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Question 1
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A 35-year-old woman is given a medication for a medical ailment during the 4th and 5th month of her pregnancy. As a result, the unborn baby has experienced reduced blood flow and a condition known as oligohydramnios sequence.
Which of the listed medications is the most probable cause of these abnormalities?Your Answer: Ramipril
Explanation:During the second and third trimesters of pregnancy, exposure to ACE inhibitors can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. This sequence refers to the abnormal physical appearance of a fetus or newborn due to low levels of amniotic fluid in the uterus. It is also associated with malformations of the patient ductus arteriosus and aortic arch. These defects are believed to be caused by the inhibitory effects of ACE inhibitors on the renin-angiotensin-aldosterone system. To avoid these risks, it is recommended to discontinue ACE inhibitors before the second trimester.
Here is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:
Drug: ACE inhibitors
Adverse effects: If given in the second and third trimesters, can cause hypoperfusion, renal failure, and the oligohydramnios sequence.Drug: Aminoglycosides
Adverse effects: Ototoxicity (damage to the ear) and deafness.Drug: Aspirin
Adverse effects: High doses can cause first trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. Low doses (e.g. 75 mg) have no significant associated risk.Drug: Benzodiazepines
Adverse effects: When given late in pregnancy, respiratory depression and a neonatal withdrawal syndrome can occur.Drug: Calcium-channel blockers
Adverse effects: If given in the first trimester, can cause phalangeal abnormalities. If given in the second and third trimesters, can cause fetal growth retardation. -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 2
Correct
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A 25-year-old traveler comes to the clinic complaining of a fever, cough, and headache that have persisted for the last week. He recently returned from a backpacking adventure in India. Additionally, he started experiencing diarrhea a few days ago, and a stool sample was sent for testing, which revealed the presence of Salmonella typhi. Which antibacterial medication would be the most suitable to prescribe for this patient?
Your Answer: Cefotaxime
Explanation:According to the latest guidelines from NICE and the BNF, the recommended initial treatment for typhoid fever is cefotaxime. It is important to note that infections originating from the Middle-East, South Asia, and South-East Asia may have multiple antibiotic resistance, so it is advisable to test for sensitivity. In cases where the microorganism is found to be sensitive, ciprofloxacin can be considered as a suitable alternative.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 3
Correct
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A 32-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to evaluate for a haemoperitoneum.
Which of the subsequent anatomical regions is evaluated as part of a typical 4 view FAST scan?Your Answer: Left upper quadrant
Explanation:A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information helps healthcare providers make decisions regarding further management of the patient.
The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.
During a standard FAST scan, four regions are assessed. The first is the subxiphoid transverse view, which is used to check for pericardial effusion and left lobe liver injuries. The second is the longitudinal view of the right upper quadrant, which helps identify right liver injuries, right kidney injuries, and fluid in the hepatorenal recess (Morison’s pouch). The third is the longitudinal view of the left upper quadrant, which is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are examined to assess the bladder and fluid in the pouch of Douglas.
In addition to the standard FAST scan, an extended FAST or eFAST may also be performed. This involves examining the left and right thoracic regions to assess for the presence of pneumothorax and haemothorax.
The hepatorenal recess is the deepest part of the peritoneal cavity when a patient is lying flat. Therefore, it is the most likely area for fluid to accumulate in a supine position.
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This question is part of the following fields:
- Trauma
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Question 4
Correct
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A 42-year-old man presents sweaty and distressed, complaining of abdominal pain and nausea. On examination, he has marked abdominal tenderness that is maximal in the epigastric area. Following his blood results, you make a diagnosis of acute pancreatitis.
His venous bloods are shown below:
Hb: 14.5 g/dL
White cell count: 15.2 x 109/L
Blood glucose 7.9 mmol/L
AST 512 IU/L
LDH 420 IU/L
Amylase: 1200 IU/L
What is the most likely underlying cause for his pancreatitis?Your Answer: Alcohol abuse
Explanation:Acute pancreatitis is a frequently encountered and serious source of acute abdominal pain. It involves the sudden inflammation of the pancreas, leading to the release of enzymes that cause self-digestion of the organ.
The clinical manifestations of acute pancreatitis include severe epigastric pain, accompanied by feelings of nausea and vomiting. The pain may radiate to the T6-T10 dermatomes or even to the shoulder tip through the phrenic nerve if the diaphragm is irritated. Other symptoms may include fever or sepsis, tenderness in the epigastric region, jaundice, and the presence of Gray-Turner sign (bruising on the flank) or Cullen sign (bruising around the belly button).
The most common causes of acute pancreatitis are gallstones and alcohol consumption. Additionally, many cases are considered idiopathic, meaning the cause is unknown. To aid in remembering the various causes, the mnemonic ‘I GET SMASHED’ can be helpful. Each letter represents a potential cause: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion stings, Hyperlipidemia/hypercalcemia, ERCP (endoscopic retrograde cholangiopancreatography), and Drugs.
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This question is part of the following fields:
- Surgical Emergencies
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Question 5
Correct
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A 42-year-old woman is brought in by ambulance following a severe car accident. There was a prolonged extraction at the scene, and a complete trauma call is initiated. She is disoriented and slightly restless. Her vital signs are as follows: heart rate 125, blood pressure 83/45, oxygen saturation 98% on high-flow oxygen, respiratory rate 31, temperature 36.1°C. Her capillary refill time is 5 seconds, and her extremities appear pale and cool to the touch. Her cervical spine is immobilized with triple precautions. The airway is clear, and her chest examination is normal. Two large-bore cannulas have been inserted in her antecubital fossa, and a comprehensive set of blood tests, including a request for a cross-match, has been sent to the laboratory. She experiences significant tenderness in the suprapubic area upon abdominal palpation, and noticeable bruising is evident around her pelvis. A pelvic X-ray reveals a vertical shear type pelvic fracture.
Approximately how much blood has she lost?Your Answer: 1500-2000 mL
Explanation:This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.
Hemorrhage can be categorized into four different classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.
In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.
In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure remains normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.
The patient in this case is in class III hemorrhage, with a blood loss of 1500-2000 mL or 30-40% of the blood volume. The pulse rate is elevated, ranging from 120-140 beats per minute, and the systolic blood pressure is decreased. The pulse pressure is also decreased, and the respiratory rate is elevated to 30-40 breaths per minute. The urine output decreases significantly to 5-15 mL per hour, and the patient may experience anxiety and confusion.
Class IV hemorrhage represents the most severe level of blood loss, with a loss of over 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is decreased, and the respiratory rate is over 40 breaths per minute. The urine output becomes negligible, and the patient may become confused and lethargic.
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This question is part of the following fields:
- Trauma
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Question 6
Correct
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A 30-year-old woman comes in with intense pain in her right flank and microscopic blood in her urine. After evaluation, you diagnose her with renal colic.
What is the ONE category of medication that has been proven to improve the passage of kidney stones in cases of renal colic?Your Answer: Calcium channel blockers
Explanation:NSAIDs are known to have a relaxing effect on the ureter, but a randomized controlled trial found no difference between NSAIDs and a placebo in terms of this effect. Currently, only two classes of drugs, calcium channel blockers and alpha-blockers, are considered effective as medical expulsive therapy (MET). Calcium channel blockers work by blocking the active calcium channel pump that the smooth muscle of the ureter uses to contract, resulting in relaxation of the muscle and improved stone passage. Alpha-blockers, on the other hand, are commonly used as the first-line treatment to enhance stone passage. They reduce the basal tone of the ureter smooth muscle, decrease the frequency of peristaltic waves, and lower ureteric contraction. This leads to a decrease in intraureteric pressure below the stone, increasing the chances of stone passage. Patients treated with calcium channel blockers or alpha-blockers have been shown to have a 65% higher likelihood of spontaneous stone passage compared to those not given these medications.
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This question is part of the following fields:
- Urology
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Question 7
Incorrect
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A 65-year-old male patient is brought into the emergency department with suspected sepsis. It is decided to intubate the patient pending transfer to the intensive care unit (ICU). Your consultant requests you to prepare propofol and suxamethonium for rapid sequence intubation. What is the mechanism of action of suxamethonium?
Your Answer: Competitive agonist of acetylcholine receptors at the neuromuscular junction
Correct Answer: Non-competitive agonist of acetylcholine receptors at the neuromuscular junction
Explanation:Suxamethonium, also called succinylcholine, is a type of drug used to block neuromuscular transmission. It acts as an agonist by binding to acetylcholine receptors at the neuromuscular junction. Unlike acetylcholine, suxamethonium is not broken down by acetylcholinesterase, which means it stays bound to the receptors for a longer time, leading to prolonged inhibition of neuromuscular transmission. Eventually, suxamethonium is metabolized by plasma cholinesterase.
Further Reading:
Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.
Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.
Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.
Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.
Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 8
Correct
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A 32 year old male presents to the emergency department with a laceration to the distal third of his finger caused by a box cutter. You intend to clean and examine the wound under local anesthesia. You gather the necessary equipment to administer a digital (ring) nerve block and prepare to inject the anesthetic at the base of the finger. How are the digital nerves arranged within the finger?
Your Answer: 2 palmar and 2 dorsal digital nerves
Explanation:The finger has a total of four digital nerves. Two of these nerves, known as the palmar digital nerves, run along the palm side of each finger. The other two nerves, called the dorsal digital nerves, are located on the back side of the finger. However, the dorsal nerve supply changes slightly at the level of the proximal IP joint. Beyond this point, the dorsal nerve supply comes from the dorsal branch of the palmar digital nerve.
Further Reading:
Digital nerve blocks are commonly used to numb the finger for various procedures such as foreign body removal, dislocation reduction, and suturing. Sensation to the finger is primarily provided by the proper digital nerves, which arise from the common digital nerve. Each common digital nerve divides into two proper digital nerves, which run along the palmar aspect of the finger. These proper digital nerves give off a dorsal branch that supplies the dorsal aspect of the finger.
The most common technique for digital nerve blocks is the digital (ring) block. The hand is cleaned and the injection sites are cleansed with an alcohol swab. A syringe containing 1% lidocaine is prepared, and the needle is inserted at the base of the finger from a dorsal approach. Lidocaine is infiltrated under the skin, and the needle is then advanced towards the palmar aspect of the finger to inject more lidocaine. This process is repeated on the opposite side of the finger.
It is important not to use lidocaine with adrenaline for this procedure, as it may cause constriction and ischemia of the digital artery. Lidocaine 1% is the preferred local anesthetic, and the maximum dose is 3 ml/kg up to 200 mg. Contraindications for digital nerve blocks include compromised circulation to the finger, infection at the planned injection site, contraindication to local anesthetic (e.g. allergy), and suspected compartment syndrome (which is rare in the finger).
Complications of digital nerve blocks can include vascular injury to the digital artery or vein, injury to the digital nerve, infection, pain, allergic reaction, intravascular injection (which can be avoided by aspirating prior to injection), and systemic local anesthetic toxicity (which is uncommon with typical doses of lidocaine).
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This question is part of the following fields:
- Basic Anaesthetics
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Question 9
Correct
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A 42 year old male intravenous drug user is brought to the emergency department due to worsening abdominal distension, fever and new onset confusion. You observe that the patient has a pre-existing diagnosis of hepatitis C but has not attended follow up or received treatment. After evaluating the patient, you notice that he has tense ascites and decide to perform abdominal paracentesis. Ascitic fluid is sent for analysis.
Which of the following findings is indicative of spontaneous bacterial peritonitis (SBP)?Your Answer: Ascitic fluid absolute neutrophil count >250 cells/mm³
Explanation:Spontaneous bacterial peritonitis (SBP) is a serious infection that can occur in individuals with ascites, which is the accumulation of fluid in the abdominal cavity. In this case, the patient is a 42-year-old male intravenous drug user with a history of hepatitis C who has not received treatment. He presents to the emergency department with worsening abdominal distension, fever, and confusion.
To evaluate the patient, an abdominal paracentesis is performed, which involves removing a sample of the ascitic fluid for analysis. The findings from the ascitic fluid analysis can provide important information about the underlying cause of the patient’s symptoms.
In the given options, the finding that is indicative of spontaneous bacterial peritonitis (SBP) is an ascitic fluid absolute neutrophil count >250 cells/mm³. Neutrophils are a type of white blood cell that are typically elevated in the presence of infection. In SBP, there is an infection of the ascitic fluid, leading to an increase in neutrophils.
The other options provided do not specifically indicate SBP. An ascitic fluid absolute lymphocyte count >150 cells/mm³ may suggest a different type of infection or inflammation. An ascitic fluid absolute erythrocyte count >200 cells/mm³ may indicate bleeding into the ascitic fluid. An ascitic fluid albumin concentration of > 2.0 g/dL (20 g/L) and an ascitic fluid protein concentration of > 3.0 g/dL (30 g/L) may suggest liver disease or other causes of ascites, but they do not specifically indicate SBP.
Therefore, in this case, the presence of an ascitic fluid absolute neutrophil count >250 cells/mm³ is the finding that is indicative of spontaneous bacterial peritonitis (SBP).
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 10
Correct
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A 45-year-old doctor in the Emergency Department complains of a red and itchy urticarial rash on her hands that appeared 15 minutes after she wore a pair of latex gloves. What is the most probable cause for the development of this rash?
Your Answer: Type I hypersensitivity reaction
Explanation:Type I hypersensitivity reactions, also known as allergic reactions, are triggered when a person is exposed again to a particular antigen, which is referred to as the allergen. These reactions are mediated by IgE and typically manifest within 15 to 30 minutes after exposure to the allergen. One common symptom of a type I hypersensitivity reaction is the rapid onset of a urticarial rash, which occurs shortly after coming into contact with the allergen, such as latex.
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This question is part of the following fields:
- Allergy
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Question 11
Correct
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A 32 year old woman is brought into the emergency department with burns to her chest and arms. The patient was trying to handle a grease fire but accidentally spilled the burning contents onto herself. Your consultant requests you to evaluate the severity of the burns. What is used to estimate the extent of a burn injury?
Your Answer: Lund and Browder chart
Explanation:TBSA, or Total Body Surface Area, is a method commonly used to estimate the size of small burns and very large burns by including the area of unburnt skin. However, it is not considered a reliable method for medium-sized burns.
Further Reading:
Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.
When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.
Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.
The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.
Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.
Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.
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This question is part of the following fields:
- Trauma
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Question 12
Incorrect
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A child presents with blurred vision, nausea, vomiting, and low sodium levels. They are taking carbamazepine for epilepsy. You suspect toxicity and send bloods for assessment.
What is the recommended therapeutic range for carbamazepine in children?Your Answer: 8-16 mg/L
Correct Answer: 4-10 mg/L
Explanation:The therapeutic range for carbamazepine is between 4 and 10 mg/L. This range indicates the optimal concentration of the medication in the bloodstream for it to be effective in treating certain conditions. It is important for healthcare professionals to monitor the levels of carbamazepine in a patient’s blood to ensure they are within this range. If the levels are too low, the medication may not be effective, while levels that are too high can lead to potential side effects. By maintaining carbamazepine levels within the therapeutic range, healthcare providers can maximize the benefits of the medication while minimizing any potential risks.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 13
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect a diagnosis of ureteric colic.
What is the preferred imaging technique for confirming the diagnosis?Your Answer: Contrast helical computed tomography
Correct Answer: Non-contrast helical computed tomography
Explanation:The term renal colic is commonly used to describe 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. However, a more accurate term is ureteric colic, as the pain usually arises from a blockage in the ureter itself.
Renal or ureteric colic typically presents with a sudden onset of severe abdominal pain on one side, starting in the lower back or flank and radiating to the genital area in women or to the groin or testicle in men.
The pain usually:
– Lasts for minutes to hours and comes in spasms, with periods of no pain or a dull ache
– Is often accompanied by nausea, vomiting, and blood in the urine
– Is often described as the most intense pain a person has ever experienced (many women describe it as worse than childbirth).People with renal or ureteric colic:
– Are restless and unable to find relief by lying still (which helps distinguish it from peritonitis)
– May have a history of previous episodes
– May have a fever and sweating if there is a urinary tract infection present
– May complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and bladder (due to irritation of the bladder muscle).If possible, a urine dipstick test should be done to support the diagnosis and check for signs of a urinary tract infection.
Checking for blood in the urine can also support the diagnosis of renal or ureteric colic. However, the absence of blood does not rule out the diagnosis and other causes of pain should be considered.
Checking for nitrite and leukocyte esterase in the urine can indicate an infection.
Pain management:
– Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic.
– Intravenous paracetamol can be given to adults, children, and young people if NSAIDs are not suitable or not providing enough pain relief.
– Opioids may be considered if both NSAIDs and intravenous paracetamol are not suitable or not providing enough pain relief.
– Antispasmodics should not be given to adults, children, and young people with suspected renal colic. -
This question is part of the following fields:
- Urology
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Question 14
Correct
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A 68 year old is brought into the emergency department by his worried husband. The patient's husband informs you that the patient appears to be more disoriented than usual and is experiencing excessive daytime sleepiness. He mentions that the patient was diagnosed with Alzheimer's disease approximately half a year ago. What is the most accurate description of the underlying pathology in Alzheimer's disease?
Your Answer: Beta-amyloid plaques and neurofibrillary tangles
Explanation:Alzheimer’s disease, the leading cause of dementia, is characterized by the presence of beta-amyloid plaques and neurofibrillary tangles in the brain. These plaques are formed due to an excessive buildup of amyloid, which can be caused by either overproduction or impaired clearance of beta-amyloid. The accumulation of amyloid plaques leads to inflammation in the surrounding brain tissue, resulting in damage to neurons. Additionally, the abnormal phosphorylation of tau protein causes it to aggregate into neurofibrillary tangles within neurons. It is important to note that Lewy bodies, composed mainly of alpha-synuclein, are associated with diseases like Parkinson’s disease and dementia with Lewy bodies. Autoimmune diseases often involve the activation of autoreactive T-cells.
Further Reading:
Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.
To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.
The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.
There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.
Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.
Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.
Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.
In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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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: Immediate 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.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 16
Incorrect
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A 72 year old female is brought into the emergency department with a history of worsening dizziness, muscle cramps, fatigue, and weakness. Examination reveals the patient to have normal blood pressure, regular heart sounds, and a pulse rate of 88 beats per minute. Respiratory examination shows resonant chest sounds in all areas, normal respiratory rate, and oxygen saturations of 96% with coarse crackles heard at the right base. Neurological examination is unremarkable. You order urine and blood tests for analysis. The results are as follows:
Na+ 122 mmol/l
K+ 5.2 mmol/l
Urea 7.1 mmol/l
Creatinine 98 µmol/l
Glucose 6.4 mmol/l
Urine osmolality 410 mosmol/kg
Which of the following actions should be included in this patient's management plan?Your Answer:
Correct Answer: Fluid restriction
Explanation:The usual approach to managing SIADH without neurological symptoms is to restrict fluid intake. In this case, the patient has SIADH, as evidenced by low serum osmolality due to low sodium levels. It is important to note that the patient’s urine osmolality is high despite the low serum osmolality.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
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This question is part of the following fields:
- Nephrology
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Question 17
Incorrect
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A 15 year old male is brought to the emergency department by his parents and admits to taking 32 paracetamol tablets 6 hours ago. Blood tests are conducted, including paracetamol levels. What is the paracetamol level threshold above which the ingestion is deemed 'significant'?
Your Answer:
Correct Answer: 75 mg/kg/24 hours
Explanation:If someone consumes at least 75 mg of paracetamol per kilogram of body weight within a 24-hour period, it is considered to be a significant ingestion. Ingesting more than 150 mg of paracetamol per kilogram of body weight within 24 hours poses a serious risk of harm.
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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 18
Incorrect
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You evaluate a 78-year-old woman who has come in after a fall. She is frail and exhibits signs of recent memory loss. You administer an abbreviated mental test score (AMTS) and record the findings in her medical records.
Which ONE of the following is NOT included in the abbreviated mental test score (AMTS)?Your Answer:
Correct Answer: Repeating back a phrase
Explanation:The 30-point Folstein mini-mental state examination (MMSE) includes a task where the examiner asks the individual to repeat back a phrase. However, this task is not included in the AMTS. The AMTS consists of ten questions that assess different aspects of cognitive function. These questions cover topics such as age, time, year, location, recognition of people, date of birth, historical events, present monarch or prime minister, counting backwards, and recall of an address. The AMTS is a useful tool for evaluating memory loss and is referenced in the RCEM syllabus.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 19
Incorrect
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You are examining the facial X-rays of a young patient who was involved in a physical altercation and sustained multiple facial injuries. What tools or techniques are utilized to aid in the interpretation of facial radiographs and facilitate the identification of facial fractures?
Your Answer:
Correct Answer: Dolan lines
Explanation:The interpretation of facial X-rays is often assisted by the use of McGrigor-Campbell lines and Dolan lines. These lines, along with accompanying notes and images, provide additional information for a more accurate analysis.
Further Reading:
Facial X-rays are commonly used to assess and diagnose facial fractures. Two standard views are typically performed: the Occipitomental view and the Occipitomental 30º view. The Occipitomental view provides a comprehensive look at the upper and middle thirds of the face, including the orbital margins, frontal sinuses, zygomatic arches, and maxillary antra. On the other hand, the Occipitomental 30º view uses a 30-degree caudal angulation to better visualize the zygomatic arches and walls of the maxillary antra, although it may compromise the clear view of the orbital margins.
To assist in the interpretation of facial X-rays, imaginary lines are often drawn across the images to highlight any asymmetry or disruption. Two commonly used sets of lines are the McGrigor-Campbell lines and Dolan’s lines. McGrigor-Campbell lines are used to aid in the interpretation of both the Occipitomental and Occipitomental 30º views. These lines include an upper line that passes through the zygomatico-frontal sutures and the upper edge of the orbits, a middle line that follows the zygomatic arch and crosses the zygomatic bone, and a lower line that passes through the condyle and coronoid process of the mandible and the walls of the maxillary antra.
Dolan’s lines, described by Dolan and Jacoby, are often used in conjunction with McGrigor-Campbell lines. These lines include the orbital line, which traces the inner margins of the orbital walls and the nasal arch, the zygomatic line, which traces the superior margin of the zygomatic arch and body, and the maxillary line, which traces the inferior margin of the zygomatic arch, body, and buttress, as well as the lateral wall of the maxillary sinus. Together, the zygomatic and maxillary lines resemble the profile of an elephant’s head and are referred to as Dolan’s elephant. These lines help provide additional information and aid in the interpretation of facial X-rays.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 20
Incorrect
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A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a preliminary diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip, and when you attempt to extend it passively, his abdominal pain intensifies.
Which muscle is most likely in contact with the inflamed structure causing these symptoms?Your Answer:
Correct Answer: Psoas major
Explanation:This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.
The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.
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This question is part of the following fields:
- Surgical Emergencies
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Question 21
Incorrect
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A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
What is the most probable underlying diagnosis?Your Answer:
Correct Answer: Liver disease
Explanation:Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).
On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.
Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.
It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.
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This question is part of the following fields:
- Haematology
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Question 22
Incorrect
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A 75 year old man with a long-standing history of hypothyroidism presents to the emergency department due to worsening confusion and fatigue. On examination you note diffuse non-pitting edema and decreased deep tendon reflexes. Observations are shown below:
Blood pressure 98/66 mmHg
Pulse 42 bpm
Respiration rate 11 bpm
Temperature 34.6ºC
Bloods are sent for analysis. Which of the following laboratory abnormalities would you expect in a patient with this condition?Your Answer:
Correct Answer: Hyponatremia
Explanation:Myxoedema coma is a condition characterized by severe hypothyroidism, leading to a state of metabolic decompensation and changes in mental status. Patients with myxoedema coma often experience electrolyte disturbances such as hypoglycemia and hyponatremia. In addition, laboratory findings typically show elevated levels of TSH, as well as low levels of T4 and T3. Other expected findings include hypoxemia and hypercapnia.
Further Reading:
The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.
Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.
The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.
Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.
Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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A 30-year-old woman with a history of schizophrenia is brought to the Emergency Department. She is exhibiting signs of acute psychosis.
Which ONE of the following statements is TRUE regarding schizophrenia?Your Answer:
Correct Answer: 10% of patients go on to commit suicide
Explanation:The occurrence of schizophrenia is consistent across all social classes. It affects individuals from all walks of life without discrimination. The likelihood of developing schizophrenia over one’s lifetime is 1%, and this probability remains the same for both men and women. However, it is worth noting that men tend to experience the onset of symptoms at a younger age compared to women, with the average age of onset falling between 15 and 45 years.
There is a recognized genetic predisposition for schizophrenia, meaning that certain individuals may have a higher likelihood of developing the condition due to their genetic makeup. The risk of schizophrenia affecting first-degree relatives, such as siblings or parents, is approximately 10%. Furthermore, the risk of children being affected by schizophrenia increases to 40%.
When considering the impact of genetics on schizophrenia, it is interesting to note that monozygotic twins, who share identical genetic material, have a concordance rate of around 50%. This suggests that genetic factors play a significant role in the development of the condition.
Tragically, approximately 10% of individuals suffering from schizophrenia ultimately die by suicide, particularly during the early stages of the illness. This highlights the importance of providing appropriate support and intervention to individuals with schizophrenia to prevent such devastating outcomes.
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This question is part of the following fields:
- Mental Health
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Question 24
Incorrect
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A 35-year-old Caucasian woman comes in with complaints of headaches, blurry vision, and occasional chest pain over the past few weeks. During her fundoscopic examination, retinal hemorrhages and bilateral papilledema are observed. Her initial vital signs are as follows: heart rate of 89, blood pressure of 228/134, oxygen saturation of 98% on room air, blood glucose level of 8.2, and a Glasgow Coma Scale score of 15/15.
What is the MOST LIKELY diagnosis for this patient?Your Answer:
Correct Answer: Malignant hypertension
Explanation:The diagnosis in this particular case is malignant (accelerated) hypertension. The patient’s blood pressure is greater than 220/110, and they also have retinal haemorrhages and papilloedema. During the examination, it is important to look for other features such as the presence of a 3rd heart sound, ankle oedema, bilateral basal crepitations, and any focal neurological deficit.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving in the Emergency Department. Her pulse rate is 145 bpm, BP is 72/38 mmHg, respiratory rate 45 breaths/minute, and her urine output over the past hour has been negligible. She is drowsy, lethargic, and confused. The patient weighs approximately 70 kg.
How would you classify her hemorrhage according to the ATLS hemorrhagic shock classification?Your Answer:
Correct Answer: Class IV
Explanation:This patient is showing significant signs of distress, including a highly elevated heart rate and respiratory rate, as well as very little urine output. Additionally, they are experiencing drowsiness, lethargy, and confusion. These symptoms indicate that the patient has suffered a class IV haemorrhage at this stage.
Recognizing the extent of blood loss based on vital signs and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for haemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy 70 kg patient. In a 70 kg male patient, the total circulating blood volume is approximately five litres, accounting for around 7% of their total body weight.
The ATLS haemorrhagic shock classification is summarized as follows:
CLASS I
Blood loss (mL): Up to 750
Blood loss (% blood volume): Up to 15%
Pulse rate (bpm): <100
Systolic BP: Normal
Pulse pressure: Normal (or increased)
Respiratory rate: 14-20
Urine output (ml/hr): >30
CNS/mental status: Slightly anxiousCLASS II
Blood loss (mL): 750-1500
Blood loss (% blood volume): 15-30%
Pulse rate (bpm): 100-120
Systolic BP: Normal
Pulse pressure: Decreased
Respiratory rate: 20-30
Urine output (ml/hr): 20-30
CNS/mental status: Mildly anxiousCLASS III
Blood loss (mL): 1500-2000
Blood loss (% blood volume): 30-40%
Pulse rate (bpm): 120-140
Systolic BP: Decreased
Pulse pressure: Decreased
Respiratory rate: 30-40
Urine output (ml/hr): 5-15
CNS/mental status: Anxious, confusedCLASS IV
Blood loss (mL): >2000
Blood loss (% blood volume): >40%
Pulse rate (bpm): >140
Systolic BP: Decreased
Pulse pressure: Decreased
Respiratory rate: >40
Urine output (ml/hr): Negligible
CNS/mental status: Confused, lethargic -
This question is part of the following fields:
- Trauma
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Question 26
Incorrect
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You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. As part of your treatment, a dose of adrenaline is given.
Which of the following is NOT a beta-adrenergic effect of adrenaline?Your Answer:
Correct Answer: Systemic vasoconstriction
Explanation:The effects of adrenaline on alpha-adrenergic receptors result in the narrowing of blood vessels throughout the body, leading to increased pressure in the coronary and cerebral arteries. On the other hand, the effects of adrenaline on beta-adrenergic receptors enhance the strength of the heart’s contractions and increase the heart rate, which can potentially improve blood flow to the coronary and cerebral arteries. However, it is important to note that these positive effects may be counteracted by the simultaneous increase in oxygen consumption by the heart, the occurrence of abnormal heart rhythms, reduced oxygen levels due to abnormal blood flow patterns, impaired small blood vessel function, and worsened heart function following a cardiac arrest.
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This question is part of the following fields:
- Trauma
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Question 27
Incorrect
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A 35-year-old woman comes in with her husband. She is extremely concerned about his frequent headaches and recent changes in his behavior. He complains of experiencing intense pain behind his left eye in the late evenings for the past two weeks. The pain typically lasts for about half an hour, and his wife mentions that he occasionally bangs his head against the wall due to the severity of the pain. Additionally, his left eye becomes watery during these episodes. A thorough neurological examination reveals no abnormalities.
What is the most probable diagnosis in this case?Your Answer:
Correct Answer: Cluster headache
Explanation:Cluster headaches are a type of headache that is commonly seen in young men in their 20s. The male to female ratio for this condition is 6:1. Smoking is also known to increase the risk of developing cluster headaches. These headaches occur in clusters, usually lasting for a few weeks every year or two. The pain experienced is severe and typically affects one side of the head, often around or behind the eye. It tends to occur at the same time each day and can cause the patient to become agitated, sometimes resorting to hitting their head against a wall or the floor in an attempt to distract from the pain.
In addition to the intense pain, cluster headaches are also associated with autonomic involvement. This can manifest as various symptoms on the same side as the headache, including conjunctival injection (redness of the eye), rhinorrhea (runny nose), lacrimation (tearing of the eye), miosis (constriction of the pupil), and ptosis (drooping of the eyelid).
On the other hand, migraine with typical aura presents with temporary visual disturbances, such as hemianopia (loss of vision in half of the visual field) or scintillating scotoma (a visual aura that appears as a shimmering or flashing area of distorted vision). Migraine without aura, on the other hand, needs to meet specific criteria set by the International Headache Society. These criteria include having at least five headache attacks lasting between 4 to 72 hours, with the headache having at least two of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and aggravation by routine physical activity.
During a migraine headache, the patient may also experience symptoms such as nausea and/or vomiting, as well as sensitivity to light (photophobia) and sound (phonophobia). It is important to note that these symptoms should not be attributed to another underlying disorder.
If a patient over the age of 50 presents with a new-onset headache, it raises the possibility of giant cell arteritis (temporal arteritis). Other symptoms and signs that may be associated with this condition include jaw claudication (pain in the jaw when chewing), systemic upset, scalp tenderness, and an elevated erythrocyte sedimentation rate (ESR).
Medication overuse headache is a condition that is suspected when a patient is using multiple medications, often at low doses, without experiencing any relief from their headaches.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A patient has been diagnosed with septic arthritis in their left knee. The joint aspirate reveals the presence of Escherichia coli.
Which of the following patient populations is at the highest risk for developing septic arthritis caused by Escherichia coli?Your Answer:
Correct Answer: Intravenous drug users
Explanation:Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.
According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 29
Incorrect
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A 68 year old man has been kept on the observation ward overnight due to a head injury and is scheduled for discharge. While eating a sandwich, he starts coughing violently. His face is turning cyanosed and he is having difficulty breathing. The cough seems ineffective at clearing his throat. He remains conscious, coughing, and exhibits noticeable stridor. What is the most suitable immediate course of action?
Your Answer:
Correct Answer: Give 5 back blows or 5 abdominal thrusts
Explanation:When an adult patient is choking and unable to clear the obstruction by coughing, the next step is to deliver either 5 back blows or abdominal thrusts. The appropriate action depends on the severity of the airway obstruction. If the choking is mild and not causing significant difficulty in breathing, it is recommended to encourage the patient to cough and closely monitor for any worsening symptoms. However, if the choking is severe and causing a complete blockage of the airway, it is necessary to administer either back blows or abdominal thrusts to dislodge the obstruction. In the event that the patient loses consciousness, immediate CPR should be initiated.
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.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 30
Incorrect
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You assess a patient with a previous diagnosis of bipolar disorder. His family members are worried about his conduct.
What is ONE characteristic symptom of mania?Your Answer:
Correct Answer: Thought disorder
Explanation:The flight of ideas observed in mania is considered a type of thought disorder. The primary clinical characteristics of mania include changes in mood, behavior, speech, and thought.
In terms of mood, individuals experiencing mania often exhibit an elated mood and a sense of euphoria. They may also display irritability and hostility instead of their usual amiability. Additionally, there is an increase in enthusiasm.
Regarding behavior, individuals in a manic state tend to be overactive and have heightened energy levels. They may lose their normal social inhibitions and engage in more risk-taking behaviors. This can also manifest as increased sexual promiscuity and libido, as well as an increased appetite.
In terms of speech, individuals with mania often speak in a pressured and rapid manner. Their conversations may be cheerful, and they may engage in rhyming or punning.
Lastly, in terms of thought, the flight of ideas is a prominent feature of mania and is classified as a thought disorder. Individuals may experience grandiose delusions and have an inflated sense of self-esteem. They may also struggle with poor attention and concentration.
Overall, mania is characterized by a range of symptoms that affect mood, behavior, speech, and thought.
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This question is part of the following fields:
- Mental Health
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