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  • Question 1 - You assess a patient with a significantly elevated calcium level.
    Which of the following...

    Incorrect

    • You assess a patient with a significantly elevated calcium level.
      Which of the following is NOT a known cause of hypercalcemia?

      Your Answer: Phaeochromocytoma

      Correct Answer: Hypothyroidism

      Explanation:

      Hypercalcaemia, which is an elevated level of calcium in the blood, is most commonly caused by primary hyperparathyroidism and malignancy in the UK. However, there are other factors that can contribute to hypercalcaemia as well. These include an increase in dietary intake of calcium, excessive intake of vitamin D, tertiary hyperparathyroidism, overactive thyroid gland (hyperthyroidism), Addison’s disease, sarcoidosis, Paget’s disease, multiple myeloma, phaeochromocytoma, and milk-alkali syndrome. Additionally, certain medications such as lithium, thiazide diuretics, and theophyllines can also lead to hypercalcaemia. It is important to be aware of these various causes in order to properly diagnose and treat this condition.

    • This question is part of the following fields:

      • Nephrology
      34.5
      Seconds
  • Question 2 - A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is...

    Incorrect

    • A 28-year-old woman who is 30 weeks pregnant is experiencing breathlessness and is undergoing investigation. A blood gas test is being conducted to aid in her management.
      What type of acid-base imbalance would you anticipate as a result of pregnancy?

      Your Answer: Metabolic alkalosis

      Correct Answer: Respiratory 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.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15.2
      Seconds
  • Question 3 - A 2-year-old male is brought to the emergency department by his father who...

    Incorrect

    • A 2-year-old male is brought to the emergency department by his father who is concerned as the child has developed a rash. The father tells you the rash started yesterday evening but only affected the face and behind the ears. Dad thought the child had a cold as he has had a dry cough, itchy eyes, and runny nose for the past 2-3 days but became concerned when the rash and high fever appeared. On examination, you note the child has a widespread rash to the trunk, limbs, and face which is maculopapular in some areas while the erythema is more confluent in other areas. There are small blue-white spots seen to the buccal mucosa. The child's temperature is 39ºC. You note the child has not received any childhood vaccines.

      What is the likely diagnosis?

      Your Answer: Rubella

      Correct Answer: Measles

      Explanation:

      The rash in measles typically begins as a maculopapular rash on the face and behind the ears. Within 24-36 hours, it spreads to the trunk and limbs. The rash may merge together, especially on the face, creating a confluent appearance. Usually, the rash appears along with a high fever. Before the rash appears, there are usually symptoms of a cold for 2-3 days. Koplik spots, which are blue-white spots on the inside of the cheeks (usually seen opposite the molars), can be observed 1-2 days before the rash appears and can be detected during a mouth examination.

      It is important to note that the rash in rubella infection is similar to that of measles. However, there are two key differences: the presence of Koplik spots and a high fever (>38.3ºC) are characteristic of measles. Erythema infectiosum, on the other hand, causes a rash that resembles a slapped cheek.

      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.

    • This question is part of the following fields:

      • Paediatric Emergencies
      34.3
      Seconds
  • Question 4 - A 30-year-old construction worker comes in with intense pain in his right eye...

    Correct

    • A 30-year-old construction worker comes in with intense pain in his right eye following an incident at the job site where a significant amount of cement dust entered his right eye.
      What is the potential pathological condition that this patient's eye may be susceptible to?

      Your Answer: Colliquative necrosis

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Ophthalmology
      19.8
      Seconds
  • Question 5 - A 72-year-old man is brought to the resuscitation area of your Emergency Department...

    Correct

    • A 72-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 37.2°C, HR 130 bpm, BP 90/50, RR 22, SaO2 97% on 2 L oxygen, GCS 13. He has intravenous access in situ, and his BM stick glucose is 2.5.
      Which of the following medications are the 'small blue tablets' most likely to be?

      Your Answer: Prednisolone

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      88.7
      Seconds
  • Question 6 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Incorrect

    • A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
      What is the most probable underlying diagnosis?

      Your Answer: Chronic renal failure

      Correct Answer: Liver disease

      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.

    • This question is part of the following fields:

      • Haematology
      50.2
      Seconds
  • Question 7 - You examine the X-ray of a 55-year-old male who has fallen onto his...

    Correct

    • You examine the X-ray of a 55-year-old male who has fallen onto his extended right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). While conducting the procedure, you take note of the duration of cuff inflation. What is the maximum duration the cuff should remain inflated?

      Your Answer: 45 minutes

      Explanation:

      According to the RCEM, the minimum time for cuff inflation during Bier’s block is 20 minutes, while the maximum time is 45 minutes.

      Further Reading:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      12.9
      Seconds
  • Question 8 - A 35 year old female presents to the emergency department complaining of loose...

    Incorrect

    • A 35 year old female presents to the emergency department complaining of loose watery stools, abdominal cramps, and intermittent vomiting for the past 48 hours. The patient mentions that several of her coworkers have been absent from work due to a stomach virus. Based on these symptoms and history, what is the most probable causative organism for this patient's condition?

      Your Answer: Escherichia coli

      Correct Answer: Norovirus

      Explanation:

      Norovirus is the leading cause of gastroenteritis in adults in the UK. Viruses are responsible for the majority of cases of infectious diarrhea, with norovirus being the most common culprit in adults. Among young children, rotavirus is the primary pathogen, although its prevalence has decreased since the introduction of a rotavirus vaccine. As of 2023, rotavirus remains the most common cause of viral gastroenteritis in children.

      Further Reading:

      Gastroenteritis is a transient disorder characterized by the sudden onset of diarrhea, with or without vomiting. It is caused by enteric infections with viruses, bacteria, or parasites. The most common viral causes of gastroenteritis in adults include norovirus, rotavirus, and adenovirus. Bacterial pathogens such as Campylobacter jejuni and coli, Escherichia coli, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, Salmonella typhi and paratyphi, and Shigella dysenteriae, flexneri, boydii, and sonnei can also cause gastroenteritis. Parasites such as Cryptosporidium, Entamoeba histolytica, and Giardia intestinalis or Giardia lamblia can also lead to diarrhea.

      Diagnosis of gastroenteritis is usually based on clinical symptoms, and investigations are not required in many cases. However, stool culture may be indicated in certain situations, such as when the patient is systemically unwell or immunocompromised, has acute painful diarrhea or blood in the stool suggesting dysentery, has recently taken antibiotics or acid-suppressing medications, or has not resolved diarrhea by day 7 or has recurrent diarrhea.

      Management of gastroenteritis in adults typically involves advice on oral rehydration. Intravenous rehydration and more intensive treatment may be necessary for patients who are systemically unwell, exhibit severe dehydration, or have intractable vomiting or high-output diarrhea. Antibiotics are not routinely required unless a specific organism is identified that requires treatment. Antidiarrheal drugs, antiemetics, and probiotics are not routinely recommended.

      Complications of gastroenteritis can occur, particularly in young children, the elderly, pregnant women, and immunocompromised individuals. These complications include dehydration, electrolyte disturbance, acute kidney injury, haemorrhagic colitis, haemolytic uraemic syndrome, reactive arthritis, Reiter’s syndrome, aortitis, osteomyelitis, sepsis, toxic megacolon, pancreatitis, sclerosing cholangitis, liver cirrhosis, weight loss, chronic diarrhea, irritable bowel syndrome, inflammatory bowel disease, acquired lactose intolerance, Guillain-Barré syndrome, meningitis, invasive entamoeba infection, and liver abscesses.

    • This question is part of the following fields:

      • Infectious Diseases
      24
      Seconds
  • Question 9 - You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple...

    Correct

    • You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple administrations of atropine, there has been no improvement in the patient's condition. Which two medications would be the most suitable options to consider next for treating this rhythm?

      Your Answer: Adrenaline/Isoprenaline

      Explanation:

      Adrenaline and isoprenaline are considered as second-line medications for the treatment of bradycardia. If atropine fails to improve the condition, transcutaneous pacing is recommended. However, if pacing is not available, the administration of second-line drugs becomes necessary. Adrenaline is typically given intravenously at a dosage of 2-10 mcg/minute, while isoprenaline is given at a dosage of 5 mcg/minute. It is important to note that glucagon is not mentioned as a treatment option for this patient’s bradycardia, as the cause of the condition is not specified as a beta-blocker overdose.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      30.5
      Seconds
  • Question 10 - A 25-year-old woman with a previous diagnosis of depression is admitted to the...

    Correct

    • A 25-year-old woman with a previous diagnosis of depression is admitted to the emergency department following an unintentional ingestion of amitriptyline tablets. Which toxidrome is commonly associated with an overdose of amitriptyline?

      Your Answer: Anticholinergic

      Explanation:

      An overdose of Amitriptyline, a tricyclic antidepressant, leads to a toxic effect known as anticholinergic toxidrome. This occurs when the muscarinic acetylcholine receptors are blocked, causing the characteristic signs and symptoms associated with this condition.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24
      Seconds
  • Question 11 - You evaluate a 45-year-old male patient with a swollen and red right calf....

    Incorrect

    • You evaluate a 45-year-old male patient with a swollen and red right calf. His D-dimer levels are elevated, and you schedule an ultrasound scan which confirms the presence of a deep vein thrombosis (DVT) in his right calf. He has a history of a previous DVT and his INR today is 2.5.
      What is the MOST suitable course of action for management in this case?

      Your Answer: He should be started on fondaparinux

      Correct Answer: His target INR should be raised to 3.5

      Explanation:

      When managing a first episode of acute venous thromboembolism (VTE), it is recommended to start warfarin in combination with a parenteral anticoagulant, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux. The parental anticoagulant should be continued for a minimum of 5 days and ideally until the international normalized ratio (INR) is above 2 for at least 24 hours.

      To prevent the extension of the blood clot and recurrence in calf deep vein thrombosis (DVT), at least 6 weeks of anticoagulant therapy is necessary. For proximal DVT, a minimum of 3 months of anticoagulant therapy is required.

      For first episodes of VTE, the ideal target INR is 2.5. However, in cases where patients experience recurrent VTE while being anticoagulated within the therapeutic range, the target INR should be increased to 3.5.

    • This question is part of the following fields:

      • Vascular
      32
      Seconds
  • Question 12 - You are treating a patient who fell from a rooftop and has sustained...

    Correct

    • You are treating a patient who fell from a rooftop and has sustained a fracture to the left calcaneus. Which of the following injuries is frequently associated with calcaneal fractures?

      Your Answer: Vertebral fracture

      Explanation:

      When patients have calcaneal fractures, it is important to evaluate them for any additional injuries that may be present. These can include vertebral fractures, fractures in the opposite calcaneus, and injuries to the cuboid bone.

      Further Reading:

      Calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.

      When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.

      In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.

      The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.

    • This question is part of the following fields:

      • Trauma
      18.2
      Seconds
  • Question 13 - A 45-year-old patient has sustained an injury to their right forearm and wrist,...

    Incorrect

    • A 45-year-old patient has sustained an injury to their right forearm and wrist, resulting in a peripheral neuropathy. Upon examination, they exhibit a lack of abduction and opposition of the right thumb. However, wrist and finger flexion remain unaffected, although there is noticeable atrophy of the thenar eminence. The patient is able to form a fist adequately. Additionally, there is a loss of sensation over the radial three and a half fingers.
      What specific nerve damage is present in this particular case?

      Your Answer: Median nerve at the elbow

      Correct Answer: Median nerve at the wrist

      Explanation:

      The median nerve originates from the lateral and medial cords of the brachial plexus and receives contributions from the ventral roots of C5-C7 (lateral cord) and C8 and T1 (medial cord). It serves both motor and sensory functions.

      In terms of motor function, the median nerve innervates the flexor muscles in the anterior compartment of the forearm, excluding the flexor carpi ulnaris and a portion of the flexor digitorum profundus, which are instead innervated by the ulnar nerve. Additionally, it innervates the thenar muscles and the lateral two lumbricals.

      Regarding sensory function, the median nerve gives rise to the palmar cutaneous branch, which provides innervation to the lateral part of the palm. It also gives rise to the digital cutaneous branch, which innervates the lateral three and a half fingers on the palmar surface of the hand.

      Within the forearm, the median nerve branches into two major branches. The first is the anterior interosseous nerve (AIN), which supplies the flexor pollicis longus, pronator quadratus, and the lateral half of the flexor digitorum profundus. The second is the palmar cutaneous branch, which provides sensory innervation to the skin of the radial palm.

      Differentiating between damage to the median nerve at the elbow and wrist can be done by considering these two branches. Injury at the elbow affects these branches, while injury at the wrist spares them. It is important to note that the palmar cutaneous branch travels superficially to the flexor retinaculum and therefore remains functional in carpal tunnel syndrome. However, it can be damaged by laceration at the wrist.

      A comparison of median nerve lesions at the wrist and elbow is presented below:

      Median nerve at elbow:
      – Motor loss: Weak wrist flexion and abduction, loss of thumb abduction and opposition, loss of flexion of index and middle fingers
      – Sensory loss: Lateral 3 and ½ fingers and nail beds, lateral side of palm
      – Hand deformity: Ulnar deviation of wrist, thenar wasting, papal benediction on flexing fingers

      Median nerve at wrist:
      – Motor loss: Loss of thumb abduction and opposition, wrist and finger flexion intact (due to intact AIN)
      – Sensory loss: Lateral 3 and ½ fingers and nail beds, lateral side of palm (but can be preserved depending upon palmar cutaneous branch)
      – Hand deformity: Thenar wasting, no ulnar deviation of wrist or papal benediction (due to intact AIN)

    • This question is part of the following fields:

      • Neurology
      57.2
      Seconds
  • Question 14 - You evaluate a 45-year-old man with a history of difficult-to-control hypertension. His initial...

    Correct

    • 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.

    • This question is part of the following fields:

      • Endocrinology
      67.6
      Seconds
  • Question 15 - You review an elderly patient with a history of heart disease that has...

    Incorrect

    • You review an elderly patient with a history of heart disease that has presented with shortness of breath, chest pain, and dizziness. Upon reviewing his cardiac tests today, you note that his ejection fraction has recently fallen significantly.
      Elderly patients should undergo cardiac intervention when their ejection fraction (EF) reaches what level?

      Your Answer: 25 ml/minute

      Correct Answer: 15 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
      59
      Seconds
  • Question 16 - A middle-aged man presents with visual difficulties. Upon examination, it is discovered that...

    Correct

    • A middle-aged man presents with visual difficulties. Upon examination, it is discovered that he has a quadrantic visual field defect. He is subsequently taken to the hospital for a CT head scan, which confirms a diagnosis of a cerebrovascular accident.
      Which of the following blood vessels is most likely to be impacted?

      Your Answer: Posterior cerebral artery

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      21.8
      Seconds
  • Question 17 - You plan to administer ketamine to sedate a toddler before suturing. After obtaining...

    Correct

    • You plan to administer ketamine to sedate a toddler before suturing. After obtaining consent and ensuring there are no contraindications, what is the recommended initial dosage of ketamine for pediatric sedation?

      Your Answer: 1.0 mg/kg by slow intravenous injection

      Explanation:

      To achieve sedation in children, it is recommended to administer an initial dose of ketamine at a rate of 1.0 mg/kg through a slow intravenous injection lasting at least one minute. It is important to note that administering the medication too quickly can lead to respiratory depression. In some cases, an additional dose of 0.5 mg/kg may be necessary to maintain the desired level of sedation.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      20.8
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  • Question 18 - A 32 year old woman is brought into the emergency department with burns...

    Correct

    • A 32 year old woman is brought into the emergency department with burns to her chest and arms. The patient was trying to handle a grease fire but accidentally spilled the burning contents onto herself. Your consultant requests you to evaluate the severity of the burns. What is used to estimate the extent of a burn injury?

      Your Answer: Lund and Browder chart

      Explanation:

      TBSA, or Total Body Surface Area, is a method commonly used to estimate the size of small burns and very large burns by including the area of unburnt skin. However, it is not considered a reliable method for medium-sized burns.

      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:

      • Trauma
      19.9
      Seconds
  • Question 19 - A 20-year-old woman presents with frequent urination, excessive thirst, and stomach pain. The...

    Incorrect

    • A 20-year-old woman presents with frequent urination, excessive thirst, and stomach pain. The results of her arterial blood gas (ABG) on air are as follows:

      pH: 7.21
      pO2: 11.4 kPa
      PCO2: 3.1 kPa
      HCO3-: 17 mmol/l
      Na+: 149 mmol/l
      Cl–: 100 mmol/l
      Lactate: 6 IU/l

      Which SINGLE statement about this patient is correct?

      Your Answer: She has a respiratory alkalosis

      Correct Answer: She is likely to have a type B lactic acidosis

      Explanation:

      Arterial blood gas (ABG) interpretation is essential for evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analyzers, they generally fall within the following ranges:

      pH: 7.35 – 7.45
      pO2: 10 – 14 kPa
      PCO2: 4.5 – 6 kPa
      HCO3-: 22 – 26 mmol/l
      Base excess: -2 – 2 mmol/l

      In this particular case, the patient’s medical history raises concerns about a possible diagnosis of diabetic ketoacidosis (DKA). The relevant ABG findings are as follows:

      Normal PO2
      Low pH (acidaemia)
      Low PCO2
      Low bicarbonate
      Raised lactate

      The anion gap refers to the concentration of unmeasured anions in the plasma. It is calculated by subtracting the primary measured cations from the primary measured anions in the serum. The reference range for anion gap varies depending on the measurement methodology but typically falls between 8 to 16 mmol/L.

      To calculate her anion gap, we can use the formula:

      Anion gap = [Na+] – [Cl-] – [HCO3-]

      Using the provided values, her anion gap can be calculated as:

      Anion gap = [149] – [100] – [17]
      Anion gap = 32

      Therefore, it is evident that she has a raised anion gap metabolic acidosis.

      It is likely that she is experiencing a type B lactic acidosis secondary to diabetic ketoacidosis. Some potential causes of type A and type B lactic acidosis are listed below:

      Type A lactic acidosis:
      – Shock (including septic shock)
      – Left ventricular failure
      – Severe anemia
      – Asphyxia
      – Cardiac arrest
      – Carbon monoxide poisoning
      – Respiratory failure
      – Severe asthma and COPD
      – Regional hypoperfusion

      Type B lactic acidosis:
      – Renal failure
      – Liver failure
      – Sepsis (non-hypoxic sepsis)
      – Thiamine deficiency
      – Alcoholic ketoacidosis
      – Diabetic ketoacidosis
      – Cyanide poisoning
      – Methanol poisoning
      – Biguanide poisoning

    • This question is part of the following fields:

      • Endocrinology
      45.3
      Seconds
  • Question 20 - A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The...

    Incorrect

    • A 32-year-old patient comes in with a complaint of excessive menstrual bleeding. The periods are not excessively painful. A recent ultrasound scan showed the presence of small fibroids, all measuring less than 2-3 cm in diameter. During the examination, a slightly enlarged uterus is palpated. The patient expresses a strong desire to start a family soon.
      What would be the most appropriate initial treatment option to consider in this case?

      Your Answer: Endometrial ablation

      Correct Answer: Tranexamic acid

      Explanation:

      Tranexamic acid is the best choice for this patient because her periods are heavy, but not very painful, and her fibroids are small. Additionally, she wants to start a family soon, so contraceptive options are not as suitable. For more information, you can refer to the NICE guidelines on the assessment and management of heavy menstrual bleeding.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      50.7
      Seconds
  • Question 21 - A 60-year-old woman is found to have immunoglobulin light chains in her urine.
    Which...

    Correct

    • A 60-year-old woman is found to have immunoglobulin light chains in her urine.
      Which of the following is the MOST LIKELY diagnosis?

      Your Answer: Multiple myeloma

      Explanation:

      Immunoglobulin light chains that are present in the urine are commonly known as Bence-Jones proteins (BJP). These proteins are primarily observed in individuals with multiple myeloma, although they can occasionally be detected in Waldenström macroglobulinemia, although this is a rare occurrence. It is important to note that BJP in the urine is not observed in the other conditions mentioned in this question.

    • This question is part of the following fields:

      • Haematology
      8.3
      Seconds
  • Question 22 - A 25-year-old soccer player comes in with a pustular red rash on his...

    Correct

    • A 25-year-old soccer player comes in with a pustular red rash on his thigh and groin region. There are vesicles present at the borders of the rash. What is the MOST suitable treatment for this condition?

      Your Answer: Topical clotrimazole

      Explanation:

      Tinea cruris, commonly known as ‘jock itch’, is a fungal infection that affects the groin area. It is primarily caused by Trichophyton rubrum and is more prevalent in young men, particularly athletes. The typical symptoms include a reddish or brownish rash that is accompanied by intense itching. Pustules and vesicles may also develop, and there is often a raised border with a clear center. Notably, the infection usually does not affect the penis and scrotum.

      It is worth mentioning that patients with tinea cruris often have concurrent tinea pedis, also known as athlete’s foot, which may have served as the source of the infection. The infection can be transmitted through sharing towels or by using towels that have come into contact with infected feet, leading to the spread of the fungus to the groin area.

      Fortunately, treatment for tinea cruris typically involves the use of topical imidazole creams, such as clotrimazole. This is usually sufficient to alleviate the symptoms and eradicate the infection. Alternatively, terbinafine cream can be used as an alternative treatment option.

    • This question is part of the following fields:

      • Dermatology
      57.2
      Seconds
  • Question 23 - A 25-year-old woman with a history of schizophrenia is brought to the Emergency...

    Correct

    • A 25-year-old woman with a history of schizophrenia is brought to the Emergency Department. She is exhibiting signs of acute psychosis.
      Which ONE of the following is acknowledged as a negative symptom of schizophrenia?

      Your Answer: Blunted affect

      Explanation:

      The first-rank symptoms of schizophrenia, as described by Kurt Schneider, include auditory hallucinations such as hearing 3rd person voices discussing the patient, experiencing thought echo, and receiving commentary on one’s actions. Additionally, passivity phenomena may occur, such as thought insertion, thought withdrawal, thought broadcast, and feelings of thoughts and actions being under external control. Delusions, which can be primary or secondary, are also common in schizophrenia.

      On the other hand, chronic schizophrenia is characterized by negative symptoms. These include poor motivation and self-care, social withdrawal, depression, flat and blunted affect, emotional incongruity, decreased activity, and poverty of thought and speech. These symptoms are often present in individuals with chronic schizophrenia.

    • This question is part of the following fields:

      • Mental Health
      45.8
      Seconds
  • Question 24 - A 25-year-old man comes in with severe bloody diarrhea caused by a gastrointestinal...

    Incorrect

    • A 25-year-old man comes in with severe bloody diarrhea caused by a gastrointestinal infection.
      Which organism is the SINGLE LEAST likely cause?

      Your Answer: Schistosoma mansoni

      Correct Answer: Enterotoxigenic Escherichia coli

      Explanation:

      Enterotoxigenic E.coli is a strain that does not invade the body and does not lead to inflammation or bloody diarrhea. On the other hand, enterogenic strains result in excessive watery diarrhea and are typically not accompanied by abdominal cramping.

      There are several infectious causes of bloody diarrhea, including Campylobacter spp., Shigella spp., Salmonella spp., Clostridium difficile, Enterohaemorrhagic Escherichia coli, Yersinia spp., Schistosomiasis, and Amoebiasis (Entamoeba histolytica).

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      12.9
      Seconds
  • Question 25 - You assess a patient with diabetes who has a past medical history of...

    Correct

    • You assess a patient with diabetes who has a past medical history of inadequate blood sugar control and diabetic neuropathy. What is the most prevalent form of diabetic neuropathy?

      Your Answer: Peripheral neuropathy

      Explanation:

      The most prevalent form of neuropathy in individuals with diabetes is peripheral neuropathy. Following closely behind is diabetic amyotrophy.

    • This question is part of the following fields:

      • Endocrinology
      25.3
      Seconds
  • Question 26 - A 42-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 42-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has severe bruising over her anterior chest wall and is experiencing chest pain. A chest X-ray reveals a significantly widened mediastinum, deviation of the trachea to the left, and fractures of the third and fourth ribs. Her vital signs are HR 88, BP 130/78, SaO2 98% on high flow oxygen.

      At which anatomical site is an injury MOST likely to have occurred in this case?

      Your Answer: Near the point of origin of the left subclavian artery

      Correct Answer: Near the ligamentum arteriosum

      Explanation:

      Traumatic aortic rupture is a relatively common cause of sudden death following major trauma, especially high-speed road traffic accidents (RTAs). It is estimated that 15-20% of deaths from RTAs are due to this injury. If the aortic rupture is promptly recognized and treated, patients who survive the initial injury can fully recover.

      Surviving patients often have an incomplete laceration near the ligamentum arteriosum of the aorta. The continuity is maintained by either an intact adventitial layer or a contained mediastinal hematoma, which prevents immediate exsanguination and death.

      Detecting traumatic aortic rupture can be challenging as many patients do not exhibit specific symptoms, and other injuries may also be present, making the diagnosis unclear.

      Chest X-ray findings can aid in the diagnosis and include fractures of the 1st and 2nd ribs, a grossly widened mediastinum, a hazy left lung field, obliteration of the aortic knob, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus (or NG tube) to the right.

      Helical contrast-enhanced CT scanning is highly sensitive and specific for detecting aortic rupture, but it should only be performed on hemodynamically stable patients.

      Treatment options include primary repair or resection of the torn segment with replacement using an interposition graft. Endovascular repair is also now considered an acceptable alternative approach.

    • This question is part of the following fields:

      • Trauma
      93.4
      Seconds
  • Question 27 - You evaluate a 32-year-old man with a previous history of intravenous drug use....

    Incorrect

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

      Your Answer: CD4 count

      Correct Answer: p24 antigen test

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      22.8
      Seconds
  • Question 28 - A 30-year-old woman with a history of schizophrenia is brought to the Emergency...

    Incorrect

    • A 30-year-old woman with a history of schizophrenia is brought to the Emergency Department. She is exhibiting signs of acute psychosis.
      Which ONE of the following is considered a positive prognostic factor in schizophrenia?

      Your Answer: Positive family history

      Correct Answer: Acute precipitating event

      Explanation:

      Good prognostic factors in schizophrenia include an acute onset, which means that the symptoms appear suddenly and intensely. Additionally, the presence of a precipitating stressful event can also indicate a better prognosis. It is also beneficial if there is no family history of schizophrenia, but a family history of depression can be considered a positive factor. An older age of onset is another good prognostic factor, as it suggests a potentially milder course of the illness. Furthermore, if there is no history of previous episodes and the individual has normal intelligence, it can contribute to a better prognosis. A preponderance of affective symptoms, such as mood-related symptoms, is also considered favorable. It is important to note that the absence of loss of emotion and receiving prompt treatment are additional factors that can improve the prognosis.

    • This question is part of the following fields:

      • Mental Health
      14.6
      Seconds
  • Question 29 - A 25-year-old patient arrives at the emergency department from working in a radiation...

    Correct

    • A 25-year-old patient arrives at the emergency department from working in a radiation lab. He informs you that he may have been exposed to dangerous radiation. The patient mentions that it has been less than 24 hours since he left lab. Which of the following tests provides the most accurate prognosis for the severity of radiation sickness?

      Your Answer: Lymphocyte count

      Explanation:

      The count of lymphocytes, a type of white blood cell, can serve as an early indication of the level of radiation exposure. The severity of the exposure can be determined by observing the decrease in lymphocyte count, which is directly related to the amount of radiation absorbed by the body. Ideally, the count is measured 12 hours after exposure and then repeated every 4 hours initially to track the rate of decrease.

      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.

    • This question is part of the following fields:

      • Environmental Emergencies
      21.7
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  • Question 30 - A 68-year-old woman comes in after experiencing an episode of weakness in her...

    Incorrect

    • A 68-year-old woman comes in after experiencing an episode of weakness in her left arm and leg that resolved within a few hours. Her family has noticed a sudden increase in forgetfulness over the past week, with difficulty remembering names of people and places and struggling to find the right words for things.

      What is the SINGLE most probable diagnosis?

      Your Answer: Alzheimer’s disease

      Correct Answer: Vascular dementia

      Explanation:

      Vascular dementia is the second most common form of dementia, accounting for approximately 25% of all cases. It occurs when the brain is damaged due to various factors, such as major strokes, multiple smaller strokes that go unnoticed (known as multi-infarct), or chronic changes in smaller blood vessels (referred to as subcortical dementia). The term vascular cognitive impairment (VCI) is increasingly used to encompass this range of diseases.

      Unlike Alzheimer’s disease, which has a gradual and subtle onset, vascular dementia can occur suddenly and typically shows a series of stepwise increases in symptom severity. The presentation and progression of the disease can vary significantly.

      There are certain features that suggest a vascular cause of dementia. These include a history of transient ischemic attacks (TIAs) or cardiovascular disease, the presence of focal neurological abnormalities, prominent memory impairment in the early stages of the disease, early onset of gait disturbance and unsteadiness, frequent unprovoked falls in the early stages, bladder symptoms (such as incontinence) without any identifiable urological condition in the early stages, and seizures.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      54.1
      Seconds
  • Question 31 - A 45-year-old man presents to the Emergency Department with a one-day history of...

    Correct

    • A 45-year-old man presents to the Emergency Department with a one-day history of central abdominal pain which has now moved to the right-hand side. His appetite is poor, and he is complaining of nausea. He has a history of chronic constipation and recently had an episode of sudden, unexplained rectal bleeding for which he has been referred to the general surgical outpatient clinic by his GP. His observations are as follows: temperature 38.4°C, HR 112, BP 134/78, RR 18. On examination, he is tender in the right iliac fossa, and his PR examination revealed rectal tenderness.
      What is the SINGLE most likely diagnosis?

      Your Answer: Acute diverticulitis

      Explanation:

      Acute diverticulitis occurs when a diverticulum becomes inflamed or perforated. This inflammation can either stay localized, forming a pericolic abscess, or spread and cause peritonitis. The typical symptoms of acute diverticulitis include abdominal pain (most commonly felt in the lower left quadrant), fever/sepsis, tenderness in the left iliac fossa, the presence of a mass in the left iliac fossa, and rectal bleeding. About 90% of cases involve the sigmoid colon, which is why left iliac fossa pain and tenderness are commonly seen.

      To diagnose acute diverticulitis, various investigations should be conducted. These include blood tests such as a full blood count, urea and electrolytes, C-reactive protein, and blood cultures. Imaging studies like abdominal X-ray, erect chest X-ray, and possibly an abdominal CT scan may also be necessary.

      Complications that can arise from acute diverticulitis include perforation leading to abscess formation or peritonitis, intestinal obstruction, massive rectal bleeding, fistulae, and strictures.

      In the emergency department, the treatment for diverticulitis should involve providing suitable pain relief, administering intravenous fluids, prescribing broad-spectrum antibiotics (such as intravenous co-amoxiclav), and advising the patient to refrain from eating or drinking. It is also important to refer the patient to the on-call surgical team for further management.

      For more information on diverticular disease, you can refer to the NICE Clinical Knowledge Summary.

    • This question is part of the following fields:

      • Surgical Emergencies
      74.3
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  • Question 32 - A 45-year-old man with a long-standing history of benign prostatic hyperplasia dribbling presents...

    Incorrect

    • A 45-year-old man with a long-standing history of benign prostatic hyperplasia dribbling presents with a fever, chills, and muscle aches. After taking a detailed history and conducting an examination, you diagnose acute bacterial prostatitis and decide to start antibiotics.
      What is the recommended duration of treatment for this condition?

      Your Answer: 28 days

      Correct Answer: 14 days

      Explanation:

      Acute bacterial prostatitis is a sudden inflammation of the prostate gland, which can be either focal or diffuse and is characterized by the presence of pus. The most common organisms that cause this condition include Escherichia coli, Streptococcus faecalis, Staphylococcus aureus, and Neisseria gonorrhoea. The infection usually reaches the prostate through direct extension from the posterior urethra or urinary bladder, but it can also spread through the blood or lymphatics. In some cases, the infection may originate from the rectum.

      According to the National Institute for Health and Care Excellence (NICE), acute prostatitis should be suspected in men who present with a sudden onset of feverish illness, which may be accompanied by rigors, arthralgia, or myalgia. Irritative urinary symptoms like dysuria, frequency, urgency, or acute urinary retention are also common. Perineal or suprapubic pain, as well as penile pain, low back pain, pain during ejaculation, and pain during bowel movements, can occur. A rectal examination may reveal an exquisitely tender prostate. A urine dipstick test showing white blood cells and a urine culture confirming urinary infection are also indicative of acute prostatitis.

      The current recommendations by NICE and the British National Formulary (BNF) for the treatment of acute prostatitis involve prescribing an oral antibiotic for a duration of 14 days, taking into consideration local antimicrobial resistance data. The first-line antibiotics recommended are Ciprofloxacin 500 mg twice daily or Ofloxacin 200 mg twice daily. If these are not suitable, Trimethoprim 200 mg twice daily can be used. Second-line options include Levofloxacin 500 mg once daily or Co-trimoxazole 960 mg twice daily, but only when there is bacteriological evidence of sensitivity and valid reasons to prefer this combination over a single antibiotic.

      For more information, you can refer to the NICE Clinical Knowledge Summary on acute prostatitis.

    • This question is part of the following fields:

      • Urology
      15.1
      Seconds
  • Question 33 - A 35-year-old man with a known history of lumbar radiculopathy causing neuropathic pain...

    Incorrect

    • A 35-year-old man with a known history of lumbar radiculopathy causing neuropathic pain presents with an increase in his symptoms. He describes the pain as a severe burning sensation on the right side of his lower back and leg. You discuss his treatment options.
      Which of the following pharmacological therapies is recommended by the current NICE guidelines for the management of neuropathic pain? Select ONE option only.

      Your Answer: Sertraline

      Correct Answer: Duloxetine

      Explanation:

      The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. The dosage should be adjusted based on how the individual responds to the medication and their ability to tolerate it. If the initial treatment does not provide relief or is not well tolerated, one of the remaining three medications can be considered as an alternative option.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      37.9
      Seconds
  • Question 34 - A 72-year-old woman with a history of hypertension and kidney disease is prescribed...

    Correct

    • A 72-year-old woman with a history of hypertension and kidney disease is prescribed a new diuretic medication. Upon reviewing her blood test results, you observe the presence of hyperkalemia.
      Which of the following diuretics is most likely to be the cause?

      Your Answer: Spironolactone

      Explanation:

      Spironolactone is a medication used to treat conditions such as congestive cardiac failure, hypertension, hepatic cirrhosis with ascites and edema, and Conn’s syndrome. It functions as a competitive aldosterone receptor antagonist, primarily working in the distal convoluted tubule. In this area, it hinders the reabsorption of sodium ions and enhances the reabsorption of potassium ions. Spironolactone is commonly known as a potassium-sparing diuretic.

      The main side effect of spironolactone is hyperkalemia, particularly when renal impairment is present. In severe cases, hyperkalemia can be life-threatening. Additionally, there is a notable occurrence of gastrointestinal disturbances, with nausea and vomiting being the most common. Women may experience menstrual disturbances, while men may develop gynecomastia, both of which are attributed to the antiandrogenic effects of spironolactone.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      14.1
      Seconds
  • Question 35 - A 35-year-old woman comes in with a painful left elbow. She is left-handed...

    Correct

    • A 35-year-old woman comes in with a painful left elbow. She is left-handed and participates in various sports. During the examination, you observe tenderness over her medial epicondyle, and her pain intensifies with resisted pronation at the wrist.

      What is the SINGLE most probable diagnosis?

      Your Answer: Golfer’s elbow

      Explanation:

      Golfer’s elbow, also known as medial epicondylitis, is a condition characterized by inflammation and pain in the flexor tendons that attach to the medial epicondyle. It is commonly caused by repetitive strain, with golf being a frequent culprit. Similarly, tennis elbow, or lateral epicondylitis, occurs when the same strain and inflammation affect the tendons at the lateral epicondyle. In both cases, pain can be worsened by resisted wrist extension. Treatment involves avoiding activities that trigger symptoms and using non-steroidal anti-inflammatory drugs for flare-ups. In more severe cases, steroid injections may be necessary.

      Ulnar neuritis presents with symptoms such as hand clumsiness, muscle weakness, and wasting in the muscles supplied by the ulnar nerve. Patients may also experience numbness or tingling in the little finger and medial half of the ring finger. This condition is caused by narrowing of the ulnar groove and can be associated with risk factors like osteoarthritis, trauma, and rheumatoid arthritis. Nerve conduction studies may be recommended, and surgical decompression may be necessary.

      De Quervain’s tenosynovitis occurs when there is inflammation of the tendon sheaths for the thumb extensor and abductor muscles. 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.

      Bursitis can develop from repeated pressure on the olecranon, resulting in swelling and discomfort in that area. Aspiration of fluid may be performed to rule out conditions like gout or sepsis. If these conditions are ruled out, bursitis often resolves on its own.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      16.2
      Seconds
  • Question 36 - A 35 year old homeless patient presents with blistered and discolored feet after...

    Correct

    • A 35 year old homeless patient presents with blistered and discolored feet after spending multiple days on the streets during freezing temperatures. Frostbite is diagnosed, and the plan is to initiate Rewarming of the affected area. Which of the following statements about frostbite is accurate?

      Your Answer: Reperfusion is usually very painful

      Explanation:

      Reperfusion after a frostbite injury can be extremely painful, so it is important to provide strong pain relief. If there are clear blisters, they should be opened and aloe vera should be applied every 6 hours. However, if there are blisters with blood, they should not be opened, but aloe vera can still be used topically. Taking 400 mg of ibuprofen orally, if there are no contraindications, can help reduce inflammation and improve the outcome of frostbite. Technetium-99m pertechnetate scintigraphy is the preferred method for assessing blood flow in the affected area. To treat frostbite, it is recommended to re-warm the affected areas by immersing them in warm water.

      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.

    • This question is part of the following fields:

      • Dermatology
      30.2
      Seconds
  • Question 37 - You are summoned to the resuscitation room to assess a 38-year-old female patient...

    Correct

    • You are summoned to the resuscitation room to assess a 38-year-old female patient who became pale and restless while having a wound stitched by one of the nurse practitioners. The nurse practitioner informs you that the patient's blood pressure dropped to 92/66 mmHg and the ECG reveals bradycardia with a heart rate of 52 bpm. Concerned about potential local anesthetic toxicity, the nurse practitioner promptly transferred the patient to the resuscitation room. Upon reviewing the cardiac monitor, you observe ectopic beats. Which anti-arrhythmic medication should be avoided in this patient?

      Your Answer: Lidocaine

      Explanation:

      Lidocaine is commonly used as both an anti-arrhythmic medication and a local anesthetic. However, it is important to note that it should not be used as an anti-arrhythmic therapy in patients with Local Anesthetic Systemic Toxicity (LAST). This is because lidocaine can potentially worsen the toxicity symptoms in these patients.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Cardiology
      32
      Seconds
  • Question 38 - You intend to utilize plain 1% lidocaine for a ring block on a...

    Correct

    • You intend to utilize plain 1% lidocaine for a ring block on a finger that requires suturing.
      Which ONE statement concerning the utilization of 1% lidocaine, in this scenario, is accurate?

      Your Answer: Lidocaine works by blocking fast voltage-gated sodium channels

      Explanation:

      Lidocaine is a tertiary amine that is primarily utilized as a local anesthetic. It can also be employed in the treatment of ventricular arrhythmias. The mechanism of action of lidocaine as a local anesthetic involves its diffusion in the form of an uncharged base through neural sheaths and the axonal membrane. It then reaches the internal surface of the cell membrane sodium channels, where it exerts its effect by blocking the fast voltage-gated sodium channels. This alteration in signal conduction prevents the depolarization of the postsynaptic neuron’s membrane, thereby inhibiting the transmission of pain signals.

      In a plain 1% lidocaine solution, each 1 ml contains 10 mg of lidocaine hydrochloride. The maximum safe dose of plain lidocaine is 3 mg/kg, with a maximum limit of 200 mg. However, when administered with adrenaline in a 1:200,000 ratio, the maximum safe dose increases to 7 mg/kg, with a maximum limit of 500 mg. It is important to note that the combination of lidocaine and adrenaline should not be used in extremities such as fingers, toes, and the nose due to the risk of vasoconstriction and tissue necrosis.

      The half-life of lidocaine ranges from 1.5 to 2 hours. It exhibits a rapid onset of action within a few minutes and has a duration of action of 30 to 60 minutes when used alone. However, when co-administered with adrenaline, its duration of action is prolonged. It is worth mentioning that lidocaine tends to induce vasodilation, primarily attributed to the inhibition of action potentials in vasoconstrictor sympathetic nerves through the blocking of sodium channels.

    • This question is part of the following fields:

      • Pain & Sedation
      18.7
      Seconds
  • Question 39 - A 25-year-old woman develops an irritating rash after a recent viral infection. The...

    Incorrect

    • A 25-year-old woman develops an irritating rash after a recent viral infection. The rash is characterized by multiple wheals of varying sizes on her skin, surrounded by redness. It is extremely itchy and accompanied by a slight burning sensation. The rash lasts for a few hours but is now nearly gone. She has a history of mild asthma but no other significant medical conditions.
      What is the MOST LIKELY diagnosis for this individual?

      Your Answer: Erythema multiforme

      Correct Answer: Urticaria

      Explanation:

      Urticaria is a condition characterized by a raised, itchy rash on the skin and mucous membranes. It can be localized or widespread and affects about 15% of people at some point in their lives. There are two forms of urticaria: acute and chronic, with the acute form being more common.

      In about 50% of cases of acute urticaria, a specific trigger can be identified. Common triggers include allergies (such as foods, bites, stings, and drugs), skin contact with irritants (like chemicals, nettles, and latex), physical stimuli (such as firm rubbing, pressure, and extremes of temperature), and viral infections.

      The main skin lesion seen in urticaria is called a wheal or wheel. Wheals typically have three characteristics: a central swelling that can be red or white in color, surrounded by a red area (known as the flare), and they are usually very itchy, sometimes accompanied by a burning sensation. Wheals are temporary and usually disappear within 1 to 24 hours, returning the skin to its normal appearance.

      Wheals can vary in size, ranging from a few millimeters to lesions as large as 10 cm in diameter. They can appear as single lesions or multiple ones, and sometimes they merge together to form large patches. In some cases, urticaria can also cause swelling of the soft tissues in the eyelids, lips, and tongue, known as angioedema.

    • This question is part of the following fields:

      • Allergy
      72.5
      Seconds
  • Question 40 - A 42 year old male patient is brought into resus with a three...

    Correct

    • A 42 year old male patient is brought into resus with a three day history of nausea and vomiting. He has decreased GCS, is hypotensive and tachycardic. His roommate informs you that he was diagnosed with Addison's disease approximately six months ago and frequently neglects to take his prescribed medication. What is the most accurate description of the underlying cause of Addison's disease?

      Your Answer: Destruction of the adrenal cortex

      Explanation:

      Addison’s disease occurs when the adrenal cortex is destroyed. The anterior pituitary gland produces and releases adrenocorticotropic hormone (ACTH), not the posterior pituitary gland. The adrenal cortex is responsible for producing cortisol, not the adrenal medulla.

      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
      56.7
      Seconds
  • Question 41 - A 3-year-old girl is brought to the Emergency Department by ambulance following an...

    Incorrect

    • A 3-year-old girl is brought to the Emergency Department by ambulance following an episode of fainting at home. The parents noticed that the girl suddenly collapsed and appeared pale. After lifting her up, she quickly regained consciousness and her color returned. After a thorough examination and investigation by the pediatric team, a diagnosis of a brief resolved unexplained event (BRUE) is made.
      Which of the following is NOT a recognized risk factor for a BRUE?

      Your Answer: History of gastro-oesophageal reflux disease

      Correct Answer: High birth weight

      Explanation:

      The term Apparent Life-Threatening Event (ALTE) has traditionally been used to describe a specific type of event. However, in 2016, the American Academy of Paediatrics (AAP) recommended replacing ALTE with a new term called Brief Resolved Unexplained Event (BRUE).

      An ALTE is defined as an episode that is frightening to the observer and is characterized by a combination of symptoms such as apnoea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), significant change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer may even fear that the infant has died.

      On the other hand, BRUE has stricter criteria and is only applicable to episodes that occur in infants under 12 months old. A BRUE is characterized by being brief (lasting less than 1 minute, typically 2-30 seconds), resolved (the infant must have returned to their baseline state), and not explained by any identifiable medical condition. It must also exhibit at least one of the following symptoms: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in muscle tone (hyper- or hypotonia), or altered level of responsiveness.

      To diagnose a BRUE, a thorough history and physical examination of the infant must be conducted, and no explanation for the event should be found. Additionally, there are several risk factors associated with the development of a BRUE, including prematurity, age less than ten weeks, recent anesthesia, airway or maxillofacial abnormalities, history of gastro-oesophageal reflux disease, previous apnoeic episode, recent upper respiratory tract infection. Low birth weight may also be a risk factor, while high birth weight has no recognized association with BRUEs.

    • This question is part of the following fields:

      • Paediatric Emergencies
      21.8
      Seconds
  • Question 42 - A 70-year-old man with a known history of Alzheimer's disease and a previous...

    Incorrect

    • A 70-year-old man with a known history of Alzheimer's disease and a previous heart attack experiences urinary incontinence and a sudden decline in his cognitive function. He denies experiencing any abdominal pain or discomfort while urinating.

      What is the SINGLE most probable diagnosis?

      Your Answer: Detrusor instability

      Correct Answer: Urinary tract infection

      Explanation:

      Symptoms of urinary tract infection (UTI) can be difficult to detect in elderly patients, especially those with dementia. Common signs like painful urination and abdominal discomfort may be absent. Instead, these patients often experience increased confusion, restlessness, and a decline in cognitive abilities. Therefore, if an elderly patient suddenly develops urinary incontinence and experiences a rapid deterioration in cognitive function, it is highly likely that they have a UTI.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      38.6
      Seconds
  • Question 43 - A 55-year-old man with a history of hypertension presented to the emergency department...

    Correct

    • A 55-year-old man with a history of hypertension presented to the emergency department with a sudden onset severe occipital headache accompanied by vomiting and neck stiffness. There is no reported history of head injury. Upon clinical examination, his temperature is recorded as 37ºC, respiratory rate at 18 per minute, pulse at 88 beats per minute, and blood pressure at 160/100. It is observed that his right eye is laterally and inferiorly deviated, with a dilated pupil and drooping of the right upper eyelid.

      Which of the following would be the most appropriate initial investigation?

      Your Answer: CT head scan

      Explanation:

      The most probable diagnosis in this case is a subarachnoid haemorrhage (SAH).

      When assessing patients who present with an SAH, there may be focal neurological signs that can indicate the potential location of the aneurysm. Common sites for aneurysms include the bifurcation of the middle cerebral artery, the junction of the anterior communicating cerebral artery, and the junction of the posterior communicating artery with the internal carotid artery. If there is complete or partial palsy of the oculomotor nerve, it suggests the rupture of a posterior communicating artery aneurysm.

      While hypertension is a risk factor for SAH, a significant increase in blood pressure may occur as a reflex response following the haemorrhage.

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

    • This question is part of the following fields:

      • Neurology
      21.9
      Seconds
  • Question 44 - A 42-year-old man comes in with a 4-day history of sudden left-sided scrotal...

    Correct

    • A 42-year-old man comes in with a 4-day history of sudden left-sided scrotal discomfort and a high body temperature. During the examination, the epididymis is sensitive and enlarged, and the skin covering the scrotum is reddened and warm to the touch. Lifting the scrotum alleviates the pain.

      What is the MOST PROBABLE diagnosis?

      Your Answer: Epididymo-orchitis

      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.

      To distinguish

    • This question is part of the following fields:

      • Urology
      12.7
      Seconds
  • Question 45 - A 35 year old is brought to the emergency room after a car...

    Correct

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

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

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

      Your Answer: Urine output

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      18.2
      Seconds
  • Question 46 - 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 to the Emergency Department with problems relating to their renal replacement therapy. You note that they are currently receiving peritoneal dialysis.

      In which of the following patient groups with end-stage renal failure should peritoneal dialysis be considered as the initial treatment option, instead of hemodialysis?

      Your Answer: Adults patients with significant associated comorbidities

      Correct Answer: Children aged two years old or younger

      Explanation:

      All individuals diagnosed with stage 5 chronic kidney disease should be given the option to choose between haemodialysis or peritoneal dialysis. Peritoneal dialysis should be prioritized as the preferred treatment for the following groups of patients: those who still have some remaining kidney function, adult patients without major additional health conditions, and children who are two years old or younger.

    • This question is part of the following fields:

      • Nephrology
      24.8
      Seconds
  • Question 47 - A 4 year old girl is brought into the emergency department with a...

    Incorrect

    • A 4 year old girl is brought into the emergency department with a two day history of sudden onset watery diarrhea accompanied by stomach cramps and feelings of nausea. Your consultant inquires if you intend to submit a stool sample for microbiological analysis. What would be a reason to send a stool sample for microbiological testing?

      Your Answer: Stools offensive smelling

      Correct Answer: Mucus present in stool

      Explanation:

      Stool samples are recommended for children with diarrhea who have recently traveled, show signs of mucus or blood in their stools, or have had diarrhea for more than a week. This patient’s symptoms align with gastroenteritis. While stool microbiological testing is not typically necessary, it should be conducted if any of the following conditions are present: recent travel, prolonged diarrhea, immunocompromised state, suspected septicemia, presence of blood and/or mucus in the stool, or uncertainty regarding the diagnosis.

      Further Reading:

      Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

      Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

      When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

      In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

      Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

      Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      36.8
      Seconds
  • Question 48 - You evaluate the ECG of a 62-year-old male who has come in with...

    Correct

    • 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.

    • This question is part of the following fields:

      • Cardiology
      13.7
      Seconds
  • Question 49 - You review a middle-aged man on the Clinical Decision Unit (CDU) who is...

    Correct

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

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

      Your Answer: Depression

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
      21.9
      Seconds
  • Question 50 - A 60-year-old woman presents with a gradual decline in her hearing. She struggles...

    Incorrect

    • A 60-year-old woman presents with a gradual decline in her hearing. She struggles to understand her husband's words at times and describes his voice as muffled. Both of her ears are affected, and her hearing worsens in noisy settings. During the examination, both of her eardrums appear normal, and Rinne's test yields normal results.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Acoustic neuroma

      Correct Answer: Presbycusis

      Explanation:

      Presbycusis is a type of hearing loss that occurs gradually as a person gets older. It affects both ears and is caused by the gradual deterioration of the hair cells in the cochlea and the cochlear nerve. The most noticeable hearing loss is at higher frequencies, and it worsens over time. People with presbycusis often have difficulty hearing speech clearly, and they may describe words as sounding muffled or blending together. A test called Rinne’s test will show normal results in cases of presbycusis. If a patient has presbycusis, it is recommended that they be referred for a hearing aid fitting.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      39.8
      Seconds
  • Question 51 - A 45-year-old man with atrial fibrillation presents to the Emergency Department with an...

    Correct

    • A 45-year-old man with atrial fibrillation presents to the Emergency Department with an unrelated medical condition. Upon reviewing his medications, you discover that he is taking warfarin as part of his management.

      Which ONE of the following supplements should be avoided?

      Your Answer: St. John’s Wort

      Explanation:

      St. John’s wort can reduce the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for patients who are taking warfarin to be aware that they should avoid using St. John’s wort as a supplement. For more information on this interaction, you can refer to the BNF section on warfarin interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      19.9
      Seconds
  • Question 52 - A 65 year old presents to the emergency department with a 3 week...

    Correct

    • A 65 year old presents to the emergency department with a 3 week history of feeling generally fatigued. You observe that the patient has been undergoing yearly echocardiograms to monitor aortic stenosis. The patient informs you that he had a tooth extraction around 10 days prior to the onset of his symptoms. You suspect that infective endocarditis may be the cause. What organism is most likely responsible for this case?

      Your Answer: Streptococcus viridans

      Explanation:

      Based on the patient’s symptoms and medical history, the most likely organism responsible for this case of infective endocarditis is Streptococcus viridans. This is because the patient has a history of aortic stenosis, which is a risk factor for developing infective endocarditis. Additionally, the patient had a tooth extraction prior to the onset of symptoms, which can introduce bacteria into the bloodstream and increase the risk of infective endocarditis. Streptococcus viridans is a common cause of infective endocarditis, particularly in patients with underlying heart valve disease.

      Further Reading:

      Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.

      The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.

      Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.

      The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.

      In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.

    • This question is part of the following fields:

      • Infectious Diseases
      23.7
      Seconds
  • Question 53 - A 32 year old male with a previous diagnosis of depression is admitted...

    Correct

    • A 32 year old male with a previous diagnosis of depression is admitted to the emergency department following an intentional overdose of amitriptyline tablets. When would it be appropriate to start administering sodium bicarbonate?

      Your Answer: QRS > 100ms on ECG

      Explanation:

      Prolonged QRS duration is associated with an increased risk of seizures and arrhythmia. Therefore, when QRS prolongation is observed, it is recommended to consider initiating treatment with sodium bicarbonate.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.4
      Seconds
  • Question 54 - A 70 year old male presents to the emergency department feeling generally fatigued....

    Incorrect

    • A 70 year old male presents to the emergency department feeling generally fatigued. On taking a history the patient reports a decline in his skin and hair condition over the past few months. Thyroid function tests are ordered which show the following:

      Test Result Normal range
      TSH 6.2 miU/L 0.27 - 4.2 miU/L
      Free T4 13 pmol/L 12.0 - 22.0 pmol/L

      What is the diagnosis?

      Your Answer: Overt hypothyroidism

      Correct Answer: Subclinical hypothyroidism

      Explanation:

      Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) levels are higher than normal, but the levels of free thyroxine (T4) are still within the normal range. On the other hand, subclinical hyperthyroidism is a condition where the TSH levels are lower than normal, but the levels of free triiodothyronine (T3) and free thyroxine (T4) are still within the normal range.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      32.6
      Seconds
  • Question 55 - A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse,...

    Incorrect

    • A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse, and thick vaginal discharge. A pregnancy test done today is negative. She has no fever and her vital signs are normal. During the exam, her abdomen feels soft, but she experiences cervical motion tenderness during a pelvic examination.

      What is the MOST suitable treatment plan?

      Your Answer: IV cefuroxime and metronidazole

      Correct Answer: IM ceftriaxone plus oral doxycycline and metronidazole

      Explanation:

      Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

      To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      45.4
      Seconds
  • Question 56 - A 40-year-old man presents with a history of a headache, fever and increasing...

    Correct

    • A 40-year-old man presents with a history of a headache, fever and increasing fatigue. He has had a recent flu-like illness but deteriorated this morning. He has marked neck stiffness and sensitivity to light. On examination, you note a petechial rash on his abdomen.
      What is the SINGLE most likely diagnosis?

      Your Answer: Neisseria meningitidis group B

      Explanation:

      This woman is displaying symptoms and signs that are in line with a diagnosis of meningococcal septicaemia. In the United Kingdom, the majority of cases of meningococcal septicaemia are caused by Neisseria meningitidis group B.

      The implementation of a vaccination program for Neisseria meningitidis group C has significantly reduced the prevalence of this particular type. However, a vaccine for group B disease is currently undergoing clinical trials and is not yet accessible for widespread use.

    • This question is part of the following fields:

      • Neurology
      50.2
      Seconds
  • Question 57 - A 35-year-old woman presents with difficulty breathing and coughing up blood after a...

    Incorrect

    • A 35-year-old woman presents with difficulty breathing and coughing up blood after a recent trip from Australia. You suspect she may have a pulmonary embolism (PE).
      Which of the following statements is true about the two-level PE Wells score?

      Your Answer: An alternative diagnosis being less likely than a PE scores -3 points

      Correct Answer: Clinical symptoms and signs of a DVT scores 3 points

      Explanation:

      The two-level PE Wells score has been simplified to determine the likelihood of a pulmonary embolism (PE) into two outcomes: likely or unlikely. A score of over 4 indicates that a PE is likely, while a score of 4 points or less indicates that a PE is unlikely.

      The allocation of points is as follows:

      – Clinical symptoms and signs of deep vein thrombosis (DVT) = 3 points
      – An alternative diagnosis that is less likely than a PE = 3 points
      – Heart rate greater than 100 = 1.5 points
      – Immobilization for more than 3 days or recent surgery within 4 weeks = 1.5 points
      – Previous history of DVT or PE = 1.5 points
      – Presence of haemoptysis = 1 point
      – Malignancy (currently on treatment, treated in the last 6 months, or palliative care) = 1 point.

    • This question is part of the following fields:

      • Respiratory
      28.4
      Seconds
  • Question 58 - A 45-year-old man has developed drug-induced lupus after starting a new medication.
    What is...

    Correct

    • A 45-year-old man has developed drug-induced lupus after starting a new medication.
      What is the PRIMARY cause of this?

      Your Answer: Hydralazine

      Explanation:

      The drugs that have the highest association with the development of drug-induced lupus are procainamide and hydralazine. While some of the other medications mentioned in this question have also been reported to cause drug-induced lupus, the strength of their association is much weaker.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.3
      Seconds
  • Question 59 - A 4 year old child is brought to the emergency department by worried...

    Correct

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

      Your Answer: Oral dexamethasone

      Explanation:

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

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      15.5
      Seconds
  • Question 60 - A 28-year-old with a past of opioid misuse is brought into the ER...

    Correct

    • A 28-year-old with a past of opioid misuse is brought into the ER after being discovered in a collapsed state with decreased level of consciousness. You are worried about the patient's airway. Your consultant recommends using a nasopharyngeal airway adjunct instead of an oropharyngeal airway adjunct. Why is a nasopharyngeal airway preferred in this scenario?

      Your Answer: Less likely to provoke the gag reflex

      Explanation:

      When a patient is semi-conscious, it is less likely for the nasopharyngeal airway adjuncts (NPA’s) to trigger the gag reflex compared to oropharyngeal airways. Therefore, NPA’s are typically the preferred option in these cases.

      Further Reading:

      Techniques to keep the airway open:

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

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

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

      Airway adjuncts:

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

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

      Laryngeal mask airway (LMA):

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      43
      Seconds
  • Question 61 - A 65-year-old patient presents with nausea and vomiting and decreased urine output. He...

    Correct

    • A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only produced a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
      What is an example of an intrinsic renal cause of AKI?

      Your Answer: Acute tubular necrosis

      Explanation:

      Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of urea and other waste products in the body and disrupts the balance of fluids and electrolytes. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.

      The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.

      Pre-renal:
      – Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
      – Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
      – Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
      – Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
      – Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
      – Renal artery stenosis
      – Hepatorenal syndrome

      Intrinsic renal:
      – Glomerular diseases (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
      – Tubular injury: acute tubular necrosis (ATN) following prolonged lack of blood supply
      – Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
      – Vascular diseases (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
      – Eclampsia

      Post-renal:
      – Kidney stones
      – Blood clot
      – Papillary necrosis
      – Urethral stricture
      – Prostatic hypertrophy or malignancy
      – Bladder tumor
      – Radiation fibrosis
      – Pelvic malignancy
      – Retroperitoneal

    • This question is part of the following fields:

      • Nephrology
      35.6
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  • Question 62 - A 28 year old male is brought to the emergency department by his...

    Correct

    • A 28 year old male is brought to the emergency department by his partner due to increasing drowsiness. The patient's partner informs you that the patient was involved in a physical altercation approximately 40 minutes ago. The patient was struck in the temple and experienced a brief loss of consciousness for about 20 seconds. Initially, the patient appeared to be fine, but after approximately 20 minutes, he started to become progressively more drowsy. A CT scan reveals the presence of an extradural hematoma.

      Which vascular structure is typically injured as the underlying cause of an extradural hematoma?

      Your Answer: Middle meningeal artery

      Explanation:

      Extradural hematoma is most frequently caused by injury to the middle meningeal artery. This artery is particularly susceptible to damage as it passes behind the pterion.

      Further Reading:

      Extradural haematoma (EDH) is a collection of blood that forms between the inner surface of the skull and the outer layer of the dura, the dura mater. It is typically caused by head trauma and is often associated with a skull fracture, with the pterion being the most common site of injury. The middle meningeal artery is the most common source of bleeding in EDH.

      Clinical features of EDH include a history of head injury with transient loss of consciousness, followed by a lucid interval and gradual loss of consciousness. Other symptoms may include severe headache, sixth cranial nerve palsies, nausea and vomiting, seizures, signs of raised intracranial pressure, and focal neurological deficits.

      Imaging of EDH typically shows a biconvex shape and may cause mass effect with brain herniation. It can be differentiated from subdural haematoma by its appearance on imaging.

      Management of EDH involves prompt referral to neurosurgery for evacuation of the haematoma. In some cases with a small EDH, conservative management may be considered. With prompt evacuation, the prognosis for EDH is generally good.

    • This question is part of the following fields:

      • Neurology
      30.5
      Seconds
  • Question 63 - A 35 year old individual arrives at the clinic with sudden vertigo that...

    Correct

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

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

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      37.6
      Seconds
  • Question 64 - A 15 year old presents to the emergency department with bleeding from the...

    Incorrect

    • A 15 year old presents to the emergency department with bleeding from the back of the throat that started 30 minutes ago. The patient had a tonsillectomy 7 days ago. The patient's vital signs are as follows:

      Blood pressure: 118/76 mmHg
      Pulse: 80 bpm
      Respiration rate: 16 bpm
      Temperature: 36.7ºC

      Upon examination, there is fresh blood visible on the tongue and posterior wall of the oropharynx, with some oozing from the right tonsillar bed. The airway appears clear. What is the most appropriate course of action in this situation?

      Your Answer: Apply silver nitrite stick to bleeding point

      Correct Answer: Administer 1g IV tranexamic acid

      Explanation:

      Patients who experience bleeding after a tonsillectomy should be treated with two primary medications. The first is IV tranexamic acid, which is given to all patients. The second is a topical vasoconstrictor, such as co-phenylcaine spray or adrenaline-soaked gauze/cotton buds. However, the use of topical vasoconstrictors is typically reserved for patients with severe bleeding until they can be reviewed by a senior medical professional or transferred to the operating theatre. Patients with mild or occasional bleeding may be instructed to gargle with hydrogen peroxide regularly during their hospital stay.

      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.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      75.2
      Seconds
  • Question 65 - A 40-year-old woman presents with symptoms of chronic heartburn, difficulty swallowing, and occasional...

    Incorrect

    • A 40-year-old woman presents with symptoms of chronic heartburn, difficulty swallowing, and occasional food blockage. She was recently given a short course of omeprazole but has not experienced any improvement in her symptoms. Her medical history includes asthma and seasonal allergies, for which she uses a salbutamol inhaler and steroid creams. She has not noticed any weight loss, has not experienced any episodes of vomiting blood, and overall feels healthy.

      What is the most probable diagnosis in this scenario?

      Your Answer: Churg-Strauss syndrome

      Correct Answer: Eosinophilic oesophagitis

      Explanation:

      Eosinophilic oesophagitis (EoE), also known as allergic inflammatory condition of the oesophagus, is characterized by the presence of eosinophils. It was identified as a clinical condition about two decades ago but has gained recognition more recently. EoE is most commonly observed in middle-aged individuals, with an average age of diagnosis ranging from 30 to 50 years. It is more prevalent in men, with a male-to-female ratio of 3:1. Allergic conditions, particularly atopy, are often associated with EoE.

      The clinical manifestations of EoE vary depending on the age of the patient. In adults, common symptoms include dysphagia, food bolus obstruction, heartburn, and chest pain. On the other hand, children with EoE may present with failure to thrive, food refusal, difficulty feeding, vomiting, and abdominal pain.

      To diagnose EoE, it is crucial to consider the possibility of this condition in patients who have persistent heartburn and/or difficulty swallowing, especially if they have a history of allergies or atopic disease. Diagnosis is confirmed by identifying more than 15 eosinophils per high-power field on an oesophageal biopsy. Allergy testing is not effective as EoE is not mediated by IgE.

      There are three main management options for EoE, all of which are considered first-line treatments. The first option is proton pump inhibitors (PPIs), which are effective in approximately one-third of patients. If an endoscopic biopsy confirms the presence of eosinophils, an 8-week trial of PPIs can be initiated. After the trial, a repeat endoscopy and biopsy should be performed to assess for persistent eosinophils. Patients who respond to PPIs are diagnosed with PPI responsive oesophageal eosinophilia, while those who do not respond are diagnosed with true eosinophilic oesophagitis.

      The second management option is dietary manipulation, which can be effective in both children and adults. It can be used as an initial treatment or in combination with pharmacological therapy. The six most commonly implicated food groups in EoE are cow’s milk, wheat, egg, soy, peanut/tree nut, and fish/shellfish. There are four main approaches to dietary manipulation: elemental diet, six food elimination diet (SFED), four food elimination diet (FFED),

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      48.7
      Seconds
  • Question 66 - A 45-year-old man with a history of bipolar affective disorder presents having ingested...

    Correct

    • A 45-year-old man with a history of bipolar affective disorder presents having ingested an excessive amount of his lithium medication. You measure his lithium level.
      At what level are toxic effects typically observed?

      Your Answer: 1.5 mmol/l

      Explanation:

      The therapeutic range for lithium typically falls between 0.4-0.8 mmol/l, although this range may differ depending on the laboratory. In general, the lower end of the range is the desired level for maintenance therapy and treatment in older individuals. Toxic effects are typically observed when levels exceed 1.5 mmol/l.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      26.4
      Seconds
  • Question 67 - You assess a patient who has been brought into the resuscitation room in...

    Correct

    • You assess a patient who has been brought into the resuscitation room in an obtunded state. The patient is wearing a MedicAlert bracelet, indicating a diagnosis of Addison's disease.
      Which ONE statement accurately describes this condition?

      Your Answer: ACTH levels are usually elevated

      Explanation:

      Addison’s disease occurs when the adrenal glands do not produce enough steroid hormones. This includes glucocorticoids, mineralocorticoids, and sex steroids. The most common cause is autoimmune adrenalitis, which accounts for about 70-80% of cases. It is more prevalent in women and typically occurs between the ages of 30 and 50.

      The clinical symptoms of Addison’s disease include weakness, lethargy, low blood pressure (especially when standing up), nausea, vomiting, weight loss, reduced hair in the armpits and pubic area, depression, and hyperpigmentation (darkening of the skin in certain areas like the palms, mouth, and exposed skin).

      Biochemically, Addison’s disease is characterized by increased levels of ACTH (a hormone that tries to stimulate the adrenal glands), low sodium levels, high potassium levels, high calcium levels, low blood sugar, and metabolic acidosis.

      People with Addison’s disease have a higher risk of developing type 1 diabetes, Hashimoto’s thyroiditis, Grave’s disease, premature ovarian failure, pernicious anemia, vitiligo, and alopecia.

      Management of Addison’s disease should be overseen by an Endocrinologist. Treatment typically involves taking 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 in case of an Addisonian crisis.

    • This question is part of the following fields:

      • Endocrinology
      37.8
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  • Question 68 - A 25-year-old traveler comes back from a journey to South America with a...

    Incorrect

    • A 25-year-old traveler comes back from a journey to South America with a fever, headache, and feeling nauseous. After a diagnosis, it is determined that she has contracted yellow fever.

      Upon examination, it is observed that she has an uncommon combination of an extremely high body temperature (39.7°C) and a relative bradycardia (48 bpm).

      What is the name of the clinical sign that she has developed, which is named after a person?

      Your Answer: Levine’s sign

      Correct Answer: Faget sign

      Explanation:

      Faget sign is a unique occurrence where a fever and a relatively slow heart rate, known as bradycardia, are observed together. This phenomenon is sometimes called sphygmothermic dissociation. It can be observed in various infectious diseases, such as yellow fever, typhoid fever, tularaemia, brucellosis, Colorado tick fever, Legionella pneumonia, and Mycoplasma pneumonia. Normally, when a person has a fever, their heart rate increases, but in cases of Faget sign, the heart rate remains slow. Another term used to describe the combination of fever and increased heart rate is Leibermeister’s rule.

      Auspitz’s sign is a characteristic feature seen in psoriasis. When the scales of psoriasis are scraped off, small bleeding spots, known as punctate bleeding spots, appear. This sign helps in the diagnosis of psoriasis.

      Frank sign is a term used to describe a diagonal crease that appears on the earlobe. It has been hypothesized that this crease may be linked to cardiovascular disease and diabetes.

      Levine’s sign refers to a specific response to chest pain caused by reduced blood flow to the heart, known as ischemic chest pain. In this sign, the person clenches their fist and holds it over their chest in an instinctive reaction to the pain.

    • This question is part of the following fields:

      • Infectious Diseases
      28.4
      Seconds
  • Question 69 - A 7-year-old boy is brought in to see you by his father following...

    Incorrect

    • A 7-year-old boy is brought in to see you by his father following an incident where he developed a rash, wheeze, and abdominal pain after accidentally eating a peanut. He has a known history of peanut allergy and carries an EpiPen junior with him at all times. His father administered the EpiPen junior, and the child now feels fine, but his father would like you to examine him.
      What is the total amount of adrenaline administered in a single dose by an EpiPen junior?

      Your Answer: 0.3 mg

      Correct Answer: 0.15 mg

      Explanation:

      An EpiPen is a device that automatically injects adrenaline and is used to treat anaphylaxis. It is often given to individuals who are at risk of experiencing anaphylaxis so that they can administer it themselves if needed.

      It is important for healthcare professionals to be familiar with the various auto-injector devices that are commonly available. In the event that an adrenaline auto-injector is the only option for treating anaphylaxis, healthcare professionals should not hesitate to use it.

      Each EpiPen auto-injector contains a single dose of 0.3 mg of adrenaline. For children, there is also a version called EpiPen Jr that contains a single dose of 0.15 mg of adrenaline.

    • This question is part of the following fields:

      • Allergy
      36
      Seconds
  • Question 70 - A 35-year-old individual presents to the emergency department complaining of progressive weakness and...

    Correct

    • A 35-year-old individual presents to the emergency department complaining of progressive weakness and numbness over the past few days. The patient reports initially experiencing numbness in both feet, which has gradually extended up to the knees. Additionally, there is weakness in both legs and numbness in the fingertips that appeared earlier today. The patient has no regular medication and is generally in good health. However, about three weeks ago, during a trip to India, the patient suffered from a week-long illness characterized by watery, occasionally bloody, diarrhea and abdominal cramps, which have completely resolved. What is the most likely causative organism?

      Your Answer: Campylobacter jejuni

      Explanation:

      This explanation suggests that the patient’s symptoms are consistent with a case of travellers diarrhoea, which is in line with their medical history. GBS typically occurs within 1-3 weeks after the initial viral or bacterial infection that caused it.

      Further Reading:

      Campylobacter jejuni is a common cause of gastrointestinal infections, particularly travellers diarrhoea. It is a gram-negative bacterium that appears as curved rods. The infection is transmitted through the feco-oral route, often through the ingestion of contaminated meat, especially poultry. The incubation period for Campylobacter jejuni is typically 1-7 days, and the illness usually lasts for about a week.

      The main symptoms of Campylobacter jejuni infection include watery, and sometimes bloody, diarrhea accompanied by abdominal cramps, fever, malaise, and headache. In some cases, complications can arise from the infection. Guillain-Barre syndrome (GBS) is one such complication that is associated with Campylobacter jejuni. Approximately 30% of GBS cases are caused by this bacterium.

      When managing Campylobacter jejuni infection, conservative measures are usually sufficient, with a focus on maintaining hydration. However, in cases where symptoms are severe, such as high fever, bloody diarrhea, or high-output diarrhea, or if the person is immunocompromised, antibiotics may be necessary. NICE recommends the use of clarithromycin, administered at a dose of 250-500 mg twice daily for 5-7 days, starting within 3 days of the onset of illness.

    • This question is part of the following fields:

      • Infectious Diseases
      20.3
      Seconds
  • Question 71 - A 30-year-old woman develops cholestatic jaundice following an adverse drug effect of a...

    Incorrect

    • A 30-year-old woman develops cholestatic jaundice following an adverse drug effect of a new medication she has been prescribed.
      Which medication is the LEAST likely to cause this adverse drug effect?

      Your Answer: Ramipril

      Correct Answer: Isoniazid

      Explanation:

      Isoniazid has the potential to induce acute hepatitis, but it is not considered a known cause of cholestatic jaundice. On the other hand, there are several drugs that have been identified as culprits for cholestatic jaundice. These include nitrofurantoin, erythromycin, cephalosporins, verapamil, NSAIDs, ACE inhibitors, tricyclic antidepressants, phenytoin, azathioprine, carbamazepine, oral contraceptive pills, diazepam, ketoconazole, and tamoxifen. It is important to be aware of these medications and their potential side effects in order to ensure patient safety.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      17.6
      Seconds
  • Question 72 - You have just performed rapid sequence induction using ketamine and rocuronium and placed...

    Correct

    • You have just performed rapid sequence induction using ketamine and rocuronium and placed an endotracheal tube under the guidance of a consultant. What category of medication does rocuronium belong to?

      Your Answer: Non-depolarizing neuromuscular blocker

      Explanation:

      Rocuronium is a type of neuromuscular blocker that does not cause depolarization.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      17.6
      Seconds
  • Question 73 - A 65-year-old man comes in with unintentional weight loss and a noticeable lump...

    Incorrect

    • A 65-year-old man comes in with unintentional weight loss and a noticeable lump in his abdomen. After a CT scan, it is discovered that he has a cancerous growth in his cecum.
      Where is the most likely location for this lump to be felt?

      Your Answer: Right lumbar

      Correct Answer: Right iliac fossa

      Explanation:

      The caecum, positioned between the ileum and the ascending colon, serves as the closest segment of the large intestine. It can be found in the right iliac fossa, just below the ileocaecal junction. In case of enlargement, it can be detected through palpation. This structure is situated within the peritoneal cavity.

    • This question is part of the following fields:

      • Surgical Emergencies
      32.2
      Seconds
  • Question 74 - A 23-year-old woman arrives at the Emergency Department after an insect flew into...

    Correct

    • A 23-year-old woman arrives at the Emergency Department after an insect flew into her ear. She is experiencing intense pain and can hear the insect buzzing. The triage nurse has given her pain relief, and she is now comfortable.
      What is the most suitable INITIAL course of action?

      Your Answer: Apply immersion oil to the ear

      Explanation:

      Insect removal from the ear can be quite challenging due to the distress it causes the patient and the inevitable movement of the insect during the process.

      To begin, it is important to make the patient comfortable by providing analgesia. In some cases, inhaled Entonox can be helpful, and if the patient is extremely distressed or experiencing significant discomfort, sedation may be necessary.

      The first step in the removal process involves immobilizing or killing the insect to prevent further movement and potential damage within the ear. This can be achieved using options such as microscope immersion oil, mineral oil, or lidocaine solution.

      Once the insect is confirmed to be dead, the actual removal can be performed using forceps or the highly effective Frazier suction technique. After inspecting the ear and ensuring the insect is no longer alive, connect the Frazier suction device to low continuous suction and slowly insert it into the patient’s external ear canal. By occluding the insufflation port, the contents of the ear canal can be suctioned out. Once no more liquid returns, withdraw the catheter and verify that the insect has been successfully removed.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      21.5
      Seconds
  • Question 75 - You assess a patient with a decreased calcium level.
    What is a known factor...

    Incorrect

    • You assess a patient with a decreased calcium level.
      What is a known factor that can cause hypocalcemia?

      Your Answer: Lithium

      Correct Answer: Rhabdomyolysis

      Explanation:

      Rhabdomyolysis leads to an increase in phosphate levels in the blood, which in turn causes a decrease in the levels of ionized calcium. On the other hand, conditions such as Addison’s disease, hyperthyroidism, the use of thiazide diuretics, and lithium can all contribute to an elevation in calcium levels. There are also other factors that can result in low calcium levels, including hypoparathyroidism, a deficiency of vitamin D, sepsis, fluoride poisoning, a lack of magnesium, renal failure, tumor lysis syndrome, pancreatitis, and the administration of EDTA infusions.

    • This question is part of the following fields:

      • Nephrology
      55
      Seconds
  • Question 76 - A child with a history of stomach pain and loose stools is being...

    Incorrect

    • A child with a history of stomach pain and loose stools is being examined for a potential diagnosis of tapeworm infection.
      What is the most suitable test to confirm this diagnosis?

      Your Answer: Check IgE levels

      Correct Answer: Recover eggs from stool sample

      Explanation:

      Two types of tapeworms, Taenia solium and Taenia saginata, can infest humans. Infestation occurs when people consume meat from intermediate hosts that contain the parasite’s tissue stages. Tapeworms compete for nutrients and infestation is often without symptoms. However, in more severe cases, individuals may experience epigastric pain, diarrhea, and vomiting. Diagnosis involves identifying characteristic eggs in the patient’s stool.

      Taenia solium infestation can also lead to a condition called cysticercosis. This occurs when larval cysts infiltrate and spread throughout the lung, liver, eye, or brain. Cysticercosis presents with neurological symptoms, seizures, and impaired vision. Confirmation of cysticercosis involves the presence of antibodies and imaging tests such as chest X-rays and CT brain scans.

      The treatment for tapeworm infestation is highly effective and involves the use of medications like niclosamide or praziquantel. However, it is important to seek specialist advice when managing Taenia infections in the central nervous system, as severe inflammatory reactions can occur.

    • This question is part of the following fields:

      • Infectious Diseases
      17.7
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  • Question 77 - A 2-year-old toddler is brought to the Emergency Department by his father with...

    Incorrect

    • A 2-year-old toddler is brought to the Emergency Department by his father with a high temperature. NICE suggests using the traffic light system to evaluate the likelihood of a severe illness in children under 3 with a fever.
      Based on the NICE traffic light system, which of the subsequent symptoms or signs indicate a high risk of a severe illness?

      Your Answer: Not crying

      Correct Answer: Appearing ill to a healthcare professional

      Explanation:

      The traffic light system is a useful tool for evaluating the potential risk of serious illness in children. This system categorizes clinical features into three groups based on severity: red (high-risk), amber (intermediate-risk), and green (low-risk).

      Children displaying any of the following symptoms or signs fall into the high-risk group for serious illness: pale/mottled/ashen/blue skin, lips or tongue; lack of response to social cues; appearing unwell to a healthcare professional; inability to wake or stay awake when roused; weak, high-pitched, or continuous cry; grunting; respiratory rate exceeding 60 breaths per minute; moderate or severe chest indrawing; reduced skin turgor; and bulging fontanelle.

      Children exhibiting any of the following symptoms or signs are considered at least intermediate-risk for serious illness: pallor of skin, lips or tongue reported by parent or caregiver; abnormal response to social cues; absence of a smile; waking only with prolonged stimulation; decreased activity; nasal flaring; dry mucous membranes; poor feeding in infants; reduced urine output; and rigors.

      Children displaying any of the following symptoms or signs are classified as low-risk for serious illness: normal color of skin, lips, and tongue; normal response to social cues; contentment and smiles; staying awake or quickly awakening; strong normal cry or absence of crying; normal skin and eyes; and moist mucous membranes.

      To summarize, children with fever and any symptoms or signs in the red column are considered high-risk, while those with fever and any symptoms or signs in the amber column (but none in the red column) are considered intermediate-risk. Children with symptoms and signs in the green column (and none in the amber or red columns) are classified as low-risk.

      For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Infectious Diseases
      27.8
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  • Question 78 - A 65 year old female patient has been brought into the department after...

    Correct

    • A 65 year old female patient has been brought into the department after being hit by a car in a vehicle-pedestrian accident. The patient needs CT imaging to evaluate the complete scope of her injuries. What are the minimum monitoring requirements for transferring a critically ill patient?

      Your Answer: ECG, oxygen saturations, blood pressure and temperature monitoring

      Explanation:

      It is crucial to continuously monitor the oxygen saturation, blood pressure, ECG, and temperature of critically ill patients during transfers. If the patient is intubated, monitoring of end-tidal CO2 is also necessary. The minimum standard monitoring requirements for any critically ill patient during transfers include ECG, oxygen saturation, blood pressure, and temperature. Additionally, if the patient is intubated, monitoring of end-tidal CO2 is mandatory. It is important to note that the guidance from ICS/FICM suggests that monitoring protocols for intra-hospital transfers should be similar to those for interhospital transfers.

      Further Reading:

      Transfer of critically ill patients in the emergency department is a common occurrence and can involve intra-hospital transfers or transfers to another hospital. However, there are several risks associated with these transfers that doctors need to be aware of and manage effectively.

      Technical risks include equipment failure or inadequate equipment, unreliable power or oxygen supply, incompatible equipment, restricted positioning, and restricted monitoring equipment. These technical issues can hinder the ability to detect and treat problems with ventilation, blood pressure control, and arrhythmias during the transfer.

      Non-technical risks involve limited personal and medical team during the transfer, isolation and lack of resources in the receiving hospital, and problems with communication and liaison between the origin and destination sites.

      Organizational risks can be mitigated by having a dedicated consultant lead for transfers who is responsible for producing guidelines, training staff, standardizing protocols, equipment, and documentation, as well as capturing data and conducting audits.

      To optimize the patient’s clinical condition before transfer, several key steps should be taken. These include ensuring a low threshold for intubation and anticipating airway and ventilation problems, securing the endotracheal tube (ETT) and verifying its position, calculating oxygen requirements and ensuring an adequate supply, monitoring for circulatory issues and inserting at least two IV accesses, providing ongoing analgesia and sedation, controlling seizures, and addressing any fractures or temperature changes.

      It is also important to have the necessary equipment and personnel for the transfer. Standard monitoring equipment should include ECG, oxygen saturation, blood pressure, temperature, and capnographic monitoring for ventilated patients. Additional monitoring may be required depending on the level of care needed by the patient.

      In terms of oxygen supply, it is standard practice to calculate the expected oxygen consumption during transfer and multiply it by two to ensure an additional supply in case of delays. The suggested oxygen supply for transfer can be calculated using the minute volume, fraction of inspired oxygen, and estimated transfer time.

      Overall, managing the risks associated with patient transfers requires careful planning, communication, and coordination to ensure the safety and well-being of critically ill patients.

    • This question is part of the following fields:

      • Basic Anaesthetics
      34.6
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  • Question 79 - A 3-year-old toddler arrives in a deteriorated state with acute and severe asthma....

    Incorrect

    • A 3-year-old toddler arrives in a deteriorated state with acute and severe asthma. The child's weight is 16 kg. In accordance with the BTS guidelines, what is the recommended dosage of prednisolone for this case?

      Your Answer: 40 mg

      Correct Answer: 20 mg

      Explanation:

      The BTS guidelines for acute asthma in children recommend administering oral steroids early in the treatment of asthma attacks. It is advised to give a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg for children over 5 years old. If a child is already taking maintenance steroid tablets, they should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the medication, the dose of prednisolone should be repeated. In cases where a child is unable to keep down orally ingested medication, intravenous steroids should be considered. Typically, treatment for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering off the medication is not necessary unless the steroid course exceeds 14 days. For more information, refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      15.7
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  • Question 80 - A 32-year-old woman with a history of sickle-cell disease undergoes a blood transfusion...

    Incorrect

    • A 32-year-old woman with a history of sickle-cell disease undergoes a blood transfusion for severe anemia. Four weeks later, she arrives at the Emergency Department complaining of a skin rash, high body temperature, and diarrhea. Laboratory tests are ordered, revealing low levels of all blood cells and abnormal liver function.

      What is the probable cause of this transfusion reaction?

      Your Answer: Bacterial contamination

      Correct Answer: T lymphocytes reacting against recipient’s tissues

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      32.9
      Seconds
  • Question 81 - A suspected CBRN (chemical, biological, radiological, and nuclear) event has resulted in a...

    Incorrect

    • A suspected CBRN (chemical, biological, radiological, and nuclear) event has resulted in a significant number of casualties. The primary clinical manifestations observed include restlessness, nausea and diarrhea, constricted airways, excessive production of saliva, profuse sweating, loss of muscle control, and seizures. Which of the following agents is the most probable cause for these symptoms?

      Your Answer: Gamma radiation

      Correct Answer: VX gas

      Explanation:

      The symptoms observed in the casualties of this CBRN event strongly indicate exposure to a nerve agent. Among the options provided, VX gas is the only nerve agent listed, making it the most likely culprit.

      Nerve agents, also known as nerve gases, are a highly toxic group of chemical warfare agents that were developed just before and during World War II. The initial compounds in this category, known as the G agents, were discovered and synthesized by German scientists. They include Tabun (GA), Sarin (GB), and Soman (GD). In the 1950s, the V agents, which are approximately 10 times more poisonous than Sarin, were synthesized. 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 a nerve agent was the Tokyo subway sarin attack in March 1995. During this attack, Sarin was released into the Tokyo subway system during rush hour, resulting in over 5,000 people seeking medical attention. Among them, 984 were moderately poisoned, 54 were severely poisoned, and 12 lost their lives.

      Nerve agents are organophosphorus esters that are chemically related to organophosphorus insecticides. They work by inhibiting acetylcholinesterase (AChE), an enzyme responsible for breaking down the neurotransmitter acetylcholine (ACh). This inhibition 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 enter the body through the skin, eyes, and respiratory tract. In vapor form, they are primarily absorbed through the respiratory tract and eyes. If a sufficient amount of the agent is absorbed, it can cause local effects followed by systemic effects throughout the body.

      The clinical symptoms observed after exposure to nerve agents are a result of the combined effects on the muscarinic, nicotinic, and central nervous systems. Muscarinic effects, often remembered using the acronym DUMBBELS, include diarrhea, urination, miosis (constriction of the pupils), bronchorrhea (excessive mucus production in the airways), bronchospasm (narrowing of the airways), emesis (vomiting), lacrimation (excessive tearing), and salivation.

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      14.8
      Seconds
  • Question 82 - You have recently conducted rapid sequence induction utilizing ketamine and rocuronium and successfully...

    Correct

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

      Your Answer: Sugammadex

      Explanation:

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

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      18.7
      Seconds
  • Question 83 - You review a 52-year-old woman who has recently been prescribed antibiotics for a...

    Incorrect

    • You review a 52-year-old woman who has recently been prescribed antibiotics for a urinary tract infection (UTI). She has a history of COPD and is currently taking salbutamol and Seretide inhalers and Phyllocontin Continus. Since starting the antibiotics, she has been experiencing nausea, vomiting, and abdominal pain.
      Which SINGLE antibiotic is she most likely to have been prescribed for her UTI?

      Your Answer: Trimethoprim

      Correct Answer: Ciprofloxacin

      Explanation:

      Phyllocontin Continus contains aminophylline, which is a combination of theophylline and ethylenediamine. It is a bronchodilator that is commonly used to manage COPD and asthma.

      In this case, the woman is showing symptoms of theophylline toxicity, which may have been triggered by the antibiotic prescribed for her urinary tract infection. Quinolone antibiotics, like ciprofloxacin, can increase the concentration of theophyllines in the blood, leading to toxicity.

      There are other medications that can also interact with theophyllines. These include macrolide antibiotics such as clarithromycin, allopurinol, antifungals like ketoconazole, and calcium-channel blockers such as amlodipine. It is important to be aware of these interactions to prevent any potential complications.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      20.9
      Seconds
  • Question 84 - You are treating a 35-year-old with limb injuries resulting from a rock climbing...

    Incorrect

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

      Your Answer: Left lateral recumbent position

      Correct Answer: Trendelenburg position

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      9.8
      Seconds
  • Question 85 - A 45-year-old woman is brought into the emergency room by an ambulance after...

    Correct

    • A 45-year-old woman is brought into the emergency room by an ambulance after being involved in a car accident. She was hit by a truck while driving her car and is suspected to have a pelvic injury. She is currently immobilized on a backboard with cervical spine protection and a pelvic binder in place.

      According to the ATLS guidelines, how much crystalloid fluid should be administered during the initial assessment?

      Your Answer: 1 L

      Explanation:

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

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

    • This question is part of the following fields:

      • Trauma
      26.9
      Seconds
  • Question 86 - A child presents with a severe acute asthma attack. After a poor response...

    Correct

    • A child presents with a severe acute asthma attack. After a poor response to their initial salbutamol nebulizer, you administer a second nebulizer that also contains ipratropium bromide.
      What is the estimated duration of action for ipratropium bromide?

      Your Answer: 3-6 hours

      Explanation:

      Ipratropium bromide is a medication that falls under the category of antimuscarinic drugs. It is commonly used to manage acute asthma and chronic obstructive pulmonary disease (COPD). While it can provide short-term relief for chronic asthma, it is generally recommended to use short-acting β2 agonists as they act more quickly and are preferred.

      According to the guidelines set by the British Thoracic Society (BTS), nebulized ipratropium bromide (0.5 mg every 4-6 hours) can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      For mild cases of chronic obstructive pulmonary disease, aerosol inhalation of ipratropium can be used for short-term relief, as long as the patient is not already using a long-acting antimuscarinic drug like tiotropium. The maximum effect of ipratropium occurs within 30-60 minutes after use, and its bronchodilating effects can last for 3-6 hours. Typically, treatment with ipratropium is recommended three times a day to maintain bronchodilation.

      The most common side effect of ipratropium bromide is dry mouth. Other potential side effects include constipation, cough, paroxysmal bronchospasm, headache, nausea, and palpitations. It is important to note that ipratropium can cause urinary retention in patients with prostatic hyperplasia and bladder outflow obstruction. Additionally, it can trigger acute closed-angle glaucoma in susceptible patients.

      For more information on the management of asthma, it is recommended to refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      18.7
      Seconds
  • Question 87 - A 25-year-old woman presents with a persistent sore throat that has been bothering...

    Incorrect

    • A 25-year-old woman presents with a persistent sore throat that has been bothering her for the past five days. She denies having any symptoms of a cold and does not have a cough. She has a clean medical history, does not take any medications, and has no known drug allergies. During the examination, she has a normal body temperature and a few tender lymph nodes in her neck. Her throat and tonsils appear red and inflamed, with a significant amount of exudate on her left tonsil.

      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: A throat swab should be taken, and antibiotics commenced if positive

      Correct Answer: She should be offered a 'back-up prescription' for penicillin V

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      115.6
      Seconds
  • Question 88 - A 65-year-old patient who was diagnosed with Parkinson's disease three years ago has...

    Correct

    • A 65-year-old patient who was diagnosed with Parkinson's disease three years ago has experienced a rapid deterioration in her overall functioning. She has been experiencing a progressive decline in her cognitive abilities, with severe memory impairment. Additionally, she has been experiencing prominent visual hallucinations and frequent fluctuations in her level of attention and alertness. Although her tremor is relatively mild, it is still present.
      What is the most probable diagnosis for this patient?

      Your Answer: Dementia with Lewy Bodies

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      29.4
      Seconds
  • Question 89 - You review a 16-year-old girl who is seeking advice on emergency contraception. The...

    Correct

    • 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.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      54.7
      Seconds
  • Question 90 - You conduct a medication review on a 68-year-old man with a history of...

    Correct

    • You conduct a medication review on a 68-year-old man with a history of angina. He is currently prescribed 10 mg bisoprolol once daily and GTN spray as needed. However, he continues to experience symptoms.
      Which ONE medication should be avoided in this patient?

      Your Answer: Verapamil

      Explanation:

      Beta-blockers, like bisoprolol, and verapamil have a strong negative effect on the force of ventricular contraction. When these medications are taken together, they can significantly reduce ventricular contraction and lead to a slow heart rate, known as bradycardia. Additionally, the risk of developing AV block is increased. In certain situations, this combination can result in severe low blood pressure or even a complete absence of heart rhythm, known as asystole. Therefore, it is important to avoid using these medications together to prevent these potentially dangerous effects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24.1
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Nephrology (1/5) 20%
Obstetrics & Gynaecology (0/3) 0%
Paediatric Emergencies (2/4) 50%
Ophthalmology (1/1) 100%
Gastroenterology & Hepatology (1/4) 25%
Haematology (1/3) 33%
Basic Anaesthetics (5/5) 100%
Infectious Diseases (2/7) 29%
Cardiology (3/3) 100%
Pharmacology & Poisoning (7/9) 78%
Vascular (0/1) 0%
Trauma (4/5) 80%
Neurology (6/7) 86%
Endocrinology (4/6) 67%
Dermatology (2/2) 100%
Mental Health (1/2) 50%
Environmental Emergencies (1/1) 100%
Elderly Care / Frailty (0/2) 0%
Surgical Emergencies (1/2) 50%
Urology (1/2) 50%
Musculoskeletal (non-traumatic) (1/2) 50%
Pain & Sedation (1/1) 100%
Allergy (0/2) 0%
Ear, Nose & Throat (2/5) 40%
Respiratory (1/3) 33%
Major Incident Management & PHEM (0/1) 0%
Resus (0/1) 0%
Safeguarding & Psychosocial Emergencies (1/1) 100%
Passmed