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Question 1
Correct
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You are part of the team managing a pediatric patient, your consultant asks you what the patient's Mallampati score is. What criteria is utilized to assess the Mallampati score?
Your Answer: The distance between the tongue base and the roof of the mouth
Explanation:The Mallampati score is a measure that assesses the distance between the base of the tongue and the roof of the mouth. This score is used to classify the level of airway obstruction during certain medical procedures. Please refer to the notes below for the complete classification.
Further Reading:
A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.
Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.
If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.
Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 2
Correct
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A 21 year old student visits the emergency department with complaints of headache and a feeling of nausea for the past 24 hours. He mentions that he started feeling unwell a few hours after he finished moving his belongings into his new shared student accommodation. Carbon monoxide poisoning is suspected. What is one of the four key questions recommended by RCEM to ask patients with suspected carbon monoxide poisoning?
Your Answer: Do symptoms improve outside of the house?
Explanation:The Royal College of Emergency Medicine (RCEM) recommends asking four important questions to individuals showing signs and symptoms of carbon monoxide poisoning. These questions can be easily remembered using the acronym COMA. The questions are as follows:
1. Is anyone else in the house, including pets, experiencing similar symptoms?
2. Do the symptoms improve when you are outside of the house?
3. Are the boilers and cooking appliances in your house properly maintained?
4. Do you have a functioning carbon monoxide alarm?Further Reading:
Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.
When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.
The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.
To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.
Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.
When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.
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This question is part of the following fields:
- Environmental Emergencies
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Question 3
Correct
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A 35-year-old diving instructor complains of pain and discharge in his right ear. Upon examination, you observe redness in the ear canal along with a significant amount of pus and debris.
What is the SINGLE most probable organism responsible for this condition?Your Answer: Pseudomonas aeruginosa
Explanation:Otitis externa, also known as swimmer’s ear, is a condition characterized by infection and inflammation of the ear canal. Common symptoms include pain, itching, and discharge from the ear. Upon examination with an otoscope, the ear canal will appear red and there may be pus and debris present.
There are several factors that can increase the risk of developing otitis externa, including skin conditions like psoriasis and eczema. Additionally, individuals who regularly expose their ears to water, such as swimmers, are more prone to this condition.
The most common organisms that cause otitis externa are Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), Gram-negative bacteria like E.coli (12%), and fungal species like Aspergillus and Candida (12%).
Treatment for otitis externa typically involves the use of topical antibiotic and corticosteroid combinations, such as Betnesol-N or Sofradex. In some cases, when the condition persists, referral to an ear, nose, and throat specialist may be necessary for auditory cleaning and the placement of an antibiotic-soaked wick.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 4
Correct
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A patient presents with a history of feeling constantly thirsty and urinating large amounts. She also experiences extreme fatigue. A diagnosis of diabetes mellitus is suspected, and a fasting blood glucose sample is scheduled.
What is the current WHO threshold for diagnosing diabetes mellitus using a fasting blood sample in this case?Your Answer: 7 mmol/l
Explanation:According to the 2011 recommendations from the World Health Organization (WHO), the following criteria are used to diagnose diabetes mellitus:
– A random venous plasma glucose concentration that exceeds 11.1 mmol/l.
– A fasting plasma glucose concentration that is higher than 7.0 mmol/l.
– A two-hour plasma glucose concentration that exceeds 11.1 mmol/l, measured two hours after consuming 75g of anhydrous glucose during an oral glucose tolerance test (OGTT).
– An HbA1c level that is greater than 48 mmol/mol (equivalent to 6.5%).These guidelines provide specific thresholds for diagnosing diabetes mellitus based on various glucose measurements and HbA1c levels. It is important for healthcare professionals to consider these criteria when evaluating individuals for diabetes mellitus.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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A 15 year old female patient is brought to the emergency department after being kicked by a horse multiple times. The patient had recently started work cleaning stables and was kicked several times whilst behind one of the horses. The patients observations are shown below:
Parameter Result
Blood pressure 108/62 mmHg
Pulse rate 124 bpm
Respiration rate 30 rpm
SpO2 95% on air
On examination there is significant bruising to the right anterolateral aspect of the chest wall, the patient is clammy, there is reduced air entry with dull percussion to the right lung base and the trachea is central. What is the likely diagnosis?Your Answer: Massive haemothorax
Explanation:Massive haemothorax is characterized by the presence of more than 1.5 litres of blood in the pleural space. The patient’s history and examination findings are indicative of haemothorax. When blood loss exceeds 1500ml, it is classified as grade 3 hypovolemic shock, which is considered severe. Symptoms such as a pulse rate over 120, respiration rate over 30, and low blood pressure align with grade 3 shock and are consistent with massive haemothorax. In the case of pneumothorax, percussion reveals a resonant or hyper-resonant sound. Chylothorax, on the other hand, is a rare condition that typically occurs due to injury to the thoracic duct.
Further Reading:
Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.
The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.
In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.
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This question is part of the following fields:
- Trauma
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Question 6
Correct
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A 57-year-old woman with a long history of frequent urination and difficulty emptying her bladder completely presents with a high fever, shivering, and body aches. She is experiencing pain in her pelvic area and has recently developed painful urination, increased frequency of urination, and a strong urge to urinate. During a rectal examination, her prostate is extremely tender. Due to a previous adverse reaction, he has been advised against taking quinolone antibiotics.
According to NICE, which of the following antibiotics is recommended as the first-line treatment for this patient's diagnosis?Your Answer: Trimethoprim
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.
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This question is part of the following fields:
- Urology
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Question 7
Correct
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A 32-year-old woman presents with a history of chronic foul-smelling discharge from her right ear. She has undergone three rounds of antibiotic drops, but the issue persists. Additionally, she is experiencing hearing difficulties in her right ear. Her medical history includes recurrent ear infections. During the examination, a retraction pocket is observed in the attic, along with granulation tissue on the tympanic membrane and a significant amount of debris.
What is the SINGLE most probable diagnosis?Your Answer: Cholesteatoma
Explanation:This individual is diagnosed with an acquired cholesteatoma, which is an expanding growth of the stratified keratinising epithelium in the middle ear. It develops due to dysfunction of the Eustachian tube and chronic otitis media caused by the retraction of the squamous elements of the tympanic membrane into the middle ear space.
The most important method for assessing the presence of a cholesteatoma is otoscopy. A retraction pocket observed in the attic or posterosuperior quadrant of the tympanic membrane is a characteristic sign of an acquired cholesteatoma. This is often accompanied by the presence of granulation tissue and squamous debris. The presence of a granular polyp within the ear canal also strongly suggests a cholesteatoma.
If left untreated, a cholesteatoma can lead to various complications including conductive deafness, facial nerve palsy, brain abscess, meningitis, and labyrinthitis. Therefore, it is crucial to urgently refer this individual to an ear, nose, and throat (ENT) specialist for a CT scan and surgical removal of the lesion.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 8
Incorrect
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You are evaluating a patient in the Emergency Department who has been treated for a head injury. He has recently been advised by his doctor to cease driving, but his daughter informs you that he is still driving.
What would be the initial course of action to take in this situation?Your Answer: Warn him that if he doesn’t stop driving, he is being irresponsible and you will have to phone the DVLA yourself
Correct Answer: Talk to the patient and ascertain whether he understands the risks to himself and others and see if you can help him realise that he should stop driving
Explanation:This question evaluates your ability to effectively communicate while promoting patient self-care and understanding of managing long-term conditions.
The most appropriate answer would be to initially talk to the patient himself. This approach allows for an assessment of the patient’s capacity to make decisions on his own. It is a gentle approach that respects his ability to make safe and sensible decisions.
In some cases, it can be helpful to include other close family members or friends when explaining a situation to a patient. However, it is important to avoid being coercive. While this option may be a good choice, it is not the best first step to take.
If all reasonable means have been tried and the patient continues to drive, there may come a time when it is necessary to contact the DVLA. However, this should be expressed in a less confrontational manner.
Suggesting to the patient’s wife to sell the car is not appropriate as it is not your place to make such a suggestion. Additionally, his wife may still need to use the car even if he cannot drive. This is not a suggestion that should be made by you.
It is not necessary to inform the DVLA immediately, as this could negatively impact the doctor-patient relationship in the future.
For more information, you can refer to the DVLA guidance on medical conditions affecting driving.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 9
Correct
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A 28-year-old woman comes in with lower abdominal pain, painful urination, pain during intercourse, and thick, yellowish vaginal discharge. Based on the clinical findings, you diagnose her with pelvic inflammatory disease (PID).
When would hospitalization be necessary in this case?Your Answer: Concurrent pregnancy
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.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 10
Incorrect
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You assess a patient with nausea, vomiting, restlessness, and palpitations. She is on theophylline for the treatment of her COPD. You suspect toxicity and order blood tests for evaluation.
What is the target range for theophylline levels?Your Answer: 30-40 mg/L
Correct Answer: 10-20 mg/L
Explanation:The therapeutic range for theophylline is quite limited, ranging from 10 to 20 micrograms per milliliter (10-20 mg/L). It is important to estimate the plasma concentration of aminophylline during long-term treatment as it can provide valuable information.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 11
Correct
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A 45 year old male patient is brought into the emergency department with a suspected severe pulmonary embolism. It is decided to intubate him pending transfer to the intensive care unit. Your consultant requests you prepare the patient for rapid sequence intubation. You start pre-oxygenating the patient. What is the recommended minimum duration for sufficient pre-oxygenation?
Your Answer: 3 minutes
Explanation:Inspired oxygen primarily works by removing nitrogen from the lungs, which would otherwise take up a significant portion of the lung capacity. This nitrogen is replaced with oxygen, leading to improved oxygenation of the tissues and an increased oxygen reserve. As a result, the patient can safely hold their breath for a longer period of time. It is recommended to preoxygenate the patient for at least 3 minutes.
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.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 12
Correct
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A 3-year-old girl is brought to the Emergency Department by her father after she accidentally spilled a cup of hot tea on her legs and feet. Her upper body is unaffected, but she is crying in agony. Her pain is evaluated using a numerical rating scale, and the triage nurse informs you that she has 'intense pain'.
Which pain relief method is most suitable to be used as a temporary measure until more effective pain relief can be given?Your Answer: Inhaled entonox
Explanation:A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.
To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.
The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.
To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.
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This question is part of the following fields:
- Pain & Sedation
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Question 13
Correct
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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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 14
Incorrect
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A 45-year-old woman presents with a history of passing fresh red blood mixed in with her last two bowel movements. She has had her bowels open three times in the past 24 hours. On examination, she is haemodynamically stable with a pulse of 85 bpm and a BP of 110/70. Her abdomen is soft and nontender, and there is no obvious source of anorectal bleeding on rectal examination.
Which investigation is recommended first-line for haemodynamically stable patients with lower gastrointestinal bleeds that require hospitalization?Your Answer: Flexible sigmoidoscopy
Correct Answer: Colonoscopy
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 15
Correct
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A 3-year-old girl is brought to the Emergency Department by her father after she accidentally spilled a cup of hot tea on her legs. Her upper body is unaffected, but she is crying in agony. Her pain is evaluated using a numerical rating scale and the triage nurse informs you that she has 'severe pain'.
According to the RCEM guidance, which of the following analgesics is recommended for managing severe pain in a child of this age?Your Answer: Intranasal diamorphine 0.1 mg/kg
Explanation:A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.
To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.
The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.
To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.
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This question is part of the following fields:
- Pain & Sedation
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Question 16
Correct
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You review a middle-aged man on the Clinical Decision Unit (CDU) who has presented following a car accident. He is accompanied by his close friend of many years, who is very concerned about him and his safety on the road. The friend is concerned as he has noticed that his friend has been forgetting important appointments and seems to be more absent-minded lately. You suspect that the patient may have cognitive impairment.
Which of the following is also most likely to be present in the history?Your Answer: She becomes agitated when taken to new surroundings
Explanation:Dementia is a collection of symptoms caused by a pathological process that leads to significant cognitive impairment, surpassing what is typically expected for a person’s age. The most prevalent form of dementia is Alzheimer’s disease.
The symptoms of dementia are diverse and encompass various aspects. These include memory loss, particularly in the short-term. Additionally, individuals with dementia may experience fluctuations in mood, which are typically responsive to external stimuli and support. It is important to note that thoughts about death are infrequent in individuals with dementia.
Furthermore, changes in personality may occur as a result of dementia. Individuals may struggle to find the right words when communicating and face difficulties in completing complex tasks. In later stages, urinary incontinence may become a concern, along with a loss of appetite and subsequent weight loss. Additionally, individuals with dementia may exhibit agitation when placed in unfamiliar settings.
Overall, dementia is characterized by a range of symptoms that significantly impact cognitive functioning.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 17
Correct
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A 65 year old male presents to the emergency department with a 3 hour history of severe chest pain that radiates to his left arm and neck. On examination, his chest is clear and his heart sounds are normal with a regular rhythm. No carotid bruits are heard. The following observations are noted:
Blood pressure: 150/90 mmHg
Pulse rate: 88 bpm
Respiration rate: 18 rpm
Oxygen saturation: 97% on room air
Temperature: 37.2ºC
An ECG reveals normal sinus rhythm and a chest X-ray shows no abnormalities. The patient's pain subsides after receiving buccal GTN (glyceryl trinitrate). Cardiac enzyme tests are pending. What is the most appropriate course of action for this patient?Your Answer: Administer 300 mg oral aspirin
Explanation:For patients suspected of having acute coronary syndromes (ACS), it is recommended that they receive 300 mg of aspirin and pain relief in the form of glyceryl trinitrate (GTN) with the option of intravenous opioids such as morphine. However, if the patient is pain-free after taking GTN, there is no need to administer morphine. The next steps in medical management or intervention will be determined once the diagnosis is confirmed.
Further Reading:
Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).
The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.
There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.
The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.
The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.
The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.
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This question is part of the following fields:
- Cardiology
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Question 18
Correct
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A 65 year old female presents to the emergency department complaining of severe abdominal pain. You note previous attendances with alcohol related injuries. On taking the history the patient admits to being a heavy drinker and estimates her weekly alcohol consumption at 80-100 units. She tells you her abdomen feels more swollen than usual and she feels nauseated. On examination of the abdomen you note it is visibly distended, tender to palpate and shifting dullness is detected on percussion. The patient's observations are shown below:
Blood pressure 112/74 mmHg
Pulse 102 bpm
Respiration rate 22 bpm
Temperature 38.6ºC
What is the most likely diagnosis?Your Answer: Spontaneous bacterial peritonitis
Explanation:Spontaneous bacterial peritonitis (SBP) is a condition that occurs as a complication of ascites, which is the accumulation of fluid in the abdomen. SBP typically presents with various symptoms such as fevers, chills, nausea, vomiting, abdominal pain, general malaise, altered mental status, and worsening ascites. This patient is at risk of developing alcoholic liver disease and cirrhosis due to their harmful levels of alcohol consumption. Harmful drinking is defined as drinking ≥ 35 units a week for women or drinking ≥ 50 units a week for men. The presence of shifting dullness and a distended abdomen are consistent with the presence of ascites. SBP is an acute bacterial infection of the ascitic fluid that occurs without an obvious identifiable cause. It is one of the most commonly encountered bacterial infections in patients with cirrhosis. Signs and symptoms of SBP include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 19
Incorrect
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A patient is experiencing lower gastrointestinal bleeding following the administration of heparin. You choose to utilize protamine sulfate to reverse the anticoagulation.
Which ONE statement about protamine sulfate is NOT true?Your Answer: 1 mg of protamine will neutralise 100 IU of heparin
Correct Answer: It is administered subcutaneously
Explanation:Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex is inactive and is used to counteract the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.
Apart from its ability to neutralize heparin, protamine sulphate also possesses a weak intrinsic anticoagulant effect. This is believed to be due to its inhibition of the formation and activity of thromboplastin.
To administer protamine sulphate, it is slowly injected intravenously. The dosage should be adjusted based on the amount of heparin to be neutralized, the time elapsed since heparin administration, and the aPTT. For every 100 IU of heparin, 1 mg of protamine is required for neutralization. However, the maximum adult dose within a 10-minute period should not exceed 50 mg.
It is important to note that protamine sulphate has additional effects on the body. It acts as a depressant on the heart muscle and may lead to bradycardia and hypotension. These effects are caused by complement activation and the release of leukotrienes.
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This question is part of the following fields:
- Haematology
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Question 20
Correct
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A 70-year-old diabetic smoker presents with central chest pain that radiates to his left shoulder and jaw. He is given 300 mg aspirin and morphine, and his pain subsides. The pain lasted approximately 90 minutes in total. His ECG shows normal sinus rhythm. He is referred to the on-call medical team for admission, and a troponin test is scheduled at the appropriate time. His blood tests today reveal a creatinine level of 298 micromoles per litre.
Which of the following medications should you also consider administering to this patient?Your Answer: Unfractionated heparin
Explanation:This patient’s medical history suggests a diagnosis of acute coronary syndrome. It is important to provide pain relief as soon as possible. This can be achieved by administering GTN (sublingual or buccal), but if there is suspicion of an acute myocardial infarction (MI), intravenous opioids such as morphine should be offered.
Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a high risk of bleeding or aspirin hypersensitivity. A single loading dose of 300 mg should be given immediately after presentation.
For patients without a high risk of bleeding and no planned coronary angiography within 24 hours of admission, fondaparinux should be administered. However, if coronary angiography is planned within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. For patients with significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin should be considered, with dose adjustment based on clotting function monitoring.
Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be given to individuals with an oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for an SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.
Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a potential treatment for adults with STEMI undergoing percutaneous coronary intervention.
For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.
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This question is part of the following fields:
- Cardiology
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Question 21
Incorrect
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A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, difficulty with coordination in her right arm, and difficulty speaking.
Which of the following blood vessels is most likely to be impacted?Your Answer: Middle cerebral artery
Correct Answer: Anterior 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.
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This question is part of the following fields:
- Neurology
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Question 22
Correct
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A 45-year-old individual presents with a swollen and painful left knee. The symptoms started three days ago. There is no history of any injury, and a joint aspirate is sent for laboratory analysis. The aspirate reveals the presence of pus cells, positively birefringent crystals, and no organisms.
What is the SINGLE most probable diagnosis?Your Answer: Pseudogout
Explanation:Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.
Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 23
Correct
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A 35 year old male is brought to the emergency department by his wife with a 24 hour history of vomiting and increasing fatigue over the past 1-2 hours. Initial tests confirm a diagnosis of diabetic ketoacidosis and the patient is started on intravenous fluids and an insulin infusion. You are reminded by your attending physician to monitor the bicarbonate level and adjust the insulin infusion rate if it is not improving as anticipated. What is the minimum desired change in bicarbonate that should be aimed for?
Your Answer: Venous bicarbonate rising by at least 3 mmol/L/hr
Explanation:When patients with diabetic ketoacidosis (DKA) are treated with insulin infusion, it is expected that their plasma bicarbonate levels will increase by at least 3 mmol/L per hour. Insulin therapy is aimed at correcting both hyperglycemia and ketoacidosis. However, if capillary ketones are not decreasing by at least 0.5 mmol/L per hour, venous bicarbonate is not rising by at least 3 mmol/L per hour, or plasma glucose is not decreasing by at least 3 mmol/L per hour, the insulin infusion rate should be reevaluated.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 24
Correct
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A 32-year-old man recently suffered a fracture in his right wrist. His cast has been taken off, and he visits you with worries about his right hand. Since the fracture, he has experienced tingling sensations in his thumb and has accidentally dropped items from his right hand a few times. These symptoms have not shown any improvement after the removal of the cast.
What is the MOST probable diagnosis?Your Answer: Ulnar neuritis
Explanation:Ulnar neuritis is characterized by hand clumsiness and can progress to muscle weakness and wasting in the ulnar nerve-supplied muscles. It may also cause numbness or tingling in the little finger and medial half of the ring finger. This condition is caused by the narrowing of the ulnar groove at the elbow and is associated with risk factors such as osteoarthritis, trauma, and rheumatoid arthritis. Nerve conduction studies and surgical decompression may be necessary for diagnosis and treatment.
De Quervain’s tenosynovitis occurs when there is inflammation of the thumb extensor and abductor tendon sheaths. This leads to pain over the radial styloid, which worsens with forced adduction and flexion of the thumb. Treatment options include anti-inflammatory medications, thumb splints, and steroid injections.
Dupuytren’s contracture occurs when the palmar fascia contracts, preventing finger extension. It commonly affects the fifth finger on the right hand and is more prevalent in men over the age of 65. Risk factors for this condition include male sex, family history, alcohol use, diabetes, smoking, trauma, and manual labor. Surgical release is necessary if the contracture affects daily activities or work.
Trigger finger occurs when a nodule becomes stuck in the tendon sheath, causing the affected finger to remain in a fixed flexed position. The ring and middle fingers are most commonly affected, and risk factors include rheumatoid arthritis and diabetes. Steroid injections or surgical removal can be used to treat this condition.
Carpal tunnel syndrome occurs when the median nerve is compressed under the flexor retinaculum, resulting in numbness, pain, and wasting of the thenar eminence in the lateral three and a half digits. Symptoms are often worse at night. While most cases are idiopathic, risk factors include obesity, oral contraceptive use, hypothyroidism, rheumatoid arthritis, pregnancy, diabetes, amyloidosis, acromegaly, tumors compressing the carpal tunnel, and previous wrist fractures. Tinel’s test and Phalen’s test can help diagnose carpal tunnel syndrome, and nerve conduction studies may be requested for further evaluation. Treatment options include splints, steroid injections, and surgical release if symptoms persist.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 25
Correct
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A 65-year-old patient presents to the emergency department and informs you that they have taken an overdose. The patient states that they are unsure of the exact number of tablets consumed but estimate it to be around 100 aspirin tablets. You are concerned about the severity of the overdose and its potential consequences. Which of the following is an indication for haemodialysis in patients with salicylate poisoning?
Your Answer: Salicylate level of 715 mg/L
Explanation:Haemodialysis is recommended for patients with salicylate poisoning if they meet any of the following criteria: plasma salicylate level exceeding 700 mg/L, metabolic acidosis that does not improve with treatment (plasma pH below 7.2), acute kidney injury, pulmonary edema, seizures, coma, unresolved central nervous system effects despite correcting acidosis, persistently high salicylate concentrations that do not respond to urinary alkalinisation. Severe cases of salicylate poisoning, especially in patients under 10 years old or over 70 years old, may require dialysis earlier than the listed indications.
Further Reading:
Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.
The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.
To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.
Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.
In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 26
Correct
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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.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 27
Correct
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A 5-year-old child is brought into the emergency room by an ambulance with sirens blaring. The child has been in a house fire and has sustained severe burns. The anesthesiologist examines the child's airway and is worried about the potential for airway blockage. Intubation is scheduled for the patient, and the necessary equipment is being prepared.
As per the ATLS recommendations, what is the smallest internal diameter endotracheal tube that should be utilized?Your Answer: 4.5 mm
Explanation:Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.
According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.
To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.
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This question is part of the following fields:
- Trauma
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Question 28
Correct
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A patient with a known history of asthma presents with symptoms of theophylline toxicity after starting a new medication.
Which of the following drugs is most likely causing this interaction?Your Answer: Fluconazole
Explanation:Theophylline, a medication commonly used to treat respiratory conditions, can be affected by certain drugs, either increasing or decreasing its plasma concentration and half-life. Drugs that can increase the plasma concentration of theophylline include calcium channel blockers like verapamil, cimetidine, fluconazole, macrolides such as erythromycin, methotrexate, and quinolones like ciprofloxacin. On the other hand, drugs like carbamazepine, phenobarbitol, phenytoin (and fosphenytoin), rifampicin, and St. John’s wort can decrease the plasma concentration of theophylline. It is important to be aware of these interactions when prescribing or taking theophylline to ensure its effectiveness and avoid potential side effects.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 29
Incorrect
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Your hospital’s pediatrics department is currently evaluating the utility of a triple marker test for use in risk stratification of patients with a suspected heart condition. The test will use troponin I, myoglobin, and heart-type fatty acid-binding protein (HFABP).
How long after a heart event do troponin I levels reach their highest point?Your Answer: 12 hours
Correct Answer: 24 hours
Explanation:The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.
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This question is part of the following fields:
- Cardiology
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Question 30
Correct
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A 45-year-old man receives a blood transfusion for anemia secondary to excessive nosebleeds. While receiving the second unit, he complains of experiencing alternating sensations of heat and cold. His temperature is measured at 38.1ºC, compared to his pre-transfusion temperature of 37ºC. Apart from this, he feels fine and does not exhibit any other symptoms.
What is the most suitable course of treatment in this case?Your Answer: Supportive measures and paracetamol
Explanation:Blood transfusion is a crucial medical treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur. One common adverse reaction is febrile transfusion reactions, which present as an unexpected rise in temperature during or after transfusion. This can be caused by cytokine accumulation or recipient antibodies reacting to donor antigens. Treatment for febrile transfusion reactions is supportive, and other potential causes should be ruled out.
Another serious complication is acute haemolytic reaction, which is often caused by ABO incompatibility due to administration errors. This reaction requires the transfusion to be stopped and IV fluids to be administered. Delayed haemolytic reactions can occur several days after a transfusion and may require monitoring and treatment for anaemia and renal function. Allergic reactions, TRALI (Transfusion Related Acute Lung Injury), TACO (Transfusion Associated Circulatory Overload), and GVHD (Graft-vs-Host Disease) are other potential complications that require specific management approaches.
In summary, blood transfusion carries risks and potential complications, but efforts have been made to improve safety procedures. It is important to be aware of these complications and to promptly address any adverse reactions that may occur during or after a transfusion.
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This question is part of the following fields:
- Haematology
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Question 31
Correct
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You requested an evaluation of a 50-year-old individual who has come in with a two-day history of dizziness. The medical student has examined the patient and provided a tentative diagnosis of vestibular neuritis. What characteristics would typically be observed in a patient with vestibular neuritis?
Your Answer: Recent viral infection
Explanation:Vestibular neuronitis is believed to occur when the vestibular nerve becomes inflamed, often following a viral infection like a cold. This condition causes a constant feeling of dizziness, which can worsen with head movements. On the other hand, BPPV (benign paroxysmal positional vertigo) is characterized by brief episodes of vertigo lasting around 10-20 seconds, triggered by specific head movements. To diagnose BPPV, the Dix-Hallpike test is performed, and a positive result is indicated by a specific type of eye movement called nystagmus. In contrast, vestibular neuritis typically presents with horizontal nystagmus that only occurs in one direction.
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
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 32
Correct
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A 32-year-old patient presents to the emergency department with a 6 cm leg laceration. After assessing the wound, it is determined that suturing under anesthesia is necessary. You intend to supervise one of the medical students in closing the wound. Before beginning the procedure, you have a discussion about the risks associated with local anesthesia. Methemoglobinemia is primarily associated with which type of anesthetic agent?
Your Answer: Prilocaine
Explanation:Methaemoglobinaemia is a condition that can occur when prilocaine is used, particularly when administered at doses higher than 16 mg/kg.
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.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 33
Correct
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A 35-year-old woman presents to the Emergency Department with a brief history of headaches, which are more severe in the morning, and blurred vision and ringing in the ears. Her headache is worse than usual today, and she has vomited multiple times. She has no significant medical history but does take the combined oral contraceptive pill. On examination, you find her to be overweight, and her neurological system examination reveals a sixth cranial nerve palsy, but no other focal neurology and fundoscopy reveals bilateral papilloedema.
What is the SINGLE most likely diagnosis?Your Answer: Idiopathic intracranial hypertension
Explanation:The most probable diagnosis in this case is idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumour cerebri. This condition typically affects overweight women in their 20s and 30s.
The clinical features of idiopathic intracranial hypertension include:
– Headache: The headache is usually worse in the morning and evenings, relieved by standing, and worsened when lying down. It can also be aggravated by coughing and sneezing. Some patients may experience pain around the shoulder girdle.
– Nausea and vomiting
– Visual field defects: These develop gradually over time.
– 6th nerve palsy and diplopia
– Bilateral papilloedemaTo investigate this condition, the patient should undergo a CT scan and/or MRI of the brain, as well as a lumbar puncture to measure the opening pressure and analyze the cerebrospinal fluid (CSF).
The primary treatment goal for idiopathic intracranial hypertension is to prevent visual loss. This can be achieved through one of the following strategies:
– Repeated lumbar puncture to control intracranial pressure (ICP)
– Medical treatment with acetazolamide
– Surgical decompression of the optic nerve sheath -
This question is part of the following fields:
- Neurology
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Question 34
Correct
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A 68 year old male attends the emergency department with a member of staff from his nursing home who is concerned that the patient has had diarrhea for the past 2 days. The patient complains of cramping pains to the lower abdomen. The carer tells you the patient has been having frequent episodes of watery foul smelling diarrhea. There is no associated vomiting and no blood in the stool. You note the patient has recently completed a 5 day course of amoxicillin for a respiratory infection that failed to resolve with a 3 day course of azithromycin treatment. The patient's regular medications are:
Lansoprazole 30 mg once daily
Acetaminophen 1g four times daily
Ibuprofen 400 mg three times daily as required for joint pain
On examination the patient's abdomen is soft with some tenderness on deep palpation of the lower quadrants but no guarding or rigidity. The patient's observations are shown below:
Temperature 37.3ºC
Blood pressure 144/84 mmHg
Pulse 88 bpm
Respiratory rate 18 bpm
Oxygen saturations 97% on air
What organism is most likely to be causing this patient's symptoms?Your Answer: Clostridium difficile
Explanation:This patient is showing signs and symptoms that align with a C.diff infection. They also have several risk factors that increase their likelihood of developing this infection, including being over the age of 65, residing in a nursing home or being hospitalized for an extended period, recent use of antibiotics, and regular use of PPI medication.
Further Reading:
Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.
Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.
Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.
Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.
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This question is part of the following fields:
- Infectious Diseases
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Question 35
Correct
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A 55-year-old woman with no permanent residence experiences a head injury after a fall. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.
During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.
Which treatment is most likely responsible for causing these symptoms?Your Answer: Intravenous glucose
Explanation:This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.
Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.
This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.
If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.
Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.
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This question is part of the following fields:
- Neurology
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Question 36
Correct
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A 28 year old male is brought into the ED after being discovered in a collapsed state. The patient is making minimal effort to breathe. The patient is a known IV drug user. The attending physician requests that you obtain an arterial blood gas sample from the radial artery. The blood gas is collected and the results are as follows:
pH 7.30
pO2 8.8 kPa
pCO2 7.4 kPa
Bicarbonate 26 mmol/L
Chloride 98 mmol/L
Potassium 5.6 mmol/L
Sodium 135 mmol/L
What type of acid-base abnormality is indicated?Your Answer: Respiratory acidosis
Explanation:Respiratory acidosis occurs when the respiratory system is unable to effectively remove carbon dioxide from the body, leading to an increase in acidity. This is often seen in cases of opioid overdose, where respiratory depression can occur. In respiratory acidosis, the bicarbonate levels may rise as the body’s metabolic system tries to compensate for the increased acidity.
Further Reading:
Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.
To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.
Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.
The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.
The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.
The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.
Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.
The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.
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This question is part of the following fields:
- Respiratory
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Question 37
Correct
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A 12-year-old girl presents with her father. She is very active and enjoys participating in various sports at a high level. Lately, she has been worried about experiencing pain in her right ankle. There is no history of injury, instability, or swelling. She is in good overall health. She can walk and run without discomfort, and the pain does not worsen after prolonged periods of rest. During the examination of her ankle, you observe tenderness and slight swelling around the lateral malleolus.
What is the SINGLE most likely diagnosis?Your Answer: Osgood-Schlatter disease
Explanation:Osgood-Schlatter disease is commonly observed in active teenagers and is characterized by pain and tenderness in the tibial tuberosity. Rest is typically recommended as part of the treatment plan, and the diagnosis is made based on clinical evaluation.
Chondromalacia patella is most prevalent in teenage girls and is often accompanied by knee pain while going up and downstairs. Discomfort tends to worsen after prolonged periods of sitting. Treatment options include pain relief medication and physiotherapy.
Prepatellar bursitis, also known as housemaid’s knee, is linked to excessive kneeling.
Pseudogout is an inflammatory arthritis caused by the accumulation of pyrophosphate crystals. While the knees are frequently affected, it is unlikely to occur in this age group.
Still’s disease accounts for approximately 10% of cases of juvenile chronic arthritis. It typically involves multiple systems in the body and is often characterized by fever, rash, swollen lymph nodes, and joint pain.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 38
Incorrect
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A 45-year-old individual is preparing to board a flight for a business conference and has concerns regarding the potential risk of developing DVT. They would like to inquire about the minimum duration of travel that is considered to pose an elevated risk of DVT during air travel.
Your Answer: 6 hours
Correct Answer: 4 hours
Explanation:The World Health Organisation Research into Global Hazards of Travel (Wright) Project found that the main factor contributing to deep venous thrombosis is being immobile, and the risk of developing a blood clot is higher when traveling for more than 4 hours. According to the Wright Study, the absolute risk of experiencing deep venous thrombosis during flights lasting over 4 hours was found to be one in 4656. For more information on this topic, you can refer to the guidance provided by the Civil Aviation Authority for medical professionals.
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This question is part of the following fields:
- Vascular
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Question 39
Correct
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A 25-year-old female patient arrives at the Emergency Department displaying symptoms consistent with a sexually transmitted infection.
Which of the following organisms is primarily transmitted through sexual contact?Your Answer: Chlamydia trachomatis
Explanation:Chlamydia trachomatis is a type of bacteria that is accountable for causing the infection known as chlamydia. This bacterium is mainly transmitted through sexual contact.
There are various serological variants of C. trachomatis, and each variant is associated with different patterns of disease. Specifically, types D-K are responsible for causing genitourinary infections.
In the United Kingdom, chlamydia is the most commonly diagnosed sexually transmitted infection (STI). It is also the leading preventable cause of infertility worldwide. Interestingly, around 50% of men infected with chlamydia do not experience any symptoms, while at least 70% of infected women are asymptomatic.
If left untreated, chlamydia can lead to various complications. In women, these complications may include pelvic inflammatory disease (PID), ectopic pregnancy, and tubal infertility. Men, on the other hand, may experience complications such as proctitis, epididymitis, and epididymo-orchitis.
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This question is part of the following fields:
- Sexual Health
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Question 40
Correct
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A 40-year-old woman comes in with tremor, anxiety, sweating, and nausea. Her observations reveal an elevated heart rate of 119 bpm. She typically consumes 2-3 large bottles of strong cider daily but has recently run out of money and hasn't had an alcoholic drink since the previous night.
Which assessment scale should be utilized to guide the treatment of this woman's alcohol withdrawal? Select ONE option.Your Answer: CIWA scale
Explanation:The CIWA scale, also known as the Clinical Institute Withdrawal Assessment for Alcohol scale, is a scale consisting of ten items that is utilized in the evaluation and management of alcohol withdrawal. It is currently recommended by both NICE and the Royal College of Emergency Medicine for assessing patients experiencing acute alcohol withdrawal. The maximum score on the CIWA scale is 67, with scores indicating the severity of withdrawal symptoms. A score of less than 5 suggests mild withdrawal, while a score between 6 and 20 indicates moderate withdrawal. Any score above 20 is considered severe withdrawal. The ten items evaluated on the scale encompass common symptoms and signs of alcohol withdrawal, such as nausea/vomiting, tremors, sweating, anxiety, agitation, sensory disturbances, and cognitive impairments.
In addition to the CIWA scale, there are other screening tools available for assessing various conditions. The CAGE questionnaire is commonly used to screen for alcohol-related issues. The STEPI is utilized as a screening tool for early symptoms of the schizophrenia prodrome. The EPDS is an evidence-based questionnaire that can be employed to screen for postnatal depression. Lastly, the SCOFF questionnaire is a screening tool used to identify the possible presence of eating disorders.
For further information on the assessment and management of acute alcohol withdrawal, the NICE pathway is a valuable resource. The RCEM syllabus also provides relevant information on this topic. Additionally, the MHC1 module on alcohol and substance misuse offers further reading material for those interested in this subject.
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This question is part of the following fields:
- Mental Health
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Question 41
Correct
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You are managing a patient in the resuscitation bay with suspected myxoedema coma. A member of the nursing team hands you the patient's ECG. What ECG findings would you anticipate in a patient with myxoedema coma?
Your Answer: Prolonged QT interval
Explanation:Patients with myxoedema coma often exhibit several common ECG abnormalities. These include bradycardia, a prolonged QT interval, and T wave flattening or inversion. Additionally, severe hypothyroidism (myxoedema) is associated with other ECG findings such as low QRS voltage, conduction blocks, and T wave inversions without ST deviation.
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.
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This question is part of the following fields:
- Endocrinology
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Question 42
Correct
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A 28 year old male is brought into the emergency department in a comatose state with suspected poisoning. An arterial blood gas sample is taken. The results are shown below:
pH 7.22
pO2 12.5 kpa
pCO2 5.9 kpa
Bicarbonate 14 mmol/l
Chloride 98 mmol/l
Potassium 6.1 mmol/l
Sodium 136 mmol/l
Overdose or poisoning with which of the following typically leads to this type of acid base disturbance?Your Answer: Aspirin
Explanation:Salicylate poisoning often leads to a metabolic acidosis characterized by a high anion gap. The patient in question is experiencing this type of acid-base disturbance. This particular acid-base imbalance is typically seen in cases of poisoning with substances such as glycols (ethylene and propylene), salicylates (aspirin), paracetamol, methanol, isoniazid, and paraldehyde.
Further Reading:
Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.
To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.
Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.
The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.
The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.
The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.
Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.
The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 43
Correct
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A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
Which of the following will be visible on her X-ray?Your Answer: Fracture of the zygomatic arch
Explanation:Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.
These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:
1. Widening of the zygomaticofrontal suture
2. Fracture of the zygomatic arch
3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
4. Fracture of the lateral orbital rim. -
This question is part of the following fields:
- Maxillofacial & Dental
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Question 44
Correct
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A 65 year old female is brought to the emergency department by her son. The son informs you that he visited his mother at the assisted living facility and noticed a decline in her alertness and mental state since his last visit 2 weeks ago. He expresses dissatisfaction with the facility staff, who made excuses about several caregivers being absent due to illness or vacation.
Upon assessment, the patient opens her eyes and makes incomprehensible sounds when spoken to, but is unable to speak coherently or form words. The patient exhibits localized response to painful stimuli.
What is this patient's Glasgow Coma Score?Your Answer: 10
Explanation:The GCS scoring system evaluates a patient’s level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each criterion is assigned a score, and the total score determines the patient’s GCS score. For example, if a patient has a GCS score of 10 (E3 V2 M5), it means they scored 3 out of 4 in eye opening, 2 out of 5 in verbal response, and 5 out of 6 in motor response.
Further Reading:
A subdural hematoma (SDH) is a condition where there is a collection of blood between the dura mater and the arachnoid mater of the brain. It occurs when the cortical bridging veins tear and bleed into the subdural space. Risk factors for SDH include head trauma, cerebral atrophy, advancing age, alcohol misuse, and certain medications or bleeding disorders. SDH can be classified as acute, subacute, or chronic depending on its age or speed of onset. Acute SDH is typically the result of head trauma and can progress to become chronic if left untreated.
The clinical presentation of SDH can vary depending on the nature of the condition. In acute SDH, patients may initially feel well after a head injury but develop more serious neurological symptoms later on. Chronic SDH may be detected after a CT scan is ordered to investigate confusion or cognitive decline. Symptoms of SDH can include increasing confusion, progressive decline in neurological function, seizures, headache, loss of consciousness, and even death.
Management of SDH involves an ABCDE approach, seizure management, confirming the diagnosis with CT or MRI, checking clotting and correcting coagulation abnormalities, managing raised intracranial pressure, and seeking neurosurgical opinion. Some SDHs may be managed conservatively if they are small, chronic, the patient is not a good surgical candidate, and there are no neurological symptoms. Neurosurgical intervention typically involves a burr hole craniotomy to decompress the hematoma. In severe cases with high intracranial pressure and significant brain swelling, a craniectomy may be performed, where a larger section of the skull is removed and replaced in a separate cranioplasty procedure.
CT imaging can help differentiate between subdural hematoma and other conditions like extradural hematoma. SDH appears as a crescent-shaped lesion on CT scans.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 45
Correct
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A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during their gap year.
Which of the following is NOT a viral haemorrhagic fever?Your Answer: Chagas disease
Explanation:The viral hemorrhagic fevers (VHFs) are a group of infectious diseases caused by four distinct types of RNA viruses. These include Filoviruses (such as Marburg virus and Ebola), Arenaviruses (like Lassa fever and Argentine haemorrhagic fever), Bunyaviruses (including Hantavirus and Rift Valley fever), and Flavivirus (such as Yellow fever and dengue fever). VHFs are serious multi-system disorders that can be potentially fatal. Each type of VHF has a natural reservoir, which is an animal or insect host, and they are typically found in the areas where these host species reside. Outbreaks of these hemorrhagic fevers occur sporadically and irregularly, making them difficult to predict.
The typical clinical features of VHFs include fever, headache, myalgia, fatigue, bloody diarrhea, haematemesis, petechial rashes and ecchymoses, edema, confusion and agitation, as well as hypotension and circulatory collapse.
On the other hand, Chagas disease is not classified as a VHF. It is a tropical disease caused by the protozoan Trypanosoma cruzi. This disease is transmitted by Triatomine insects, commonly known as kissing bugs. Initially, Chagas disease causes a mild acute illness that resembles flu. However, around 10% of individuals develop chronic Chagas disease, which can lead to various complications. These complications include cardiac issues like dilated cardiomyopathy, neurological problems such as neuritis, and gastrointestinal complications like megacolon.
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This question is part of the following fields:
- Infectious Diseases
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Question 46
Correct
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What is the underlying cause of Korsakoff's psychosis in a 45-year-old man with a history of chronic alcohol abuse?
Your Answer: Thiamine deficiency
Explanation:Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a classic triad of symptoms, which include acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination and balance). Additional possible features of this condition may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. In the majority of cases, peripheral neuropathy (nerve damage) is also observed, typically affecting the legs.
The condition is marked by the presence of acute capillary haemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while CT scanning is not very useful for diagnosis.
If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia (difficulty remembering past events), an inability to memorize new information, disordered time appreciation, and confabulation (fabrication of false memories).
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This question is part of the following fields:
- Mental Health
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Question 47
Incorrect
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A 68 year old female is brought into the emergency home from her nursing home due to severe diarrhea for the past 3 days. You observe that over the past month the patient has undergone three rounds of antibiotics for recurrent cellulitis. You contemplate the likelihood of a Clostridium difficile infection. What proportion of antibiotic-associated diarrhea is attributed to Clostridium difficile infection?
Your Answer: 5-10%
Correct Answer: 20-30%
Explanation:Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.
Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.
Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.
Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.
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This question is part of the following fields:
- Infectious Diseases
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Question 48
Correct
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A 35-year-old patient presents with concerns about a recent alteration in her usual vaginal discharge. She is not sexually active at the moment and has no other systemic health issues. She does not report any itching symptoms but has observed a strong fishy odor and a greyish-white appearance in the discharge.
What is the MOST PROBABLE diagnosis in this case?Your Answer: Bacterial vaginosis
Explanation:Bacterial vaginosis (BV) is a common condition that affects up to a third of women during their childbearing years. It occurs when there is an overgrowth of bacteria, specifically Gardnerella vaginalis. This bacterium is anaerobic, meaning it thrives in environments without oxygen. As it multiplies, it disrupts the balance of bacteria in the vagina, leading to a rise in pH levels due to a decrease in lactic acid-producing lactobacilli. It’s important to note that BV is not a sexually transmitted infection.
The main symptom of BV is a greyish discharge with a distinct fishy odor. However, it’s worth mentioning that up to 50% of affected women may not experience any symptoms at all.
To diagnose BV, healthcare providers often use Amsel’s criteria. This involves looking for the presence of three out of four specific criteria: a vaginal pH greater than 4.5, a positive fishy smell when potassium hydroxide is added (known as the whiff test), the presence of clue cells on microscopy, and a thin, white, homogeneous discharge.
The primary treatment for BV is oral metronidazole, typically taken for 5-7 days. This medication has an initial cure rate of about 75%. It’s important to note that pregnant patients with BV require special attention, as the condition is associated with an increased risk of late miscarriage, early labor, and chorioamnionitis (inflammation of the fetal membranes). Therefore, prompt treatment is crucial for these patients.
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This question is part of the following fields:
- Sexual Health
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Question 49
Correct
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A 70-year-old woman presents with a 4-day history of feeling generally unwell and having experienced fevers at home. She has a history of breast cancer for which she is currently undergoing radiation therapy. Her vital signs are as follows: HR 100 bpm, BP 120/80, SaO2 95% on room air, temperature 38.5°C.
The results of her complete blood count are as follows:
Hemoglobin (Hb) 9.2 g/dl
Mean Corpuscular Volume (MCV) 80 fl
Platelets 60 x 109/l
White Cell Count (WCC) 1.2 x 109/l
Lymphocytes 0.4 x 109/l
Neutrophils 0.6 x 109/l
Monocytes 0.1 x 109/l
Which of the following antibiotics would be most appropriate for the initial empiric treatment of this patient?Your Answer: Tazocin alone
Explanation:The patient is showing signs of pancytopenia along with a fever, indicating a likely case of neutropenic sepsis. Their blood test results reveal microcytic anemia, leucopenia (with significant neutropenia), and thrombocytopenia. Neutropenic sepsis is a serious condition that can be life-threatening, characterized by a low neutrophil count. There are several potential causes of neutropenia, including cytotoxic chemotherapy, immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, and nutritional deficiencies.
To diagnose neutropenic sepsis in patients undergoing anticancer treatment, their neutrophil count should be 0.5 x 109 per liter or lower, and they should have either a temperature above 38°C or other signs and symptoms indicative of clinically significant sepsis. According to the current NICE guidelines, initial empiric antibiotic therapy for suspected neutropenic sepsis should involve monotherapy with piperacillin with tazobactam (Tazocin 4.5 g IV). It is not recommended to use an aminoglycoside, either alone or in combination therapy, unless there are specific patient-related or local microbiological reasons to do so.
Reference:
NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’ -
This question is part of the following fields:
- Oncological Emergencies
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Question 50
Correct
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A 68 year old is brought into the emergency department after being bitten on the leg by a patient with Alzheimer's disease at a nearby nursing home. The bite wound seems to have only punctured the skin without any ongoing bleeding or signs of infection such as redness, swelling, or discharge. Despite the absence of current infection, you decide to administer prophylactic antibiotics. What is the recommended length of time for prophylactic antibiotics in a non-infected human bite wound?
Your Answer: 3 days
Explanation:In cases of human bite wounds where the skin is broken but no blood is drawn, it is recommended to consider antibiotic prophylaxis, especially if the bite occurs in a high-risk area like the hands. According to NICE guidelines, a 3-day course of antibiotics is usually sufficient for prophylaxis in bite wounds. However, if the bite wound becomes infected, a 5-day course of antibiotics is advised for treatment.
Further Reading:
Bite wounds from animals and humans can cause significant injury and infection. It is important to properly assess and manage these wounds to prevent complications. In human bites, both the biter and the injured person are at risk of infection transmission, although the risk is generally low.
Bite wounds can take various forms, including lacerations, abrasions, puncture wounds, avulsions, and crush or degloving injuries. The most common mammalian bites are associated with dogs, cats, and humans.
When assessing a human bite, it is important to gather information about how and when the bite occurred, who was involved, whether the skin was broken or blood was involved, and the nature of the bite. The examination should include vital sign monitoring if the bite is particularly traumatic or sepsis is suspected. The location, size, and depth of the wound should be documented, along with any functional loss or signs of infection. It is also important to check for the presence of foreign bodies in the wound.
Factors that increase the risk of infection in bite wounds include the nature of the bite, high-risk sites of injury (such as the hands, feet, face, genitals, or areas of poor perfusion), wounds penetrating bone or joints, delayed presentation, immunocompromised patients, and extremes of age.
The management of bite wounds involves wound care, assessment and administration of prophylactic antibiotics if indicated, assessment and administration of tetanus prophylaxis if indicated, and assessment and administration of antiviral prophylaxis if indicated. For initial wound management, any foreign bodies should be removed, the wound should be encouraged to bleed if fresh, and thorough irrigation with warm, running water or normal saline should be performed. Debridement of necrotic tissue may be necessary. Bite wounds are usually not appropriate for primary closure.
Prophylactic antibiotics should be considered for human bites that have broken the skin and drawn blood, especially if they involve high-risk areas or the patient is immunocompromised. Co-amoxiclav is the first-line choice for prophylaxis, but alternative antibiotics may be used in penicillin-allergic patients. Antibiotics for wound infection should be based on wound swab culture and sensitivities.
Tetanus prophylaxis should be administered based on the cleanliness and risk level of the wound, as well as the patient’s vaccination status. Blood-borne virus risk should also be assessed, and testing for hepatitis B, hepatitis C, and HIV should be done.
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This question is part of the following fields:
- Infectious Diseases
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Question 51
Correct
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After reviewing the management of a pediatric patient who recently presented to the emergency department with diabetic ketoacidosis (DKA), your consultant has scheduled a teaching session to assess the trainee's understanding of DKA management. You are tasked with determining the target minimum rate of blood glucose reduction in a pediatric patient receiving fluid and insulin therapy.
Your Answer: 3 mmol/L/hr
Explanation:Patients who are being treated with insulin infusion for diabetic ketoacidosis (DKA) should expect their plasma glucose levels to decrease by at least 3 mmol/L per hour. The purpose of the insulin infusion is to correct both hyperglycemia and ketoacidosis. It is important to regularly review and check the insulin infusion to ensure it is working effectively. If any of the following are observed, the infusion rate should be adjusted accordingly: capillary ketones are not decreasing by at least 0.5 mmol/L per hour, venous bicarbonate is not increasing by at least 3 mmol/L per hour, or plasma glucose is not decreasing by at least 3 mmol/L per hour.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 52
Correct
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A 60-year-old man who has recently finished a round of antibiotics comes in with excessive, foul-smelling diarrhea. After further examination, he is diagnosed with Clostridium Difficile diarrhea.
Which of the following antibiotics carries the highest risk of causing Clostridium Difficile diarrhea?Your Answer: Clindamycin
Explanation:Clostridium difficile is a type of bacteria that is Gram-positive, anaerobic, and capable of forming spores. When individuals take broad-spectrum antibiotics, it can disrupt the normal bacteria in the bowel and allow C. difficile to multiply. This can lead to inflammation and bleeding in the mucosa of the large intestine, resulting in a distinct appearance known as pseudomembranous. The main symptoms of C. difficile infection (CDI) include abdominal cramps, bloody and/or watery diarrhea, and fever. It is worth noting that the majority of CDI cases occur in individuals over the age of 65.
CDI is considered to be the most severe consequence of antibiotic treatment and is now a significant cause of illness and death. While CDI can occur after treatment with any antibiotic, the risk is particularly high with prolonged use of broad-spectrum antibiotics. Recently, two research groups conducted a meta-analysis to assess the risk associated with different classes of antibiotics.
Their findings revealed that the risk of CDI increased nearly sevenfold after antibiotic treatment (odds ratio, 6.91). Among the various antibiotic classes, clindamycin posed the greatest risk (odds ratio, 20.43), followed by fluoroquinolones (odds ratio, 5.65), cephalosporins (odds ratio, 4.47), penicillins (odds ratio, 3.25), macrolides (odds ratio, 2.55), and trimethoprim/sulfonamides (odds ratio, 1.84). Tetracyclines, on the other hand, were not found to be associated with an increased risk of CDI (odds ratio, 0.91).
For more information on this topic, you may consider reading the article Antibiotic Classes and Risk for Clostridium difficile Infection.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 53
Incorrect
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You are asked to review a 7-year-old girl that is feeling sick in the Paediatric Emergency Department. You observe from her urea & electrolytes that her potassium is elevated at 6.2 mmol/l.
What is the most frequent cause of hyperkalaemia in children?Your Answer: Renal tubular acidosis
Correct Answer: Renal failure
Explanation:Hyperkalaemia is a condition characterized by a high level of potassium in the blood, specifically a plasma potassium level greater than 5.5 mmol/l. It can be further classified into three categories based on the severity of the condition. Mild hyperkalaemia refers to a potassium level ranging from 5.5-5.9 mmol/l, while moderate hyperkalaemia is defined as a potassium level between 6.0-6.4 mmol/l. Severe hyperkalaemia is indicated by a potassium level exceeding 6.5 mmol/l.
The most common cause of hyperkalaemia in renal failure, which can occur either acutely or chronically. However, there are other factors that can contribute to this condition as well. These include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.
Overall, hyperkalaemia is a medical condition that requires attention and management, as it can have significant implications for the body’s normal functioning.
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This question is part of the following fields:
- Nephrology
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Question 54
Correct
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You are evaluating a 42-year-old woman in the ER after a fall. During the examination, you observe multiple clinical manifestations consistent with Cushing syndrome. What is the most probable underlying cause of Cushing syndrome in this case?
Your Answer: Pituitary adenoma
Explanation:Cushing syndrome is most commonly caused by the use of external glucocorticoids. However, when it comes to endogenous causes, pituitary adenoma, also known as Cushing’s disease, is the leading culprit.
Further Reading:
Cushing’s syndrome is a clinical syndrome caused by prolonged exposure to high levels of glucocorticoids. The severity of symptoms can vary depending on the level of steroid exposure. There are two main classifications of Cushing’s syndrome: ACTH-dependent disease and non-ACTH-dependent disease. ACTH-dependent disease is caused by excessive ACTH production from the pituitary gland or ACTH-secreting tumors, which stimulate excessive cortisol production. Non-ACTH-dependent disease is characterized by excess glucocorticoid production independent of ACTH stimulation.
The most common cause of Cushing’s syndrome is exogenous steroid use. Pituitary adenoma is the second most common cause and the most common endogenous cause. Cushing’s disease refers specifically to Cushing’s syndrome caused by an ACTH-producing pituitary tumor.
Clinical features of Cushing’s syndrome include truncal obesity, supraclavicular fat pads, buffalo hump, weight gain, moon facies, muscle wasting and weakness, diabetes or impaired glucose tolerance, gonadal dysfunction, hypertension, nephrolithiasis, skin changes (such as skin atrophy, striae, easy bruising, hirsutism, acne, and hyperpigmentation in ACTH-dependent causes), depression and emotional lability, osteopenia or osteoporosis, edema, irregular menstrual cycles or amenorrhea, polydipsia and polyuria, poor wound healing, and signs related to the underlying cause, such as headaches and visual problems.
Diagnostic tests for Cushing’s syndrome include 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test, and late-night salivary cortisol. Other investigations aim to assess metabolic disturbances and identify the underlying cause, such as plasma ACTH, full blood count (raised white cell count), electrolytes, and arterial blood gas analysis. Imaging, such as CT or MRI of the abdomen, chest, and/or pituitary, may be required to assess suspected adrenal tumors, ectopic ACTH-secreting tumors, and pituitary tumors. The choice of imaging is guided by the ACTH result, with undetectable ACTH and elevated serum cortisol levels indicating ACTH-independent Cushing’s syndrome and raised ACTH suggesting an ACTH-secreting tumor.
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This question is part of the following fields:
- Endocrinology
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Question 55
Correct
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A toddler is brought in with a rash and a high fever. You suspect a potential diagnosis of bacterial meningitis.
Based on the current NICE guidelines, which of the following features is LEAST indicative of this condition?Your Answer: Focal seizures
Explanation:NICE has emphasized that certain indications and manifestations may indicate specific diseases as the underlying cause of fever. For instance, symptoms such as neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus are suggestive of bacterial meningitis. On the other hand, NICE has identified focal seizures and focal neurological signs as the most indicative of herpes simplex encephalitis. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 56
Correct
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You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methemoglobinemia. What test would you employ to confirm this diagnosis?
Your Answer: MetHb
Explanation:COHb is a measure used to evaluate the presence of carbon monoxide poisoning in individuals who are in good health. hHb refers to deoxygenated haemoglobin.
Further Reading:
Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.
Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.
Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.
Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.
Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.
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This question is part of the following fields:
- Respiratory
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Question 57
Correct
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You are the designated team leader in the resuscitation of a cardiac arrest patient. Your colleague disagrees with the decision to continue with the resuscitation.
What is the most appropriate course of action for you to take?Your Answer: Listen to the reason that they disagree and if their concerns are justified, change your decision accordingly
Explanation:In a resuscitation scenario, problem-solving and teamwork are crucial. The pressure is high, and tough decisions need to be made. As the team leader, it is important to value the opinions of other team members, especially those with more experience. By listening to the registrar’s perspective, you may gain new insights that could impact your decision-making process. Collaboration is key in such situations, and if you find yourself unsure of the best course of action, don’t hesitate to seek assistance.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 58
Correct
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A 35-year-old traveler returns from a vacation in India with a high temperature and stomach issues. After medical examination, he is confirmed to have typhoid fever.
Your Answer: The incubation period is between 7 and 21 days
Explanation:Typhoid fever is a bacterial infection caused by Salmonella typhi. Paratyphoid fever, on the other hand, is a similar illness caused by Salmonella paratyphi. Together, these two conditions are collectively known as the enteric fevers.
Typhoid fever is prevalent in India and many other parts of Asia, Africa, Central America, and South America. It is primarily transmitted through the consumption of contaminated food or water that has been infected by the feces of an acutely infected or recovering person, or a chronic carrier. About 1-6% of individuals infected with S. typhi become chronic carriers. The incubation period for this illness ranges from 7 to 21 days.
During the first week of the illness, patients experience weakness and lethargy, accompanied by a gradually increasing fever. The onset of the illness is usually subtle, and constipation is more common than diarrhea in the early stages. Other early symptoms include headaches, abdominal pain, and nosebleeds. In cases of typhoid fever, the fever can occur with a relatively slow heart rate, known as Faget’s sign.
As the illness progresses into the second week, patients often become too fatigued to get out of bed. Diarrhea becomes more prominent, the fever intensifies, and patients may become agitated and delirious. The abdomen may become tender and swollen, and approximately 75% of patients develop an enlarged spleen. In up to a third of patients, red macules known as Rose spots may appear.
In the third week, the illness can lead to various complications. Intestinal bleeding may occur due to bleeding in congested Peyer’s patches. Other potential complications include intestinal perforation, secondary pneumonia, encephalitis, myocarditis, metastatic abscesses, and septic shock.
After the third week, surviving patients begin to show signs of improvement, with the fever and symptoms gradually subsiding over the course of 7-14 days. Untreated patients have a mortality rate of 15-30%. Traditionally, drugs like ampicillin and trimethoprim have been used for treatment. However, due to the emergence of multidrug resistant cases, azithromycin or fluoroquinolones are now the primary treatment options.
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This question is part of the following fields:
- Infectious Diseases
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Question 59
Correct
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You are part of the resus team treating a 42-year-old female patient. Due to deteriorating GCS, your consultant advises you to prepare for rapid sequence induction. You contemplate which induction agent is most appropriate for this patient. What side effect of etomidate prevents its use in septic patients?
Your Answer: Adrenal suppression
Explanation:Etomidate is not recommended for use in septic patients because it can suppress adrenal cortisol production, leading to increased morbidity and mortality in sepsis cases. However, it is a suitable choice for haemodynamically unstable patients who are not experiencing sepsis, as it does not cause significant hypotension like other induction agents. Additionally, etomidate can be beneficial for patients with head injuries and elevated intracranial pressure, as it reduces cerebral blood flow and intracranial pressure.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 60
Correct
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A 32-year-old construction worker is brought into the emergency department with burns to the right forearm. The patient explains that he was smoking a cigarette while driving back from work when the cigarette accidentally fell onto his arm, igniting his sleeve which might have been soaked in gasoline from work. You observe circumferential burns encompassing the entire right forearm. What would be your primary concern regarding potential complications?
Your Answer: Compartment syndrome
Explanation:Compartment syndrome can occur when there are circumferential burns on the arms or legs. This typically happens with full thickness burns, where the burnt skin becomes stiff and compresses the compartment, making it difficult for blood to flow out. To treat this condition, escharotomy and possibly fasciotomy may be necessary.
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.
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This question is part of the following fields:
- Trauma
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Question 61
Correct
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The charge nurse approaches you to ask you to speak to an elderly woman who is dissatisfied and would like to file a complaint. She visited the emergency department with complaints of stomach discomfort and was examined by one of the male junior doctors currently on duty in the department. She alleges that he conducted a pelvic examination without providing sufficient explanation, and she is worried that it was unnecessary. Additionally, there was no chaperone present.
How would you handle this scenario?Your Answer: Speak to the patient to find out what happened, review the notes, discuss with the nursing staff on duty. Discuss with the consultant on duty; this will need further detailed investigation.
Explanation:Managing a difficult situation that involves teamwork and patient safety can be challenging. The first priority is to ensure the patient’s safety from a clinical standpoint. It is important to promptly inform the consultant on duty about the incident and gather all relevant information.
In the meantime, it is crucial to gather information from the patient, nursing staff, and written notes to fully understand the situation. A thorough investigation will be necessary, including a discussion with the doctor involved. Complaints of this nature must be taken seriously, and it may be necessary to send the doctor home while the investigation takes place.
Additionally, it is important to escalate the matter to the hospital hierarchy to ensure appropriate action is taken. The doctor should also be directed to support services as this process is likely to be stressful for them.
For further guidance on this matter, it is recommended to refer to the GMC Guidance on Intimate Examinations and Chaperones.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 62
Incorrect
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A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on the medication she takes for her heart condition. She informs you that she consumed verapamil immediate-release 240 mg tablets approximately 30 minutes ago. However, her spouse promptly discovered her and brought her to the hospital. Currently, she shows no signs of symptoms. Typically, how much time passes before symptoms manifest in cases of this overdose?
Your Answer: 3-6 hours
Correct Answer: 1-2 hours
Explanation:Calcium-channel blocker overdose is a serious condition that should always be taken seriously as it can be potentially life-threatening. The two most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
Significant toxicity can occur with the ingestion of more than 10 tablets of verapamil (160 mg or 240 mg immediate or sustained-release capsules) or diltiazem (180 mg, 240 mg or 360 mg immediate or sustained-release capsules). In children, even 1-2 tablets of immediate or sustained-release verapamil or diltiazem can be harmful. Symptoms usually appear within 1-2 hours of taking standard preparations, but with slow-release versions, the onset of severe toxicity may be delayed by 12-16 hours, with peak effects occurring after 24 hours.
The main clinical manifestations of calcium-channel blocker overdose include nausea and vomiting, low blood pressure, slow heart rate and first-degree heart block, heart muscle ischemia and stroke, kidney failure, pulmonary edema, and high blood sugar levels.
When managing a patient with calcium-channel blocker overdose, certain bedside investigations are crucial. These include checking blood glucose levels, performing an electrocardiogram (ECG), and obtaining an arterial blood gas sample. Additional investigations that can provide helpful information include assessing urea and electrolyte levels, conducting a chest X-ray to check for pulmonary edema, and performing an echocardiography.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 63
Correct
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A 36 year old male is brought into the emergency department following a syncopal episode. The patient reports several weeks of generalized weakness, muscle aches, and feeling dizzy when standing which has been gradually worsening. On examination, you note pigmented areas on the lips, tongue, and gums with patches of vitiligo around the hands and wrists. Observation and blood test results are shown below:
Hb 132 g/l
Platelets 124 * 109/l
WBC 8.0 * 109/l
Na+ 128 mmol/l
K+ 6.2 mmol/l
Urea 8.9 mmol/l
Creatinine 95 µmol/l
Glucose 3.1 mmol/l
Blood pressure 94/56 mmHg
Pulse 102 bpm
Respirations 18 bpm
Oxygen sats 97% on air
What is the most likely diagnosis?Your Answer: Addison's disease
Explanation:Addison’s disease, also known as adrenal insufficiency, is characterized by a gradual onset of symptoms over several weeks, although it can sometimes occur suddenly. The diagnosis of Addison’s disease can be challenging as its symptoms, such as fatigue, muscle pain, weight loss, and nausea, are non-specific. However, a key feature is low blood pressure. The disease is associated with changes in pigmentation, ranging from increased pigmentation due to elevated ACTH levels to the development of vitiligo caused by the autoimmune destruction of melanocytes.
Patients with Addison’s disease often exhibit hyponatremia (low sodium levels) and hyperkalemia (high potassium levels). If the patient is dehydrated, this may be reflected in elevated urea and creatinine levels. While hypercalcemia (high calcium levels) and hypoglycemia (low blood sugar levels) can occur in Addison’s disease, they are less common than hyponatremia and hyperkalemia.
In contrast, diabetes insipidus, characterized by normal or elevated sodium levels, does not cause pigmentation changes. Cushing’s syndrome, which results from excess steroid production, is almost the opposite of Addison’s disease, with hypertension (high blood pressure) and hypokalemia (low potassium levels) being typical symptoms. Phaeochromocytoma, on the other hand, is associated with episodes of high blood pressure and hyperglycemia (high blood sugar levels).
Further Reading:
Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.
The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.
The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.
Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.
There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.
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This question is part of the following fields:
- Endocrinology
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Question 64
Correct
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A 68 year old female visits the emergency department with complaints of lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable and a diagnosis of acute urinary retention is made. To determine if any medications may be contributing to the condition, you inquire about the patient's drug history. Which of the following drug classes is NOT known to cause urinary retention?
Your Answer: 5α-reductase inhibitors
Explanation:Urinary retention can be caused by various drug classes. One such class is 5α-reductase inhibitors like finasteride, which are prescribed to alleviate obstructive symptoms caused by an enlarged prostate. Some commonly known drugs that can lead to urinary retention include alcohol, anticholinergics, decongestants (such as phenylephrine and pseudoephedrine), disopyramide, antihistamines (like diphenhydramine and phenergan), and amphetamines.
Further Reading:
Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.
There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.
The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.
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This question is part of the following fields:
- Urology
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Question 65
Correct
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You evaluate a 38-year-old woman who was hit on the side of her leg by a soccer player while spectating the match from the sidelines. You suspect a tibial plateau fracture and order an X-ray of the affected knee. Besides the fracture line, what other radiographic indication is frequently observed in individuals with acute tibial plateau fractures?
Your Answer: Lipohaemathrosis evident in suprapatellar pouch
Explanation:Lipohaemathrosis is commonly seen in the suprapatellar pouch in individuals who have tibial plateau fractures. Notable X-ray characteristics of tibial plateau fractures include a visible fracture of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch.
Further Reading:
Tibial plateau fractures are a type of traumatic lower limb and joint injury that can involve the medial or lateral tibial plateau, or both. These fractures are classified using the Schatzker classification, with higher grades indicating a worse prognosis. X-ray imaging can show visible fractures of the tibial plateau and the presence of lipohaemathrosis in the suprapatellar pouch. However, X-rays often underestimate the severity of these fractures, so CT scans are typically used for a more accurate assessment.
Tibial spine fractures, on the other hand, are separate from tibial plateau fractures. They occur when the tibial spine is avulsed by the anterior cruciate ligament (ACL). This can happen due to forced knee hyperextension or a direct blow to the femur when the knee is flexed. These fractures are most common in children aged 8-14.
Tibial tuberosity avulsion fractures primarily affect adolescent boys and are often caused by jumping or landing from a jump. These fractures can be associated with Osgood-Schlatter disease. The treatment for these fractures depends on their grading. Low-grade fractures may be managed with immobilization for 4-6 weeks, while more significant avulsions are best treated with surgical fixation.
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This question is part of the following fields:
- Trauma
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Question 66
Correct
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You evaluate a 72-year-old in the emergency department who has come in with complaints of back pain. After conducting a thorough assessment, you observe that the patient possesses several risk factors for osteoporosis. You recommend that the patient undergo a formal evaluation to determine their risk of osteoporotic fractures. Which tool is considered the gold standard for this assessment?
Your Answer: Qfracture
Explanation:QFracture is a highly regarded tool used to predict the risk of osteoporotic fractures and determine if a DXA bone assessment is necessary. It is considered the preferred and gold standard tool by NICE and SIGN. FRAX is another fracture risk assessment tool that is also used to determine the need for a DXA bone assessment. The Rockwood score and electronic frailty Index (eFI) are both frailty scores. The informant questionnaire on cognitive decline in the elderly is a tool used to assess cognitive decline in older individuals.
Further Reading:
Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.
Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.
The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.
There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.
Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.
Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.
Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 67
Correct
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A 42-year-old woman was involved in a car accident where her vehicle collided with a wall at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel. She is experiencing severe bruising on her anterior chest wall and is complaining of chest pain. A chest X-ray reveals a significantly widened mediastinum, tracheal deviation to the right, and fractures of the first and second ribs. Her vital signs are as follows: heart rate of 94, blood pressure of 128/73, and oxygen saturation of 99% on high flow oxygen.
What is the SINGLE most likely diagnosis?Your Answer: Traumatic aortic rupture
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.
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This question is part of the following fields:
- Trauma
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Question 68
Correct
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A 42-year-old woman comes in with a painful, red left eye and sensitivity to light. She also reports seeing floaters and experiencing a dull, throbbing headache. She is currently being evaluated by the rheumatology team for persistent pain and stiffness in her upper back and discomfort in her buttocks and thighs. Her eye appears red, and a hypopyon is visible.
What is the SINGLE most probable diagnosis?Your Answer: Anterior uveitis
Explanation:The most probable diagnosis in this case is anterior uveitis, which refers to inflammation of the iris. It typically presents with symptoms such as a painful and red eye, sensitivity to light, excessive tearing, and decreased visual clarity. The photo above shows a possible indication of this condition, with the presence of pus in the front chamber of the eye, known as hypopyon.
Anterior uveitis can have various causes, including idiopathic cases where no specific cause is identified. Other potential triggers include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). Additionally, certain malignancies like non-Hodgkin lymphoma, ocular melanoma, and retinoblastoma can be associated with anterior uveitis.
It is worth noting that there is a strong link between the HLA-B27 genotype and anterior uveitis, with approximately 50% of patients having this genetic marker. In this particular case, the likely underlying diagnosis is ankylosing spondylitis, a condition characterized by chronic pain and stiffness in the mid-spine area and sacroiliitis. It is important to mention that around 30% of men with unilateral uveitis will be found to have ankylosing spondylitis.
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This question is part of the following fields:
- Ophthalmology
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Question 69
Correct
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You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a pronounced first heart sound (S1).
What is the most probable cause of this finding?Your Answer: Mitral stenosis
Explanation:The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.
A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).
A loud S1 can be associated with the following conditions:
– Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
– Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
– Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
– Mitral valve prolapse
– Thin individualsA soft S1 can be associated with the following conditions:
– Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
– Prolonged PR interval (e.g. heart block, digoxin toxicity)
– Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
– Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)A split S1 can be associated with the following conditions:
– Right bundle branch block
– LV pacing
– Ebstein anomaly -
This question is part of the following fields:
- Cardiology
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Question 70
Correct
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A 5-year-old child comes in with a high-grade fever, excessive drooling, and inability to speak. The child has obvious stridor and a rapid heart rate. During the examination, there is tenderness in the front of the neck around the hyoid bone and swollen lymph nodes in the neck.
What is the SINGLE most probable diagnosis?Your Answer: Acute epiglottitis
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 71
Correct
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A 45-year-old smoker with a diagnosis of advanced lung cancer with spinal metastases experiences a severe, shooting pain in his left leg. He is currently using a fentanyl patch, but it is not providing relief for the pain.
What would be the most appropriate next course of treatment for this patient?Your Answer: Gabapentin
Explanation:This patient is currently experiencing neuropathic pain due to spinal metastases from their lung malignancy.
The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. If the initial treatment is not effective or well-tolerated, one of the remaining three drugs can be considered. If the second and third drugs tried also prove to be ineffective or not well-tolerated, it may be necessary to switch to a different medication. Tramadol should only be considered as a last resort for acute rescue therapy.
For more information on the pharmacological management of neuropathic pain in adults, please refer to the NICE guidance.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 72
Correct
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You assess a patient who is currently undergoing systemic anticancer treatment. She presents with a high fever, and you have concerns about the potential occurrence of neutropenic sepsis.
Which of the following statements is accurate regarding neutropenic sepsis?Your Answer: Specialist management in an acute hospital setting involves implementing the standard UK Sepsis Trust 'Sepsis Six' bundle
Explanation:Neutropenic sepsis is a serious complication that can occur in individuals with low neutrophil counts, known as neutropenia. There are several potential causes of neutropenia, including certain medications like chemotherapy and immunosuppressive drugs, stem cell transplantation, infections, bone marrow disorders, and nutritional deficiencies. In adults, mortality rates as high as 20% have been reported.
To diagnose neutropenic sepsis, doctors look for a neutrophil count of 0.5 x 109 per litre or lower in patients undergoing cancer treatment. Additionally, patients must have either a temperature higher than 38°C or other signs and symptoms consistent with significant sepsis. Cancer treatments can suppress the bone marrow ability to respond to infections, making neutropenic sepsis more likely. This is most commonly seen with systemic chemotherapy but can also occur after radiotherapy.
According to the current guidelines from the National Institute for Health and Care Excellence (NICE), adult patients with acute leukemia, stem cell transplants, or solid tumors who are expected to experience significant neutropenia due to chemotherapy should be offered prophylaxis with a fluoroquinolone antibiotic, such as ciprofloxacin. This should be taken during the expected period of neutropenia.
When managing neutropenic sepsis, it is important to promptly implement the UK Sepsis Trust Sepsis Six bundle within the first hour of recognizing sepsis. This involves specialist assessment and management in an acute hospital setting.
The NICE guidelines recommend using piperacillin with tazobactam (Tazocin) as the initial empiric antibiotic therapy for patients suspected of having neutropenic sepsis. It is advised not to use an aminoglycoside, either alone or in combination therapy, unless there are specific patient-related or local microbiological indications.
Reference:
NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’ -
This question is part of the following fields:
- Oncological Emergencies
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Question 73
Correct
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A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.
What is the most suitable initial treatment in this case?Your Answer: IV magnesium sulphate
Explanation:Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 74
Correct
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A 68-year-old woman, who has been smoking for her entire life, is diagnosed with a small cell carcinoma of the lung. After further examination, it is revealed that she has developed the syndrome of inappropriate ADH secretion (SIADH) as a result of this.
What kind of electrolyte disturbance would you anticipate in this case?Your Answer: Low serum Na, low serum osmolarity, high urine osmolarity
Explanation:Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by the excessive and uncontrollable release of antidiuretic hormone (ADH). This can occur either from the posterior pituitary gland or from an abnormal non-pituitary source. There are various conditions that can disrupt the regulation of ADH secretion in the central nervous system and lead to SIADH. These include CNS damage such as meningitis or subarachnoid hemorrhage, paraneoplastic syndromes like small cell carcinoma of the lung, infections such as atypical pneumonia or cerebral abscess, and certain drugs like carbamazepine, TCAs, and SSRIs.
The typical biochemical profile observed in SIADH is characterized by low levels of serum sodium (usually less than 135 mmol/l), low serum osmolality, and high urine osmolality.
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This question is part of the following fields:
- Oncological Emergencies
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Question 75
Correct
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A 35-year-old man is admitted to the Clinical Decision Unit (CDU) in the early hours of the morning. He was brought in by the police as he’d been causing a disturbance in the street. They were concerned that he might have medical issues that need reviewing. He is well known to the department and has a long history of multiple attendances, usually related to substance abuse. He appeared intoxicated on admission, and the decision was made to observe him overnight. He is now fully alert and orientated, and is very apologetic about his behavior the previous night. He does not want to wait to be reviewed by the doctors and wants to go home.
What is the best course of action for you to take? Select ONE option only.Your Answer: Refer the patient for follow up in the community by the alcohol outreach team
Explanation:This question is assessing various aspects, such as your ability to make decisions, manage long-term conditions, and promote patient self-care.
The most appropriate action would be to get in touch with the community alcohol outreach team to ensure that the patient receives proper follow-up care. Additionally, it is important to assess the patient’s Glasgow Coma Scale (GCS) before considering self-discharge. However, this does not indicate the need for long-term follow-up.
Asking a family member to monitor the patient is not a safe or suitable solution, and providing intravenous fluids and nutritional advice does not address the underlying long-term issues in this case. It would be potentially dangerous to suggest that the patient stops drinking immediately.
Overall, contacting the community alcohol outreach team for follow-up care is the best course of action in this situation.
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This question is part of the following fields:
- Mental Health
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Question 76
Correct
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A 45-year-old man presents with a severe exacerbation of his asthma. You have been asked to administer a loading dose of albuterol. He weighs 70 kg.
What is the appropriate loading dose for him?Your Answer: 250 mg over 15 minutes
Explanation:The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a patient weighing 50 kg, the appropriate loading dose would be 250 mg. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.
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This question is part of the following fields:
- Respiratory
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Question 77
Correct
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You are with a hiking group at an elevation of 3100 meters. One of your members, who is experiencing a headache, nausea, and fatigue, is diagnosed with acute mountain sickness (AMS). Which medication would be the most suitable for treating AMS?
Your Answer: Dexamethasone
Explanation:Dexamethasone is the preferred medication for treating Acute Mountain Sickness (AMS) and High Altitude Cerebral Edema (HACE). In cases of mild AMS, simply halting the ascent and giving the body time to acclimatize may be sufficient. However, if mild AMS persists or worsens, or if the patient experiences moderate to severe AMS, descending to a lower altitude is the most effective treatment, preferably with the addition of supplemental oxygen. Dexamethasone is the recommended medication for managing both AMS and HACE.
Further Reading:
High Altitude Illnesses
Altitude & Hypoxia:
– As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
– Hypoxia occurs at altitude due to decreased inspired oxygen.
– At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.Acute Mountain Sickness (AMS):
– AMS is a clinical syndrome caused by hypoxia at altitude.
– Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
– Symptoms usually occur after 6-12 hours above 2500m.
– Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
– The Lake Louise AMS score is used to assess the severity of AMS.
– Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
– Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
– Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.High Altitude Pulmonary Edema (HAPE):
– HAPE is a progression of AMS but can occur without AMS symptoms.
– It is the leading cause of death related to altitude illness.
– Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
– Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
– Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.High Altitude Cerebral Edema (HACE):
– HACE is thought to result from vasogenic edema and increased vascular pressure.
– It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
– Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
– Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
– Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis. -
This question is part of the following fields:
- Environmental Emergencies
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Question 78
Correct
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A teenager presents following a fall. You observe that they are dressed very casually and have a strong smell of alcohol. Looking at their medical records, you notice that they have had multiple similar presentations in the past few months. You decide to administer a screening questionnaire to assess for potential alcohol dependency.
According to the current NICE guidelines, which of the following screening tests is recommended for this purpose?Your Answer: AUDIT
Explanation:The Alcohol Use Disorder Identification Test (AUDIT) has been developed by the World Health Organization as a straightforward screening tool to detect early signs of hazardous and harmful drinking, as well as mild dependence. This assessment is more comprehensive than the CAGE questionnaire and is currently recommended by NICE for identifying alcohol misuse.
NICE, the National Institute for Health and Care Excellence, suggests the use of specific assessment tools to evaluate the nature and severity of alcohol misuse. These tools include AUDIT for identification and as a routine outcome measure, SADQ or LDQ for assessing the severity of dependence, CIWA-Ar for evaluating the severity of withdrawal symptoms, and APQ for understanding the nature and extent of problems resulting from alcohol misuse.
For more information on this topic, you can refer to the NICE guidance titled Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.
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This question is part of the following fields:
- Mental Health
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Question 79
Correct
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A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
Which of the following signs or symptoms would NOT raise suspicion of HELLP syndrome in a pregnant patient?Your Answer: Symptoms occurring around 16 weeks gestation
Explanation:HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.
The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.
Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.
Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 80
Correct
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You are overseeing the care of a 68-year-old individual with COPD. The patient has recently started using BiPAP. What is the desired range for oxygen saturation in a patient with COPD and type 2 respiratory failure who is receiving BiPAP?
Your Answer: 88-92%
Explanation:In patients with COPD and type 2 respiratory failure, the desired range for oxygen saturation while receiving BiPAP is typically 88-92%.
Maintaining oxygen saturation within this range is crucial for individuals with COPD as it helps strike a balance between providing enough oxygen to meet the body’s needs and avoiding the risk of oxygen toxicity. Oxygen saturation levels below 88% may indicate inadequate oxygenation, while levels above 92% may lead to oxygen toxicity and other complications.
Further Reading:
Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.
CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.
BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.
The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.
In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.
Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.
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This question is part of the following fields:
- Respiratory
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Question 81
Correct
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You are present at a child cardiac arrest scene. The blood gas shows that the patient is extremely acidotic and has a high potassium level. The attending physician suggests that sodium bicarbonate is administered.
What dose of sodium bicarbonate should be given in this case?Your Answer: 1 ml/kg 8.4%
Explanation:The regular use of sodium bicarbonate in pediatric cardiac arrest is not commonly advised. However, it may be considered in cases of prolonged arrests, and it serves a specific purpose in treating hyperkalemia and the arrhythmias caused by tricyclic antidepressant overdose.
When sodium bicarbonate is administered, the appropriate dosage is 1 ml per kilogram of 8.4% sodium bicarbonate.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 82
Correct
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You are caring for a hypoxic patient in the resuscitation bay. One of the potential diagnoses is methaemoglobinaemia. If the diagnosis of methaemoglobinaemia is confirmed, which of the following treatments would be the most appropriate to administer?
Your Answer: Methylene blue
Explanation:If IV methylene blue is obtained, it is typically used to treat a specific cause. However, if there is no response to methylene blue, alternative treatments such as hyperbaric oxygen or exchange transfusion may be considered. In cases where the cause is NADH-methaemoglobinaemia reductase deficiency, ascorbic acid can be used as a potential treatment.
Further Reading:
Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.
Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.
Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.
Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.
Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 83
Incorrect
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A 25-year-old man comes in with a persistent sore throat that has lasted for five days. He denies having a cough. During the examination, his temperature is measured at 39°C and a few tender anterior cervical lymph nodes are found. There is a noticeable amount of exudate on his right tonsil, which appears red and inflamed.
What is his FeverPAIN score?Your Answer: 3
Correct Answer: 4
Explanation:The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.
If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.
The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.
Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 84
Incorrect
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A 35-year-old patient with a history of schizophrenia comes in with side effects from a medication that he recently began taking for this condition. Upon examination, you observe that he is experiencing severe muscular rigidity, a decreased level of consciousness, and a body temperature of 40ºC.
Which of the following medications is most likely causing these symptoms?Your Answer: Olanzapine
Correct Answer: Chlorpromazine
Explanation:First-generation antipsychotics, also known as conventional or typical antipsychotics, are potent blockers of dopamine D2 receptors. However, these drugs also have varying effects on other receptors such as serotonin type 2 (5-HT2), alpha1, histaminic, and muscarinic receptors.
One of the major drawbacks of first-generation antipsychotics is their high incidence of extrapyramidal side effects. These include rigidity, bradykinesia, dystonias, tremor, akathisia, and tardive dyskinesia. Additionally, there is a rare but life-threatening reaction called neuroleptic malignant syndrome (NMS) that can occur with these medications. NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. It typically occurs shortly after starting or increasing the dose of a neuroleptic medication.
In contrast, second-generation antipsychotics, also known as novel or atypical antipsychotics, have a lower risk of extrapyramidal side effects and NMS compared to their first-generation counterparts. However, they are associated with higher rates of metabolic effects and weight gain.
It is important to differentiate serotonin syndrome from NMS as they share similar features. Serotonin syndrome is most commonly caused by serotonin-specific reuptake inhibitors.
Here are some commonly encountered examples of first- and second-generation antipsychotics:
First-generation:
– Chlopromazine
– Haloperidol
– Fluphenazine
– TrifluoperazineSecond-generation:
– Clozapine
– Olanzapine
– Quetiapine
– Risperidone
– Aripiprazole -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 85
Correct
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A 45-year-old patient comes to the emergency department with a complaint of increasing hearing loss in the right ear over the past few months. During the examination, tuning fork tests are performed. Weber's test shows lateralization to the left side, and Rinne's testing is positive in both ears.
Based on this assessment, which of the following diagnoses is most likely?Your Answer: Acoustic neuroma
Explanation:Based on the assessment findings, the most likely diagnosis for the 45-year-old patient with increasing hearing loss in the right ear is an acoustic neuroma. This is suggested by the lateralization of Weber’s test to the left side, indicating that sound is being heard better in the left ear. Additionally, the positive Rinne’s test in both ears suggests that air conduction is better than bone conduction, which is consistent with an acoustic neuroma. Other possible diagnoses such as otosclerosis, otitis media, cerumen impaction, and tympanic membrane perforation are less likely based on the given information.
Further Reading:
Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.
Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.
To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.
Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 86
Correct
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You are requested to evaluate a 45-year-old woman who has come in with an episode of dizziness. The patient mentions that she suspects she may be experiencing symptoms of Meniere's syndrome.
What would be a typical observation in a patient with Meniere's syndrome?Your Answer: Associated tinnitus and low frequency hearing loss
Explanation:Meniere’s disease is characterized by recurring episodes of vertigo, tinnitus, and low frequency hearing loss that typically last for a few minutes to a few hours. A patient with Meniere’s disease would be expected to experience these symptoms. During the Weber test, the sound would be heard loudest in the unaffected (contralateral) side. The Romberg test would show a positive result, indicating impaired balance. Additionally, the Fukuda (also known as Unterberger) stepping test would also be positive, suggesting a tendency to veer or lean to one side while walking.
Further Reading:
Meniere’s disease is a disorder of the inner ear that is characterized by recurrent episodes of vertigo, tinnitus, and low frequency hearing loss. The exact cause of the disease is unknown, but it is believed to be related to excessive pressure and dilation of the endolymphatic system in the middle ear. Meniere’s disease is more common in middle-aged adults, but can occur at any age and affects both men and women equally.
The clinical features of Meniere’s disease include episodes of vertigo that can last from minutes to hours. These attacks often occur in clusters, with several episodes happening in a week. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure. Nystagmus and a positive Romberg test are common findings, and the Fukuda stepping test may also be positive. While symptoms are typically unilateral, bilateral symptoms may develop over time.
Rinne’s and Weber’s tests can be used to help diagnose Meniere’s disease. In Rinne’s test, air conduction should be better than bone conduction in both ears. In Weber’s test, the sound should be heard loudest in the unaffected (contralateral) side due to the sensorineural hearing loss.
The natural history of Meniere’s disease is that symptoms often resolve within 5-10 years, but most patients are left with some residual hearing loss. Psychological distress is common among patients with this condition.
The diagnostic criteria for Meniere’s disease include clinical features consistent with the disease, confirmed sensorineural hearing loss on audiometry, and exclusion of other possible causes.
Management of Meniere’s disease involves an ENT assessment to confirm the diagnosis and perform audiometry. Patients should be advised to inform the DVLA and may need to cease driving until their symptoms are under control. Acute attacks can be treated with buccal or intramuscular prochlorperazine, and hospital admission may be necessary in some cases. Betahistine may be beneficial for prevention of symptoms.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 87
Incorrect
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A 45-year-old woman presents with overall fatigue and increased skin pigmentation. She has a history of bilateral adrenalectomy for Cushing's syndrome 10 years ago. During the examination of her visual fields, a bitemporal hemianopia is discovered.
What is the SINGLE most probable diagnosis?Your Answer: Addison’s disease
Correct Answer: Nelson’s syndrome
Explanation:Nelson’s syndrome is a rare condition that occurs many years after a bilateral adrenalectomy for Cushing’s syndrome. It is believed to develop due to the loss of the normal negative feedback control that suppresses high cortisol levels. As a result, the hypothalamus starts producing CRH again, which stimulates the growth of a pituitary adenoma that produces adrenocorticotropic hormone (ACTH).
Only 15-20% of patients who undergo bilateral adrenalectomy will develop this condition, and it is now rarely seen as the procedure is no longer commonly performed.
The symptoms and signs of Nelson’s syndrome are related to the growth of the pituitary adenoma and the increased production of ACTH and melanocyte-stimulating hormone (MSH) from the adenoma. These may include headaches, visual field defects (up to 50% of cases), increased skin pigmentation, and the possibility of hypopituitarism.
ACTH levels will be significantly elevated (usually >500 ng/L). Thyroxine, TSH, gonadotrophin, and sex hormone levels may be low. Prolactin levels may be high, but not as high as with a prolactin-producing tumor. MRI or CT scanning can be helpful in identifying the presence of an expanding pituitary mass.
The treatment of choice for Nelson’s syndrome is trans-sphenoidal surgery.
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This question is part of the following fields:
- Endocrinology
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Question 88
Correct
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A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:
Hemoglobin (Hb): 115 g/l
Platelets: 155 * 109/l
White blood cells (WBC): 6.4 * 109/l
Sodium: 138 mmol/l
Potassium: 3.8 mmol/l
Urea: 4.1 mmol/l
Creatinine: 74 µmol/l
Glomerular filtration rate (GFR): 68 mL/min/1.73m2
An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?Your Answer: 3
Explanation:Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.
AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.
Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.
Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.
Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.
Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.
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This question is part of the following fields:
- Cardiology
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Question 89
Incorrect
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A child presents with blurred vision, nausea, vomiting, and low sodium levels. They are taking carbamazepine for epilepsy. You suspect toxicity and send bloods for assessment.
What is the recommended therapeutic range for carbamazepine in children?Your Answer: 15-20 mg/L
Correct Answer: 4-10 mg/L
Explanation:The therapeutic range for carbamazepine is between 4 and 10 mg/L. This range indicates the optimal concentration of the medication in the bloodstream for it to be effective in treating certain conditions. It is important for healthcare professionals to monitor the levels of carbamazepine in a patient’s blood to ensure they are within this range. If the levels are too low, the medication may not be effective, while levels that are too high can lead to potential side effects. By maintaining carbamazepine levels within the therapeutic range, healthcare providers can maximize the benefits of the medication while minimizing any potential risks.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 90
Incorrect
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You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has mild-to-moderate Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
Which ONE of the following drugs is NOT recommended by NICE to improve cognition in patients suffering from Alzheimer’s disease?Your Answer: Aricept
Correct Answer: Moclobemide
Explanation:According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.
On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 91
Correct
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A 25 year old woman is brought to the emergency department by her roommate after intentionally overdosing on amitriptyline. What is a typical clinical sign of toxicity in this case?
Your Answer: Dilated pupils
Explanation:An overdose of Amitriptyline can lead to the development of an anticholinergic toxidrome. This toxidrome is characterized by various symptoms, which can be remembered using the phrase ‘mad as a hatter, hot as hell, red as a beat, dry as a bone, and blind as a bat’. Some of these symptoms include a dry mouth and an elevated body temperature.
Further Reading:
Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.
TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.
Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.
Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.
There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 92
Correct
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A 2-year-old girl is brought in by her father with a reported high temperature at home. The triage nurse measures her temperature again as part of her initial assessment.
Which of the following is suggested by NICE as being an acceptable method of measuring body temperature in this age group?Your Answer: Infra-red tympanic thermometer
Explanation:In infants who are less than 4 weeks old, it is recommended to measure their body temperature using an electronic thermometer placed in the armpit.
For children between the ages of 4 weeks and 5 years, there are several methods that can be used to measure body temperature. These include using an electronic thermometer in the armpit, a chemical dot thermometer in the armpit, or an infra-red tympanic thermometer.
It is important to note that measuring temperature orally or rectally should be avoided in this age group. Additionally, forehead chemical thermometers are not reliable and should not be used.
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This question is part of the following fields:
- Infectious Diseases
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Question 93
Correct
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You assess a patient who is experiencing difficulty in closing their right eye due to a nerve injury. Currently, the eye is dry and necessitates regular administration of eye drops. Your consultant informs you that the orbicularis oculi muscle is solely responsible for closing the eye and suggests that if the symptoms cannot be improved, the patient may require surgical closure of the eye.
Which nerve has been affected in this scenario?Your Answer: Facial nerve
Explanation:The orbicularis oculi muscle encircles the eye socket and extends into the eyelid. It is composed of two parts: the orbital part, which forcefully closes the eye, and the palpebral part, which gently closes the eye. The innervation of the orbicularis oculi muscle is provided by the facial nerve. In the event of facial nerve damage, the orbicularis oculi muscle loses its functionality. As the sole muscle responsible for closing the eyelids, this can have significant clinical implications. The inability to shut the eye can lead to dryness of the cornea and the development of exposure keratitis. While mild cases can be managed with regular use of eye drops, severe cases may require surgical closure of the eye.
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This question is part of the following fields:
- Ophthalmology
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Question 94
Incorrect
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A 35-year-old woman with a long history of heavy alcohol abuse and liver cirrhosis comes in with a fever, abdominal pain, worsening ascites, and confusion. You suspect she may have spontaneous bacterial peritonitis and decide to perform an ascitic tap.
Which of the following is NOT a reason to avoid performing an ascitic tap?Your Answer: An uncooperative patient
Correct Answer: Platelet count of 40 x 103/µl
Explanation:Diagnosing spontaneous bacterial peritonitis (SBP) requires an abdominal paracentesis of ascitic tap. Other reasons for performing a diagnostic tap include determining the cause of ascites, distinguishing between transudate and exudate, and detecting cancerous cells. Additionally, a therapeutic paracentesis can be done to alleviate respiratory distress or abdominal pain caused by the ascites.
However, there are certain contraindications to consider. These include having an uncooperative patient, a skin infection at the proposed puncture site, being pregnant, or experiencing severe bowel distension. Relative contraindications involve having severe thrombocytopenia (platelet count less than 20 x 103/μL) or coagulopathy (INR greater than 2.0).
For patients with an INR greater than 2.0, it is recommended to administer fresh frozen plasma (FFP) before the procedure. One approach is to infuse one unit of fresh frozen plasma prior to the procedure and then proceed with the paracentesis while the second unit is being infused.
In the case of patients with a platelet count lower than 20 x 103/μL, it is advisable to provide a platelet infusion before the procedure.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 95
Correct
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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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 96
Correct
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A patient with a past medical history of epigastric discomfort and diarrhea is diagnosed with a tapeworm infection. The infection was acquired after consuming a beef dish that was contaminated with the parasite.
Which of the following organisms is most likely responsible for causing this infestation?Your Answer: Taenia saginata
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.
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This question is part of the following fields:
- Infectious Diseases
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Question 97
Correct
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A 68 year old male is brought into the emergency department after a significant episode of haematemesis. The patient is transferred to the resuscitation bay upon arrival, and large bore intravenous access is established while blood samples are sent for analysis and cross matching. You observe that the patient has a medical history of liver cirrhosis and suspect a bleed from oesophageal varices.
Which of the following medications should be prioritized for administration, as it has been proven to enhance survival in patients with gastro-oesophageal variceal bleeding?Your Answer: Terlipressin
Explanation:Terlipressin, a vasopressin analogue, has been found to significantly enhance survival rates in cases of acute upper gastrointestinal variceal haemorrhage when compared to a placebo. Alternatively, somatostatin and its analogue octreotide have also demonstrated similar benefits and can be used as alternatives. It is not recommended to administer proton pump inhibitors (PPIs) before endoscopy in cases of acute upper GI bleeds, but they are advised after endoscopy for non-variceal upper GI bleeds. There is no consensus on whether PPIs improve outcomes in variceal bleeding. Recombinant factor Vlla should only be considered if other blood products have failed to correct coagulopathy. Studies indicate that tranexamic acid does not reduce mortality from upper GI bleeding and may actually increase the risk of thromboembolic events.
Further Reading:
Upper gastrointestinal bleeding (UGIB) refers to the loss of blood from the gastrointestinal tract, occurring in the upper part of the digestive system. It can present as haematemesis (vomiting blood), coffee-ground emesis, bright red blood in the nasogastric tube, or melaena (black, tarry stools). UGIB can lead to significant hemodynamic compromise and is a major health burden, accounting for approximately 70,000 hospital admissions each year in the UK with a mortality rate of 10%.
The causes of UGIB vary, with peptic ulcer disease being the most common cause, followed by gastritis/erosions, esophagitis, and other less common causes such as varices, Mallory Weiss tears, and malignancy. Swift assessment, hemodynamic resuscitation, and appropriate interventions are essential for the management of UGIB.
Assessment of patients with UGIB should follow an ABCDE approach, and scoring systems such as the Glasgow-Blatchford bleeding score (GBS) and the Rockall score are recommended to risk stratify patients and determine the urgency of endoscopy. Transfusion may be necessary for patients with massive hemorrhage, and platelet transfusion, fresh frozen plasma (FFP), and prothrombin complex concentrate may be offered based on specific criteria.
Endoscopy plays a crucial role in the management of UGIB. Unstable patients with severe acute UGIB should undergo endoscopy immediately after resuscitation, while all other patients should undergo endoscopy within 24 hours of admission. Endoscopic treatment of non-variceal bleeding may involve mechanical methods of hemostasis, thermal coagulation, or the use of fibrin or thrombin with adrenaline. Proton pump inhibitors should only be used after endoscopy.
Variceal bleeding requires specific management, including the use of terlipressin and prophylactic antibiotics. Oesophageal varices can be treated with band ligation or transjugular intrahepatic portosystemic shunts (TIPS), while gastric varices may be treated with endoscopic injection of N-butyl-2-cyanoacrylate or TIPS if bleeding is not controlled.
For patients taking NSAIDs, aspirin, or clopidogrel, low-dose aspirin can be continued once hemostasis is achieved, NSAIDs should be stopped in patients presenting with UGIB
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 98
Correct
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A 5 year old male is brought into the emergency department by his parents. They inform you that the patient started experiencing diarrhea and vomiting 3 days ago. The vomiting stopped yesterday, but the diarrhea has persisted and the parents are worried because the patient seems restless and not acting like himself. There is no recent history of traveling abroad, no significant medical history, the patient is up to date with vaccinations, and the parents have not noticed any blood or mucus in the stool. During the clinical examination, you observe jittery movements in the limbs and head, increased muscle tone, and exaggerated reflexes in the limbs. There is some tenderness upon deep palpation of the abdomen, but no guarding. The central and peripheral capillary refill time is approximately 3 seconds, and the extremities feel warm.
What investigation would be most beneficial for this patient?Your Answer: Urea & electrolytes
Explanation:Children with gastroenteritis who exhibit jittery movements, increased muscle tone, hyper-reflexia, or convulsions should be suspected of having hypernatraemic dehydration. This condition occurs when there is an excessive amount of sodium in the body. In this case, the patient’s history aligns with gastroenteritis, which puts them at risk for hypernatraemia. The presence of jittery movements, increased muscle tone, and hyper-reflexia further support this suspicion. To confirm the diagnosis, it is recommended to send a sample for urea and electrolyte testing to assess the patient’s sodium levels.
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.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 99
Correct
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A 45-year-old woman presents with recurrent episodes of central chest pain that radiate to her left arm. She has a history of angina and uses a GTN spray for relief. She reports that the pains have been occurring more frequently in the past few days and have been triggered by less exertion. Currently, she is not experiencing any pain, and her ECG shows normal sinus rhythm with no abnormalities in T wave or ST-segment.
What is the SINGLE most probable diagnosis?Your Answer: Unstable angina
Explanation:Unstable angina is characterized by the presence of one or more of the following symptoms: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The electrocardiogram (ECG) may appear normal or show T-wave/ST-segment changes, and cardiac enzymes are typically within normal range.
On the other hand, stable angina is defined by central chest pain that is triggered by activities such as exercise and emotional stress. This pain may radiate to the jaw or left arm and is relieved by resting for a few minutes. It is usually brought on by a predictable amount of exertion.
Prinzmetal angina, although rare, is a variant of angina that primarily occurs at rest between midnight and early morning. The attacks can be severe and tend to happen in clusters. This type of angina is caused by coronary artery spasm, and patients may have normal coronary arteries.
Decubitus angina, on the other hand, is angina that occurs when lying down. It often develops as a result of cardiac failure due to an increased volume of blood within the blood vessels, which places additional strain on the heart.
Lastly, Ludwig’s angina is an extremely serious and potentially life-threatening cellulitis that affects the submandibular area. It most commonly arises from an infection in the floor of the mouth, which then spreads to the submandibular space.
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This question is part of the following fields:
- Cardiology
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Question 100
Correct
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A 25-year-old patient comes in with a painful and red left eye. Upon examination, you observe conjunctival erythema and the presence of mucopurulent discharge and lid crusting. Based on these findings, you diagnose the patient with bacterial conjunctivitis. However, the patient cannot use the first-line treatment due to a previous reaction. According to the current NICE guidance, what is the recommended second-line antibiotic for managing bacterial conjunctivitis?
Your Answer: Fusidic acid 1% drops
Explanation:When it comes to managing bacterial conjunctivitis, NICE provides some helpful guidance. It is important to inform the patient that most cases of bacterial conjunctivitis will resolve on their own within 5-7 days without any treatment. However, in severe cases or situations where a quick resolution is necessary, topical antibiotics may be necessary. In some cases, it may be appropriate to delay treatment and advise the patient to start using topical antibiotics if their symptoms have not improved within 3 days.
There are a few options for topical antibiotics that can be used. One option is Chloramphenicol 0.5% drops, which should be applied every 2 hours for 2 days and then 4 times daily for 5 days. Another option is Chloramphenicol 1% ointment, which should be applied four times daily for 2 days and then twice daily for 5 days. Fusidic acid 1% eye drops can also be used as a second-line treatment and should be applied twice daily for 7 days.
By following these guidelines, healthcare professionals can effectively manage bacterial conjunctivitis and provide appropriate treatment options for their patients.
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This question is part of the following fields:
- Ophthalmology
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Question 101
Correct
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A 4-year-old girl presents accompanied by her Mom. She suffers from asthma for which she takes a salbutamol inhaler as needed. She has had a runny nose for the past few days and has developed wheezing this evening.
Which ONE characteristic indicates acute severe asthma in this age range?Your Answer: Use of accessory muscles
Explanation:The presence of certain clinical features can indicate the possibility of acute severe asthma in children over the age of 5. These features include oxygen saturations below 92%, peak flow measurements below 50% of what is expected, a heart rate exceeding 120 beats per minute, a respiratory rate exceeding 30 breaths per minute, and the use of accessory muscles.
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This question is part of the following fields:
- Respiratory
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Question 102
Correct
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A 72-year-old man with a history of COPD complains of a headache, dizziness, and palpitations. He is currently taking modified-release theophylline for his COPD. You suspect theophylline toxicity and schedule a blood test to check his levels.
When should the blood sample be taken after his last oral dose?Your Answer: 4-6 hours
Explanation:In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.
To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 103
Correct
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You assess a patient with airway obstruction in the resuscitation area of the Emergency Department at your hospital.
Which of the following is the LEAST probable cause?Your Answer: GCS score of 9
Explanation:The airway is deemed at risk when the Glasgow Coma Scale (GCS) falls below 8. There are various factors that can lead to airway obstruction, including the presence of blood or vomit in the airway, a foreign object such as a tooth or food blocking the passage, direct injury to the face or throat, inflammation of the epiglottis (epiglottitis), involuntary closure of the larynx (laryngospasm), constriction of the bronchial tubes (bronchospasm), swelling in the pharynx due to infection or fluid accumulation (oedema), excessive bronchial secretions, and blockage of a tracheostomy tube.
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This question is part of the following fields:
- Trauma
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Question 104
Incorrect
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You assess a 48-year-old woman who has experienced an anaphylactic reaction after mistakenly consuming peanuts in a dish at a Thai eatery. She has a history of hypertension, but her blood pressure is effectively managed with a daily dose of atenolol 50 mg and amlodipine 5 mg. You have given her two injections of IM adrenaline, but her condition continues to worsen.
Which of the following interventions is most likely to quickly improve her condition?Your Answer: IV hydrocortisone
Correct Answer: IM glucagon
Explanation:Patients who are on beta-blockers may not respond effectively to adrenaline during anaphylaxis. Research conducted on animals and reported cases have indicated that glucagon can be utilized to counteract the effects of beta-blockade if initial adrenaline doses prove ineffective.
Although prednisolone and hydrocortisone can be beneficial later on, it typically takes 6-8 hours for them to take full effect. Therefore, they are unlikely to have any impact on the patient during the brief period it will take for the ambulance to arrive.
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This question is part of the following fields:
- Allergy
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