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  • Question 1 - Your hospital’s pediatrics department is currently evaluating the utility of a triple marker...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Cardiology
      5.2
      Seconds
  • Question 2 - A 32 year old male presents to the emergency department complaining of sudden...

    Incorrect

    • A 32 year old male presents to the emergency department complaining of sudden shortness of breath. During the initial assessment, the patient mentions that he is currently 28 weeks into his partner's pregnancy. While the nurse is still conducting the assessment, the patient suddenly collapses and the nurse urgently calls for your assistance. The patient has no detectable pulse and is not making any effort to breathe. You decide to initiate cardiopulmonary resuscitation (CPR).

      What adjustments should be made to the management of cardiac arrest when performing CPR on a pregnant patient?

      Your Answer: 40-45 degree left lateral tilt

      Correct Answer: Hand position for chest compressions 2-3 cm higher

      Explanation:

      When administering CPR to a pregnant patient, it is important to make certain modifications. Firstly, the hand position for chest compressions should be adjusted to be 2-3 cm higher than usual. Additionally, the uterus should be manually displaced to the left in order to minimize compression on the inferior vena cava. If possible, a 15-30 degree left lateral tilt should be implemented. If resuscitation efforts do not result in the return of spontaneous circulation, it is advisable to seek urgent obstetric input for potential consideration of a C-section delivery. Lastly, when inserting an ET tube, it may be necessary to use a size that is 0.5-1.0mm smaller due to potential narrowing of the trachea caused by edema.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      37.9
      Seconds
  • Question 3 - You are requested to evaluate a 7-year-old girl who is feeling sick in...

    Correct

    • You are requested to evaluate a 7-year-old girl who is feeling sick in the Pediatric Emergency Department. Upon reviewing her urea & electrolytes, you observe that her potassium level is elevated at 6.7 mmol/l. She is experiencing occasional palpitations.
      As per the APLS guidelines, which medication should be administered promptly when an arrhythmia is present in a child with notable hyperkalemia?

      Your Answer: Calcium chloride

      Explanation:

      Hyperkalemia is a condition where the level of potassium in the blood is higher than normal, specifically greater than 5.5 mmol/l. It can be categorized as mild, moderate, or severe depending on the potassium level. Mild hyperkalemia is when the potassium level is between 5.5-5.9 mmol/l, moderate hyperkalemia is between 6.0-6.4 mmol/l, and severe hyperkalemia is above 6.5 mmol/l. The most common cause of hyperkalemia is renal failure, which can be acute or chronic. Other causes include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.

      In the treatment of hyperkalemia, calcium plays a crucial role. It works by counteracting the harmful effects of high potassium levels on the heart by stabilizing the cardiac cell membrane. Calcium acts quickly, with its effects seen within 15 minutes, but its effects are relatively short-lived. It is considered a first-line treatment for arrhythmias and significant ECG abnormalities caused by hyperkalemia. However, it is rare to see arrhythmias occur at potassium levels below 7.5 mmol/l.

      It’s important to note that calcium does not lower the serum level of potassium. Therefore, when administering calcium, other therapies that actually help lower potassium levels, such as insulin and salbutamol, should also be used. Insulin and salbutamol are effective in reducing serum potassium levels.

      When choosing between calcium chloride and calcium gluconate, calcium chloride is preferred when hyperkalemia is accompanied by hemodynamic compromise. This is because calcium chloride contains three times more elemental calcium than an equal volume of calcium gluconate.

    • This question is part of the following fields:

      • Nephrology
      5.9
      Seconds
  • Question 4 - A 52-year-old woman comes in with a persistent sore throat that has lasted...

    Correct

    • A 52-year-old woman comes in with a persistent sore throat that has lasted for five days. She has also been dealing with cold symptoms for the past few days and has a bothersome dry cough. She denies having a fever and her temperature is normal today. During the examination, there are no noticeable swollen lymph nodes in her neck and her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.

      What is her FeverPAIN score?

      Your Answer: 0

      Explanation:

      The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      15.6
      Seconds
  • Question 5 - A 25-year-old individual presents on a Tuesday morning after being bitten by a...

    Correct

    • A 25-year-old individual presents on a Tuesday morning after being bitten by a tick a few days ago while hiking in the woods. The tick was promptly removed and there have been no symptoms experienced since. After conducting some online research, the individual is extremely worried about the potential of acquiring Lyme disease.

      What is the MOST suitable course of action in this situation?

      Your Answer: Reassurance only, no need to test or treat

      Explanation:

      According to the current NICE guidance, it is not recommended to diagnose Lyme disease in individuals who do not show any symptoms, even if they have been bitten by a tick. Therefore, there is no need to conduct tests or provide treatment in such cases. It is important to reassure these patients that the majority of ticks do not transmit Lyme disease. However, it is advised that they remain vigilant for any potential symptoms and return for re-evaluation if necessary. The ‘Be Tick Aware’ campaign by Public Health England can serve as a helpful resource for further information.

    • This question is part of the following fields:

      • Environmental Emergencies
      19.1
      Seconds
  • Question 6 - A 42-year-old man comes in with bleeding from a tooth socket that began...

    Incorrect

    • A 42-year-old man comes in with bleeding from a tooth socket that began 2 hours after a dental extraction. His vital signs are as follows: heart rate of 88 bpm, blood pressure of 128/82, oxygen saturation of 99% on room air, and a temperature of 36.4°C.
      What kind of dental bleeding has occurred in this case?

      Your Answer: Primary haemorrhage

      Correct Answer: Reactionary haemorrhage

      Explanation:

      This patient is experiencing a reactionary haemorrhage following their recent dental extraction.

      There are three types of haemorrhage that can occur after a dental extraction. The first is immediate haemorrhage, which happens at the time of extraction. The second is reactionary haemorrhage, which occurs 2-3 hours after the extraction when the vasoconstrictor effects of the local anaesthetic wear off. The third is secondary haemorrhage, which typically happens at 48-72 hours and occurs if the clot becomes infected.

      To manage this situation, the first step is to clean and rinse the mouth, removing any excessive clot. Then, a square of gauze should be rolled up into a pledgelet that is approximately twice the size of the bleeding socket and inserted. The patient should be instructed to bite down on it to apply pressure for about 10-20 minutes.

      If the bleeding continues after this initial management, the area should be anaesthetised using lidocaine with adrenaline. Following the anaesthesia, a horizontal mattress suture should be inserted, pulling the gum over the bone edges tightly enough to blanch them. It is important to refer the patient to the on-call dental surgeon at this point.

      There are several risk factors for dental haemorrhage, including hypertension, the use of anticoagulants such as warfarin, and hereditary bleeding disorders like von Willebrand disease or haemophilia.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      11.9
      Seconds
  • Question 7 - You plan to use plain 1% lidocaine for a nerve block on a...

    Correct

    • You plan to use plain 1% lidocaine for a nerve block on a foot that requires surgery.
      Which SINGLE statement regarding lidocaine is FALSE?

      Your Answer: It tends to cause vasoconstriction

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Pain & Sedation
      19.9
      Seconds
  • Question 8 - A 7-year-old boy presents with a sore throat and a dry cough that...

    Correct

    • A 7-year-old boy presents with a sore throat and a dry cough that has been present for five days. He has no medical history of note, takes no medication and reports no known drug allergies. On examination, he is febrile with a temperature of 38.5°C and has a few tender anterior cervical lymph nodes. His throat and tonsils appear red and inflamed, and you can see copious exudate on his right tonsil.
      Using the FeverPAIN Score to assess his sore throat, which of the following would be the MOST APPROPRIATE management for him at this stage?

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

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      23.5
      Seconds
  • Question 9 - A 28-year-old individual presents to the emergency department with burns on their hands....

    Correct

    • A 28-year-old individual presents to the emergency department with burns on their hands. After evaluation, it is determined that the patient has superficial partial thickness burns on the entire palmar surfaces of both hands. The burns do not extend beyond the wrist joint due to the patient wearing a thick jacket.

      To document the extent of the burns on a Lund and Browder chart, what percentage of the total body surface area is affected by this burn injury?

      Your Answer: 2-3%

      Explanation:

      Based on the Lund and Browder chart, the total percentage of burns is calculated as 3 since it affects one side of both hands.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      12.1
      Seconds
  • Question 10 - A middle-aged intravenous drug user with an unstable living situation complains of intense...

    Correct

    • A middle-aged intravenous drug user with an unstable living situation complains of intense back pain, fever, and weakness in the left leg. The pain has been disrupting his sleep and making it hard for him to walk. During the examination, tenderness is observed in the lower lumbar spine, and there is weakness in left knee extension and foot dorsiflexion.
      What is the probable organism responsible for these symptoms in this individual?

      Your Answer: Staphylococcus aureus

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in 1-2% of cases post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, refusal to walk may also be a symptom.

      When diagnosing discitis, MRI is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. CT scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      17.2
      Seconds
  • Question 11 - A 35 year old male is brought into the emergency department after ingesting...

    Correct

    • A 35 year old male is brought into the emergency department after ingesting 150 paracetamol tablets in a impulsive suicide attempt. The patient is now worried about the potential liver failure and other possible injuries associated with paracetamol overdose. What other organs or systems are at risk of injury in cases of paracetamol overdose?

      Your Answer: Renal tubule

      Explanation:

      When someone takes too much paracetamol, it can harm their liver cells and the tubules in their kidneys. This is because paracetamol produces a harmful substance called NAPQI, which is normally combined with glutathione. However, when there is too much NAPQI, it can cause damage and death to liver and kidney cells.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      9.7
      Seconds
  • Question 12 - A 30-year-old woman is injured in a car crash and sustains severe facial...

    Correct

    • A 30-year-old woman is injured in a car crash and sustains severe facial injuries. X-rays and CT scans of her face show that she has a Le Fort I fracture.
      What is the most accurate description of a Le Fort I fracture?

      Your Answer: ‘Floating palate’

      Explanation:

      Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.

      The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.

      Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.

      Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.

      Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      5.5
      Seconds
  • Question 13 - A 68-year-old woman presents with a 4-month history of easy bruising and fatigue....

    Correct

    • A 68-year-old woman presents with a 4-month history of easy bruising and fatigue. She has also experienced frequent nosebleeds over the past few weeks. She has had two respiratory infections and a urinary tract infection in the recent months and reports feeling unwell. You have arranged for her to undergo a series of blood tests, and the results of her complete blood count are as follows:

      Hemoglobin (Hb): 7.4 g/dl (13-17 g/dl)
      Mean Corpuscular Volume (MCV): 103 fl (80-100 fl)
      Platelets: 46 x 109/l (150-400 x 109/l)
      White Blood Cell Count (WCC): 4.4 x 109/l (4-11 x 109/l)
      Neutrophils: 0.8 x 109/l (2.5-7.5 x 109/l)
      Lymphocytes: 3.4 x 109/l (1.3-3.5 x 109/l)
      Monocytes: 0.4 x 109/l (0.2-0.8 x 109/l)
      Reticulocytes: 70 x 109/l (50-100 x 109/l)

      What is the SINGLE most likely diagnosis?

      Your Answer: Myelodysplastic syndrome

      Explanation:

      Myelodysplastic syndromes are a group of disorders affecting the haemopoietic stem cell, leading to ineffective production of myeloid blood cells. These conditions typically manifest between the ages of 60 and 75 and are more prevalent in men than women.

      The clinical features of myelodysplastic syndromes include tiredness due to anaemia (the most common presentation), easy bruising, and a tendency to bleed. Laboratory findings often reveal anaemia (usually macrocytic or normocytic), neutropenia, thrombocytopenia, and abnormal cell morphology with oddly shaped macrocytes.

      Chronic lymphocytic leukaemia (CLL) is the most common form of adult leukaemia, primarily affecting B-lymphocytes. It often presents asymptomatically in patients who undergo routine blood tests revealing elevated white cell counts and lymphocytosis. Men over the age of 50 account for over 75% of CLL cases. Blood films typically show a predominance of mature-looking lymphocytes and smear cells.

      Iron deficiency anaemia is characterized by hypochromic microcytic anaemia and a reduced red blood cell count. Peripheral blood smears in iron deficiency anaemia may exhibit poikilocytosis (varying shapes) and anisocytosis (varying sizes). Pencil cells are also observed in this condition.

      Vitamin B12 and folate deficiency can also cause macrocytic anaemia. However, the severity of anaemia and macrocytosis would generally need to be much more pronounced to result in neutropenia and thrombocytopenia. Therefore, a myelodysplastic syndrome is more likely in such cases.

    • This question is part of the following fields:

      • Haematology
      27.2
      Seconds
  • Question 14 - A 3 year old boy is brought into the emergency department by concerned...

    Correct

    • A 3 year old boy is brought into the emergency department by concerned parents. The parents inform you that the patient has had a persistent cough and runny nose for the past 2-3 days. However, today they noticed that the patient was having difficulty breathing and was coughing up a lot of mucus. They suspected that the patient might have croup. Upon examination, you hear audible stridor and observe rapid breathing. There are no signs of difficulty swallowing or excessive drooling. The patient is given dexamethasone and nebulized adrenaline, but subsequent observations reveal an increase in respiratory rate and the patient appears increasingly tired.

      What is the most likely underlying diagnosis?

      Your Answer: Bacterial tracheitis

      Explanation:

      Patients who have bacterial tracheitis usually do not show any improvement when treated with steroids and adrenaline nebulizers. The symptoms of bacterial tracheitis include a prelude of upper respiratory tract infection symptoms, followed by a rapid decline in health with the presence of stridor and difficulty breathing. Despite treatment with steroids and adrenaline, there is no improvement in the patient’s condition. On the other hand, patients with epiglottitis commonly experience difficulty swallowing and excessive saliva production.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      7.8
      Seconds
  • Question 15 - You are present at a child cardiac arrest scene. The blood gas shows...

    Correct

    • 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.

    • This question is part of the following fields:

      • Paediatric Emergencies
      68.7
      Seconds
  • Question 16 - A 42-year-old woman presents with a history of progressively worsening weakness in her...

    Correct

    • A 42-year-old woman presents with a history of progressively worsening weakness in her right arm. She denies any history of speech difficulties, neck pain, or issues with hand coordination. On examination, there is noticeable muscle wasting in her right upper limb with an upward plantar response. Fasciculations are also observed in her right forearm. There is no apparent sensory loss.
      What is the SINGLE most probable diagnosis?

      Your Answer: Amyotrophic Lateral Sclerosis (ALS)

      Explanation:

      Motor Neuron Disease (MND) is a group of degenerative diseases that primarily involve the loss of specific neurons in the motor cortex, cranial nerve nuclei, and anterior horn cells. Both upper and lower motor neurons are affected in this condition. It is important to note that MND does not cause any sensory or sphincter disturbances, and it does not affect eye movements.

      MND is relatively uncommon, with a prevalence of approximately 5-7 cases per 100,000 individuals. The median age of onset in the United Kingdom is 60 years, and unfortunately, it often leads to fatality within 2 to 4 years of diagnosis. The treatment for MND mainly focuses on providing supportive care through a multidisciplinary approach.

      There are four distinct clinical patterns observed in MND. The first pattern, known as Amyotrophic Lateral Sclerosis (ALS), accounts for up to 50% of MND cases. It involves the loss of motor neurons in both the motor cortex and the anterior horn of the spinal cord. Clinically, individuals with ALS experience weakness and exhibit signs of both upper and lower motor neuron involvement.

      The second pattern, called Progressive Bulbar Palsy, occurs in up to 10% of MND cases. This condition specifically affects cranial nerves IX-XII, resulting in Bulbar and pseudobulbar palsy.

      Progressive Muscular Atrophy is the third pattern, also seen in up to 10% of MND cases. It primarily affects the anterior horn cells, leading to the presence of only lower motor neuron signs.

      Lastly, Primary Lateral Sclerosis involves the loss of Betz cells in the motor cortex. Clinically, individuals with this pattern exhibit upper motor neuron signs, including marked spastic leg weakness and pseudobulbar palsy.

    • This question is part of the following fields:

      • Neurology
      36
      Seconds
  • Question 17 - A 6-year-old girl comes to her pediatrician complaining of a headache, neck stiffness,...

    Correct

    • A 6-year-old girl comes to her pediatrician complaining of a headache, neck stiffness, and sensitivity to light. Her vital signs are as follows: heart rate 124, blood pressure 86/43, respiratory rate 30, oxygen saturation 95%, and temperature 39.5oC. She has recently developed a rash of small red spots on her legs that do not fade when pressed.
      What is the MOST suitable next course of action in managing this patient?

      Your Answer: Give IM benzylpenicillin 600 mg

      Explanation:

      In a child with a non-blanching rash, it is important to consider the possibility of meningococcal septicaemia. This is especially true if the child appears unwell, has purpura (lesions larger than 2 mm in diameter), a capillary refill time of more than 3 seconds, or neck stiffness. In the UK, most cases of meningococcal septicaemia are caused by Neisseria meningitidis group B.

      In this particular case, the child is clearly very sick and showing signs of septic shock. It is crucial to administer a single dose of benzylpenicillin without delay and arrange for immediate transfer to the nearest Emergency Department via ambulance.

      The recommended doses of benzylpenicillin based on age are as follows:
      – Infants under 1 year of age: 300 mg of IM or IV benzylpenicillin
      – Children aged 1 to 9 years: 600 mg of IM or IV benzylpenicillin
      – Children and adults aged 10 years or older: 1.2 g of IM or IV benzylpenicillin.

    • This question is part of the following fields:

      • Infectious Diseases
      15.4
      Seconds
  • Question 18 - A 68-year-old diabetic man presents with a gradual decrease in consciousness and confusion...

    Correct

    • A 68-year-old diabetic man presents with a gradual decrease in consciousness and confusion over the past week. He normally controls his diabetes with metformin 500 mg twice a day. He recently received treatment for a urinary tract infection from his doctor, and his family reports that he has been excessively thirsty. He has vomited multiple times today. A urine dipstick test shows a small amount of white blood cells and moderate ketones. The results of his arterial blood gas test are as follows:

      pH: 7.29
      pO2: 11.1 kPa
      pCO2: 4.6 kPa
      HCO3-: 22 mmol/l
      Na+: 154 mmol/l
      K+: 3.2 mmol/l
      Cl-: 100 mmol/l
      Urea: 17.6 mmol/l
      Glucose: 32 mmol/l

      What is his serum osmolality?

      Your Answer: 364 mmol/l

      Explanation:

      In an elderly patient with a history of gradual decline accompanied by high blood sugar levels, excessive thirst, and recent infection, the most likely diagnosis is hyperosmolar hyperglycemic state (HHS). This condition can be life-threatening, with a mortality rate of approximately 50%. Common symptoms include dehydration, elevated blood sugar levels, altered mental status, and electrolyte imbalances. About half of the patients with HHS also experience hypernatremia.

      To calculate the serum osmolality, the formula is 2(K+ + Na+) + urea + glucose. In this case, the serum osmolality is 364 mmol/l, indicating a high level. It is important to discontinue the use of metformin in this patient due to the risk of metformin-associated lactic acidosis (MALA). Additionally, an intravenous infusion of insulin should be initiated.

      The treatment goals for HHS are to address the underlying cause and gradually and safely:
      – Normalize the osmolality
      – Replace fluid and electrolyte losses
      – Normalize blood glucose levels

      If significant ketonaemia is present (3ÎČ-hydroxybutyrate is more than 1 mmol/L), it indicates a relative lack of insulin, and insulin should be administered immediately. However, if significant ketonaemia is not present, insulin should not be started.

      Patients with HHS are at a high risk of thromboembolism, and it is recommended to routinely administer low molecular weight heparin. In cases where the serum osmolality exceeds 350 mmol/l, full heparinization should be considered.

    • This question is part of the following fields:

      • Endocrinology
      75.9
      Seconds
  • Question 19 - A 72 year old male patient presents to the emergency department complaining of...

    Correct

    • A 72 year old male patient presents to the emergency department complaining of worsening shortness of breath. You observe moderate mitral stenosis on the patient's most recent echocardiogram 10 months ago.

      What is a typical finding in individuals with mitral stenosis?

      Your Answer: Loud 1st heart sound

      Explanation:

      Mitral stenosis is a condition characterized by a narrowing of the mitral valve in the heart. One of the key features of this condition is a loud first heart sound, which is often described as having an opening snap. This sound is typically heard during mid-late diastole and is best heard during expiration. Other signs of mitral stenosis include a low volume pulse, a flushed appearance of the cheeks (known as malar flush), and the presence of atrial fibrillation. Additionally, patients with mitral stenosis may exhibit signs of pulmonary edema, such as crepitations (crackling sounds) in the lungs and the production of white or pink frothy sputum. It is important to note that a water hammer pulse is associated with a different condition called aortic regurgitation.

      Further Reading:

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

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

    • This question is part of the following fields:

      • Cardiology
      19.2
      Seconds
  • Question 20 - A 35 year old female is brought into the emergency department (ED) with...

    Correct

    • A 35 year old female is brought into the emergency department (ED) with a decreased level of consciousness. An arterial blood gas sample is collected. The results are as follows:

      pH 7.21
      pO2 12.6 kPa
      pCO2 6.9 kPa
      Bicarbonate 16 mmol/L
      Chloride 96 mmol/L
      Potassium 5.4 mmol/L
      Sodium 135 mmol/L

      Which of the following options best describes the acid-base disturbance?

      Your Answer: Mixed acidosis

      Explanation:

      In cases of mixed acidosis, both the respiratory and metabolic systems play a role in causing the low pH levels. This means that the patient’s acidotic state is a result of both low bicarbonate levels in the metabolic system and high levels of CO2 in the respiratory system.

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      38.7
      Seconds
  • Question 21 - A 3-year-old boy is brought in by his father with a red and...

    Correct

    • A 3-year-old boy is brought in by his father with a red and itchy right eye. On examination, there is mild redness of the conjunctiva, and small bumps are visible on the inside of the eyelid. The eyelid is swollen, and there are a few small red spots on the white part of the eye. The eye is watery, and there is no pus. He recently had a mild cold. You diagnose him with viral conjunctivitis.
      According to the current NICE guidance, which of the following should NOT be included in the management of this patient?

      Your Answer: The child should be excluded from school until the infection has resolved

      Explanation:

      When it comes to managing viral conjunctivitis, it’s important to reassure the patient that most cases are self-limiting and don’t require antimicrobial treatment. In fact, viral conjunctivitis usually resolves on its own within one to two weeks. However, there are some self-care measures that can help ease symptoms. These include cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water, applying cool compresses around the eye area, and using lubricating drops or artificial tears. It’s also important to avoid prescribing antibiotics if possible.

      It’s crucial to inform the person that infective conjunctivitis is contagious and they should take steps to prevent spreading the infection to their other eye and other people. This includes washing hands frequently with soap and water, using separate towels and flannels, and avoiding close contact with others, especially if they are a healthcare professional or child-care provider. It’s worth noting that the infection can be contagious for up to 14 days from onset.

      According to Public Health England, there is no recommended exclusion period from school, nursery, or childminders unless there is an outbreak or cluster of cases. It’s important to provide written information to the patient, explain the red flags for an urgent review, and advise them to seek further help if symptoms persist beyond 7 days. If the person returns with symptoms of conjunctivitis, it may be necessary to consider sending swabs for viral PCR and bacterial culture, as well as prescribing empirical topical antibiotics if they haven’t already been prescribed. If symptoms persist for more than 7-10 days after initiating treatment, it may be necessary to discuss with or refer to ophthalmology.

    • This question is part of the following fields:

      • Ophthalmology
      39.2
      Seconds
  • Question 22 - A 65-year-old woman presents to the Emergency Department with her husband. After lunch...

    Incorrect

    • A 65-year-old woman presents to the Emergency Department with her husband. After lunch this afternoon, she noticed some difficulty ‘finding the right words’ and her husband said that her speech was slurred. The episode lasted for about 2 hours, and she now feels back to normal. When you examine her, she has a blood pressure of 140/90; her speech is normal and cranial nerves are intact. A thorough peripheral neurological examination reveals no deficit. She has no previous history of diabetes.
      What is the SINGLE most appropriate next step in her management?

      Your Answer: Give 300 mg aspirin immediately and seen by a specialist for assessment within 24 hours of onset of symptoms

      Correct Answer:

      Explanation:

      This individual has a typical history for a transient ischaemic attack (TIA). According to the NICE recommendations, it is advised to offer aspirin (300 mg daily) to individuals who have experienced a suspected TIA, unless there are contraindications. This treatment should be started immediately. It is also important to refer individuals who have had a suspected TIA for specialist assessment and investigation, with the aim of being seen within 24 hours of symptom onset. Scoring systems, such as ABCD2, should not be used to assess the risk of subsequent stroke or determine the urgency of referral for individuals with a suspected or confirmed TIA. Secondary prevention measures, in addition to aspirin, should be offered as soon as possible after the diagnosis of TIA is confirmed.

      In terms of imaging, it is not recommended to offer CT brain scanning to individuals with a suspected TIA, unless there is clinical suspicion of an alternative diagnosis that CT could detect. After a specialist assessment in the TIA clinic, MRI (including diffusion-weighted and blood-sensitive sequences) may be considered to determine the area of ischaemia, detect haemorrhage, or identify alternative pathologies. If an MRI is performed, it should ideally be done on the same day as the assessment. Carotid imaging is also important for everyone with a TIA who is considered a candidate for carotid endarterectomy, and this should be done urgently.

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

    • This question is part of the following fields:

      • Neurology
      31.9
      Seconds
  • Question 23 - A 35 year old female is brought into the emergency department (ED) due...

    Correct

    • A 35 year old female is brought into the emergency department (ED) due to an altered level of consciousness. An arterial blood gas sample is collected. The results are as follows:

      pH: 7.25
      pO2: 12.8 kPa
      pCO2: 5.9 kPa
      Bicarbonate: 14 mmol/L
      Chloride: 98 mmol/L
      Potassium: 6.0 mmol/L
      Sodium: 137 mmol/L

      Which of the following options best describes the anion gap?

      Your Answer: High anion gap acidosis

      Explanation:

      An anion gap greater than 11 is considered high when using modern ion-selective electrode analyzers. This indicates a condition known as high anion gap acidosis. The anion gap can be calculated using the equation: ([Na+] + [K+]) – ([Cl-] + [HCO3-]). In this particular case, the calculation results in a value of 30.4 mmol/l. Anion gaps greater than 11 are considered high.

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      29.5
      Seconds
  • Question 24 - A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As...

    Incorrect

    • A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As a result of this medication, the newborn develops a defect.
      What is the most probable defect that will occur as a result of using this drug during pregnancy?

      Your Answer: Persistent pulmonary hypertension of the newborn

      Correct Answer: Haemorrhagic disease of the newborn

      Explanation:

      There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.

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

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.

      Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.

      Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.

      Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.

      Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      305
      Seconds
  • Question 25 - A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms...

    Incorrect

    • A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms of sepsis. The baby was born prematurely at 32 weeks gestation. A diagnosis of neonatal pneumonia is suspected.
      What is the SINGLE most probable causative organism?

      Your Answer: Streptococcus pneumoniae

      Correct Answer: Escherichia Coli

      Explanation:

      Pneumonia in newborns is typically caused by organisms that inhabit the mother’s genital tract. Despite the widespread use of chemoprophylaxis to prevent maternal carriage, Group B haemolytic Streptococcus remains a common culprit in early-onset infections in full-term and near-term infants aged less than three days. Among very low birth weight infants, Escherichia Coli is the most frequently encountered bacterial strain. Additionally, neonatal pneumonia can be caused by other bacteria such as Chlamydia trachomatis, Listeria monocytogenes, and Haemophilus influenzae.

    • This question is part of the following fields:

      • Neonatal Emergencies
      17.1
      Seconds
  • Question 26 - A 60-year-old woman undergoes a blood transfusion due to ongoing vaginal bleeding and...

    Correct

    • A 60-year-old woman undergoes a blood transfusion due to ongoing vaginal bleeding and a haemoglobin level of 5 mg/dL. Shortly after starting the transfusion, she experiences discomfort and a burning sensation at the site of her cannula. She also reports feeling nauseous, experiencing intense back pain, and having a sense of impending disaster. Her temperature is measured and is found to be 38.9°C.
      What is the probable cause of this transfusion reaction?

      Your Answer: ABO incompatibility

      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 usage, errors and adverse reactions still occur.

      One serious complication is acute haemolytic transfusion reactions, which happen when incompatible red cells are transfused and react with the patient’s own antibodies. This usually occurs due to human error, such as mislabelling sample tubes or request forms. Symptoms of this reaction include a feeling of impending doom, fever, chills, pain and warmth at the transfusion site, nausea, vomiting, and back, joint, and chest pain. Immediate action should be taken to stop the transfusion, replace the donor blood with normal saline or another suitable crystalloid, and check the blood to confirm the intended recipient. IV diuretics may be administered to increase renal blood flow, and urine output should be maintained.

      Another common complication is febrile transfusion reaction, which presents with a 1-degree rise in temperature from baseline, along with chills and malaise. This reaction is usually caused by cytokines from leukocytes in the transfused blood components. Supportive treatment is typically sufficient, and paracetamol can be helpful.

      Allergic reactions can also occur, usually due to foreign plasma proteins or anti-IgA. These reactions often present with urticaria, pruritus, and hives, and in severe cases, laryngeal edema or bronchospasm may occur. Symptomatic treatment with antihistamines is usually enough, and there is usually no need to stop the transfusion. However, if anaphylaxis occurs, the transfusion should be stopped, and the patient should be administered adrenaline and treated according to the ALS protocol.

      Transfusion-related acute lung injury (TRALI) is a severe complication characterized by non-cardiogenic pulmonary edema within 6 hours of transfusion. It is associated with antibodies in the donor blood reacting with recipient leukocyte antigens. This is the most common cause of death related to transfusion reactions. Treatment involves stopping the transfusion, administering oxygen, and providing aggressive respiratory support in approximately 75% of patients. Diuretic usage should be avoided.

    • This question is part of the following fields:

      • Haematology
      18.6
      Seconds
  • Question 27 - A 45-year-old patient is admitted to the emergency department with severe burns. It...

    Correct

    • A 45-year-old patient is admitted to the emergency department with severe burns. It is determined that a central venous catheter needs to be inserted. Before the central line insertion, the skin on the front of the neck is numbed with 1% lidocaine.

      Which vein in the anterior neck triangle is utilized for the placement of the central venous line?

      Your Answer: Internal jugular vein

      Explanation:

      The internal jugular vein is situated in the anterior triangle of the neck and is frequently utilized for the insertion of central lines. It is important for candidates to have a good understanding of the anatomy of the anterior triangle, including its contents, according to the RCEM.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      3.7
      Seconds
  • Question 28 - A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct...

    Correct

    • A 32-year-old individual presents with a sudden worsening of asthma symptoms. You conduct an arterial blood gas test and find that their PaCO2 level is 4.8 kPa.
      How would you categorize this asthma exacerbation?

      Your Answer: Life-threatening asthma

      Explanation:

      The BTS guidelines categorize acute asthma into four classifications: moderate, acute severe, life-threatening, and near-fatal.

      Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the best or predicted value. There are no signs of acute severe asthma present in this classification.

      Acute severe asthma is identified by any one of the following criteria: a PEFR between 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, or the inability to complete sentences in one breath.

      Life-threatening asthma is determined by any one of the following indicators: a PEFR below 33% of the best or predicted value, a blood oxygen saturation level (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kilopascals (kPa), a normal partial pressure of carbon dioxide (PaCO2) between 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.

      Near-fatal asthma is characterized by elevated PaCO2 levels and/or the need for mechanical ventilation with increased inflation pressures.

    • This question is part of the following fields:

      • Respiratory
      7.8
      Seconds
  • Question 29 - A 32-year-old individual arrives at the emergency department complaining of bloody diarrhea that...

    Correct

    • A 32-year-old individual arrives at the emergency department complaining of bloody diarrhea that has been ongoing for two days. The patient mentions experiencing a similar episode six months ago, although it was less severe and resolved within a week. The possibility of inflammatory bowel disease (IBD) crosses your mind. Which of the following statements about IBD is accurate?

      Your Answer: The terminal ileum is the most common site affected by Crohn's

      Explanation:

      Crohn’s disease is characterized by skip lesions, which are not present in ulcerative colitis. Unlike ulcerative colitis, Crohn’s disease causes inflammation throughout the entire thickness of the intestinal wall, not just the mucosa. Interestingly, smoking increases the risk of developing Crohn’s disease but decreases the risk of ulcerative colitis. Additionally, having an appendicectomy before adulthood is believed to protect against ulcerative colitis, whereas it actually increases the risk of developing Crohn’s disease for about 5 years after the surgery.

      Further Reading:

      Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation of the intestinal tract and an imbalance of the intestinal microbiota. The two main forms of IBD are Crohn’s disease and ulcerative colitis (UC). In some cases, it is not possible to differentiate between Crohn’s disease and UC, and the term inflammatory bowel disease type-unclassified may be used.

      Crohn’s disease is a chronic, relapsing-remitting inflammatory disease that can affect any part of the gastrointestinal tract, from the mouth to the anus. It most commonly involves the ileum and colon. The inflammation in Crohn’s disease affects all layers of the intestinal wall, leading to complications such as strictures, fistulas, and adhesions. Risk factors for developing Crohn’s disease include a family history, smoking, infectious gastroenteritis, appendicectomy, and the use of NSAIDs and oral contraceptive drugs. Symptoms of Crohn’s disease can vary but often include diarrhea, abdominal pain, weight loss, and perianal disease. Extraintestinal features, such as arthritis, erythema nodosum, and uveitis, can also occur.

      Ulcerative colitis is a chronic, relapsing-remitting inflammatory disease that primarily affects the large bowel. The inflammation in UC is limited to the intestinal mucosa and does not involve skip lesions like in Crohn’s disease. Risk factors for developing UC include a family history, not smoking, and no appendix. Symptoms of UC include bloody diarrhea, urgency, tenesmus, and abdominal pain. Extraintestinal features, such as arthritis and uveitis, can also occur. Complications of UC include toxic megacolon, bowel obstruction, bowel perforation, strictures, fistula formation, anemia, malnutrition, and colorectal cancer.

      Diagnosing IBD involves various investigations, including blood tests, stool microscopy and culture, fecal calprotectin testing, endoscopy with biopsy, and imaging modalities such as CT and MR enterography. The management of Crohn’s disease and UC is complex and may involve corticosteroids, immunosuppressive drugs, biologic therapy, surgery, and nutritional support. Patients with IBD should also be monitored for nutritional deficiencies, colorectal cancer, and osteoporosis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      18.4
      Seconds
  • Question 30 - A 22 year old presents to the emergency department with a complaint of...

    Correct

    • A 22 year old presents to the emergency department with a complaint of hematemesis that started 30 minutes ago. The patient had a tonsillectomy 7 days ago. The patient's vital signs are as follows:

      Blood pressure: 116/68 mmHg
      Pulse: 102 bpm
      Respiration rate: 15 bpm
      Temperature: 36.5ÂșC

      During examination, fresh clotted blood is visible in the right tonsillar fossa and there is profuse bleeding into the oropharynx. The patient's airway appears to be open. The ENT registrar has been informed and will arrive in approximately 10 minutes after finishing with a patient in the operating room. What is the most appropriate action to take in this situation?

      Your Answer: Apply adrenaline soaked dental roll to the bleeding point directing the pressure laterally

      Explanation:

      In patients who have undergone tonsillectomy and are experiencing severe bleeding, it is recommended to apply either Co-phenylcaine spray (a combination of lidocaine and phenylephrine) or 1:10,000 adrenaline soaked gauze/dental roll to the bleeding points. This helps to constrict the blood vessels and slow down the bleeding rate.

      To apply topical adrenaline, a dental roll or gauze soaked in 1:10,000 adrenaline solution is used. It is applied to the bleeding point using Magill’s forceps, with pressure directed laterally (not posteriorly). However, this may not be possible if the patient has a strong gag reflex. To minimize the risk of inhalation and facilitate suction, the patient’s head should be tilted to the side and/or forwards.

      For light or intermittent bleeding, hydrogen peroxide gargles can be used. However, they are not recommended for heavy bleeds.

      Further Reading:

      Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.

      Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.

      Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.

      The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.

      Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.

      Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.

      If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      15.6
      Seconds
  • Question 31 - A 25-year-old man comes in with severe bloody diarrhea caused by a gastrointestinal...

    Incorrect

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

      Your Answer: Salmonella enterica

      Correct Answer: Enterotoxigenic Escherichia coli

      Explanation:

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      13
      Seconds
  • Question 32 - A 35-year-old woman with a history of sickle cell disease undergoes a blood...

    Correct

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

      Your Answer: Monitor renal function and haemoglobin

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      23.6
      Seconds
  • Question 33 - A 2 year old male is brought to the emergency department by concerned...

    Correct

    • A 2 year old male is brought to the emergency department by concerned parents. The child started experiencing episodes of diarrhea and vomiting 2 days ago which have continued today. They are worried as the patient has become lethargic throughout the day and hasn't urinated for several hours. After initial assessment, you decide to administer a 10 ml/kg bolus of 0.9% sodium chloride fluid to treat suspected shock. After giving the fluid bolus, you repeat the patient's observations as shown below:

      Initial observation observation after fluid bolus
      Pulse 160 148
      Respiration rate 52 42
      Capillary refill time 5s 4s
      Temperature 37.8ÂșC 37.8ÂșC

      You notice the patient still has cool extremities and mottled skin. What is the most appropriate next step in managing this patient?

      Your Answer: Administer further 10 ml/kg 0.9% sodium chloride fluid bolus

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      20.8
      Seconds
  • Question 34 - A 21-year-old man comes in with a suddenly painful and swollen right testis...

    Correct

    • A 21-year-old man comes in with a suddenly painful and swollen right testis and intense abdominal pain. The pain started while he was asleep, and he has experienced multiple episodes of vomiting. His cremasteric reflex is not present, and the testis is too sensitive to touch.
      What is the SINGLE most probable diagnosis?

      Your Answer: Testicular torsion

      Explanation:

      Testicular torsion is the correct diagnosis in this case. When a patient presents with sudden, severe, and acute testicular pain, testicular torsion should be assumed until proven otherwise. There are several historical factors that support this diagnosis. These include the pain occurring suddenly, being accompanied by vomiting, happening during sleep (as half of torsions occur during sleep), a previous history of torsion in the other testis, previous episodes that have resolved recently, and a history of undescended testis.

      On examination, there are certain findings that further suggest testicular torsion. The testis may be positioned high in the scrotum and too tender to touch. The opposite testis may lie horizontally (known as Angell’s sign). Pain is not relieved by elevating the testis (negative Prehn’s sign), and the cremasteric reflex may be absent.

      It is important to recognize that testicular torsion is a surgical emergency that requires immediate assessment and intervention to restore blood flow. Irreversible damage can occur within six hours of onset, so prompt treatment is crucial in this patient.

    • This question is part of the following fields:

      • Urology
      5.4
      Seconds
  • Question 35 - A 3-year-old boy is brought in by his father with symptoms of fever...

    Correct

    • A 3-year-old boy is brought in by his father with symptoms of fever and irritability. He also complains of lower abdominal pain and stinging during urination. A urine dipstick is performed on a clean catch urine, which reveals the presence of blood, protein, leucocytes, and nitrites. You diagnose him with a urinary tract infection (UTI) and prescribe antibiotics. His blood tests today show that his eGFR is 38 ml/minute. He has no history of other UTIs or infections requiring antibiotics in the past 12 months.
      Which of the following antibiotics is the most appropriate to prescribe in this case?

      Your Answer: Trimethoprim

      Explanation:

      For the treatment of young people under 16 years with lower urinary tract infection (UTI), it is important to obtain a urine sample before starting antibiotics. This sample can be tested using a dipstick or sent for culture and susceptibility testing. In cases where children under 5 present with fever along with lower UTI, it is recommended to follow the guidance outlined in the NICE guideline on fever in under 5s.

      Immediate antibiotic prescription should be offered to children and young people under 16 years with lower UTI. When making this prescription, it is important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to resistant bacteria. If a urine sample has been sent for culture and sensitivity testing, the choice of antibiotic should be reviewed once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, a narrow-spectrum antibiotic should be used whenever possible.

      For non-pregnant women aged 16 years and under, the following antibiotics can be considered:
      – Children under 3 months: It is recommended to refer to a pediatric specialist and treat with an intravenous antibiotic in line with the NICE guideline on fever in under 5s.
      – First-choice in children over 3 months: Nitrofurantoin (if eGFR >45 ml/minute) or Trimethoprim (if low risk of resistance*).
      – Second-choice in children over 3 months (when there is no improvement in lower UTI symptoms on first-choice for at least 48 hours, or when first-choice is not suitable): Nitrofurantoin (if eGFR >45 ml/minute and not used as first-choice), Amoxicillin (only if culture results are available and susceptible), or Cefalexin.

      Please refer to the BNF for children for dosing information. It is important to consider the risk of resistance when choosing antibiotics. A lower risk of resistance may be more likely if the antibiotic has not been used in the past 3 months, if previous urine culture suggests susceptibility (but was not used), and in younger people in areas where local epidemiology data suggest low resistance. On the other hand, a higher risk of resistance may be more likely with recent antibiotic use and in older people in residential facilities.

    • This question is part of the following fields:

      • Urology
      15.4
      Seconds
  • Question 36 - A 68 year old male is brought to the emergency department by a...

    Correct

    • A 68 year old male is brought to the emergency department by a concerned coworker who noticed that the patient seemed unsteady on his feet and very short of breath when walking to his car. The patient tells you they usually feel a bit short of breath when doing things like walking to their car or going up the stairs. On examination you note a regular pulse, rate 88 bpm, but an audible ejection systolic murmur loudest at the left sternal edge. Blood pressure is 148/94 mmHg. What is the likely diagnosis?

      Your Answer: Aortic stenosis

      Explanation:

      Severe aortic stenosis (AS) is characterized by several distinct features. These include a slow rising pulse, an ejection systolic murmur that is heard loudest in the aortic area and may radiate to the carotids, and a soft or absent S2 heart sound. Additionally, patients with severe AS often have a narrow pulse pressure and may exhibit an S4 heart sound.

      AS is commonly caused by hypertension, although blood pressure findings can vary. In severe cases, patients may actually be hypotensive due to impaired cardiac output. Symptoms of severe AS typically include Presyncope or syncope, exertional chest pain, and shortness of breath. These symptoms can be remembered using the acronym SAD (Syncope, Angina, Dyspnoea).

      It is important to note that aortic stenosis primarily affects older individuals, as it is a result of scarring and calcium buildup in the valve. Age-related AS typically begins after the age of 60, but symptoms may not appear until patients are in their 70s or 80s.

      Diastolic murmurs, on the other hand, are associated with conditions such as aortic regurgitation, pulmonary regurgitation, and mitral stenosis.

      Further Reading:

      Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.

      Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.

      Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).

      Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.

    • This question is part of the following fields:

      • Cardiology
      14.9
      Seconds
  • Question 37 - A middle-aged patient with a previous cancer diagnosis complains of recent onset back...

    Correct

    • A middle-aged patient with a previous cancer diagnosis complains of recent onset back pain. After conducting a thorough examination, your findings raise significant alarm. You begin to suspect the presence of metastatic spinal cord compression (MSCC).
      What specific feature is the strongest indicator of MSCC?

      Your Answer: Localised spinal tenderness

      Explanation:

      Metastatic spinal cord compression (MSCC) occurs when a tumor mass compresses the thecal sac and its components, leading to a spinal emergency. If the pressure on the spinal cord is not relieved promptly, it can result in irreversible loss of neurological function. The most crucial factor for predicting functional outcomes is the patient’s neurological function before treatment. Therefore, delayed treatment can lead to permanent disability and a decrease in quality of life.

      The most common cancers that cause MSCC include prostate, lung, breast, and myeloma. In approximately 10 to 20% of cancer patients, MSCC is the first noticeable symptom. It is important to consider MSCC in any patient with a history of cancer if they experience any of the following symptoms: severe or worsening lower back pain, nocturnal pain that disrupts sleep, localized spinal tenderness, radicular pain, or neurological symptoms.

      Thoracic pain can also be an indicator of MSCC or an aortic aneurysm. In patients aged 60 or older with persistent back pain, myeloma should be considered. For patients aged 60 or older with accompanying weight loss, pancreatic cancer should be taken into consideration.

    • This question is part of the following fields:

      • Oncological Emergencies
      16.6
      Seconds
  • Question 38 - A 38-year-old individual is brought into the emergency department by concerned friends. They...

    Correct

    • A 38-year-old individual is brought into the emergency department by concerned friends. They inform you that the person is a heavy drinker and they frequently witness them intoxicated. However, today the patient was unable to maintain their balance and appeared extremely disoriented. Upon examination, the patient displays an unsteady gait and you observe limited lateral eye movements. You suspect that the patient may have Wernicke's encephalopathy and is displaying Wernicke's triad. What percentage of patients presenting with Wernicke's encephalopathy will exhibit this triad of symptoms?

      Your Answer: 10%

      Explanation:

      If a patient does not exhibit the triad of symptoms associated with Wernicke’s, the clinician should not assume that the patient does not have the condition.

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      2.4
      Seconds
  • Question 39 - A 4 year old female is brought into the emergency department by concerned...

    Correct

    • A 4 year old female is brought into the emergency department by concerned parents. They inform you that the patient started vomiting yesterday and has had multiple episodes of diarrhea since then. The patient has been drinking less than usual and has vomited after being given a drink. The parents mention that there has been no recent travel and that the patient's immunizations are up to date. On examination, the patient has dry lips and buccal mucosa. The abdomen is soft, but the child becomes irritable when the abdomen is palpated. The peripheries are warm with a capillary refill time of 2.5 seconds. The patient's vital signs are as follows:

      Pulse: 146 bpm
      Respiration rate: 32 bpm
      Temperature: 37.9ÂșC

      What is the most likely diagnosis?

      Your Answer: Viral gastroenteritis

      Explanation:

      Based on the given information, the most likely diagnosis for the 4-year-old female patient is viral gastroenteritis. This is supported by the symptoms of vomiting and diarrhea, as well as the fact that the patient has been drinking less than usual and has vomited after being given a drink. The absence of recent travel and up-to-date immunizations also suggest that this is a viral rather than a bacterial infection.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      14.5
      Seconds
  • Question 40 - A 35-year-old woman comes in with a painful left elbow. She is left-handed...

    Incorrect

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Tennis elbow

      Correct Answer: Golfer’s elbow

      Explanation:

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

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

      De Quervain’s tenosynovitis occurs when there is inflammation of the tendon sheaths for the thumb extensor and abductor muscles. This leads to pain over the radial styloid, which worsens with forced adduction and flexion of the thumb. Treatment options include anti-inflammatory medications, thumb splints, and steroid injections.

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

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      35.1
      Seconds
  • Question 41 - A 72-year-old male visits the emergency department on a weekend complaining of colicky...

    Correct

    • A 72-year-old male visits the emergency department on a weekend complaining of colicky abdominal pain and frequent episodes of diarrhea. The patient mentions that he had given a stool sample to his GP earlier in the week, but he is worried because the diarrhea has worsened. The pathology report confirms the presence of clostridium difficile toxin in the stool sample. Which of the medications the patient regularly takes are known to increase the risk of clostridium difficile diarrhea?

      Your Answer: Lansoprazole

      Explanation:

      Regular use of medications that decrease gastric acid secretion, such as proton pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) and H2 receptor antagonists like ranitidine, can increase the risk of developing clostridium difficile diarrhoea. However, it is important to note that antibiotics are the most common cause of this condition.

      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.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      7.5
      Seconds
  • Question 42 - A 70-year-old man with atrial fibrillation comes to the Emergency Department with an...

    Correct

    • A 70-year-old man with atrial fibrillation comes to the Emergency Department with an unrelated medical issue. While reviewing his medications, you find out that he is taking warfarin as part of his treatment.
      Which ONE of the following beverages should he avoid?

      Your Answer: Cranberry juice

      Explanation:

      Warfarin has been found to heighten the likelihood of bleeding events when consumed alongside specific juices, such as cranberry juice and grapefruit juice. As a result, individuals who are taking warfarin should be cautioned against consuming these beverages. For more information on this topic, please refer to the BNF section on warfarin interactions and the interaction between warfarin and cranberry juice.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      2.7
      Seconds
  • Question 43 - A 35-year-old West Indian woman with a past medical history of bilateral wrist...

    Correct

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Systemic lupus erythematosus

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Dermatology
      5.5
      Seconds
  • Question 44 - You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of...

    Correct

    • You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of an acute coronary syndrome (ACS).
      Which ONE statement about ACS is NOT TRUE?

      Your Answer: Cardiac enzymes are usually elevated in unstable angina

      Explanation:

      Cardiac enzymes do not increase in unstable angina. However, if cardiac markers do rise, it is classified as a non-ST elevation myocardial infarction (NSTEMI). Both unstable angina and NSTEMI can have a normal ECG. An extended ventricular activation time indicates damage to the heart muscle. This occurs because infarcting myocardium conducts electrical impulses at a slower pace, resulting in a prolonged interval between the start of the QRS complex and the apex of the R wave. A positive troponin test indicates the presence of necrosis in cardiac myocytes.

      Summary:
      Marker | Initial Rise | Peak | Normal at
      Creatine kinase | 4-8 hours | 18 hours 2-3 days | CK-MB = main cardiac isoenzyme
      Myoglobin | 1-4 hours | 6-7 hours | 24 hours | Low specificity due to skeletal muscle damage
      Troponin I | 3-12 hours | 24 hours | 3-10 days | Appears to be the most sensitive and specific
      HFABP | 1-2 hours | 5-10 hours | 24 hours | HFABP = heart fatty acid binding protein
      LDH | 10 hours | 24-48 hours | 14 days | Cardiac muscle mainly contains LDH

    • This question is part of the following fields:

      • Cardiology
      10.5
      Seconds
  • Question 45 - A 65-year-old patient with a past medical history of chronic congestive cardiac failure...

    Correct

    • A 65-year-old patient with a past medical history of chronic congestive cardiac failure complains of feeling fatigued and generally not well. She is currently on high doses of furosemide as prescribed by her heart failure specialist. Upon reviewing her blood test results, you observe that her electrolyte levels are abnormal.
      Which of the following electrolyte imbalances is most likely to be present?

      Your Answer: Low sodium, low potassium

      Explanation:

      Loop diuretics, like furosemide, commonly result in several electrolyte imbalances. These imbalances include hyponatremia, which is a decrease in sodium levels in the blood. Another common imbalance is hypokalemia, which refers to low levels of potassium. Additionally, loop diuretics can cause hypocalcemia, a condition characterized by low levels of calcium in the blood. Another electrolyte affected by loop diuretics is magnesium, as they can lead to hypomagnesemia, which is a deficiency of magnesium. Lastly, loop diuretics can cause hypochloremic alkalosis, which is a condition characterized by low levels of chloride in the blood and an increase in blood pH.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      8.2
      Seconds
  • Question 46 - A 60 year old female comes to the emergency department complaining of sudden...

    Correct

    • A 60 year old female comes to the emergency department complaining of sudden difficulty in breathing. Upon examination, it is observed that the patient has had a tracheostomy for a prolonged period due to being on a ventilator after a severe head injury. Following the emergency tracheostomy algorithm, the tracheostomy is removed, but the patient's condition does not improve. What should be the next course of action in managing this patient?

      Your Answer: Cover the stoma and begin bag valve mask ventilation

      Explanation:

      When attempting to ventilate a patient with a tracheostomy, the first approach is usually through the mouth. If this is not successful, ventilation through the tracheostomy stoma is appropriate. After removing the tracheostomy, the doctor should begin ventilating the patient through the mouth by performing standard oral manoeuvres and covering the stoma with a hand or swab. If these measures fail, the clinician should then proceed to ventilate through the tracheostomy stoma using a bag valve mask and appropriate adjuncts such as oral or nasal adjuncts or an LMA.

      Further Reading:

      Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

      When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

      Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      15.3
      Seconds
  • Question 47 - A 35-year-old individual presents with intense one-sided abdominal pain starting in the right...

    Correct

    • A 35-year-old individual presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. They are also experiencing severe nausea and vomiting. The urine dipstick test shows the presence of blood. A CT KUB scan is scheduled, and a diagnosis of ureteric colic is confirmed.
      Which of the following is NOT a reason for immediate hospital admission in a patient with ureteric colic?

      Your Answer: Frank haematuria

      Explanation:

      Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.

      The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the flank or loin area and radiating to the groin or testicle in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.

      The pain experienced during renal or ureteric colic is often described as the most intense pain a person has ever felt, with many women comparing it to the pain of childbirth. Restlessness and an inability to find relief by lying still are common signs, which can help differentiate renal colic from peritonitis. Previous episodes of similar pain may also be reported by the individual. In cases where there is a concomitant urinary infection, fever and sweating may be present. Additionally, the person may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.

      It is important to seek urgent medical attention if certain conditions are met. These include signs of systemic infection or sepsis, such as fever or sweating, or if the person is at a higher risk of acute kidney injury, such as having pre-existing chronic kidney disease, a solitary or transplanted kidney, or suspected bilateral obstructing stones. Hospital admission is also necessary if the person is dehydrated and unable to consume fluids orally due to nausea and/or vomiting. If there is uncertainty regarding the diagnosis, it is recommended to consult further resources, such as the NICE guidelines on the assessment and management of renal and ureteric stones.

    • This question is part of the following fields:

      • Urology
      10.4
      Seconds
  • Question 48 - You evaluate a 35-year-old woman who has recently been diagnosed with epilepsy. She...

    Incorrect

    • You evaluate a 35-year-old woman who has recently been diagnosed with epilepsy. She has been initiated on an anti-epileptic drug but has subsequently developed a tremor when assuming a certain posture.
      Which INDIVIDUAL anti-epileptic medication is most likely to be accountable for this?

      Your Answer: Phenytoin

      Correct Answer: Sodium valproate

      Explanation:

      Postural tremor is frequently seen as a neurological side effect in individuals taking sodium valproate. Additionally, a resting tremor may also manifest. It has been observed that around 25% of patients who begin sodium valproate therapy develop a tremor within the first year. Other potential side effects of sodium valproate include gastric irritation, nausea and vomiting, involuntary movements, temporary hair loss, weight gain in females, and impaired liver function.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      8.3
      Seconds
  • Question 49 - A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her...

    Correct

    • A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her left loin. During the examination, she experiences tenderness over the left renal angle, and her temperature is 38.6°C. The triage nurse has already inserted a cannula, and a complete set of blood tests has been sent to the lab.

      What is the SINGLE most probable diagnosis?

      Your Answer: Pyelonephritis

      Explanation:

      This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.

      According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.

      NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).

      For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.

      For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.

    • This question is part of the following fields:

      • Urology
      7.2
      Seconds
  • Question 50 - A young colleague has encountered a 28-year-old mountaineer who has developed frostbite to...

    Correct

    • A young colleague has encountered a 28-year-old mountaineer who has developed frostbite to the toes of the left foot after being stranded on a snowy peak for several hours. Your colleague wants to start Rewarming the affected area by immersing it in water and seeks your guidance. What temperature should the water be maintained at for the Rewarming process?

      Your Answer: 40-42ÂșC

      Explanation:

      To treat frostbite, it is important to quickly warm the affected area by immersing it in water that is consistently kept at a temperature of 40-42ÂșC. The Rewarming process should be continued until the affected area feels flexible and shows signs of redness, which typically takes around 15 to 30 minutes. It is recommended to provide strong pain relief medication during this process, as reperfusion can be extremely painful.

      Further Reading:

      Hypothermia is defined as a core temperature below 35ÂșC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in depressed myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

      In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

      Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ÂșC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

      Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

    • This question is part of the following fields:

      • Environmental Emergencies
      5.2
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (4/4) 100%
Obstetrics & Gynaecology (0/1) 0%
Nephrology (1/1) 100%
Ear, Nose & Throat (4/4) 100%
Environmental Emergencies (2/2) 100%
Maxillofacial & Dental (1/2) 50%
Pain & Sedation (1/1) 100%
Trauma (1/1) 100%
Musculoskeletal (non-traumatic) (1/2) 50%
Pharmacology & Poisoning (3/5) 60%
Haematology (3/3) 100%
Paediatric Emergencies (4/4) 100%
Neurology (1/2) 50%
Infectious Diseases (1/1) 100%
Endocrinology (1/1) 100%
Respiratory (3/3) 100%
Ophthalmology (1/1) 100%
Neonatal Emergencies (0/1) 0%
Resus (1/1) 100%
Gastroenterology & Hepatology (3/4) 75%
Urology (4/4) 100%
Oncological Emergencies (1/1) 100%
Dermatology (1/1) 100%
Passmed