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Question 1
Incorrect
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A 45-year-old man comes in with sudden onset of severe lower back pain. Upon evaluation, you determine that prescribing ibuprofen and codeine phosphate would be appropriate. The patient has a history of depression and is currently taking fluoxetine. In which ONE situation would you consider adding a PPI to provide gastro-protection?
Your Answer: Ibuprofen dose of 400 mg TDS
Correct Answer: Co-prescription of fluoxetine
Explanation:According to the current recommendations by NICE, it is advised to consider gastro-protection for patients who meet more than one of the following criteria: using the highest recommended dose of an NSAID, being 65 years or older, having a history of peptic ulcer or gastrointestinal bleeding, taking medications that increase the risk, using low dose aspirin, anticoagulants, corticosteroids, or anti-depressants including SSRIs and SNRIs, requiring prolonged NSAID usage, having osteoarthritis or rheumatoid arthritis at any age, or experiencing long-term back pain if older than 45.
If gastro-protection is necessary, it is recommended to choose either omeprazole 20 mg daily or lansoprazole 15-30 mg daily as the preferred PPIs.
In the case of this patient, they are currently taking 400 mg of ibuprofen three times a day, which is within the maximum recommended dose of 2.4 g daily. Therefore, there is no need for gastro-protection based on the dosage of ibuprofen alone. Additionally, factors such as co-prescription of codeine, a raised BMI, and a family history of peptic ulceration would also not warrant the need for gastro-protection.
For more information, you can refer to the NICE Clinical Knowledge Summary on prescribing issues with NSAIDs.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 2
Correct
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Your hospital’s cardiology department is currently evaluating the utility of a triple marker test for use risk stratification of patients with a suspected acute coronary syndrome. The test will use troponin I, myoglobin and heart-type fatty acid-binding protein (HFABP).
How long after heart attack do troponin I levels return to normal?Your Answer: 3-10 days
Explanation:The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.
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This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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You evaluate the airway and breathing of a child who has been brought into the emergency room by an ambulance after being rescued from a house fire. You suspect that the child may have signs of airway obstruction.
Which of the following statements about managing the airway and breathing in burned patients is correct?Your Answer: 100% oxygen should be continued until carboxyhaemoglobin levels fall to <5%
Correct Answer:
Explanation:Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.
According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.
To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.
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This question is part of the following fields:
- Trauma
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Question 4
Incorrect
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A 68-year-old man with a history of atrial fibrillation (AF) presents a small, surface-level, cut on his leg that is oozing and still bleeding despite applying pressure for approximately 30 minutes. He is currently taking warfarin for his AF and his INR today is 6.7.
What is the most suitable approach to manage the reversal of his warfarin?Your Answer:
Correct Answer: Stop warfarin and give IV vitamin K
Explanation:The current recommendations from NICE for managing warfarin in the presence of bleeding or an abnormal INR are as follows:
In cases of major active bleeding, regardless of the INR level, the first step is to stop administering warfarin. Next, 5 mg of vitamin K (phytomenadione) should be given intravenously. Additionally, dried prothrombin complex concentrate, which contains factors II, VII, IX, and X, should be administered. If dried prothrombin complex is not available, fresh frozen plasma can be given at a dose of 15 ml/kg.
If the INR is greater than 8.0 and there is minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.
If the INR is greater than 8.0 with no bleeding, warfarin should be stopped. Oral administration of 1-5 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.
If the INR is between 5.0-8.0 with minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and warfarin can be restarted once the INR is less than 5.0.
If the INR is between 5.0-8.0 with no bleeding, one or two doses of warfarin should be withheld, and the subsequent maintenance dose should be reduced.
For more information, please refer to the NICE Clinical Knowledge Summary on the management of warfarin therapy and the BNF guidance on the use of phytomenadione.
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This question is part of the following fields:
- Haematology
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Question 5
Incorrect
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A 62-year-old man presents sweaty and distressed, complaining of abdominal pain and nausea. On examination, he has marked abdominal tenderness that is maximal in the epigastric area. Following his blood results, you make a diagnosis of acute pancreatitis. He is a non-drinker.
His venous bloods are shown below:
Hb: 13.5 g/dL
White cell count: 14.2 x 109/L
Blood glucose 7.9 mmol/L
AST 275 IU/L
LDH 290 IU/L
Amylase: 980 IU/L
What is his Ranson score at admission?Your Answer:
Correct Answer: Three
Explanation:Acute pancreatitis is a common and serious cause of acute abdominal pain. It occurs when the pancreas becomes inflamed, leading to the release of enzymes that cause the organ to digest itself. The symptoms of acute pancreatitis include severe epigastric pain, nausea, vomiting, and pain that may radiate to the T6-T10 dermatomes or shoulder tip due to irritation of the phrenic nerve. Other signs include fever, tenderness in the epigastric area, jaundice, and the presence of Gray-Turner and Cullen signs, which are ecchymosis of the flank and peri-umbilical area, respectively.
To determine the severity of acute pancreatitis, the Ranson criteria are used as a clinical prediction rule. A score greater than three indicates severe pancreatitis with a mortality rate of over 15%. The criteria assessed upon admission include age over 55 years, white cell count above 16 x 109/L, blood glucose level higher than 11 mmol/L, serum AST level exceeding 250 IU/L, and serum LDH level surpassing 350 IU/L.
In this particular case, the patient’s Ranson score is three. This is based on the fact that she is 56 years old, her white cell count is 16.7 x 109/L, and her AST level is 358 IU/L.
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This question is part of the following fields:
- Surgical Emergencies
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Question 6
Incorrect
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A 45-year-old hiker is brought in by helicopter after being stranded on a hillside overnight. The rescue team informs you that according to the Swiss Staging system, he is at stage IV.
What is the most accurate description of his current medical condition?Your Answer:
Correct Answer: Not breathing
Explanation:Hypothermia occurs when the core body temperature drops below 35°C. It is categorized as mild (32-35°C), moderate (28-32°C), or severe (<28°C). Rescuers at the scene can use the Swiss staging system to describe the condition of victims. The stages range from clearly conscious and shivering to unconscious and not breathing, with death due to irreversible hypothermia being the most severe stage. There are several risk factors for hypothermia, including environmental exposure, unsatisfactory housing, poverty, lack of cold awareness, drugs, alcohol, acute confusion, hypothyroidism, and sepsis. The clinical features of hypothermia vary depending on the severity. At 32-35°C, symptoms may include apathy, amnesia, ataxia, and dysarthria. At 30-32°C, there may be a decreased level of consciousness, hypotension, arrhythmias, respiratory depression, and muscular rigidity. Below 30°C, ventricular fibrillation may occur, especially with excessive movement or invasive procedures. Diagnosing hypothermia involves checking the core temperature using an oesophageal, rectal, or tympanic probe with a low reading thermometer. Rectal and tympanic temperatures may lag behind core temperature and are unreliable in hypothermia. Various investigations should be carried out, including blood tests, blood glucose, amylase, blood cultures, arterial blood gas, ECG, chest X-ray, and CT head if there is suspicion of head injury or CVA. The management of hypothermia involves supporting the ABCs, treating the patient in a warm room, removing wet clothes and drying the skin, monitoring the ECG, providing warmed, humidified oxygen, correcting hypoglycemia with IV glucose, and handling the patient gently to avoid VF arrest. Rewarming methods include passive Rewarming with warm blankets or Bair hugger/polythene sheets, surface Rewarming with a water bath, core Rewarming with heated, humidified oxygen or peritoneal lavage, and extracorporeal Rewarming via cardiopulmonary bypass for severe hypothermia/cardiac arrest. In the case of hypothermic cardiac arrest, CPR should be performed with chest compressions and ventilations at standard rates.
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This question is part of the following fields:
- Environmental Emergencies
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Question 7
Incorrect
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A 6-year-old boy is brought to the Emergency Department by his parents following a brief self-limiting seizure at home. He was diagnosed with strep throat by his pediatrician yesterday and started on antibiotics. Despite this, he has been experiencing intermittent high fevers throughout the day. After a thorough evaluation, you determine that he has had a febrile seizure.
What is his estimated risk of developing epilepsy in the long term?Your Answer:
Correct Answer: 6%
Explanation:Febrile convulsions are harmless, generalized seizures that occur in otherwise healthy children who have a fever due to an infection outside the brain. To diagnose febrile convulsions, the child must be developing normally, the seizure should last less than 20 minutes, have no complex features, and not cause any lasting abnormalities.
The prognosis for febrile convulsions is generally positive. There is a 30 to 50% chance of experiencing recurrent febrile convulsions, with a 10% risk of recurrence within the first 24 hours. The likelihood of developing long-term epilepsy is around 6%.
Complex febrile convulsions are characterized by certain factors. These include focal seizures, seizures lasting longer than 15 minutes, experiencing more than one convulsion during a single fever episode, or the child being left with a focal neurological deficit.
Overall, febrile convulsions are typically harmless and do not cause any lasting damage.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a traumatic brain injury. What should be included in the initial management of a patient with elevated intracranial pressure (ICP)?
Your Answer:
Correct Answer: Maintain systolic blood pressure >90 mmHg
Explanation:Maintaining adequate blood pressure is crucial in managing increased intracranial pressure (ICP). The recommended blood pressure targets may vary depending on the source. The Scottish Intercollegiate Guidelines Network (SIGN) suggests maintaining an adequate blood pressure, while the 4th edition of the Brain Trauma Foundation recommends maintaining a systolic blood pressure (SBP) above 100 mm Hg for individuals aged 50-69 years (or above 110 mm Hg for those aged 15-49 years) to reduce mortality and improve outcomes.
When managing a patient with increased ICP, the initial steps should include maintaining normal body temperature to prevent fever, positioning the patient with a 30º head-up tilt, and administering analgesia and sedation as needed. It is important to monitor and maintain blood pressure, using inotropes if necessary to achieve the target. Additionally, preparations should be made to use medications such as Mannitol or hypertonic saline to lower ICP if required. Hyperventilation may also be considered, although it carries the risk of inducing ischemia and requires monitoring of carbon dioxide levels.
Further Reading:
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.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 25-year-old woman presents with a persistent sore throat that has been bothering her for the past five days. She denies having any symptoms of a cold and does not have a cough. She has a clean medical history, does not take any medications, and has no known drug allergies. During the examination, she has a normal body temperature and a few tender lymph nodes in her neck. Her throat and tonsils appear red and inflamed, with a significant amount of exudate on her left tonsil.
Using the FeverPAIN Score to evaluate her sore throat, what would be the most appropriate course of action for her at this point?Your Answer:
Correct Answer: She should be offered a 'back-up prescription' for penicillin V
Explanation:The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.
The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.
According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 10
Incorrect
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A child is brought in by their family with noticeable tremors, muscle contractions, muscle spasms, and slow movements. They have a significant history of mental health issues and are currently taking multiple medications.
Which of the following medications is most likely causing these side effects?Your Answer:
Correct Answer: Haloperidol
Explanation:Extrapyramidal side effects refer to drug-induced movements that encompass acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome. These side effects occur due to the blockade or depletion of dopamine in the basal ganglia, leading to a lack of dopamine that often resembles idiopathic disorders of the extrapyramidal system.
The primary culprits behind extrapyramidal side effects are the first-generation antipsychotics, which act as potent antagonists of the dopamine D2 receptor. Among these antipsychotics, haloperidol and fluphenazine are the two drugs most commonly associated with extrapyramidal side effects. On the other hand, second-generation antipsychotics like olanzapine have lower rates of adverse effects on the extrapyramidal system compared to their first-generation counterparts.
While less frequently, other medications can also contribute to extrapyramidal symptoms. These include certain antidepressants, lithium, various anticonvulsants, antiemetics, and, in rare cases, oral contraceptive agents.
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This question is part of the following fields:
- Pharmacology & Poisoning
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