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  • Question 1 - A 72-year-old woman presents with worsening abdominal distension and discomfort. During the examination,...

    Correct

    • A 72-year-old woman presents with worsening abdominal distension and discomfort. During the examination, she exhibits significant dependent edema and an elevated JVP. Cardiac auscultation reveals a pansystolic murmur. The abdomen is distended and tender, with the presence of shifting dullness.

      What is the SINGLE most probable diagnosis?

      Your Answer: Tricuspid regurgitation

      Explanation:

      Tricuspid regurgitation is commonly caused by right ventricular dilatation, often as a result of heart failure. Other factors that can contribute to this condition include right ventricular infarction and cor pulmonale. The clinical signs of right-sided heart failure are frequently observed, such as an elevated jugular venous pressure, peripheral edema, hepatomegaly, and ascites.

      The murmur associated with tricuspid regurgitation is a pansystolic murmur that is most audible at the tricuspid area during inspiration. A thrill may also be felt at the left sternal edge. Reverse splitting of the second heart sound can occur due to the early closure of the pulmonary valve. Additionally, a third heart sound may be present due to rapid filling of the right ventricle.

    • This question is part of the following fields:

      • Cardiology
      30.2
      Seconds
  • Question 2 - You are managing a 35 year old patient with severe burns. You determine...

    Incorrect

    • You are managing a 35 year old patient with severe burns. You determine that the patient needs urgent fluid replacement. The patient weighs 75 kg and has burns covering 15% of their total body surface area. How much fluid should be administered to the patient over a 24-hour period?

      Your Answer: 4000 ml

      Correct Answer: 6400 ml

      Explanation:

      To calculate the total fluid requirement over 24 hours, you need to multiply the TBSA (Total Body Surface Area) by the weight in kilograms. In this particular case, the calculation would be 4 multiplied by 20 multiplied by 80, resulting in a total of 6400 milliliters.

      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
      90.9
      Seconds
  • Question 3 - A 42 year old female presents to the emergency department complaining of chest...

    Correct

    • A 42 year old female presents to the emergency department complaining of chest pain. The patient appears highly anxious and mentions that she recently had a fasting blood test to screen for diabetes. She was informed that her result was abnormal and needs to follow up with her GP. Concerned about the potential cardiovascular complications associated with diabetes, she expresses worry about her heart. Upon reviewing the pathology system, you come across a recent fasting glucose result. What is the diagnostic threshold for diabetes?

      Your Answer: fasting plasma glucose level ≥ 7.0 mmol/l

      Explanation:

      A fasting plasma glucose level of 7.0 mmol/l or higher is indicative of diabetes mellitus. However, it is important to note that hyperglycemia can also occur in individuals with acute infection, trauma, circulatory issues, or other forms of stress, and may only be temporary. Therefore, it is not recommended to diagnose diabetes based on a single test result, and the test should be repeated for confirmation.

      Further Reading:

      Diabetes Mellitus:
      – Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
      – Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
      – Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
      – Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.

      Hypoglycemia:
      – Definition: lower than normal blood glucose concentration.
      – Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
      – Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
      – Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
      – Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.

      Treatment of neonatal hypoglycemia:
      – Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
      – Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
      – Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
      – If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.

      Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.

    • This question is part of the following fields:

      • Endocrinology
      18.8
      Seconds
  • Question 4 - A 68 year old male is brought to the emergency department after falling...

    Correct

    • A 68 year old male is brought to the emergency department after falling while getting out of bed this morning. The patient reports feeling dizzy and experiencing tunnel vision upon standing up, followed by a brief loss of consciousness. The patient mentions having had several similar episodes over the past few months, usually when getting out of bed or occasionally getting up from the couch. It is noted that the patient is taking amlodipine and fluoxetine. What would be the most suitable initial test to perform?

      Your Answer: Lying and standing blood pressures

      Explanation:

      Orthostatic hypotension is diagnosed using lying and standing blood pressure measurements. This condition is often seen in older individuals who are taking multiple medications for hypertension and depression. The patient exhibits symptoms such as light-headedness, dizziness, weakness, and tunnel vision when standing up. These symptoms do not occur when lying down and worsen upon standing, but can be relieved by sitting or lying down. They are typically more pronounced in the morning, in hot environments, after meals, after standing still, and after exercise. No other signs suggest an alternative diagnosis.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      18.4
      Seconds
  • Question 5 - A 35 year old male is brought to the emergency department with severe...

    Correct

    • A 35 year old male is brought to the emergency department with severe head and chest injuries. As his GCS continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). What is the appropriate dosage of sodium thiopentone for an adult undergoing RSI?

      Your Answer: 3-5 mg/kg

      Explanation:

      To perform rapid sequence induction in adults, it is recommended to administer a dose of sodium thiopentone ranging from 3 to 5 mg per kilogram of body weight.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      11.7
      Seconds
  • Question 6 - A 42-year-old woman comes in with lower abdominal pain and a small amount...

    Correct

    • A 42-year-old woman comes in with lower abdominal pain and a small amount of rectal bleeding. During the examination, she has a slight fever (38.1°C) and experiences tenderness in the left iliac fossa. She has a long history of constipation.

      What is the SINGLE most probable diagnosis?

      Your Answer: Acute diverticulitis

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Surgical Emergencies
      9.5
      Seconds
  • Question 7 - A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and...

    Correct

    • A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
      Which of the following is NOT an acknowledged complication of HELLP syndrome? Select ONE option.

      Your Answer: Polycythaemia

      Explanation:

      HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.

      The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.

      Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.

      Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      26.8
      Seconds
  • Question 8 - A middle-aged patient with a previous cancer diagnosis complains of recently developed back...

    Correct

    • A middle-aged patient with a previous cancer diagnosis complains of recently developed back pain. After conducting a thorough examination, your findings raise significant alarm. You begin to consider the likelihood of a metastatic spinal cord compression (MSCC) diagnosis.
      Among the following types of cancer, which one is most frequently associated with MSCC?

      Your Answer: Prostate cancer

      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 outcome 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 are 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 progressive lumbar back pain, nocturnal pain that disrupts sleep, localized spinal tenderness, radicular pain, or neurological symptoms.

      Thoracic pain can also be an indicator of MSCC, but it can also be caused by an aortic aneurysm. In patients aged 60 or older with persistent back pain, myeloma should be considered. Similarly, in patients aged 60 or older with accompanying weight loss, pancreatic cancer should be considered.

    • This question is part of the following fields:

      • Oncological Emergencies
      4.6
      Seconds
  • Question 9 - You are requested to observe and approve a DOPS form for a final...

    Correct

    • You are requested to observe and approve a DOPS form for a final year medical student who will be conducting nasal cautery on a 68-year-old patient experiencing epistaxis. You inquire with the student regarding potential complications associated with the procedure. What is a commonly acknowledged complication of nasal cautery?

      Your Answer: Septal perforation

      Explanation:

      Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

      The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

      If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

      Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

      In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      4.1
      Seconds
  • Question 10 - A 75-year-old gentleman is brought in by ambulance from his assisted living facility...

    Incorrect

    • A 75-year-old gentleman is brought in by ambulance from his assisted living facility with a decreased level of consciousness. He has a history of type II diabetes mellitus, which is managed with glibenclamide and metformin. He is unconscious but breathing on his own and has a strong pulse. You order a blood glucose test, and his result is 1.0 mmol/l. Intravenous access has been established.
      What is the MOST appropriate initial step in managing this patient?

      Your Answer: Administer 1 mg glucagon IM or SC

      Correct Answer: Administer 150 mL of 10% dextrose

      Explanation:

      This woman is experiencing hypoglycemia, most likely due to her treatment with glibenclamide. Hypoglycemia is defined as having a blood glucose level below 3.0 mmol/l, and it is crucial to promptly treat this condition to prevent further complications such as seizures, stroke, or heart problems.

      If the patient is conscious and able to swallow, a fast-acting carbohydrate like sugar or GlucoGel can be given orally. However, since this woman is unconscious, this option is not feasible.

      In cases where intravenous access is available, like in this situation, an intravenous bolus of dextrose should be administered. The recommended doses are either 75 mL of 20% dextrose or 150 mL of 10% dextrose.

      When a patient is at home and intravenous access is not possible, the preferred initial treatment is glucagon. Under these circumstances, 1 mg of glucagon can be given either intramuscularly (IM) or subcutaneously (SC).

      It is important to note that immediate action is necessary to address hypoglycemia and prevent any potential complications.

    • This question is part of the following fields:

      • Endocrinology
      20.2
      Seconds
  • Question 11 - You are treating a patient who fell from a rooftop and has sustained...

    Correct

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

      Your Answer: Vertebral fracture

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      8.5
      Seconds
  • Question 12 - You assess a 58-year-old individual who has arrived at the emergency department complaining...

    Correct

    • You assess a 58-year-old individual who has arrived at the emergency department complaining of chest pain resembling a cardiac condition. Upon reviewing the patient's medical history, you discover a previous diagnosis of hyperaldosteronism. In terms of aldosterone production, where is it typically synthesized?

      Your Answer: Zona glomerulosa of the adrenal cortex

      Explanation:

      The secretion of aldosterone occurs in the zona glomerulosa of the adrenal cortex.

      Further Reading:

      Hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal glands. It can be classified into primary and secondary hyperaldosteronism. Primary hyperaldosteronism, also known as Conn’s syndrome, is typically caused by adrenal hyperplasia or adrenal tumors. Secondary hyperaldosteronism, on the other hand, is a result of high renin levels in response to reduced blood flow across the juxtaglomerular apparatus.

      Aldosterone is the main mineralocorticoid steroid hormone produced by the adrenal cortex. It acts on the distal renal tubule and collecting duct of the nephron, promoting the reabsorption of sodium ions and water while secreting potassium ions.

      The causes of hyperaldosteronism vary depending on whether it is primary or secondary. Primary hyperaldosteronism can be caused by adrenal adenoma, adrenal hyperplasia, adrenal carcinoma, or familial hyperaldosteronism. Secondary hyperaldosteronism can be caused by renal artery stenosis, reninoma, renal tubular acidosis, nutcracker syndrome, ectopic tumors, massive ascites, left ventricular failure, or cor pulmonale.

      Clinical features of hyperaldosteronism include hypertension, hypokalemia, metabolic alkalosis, hypernatremia, polyuria, polydipsia, headaches, lethargy, muscle weakness and spasms, and numbness. It is estimated that hyperaldosteronism is present in 5-10% of patients with hypertension, and hypertension in primary hyperaldosteronism is often resistant to drug treatment.

      Diagnosis of hyperaldosteronism involves various investigations, including U&Es to assess electrolyte disturbances, aldosterone-to-renin plasma ratio (ARR) as the gold standard diagnostic test, ECG to detect arrhythmia, CT/MRI scans to locate adenoma, fludrocortisone suppression test or oral salt testing to confirm primary hyperaldosteronism, genetic testing to identify familial hyperaldosteronism, and adrenal venous sampling to determine lateralization prior to surgery.

      Treatment of primary hyperaldosteronism typically involves surgical adrenalectomy for patients with unilateral primary aldosteronism. Diet modification with sodium restriction and potassium supplementation may also be recommended.

    • This question is part of the following fields:

      • Endocrinology
      8.2
      Seconds
  • Question 13 - A 62 year old female presents to the emergency department with a three...

    Correct

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

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

      Your Answer: Full Rockall score

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      34.6
      Seconds
  • Question 14 - A 45-year-old woman is brought in by ambulance. She has ingested a significant...

    Correct

    • A 45-year-old woman is brought in by ambulance. She has ingested a significant amount of aspirin.

      Which acid-base disorder would you anticipate to be present during the advanced stages of an aspirin overdose?

      Your Answer: Raised anion gap metabolic acidosis

      Explanation:

      An overdose of aspirin often leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the stimulation of the respiratory center causes hyperventilation and results in respiratory alkalosis. However, as the overdose progresses, the direct acidic effects of aspirin cause an increase in the anion gap and metabolic acidosis.

      Here is a summary of common causes for different acid-base disorders:

      Respiratory alkalosis can be caused by hyperventilation due to factors such as anxiety, pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, and the early stages of aspirin overdose.

      Respiratory acidosis can occur in individuals with chronic obstructive pulmonary disease (COPD), life-threatening asthma, pulmonary edema, sedative drug overdose (such as opioids or benzodiazepines), neuromuscular diseases, and obesity.

      Metabolic alkalosis can be caused by vomiting, potassium depletion (often due to diuretic usage), Cushing’s syndrome, and Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can result from conditions such as lactic acidosis (caused by factors like hypoxemia, shock, sepsis, or tissue infarction), ketoacidosis (associated with diabetes, starvation, or excessive alcohol consumption), renal failure, and poisoning (including the late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Metabolic acidosis with a normal anion gap can be seen in renal tubular acidosis, diarrhea, ammonium chloride ingestion, and adrenal insufficiency.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.1
      Seconds
  • Question 15 - A 68 year old man presents to the emergency department due to increasing...

    Correct

    • A 68 year old man presents to the emergency department due to increasing confusion and drowsiness over the past few days. The patient's wife tells you the patient has had a cough for the past week and apart from lisinopril takes no other regular medication. On examination you note cool extremities, diffuse non-pitting oedema and reduced tendon reflexes. Observations are shown below:

      Blood pressure 100/64 mmHg
      Pulse 44 bpm
      Respiration rate 10 bpm
      Temperature 34.3ºC

      What is the most likely diagnosis?

      Your Answer: Myxoedema coma

      Explanation:

      Patients who have myxoedema coma usually show symptoms such as lethargy, bradycardia, hypothermia, worsening mental state, seizures, and/or coma. This patient has hypothyroidism and takes thyroxine regularly, which aligns with the signs and symptoms of myxoedema coma. It is worth noting that infections often act as a trigger, and this patient has developed a cough in the last week.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 16 - A 68-year-old man with asthma has been experiencing persistent diarrhea for the past...

    Correct

    • A 68-year-old man with asthma has been experiencing persistent diarrhea for the past week. A stool sample has been sent for analysis, which has cultured Salmonella enteritidis. He currently takes a daily maintenance dose of prednisolone for control of his asthma.
      Which of the following antibacterial agents would be most suitable to prescribe in this situation?

      Your Answer: Ciprofloxacin

      Explanation:

      The current recommendations by NICE and the BNF for non-typhoid salmonella enteritis suggest that ciprofloxacin should be used as the first-line treatment if necessary. Alternatively, cefotaxime can be considered as a suitable alternative. It is important to note that cases of salmonella enteritis often resolve on their own without treatment and are frequently self-limiting. Therefore, the BNF advises against treatment unless there is a risk of developing invasive infection. This includes individuals who are immunocompromised, have haemoglobinopathy, or are children under 6 months old. However, in the case of an elderly patient who is regularly taking corticosteroids, treatment would be recommended.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      23.9
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  • Question 17 - You review a 72-year-old man who is currently on the Clinical Decision Unit...

    Correct

    • You review a 72-year-old man who is currently on the Clinical Decision Unit (CDU) after undergoing surgery for a hip fracture that occurred as a result of a fall. He informs you that he experienced the onset of menopause in his early 50s. His primary care physician recently arranged for a DEXA scan, and you have obtained the results from the CDU computer. The scan reveals a T-score of -3.0 standard deviations. Upon reviewing his medical history and family history, you discover that his father suffered a hip fracture in his early 60s, and the patient himself has a body mass index of 21 kg/m2.

      Which SINGLE statement regarding this case is true?

      Your Answer: She has osteoporosis and ideally should be started on a combination of treatment such as alendronate and calcichew D3 forte

      Explanation:

      Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      10.4
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  • Question 18 - While handling a difficult case, you come across a situation where you believe...

    Correct

    • While handling a difficult case, you come across a situation where you believe it may be necessary to violate patient confidentiality. You consult with your supervisor.
      Which ONE of the following is an illustration of a scenario where patient confidentiality can be breached?

      Your Answer: Informing the police of a psychiatric patient’s homicidal intent towards his neighbour

      Explanation:

      Instances where confidentiality may be breached include situations where there is a legal obligation, such as informing the Health Protection Agency (HPA) about a notifiable disease. Another example is in legal cases where a judge requests information. Additionally, confidentiality may be breached when there is a risk to the public, such as potential terrorism or serious criminal activity. It may also be breached when there is a risk to others, such as when a patient expresses homicidal intent towards a specific individual. Furthermore, confidentiality may be breached in cases relevant to statutory regulatory bodies, such as informing the Driver and Vehicle Licensing Agency (DVLA) about a patient who continues to drive despite a restriction.

      However, it is important to note that there are examples where confidentiality should not be breached. It is inappropriate to disclose a patient’s diagnosis to third parties without their consent, including the police. The police should only be informed about what occurs within a consultation if there is a serious threat to the public or an individual.

      If there is a consideration to breach patient confidentiality, it is crucial to seek the patient’s consent first. If consent is refused, it is advisable to seek guidance from your local trust and your medical defence union.

      For more information, you can refer to the General Medical Council (GMC) guidance on patient confidentiality.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
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  • Question 19 - A 25 year old female has been brought into the emergency department (ED)...

    Correct

    • A 25 year old female has been brought into the emergency department (ED) in the early hours of the morning after being discovered unresponsive in a parking lot behind a nightclub by the authorities. The paramedics initiated cardiopulmonary resuscitation (CPR) which has been ongoing since the patient's arrival in the ED. The patient's core temperature is recorded at 28ºC. You contemplate the most effective Rewarming strategy to employ. Which method of Rewarming is known for producing a rapid increase in core body temperature?

      Your Answer: Cardiopulmonary bypass

      Explanation:

      Cardiopulmonary bypass (CPB) is the most efficient technique for warming up a patient who is experiencing hypothermia. While other methods may also be suitable and may have already been initiated by the paramedic team, CPB stands out as the most effective approach.

      Further Reading:

      Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.

      ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.

      Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.

      Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.

    • This question is part of the following fields:

      • Environmental Emergencies
      6.6
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  • Question 20 - A 28-year-old woman comes in with a one-week history of occasional dizzy spells...

    Correct

    • A 28-year-old woman comes in with a one-week history of occasional dizzy spells and feeling generally under the weather. She experienced one brief episode where she fainted. She was diagnosed with systemic lupus erythematosus four months ago and has been prescribed high-dose ibuprofen. During the examination, she has swelling in her hands and feet but no other notable findings. Her EKG shows broad QRS complexes and tall peaked T waves.
      Which ONE blood test will confirm the diagnosis?

      Your Answer: Urea and electrolytes

      Explanation:

      This patient’s ECG shows signs consistent with hyperkalemia, including broad QRS complexes, tall-peaked T waves, and bizarre p waves. It is estimated that around 10% of patients with SLE have hyperkalemia, which is believed to be caused by hyporeninemic hypoaldosteronism. Additionally, the patient has been taking a high dose of ibuprofen, which can also contribute to the development of hyperkalemia. NSAIDs are thought to induce hyperkalemia by reducing renin secretion, leading to decreased potassium excretion.

    • This question is part of the following fields:

      • Cardiology
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  • Question 21 - A 25-year-old patient presents with a 48-hour history of right-sided facial weakness accompanied...

    Correct

    • A 25-year-old patient presents with a 48-hour history of right-sided facial weakness accompanied by pain behind the right ear. On examination, there is noticeable asymmetry in the face, with the patient unable to raise the right eyebrow or lift the right side of the mouth. There is no tenderness or swelling in the mastoid area, and the external auditory canal and tympanic membrane appear normal. Evaluation of the remaining cranial nerves shows no abnormalities, and there are no other focal neurological deficits detected. What is the most appropriate initial management for this patient?

      Your Answer: Prescribe prednisolone 50 mg daily for 10 days

      Explanation:

      The main treatment options for Bell’s palsy are oral prednisolone and proper eye care. Referral to a specialist is typically not necessary. It is recommended to start steroid treatment within 72 hours of symptom onset. Currently, NICE does not recommend the use of antiviral medications for Bell’s palsy.

      Further Reading:

      Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.

      Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.

      When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.

      Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.

      Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      304.9
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  • Question 22 - A 60-year-old patient arrives at the Emergency Department with a deep cut on...

    Correct

    • A 60-year-old patient arrives at the Emergency Department with a deep cut on their leg. They have a history of alcoholism and typically consumes 10-12 drinks daily. Despite previous attempts at sobriety, they have consistently relapsed within a few days. It is currently 11 am, and they have already consumed alcohol today.
      What would be the most suitable course of action to pursue?

      Your Answer: Explore the reasons behind their previous relapses and the methods they have used to stop drinking in the past

      Explanation:

      When addressing the management of long-term alcohol abuse and promoting self-care, it is important to start by exploring the reasons behind the patient’s previous relapses. This will help understand her beliefs and understanding of her condition and identify any simple, supportive measures that can aid in her efforts to stop drinking.

      Referral to the Community Drug and Alcohol Team (CDAT) may be necessary at some point. Depending on the severity and duration of her alcohol abuse, she may be suitable for outpatient or community detox. However, if her drinking has been sustained and heavy for many years, she may require admission for additional support. It is important to note that there is often a long wait for available beds, so it would be more prudent to thoroughly explore her history before making this referral.

      While arranging for her liver function to be tested could be part of the general work-up, it is unlikely to be necessary for a leg laceration. It is crucial to avoid suddenly abstaining or prescribing chlordiazepoxide, as these actions can be potentially dangerous. Abrupt detoxification may lead to delirium tremens, which can have catastrophic effects. Chlordiazepoxide may be used under the supervision of experienced professionals, but close monitoring and regular appointments with a GP or specialist are essential.

    • This question is part of the following fields:

      • Mental Health
      58.4
      Seconds
  • Question 23 - A 40-year-old male patient presents with a history of dizziness and fainting episodes....

    Incorrect

    • A 40-year-old male patient presents with a history of dizziness and fainting episodes. He has also been suffering from a mild flu-like illness for the past few days. He had a syncopal episode in the department and was moved into the resuscitation area. His observations are as follows: Temperature 38.4°C, HR 112, BP 78/44, oxygen saturation 98% on high-flow oxygen, GCS 14/15, BM 1.5.
      His initial blood results are shown below:
      Na+: 118 mmol/l
      K+: 6.1 mmol/l
      Urea: 11.6 mmol/l
      Creatinine: 132 mmol/l
      Which of the following investigations is most appropriate to confirm the underlying diagnosis?

      Your Answer: 24-hour urinary cortisol collection

      Correct Answer: Synacthen test

      Explanation:

      This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. It is more commonly seen in women than men and typically occurs between the ages of 30 and 50.

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

      The most common trigger for an Addisonian crisis in patients with Addison’s disease is the intentional or accidental withdrawal of steroid therapy. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.

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

      Biochemical markers of Addison’s disease typically include increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Confirmatory investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and testing for adrenocortical antibodies.

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

    • This question is part of the following fields:

      • Endocrinology
      27.6
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  • Question 24 - A 22-year-old individual comes in with a painful, itchy, red left eye. During...

    Correct

    • A 22-year-old individual comes in with a painful, itchy, red left eye. During the examination, there is noticeable redness in the conjunctiva, and follicles are observed on the inner eyelid when it is turned inside out. They recently had a mild and short-lived upper respiratory tract infection, but there are no other significant medical history.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Viral conjunctivitis

      Explanation:

      Conjunctivitis is the most common reason for red eyes, accounting for about 35% of all eye problems seen in general practice. It occurs when the conjunctiva, the thin layer covering the white part of the eye, becomes inflamed. Conjunctivitis can be caused by an infection or an allergic reaction.

      Infective conjunctivitis is inflammation of the conjunctiva caused by a viral, bacterial, or parasitic infection. The most common type of infective conjunctivitis is viral, with adenoviruses being the main culprits. Bacterial conjunctivitis is also common and is usually caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.

      The symptoms of infective conjunctivitis include sudden redness of the conjunctiva, discomfort described as a gritty or burning sensation, watering of the eyes, and discharge that may temporarily blurry vision. It can be challenging to differentiate between viral and bacterial conjunctivitis based on symptoms alone.

      Here are some key features that can help distinguish between viral and bacterial conjunctivitis:

      Features suggestive of viral conjunctivitis:
      – Mild to moderate redness of the conjunctiva
      – Presence of follicles on the inner surface of the eyelids
      – Swelling of the eyelids
      – Small, pinpoint bleeding under the conjunctiva
      – Pseudomembranes (thin layers of tissue) may form on the inner surface of the eyelids in severe cases, often caused by adenovirus
      – Less discharge (usually watery) compared to bacterial conjunctivitis
      – Mild to moderate itching
      – Symptoms of upper respiratory tract infection and swollen lymph nodes in front of the ears

      Features suggestive of bacterial conjunctivitis:
      – Purulent or mucopurulent discharge with crusting of the eyelids, which may cause them to stick together upon waking
      – Mild or no itching
      – Swollen lymph nodes in front of the ears, which are often present in severe bacterial conjunctivitis
      – If the discharge is copious and mucopurulent, infection with Neisseria gonorrhoeae should be considered.

      By considering these distinguishing features, healthcare professionals can better diagnose and manage cases of conjunctivitis.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 25 - A child arrives at the Emergency Department with a petechial rash, headache, neck...

    Correct

    • A child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis.
      What is the most suitable initial approach to management?

      Your Answer: Give ceftriaxone 2 g IV

      Explanation:

      Due to the potentially life-threatening nature of the disease, it is crucial to initiate treatment without waiting for laboratory confirmation. Immediate administration of antibiotics is necessary.

      In a hospital setting, the preferred agents for treatment are IV ceftriaxone (2 g for adults; 80 mg/kg for children) or IV cefotaxime (2 g for adults; 80 mg/kg for children). In the prehospital setting, IM benzylpenicillin can be given as an alternative. If there is a history of anaphylaxis to cephalosporins, chloramphenicol is a suitable alternative.

      It is important to prioritize prompt treatment due to the severity of the disease. The recommended antibiotics should be administered as soon as possible to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Neurology
      6.6
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  • Question 26 - A 4 year old girl is brought into the emergency department with a...

    Incorrect

    • A 4 year old girl is brought into the emergency department with a 1 day history of feeling unwell and being tired. She is diagnosed with diabetic ketoacidosis based on her urine dipstick and venous blood sample (results shown below):

      pH 7.15
      bicarbonate 11 mmol/l
      glucose 28 mmol/ll

      The parents inform you that the patient weighs around 20 kg. You determine that the patient is not in shock but needs a fluid bolus due to dehydration. You prescribe a 200 ml bolus to be given over 30 minutes. What is the correct rate for the patient's ongoing intravenous fluid requirements after the bolus?

      Your Answer: 118 ml/hr

      Correct Answer: 79 ml/hr

      Explanation:

      To calculate the overall rate of fluid administration for a patient, we need to consider both the deficit and maintenance requirements. The deficit is determined by the weight of the patient, with a 1kg deficit equaling 1000ml. However, we also need to subtract the 200 ml bolus from the deficit calculation. So, the deficit is 1000 ml – 200 ml = 800 ml.

      The deficit calculation is for the next 48 hours, while maintenance is calculated per day. For maintenance, we use the Holliday-Segar formula based on the patient’s weight. For this patient, the formula is as follows:

      – 100 ml/kg/day for the first 10 kg of body weight = 10 x 100 = 1000 ml
      – 50 ml/kg/day for the next 10 to 20 kg = 50 x 10 = 500 ml
      – 20 ml/kg/day for each additional kilogram above 20 kg = 0 (as the patient only weighs 20kg)

      So, the total maintenance requirement is 1500 ml per day (over 24 hours), which equals 62 ml/hour.

      To determine the overall rate, we add the maintenance requirement (62 ml/hr) to the deficit requirement (17 ml/hr). Therefore, the overall rate of fluid administration for this patient is 79 ml/hr.

      Further Reading:

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.

      The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.

      DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.

      The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.

      Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.

      Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.

    • This question is part of the following fields:

      • Paediatric Emergencies
      333.1
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  • Question 27 - A 40-year-old man is brought to the Emergency Department by his wife after...

    Incorrect

    • A 40-year-old man is brought to the Emergency Department by his wife after taking an excessive amount of one of his prescribed medications. Upon further inquiry, you uncover that he has overdosed on quetiapine. You consult with your supervisor about the case, and she clarifies that the symptoms of this type of poisoning are caused by the blocking of central and peripheral acetylcholine receptors.
      What is one of the clinical effects that arises from the blockade of central acetylcholine receptors?

      Your Answer: Urinary retention

      Correct Answer: Tremor

      Explanation:

      Anticholinergic drugs work by blocking the effects of acetylcholine, a neurotransmitter, in both the central and peripheral nervous systems. These drugs are commonly used in clinical practice and include antihistamines, typical and atypical antipsychotics, anticonvulsants, antidepressants, antispasmodics, antiemetics, antiparkinsonian agents, antimuscarinics, and certain plants. When someone ingests an anticholinergic drug, they may experience a toxidrome, which is characterized by an agitated delirium and various signs of acetylcholine receptor blockade in the central and peripheral systems.

      The central effects of anticholinergic drugs result in an agitated delirium, which is marked by fluctuating mental status, confusion, restlessness, visual hallucinations, picking at objects in the air, mumbling, slurred speech, disruptive behavior, tremor, myoclonus, and in rare cases, coma or seizures. On the other hand, the peripheral effects can vary and may include dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      32.5
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  • Question 28 - A 35-year-old woman is diagnosed with meningococcal sepsis. An arterial blood gas is...

    Correct

    • A 35-year-old woman is diagnosed with meningococcal sepsis. An arterial blood gas is performed, and lactic acidosis is detected.
      What type of acid-base disorder would you anticipate in a patient with sepsis-induced lactic acidosis?

      Your Answer: Raised anion gap metabolic acidosis

      Explanation:

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.

      Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).

      Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Infectious Diseases
      3.5
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  • Question 29 - A 35 year old male is brought into the emergency department due to...

    Correct

    • A 35 year old male is brought into the emergency department due to sudden fever and a sore throat with difficulty swallowing for the past 12 hours. Upon examination, the patient is sitting upright, experiencing excessive saliva drooling, and has a muffled voice resembling a 'hot potato' when answering questions. Additionally, the patient produces high-pitched inspiratory sounds during breathing.

      What is the primary investigation that should be prioritized for this patient?

      Your Answer: Fibre-optic laryngoscopy

      Explanation:

      Fibre-optic laryngoscopy is considered the most reliable method for diagnosing epiglottitis. In this case, the patient’s symptoms align with those typically seen in epiglottitis. It is crucial to prioritize the assessment of the airway before conducting any invasive procedures, such as using a tongue depressor to examine the oral cavity or performing needle aspiration of the tonsils.

      Further Reading:

      Epiglottitis is a rare but serious condition characterized by inflammation and swelling of the epiglottis, which can lead to a complete blockage of the airway. It is more commonly seen in children between the ages of 2-6, but can also occur in adults, particularly those in their 40s and 50s. Streptococcus infections are now the most common cause of epiglottitis in the UK, although other bacterial agents, viruses, fungi, and iatrogenic causes can also be responsible.

      The clinical features of epiglottitis include a rapid onset of symptoms, high fever, sore throat, painful swallowing, muffled voice, stridor and difficulty breathing, drooling of saliva, irritability, and a characteristic tripod positioning with the arms forming the front two legs of the tripod. It is important for healthcare professionals to avoid examining the throat or performing any potentially upsetting procedures until the airway has been assessed and secured.

      Diagnosis of epiglottitis is typically made through fibre-optic laryngoscopy, which is considered the gold standard investigation. Lateral neck X-rays may also show a characteristic thumb sign, indicating an enlarged and swollen epiglottis. Throat swabs and blood cultures may be taken once the airway is secured to identify the causative organism.

      Management of epiglottitis involves assessing and securing the airway as the top priority. Intravenous or oral antibiotics are typically prescribed, and supplemental oxygen may be given if intubation or tracheostomy is planned. In severe cases where the airway is significantly compromised, intubation or tracheostomy may be necessary. Steroids may also be used, although the evidence for their benefit is limited.

      Overall, epiglottitis is a potentially life-threatening condition that requires urgent medical attention. Prompt diagnosis, appropriate management, and securing the airway are crucial in ensuring a positive outcome for patients with this condition.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      12.2
      Seconds
  • Question 30 - An older woman arrives at the Emergency Department in the afternoon, reporting chest...

    Incorrect

    • An older woman arrives at the Emergency Department in the afternoon, reporting chest discomfort. She has visited the hospital four times within the past two weeks with similar symptoms, and each time her examination and all tests came back normal. She lives alone but has family members living nearby. Her cat passed away recently. During today's examination, she appears to be in a slightly low mood. All systems examinations, ECG, and tests conducted today show no abnormalities.
      What is the best course of action for managing this patient? Choose ONE option.

      Your Answer: Discuss her low mood, reassure her and discharge her home

      Correct Answer: Send a discharge summary to the GP outlining your findings and suggest that she may benefit from some social support

      Explanation:

      When it comes to decision making and utilizing the wider medical team, it is crucial to always consider the possibility of new medical issues, even if the symptoms have occurred multiple times before. In the case of chest pain in elderly individuals, it is important to conduct further investigations, even if the presentation is similar to previous instances.

      In addition, this patient appears to be displaying signs of depression. The loss of a pet can intensify feelings of loneliness. To address this, it would be wise to send a discharge summary to the patient’s general practitioner, outlining the findings and suggesting the potential benefits of providing social support for the patient.

      By rephrasing and organizing the information with paragraph spacing, the explanation becomes clearer and easier to read.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      64.5
      Seconds
  • Question 31 - A 5 year old girl is brought into the emergency room. Her father...

    Correct

    • A 5 year old girl is brought into the emergency room. Her father entered the room as she was about to eat a cashew. Within a few minutes, her face began to swell. You determine that she is experiencing anaphylaxis. After administering the necessary medication, you decide to administer an IV fluid challenge. How much crystalloid would you administer to a child in this scenario?

      Your Answer: 10 ml/kg

      Explanation:

      According to the 2021 resus council guidelines, when administering an IV fluid challenge to a child with anaphylaxis, the recommended dose is 10 ml/kg. It is important to note that prior to the update, the advised dose was 20 ml/kg. In an exam, if you are provided with the child’s weight, you may be required to calculate the volume requirement.

      Further Reading:

      Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.

      When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.

      The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.

      In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.

      Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.

    • This question is part of the following fields:

      • Paediatric Emergencies
      9.5
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  • Question 32 - A 35-year-old weightlifter who admits to heavy use of anabolic steroids presents with...

    Correct

    • A 35-year-old weightlifter who admits to heavy use of anabolic steroids presents with extremely severe acne. He has numerous disfiguring, ulcerated, nodular lesions covering his face, back, and chest. Many of the lesions have bleeding crusts, and he has significant scarring. Some of the lesions have also connected and formed sinuses. He is also experiencing general malaise, joint pain, and a feverish feeling. You take his temperature and it is currently 39°C.
      What is the MOST appropriate course of action for managing this patient?

      Your Answer: Refer for hospital admission

      Explanation:

      Acne conglobata is an extremely severe form of acne where acne nodules come together and create sinuses. Acne fulminans, on the other hand, is a rare and severe complication of acne conglobata that is accompanied by systemic symptoms. It is linked to elevated levels of androgenic hormones, specific autoimmune conditions, and a genetic predisposition.

      The typical clinical characteristics of acne fulminans are as follows:

      – Sudden and abrupt onset
      – Inflammatory and ulcerated nodular acne primarily found on the chest and back
      – Often painful lesions
      – Ulcers on the upper trunk covered with bleeding crusts
      – Severe acne scarring
      – Fluctuating fever
      – Painful joints and arthropathy
      – General feeling of illness (malaise)
      – Loss of appetite and weight loss
      – Enlarged liver and spleen (hepatosplenomegaly)

      It is crucial to refer patients immediately for a specialist evaluation and hospital admission. Treatment options for acne fulminans include systemic corticosteroids, dapsone, ciclosporin, and high-dose intravenous antibiotics.

    • This question is part of the following fields:

      • Dermatology
      25.3
      Seconds
  • Question 33 - A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing....

    Correct

    • A 35-year-old man comes in with a cough, chest discomfort, and difficulty breathing. After conducting a clinical evaluation, you determine that he has community-acquired pneumonia. He has no significant medical history and no reported drug allergies.
      What is the most suitable antibiotic to prescribe in this situation?

      Your Answer: Amoxicillin

      Explanation:

      This patient is displaying symptoms and signs that are consistent with community-acquired pneumonia (CAP). The most common cause of CAP in an adult patient who is otherwise in good health is Streptococcus pneumoniae.

      When it comes to treating community-acquired pneumonia, the first-line antibiotic of choice is amoxicillin. According to the NICE guidelines, patients who are allergic to penicillin should be prescribed a macrolide (such as clarithromycin) or a tetracycline (such as doxycycline).

      For more information, you can refer to the NICE guidelines on the diagnosis and management of pneumonia in adults.

    • This question is part of the following fields:

      • Respiratory
      12.6
      Seconds
  • Question 34 - A 45-year-old woman presents with a severe, widespread, bright red rash covering her...

    Incorrect

    • A 45-year-old woman presents with a severe, widespread, bright red rash covering her entire torso, face, arms and upper legs. The skin is scaling and peeling in places and feels hot to touch. She is referred to the on-call dermatologist and a diagnosis of exfoliative erythroderma is made.
      What is the SINGLE most likely underlying cause?

      Your Answer: Psoriasis

      Correct Answer: Atopic dermatitis

      Explanation:

      Erythroderma is a condition characterized by widespread redness affecting more than 90% of the body surface. It is also known as exfoliative erythroderma due to the presence of skin exfoliation. Another term used to describe this condition is the red man syndrome.

      The clinical features of exfoliative erythroderma include the rapid spread of redness to cover more than 90% of the body surface. Scaling of the skin occurs between days 2 and 6, leading to thickening of the skin. Despite the skin feeling hot, patients often experience a sensation of coldness. Keratoderma, which is the thickening of the skin on the palms and soles, may develop. Over time, erythema and scaling of the scalp can result in hair loss. The nails may become thickened, ridged, and even lost. Lymphadenopathy, or enlarged lymph nodes, is a common finding. In some cases, the patient’s overall health may be compromised.

      Exfoliative erythroderma can be caused by various factors, including eczema (with atopic dermatitis being the most common underlying cause), psoriasis, lymphoma and leukemia (with cutaneous T-cell lymphoma and Hodgkin lymphoma being the most common malignant causes), certain drugs (more than 60 drugs have been implicated, with sulphonamides, isoniazid, penicillin, antimalarials, phenytoin, captopril, and cimetidine being the most commonly associated), idiopathic (unknown cause), and rare conditions such as pityriasis rubra pilaris and pemphigus foliaceus. Withdrawal of corticosteroids, underlying infections, hypocalcemia, and the use of strong coal tar preparations can also precipitate exfoliative erythroderma.

      Potential complications of exfoliative erythroderma include dehydration, hypothermia, cardiac failure, overwhelming secondary infection, protein loss and edema, anemia (due to loss of iron, B12, and folate), and lymphadenopathy.

      Management of exfoliative erythroderma should involve referring the patient to the medical on-call team and dermatology for admission. It is important to keep the patient warm and start intravenous fluids, such as warmed 0.9% saline. Applying generous amounts of emollients and wet dressings can help alleviate

    • This question is part of the following fields:

      • Dermatology
      14.6
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  • Question 35 - You are requested to assess a 52-year-old individual who has experienced cyanosis and...

    Correct

    • You are requested to assess a 52-year-old individual who has experienced cyanosis and a severe headache after receiving a local anesthetic injection for a regional block. The junior doctor is currently collecting a venous blood sample for analysis. What would be the most suitable course of treatment in this case?

      Your Answer: IV methylene blue 1-2 mg/kg over 5 mins

      Explanation:

      If a patient is critically ill and shows symptoms highly indicative of methemoglobinemia, treatment may be started before the blood results are available.

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      23.8
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  • Question 36 - A 45 year old presents to the emergency department due to increasing fatigue...

    Correct

    • A 45 year old presents to the emergency department due to increasing fatigue and occasional confusion over the past few days. The patient has type 2 diabetes mellitus. A capillary blood glucose is taken at triage and reads 'hi'. Bloods are collected and sent for analysis. The results are as follows:

      Na+ 146 mmol/l
      K+ 5.7 mmol/l
      Urea 21 mmol/l
      Creatinine 138 µmol/l
      Glucose 38 mmol/l
      pH 7.35
      Bicarbonate 19 mmol/l

      What is the calculated plasma osmolality for this patient?

      Your Answer: 351 mOsm/kg

      Explanation:

      The plasma osmolality for this patient can be calculated by multiplying the sodium concentration by 2, adding the glucose concentration, and then adding the urea concentration. In this case, the calculation would be (2 x 146) + 38 + 21.

      Further Reading:

      Hyperosmolar hyperglycaemic state (HHS) is a syndrome that occurs in people with type 2 diabetes and is characterized by extremely high blood glucose levels, dehydration, and hyperosmolarity without significant ketosis. It can develop over days or weeks and has a mortality rate of 5-20%, which is higher than that of diabetic ketoacidosis (DKA). HHS is often precipitated by factors such as infection, inadequate diabetic treatment, physiological stress, or certain medications.

      Clinical features of HHS include polyuria, polydipsia, nausea, signs of dehydration (hypotension, tachycardia, poor skin turgor), lethargy, confusion, and weakness. Initial investigations for HHS include measuring capillary blood glucose, venous blood gas, urinalysis, and an ECG to assess for any potential complications such as myocardial infarction. Osmolality should also be calculated to monitor the severity of the condition.

      The management of HHS aims to correct dehydration, hyperglycaemia, hyperosmolarity, and electrolyte disturbances, as well as identify and treat any underlying causes. Intravenous 0.9% sodium chloride solution is the principal fluid used to restore circulating volume and reverse dehydration. If the osmolality does not decline despite adequate fluid balance, a switch to 0.45% sodium chloride solution may be considered. Care must be taken in correcting plasma sodium and osmolality to avoid complications such as cerebral edema and osmotic demyelination syndrome.

      The rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours, and the fall in blood glucose should be no more than 5 mmol/L per hour. Low-dose intravenous insulin may be initiated if the blood glucose is not falling with fluids alone or if there is significant ketonaemia. Potassium replacement should be guided by the potassium level, and the patient should be encouraged to drink as soon as it is safe to do so.

      Complications of treatment, such as fluid overload, cerebral edema, or central pontine myelinolysis, should be assessed for, and underlying precipitating factors should be identified and treated. Prophylactic anticoagulation is required in most patients, and all patients should be assumed to be at high risk of foot ulceration, necessitating appropriate foot protection and daily foot checks.

    • This question is part of the following fields:

      • Endocrinology
      30.6
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  • Question 37 - A 3-year-old child is brought to the emergency department by concerned parents. The...

    Correct

    • A 3-year-old child is brought to the emergency department by concerned parents. The parents inform you that the patient had a slight fever, a runny nose, and a decreased appetite for 2 days before developing a barking cough, which seems to have worsened overnight. Upon examination, the child presents with a seal-like barking cough accompanied by stridor and mild sternal recession at rest. The child appears alert and not agitated. Oxygen saturation levels are 96% on room air, and mild bilateral decreased air entry is noted upon chest auscultation. The child's mother inquires if this could be croup.

      What is the most appropriate evaluation?

      Your Answer: Moderate croup

      Explanation:

      A person’s level of consciousness is determined by their alertness. In this case, the score for alertness is 0, indicating that the person is not alert. Based on the scoring system, a total score of 4 suggests a moderate case of croup. Moderate croup is typically diagnosed when the scores range from 3 to 5.

      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
      96.3
      Seconds
  • Question 38 - A 62 year old male is brought into the emergency department by concerned...

    Correct

    • A 62 year old male is brought into the emergency department by concerned bystanders who witnessed the patient vomit blood outside a local bar. The patient is familiar to the department due to multiple alcohol-related visits in the past and has a previous diagnosis of alcohol-related liver cirrhosis. The patient experiences another episode of large volume bright red hematemesis shortly after arriving in the emergency department and is transferred to resus. The patient's initial vital signs are as follows:

      Blood pressure: 98/70 mmHg
      Pulse: 126 bpm
      Respiration rate: 24 bpm
      Temperature: 36.4ºC

      Which of the following treatments should be administered as a priority?

      Your Answer: Terlipressin

      Explanation:

      When a variceal bleed is suspected, it is important to start treatment with either terlipressin or somatostatin as soon as possible. These medications help control the bleeding and are typically continued for 3-5 days if variceal haemorrhage is confirmed. Additionally, an upper GI endoscopy may be performed to either band the varices or inject a sclerosing agent to stop the bleeding. If the bleeding is difficult to control, a Sengstaken-Blakemore tube may be inserted until further treatment can be administered. Once the bleeding is under control and the patient has been resuscitated, antibiotic prophylaxis should be prescribed. Ceftriaxone or fluoroquinolones are commonly used for this purpose. Proton pump inhibitors are not recommended unless there is a specific need for treating peptic ulcer disease. Beta blockers like carvedilol are used to prevent variceal bleeding but are not effective in treating active bleeding. Vitamin K is typically not used in the acute setting of variceal bleeding.

      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.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      10.4
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  • Question 39 - A 35-year-old construction worker presents with confusion, vomiting, and complaining of a headache....

    Correct

    • A 35-year-old construction worker presents with confusion, vomiting, and complaining of a headache. There is currently a scorching heatwave, and he has been working outdoors in heavy protective gear. His skin is dry and hot, he is hyperventilating, and his core temperature is currently 41.7°C. He is very agitated and shivering severely at present.
      Which of the following is the LEAST suitable treatment option for this patient?

      Your Answer: Dantrolene

      Explanation:

      Heat stroke is a condition characterized by a core temperature higher than 40.6°C, accompanied by changes in mental state and varying levels of organ dysfunction. There are two forms of heat stroke: classic non-exertional heat stroke, which occurs during high environmental temperatures and typically affects elderly patients during heat waves, and exertional heat stroke, which occurs during strenuous physical exercise in hot conditions, such as endurance athletes competing in hot weather.

      The main treatment for heat stroke involves supportive measures. It is important to rapidly reduce the core temperature to around 39.0°C. Patients with severe heat stroke should be managed in a critical care setting. The ABCDE approach should be followed, with a focus on cooling the patient. This includes obtaining a definitive airway if the patient is unresponsive, providing ventilation if necessary, using haemodynamic monitoring to guide fluid therapy, correcting electrolyte imbalances, managing blood glucose levels, removing clothes, eliminating the cause of hyperthermia, and monitoring core and skin temperatures.

      There are various cooling techniques that can be used, although there is limited evidence on which approach is the most effective. Some possible methods include simple measures like cold drinks, fanning, ice water packs, and spraying tepid water. Cold water immersion therapy can be beneficial, but it requires the patient to be stable and cooperative, making it impractical for very sick patients. Advanced cooling techniques, such as cold IV fluids, surface cooling devices, intravascular cooling devices, and extracorporeal circuits, may be used for sicker patients.

      Benzodiazepines, like diazepam, can be helpful in managing agitation and shivering in heat stroke patients. They not only reduce excessive heat production but also help to calm the patient. In severe cases of agitation, paralysis may be necessary. Dantrolene is commonly used, although there is currently limited high-level evidence to support its use. Neuroleptics, such as chlorpromazine, which were once commonly used, should be avoided due to their potential adverse effects, including lowering the seizure threshold, interfering with thermoregulation, causing anticholinergic side effects, hypotension, and hepatotoxicity.

    • This question is part of the following fields:

      • Environmental Emergencies
      3.7
      Seconds
  • Question 40 - A 45-year-old man presents with rigidity and slowness of movement. Following a referral...

    Incorrect

    • A 45-year-old man presents with rigidity and slowness of movement. Following a referral to a specialist, a diagnosis of Parkinson’s disease is made. The patient is in the early stages of the disease at present.

      Which of the following clinical features is most likely to also be present?

      Your Answer: Postural instability

      Correct Answer: Hypokinesia

      Explanation:

      Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:

      – Hypokinesia (reduced movement)
      – Bradykinesia (slow movement)
      – Rest tremor (usually occurring at a rate of 4-6 cycles per second)
      – Rigidity (increased muscle tone and ‘cogwheel rigidity’)

      Other commonly observed clinical features include:

      – Gait disturbance (characterized by a shuffling gait and loss of arm swing)
      – Loss of facial expression
      – Monotonous, slurred speech
      – Micrographia (small, cramped handwriting)
      – Increased salivation and dribbling
      – Difficulty with fine movements

      Initially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:

      – Postural instability
      – Cognitive impairment
      – Orthostatic hypotension

      Although PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.

    • This question is part of the following fields:

      • Neurology
      11.1
      Seconds
  • Question 41 - A 25-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 25-year-old woman is brought in by ambulance following a car accident where she was a passenger in a car hit by a truck at high speed. She is 32 weeks pregnant. Her vital signs are as follows: HR 98, BP 120/80, SaO2 99% on high-flow oxygen, RR 20, temperature 36.8°C. Her cervical spine is triply immobilized. The airway is clear, and her chest examination is unremarkable. She has experienced a small amount of vaginal bleeding and is experiencing abdominal pain. On examination, the uterus is tender and there are frequent uterine contractions.
      What is the SINGLE most likely diagnosis?

      Your Answer: Uterine rupture

      Correct Answer: Abruptio placentae

      Explanation:

      The primary cause of fetal death in trauma during pregnancy is maternal shock and maternal death. The second most common cause of fetal death is placental abruption. Abruptio placentae can be identified by the following signs: vaginal bleeding (present in 70% of cases), uterine tenderness, frequent uterine contractions, uterine tetany, and uterine irritability. While uterine ultrasonography can be helpful in diagnosing abruptio placentae, it is not definitive. A CT scan may also show signs of abruptio placenta. It is important to note that abruption can occur even after minor injuries later in pregnancy.

      Uterine rupture is a much rarer occurrence but is a catastrophic event that leads to rapid maternal and fetal death without immediate surgical intervention. Signs that suggest uterine rupture include vaginal hemorrhage, abdominal tenderness, abdominal guarding and rigidity, rebound tenderness, profound shock, abnormal fetal lie (such as oblique or transverse lie), easy palpation of fetal parts due to their location outside the uterus, and difficulty in palpating the uterine fundus when there is a rupture.

      It is crucial to be aware of these signs and symptoms in order to promptly identify and address any potential complications during pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      48.1
      Seconds
  • Question 42 - A 28-year-old woman presents after experiencing a syncopal episode earlier in the day....

    Correct

    • A 28-year-old woman presents after experiencing a syncopal episode earlier in the day. She fainted while jogging on the treadmill at her local gym. She regained consciousness quickly and currently feels completely fine. Upon examination, she has a slim physique, normal heart sounds without any additional sounds or murmurs, clear lungs, and a soft abdomen. She is originally from Thailand and mentions that her mother passed away suddenly in her 30s.

      Her ECG reveals:
      - Right bundle branch block pattern
      - Downward-sloping 'coved' ST elevation in leads V1-V3
      - Widespread upward-sloping ST depression in other leads

      What is the SINGLE most likely diagnosis?

      Your Answer: Brugada syndrome

      Explanation:

      Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.

      One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.

    • This question is part of the following fields:

      • Cardiology
      17.1
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  • Question 43 - A 52-year-old individual is brought into the emergency department after being discovered unresponsive...

    Correct

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

      Your Answer: Acetate

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      74.6
      Seconds
  • Question 44 - You evaluate the ECG of a 62-year-old male who has come in with...

    Correct

    • You evaluate the ECG of a 62-year-old male who has come in with episodes of Presyncope. What is the most suitable threshold to utilize in differentiating between a normal and prolonged QTc?

      Your Answer: 450 ms

      Explanation:

      An abnormal QTc, which is the measurement of the time it takes for the heart to recharge between beats, is generally considered to be greater than 450 ms in males. However, some sources may use a cutoff of greater than 440 ms as abnormal in males. To further categorize the QTc, a measurement of 430ms or less is considered normal, 431-450 ms is borderline, and 450 ms or more is considered abnormal in males. Females typically have a longer QTc, so the categories for them are often quoted as less than 450 ms being normal, 451-470 ms being borderline, and greater than 470ms being abnormal.

      Further Reading:

      Long QT syndrome (LQTS) is a condition characterized by a prolonged QT interval on an electrocardiogram (ECG), which represents abnormal repolarization of the heart. LQTS can be either acquired or congenital. Congenital LQTS is typically caused by gene abnormalities that affect ion channels responsible for potassium or sodium flow in the heart. There are 15 identified genes associated with congenital LQTS, with three genes accounting for the majority of cases. Acquired LQTS can be caused by various factors such as certain medications, electrolyte imbalances, hypothermia, hypothyroidism, and bradycardia from other causes.

      The normal QTc values, which represent the corrected QT interval for heart rate, are typically less than 450 ms for men and less than 460ms for women. Prolonged QTc intervals are considered to be greater than these values. It is important to be aware of drugs that can cause QT prolongation, as this can lead to potentially fatal arrhythmias. Some commonly used drugs that can cause QT prolongation include antimicrobials, antiarrhythmics, antipsychotics, antidepressants, antiemetics, and others.

      Management of long QT syndrome involves addressing any underlying causes and using beta blockers. In some cases, an implantable cardiac defibrillator (ICD) may be recommended for patients who have experienced recurrent arrhythmic syncope, documented torsades de pointes, previous ventricular tachyarrhythmias or torsades de pointes, previous cardiac arrest, or persistent syncope. Permanent pacing may be used in patients with bradycardia or atrioventricular nodal block and prolonged QT. Mexiletine is a treatment option for those with LQT3. Cervicothoracic sympathetic denervation may be considered in patients with recurrent syncope despite beta-blockade or in those who are not ideal candidates for an ICD. The specific treatment options for LQTS depend on the type and severity of the condition.

    • This question is part of the following fields:

      • Cardiology
      3.4
      Seconds
  • Question 45 - A 45-year-old woman undergoes a blood transfusion for anemia caused by excessive vaginal...

    Correct

    • A 45-year-old woman undergoes a blood transfusion for anemia caused by excessive vaginal bleeding. While receiving the second unit of blood, she experiences sensations of both heat and coldness. Her temperature is recorded at 38.1ºC, whereas her pre-transfusion temperature was 37ºC. Apart from this, she feels fine and does not exhibit any other symptoms.
      What is the probable cause of this transfusion reaction?

      Your Answer: Cytokines from leukocytes

      Explanation:

      Blood transfusion is a crucial medical treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur. One common adverse reaction is febrile transfusion reactions, which present as an unexpected rise in temperature during or after transfusion. This can be caused by cytokine accumulation or recipient antibodies reacting to donor antigens. Treatment for febrile transfusion reactions is supportive, and other potential causes should be ruled out.

      Another serious complication is acute haemolytic reaction, which is often caused by ABO incompatibility due to administration errors. This reaction requires the transfusion to be stopped and IV fluids to be administered. Delayed haemolytic reactions can occur several days after a transfusion and may require monitoring and treatment for anaemia and renal function. Allergic reactions, TRALI (Transfusion Related Acute Lung Injury), TACO (Transfusion Associated Circulatory Overload), and GVHD (Graft-vs-Host Disease) are other potential complications that require specific management approaches.

      In summary, blood transfusion carries risks and potential complications, but efforts have been made to improve safety procedures. It is important to be aware of these complications and to promptly address any adverse reactions that may occur during or after a transfusion.

    • This question is part of the following fields:

      • Haematology
      96.2
      Seconds
  • Question 46 - A 67 year old male is brought into the emergency department by concerned...

    Correct

    • A 67 year old male is brought into the emergency department by concerned neighbors. They inform you that the patient is frequently intoxicated, but this morning they discovered him wandering in the street and he appeared extremely disoriented and unstable, which is out of character for him. Upon reviewing the patient's medical records, you observe that he has been experiencing abnormal liver function tests for several years and a history of alcohol abuse has been documented. You suspect that the underlying cause of his condition is Wernicke's encephalopathy.

      Your Answer: Vitamin B1 deficiency

      Explanation:

      Wernicke’s encephalopathy is a sudden neurological condition that occurs due to a lack of thiamine (vitamin B1). It is characterized by symptoms such as confusion, difficulty with coordination, low body temperature, low blood pressure, involuntary eye movements, and vomiting.

      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
      17.9
      Seconds
  • Question 47 - A 12-year-old boy presents with double vision. He is holding his head tilted...

    Incorrect

    • A 12-year-old boy presents with double vision. He is holding his head tilted to the left-hand side. On examination of his eye movements, you note that both eyes can look normally to the right, but on looking to the left, his left eye cannot turn outwards past the midline. The right eye is unaffected when looking to the left.
      What is the SINGLE most likely nerve to be involved in this case?

      Your Answer: Left abducens nerve

      Correct Answer: Right abducens nerve

      Explanation:

      This patient is experiencing a condition called right-sided abducens nerve palsy, which means that their sixth cranial nerve is paralyzed. As a result, the lateral rectus muscle, which is responsible for moving the eye outward, is also paralyzed. This means that the patient’s right eye is unable to turn outward. This can lead to a condition called convergent strabismus, where the eyes are not aligned properly, and diplopia, which is double vision. To compensate for the double vision, patients often tilt their head towards the side of the paralyzed muscle.

    • This question is part of the following fields:

      • Ophthalmology
      66.2
      Seconds
  • Question 48 - A 25-year-old woman presents to the emergency department with a complaint of progressive...

    Correct

    • A 25-year-old woman presents to the emergency department with a complaint of progressive lip swelling that began 1 hour ago. Upon reviewing her medical history, it is noted that she has a previous diagnosis of hereditary angioedema (HAE). The following findings have been documented:

      - Blood pressure: 120/80 mmHg
      - Pulse rate: 90 beats per minute
      - Respiratory rate: 16 breaths per minute
      - Temperature: 37.5 degrees Celsius

      What is the primary concern regarding this patient?

      Your Answer: Airway obstruction

      Explanation:

      The primary concern regarding this patient is airway obstruction. The patient’s complaint of progressive lip swelling, along with her previous diagnosis of hereditary angioedema (HAE), suggests that she may be experiencing an allergic reaction. Angioedema can cause swelling in various parts of the body, including the lips, tongue, and throat. If the swelling progresses and affects the airway, it can lead to difficulty breathing and potentially block the airway completely. This can be a life-threatening emergency and requires immediate intervention to ensure the patient’s airway remains open and they can breathe properly.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Respiratory
      9.7
      Seconds
  • Question 49 - A 45-year-old presents to the emergency department with palpitations and episodes of fainting....

    Correct

    • A 45-year-old presents to the emergency department with palpitations and episodes of fainting. It is determined that the patient would benefit from cardioversion. You have a discussion about the treatment options, advantages, and potential risks. What is the definition of material risk?

      Your Answer: Risk associated with an intervention that carries significant risk of harm or adverse outcome

      Explanation:

      Material risk refers to a significant potential for harm that a reasonable person would consider when deciding whether to undergo a medical or surgical treatment. It is an important factor to consider when obtaining consent for the treatment. Montgomery defines material risk as any risk that a reasonable person in the patient’s position would find significant. Relative risk, on the other hand, compares the risk between two different groups of people. Relative risk reduction measures the decrease in the risk of an adverse event in the treatment group compared to an untreated group. Side effect risk quantifies the likelihood of developing a side effect from a treatment, whether minor or major. Lastly, 1/ARR represents the number needed to treat in order to achieve a desired outcome.

      Further Reading:

      Patients have the right to determine what happens to their own bodies, and for consent to be valid, certain criteria must be met. These criteria include the person being informed about the intervention, having the capacity to consent, and giving consent voluntarily and freely without any pressure or undue influence.

      In order for a person to be deemed to have capacity to make a decision on a medical intervention, they must be able to understand the decision and the information provided, retain that information, weigh up the pros and cons, and communicate their decision.

      Valid consent can only be provided by adults, either by the patient themselves, a person authorized under a Lasting Power of Attorney, or someone with the authority to make treatment decisions, such as a court-appointed deputy or a guardian with welfare powers.

      In the UK, patients aged 16 and over are assumed to have the capacity to consent. If a patient is under 18 and appears to lack capacity, parental consent may be accepted. However, a young person of any age may consent to treatment if they are considered competent to make the decision, known as Gillick competence. Parental consent may also be given by those with parental responsibility.

      The Fraser guidelines apply to the prescription of contraception to under 16’s without parental involvement. These guidelines allow doctors to provide contraceptive advice and treatment without parental consent if certain criteria are met, including the young person understanding the advice, being unable to be persuaded to inform their parents, and their best interests requiring them to receive contraceptive advice or treatment.

      Competent adults have the right to refuse consent, even if it is deemed unwise or likely to result in harm. However, there are exceptions to this, such as compulsory treatment authorized by the mental health act or if the patient is under 18 and refusing treatment would put their health at serious risk.

      In emergency situations where a patient is unable to give consent, treatment may be provided without consent if it is immediately necessary to save their life or prevent a serious deterioration of their condition. Any treatment decision made without consent must be in the patient’s best interests, and if a decision is time-critical and the patient is unlikely to regain capacity in time, a best interest decision should be made. The treatment provided should be the least restrictive on the patient’s future choices.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      8
      Seconds
  • Question 50 - A 32-year-old patient with a known history of asthma presents with a worsening...

    Incorrect

    • A 32-year-old patient with a known history of asthma presents with a worsening of his asthma symptoms. He typically uses a salbutamol inhaler, beclomethasone inhaler, and theophylline. However, his theophylline levels are currently below the therapeutic range. It seems that a newly prescribed medication may be causing a decrease in his theophylline levels.
      Which of the following drugs is most likely causing this interaction?

      Your Answer: Erythromycin

      Correct Answer: Phenytoin

      Explanation:

      Theophylline, a medication commonly used to treat respiratory conditions, can be affected by certain drugs, either increasing or decreasing its plasma concentration and half-life. Drugs that can increase the plasma concentration of theophylline include calcium channel blockers like verapamil, cimetidine, fluconazole, macrolides such as erythromycin, methotrexate, and quinolones like ciprofloxacin. On the other hand, drugs like carbamazepine, phenobarbitol, phenytoin (and fosphenytoin), rifampicin, and St. John’s wort can decrease the plasma concentration of theophylline. It is important to be aware of these interactions when prescribing or taking theophylline to ensure its effectiveness and avoid potential side effects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.7
      Seconds
  • Question 51 - A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated...

    Incorrect

    • A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
      Which of the following conditions is NOT linked to ulcerative colitis disease?

      Your Answer: Pyoderma gangrenosum

      Correct Answer: Smoking

      Explanation:

      Ulcerative colitis is a condition that is less common among smokers, as around 70-80% of individuals affected by this disease are non-smokers. There are several recognized associations of ulcerative colitis, including aphthous ulcers, uveitis and episcleritis, seronegative spondyloarthropathies, sacroiliitis, erythema nodosum, pyoderma gangrenosum, finger clubbing, autoimmune hemolytic anemia, primary biliary cirrhosis, primary sclerosing cholangitis, and chronic active hepatitis. These conditions often coexist with ulcerative colitis and can provide additional insight into the disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      29.7
      Seconds
  • Question 52 - A 72 year old female who is a known heavy smoker visits the...

    Correct

    • A 72 year old female who is a known heavy smoker visits the emergency department. She has experienced a worsening productive cough for the past week and feels breathless. An arterial blood gas is obtained and the results are as follows:

      Parameter Result
      pH 7.31
      pO2 9.1 kPa
      pCO2 6.5 kPa
      Bicarbonate 32 mmol/l
      Base Excess +4

      Which of the following options most accurately characterizes this blood gas result?

      Your Answer: Respiratory acidosis with metabolic compensation

      Explanation:

      The typical pH range for blood is 7.35-7.45. The blood gases indicate a condition called respiratory acidosis, which is partially corrected by metabolic processes. This condition may also be referred to as type 2 respiratory failure, characterized by low oxygen levels and high carbon dioxide levels in the blood.

      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
      100.7
      Seconds
  • Question 53 - A 65 year old female patient has been brought into the department after...

    Correct

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

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

      Explanation:

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

      Further Reading:

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      22.4
      Seconds
  • Question 54 - A 65-year-old woman with a history of heavy smoking and a confirmed diagnosis...

    Incorrect

    • A 65-year-old woman with a history of heavy smoking and a confirmed diagnosis of peripheral vascular disease comes in with symptoms suggestive of acute limb ischemia. After conducting a series of tests, the medical team suspects an embolus as the likely cause.
      Which of the following investigations would be the LEAST useful in determining the origin of the embolus?

      Your Answer: Aortic ultrasound

      Correct Answer: Thrombophilia screen

      Explanation:

      Acute limb ischaemia refers to a sudden reduction in blood flow to a limb, which puts the limb’s viability at risk. This condition is most commonly caused by either a sudden blockage of a previously partially blocked artery due to a blood clot or by an embolus that travels from a distant site. It is considered a surgical emergency, as without prompt surgical intervention, complete acute ischaemia can lead to extensive tissue death within six hours.

      The leading cause of acute limb ischaemia is the sudden blockage of a narrowed arterial segment due to a blood clot, accounting for 60% of cases. The second most common cause is an embolism, which makes up 30% of cases. Emboli can originate from various sources, such as a blood clot in the left atrium of patients with atrial fibrillation (which accounts for 80% of peripheral emboli), a clot formed on the heart’s wall following a heart attack, or from prosthetic heart valves. It is crucial to differentiate between these two conditions, as their treatment and prognosis differ.

      To properly investigate acute limb ischaemia, several important tests should be arranged. These include a hand-held Doppler ultrasound scan, which can help determine if there is any remaining arterial flow. Blood tests, such as a full blood count, erythrocyte sedimentation rate, blood glucose level, and thrombophilia screen, are also necessary. If there is uncertainty regarding the diagnosis, urgent arteriography should be performed.

      In cases where an embolus is suspected as the cause, additional investigations are needed to identify its source. These may include an electrocardiogram to detect atrial fibrillation, an echocardiogram to assess the heart’s function, an ultrasound of the aorta, and ultrasounds of the popliteal and femoral arteries.

      By rewriting the explanation and using paragraph spacing, the information is presented in a clearer and more organized manner.

    • This question is part of the following fields:

      • Vascular
      33.3
      Seconds
  • Question 55 - You are following up on a 21-year-old patient you saw who was admitted...

    Incorrect

    • You are following up on a 21-year-old patient you saw who was admitted following a paracetamol overdose. Which of the following is a poor prognostic indicator and indication for liver transplant in paracetamol overdose?

      Your Answer: Arterial pH < 7.30 on or after day 2 following overdose

      Correct Answer:

      Explanation:

      A pH level in the arteries that is below 7.30 on or after the second day following a paracetamol overdose is considered a poor indicator of prognosis. Additionally, a prolonged prothrombin time (PT) of over 100 seconds (indicated by an international normalized ratio (INR) of over 6.5), along with a high plasma creatinine level of over 300 μmol/L and grade 3 or 4 hepatic encephalopathy, are also poor prognostic indicators and may indicate the need for a liver transplant. Furthermore, an increase in PT between the third and fourth day after the overdose is also considered a poor prognostic indicator.

      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
      22.6
      Seconds
  • Question 56 - A 45-year-old man presents with a history of feeling generally unwell and having...

    Correct

    • A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently receiving radiation therapy. His observations are as follows: HR 92 bpm, BP 130/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
      According to the current NICE guidelines what is the cut off point for the neutrophil count for a diagnosis of neutropenic sepsis to be made?

      Your Answer: 0.5 x 109 per litre or lower

      Explanation:

      Neutropenic sepsis is a serious complication that can arise when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is commonly seen in individuals undergoing treatments such as cytotoxic chemotherapy or taking immunosuppressive drugs. Other causes of neutropenia include infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, as well as nutritional deficiencies.

      To diagnose neutropenic sepsis, doctors look for specific criteria in patients receiving anticancer treatment. These criteria include having a neutrophil count of 0.5 x 109 per liter or lower, along with either a body temperature higher than 38°C or other signs and symptoms that indicate a clinically significant sepsis.

    • This question is part of the following fields:

      • Oncological Emergencies
      5.3
      Seconds
  • Question 57 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Correct

    • A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a history of long-term smoking.

      What is the SINGLE most probable diagnosis?

      Your Answer: Superior vena cava syndrome

      Explanation:

      This patient has come in with worsening shortness of breath and coughing up blood. They have a long history of smoking, and the likely diagnosis is superior vena cava obstruction caused by a primary bronchial tumor.

      The typical symptoms of superior vena cava obstruction include breathlessness, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

      Given the severity of the symptoms, this man needs to be urgently referred and admitted to the hospital. To provide immediate relief, his head should be elevated and he should be given supplemental oxygen. Corticosteroids and diuretics may also be administered. Further investigation through CT scanning is necessary, and radiotherapy may be recommended as a treatment option.

    • This question is part of the following fields:

      • Respiratory
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  • Question 58 - A 45-year-old man is brought in to the Emergency Department by his wife....

    Correct

    • A 45-year-old man is brought in to the Emergency Department by his wife. He is experiencing multiple episodes of vertigo, each lasting almost all day, before resolving spontaneously. He usually vomits during the attacks and complains of a sensation of fullness in his ears. He also states that his hearing has been worse than usual recently, and he is also experiencing symptoms of tinnitus.

      What is the SINGLE most likely diagnosis?

      Your Answer: Meniere’s disease

      Explanation:

      Meniere’s disease is a condition that affects the inner ear due to changes in fluid volume within the vestibular labyrinth. This leads to the progressive distension of the labyrinth, known as endolymphatic hydrops, which causes damage to the vestibular system and the cochlea. The classic symptoms associated with Meniere’s disease are vertigo, hearing loss, and tinnitus.

      The main clinical features of Meniere’s disease include episodes of vertigo that typically last for 2-3 hours. These episodes are usually shorter than 24 hours in duration. Hearing loss, which is often gradual and affects only one ear, is also a common symptom. Tinnitus, a ringing or buzzing sound in the ears, is frequently associated with Meniere’s disease. Other symptoms may include a sensation of fullness or pressure in the ears, as well as nausea and vomiting. Nystagmus, an involuntary eye movement, may occur away from the side of the lesion. Meniere’s disease is more prevalent in individuals who suffer from migraines.

      The management of Meniere’s disease aims to alleviate acute attacks, reduce their severity and frequency, and improve hearing while minimizing the impact of tinnitus. If Meniere’s disease is suspected, patients should be referred to an ear, nose, and throat specialist.

      During acute attacks, medications such as prochlorperazine, cinnarizine, and cyclizine can help reduce nausea and vertigo symptoms. If vomiting is present, buccal or intramuscular administration of these medications may be necessary. In severe cases, hospital admission may be required to prevent dehydration.

      For long-term prevention, lifestyle measures can be beneficial. Avoiding caffeine, chocolate, alcohol, and tobacco is recommended. Excessive fatigue should also be avoided. Following a low-salt diet may be helpful. Betahistine, a medication that initially starts at a dose of 16 mg three times a day, can be used for prophylaxis to reduce the frequency and severity of attacks. Diuretics may also be beneficial, but they are typically not recommended for primary care use.

      Overall, the management of Meniere’s disease involves a combination of lifestyle changes and medication to control symptoms and improve the patient’s quality of life.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 59 - A 35-year-old Caucasian woman comes in with complaints of headaches, blurry vision, and...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Cardiology
      13
      Seconds
  • Question 60 - You assess a 42-year-old woman who has a background of schizophrenia. She was...

    Incorrect

    • You assess a 42-year-old woman who has a background of schizophrenia. She was initiated on an atypical antipsychotic drug a few months ago and has since experienced significant weight gain.
      Which SPECIFIC atypical antipsychotic medication is most likely to be accountable for her weight gain?

      Your Answer: Risperidone

      Correct Answer: Clozapine

      Explanation:

      Clozapine is the atypical antipsychotic that is most likely to result in notable weight gain. Additionally, it is linked to the emergence of impaired glucose metabolism and metabolic syndrome.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 61 - A patient presents with a history of feeling constantly thirsty and urinating large...

    Correct

    • A patient presents with a history of feeling constantly thirsty and urinating large amounts. She also experiences extreme fatigue. A diagnosis of diabetes mellitus is suspected, and a fasting blood glucose sample is scheduled.
      What is the current WHO threshold for diagnosing diabetes mellitus using a fasting blood sample in this case?

      Your Answer: 7 mmol/l

      Explanation:

      According to the 2011 recommendations from the World Health Organization (WHO), the following criteria are used to diagnose diabetes mellitus:

      – A random venous plasma glucose concentration that exceeds 11.1 mmol/l.
      – A fasting plasma glucose concentration that is higher than 7.0 mmol/l.
      – A two-hour plasma glucose concentration that exceeds 11.1 mmol/l, measured two hours after consuming 75g of anhydrous glucose during an oral glucose tolerance test (OGTT).
      – An HbA1c level that is greater than 48 mmol/mol (equivalent to 6.5%).

      These guidelines provide specific thresholds for diagnosing diabetes mellitus based on various glucose measurements and HbA1c levels. It is important for healthcare professionals to consider these criteria when evaluating individuals for diabetes mellitus.

    • This question is part of the following fields:

      • Endocrinology
      4.8
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  • Question 62 - A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell...

    Incorrect

    • A 45-year-old woman presents with a bout of hemoptysis. She feels generally unwell and has experienced recent weight loss. Additionally, she has developed a rash. Her medical history includes a diagnosis of asthma last year and allergic rhinitis. On examination, she has a normal body temperature, her blood pressure is 180/95, and she has a purpuric rash primarily on her legs. During chest examination, a few scattered wheezes are heard.

      Recently, she had a blood test, and the results are as follows:
      - Hemoglobin (Hb): 10.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 23.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 8.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
      - Eosinophils: 15.7 x 109/l (normal range: 0.04-0.44 x 109/l)
      - C-reactive protein (CRP): 107 mg/l (normal range: <5 mg/l)
      - Sodium (Na): 142 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.6 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 255 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 14.8 mmol/l (normal range: 2.5-7.5 mmol/l)

      What is the SINGLE most likely diagnosis?

      Your Answer: Wegener’s granulomatosis

      Correct Answer: Churg-Strauss syndrome

      Explanation:

      This individual has presented with haemoptysis and a purpuric rash, alongside a history of asthma and allergic rhinitis. Blood tests have revealed elevated inflammatory markers, pronounced eosinophilia, and acute renal failure. The most likely diagnosis in this case is Churg-Strauss syndrome.

      Churg-Strauss syndrome is a rare autoimmune vasculitis that affects small and medium-sized blood vessels. The American College of Rheumatology has established six criteria for diagnosing Churg-Strauss syndrome. The presence of at least four of these criteria is highly indicative of the condition:

      1. Asthma (wheezing, expiratory rhonchi)
      2. Eosinophilia of more than 10% in peripheral blood
      3. Paranasal sinusitis
      4. Pulmonary infiltrates (which may be transient)
      5. Histological confirmation of vasculitis with extravascular eosinophils
      6. Mononeuritis multiplex or polyneuropathy

      Churg-Strauss syndrome can affect various organ systems, with the most common clinical features including:

      – Constitutional symptoms: fever, fatigue, weight loss, and arthralgia
      – Respiratory symptoms: asthma, haemoptysis, allergic rhinitis, and sinusitis
      – Cardiovascular symptoms: heart failure, myocarditis, and myocardial infarction
      – Gastrointestinal symptoms: gastrointestinal bleeding, bowel ischaemia, and appendicitis
      – Dermatological symptoms: purpura, livedo reticularis, and skin nodules
      – Renal symptoms: glomerulonephritis, renal failure, and hypertension
      – Neurological symptoms: mononeuritis multiplex

      Investigations often reveal eosinophilia, anaemia, elevated CRP and ESR, elevated creatinine, and elevated serum IgE levels. Approximately 70% of patients test positive for p-ANCA.

      The mainstay of treatment for Churg-Strauss syndrome is high-dose steroids. In cases with life-threatening complications, cyclophosphamide and azathioprine are often administered.

      Polyarteritis nodosa is another vasculitic disorder that affects small and medium-sized blood vessels. It can impact the gastrointestinal tract, kidneys, skin, and joints, but it is not typically associated with rhinitis or asthma.

    • This question is part of the following fields:

      • Respiratory
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  • Question 63 - A 52 year old male is brought into the emergency room after an...

    Correct

    • A 52 year old male is brought into the emergency room after an accident at a construction site resulting in a severe blunt abdominal injury. The patient is experiencing hypotension. The surgical team is preparing for immediate transfer to the operating room. The consultant requests you to prepare intravenous ketamine for rapid sequence induction. What would be the appropriate initial dose of IV ketamine for this patient?

      Your Answer: 1.5 mg/kg IV

      Explanation:

      The recommended dose of ketamine for rapid sequence intubation (RSI) is typically 1.5 mg/kg administered intravenously. This dosage is commonly used in UK medical centers. According to the British National Formulary (BNF), intravenous induction doses of ketamine range from 0.5 to 2 mg/kg for longer procedures and 1 to 4.5 mg/kg for shorter procedures. Ketamine is known to cause an increase in blood pressure, making it a suitable option for individuals with hemodynamic compromise.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 64 - A 45 year old patient presents to the emergency department with a head...

    Incorrect

    • A 45 year old patient presents to the emergency department with a head laceration sustained following a fall while under the influence of alcohol. You determine to evaluate the patient's alcohol consumption. Which screening tool does NICE (National Institute for Health and Care Excellence) recommend for assessing risky drinking?

      Your Answer: CAGE

      Correct Answer: AUDIT

      Explanation:

      The AUDIT screening tool is recommended by NICE for identifying patients who may be at risk of hazardous drinking.

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

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 65 - A healthy and active 45-year-old woman comes in with paralysis of the facial...

    Correct

    • A healthy and active 45-year-old woman comes in with paralysis of the facial muscles on the right side. She is unable to frown or raise her eyebrow on the right side. When instructed to close her eyes and bare her teeth, the right eyeball rolls up and outwards. These symptoms began 24 hours ago. She has no significant medical history, and the rest of her examination appears normal.

      What is the most probable diagnosis in this case?

      Your Answer: Bell’s palsy

      Explanation:

      The patient has presented with a facial palsy that affects only the left side and involves the lower motor neurons. This can be distinguished from an upper motor neuron lesion because the patient is unable to raise their eyebrow and the upper facial muscles are also affected. Additionally, the patient demonstrates a phenomenon known as Bell’s phenomenon, where the eye on the affected side rolls upwards and outwards when attempting to close the eye and bare the teeth.

      Approximately 80% of sudden onset lower motor neuron facial palsies are attributed to Bell’s palsy. It is believed that this condition is caused by swelling of the facial nerve within the petrous temporal bone, which is secondary to a latent herpesvirus, specifically HSV-1 and HZV.

      There are other potential causes for an isolated lower motor neuron facial nerve palsy, including Ramsay-Hunt syndrome (caused by the herpes zoster virus), trauma, parotid gland tumor, cerebellopontine angle tumor (such as an acoustic neuroma), middle ear infection, cholesteatoma, and sarcoidosis.

      However, Ramsay-Hunt syndrome is unlikely in this case since there is no presence of pain or pustular lesions in and around the ear. An acoustic neuroma is also less likely, especially without any symptoms of sensorineural deafness or tinnitus. Furthermore, there are no clinical features consistent with an inner ear infection.

      The recommended treatment for this patient is the administration of steroids, and appropriate follow-up should be organized.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 66 - A 28 year old male comes to the emergency department complaining of a...

    Correct

    • A 28 year old male comes to the emergency department complaining of a sore throat that has been bothering him for the past 2 days. The patient mentions that he has been experiencing a dry cough on and off for the past day or two. During the examination, the patient's temperature is measured at 38.4°C, blood pressure at 132/86 mmHg, and pulse rate at 90 bpm. Both tonsils appear inflamed with white/yellow exudate visible on their surface, and there is tenderness when palpating the enlarged anterior cervical lymph nodes.

      What would be the most appropriate course of action for managing this patient?

      Your Answer: Prescribe phenoxymethylpenicillin 500 mg four times daily for 10 days

      Explanation:

      Phenoxymethylpenicillin is the preferred antibiotic for treating streptococcal sore throat, especially in patients with a CENTOR score of 3/4 and a FeverPAIN score of 4/5. In such cases, antibiotics are necessary to effectively treat the infection.

      Further Reading:

      Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

      Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

      When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

      Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

      To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 67 - A 40-year-old woman with a previous diagnosis of genital warts has observed a...

    Correct

    • A 40-year-old woman with a previous diagnosis of genital warts has observed a significant escalation in the quantity and magnitude of her lesions.

      What is the PRIMARY factor most likely accountable for this deterioration?

      Your Answer: Pregnancy

      Explanation:

      During pregnancy, genital warts have the potential to grow larger in size and increase in number. This is because pregnancy causes a state of immunosuppression, which means that the patient’s immune system is unable to effectively suppress the latent HPV virus. Additionally, there are other factors that can contribute to the growth of genital warts. These include areas of moist skin, non-hair bearing skin, poor hygiene, and the presence of vaginal discharge.

    • This question is part of the following fields:

      • Sexual Health
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  • Question 68 - A 14-year-old girl comes in with a sudden onset of a painful throat...

    Correct

    • A 14-year-old girl comes in with a sudden onset of a painful throat that has been bothering her for the past day. She has no history of coughing or cold symptoms. During the examination, her temperature is measured at 38.5°C, and there is visible exudate on her right tonsil, which also appears to be swollen and red. No anterior cervical lymph nodes can be felt. What is her FeverPAIN Score for assessing her sore throat?

      Your Answer: 5

      Explanation:

      Two scoring systems are suggested by NICE to aid in the evaluation of sore throat: The Centor Clinical Prediction Score and The FeverPAIN Score.

      The FeverPAIN score was developed from a study involving 1760 adults and children aged three and above. The score was tested in a trial that compared three prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, or a combination of the score with the use of a near-patient test (NPT) for streptococcus. Utilizing the score resulted in faster symptom resolution and a reduction in the prescription of antibiotics (both reduced by one third). The inclusion of the NPT did not provide any additional benefit.

      The score comprises of five factors, each of which is assigned one point: Fever (Temp >38°C) in the last 24 hours, Purulence, Attended rapidly in under three days, Inflamed tonsils, and No cough or coryza.

      Based on the score, the recommendations are as follows:
      – Score 0-1 = 13-18% likelihood of streptococcus infection, antibiotics are not recommended.
      – Score 2-3 = 34-40% likelihood of streptococcus infection, consider delayed prescribing of antibiotics (3-5 day ‘backup prescription’).
      – Score 4-5 = 62-65% likelihood of streptococcus infection, use immediate antibiotics if severe, or a 48-hour short ‘backup prescription.’

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 69 - A 35 year old male comes to the emergency department complaining of a...

    Correct

    • A 35 year old male comes to the emergency department complaining of a growing area of redness that has been spreading from a mosquito bite for the past two days. Upon examination, you observe slightly tender redness on the right lower limb, which feels warm and mildly painful to touch. The patient does not have a fever, and vital signs are within normal range.

      You determine that the patient has mild cellulitis. What is the most suitable course of action?

      Your Answer: Discharge with oral flucloxacillin

      Explanation:

      Flucloxacillin is recommended as the initial treatment for mild cellulitis, according to NICE guidelines. The recommended dosage for flucloxacillin is 500-1000 mg taken four times a day for a period of 5-7 days. However, if a patient is allergic to penicillin or if flucloxacillin is not suitable for them, alternative medications such as clarithromycin, doxycycline, or erythromycin can be used as second-line options. It is important to note that for cellulitis near the eyes, co-amoxiclav is advised as the first-line treatment, while for cellulitis in patients with lymphedema who do not require hospital admission, amoxicillin is recommended as the first-line treatment.

      Further Reading:

      Cellulitis is an inflammation of the skin and subcutaneous tissues caused by an infection, usually by Streptococcus pyogenes or Staphylococcus aureus. It commonly occurs on the shins and is characterized by symptoms such as erythema, pain, swelling, and heat. In some cases, there may also be systemic symptoms like fever and malaise.

      The NICE Clinical Knowledge Summaries recommend using the Eron classification to determine the appropriate management of cellulitis. Class I cellulitis refers to cases without signs of systemic toxicity or uncontrolled comorbidities. Class II cellulitis involves either systemic illness or the presence of a co-morbidity that may complicate or delay the resolution of the infection. Class III cellulitis is characterized by significant systemic upset or limb-threatening infection due to vascular compromise. Class IV cellulitis involves sepsis syndrome or a severe life-threatening infection like necrotizing fasciitis.

      According to the guidelines, patients with Eron Class III or Class IV cellulitis should be admitted for intravenous antibiotics. This also applies to patients with severe or rapidly deteriorating cellulitis, very young or frail individuals, immunocompromised patients, those with significant lymphedema, and those with facial or periorbital cellulitis (unless very mild). Patients with Eron Class II cellulitis may not require admission if the necessary facilities and expertise are available in the community to administer intravenous antibiotics and monitor the patient.

      The recommended first-line treatment for mild to moderate cellulitis is flucloxacillin. For patients allergic to penicillin, clarithromycin or clindamycin is recommended. In cases where patients have failed to respond to flucloxacillin, local protocols may suggest the use of oral clindamycin. Severe cellulitis should be treated with intravenous benzylpenicillin and flucloxacillin.

      Overall, the management of cellulitis depends on the severity of the infection and the presence of any systemic symptoms or complications. Prompt treatment with appropriate antibiotics is crucial to prevent further complications and promote healing.

    • This question is part of the following fields:

      • Dermatology
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  • Question 70 - A 9 year old girl is brought into the emergency department with a...

    Correct

    • A 9 year old girl is brought into the emergency department with a worsening sore throat, fever, and feeling unwell. The patient reports that the symptoms began 4 days ago. During the examination, the patient has a temperature of 38.1ºC, bilateral palpable cervical lymphadenopathy, and exudate on both tonsils. Glandular fever is suspected.

      What would be the most suitable approach for investigation?

      Your Answer: Arrange blood test for Epstein-Barr virus (EBV) viral serology in 2-3 days time

      Explanation:

      The most suitable approach for investigation in this case would be to send a blood test for Epstein-Barr virus (EBV) viral serology. Glandular fever, also known as infectious mononucleosis, is commonly caused by the Epstein-Barr virus. The symptoms described by the patient, including a sore throat, fever, and feeling unwell, are consistent with this condition. To confirm the diagnosis, a blood test for EBV viral serology can be performed. This test detects antibodies produced by the body in response to the virus. It is important to note that the Monospot test, which is another blood test for infectious mononucleosis, may not be as accurate in younger children. Therefore, the most appropriate option would be to send a blood test for EBV viral serology in 2-3 days time. This will allow for the detection of specific antibodies and provide a more accurate diagnosis.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
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  • Question 71 - A 32 year old male is brought into the emergency department by ambulance...

    Correct

    • A 32 year old male is brought into the emergency department by ambulance after complaining of difficulty breathing whilst at a bar. The paramedics administered 15 litres of oxygen as the patient's oxygen saturations at the scene were 82% on air. The saturations improved to 84% on 100% oxygen. You observe that the patient appears pale but is able to speak in full sentences. The patient informs you that he had sniffed poppers a few minutes before feeling unwell. What is the likely cause of this patient's hypoxia?

      Your Answer: Methaemoglobinaemia

      Explanation:

      Methaemoglobinaemia is a condition that can be caused by nitrates, including amyl nitrite.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Haematology
      33.3
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  • Question 72 - A 25-year-old man is given a medication for a health condition during the...

    Correct

    • A 25-year-old man is given a medication for a health condition during the 2nd trimester of his partner's pregnancy. As a result, the newborn developed kernicterus and early closure of the ductus arteriosus.
      Which of the following medications is the most probable cause of these abnormalities?

      Your Answer: Aspirin

      Explanation:

      The use of low-dose aspirin during pregnancy is considered safe and can be used to manage recurrent miscarriage, clotting disorders, and pre-eclampsia. On the other hand, high-dose aspirin carries several risks, especially if used in the third trimester. These risks include delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus (a condition that affects the brain due to high levels of bilirubin). Additionally, there is a slight increase in the risk of first-trimester abortion if high-dose aspirin is used early in pregnancy.

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

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

      Drug: Aminoglycosides (e.g. gentamicin)
      Adverse effects: Aminoglycosides can cause ototoxicity (damage to the ear) and deafness.

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      15.5
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  • Question 73 - A 45-year-old man with atrial fibrillation presents to the Emergency Department with an...

    Correct

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

      Which ONE of the following supplements should be avoided?

      Your Answer: St. John’s Wort

      Explanation:

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      5
      Seconds
  • Question 74 - A 45 year old male presents to the emergency department with complaints of...

    Correct

    • A 45 year old male presents to the emergency department with complaints of fatigue, headache, muscle spasms, and tingling sensations in the limbs. The patient has no regular medication and no significant medical history. You decide to order blood tests for analysis. The patient's blood results and observations are as follows:

      Sodium (Na+): 152 mmol/l
      Potassium (K+): 3.3 mmol/l
      Urea: 4.0 mmol/l
      Creatinine: 71 µmol/l

      Blood pressure: 180/96 mmHg
      Pulse rate: 80
      Respiration rate: 14
      Oxygen saturation: 98% on air
      Temperature: 36.8ºC

      What is the most likely diagnosis?

      Your Answer: Conn's syndrome

      Explanation:

      Conn’s syndrome, also known as primary hyperaldosteronism, is often characterized by hypertension along with hypokalaemia and hypernatraemia. On the other hand, Addison’s disease typically leads to hypotension, hyponatremia, and hyperkalaemia. Hyponatraemia is commonly associated with pituitary adenoma, while acute renal failure (ARF) is characterized by elevated levels of urea and creatinine, and hyperkalaemia is frequently observed in ARF.

      Further Reading:

      Hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal glands. It can be classified into primary and secondary hyperaldosteronism. Primary hyperaldosteronism, also known as Conn’s syndrome, is typically caused by adrenal hyperplasia or adrenal tumors. Secondary hyperaldosteronism, on the other hand, is a result of high renin levels in response to reduced blood flow across the juxtaglomerular apparatus.

      Aldosterone is the main mineralocorticoid steroid hormone produced by the adrenal cortex. It acts on the distal renal tubule and collecting duct of the nephron, promoting the reabsorption of sodium ions and water while secreting potassium ions.

      The causes of hyperaldosteronism vary depending on whether it is primary or secondary. Primary hyperaldosteronism can be caused by adrenal adenoma, adrenal hyperplasia, adrenal carcinoma, or familial hyperaldosteronism. Secondary hyperaldosteronism can be caused by renal artery stenosis, reninoma, renal tubular acidosis, nutcracker syndrome, ectopic tumors, massive ascites, left ventricular failure, or cor pulmonale.

      Clinical features of hyperaldosteronism include hypertension, hypokalemia, metabolic alkalosis, hypernatremia, polyuria, polydipsia, headaches, lethargy, muscle weakness and spasms, and numbness. It is estimated that hyperaldosteronism is present in 5-10% of patients with hypertension, and hypertension in primary hyperaldosteronism is often resistant to drug treatment.

      Diagnosis of hyperaldosteronism involves various investigations, including U&Es to assess electrolyte disturbances, aldosterone-to-renin plasma ratio (ARR) as the gold standard diagnostic test, ECG to detect arrhythmia, CT/MRI scans to locate adenoma, fludrocortisone suppression test or oral salt testing to confirm primary hyperaldosteronism, genetic testing to identify familial hyperaldosteronism, and adrenal venous sampling to determine lateralization prior to surgery.

      Treatment of primary hyperaldosteronism typically involves surgical adrenalectomy for patients with unilateral primary aldosteronism. Diet modification with sodium restriction and potassium supplementation may also be recommended.

    • This question is part of the following fields:

      • Nephrology
      62
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  • Question 75 - A 68-year-old man suffers a fractured neck of femur. He is later diagnosed...

    Correct

    • A 68-year-old man suffers a fractured neck of femur. He is later diagnosed with osteoporosis and is prescribed medication for the secondary prevention of osteoporotic fragility fractures.
      What is the recommended initial treatment for the secondary prevention of osteoporotic fragility fractures?

      Your Answer: Oral bisphosphonate

      Explanation:

      Oral bisphosphonates are the primary choice for treating osteoporotic fragility fractures in individuals who have already experienced such fractures. After a fragility fracture, it is advised to start taking a bisphosphonate, typically alendronic acid, and consider supplementing with calcium and vitamin D.

      There are other treatment options available for preventing fragility fractures after an initial occurrence. These include raloxifene, teriparatide, and denosumab.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      14.2
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  • Question 76 - You are overseeing the care of a 70-year-old male who suffered extensive burns...

    Correct

    • You are overseeing the care of a 70-year-old male who suffered extensive burns in a residential fire. After careful calculation, you have determined that the patient will require 6 liters of fluid over the course of the next 24 hours. Which intravenous fluid would be the most suitable to prescribe?

      Your Answer: Hartmann's solution

      Explanation:

      When it comes to managing acute burns, Hartmann’s or lactated Ringers are the preferred intravenous fluids. There is no scientific evidence to support the use of colloids in burn management. In the United Kingdom, Hartmann’s solution is the most commonly used fluid for this purpose.

      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
      9.1
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  • Question 77 - What is the threshold MASCC Risk Index Score for identifying patients as low...

    Incorrect

    • What is the threshold MASCC Risk Index Score for identifying patients as low risk for outpatient treatment with early antibiotics in cases of neutropenic sepsis?

      Your Answer: 20

      Correct Answer: 21

      Explanation:

      The MASCC Risk Index Score, developed by the Multinational Association of Supportive Care in Cancer, is a globally recognized scoring system that helps identify patients with neutropenic sepsis who have a low risk of complications and can potentially be treated as outpatients with early administration of antibiotics. This scoring system takes into account various characteristics to determine the risk level of the patient. These characteristics include the burden of febrile neutropenia with no or mild symptoms, absence of hypotension, no history of chronic obstructive pulmonary disease, presence of a solid tumor or hematological malignancy without previous fungal infection, absence of dehydration requiring parenteral fluids, burden of febrile neutropenia with moderate symptoms, being in an outpatient setting at the onset of fever, and age below 60 years. Each characteristic is assigned a certain number of points, and a total score of 21 or higher indicates a low risk, while a score below 21 indicates a high risk. The MASCC Risk Index Score has been validated internationally and has shown a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%. For more detailed information, you can refer to the article titled Identifying Patients at Low Risk for FN Complications: Development and Validation of the MASCC Risk Index Score.

    • This question is part of the following fields:

      • Oncological Emergencies
      18.4
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  • Question 78 - A 60-year-old man presents with frequent urination and excessive thirst. He has a...

    Correct

    • A 60-year-old man presents with frequent urination and excessive thirst. He has a history of bipolar affective disorder, which has been effectively managed with lithium for many years.

      You schedule blood tests for him, and the results are as follows:

      Na: 150 mmol/L (135-147 mmol/L)
      K: 3.7 mmol/L (3.5-5.5 mmol/L)
      Urea: 9.5 mmol/L (2.0-6.6 mmol/L)
      Creatinine: 127 mmol/L (75-125 mmol/L)

      What is the SINGLE most likely diagnosis?

      Your Answer: Nephrogenic diabetes insipidus

      Explanation:

      Diabetes insipidus is a condition where the body is unable to produce concentrated urine. It is characterized by excessive thirst, increased urination, and constant need to drink fluids. There are two main types of diabetes insipidus: cranial (central) and nephrogenic.

      Cranial diabetes insipidus occurs when there is a deficiency of vasopressin, also known as antidiuretic hormone. This hormone helps regulate the amount of water reabsorbed by the kidneys. In patients with cranial diabetes insipidus, urine output can be as high as 10-15 liters per day. However, with adequate fluid intake, most patients are able to maintain normal sodium levels. The causes of cranial diabetes insipidus can vary, with 30% of cases being idiopathic (unknown cause) and another 30% being secondary to head injuries. Other causes include neurosurgery, brain tumors, meningitis, granulomatous disease (such as sarcoidosis), and certain medications like naloxone and phenytoin. There is also a very rare inherited form of cranial diabetes insipidus that is associated with diabetes mellitus, optic atrophy, nerve deafness, and bladder atonia.

      On the other hand, nephrogenic diabetes insipidus occurs when there is resistance to the action of vasopressin in the kidneys. Similar to cranial diabetes insipidus, urine output is significantly increased in patients with nephrogenic diabetes insipidus. Serum sodium levels can be maintained through excessive fluid intake or may be elevated. The causes of nephrogenic diabetes insipidus include chronic renal disease, metabolic disorders like hypercalcemia and hypokalemia, and certain medications like long-term use of lithium and demeclocycline.

      Based on the history of long-term lithium use in this particular case, nephrogenic diabetes insipidus is the most likely diagnosis.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      37.5
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  • Question 79 - 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
      6
      Seconds
  • Question 80 - You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric...

    Incorrect

    • You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric Intensive Care Unit with meningococcal meningitis. She provided close care for her son before his admission and is worried about the potential of contracting the disease herself. She is currently 20 weeks pregnant.
      What is the MOST suitable option for chemoprophylaxis in her situation?

      Your Answer: Penicillin V 500 mg QDS for 7 days

      Correct Answer: Ceftriaxone 250 mg IM

      Explanation:

      For individuals who have been in contact with patients diagnosed with Neisseria meningitidis meningitis, the recommended medication to prevent the infection is rifampicin 600 mg taken orally twice a day for two days. Alternatively, a single oral dose of ciprofloxacin 500 mg can also be administered. However, it is important to note that both rifampicin and ciprofloxacin should not be used during pregnancy and are contraindicated in such cases. Therefore, in situations involving pregnant individuals, the preferred option is a single 250 mg dose of ceftriaxone given intramuscularly.

    • This question is part of the following fields:

      • Neurology
      36.6
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  • Question 81 - A 72-year-old male is brought to the emergency department after experiencing respiratory distress....

    Correct

    • A 72-year-old male is brought to the emergency department after experiencing respiratory distress. You observe that the patient has a tracheostomy tube in place, which the patient's wife informs you was inserted before undergoing radiation therapy. The patient finished radiation therapy one month ago. What should be the initial step in evaluating this patient?

      Your Answer: Remove inner tube

      Explanation:

      When a patient with a tracheostomy is experiencing difficulty breathing, the first step is to assess their condition and provide them with oxygen. If there is suspected obstruction, one of the initial steps to resolve it is to remove the inner tube of the tracheostomy. After that, the mouth and tracheostomy should be examined, and if the patient is breathing, high flow oxygen should be applied to both the mouth and the tracheostomy stoma site. The next steps in managing the patient would be to pass a suction catheter. If the catheter cannot be passed, the cuff should be deflated. If the patient does not stabilize or improve, the tracheostomy tube should be removed. This order of steps is summarized in the green algorithm.

      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
      16.2
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  • Question 82 - A 40-year-old woman comes in with tremor, anxiety, sweating, and nausea. Her observations...

    Correct

    • A 40-year-old woman comes in with tremor, anxiety, sweating, and nausea. Her observations reveal an elevated heart rate of 119 bpm. She typically consumes 2-3 large bottles of strong cider daily but has recently run out of money and hasn't had an alcoholic drink since the previous night.
      Which assessment scale should be utilized to guide the treatment of this woman's alcohol withdrawal? Select ONE option.

      Your Answer: CIWA scale

      Explanation:

      The CIWA scale, also known as the Clinical Institute Withdrawal Assessment for Alcohol scale, is a scale consisting of ten items that is utilized in the evaluation and management of alcohol withdrawal. It is currently recommended by both NICE and the Royal College of Emergency Medicine for assessing patients experiencing acute alcohol withdrawal. The maximum score on the CIWA scale is 67, with scores indicating the severity of withdrawal symptoms. A score of less than 5 suggests mild withdrawal, while a score between 6 and 20 indicates moderate withdrawal. Any score above 20 is considered severe withdrawal. The ten items evaluated on the scale encompass common symptoms and signs of alcohol withdrawal, such as nausea/vomiting, tremors, sweating, anxiety, agitation, sensory disturbances, and cognitive impairments.

      In addition to the CIWA scale, there are other screening tools available for assessing various conditions. The CAGE questionnaire is commonly used to screen for alcohol-related issues. The STEPI is utilized as a screening tool for early symptoms of the schizophrenia prodrome. The EPDS is an evidence-based questionnaire that can be employed to screen for postnatal depression. Lastly, the SCOFF questionnaire is a screening tool used to identify the possible presence of eating disorders.

      For further information on the assessment and management of acute alcohol withdrawal, the NICE pathway is a valuable resource. The RCEM syllabus also provides relevant information on this topic. Additionally, the MHC1 module on alcohol and substance misuse offers further reading material for those interested in this subject.

    • This question is part of the following fields:

      • Mental Health
      7.7
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  • Question 83 - A 32-year-old musician is currently participating in a community withdrawal program for a...

    Correct

    • A 32-year-old musician is currently participating in a community withdrawal program for a substance misuse issue. He has been attempting to quit for more than a year and consistently attends a community support group for his problem. The healthcare team in charge of his treatment have prescribed him Acamprosate to aid with his withdrawal.
      What substance is he most likely trying to withdraw from?

      Your Answer: Alcohol

      Explanation:

      Acamprosate, also known as Campral, is a medication used in the treatment of alcohol dependence. It is believed to work by stabilizing a chemical pathway in the brain that is disrupted during alcohol withdrawal. For optimal results, Acamprosate should be used alongside psychosocial support, as it helps reduce alcohol consumption and promote abstinence.

      When starting treatment with Acamprosate, it is important to begin as soon as possible after assisted withdrawal. The typical dosage is 1998 mg (666 mg three times a day), unless the patient weighs less than 60 kg, in which case a maximum of 1332 mg per day should be prescribed.

      Generally, Acamprosate is prescribed for up to 6 months. However, for those who benefit from the medication and wish to continue, it can be taken for a longer duration. If drinking persists 4-6 weeks after starting the drug, it should be discontinued.

      Patients who are prescribed Acamprosate should be closely monitored, with regular check-ins at least once a month for the first six months. If the medication is continued beyond six months, the frequency of check-ins can be reduced but should still occur at regular intervals.

      While routine blood tests are not mandatory, they can be considered if there is a need to monitor liver function recovery or as a motivational tool to show patients their progress.

    • This question is part of the following fields:

      • Mental Health
      18.6
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  • Question 84 - A 30-year-old man presents to the emergency department following an altercation at a...

    Correct

    • A 30-year-old man presents to the emergency department following an altercation at a nightclub. The patient sustained a bite during the altercation, resulting in an occlusal injury to his arm. There is notable redness surrounding the wound. It is determined that the patient should be administered antibiotics. What is the most suitable initial antibiotic treatment for an infected human bite wound?

      Your Answer: Co-amoxiclav

      Explanation:

      When it comes to preventing infection in human bite wounds, Co-amoxiclav is the recommended first-line antibiotic prophylaxis. Human bites can occur either from biting or from clenched-fist injuries, commonly known as fight bites. Co-amoxiclav is the preferred choice for prophylaxis in cases where there is a risk of infection or when an infection is already present in a human bite wound.

      Further Reading:

      Bite wounds from animals and humans can cause significant injury and infection. It is important to properly assess and manage these wounds to prevent complications. In human bites, both the biter and the injured person are at risk of infection transmission, although the risk is generally low.

      Bite wounds can take various forms, including lacerations, abrasions, puncture wounds, avulsions, and crush or degloving injuries. The most common mammalian bites are associated with dogs, cats, and humans.

      When assessing a human bite, it is important to gather information about how and when the bite occurred, who was involved, whether the skin was broken or blood was involved, and the nature of the bite. The examination should include vital sign monitoring if the bite is particularly traumatic or sepsis is suspected. The location, size, and depth of the wound should be documented, along with any functional loss or signs of infection. It is also important to check for the presence of foreign bodies in the wound.

      Factors that increase the risk of infection in bite wounds include the nature of the bite, high-risk sites of injury (such as the hands, feet, face, genitals, or areas of poor perfusion), wounds penetrating bone or joints, delayed presentation, immunocompromised patients, and extremes of age.

      The management of bite wounds involves wound care, assessment and administration of prophylactic antibiotics if indicated, assessment and administration of tetanus prophylaxis if indicated, and assessment and administration of antiviral prophylaxis if indicated. For initial wound management, any foreign bodies should be removed, the wound should be encouraged to bleed if fresh, and thorough irrigation with warm, running water or normal saline should be performed. Debridement of necrotic tissue may be necessary. Bite wounds are usually not appropriate for primary closure.

      Prophylactic antibiotics should be considered for human bites that have broken the skin and drawn blood, especially if they involve high-risk areas or the patient is immunocompromised. Co-amoxiclav is the first-line choice for prophylaxis, but alternative antibiotics may be used in penicillin-allergic patients. Antibiotics for wound infection should be based on wound swab culture and sensitivities.

      Tetanus prophylaxis should be administered based on the cleanliness and risk level of the wound, as well as the patient’s vaccination status. Blood-borne virus risk should also be assessed, and testing for hepatitis B, hepatitis C, and HIV should be done.

    • This question is part of the following fields:

      • Infectious Diseases
      9.3
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  • Question 85 - You are tasked with organizing a teaching session for the senior residents on...

    Correct

    • You are tasked with organizing a teaching session for the senior residents on head injuries & increased intracranial pressure. What is the intracranial volume of a typical adult?

      Your Answer: 1400ml

      Explanation:

      On average, the intracranial volume in adults is around 1400ml.

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
      3.2
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  • Question 86 - A 62 year old man is brought into the emergency department by his...

    Correct

    • A 62 year old man is brought into the emergency department by his daughter. The patient had been dozing on the beach chair for a few hours during the scorching weather but then became increasingly disoriented and started vomiting. The patient takes furosemide for swollen ankles. The patients observations are shown below:

      Blood pressure 118/68 mmHg
      Pulse 108 bpm
      Respiratory rate 24 bpm
      Temperature 41.4ºC
      Oxygen sats 96% on air

      The patient's skin is hot and dry to the touch. What is the most likely diagnosis?

      Your Answer: Heat stroke

      Explanation:

      Anhydrosis, or the inability to sweat, is frequently observed in individuals who experience heat stroke. This patient exhibits the main characteristics of heat stroke, including a core body temperature exceeding 40ºC and encephalopathy, which is evident through significant confusion. Additionally, the patient’s use of diuretics and advanced age are risk factors that increase the likelihood of developing severe heat-related illness. It is important to note that in the UK, most fatalities resulting from heat stroke occur in individuals aged 70 or older, typically within the initial days of a heat wave.

      Further Reading:

      Heat Stroke:
      – Core temperature >40°C with central nervous system dysfunction
      – Classified into classic/non-exertional heat stroke and exertional heat stroke
      – Classic heat stroke due to passive exposure to severe environmental heat
      – Exertional heat stroke due to strenuous physical activity in combination with excessive environmental heat
      – Mechanisms to reduce core temperature overwhelmed, leading to tissue damage
      – Symptoms include high body temperature, vascular endothelial surface damage, inflammation, dehydration, and renal failure
      – Management includes cooling methods and supportive care
      – Target core temperature for cooling is 38.5°C

      Heat Exhaustion:
      – Mild to moderate heat illness that can progress to heat stroke if untreated
      – Core temperature elevated but <40°C
      – Symptoms include nausea, vomiting, dizziness, and mild neurological symptoms
      – Normal thermoregulation is disrupted
      – Management includes moving patient to a cooler environment, rehydration, and rest

      Other Heat-Related Illnesses:
      – Heat oedema: transitory swelling of hands and feet, resolves spontaneously
      – Heat syncope: results from volume depletion and peripheral vasodilatation, managed by moving patient to a cooler environment and rehydration
      – Heat cramps: painful muscle contractions associated with exertion, managed with cooling, rest, analgesia, and rehydration

      Risk Factors for Severe Heat-Related Illness:
      – Old age, very young age, chronic disease and debility, mental illness, certain medications, housing issues, occupational factors

      Management:
      – Cooling methods include spraying with tepid water, fanning, administering cooled IV fluids, cold or ice water immersion, and ice packs
      – Benzodiazepines may be used to control shivering
      – Rapid cooling to achieve rapid normothermia should be avoided to prevent overcooling and hypothermia
      – Supportive care includes intravenous fluid replacement, seizure treatment if required, and consideration of haemofiltration
      – Some patients may require liver transplant due to significant liver damage
      – Patients with heat stroke should ideally be managed in a HDU/ICU setting with CVP and urinary catheter output measurements

    • This question is part of the following fields:

      • Environmental Emergencies
      35.8
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  • Question 87 - A 35 year old male comes to the emergency department with sudden onset...

    Correct

    • A 35 year old male comes to the emergency department with sudden onset of facial weakness on one side that has occurred within the last 72 hours. You are considering the possible causes for this condition. What would assist in differentiating between an upper motor neuron and lower motor neuron lesion?

      Your Answer: Forehead sparing

      Explanation:

      When there is damage to the facial nerve in the LMN, the patient will experience paralysis in the forehead and will be unable to wrinkle their brow. However, in an upper motor neuron lesion, the frontalis muscle is not affected, so the patient can still furrow their brow normally and their ability to close their eyes and blink is not affected. Lower motor neuron lesions affect the final part of the nerve pathway to all branches of the facial nerve, resulting in paralysis of the forehead and the rest of the face on that side. It is important to note that the speed of onset may provide some clues about the cause of the lesion, but it does not help determine the specific location of the damage.

      Further Reading:

      Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.

      Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.

      When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.

      Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.

      Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.

    • This question is part of the following fields:

      • Neurology
      26.4
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  • Question 88 - A 7 year old girl is brought into the emergency department after being...

    Correct

    • A 7 year old girl is brought into the emergency department after being bitten by a bee. The patient's arm has started to swell and she is having difficulty breathing. You diagnose anaphylaxis and decide to administer adrenaline. What is the most suitable dose to give this patient?

      Your Answer: 300 micrograms (0.3ml 1 in 1,000) by intramuscular injection

      Explanation:

      A 7-year-old girl is brought to the emergency department after being bitten by a bee. She is experiencing swelling in her arm and difficulty breathing, which are signs of anaphylaxis. To treat this condition, the most suitable dose of adrenaline to administer to the patient is 300 micrograms (0.3ml 1 in 1,000) by intramuscular injection.

      Further Reading:

      Anaphylaxis is a severe and life-threatening hypersensitivity reaction that can have sudden onset and progression. It is characterized by skin or mucosal changes and can lead to life-threatening airway, breathing, or circulatory problems. Anaphylaxis can be allergic or non-allergic in nature.

      In allergic anaphylaxis, there is an immediate hypersensitivity reaction where an antigen stimulates the production of IgE antibodies. These antibodies bind to mast cells and basophils. Upon re-exposure to the antigen, the IgE-covered cells release histamine and other inflammatory mediators, causing smooth muscle contraction and vasodilation.

      Non-allergic anaphylaxis occurs when mast cells degrade due to a non-immune mediator. The clinical outcome is the same as in allergic anaphylaxis.

      The management of anaphylaxis is the same regardless of the cause. Adrenaline is the most important drug and should be administered as soon as possible. The recommended doses for adrenaline vary based on age. Other treatments include high flow oxygen and an IV fluid challenge. Corticosteroids and chlorpheniramine are no longer recommended, while non-sedating antihistamines may be considered as third-line treatment after initial stabilization of airway, breathing, and circulation.

      Common causes of anaphylaxis include food (such as nuts, which is the most common cause in children), drugs, and venom (such as wasp stings). Sometimes it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.

      The Resuscitation Council (UK) provides guidelines for the management of anaphylaxis, including a visual algorithm that outlines the recommended steps for treatment.

    • This question is part of the following fields:

      • Paediatric Emergencies
      13
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  • Question 89 - A 65 year old male presents to the emergency department with sudden onset...

    Incorrect

    • A 65 year old male presents to the emergency department with sudden onset of central back pain. After evaluation, you order an X-ray which reveals anterior wedging of the L2 vertebra. You suspect the patient may have undiagnosed osteoporosis. Which of the following statements about osteoporosis is correct?

      Your Answer: Osteoporosis is diagnosed using skeletal scintigraphy

      Correct Answer: Osteoporosis is defined as a T-score of less than -2.5

      Explanation:

      Osteoporosis is a condition characterized by weak and brittle bones, making them more prone to fractures. In this case, the patient’s sudden onset of central back pain and the X-ray findings of anterior wedging of the L2 vertebra suggest the possibility of undiagnosed osteoporosis.

      One correct statement about osteoporosis is that it is defined as a T-score of less than -2.5. The T-score is a measure of bone density and is used to diagnose osteoporosis. A T-score of -2.5 or lower indicates a significant decrease in bone density and an increased risk of fractures.

      Skeletal scintigraphy is not used to diagnose osteoporosis. Instead, it is commonly used to evaluate for other conditions such as bone infections or tumors.

      The pubic rami is not the most common site for osteoporotic fractures. Osteoporotic fractures commonly occur in the spine (vertebral fractures), hip, and wrist.

      Osteoporosis is not characterized by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase. This description is more consistent with a condition called Paget’s disease of bone.

      The prevalence of osteoporosis is not approximately 10% at 50 years of age. The prevalence of osteoporosis increases with age, and it is estimated that around 50% of women and 25% of men over the age of 50 will experience an osteoporotic fracture in their lifetime.

      Further Reading:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      42.1
      Seconds
  • Question 90 - A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation....

    Correct

    • A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation. She remembers experiencing a flu-like illness and skin rash early in the pregnancy after being bitten by a mosquito while visiting relatives in Brazil.

      What is the SINGLE most probable organism responsible for causing this birth defect?

      Your Answer: Zika virus

      Explanation:

      The Zika virus is a newly emerging virus that is transmitted by mosquitoes. It was first discovered in humans in Uganda in 1952. Recently, there has been a significant outbreak of the virus in South America.

      When a person contracts the Zika virus, about 1 in 5 individuals will experience clinical illness, while the rest will show no symptoms at all. The most common symptoms of the virus include fever, rash, joint pain, and conjunctivitis. These symptoms typically last for no more than a week.

      While not completely conclusive, the evidence from the recent outbreak strongly suggests a connection between Zika virus infection and microcephaly.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      6.4
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  • Question 91 - A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing...

    Correct

    • A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing and appears visibly distressed. Despite his discomfort, he remains mentally alert and reports moderate levels of pain. He has been informed that he has only a few days left to live. Currently, his oxygen saturation levels are at 95% when breathing regular air, and there are no specific signs of chest abnormalities.
      What would be the most suitable course of action to alleviate his breathlessness in this situation?

      Your Answer: Oral morphine

      Explanation:

      Here are some suggestions for managing breathlessness in the final days of life, as provided by NICE:

      1. It is important to identify and treat any reversible causes of breathlessness in the dying person, such as pulmonary edema or pleural effusion.

      2. Non-pharmacological methods can be considered for managing breathlessness in someone nearing the end of life. It is not recommended to start oxygen therapy as a routine measure. Oxygen should only be offered to individuals who are known or suspected to have symptomatic hypoxemia.

      3. Breathlessness can be managed using different medications, including opioids, benzodiazepines, or a combination of both.

      For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      32.4
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  • Question 92 - A 45-year-old man comes in with vomiting, disorientation, and decreased urine production. His...

    Incorrect

    • A 45-year-old man comes in with vomiting, disorientation, and decreased urine production. His creatinine levels have increased by 150% compared to his usual levels over the past week. After conducting additional tests, the patient is diagnosed with acute kidney injury (AKI).
      What stage of AKI does he fall under?

      Your Answer: Stage 3

      Correct Answer: Stage 2

      Explanation:

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

      AKI is categorized into three stages based on specific criteria. In stage 1, there is a rise in creatinine levels of 26 micromol/L or more within 48 hours, or a rise of 50-99% from baseline within 7 days (1.5-1.99 times the baseline). Additionally, a urine output of less than 0.5 mL/kg/hour for more than 6 hours is indicative of stage 1 AKI.

      Stage 2 AKI is characterized by a creatinine rise of 100-199% from baseline within 7 days (2.0-2.99 times the baseline), or a urine output of less than 0.5 mL/kg/hour for more than 12 hours.

      In stage 3 AKI, there is a creatinine rise of 200% or more from baseline within 7 days (3.0 or more times the baseline). Alternatively, a creatinine rise to 354 micromol/L or more with an acute rise of 26 micromol/L or more within 48 hours, or a rise of 50% or more within 7 days, is indicative of stage 3 AKI. Additionally, a urine output of less than 0.3 mL/kg/hour for 24 hours or anuria (no urine output) for 12 hours also falls under stage 3 AKI.

    • This question is part of the following fields:

      • Nephrology
      16.4
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  • Question 93 - A 75 year old man with a long-standing history of hypothyroidism presents to...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Endocrinology
      12
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  • Question 94 - You are summoned to the resuscitation room to assist with a 6-year-old patient...

    Correct

    • You are summoned to the resuscitation room to assist with a 6-year-old patient who has arrived with a cardiac arrest.

      Which of the following medication dosages for pediatric cardiac arrest is accurate?

      Your Answer: Sodium bicarbonate 8.4% 1 ml/kg

      Explanation:

      The doses of commonly used drugs in paediatric cardiac arrest are summarized in the following table:

      Drug: Adrenaline (epinephrine) IV/IO
      Dose: 10 mcg/kg

      Drug: Adrenaline (epinephrine) ET bolus
      Dose: 100 mcg/kg

      Drug: Amiodarone IV infusion
      Dose: 5 mg/kg over 3 minutes (maximum 300 mg)

      Drug: Calcium gluconate 10%
      Dose: 0.3-0.5 ml/kg

      Drug: Lidocaine IV/IO
      Dose: 1 mg/kg (maximum 100 mg)

      Drug: Magnesium sulphate IV
      Dose: 25-50 mg/kg

      Drug: Sodium bicarbonate IV
      Dose: 1 ml/kg 8.4%

    • This question is part of the following fields:

      • Paediatric Emergencies
      8.1
      Seconds
  • Question 95 - You observe that a patient's temperature has risen to 41.5ºC after undergoing rapid...

    Correct

    • You observe that a patient's temperature has risen to 41.5ºC after undergoing rapid sequence induction. You are worried that the patient might have developed malignant hyperthermia. What is the primary drug used to treat malignant hyperthermia?

      Your Answer: Dantrolene

      Explanation:

      The primary treatment for malignant hyperthermia is dantrolene. Dantrolene works by blocking the release of calcium through calcium channels, resulting in the relaxation of skeletal muscles.

      Further Reading:

      Malignant hyperthermia is a rare and life-threatening syndrome that can be triggered by certain medications in individuals who are genetically susceptible. The most common triggers are suxamethonium and inhalational anaesthetic agents. The syndrome is caused by the release of stored calcium ions from skeletal muscle cells, leading to uncontrolled muscle contraction and excessive heat production. This results in symptoms such as high fever, sweating, flushed skin, rapid heartbeat, and muscle rigidity. It can also lead to complications such as acute kidney injury, rhabdomyolysis, and metabolic acidosis. Treatment involves discontinuing the trigger medication, administering dantrolene to inhibit calcium release and promote muscle relaxation, and managing any associated complications such as hyperkalemia and acidosis. Referral to a malignant hyperthermia center for further investigation is also recommended.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11
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  • Question 96 - A 25-year-old man comes in with severe bloody diarrhea caused by a gastrointestinal...

    Correct

    • 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: 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
      4.7
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  • Question 97 - A 35-year-old individual presents to the emergency department complaining of abdominal pain that...

    Correct

    • A 35-year-old individual presents to the emergency department complaining of abdominal pain that started approximately 30 minutes after consuming a spicy meal. The patient reports not taking any regular or over-the-counter medications and denies any recreational drug use. They mention experiencing abdominal pain after eating for a few weeks and recently visited their general practitioner (GP) who requested a stool sample for testing. The patient states that the pain has worsened since then and they are also experiencing nausea. Upon reviewing the pathology results, it is noted that the stool sample tested positive for helicobacter pylori. The suspicion is that the patient has an h.pylori associated peptic ulcer. According to NICE guidelines, what is the recommended first-line treatment for this condition?

      Your Answer: Amoxicillin plus clarithromycin plus omeprazole for 7 days

      Explanation:

      The recommended first-line antibiotics for eradicating H. pylori are amoxicillin in combination with either clarithromycin or metronidazole. According to NICE guidelines, for H. pylori-associated ulcers not caused by NSAID use, a 7-day eradication therapy is advised. This therapy consists of taking amoxicillin 1 g twice daily, along with either clarithromycin 500 mg twice daily or metronidazole 400 mg twice daily. Additionally, a proton pump inhibitor should be taken twice daily, with several options available. Please refer to the yellow box at the end of the notes for appropriate PPI choices.

      Further Reading:

      Peptic ulcer disease (PUD) is a condition characterized by a break in the mucosal lining of the stomach or duodenum. It is caused by an imbalance between factors that promote mucosal damage, such as gastric acid, pepsin, Helicobacter pylori infection, and NSAID drug use, and factors that maintain mucosal integrity, such as prostaglandins, mucus lining, bicarbonate, and mucosal blood flow.

      The most common causes of peptic ulcers are H. pylori infection and NSAID use. Other factors that can contribute to the development of ulcers include smoking, alcohol consumption, certain medications (such as steroids), stress, autoimmune conditions, and tumors.

      Diagnosis of peptic ulcers involves screening for H. pylori infection through breath or stool antigen tests, as well as upper gastrointestinal endoscopy. Complications of PUD include bleeding, perforation, and obstruction. Acute massive hemorrhage has a case fatality rate of 5-10%, while perforation can lead to peritonitis with a mortality rate of up to 20%.

      The symptoms of peptic ulcers vary depending on their location. Duodenal ulcers typically cause pain that is relieved by eating, occurs 2-3 hours after eating and at night, and may be accompanied by nausea and vomiting. Gastric ulcers, on the other hand, cause pain that occurs 30 minutes after eating and may be associated with nausea and vomiting.

      Management of peptic ulcers depends on the underlying cause and presentation. Patients with active gastrointestinal bleeding require risk stratification, volume resuscitation, endoscopy, and proton pump inhibitor (PPI) therapy. Those with perforated ulcers require resuscitation, antibiotic treatment, analgesia, PPI therapy, and urgent surgical review.

      For stable patients with peptic ulcers, lifestyle modifications such as weight loss, avoiding trigger foods, eating smaller meals, quitting smoking, reducing alcohol consumption, and managing stress and anxiety are recommended. Medication review should be done to stop causative drugs if possible. PPI therapy, with or without H. pylori eradication therapy, is also prescribed. H. pylori testing is typically done using a carbon-13 urea breath test or stool antigen test, and eradication therapy involves a 7-day triple therapy regimen of antibiotics and PPI.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      11.2
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  • Question 98 - You are caring for an elderly patient with chronic kidney disease who has...

    Correct

    • You are caring for an elderly patient with chronic kidney disease who has been ordered intravenous fluids containing potassium chloride. You are closely observing the patient for the development of hyperkalemia. What is the initial ECG change typically observed in patients with hyperkalemia?

      Your Answer: Tall Tented T-waves

      Explanation:

      The earliest ECG change typically observed in hyperkalemia is the presence of tall tented T-waves.

      Further Reading:

      Vasoactive drugs can be classified into three categories: inotropes, vasopressors, and unclassified. Inotropes are drugs that alter the force of muscular contraction, particularly in the heart. They primarily stimulate adrenergic receptors and increase myocardial contractility. Commonly used inotropes include adrenaline, dobutamine, dopamine, isoprenaline, and ephedrine.

      Vasopressors, on the other hand, increase systemic vascular resistance (SVR) by stimulating alpha-1 receptors, causing vasoconstriction. This leads to an increase in blood pressure. Commonly used vasopressors include norepinephrine, metaraminol, phenylephrine, and vasopressin.

      Electrolytes, such as potassium, are essential for proper bodily function. Solutions containing potassium are often given to patients to prevent or treat hypokalemia (low potassium levels). However, administering too much potassium can lead to hyperkalemia (high potassium levels), which can cause dangerous arrhythmias. It is important to monitor potassium levels and administer it at a controlled rate to avoid complications.

      Hyperkalemia can be caused by various factors, including excessive potassium intake, decreased renal excretion, endocrine disorders, certain medications, metabolic acidosis, tissue destruction, and massive blood transfusion. It can present with cardiovascular, respiratory, gastrointestinal, and neuromuscular symptoms. ECG changes, such as tall tented T-waves, prolonged PR interval, flat P-waves, widened QRS complex, and sine wave, are also characteristic of hyperkalemia.

      In summary, vasoactive drugs can be categorized as inotropes, vasopressors, or unclassified. Inotropes increase myocardial contractility, while vasopressors increase systemic vascular resistance. Electrolytes, particularly potassium, are important for bodily function, but administering too much can lead to hyperkalemia. Monitoring potassium levels and ECG changes is crucial in managing hyperkalemia.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      22
      Seconds
  • Question 99 - A 42-year-old woman is brought in by ambulance following a high-speed car accident....

    Correct

    • A 42-year-old woman is brought in by ambulance following a high-speed car accident. There was a prolonged extraction at the scene, and a full trauma call is made. 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 needles have been inserted in her antecubital fossa, and a complete 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.
      What approximate percentage of her circulatory volume has she lost?

      Your Answer: 30-40%

      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.

    • This question is part of the following fields:

      • Trauma
      17.7
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  • Question 100 - A 32-year-old woman presents with bleeding gums and easy bruising. She also reports...

    Correct

    • A 32-year-old woman presents with bleeding gums and easy bruising. She also reports feeling extremely tired lately and has been experiencing recurrent chest infections for the past few months. She had mononucleosis approximately six months ago and believes her symptoms started after that. Her complete blood count today shows the following results:
      Hemoglobin: 5.4 g/dl (11.5-14 g/dl)
      Mean Corpuscular Volume: 89 fl (80-100 fl)
      White Cell Count: 1.1 x 109/l (4-11 x 109/l)
      Platelets: 17 x 109/l (150-450 x 109/l)
      What is the SINGLE most likely diagnosis?

      Your Answer: Aplastic anaemia

      Explanation:

      Aplastic anaemia is a rare and potentially life-threatening condition where the bone marrow fails to produce enough blood cells. This results in a decrease in the number of red blood cells, white blood cells, and platelets in the body, a condition known as pancytopenia. The main cause of aplastic anaemia is damage to the bone marrow and the stem cells that reside there. This damage can be caused by various factors such as autoimmune disorders, certain medications like sulphonamide antibiotics and phenytoin, viral infections like EBV and parvovirus, chemotherapy, radiotherapy, or inherited conditions like Fanconi anaemia. Patients with aplastic anaemia typically experience symptoms such as anaemia, recurrent infections due to a low white blood cell count, and an increased tendency to bleed due to low platelet levels.

    • This question is part of the following fields:

      • Haematology
      16
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (5/5) 100%
Trauma (3/4) 75%
Endocrinology (6/8) 75%
Elderly Care / Frailty (4/5) 80%
Basic Anaesthetics (4/4) 100%