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  • Question 1 - A 45-year-old woman comes in with nausea, disorientation, and decreased urine production. Her...

    Correct

    • A 45-year-old woman comes in with nausea, disorientation, and decreased urine production. Her urine output has dropped to 0.4 mL/kg/hour over the last 15 hours. After conducting additional tests, she is diagnosed with acute kidney injury (AKI).
      What stage of AKI does she have?

      Your 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
      25.5
      Seconds
  • Question 2 - A 52 year old male visits the emergency department after crashing into the...

    Correct

    • A 52 year old male visits the emergency department after crashing into the side of a car while riding his bicycle downhill at a fast pace. The handlebars were forcefully pushed into his abdomen, resulting in a noticeable large contusion on the front of his abdominal wall. The patient's vital signs are as follows:

      Blood pressure: 92/60 mmHg
      Pulse rate: 104 bpm
      Temperature: 37.1ºC
      SpO2: 97% on room air

      Which two abdominal organs are most commonly affected in cases of blunt abdominal trauma?

      Your Answer: Liver and spleen

      Explanation:

      Blunt abdominal trauma often results in injury to the liver and spleen, which are the two organs most commonly affected. The liver, being the largest and located in a vulnerable position, is particularly prone to injury in such cases.

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

    • This question is part of the following fields:

      • Trauma
      9.7
      Seconds
  • Question 3 - A 35-year-old woman comes in with a red, hot, swollen left knee a...

    Incorrect

    • A 35-year-old woman comes in with a red, hot, swollen left knee a few days after returning from a vacation in Thailand. She also reports feeling generally unwell and has a rash on her trunk. Which antibiotic would be the most suitable for this patient?

      Your Answer: Clindamycin

      Correct Answer: Cefotaxime

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      33
      Seconds
  • Question 4 - You are requested to evaluate a 42-year-old individual with a knee injury sustained...

    Correct

    • You are requested to evaluate a 42-year-old individual with a knee injury sustained from leaping off a tall wall and landing on a leg that was completely extended. It is suspected that the patient may have experienced a quadriceps tendon rupture. Which of the subsequent observations would indicate this diagnosis?

      Your Answer: Loss of of active knee extension

      Explanation:

      When a complete quadriceps rupture occurs, it leads to the inability to actively extend the knee. Please refer to the following notes for more detailed information.

      Further Reading:

      A quadriceps tendon tear or rupture is a traumatic lower limb and joint injury that occurs when there is heavy loading on the leg, causing forced contraction of the quadriceps while the foot is planted and the knee is partially bent. These tears most commonly happen at the osteotendinous junction between the tendon and the superior pole of the patella. Quadriceps tendon ruptures are more common than patellar tendon ruptures.

      When a quadriceps tendon tear occurs, the patient usually experiences a tearing sensation and immediate pain. They will then typically complain of pain around the knee and over the tendon. Clinically, there will often be a knee effusion and weakness or inability to actively extend the knee.

      In cases of complete quadriceps tears, the patella will be displaced distally, resulting in a low lying patella or patella infera, also known as patella baja. Radiological measurements, such as the Insall-Salvati ratio, can be used to measure patella height. The Insall-Salvati ratio is calculated by dividing the patellar tendon length by the patellar length. A normal ratio is between 0.8 to 1.2, while a low lying patella (patella baja) is less than 0.8 and a high lying patella (patella alta) is greater than 1.2.

    • This question is part of the following fields:

      • Trauma
      11.2
      Seconds
  • Question 5 - A 22 year old male patient is brought into the emergency department with...

    Correct

    • A 22 year old male patient is brought into the emergency department with a stab wound to the left side of the chest. During assessment, you observe a 2 cm wide entry wound overlying the 4th intercostal space anterior axillary line, and you can hear a bubbling sound when the patient exhales. Upon examination, the trachea is central, there is reduced air entry on the left side, and percussion reveals a resonant left hemithorax.

      What is the probable diagnosis?

      Your Answer: Open pneumothorax

      Explanation:

      An open pneumothorax, also known as a sucking chest wound, occurs when air enters the pleural space due to an open chest wound or physical defect. This can lead to ineffective ventilation, causing hypoxia and hypercarbia. Air can enter the pleural cavity passively or be sucked in during inspiration, leading to lung collapse on that side. Sucking wounds can be heard audibly as air passes through the chest defect, and entry wounds are usually visible.

      To manage an open pneumothorax, respiratory compromise can be alleviated by covering the wound with a dressing or using a chest seal device. It is important to ensure that one side of the dressing is not occluded, allowing the dressing to function as a flutter valve and prevent significant air ingress during inspiration while allowing air to escape the pleural cavity. If tension pneumothorax is suspected after applying a dressing, the dressing may need to be temporarily removed for decompression.

      Intubation and intermittent positive pressure ventilation (IPPV) can be used to ventilate the patient and alleviate respiratory distress. Definitive management involves either inserting a chest drain or surgically repairing the defect. Surgical repair is typically preferred, especially for large wounds.

    • This question is part of the following fields:

      • Trauma
      19.5
      Seconds
  • Question 6 - You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would...

    Incorrect

    • You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would like to ask you some questions about her diagnosis.
      Which ONE statement about this condition is accurate?

      Your Answer: It most commonly affects the posterior pituitary

      Correct Answer: Diabetes insipidus may occur

      Explanation:

      Sheehan’s syndrome is a condition where the pituitary gland becomes damaged due to insufficient blood flow and shock during and after childbirth, leading to hypopituitarism. The risk of developing this syndrome is higher in pregnancies with conditions that increase the chances of bleeding, such as placenta praevia and multiple pregnancies. However, Sheehan’s syndrome is quite rare, affecting only 1 in 10,000 pregnancies.

      During pregnancy, the anterior pituitary gland undergoes hypertrophy, making it more vulnerable to ischaemia in the later stages. While the posterior pituitary gland is usually not affected due to its own direct blood supply, there have been rare cases where it is involved. In these instances, central diabetes insipidus, a form of posterior pituitary dysfunction, can occur as a complication of Sheehan’s syndrome.

      The clinical features of Sheehan’s syndrome include the absence or infrequency of menstrual periods, the inability to produce milk and breastfeed (galactorrhoea), decreased libido, fatigue and tiredness, loss of pubic and axillary hair, and the potential development of secondary hypothyroidism and adrenal insufficiency. Serum prolactin levels are typically low (less than 5ng/ml). An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.

      Treatment for Sheehan’s syndrome involves hormone replacement therapy. With appropriate management, the prognosis for this condition is excellent.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      11.2
      Seconds
  • Question 7 - A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain...

    Correct

    • A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain radiating down the inner side of his left upper arm into his forearm and hand. He has a history of heavy smoking and has been diagnosed with COPD. Upon examination, he exhibits weakness and noticeable muscle wasting in his forearm and hand on the same side. Additionally, he has a Horner's syndrome on the affected side. The Chest X-ray image is provided below:

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Pancoast tumour

      Explanation:

      This patient presents with a noticeable mass at the top of the right lung, which is clearly visible on the chest X-ray. Based on the symptoms and clinical presentation, it is highly likely that this is a Pancoast tumor, and the overall diagnosis is Pancoast syndrome.

      A Pancoast tumor is a type of tumor that develops at the apex of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. The majority of Pancoast tumors are classified as non-small cell cancers.

      Pancoast syndrome occurs when the tumor invades various structures and tissues around the thoracic inlet. This includes the invasion of the cervical sympathetic plexus on the same side as the tumor, leading to the development of Horner’s syndrome. Additionally, there may be reflex sympathetic dystrophy in the arm on the affected side, resulting in increased sensitivity to touch and changes in the skin.

      Patients with Pancoast syndrome may also experience shoulder and arm pain due to the tumor invading the brachial plexus roots C8-T1. This can lead to muscle wasting in the hand and tingling sensations in the inner side of the arm. In some cases, there may be involvement of the unilateral recurrent laryngeal nerve, causing unilateral vocal cord paralysis and resulting in a hoarse voice and/or a bovine cough. Phrenic nerve involvement is less common but can also occur.

      Horner’s syndrome, which is a key feature of Pancoast syndrome, is caused by compression of the sympathetic chain from the hypothalamus to the orbit. The three main symptoms of Horner’s syndrome are drooping of the eyelid (ptosis), constriction of the pupil (pupillary miosis), and lack of sweating on the forehead (anhydrosis).

    • This question is part of the following fields:

      • Respiratory
      23.4
      Seconds
  • Question 8 - You are asked to evaluate a 14 year old who has arrived at...

    Correct

    • You are asked to evaluate a 14 year old who has arrived at the emergency department with a sore throat, fatigue, and fever lasting for 5 days. After conducting your examination, you inform the patient that you suspect she may have mononucleosis.

      Which of the following is a commonly known complication of mononucleosis?

      Your Answer: Splenic rupture

      Explanation:

      Glandular fever, also known as infectious mononucleosis, can lead to a rare but potentially life-threatening complication called splenic rupture. Although splenomegaly (enlarged spleen) is common in glandular fever, it often does not cause any symptoms and cannot be felt during a physical examination. However, this increases the risk of splenic rupture, which can occur spontaneously or with minimal trauma. The spleen typically reaches its maximum size around two weeks into the illness before gradually shrinking. To prevent splenic rupture, patients are advised to avoid heavy lifting and contact sports for at least one month from the onset of the illness. Other complications of glandular fever include prolonged fatigue, mild hepatitis leading to jaundice, thrombocytopenia (low platelet count) with an increased risk of bleeding, neurological conditions such as Guillain-Barré syndrome, optic neuritis, Bell’s palsy, myocarditis, and nephritis.

      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:

      • Infectious Diseases
      8.2
      Seconds
  • Question 9 - You start cephalexin treatment for a 70-year-old man with a lower respiratory tract...

    Incorrect

    • You start cephalexin treatment for a 70-year-old man with a lower respiratory tract infection. He has a history of chronic kidney disease, and his glomerular filtration rate (GFR) is currently 9 ml/minute.

      What is the most appropriate course of action when prescribing this medication to this patient?

      Your Answer: The drug dose should be reduced

      Correct Answer: The dose frequency should be reduced

      Explanation:

      Cephalexin is a type of cephalosporin medication that is eliminated from the body through the kidneys. Cephalosporin drugs have been linked to direct harm to the kidneys and can build up in individuals with kidney problems.

      The typical dosage for cephalexin is 250 mg taken four times a day. For more severe infections or infections caused by organisms that are less susceptible to the medication, the dosage may be doubled. The manufacturer recommends reducing the frequency of dosing in individuals with kidney impairment. In cases where the glomerular filtration rate (GFR) is less than 10 ml/minute, the recommended dosage is 250-500 mg taken once or twice a day, depending on the severity of the infection.

    • This question is part of the following fields:

      • Nephrology
      46.4
      Seconds
  • Question 10 - A 27 year old male presents to the emergency department with noticeable swelling...

    Incorrect

    • A 27 year old male presents to the emergency department with noticeable swelling and bruising on his face. He reports being attacked and punched in the face repeatedly. A zygomatic fracture is suspected, prompting you to request facial X-rays. What are the two standard X-ray views included in the facial X-ray series?

      Your Answer: Anteroposterior and OPG

      Correct Answer: Occipitomental and occipitomental 30º

      Explanation:

      The standard facial X-ray series consists of two occipitomental x-rays: the Occipitomental (or Occipitomental 15º) and the Occipitomental 30º. The Occipitomental view captures the upper and middle thirds of the face, showing important structures such as the orbital margins, frontal sinuses, zygomatic arches, and maxillary antra. On the other hand, the Occipitomental 30º view uses a 30º caudal angulation, resulting in a less clear visualization of the orbits but a clearer view of the zygomatic arches and the walls of the maxillary antra.

      Further Reading:

      Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.

      Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.

      Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.

      Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.

      Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      16.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Nephrology (1/2) 50%
Trauma (3/3) 100%
Musculoskeletal (non-traumatic) (0/1) 0%
Obstetrics & Gynaecology (0/1) 0%
Respiratory (1/1) 100%
Infectious Diseases (1/1) 100%
Maxillofacial & Dental (0/1) 0%
Passmed