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  • Question 1 - You assess a 70-year-old woman who is admitted to the clinical decision unit...

    Correct

    • You assess a 70-year-old woman who is admitted to the clinical decision unit (CDU) after a fall last night. She has a significant cardiac history, having experienced a heart attack 3 years ago and is currently being evaluated for cardiac arrhythmias. She occasionally experiences episodes of angina. Upon reviewing her medication list, you identify one specific medication that should be discontinued immediately.

      Your Answer: Verapamil

      Explanation:

      Verapamil is a type of calcium-channel blocker that is commonly used to treat irregular heart rhythms and chest pain. It is important to note that verapamil should not be taken at the same time as beta-blockers like atenolol. This is because when these medications are combined, they can have a negative impact on the heart’s ability to contract and its heart rate. This can lead to low blood pressure, slow heart rate, problems with the electrical signals in the heart, heart failure, and even a pause in the heart’s normal rhythm. However, the other medications mentioned in this question can be safely used together with beta-blockers.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      14.7
      Seconds
  • Question 2 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Correct

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with central chest discomfort. Her ECG showed ST depression in the inferior leads, but her discomfort subsides, and ECG returns to normal after receiving GTN spray and IV morphine. She was also given 300 mg of aspirin in the ambulance en route to the hospital. Her vital signs are as follows: SaO2 99% on room air, HR 89 bpm, and BP 139/82 mmHg. A troponin test has been scheduled and she is scheduled for an urgent coronary angiography.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Unfractionated heparin

      Explanation:

      This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).

      Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.

      Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
      11.3
      Seconds
  • Question 3 - A 55 year old female patient is brought into the emergency department with...

    Incorrect

    • A 55 year old female patient is brought into the emergency department with urosepsis. It is decided to intubate her pending transfer to ITU. Your consultant requests you prepare propofol and suxamethonium for rapid sequence intubation (RSI). What is the recommended dose of suxamethonium for RSI in adults?

      Your Answer: 2.5 mg/kg

      Correct Answer: 1.5 mg/kg

      Explanation:

      The appropriate dosage of suxamethonium for rapid sequence intubation (RSI) in adults is between 1 and 1.5 milligrams per kilogram of body weight.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      8
      Seconds
  • Question 4 - You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of...

    Correct

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

      Your Answer: Cardiac enzymes are usually elevated in unstable angina

      Explanation:

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

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

    • This question is part of the following fields:

      • Cardiology
      19
      Seconds
  • Question 5 - A 42-year-old woman presents with a history of progressively worsening weakness in her...

    Correct

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

      Your Answer: Amyotrophic Lateral Sclerosis (ALS)

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      14
      Seconds
  • Question 6 - You are asked to help with a 68-year-old patient who initially arrived at...

    Correct

    • You are asked to help with a 68-year-old patient who initially arrived at the emergency department complaining of chest discomfort and was found to have a slow heart rate before experiencing a cardiac arrest. Which of the following statements about medications used during cardiac arrest and peri-arrest is accurate?

      Your Answer: Atropine is an antagonist of muscarinic acetylcholine receptors

      Explanation:

      Atropine acts as a blocker for muscarinic acetylcholine receptors, making it an antagonist. It is commonly administered during peri-arrest bradycardia. In adults, a dose of 500 mcg is given every 3-5 minutes, with a maximum total dose of 3mg. On the other hand, the initial intravenous dose of amiodarone is 300 mg. Amiodarone works by prolonging repolarization and decreasing myocardial excitability. Additionally, lidocaine functions by blocking sodium channels.

      Further Reading:

      In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.

      Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.

      Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.

      Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.

      Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.

      Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.

      It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.

    • This question is part of the following fields:

      • Basic Anaesthetics
      21.1
      Seconds
  • Question 7 - A 75 year old female is brought to the hospital by paramedics after...

    Correct

    • A 75 year old female is brought to the hospital by paramedics after experiencing a cardiac arrest at home during a family gathering. The patient is pronounced deceased shortly after being admitted to the hospital. The family informs you that the patient had been feeling unwell for the past few days but chose not to seek medical attention due to concerns about the Coronavirus. The family inquires about the likelihood of the patient surviving if the cardiac arrest had occurred within the hospital?

      Your Answer: 20%

      Explanation:

      For the exam, it is important to be familiar with the statistics regarding the outcomes of outpatient and inpatient cardiac arrest in the UK.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      10.7
      Seconds
  • Question 8 - A 42-year-old man comes in with bleeding from a tooth socket that began...

    Correct

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

      Your Answer: Reactionary haemorrhage

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Maxillofacial & Dental
      4.7
      Seconds
  • Question 9 - A 35-year-old woman comes in with a 3-day history of mild discomfort while...

    Correct

    • A 35-year-old woman comes in with a 3-day history of mild discomfort while urinating. She also reports increased frequency of urination. She denies any urgency or excessive urination and has not observed any blood in her urine. On physical examination, her abdomen is soft and nontender.

      What is the MOST suitable course of action for management?

      Your Answer: Use a urine dipstick test to help in this patient’s diagnosis

      Explanation:

      Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. To effectively manage UTIs, SIGN has developed excellent guidelines. According to these guidelines, if a patient presents with mild symptoms of a UTI (experiencing two or fewer classical symptoms), it is recommended to use a dipstick test to aid in the diagnosis and treatment process.

    • This question is part of the following fields:

      • Urology
      15.8
      Seconds
  • Question 10 - A 32-year-old artist returns from a vacation in Thailand with a severely painful...

    Correct

    • A 32-year-old artist returns from a vacation in Thailand with a severely painful and red right eye. The symptoms appeared rapidly within a day, and the eye now has excessive mucopurulent discharge and swelling of the eyelid. During the examination, tender pre-auricular lymphadenopathy is observed on the right side. Upon further inquiry, the patient confesses to having visited a sex worker during their trip to Thailand.

      Which of the following antibiotics would be the most suitable to prescribe for this individual?

      Your Answer: Ceftriaxone

      Explanation:

      Sexually transmitted eye infections can be quite severe and are often characterized by prolonged mucopurulent discharge. There are two main causes of these infections: Chlamydia trachomatis and Neisseria gonorrhoea. Differentiating between the two can be done by considering certain features.

      Chlamydia trachomatis infection typically presents with chronic low-grade irritation and mucous discharge that lasts for more than two weeks in sexually active individuals. It may also be accompanied by pre-auricular lymphadenopathy. This type of infection is usually unilateral but can sometimes affect both eyes.

      On the other hand, Neisseria gonorrhoea infection tends to develop rapidly, usually within 12 to 24 hours. It is characterized by copious mucopurulent discharge, eyelid swelling, and tender preauricular lymphadenopathy. This type of infection carries a higher risk of complications, such as uveitis, severe keratitis, and corneal perforation.

      Based on the patient’s symptoms, it appears that they are more consistent with a Neisseria gonorrhoea infection. The rapid onset, copious discharge, and tender preauricular lymphadenopathy are indicative of this type of infection.

      Treatment for gonococcal conjunctivitis in adults is typically based on limited research. However, a study has shown that all 12 patients responded well to a single 1 g intramuscular injection of ceftriaxone, along with a single episode of ocular lavage with saline.

      In summary, sexually transmitted eye infections can be caused by either Chlamydia trachomatis or Neisseria gonorrhoea. Differentiating between the two is important in order to provide appropriate treatment. The patient in this case exhibits symptoms that align more closely with a Neisseria gonorrhoea infection, which carries a higher risk of complications. Treatment options for gonococcal conjunctivitis are limited, but a single injection of ceftriaxone has shown positive results in previous studies.

    • This question is part of the following fields:

      • Ophthalmology
      11
      Seconds
  • Question 11 - A 32-year-old woman with a history of sickle-cell disease undergoes a blood transfusion...

    Incorrect

    • A 32-year-old woman with a history of sickle-cell disease undergoes a blood transfusion for severe anemia. Four weeks later, she arrives at the Emergency Department complaining of a skin rash, high temperature, and diarrhea. The medical team orders blood tests, which reveal low levels of all blood cells and abnormal liver function. What is the most probable transfusion reaction that occurred?

      Your Answer: Delayed haemolytic reaction

      Correct Answer: Graft-vs-host disease

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      27.4
      Seconds
  • Question 12 - You witness the sudden arrival of a baby in one of the cubicles...

    Correct

    • You witness the sudden arrival of a baby in one of the cubicles within the Emergency Department. Your consultant evaluates the newborn one minute after birth and notifies you that:
      The limbs appear bluish, while the body has a pink hue.
      The heart rate measures 110 beats per minute.
      The baby responds with cries upon stimulation.
      There is noticeable flexion in the limbs.
      The baby's cry is strong and robust.
      What is the Apgar score of the neonate at one minute?

      Your Answer: 8

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
      26.1
      Seconds
  • Question 13 - A 7 year old girl is brought into the emergency department with a...

    Incorrect

    • A 7 year old girl is brought into the emergency department with a 24 hour history of vomiting and becoming increasingly tired. A capillary blood glucose is taken and the result is shown as 25 mmol/l. You suspect diabetic ketoacidosis (DKA). Which of the following is included in the diagnostic criteria for DKA?

      Your Answer: Blood pH <7.3 or bicarbonate <15 mmol/L

      Correct Answer:

      Explanation:

      To diagnose diabetic ketoacidosis (DKA), all three of the following criteria must be present: ketonaemia (≥3 mmol/L) or ketonuria (> 2+ on urine dipstick), blood glucose > 11 mmol/L or known diabetes mellitus, and blood pH <7.3 or bicarbonate < 15 mmol/L. It is important to note that plasma osmolality and anion gap, although typically elevated in DKA, are not included in the diagnostic criteria. 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:

      • Endocrinology
      19.3
      Seconds
  • Question 14 - A 32 year old male is brought into the emergency department with wheezing...

    Correct

    • A 32 year old male is brought into the emergency department with wheezing and swelling of the lips. The patient's friend informs you that he has a nut allergy. Anaphylaxis is suspected. What is the underlying pathophysiology of anaphylaxis?

      Your Answer: IgE mediated immediate reaction

      Explanation:

      Anaphylaxis is a severe allergic reaction that is caused by the immune system overreaction to a specific allergen. This reaction is classified as a Type I hypersensitivity reaction, which means it is mediated by the IgE antibodies.

      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.
      https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf

    • This question is part of the following fields:

      • Allergy
      5.6
      Seconds
  • Question 15 - A 10-year-old girl comes in with sudden abdominal pain. She has a high...

    Correct

    • A 10-year-old girl comes in with sudden abdominal pain. She has a high temperature and feels very nauseous. During the examination, she experiences tenderness in the right iliac fossa. You suspect she may have acute appendicitis.
      What is the surface marking for McBurney's point in this case?

      Your Answer: One-third of the distance from the anterior superior iliac spine to the umbilicus

      Explanation:

      Appendicitis is a condition characterized by the acute inflammation of the appendix. It is a common cause of the acute abdomen, particularly affecting children and young adults in their 20s and 30s. The typical presentation of appendicitis involves experiencing poorly localized periumbilical pain, which is pain originating from the visceral peritoneum. Within a day or two, this pain tends to localize to a specific point known as McBurney’s point, which is associated with pain from the parietal peritoneum. Alongside the pain, individuals with appendicitis often experience symptoms such as fever, loss of appetite, and nausea.

      McBurney’s point is defined as the point that lies one-third of the distance from the anterior superior iliac spine to the umbilicus. This point roughly corresponds to the most common position where the base of the appendix attaches to the caecum.

    • This question is part of the following fields:

      • Surgical Emergencies
      8.6
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  • Question 16 - A 2 year old toddler is brought into the resuscitation bay after collapsing...

    Incorrect

    • A 2 year old toddler is brought into the resuscitation bay after collapsing and having a seizure. A capillary blood glucose test shows a reading of 0.9 mmol/L. Your consultant instructs you to initiate an intravenous glucose infusion. What is the most suitable dosage?

      Your Answer: 20 mL/kg/hour of 20% dextrose

      Correct Answer: 5 mL/kg/hour of 10% dextrose

      Explanation:

      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:

      • Neonatal Emergencies
      10.9
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  • Question 17 - A 65 year old is brought into the emergency department (ED) after experiencing...

    Correct

    • A 65 year old is brought into the emergency department (ED) after experiencing a head injury. As part of the initial assessment, you evaluate the patient's Glasgow Coma Scale (GCS) score. In an adult patient, what is the minimum GCS score that necessitates an urgent CT scan of the head?

      Your Answer: 13

      Explanation:

      In an adult patient, a Glasgow Coma Scale (GCS) score of 13 or lower necessitates an urgent CT scan of the head. The GCS is a neurological assessment tool that evaluates a patient’s level of consciousness and neurological functioning. It consists of three components: eye opening, verbal response, and motor response. Each component is assigned a score ranging from 1 to 4 or 5, with a higher score indicating a higher level of consciousness.

      A GCS score of 15 is considered normal and indicates that the patient is fully conscious. A score of 14 or 13 suggests a mild impairment in consciousness, but it may not necessarily require an urgent CT scan unless there are other concerning symptoms or signs. However, a GCS score of 11 or 9 indicates a moderate to severe impairment in consciousness, which raises concerns for a potentially serious head injury. In these cases, an urgent CT scan of the head is necessary to assess for any structural brain abnormalities or bleeding that may require immediate intervention.

      Therefore, in this case, the minimum GCS score that necessitates an urgent CT scan of the head is 13.

      Further Reading:

      Indications for CT Scanning in Head Injuries (Adults):
      – CT head scan should be performed within 1 hour if any of the following features are present:
      – GCS < 13 on initial assessment in the ED
      – GCS < 15 at 2 hours after the injury on assessment in the ED
      – Suspected open or depressed skull fracture
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – Post-traumatic seizure
      – New focal neurological deficit
      – > 1 episode of vomiting

      Indications for CT Scanning in Head Injuries (Children):
      – CT head scan should be performed within 1 hour if any of the features in List 1 are present:
      – Suspicion of non-accidental injury
      – Post-traumatic seizure but no history of epilepsy
      – GCS < 14 on initial assessment in the ED for children more than 1 year of age
      – Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
      – At 2 hours after the injury, GCS < 15
      – Suspected open or depressed skull fracture or tense fontanelle
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – New focal neurological deficit
      – For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

      – CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
      – Loss of consciousness lasting more than 5 minutes (witnessed)
      – Abnormal drowsiness
      – Three or more discrete episodes of vomiting
      – Dangerous mechanism of injury (high-speed road traffic accident, fall from a height of

    • This question is part of the following fields:

      • Neurology
      8.7
      Seconds
  • Question 18 - A 28 year old female is brought into the emergency department after a...

    Correct

    • A 28 year old female is brought into the emergency department after a jet skiing accident at a local lake. The patient fell off the jet ski but her leg got caught in the handlebars and she was submerged for 2-3 minutes before being freed. The patient's friends started rescue breaths and chest compressions as the patient was unconscious but were stopped after approximately 30 seconds by an off duty lifeguard who assessed the patient and determined she was breathing spontaneously and had a pulse. On examination, the patient is breathing spontaneously with intermittent coughing, oxygen saturation levels are 97% on room air, a few crackling sounds are heard in the lower parts of the lungs, and the patient's Glasgow Coma Scale score is 13 out of 15.

      Which of the following should be included in the initial management of this patient?

      Your Answer: Obtain an arterial blood gas sample for evidence of hypoxia

      Explanation:

      It is recommended to obtain an arterial blood gas (ABG) sample from all patients who have experienced submersion (drowning) as even individuals without symptoms may have a surprising level of hypoxia. Draining the lungs is not effective and not recommended. There is no strong evidence to support the routine use of antibiotics as a preventive measure. Steroids have not been proven to be effective in treating drowning. All drowning patients, except those with normal oxygen levels, normal saturations, and normal lung sounds, should receive supplemental oxygen as significant hypoxia can occur without causing difficulty in breathing.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

    • This question is part of the following fields:

      • Trauma
      11.4
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  • Question 19 - A 60-year-old individual arrives at the emergency department complaining of a nosebleed. The...

    Correct

    • A 60-year-old individual arrives at the emergency department complaining of a nosebleed. The patient informs you that they have been applying pressure to the soft part of their nose for 10 minutes. You request the patient to release the pressure for examination purposes, but upon doing so, bleeding commences from both nostrils, and the bleeding point remains unseen. What would be the most suitable course of action for managing this patient?

      Your Answer: Insert bilateral nasal tampons

      Explanation:

      Nasal packing is recommended for cases of bilateral epistaxis (nosebleeds on both sides) and when it is difficult to locate the source of bleeding. If initial first aid measures, such as applying pressure to the soft part of the nose, do not stop the bleeding or if there is no visible bleeding point, nasal packing is necessary. In the UK, the most commonly used methods for nasal packing are Merocel nasal tampons and rapid-rhino inflatable nasal packs. If anterior nasal packing fails to control the bleeding, posterior nasal packing with a Foley catheter may be considered. Ideally, this procedure should be performed by an ENT surgeon, but if specialist input is not immediately available, a trained clinician in the emergency department can carry it out.

      Further Reading:

      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
      9.4
      Seconds
  • Question 20 - A 60-year-old man comes to the clinic complaining of abdominal pain. He has...

    Incorrect

    • A 60-year-old man comes to the clinic complaining of abdominal pain. He has a past medical history of a duodenal ulcer. During his visit, he experiences two episodes of vomiting blood.

      Which blood vessel is most likely to be involved?

      Your Answer:

      Correct Answer: Gastroduodenal artery

      Explanation:

      Peptic ulcer disease is a fairly common condition that can affect either the stomach or the duodenum. However, the duodenum is more commonly affected, and in these cases, it is caused by a break in the mucosal lining of the duodenum.

      This condition is more prevalent in men and is most commonly seen in individuals between the ages of 20 and 60. In fact, over 95% of patients with duodenal ulcers are found to be infected with H. pylori. Additionally, chronic usage of nonsteroidal anti-inflammatory drugs (NSAIDs) is often associated with the development of duodenal ulcers.

      When it comes to the location of duodenal ulcers, they are most likely to occur in the superior (first) part of the duodenum, which is positioned in front of the body of the L1 vertebra.

      The typical clinical features of duodenal ulcers include experiencing epigastric pain that radiates to the back, with the pain often worsening at night. This pain typically occurs 2-3 hours after eating and is relieved by consuming food and drinking milk. It can also be triggered by skipping meals or experiencing stress.

      Possible complications that can arise from duodenal ulcers include perforation, which can lead to peritonitis, as well as gastrointestinal hemorrhage. Gastrointestinal hemorrhage can manifest as haematemesis (vomiting blood), melaena (black, tarry stools), or occult bleeding. Strictures causing obstruction can also occur as a result of duodenal ulcers.

      In cases where gastrointestinal hemorrhage occurs as a result of duodenal ulceration, it is usually due to erosion of the gastroduodenal artery.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology & Poisoning (1/1) 100%
Cardiology (3/3) 100%
Basic Anaesthetics (1/2) 50%
Neurology (2/2) 100%
Maxillofacial & Dental (1/1) 100%
Urology (1/1) 100%
Ophthalmology (1/1) 100%
Haematology (0/1) 0%
Neonatal Emergencies (1/2) 50%
Endocrinology (0/1) 0%
Allergy (1/1) 100%
Surgical Emergencies (1/1) 100%
Trauma (1/1) 100%
Ear, Nose & Throat (1/1) 100%
Passmed