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Question 1
Correct
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You review a 72-year-old man who is currently on the Clinical Decision Unit (CDU) after undergoing surgery for a hip fracture that occurred as a result of a fall. He informs you that he experienced the onset of menopause in his early 50s. His primary care physician recently arranged for a DEXA scan, and you have obtained the results from the CDU computer. The scan reveals a T-score of -3.0 standard deviations. Upon reviewing his medical history and family history, you discover that his father suffered a hip fracture in his early 60s, and the patient himself has a body mass index of 21 kg/m2.
Which SINGLE statement regarding this case is true?Your Answer: She has osteoporosis and ideally should be started on a combination of treatment such as alendronate and calcichew D3 forte
Explanation:Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 2
Correct
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A 45-year-old office worker comes in with a few weeks of persistent lower back pain. The pain is severe and has greatly affected their ability to move. You discuss the available treatment options.
Which of the following medication treatments is NOT recommended according to the current NICE guidelines? Choose ONE option.Your Answer: Paracetamol alone
Explanation:The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 3
Incorrect
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A 35-year-old man with a history of bipolar affective disorder presents with symptoms suggestive of lithium toxicity.
Which of the following symptoms is LEAST likely to be observed?Your Answer: Increased muscle tone
Correct Answer: SIADH
Explanation:SIADH is a medical condition that is not brought on by lithium toxicity. However, lithium toxicity does have its own distinct set of symptoms. These symptoms include nausea and vomiting, diarrhea, tremors, ataxia, confusion, increased muscle tone, clonus, nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is important to note that SIADH and lithium toxicity are separate conditions with their own unique characteristics.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 4
Correct
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A child presents to the Pediatric Emergency Department with stridor, a hoarse voice, and difficulty breathing. After a comprehensive history and examination, acute epiglottitis is suspected as the diagnosis.
What is the preferred and most accurate investigation to confirm this diagnosis?Your Answer: Fibre-optic laryngoscopy
Explanation:Acute epiglottitis is a condition characterized by inflammation of the epiglottis. It can be life-threatening as it can completely block the airway, especially if not diagnosed promptly. In the past, the most common cause was Haemophilus influenzae type b (Hib), but with the widespread use of the Hib vaccine, it has become rare in children and is now more commonly seen in adults caused by Streptococcus spp like Streptococcus pyogenes and Streptococcus pneumonia. Other bacterial causes include Staphylococcus aureus, Pseudomonas spp, Moraxella catarrhalis, and Mycobacterium tuberculosis.
The typical symptoms of acute epiglottitis include fever, sore throat (initially resembling a viral sore throat), painful swallowing, difficulty swallowing secretions (seen as drooling in children), muffled voice (referred to as ‘hot potato’ voice), rapid heartbeat, tenderness in the front of the neck over the hyoid bone, cervical lymph node enlargement, and rapid deterioration in children.
To diagnose acute epiglottitis, the gold standard investigation is fibre-optic laryngoscopy, which allows direct visualization of the epiglottis. However, laryngoscopy should only be performed in settings prepared for intubation or tracheostomy in case upper airway obstruction occurs. If laryngoscopy is not possible, a lateral neck X-ray may be helpful, as it can show the characteristic ‘thumbprint sign’.
Management of acute epiglottitis usually involves conservative measures such as intravenous or oral antibiotics. However, in some cases, intubation may be necessary.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 5
Incorrect
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You review a child with a history of attention deficit hyperactivity disorder (ADHD) who is currently experiencing severe symptoms. He hands you a note to read that expresses his thoughts about his condition. However, you struggle to comprehend it as it is excessively verbose and highly disorganized.
Which ONE of the following cognitive impairments is he exhibiting?Your Answer: Word salad
Correct Answer: Graphorrhea
Explanation:Graphorrhoea is a communication disorder characterized by an excessive use of words and a tendency to ramble in written work. It is similar to word salad, but specifically occurs in written form. This condition is often observed in individuals with schizophrenia.
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This question is part of the following fields:
- Mental Health
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Question 6
Correct
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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.
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This question is part of the following fields:
- Haematology
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Question 7
Correct
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A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is currently prescribed 15 mg sustained-release morphine twice daily for pain management, but is now encountering breakthrough pain.
According to NICE guidelines, what is the recommended first-line rescue medication for breakthrough pain?Your Answer: Oral immediate-release morphine
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 8
Correct
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A 32-year-old man with a history of severe asthma is brought to the Emergency Department by his girlfriend. He is experiencing extreme shortness of breath and wheezing, and his condition worsens rapidly. After receiving back-to-back nebulizer treatments, hydrocortisone, and IV magnesium sulfate, he is taken to resus, and the intensive care team is called for consultation. He is now severely hypoxic and has developed confusion. It is decided that the patient needs to be intubated.
Which of the following medications would be the most appropriate choice for inducing anesthesia in this patient?Your Answer: Ketamine
Explanation:Intubation is rarely necessary for asthmatic patients, with only about 2% of asthma attacks requiring it. Most severe cases can be managed using non-invasive ventilation techniques. However, intubation can be a life-saving measure for asthmatic patients in critical condition. The indications for intubation include severe hypoxia, altered mental state, failure to respond to medications or non-invasive ventilation, and respiratory or cardiac arrest.
Before intubation, it is important to preoxygenate the patient and administer intravenous fluids. Nasal oxygen during intubation can provide additional time. Intravenous fluids are crucial because patients with acute asthma exacerbations can experience significant fluid loss, which can lead to severe hypotension during intubation and positive pressure ventilation.
There is no perfect combination of drugs for rapid sequence induction (RSI), but ketamine is often the preferred choice. Ketamine has bronchodilatory properties and does not cause hypotension as a side effect. Propofol can also be used, but it carries a risk of hypotension. In some cases, a subdissociative dose of ketamine can be helpful to facilitate the use of non-invasive ventilation in a hypoxic or combative patient.
Rocuronium and suxamethonium are commonly used as paralytic agents. Rocuronium has the advantage of providing a longer period of paralysis, which helps avoid ventilator asynchrony in the early stages of management.
Proper mechanical ventilation is essential, and it involves allowing the patient enough time to fully exhale the delivered breath and prevent hyperinflation. Therefore, permissive hypercapnia is typically used, and the ventilator settings should be adjusted accordingly. The recommended settings are a respiratory rate of 6-8 breaths per minute and a tidal volume of 6 ml per kilogram of body weight.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 9
Correct
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A 32-year-old woman with a history of schizophrenia describes a sensation in which her thoughts are heard as if they are being spoken aloud. She states that it feels almost as though her thoughts are ‘being echoed by a voice in her mind’. She hears the voice at the exact same time as thinking the thoughts.
Which ONE of the following thought disorders is she displaying?Your Answer: Gedankenlautwerden
Explanation:Thought echo is a phenomenon where a patient perceives their own thoughts as if they are being spoken out loud. When there is a slight delay in this perception, it is referred to as echo de la pensée. On the other hand, when the thoughts are heard simultaneously, it is known as Gedankenlautwerden.
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This question is part of the following fields:
- Mental Health
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Question 10
Incorrect
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A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms of sepsis. The baby was born prematurely at 32 weeks gestation. A diagnosis of neonatal pneumonia is suspected.
What is the SINGLE most probable causative organism?Your Answer: Respiratory syncytial virus
Correct Answer: Escherichia Coli
Explanation:Pneumonia in newborns is typically caused by organisms that inhabit the mother’s genital tract. Despite the widespread use of chemoprophylaxis to prevent maternal carriage, Group B haemolytic Streptococcus remains a common culprit in early-onset infections in full-term and near-term infants aged less than three days. Among very low birth weight infants, Escherichia Coli is the most frequently encountered bacterial strain. Additionally, neonatal pneumonia can be caused by other bacteria such as Chlamydia trachomatis, Listeria monocytogenes, and Haemophilus influenzae.
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This question is part of the following fields:
- Neonatal Emergencies
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Question 11
Correct
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A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
Which of the following statements is NOT true regarding the ECG in atrial fibrillation?Your Answer: Ashman beats have a poor prognosis
Explanation:The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.
In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.
The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.
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This question is part of the following fields:
- Cardiology
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Question 12
Correct
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You review a 72-year-old woman with a diagnosis of lung cancer. You can see from her notes that she has an advanced decision in place.
Which SINGLE statement is true regarding an advanced decision?Your Answer: It can be used by Jehovah’s witnesses to refuse blood transfusions
Explanation:An advance decision, also known as an advance directive in Scotland, is a statement made by a patient expressing their desire to refuse certain types of medical treatment or care in the event that they become unable to make or communicate decisions for themselves. These statements serve as a means of effectively communicating the patient’s wishes to healthcare professionals and family members, helping to avoid any confusion that may arise. If a patient reaches a point where they are no longer capable of making informed decisions about their care, an advance decision can provide clarity and guidance.
An advance decision can typically be utilized in the following situations: making decisions regarding CPR, determining the use of IV fluids and parenteral nutrition, deciding on specific procedures, and addressing the use of blood products for Jehovah’s Witnesses. However, it is important to note that advance decisions have their limitations and cannot be used to grant a relative lasting power of attorney, appoint a spokesperson to make decisions on the patient’s behalf, request a specific medical treatment, advocate for something illegal (such as assisted suicide), refuse treatment for a mental health condition, or authorize treatments that are not in the patient’s best interests.
A doctor is legally obligated to adhere to an advance decision unless certain circumstances arise. These circumstances include changes that invalidate the decision, advances or changes in treatment that alter the circumstances, ambiguity in the wording of the decision, or if the decision is unsigned or its authenticity is in doubt. If there are any doubts about the validity of an advance decision, it is advisable to seek legal advice. Unfortunately, there have been instances where advance decisions have been forged or signed under duress, and any suspicions of this nature should be raised.
It is important to note that there is no specific time period for which an advance decision remains valid.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 13
Correct
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What is the underlying cause of Korsakoff's psychosis in a 45-year-old man with a history of chronic alcohol abuse?
Your Answer: Thiamine deficiency
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 classic triad of symptoms, which include acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination and balance). Additional possible features of this condition may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. In the majority of cases, peripheral neuropathy (nerve damage) is also observed, typically affecting the legs.
The condition is marked by the presence of acute capillary haemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while 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 (difficulty remembering past events), an inability to memorize new information, disordered time appreciation, and confabulation (fabrication of false memories).
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This question is part of the following fields:
- Mental Health
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Question 14
Correct
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A 35-year-old woman is involved in a car crash and sustains severe facial injuries. Facial X-rays and CT scans show the presence of a Le Fort III fracture.
What is the most probable cause of this injury?Your Answer: A force through the nasal bridge and upper part of the maxilla
Explanation:Le Fort fractures are intricate fractures of the midface, which involve the maxillary bone and the surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the separation of the pterygomaxillary due to trauma. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening situations and disfigurement.
The causes of Le Fort fractures vary depending on the type of fracture. Common mechanisms include motor vehicle accidents, sports injuries, assaults, and falls from significant heights. Patients with Le Fort fractures often have concurrent head and cervical spine injuries. Additionally, they frequently experience other facial fractures, as well as neuromuscular injuries and dental avulsions.
The specific type of fracture sustained is determined by the direction of the force applied to the face. Le Fort type I fractures typically occur when a force is directed downward against the upper teeth. Le Fort type II fractures are usually the result of a force applied to the lower or mid maxilla. Lastly, Le Fort type III fractures are typically caused by a force applied to the nasal bridge and upper part of the maxilla.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 15
Correct
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A 22-year-old traveler returns from a recent backpacking trip to Africa with headaches and intermittent fevers. He describes intense chills, followed by feeling hot and then sweating profusely.
On examination, he is drowsy and has a temperature of 39.4°C. You perform a bedside blood glucose measurement, which is 1.9 mmol/l. There are no palpable lymph nodes or rash, but examination of his abdomen reveals hepatosplenomegaly. Intravenous glucose is administered, and his blood glucose improves to 4.4 mmol/l.
His blood tests today are as follows:
Hemoglobin: 7.8 g/dl (13-17 g/dl)
Platelets: 46 x 109/l (150-400 x 109/l)
White blood cell count: 10.7 x 109/l (4-11 x 109/l)
Sodium: 134 mmol/L (135-147 mmol/L)
Potassium: 4.9 mmol/L (3.5-5.5 mmol/L)
Urea: 11.5 mmol/L (2.0-6.6 mmol/L)
Creatinine: 278 mmol/L (75-125 mmol/L)
What is the SINGLE most appropriate first-line treatment?Your Answer: Artemisinin-based combination therapy
Explanation:Malaria is an infectious disease caused by the female Anopheles mosquito. It is caused by the Plasmodium parasite and there are five species that can infect humans. These species are Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi.
The main symptom of malaria is the malarial paroxysm, which is a cyclical occurrence of cold chills, followed by intense heat, and then profuse sweating. Upon examination, patients with malaria may show signs of anemia, jaundice, and have an enlarged liver and spleen. The full blood count often reveals a combination of anemia and low platelet count.
Plasmodium falciparum is the most severe form of malaria and is responsible for most deaths. Severe malaria is indicated by symptoms such as impaired consciousness, seizures, low blood sugar, anemia, kidney problems, difficulty breathing, and spontaneous bleeding. Given the presentation, it is likely that this patient has Plasmodium falciparum malaria.
Thick and thin blood films are the gold-standard diagnostic tests for malaria. However, it is possible for a patient to have malaria even if the blood film is negative. In such cases, at least two additional blood films should be obtained within 48 hours to confirm or exclude the diagnosis.
Artemisinin-based combination therapy (ACT) is currently recommended for the treatment of Plasmodium falciparum malaria. ACT involves combining fast-acting artemisinin-based drugs with another drug from a different class. Some companion drugs used in ACT include lumefantrine, mefloquine, amodiaquine, sulfadoxine/pyrimethamine, piperaquine, and chlorproguanil/dapsone. If ACT is not available, oral quinine or atovaquone with proguanil hydrochloride can be used. Quinine should be combined with another drug, usually oral doxycycline, for prolonged treatment.
Severe or complicated cases of Plasmodium falciparum malaria should be managed in a high dependency unit or intensive care setting. Intravenous artesunate is recommended for all patients with severe or complicated malaria, or those at high risk of developing severe disease. After a minimum of 24 hours of intravenous treatment, and when the patient
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This question is part of the following fields:
- Infectious Diseases
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Question 16
Correct
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A 35 year old firefighter is recommended to go to the emergency department after responding to a house fire where a gas explosion occurred. The firefighter helped evacuate the residents and then inspected the basement where a leaking gas pipe was found.
What is the most suitable agent to offer this patient for decontamination?Your Answer: Prussian blue
Explanation:Prussian blue is a substance that helps remove radioactive caesium from the body, a process known as decorporation. It is specifically effective for caesium exposure. When taken orally, Prussian blue binds to the radioactive caesium, forming a compound that can be excreted from the body, preventing further absorption. By using Prussian blue, the whole body radiation dose can be reduced by approximately two-thirds. Radioactive caesium is utilized in various medical, geological, and industrial applications, although incidents of environmental contamination are rare, they have been reported in Western Australia and Eastern Thailand during the first quarter of 2023.
Further Reading:
Radiation exposure refers to the emission or transmission of energy in the form of waves or particles through space or a material medium. There are two types of radiation: ionizing and non-ionizing. Non-ionizing radiation, such as radio waves and visible light, has enough energy to move atoms within a molecule but not enough to remove electrons from atoms. Ionizing radiation, on the other hand, has enough energy to ionize atoms or molecules by detaching electrons from them.
There are different types of ionizing radiation, including alpha particles, beta particles, gamma rays, and X-rays. Alpha particles are positively charged and consist of 2 protons and 2 neutrons from the atom’s nucleus. They are emitted from the decay of heavy radioactive elements and do not travel far from the source atom. Beta particles are small, fast-moving particles with a negative electrical charge that are emitted from an atom’s nucleus during radioactive decay. They are more penetrating than alpha particles but less damaging to living tissue. Gamma rays and X-rays are weightless packets of energy called photons. Gamma rays are often emitted along with alpha or beta particles during radioactive decay and can easily penetrate barriers. X-rays, on the other hand, are generally lower in energy and less penetrating than gamma rays.
Exposure to ionizing radiation can damage tissue cells by dislodging orbital electrons, leading to the generation of highly reactive ion pairs. This can result in DNA damage and an increased risk of future malignant change. The extent of cell damage depends on factors such as the type of radiation, time duration of exposure, distance from the source, and extent of shielding.
The absorbed dose of radiation is directly proportional to time, so it is important to minimize the amount of time spent in the vicinity of a radioactive source. A lethal dose of radiation without medical management is 4.5 sieverts (Sv) to kill 50% of the population at 60 days. With medical management, the lethal dose is 5-6 Sv. The immediate effects of ionizing radiation can range from radiation burns to radiation sickness, which is divided into three main syndromes: hematopoietic, gastrointestinal, and neurovascular. Long-term effects can include hematopoietic cancers and solid tumor formation.
In terms of management, support is mainly supportive and includes IV fluids, antiemetics, analgesia, nutritional support, antibiotics, blood component substitution, and reduction of brain edema.
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This question is part of the following fields:
- Environmental Emergencies
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Question 17
Correct
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A 30-year-old woman comes in with facial swelling that worsens when she eats. You suspect she may have sialolithiasis.
Which salivary gland is most likely to be impacted?Your Answer: Submandibular gland
Explanation:Sialolithiasis is a medical condition characterized by the formation of a calcified stone, known as a sialolith, within one of the salivary glands. The submandibular gland, specifically Wharton’s duct, is the site of approximately 90% of these occurrences, while the parotid gland accounts for most of the remaining cases. In rare instances, sialoliths may also develop in the sublingual gland or minor salivary glands.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 18
Incorrect
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A 35-year-old woman comes in with complaints of painful urination and frequent urination. A urine dipstick test is conducted, which shows the presence of blood, protein, white blood cells, and nitrites. Based on these findings, you diagnose her with a urinary tract infection and prescribe antibiotics.
Which antibiotic has the highest resistance rate against E.coli in the UK?Your Answer: Cefalexin
Correct Answer: Trimethoprim
Explanation:Nitrofurantoin is currently the preferred antibiotic for treating uncomplicated urinary tract infections in non-pregnant women. However, antibiotic resistance is becoming a significant concern in the management of urinary tract infections and pyelonephritis in the UK. In England, the resistance of E. coli (the main bacteria causing these infections) to certain antibiotics is as follows:
Trimethoprim: 30.3% (varies between areas from 27.1% to 33.4%)
Co-amoxiclav: 19.8% (varies between areas from 10.8% to 30.7%)
Ciprofloxacin: 10.6% (varies between areas from 7.8% to 13.7%)
Cefalexin: 9.9% (varies between areas from 8.1% to 11.4%) -
This question is part of the following fields:
- Urology
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Question 19
Correct
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With freezing temperatures anticipated, your consultant requests that you organize a teaching session for the junior physicians regarding the management of frostbite. What imaging modality is preferred for evaluating perfusion abnormalities in extremities impacted by frostbite?
Your Answer: Technetium 99 (Tc-99) pertechnetate scintigraphy
Explanation:Technetium 99 (Tc-99) pertechnetate scintigraphy is the preferred imaging method for evaluating frostbite. This technique is highly accurate in detecting tissue damage and provides both sensitivity and specificity.
Further Reading:
Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.
In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.
Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.
Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.
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This question is part of the following fields:
- Dermatology
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Question 20
Correct
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A 35-year-old woman has experienced a fracture of the left humerus. During examination, it is found that she has weakness in extending her wrist and metacarpophalangeal joints, leading to wrist drop and an inability to grip with her left hand. However, she still has preserved extension of the elbow. Additionally, there is a loss of sensation over the dorsal aspect of the forearm from below the elbow to the 1st dorsal interosseous.
Which nerve has been damaged in this particular case?Your Answer: Radial nerve
Explanation:Radial nerve injuries often occur in conjunction with fractures of the humerus. The most common cause of a radial nerve palsy is external compression or trauma to the radial nerve as it passes through the spiral groove in the middle of the humerus.
There are several factors that can lead to damage of the radial nerve in the spiral groove. These include trauma, such as a fracture in the middle of the humerus, compression known as Saturday night palsy, and iatrogenic causes like injections.
When the radial nerve is injured within the spiral groove, it results in weakness of the wrist and metacarpophalangeal joints. However, elbow extension is not affected because the branches to the triceps and anconeus muscles originate before the spiral groove. The interphalangeal joints remain unaffected as well, as they are supplied by the median and ulnar nerves. Sensory loss will be experienced over the dorsal aspect of the forearm, extending from below the elbow to the 1st dorsal interosseous.
In contrast, injury to the radial nerve in the axilla will also cause weakness of elbow extension and sensory loss in the distribution of the more proximal cutaneous branches. This helps distinguish it from injury in the spiral groove.
In the forearm, the posterior interosseous branch of the radial nerve can also be damaged. This can occur due to injury to the radial head or entrapment in the supinator muscle under the arcade of Frohse. However, this type of injury can be easily distinguished from injury in the spiral groove because there is no sensory involvement and no wrist drop, thanks to the preservation of the extensor carpi radialis longus. Nonetheless, there will still be weakness in the wrist and fingers.
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This question is part of the following fields:
- Neurology
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Question 21
Correct
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You evaluate the pupillary light reflex in a patient with a cranial nerve impairment. Upon shining the light into the left eye, there is no alteration in pupil size in either the left or right eye. However, when the light is directed into the right eye, both the left and right pupils constrict.
What is the location of the lesion in this scenario?Your Answer: Left optic nerve
Explanation:The pupillary light reflex is a reflex that regulates the size of the pupil in response to the intensity of light that reaches the retina. It consists of two separate pathways, the afferent pathway and the efferent pathway.
The afferent pathway begins with light entering the pupil and stimulating the retinal ganglion cells in the retina. These cells then transmit the light signal to the optic nerve. At the optic chiasm, the nasal retinal fibers cross to the opposite optic tract, while the temporal retinal fibers remain in the same optic tract. The fibers from the optic tracts then project and synapse in the pretectal nuclei in the dorsal midbrain. From there, the pretectal nuclei send fibers to the ipsilateral Edinger-Westphal nucleus via the posterior commissure.
On the other hand, the efferent pathway starts with the Edinger-Westphal nucleus projecting preganglionic parasympathetic fibers. These fibers exit the midbrain and travel along the oculomotor nerve. They then synapse on post-ganglionic parasympathetic fibers in the ciliary ganglion. The post-ganglionic fibers, known as the short ciliary nerves, innervate the sphincter muscle of the pupils, causing them to constrict.
The result of these pathways is that when light is shone in one eye, both the direct pupillary light reflex (ipsilateral eye) and the consensual pupillary light reflex (contralateral eye) occur.
Lesions affecting the pupillary light reflex can be identified by comparing the direct and consensual reactions to light in both eyes. If the optic nerve of the first eye is damaged, both the direct and consensual reflexes in the second eye will be lost. However, when light is shone into the second eye, the pupil of the first eye will still constrict. If the optic nerve of the second eye is damaged, the second eye will constrict consensually when light is shone into the unaffected first eye. If the oculomotor nerve of the first eye is damaged, the first eye will have no direct light reflex, but the second eye will still constrict consensually. Finally, if the oculomotor nerve of the second eye is damaged, there will be no consensual constriction of the second eye when light is shone into the unaffected first eye.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Correct
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A 52-year-old individual is brought to the emergency room after a car accident. They present with a fracture in the middle of their left femur and complain of abdominal pain. The patient appears restless. The following are their vital signs:
Blood pressure: 112/94 mmHg
Pulse rate: 102 bpm
Respiration rate: 21 rpm
SpO2: 97% on room air
Temperature: 36 ºC
Considering the possibility of significant blood loss, what grade of hypovolemic shock would you assign to this patient?Your Answer: Grade 2
Explanation:Grade 2 shock is characterized by a pulse rate of 100 to 120 beats per minute and a respiratory rate of 20 to 30 breaths per minute. These clinical features align with the symptoms of grade 2 hypovolemic shock, as indicated in the below notes.
Further Reading:
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
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This question is part of the following fields:
- Trauma
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Question 23
Incorrect
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A 45-year-old patient arrives at the Emergency Department after having a wisdom tooth extraction performed by her dentist yesterday. She continues to experience a lack of feeling over the front two-thirds of her tongue on the left side.
Which nerve is MOST likely to have been damaged during this procedure?Your Answer: Inferior alveolar nerve
Correct Answer: Lingual nerve
Explanation:The lingual nerve, a branch of the mandibular division of the trigeminal nerve, provides sensory innervation to the front two-thirds of the tongue and the floor of the mouth. It also carries fibers of the chorda tympani, a branch of the facial nerve, which returns taste information from the front two-thirds of the tongue. The diagram below illustrates the relationships of the lingual nerve in the oral cavity.
The most common cause of lingual nerve injuries is wisdom tooth surgery. Approximately 2% of wisdom tooth extractions result in temporary injury, while permanent damage occurs in 0.2% of cases. Additionally, the nerve can be harmed during dental injections for local anesthesia.
The anterior superior alveolar nerve, a branch of the maxillary division of the trigeminal nerve, provides sensation to the incisor and canine teeth.
The inferior alveolar nerve, another branch of the mandibular division of the trigeminal nerve, supplies sensation to the lower teeth.
The zygomatic nerve, a branch of the maxillary division of the trigeminal nerve, offers sensation to the skin over the zygomatic and temporal bones.
Lastly, the mylohyoid nerve is a motor nerve that supplies the mylohyoid and the anterior belly of the digastric.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 24
Correct
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A 60-year-old man presents with worsening symptoms of shortness of breath. You examine his cardiovascular system and discover a slow-rising, low-volume pulse. His apex beat is sustained, and you can auscultate an ejection systolic murmur that is loudest in the aortic area that radiates to the carotids.
What is the SINGLE most likely diagnosis?Your Answer: Aortic stenosis
Explanation:Aortic stenosis is a common condition where the valve in the heart becomes narrowed due to the progressive calcification that occurs with age. This typically occurs around the age of 70. Other causes of aortic stenosis include calcification of a congenital bicuspid aortic valve and rheumatic fever.
The symptoms of aortic stenosis can vary but commonly include difficulty breathing during physical activity, fainting, dizziness, chest pain (angina), and in severe cases, sudden death. However, it is also possible for aortic stenosis to be asymptomatic, meaning that there are no noticeable symptoms.
When examining a patient with aortic stenosis, there are several signs that may be present. These include a slow-rising and low-volume pulse, a narrow pulse pressure, a sustained apex beat, a thrill (a vibrating sensation) in the area of the aorta, and an ejection click if the valve is pliable. Additionally, there is typically an ejection systolic murmur, which is a specific type of heart murmur, that can be heard loudest in the aortic area (located at the right sternal edge, 2nd intercostal space) and may radiate to the carotid arteries.
It is important to differentiate aortic stenosis from aortic sclerosis, which is a degeneration of the aortic valve but does not cause obstruction of the left ventricular outflow tract. Aortic sclerosis can be distinguished by the presence of a normal pulse character and the absence of radiation of the murmur.
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This question is part of the following fields:
- Cardiology
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Question 25
Correct
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You are examining the hip X-rays of a 78-year-old woman who slipped while getting out of bed. What can be helpful in identifying a femoral neck fracture on the anteroposterior X-ray?
Your Answer: Shenton's line
Explanation:Shenton’s line is a useful tool for identifying hip fractures on radiographs. It is a curved line that is drawn along the bottom edge of the upper pubic bone and the inner lower edge of the femur neck. This line should be smooth and uninterrupted. If there are any breaks or irregularities in the line, it could indicate a fracture, dysplasia, or dislocation.
Further Reading:
Fractured neck of femur is a common injury, especially in elderly patients who have experienced a low impact fall. Risk factors for this type of fracture include falls, osteoporosis, and other bone disorders such as metastatic cancers, hyperparathyroidism, and osteomalacia.
There are different classification systems for hip fractures, but the most important differentiation is between intracapsular and extracapsular fractures. The blood supply to the femoral neck and head is primarily from ascending cervical branches that arise from an arterial anastomosis between the medial and lateral circumflex branches of the femoral arteries. Fractures in the intracapsular region can damage the blood supply and lead to avascular necrosis (AVN), with the risk increasing with displacement. The Garden classification can be used to classify intracapsular neck of femur fractures and determine the risk of AVN. Those at highest risk will typically require hip replacement or arthroplasty.
Fractures below or distal to the capsule are termed extracapsular and can be further described as intertrochanteric or subtrochanteric depending on their location. The blood supply to the femoral neck and head is usually maintained with these fractures, making them amenable to surgery that preserves the femoral head and neck, such as dynamic hip screw fixation.
Diagnosing hip fractures can be done through radiographs, with Shenton’s line and assessing the trabecular pattern of the proximal femur being helpful techniques. X-rays should be obtained in both the AP and lateral views, and if an occult fracture is suspected, an MRI or CT scan may be necessary.
In terms of standards of care, it is important to assess the patient’s pain score within 15 minutes of arrival in the emergency department and provide appropriate analgesia within the recommended timeframes. Patients with moderate or severe pain should have their pain reassessed within 30 minutes of receiving analgesia. X-rays should be obtained within 120 minutes of arrival, and patients should be admitted within 4 hours of arrival.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 26
Correct
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A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain. He has recently returned from a trip to Australia. He has no past medical history of note and suffers no known allergies. His observations are as follows: temperature 38.2°C, oxygen saturations 93% on air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, he has a tender, swollen left calf, and his chest is clear.
What is the SINGLE investigation most likely to confirm the diagnosis?Your Answer: CT pulmonary angiogram
Explanation:The clinical history and examination strongly suggest that the patient has a pulmonary embolism caused by a deep vein thrombosis in his right leg.
The typical symptoms of a pulmonary embolism include shortness of breath, chest pain that worsens with breathing, coughing, and/or coughing up blood. There may also be symptoms indicating the presence of a deep vein thrombosis. Other signs include rapid breathing and heart rate, fever, and in severe cases, signs of shock, an abnormal heart rhythm, and increased pressure in the jugular veins.
Given the patient’s high probability Wells score, it is recommended that an immediate CT pulmonary angiogram (CPTA) be performed. This test is considered the most reliable method for diagnosing a pulmonary embolism. A d-dimer test would not provide any additional benefit in this case. While a chest X-ray and ECG may provide useful information, they alone cannot confirm the diagnosis.
For patients who have an allergy to contrast media, renal impairment, or are at high risk from radiation exposure, a ventilation/perfusion single-photon emission computed tomography (V/Q SPECT) scan or a V/Q planar scan can be offered as an alternative to CTPA.
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This question is part of the following fields:
- Respiratory
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Question 27
Correct
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A 32-year-old musician is currently participating in a community withdrawal program for a substance misuse issue. He has been attempting to quit for more than a year and consistently attends a community support group for his problem. The healthcare team in charge of his treatment have prescribed him Acamprosate to aid with his withdrawal.
What substance is he most likely trying to withdraw from?Your Answer: Alcohol
Explanation:Acamprosate, also known as Campral, is a medication used in the treatment of alcohol dependence. It is believed to work by stabilizing a chemical pathway in the brain that is disrupted during alcohol withdrawal. For optimal results, Acamprosate should be used alongside psychosocial support, as it helps reduce alcohol consumption and promote abstinence.
When starting treatment with Acamprosate, it is important to begin as soon as possible after assisted withdrawal. The typical dosage is 1998 mg (666 mg three times a day), unless the patient weighs less than 60 kg, in which case a maximum of 1332 mg per day should be prescribed.
Generally, Acamprosate is prescribed for up to 6 months. However, for those who benefit from the medication and wish to continue, it can be taken for a longer duration. If drinking persists 4-6 weeks after starting the drug, it should be discontinued.
Patients who are prescribed Acamprosate should be closely monitored, with regular check-ins at least once a month for the first six months. If the medication is continued beyond six months, the frequency of check-ins can be reduced but should still occur at regular intervals.
While routine blood tests are not mandatory, they can be considered if there is a need to monitor liver function recovery or as a motivational tool to show patients their progress.
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This question is part of the following fields:
- Mental Health
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Question 28
Correct
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A 45-year-old man comes in with a 4-day history of sudden pain in his left scrotum and a high body temperature. During the examination, the epididymis is swollen and tender, and the skin covering the scrotum is red and warm to the touch. Lifting the scrotum provides relief from the pain.
What is the most probable organism responsible for this condition?Your Answer: Escherichia coli
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.
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This question is part of the following fields:
- Urology
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Question 29
Incorrect
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You are evaluating a 4-year-old girl who has been diagnosed with diabetic ketoacidosis (DKA). She had initially improved after receiving fluids, but her condition has worsened in the past hour. She is now expressing discomfort due to a headache and is displaying irritability. She has also started vomiting again, and the nursing staff has observed an increase in her blood pressure and a decrease in her heart rate.
What would be the most suitable course of treatment for this patient?Your Answer: Hypotonic saline
Correct Answer: Mannitol
Explanation:Cerebral edema is the most significant complication of diabetic ketoacidosis (DKA), leading to death in many cases. It occurs in approximately 0.2-1% of DKA cases. The high blood glucose levels cause an osmolar gradient, resulting in the movement of water from the intracellular fluid (ICF) to the extracellular fluid (ECF) space and a decrease in cell volume. When insulin and intravenous fluids are administered to correct the condition, the effective osmolarity decreases rapidly, causing a reversal of the fluid shift and the development of cerebral edema.
Cerebral edema is associated with a higher mortality rate and poor neurological outcomes. To prevent its occurrence, it is important to slowly normalize osmolarity over a period of 48 hours, paying attention to glucose and sodium levels, as well as ensuring proper hydration. Monitoring the child for symptoms such as headache, recurrent vomiting, irritability, changes in Glasgow Coma Scale (GCS), abnormal slowing of heart rate, and increasing blood pressure is crucial.
If cerebral edema does occur, it should be treated with either a hypertonic (3%) saline solution at a dosage of 3 ml/kg or a mannitol infusion at a dosage of 250-500 mg/kg over a 20-minute period.
In addition to cerebral edema, there are other complications associated with DKA in children, including cardiac arrhythmias, pulmonary edema, and acute renal failure.
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This question is part of the following fields:
- Endocrinology
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Question 30
Correct
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A 35-year-old woman is injured in a car crash and sustains severe facial trauma. Imaging tests show that she has a Le Fort III fracture.
What is the most accurate description of the injury pattern seen in a Le Fort III fracture?Your Answer: Transverse fracture of the midface
Explanation:Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.
The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.
Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.
Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.
Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 31
Correct
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You are requested to evaluate a 42-year-old individual with a knee injury sustained from leaping off a tall wall and landing on a leg that was completely extended. It is suspected that the patient may have experienced a quadriceps tendon rupture. Which of the subsequent observations would indicate this diagnosis?
Your Answer: Loss of of active knee extension
Explanation:When a complete quadriceps rupture occurs, it leads to the inability to actively extend the knee. Please refer to the following notes for more detailed information.
Further Reading:
A quadriceps tendon tear or rupture is a traumatic lower limb and joint injury that occurs when there is heavy loading on the leg, causing forced contraction of the quadriceps while the foot is planted and the knee is partially bent. These tears most commonly happen at the osteotendinous junction between the tendon and the superior pole of the patella. Quadriceps tendon ruptures are more common than patellar tendon ruptures.
When a quadriceps tendon tear occurs, the patient usually experiences a tearing sensation and immediate pain. They will then typically complain of pain around the knee and over the tendon. Clinically, there will often be a knee effusion and weakness or inability to actively extend the knee.
In cases of complete quadriceps tears, the patella will be displaced distally, resulting in a low lying patella or patella infera, also known as patella baja. Radiological measurements, such as the Insall-Salvati ratio, can be used to measure patella height. The Insall-Salvati ratio is calculated by dividing the patellar tendon length by the patellar length. A normal ratio is between 0.8 to 1.2, while a low lying patella (patella baja) is less than 0.8 and a high lying patella (patella alta) is greater than 1.2.
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This question is part of the following fields:
- Trauma
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Question 32
Correct
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A 35-year-old man comes in with swelling of his face, particularly his upper lip, and his hands. He has a confirmed diagnosis of hereditary angioedema.
Which of the following statements about hereditary angioedema is correct?Your Answer: Long-term prophylaxis can be achieved with tranexamic acid
Explanation:Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.
Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.
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This question is part of the following fields:
- Allergy
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Question 33
Incorrect
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A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during their gap year.
Which of the following is NOT a viral haemorrhagic fever?Your Answer: Yellow fever
Correct Answer: Chagas disease
Explanation:The viral hemorrhagic fevers (VHFs) are a group of infectious diseases caused by four distinct types of RNA viruses. These include Filoviruses (such as Marburg virus and Ebola), Arenaviruses (like Lassa fever and Argentine haemorrhagic fever), Bunyaviruses (including Hantavirus and Rift Valley fever), and Flavivirus (such as Yellow fever and dengue fever). VHFs are serious multi-system disorders that can be potentially fatal. Each type of VHF has a natural reservoir, which is an animal or insect host, and they are typically found in the areas where these host species reside. Outbreaks of these hemorrhagic fevers occur sporadically and irregularly, making them difficult to predict.
The typical clinical features of VHFs include fever, headache, myalgia, fatigue, bloody diarrhea, haematemesis, petechial rashes and ecchymoses, edema, confusion and agitation, as well as hypotension and circulatory collapse.
On the other hand, Chagas disease is not classified as a VHF. It is a tropical disease caused by the protozoan Trypanosoma cruzi. This disease is transmitted by Triatomine insects, commonly known as kissing bugs. Initially, Chagas disease causes a mild acute illness that resembles flu. However, around 10% of individuals develop chronic Chagas disease, which can lead to various complications. These complications include cardiac issues like dilated cardiomyopathy, neurological problems such as neuritis, and gastrointestinal complications like megacolon.
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This question is part of the following fields:
- Infectious Diseases
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Question 34
Correct
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A 32-year-old woman presents with a history of increased cough and wheeze over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebuliser, her peak flow improves to 455 L/min, and she feels much better.
What is the SINGLE most appropriate next step in her management?Your Answer: Give oral prednisolone 40 mg
Explanation:This man is experiencing an acute asthma episode. His initial peak flow is 55% of his best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, specifically a dose of prednisolone 40-50 mg orally.
Chest X-rays are not routinely performed to investigate acute asthma. However, they should be considered in certain situations, including suspected pneumomediastinum, consolidation, life-threatening asthma, inadequate response to treatment, and the need for ventilation.
Nebulised ipratropium bromide is only added to treatment with nebulised salbutamol in patients with acute severe or life-threatening asthma, or those who do not respond well to salbutamol therapy. Therefore, it is not necessary in this particular case.
While it may be reasonable to prescribe an antihistamine for a patient with a history of worsening hay fever, it should not be prioritized over treatment with steroids.
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This question is part of the following fields:
- Respiratory
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Question 35
Correct
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You review the X-ray's of a young patient and they confirm a zygomatic fracture.
All of the following are reasons for immediate referral to the ophthalmologist or maxillofacial surgeons EXCEPT for which one?Your Answer: Otalgia
Explanation:If a patient with a zygoma fracture experiences visual disturbance, limited eye movements (especially upward gaze), or shows a teardrop sign on a facial X-ray, it is important to refer them urgently to ophthalmology or maxillofacial surgeons.
Further Reading:
Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.
Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.
Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.
Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.
Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 36
Correct
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A 4-year-old girl is brought in by her father. She is complaining of left-sided ear pain and symptoms of a cold. On examination, she has a red eardrum on the left-hand side. She does not have a fever and appears to be in good health. You determine that she has acute otitis media.
What would be a valid reason to prescribe antibiotics for this child?Your Answer: Otorrhoea
Explanation:According to a Cochrane review conducted in 2008, it was discovered that approximately 80% of children experiencing acute otitis media were able to recover within a span of two days. However, the use of antibiotics only resulted in a reduction of pain for about 7% of children after the same two-day period. Furthermore, the administration of antibiotics did not show any significant impact on the rates of hearing loss, recurrence, or perforation. In cases where antibiotics are deemed necessary for children with otitis media, some indications include being under the age of two, experiencing discharge from the ear (otorrhoea), and having bilateral acute otitis media.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 37
Correct
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You evaluate the ECG of a 62-year-old male who has come in with episodes of Presyncope. What is the most suitable threshold to utilize in differentiating between a normal and prolonged QTc?
Your Answer: 450 ms
Explanation:An abnormal QTc, which is the measurement of the time it takes for the heart to recharge between beats, is generally considered to be greater than 450 ms in males. However, some sources may use a cutoff of greater than 440 ms as abnormal in males. To further categorize the QTc, a measurement of 430ms or less is considered normal, 431-450 ms is borderline, and 450 ms or more is considered abnormal in males. Females typically have a longer QTc, so the categories for them are often quoted as less than 450 ms being normal, 451-470 ms being borderline, and greater than 470ms being abnormal.
Further Reading:
Long QT syndrome (LQTS) is a condition characterized by a prolonged QT interval on an electrocardiogram (ECG), which represents abnormal repolarization of the heart. LQTS can be either acquired or congenital. Congenital LQTS is typically caused by gene abnormalities that affect ion channels responsible for potassium or sodium flow in the heart. There are 15 identified genes associated with congenital LQTS, with three genes accounting for the majority of cases. Acquired LQTS can be caused by various factors such as certain medications, electrolyte imbalances, hypothermia, hypothyroidism, and bradycardia from other causes.
The normal QTc values, which represent the corrected QT interval for heart rate, are typically less than 450 ms for men and less than 460ms for women. Prolonged QTc intervals are considered to be greater than these values. It is important to be aware of drugs that can cause QT prolongation, as this can lead to potentially fatal arrhythmias. Some commonly used drugs that can cause QT prolongation include antimicrobials, antiarrhythmics, antipsychotics, antidepressants, antiemetics, and others.
Management of long QT syndrome involves addressing any underlying causes and using beta blockers. In some cases, an implantable cardiac defibrillator (ICD) may be recommended for patients who have experienced recurrent arrhythmic syncope, documented torsades de pointes, previous ventricular tachyarrhythmias or torsades de pointes, previous cardiac arrest, or persistent syncope. Permanent pacing may be used in patients with bradycardia or atrioventricular nodal block and prolonged QT. Mexiletine is a treatment option for those with LQT3. Cervicothoracic sympathetic denervation may be considered in patients with recurrent syncope despite beta-blockade or in those who are not ideal candidates for an ICD. The specific treatment options for LQTS depend on the type and severity of the condition.
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This question is part of the following fields:
- Cardiology
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Question 38
Correct
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A 30-year-old woman presents with a persistent sore throat that has been bothering her for five days. She has also been experiencing symptoms of a cold for the past few days and has a bothersome dry cough. Upon examination, she does not have a fever and there are no swollen lymph nodes in her neck. Her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.
Using the FeverPAIN Score to evaluate her sore throat, what would be the most appropriate course of action for her at this point?Your Answer: No treatment is required, and she should be reassured
Explanation:The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.
The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.
According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 39
Correct
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A 45-year-old woman comes in with a one-week history of fatigue, fever, headache, muscle aches, and a dry cough that has now started to produce a small amount of sputum. She has also been experiencing occasional episodes of diarrhea for the past two days. During the examination, audible crackles are heard at the base of her lungs. Her blood test results today show evidence of hemolytic anemia and the presence of cold agglutinins.
What is the SINGLE most appropriate antibiotic to prescribe for this patient?Your Answer: Clarithromycin
Explanation:This patient presents with symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection with Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness.
Mycoplasma pneumoniae infection is commonly associated with the development of erythema multiforme, a rash characterized by multiple red lesions on the limbs that evolve into target lesions a few days after the rash appears. Additionally, this infection can also cause Steven-Johnson syndrome. It is worth noting that haemolytic anaemia with cold agglutinins can complicate Mycoplasma pneumoniae infections, providing further evidence for the diagnosis.
The recommended first-line antibiotic for treating this case would be a macrolide, such as clarithromycin. Doxycycline can also be used but is generally considered a second-line option.
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This question is part of the following fields:
- Respiratory
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Question 40
Correct
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A 45 year old female comes to the emergency department 2 weeks after having a tracheostomy placed, complaining of bleeding around the tracheostomy site and experiencing small amounts of blood in her cough. What is the primary concern for the clinician regarding the underlying cause?
Your Answer: Tracheo-innominate fistula
Explanation:Tracheo-innominate fistula (TIF) should be considered as a possible diagnosis in patients experiencing bleeding after a tracheostomy. This bleeding, occurring between 3 days and 6 weeks after the tracheostomy procedure, should be treated as TIF until ruled out. While this complication is uncommon, it is extremely dangerous and often leads to death if not promptly addressed through surgical intervention. Therefore, any bleeding from a tracheostomy tube should be regarded as potentially life-threatening.
Further Reading:
Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.
When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.
Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 41
Incorrect
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You assess a 65-year-old woman with a history of progressively increasing shortness of breath. As part of the patient's treatment plan, your supervisor requests that you carry out a pleural aspiration.
Based on the BTS guidelines, what is one of the indications for performing a pleural aspiration?Your Answer: Unilateral transudative pleural effusion
Correct Answer: Unilateral exudative pleural effusion
Explanation:A pleural effusion refers to an excess accumulation of fluid in the pleural cavity, which is the space between the parietal and visceral pleura. Normally, this cavity contains a small amount of lubricating fluid, around 5-10 ml, that allows the pleurae to slide smoothly over each other. This fluid also creates surface tension, bringing the two membranes together and ensuring that as the thorax expands, the lungs expand and fill with air. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.
Percutaneous pleural aspiration is commonly performed for two main reasons. Firstly, it is used to investigate pleural effusion, particularly when it is unilateral and exudative in nature. Secondly, it provides symptomatic relief for breathlessness caused by pleural effusion. However, the British Thoracic Society (BTS) guidelines recommend that pleural aspiration should not be carried out if there is suspicion of unilateral or bilateral transudative effusion, unless there are atypical features or failure of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.
During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line, about 10 cm lateral to the spine, and one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.
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This question is part of the following fields:
- Respiratory
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Question 42
Incorrect
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You analyze the results of renal function tests conducted on a patient who is currently using a non-steroidal anti-inflammatory drug (NSAID). What impact would you anticipate NSAID treatment to have on renal measurements?
Your Answer: Decreased renal plasma flow, increased filtration fraction, decreased GFR
Correct Answer: Decreased renal plasma flow, no change in filtration fraction, decreased GFR
Explanation:NSAIDs have been found to have a relatively high occurrence of renal adverse drug reactions (ADRs). These ADRs primarily occur due to changes in renal haemodynamics caused by alterations in prostaglandin levels.
Normally, prostaglandins play a role in dilating the afferent arteriole of the glomerulus. This dilation helps maintain normal glomerular perfusion and glomerular filtration rate (GFR).
However, NSAIDs work by reducing prostaglandin levels. This reduction leads to unopposed vasoconstriction of the afferent arteriole, resulting in decreased renal plasma flow. Consequently, this decrease in renal plasma flow leads to a decrease in GFR. It is important to note that NSAIDs do not have any impact on the filtration fraction itself.
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This question is part of the following fields:
- Nephrology
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Question 43
Correct
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You review a 70-year-old man with a history of hypertension and atrial fibrillation, who is currently on the clinical decision unit (CDU). His most recent blood results reveal significant renal impairment.
His current medications are as follows:
Digoxin 250 mcg once daily
Atenolol 50 mg once daily
Aspirin 75 mg once daily
What is the SINGLE most suitable medication adjustment to initiate for this patient?Your Answer: Reduce dose of digoxin
Explanation:Digoxin is eliminated through the kidneys, and if renal function is compromised, it can lead to elevated levels of digoxin and potential toxicity. To address this issue, it is necessary to decrease the patient’s digoxin dosage and closely monitor their digoxin levels and electrolyte levels.
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This question is part of the following fields:
- Nephrology
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Question 44
Correct
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A student nurse on a clinical rotation in the Emergency Department experiences a needlestick injury from a patient with a history of chronic hepatitis B.
Which ONE statement about hepatitis B prophylaxis is accurate?Your Answer: An accelerated regime is available for post-exposure prophylaxis
Explanation:Hepatitis B vaccination is included in the routine childhood immunisation schedule to provide long-term protection against hepatitis for children under 1 year of age. For these children, the vaccination consists of a primary course that includes the diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis, and Haemophilus influenza type B vaccine. This primary course is given at 4 weekly intervals.
The Hepatitis B vaccine is a conjugate vaccine that contains a surface antigen of the hepatitis virus (HBsAg) and is combined with an aluminium adjuvant to enhance its effectiveness. It is produced using a recombinant DNA technique.
When administering the vaccine to adults and older children, the preferred injection site is the deltoid muscle. However, in younger children, the anterolateral thigh is the preferred site. It is not recommended to inject the vaccine in the gluteal area as it has been found to have reduced efficacy.
The standard vaccination regime for Hepatitis B consists of three primary doses. The initial dose is followed by further doses at one and six months later. A booster dose is recommended at five years if the individual is still at risk.
In cases of post-exposure prophylaxis, an accelerated vaccination regime is used. This involves administering a vaccination at the time of exposure, followed by repeat doses at one and two months later.
In high-risk situations, Hepatitis B immunoglobulin can be given up to 7 days after exposure. Ideally, it should be administered within 12 hours, but according to the BNF, it can still be effective if given within 7 days after exposure.
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This question is part of the following fields:
- Infectious Diseases
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Question 45
Incorrect
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A 72-year-old man comes to the Emergency Department complaining of fatigue and overall feeling unwell. He is currently taking 5 mg of bendroflumethiazide every day for his high blood pressure. After conducting a complete blood test, it is discovered that his potassium level is 2.0 mmol/l. What type of acid-base disorder would you anticipate in a patient who has potassium depletion due to the use of thiazide diuretics?
Your Answer: Raised anion gap metabolic acidosis
Correct Answer: Metabolic alkalosis
Explanation:Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.
Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.
Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.
Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).
Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.
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This question is part of the following fields:
- Nephrology
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Question 46
Correct
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Your consultant requests you to arrange a teaching session on secondary causes of hypertension. Which of the subsequent electrolyte abnormalities would be in line with a diagnosis of Conn's syndrome?
Your Answer: Hypokalaemia and hypernatraemia
Explanation:Patients with primary hyperaldosteronism typically present with hypertension and hypokalemia. This is due to the fact that aldosterone encourages the reabsorption of sodium and the excretion of potassium, leading to an imbalance in these electrolytes. Additionally, hypernatremia, or high levels of sodium in the blood, is often observed in these patients.
Further Reading:
Hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal glands. It can be classified into primary and secondary hyperaldosteronism. Primary hyperaldosteronism, also known as Conn’s syndrome, is typically caused by adrenal hyperplasia or adrenal tumors. Secondary hyperaldosteronism, on the other hand, is a result of high renin levels in response to reduced blood flow across the juxtaglomerular apparatus.
Aldosterone is the main mineralocorticoid steroid hormone produced by the adrenal cortex. It acts on the distal renal tubule and collecting duct of the nephron, promoting the reabsorption of sodium ions and water while secreting potassium ions.
The causes of hyperaldosteronism vary depending on whether it is primary or secondary. Primary hyperaldosteronism can be caused by adrenal adenoma, adrenal hyperplasia, adrenal carcinoma, or familial hyperaldosteronism. Secondary hyperaldosteronism can be caused by renal artery stenosis, reninoma, renal tubular acidosis, nutcracker syndrome, ectopic tumors, massive ascites, left ventricular failure, or cor pulmonale.
Clinical features of hyperaldosteronism include hypertension, hypokalemia, metabolic alkalosis, hypernatremia, polyuria, polydipsia, headaches, lethargy, muscle weakness and spasms, and numbness. It is estimated that hyperaldosteronism is present in 5-10% of patients with hypertension, and hypertension in primary hyperaldosteronism is often resistant to drug treatment.
Diagnosis of hyperaldosteronism involves various investigations, including U&Es to assess electrolyte disturbances, aldosterone-to-renin plasma ratio (ARR) as the gold standard diagnostic test, ECG to detect arrhythmia, CT/MRI scans to locate adenoma, fludrocortisone suppression test or oral salt testing to confirm primary hyperaldosteronism, genetic testing to identify familial hyperaldosteronism, and adrenal venous sampling to determine lateralization prior to surgery.
Treatment of primary hyperaldosteronism typically involves surgical adrenalectomy for patients with unilateral primary aldosteronism. Diet modification with sodium restriction and potassium supplementation may also be recommended.
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This question is part of the following fields:
- Endocrinology
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Question 47
Correct
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A 45-year-old hiker is brought in by helicopter after being stranded on a hillside overnight. The rescue team informs you that according to the Swiss Staging system, he is at stage II.
What is the most accurate description of his current medical condition?Your Answer: Impaired consciousness without shivering
Explanation:Hypothermia occurs when the core body temperature drops below 35°C. It is categorized as mild (32-35°C), moderate (28-32°C), or severe (<28°C). Rescuers at the scene can use the Swiss staging system to describe the condition of victims. The stages range from clearly conscious and shivering to unconscious and not breathing, with death due to irreversible hypothermia being the most severe stage. There are several risk factors for hypothermia, including environmental exposure, unsatisfactory housing, poverty, lack of cold awareness, drugs, alcohol, acute confusion, hypothyroidism, and sepsis. The clinical features of hypothermia vary depending on the severity. At 32-35°C, symptoms may include apathy, amnesia, ataxia, and dysarthria. At 30-32°C, there may be a decreased level of consciousness, hypotension, arrhythmias, respiratory depression, and muscular rigidity. Below 30°C, ventricular fibrillation may occur, especially with excessive movement or invasive procedures. Diagnosing hypothermia involves checking the core temperature using an oesophageal, rectal, or tympanic probe with a low reading thermometer. Rectal and tympanic temperatures may lag behind core temperature and are unreliable in hypothermia. Various investigations should be carried out, including blood tests, blood glucose, amylase, blood cultures, arterial blood gas, ECG, chest X-ray, and CT head if there is suspicion of head injury or CVA. The management of hypothermia involves supporting the ABCs, treating the patient in a warm room, removing wet clothes and drying the skin, monitoring the ECG, providing warmed, humidified oxygen, correcting hypoglycemia with IV glucose, and handling the patient gently to avoid VF arrest. Re-warming methods include passive re-warming with warm blankets or Bair hugger/polythene sheets, surface re-warming with a water bath, core re-warming with heated, humidified oxygen or peritoneal lavage, and extracorporeal re-warming via cardiopulmonary bypass for severe hypothermia/cardiac arrest. In the case of hypothermic cardiac arrest, CPR should be performed with chest compressions and ventilations at standard rates.
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This question is part of the following fields:
- Environmental Emergencies
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Question 48
Incorrect
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A young man presents to the Emergency Department with symptoms of acute alcohol withdrawal. He is requesting admission for ‘inpatient detox’ and states he would like some ‘medication to alleviate his symptoms’.
Which of the following is NOT a reason for admitting this patient?Your Answer: Age under 16
Correct Answer: Previous successful inpatient detox
Explanation:NICE provides a list of reasons for admitting patients with acute alcohol withdrawal. These include individuals who are deemed to be at risk of experiencing withdrawal seizures or delirium tremens. Additionally, young people under the age of 16 who are going through acute alcohol withdrawal may also require admission. Furthermore, vulnerable individuals, such as those who are frail, have cognitive impairment or multiple comorbidities, lack social support, or have learning difficulties, may also benefit from being admitted for acute alcohol withdrawal. For more information, please refer to the NICE pathway for acute alcohol withdrawal.
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This question is part of the following fields:
- Mental Health
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Question 49
Correct
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A 65 year old female is brought into the emergency department by her husband following a fall. The patient seems unsure about how the fall occurred. The patient's husband takes you aside to express his growing concern about the patient's memory and overall functioning in the past year. He has previously suggested visiting the doctor about it, but the patient has consistently refused, claiming to be perfectly fine. The patient's husband is worried that the patient might be suffering from dementia. What is the leading cause of dementia?
Your Answer: Alzheimer's disease
Explanation:Dementia is a condition characterized by a decline in cognitive abilities, such as memory, thinking, and reasoning, that is severe enough to interfere with daily functioning. There are several different causes of dementia, but the leading cause is Alzheimer’s disease. Alzheimer’s disease is a progressive brain disorder that affects memory, thinking, and behavior. It is the most common cause of dementia, accounting for approximately 60-80% of cases.
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.
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This question is part of the following fields:
- Neurology
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Question 50
Correct
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You evaluate a 48-year-old teacher with a persistent dry cough that has been ongoing for several months. The patient also reports mild shortness of breath while walking around the school. They used to smoke but quit ten years ago. The patient has a normal body temperature and all other vital signs are within normal limits. During the examination, finger clubbing is noted on their hands. Chest examination reveals bilateral fine inspiratory crackles at the bases of both lungs, but no wheezing is detected. Spirometry results came back normal.
What is the SINGLE most likely diagnosis?Your Answer: Idiopathic pulmonary fibrosis
Explanation:Based on the clinical features of this individual, it is highly likely that they have pulmonary fibrosis. The key to determining the correct diagnosis is to differentiate between extrinsic allergic alveolitis (EAA) and idiopathic pulmonary fibrosis (IPF), also known as cryptogenic fibrosing alveolitis (CFA).
In this case, the gentleman does not have any occupational risk factors for EAA and exhibits digital clubbing. While clubbing is not commonly seen in EAA, it is a frequent occurrence in IPF. Therefore, based on these factors, IPF is the more probable diagnosis.
Spirometry results in IPF can either be normal or show a restrictive pattern, whereas an obstructive pattern would be expected in COPD. The history and clinical features presented do not align with the other diagnoses mentioned in this question.
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This question is part of the following fields:
- Respiratory
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Question 51
Correct
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You review a 16-year-old girl who is seeking advice on emergency contraception. The ‘Fraser guidelines’ are used to clarify the legal position of treating individuals under the age of 17 without parental consent.
Which of the following statements does not form part of the Fraser guidelines?Your Answer: That the patient must not have a learning disability or mental illness
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.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 52
Incorrect
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A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving at the Emergency Department. Her pulse rate is 88 bpm, BP is 130/50 mmHg, respiratory rate 16 breaths/minute, and her urine output over the past hour has been 40 ml. She has some bruising evident on her arm and is slightly nervous. The patient weighs approximately 65 kg.
How would you classify her haemorrhage according to the ATLS haemorrhagic shock classification?Your Answer: Class II
Correct Answer: Class I
Explanation:This patient’s physiological parameters are mostly within normal range, but there is an increased pulse pressure and slight anxiety, suggesting a class I haemorrhage. It is crucial to be able to identify the degree of blood loss based on vital signs and mental status changes. The Advanced Trauma Life Support (ATLS) classification for haemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy 70 kg individual. In a 70 kg male patient, the total circulating blood volume is approximately five litres, which accounts for about 7% of their total body weight.
The ATLS haemorrhagic shock classification is as follows:
CLASS I:
– Blood loss: Up to 750 mL
– Blood loss (% blood volume): Up to 15%
– Pulse rate: Less than 100 bpm
– Systolic BP: Normal
– Pulse pressure: Normal (or increased)
– Respiratory rate: 14-20 breaths per minute
– Urine output: Greater than 30 ml/hr
– CNS/mental status: Slightly anxiousCLASS II:
– Blood loss: 750-1500 mL
– Blood loss (% blood volume): 15-30%
– Pulse rate: 100-120 bpm
– Systolic BP: Normal
– Pulse pressure: Decreased
– Respiratory rate: 20-30 breaths per minute
– Urine output: 20-30 ml/hr
– CNS/mental status: Mildly anxiousCLASS III:
– Blood loss: 1500-2000 mL
– Blood loss (% blood volume): 30-40%
– Pulse rate: 120-140 bpm
– Systolic BP: Decreased
– Pulse pressure: Decreased
– Respiratory rate: 30-40 breaths per minute
– Urine output: 5-15 ml/hr
– CNS/mental status: Anxious, confusedCLASS IV:
– Blood loss: More than 2000 mL
– Blood loss (% blood volume): More than 40%
– Pulse rate: Greater than 140 bpm
– Systolic BP: Decreased
– Pulse pressure: Decreased
– Respiratory rate: More than 40 breaths per minute
– Urine output: Negligible
– CNS/mental status: Confused, lethargic -
This question is part of the following fields:
- Trauma
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Question 53
Correct
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You are requested to evaluate a 6-year-old child who has arrived at the emergency department displaying irritability, conjunctivitis, fever, and a widespread rash. Upon further investigation, you discover that the patient is a refugee and has not received several vaccinations. The diagnosis of measles is confirmed.
What guidance should you provide regarding the exclusion of this child from school due to measles?Your Answer: 4 days from onset of rash
Explanation:The current school exclusion advice for certain infectious diseases with a rash is as follows:
– For chickenpox, children should be excluded for at least 5 days from the onset of the rash and until all blisters have crusted over.
– In the case of measles, children should be excluded for 4 days from the onset of the rash, provided they are well enough to attend.
– Mumps requires a 5-day exclusion after the onset of swelling.
– Rubella, also known as German measles, requires a 5-day exclusion from the onset of the rash.
– Scarlet fever necessitates exclusion until 24 hours after starting antibiotic treatment.It is important to note that school exclusion advice has undergone changes in recent years, and the information provided above reflects the updated advice as of May 2022.
Further Reading:
Measles is a highly contagious viral infection caused by an RNA paramyxovirus. It is primarily spread through aerosol transmission, specifically through droplets in the air. The incubation period for measles is typically 10-14 days, during which patients are infectious from 4 days before the appearance of the rash to 4 days after.
Common complications of measles include pneumonia, otitis media (middle ear infection), and encephalopathy (brain inflammation). However, a rare but fatal complication called subacute sclerosing panencephalitis (SSPE) can also occur, typically presenting 5-10 years after the initial illness.
The onset of measles is characterized by a prodrome, which includes symptoms such as irritability, malaise, conjunctivitis, and fever. Before the appearance of the rash, white spots known as Koplik spots can be seen on the buccal mucosa. The rash itself starts behind the ears and then spreads to the entire body, presenting as a discrete maculopapular rash that becomes blotchy and confluent.
In terms of complications, encephalitis typically occurs 1-2 weeks after the onset of the illness. Febrile convulsions, giant cell pneumonia, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis are also possible complications of measles.
When managing contacts of individuals with measles, it is important to offer the MMR vaccine to children who have not been immunized against measles. The vaccine-induced measles antibody develops more rapidly than that following natural infection, so it should be administered within 72 hours of contact.
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This question is part of the following fields:
- Infectious Diseases
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Question 54
Incorrect
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A 25-year-old patient complains of a red and painful right eye. Upon examination, you observe conjunctival erythema. There is also mucopurulent discharge and lid crusting present in the eye. Based on the current NICE guidance, what is the recommended first-line antibiotic for treating bacterial conjunctivitis?
Your Answer: Chloramphenicol 1% drops
Correct Answer: Chloramphenicol 1% ointment
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.
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This question is part of the following fields:
- Ophthalmology
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Question 55
Correct
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A 45 year old female patient has been brought to the emergency department with multiple injuries following a fall while hiking in the mountains. You observe significant injuries to the face. There is also bruising to the chest wall and a fracture dislocation to the ankle. The patient has undergone rapid sequence induction with Propofol and Suxamethonium. A chest X-ray shows multiple rib fractures but no pneumothorax or visible pulmonary contusion. You notice that the patient's end tidal CO2 has steadily increased since being intubated from 4.5 KPa to 7.4 KPa. You observe esophageal temperature is 39.3ºC. What is the likely cause of these readings?
Your Answer: Malignant hyperthermia
Explanation:The earliest and most frequent clinical indication of malignant hyperthermia is typically an increase in end tidal CO2. An unexplained elevation in end tidal CO2 is often the initial and most reliable sign of this condition.
Further Reading:
Malignant hyperthermia is a rare and life-threatening syndrome that can be triggered by certain medications in individuals who are genetically susceptible. The most common triggers are suxamethonium and inhalational anaesthetic agents. The syndrome is caused by the release of stored calcium ions from skeletal muscle cells, leading to uncontrolled muscle contraction and excessive heat production. This results in symptoms such as high fever, sweating, flushed skin, rapid heartbeat, and muscle rigidity. It can also lead to complications such as acute kidney injury, rhabdomyolysis, and metabolic acidosis. Treatment involves discontinuing the trigger medication, administering dantrolene to inhibit calcium release and promote muscle relaxation, and managing any associated complications such as hyperkalemia and acidosis. Referral to a malignant hyperthermia center for further investigation is also recommended.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 56
Incorrect
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A 25-year-old from West Africa presents with joint pain, muscle pain, and symptoms similar to the flu. In the past day or two, he has also developed stomach pain and diarrhea. During the examination, his temperature is measured at 38.7°C, and he experiences tenderness in the upper right quadrant of his abdomen along with an enlarged liver and spleen. He remembers having an itchy rash and a few blisters on his arm after swimming in a local river a few weeks ago. Blood tests show a significant increase in eosinophils.
What is the MOST appropriate initial treatment option?Your Answer: Mebendazole
Correct Answer: Praziquantel
Explanation:Schistosomiasis, also known as bilharzia, is a tropical disease caused by parasitic trematodes (flukes) of the Schistosoma type. It is transmitted through contaminated water that has been contaminated with faeces or urine containing eggs. The disease requires a specific freshwater snail as an intermediate host and human contact with water inhabited by the snail. There are five species of Schistosoma that cause human disease: S. japonicum, S. mansoni, S. haematobium, S. intercalatum, and S. mekongi. Schistosomiasis is a significant public health issue, second only to malaria, with over 200 million people infected worldwide. It is prevalent in the Middle East, Africa, and parts of South America and the Caribbean. Infection can manifest as acute or chronic.
Acute schistosomiasis is characterized by the early clinical sign of swimmers itch, which causes blisters and an urticarial response in the area where the parasite enters the skin. Most acute infections are asymptomatic, but some patients may develop an acute syndrome. The most common acute syndrome is known as Katayama fever, which typically occurs in individuals with no previous exposure. It is caused by an allergic reaction to the sudden release of highly antigenic eggs and usually presents a few weeks after initial exposure to S. japonicum. Symptoms of Katayama fever include fever, flu-like illness, arthralgia, myalgia, abdominal pain, diarrhea, and cough. Patients may also experience right upper quadrant tenderness and hepatosplenomegaly. An extremely high eosinophil count is commonly observed.
Chronic schistosomiasis can manifest as intestinal or urogenital forms. Intestinal schistosomiasis occurs when adult worms migrate from the liver to the mesenteric venules, where female worms continuously lay eggs. Common symptoms include abdominal pain and bloody diarrhea. Advanced cases may present with hepatosplenomegaly and portal hypertension. Schistosomiasis is the second most common cause of oesophageal varices worldwide. Urogenital schistosomiasis occurs when adult worms migrate to the vesical plexus. The hallmark sign is haematuria. In women, it may cause genital and vaginal lesions, as well as dyspareunia.
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This question is part of the following fields:
- Infectious Diseases
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Question 57
Correct
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A 55-year-old man on treatment for a urinary tract infection returns after 48 hours because his symptoms have not improved. Unfortunately, the sensitivities from the urine sample that was sent to the lab are still unavailable. He has a history of chronic kidney disease, and his blood tests today show that his eGFR is 40 ml/minute. He has been taking trimethoprim 200 PO BD for the past two days.
Which of the following antibiotics is the most suitable to prescribe in this situation?Your Answer: Pivmecillinam
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.
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This question is part of the following fields:
- Urology
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Question 58
Correct
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Following the case of a 45 year old male who was treated in the resuscitation bay for hypovolaemic shock following a secondary post-tonsillectomy haemorrhage, your consultant requests you to prepare a teaching session for the junior doctors on the topic.
Concerning secondary post-tonsillectomy bleeding, at what age does this usually occur?Your Answer: 5-10 days post procedure
Explanation:Secondary post-tonsillectomy hemorrhage commonly happens between 5 to 10 days after the procedure. This type of bleeding is usually caused by the shedding of the eschar, injury from eating solid foods, infection in the tonsil bed, use of nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery, or unknown reasons.
Further Reading:
Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.
Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.
Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.
The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.
Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.
Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.
If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 59
Correct
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A 25 year old woman is brought to the emergency department by her roommate after intentionally overdosing on amitriptyline. What is a typical clinical sign of toxicity in this case?
Your Answer: Dilated pupils
Explanation:An overdose of Amitriptyline can lead to the development of an anticholinergic toxidrome. This toxidrome is characterized by various symptoms, which can be remembered using the phrase ‘mad as a hatter, hot as hell, red as a beat, dry as a bone, and blind as a bat’. Some of these symptoms include a dry mouth and an elevated body temperature.
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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 60
Correct
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A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
Which of the following will be visible on her X-ray?Your Answer: Fracture of the zygomatic arch
Explanation:Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.
These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:
1. Widening of the zygomaticofrontal suture
2. Fracture of the zygomatic arch
3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
4. Fracture of the lateral orbital rim. -
This question is part of the following fields:
- Maxillofacial & Dental
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Question 61
Correct
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A 60-year-old man comes in with decreased vision and floaters in his right eye. Upon fundoscopy, you observe a section of sensory retina protruding towards the center of the eye. A diagnosis of retinal detachment is confirmed.
Which of the following statements about retinal detachment is correct?Your Answer: A retina which remains fixed at six months post-surgical repair is unlikely to become detached again
Explanation:Retinal detachment is a condition where the retina separates from the retinal pigment epithelium, resulting in a fluid-filled space between them. This case presents a classic description of retinal detachment. Several risk factors increase the likelihood of developing this condition, including myopia, being male, having a family history of retinal detachment, previous episodes of retinal detachment, blunt ocular trauma, previous cataract surgery, diabetes mellitus (especially if proliferative retinopathy is present), glaucoma, and cataracts.
The clinical features commonly associated with retinal detachment include flashes of light, particularly at the edges of vision (known as photopsia), a dense shadow in the peripheral vision that spreads towards the center, a sensation of a curtain drawing across the eye, and central visual loss. Fundoscopy, a procedure to examine the back of the eye, reveals a sheet of sensory retina billowing towards the center of the eye. Additionally, a positive Amsler grid test, where straight lines appear curved or wavy, may indicate retinal detachment.
Other possible causes of floaters include posterior vitreous detachment, retinal tears, vitreous hemorrhage, and migraine with aura. However, in this case, the retinal appearance described is consistent with retinal detachment.
It is crucial to arrange an urgent same-day ophthalmology referral for this patient. Fortunately, approximately 90% of retinal detachments can be successfully repaired with one operation, and an additional 6% can be salvaged with subsequent procedures. If the retina remains fixed six months after surgery, the likelihood of it becoming detached again is low.
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This question is part of the following fields:
- Ophthalmology
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Question 62
Incorrect
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A 42-year-old woman presents with a skin condition that has occurred secondary to a systemic illness that she suffers from.
Which skin condition is NOT correctly paired with its associated systemic illness?Your Answer: Pyoderma gangrenosum and ulcerative colitis
Correct Answer: Vitiligo and Cushing’s disease
Explanation:Many systemic illnesses have distinct dermatological associations. Some of these are listed below:
Addison’s disease is characterized by pigmentation and vitiligo.
Cushing’s disease is associated with pigmentation, striae, hirsutism, and acne.
Diabetes mellitus can cause necrobiosis lipoidica, which presents as shiny, yellowish plaques on the shin. It can also lead to xanthoma, a condition characterized by yellowish lipid deposits in the skin, and granuloma annulare, which manifests as palpable ring lesions on the hands, face, or feet.
Hyperlipidemia is linked to xanthoma and xanthomata, which are yellowish plaques on the eyelids.
Crohn’s disease is associated with erythema nodosum.
Ulcerative colitis can cause pyoderma gangrenosum and erythema nodosum.
Liver disease often presents with pruritus, spider naevi, and erythema.
Malignancy can lead to mycosis fungoides, a type of lymphoma that affects the skin. It is also associated with acanthosis nigricans, which is often seen in gastrointestinal malignancies.
Hypothyroidism is linked to alopecia, while thyrotoxicosis can cause both alopecia and pretibial myxedema.
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This question is part of the following fields:
- Dermatology
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Question 63
Incorrect
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A 45-year-old woman presents with symptoms of confusion. An MRI scan is performed, which reveals a temporal lobe infarct.
Which SINGLE clinical feature would you NOT anticipate to observe during the examination of this patient?Your Answer: Receptive dysphasia
Correct Answer: Expressive dysphasia
Explanation:The temporal lobes play a crucial role in various functions such as processing visual and auditory information, storing memories, and helping us categorize objects. However, if this area of the brain is affected by a stroke, a space-occupying lesion, or trauma, it can lead to several issues. These include problems with understanding and producing language (known as receptive dysphasia), difficulty recognizing faces (prosopagnosia), an inability to categorize objects, difficulty understanding auditory information (auditory agnosia), and impaired perception of music.
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This question is part of the following fields:
- Neurology
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Question 64
Correct
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You evaluate a 45-year-old man with a history of difficult-to-control hypertension. His initial diagnosis was made after ambulatory blood pressure monitoring. He is currently taking Lisinopril 10 mg once daily and Amlodipine 10 mg once daily. Despite this treatment, his blood pressure today is 156/98. On examination, he appears normal and is otherwise in good health. A recent blood test shows the following results:
Sodium: 145 mmol/L (135-147 mmol/L)
Potassium: 3.2 mmol/L (3.5-5.5 mmol/L)
Urea: 6.3 mmol/L (2.0-6.6 mmol/L)
Creatinine: 88 mmol/L (75-125 mmol/L)
What is the MOST LIKELY diagnosis?Your Answer: Primary hyperaldosteronism
Explanation:The most probable diagnosis in this case is primary hyperaldosteronism, which is caused by either an adrenal adenoma (Conn’s syndrome) or bilateral idiopathic adrenal hyperplasia. Conn’s syndrome is likely in a patient who has difficult-to-control hypertension, low levels of potassium (hypokalaemia), and elevated or high normal levels of sodium. If the aldosterone:renin ratio is raised (>30), it further suggests primary hyperaldosteronism. CT scanning can be used to differentiate between an adrenal adenoma and adrenal hyperplasia. Treatment for hyperaldosteronism caused by an adenoma typically involves 4-6 weeks of spironolactone therapy followed by surgical removal of the adenoma. Adrenal hyperplasia usually responds well to potassium-sparing diuretics alone, such as spironolactone or amiloride.
Renal artery stenosis could also be suspected in a case of resistant hypertension, but it would be expected to cause a decline in renal function when taking a full dose of an ACE inhibitor like ramipril. However, in this case, the patient’s renal function is completely normal.
Phaeochromocytoma is associated with symptoms such as headaches, palpitations, tremors, and excessive sweating. The hypertension in phaeochromocytoma tends to occur in episodes. Since these symptoms are absent in this patient, a diagnosis of phaeochromocytoma is unlikely.
Cushing’s syndrome is characterized by various other clinical features, including weight gain, central obesity, a hump-like accumulation of fat on the back (buffalo hump), muscle wasting in the limbs, excessive hair growth (hirsutism), thinning of the skin, easy bruising, acne, and depression. Since this patient does not exhibit any of these features, Cushing’s syndrome is unlikely.
White coat syndrome is an unlikely diagnosis in this case because the initial diagnosis of hypertension was made based on ambulatory blood pressure monitoring.
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This question is part of the following fields:
- Endocrinology
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Question 65
Incorrect
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A 68-year-old diabetic man presents with a gradual decrease in consciousness and confusion over the past week. He normally controls his diabetes with metformin 500 mg twice a day. He recently received treatment for a urinary tract infection from his GP, and his family reports that he has been excessively thirsty. He has vomited multiple times today. A urine dipstick test shows a trace of leukocytes and 2+ ketones. The results of his arterial blood gas analysis are as follows:
pH: 7.29
pO2: 11.1 kPa
pCO2: 4.6 kPa
HCO3-: 22 mmol/l
Na+: 154 mmol/l
K+: 3.2 mmol/l
Cl-: 100 mmol/l
Urea: 17.6 mmol/l
Glucose: 32 mmol/l
Which investigation would be most helpful in guiding his management?Your Answer: Serum glucose
Correct Answer: Serum 3β-hydroxybutyrate
Explanation:In an elderly patient with a history of gradual decline accompanied by symptoms of hyperglycemia, excessive thirst, recent infection, and very high blood sugar levels, the most likely diagnosis is a hyperosmolar hyperglycemic state (HHS). This condition can be life-threatening, with a mortality rate of approximately 50%. Common symptoms include high blood sugar levels, dehydration, altered mental status, and electrolyte imbalances. About 50% of patients with HHS also experience hypernatremia, an elevated sodium level in the blood.
To calculate the serum osmolality, the following formula can be used: 2 (K+ + Na+) + urea + glucose. In this particular case, the calculation would be 2 (3.2 + 154) + 17.6 + 32 = 364 mmol/l. Patients with HHS typically have a serum osmolality greater than 350 mmol/l.
In order to manage HHS, it is important to address the underlying cause and gradually and safely achieve the following goals:
1. Normalize the osmolality
2. Replace fluid and electrolyte losses
3. Normalize blood glucose levelsGiven the presence of 1+ ketones in the patient’s urine, which is likely due to vomiting and a mild acidosis, it is recommended to discontinue the use of metformin due to the risk of metformin-associated lactic acidosis (MALA). Additionally, an intravenous infusion of insulin should be initiated in this case.
If significant ketonaemia is present (3β-hydroxybutyrate is more than 1 mmol/L), it indicates a relative deficiency of insulin, and insulin treatment should be started immediately. However, if significant ketonaemia is not present, insulin should not be initiated.
Patients with HHS are at a high risk of developing thromboembolism, and therefore, routine administration of low molecular weight heparin is recommended. In cases where the serum osmolality exceeds 350 mmol/l, full heparinization should be considered.
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This question is part of the following fields:
- Endocrinology
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Question 66
Incorrect
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A 25-year-old man comes in with a persistent sore throat that has lasted for five days. He denies having a cough. During the examination, his temperature is measured at 39°C and a few tender anterior cervical lymph nodes are found. There is a noticeable amount of exudate on his right tonsil, which appears red and inflamed.
What is his FeverPAIN score?Your Answer: 3
Correct Answer: 4
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.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 67
Incorrect
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A patient presenting with abdominal pain and abnormal liver function tests undergoes hepatitis screening and is found to have chronic hepatitis B infection.
Which ONE blood test result is indicative of a patient being chronically infected with hepatitis B?Your Answer: HBsAg positive, anti-HBs positive, anti-HBc negative
Correct Answer: HBsAg positive, anti-HBc positive, IgM anti-HBc negative
Explanation:Hepatitis B surface antigen (HBsAg) is a protein found on the surface of the hepatitis B virus. It can be detected in high levels in the blood during both acute and chronic hepatitis B virus infections. The presence of HBsAg indicates that the person is capable of spreading the infection to others. Normally, the body produces antibodies to HBsAg as part of the immune response to the infection. HBsAg is also used to create the hepatitis B vaccine.
Hepatitis B surface antibody (anti-HBs) indicates that a person has recovered from the hepatitis B virus infection and is now immune to it. This antibody can also develop in individuals who have been successfully vaccinated against hepatitis B.
Total hepatitis B core antibody (anti-HBc) appears when symptoms of acute hepatitis B begin and remains present for life. The presence of anti-HBc indicates that a person has either had a previous or ongoing infection with the hepatitis B virus, although the exact time frame cannot be determined. This antibody is not present in individuals who have received the hepatitis B vaccine.
IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates a recent infection or acute hepatitis B. If this antibody is present, it suggests that the infection occurred within the past six months.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 68
Correct
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A 35-year-old woman presents with watery diarrhea that has been present since her return from a hiking trip in Peru 8 weeks ago. She has also experienced abdominal cramps and bloating and excessive gas. Stool cultures were done, which came back negative. She was referred to a gastroenterologist and had a small bowel tissue biopsy, which showed subtotal villous atrophy.
What is the SINGLE most suitable next step in management?Your Answer: Commence metronidazole
Explanation:This patient is displaying symptoms consistent with a malabsorption syndrome, which is supported by the findings of subtotal villous atrophy in his small bowel biopsy. Based on this information, the possible causes can be narrowed down to tropical sprue, coeliac disease, and giardiasis.
Considering that the patient was previously healthy before his trip to Nepal, it is unlikely that he has coeliac disease. Additionally, tropical sprue is rare outside of the regions around the equator and is uncommon in Nepal. On the other hand, giardiasis is prevalent in Nepal and is the most probable cause of the patient’s symptoms.
Giardiasis is a chronic diarrheal illness caused by a parasite called Giardia lamblia. Infection occurs when individuals ingest cysts present in contaminated food or water. Common symptoms associated with giardiasis include chronic diarrhea, weakness, abdominal cramps, flatulence, smelly and greasy stools, nausea, vomiting, and weight loss.
Stool culture often yields negative results, so the preferred diagnostic test is a stool ova and parasite (O&P) examination. This test should be repeated three times for accuracy. Additionally, the small bowel biopsy should be re-evaluated to check for the presence of Giardia lamblia.
The standard treatment for giardiasis involves antibiotic therapy with a nitroimidazole antibiotic, such as metronidazole.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 69
Correct
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A 72-year-old woman comes in with a history of passing fresh red blood mixed in with her last three bowel movements. She is experiencing low blood pressure, and her shock index is calculated to be 1.4.
Which initial investigation is recommended for hospitalized patients with lower gastrointestinal bleeding who are in a state of hemodynamic instability?Your Answer: CT angiography
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 70
Incorrect
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A 30-year-old woman is given a medication for a medical condition during her pregnancy. As a result, the newborn is born with a neural tube defect and hemorrhagic disease of the newborn.
Which of the listed medications is the most probable cause of these abnormalities?Your Answer: Heparin
Correct Answer: Carbamazepine
Explanation:There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.
Below is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.
Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.
Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.
Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 71
Correct
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A 42-year-old woman presents with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever felt. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in open-toed sandals. The skin over the affected area appears red and shiny.
What is the MOST likely diagnosis?Your Answer: Gout
Explanation:The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, and if acute pain develops in that joint over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. Pseudogout is also a possibility, but it is much less likely. In this case, gout is the most probable diagnosis.
The joint that is most commonly affected in acute gout is the first metatarsal-phalangeal joint, which accounts for 50-75% of cases.
The main cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.
For the treatment of acute gout attacks, NSAIDs or colchicine are generally used.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 72
Correct
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A patient presents with a history of feeling constantly thirsty and urinating large amounts. She also experiences extreme fatigue. A diagnosis of diabetes mellitus is suspected, and a fasting blood glucose sample is scheduled.
What is the current WHO threshold for diagnosing diabetes mellitus using a fasting blood sample in this case?Your Answer: 7 mmol/l
Explanation:According to the 2011 recommendations from the World Health Organization (WHO), the following criteria are used to diagnose diabetes mellitus:
– A random venous plasma glucose concentration that exceeds 11.1 mmol/l.
– A fasting plasma glucose concentration that is higher than 7.0 mmol/l.
– A two-hour plasma glucose concentration that exceeds 11.1 mmol/l, measured two hours after consuming 75g of anhydrous glucose during an oral glucose tolerance test (OGTT).
– An HbA1c level that is greater than 48 mmol/mol (equivalent to 6.5%).These guidelines provide specific thresholds for diagnosing diabetes mellitus based on various glucose measurements and HbA1c levels. It is important for healthcare professionals to consider these criteria when evaluating individuals for diabetes mellitus.
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This question is part of the following fields:
- Endocrinology
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Question 73
Correct
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A 32-year-old man that has been involved in a car crash develops symptoms of acute airway blockage. You determine that he needs intubation through a rapid sequence induction. You intend to use etomidate as your induction medication.
Etomidate functions by acting on what type of receptor?Your Answer: Gamma-aminobutyric acid (GABA)
Explanation:Etomidate is a derivative of imidazole that is commonly used to induce anesthesia due to its short-acting nature. Its main mechanism of action is believed to involve the modulation of fast inhibitory synaptic transmission within the central nervous system by acting on GABA type A receptors.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 74
Correct
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A 32 year old male is brought into the emergency department following a car accident. You evaluate the patient's risk of cervical spine injury using the Canadian C-spine rule. What is included in the assessment for the Canadian C-spine rule?
Your Answer: Ask patient to rotate their neck 45 degrees to the left and right
Explanation:The Canadian C-spine assessment includes evaluating for tenderness along the midline of the spine, checking for any abnormal sensations in the limbs, and assessing the ability to rotate the neck 45 degrees to the left and right. While a significant portion of the assessment relies on gathering information from the patient’s history, there are also physical examination components involved. These include testing for tenderness along the midline of the cervical spine, asking the patient to perform neck rotations, ensuring they are comfortable in a sitting position, and assessing for any sensory deficits in the limbs. It is important to note that any reported paraesthesia in the upper or lower limbs can also be taken into consideration during the assessment.
Further Reading:
When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.
If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.
NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.
Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.
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This question is part of the following fields:
- Trauma
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Question 75
Correct
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What is the mode of action of VX gas in a suspected CBRN incident with a high number of casualties?
Your Answer: Inhibition of acetylcholinesterase
Explanation:The nerve agents, also known as nerve gases, are a group of highly toxic chemical warfare agents that were initially developed just before and during World War II.
The first compounds to be created are referred to as the G agents (with G representing German, as they were discovered and synthesized by German scientists). These include Tabun (GA), Sarin (GB), and Soman (GD).
In the 1950s, the V agents (with V standing for venomous) were synthesized, and they are approximately 10 times more poisonous than sarin. These include Venomous agent X (VX), Venomous agent E (VE), Venomous agent G (VG), and Venomous agent M (VM).
One of the most well-known incidents involving the use of a nerve agent was the March 1995 Tokyo subway sarin attack. During this attack, Sarin was released into the Tokyo subway system during rush hour. As a result, over 5,000 people sought medical attention. Among them, 984 were moderately poisoned, 54 were severely poisoned, and 12 lost their lives.
The nerve agents are organophosphorus esters that are chemically related to organophosphorus insecticides. They work by inhibiting acetylcholinesterase (AChE), an enzyme that breaks down the neurotransmitter acetylcholine (ACh). This leads to an accumulation of ACh at both muscarinic and nicotinic cholinergic receptors.
Nerve agents can be absorbed through any body surface. When dispersed as a spray or aerosol, they can be absorbed through the skin, eyes, and respiratory tract. When dispersed as a vapor, they are primarily absorbed through the respiratory tract and eyes. If a sufficient amount of agent is absorbed, local effects are followed by generalized systemic effects.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 76
Correct
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An 8-year-old boy is brought to the emergency department by concerned parents. The parents inform you that the patient has had a fever with temperatures ranging between 37.5 and 38.1ºC and a runny nose for a few days before developing a barking cough. During examination, you observe stridor at rest and moderate sternal recession (retractions). The child appears lethargic and does not consistently respond to verbal stimuli. Oxygen saturation levels are 94% on air, and there is marked bilateral decreased air entry upon auscultation of the chest. The child's mother inquires if this could be croup.
Your consultant requests you to calculate the Westley score for this child. What is the correct score?Your Answer: 11
Explanation:Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.
The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.
In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.
Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.
When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies
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This question is part of the following fields:
- Paediatric Emergencies
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Question 77
Correct
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A 45-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few days with vomiting and diarrhea. His wife tells you that he was started on a medication by his GP six months ago for pain and stiffness around his shoulders, upper arms, and hips. She describes this medication as being '6 small blue tablets.' He has been unable to take these tablets for the past few days. On examination, he is pale and sweaty and appears confused. His observations are as follows: temperature 36.9°C, HR 140 bpm, BP 83/42, RR 24, SaO2 98% on 2 L oxygen, GCS 14. He has intravenous access in situ, and his BM stick glucose is 2.1.
Which rheumatological condition is it most likely that his GP is treating?Your Answer: Polymyalgia rheumatica
Explanation:This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. The most likely underlying rheumatological diagnosis in this case is polymyalgia rheumatica, and it is likely that the GP started the patient on prednisolone medication.
Addison’s disease occurs when the adrenal glands underproduce steroid hormones, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.
An Addisonian crisis is most commonly triggered by the deliberate or accidental withdrawal of steroid therapy in patients with Addison’s disease. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.
The clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main features are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and coma.
Biochemically, Addison’s disease is characterized by increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may include the Synacthen test, plasma ACTH level, plasma renin level, and adrenocortical antibodies.
Management of Addison’s disease should be overseen by an Endocrinologist. Typically, patients require hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet, being aware of the possibility of an Addisonian crisis.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 78
Correct
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You are summoned to aid a 67-year-old patient who is in resus and has experienced two defibrillation attempts for cardiac arrest. Unfortunately, there is no supply of amiodarone available, so your consultant requests you to prepare lidocaine for administration following the next shock. What is the mechanism of action of lidocaine in the context of cardiac arrest?
Your Answer: Blockade of sodium channels
Explanation:Lidocaine functions by inhibiting the activity of voltage-gated sodium channels, preventing the flow of sodium ions through these channels.
Further Reading:
In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.
Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.
Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.
Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.
Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.
Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.
It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 79
Correct
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A 35-year-old woman comes in with an ear injury that happened while playing soccer earlier today. The helix of her ear is swollen, red, and causing pain. The swelling is soft and can be compressed.
What is the SINGLE most probable diagnosis?Your Answer: Auricular subchondral haematoma
Explanation:This patient has developed an acute auricular subchondral haematoma. It occurs when blood and serum collect in the space between the cartilage and the supporting perichondrium due to a shearing force that separates the perichondrium from the underlying cartilage.
It is important to differentiate this condition from cauliflower ear, which is a common complication that arises when an auricular haematoma is not treated. If a subchondral haematoma is left untreated, the damaged perichondrium forms a fibrocartilage plate, leading to scarring and cartilage regeneration. This results in an irregular and thickened pinna, typically along the helical rim.
The management of an auricular haematoma involves the following steps:
1. Infiltration with a local anaesthetic, such as 1% lidocaine.
2. Drainage or needle aspiration of the haematoma.
3. Application of firm packing and compression bandaging to prevent re-accumulation.
4. Administration of broad-spectrum antibiotics.By following these management steps, the patient can effectively address and treat the auricular haematoma.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 80
Correct
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A 35-year-old woman comes in with a femoral shaft fracture sustained in a car accident. You have been requested to administer a femoral nerve block.
Which of the following two landmarks should be utilized?Your Answer: The anterior superior iliac spine and the pubic symphysis
Explanation:To perform a landmark guided femoral nerve block, first locate the inguinal ligament. This can be done by drawing an imaginary line between the anterior superior iliac spine (ASIS) and the pubic symphysis. The femoral nerve passes through the center of this line and is most superficial at the level of the inguinal crease.
Next, palpate the femoral pulse at the level of the inguinal ligament. The femoral nerve is located approximately 1-1.5 cm lateral to this point. This is where the needle entry point should be.
By following these steps and using the landmarks provided, you can accurately perform a femoral nerve block.
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This question is part of the following fields:
- Pain & Sedation
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Question 81
Correct
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Your hospital’s neurology department is currently evaluating the utility of a triple marker test for use in diagnosing patients with suspected stroke. The test will use brain natriuretic peptide (BNP), neuron-specific enolase (NSE), and S100B protein.
How long after a stroke do levels of glial fibrillary acidic protein (GFAP) start to increase?Your Answer: 4-8 hours
Explanation:The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.
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This question is part of the following fields:
- Cardiology
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Question 82
Correct
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A 32 year old female presents to the emergency department after an explosion occurred in her garage. The patient reports inhaling fumes and experiencing symptoms of nausea and dizziness since then. While triaging the patient, law enforcement officers arrive to interview her and inform you that the patient seemed to be operating a methamphetamine lab in her garage, which contained various dangerous chemicals. Your plan is to initiate decontamination procedures. Which of the following methods has been proven to eliminate up to 90% of the contamination?
Your Answer: Removal of patient clothing to underwear
Explanation:To remove contaminated material, it is recommended to remove and dispose of clothing. It is important to seal the clothing and treat it as hazardous waste. If wet decontamination is being utilized, patients should shower using warm water and detergent.
Further Reading:
Chemical incidents can occur as a result of leaks, spills, explosions, fires, terrorism, or the use of chemicals during wars. Industrial sites that use chemicals are required to conduct risk assessments and have accident plans in place for such incidents. Health services are responsible for decontamination, unless mass casualties are involved, and all acute health trusts must have major incident plans in place.
When responding to a chemical incident, hospitals prioritize containment of the incident and prevention of secondary contamination, triage with basic first aid, decontamination if not done at the scene, recognition and management of toxidromes (symptoms caused by exposure to specific toxins), appropriate supportive or antidotal treatment, transfer to definitive treatment, a safe end to the hospital response, and continuation of business after the event.
To obtain advice when dealing with chemical incidents, the two main bodies are Toxbase and the National Poisons Information Service. Signage on containers carrying chemicals and material safety data sheets (MSDS) accompanying chemicals also provide information on the chemical contents and their hazards.
Contamination in chemical incidents can occur in three phases: primary contamination from the initial incident, secondary contamination spread via contaminated people leaving the initial scene, and tertiary contamination spread to the environment, including becoming airborne and waterborne. The ideal personal protective equipment (PPE) for chemical incidents is an all-in-one chemical-resistant overall with integral head/visor and hands/feet worn with a mask, gloves, and boots.
Decontamination of contaminated individuals involves the removal and disposal of contaminated clothing, followed by either dry or wet decontamination. Dry decontamination is suitable for patients contaminated with non-caustic chemicals and involves blotting and rubbing exposed skin gently with dry absorbent material. Wet decontamination is suitable for patients contaminated with caustic chemicals and involves a warm water shower while cleaning the body with simple detergent.
After decontamination, the focus shifts to assessing the extent of any possible poisoning and managing it. The patient’s history should establish the chemical the patient was exposed to, the volume and concentration of the chemical, the route of exposure, any protective measures in place, and any treatment given. Most chemical poisonings require supportive care using standard resuscitation principles, while some chemicals have specific antidotes. Identifying toxidromes can be useful in guiding treatment, and specific antidotes may be administered accordingly.
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This question is part of the following fields:
- Environmental Emergencies
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Question 83
Correct
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You assess a patient who has recently been diagnosed with chronic myeloid leukemia (CML).
Which ONE statement about CML is accurate?Your Answer: The Philadelphia chromosome is present in over 80% of cases
Explanation:Chronic myeloid leukaemia (CML) is a type of blood disorder that arises from an abnormal pluripotent haemopoietic stem cell. The majority of CML cases, more than 80%, are caused by a cytogenetic abnormality called the Philadelphia chromosome. This abnormality occurs when there is a reciprocal translocation between the long arms of chromosomes 9 and 22.
CML typically develops slowly over a period of several years, known as the chronic stage. During this stage, patients usually do not experience any symptoms, and it is often discovered incidentally through routine blood tests. Around 90% of CML cases are diagnosed during this stage. In the bone marrow, less than 10% of the white cells are immature blasts.
Symptoms start to appear when the CML cells begin to expand, which is known as the accelerated stage. Approximately 10% of cases are diagnosed during this stage. Between 10 and 30% of the blood cells in the bone marrow are blasts at this point. Common clinical features during this stage include tiredness, fatigue, fever, night sweats, abdominal distension, left upper quadrant pain (splenic infarction), splenomegaly (enlarged spleen), hepatomegaly (enlarged liver), easy bruising, gout (due to rapid cell turnover), and hyperviscosity (which can lead to complications like stroke, priapism, etc.).
In some cases, a small number of patients may present with a blast crisis, also known as the blast stage. During this stage, more than 30% of the blood cells in the bone marrow are immature blast cells. Patients in this stage are generally very ill, experiencing severe constitutional symptoms such as fever, weight loss, and bone pain, as well as infections and bleeding tendencies.
Laboratory findings in CML include a significantly elevated white cell count (often greater than 100 x 109/l), a left shift with an increased number of immature leukocytes, mild to moderate normochromic, normocytic anaemia, variable platelet counts (low, normal, or elevated), presence of the Philadelphia chromosome in more than 80% of cases, and elevated levels of serum uric acid and alkaline phosphatase.
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This question is part of the following fields:
- Haematology
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Question 84
Correct
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A 60-year-old woman presents to the Emergency Department following an episode of hematemesis. You assess her risk using a scoring system to determine whether or not she can be discharged.
Which of the following scoring systems is most suitable to use in this scenario?Your Answer: Glasgow-Blatchford score
Explanation:The Glasgow-Blatchford Score (GBS) is a helpful tool for determining whether patients with acute upper gastrointestinal bleeding (AUGIB) can be discharged from emergency departments. Patients with scores of less than 1 can be considered for discharge. Unlike the full Rockall score, the GBS does not rely on endoscopic findings. The full Rockall score is also used to assess risk in patients with AUGIB, but it relies on endoscopic findings and is not suitable for use during initial assessment. The Oakland score, on the other hand, is an assessment tool specifically designed for evaluating risk in patients with acute lower gastrointestinal bleeding (ALGIB). The EVendo scoring system is used to predict the presence and size of oesophageal varices before screening endoscopy in patients over 18 years old with known or suspected liver cirrhosis. Lastly, the HAS-BLED scoring system is used to estimate the risk of major bleeding in patients on anticoagulation therapy, helping to assess the risk-benefit in atrial fibrillation care.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 85
Correct
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. Her urine test shows blood. A CT scan is scheduled and confirms a diagnosis of ureteric colic. She was given diclofenac through an intramuscular injection, but her pain is still not well managed.
According to the latest NICE guidelines, what is the recommended next option for pain relief in this patient?Your Answer: Intravenous paracetamol
Explanation:Renal colic, also known as ureteric colic, refers to 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. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 86
Incorrect
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A 32-year-old man recently suffered a fracture in his right wrist. His cast has been taken off, and he visits you with worries about his right hand. Since the fracture, he has experienced tingling sensations in his thumb and has accidentally dropped items from his right hand a few times. These symptoms have not shown any improvement after the removal of the cast.
What is the MOST probable diagnosis?Your Answer: Carpal tunnel syndrome
Correct Answer: Ulnar neuritis
Explanation:Ulnar neuritis is characterized by hand clumsiness and can progress to muscle weakness and wasting in the ulnar nerve-supplied muscles. It may also cause numbness or tingling in the little finger and medial half of the ring finger. This condition is caused by the narrowing of the ulnar groove at the elbow and is associated with risk factors such as osteoarthritis, trauma, and rheumatoid arthritis. Nerve conduction studies and surgical decompression may be necessary for diagnosis and treatment.
De Quervain’s tenosynovitis occurs when there is inflammation of the thumb extensor and abductor tendon sheaths. This leads to pain over the radial styloid, which worsens with forced adduction and flexion of the thumb. Treatment options include anti-inflammatory medications, thumb splints, and steroid injections.
Dupuytren’s contracture occurs when the palmar fascia contracts, preventing finger extension. It commonly affects the fifth finger on the right hand and is more prevalent in men over the age of 65. Risk factors for this condition include male sex, family history, alcohol use, diabetes, smoking, trauma, and manual labor. Surgical release is necessary if the contracture affects daily activities or work.
Trigger finger occurs when a nodule becomes stuck in the tendon sheath, causing the affected finger to remain in a fixed flexed position. The ring and middle fingers are most commonly affected, and risk factors include rheumatoid arthritis and diabetes. Steroid injections or surgical removal can be used to treat this condition.
Carpal tunnel syndrome occurs when the median nerve is compressed under the flexor retinaculum, resulting in numbness, pain, and wasting of the thenar eminence in the lateral three and a half digits. Symptoms are often worse at night. While most cases are idiopathic, risk factors include obesity, oral contraceptive use, hypothyroidism, rheumatoid arthritis, pregnancy, diabetes, amyloidosis, acromegaly, tumors compressing the carpal tunnel, and previous wrist fractures. Tinel’s test and Phalen’s test can help diagnose carpal tunnel syndrome, and nerve conduction studies may be requested for further evaluation. Treatment options include splints, steroid injections, and surgical release if symptoms persist.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 87
Correct
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A 62 year old male arrives at the emergency department complaining of abrupt tearing chest pain that extends to the throat and back. The possibility of aortic dissection is being considered. What is the primary location for dissection?
Your Answer: Ascending aorta
Explanation:The primary location for aortic dissection, which is being considered in this case, is the ascending aorta.
Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.
The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.
Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.
Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.
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This question is part of the following fields:
- Cardiology
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Question 88
Incorrect
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A 72-year-old woman with a history of type II diabetes and hypertension presents with central chest discomfort. Her ECG showed ST depression in the inferior leads, but her discomfort subsides, and ECG returns to normal after receiving GTN spray and IV morphine. She was also given 300 mg of aspirin in the ambulance en route to the hospital. Her vital signs are as follows: SaO2 99% on room air, HR 89 bpm, and BP 139/82 mmHg. A troponin test has been scheduled and she is scheduled for an urgent coronary angiography.
Which of the following medications should you also consider administering to this patient?Your Answer: Bivalirudin
Correct Answer: Unfractionated heparin
Explanation:This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).
Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.
Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.
Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.
Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.
Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.
For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.
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This question is part of the following fields:
- Cardiology
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Question 89
Correct
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You are evaluating a 70-year-old individual in the emergency department. Laboratory results indicate a serum potassium level of 6.9 mmol/L. An electrocardiogram (ECG) is conducted. Which of the subsequent ECG alterations is linked to hyperkalemia?
Your Answer: P-wave flattening
Explanation:Hyperkalaemia, a condition characterized by high levels of potassium in the blood, can be identified through specific changes seen on an electrocardiogram (ECG). One of these changes is the tenting of T-waves, where the T-waves become tall and pointed. Additionally, the P-wave, which represents atrial depolarization, may widen and flatten. Other ECG changes associated with hyperkalaemia include a prolonged PR interval, flat P-waves, wide P-waves, widened QRS complex, the appearance of a sine wave pattern, and the possibility of heart block.
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.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 90
Incorrect
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A 45-year-old man presents with a 4-day history of sudden right-sided scrotal pain and high fever. On examination, the epididymis is tender and swollen, and the overlying scrotal skin is red and warm to the touch. Lifting the scrotum provides relief from the pain. He has a history of epilepsy and takes phenytoin for it. He has no other significant medical history and no known allergies to medications.
What is the most suitable treatment for this patient?Your Answer: Ceftriaxone plus doxycycline
Correct Answer: Co-amoxiclav
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.
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This question is part of the following fields:
- Urology
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Question 91
Correct
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A 62 year old male is brought into the emergency department by concerned family members. They inform you that the patient is a heavy drinker but appeared very confused and disoriented, which is unusual for him. The patient scores 4/10 on the abbreviated mental test score (AMTS). Upon examination, you observe that the patient has yellowing of the eyes, shifting dullness on abdominal palpation, dilated abdominal veins, and asterixis. The patient's vital signs and initial blood tests are as follows:
Blood pressure: 122/80 mmHg
Pulse: 92 bpm
Respiration rate: 18 bpm
Temperature: 37.7ºC
Bilirubin: 68 µmol/l
ALP: 198 u/l
ALT: 274 u/l
Albumin: 26 g/l
INR: 1.7
What is the most likely diagnosis?Your Answer: Hepatic encephalopathy
Explanation:Hepatic encephalopathy occurs when a person with liver disease experiences an episode where their brain function is affected. This happens because the liver is unable to properly process waste products, leading to an accumulation of nitrogenous waste in the body. These waste products then cross into the brain, where they cause changes in the brain’s osmotic pressure and disrupt neurotransmitter function. As a result, individuals may experience altered consciousness, behavior, and personality. Symptoms can range from confusion and forgetfulness to coma, and signs such as slurred speech and increased muscle tone may also be present. Hepatic encephalopathy is often triggered by factors like gastrointestinal bleeding, infections, or certain medications.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 92
Correct
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You assess a client who has recently developed severe depression and contemplate the potential presence of an underlying organic factor contributing to this condition.
Which ONE of the following could be a potential organic factor leading to depression?Your Answer: Hypercalcaemia
Explanation:Hypercalcaemia is often linked to feelings of sadness and low mood, while hypocalcaemia does not typically have this association. Temporal arteritis is known to cause sudden episodes of psychosis, but it is not commonly associated with depression. On the other hand, hyperkalaemia does not have a connection to depression. Lastly, when someone experiences a deficiency in thiamine, they may exhibit symptoms of acute confusion, but depression is not typically one of these symptoms.
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This question is part of the following fields:
- Mental Health
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Question 93
Correct
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A 60-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals that they have microcytic anemia.
Which of the following is the LEAST probable underlying diagnosis?Your Answer: Hypothyroidism
Explanation:Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).
On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.
Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.
It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.
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This question is part of the following fields:
- Haematology
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Question 94
Correct
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A 37 year old male presents to the emergency department complaining of sudden onset headache, tremor, and palpitations. During triage, his blood pressure is measured at 220/110 mmHg. You start considering the likelihood of secondary causes of hypertension, including the possibility of extra-adrenal phaeochromocytoma. What percentage of phaeochromocytoma cases are extra-adrenal?
Your Answer: 10-15%
Explanation:The correct answer is 10-15%. This means that out of all phaeochromocytoma cases, approximately 10-15% occur outside of the adrenal glands.
Further Reading:
Phaeochromocytoma is a rare neuroendocrine tumor that secretes catecholamines. It typically arises from chromaffin tissue in the adrenal medulla, but can also occur in extra-adrenal chromaffin tissue. The majority of cases are spontaneous and occur in individuals aged 40-50 years. However, up to 30% of cases are hereditary and associated with genetic mutations. About 10% of phaeochromocytomas are metastatic, with extra-adrenal tumors more likely to be metastatic.
The clinical features of phaeochromocytoma are a result of excessive catecholamine production. Symptoms are typically paroxysmal and include hypertension, headaches, palpitations, sweating, anxiety, tremor, abdominal and flank pain, and nausea. Catecholamines have various metabolic effects, including glycogenolysis, mobilization of free fatty acids, increased serum lactate, increased metabolic rate, increased myocardial force and rate of contraction, and decreased systemic vascular resistance.
Diagnosis of phaeochromocytoma involves measuring plasma and urine levels of metanephrines, catecholamines, and urine vanillylmandelic acid. Imaging studies such as abdominal CT or MRI are used to determine the location of the tumor. If these fail to find the site, a scan with metaiodobenzylguanidine (MIBG) labeled with radioactive iodine is performed. The highest sensitivity and specificity for diagnosis is achieved with plasma metanephrine assay.
The definitive treatment for phaeochromocytoma is surgery. However, before surgery, the patient must be stabilized with medical management. This typically involves alpha-blockade with medications such as phenoxybenzamine or phentolamine, followed by beta-blockade with medications like propranolol. Alpha blockade is started before beta blockade to allow for expansion of blood volume and to prevent a hypertensive crisis.
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This question is part of the following fields:
- Endocrinology
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Question 95
Correct
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A 58 year old male presents to the emergency department after experiencing dizziness and fainting. An ECG reveals bradycardia with a pulse rate of 44 bpm. His blood pressure is 90/60. The resident physician administers atropine. Which of the following conditions would be a contraindication for giving atropine?
Your Answer: Paralytic ileus
Explanation:Atropine is a medication that slows down the movement of the digestive system and is not recommended for use in individuals with intestinal blockage. It works by blocking the effects of a neurotransmitter called acetylcholine, which is responsible for promoting gastrointestinal motility and the emptying of the stomach. Therefore, atropine should not be given to patients with gastrointestinal obstruction as it can further hinder the movement of the intestines.
Further Reading:
Types of Heart Block:
1. Atrioventricular (AV) Blocks:
– Disrupt electrical conduction between the atria and ventricles at the AV node.
– Three degrees of AV block: first degree, second degree (type 1 and type 2), and third degree (complete) AV block.– First degree AV block: PR interval > 0.2 seconds.
– Second degree AV block:
– Type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs.
– Type 2 (Mobitz II): PR interval is constant, but the P wave is often not followed by a QRS complex.
– Third degree (complete) AV block: no association between the P waves and QRS complexes.Features of complete heart block: syncope, heart failure, regular bradycardia (30-50 bpm), wide pulse pressure, JVP (jugular venous pressure) cannon waves in neck, variable intensity of S1.
2. Bundle Branch Blocks:
– Electrical conduction travels from the bundle of His to the left and right bundle branches.
– Diagnosed when the duration of the QRS complex on the ECG exceeds 120 ms.– Right bundle branch block (RBBB).
– Left bundle branch block (LBBB).
– Left anterior fascicular block (LAFB).
– Left posterior fascicular block (LPFB).
– Bifascicular block.
– Trifascicular block.ECG features of bundle branch blocks:
– RBBB: QRS duration > 120 ms, RSR’ pattern in V1-3 (M-shaped QRS complex), wide S wave in lateral leads (I, aVL, V5-6).
– LBBB: QRS duration > 120 ms, dominant S wave in V1, broad, notched (‘M’-shaped) R wave in V6, broad monophasic R wave in lateral leads (I, aVL, V5-6), absence of Q waves in lateral leads, prolonged R wave peak time > 60 ms in leads V5-6.WiLLiaM MaRROW is a useful mnemonic for remembering the morphology of the QRS in leads V1 and V6 for LBBB.
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This question is part of the following fields:
- Cardiology
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Question 96
Correct
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A 70-year-old woman comes in with complaints of tiredness and frequent nosebleeds. During the examination, she displays a widespread petechial rash and enlarged gums.
What is the SINGLE most probable diagnosis?Your Answer: Acute myeloid leukaemia (AML)
Explanation:Leukaemic infiltrates in the gingiva are frequently observed in cases of acute myeloid leukaemia. This type of leukaemia primarily affects adults and is most commonly seen in individuals between the ages of 65 and 70. The typical presentation of acute myeloid leukaemia involves clinical symptoms that arise as a result of leukaemic infiltration in the bone marrow and other areas outside of the marrow. These symptoms may include anaemia (resulting in lethargy, pallor, and breathlessness), thrombocytopaenia (manifesting as petechiae, bruising, epistaxis, and bleeding), neutropenia (leading to increased susceptibility to infections), hepatosplenomegaly, and infiltration of the gingiva.
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This question is part of the following fields:
- Haematology
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Question 97
Incorrect
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A 6-month-old girl is brought by her parents to see her pediatrician due to a history of fever, cough, and difficulty breathing. The pediatrician diagnoses her with acute bronchiolitis and calls the Emergency Department to discuss whether the child will require admission.
What would be a reason for referring the child to the hospital?Your Answer: <50% of usual feed intake over past 24 hours
Correct Answer:
Explanation:Bronchiolitis is a respiratory infection that primarily affects infants aged 2 to 6 months. It is typically caused by a viral infection, with respiratory syncytial virus (RSV) being the most common culprit. RSV infections are most prevalent during the winter months, from November to March. In fact, bronchiolitis is the leading cause of hospitalization among infants in the UK.
The symptoms of bronchiolitis include poor feeding (consuming less than 50% of their usual intake in the past 24 hours), lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis (bluish discoloration of the skin), and low oxygen saturation levels. For children aged 6 weeks and older, oxygen saturation levels below 90% indicate a need for medical attention. For babies under 6 weeks or those with underlying health conditions, oxygen saturation levels below 92% require medical attention.
To confirm the diagnosis of bronchiolitis, a nasopharyngeal aspirate can be taken for rapid testing of RSV. This test is useful in preventing unnecessary further testing and allows for the isolation of the infected infant.
Most infants with bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.
However, hospital referral and admission are recommended in cases of poor feeding, lethargy, a history of apnea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, and oxygen saturation levels below 94%. If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers for the treatment of bronchiolitis.
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This question is part of the following fields:
- Respiratory
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Question 98
Correct
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A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his mother's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable. The attending physician recommends giving a dose of activated charcoal. The child weighs 15 kg.
What is the appropriate dosage of activated charcoal to administer in this case?Your Answer: 20 g orally
Explanation:Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.
Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.
The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 99
Correct
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You are summoned to the resuscitation room to assist with a 6-year-old patient who has arrived with a cardiac arrest.
Which of the following medication dosages for pediatric cardiac arrest is accurate?Your Answer: Sodium bicarbonate 8.4% 1 ml/kg
Explanation:The doses of commonly used drugs in paediatric cardiac arrest are summarized in the following table:
Drug: Adrenaline (epinephrine) IV/IO
Dose: 10 mcg/kgDrug: Adrenaline (epinephrine) ET bolus
Dose: 100 mcg/kgDrug: Amiodarone IV infusion
Dose: 5 mg/kg over 3 minutes (maximum 300 mg)Drug: Calcium gluconate 10%
Dose: 0.3-0.5 ml/kgDrug: Lidocaine IV/IO
Dose: 1 mg/kg (maximum 100 mg)Drug: Magnesium sulphate IV
Dose: 25-50 mg/kgDrug: Sodium bicarbonate IV
Dose: 1 ml/kg 8.4% -
This question is part of the following fields:
- Paediatric Emergencies
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Question 100
Correct
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A 35-year-old woman with a long-standing history of heavy alcohol abuse and liver cirrhosis presents with a fever, abdominal pain, worsening ascites, and confusion.
What is the SINGLE most appropriate initial investigation?Your Answer: Abdominal paracentesis
Explanation:Spontaneous bacterial peritonitis (SBP) is a sudden bacterial infection of the fluid in the abdomen. It typically occurs in patients with high blood pressure in the portal vein, and about 70% of patients are classified as Child-Pugh class C. In any given year, around 30% of patients with ascites, a condition characterized by fluid buildup in the abdomen, will develop SBP.
SBP can present with a wide range of symptoms, so it’s important to be vigilant when caring for patients with ascites, especially if there is a sudden decline in their condition. Some patients may not show any symptoms at all.
Common clinical features of SBP include fever, chills, nausea, vomiting, abdominal pain, tenderness, worsening ascites, general malaise, and hepatic encephalopathy. Certain factors can increase the risk of developing SBP, such as severe liver disease, gastrointestinal bleeding, urinary tract infection, intestinal bacterial overgrowth, indwelling lines (e.g., central venous catheters or urinary catheters), previous episodes of SBP, and low levels of protein in the ascitic fluid.
To diagnose SBP, an abdominal paracentesis, also known as an ascitic tap, is performed. This involves locating the area of dullness on the flank, next to the rectus abdominis muscle, and performing the tap about 5 cm above and towards the midline from the anterior superior iliac spines.
Certain features on the analysis of the peritoneal fluid strongly suggest SBP, including a total white cell count in the ascitic fluid of more than 500 cells/µL, a total neutrophil count of more than 250 cells/µL, a lactate level in the ascitic fluid of more than 25 mg/dL, a pH of less than 7.35, and the presence of bacteria on Gram-stain.
Patients diagnosed with SBP should be admitted to the hospital and given broad-spectrum antibiotics. The preferred choice is an intravenous 3rd generation cephalosporin, such as ceftriaxone. If the patient is allergic to beta-lactam antibiotics, ciprofloxacin can be considered as an alternative. Administering intravenous albumin can help reduce the risk of kidney failure and mortality.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 101
Correct
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A 21 year old male presents to the emergency department with a 3 day history of a sore throat and fever. The patient denies having a cough. On examination, the patient's temperature is 37.9°C, blood pressure is 120/80 mmHg, and pulse rate is 90 bpm. There is visible white exudate on both tonsils, which are severely inflamed, and tenderness on palpation of the lymph nodes around the sternocleidomastoid muscles bilaterally.
What is this patient's FeverPAIN score?Your Answer: 4
Explanation:The FeverPAIN score is a clinical scoring system that helps determine the likelihood of a streptococcal infection and whether antibiotic treatment is necessary. It consists of several criteria that are assessed to assign a score.
Firstly, if the patient has a fever higher than 38°C, they score 0 or 1 depending on the presence or absence of this symptom.
Secondly, the presence of purulence, such as pharyngeal or tonsillar exudate, results in a score of 1.
Thirdly, if the patient sought medical attention within 3 days or less, they score 1.
Fourthly, if the patient has severely inflamed tonsils, they score 1.
Lastly, if the patient does not have a cough or coryza (nasal congestion), they score 1.
By adding up the scores from each criterion, the FeverPAIN score can help healthcare professionals determine the likelihood of a streptococcal infection and guide the decision on whether antibiotic treatment is necessary. In this particular case, the patient has a score of 4.
Further Reading:
Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.
Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.
When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.
Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.
To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 102
Correct
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A 40-year-old woman is prescribed haloperidol for a psychiatric condition in the 2nd-trimester of her pregnancy. As a result of this treatment, the newborn develops a malformation.
Which of the following malformations is the most likely to occur as a result of using this medication during pregnancy?Your Answer: Extrapyramidal syndrome
Explanation:Haloperidol, when administered during the third trimester of pregnancy, can lead to extrapyramidal symptoms in the newborn. These symptoms may include agitation, poor feeding, excessive sleepiness, and difficulty breathing. The severity of these side effects can vary, with some infants requiring intensive care and extended hospital stays. It is important to closely monitor exposed neonates for signs of extrapyramidal syndrome or withdrawal. Haloperidol should only be used during pregnancy if the benefits clearly outweigh the risks to the fetus.
Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given during the second and third trimesters, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When administered late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given during the first trimester, these drugs can cause phalangeal abnormalities. If given during the second and third trimesters, they can result in fetal growth retardation.
Carbamazepine: This drug can lead to hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Administration of chloramphenicol can cause gray baby syndrome in newborns.
Corticosteroids: If given during the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered during the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given during the first trimester, haloperidol may cause limb malformations. If given during the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 103
Correct
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A 10-year-old girl is brought into the Emergency Department with stomach pain and throwing up. Her mom tells you that she has been losing weight lately and seems to be drinking a lot and peeing a lot. During the examination, she appears tired and you notice that she is dehydrated. She is breathing deeply and quickly. Her blood sugar levels are found to be very high when her blood is tested.
Which of the following tests will be most useful in confirming the diagnosis?Your Answer: Urine dipstick
Explanation:The most probable diagnosis in this case is diabetic ketoacidosis (DKA). To confirm the diagnosis, it is important to establish that his blood glucose levels are high, he has significant ketonuria or ketonaemia, and that he is experiencing acidosis. Therefore, out of the options provided, a urine dipstick test will be the most useful.
DKA is a life-threatening condition that occurs when there is a lack of insulin, leading to an inability to metabolize glucose. This results in hyperglycemia and an osmotic diuresis, causing excessive thirst and increased urine production. If the urine output exceeds the patient’s ability to drink, dehydration becomes inevitable. Additionally, without insulin, fat becomes the primary energy source, leading to the production of large amounts of ketones and metabolic acidosis.
DKA is characterized by three main factors:
1. Hyperglycemia (blood glucose > 11 mmol/l)
2. Ketonaemia (> 3 mmol/l) or significant ketonuria (> 2+ on urine dipstick)
3. Acidosis (bicarbonate < 15 mmol/l and/or venous pH < 7.3) The clinical features of DKA include nausea, vomiting, excessive thirst, excessive urine production, abdominal pain, signs of dehydration, a smell of ketones on the breath (similar to pear drops), deep and rapid respiration (Kussmaul breathing), confusion or reduced consciousness, and tachycardia, hypotension, and shock. The following investigations should be performed:
– Blood glucose measurement
– Urine dipstick test (will show marked glycosuria and ketonuria)
– Blood ketone assay (more sensitive and specific than urine dipstick)
– Blood tests including full blood count (FBC) and urea and electrolytes (U&Es)
– Arterial or venous blood gas analysis (to assess for metabolic acidosis)The principles of managing DKA are as follows:
– Fluid boluses should only be given to reverse signs of shock and should be administered slowly in 10 ml/kg aliquots. If there are no signs of shock, fluid boluses should not be given, and specialist advice should be sought if a second bolus is required.
– Rehydration should be done with replacement therapy over 48 hours after signs of shock have been reversed.
– The first 20 ml/kg of fluid resuscitation should be given in addition -
This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 104
Correct
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A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Australia. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
What is the PRIMARY diagnosis in this case?Your Answer: Pulmonary embolism
Explanation:Based on the clinical history and examination, it strongly indicates that the patient has developed a pulmonary embolism due to a deep vein thrombosis in his right leg.
The symptoms commonly associated with a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. These symptoms may also suggest the presence of a deep vein thrombosis. Other clinical features that may be observed are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.
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This question is part of the following fields:
- Respiratory
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