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  • Question 1 - A child with a known history of latex allergy arrives at the Emergency...

    Incorrect

    • A child with a known history of latex allergy arrives at the Emergency Department with a severe allergic reaction caused by accidental exposure.
      Which of the following foods is this child MOST likely to have an allergy to as well?

      Your Answer: Apple

      Correct Answer: Avocado

      Explanation:

      The connection between latex sensitivity and food allergy is commonly known as the latex-fruit syndrome. Foods that have been found to be allergenic in relation to latex are categorized into high, moderate, or low risk groups.

      High risk foods include banana, avocado, chestnut, and kiwi fruit.

      Moderate risk foods include apple, carrot, celery, melon, papaya, potato, and tomato.

      Citrus fruits and pears are considered to have a low risk of causing allergic reactions in individuals with latex sensitivity.

    • This question is part of the following fields:

      • Allergy
      17.7
      Seconds
  • Question 2 - You review a patient with a history of renal failure that has presented...

    Incorrect

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

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

      Your Answer: 5 ml/minute

      Correct Answer: 10 ml/minute

      Explanation:

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

    • This question is part of the following fields:

      • Nephrology
      22.4
      Seconds
  • Question 3 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. She has suffered significant midface trauma, and the anesthesiologist decides to secure a definitive airway by intubating the patient.

      Which of the following does NOT indicate proper placement of the endotracheal tube?

      Your Answer: Presence of borborygmi in the epigastrium

      Explanation:

      The presence of borborygmi in the epigastrium can indicate that the endotracheal tube (ETT) is incorrectly placed in the esophagus. There are several ways to verify the correct placement of the endotracheal tube (ETT).

      One method is through direct visualization, where the ETT is observed passing through the vocal cords. Another method is by checking for fogging in the ETT, which can indicate proper placement. Auscultation of bilateral equal breath sounds is also a reliable way to confirm correct ETT placement.

      Additionally, the absence of borborygmi in the epigastrium is a positive sign that the ETT is in the correct position. Capnography or using a CO2 detector can provide further confirmation of proper ETT placement. Finally, chest radiography can be used to visually assess the placement of the endotracheal tube.

    • This question is part of the following fields:

      • Basic Anaesthetics
      31
      Seconds
  • Question 4 - You evaluate a patient who has sustained burns in a house fire. Your...

    Correct

    • You evaluate a patient who has sustained burns in a house fire. Your attending physician inquires whether immediate fluid resuscitation is necessary for this patient. What burn assessment finding in a pediatric patient should trigger the initiation of immediate fluid resuscitation?

      Your Answer: Burns greater than 15% of total body surface area

      Explanation:

      In pediatric patients who have sustained burns in a house fire, the presence of burns greater than 15% of the total body surface area should trigger the initiation of immediate fluid resuscitation.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Paediatric Emergencies
      20.8
      Seconds
  • Question 5 - A 35-year-old man is brought into resus by blue light ambulance. He has...

    Incorrect

    • A 35-year-old man is brought into resus by blue light ambulance. He has been involved in a car accident and has suffered severe injuries. You assess his airway and are concerned about the potential for airway obstruction.
      What is the primary risk factor for airway obstruction in a patient with severe injuries?

      Your Answer: Adherent burned clothes on the chest wall

      Correct Answer: A carboxyhaemoglobin level of 15%

      Explanation:

      Early assessment of the airway is a critical aspect of managing a patient who has suffered burns. Airway blockage can occur rapidly due to direct injury, such as inhalation injury, or as a result of swelling caused by the burn. If there is a history of trauma, the airway should be evaluated and treated while maintaining control of the cervical spine.

      Signs of airway obstruction may not be immediately apparent, as swelling typically does not occur right away. Children with thermal burns are at a higher risk of airway obstruction compared to adults due to their smaller airway size, so they require careful observation.

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

    • This question is part of the following fields:

      • Trauma
      45.7
      Seconds
  • Question 6 - You are managing a 72-year-old male patient who has been intubated as a...

    Correct

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What is one of the four diagnostic criteria for ARDS?

      Your Answer: Presence of hypoxaemia

      Explanation:

      One of the diagnostic criteria for ARDS is the presence of hypoxemia. Other criteria include the onset of symptoms within 7 days of a clinical insult or new/worsening respiratory symptoms, bilateral opacities on chest X-ray that cannot be fully explained by other conditions, and respiratory failure that cannot be fully attributed to cardiac failure or fluid overload.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

    • This question is part of the following fields:

      • Respiratory
      78
      Seconds
  • Question 7 - A 10 year old boy is brought into the emergency department after falling...

    Correct

    • A 10 year old boy is brought into the emergency department after falling through the ice while playing on a frozen pond. The child was submerged up to his waist and it took his friends approximately 10-15 minutes to pull him out of the water completely. The child then spent an additional 10 minutes outside in wet clothes with an air temperature of -4ºC before an adult arrived and took him to the emergency department. A core temperature reading is taken and recorded as 29.6ºC. How would you best classify the patient?

      Your Answer: Moderate hypothermia

      Explanation:

      Moderate hypothermia is indicated by core temperatures ranging from 28-32ºC.

      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 depressed 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.

    • This question is part of the following fields:

      • Environmental Emergencies
      21.1
      Seconds
  • Question 8 - You are called into the pediatric resuscitation room to assist with a child...

    Correct

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

      How long should the brief pause in chest compressions last?

      Your Answer: ≤ 5 seconds

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      16.7
      Seconds
  • Question 9 - You are working in the pediatric emergency department and are asked to review...

    Correct

    • You are working in the pediatric emergency department and are asked to review a child's blood gas results by the resident. What is the typical range for partial pressure of carbon dioxide (pCO2)?

      Your Answer: 4.4-6.4 kPa

      Explanation:

      The typical range for the partial pressure of carbon dioxide (pCO2) is 4.4-6.4 kilopascals (kPa). In terms of arterial blood gas (ABG) results, the normal range for pO2 (partial pressure of oxygen) is 10-14.4 kPa or 70-100 millimeters of mercury (mmHg). The normal range for pCO2 is 4.4-6.4 kPa or 35-45 mmHg. Additionally, the normal range for bicarbonate levels is 23-28 millimoles per liter (mmol/L).

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      17.3
      Seconds
  • Question 10 - A 45-year-old man presents to the Emergency Department acutely unwell with abdominal and...

    Correct

    • A 45-year-old man presents to the Emergency Department acutely unwell with abdominal and lower limb pain. He had a syncopal episode in the department and was moved into the resuscitation area. He had been taking prednisolone for temporal arteritis until recently when he had suddenly stopped them. His observations are as follows: temperature 38.9°C, HR 119, BP 79/42, Sats 98% on high flow oxygen, GCS 14/15, BM 1.4.
      His initial blood results are shown below:
      Na+: 114 mmol/l
      K+: 7.1 mmol/l
      Urea: 17.6 mmol/l
      Creatinine: 150 mmol/l
      What is the SINGLE most likely diagnosis?

      Your Answer: Adrenal insufficiency

      Explanation:

      Acute adrenal insufficiency, also known as Addisonian crisis, is a rare condition that can have catastrophic consequences if not diagnosed in a timely manner. It is more prevalent in women and typically occurs between the ages of 30 and 50.

      Addison’s disease is caused by a deficiency in the production of steroid hormones by the adrenal glands, affecting glucocorticoid, mineralocorticoid, and sex steroid production. The main causes of Addison’s disease include autoimmune adrenalitis, bilateral adrenalectomy, Waterhouse-Friderichsen syndrome, tuberculosis, and congenital adrenal hyperplasia.

      An Addisonian crisis can be triggered by the intentional or accidental withdrawal of steroid therapy, as well as factors such as 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 in areas such as palmar creases, buccal mucosa, and exposed skin.

      During an Addisonian crisis, the main symptoms are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and even coma.

      Biochemical features that can confirm the diagnosis of Addison’s disease include increased ACTH levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and adrenocortical antibody testing.

      Management of Addison’s disease should be overseen by an Endocrinologist. Treatment typically involves the administration of hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also require thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and MedicAlert bracelet to alert healthcare professionals of their condition and the potential for an Addisonian crisis.

    • This question is part of the following fields:

      • Endocrinology
      68
      Seconds
  • Question 11 - A 20 year old college student comes to the ER with a sore...

    Incorrect

    • A 20 year old college student comes to the ER with a sore throat that has been bothering them for the past 10 days. After conducting a physical examination, you inform the patient that you suspect they may have glandular fever. You proceed to order blood tests.

      Which of the following findings would support a diagnosis of glandular fever?

      Your Answer: Monocytosis

      Correct Answer: Lymphocytosis

      Explanation:

      In the blood tests, certain findings can support a diagnosis of glandular fever. One of these findings is lymphocytosis, which refers to an increased number of lymphocytes in the blood. Lymphocytes are a type of white blood cell that plays a crucial role in the immune response. In glandular fever, the Epstein-Barr virus (EBV) is the most common cause, and it primarily infects and activates lymphocytes, leading to their increased numbers in the blood.

      On the other hand, neutropenia (a decreased number of neutrophils) and neutrophilia (an increased number of neutrophils) are not typically associated with glandular fever. Neutrophils are another type of white blood cell that helps fight off bacterial infections. In glandular fever, the primary involvement is with lymphocytes rather than neutrophils.

      Monocytosis, which refers to an increased number of monocytes, can also be seen in glandular fever. Monocytes are another type of white blood cell that plays a role in the immune response. Their increased numbers can be a result of the immune system’s response to the Epstein-Barr virus.

      Eosinophilia, an increased number of eosinophils, is not commonly associated with glandular fever. Eosinophils are white blood cells involved in allergic reactions and parasitic infections, and their elevation is more commonly seen in those conditions.

      In summary, the presence of lymphocytosis and possibly monocytosis in the blood tests would support a diagnosis of glandular fever, while neutropenia, neutrophilia, and eosinophilia are less likely to be associated with this condition.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      20.2
      Seconds
  • Question 12 - A 45-year-old construction worker comes in with intense lower back pain. He has...

    Correct

    • A 45-year-old construction worker comes in with intense lower back pain. He has experienced back pain on and off for several years, but it has recently worsened significantly. He is walking with a noticeable limp, and during the examination, you observe that he has weakness in knee extension. You decide to conduct a digital rectal examination and discover that his anal sphincter tone is unexpectedly loose.

      What is the SINGLE most probable diagnosis?

      Your Answer: Cauda equina syndrome

      Explanation:

      Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc in the spine ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on a bundle of nerves in the lower back and sacrum. When this happens, it can lead to problems with controlling the bladder and bowels.

      There are certain signs that may indicate the presence of CES, which are known as red flags. These include experiencing sciatica on both sides of the body, having a severe or worsening neurological deficit in both legs, such as significant weakness in the muscles that extend the knee, turn the ankle outward, or lift the foot upward. Other red flags include difficulty starting to urinate or a decreased sensation of the flow of urine, a loss of feeling when the rectum is full, a loss of sensation in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and a looseness in the anal sphincter muscle.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      21.2
      Seconds
  • Question 13 - A 36 year old male is brought into the emergency department following a...

    Incorrect

    • A 36 year old male is brought into the emergency department following a syncopal episode. The patient reports several weeks of generalized weakness, muscle aches, and feeling dizzy when standing which has been gradually worsening. On examination, you note pigmented areas on the lips, tongue, and gums with patches of vitiligo around the hands and wrists. Observation and blood test results are shown below:

      Hb 132 g/l
      Platelets 124 * 109/l
      WBC 8.0 * 109/l
      Na+ 128 mmol/l
      K+ 6.2 mmol/l
      Urea 8.9 mmol/l
      Creatinine 95 µmol/l
      Glucose 3.1 mmol/l

      Blood pressure 94/56 mmHg
      Pulse 102 bpm
      Respirations 18 bpm
      Oxygen sats 97% on air

      What is the most likely diagnosis?

      Your Answer: Cushing's syndrome

      Correct Answer: Addison's disease

      Explanation:

      Addison’s disease, also known as adrenal insufficiency, is characterized by a gradual onset of symptoms over several weeks, although it can sometimes occur suddenly. The diagnosis of Addison’s disease can be challenging as its symptoms, such as fatigue, muscle pain, weight loss, and nausea, are non-specific. However, a key feature is low blood pressure. The disease is associated with changes in pigmentation, ranging from increased pigmentation due to elevated ACTH levels to the development of vitiligo caused by the autoimmune destruction of melanocytes.

      Patients with Addison’s disease often exhibit hyponatremia (low sodium levels) and hyperkalemia (high potassium levels). If the patient is dehydrated, this may be reflected in elevated urea and creatinine levels. While hypercalcemia (high calcium levels) and hypoglycemia (low blood sugar levels) can occur in Addison’s disease, they are less common than hyponatremia and hyperkalemia.

      In contrast, diabetes insipidus, characterized by normal or elevated sodium levels, does not cause pigmentation changes. Cushing’s syndrome, which results from excess steroid production, is almost the opposite of Addison’s disease, with hypertension (high blood pressure) and hypokalemia (low potassium levels) being typical symptoms. Phaeochromocytoma, on the other hand, is associated with episodes of high blood pressure and hyperglycemia (high blood sugar levels).

      Further Reading:

      Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.

      The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.

      The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.

      Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.

      There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.

    • This question is part of the following fields:

      • Endocrinology
      50.7
      Seconds
  • Question 14 - You evaluate a 35-year-old male patient who has been diagnosed with an anal...

    Incorrect

    • You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
      What would be the most suitable next step in managing this patient's condition?

      Your Answer: Sphincterotomy

      Correct Answer: Botulinum toxin injection

      Explanation:

      An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.

      Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.

      The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)

      Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.

    • This question is part of the following fields:

      • Surgical Emergencies
      43.9
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  • Question 15 - A 45-year-old woman comes in with a swollen, red, and painful left knee....

    Correct

    • A 45-year-old woman comes in with a swollen, red, and painful left knee. The doctor suspects septic arthritis and sends a joint aspirate to the lab.
      What is the most common organism that causes septic arthritis?

      Your Answer: Staphylococcus aureus

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      26.6
      Seconds
  • Question 16 - A young man presents to the Emergency Department with symptoms of acute alcohol...

    Correct

    • 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 a reason for admitting this patient?

      Your Answer: Age under 16

      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.

    • This question is part of the following fields:

      • Mental Health
      24.1
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  • Question 17 - A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his...

    Correct

    • A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is started on regular maintenance treatment with potent opioids for his pain.
      According to NICE, what is the recommended initial 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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      18.1
      Seconds
  • Question 18 - A young woman with a previous case of urethritis has a urethral swab...

    Incorrect

    • A young woman with a previous case of urethritis has a urethral swab sent to the laboratory for examination. Neisseria gonorrhoeae is identified in the sample, confirming a diagnosis of gonorrhea.

      Which ONE statement about Neisseria gonorrhoeae is accurate?

      Your Answer: Treatment should wait until sensitivity results are available

      Correct Answer: It adheres to the genitourinary epithelium via pili

      Explanation:

      Neisseria gonorrhoeae is a type of bacteria that causes the sexually transmitted infection known as gonorrhoea. It is a Gram-negative diplococcus, meaning it appears as pairs of bacteria under a microscope. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important characteristic of Neisseria gonorrhoeae is its ability to undergo antigenic variation, which means that recovering from an infection does not provide immunity and reinfection is possible.

      When Neisseria gonorrhoeae infects the body, it first attaches to the genitourinary epithelium using pili, which are hair-like structures on the surface of the bacteria. It then invades the epithelial layer and triggers a local acute inflammatory response. In men, the clinical features of gonorrhoea often include urethritis (inflammation of the urethra) in about 80% of cases, dysuria (painful urination) in around 50% of cases, and mucopurulent discharge. Rectal infection may also occur, usually without symptoms, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is usually asymptomatic in men.

      In women, the clinical features of gonorrhoea commonly include vaginal discharge in about 50% of cases, lower abdominal pain in around 25% of cases, dysuria in 10-15% of cases, and pelvic/lower abdominal tenderness in less than 5% of cases. Endocervical discharge and/or bleeding may also be present. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge, and pharyngitis is usually asymptomatic in women as well.

      Complications of Neisseria gonorrhoeae infection can be serious and include pelvic inflammatory disease (PID) in women, epididymo-orchitis or prostatitis in men, arthritis, dermatitis, pericarditis and/or myocarditis, hepatitis, and meningitis.

      To diagnose gonorrhoea, samples of pus from the urethra, cervix, rectum, or throat should be collected and promptly sent to the laboratory in specialized transport medium. Traditionally, diagnosis has been made using Gram-stain and culture techniques, but newer PCR testing methods are becoming more commonly used.

    • This question is part of the following fields:

      • Sexual Health
      17.5
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  • Question 19 - You evaluate a 45-year-old Asian man with a heart murmur. During auscultation, you...

    Incorrect

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

      Your Answer: Mitral regurgitation

      Correct Answer: Mitral stenosis

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      28
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  • Question 20 - A 62 year old female presents to the emergency department with a three...

    Correct

    • A 62 year old female presents to the emergency department with a three day history of nausea and upper abdominal pain. The patient is concerned as the nausea became severe enough to cause her to vomit today and she noticed dark blood in the vomitus. The patient takes simvastatin daily for high cholesterol and has recently been taking ibuprofen to treat knee pain. You are able to schedule her for an endoscopy today.

      Upon returning to the ED, you decide to conduct a risk assessment for upper gastrointestinal bleeding. Which of the following tools would be the most appropriate to use?

      Your Answer: Full Rockall score

      Explanation:

      According to NICE guidelines, when evaluating patients with acute upper GI bleeding, it is recommended to use the Blatchford score during the initial assessment and the full Rockall score after endoscopy. The Rockall score is specifically designed to assess the risk of re-bleeding or death in these patients. If a patient’s post-endoscopic Rockall score is less than 3, they are considered to have a low risk of re-bleeding or death and may be eligible for early discharge.

      Further Reading:

      Upper gastrointestinal bleeding (UGIB) refers to the loss of blood from the gastrointestinal tract, occurring in the upper part of the digestive system. It can present as haematemesis (vomiting blood), coffee-ground emesis, bright red blood in the nasogastric tube, or melaena (black, tarry stools). UGIB can lead to significant hemodynamic compromise and is a major health burden, accounting for approximately 70,000 hospital admissions each year in the UK with a mortality rate of 10%.

      The causes of UGIB vary, with peptic ulcer disease being the most common cause, followed by gastritis/erosions, esophagitis, and other less common causes such as varices, Mallory Weiss tears, and malignancy. Swift assessment, hemodynamic resuscitation, and appropriate interventions are essential for the management of UGIB.

      Assessment of patients with UGIB should follow an ABCDE approach, and scoring systems such as the Glasgow-Blatchford bleeding score (GBS) and the Rockall score are recommended to risk stratify patients and determine the urgency of endoscopy. Transfusion may be necessary for patients with massive hemorrhage, and platelet transfusion, fresh frozen plasma (FFP), and prothrombin complex concentrate may be offered based on specific criteria.

      Endoscopy plays a crucial role in the management of UGIB. Unstable patients with severe acute UGIB should undergo endoscopy immediately after resuscitation, while all other patients should undergo endoscopy within 24 hours of admission. Endoscopic treatment of non-variceal bleeding may involve mechanical methods of hemostasis, thermal coagulation, or the use of fibrin or thrombin with adrenaline. Proton pump inhibitors should only be used after endoscopy.

      Variceal bleeding requires specific management, including the use of terlipressin and prophylactic antibiotics. Oesophageal varices can be treated with band ligation or transjugular intrahepatic portosystemic shunts (TIPS), while gastric varices may be treated with endoscopic injection of N-butyl-2-cyanoacrylate or TIPS if bleeding is not controlled.

      For patients taking NSAIDs, aspirin, or clopidogrel, low-dose aspirin can be continued once hemostasis is achieved, NSAIDs should be stopped in patients presenting with UGIB.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      19.6
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  • Question 21 - A 72 year old male patient has arrived at the emergency department after...

    Correct

    • A 72 year old male patient has arrived at the emergency department after injuring himself in a fall. Upon reviewing the patient's medical history, you discover that he was diagnosed with mitral stenosis last year. You advise the medical students to assess the patient for indications of this condition.

      What is a typical symptom observed in individuals with mitral stenosis?

      Your Answer: Malar flush

      Explanation:

      One of the clinical features of mitral stenosis is malar flush, which refers to a reddening or flushing of the cheeks. Other clinical features include a mid-late diastolic murmur that is best heard during expiration, a loud S1 heart sound with an opening snap, a low volume pulse, atrial fibrillation, and signs of pulmonary edema such as crepitations or the presence of white or pink frothy sputum.

      Further Reading:

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

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

    • This question is part of the following fields:

      • Cardiology
      19.6
      Seconds
  • Question 22 - A 72-year-old man with a history of COPD complains of a headache, dizziness,...

    Correct

    • A 72-year-old man with a history of COPD complains of a headache, dizziness, and palpitations. He is currently taking modified-release theophylline for his COPD. You suspect theophylline toxicity and schedule a blood test to check his levels.
      When should the blood sample be taken after his last oral dose?

      Your Answer: 4-6 hours

      Explanation:

      In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.

      To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      21
      Seconds
  • Question 23 - A 25-year-old woman is brought into the Emergency Department by the Security Guards....

    Incorrect

    • A 25-year-old woman is brought into the Emergency Department by the Security Guards. She is restrained and has scratched one of the Security Guards accompanying her. She is highly agitated and combative and has a history of bipolar disorder. She is given an initial dose of intramuscular olanzapine combined with intramuscular lorazepam. However, she shows no response and remains highly agitated and combative.

      According to the NICE guidelines for short-term management of highly agitated and combative patients, which of the following drugs should be used next?

      Your Answer: Propofol

      Correct Answer: Lorazepam

      Explanation:

      Rapid tranquillisation involves the administration of medication through injection when oral medication is not feasible or appropriate and immediate sedation is necessary. The current guidelines from NICE recommend two options for rapid tranquillisation in adults: intramuscular lorazepam alone or a combination of intramuscular haloperidol and intramuscular promethazine. The choice of medication depends on various factors such as advanced statements, potential intoxication, previous responses to these medications, interactions with other drugs, and existing physical health conditions or pregnancy.

      If there is insufficient information to determine the appropriate medication or if the individual has not taken antipsychotic medication before, intramuscular lorazepam is recommended. However, if there is evidence of cardiovascular disease or a prolonged QT interval, or if an electrocardiogram has not been conducted, the combination of intramuscular haloperidol and intramuscular promethazine should be avoided, and intramuscular lorazepam should be used instead.

      If there is a partial response to intramuscular lorazepam, a second dose should be considered. If there is no response to intramuscular lorazepam, then intramuscular haloperidol combined with intramuscular promethazine should be considered. If there is a partial response to this combination, a further dose should be considered.

      If there is no response to intramuscular haloperidol combined with intramuscular promethazine and intramuscular lorazepam has not been used yet, it should be considered. However, if intramuscular lorazepam has already been administered, it is recommended to arrange an urgent team meeting to review the situation and seek a second opinion if necessary.

      After rapid tranquillisation, the patient should be closely monitored for any side effects, and their vital signs should be regularly checked, including heart rate, blood pressure, respiratory rate, temperature, hydration level, and level of consciousness. These observations should be conducted at least hourly until there are no further concerns about the patient’s physical health.

      For more information, refer to the NICE guidance on violence and aggression: short-term management in mental health, health, and community settings.

    • This question is part of the following fields:

      • Mental Health
      40.2
      Seconds
  • Question 24 - You assess a patient with one-sided hearing loss, ringing in the ears, and...

    Incorrect

    • You assess a patient with one-sided hearing loss, ringing in the ears, and numbness in the face. An MRI scan shows the presence of an acoustic neuroma.
      Which of the following nerves is the LEAST likely to be affected?

      Your Answer: Glossopharyngeal nerve

      Correct Answer: Trochlear nerve

      Explanation:

      An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.

      The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically experience a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Headaches may also be present, and in rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may be affected.

      It’s important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      17.2
      Seconds
  • Question 25 - A 7-year-old child experiences an anaphylactic reaction after being stung by a bee....

    Incorrect

    • A 7-year-old child experiences an anaphylactic reaction after being stung by a bee.
      What dosage of IV hydrocortisone should be administered in this situation?

      Your Answer: 50 mg

      Correct Answer: 100 mg

      Explanation:

      Corticosteroids can be beneficial in preventing or reducing prolonged reactions. According to the current APLS guidelines, the recommended doses of hydrocortisone for different age groups are as follows:

      – Children under 6 months: 25 mg administered slowly via intramuscular (IM) or intravenous (IV) route.
      – Children aged 6 months to 6 years: 50 mg administered slowly via IM or IV route.
      – Children aged 6 to 12 years: 100 mg administered slowly via IM or IV route.
      – Children over 12 years: 200 mg administered slowly via IM or IV route.
      – Adults: 200 mg administered slowly via IM or IV route.

      It is important to note that the most recent ALS guidelines do not recommend the routine use of corticosteroids for treating anaphylaxis in adults. However, the current APLS guidelines still advocate for the use of corticosteroids in children to manage anaphylaxis.

    • This question is part of the following fields:

      • Allergy
      28.1
      Seconds
  • Question 26 - A 35-year-old woman is given a medication for a medical ailment during the...

    Incorrect

    • A 35-year-old woman is given a medication for a medical ailment during the 4th and 5th month of her pregnancy. As a result, the unborn baby has experienced reduced blood flow and a condition known as oligohydramnios sequence.
      Which of the listed medications is the most probable cause of these abnormalities?

      Your Answer: Sertraline

      Correct Answer: Ramipril

      Explanation:

      During the second and third trimesters of pregnancy, exposure to ACE inhibitors can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. This sequence refers to the abnormal physical appearance of a fetus or newborn due to low levels of amniotic fluid in the uterus. It is also associated with malformations of the patient ductus arteriosus and aortic arch. These defects are believed to be caused by the inhibitory effects of ACE inhibitors on the renin-angiotensin-aldosterone system. To avoid these risks, it is recommended to discontinue ACE inhibitors before the second trimester.

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

      Drug: ACE inhibitors
      Adverse effects: If given in the second and third trimesters, can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Drug: Aminoglycosides
      Adverse effects: Ototoxicity (damage to the ear) and deafness.

      Drug: Aspirin
      Adverse effects: High doses can cause first trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. Low doses (e.g. 75 mg) have no significant associated risk.

      Drug: Benzodiazepines
      Adverse effects: When given late in pregnancy, respiratory depression and a neonatal withdrawal syndrome can occur.

      Drug: Calcium-channel blockers
      Adverse effects: If given in the first trimester, can cause phalangeal abnormalities. If given in the second and third trimesters, can cause fetal growth retardation.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      25.1
      Seconds
  • Question 27 - A 42 year old male patient is brought into resus with a two...

    Incorrect

    • A 42 year old male patient is brought into resus with a two day history of nausea and vomiting. He has reduced GCS, is hypotensive and tachycardic. His wife tells you he has Addison's but frequently neglects to take his medication. Concerning Addison's, which electrolyte imbalance is most frequently linked to the condition?

      Your Answer: Hypokalaemia

      Correct Answer: Hyponatraemia

      Explanation:

      The electrolyte imbalances that are commonly observed in individuals with Addison’s disease are decreased sodium levels, increased potassium levels, increased calcium levels, and decreased glucose levels. In cases of Addisonian crisis, which is a severe form of Addison’s disease, patients may also experience hyponatremia (low sodium levels), hyperkalemia (high potassium levels), hypercalcemia (high calcium levels), and hypoglycemia (low glucose levels). Additionally, these patients may often develop acidosis.

      Further Reading:

      Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.

      The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.

      The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.

      Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.

      There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.

    • This question is part of the following fields:

      • Endocrinology
      31.1
      Seconds
  • Question 28 - You request your colleague to assess a patient you have evaluated with wrist...

    Incorrect

    • You request your colleague to assess a patient you have evaluated with wrist discomfort. After conducting a thorough history and examination, your colleague diagnoses the individual with de Quervain's tenosynovitis.
      Which specific tendon is commonly impacted in cases of de Quervain's tenosynovitis?

      Your Answer: Extensor carpi radialis brevis

      Correct Answer: Extensor pollicis brevis

      Explanation:

      De Quervain’s tenosynovitis is a condition characterized by inflammation and thickening of the sheath that contains the tendons of the extensor pollicis brevis and abductor pollicis longus. This leads to pain on the radial side of the wrist. The condition is more commonly observed in men than women, particularly in the age group of 30 to 50 years. It is often associated with repetitive activities that involve pinching and grasping.

      During examination, swelling and tenderness along the tendon sheath may be observed. The tendon sheath itself may also appear thickened. The most pronounced tenderness is usually felt over the tip of the radial styloid. A positive Finkelstein’s test, which involves flexing the wrist and moving it towards the ulnar side while the thumb is flexed across the palm, can help confirm the diagnosis.

      Treatment for De Quervain’s tenosynovitis involves avoiding movements that can trigger symptoms and using a thumb splint to immobilize the thumb. In cases where symptoms persist, a local corticosteroid injection or surgical decompression may be considered.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      28.5
      Seconds
  • Question 29 - A 35-year-old woman presents with intense one-sided abdominal pain starting in the right...

    Incorrect

    • A 35-year-old woman presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. Her urine dipstick shows the presence of blood. A CT KUB is scheduled, and a diagnosis of ureteric colic is confirmed.
      Which of the following is NOT a factor that increases the risk of developing urinary tract stones?

      Your Answer: Higher socio-economic class

      Correct Answer: Excessive citrate in the urine

      Explanation:

      There are several known risk factors for developing urinary tract stones. These include anatomical abnormalities in the renal system, such as a horseshoe kidney or ureteral stricture. Having a family history of renal stones, hypertension, gout, or hyperparathyroidism can also increase the risk. Immobilization, relative dehydration, and certain metabolic disorders that increase solute excretion, like chronic metabolic acidosis or hypercalciuria, are also risk factors. Additionally, a deficiency of citrate in the urine, cystinuria (a genetic aminoaciduria), and the use of certain drugs like diuretics or calcium/vitamin D supplements can contribute to stone formation. Residence in hot and dry climates and belonging to a higher socio-economic class have also been associated with an increased risk.

    • This question is part of the following fields:

      • Urology
      23.2
      Seconds
  • Question 30 - A 52-year-old individual is brought into the emergency department after being discovered unresponsive...

    Incorrect

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

      Your Answer: CYPE21 (cytochrome P450 2E1)

      Correct Answer: Acetate

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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