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  • Question 1 - A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination...

    Incorrect

    • A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination of her cardiovascular system, you find a collapsing pulse. Her apex beat is hyperkinetic and displaced to the side. During auscultation, you detect an early diastolic murmur that is most pronounced when the patient is sitting forward and exhaling.

      What is the SINGLE most probable diagnosis?

      Your Answer: Mitral stenosis

      Correct Answer: Aortic regurgitation

      Explanation:

      Aortic regurgitation is a condition where the aortic valve fails to close tightly, resulting in the backflow of blood from the aorta into the left ventricle during ventricular diastole. This valvular lesion presents with various clinical symptoms and signs.

      The clinical symptoms of aortic regurgitation include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. These symptoms are experienced by patients during physical activity, while lying flat, and during episodes of sudden nighttime breathlessness, respectively.

      On the other hand, the clinical signs of aortic regurgitation can be observed during physical examination. These signs include a collapsing pulse, widened pulse pressure, hyperkinetic laterally displaced apex beat, and a thrill in the aortic area. Additionally, an early diastolic murmur can be heard, which is loudest at the lower left sternal edge when the patient is sitting forward and exhaling.

      Aortic regurgitation is also associated with several eponymous signs, which are named after the physicians who first described them. These signs include Corrigan’s sign, which is characterized by visible and forceful neck pulsation. De Musset’s sign refers to head nodding in time with the heartbeat. Quincke’s sign is the observation of visible nail bed capillary pulsation. Duroziez’s sign is the presence of a diastolic murmur heard proximal to femoral artery compression. Traube’s sign is the perception of a pistol shot sound over the femoral arteries. The Lighthouse sign is the blanching and flushing of the forehead. Becker’s sign is the pulsation seen in retinal vessels. Rosenbach’s sign is the presence of a pulsatile liver. Lastly, Muller’s sign refers to pulsations of the uvula.

      In summary, aortic regurgitation is a valvular lesion that leads to the incomplete closure of the aortic valve. It manifests with various clinical symptoms, signs, and eponymous findings, which can be identified through careful examination and observation.

    • This question is part of the following fields:

      • Cardiology
      861.6
      Seconds
  • Question 2 - A 2-year-old toddler is brought to the Emergency Department by his father with...

    Incorrect

    • A 2-year-old toddler is brought to the Emergency Department by his father with a high temperature. NICE suggests using the traffic light system to evaluate the likelihood of a severe illness in children under 3 with a fever.
      Based on the NICE traffic light system, which of the subsequent symptoms or signs indicate a high risk of a severe illness?

      Your Answer: Not responding normally to social cues

      Correct Answer: Appearing ill to a healthcare professional

      Explanation:

      The traffic light system is a useful tool for evaluating the potential risk of serious illness in children. This system categorizes clinical features into three groups based on severity: red (high-risk), amber (intermediate-risk), and green (low-risk).

      Children displaying any of the following symptoms or signs fall into the high-risk group for serious illness: pale/mottled/ashen/blue skin, lips or tongue; lack of response to social cues; appearing unwell to a healthcare professional; inability to wake or stay awake when roused; weak, high-pitched, or continuous cry; grunting; respiratory rate exceeding 60 breaths per minute; moderate or severe chest indrawing; reduced skin turgor; and bulging fontanelle.

      Children exhibiting any of the following symptoms or signs are considered at least intermediate-risk for serious illness: pallor of skin, lips or tongue reported by parent or caregiver; abnormal response to social cues; absence of a smile; waking only with prolonged stimulation; decreased activity; nasal flaring; dry mucous membranes; poor feeding in infants; reduced urine output; and rigors.

      Children displaying any of the following symptoms or signs are classified as low-risk for serious illness: normal color of skin, lips, and tongue; normal response to social cues; contentment and smiles; staying awake or quickly awakening; strong normal cry or absence of crying; normal skin and eyes; and moist mucous membranes.

      To summarize, children with fever and any symptoms or signs in the red column are considered high-risk, while those with fever and any symptoms or signs in the amber column (but none in the red column) are considered intermediate-risk. Children with symptoms and signs in the green column (and none in the amber or red columns) are classified as low-risk.

      For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Infectious Diseases
      7.9
      Seconds
  • Question 3 - You are requested to evaluate a 75-year-old individual who has been examined by...

    Incorrect

    • You are requested to evaluate a 75-year-old individual who has been examined by a medical student. The patient complained of swelling on one side of the face, and the medical student has tentatively diagnosed it as a salivary gland stone. Where is the most frequent location for salivary gland stones to occur?

      Your Answer: Ducts of Rivinus

      Correct Answer: Wharton's duct

      Explanation:

      This area contains stones made of stone. The parotid duct opens into the vestibule of the mouth, specifically between the cheek and gums, at a spot called the parotid papilla. This papilla is located across from the second upper molar tooth.
      The sublingual gland is drained by a series of 8-20 excretory ducts known as the ducts of Rivinus. The largest duct in this system is called Bartholin’s duct. It is worth noting that stones in the sublingual gland are extremely rare.

      Further Reading:

      Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.

      There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.

      Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.

      Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac

    • This question is part of the following fields:

      • Ear, Nose & Throat
      14.3
      Seconds
  • Question 4 - A 14-year-old girl comes in with a sudden onset of a painful throat...

    Incorrect

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

      Your Answer: 2

      Correct Answer: 3

      Explanation:

      There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.

      The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. This score was created and tested in US Emergency Departments, specifically for adult patients.

      The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.

      According to the current NICE guidance, the Centor score can be used to guide management in the following way:
      – A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
      – A score of 3 to 4 indicates a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a backup prescription should be considered.

      By utilizing these scoring systems, healthcare professionals can make more informed decisions regarding the management and treatment of patients with sore throat.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      10.3
      Seconds
  • Question 5 - The right of capable individuals to make well-informed choices regarding their personal healthcare...

    Incorrect

    • The right of capable individuals to make well-informed choices regarding their personal healthcare pertains to which of the subsequent principles?

      Your Answer: Justice

      Correct Answer: Autonomy

      Explanation:

      The principle of autonomy pertains to the right of capable individuals to make well-informed choices regarding their personal healthcare. Autonomy emphasizes the importance of respecting an individual’s ability to make decisions about their own health, based on their own values, beliefs, and preferences. It recognizes that individuals have the right to be informed about their healthcare options, to give informed consent, and to have their choices respected by healthcare providers. Autonomy is a fundamental principle in medical ethics that promotes patient-centered care and respects the individual’s right to self-determination.

      Further Reading:

      Principles of Medical Ethics:

      1. Autonomy: Competent adults have the right to make informed decisions about their own medical care.
      2. Beneficence: Healthcare professionals should take actions that serve the best interests of patients.
      3. Non-maleficence: Healthcare professionals should not take actions that may injure or harm patients.
      4. Justice: Healthcare professionals should take actions that are fair and equitable to both the individual and society as a whole.

      Confidentiality:

      1. Use minimum necessary personal information and consider anonymizing information if possible.
      2. Manage and protect personal information to prevent improper access, disclosure, or loss.
      3. Understand and adhere to information governance appropriate to your role.
      4. Comply with the law when handling personal information.
      5. Share relevant information for direct care unless the patient objects.
      6. Obtain explicit consent to disclose identifiable information for purposes other than care or local clinical audit, unless required by law or justified in the public interest.
      7. Inform patients about disclosures of personal information they would not reasonably expect, unless not practicable or undermines the purpose of the disclosure.
      8. Support patients in accessing their information and respecting their legal rights.

      Obtaining Patient’s Consent for Disclosure:

      – Consent should be obtained for disclosing personal information for purposes other than direct care or local clinical audit, unless required by law or not appropriate or practicable.

      Situations Where Patient Consent is Not Required for Disclosure:

      – Adults at risk of or suffering abuse or neglect, as required by law.
      – Adults lacking capacity, if neglect or harm is suspected, unless not overall beneficial to the patient.
      – When required by law or approved through a statutory process.
      – When justified in the public interest, such as for the prevention, detection, or prosecution of serious crime, patient’s fitness to drive, serious communicable disease, or posing a serious risk to others through being unfit for work.

      Confidentiality Following a Patient’s Death:

      – Respect the patient’s confidentiality even after their death.
      – If the patient previously requested not to share personal information with those close to them, abide by their wishes.
      – Be considerate, sensitive, and responsive to those close to the patient, providing as much information as possible.

      The Law & Caldicott Guardians:

      Data Protection Act:
      – Sets rules and standards for the use and handling of personal data by organizations.
      – Personal data must be used fairly, lawfully, transparently, and for specified purposes.
      – Individuals have rights

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      8
      Seconds
  • Question 6 - You conduct a medication review on a 68-year-old man with a history of...

    Incorrect

    • You conduct a medication review on a 68-year-old man with a history of angina. He is currently prescribed 10 mg bisoprolol once daily and GTN spray as needed. However, he continues to experience symptoms.
      Which ONE medication should be avoided in this patient?

      Your Answer: Isosorbide mononitrate

      Correct Answer: Verapamil

      Explanation:

      Beta-blockers, like bisoprolol, and verapamil have a strong negative effect on the force of ventricular contraction. When these medications are taken together, they can significantly reduce ventricular contraction and lead to a slow heart rate, known as bradycardia. Additionally, the risk of developing AV block is increased. In certain situations, this combination can result in severe low blood pressure or even a complete absence of heart rhythm, known as asystole. Therefore, it is important to avoid using these medications together to prevent these potentially dangerous effects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      8.3
      Seconds
  • Question 7 - You are summoned to aid a 67-year-old patient who is in resus and...

    Incorrect

    • You are summoned to aid a 67-year-old patient who is in resus and has experienced two defibrillation attempts for cardiac arrest. Unfortunately, there is no supply of amiodarone available, so your consultant requests you to prepare lidocaine for administration following the next shock. What is the mechanism of action of lidocaine in the context of cardiac arrest?

      Your Answer: Blockade of magnesium channels

      Correct Answer: Blockade of sodium channels

      Explanation:

      Lidocaine functions by inhibiting the activity of voltage-gated sodium channels, preventing the flow of sodium ions through these 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
      37.7
      Seconds
  • Question 8 - A 14 year old female is brought to the emergency department by her...

    Incorrect

    • A 14 year old female is brought to the emergency department by her parents approximately 90 minutes after taking an overdose. The patient tells you she was at her friend's house and they got into an argument which ended with her friend telling her she was ending their friendship. The patient grabbed a bottle of pills from the bathroom and swallowed all of them before leaving. She didn't tell her friend she had taken the pills and wanted her to feel guilty but now regrets her actions. The patient tells you she didn't read the name on the bottle and threw the bottle away as she walked home. The patient also tells you she didn't see how many pills were in the bottle but thinks there were 20-30 of them. Several attempts to contact the patient's friend to try and clarify the identity of the pills are unsuccessful. The patient advises you she feels nauseated and has ringing in her ears. You also note the patient is hyperventilating. A blood gas sample is taken and is shown below:

      Parameter Result
      pH 7.49
      pO2 14.3 KPa
      pCO2 3.4 KPa
      HCO3- 25 mmol/L
      BE -1

      Which of the following best describes the acid base disturbance?

      Your Answer:

      Correct Answer: Respiratory alkalosis

      Explanation:

      An elevated pH (normal range 7.34-7.45) suggests alkalosis. A low pCO2 (normal range 4.4-6.0 Kpa) indicates that the respiratory system is causing the alkalosis. The metabolic system, on the other hand, is not contributing to either alkalosis or acidosis as both the bicarbonate and base excess levels are within the normal ranges.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      0
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  • Question 9 - A 35-year-old diving instructor complains of pain and discharge in his right ear....

    Incorrect

    • A 35-year-old diving instructor complains of pain and discharge in his right ear. Upon examination, you observe redness in the ear canal along with a significant amount of pus and debris.
      What is the SINGLE most probable organism responsible for this condition?

      Your Answer:

      Correct Answer: Pseudomonas aeruginosa

      Explanation:

      Otitis externa, also known as swimmer’s ear, is a condition characterized by infection and inflammation of the ear canal. Common symptoms include pain, itching, and discharge from the ear. Upon examination with an otoscope, the ear canal will appear red and there may be pus and debris present.

      There are several factors that can increase the risk of developing otitis externa, including skin conditions like psoriasis and eczema. Additionally, individuals who regularly expose their ears to water, such as swimmers, are more prone to this condition.

      The most common organisms that cause otitis externa are Pseudomonas aeruginosa (50%), Staphylococcus aureus (23%), Gram-negative bacteria like E.coli (12%), and fungal species like Aspergillus and Candida (12%).

      Treatment for otitis externa typically involves the use of topical antibiotic and corticosteroid combinations, such as Betnesol-N or Sofradex. In some cases, when the condition persists, referral to an ear, nose, and throat specialist may be necessary for auditory cleaning and the placement of an antibiotic-soaked wick.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      0
      Seconds
  • Question 10 - A teenager comes to the Emergency Department, who is known to have a...

    Incorrect

    • A teenager comes to the Emergency Department, who is known to have a history of substance abuse. In the waiting area, they become aggressive and start demanding to be seen immediately. When this does not happen right away, they begin to shout and threaten some of the other patients in the waiting area.
      What steps should you take in this situation?

      Your Answer:

      Correct Answer: Ask the reception staff to call security

      Explanation:

      In a clinical setting, the prioritization of patient safety and the safety of staff members is crucial. Violence against other patients and health professionals is not tolerated. However, it is important to consider that the patient in question may be intoxicated or experiencing delirium tremens, which could impair their insight into their own behavior.

      To address this situation, it would be wise to call local security as a precautionary measure. This action can serve as a backup if additional assistance is required. However, involving the police at this stage may escalate the situation unnecessarily and potentially agitate the patient further.

      Administering sedation to the patient without understanding their medical history or gathering more information would not be appropriate. It is essential to have a comprehensive understanding of the patient’s condition before considering any interventions.

      Similarly, asking the patient to leave the department immediately could potentially worsen the situation. It is important to approach the situation with caution and consider alternative strategies to de-escalate the situation effectively.

    • This question is part of the following fields:

      • Mental Health
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  • Question 11 - A 68 year old female is brought into the emergency department following a...

    Incorrect

    • A 68 year old female is brought into the emergency department following a fall. The patient is accompanied by her children who inform you that there have been several falls in recent weeks. These falls tend to happen in the morning when the patient gets out of bed and appear to have worsened since the GP altered the patient's usual medication. You suspect orthostatic hypotension. What is the most suitable test to confirm the diagnosis?

      Your Answer:

      Correct Answer: Measure lying and standing blood pressure (BP) with repeated BP measurements while standing for 3 minutes

      Explanation:

      To measure blood pressure while standing, you will need to take repeated measurements for a duration of 3 minutes. This involves measuring both lying and standing blood pressure.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 12 - 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:

      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
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  • Question 13 - A 45-year-old teacher complains of a red and itchy urticarial rash on her...

    Incorrect

    • A 45-year-old teacher complains of a red and itchy urticarial rash on her hands that appeared 15 minutes after she wore a pair of latex gloves. What is the most probable cause for the development of this rash?

      Your Answer:

      Correct Answer: Type I hypersensitivity reaction

      Explanation:

      Type I hypersensitivity reactions are allergic reactions that occur when a person is exposed again to a particular antigen, known as an allergen. These reactions are triggered by IgE and typically happen within 15 to 30 minutes after exposure to the allergen.

      A rapid onset of an urticarial rash, which occurs shortly after being exposed to an allergen (such as latex), is highly likely to be caused by a type I hypersensitivity reaction.

    • This question is part of the following fields:

      • Allergy
      0
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  • Question 14 - A 25-year-old woman has a history of unstable relationships, excessive anger, fluctuating moods,...

    Incorrect

    • A 25-year-old woman has a history of unstable relationships, excessive anger, fluctuating moods, uncertainty about her personal identity, self-harm, and impulsive behavior that causes harm.
      Which of the following is the SINGLE MOST likely diagnosis?

      Your Answer:

      Correct Answer: Borderline personality disorder

      Explanation:

      Borderline personality disorder is characterized by a range of clinical features. These include having unstable relationships, experiencing undue anger, and having variable moods. Individuals with this disorder often struggle with chronic boredom and may have doubts about their personal identity. They also tend to have an intolerance of being left alone and may engage in self-injury. Additionally, they exhibit impulsive behavior that can be damaging to themselves.

    • This question is part of the following fields:

      • Mental Health
      0
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  • Question 15 - A 35-year-old woman is involved in a car crash and sustains severe facial...

    Incorrect

    • A 35-year-old woman is involved in a car crash and sustains severe facial injuries. Facial X-rays and CT scans show the presence of a Le Fort I fracture.
      What is the most probable cause of this injury?

      Your Answer:

      Correct Answer: A force directed in a downward direction against the upper teeth

      Explanation:

      Le Fort fractures are intricate fractures of the midface, which involve the maxillary bone and the surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the separation of the pterygomaxillary due to trauma. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening situations and disfigurement.

      The causes of Le Fort fractures vary depending on the type of fracture. Common mechanisms include motor vehicle accidents, sports injuries, assaults, and falls from significant heights. Patients with Le Fort fractures often have concurrent head and cervical spine injuries. Additionally, they frequently experience other facial fractures, as well as neuromuscular injuries and dental avulsions.

      The specific type of fracture sustained is determined by the direction of the force applied to the face. Le Fort type I fractures typically occur when a force is directed downward against the upper teeth. Le Fort type II fractures are usually the result of a force applied to the lower or mid maxilla. Lastly, Le Fort type III fractures are typically caused by a force applied to the nasal bridge and upper part of the maxilla.

    • This question is part of the following fields:

      • Maxillofacial & Dental
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  • Question 16 - A hiker is airlifted by helicopter after being rescued from a mountain expedition....

    Incorrect

    • A hiker is airlifted by helicopter after being rescued from a mountain expedition. During chest examination, the doctor detects bibasal crackles and symptoms that indicate altitude sickness.
      What type of acid-base imbalance would you anticipate at high elevations?

      Your Answer:

      Correct Answer: Respiratory alkalosis

      Explanation:

      The following provides a summary of common causes for different acid-base disorders.

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

      Respiratory acidosis, on the other hand, is often associated with chronic obstructive pulmonary disease (COPD), life-threatening asthma, pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

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

      Metabolic acidosis with a raised anion gap can be caused by lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction), ketoacidosis (such as in diabetes, starvation, or alcohol excess), renal failure, or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

      Lastly, metabolic acidosis with a normal anion gap can be a result of conditions like diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 17 - You review a 62-year-old woman who presents with vaginal discharge. She has been...

    Incorrect

    • You review a 62-year-old woman who presents with vaginal discharge. She has been experiencing these symptoms for the past six weeks and describes the discharge as having a slight odor. The patient is not sexually active and has never had a similar discharge before. Additionally, she reports a single episode of visible blood in her urine one week ago but has not experienced any further episodes or discomfort while urinating.

      What would be the MOST SUITABLE next course of action for managing this patient?

      Your Answer:

      Correct Answer: Organise a direct access ultrasound scan

      Explanation:

      According to the latest NICE guidance, it is recommended that women aged 55 and over with unexplained symptoms of vaginal discharge should undergo a direct access ultrasound scan to assess for endometrial cancer. This recommendation applies to women who are experiencing these symptoms for the first time or who have thrombocytosis, haematuria (blood in the urine), visible haematuria, low haemoglobin levels, or high blood glucose levels. For more information, please refer to the NICE referral guidelines on the recognition and referral of suspected cancer.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 18 - A 60-year-old man who has recently finished a round of antibiotics comes in...

    Incorrect

    • A 60-year-old man who has recently finished a round of antibiotics comes in with excessive, foul-smelling diarrhea. After further examination, he is diagnosed with Clostridium Difficile diarrhea.
      Which of the following antibiotics carries the highest risk of causing Clostridium Difficile diarrhea?

      Your Answer:

      Correct Answer: Clindamycin

      Explanation:

      Clostridium difficile is a type of bacteria that is Gram-positive, anaerobic, and capable of forming spores. When individuals take broad-spectrum antibiotics, it can disrupt the normal bacteria in the bowel and allow C. difficile to multiply. This can lead to inflammation and bleeding in the mucosa of the large intestine, resulting in a distinct appearance known as pseudomembranous. The main symptoms of C. difficile infection (CDI) include abdominal cramps, bloody and/or watery diarrhea, and fever. It is worth noting that the majority of CDI cases occur in individuals over the age of 65.

      CDI is considered to be the most severe consequence of antibiotic treatment and is now a significant cause of illness and death. While CDI can occur after treatment with any antibiotic, the risk is particularly high with prolonged use of broad-spectrum antibiotics. Recently, two research groups conducted a meta-analysis to assess the risk associated with different classes of antibiotics.

      Their findings revealed that the risk of CDI increased nearly sevenfold after antibiotic treatment (odds ratio, 6.91). Among the various antibiotic classes, clindamycin posed the greatest risk (odds ratio, 20.43), followed by fluoroquinolones (odds ratio, 5.65), cephalosporins (odds ratio, 4.47), penicillins (odds ratio, 3.25), macrolides (odds ratio, 2.55), and trimethoprim/sulfonamides (odds ratio, 1.84). Tetracyclines, on the other hand, were not found to be associated with an increased risk of CDI (odds ratio, 0.91).

      For more information on this topic, you may consider reading the article Antibiotic Classes and Risk for Clostridium difficile Infection.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 19 - A 52 year old male is brought into the emergency department acutely ill...

    Incorrect

    • A 52 year old male is brought into the emergency department acutely ill and is transferred to resus. Your consultant suspects thyrotoxic crisis and instructs you to prepare the necessary medication. What drugs are typically administered during the initial treatment of thyrotoxic crisis?

      Your Answer:

      Correct Answer: Antithyroid drug, beta blocker, corticosteroids and iodine solution

      Explanation:

      Thyroid storm, also known as thyrotoxic crisis, is a rare and dangerous complication of hyperthyroidism. The initial management of this condition involves the use of specific medications. These medications include a beta blocker, a corticosteroid, an antithyroid drug, and an iodine solution.

      The beta blocker used is typically propranolol, which is administered intravenously at a dose of 1 mg over 1 minute. If a beta blocker is contraindicated, a calcium channel blocker such as diltiazem may be used instead, at a dose of 0.25 mg/kg over 2 minutes.

      For corticosteroids, hydrocortisone is commonly used and given intravenously at a dose of 200 mg. Alternatively, dexamethasone can be used at a dose of 2 mg intravenously.

      The antithyroid drug used is usually propylthiouracil, which is given orally, through a nasogastric tube, or rectally, at a dose of 200 mg.

      An iodine solution, specifically Lugol’s iodine, is also part of the initial management. However, it should not be administered until at least 1 hour after the antithyroid drug has been given. This is because iodine can exacerbate thyrotoxicosis by stimulating thyroid hormone synthesis. Propylthiouracil, on the other hand, inhibits the normal interactions of iodine and peroxidase with thyroglobulin, preventing the formation of T4 and T3. Therefore, it is given first and allowed time to take effect before iodine is administered.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 20 - A 35-year-old woman presents to the Emergency Department with a brief history of...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department with a brief history of headaches, which are more severe in the morning, and blurred vision and ringing in the ears. Her headache is worse than usual today, and she has vomited multiple times. She has no significant medical history but does take the combined oral contraceptive pill. On examination, you find her to be overweight, and her neurological system examination reveals a sixth cranial nerve palsy, but no other focal neurology and fundoscopy reveals bilateral papilloedema.

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

      The most probable diagnosis in this case is idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumour cerebri. This condition typically affects overweight women in their 20s and 30s.

      The clinical features of idiopathic intracranial hypertension include:
      – Headache: The headache is usually worse in the morning and evenings, relieved by standing, and worsened when lying down. It can also be aggravated by coughing and sneezing. Some patients may experience pain around the shoulder girdle.
      – Nausea and vomiting
      – Visual field defects: These develop gradually over time.
      – 6th nerve palsy and diplopia
      – Bilateral papilloedema

      To investigate this condition, the patient should undergo a CT scan and/or MRI of the brain, as well as a lumbar puncture to measure the opening pressure and analyze the cerebrospinal fluid (CSF).

      The primary treatment goal for idiopathic intracranial hypertension is to prevent visual loss. This can be achieved through one of the following strategies:
      – Repeated lumbar puncture to control intracranial pressure (ICP)
      – Medical treatment with acetazolamide
      – Surgical decompression of the optic nerve sheath

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A 75-year-old gentleman is brought in by ambulance from his assisted living facility...

    Incorrect

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

      Your Answer:

      Correct Answer: Administer 150 mL of 10% dextrose

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 22 - A young hiker who got stranded while hiking in freezing temperatures is brought...

    Incorrect

    • A young hiker who got stranded while hiking in freezing temperatures is brought to the emergency department with severe hypothermia and experiences cardiac arrest during transportation. You are working in a hospital equipped with Cardiopulmonary bypass (CPB) facilities. The patient is transferred to undergo CPB treatment. What is the likelihood of survival in cases of hypothermic cardiac-respiratory arrest?

      Your Answer:

      Correct Answer: 50%

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 23 - A 3-year-old girl is hit by a car while crossing the street. She...

    Incorrect

    • A 3-year-old girl is hit by a car while crossing the street. She is brought to the resus area of your Emergency Department by a blue light ambulance. A trauma call is initiated, and a primary survey is conducted. She is stable hemodynamically, and the only abnormality found is a severely swollen and deformed left thigh area. An X-ray is taken, which shows a fracture in the proximal femoral shaft. The child is experiencing significant pain, and you decide to apply skin traction to immobilize the fracture. You also plan to administer a dose of intranasal diamorphine.
      The child weighs 15 kg. What is the appropriate dose of intranasal diamorphine to administer?

      Your Answer:

      Correct Answer: 2 mg

      Explanation:

      Femoral shaft fractures are quite common among children and have a significant impact on both the child and their family. It is important to carefully examine children with these fractures for any associated injuries, such as soft-tissue injury, head trauma, or additional fractures. In fact, up to 40% of children who experience a femoral shaft fracture due to high-energy trauma may have these associated injuries. Additionally, a thorough neurovascular examination should be conducted.

      Rapidly immobilizing the limb is crucial for managing pain and limiting further blood loss from the fracture. For distal femoral shaft fractures, well-padded long leg splints with split plaster casts can be applied. However, for more proximal shaft fractures, long leg splints alone may not provide adequate control. In these cases, skin traction is a better option. Skin traction involves attaching a large foam pad to the patient’s lower leg using spray adhesive. A weight, approximately 10% of the child’s body weight, is then applied to the foam pad and allowed to hang over the foot of the bed. This constant longitudinal traction helps keep the bone fragments aligned.

      When children experience severe pain, it is important to manage it aggressively yet safely. Immobilizing the fracture can provide significant relief. The Royal College of Emergency Medicine recommends other pain control measures for children, such as intranasal diamorphine (0.1 mg/kg in 0.2 ml sterile water), intravenous morphine (0.1-0.2 mg/kg), and oral analgesia (e.g., paracetamol 20 mg/kg, max 1 g, and ibuprofen 10 mg/kg, max 400 mg).

    • This question is part of the following fields:

      • Pain & Sedation
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  • Question 24 - A 35-year-old woman has recently started taking a new medication. She is experiencing...

    Incorrect

    • A 35-year-old woman has recently started taking a new medication. She is experiencing severe muscle pains.
      Which ONE of the following drugs is most likely to cause myopathy as a side effect?

      Your Answer:

      Correct Answer: Simvastatin

      Explanation:

      Statins, although generally safe and well-tolerated, can cause myopathy and myotoxicity. This range of muscle-related side effects can vary from mild muscle pain to the most severe case of rhabdomyolysis, which can lead to kidney failure, blood clotting issues, and even death.

      The different levels of myotoxicity associated with statins are as follows:
      – Myalgia: muscle symptoms without an increase in creatine kinase (CK) levels.
      – Asymptomatic myopathy: elevated CK levels without muscle symptoms.
      – Myositis: muscle symptoms with CK levels elevated less than 10 times the upper limit of normal.
      – Rhabdomyolysis: muscle symptoms with CK levels elevated more than 10 times the upper limit of normal, potentially leading to myoglobinuria (presence of myoglobin in urine) and renal failure.

      Most statins are broken down by the cytochrome P450 enzyme system. When taken with drugs that strongly inhibit this system, the concentration of statins in the blood can significantly increase. This, in turn, raises the risk of myopathy. A well-known example of this is the combination of statins with macrolide antibiotics like erythromycin and clarithromycin. Co-prescribing these drugs with statins has been linked to a higher risk of myopathy, hospitalization due to rhabdomyolysis, acute kidney injury, and increased mortality rates.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 25 - A 32 year old with a documented peanut allergy is currently receiving treatment...

    Incorrect

    • A 32 year old with a documented peanut allergy is currently receiving treatment for an anaphylactic reaction. What are the most likely cardiovascular manifestations that you would observe in a patient experiencing an episode of anaphylaxis?

      Your Answer:

      Correct Answer: Hypotension and tachycardia

      Explanation:

      Anaphylaxis, also known as anaphylactic shock, is characterized by certain symptoms similar to other types of shock. These symptoms include low blood pressure (hypotension), rapid heart rate (tachycardia), irregular heart rhythm (arrhythmia), changes in the electrocardiogram (ECG) indicating reduced blood flow to the heart (myocardial ischemia), such as ST elevation, and in severe cases, cardiac arrest.

      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:

      • Cardiology
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  • Question 26 - A 68 year old male is brought to the emergency department after falling...

    Incorrect

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

      Your Answer:

      Correct Answer: Lying and standing blood pressures

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 27 - A 42-year-old woman comes in with dysuria, chills, and pain in her left...

    Incorrect

    • A 42-year-old woman comes in with dysuria, chills, and pain in her left side. During the examination, she shows tenderness in the left renal angle and has a temperature of 38.6°C. The triage nurse has already inserted a cannula and sent her blood samples to the lab.
      What is the MOST suitable antibiotic to prescribe for this patient?

      Your Answer:

      Correct Answer: Cefuroxime

      Explanation:

      This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.

      According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.

      NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).

      For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.

      For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.

    • This question is part of the following fields:

      • Urology
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  • Question 28 - What is the underlying cause of Korsakoff's psychosis in a 45-year-old man with...

    Incorrect

    • What is the underlying cause of Korsakoff's psychosis in a 45-year-old man with a history of chronic alcohol abuse?

      Your Answer:

      Correct Answer: Thiamine deficiency

      Explanation:

      Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a classic triad of symptoms, which include acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination and balance). Additional possible features of this condition may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. In the majority of cases, peripheral neuropathy (nerve damage) is also observed, typically affecting the legs.

      The condition is marked by the presence of acute capillary haemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia (difficulty remembering past events), an inability to memorize new information, disordered time appreciation, and confabulation (fabrication of false memories).

    • This question is part of the following fields:

      • Mental Health
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  • Question 29 - A 40-year-old man experiences anaphylaxis after being stung by a bee. He is...

    Incorrect

    • A 40-year-old man experiences anaphylaxis after being stung by a bee. He is rushed to the resuscitation room for immediate treatment.

      Which category of hypersensitivity reaction does anaphylaxis exemplify?

      Your Answer:

      Correct Answer: Type I

      Explanation:

      Anaphylaxis is a type I hypersensitivity reaction, where the body’s response is triggered by the attachment of an antigen to a specific antibody. This attachment then leads to the release of histamine and other mediators, such as leukotrienes, tumor necrosis factor, and various cytokines, from mast cells and basophils. These substances are released when these cells are exposed to the antigen.

    • This question is part of the following fields:

      • Allergy
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  • Question 30 - You evaluate a child with a limp and complaints of hip discomfort. An...

    Incorrect

    • You evaluate a child with a limp and complaints of hip discomfort. An X-ray is conducted, and the diagnosis of Perthes' disease is confirmed.
      Which ONE statement about this condition is accurate?

      Your Answer:

      Correct Answer: A positive family history is present in 10-15% of cases

      Explanation:

      Perthes’ disease is a hip disorder that occurs in childhood due to a disruption in the blood supply to the femoral head. This leads to a lack of blood flow, causing the bone to die. The condition typically affects children between the ages of 4 and 10, with boys being more commonly affected than girls. In about 10-15% of cases, there is a family history of the disease, and approximately 15% of patients have the condition in both hips.

      The progression of Perthes’ disease can be seen through characteristic changes on X-rays, which can take between 2 and 4 years to fully heal. The earliest sign is an increased density of the epiphysis (the end of the bone) and widening of the medial joint space. As the disease progresses, the epiphysis may fragment and the head of the femur may flatten. Over time, the bone gradually heals, with the dense bone being reabsorbed and replaced by new bone. This process continues until growth stops, and the bone is remodeled.

      Children with Perthes’ disease typically present with hip pain and a limp. The pain can vary in severity, and clinical signs may be minor, with only a slight restriction in hip joint movement.

      The treatment of Perthes’ disease is a topic of debate. Around 50% of patients can achieve good results with conservative management alone, without the need for surgery. Surgical intervention, such as osteotomy (reshaping the bone), is usually reserved for cases where the disease progresses unfavorably or when conservative treatment fails. Potential complications of Perthes’ disease include permanent hip deformity and secondary arthritis.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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SESSION STATS - PERFORMANCE PER SPECIALTY

Cardiology (0/1) 0%
Elderly Care / Frailty (1/1) 100%
Mental Health (1/1) 100%
Basic Anaesthetics (1/1) 100%
Pharmacology & Poisoning (1/1) 100%
Ear, Nose & Throat (0/1) 0%
Haematology (1/1) 100%
Passmed