoors and unconscious. CPR was initiated in the ambulance. You observe that the patient is hypothermic with a temperature of 30.4ÂșC. What modifications would you make to the management of cardio-respiratory arrest based on this finding?

      Your Answer: Use corrected arterial blood gas results

      Correct Answer: Pulse check for up to 1 minute

      Explanation:

      In patients with hypothermia, the pulse check during CPR should be extended to 1 minute. Additionally, several adjustments need to be made to the CPR protocol. Firstly, mechanical ventilation should be used due to the stiffness of the chest wall. Secondly, the dosing or omission of cardiac arrest drugs should be adjusted based on the patient’s temperature. The defibrillation pattern should also be modified, with 3 shocks attempted before re-attempting defibrillation only when the body temperature is above 30ÂșC. Certain electrolyte disturbances, such as mild hypokalemia, should not be treated as potassium levels typically rise with Rewarming. It is important to plan for prolonged resuscitation in these cases. Lastly, uncorrected ABG results should be used, without adjusting for temperature.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      54.5
      Seconds
  • Question 2 - A 35-year-old woman comes in with intense one-sided abdominal pain starting in the...

    Correct

    • A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect a diagnosis of ureteric colic.
      What is the preferred imaging technique for confirming the diagnosis?

      Your Answer: Non-contrast helical computed tomography

      Explanation:

      The term renal colic is commonly used to describe a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. However, a more accurate term is ureteric colic, as the pain usually arises from a blockage in the ureter itself.

      Renal or ureteric colic typically presents with a sudden onset of severe abdominal pain on one side, starting in the lower back or flank and radiating to the genital area in women or to the groin or testicle in men.

      The pain usually:
      – Lasts for minutes to hours and comes in spasms, with periods of no pain or a dull ache
      – Is often accompanied by nausea, vomiting, and blood in the urine
      – Is often described as the most intense pain a person has ever experienced (many women describe it as worse than childbirth).

      People with renal or ureteric colic:
      – Are restless and unable to find relief by lying still (which helps distinguish it from peritonitis)
      – May have a history of previous episodes
      – May have a fever and sweating if there is a urinary tract infection present
      – May complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and bladder (due to irritation of the bladder muscle).

      If possible, a urine dipstick test should be done to support the diagnosis and check for signs of a urinary tract infection.

      Checking for blood in the urine can also support the diagnosis of renal or ureteric colic. However, the absence of blood does not rule out the diagnosis and other causes of pain should be considered.

      Checking for nitrite and leukocyte esterase in the urine can indicate an infection.

      Pain management:
      – Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic.
      – Intravenous paracetamol can be given to adults, children, and young people if NSAIDs are not suitable or not providing enough pain relief.
      – Opioids may be considered if both NSAIDs and intravenous paracetamol are not suitable or not providing enough pain relief.
      – Antispasmodics should not be given to adults, children, and young people with suspected renal colic.

    • This question is part of the following fields:

      • Urology
      23.4
      Seconds
  • Question 3 - A 35 year old man presents to the emergency department complaining of worsening...

    Correct

    • A 35 year old man presents to the emergency department complaining of worsening difficulty breathing that has been developing over the last 2 days. His partner mentioned that he looked pale. He informs you that he usually doesn't take any medications but started taking chloroquine for malaria prevention 5 days ago as he is planning to travel to Kenya next week. His oxygen saturation is 89% on room air and you observe that he appears bluish in color. Upon obtaining a blood gas, you notice that his blood has a chocolate-like hue. What is the probable diagnosis?

      Your Answer: Methaemoglobinaemia

      Explanation:

      Methaemoglobinaemia is a condition characterized by various symptoms such as headache, anxiety, acidosis, arrhythmia, seizure activity, reduced consciousness or coma. One notable feature is the presence of brown or chocolate coloured blood. It is important to note that the patient is taking chloroquine, which is a known trigger for methaemoglobinaemia. Additionally, despite the condition, the patient’s arterial blood gas analysis shows a normal partial pressure of oxygen.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Haematology
      34.1
      Seconds
  • Question 4 - A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain...

    Correct

    • A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain radiating down the inner side of his left upper arm into his forearm and hand. He has a history of heavy smoking and has been diagnosed with COPD. Upon examination, he exhibits weakness and noticeable muscle wasting in his forearm and hand on the same side. Additionally, he has a Horner's syndrome on the affected side. The Chest X-ray image is provided below:

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Pancoast tumour

      Explanation:

      This patient presents with a noticeable mass at the top of the right lung, which is clearly visible on the chest X-ray. Based on the symptoms and clinical presentation, it is highly likely that this is a Pancoast tumor, and the overall diagnosis is Pancoast syndrome.

      A Pancoast tumor is a type of tumor that develops at the apex of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. The majority of Pancoast tumors are classified as non-small cell cancers.

      Pancoast syndrome occurs when the tumor invades various structures and tissues around the thoracic inlet. This includes the invasion of the cervical sympathetic plexus on the same side as the tumor, leading to the development of Horner’s syndrome. Additionally, there may be reflex sympathetic dystrophy in the arm on the affected side, resulting in increased sensitivity to touch and changes in the skin.

      Patients with Pancoast syndrome may also experience shoulder and arm pain due to the tumor invading the brachial plexus roots C8-T1. This can lead to muscle wasting in the hand and tingling sensations in the inner side of the arm. In some cases, there may be involvement of the unilateral recurrent laryngeal nerve, causing unilateral vocal cord paralysis and resulting in a hoarse voice and/or a bovine cough. Phrenic nerve involvement is less common but can also occur.

      Horner’s syndrome, which is a key feature of Pancoast syndrome, is caused by compression of the sympathetic chain from the hypothalamus to the orbit. The three main symptoms of Horner’s syndrome are drooping of the eyelid (ptosis), constriction of the pupil (pupillary miosis), and lack of sweating on the forehead (anhydrosis).

    • This question is part of the following fields:

      • Respiratory
      45.8
      Seconds
  • Question 5 - A 35 year old individual arrives at the clinic with sudden vertigo that...

    Incorrect

    • A 35 year old individual arrives at the clinic with sudden vertigo that started within the last day. You suspect the presence of vestibular neuronitis. What characteristics would you anticipate in a patient with vestibular neuronitis?

      Your Answer: Hearing loss on the affected side

      Correct Answer: Nystagmus with fast phase away from the affected ear

      Explanation:

      Vestibular neuronitis does not typically cause hearing loss, tinnitus, or focal neurological deficits. However, it is characterized by the presence of nystagmus, which is a rapid, involuntary eye movement. In vestibular neuronitis, nystagmus is usually fine horizontal or mixed horizontal-torsional. It consistently beats in the same direction, regardless of head rotation, and can be reduced when focusing on a fixed point.

      Further Reading:

      Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

      Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

      Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

      The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

    • This question is part of the following fields:

      • Ear, Nose & Throat
      38.2
      Seconds
  • Question 6 - A 30 year old patient is brought to the emergency department by bystanders...

    Correct

    • A 30 year old patient is brought to the emergency department by bystanders after a hit and run incident. Upon examination, you observe that the patient is experiencing difficulty breathing and has tracheal deviation towards the left side. Based on these findings, you suspect the presence of a tension pneumothorax. What signs would you anticipate observing in this patient?

      Your Answer: Elevated jugular venous pressure

      Explanation:

      Tension pneumothorax is a condition characterized by certain clinical signs. These signs include pulsus paradoxus, which is an abnormal decrease in blood pressure during inspiration; elevated JVP or distended neck veins; diaphoresis or excessive sweating; and cyanosis, which is a bluish discoloration of the skin. Tracheal deviation to the left is often observed in patients with a right-sided pneumothorax. On the affected side, hyper-resonance and absent breath sounds can be expected. Patients with tension pneumothorax typically appear agitated and distressed, and they experience noticeable difficulty in breathing. Hypotension, a pulse rate exceeding 135 bpm, pulsus paradoxus, and elevated JVP are additional signs associated with tension pneumothorax. These signs occur because the expanding pneumothorax compresses the mediastinum, leading to impaired venous return and cardiac output.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

    • This question is part of the following fields:

      • Respiratory
      25.4
      Seconds
  • Question 7 - A 25-year-old female patient arrives at the Emergency Department displaying clinical symptoms of...

    Correct

    • A 25-year-old female patient arrives at the Emergency Department displaying clinical symptoms of a sexually transmitted infection.
      Which of the following organisms is NOT typically transmitted through sexual contact?

      Your Answer: Hepatitis A

      Explanation:

      The primary way hepatitis A is transmitted is through the ingestion of fecal matter containing the virus. On the other hand, all the other organisms mentioned in this question are typically transmitted through sexual contact.

    • This question is part of the following fields:

      • Sexual Health
      15.6
      Seconds
  • Question 8 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. She is connected to an ECG monitor, and you observe the presence of an arrhythmia.
      What is the most frequently encountered type of arrhythmia in Wolff-Parkinson-White syndrome?

      Your Answer: Atrioventricular nodal re-entrant tachycardia

      Correct Answer: Atrioventricular re-entrant tachycardia

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
      50.8
      Seconds
  • Question 9 - You evaluate a 3-year-old who has been brought to the emergency department due...

    Incorrect

    • You evaluate a 3-year-old who has been brought to the emergency department due to difficulty feeding, irritability, and a high fever. During the examination, you observe a red post-auricular lump, which raises concerns for mastoiditis. What is a commonly known complication associated with mastoiditis?

      Your Answer: Oculomotor nerve palsy

      Correct Answer: Facial nerve palsy

      Explanation:

      Mastoiditis can lead to the development of cranial nerve palsies, specifically affecting the trigeminal (CN V), abducens (CN VI), and facial (CN VII) nerves. This occurs when the infection spreads to the petrous apex of the temporal bone, where these nerves are located. The close proximity of the sixth cranial nerve and the trigeminal ganglion, separated only by the dura mater, can result in inflammation and subsequent nerve damage. Additionally, the facial nerve is at risk as it passes through the mastoid via the facial canal.

      Further Reading:

      Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.

      Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.

      Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.

      Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).

      Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      34.4
      Seconds
  • Question 10 - You are caring for a hypoxic patient in the resuscitation bay. One of...

    Correct

    • You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methaemoglobinaemia. If the diagnosis of methaemoglobinaemia is confirmed, which of the following treatments would be the most appropriate to administer?

      Your Answer: Methylene blue

      Explanation:

      If IV methylene blue is obtained, it is typically used to treat a specific cause. However, if there is no response to methylene blue, alternative treatments such as hyperbaric oxygen or exchange transfusion may be considered. In cases where the cause is NADH-methaemoglobinaemia reductase deficiency, ascorbic acid can be used as a potential treatment.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      20.1
      Seconds
  • Question 11 - A 22-year-old individual arrives at the emergency department complaining of jaw pain and...

    Correct

    • A 22-year-old individual arrives at the emergency department complaining of jaw pain and difficulty in fully closing their mouth. They explain that this issue arose while yawning. The patient has a medical history of Ehlers Danlos syndrome. What is the probable diagnosis?

      Your Answer: Dislocated temporomandibular joint

      Explanation:

      The most frequent cause of atraumatic TMJ dislocation is yawning. Individuals with connective tissue disorders like Marfan’s and Ehlers-Danlos syndromes have a higher susceptibility to atraumatic dislocation.

      Further Reading:

      TMJ dislocation occurs when the mandibular condyle is displaced from its normal position in the mandibular fossa of the temporal bone. The most common type of dislocation is bilateral anterior dislocation. This occurs when the mandible is dislocated forward and the masseter and pterygoid muscles spasm, locking the condyle in place.

      The temporomandibular joint is unique because it has an articular disc that separates the joint into upper and lower compartments. Dislocation can be caused by trauma, such as a direct blow to the open mouth, or by traumatic events like excessive mouth opening during yawning, laughing, shouting, or eating. It can also occur during dental work.

      Signs and symptoms of TMJ dislocation include difficulty fully opening or closing the mouth, pain or tenderness in the TMJ region, jaw pain, ear pain, difficulty chewing, and facial pain. Connective tissue disorders like Marfan’s and Ehlers-Danlos syndrome can increase the likelihood of dislocation.

      If TMJ dislocation is suspected, X-rays may be done to confirm the diagnosis. The best initial imaging technique is an orthopantomogram (OPG) or a standard mandibular series.

      Management of anterior dislocations involves reducing the dislocated mandible, which is usually done in the emergency department. Dislocations to the posterior, medial, or lateral side are usually associated with a mandibular fracture and should be referred to a maxillofacial surgeon.

      Reduction of an anterior dislocation involves applying distraction forces to the mandible. This can be done by gripping the mandible externally or intra-orally. In some cases, procedural sedation or local anesthesia may be used, and in rare cases, reduction may be done under general anesthesia.

      After reduction, a post-reduction X-ray is done to confirm adequate reduction and rule out any fractures caused by the procedure. Discharge advice includes following a soft diet for at least 48 hours, avoiding wide mouth opening for at least 2 weeks, and supporting the mouth with the hand during yawning or laughing. A Barton bandage may be used to support the mandible if the patient is unable to comply with the discharge advice. Referral to a maxillofacial surgeon as an outpatient is also recommended.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      24.4
      Seconds
  • Question 12 - A 65-year-old man is brought in to see you by his wife. She...

    Correct

    • A 65-year-old man is brought in to see you by his wife. She is concerned that he may have had a 'mini-stroke.' After conducting a comprehensive history and examination, you conclude that it is highly probable that he has experienced a transient ischemic attack (TIA). You decide to refer him to the nearby specialist TIA clinic.
      What imaging procedure is most likely to be arranged at the TIA clinic?

      Your Answer: Carotid imaging

      Explanation:

      The NICE recommendations for managing patients with suspected TIA are as follows:

      – Offer aspirin (300 mg daily) to individuals who have experienced a suspected TIA, unless there are contraindications. This treatment should be started immediately.
      – Immediately refer individuals who have had a suspected TIA for specialist assessment and investigation. They should be seen within 24 hours of the onset of symptoms.
      – Avoid using scoring systems, such as ABCD2, to assess the risk of subsequent stroke or determine the urgency of referral for individuals with suspected or confirmed TIA.
      – Provide secondary prevention measures, in addition to aspirin, as soon as possible after confirming the diagnosis of TIA.

      The NICE recommendations for imaging in individuals with suspected TIA or acute non-disabling stroke are as follows:

      – Do not offer CT brain scanning to individuals with suspected TIA, unless there is clinical suspicion of an alternative diagnosis that CT could detect.
      – After a specialist assessment in the TIA clinic, consider performing an MRI (including diffusion-weighted and blood-sensitive sequences) to determine the area of ischemia, detect hemorrhage, or identify alternative pathologies. If an MRI is conducted, it should be done on the same day as the assessment.
      – Carotid imaging is necessary for all individuals with TIA who, after specialist assessment, are considered candidates for carotid endarterectomy. This imaging should be done urgently.

      For more information, refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old: diagnosis and initial management.

    • This question is part of the following fields:

      • Neurology
      34
      Seconds
  • Question 13 - A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal...

    Correct

    • A 25-year-old woman comes in with a slight vaginal bleeding and lower abdominal discomfort. Her pregnancy test shows positive results. During the examination, she experiences tenderness in the right iliac fossa and right-sided adnexa. Additionally, she exhibits cervical motion tenderness.

      What is the SINGLE most probable diagnosis?

      Your Answer: Ectopic pregnancy

      Explanation:

      Bleeding in a confirmed early pregnancy, along with adnexal tenderness and cervical motion tenderness, is indicative of an ectopic pregnancy until proven otherwise. The amount of bleeding caused by an ectopic pregnancy can range from no bleeding or slight spotting to a level similar to a normal menstrual period. It is important to note that 90% of patients with an ectopic pregnancy experience abdominal pain. Other clinical features that may be present include shoulder tip pain, which is caused by irritation of the diaphragm, as well as adnexal tenderness, cervical motion tenderness, rebound tenderness, guarding, and adnexal masses in some cases. Additionally, hypotension and shock may occur.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      19.2
      Seconds
  • Question 14 - A 6-week-old baby girl is brought to the Emergency Department by her parents...

    Correct

    • A 6-week-old baby girl is brought to the Emergency Department 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 feel a small mass in the upper abdomen. A venous blood gas is performed.
      What is the definitive treatment for the diagnosis in this case?

      Your Answer: Ramstedt pyloromyotomy

      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
      31.1
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  • Question 15 - A 35 year old female is brought into the emergency department after being...

    Incorrect

    • A 35 year old female is brought into the emergency department after being hit by a truck that had veered onto the sidewalk where the patient was standing. The patient has a significant bruise on the back of her head and seems lethargic.

      You are worried about increased intracranial pressure (ICP). Which of the following physical signs suggest elevated ICP?

      Your Answer: Narrow pulse pressure

      Correct Answer: Vomiting

      Explanation:

      Vomiting after a head injury should raise concerns about increased intracranial pressure (ICP). Signs of elevated ICP include vomiting, changes in pupil size or shape in one eye, decreased cognitive function or consciousness, abnormal findings during fundoscopy (such as blurry optic discs or bleeding in the retina), cranial nerve dysfunction (most commonly affecting CN III and VI), weakness on one side of the body (a late sign), bradycardia (slow heart rate), high blood pressure, and a wide pulse pressure. Irregular breathing that may progress to respiratory distress, focal neurological deficits, and seizures can also be indicative of elevated ICP.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      36
      Seconds
  • Question 16 - A 5 year old girl is brought into the emergency department by worried...

    Incorrect

    • A 5 year old girl is brought into the emergency department by worried parents. The child mentioned having stomach pain and feeling nauseous yesterday but began vomiting this morning and now appears sleepy. After evaluating her, you examine the results of the venous blood gas and glucose (provided below):

      pH 7.25
      Bicarbonate 13 mmol/l
      Glucose 28 mmol/l

      The girl weighs 20kg. What is the calculated fluid deficit for this patient?

      Your Answer: 1400ml

      Correct Answer: 1000ml

      Explanation:

      Fluid deficit in children and young people with severe diabetic ketoacidosis (DKA) is determined by measuring their blood pH and bicarbonate levels. If the blood pH is below 7.1 and/or the bicarbonate level is below 5, it indicates a fluid deficit. This simplified explanation uses a cutoff value of 5 to determine the severity of the fluid deficit in DKA.

      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:

      • Gastroenterology & Hepatology
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  • Question 17 - A 35-year-old male is brought to the emergency department with a severe head...

    Correct

    • A 35-year-old male is brought to the emergency department with a severe head injury. Due to a decreasing Glasgow Coma Scale (GCS), it is decided to intubate him. You prepare for rapid sequence induction (RSI) and plan to use propofol as the induction agent. Which of the following statements about propofol and its impact on blood pressure is accurate?

      Your Answer: Propofol causes hypotension via venodilation

      Explanation:

      The administration of propofol can result in venodilation, leading to a significant drop in blood pressure. This effect is particularly significant in patients who are already experiencing unstable blood flow.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      26.3
      Seconds
  • Question 18 - A 68 year old male is brought into the emergency department with a...

    Incorrect

    • A 68 year old male is brought into the emergency department with a two week history of worsening nausea, muscle aches, fatigue, and weakness. You send urine and blood samples for analysis. The results are shown below:

      Na+ 126 mmol/l
      K+ 5.3 mmol/l
      Urea 7.0 mmol/l
      Creatinine 90 ”mol/l
      Glucose 6.0 mmol/l
      Urine osmolality 880 mosmol/kg

      You review the patient's medications. Which drug is most likely responsible for this patient's symptoms?

      Your Answer: Prednisolone

      Correct Answer: Sertraline

      Explanation:

      This patient is experiencing hyponatremia, which is characterized by low plasma osmolality and high urine osmolality, indicating syndrome of inappropriate antidiuretic hormone secretion (SIADH). One of the most common causes of SIADH is the use of SSRIs. On the other hand, lithium, sodium bicarbonate, and corticosteroids are known to cause hypernatremia. Plasma osmolality can be calculated using the formula (2 x Na) + Glucose + Urea. In this patient, the calculated osmolality is 265 mosmol/kg, which falls within the normal range of 275-295 mosmol/kg.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Nephrology
      29.2
      Seconds
  • Question 19 - A 45-year-old woman who is originally from Brazil has recently developed dilated cardiomyopathy...

    Correct

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

      Your Answer: Chagas disease

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      34.5
      Seconds
  • Question 20 - You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would...

    Incorrect

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

      Your Answer: It most commonly affects the posterior pituitary

      Correct Answer: Diabetes insipidus may occur

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      33.2
      Seconds
  • Question 21 - A 35-year-old woman currently nursing her baby has developed a painful, red lump...

    Correct

    • A 35-year-old woman currently nursing her baby has developed a painful, red lump in her left breast. She feels chilled and generally not well and has a temperature of 38.6°C. During examination, she has a significant red area on the outer side of the nipple on her left breast. The entire breast seems swollen and inflamed.

      What is the SINGLE most probable diagnosis?

      Your Answer: Breast abscess

      Explanation:

      This patient is experiencing a breast abscess that has developed as a result of lactational mastitis. When milk is not properly drained, it can lead to an overgrowth of bacteria and subsequently cause an infection in the breast. If left untreated, this infection can lead to the accumulation of pus in a specific area of the breast. It is estimated that around 5-10% of women with infectious mastitis will develop a breast abscess. The recommended treatment involves a combination of antibiotics, such as flucloxacillin or co-amoxiclav, along with either aspiration or incision and drainage of the abscess.

    • This question is part of the following fields:

      • Surgical Emergencies
      22.5
      Seconds
  • Question 22 - A 7-year-old girl comes in with a painful throat and a dry cough...

    Correct

    • A 7-year-old girl comes in with a painful throat and a dry cough that has been bothering her for two days. During the examination, she does not have a fever and has a few tender lymph nodes in the front of her neck. Her throat and tonsils look red and inflamed, but there is no pus on her tonsils.
      What is her FeverPAIN score?

      Your Answer: 2

      Explanation:

      The FeverPAIN score is a scoring system that is 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, different recommendations are given regarding the use of antibiotics.

      If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

      The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

      Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      55.5
      Seconds
  • Question 23 - A 32-year-old man is brought to the hospital with a known notifiable illness.
    Which...

    Correct

    • A 32-year-old man is brought to the hospital with a known notifiable illness.
      Which of the following is the LEAST probable diagnosis?

      Your Answer: Leptospirosis

      Explanation:

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

      Registered medical practitioners (RMPs) are legally obligated to notify the designated proper officer at their local council or local health protection team (HPT) when they suspect cases of certain infectious diseases.

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

      It is worth noting that leptospirosis is not considered a notifiable disease, making it the least likely option among the diseases listed above.

    • This question is part of the following fields:

      • Infectious Diseases
      34.8
      Seconds
  • Question 24 - A 65 year old male is brought to the emergency department after experiencing...

    Incorrect

    • A 65 year old male is brought to the emergency department after experiencing a sudden decline in health over the past 72 hours. The patient appears slightly confused and restless. Here are the observations:

      Blood pressure: 178/94 mmHg
      Pulse: 122 bpm
      Respiration rate: 24 bpm
      Temperature: 39.5ÂșC

      An ECG is conducted, revealing rapid atrial fibrillation. During the examination, the patient exhibits crackling sounds in the lower parts of the lungs, pitting edema in both legs below the knee, and a mild yellowish tint in the sclera. The patient's GP office is contacted to obtain further information about their medical history. The patient is prescribed carbimazole and bisoprolol, but they have not renewed their prescription on time. What is the most probable diagnosis?

      Your Answer: Myxoedema coma

      Correct Answer: Thyroid storm

      Explanation:

      The patient is showing signs of confusion and restlessness. Upon examination, it is found that the patient has high blood pressure, a rapid pulse rate, increased respiration rate, and a high temperature. An ECG reveals rapid atrial fibrillation. Additionally, the patient exhibits crackling sounds in the lower parts of the lungs, pitting edema in both legs below the knee, and a mild yellowish tint in the sclera. The patient’s medical history is obtained from their GP office, which reveals that they have not renewed their prescription for carbimazole and bisoprolol on time. Based on these findings, the most probable diagnosis is a thyroid storm.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      49.1
      Seconds
  • Question 25 - A young patient has developed a tremor and is experiencing nausea and vomiting...

    Correct

    • A young patient has developed a tremor and is experiencing nausea and vomiting as a result of taking a prescribed medication. Additionally, the patient has developed nephrogenic diabetes insipidus.
      Which of the following medications is most likely to be the cause of these symptoms?

      Your Answer: Lithium

      Explanation:

      Lithium is a commonly prescribed medication for bipolar disorder, as it helps stabilize mood. The recommended therapeutic range for lithium levels is typically between 0.4 and 0.8 mmol/l, although this range may vary depending on the laboratory. For maintenance therapy and treatment in older individuals, the lower end of the range is usually targeted. Toxic effects of lithium are typically observed when levels exceed 1.5 mmol/l. It is important to monitor lithium levels one week after starting therapy and after any dosage adjustments.

      One potential side effect of lithium is the development of nephrogenic diabetes insipidus, a condition that affects the kidneys’ ability to concentrate urine. However, lithium does not cause diabetes mellitus. Another known side effect is hypothyroidism, which is a decrease in thyroid hormone production, but it does not lead to hyperthyroidism, an overactive thyroid.

      Signs of lithium toxicity include nausea, vomiting, diarrhea, tremors, ataxia (loss of coordination), confusion, increased muscle tone, clonus (repetitive, involuntary muscle contractions), nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is crucial to be aware of these symptoms and seek medical attention if they occur.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24
      Seconds
  • Question 26 - A 30-year-old man comes to the clinic complaining of pain in his right...

    Incorrect

    • A 30-year-old man comes to the clinic complaining of pain in his right testis that has been bothering him for the past five days. The pain has been increasing gradually and he has also noticed swelling in the affected testis. During the examination, his temperature is measured at 38.5°C and the scrotum appears red and swollen on the affected side. Palpation reveals extreme tenderness in the testis.
      What is the most probable organism responsible for this condition?

      Your Answer: Staphylococcus aureus

      Correct Answer: Neisseria gonorrhoeae

      Explanation:

      Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.

      The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.

      Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.

      While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.

      Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.

      The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.

    • This question is part of the following fields:

      • Urology
      26.6
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  • Question 27 - A 10-year-old girl comes in with excessive thirst, frequent urination, and increased thirst....

    Incorrect

    • A 10-year-old girl comes in with excessive thirst, frequent urination, and increased thirst. She has been feeling very fatigued lately and has experienced significant weight loss. Blood tests show normal levels of urea and electrolytes, but her bicarbonate level is 18 mmol/l (reference range 22-26 mmol/l). A urine dipstick test reveals 2+ protein and 3+ ketones.

      What is the SINGLE most probable diagnosis?

      Your Answer: Type 2 diabetes mellitus

      Correct Answer: Type 1 diabetes mellitus

      Explanation:

      This child is displaying a typical pattern of symptoms for type I diabetes mellitus. He has recently experienced increased urination, excessive thirst, weight loss, and fatigue. Blood tests have revealed metabolic acidosis, and the presence of ketones in his urine indicates the development of diabetic ketoacidosis.

    • This question is part of the following fields:

      • Endocrinology
      38.5
      Seconds
  • Question 28 - A 6-year-old girl is brought in by her parents with wheezing and difficulty...

    Correct

    • A 6-year-old girl is brought in by her parents with wheezing and difficulty breathing. Over the past few days, she has been feeling sick and has had a decreased appetite. Her parents have noticed that she seems to struggle with breathing, especially when she is playing or exerting herself. Her oxygen levels are at 90% on room air, but all her other vital signs are normal. A chest X-ray is taken, which is shows left lung appears overinflated and hyperlucent, with concomitant rib flaring and a depressed ipsilateral hemidiaphragm. What is the MOST likely diagnosis for this patient?

      Your Answer: Inhaled foreign body

      Explanation:

      This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.

      Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.

      Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.

      While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.

      To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.

      Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.

      Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).

    • This question is part of the following fields:

      • Respiratory
      58.6
      Seconds
  • Question 29 - A 35-year-old presents to the emergency department complaining of palpitations. During the history-taking,...

    Correct

    • A 35-year-old presents to the emergency department complaining of palpitations. During the history-taking, the patient reveals a recent weight loss of approximately 10 kg over the past 6 months and the presence of hand tremors. Thyroid function tests are ordered and the results confirm hyperthyroidism. What is the predominant cause of thyrotoxicosis in the United Kingdom?

      Your Answer: Graves' disease

      Explanation:

      TSH-secreting pituitary adenoma is an uncommon cause of hyperthyroidism in the United Kingdom, accounting for only a small number of cases.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      20.2
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  • Question 30 - A 35-year-old West Indian woman with a past medical history of bilateral wrist...

    Correct

    • A 35-year-old West Indian woman with a past medical history of bilateral wrist and hand pain comes to the clinic complaining of a red rash on her cheeks and nose.

      What is the SINGLE most probable diagnosis?

      Your Answer: Systemic lupus erythematosus

      Explanation:

      Systemic lupus erythematosus (SLE) is a connective tissue disorder that affects multiple systems in the body. It is characterized by skin rashes, joint pain, and the presence of antibodies against double-stranded DNA. SLE is more commonly seen in young women, with a ratio of 10 females to 1 male. It is also more prevalent in West Indian populations.

      One of the classic signs of SLE is the presence of a butterfly rash. This rash appears as redness over the bridge of the nose and cheeks. It is often worsened by exposure to sunlight and can occur before other symptoms of SLE develop.

      Joint involvement is common in SLE and can affect both large and small joints. The knee, proximal interphalangeal, wrist, and metacarpophalangeal joints are most frequently affected.

    • This question is part of the following fields:

      • Dermatology
      14.2
      Seconds
  • Question 31 - A 21 year old college student comes to the emergency department complaining of...

    Incorrect

    • A 21 year old college student comes to the emergency department complaining of feeling unwell, having a fever, and experiencing a severe sore throat. After evaluating the patient, you inform them that you suspect they may have contracted infectious mononucleosis. The patient inquires if it is possible to have caught this by kissing someone a week ago.

      What is the usual duration of the incubation period for infectious mononucleosis?

      Your Answer: 7-14 days

      Correct Answer: 4-8 weeks

      Explanation:

      Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.

      The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.

      Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.

      Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.

      Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.

    • This question is part of the following fields:

      • Infectious Diseases
      29.3
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  • Question 32 - A 60-year-old man presents with visible jaundice, fatigue, and intense itching. He has...

    Incorrect

    • A 60-year-old man presents with visible jaundice, fatigue, and intense itching. He has noticed that his stools float and that they have become pale, foul-smelling, and oily in appearance. He has no history of abdominal pain. He has a past medical history of Crohn's disease, which has been controlled with mesalazine. On examination, you notice yellowish pigmentation of the skin, sclerae, and mucous membranes. His abdomen is soft but can palpate a firm liver edge 5 cm below the costal margin. He also has numerous scratch marks covering his abdomen and upper thighs. His liver function tests are shown below:
      Bilirubin 102 mmol (3-20)
      ALT 235 IU/L (5-40)
      ALP: 1501 IU/L (20-140)
      pANCA: positive
      cANCA: negative
      ANA: negative
      SMA: negative
      What is the SINGLE most likely diagnosis?

      Your Answer: Primary biliary cirrhosis

      Correct Answer: Primary sclerosing cholangitis

      Explanation:

      This woman is showing signs of obstructive jaundice along with a history of ulcerative colitis. The most probable diagnosis in this case is primary sclerosing cholangitis (PSC). PSC is a condition that causes inflammation and blockage of the bile ducts, leading to progressive damage. It is characterized by recurrent episodes of cholangitis and the development of scar tissue in the bile ducts. In severe cases, it can lead to liver cirrhosis, liver failure, and even liver cancer. PSC is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis.

      The underlying cause of PSC is believed to be autoimmune in nature. Around 80% of patients with PSC test positive for p-ANCA antibodies, which are associated with autoimmune diseases. Other antibodies such as antinuclear antibodies (ANA) and anti-smooth muscle antibodies may also be present, but they are only found in about one-third of PSC patients.

      Autoimmune hepatitis, on the other hand, is a liver inflammation caused by a decrease in regulatory T-cells (Treg cells), leading to the production of autoantibodies against hepatocyte surface antigens. It primarily affects women (70%) between the ages of 15 and 40. The condition causes chronic and progressive hepatitis, often presenting in the later stages when the patient is severely unwell and jaundiced. Liver function tests typically show significantly elevated levels of transaminases (ALT and AST), often more than ten times the normal range. Alkaline phosphatase (ALP) levels may be normal or slightly elevated. Antinuclear antibodies (ANA) are positive in approximately 80% of cases, while smooth muscle antibodies (SMA) are positive in about 70% of cases. Antimitochondrial antibodies are usually low or absent.

      Primary biliary cirrhosis is another autoimmune liver disease that leads to the progressive destruction of the small bile ducts in the liver, primarily affecting the intralobular ducts. This results in cholestatic jaundice, liver fibrosis, and eventually cirrhosis. The condition is more common in women (90%) and typically occurs between the ages of 30 and 65. Liver function tests show predominantly elevated levels of alkaline phosphatase (ALP), often before any symptoms or signs of the disease appear.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      35.3
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  • Question 33 - A 7-year-old boy presents with sudden stomach pain. The surgical team suspects acute...

    Correct

    • A 7-year-old boy presents with sudden stomach pain. The surgical team suspects acute appendicitis and recommends surgery. The child is feeling tired and it is challenging for the clinicians to explain the procedure to him. He is accompanied by his grandfather and his parents are currently on vacation in Australia and cannot be reached. Which of the following statements is correct regarding his care?

      Your Answer: The carer can consent on behalf of the child

      Explanation:

      Parents are not always present with their children, and in certain situations, they may delegate their parental responsibility to others, such as grandparents. In such cases, it is not always necessary to consult the parents, unless the healthcare professional anticipates significant differences in their opinions.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      27.5
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  • Question 34 - A 25-year-old woman arrives at the emergency department with complaints of lip swelling...

    Incorrect

    • A 25-year-old woman arrives at the emergency department with complaints of lip swelling that began 30 minutes ago. During her medical history, she mentions that her sister experienced a similar episode and was recently diagnosed with hereditary angioedema (HAE). What is the main treatment for this condition?

      Your Answer: Pyridostigmine

      Correct Answer: C1 Esterase Inhibitor Replacement Protein

      Explanation:

      The explanation states that the increased activity of the enzyme kininogenase is caused by hormonal factors, specifically oestrogen, as well as genetic factors.

      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
      21.9
      Seconds
  • Question 35 - You are managing a 65 year old male who has presented to the...

    Incorrect

    • You are managing a 65 year old male who has presented to the emergency department with a 3 hour history of epistaxis. On examination there is significant bleeding from both nostrils and you are unable to identify a bleeding point. Your consultant asks if you are concerned about a posterior bleed.

      Posterior epistaxis is most commonly associated with bleeding from which of the following?

      Your Answer: kiesselbach plexus

      Correct Answer: Sphenopalatine artery

      Explanation:

      Posterior epistaxis, which is bleeding from the back of the nose, is typically caused by bleeding from the sphenopalatine artery or its branches. The most common surgical treatment for posterior epistaxis involves tying off the sphenopalatine artery. It is important to note that there is some disagreement in the literature regarding the exact location of the bleeding, with some sources referring to Woodruff’s plexus. However, cadaveric studies suggest that Woodruff’s plexus is more likely a venous anastomosis rather than an arterial one involving branches of the sphenopalatine artery.

      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
      33.7
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  • Question 36 - A 35-year-old man is brought into the emergency room by an ambulance with...

    Incorrect

    • A 35-year-old man is brought into the emergency room by an ambulance with flashing lights. He has been involved in a building fire and has sustained severe burns. You evaluate his airway and have concerns about potential airway blockage. You decide to perform intubation on the patient and begin preparing the required equipment.
      Which of the following is NOT a reason for performing early intubation in a burn patient?

      Your Answer: Accessory respiratory muscle use

      Correct Answer: Superficial partial-thickness circumferential neck burns

      Explanation:

      Early assessment of the airway is a critical aspect of managing a burned patient. Airway obstruction can occur rapidly due to direct injury or swelling from the burn. If there is a history of trauma, the airway should be evaluated while maintaining cervical spine control.

      There are several risk factors for airway obstruction in burned patients, including inhalation injury, soot in the mouth or nostrils, singed nasal hairs, burns to the head, face, and neck, burns inside the mouth, large burn area and increasing burn depth, associated trauma, and a carboxyhemoglobin level above 10%.

      In cases where significant swelling is anticipated, it may be necessary to urgently secure the airway with an uncut endotracheal tube before the swelling becomes severe. Delaying recognition of impending airway obstruction can make intubation difficult, and a surgical airway may be required.

      The American Burn Life Support (ABLS) guidelines recommend early intubation in certain situations. These include signs of airway obstruction, extensive burns, deep facial burns, burns inside the mouth, significant swelling or risk of swelling, difficulty swallowing, respiratory compromise, decreased level of consciousness, and anticipated transfer of a patient with a large burn and airway issues without qualified personnel to intubate during transport.

      Circumferential burns of the neck can cause tissue swelling around the airway, making early intubation necessary in these cases as well.

    • This question is part of the following fields:

      • Trauma
      21.5
      Seconds
  • Question 37 - A 42-year-old woman comes in with a suddenly painful right eye and sensitivity...

    Correct

    • A 42-year-old woman comes in with a suddenly painful right eye and sensitivity to light. She describes her eye as feeling gritty and it is noticeably watery. The patient has been experiencing a mild cold for the past few days. You administer fluorescein drops to her eye, which reveal the presence of a dendritic ulcer.

      What is the most suitable treatment for this patient?

      Your Answer: Acyclovir ointment

      Explanation:

      There are two types of infectious agents that can lead to the development of a dendritic ulcer. The majority of cases (80%) are caused by the herpes simplex virus (type I), while the remaining cases (20%) are caused by the herpes zoster virus. To effectively treat this condition, the patient should follow a specific treatment plan. This includes applying acyclovir ointment topically five times a day for a duration of 10 days. Additionally, prednisolone 0.5% drops should be used 2-4 times daily. It is also recommended to take oral high dose vitamin C, as it has been shown to reduce the healing time of dendritic ulcers.

    • This question is part of the following fields:

      • Ophthalmology
      21.9
      Seconds
  • Question 38 - A 35-year-old construction worker presents with confusion, vomiting, and complaining of a severe...

    Correct

    • A 35-year-old construction worker presents with confusion, vomiting, and complaining of a severe headache. There is currently a scorching heatwave, and he has been working outdoors in heavy protective gear all day. He remembers feeling extremely thirsty and experiencing muscle cramps earlier, but his symptoms have worsened since then. His skin feels dry and hot, he is breathing rapidly, and his core temperature is currently 41.7°C.

      What is the SINGLE most probable diagnosis?

      Your Answer: Heat stroke

      Explanation:

      Heat stroke is a condition characterized by a core temperature greater than 40.6°C, accompanied by changes in mental state and varying levels of organ dysfunction. There are two forms of heat stroke: classic non-exertional heat stroke, which occurs during high environmental temperatures and typically affects elderly patients during heat waves, and exertional heat stroke, which occurs during strenuous physical exercise in high environmental temperatures, such as endurance athletes competing in hot conditions. Heat stroke happens when the body’s thermoregulation is overwhelmed by excessive environmental heat, excessive metabolic heat production, and insufficient heat loss.

      Several risk factors increase the likelihood of developing heat stroke. These include hot and humid environmental conditions, age (with the elderly and infants being particularly vulnerable), physical factors like obesity, excessive exertion, and dehydration, as well as medical comorbidities such as anorexia, cardiovascular disease, skin conditions, poorly controlled diabetes, Parkinson’s disease, and thyrotoxicosis. Certain drugs, including alcohol, amphetamines, anticholinergics, beta-blockers, cocaine, diuretics, phenothiazines, SSRIs, and sympathomimetics, can also increase the risk of heat stroke.

      The typical clinical features of heat stroke include a core temperature greater than 40.6°C. Early signs may include extreme fatigue, headache, syncope, facial flushing, vomiting, and diarrhea. The skin is usually hot and dry, although sweating can occur in around 50% of cases of exertional heat stroke. The loss of the ability to sweat is a late and concerning sign. Hyperventilation is almost always present. Heat stroke can also lead to cardiovascular dysfunction, such as arrhythmias, hypotension, and shock, respiratory dysfunction including acute respiratory distress syndrome (ARDS), and central nervous system dysfunction, including seizures and coma. If the temperature rises above 41.5°C, multi-organ failure, coagulopathy, and rhabdomyolysis can occur.

      Heat cramps, on the other hand, typically present with intense thirst and muscle cramps. Body temperature is often elevated but usually remains below 40°C. Sweating, heat dissipation mechanisms, and cognition are preserved, and there is no neurological impairment.

      Heat exhaustion usually precedes heat stroke and, if left untreated, can progress to heat stroke. Heat dissipation is still functioning, and the body temperature is usually below 41°C.

    • This question is part of the following fields:

      • Environmental Emergencies
      25.1
      Seconds
  • Question 39 - A 42-year-old woman with a long history of anxiety presents having taken a...

    Incorrect

    • A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the pills she takes for insomnia. She informs you that the pill she takes for this condition is zolpidem 10 mg. She consumed the pills approximately 2 hours ago. She is currently experiencing tachycardia, with her most recent heart rate reading being 120 beats per minute. She weighs 65 kg. You administer a dose of propranolol, but there is no improvement in her condition.
      Which of the following treatments could now be given to support her cardiovascular system?

      Your Answer: Magnesium sulphate

      Correct Answer: High dose insulin – euglycaemic therapy

      Explanation:

      Calcium-channel blocker overdose is a serious condition that can be life-threatening. The 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 are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

      When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.

      The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:

      1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.

      2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.

      3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.

      4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.

      5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.

      6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      36
      Seconds
  • Question 40 - A 28-year-old woman presents after experiencing a syncopal episode earlier in the day....

    Incorrect

    • A 28-year-old woman presents after experiencing a syncopal episode earlier in the day. She fainted while jogging on the treadmill at her local gym. She regained consciousness quickly and currently feels completely fine. Upon examination, she has a slim physique, normal heart sounds without any additional sounds or murmurs, clear lungs, and a soft abdomen. She is originally from Thailand and mentions that her mother passed away suddenly in her 30s.

      Her ECG reveals:
      - Right bundle branch block pattern
      - Downward-sloping 'coved' ST elevation in leads V1-V3
      - Widespread upward-sloping ST depression in other leads

      What is the SINGLE most likely diagnosis?

      Your Answer: Hypertrophic cardiomyopathy

      Correct Answer: Brugada syndrome

      Explanation:

      Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.

      One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.

    • This question is part of the following fields:

      • Cardiology
      31.7
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  • Question 41 - A 32 year old female presents to the emergency department with a one...

    Correct

    • A 32 year old female presents to the emergency department with a one day history of gradually worsening suprapubic pain, increased urinary frequency, and foul-smelling urine. The patient has a temperature of 37.2ÂșC and her vital signs are within normal limits. Urine dipstick testing reveals the presence of nitrites, leukocytes, and blood. The patient reports no regular medication use and the last time she took any acute medication was approximately 6 months ago when she was prescribed antihistamines for hayfever symptoms. Based on these findings, the most likely cause of her symptoms is a urinary tract infection. What is the most probable causative organism?

      Your Answer: Escherichia coli

      Explanation:

      Based on the patient’s symptoms of suprapubic pain, increased urinary frequency, and foul-smelling urine, along with the presence of nitrites, leukocytes, and blood in the urine dipstick test, the most likely cause of her symptoms is a urinary tract infection (UTI). The most probable causative organism for UTIs is Escherichia coli.

      Further Reading:

      A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system, from the kidneys to the bladder. It is characterized by symptoms such as dysuria, nocturia, polyuria, urgency, incontinence, and changes in urine appearance and odor. UTIs can be classified as lower UTIs, which affect the bladder, or upper UTIs, which involve the kidneys. Recurrent UTIs can be due to relapse or re-infection, and the number of recurrences considered significant depends on age and sex. Uncomplicated UTIs occur in individuals with a normal urinary tract and kidney function, while complicated UTIs are caused by anatomical, functional, or pharmacological factors that make the infection persistent, recurrent, or resistant to treatment.

      The most common cause of UTIs is Escherichia coli, accounting for 70-95% of cases. Other causative organisms include Staphylococcus saprophyticus, Proteus mirabilis, and Klebsiella species. UTIs are typically caused by bacteria from the gastrointestinal tract entering the urinary tract through the urethra. Other less common mechanisms of entry include direct spread via the bloodstream or instrumentation of the urinary tract, such as catheter insertion.

      Diagnosis of UTIs involves urine dipstick testing and urine culture. A urine culture should be sent in certain circumstances, such as in male patients, pregnant patients, women aged 65 years or older, patients with persistent or unresolved symptoms, recurrent UTIs, patients with urinary catheters, and those with risk factors for resistance or complicated UTIs. Further investigations, such as cystoscopy and imaging, may be required in cases of recurrent UTIs or suspected underlying causes.

      Management of UTIs includes simple analgesia, advice on adequate fluid intake, and the prescription of appropriate antibiotics. The choice of antibiotic depends on the patient’s gender and risk factors. For women, first-line antibiotics include nitrofurantoin or trimethoprim, while second-line options include nitrofurantoin (if not used as first-line), pivmecillinam, or fosfomycin. For men, trimethoprim or nitrofurantoin are the recommended antibiotics. In cases of suspected acute prostatitis, fluoroquinolone antibiotics such as ciprofloxacin or ofloxacin may be prescribed for a 4-week course.

    • This question is part of the following fields:

      • Urology
      43.7
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  • Question 42 - A 30-year-old construction worker comes in with intense pain in his left eye...

    Correct

    • A 30-year-old construction worker comes in with intense pain in his left eye following an incident at the job site where a significant amount of cement dust blew into his eye.

      What should be utilized as an irrigation solution for the affected eye?

      Your Answer: 0.9% normal saline

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Ophthalmology
      15.8
      Seconds
  • Question 43 - You are summoned to the resuscitation room to assist with a 68-year-old patient...

    Correct

    • You are summoned to the resuscitation room to assist with a 68-year-old patient who has experienced cardiac arrest. The team has initiated the initial round of chest compressions and has connected the monitoring equipment. You propose a brief pause in chest compressions to assess if the rhythm is suitable for defibrillation. The patient's rhythm is indeed defibrillated. However, despite administering three successive shocks, there is no spontaneous return of circulation. What are the two appropriate medications to administer now, and what are their respective doses?

      Your Answer: Adrenaline 1 mg IV & amiodarone 300 mg IV

      Explanation:

      After the third shock is administered to patients with a shockable rhythm, it is recommended to administer two drugs: adrenaline and amiodarone. Adrenaline should be given at a dose of 1 mg intravenously (or intraosseously) for adult patients in cardiac arrest with a shockable rhythm. For adult patients in cardiac arrest who are in ventricular fibrillation or pulseless ventricular tachycardia, amiodarone should be given at a dose of 300 mg intravenously (or intraosseously) after three shocks have been administered. In cases where amiodarone is unavailable, lidocaine may be used as an alternative.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Resus
      30.7
      Seconds
  • Question 44 - A 35-year-old male presents to the emergency department complaining of gradual onset sharp...

    Correct

    • A 35-year-old male presents to the emergency department complaining of gradual onset sharp chest pain over the past 24 hours. The patient reports that the pain worsens with deep inspiration and feels more comfortable when sitting leaning forward. When asked about pain radiation, the patient confirms that the pain extends to the left side of the neck and points to the ridge of the trapezius. Physical examination reveals clear lung fields, regular rhythm with quiet heart sounds, and no murmurs. The patient's vital signs are as follows:

      Blood pressure: 108/66 mmHg
      Pulse rate: 94 bpm
      Respiratory rate: 18 rpm
      Temperature: 37.3ÂșC
      Oxygen saturations: 97% on room air

      What is the most likely diagnosis?

      Your Answer: Acute pericarditis

      Explanation:

      Radiation to the trapezius ridge is a distinct symptom of acute pericarditis. The patient in question exhibits characteristics that align with a diagnosis of pericarditis. Pericarditis is a common condition affecting the pericardium, and it is often considered as a potential cause for chest pain. It is worth noting that the specific radiation of pain to the trapezius ridge is highly indicative of pericarditis, as it occurs when the phrenic nerve, which also innervates the trapezius muscle, becomes irritated while passing through the pericardium.

      Further Reading:

      Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.

    • This question is part of the following fields:

      • Cardiology
      28.5
      Seconds
  • Question 45 - A 2-year-old boy presents with a high temperature and foul-smelling urine. His mother...

    Incorrect

    • A 2-year-old boy presents with a high temperature and foul-smelling urine. His mother is worried that he might have a urinary tract infection.
      Which of the following symptoms is NOT mentioned by NICE as indicative of a UTI in this age range?

      Your Answer: Urinary frequency

      Correct Answer: Haematuria

      Explanation:

      According to NICE, the presence of certain clinical features in a child between three months and five years old may indicate a urinary tract infection (UTI). These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information on this topic, 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:

      • Urology
      44
      Seconds
  • Question 46 - A 28-year-old woman is brought in by ambulance after intentionally swallowing 17 tablets...

    Correct

    • A 28-year-old woman is brought in by ambulance after intentionally swallowing 17 tablets of 300 mg aspirin. The overdose occurred three hours ago.
      What is true regarding her treatment in the Emergency Department?

      Your Answer: No specific antidote is available in this case

      Explanation:

      Salicylate poisoning is a fairly common form of poisoning that can lead to organ damage and death if not treated promptly. The symptoms of salicylate poisoning include nausea, vomiting, ringing in the ears, hearing loss, excessive sweating, dehydration, rapid breathing, flushed skin, and high fever in children. In severe cases, convulsions, swelling of the brain, coma, kidney failure, fluid in the lungs, and unstable heart function can occur.

      The treatment for salicylate poisoning involves stabilizing the patient’s airway, breathing, and circulation as needed, preventing further absorption of the poison, enhancing its elimination from the body, correcting any metabolic abnormalities, and providing supportive care. Unfortunately, there is no specific antidote available for salicylates. If a large amount of salicylate has been ingested within the past hour (more than 4.5 grams in adults or more than 2 grams in children), gastric lavage (stomach pumping) and administration of activated charcoal (50 grams) are recommended to reduce absorption and increase elimination.

      Medical investigations for salicylate poisoning should include measuring the level of salicylate in the blood, analyzing arterial blood gases, performing an electrocardiogram (ECG), checking blood glucose levels, assessing kidney function and electrolyte levels, and evaluating blood clotting. ECG abnormalities that may be present include widening of the QRS complex, AV block, and ventricular arrhythmias.

      The severity of salicylate poisoning is determined by the level of salicylate in the blood. Mild poisoning is defined as a salicylate level below 450 mg/L, moderate poisoning is between 450-700 mg/L, and severe poisoning is above 700 mg/L. In severe cases, aggressive intravenous fluid therapy is necessary to correct dehydration, and administration of 1.26% sodium bicarbonate can help eliminate the salicylate from the body. It is important to maintain a urine pH of greater than 7.5, ideally between 8.0-8.5. However, forced alkaline diuresis is no longer recommended. Life-threatening cases may require admission to the intensive care unit, intubation and ventilation, and possibly hemodialysis.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      32.8
      Seconds
  • Question 47 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Correct

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to evaluate the patient and initiate her treatment.

      Which of the following is the most suitable INITIAL treatment?

      Your Answer: Intravenous thiamine

      Explanation:

      Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a triad of symptoms, including acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional features may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, which typically affects the legs.

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      18.1
      Seconds
  • Question 48 - You are tasked with organizing a teaching session for the senior residents on...

    Incorrect

    • You are tasked with organizing a teaching session for the senior residents on head injuries & increased intracranial pressure. What is the intracranial volume of a typical adult?

      Your Answer: 450ml

      Correct Answer: 1400ml

      Explanation:

      On average, the intracranial volume in adults is around 1400ml.

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      14.6
      Seconds
  • Question 49 - A 25-year-old woman is brought in by ambulance following a car crash where...

    Incorrect

    • A 25-year-old woman is brought in by ambulance following a car crash where she was a passenger in a vehicle struck by a truck at a high velocity. She is 32 weeks pregnant.

      What is the primary cause of fetal demise in traumatic incidents during pregnancy?

      Your Answer: Placental abruption

      Correct Answer: Maternal shock

      Explanation:

      The primary reason for foetal death in trauma during pregnancy is maternal shock and maternal mortality. The second most prevalent cause of foetal death is placental abruption.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      21.1
      Seconds
  • Question 50 - A 72-year-old woman presents with severe central chest pain. An ECG is performed,...

    Incorrect

    • A 72-year-old woman presents with severe central chest pain. An ECG is performed, which shows ST elevation in the anterolateral leads. She was given aspirin and morphine upon arrival. Her observations are as follows: SaO2 99% on air, HR 89 bpm, and BP 149/87 mmHg. Upon discussion with the cardiology team, a decision is made to perform an urgent percutaneous coronary intervention (PCI).
      Which of the following medications could you also consider administering to this patient?

      Your Answer: Bisoprolol

      Correct Answer: Bivalirudin

      Explanation:

      This patient is displaying symptoms consistent with a diagnosis of an acute myocardial infarction. It is important to provide pain relief as soon as possible. One option for pain relief is GTN, which can be taken sublingually or buccally. However, if there is suspicion of an acute myocardial infarction, it is recommended to offer intravenous opioids such as morphine.

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

      For patients without a high bleeding risk who do not have coronary angiography planned within 24 hours of admission, fondaparinux should be administered. However, for patients who are likely to undergo coronary angiography within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. In cases of significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin with dose adjustment guided by clotting function monitoring can also be considered as an alternative to fondaparinux.

      Routine administration of oxygen is no longer recommended, but it is important to monitor oxygen saturation using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with an oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, with a target SpO2 range of 94-98%. For individuals with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, a target SpO2 range of 88-92% should be aimed for 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 who are undergoing percutaneous coronary intervention.

      For more information, please 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
      29.8
      Seconds
  • Question 51 - The Emergency Medicine consultant in charge of the department today asks for your...

    Incorrect

    • The Emergency Medicine consultant in charge of the department today asks for your attention to present a case of superior orbital fissure syndrome (SOFS) in a 30-year-old woman with a Le Fort II fracture of the midface after a car accident.

      Which of the following anatomical structures does NOT traverse through the superior orbital fissure?

      Your Answer: Abducens nerve

      Correct Answer: Facial vein

      Explanation:

      The superior orbital fissure is a gap in the back wall of the orbit, created by the space between the greater and lesser wings of the sphenoid bone. Several structures pass through it to enter the orbit, starting from the top and going downwards. These include the lacrimal nerve (a branch of CN V1), the frontal nerve (another branch of CN V1), the superior ophthalmic vein, the trochlear nerve (CN IV), the superior division of the oculomotor nerve (CN III), the nasociliary nerve (a branch of CN V1), the inferior division of the oculomotor nerve (CN III), the abducens nerve (CN VI), and the inferior ophthalmic vein.

      Adjacent to the superior orbital fissure, on the back wall of the orbit and towards the middle, is the optic canal. The optic nerve (CN II) exits the orbit through this canal, along with the ophthalmic artery.

      Superior orbital fissure syndrome (SOFS) is a condition characterized by a combination of symptoms and signs that occur when cranial nerves III, IV, V1, and VI are compressed or injured as they pass through the superior orbital fissure. This condition also leads to swelling and protrusion of the eye due to impaired drainage and congestion. The main causes of SOFS are trauma, tumors, and inflammation. It is important to note that CN II is not affected by this syndrome, as it follows a separate path through the optic canal.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      766.6
      Seconds
  • Question 52 - A 7 year old boy is brought to the emergency department by his...

    Incorrect

    • A 7 year old boy is brought to the emergency department by his father complaining of stomach pain. The boy has had a sore throat for 2-3 days before the stomach pain began. The patient has normal vital signs and is able to provide a clear history. During the examination, you observe a rash on his legs that consists of small raised red-purple spots that do not fade when pressure is applied. His abdomen is soft with no signs of guarding or palpable organ enlargement.

      What is the most probable diagnosis?

      Your Answer: Meningococcal septicaemia

      Correct Answer: Henoch-Schonlein purpura

      Explanation:

      Renal disease is not commonly seen as a presenting sign or symptom, but approximately a certain percentage of individuals may develop it. In the case of meningococcal septicaemia, patients usually experience acute illness along with abnormal observations and confusion. Immune thrombocytopenia (ITP) is known to cause easy bruising and nosebleeds, but it does not have the same distribution pattern as HSP and does not come with abdominal pain or joint pain. On the other hand, viral urticaria and roseola typically result in a rash that blanches.

      Further Reading:

      Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that is mediated by IgA. It is commonly seen in children following an infection, with 90% of cases occurring in children under 10 years of age. The condition is characterized by a palpable purpuric rash, abdominal pain, gastrointestinal upset, and polyarthritis. Renal involvement occurs in approximately 50% of cases, with renal impairment typically occurring within 1 day to 1 month after the onset of other symptoms. However, renal impairment is usually mild and self-limiting, although 10% of cases may have serious renal impairment at presentation and 1% may progress to end-stage kidney failure long term. Treatment for HSP involves analgesia for arthralgia, and treatment for nephropathy is generally supportive. The prognosis for HSP is usually excellent, with the condition typically resolving fully within 4 weeks, especially in children without renal involvement. However, around 1/3rd of patients may experience relapses, which can occur for several months.

    • This question is part of the following fields:

      • Nephrology
      32.1
      Seconds
  • Question 53 - A 30-year-old woman presents with a painful knee. She first noticed the pain...

    Incorrect

    • A 30-year-old woman presents with a painful knee. She first noticed the pain a few days ago and is now experiencing general malaise and a fever. Upon examination, the joint appears swollen, hot, and red. The patient is hesitant to move the knee due to the intense pain. No other joints are affected.
      What is the MOST LIKELY causative organism in this scenario?

      Your Answer: Neisseria gonorrhoea

      Correct Answer: Staphylococcus aureus

      Explanation:

      Septic arthritis in adults is most commonly caused by Staphylococcus aureus. However, Streptococcus spp. is the most common group of bacteria responsible for this condition. In the past, Haemophilus influenzae used to be a significant cause of septic arthritis, but with the introduction of vaccination programs, its occurrence has significantly decreased. Other bacteria that can lead to septic arthritis include E. Coli, Salmonella, Neisseria gonorrhoea, and Mycobacterium.

      It is important to note that viruses can also be a cause of septic arthritis. Examples of such viruses include hepatitis A, B, and C, coxsackie, adenovirus, and parvovirus. Additionally, fungi can also be responsible for septic arthritis, with Histoplasmosa and Blastomyces being notable examples.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      32.3
      Seconds
  • Question 54 - A 14 year old patient is brought into the emergency department struggling to...

    Correct

    • A 14 year old patient is brought into the emergency department struggling to breathe. Upon initial assessment, you observe tracheal deviation to the right, absence of breath sounds in the left hemithorax, and hyper-resonant percussion in the left hemithorax.

      What is the most crucial immediate intervention for this patient?

      Your Answer: Needle thoracocentesis

      Explanation:

      The key initial management for tension pneumothorax is needle thoracocentesis. This procedure is crucial as it rapidly decompresses the tension and allows for more definitive management to be implemented. It is important to note that according to ATLS guidelines, needle thoracocentesis should no longer be performed at the second intercostal space midclavicular line. Studies have shown that the fourth or fifth intercostal space midaxillary line is more successful in reaching the thoracic cavity in adult patients. Therefore, ATLS now recommends this location for needle decompression in adult patients.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

    • This question is part of the following fields:

      • Respiratory
      13.5
      Seconds
  • Question 55 - You are called into the pediatric resuscitation room to assist with a child...

    Incorrect

    • You are called into the pediatric resuscitation room to assist with a child who has arrested. The team have just started the first cycle of chest compressions and have attached monitoring. You suggest briefly pausing chest compressions to check if the rhythm is shockable.

      How long should the brief pause in chest compressions last?

      Your Answer: 5-10 seconds

      Correct Answer: ≀ 5 seconds

      Explanation:

      The duration of the pause in chest compressions should be kept short, not exceeding 5 seconds. This applies to both pausing to assess the rhythm and pausing to administer a shock if the rhythm is deemed shockable. It is important to note that a pulse check lasting less than two seconds may fail to detect a palpable pulse, particularly in individuals with a slow heart rate (bradycardia).

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Resus
      16.6
      Seconds
  • Question 56 - A 25-year-old woman has a history of unstable relationships, excessive anger, fluctuating moods,...

    Incorrect

    • A 25-year-old woman has a history of unstable relationships, excessive anger, fluctuating moods, uncertainty about her personal identity, self-harm, and impulsive behavior that causes harm.
      Which of the following is the SINGLE MOST likely diagnosis?

      Your Answer: Bipolar affective disorder

      Correct Answer: Borderline personality disorder

      Explanation:

      Borderline personality disorder is characterized by a range of clinical features. These include having unstable relationships, experiencing undue anger, and having variable moods. Individuals with this disorder often struggle with chronic boredom and may have doubts about their personal identity. They also tend to have an intolerance of being left alone and may engage in self-injury. Additionally, they exhibit impulsive behavior that can be damaging to themselves.

    • This question is part of the following fields:

      • Mental Health
      16.1
      Seconds
  • Question 57 - A 35-year-old woman with a history of sickle cell disease undergoes a blood...

    Correct

    • A 35-year-old woman with a history of sickle cell disease undergoes a blood transfusion. After one week, she experiences a slight fever and notices dark urine. Blood tests are ordered, revealing elevated bilirubin and LDH levels, as well as a positive Direct Antiglobulin Test (DAT).
      What is the most suitable course of treatment for this patient?

      Your Answer: Monitor renal function and haemoglobin

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      23.6
      Seconds
  • Question 58 - A 30-year-old patient presents to the emergency department with an inability to close...

    Incorrect

    • A 30-year-old patient presents to the emergency department with an inability to close their mouth following an accidental elbow to the jaw. The suspicion is a dislocated temporomandibular joint (TMJ). Typically, in which direction does TMJ dislocation occur?

      Your Answer: Posterior

      Correct Answer: Anterior

      Explanation:

      In most cases, TMJ dislocation occurs in an anterior and bilateral manner.

      TMJ dislocation occurs when the mandibular condyle is displaced from its normal position in the mandibular fossa of the temporal bone. The most common type of dislocation is bilateral anterior dislocation. This occurs when the mandible is dislocated forward and the masseter and pterygoid muscles spasm, locking the condyle in place.

      The temporomandibular joint is unique because it has an articular disc that separates the joint into upper and lower compartments. Dislocation can be caused by trauma, such as a direct blow to the open mouth, or by traumatic events like excessive mouth opening during yawning, laughing, shouting, or eating. It can also occur during dental work.

      Signs and symptoms of TMJ dislocation include difficulty fully opening or closing the mouth, pain or tenderness in the TMJ region, jaw pain, ear pain, difficulty chewing, and facial pain. Connective tissue disorders like Marfan’s and Ehlers-Danlos syndrome can increase the likelihood of dislocation.

      If TMJ dislocation is suspected, X-rays may be done to confirm the diagnosis. The best initial imaging technique is an orthopantomogram (OPG) or a standard mandibular series.

      Management of anterior dislocations involves reducing the dislocated mandible, which is usually done in the emergency department. Dislocations to the posterior, medial, or lateral side are usually associated with a mandibular fracture and should be referred to a maxillofacial surgeon.

      Reduction of an anterior dislocation involves applying distraction forces to the mandible. This can be done by gripping the mandible externally or intra-orally. In some cases, procedural sedation or local anesthesia may be used, and in rare cases, reduction may be done under general anesthesia.

      After reduction, a post-reduction X-ray is done to confirm adequate reduction and rule out any fractures caused by the procedure. Discharge advice includes following a soft diet for at least 48 hours, avoiding wide mouth opening for at least 2 weeks, and supporting the mouth with the hand during yawning or laughing. A Barton bandage may be used to support the mandible if the patient is unable to comply with the discharge advice. Referral to a maxillofacial surgeon as an outpatient is also recommended.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      16.9
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  • Question 59 - You are caring for a hypoxic patient in the resuscitation bay. One of...

    Correct

    • You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methemoglobinemia. What test would you employ to confirm this diagnosis?

      Your Answer: MetHb

      Explanation:

      COHb is a measure used to evaluate the presence of carbon monoxide poisoning in individuals who are in good health. hHb refers to deoxygenated haemoglobin.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Respiratory
      12.1
      Seconds
  • Question 60 - A 45-year-old woman is brought into the emergency room by an ambulance with...

    Incorrect

    • A 45-year-old woman is brought into the emergency room by an ambulance with sirens blaring after being involved in a car accident. She was hit by a truck while crossing the street and is suspected to have a pelvic injury. Her blood pressure is unstable, and the hospital has initiated the massive transfusion protocol. You decide to administer tranexamic acid as well.
      What is the recommended time frame for administering tranexamic acid in a trauma situation?

      Your Answer: Within 1 hour

      Correct Answer: Within 3 hours

      Explanation:

      ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

      Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

    • This question is part of the following fields:

      • Trauma
      17
      Seconds
  • Question 61 - A 68-year-old woman with a history of chronic anemia receives a blood transfusion...

    Correct

    • A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment protocol. She has a known history of heart failure, for which she takes metoprolol and hydrochlorothiazide. She becomes short of breath, volume overloaded, and edematous during the transfusion.
      Which of the following tests will be most useful in confirming the diagnosis?

      Your Answer: BNP

      Explanation:

      Transfusion-associated circulatory overload (TACO) is a reaction that occurs when a large volume of blood is infused rapidly. It is the second leading cause of deaths related to transfusions, accounting for about 20% of all fatalities.

      TACO typically happens in patients with limited cardiac reserve or chronic anemia who receive a fast blood transfusion. Elderly individuals, infants, and severely anemic patients are particularly vulnerable.

      The common signs of TACO include acute respiratory distress, rapid heartbeat, high blood pressure, the appearance of acute or worsening fluid accumulation in the lungs on a chest X-ray, and evidence of excessive fluid retention.

      The B-type natriuretic peptide (BNP) can be a helpful diagnostic tool for TACO. Usually, the BNP level is elevated to at least 1.5 times the baseline before the transfusion.

      In many cases, simply slowing down the rate of transfusion, positioning the patient upright, and administering diuretics will be sufficient. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.

    • This question is part of the following fields:

      • Haematology
      23.7
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  • Question 62 - You admit a 65-year-old woman to the clinical decision unit (CDU) following a...

    Incorrect

    • You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has mild-to-moderate Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
      Which ONE of the following medications can be used as a first-line drug in the management of mild-to-moderate Alzheimer’s disease?

      Your Answer: Memantine

      Correct Answer: Rivastigmine

      Explanation:

      According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.

      On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      32.3
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  • Question 63 - A 42-year-old woman is brought in by ambulance following a high-speed car accident....

    Correct

    • A 42-year-old woman is brought in by ambulance following a high-speed car accident. There was a prolonged extraction at the scene, and a full trauma call is made. She is disoriented and slightly restless. Her vital signs are as follows: heart rate 125, blood pressure 83/45, oxygen saturation 98% on high-flow oxygen, respiratory rate 31, temperature 36.1°C. Her capillary refill time is 5 seconds, and her extremities appear pale and cool to the touch. Her cervical spine is immobilized with triple precautions. The airway is clear, and her chest examination is normal. Two large-bore needles have been inserted in her antecubital fossa, and a complete set of blood tests, including a request for a cross-match, has been sent to the laboratory. She experiences significant tenderness in the suprapubic area upon abdominal palpation, and noticeable bruising is evident around her pelvis. A pelvic X-ray reveals a vertical shear type pelvic fracture.
      What approximate percentage of her circulatory volume has she lost?

      Your Answer: 30-40%

      Explanation:

      This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.

      Hemorrhage can be categorized into four different classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.

      In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.

      In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure remains normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.

      The patient in this case is in class III hemorrhage, with a blood loss of 1500-2000 mL or 30-40% of the blood volume. The pulse rate is elevated, ranging from 120-140 beats per minute, and the systolic blood pressure is decreased. The pulse pressure is also decreased, and the respiratory rate is elevated to 30-40 breaths per minute. The urine output decreases significantly to 5-15 mL per hour, and the patient may experience anxiety and confusion.

      Class IV hemorrhage represents the most severe level of blood loss, with a loss of over 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is decreased, and the respiratory rate is over 40 breaths per minute. The urine output becomes negligible, and the patient may become confused and lethargic.

    • This question is part of the following fields:

      • Trauma
      61.1
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  • Question 64 - A 42-year-old woman is noted to have 'Auer rods' on her peripheral blood...

    Incorrect

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

      Your Answer: Post splenectomy

      Correct Answer: Acute myeloid leukaemia

      Explanation:

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

    • This question is part of the following fields:

      • Haematology
      14.2
      Seconds
  • Question 65 - You are requested to evaluate an older adult patient who has been transported...

    Incorrect

    • You are requested to evaluate an older adult patient who has been transported to the emergency department by ambulance after experiencing a fall overnight. What proportion of falls in the elderly population lead to significant lacerations, traumatic brain injuries, or fractures?

      Your Answer: 25%

      Correct Answer: 50%

      Explanation:

      According to NICE 2019, a significant number of falls in older individuals lead to severe injuries such as major lacerations, traumatic brain injuries, or fractures. Therefore, it is crucial for emergency department clinicians to approach patients over the age of 65 who come in with falls with a heightened level of suspicion.

      Further Reading:

      Falls are a common occurrence in the elderly population, with a significant number of individuals over the age of 65 experiencing at least one fall per year. These falls are often the result of various risk factors, including impaired balance, muscle weakness, visual impairment, cognitive impairment, depression, alcohol misuse, polypharmacy, and environmental hazards. The more risk factors a person has, the higher their risk of falling.

      Falls can have serious complications, particularly in older individuals. They are a leading cause of injury, injury-related disability, and death in this population. Approximately 50% of falls in the elderly result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people living in the community lead to hospitalization or fractures. Hip fractures, in particular, are commonly caused by falls and have a high mortality rate within one year.

      Complications of falls include fractures, soft tissue injuries, fragility fractures, distress, pain, loss of self-confidence, reduced quality of life, loss of independence, fear of falls and activity avoidance, social isolation, increasing frailty, functional decline, depression, and institutionalization. Additionally, individuals who remain on the floor for more than one hour after a fall are at risk of dehydration, pressure sores, pneumonia, hypothermia, and rhabdomyolysis.

      Assessing falls requires a comprehensive history, including the course of events leading up to the fall, any pre-fall symptoms, and details about the fall itself. A thorough examination is also necessary, including an assessment of injuries, neurological and cardiovascular function, tests for underlying causes, vision assessment, and medication review. Home hazard assessments and frailty assessments are also important components of the assessment process.

      Determining the frailty of older patients is crucial in deciding if they can be safely discharged and what level of care they require. The clinical Frailty Scale (CFS or Rockwood score) is commonly used for this purpose. It helps healthcare professionals evaluate the overall frailty of a patient and make appropriate care decisions.

      In summary, falls are a significant concern in the elderly population, with multiple risk factors contributing to their occurrence. These falls can lead to serious complications and have a negative impact on an individual’s quality of life. Assessing falls requires a comprehensive approach, including a thorough history, examination, and consideration of frailty.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      45.2
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  • Question 66 - A 45-year-old woman with no permanent residence sustains a head injury after a...

    Correct

    • A 45-year-old woman with no permanent residence sustains a head injury after a fall. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.

      During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.

      Which medication has caused the onset of this condition?

      Your Answer: Wernicke’s encephalopathy

      Explanation:

      This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.

      Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.

      This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.

      Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.

    • This question is part of the following fields:

      • Neurology
      55.9
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  • Question 67 - A 65 year old male is brought to the emergency department by a...

    Correct

    • 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: 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
      15
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  • Question 68 - A 5-year-old boy has had multiple observed instances of momentary pauses that lasted...

    Correct

    • A 5-year-old boy has had multiple observed instances of momentary pauses that lasted only a few seconds each. He ceases his activities and gazes emptily during these occurrences. The results of his brain scan indicated no abnormalities.
      What kind of seizure has he encountered?

      Your Answer: Absence seizure

      Explanation:

      This patient has been experiencing absence seizures, which are a form of primary generalized epilepsy that is frequently observed in children.

      The defining characteristic of absence seizures is a sudden and immediate loss of consciousness, causing a disruption in ongoing activities. During these episodes, individuals may exhibit a vacant stare and occasionally a brief upward movement of the eyes.

      While an EEG cannot definitively confirm or rule out an epilepsy diagnosis, it does provide valuable information in the diagnostic process. In the case of absence seizures, EEG results typically reveal generalized spike-and-slow wave complexes occurring at a frequency of 3-4 Hz.

    • This question is part of the following fields:

      • Neurology
      22.3
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  • Question 69 - The ‘Smith guidelines’ are used to clarify the legal position of treating teenagers...

    Correct

    • The ‘Smith guidelines’ are used to clarify the legal position of treating teenagers under the age of 18 without parental consent.

      Your Answer: Unless the treatment is given the mental health of the patient is likely to suffer

      Explanation:

      The Fraser guidelines pertain to the guidelines established by Lord Fraser during the Gillick case in 1985. These guidelines specifically address the provision of contraceptive advice to individuals under the age of 16. According to the Fraser guidelines, a doctor may proceed with providing advice and treatment if they are satisfied with the following criteria:

      1. The individual (despite being under 16 years old) possesses a sufficient understanding of the advice being given.
      2. The doctor is unable to convince the individual to inform their parents or allow the doctor to inform the parents about seeking contraceptive advice.
      3. The individual is likely to engage in sexual intercourse, regardless of whether they receive contraceptive treatment.
      4. Without contraceptive advice or treatment, the individual’s physical and/or mental health is likely to deteriorate.
      5. The doctor deems it in the individual’s best interests to provide contraceptive advice, treatment, or both without parental consent.

      In summary, the Fraser guidelines outline the conditions under which a doctor can offer contraceptive advice to individuals under 16 years old, ensuring their well-being and best interests are taken into account.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      11.8
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  • Question 70 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Incorrect

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After conducting a clinical evaluation, you determine that he has community-acquired pneumonia. He has no significant medical history and no reported drug allergies.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer: Co-amoxiclav

      Correct Answer: Amoxicillin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

    • This question is part of the following fields:

      • Respiratory
      19
      Seconds
  • Question 71 - A child is brought in by their family with noticeable tremors, muscle contractions,...

    Correct

    • A child is brought in by their family with noticeable tremors, muscle contractions, muscle spasms, and slow movements. They have a significant history of mental health issues and are currently taking multiple medications.
      Which of the following medications is most likely causing these side effects?

      Your Answer: Haloperidol

      Explanation:

      Extrapyramidal side effects refer to drug-induced movements that encompass acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome. These side effects occur due to the blockade or depletion of dopamine in the basal ganglia, leading to a lack of dopamine that often resembles idiopathic disorders of the extrapyramidal system.

      The primary culprits behind extrapyramidal side effects are the first-generation antipsychotics, which act as potent antagonists of the dopamine D2 receptor. Among these antipsychotics, haloperidol and fluphenazine are the two drugs most commonly associated with extrapyramidal side effects. On the other hand, second-generation antipsychotics like olanzapine have lower rates of adverse effects on the extrapyramidal system compared to their first-generation counterparts.

      While less frequently, other medications can also contribute to extrapyramidal symptoms. These include certain antidepressants, lithium, various anticonvulsants, antiemetics, and, in rare cases, oral contraceptive agents.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      17.5
      Seconds
  • Question 72 - A 32 year old male attends the emergency department following a fall in...

    Incorrect

    • A 32 year old male attends the emergency department following a fall in which he sustained a minor head injury. You observe that the patient is a Ukrainian refugee and has recently arrived in the UK. During the assessment, you notice a significant goitre. Upon checking his thyroid function, it confirms hypothyroidism. What is the most probable reason for his hypothyroidism?

      Your Answer: Hashimoto's thyroiditis

      Correct Answer: Iodine deficiency

      Explanation:

      Iodine deficiency is a widespread issue globally and is the leading cause of hypothyroidism worldwide. It is particularly prevalent in numerous African countries, as well as in developed nations such as Norway, Germany, Russia, and Ukraine. In the UK, however, autoimmune thyroiditis is the most common cause of hypothyroidism.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 73 - A 52-year-old individual is brought into the emergency department after being discovered unresponsive...

    Correct

    • A 52-year-old individual is brought into the emergency department after being discovered unresponsive on a park bench. The patient is a familiar face to the department, having had numerous previous visits related to alcohol abuse. Upon reviewing the patient's medical history, you observe a diagnosis of liver cirrhosis, which prompts a conversation with your consultant about the underlying mechanisms by which alcohol affects the liver. In terms of alcohol metabolism by the liver, what is the resulting product of acetaldehyde oxidation?

      Your Answer: Acetate

      Explanation:

      The process of alcohol oxidation involves two steps. Firstly, alcohol is converted into acetaldehyde, and then acetaldehyde is further converted into acetate. During the oxidation of acetaldehyde, reactive oxygen species are produced along with acetate. This oxidation process is facilitated by three enzyme systems: catalase, CYPE21, and alcohol dehydrogenase. NAD+ acts as a coenzyme for alcohol dehydrogenase during this entire process.

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      50.2
      Seconds
  • Question 74 - Your Pediatric Department has implemented a protocol for conducting landmark guided fascia iliaca...

    Correct

    • Your Pediatric Department has implemented a protocol for conducting landmark guided fascia iliaca compartment blocks (FICB) for pediatric patients with a fractured femoral neck.
      Which of the following two landmarks should be utilized?

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

      Explanation:

      The fascia iliaca compartment is a space within the body that has specific boundaries. It is located at the front of the hip and is surrounded by various muscles and structures. The anterior limit of this compartment is formed by the posterior surface of the fascia iliaca, which covers the iliacus muscle. Additionally, the medial reflection of this fascia covers every surface of the psoas major muscle. On the posterior side, the limit is formed by the anterior surface of the iliacus muscle and the psoas major muscle. The medial boundary is the vertebral column, while the cranially lateral boundary is the inner lip of the iliac crest. This compartment is also continuous with the space between the quadratus lumborum muscle and its fascia in a cranio-medial direction.

      The fascia iliaca compartment is important because it allows for the deposition of local anesthetic in sufficient volumes. This can be achieved through a straightforward injection, which targets the femoral and lateral femoral cutaneous nerves. These nerves supply sensation to the medial, anterior, and lateral thigh. Occasionally, the obturator nerve is also blocked, although this can vary from person to person.

      To perform a fascia iliaca compartment block (FICB), specific landmarks need to be identified. An imaginary line is drawn between the anterior superior iliac spine (ASIS) and the pubic tubercle. This line is then divided into thirds. The injection entry point is marked 1 cm caudal (inferior) from the junction of the lateral and middle third.

      However, there are certain contraindications to performing a FICB. These include patient refusal, anticoagulation or bleeding disorders, allergy to local anesthetics, previous femoral bypass surgery, and infection or inflammation over the injection site.

      As with any medical procedure, there are potential complications associated with a FICB. These can include intravascular injection, local anesthetic toxicity, allergy to the local anesthetic, temporary or permanent nerve damage, infection, and block failure. It is important for healthcare professionals to be aware of these risks and take appropriate precautions when performing a FICB.

    • This question is part of the following fields:

      • Pain & Sedation
      24.1
      Seconds
  • Question 75 - A 28 year old male presents to the emergency department after experiencing 4...

    Incorrect

    • 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: 8 hours

      Correct 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
      24.9
      Seconds
  • Question 76 - A patient with a previous history of painless rectal bleeding episodes is found...

    Incorrect

    • A patient with a previous history of painless rectal bleeding episodes is found to have a Meckel's diverticulum during a colonoscopy.

      Which ONE statement about Meckel's diverticulum is accurate?

      Your Answer: The majority present with diverticulitis

      Correct Answer: They receive their blood supply from the mesentery of the ileum

      Explanation:

      A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.

      When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.

      Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.

      These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.

      To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
      – It is found in 2% of the population.
      – It is more common in men, with a ratio of 2:1 compared to women.
      – It is located 2 feet away from the ileocaecal valve.
      – It is approximately 2 inches long.
      – It often contains two types of abnormal tissue: gastric and pancreatic.
      – The most common age for clinical presentation is 2 years old.

    • This question is part of the following fields:

      • Surgical Emergencies
      28.6
      Seconds
  • Question 77 - A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing...

    Correct

    • A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing and appears visibly distressed. Despite his discomfort, he remains mentally alert and reports moderate levels of pain. He has been informed that he has only a few days left to live. Currently, his oxygen saturation levels are at 95% when breathing regular air, and there are no specific signs of chest abnormalities.
      What would be the most suitable course of action to alleviate his breathlessness in this situation?

      Your Answer: Oral morphine

      Explanation:

      Here are some suggestions for managing breathlessness in the final days of life, as provided by NICE:

      1. It is important to identify and treat any reversible causes of breathlessness in the dying person, such as pulmonary edema or pleural effusion.

      2. Non-pharmacological methods can be considered for managing breathlessness in someone nearing the end of life. It is not recommended to start oxygen therapy as a routine measure. Oxygen should only be offered to individuals who are known or suspected to have symptomatic hypoxemia.

      3. Breathlessness can be managed using different medications, including opioids, benzodiazepines, or a combination of both.

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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      36.1
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  • Question 78 - You are summoned to the resuscitation area to assist with a patient experiencing...

    Correct

    • You are summoned to the resuscitation area to assist with a patient experiencing status epilepticus.
      Which ONE statement about the utilization of benzodiazepines in status epilepticus is accurate?

      Your Answer: Diazepam can be given by the intravenous route

      Explanation:

      Between 60 and 80% of individuals who experience seizures will have their seizure stopped by a single dose of intravenous benzodiazepine. Benzodiazepines have a high solubility in lipids and can quickly pass through the blood-brain barrier. This is why they have a fast onset of action.

      As the initial treatment, intravenous lorazepam should be administered. If intravenous lorazepam is not accessible, intravenous diazepam can be used instead. In cases where it is not possible to establish intravenous access promptly, buccal midazolam can be utilized.

    • This question is part of the following fields:

      • Neurology
      39.2
      Seconds
  • Question 79 - A 40-year-old man presents with a sudden worsening of his asthma symptoms. His...

    Incorrect

    • A 40-year-old man presents with a sudden worsening of his asthma symptoms. His heart rate is 110 bpm, respiratory rate 30/min, and his oxygen levels are 88% on room air. He is feeling fatigued and his breathing is labored, with no audible sounds in his chest. He has already received consecutive salbutamol nebulizers, a single ipratropium bromide nebulizer, and 40 mg of prednisolone orally. The ICU outreach team has been notified and will arrive soon.
      Which of the following medications would be most appropriate to administer while waiting for the ICU outreach team to arrive?

      Your Answer: IV salbutamol

      Correct Answer: IV aminophylline

      Explanation:

      This patient exhibits signs of potentially life-threatening asthma. In adults, acute severe asthma is characterized by a peak expiratory flow (PEF) of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, and an inability to complete sentences in one breath. On the other hand, life-threatening asthma is indicated by a PEF below 33% of the best or predicted value, a blood oxygen saturation (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kPA, a normal partial pressure of carbon dioxide (PaCO2) within the range of 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, and hypotension.

      To address acute asthma in adults, the recommended drug doses include administering 5 mg of salbutamol through an oxygen-driven nebulizer, delivering 500 mcg of ipratropium bromide via an oxygen-driven nebulizer, providing 40-50 mg of prednisolone orally, administering 100 mg of hydrocortisone intravenously, and infusing 1.2-2 g of magnesium sulfate intravenously over a period of 20 minutes.

      According to the current Advanced Life Support (ALS) guidelines, it is advisable to seek senior advice before considering the use of intravenous aminophylline in cases of severe or life-threatening asthma. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by a continuous infusion of 500-700 mcg/kg/hour. To prevent toxicity, it is important to maintain serum theophylline levels below 20 mcg/ml.

      In situations where inhaled therapy is not feasible, intravenous salbutamol can be considered, with a slow administration of 250 mcg. However, it should only be used when a patient is receiving bag-mask ventilation.

      It is worth noting that there is currently no evidence supporting the use of leukotriene receptor antagonists, such as montelukast, or Heliox in the management of acute severe or life-threatening asthma.

    • This question is part of the following fields:

      • Respiratory
      30.3
      Seconds
  • Question 80 - A 35-year-old man visits the emergency department 2 days after experiencing a head...

    Incorrect

    • A 35-year-old man visits the emergency department 2 days after experiencing a head injury. The patient is worried about his excessive urination and fatigue since the injury. You suspect that he may have diabetes insipidus (DI). What is a characteristic symptom of diabetes insipidus?

      Your Answer: Hyponatraemia

      Correct Answer: Serum osmolality > 300 mOsm/kg

      Explanation:

      Diabetes insipidus is characterized by low urine osmolality and high serum osmolality. This occurs because the kidneys are unable to properly reabsorb water and sodium, resulting in diluted urine with low osmolality. On the other hand, the loss of water and sodium leads to dehydration and concentration of the serum, causing a rise in serum osmolality. Hypernatremia is a common finding in patients with diabetes insipidus. In cases of nephrogenic diabetes insipidus, hypokalemia and hypercalcemia may also be observed. Glucose levels are typically normal, unless the patient also has diabetes mellitus.

      Further Reading:

      Diabetes insipidus (DI) is a condition characterized by either a decrease in the secretion of antidiuretic hormone (cranial DI) or insensitivity to antidiuretic hormone (nephrogenic DI). Antidiuretic hormone, also known as arginine vasopressin, is produced in the hypothalamus and released from the posterior pituitary. The typical biochemical disturbances seen in DI include elevated plasma osmolality, low urine osmolality, polyuria, and hypernatraemia.

      Cranial DI can be caused by various factors such as head injury, CNS infections, pituitary tumors, and pituitary surgery. Nephrogenic DI, on the other hand, can be genetic or result from electrolyte disturbances or the use of certain drugs. Symptoms of DI include polyuria, polydipsia, nocturia, signs of dehydration, and in children, irritability, failure to thrive, and fatigue.

      To diagnose DI, a 24-hour urine collection is done to confirm polyuria, and U&Es will typically show hypernatraemia. High plasma osmolality with low urine osmolality is also observed. Imaging studies such as MRI of the pituitary, hypothalamus, and surrounding tissues may be done, as well as a fluid deprivation test to evaluate the response to desmopressin.

      Management of cranial DI involves supplementation with desmopressin, a synthetic form of arginine vasopressin. However, hyponatraemia is a common side effect that needs to be monitored. In nephrogenic DI, desmopressin supplementation is usually not effective, and management focuses on ensuring adequate fluid intake to offset water loss and monitoring electrolyte levels. Causative drugs need to be stopped, and there is a risk of developing complications such as hydroureteronephrosis and an overdistended bladder.

    • This question is part of the following fields:

      • Endocrinology
      24.7
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  • Question 81 - A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated...

    Incorrect

    • A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
      Which of the following conditions is NOT linked to Crohn's disease?

      Your Answer: Smoking

      Correct Answer: Primary sclerosing cholangitis

      Explanation:

      Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing inflammation and blockage over time. This leads to recurrent episodes of cholangitis and progressive scarring of the bile ducts. Ultimately, PSC can result in liver cirrhosis, liver failure, and even hepatocellular carcinoma. It is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis. However, there is no association between PSC and Crohn’s disease.

      On the other hand, Crohn’s disease has its own set of recognized associations. For instance, there is an increased incidence of Crohn’s disease among smokers, with approximately 50-60% of Crohn’s patients being smokers. Other associations include the presence of aphthous ulcers, uveitis and episcleritis (eye inflammation), seronegative spondyloarthropathies (inflammatory joint diseases), erythema nodosum (painful skin nodules), pyoderma gangrenosum (skin ulceration), finger clubbing, autoimmune hemolytic anemia, cholelithiasis (gallstones), and osteoporosis.

      It is important to note the distinct associations and characteristics of these two conditions, as they have different implications for diagnosis, treatment, and management.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      22
      Seconds
  • Question 82 - A 45-year-old woman develops hypothyroidism secondary to the administration of a medication for...

    Incorrect

    • A 45-year-old woman develops hypothyroidism secondary to the administration of a medication for a thyroid condition.

      Which of the following medications is most likely to be responsible?

      Your Answer: Flecainide

      Correct Answer: Amiodarone

      Explanation:

      Amiodarone has a chemical structure that is similar to thyroxine and has the ability to bind to the nuclear thyroid receptor. This medication has the potential to cause both hypothyroidism and hyperthyroidism, although hypothyroidism is more commonly observed, affecting around 5-10% of patients.

      There are several side effects associated with the use of amiodarone. These include the formation of microdeposits in the cornea, increased sensitivity to sunlight resulting in photosensitivity, feelings of nausea, disturbances in sleep patterns, and the development of either hyperthyroidism or hypothyroidism. In addition, there have been reported cases of acute hepatitis and jaundice, peripheral neuropathy, lung fibrosis, and QT prolongation.

      It is important to be aware of these potential side effects when considering the use of amiodarone as a treatment option. Regular monitoring and close medical supervision are necessary to detect and manage any adverse reactions that may occur.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      55
      Seconds
  • Question 83 - A 6-year-old girl presents very sick with severe acute asthma. She has received...

    Correct

    • A 6-year-old girl presents very sick with severe acute asthma. She has received one dose of salbutamol through a spacer device, 20 mg of oral prednisolone, and a single dose of nebulized salbutamol and ipratropium bromide combined. She remains sick and has oxygen saturations on air of 90%. Her heart rate is 142 bpm, and her respiratory rate is 40/minute. Examination of her chest reveals widespread wheezing but good air entry.

      What is the most appropriate next step in her management?

      Your Answer: Further salbutamol nebuliser with 150 mg magnesium sulphate added

      Explanation:

      The BTS guidelines for managing acute asthma in children over the age of 2 recommend the following approaches:

      Bronchodilator therapy is the first-line treatment for acute asthma. Inhaled ÎČ agonists are preferred, and a pmDI + spacer is the recommended option for children with mild to moderate asthma. It is important to individualize drug dosing based on the severity of the condition and adjust it according to the patient’s response. If initial ÎČ agonist treatment does not alleviate symptoms, ipratropium bromide can be added to the nebulized ÎČ2 agonist solution. In cases where children with a short duration of acute severe asthma symptoms have an oxygen saturation level below 92%, it is advisable to consider adding 150 mg of magnesium sulfate to each nebulized salbutamol and ipratropium within the first hour.

      Long-acting ÎČ2 agonists should be discontinued if short-acting ÎČ2 agonists are required more frequently than every four hours.

      Steroid therapy should be initiated early in the treatment of acute asthma attacks. For children aged 2-5 years, a dose of 20 mg prednisolone is recommended, while children over the age of 5 should receive a dose of 30-40 mg. Children already on maintenance steroid tablets should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the initial dose of prednisolone, the dose should be repeated. In cases where a child is unable to retain orally ingested medication, intravenous steroids should be considered. Typically, treatment with oral steroids for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering is not necessary unless the course of steroids exceeds 14 days.

      In cases where initial inhaled therapy does not yield a response in severe asthma attacks, the early addition of a single bolus dose of intravenous salbutamol (15 micrograms/kg over 10 minutes) should be considered. Aminophylline is not recommended for children with mild to moderate acute asthma, but it may be considered for those with severe or life-threatening asthma that is unresponsive to maximum doses of bronchodilators and steroids. The use of IV magnesium sulfate as a treatment for acute asthma in children is considered safe, although its role in management is not yet fully established.

    • This question is part of the following fields:

      • Respiratory
      27.9
      Seconds
  • Question 84 - You are resuscitating a 68-year-old patient with suspected sepsis and your attending physician...

    Correct

    • You are resuscitating a 68-year-old patient with suspected sepsis and your attending physician requests you perform a central line insertion. You discuss the most appropriate approach for the central line. Which approach carries the highest risk of infection?

      Your Answer: Femoral

      Explanation:

      The risk of infection is highest with femoral central lines.

      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
      69.8
      Seconds
  • Question 85 - A 25 year old is brought into the emergency department after being found...

    Correct

    • A 25 year old is brought into the emergency department after being found unresponsive in a park. It is believed the patient had been drinking alcohol at a nearby bar and decided to walk home in the freezing weather. The patient's temperature is recorded as 27.8ÂșC. What grade of hypothermia is this?

      Your Answer: Severe hypothermia

      Explanation:

      Severe hypothermia is defined as having a core body temperature below 28ÂșC. The Royal College of Emergency Medicine (RCEM) also uses the term profound hypothermia to describe individuals with a core temperature below 20ÂșC.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      23.3
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  • Question 86 - A 30-year-old woman who is being treated for a urinary tract infection comes...

    Incorrect

    • 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: Co-amoxiclav

      Correct 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
      64.8
      Seconds
  • Question 87 - You evaluate a 32-year-old man with a previous history of intravenous drug use....

    Incorrect

    • You evaluate a 32-year-old man with a previous history of intravenous drug use. He acknowledges sharing needles in the past. Currently, he presents with symptoms resembling the flu and a skin rash. You suspect that he might be going through an HIV seroconversion illness.
      Choose from the following options the test that can provide the most accurate diagnosis of HIV during this stage.

      Your Answer: ELISA antibody test

      Correct Answer: p24 antigen test

      Explanation:

      ELISA and other antibody tests are highly sensitive methods for detecting the presence of HIV. However, they cannot be used in the early stages of the disease. There is usually a window period of 6-12 weeks before antibodies are produced, and these tests will yield negative results during a seroconversion illness.

      The p24 antigen, which is the viral protein that forms the majority of the HIV core, is present in high concentrations in the first few weeks after infection. Therefore, the p24 antigen test is a valuable tool for diagnosing very early infections, such as those occurring during a seroconversion illness.

      During the early stages of HIV infection, CD4 and CD8 counts are typically within the normal range and cannot be used for diagnosis in such cases.

      The ‘rapid HIV test’ is an antibody test for HIV. Consequently, it will also yield negative results during the early ‘window period’. This test is referred to as ‘rapid’ because it can detect antibodies in blood or saliva much faster than other antibody tests, with results often available within 20 minutes.

    • This question is part of the following fields:

      • Infectious Diseases
      32.2
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  • Question 88 - A 72 year old male presents to the emergency department with a painful...

    Incorrect

    • A 72 year old male presents to the emergency department with a painful swollen right arm that has developed over the past 24 hours. On examination there is erythema over most of the upper arm and forearm on the right side which is tender and hot to touch. The patient's observations are shown below:

      Blood pressure 130/90 mmHg
      Pulse 100 bpm
      Respiration rate 18 bpm
      Temperature 38.2ÂșC

      What is the most suitable course of action?

      Your Answer: Discharge with oral antibiotics

      Correct Answer: Admit for IV antibiotic therapy

      Explanation:

      Patients who have Eron class III or IV cellulitis should be hospitalized and treated with intravenous antibiotics. In this case, the patient is experiencing cellulitis along with symptoms of significant systemic distress, such as rapid heart rate and breathing. This places the patient in the Eron Class III category, which necessitates admission for intravenous antibiotic therapy.

      Further Reading:

      Cellulitis is an inflammation of the skin and subcutaneous tissues caused by an infection, usually by Streptococcus pyogenes or Staphylococcus aureus. It commonly occurs on the shins and is characterized by symptoms such as erythema, pain, swelling, and heat. In some cases, there may also be systemic symptoms like fever and malaise.

      The NICE Clinical Knowledge Summaries recommend using the Eron classification to determine the appropriate management of cellulitis. Class I cellulitis refers to cases without signs of systemic toxicity or uncontrolled comorbidities. Class II cellulitis involves either systemic illness or the presence of a co-morbidity that may complicate or delay the resolution of the infection. Class III cellulitis is characterized by significant systemic upset or limb-threatening infection due to vascular compromise. Class IV cellulitis involves sepsis syndrome or a severe life-threatening infection like necrotizing fasciitis.

      According to the guidelines, patients with Eron Class III or Class IV cellulitis should be admitted for intravenous antibiotics. This also applies to patients with severe or rapidly deteriorating cellulitis, very young or frail individuals, immunocompromised patients, those with significant lymphedema, and those with facial or periorbital cellulitis (unless very mild). Patients with Eron Class II cellulitis may not require admission if the necessary facilities and expertise are available in the community to administer intravenous antibiotics and monitor the patient.

      The recommended first-line treatment for mild to moderate cellulitis is flucloxacillin. For patients allergic to penicillin, clarithromycin or clindamycin is recommended. In cases where patients have failed to respond to flucloxacillin, local protocols may suggest the use of oral clindamycin. Severe cellulitis should be treated with intravenous benzylpenicillin and flucloxacillin.

      Overall, the management of cellulitis depends on the severity of the infection and the presence of any systemic symptoms or complications. Prompt treatment with appropriate antibiotics is crucial to prevent further complications and promote healing.

    • This question is part of the following fields:

      • Dermatology
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  • Question 89 - A 82 year old woman is brought into the emergency department by her...

    Correct

    • A 82 year old woman is brought into the emergency department by her two daughters. They are worried as the patient has become more disoriented and restless over the past two nights and has started shouting out. The patient's daughters inform you that the patient has limited mobility, relying on a wheelchair except for very short distances, but typically maintains normal awareness. When attempting to gather a medical history, the patient angrily tells you to 'go away' and repeatedly asks her daughters 'where am I?'

      Your Answer: 1 mg haloperidol by intramuscular injection

      Explanation:

      In cases of delirium with challenging behavior, short-term low-dose haloperidol is typically the preferred medication. This patient is likely experiencing delirium due to a urinary tract infection. If the patient’s behavior becomes aggressive or poses a risk to themselves or others, pharmacological intervention may be necessary if non-verbal and verbal de-escalation techniques are ineffective or inappropriate. It is important to note that antipsychotics should be avoided in patients with Parkinson’s disease. Low-dose haloperidol can be administered orally or through an intramuscular injection. However, if the patient refuses oral medication, alternative methods may need to be considered.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
      46.3
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  • Question 90 - A 75-year-old man is brought to the resuscitation area of your Emergency Department...

    Correct

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

      Your Answer: Addisonian crisis

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      43.7
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  • Question 91 - A 40-year-old man comes in with pain in his right testicle. He has...

    Incorrect

    • A 40-year-old man comes in with pain in his right testicle. He has observed that it begins to ache around midday and becomes most severe by the end of the day. He has never fathered any children. He is in good overall health and has no record of experiencing nausea, vomiting, or fever.
      What is the MOST PROBABLE single diagnosis?

      Your Answer: Orchitis

      Correct Answer: Varicocele

      Explanation:

      A Varicocele is a condition characterized by the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more commonly found in the left testis than in the right and may be associated with infertility. The increased temperature caused by the varicosities is believed to be the reason for this. Symptoms include a dull ache in the testis, which tends to worsen after exercise or towards the end of the day. The presence of Varicocele can often be observed during a standing examination. Treatment usually involves conservative measures, although surgery may be necessary in severe cases.

      A hydrocoele can occur at any age and is characterized by the accumulation of fluid in the tunica vaginalis. It presents as swelling in the scrotum, which can be palpated above. The surface of the hydrocoele is smooth and it can be transilluminated. The testis is contained within the swelling and cannot be felt separately. Primary or secondary causes can lead to the development of a hydrocoele. In adults, an ultrasound is typically performed to rule out secondary causes, such as an underlying tumor. Conservative management is often sufficient unless the hydrocoele is large.

      Testicular cancer is the most common cancer affecting men between the ages of 20 and 34. Recent campaigns have emphasized the importance of self-examination for early detection. Risk factors include undescended testes, which increase the risk by 10 times if bilateral. A previous history of testicular cancer carries a 4% risk of developing a second cancer. The usual presentation is a painless lump in the testis, which can also manifest as a secondary hydrocoele. Approximately 60% of cases are seminomas, which are slow-growing and typically confined to the testis at the time of diagnosis. Stage 1 seminomas have a 98% 5-year survival rate. Teratomas, which can grow more rapidly, account for 40% of cases and can occur alongside seminomas. Mixed type tumors are treated as teratomas due to their higher aggressiveness. Surgical intervention, with or without chemotherapy and radiotherapy, is the primary treatment approach.

      Epididymo-orchitis refers to inflammation of the testis and epididymis caused by an infection. The most common viral agent is mumps, while gonococci and coliforms are the most common bacterial agent.

    • This question is part of the following fields:

      • Urology
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  • Question 92 - A 25-year-old woman with a previous history of depression is admitted to the...

    Incorrect

    • A 25-year-old woman with a previous history of depression is admitted to the emergency department following an overdose of amitriptyline tablets. The patient displays notable signs of toxicity, prompting the administration of intravenous sodium bicarbonate. What is the objective of this treatment?

      Your Answer: Serum pH 7.35 to 7.45

      Correct Answer: Serum pH 7.45 to 7.55

      Explanation:

      Sodium bicarbonate is used to treat severe TCA toxicity by reducing the risk of seizures and arrhythmia. The goal is to increase the serum pH to a range of 7.45 to 7.55 through alkalinisation.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 93 - You are part of the team working on a child with severe burns....

    Incorrect

    • You are part of the team working on a child with severe burns. The child has a suspected inhalation injury and needs to be intubated before being transferred to the local burns unit. During direct laryngoscopy, which classification system is used to evaluate the glottic opening?

      Your Answer: Mallampati score

      Correct Answer: Cormack and Lehane classification

      Explanation:

      The tracheal opening can be classified using the Cormack-Lehane grading system. This system categorizes the views obtained through direct laryngoscopy based on the structures that are visible. More information about this classification system can be found in the notes provided below.

      Further Reading:

      A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.

      Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.

      If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.

      Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.

    • This question is part of the following fields:

      • Basic Anaesthetics
      21.7
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  • Question 94 - A 35 year old is brought to the emergency room after a car...

    Correct

    • A 35 year old is brought to the emergency room after a car accident. He has a left sided mid-shaft femoral fracture and is experiencing abdominal pain. He appears restless. The patient's vital signs are as follows:

      Blood pressure: 112/94 mmHg
      Pulse rate: 102 bpm
      Respiration rate: 21 rpm
      SpO2: 97% on room air
      Temperature: 36 ÂșC

      Which of the following additional parameters would be most helpful in monitoring this patient?

      Your Answer: Urine output

      Explanation:

      Shock is a condition characterized by inadequate tissue perfusion due to circulatory insufficiency. It can be caused by fluid loss or redistribution, as well as impaired cardiac output. The main causes of shock include haemorrhage, diarrhoea and vomiting, burns, diuresis, sepsis, neurogenic shock, anaphylaxis, massive pulmonary embolism, tension pneumothorax, cardiac tamponade, myocardial infarction, and myocarditis.

      One common cause of shock is haemorrhage, which is frequently encountered in the emergency department. Haemorrhagic shock can be classified into different types based on the amount of blood loss. Type 1 haemorrhagic shock involves a blood loss of 15% or less, with less than 750 ml of blood loss. Patients with type 1 shock may have normal blood pressure and heart rate, with a respiratory rate of 12 to 20 breaths per minute.

      Type 2 haemorrhagic shock involves a blood loss of 15 to 30%, with 750 to 1500 ml of blood loss. Patients with type 2 shock may have a pulse rate of 100 to 120 beats per minute and a respiratory rate of 20 to 30 breaths per minute. Blood pressure is typically normal in type 2 shock.

      Type 3 haemorrhagic shock involves a blood loss of 30 to 40%, with 1.5 to 2 litres of blood loss. Patients with type 3 shock may have a pulse rate of 120 to 140 beats per minute and a respiratory rate of more than 30 breaths per minute. Urine output is decreased to 5-15 mls per hour.

      Type 4 haemorrhagic shock involves a blood loss of more than 40%, with more than 2 litres of blood loss. Patients with type 4 shock may have a pulse rate of more than 140 beats per minute and a respiratory rate of more than 35 breaths per minute. They may also be drowsy, confused, and possibly experience loss of consciousness. Urine output may be minimal or absent.

      In summary, shock is a condition characterized by inadequate tissue perfusion. Haemorrhage is a common cause of shock, and it can be classified into different types based on the amount of blood loss. Prompt recognition and management of shock are crucial in order to prevent further complications and improve patient outcomes

    • This question is part of the following fields:

      • Trauma
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  • Question 95 - A 65 year old female is brought into the hospital after experiencing a...

    Correct

    • A 65 year old female is brought into the hospital after experiencing a cardiac arrest at the nearby soccer field where she was watching a game. The patient was promptly assessed by the medical team at the field and received a shock from an automated defibrillator device, leading to a return of spontaneous circulation.

      Your consultant informs you that the objective now is to minimize the severity of the post-cardiac arrest syndrome. Which of the following is NOT one of the four elements of the post-cardiac arrest syndrome?

      Your Answer: Post-cardiac arrest renal dysfunction

      Explanation:

      The post-cardiac arrest syndrome consists of four components. The first component is post-cardiac arrest brain injury, which refers to any damage or impairment to the brain that occurs after a cardiac arrest. The second component is post-cardiac arrest myocardial dysfunction, which is a condition where the heart muscle does not function properly after a cardiac arrest.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Resus
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  • Question 96 - 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
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  • Question 97 - 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 category of medication that has been proven to improve the passage of kidney stones in cases of renal colic?

      Your Answer: Beta-agonists

      Correct Answer: Calcium channel blockers

      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
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  • Question 98 - 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: Dementia with Lewy Bodies

      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
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  • Question 99 - A 4 year old child is brought to the emergency department by worried...

    Correct

    • A 4 year old child is brought to the emergency department by worried parents. The parents inform you that the patient had a slight fever and a runny nose for 2 days before they observed a barking cough. What would be the most suitable course of treatment?

      Your Answer: Oral dexamethasone

      Explanation:

      Corticosteroids are the primary treatment for croup, a condition characterized by a barking cough in infants. To address this, oral dexamethasone is administered at a dosage of 0.15mg/kg. In cases of severe croup, nebulized adrenaline is utilized.

      Further Reading:

      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
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  • Question 100 - A 38 year old is participating in a charity mountain trek up Mount...

    Incorrect

    • A 38 year old is participating in a charity mountain trek up Mount Kilimanjaro but falls ill at an elevation of 3800m. What clinical feature helps differentiate high altitude cerebral edema from acute mountain sickness?

      Your Answer: Vomiting

      Correct Answer: Ataxia

      Explanation:

      High Altitude Cerebral Edema (HACE) is a condition that develops from acute mountain sickness (AMS). Ataxia, which refers to a lack of coordination, is the primary early indication of HACE. The mentioned symptoms are typical characteristics of AMS.

      Further Reading:

      High Altitude Illnesses

      Altitude & Hypoxia:
      – As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
      – Hypoxia occurs at altitude due to decreased inspired oxygen.
      – At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.

      Acute Mountain Sickness (AMS):
      – AMS is a clinical syndrome caused by hypoxia at altitude.
      – Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
      – Symptoms usually occur after 6-12 hours above 2500m.
      – Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
      – The Lake Louise AMS score is used to assess the severity of AMS.
      – Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
      – Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
      – Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.

      High Altitude Pulmonary Edema (HAPE):
      – HAPE is a progression of AMS but can occur without AMS symptoms.
      – It is the leading cause of death related to altitude illness.
      – Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
      – Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
      – Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.

      High Altitude Cerebral Edema (HACE):
      – HACE is thought to result from vasogenic edema and increased vascular pressure.
      – It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
      – Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
      – Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
      – Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis.

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      • Environmental Emergencies
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