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  • Question 1 - You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the...

    Incorrect

    • You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the ulnar nerve in his left arm.
      Which of the following hand muscles is MOST likely to be impacted in this individual?

      Your Answer: Opponens pollicis

      Correct Answer: Medial two lumbricals

      Explanation:

      The ulnar nerve provides innervation to several muscles in the hand. These include the palmar interossei, dorsal interossei, medial two lumbricals, and abductor digiti minimi. On the other hand, the median nerve innervates the opponens pollicis, lateral two lumbricals, and flexor pollicis brevis. Lastly, the radial nerve is responsible for innervating the extensor digitorum muscle.

    • This question is part of the following fields:

      • Neurology
      14
      Seconds
  • Question 2 - You have been tasked with arranging a case-based teaching session for the junior...

    Incorrect

    • You have been tasked with arranging a case-based teaching session for the junior doctors in the emergency department regarding vertigo. Which of the subsequent clinical features aligns with a central origin of vertigo?

      Your Answer: Positive head impulse test

      Correct Answer: Inability to stand up with the eyes open

      Explanation:

      If a person is unable to stand up or walk, even with their eyes open, it is likely that the cause of their vertigo is central in nature. Additional features that increase suspicion of a central cause include focal neurology, prolonged and severe vertigo (although this can also be seen in vestibular neuronitis or Meniere’s disease), new-onset headache or recent trauma, a normal head impulse test, and the presence of cardiovascular risk factors.

      Further Reading:

      Vertigo is a symptom characterized by a false sensation of movement, such as spinning or rotation, in the absence of any actual physical movement. It is not a diagnosis itself, but rather a description of the sensation experienced by the individual. Dizziness, on the other hand, refers to a perception of disturbed or impaired spatial orientation without a false sense of motion.

      Vertigo can be classified as either peripheral or central. Peripheral vertigo is more common and is caused by problems in the inner ear that affect the labyrinth or vestibular nerve. Examples of peripheral vertigo include BPPV, vestibular neuritis, labyrinthitis, and Meniere’s disease. Central vertigo, on the other hand, is caused by pathology in the brain, such as in the brainstem or cerebellum. Examples of central vertigo include migraine, TIA and stroke, cerebellar tumor, acoustic neuroma, and multiple sclerosis.

      There are certain features that can help differentiate between peripheral and central vertigo. Peripheral vertigo is often associated with severe nausea and vomiting, hearing loss or tinnitus, and a positive head impulse test. Central vertigo may be characterized by prolonged and severe vertigo, new-onset headache, recent trauma, cardiovascular risk factors, inability to stand or walk with eyes open, focal neurological deficit, and a negative head impulse test.

      Nystagmus, an involuntary eye movement, can also provide clues about the underlying cause of vertigo. Central causes of vertigo often have nystagmus that is direction-changing on lateral gaze, purely vertical or torsional, not suppressed by visual fixation, non-fatigable, and commonly large amplitude. Peripheral causes of vertigo often have horizontal nystagmus with a torsional component that does not change direction with gaze, disappears with fixation of the gaze, and may have large amplitude early in the course of Meniere’s disease or vestibular neuritis.

      There are various causes of vertigo, including viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo, Meniere’s disease, vertebrobasilar ischemia, and acoustic neuroma. Each of these disorders has its own unique characteristics and may be associated with other symptoms such as hearing loss, tinnitus, or neurological deficits.

      When assessing a patient with vertigo, it is important to perform a cardiovascular and neurological examination, including assessing cranial nerves, cerebellar signs, eye movements, gait, coordination, and evidence of peripheral

    • This question is part of the following fields:

      • Neurology
      23.8
      Seconds
  • Question 3 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. She is connected to an ECG monitor, and you observe the presence of an arrhythmia.
      What is the most frequently encountered type of arrhythmia in Wolff-Parkinson-White syndrome?

      Your Answer: Ventricular tachycardia

      Correct Answer: Atrioventricular re-entrant tachycardia

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
      12.4
      Seconds
  • Question 4 - A 35 year old male presents to the emergency department and admits to...

    Incorrect

    • A 35 year old male presents to the emergency department and admits to ingesting 60 paracetamol tablets 9 hours ago. What is the primary intervention for this patient?

      Your Answer: N-acetyl-p-benzoquinone imine

      Correct Answer: N-acetylcysteine

      Explanation:

      N-acetylcysteine (NAC) enhances the production of glutathione, a substance that helps in the detoxification process. Specifically, NAC aids in the conjugation of NAPQI, a harmful metabolite of paracetamol, with glutathione, thereby neutralizing its toxicity.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      6.2
      Seconds
  • Question 5 - A 25-year-old traveler comes to the clinic complaining of a fever, cough, and...

    Incorrect

    • A 25-year-old traveler comes to the clinic complaining of a fever, cough, and headache that have persisted for the last week. He recently returned from a backpacking adventure in India. Additionally, he started experiencing diarrhea a few days ago, and a stool sample was sent for testing, which revealed the presence of Salmonella typhi. Which antibacterial medication would be the most suitable to prescribe for this patient?

      Your Answer: Clarithromycin

      Correct Answer: Cefotaxime

      Explanation:

      According to the latest guidelines from NICE and the BNF, the recommended initial treatment for typhoid fever is cefotaxime. It is important to note that infections originating from the Middle-East, South Asia, and South-East Asia may have multiple antibiotic resistance, so it is advisable to test for sensitivity. In cases where the microorganism is found to be sensitive, ciprofloxacin can be considered as a suitable alternative.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      7.3
      Seconds
  • Question 6 - You assess a patient who has recently been diagnosed with chronic myeloid leukemia...

    Incorrect

    • You assess a patient who has recently been diagnosed with chronic myeloid leukemia (CML).
      Which ONE statement about CML is accurate?

      Your Answer: First-line treatment is allogeneic bone marrow transplantation

      Correct Answer: The Philadelphia chromosome is present in over 80% of cases

      Explanation:

      Chronic myeloid leukaemia (CML) is a type of blood disorder that arises from an abnormal pluripotent haemopoietic stem cell. The majority of CML cases, more than 80%, are caused by a cytogenetic abnormality called the Philadelphia chromosome. This abnormality occurs when there is a reciprocal translocation between the long arms of chromosomes 9 and 22.

      CML typically develops slowly over a period of several years, known as the chronic stage. During this stage, patients usually do not experience any symptoms, and it is often discovered incidentally through routine blood tests. Around 90% of CML cases are diagnosed during this stage. In the bone marrow, less than 10% of the white cells are immature blasts.

      Symptoms start to appear when the CML cells begin to expand, which is known as the accelerated stage. Approximately 10% of cases are diagnosed during this stage. Between 10 and 30% of the blood cells in the bone marrow are blasts at this point. Common clinical features during this stage include tiredness, fatigue, fever, night sweats, abdominal distension, left upper quadrant pain (splenic infarction), splenomegaly (enlarged spleen), hepatomegaly (enlarged liver), easy bruising, gout (due to rapid cell turnover), and hyperviscosity (which can lead to complications like stroke, priapism, etc.).

      In some cases, a small number of patients may present with a blast crisis, also known as the blast stage. During this stage, more than 30% of the blood cells in the bone marrow are immature blast cells. Patients in this stage are generally very ill, experiencing severe constitutional symptoms such as fever, weight loss, and bone pain, as well as infections and bleeding tendencies.

      Laboratory findings in CML include a significantly elevated white cell count (often greater than 100 x 109/l), a left shift with an increased number of immature leukocytes, mild to moderate normochromic, normocytic anaemia, variable platelet counts (low, normal, or elevated), presence of the Philadelphia chromosome in more than 80% of cases, and elevated levels of serum uric acid and alkaline phosphatase.

    • This question is part of the following fields:

      • Haematology
      8.5
      Seconds
  • Question 7 - A 25 year old female is brought to the emergency department with a...

    Correct

    • A 25 year old female is brought to the emergency department with a gunshot wound to the abdomen. You observe that the patient is breathing rapidly and her neck veins are distended. The trachea is centrally located. Her vital signs are as follows:

      Blood pressure: 88/56 mmHg
      Heart rate: 127 bpm
      Respiration rate: 28 rpm
      SpO2: 99% on 15L oxygen

      What is the probable diagnosis?

      Your Answer: Cardiac tamponade

      Explanation:

      Cardiac tamponade is characterized by several classical signs, including distended neck veins, muffled heart sounds, and hypotension. When neck veins are distended, it suggests that the right ventricle is not filling properly. In cases of trauma, this is often caused by the compression of air (tension pneumothorax) or fluid (blood in the pericardial space). One important distinguishing feature is the deviation of the trachea.

      Further Reading:

      Cardiac tamponade, also known as pericardial tamponade, occurs when fluid accumulates in the pericardial sac and compresses the heart, leading to compromised blood flow. Classic clinical signs of cardiac tamponade include distended neck veins, hypotension, muffled heart sounds, and pulseless electrical activity (PEA). Diagnosis is typically done through a FAST scan or an echocardiogram.

      Management of cardiac tamponade involves assessing for other injuries, administering IV fluids to reduce preload, performing pericardiocentesis (inserting a needle into the pericardial cavity to drain fluid), and potentially performing a thoracotomy. It is important to note that untreated expanding cardiac tamponade can progress to PEA cardiac arrest.

      Pericardiocentesis can be done using the subxiphoid approach or by inserting a needle between the 5th and 6th intercostal spaces at the left sternal border. Echo guidance is the gold standard for pericardiocentesis, but it may not be available in a resuscitation situation. Complications of pericardiocentesis include ST elevation or ventricular ectopics, myocardial perforation, bleeding, pneumothorax, arrhythmia, acute pulmonary edema, and acute ventricular dilatation.

      It is important to note that pericardiocentesis is typically used as a temporary measure until a thoracotomy can be performed. Recent articles published on the RCEM learning platform suggest that pericardiocentesis has a low success rate and may delay thoracotomy, so it is advised against unless there are no other options available.

    • This question is part of the following fields:

      • Cardiology
      60.7
      Seconds
  • Question 8 - A 30-year-old woman with a history of bipolar disorder presents with a side...

    Incorrect

    • A 30-year-old woman with a history of bipolar disorder presents with a side effect from the mood stabilizer medication that she is currently taking.

      Which SINGLE statement regarding the side effects of mood stabilizer drugs is FALSE?

      Your Answer: There is an increased risk of mortality in elderly patients with dementia-related psychosis treated with haloperidol

      Correct Answer: Dystonia tends to only appear after long-term treatment

      Explanation:

      Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.

      Tardive dyskinesia, which involves involuntary rhythmic movements of the tongue, face, and jaw, typically occurs after prolonged treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative medication, and treatment options are generally ineffective.

      Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to appear after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.

      Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.

      In individuals with renal impairment, there is an increased sensitivity of the brain to antipsychotic drugs, necessitating the use of reduced doses.

      Elderly patients with dementia-related psychosis who are treated with haloperidol face an elevated risk of mortality. This is believed to be due to an increased likelihood of cardiovascular events and infections such as pneumonia.

      Contraindications for the use of antipsychotic drugs include reduced consciousness or coma, central nervous system depression, and the presence of phaeochromocytoma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      120.9
      Seconds
  • Question 9 - A 42 year old male presents to the emergency department with complaints of...

    Correct

    • A 42 year old male presents to the emergency department with complaints of vertigo that appears to be triggered by head movements. The patient first noticed these symptoms upon waking up in the morning. You suspect benign paroxysmal positional vertigo.

      What is the most probable location of the underlying pathology causing this patient's symptoms?

      Your Answer: Posterior semicircular canal

      Explanation:

      Otoliths are commonly found in the inferior semicircular canal of patients, while their presence in the anterior semicircular canal is extremely uncommon.

      Further Reading:

      Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.

      The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.

      Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      6.4
      Seconds
  • Question 10 - A 5-year-old boy is brought to the Emergency Department by his mother. He...

    Correct

    • A 5-year-old boy is brought to the Emergency Department by his mother. He is known to have eczema and has recently experienced a worsening of his symptoms with some of the affected areas having weeping and crusting lesions. Upon examining his skin, you observe multiple flexural areas involved with numerous weeping lesions. He has no known allergies to any medications.

      What is the MOST suitable course of action for management?

      Your Answer: Oral flucloxacillin

      Explanation:

      Based on the child’s medical history, it appears that they have multiple areas of infected eczema. In such cases, the NICE guidelines recommend starting treatment with flucloxacillin as the first-line option for bacterial infections. This is because staphylococcus and/or streptococcus bacteria are the most common causes of these infections. Swabs should only be taken if there is a likelihood of antibiotic resistance or if a different pathogen is suspected. In cases where the child is allergic to flucloxacillin, erythromycin can be used as an alternative. If the child cannot tolerate erythromycin, clarithromycin is the recommended option. For more information, you can refer to the NICE Clinical Knowledge Summary on the management of infected eczema.

    • This question is part of the following fields:

      • Dermatology
      6.7
      Seconds
  • Question 11 - A 65-year-old male patient is brought into the emergency department with suspected sepsis....

    Correct

    • A 65-year-old male patient is brought into the emergency department with suspected sepsis. It is decided to intubate the patient pending transfer to the intensive care unit (ICU). Your consultant requests you to prepare propofol and suxamethonium for rapid sequence intubation. What is the mechanism of action of suxamethonium?

      Your Answer: Non-competitive agonist of acetylcholine receptors at the neuromuscular junction

      Explanation:

      Suxamethonium, also called succinylcholine, is a type of drug used to block neuromuscular transmission. It acts as an agonist by binding to acetylcholine receptors at the neuromuscular junction. Unlike acetylcholine, suxamethonium is not broken down by acetylcholinesterase, which means it stays bound to the receptors for a longer time, leading to prolonged inhibition of neuromuscular transmission. Eventually, suxamethonium is metabolized by plasma cholinesterase.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      22.3
      Seconds
  • Question 12 - A middle-aged woman presents with symptoms that can be associated with sexually transmitted...

    Correct

    • A middle-aged woman presents with symptoms that can be associated with sexually transmitted infection (STI). Following her investigations, she is diagnosed with the most common cause of STI in the UK.

      Which of the following is the SINGLE most likely diagnosis?

      Your Answer: Chlamydia

      Explanation:

      Chlamydia trachomatis is a type of Gram-negative bacteria that is responsible for causing the sexually transmitted infection known as chlamydia. This bacterium is typically either coccoid or rod-shaped in its appearance.

      There are various serological variants of C. trachomatis, and each variant is associated with different patterns of disease. Specifically, types D-K are responsible for causing genitourinary infections.

      In the United Kingdom, chlamydia is the most commonly diagnosed sexually transmitted infection (STI). It is also the leading preventable cause of infertility worldwide. Interestingly, around 50% of men infected with chlamydia do not experience any symptoms, while at least 70% of infected women are asymptomatic.

      If left untreated, chlamydia can lead to various complications. In women, these complications may include pelvic inflammatory disease (PID), ectopic pregnancy, and tubal infertility. Men, on the other hand, may experience complications such as proctitis, epididymitis, and epididymo-orchitis.

    • This question is part of the following fields:

      • Sexual Health
      5.3
      Seconds
  • Question 13 - A 5 year old girl is brought into the emergency department after stepping...

    Incorrect

    • A 5 year old girl is brought into the emergency department after stepping on a sharp object while playing barefoot in the backyard. The wound needs to be stitched under anesthesia. While obtaining parental consent from the accompanying adult, you notice that the adult has a different last name than the child. When asked about their relationship to the child, the adult states that they are like a mother to the child. In which of the following situations could this person provide consent for the child?

      Your Answer: Biological father of the child

      Correct Answer: Is currently married to the child’s mother

      Explanation:

      From the moment a child is born, the mother is automatically granted parental responsibility. However, fathers must fulfill specific criteria in order to have the same rights. A father can provide consent on behalf of the child if he meets any of the following conditions: being married to the child’s mother, having been married to the child’s mother at the time of birth but subsequently divorced, being listed as the child’s father on the birth certificate, obtaining parental responsibility through a court order or a parental responsibility agreement with the mother, or legally adopting the child.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      18.4
      Seconds
  • Question 14 - A 72 year old is brought to the emergency department by ambulance due...

    Correct

    • A 72 year old is brought to the emergency department by ambulance due to sudden onset of confusion. The patient's spouse is concerned the sudden decrease in consciousness is due to a hemorrhage as the patient is on blood thinners. Neurological examination reveals flaccid paralysis. Cardiopulmonary resuscitation is initiated before CT scan as the patient experiences a respiratory arrest. Which of the following syndromes is this patient most likely suffering from?

      Your Answer: Tonsillar herniation

      Explanation:

      Tonsillar herniation occurs when the cerebellar tonsils are pushed through the foramen magnum. This condition is characterized by a decrease in consciousness, respiratory arrest, and flaccid paralysis.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      16.3
      Seconds
  • Question 15 - A 62 year old female is brought to the emergency department by her...

    Correct

    • A 62 year old female is brought to the emergency department by her husband who is concerned that the patient has been experiencing abdominal pain and also appears slightly confused. He informs you that the patient is a heavy drinker and you observe that the patient was diagnosed with liver cirrhosis 8 months ago. The patient has difficulty focusing during the Abbreviated Mental Test Score (AMTS) but scores 7/10. Upon examination, you notice mild ascites. You suspect the patient has moderate (grade 2) hepatic encephalopathy secondary to liver cirrhosis. The patient's initial blood tests are as follows:

      Bilirubin 45 µmol/l
      ALP 210 u/l
      ALT 300 u/l
      γGT 160 u/l
      Albumin 27 g/l
      INR 1.9

      What is this patient's Child Pugh score?

      Your Answer: 13

      Explanation:

      This patient’s Child Pugh score is 9. The Child Pugh score is a scoring system used to assess the severity of liver disease and the prognosis of patients with cirrhosis. It takes into account five variables: bilirubin levels, albumin levels, INR (international normalized ratio), ascites, and hepatic encephalopathy. Each variable is assigned a score from 1 to 3, with 3 indicating the most severe impairment.

      In this case, the patient’s bilirubin level is 45 µmol/l, which corresponds to a score of 2. The albumin level is 27 g/l, which also corresponds to a score of 3. The INR is 1.9, which corresponds to a score of 2. The presence of moderate ascites indicates a score of 3. Finally, the patient has moderate hepatic encephalopathy, which corresponds to a score of 3.

      Adding up the scores for each variable, we get a total score of 13. This indicates that the patient has moderate to severe liver disease and a poorer prognosis.

      Further Reading:
      Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.

      Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.

      The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.

      Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.

      Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.

      Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.

      Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 16 - A child arrives at the Emergency Department with a petechial rash, headache, neck...

    Incorrect

    • A child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis. The child has a previous history of experiencing anaphylaxis in response to cephalosporin antibiotics.
      Which antibiotic would you administer to this child?

      Your Answer: Cefotaxime

      Correct Answer: Chloramphenicol

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Neurology
      20.4
      Seconds
  • Question 17 - A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her...

    Incorrect

    • A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, difficulty with coordination in her right arm, and difficulty speaking.
      Which of the following blood vessels is most likely to be impacted?

      Your Answer: Middle cerebral artery

      Correct Answer: Anterior cerebral artery

      Explanation:

      The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:

      Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.

      Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.

      Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.

      It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.

    • This question is part of the following fields:

      • Neurology
      88.7
      Seconds
  • Question 18 - You are with a hiking group and have ascended from an elevation of...

    Incorrect

    • You are with a hiking group and have ascended from an elevation of 2800m to 3400 meters over the past two days. One of your group members is experiencing difficulty breathing while at rest and has developed a dry cough. The individual's vital signs are as follows:

      Blood pressure: 150/92 mmHg
      Pulse: 126 bpm
      Respiration rate: 28 bpm
      Oxygen saturations: 86% on air

      Which of the following medications would be most appropriate to administer to this individual?

      Your Answer: Acetazolamide

      Correct Answer: Nifedipine

      Explanation:

      Nifedipine is the preferred medication for treating high altitude pulmonary edema (HAPE). When a patient shows signs of HAPE, the best course of action is to immediately descend to a lower altitude while receiving supplemental oxygen. However, if descent is not possible, nifedipine can be used to alleviate symptoms and assist with descent. Nifedipine works by reducing the pressure in the pulmonary artery. On the other hand, dexamethasone is the preferred medication for treating acute mountain sickness and high altitude cerebral edema (HACE).

      Further Reading:

      High Altitude Illnesses

      Altitude & Hypoxia:
      – As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
      – Hypoxia occurs at altitude due to decreased inspired oxygen.
      – At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.

      Acute Mountain Sickness (AMS):
      – AMS is a clinical syndrome caused by hypoxia at altitude.
      – Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
      – Symptoms usually occur after 6-12 hours above 2500m.
      – Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
      – The Lake Louise AMS score is used to assess the severity of AMS.
      – Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
      – Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
      – Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.

      High Altitude Pulmonary Edema (HAPE):
      – HAPE is a progression of AMS but can occur without AMS symptoms.
      – It is the leading cause of death related to altitude illness.
      – Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
      – Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
      – Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.

      High Altitude Cerebral Edema (HACE):
      – HACE is thought to result from vasogenic edema and increased vascular pressure.
      – It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
      – Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
      – Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
      – Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis.

    • This question is part of the following fields:

      • Environmental Emergencies
      4.5
      Seconds
  • Question 19 - A 35-year-old man with a history of anxiety and panic disorder has ingested...

    Correct

    • A 35-year-old man with a history of anxiety and panic disorder has ingested an excessive amount of diazepam.
      Which of the following antidotes is appropriate for cases of benzodiazepine poisoning?

      Your Answer: Flumazenil

      Explanation:

      There are various specific remedies available for different types of poisons and overdoses. The following list provides an outline of some of these antidotes:

      Poison: Benzodiazepines
      Antidote: Flumazenil

      Poison: Beta-blockers
      Antidotes: Atropine, Glucagon, Insulin

      Poison: Carbon monoxide
      Antidote: Oxygen

      Poison: Cyanide
      Antidotes: Hydroxocobalamin, Sodium nitrite, Sodium thiosulphate

      Poison: Ethylene glycol
      Antidotes: Ethanol, Fomepizole

      Poison: Heparin
      Antidote: Protamine sulphate

      Poison: Iron salts
      Antidote: Desferrioxamine

      Poison: Isoniazid
      Antidote: Pyridoxine

      Poison: Methanol
      Antidotes: Ethanol, Fomepizole

      Poison: Opioids
      Antidote: Naloxone

      Poison: Organophosphates
      Antidotes: Atropine, Pralidoxime

      Poison: Paracetamol
      Antidotes: Acetylcysteine, Methionine

      Poison: Sulphonylureas
      Antidotes: Glucose, Octreotide

      Poison: Thallium
      Antidote: Prussian blue

      Poison: Warfarin
      Antidote: Vitamin K, Fresh frozen plasma (FFP)

      By utilizing these specific antidotes, medical professionals can effectively counteract the harmful effects of various poisons and overdoses.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      70.9
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  • Question 20 - A 28-year-old man is brought in by ambulance. He is unconscious and was...

    Correct

    • A 28-year-old man is brought in by ambulance. He is unconscious and was discovered next to an empty container of antifreeze by his girlfriend.
      What type of acid-base imbalance would you anticipate in a patient with ethylene glycol poisoning?

      Your Answer: Raised anion gap metabolic acidosis

      Explanation:

      The following list 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 is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      7.7
      Seconds
  • Question 21 - You are part of the team performing CPR on a child who has...

    Correct

    • You are part of the team performing CPR on a child who has gone into cardiac arrest. A healthcare assistant (HCA) takes over chest compressions from the charge nurse. You are concerned about the rate and depth of the compressions being given. You provide guidance to the HCA on the appropriate frequency and depth of chest compressions. What is the correct rate and depth of chest compression during CPR for a child?

      Your Answer: 100-120 compressions per minute to a depth of 5-6 cm

      Explanation:

      For adults, it is recommended to perform chest compressions at a rate of 100-120 compressions per minute. The depth of the compressions should be at least 5-6 cm.

      Further Reading:

      In the event of an adult experiencing cardiorespiratory arrest, it is crucial for doctors to be familiar with the Advanced Life Support (ALS) algorithm. They should also be knowledgeable about the proper technique for chest compressions, the appropriate rhythms for defibrillation, the reversible causes of arrest, and the drugs used in advanced life support.

      During chest compressions, the rate should be between 100-120 compressions per minute, with a depth of compression of 5-6 cm. The ratio of chest compressions to rescue breaths should be 30:2. It is important to change the person giving compressions regularly to prevent fatigue.

      There are two shockable ECG rhythms that doctors should be aware of: ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). These rhythms require defibrillation.

      There are four reversible causes of cardiorespiratory arrest, known as the 4 H’s and 4 T’s. The 4 H’s include hypoxia, hypovolemia, hypo or hyperkalemia or metabolic abnormalities, and hypothermia. The 4 T’s include thrombosis (coronary or pulmonary), tension pneumothorax, tamponade, and toxins. Identifying and treating these reversible causes is crucial for successful resuscitation.

      When it comes to resus drugs, they are considered of secondary importance during CPR due to the lack of high-quality evidence for their efficacy. However, adrenaline (epinephrine) and amiodarone are the two drugs included in the ALS algorithm. Doctors should be familiar with the dosing, route, and timing of administration for both drugs.

      Adrenaline should be administered intravenously at a concentration of 1 in 10,000 (100 micrograms/mL). It should be repeated every 3-5 minutes. Amiodarone is initially given at a dose of 300 mg, either from a pre-filled syringe or diluted in 20 mL of Glucose 5%. If required, an additional dose of 150 mg can be given by intravenous injection. This is followed by an intravenous infusion of 900 mg over 24 hours. The first dose of amiodarone is given after 3 shocks.

    • This question is part of the following fields:

      • Resus
      7.5
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  • Question 22 - A 55-year-old man receives a blood transfusion. Shortly after the transfusion is started,...

    Correct

    • A 55-year-old man receives a blood transfusion. Shortly after the transfusion is started, he experiences chills and shivering. His vital signs are as follows: heart rate of 116 beats per minute, blood pressure of 80/48, temperature of 40°C, and oxygen saturation of 97% on room air.

      What is the most suitable course of action for treatment?

      Your Answer: Stop the transfusion and administer antibiotics

      Explanation:

      Transfusion transmitted bacterial infection is a rare complication that can occur during blood transfusion. It is more commonly associated with platelet transfusion, as platelets are stored at room temperature. Additionally, previously frozen components that are thawed using a water bath and red cell components stored for several weeks are also at a higher risk for bacterial infection.

      Both Gram-positive and Gram-negative bacteria have been implicated in transfusion-transmitted bacterial infection, but Gram-negative bacteria are known to cause more severe illness and have higher rates of morbidity and mortality. Among the bacterial organisms, Yersinia enterocolitica is the most commonly associated with this type of infection. This particular organism is able to multiply at low temperatures and utilizes iron as a nutrient, making it well-suited for proliferation in blood stores.

      The clinical features of transfusion-transmitted bacterial infection typically manifest shortly after the transfusion begins. These features include a high fever, chills and rigors, nausea and vomiting, tachycardia, hypotension, and even circulatory collapse.

      If there is suspicion of a transfusion-transmitted bacterial infection, it is crucial to immediately stop the transfusion. Blood cultures and a Gram-stain should be requested to identify the specific bacteria causing the infection. Broad-spectrum antibiotics should be initiated promptly. Furthermore, the blood pack should be returned to the blood bank urgently for culture and Gram-stain analysis.

    • This question is part of the following fields:

      • Haematology
      15.3
      Seconds
  • Question 23 - A 42 year old male patient is brought into resus with a two...

    Correct

    • A 42 year old male patient is brought into resus with a two day history of nausea and vomiting. He has reduced GCS, is hypotensive and tachycardic. His wife tells you he has Addison's but frequently neglects to take his medication. Concerning Addison's, which electrolyte imbalance is most frequently linked to the condition?

      Your Answer: Hyponatraemia

      Explanation:

      The electrolyte imbalances that are commonly observed in individuals with Addison’s disease are decreased sodium levels, increased potassium levels, increased calcium levels, and decreased glucose levels. In cases of Addisonian crisis, which is a severe form of Addison’s disease, patients may also experience hyponatremia (low sodium levels), hyperkalemia (high potassium levels), hypercalcemia (high calcium levels), and hypoglycemia (low glucose levels). Additionally, these patients may often develop acidosis.

      Further Reading:

      Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.

      The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.

      The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.

      Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.

      There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.

    • This question is part of the following fields:

      • Endocrinology
      27.8
      Seconds
  • Question 24 - You evaluate a child with a limp and hip discomfort. An X-ray is...

    Correct

    • You evaluate a child with a limp and hip discomfort. An X-ray is conducted, and a diagnosis of Slipped upper femoral epiphysis (SUFE) is established.
      Which ONE statement about this condition is accurate?

      Your Answer: Trethowan’s sign may be present in the early stages

      Explanation:

      Slipped upper femoral epiphysis (SUFE), also referred to as slipped capital femoral epiphysis, is a rare but significant hip disorder that primarily affects children. It occurs when the growth plate slips at the epiphysis, causing the head of the femur to shift from its normal position on the femoral neck. Specifically, the femoral epiphysis remains in the acetabulum while the metaphysis moves forward and externally rotates.

      SUFE typically presents later in boys, usually between the ages of 10 and 17, compared to girls who typically experience it between 8 and 15 years of age. Several risk factors contribute to its development, including being male, being overweight, having immature skeletal maturity, having a positive family history, being of Pacific Island or African origin, having hypothyroidism, growth hormone deficiency, or hypogonadism.

      Patients with SUFE commonly experience hip pain and a limp. In severe cases, a leg length discrepancy may be noticeable. While the condition may not be immediately apparent on an anteroposterior (AP) film, it is usually detectable on a frog-leg lateral film. A diagnostic sign is the failure of a line drawn up the lateral edge of the femoral neck (known as the line of Klein) to intersect the epiphysis during the acute stage, also known as Trethowan’s sign.

      Surgical pinning is the most common treatment for SUFE. In approximately 20% of cases, bilateral SUFE occurs, prompting some surgeons to recommend prophylactic pinning of the unaffected hip. If a significant deformity is present, osteotomies or even arthroplasty may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      10
      Seconds
  • Question 25 - A 65-year-old man comes in with a 2-hour history of left-sided weakness and...

    Correct

    • A 65-year-old man comes in with a 2-hour history of left-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage, and he is being prepared for thrombolysis. According to the current NICE guidelines, which thrombolytic agent is recommended for the treatment of acute ischemic stroke?

      Your Answer: Alteplase

      Explanation:

      According to the current guidelines from NICE, alteplase is recommended as a thrombolysis treatment for acute ischaemic stroke. For more information, you can refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over the age of 16.

    • This question is part of the following fields:

      • Neurology
      54
      Seconds
  • Question 26 - A 35-year-old man with a history of bipolar affective disorder presents with symptoms...

    Incorrect

    • A 35-year-old man with a history of bipolar affective disorder presents with symptoms suggestive of lithium toxicity.
      Which of the following symptoms is LEAST likely to be observed?

      Your Answer: Increased muscle tone

      Correct Answer: SIADH

      Explanation:

      SIADH is a medical condition that is not brought on by lithium toxicity. However, lithium toxicity does have its own distinct set of symptoms. These symptoms include nausea and vomiting, diarrhea, tremors, ataxia, confusion, increased muscle tone, clonus, nephrogenic diabetes insipidus, convulsions, coma, and renal failure. It is important to note that SIADH and lithium toxicity are separate conditions with their own unique characteristics.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      5
      Seconds
  • Question 27 - You are overseeing the care of a 70-year-old male who suffered extensive burns...

    Correct

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

      Your Answer: Hartmann's solution

      Explanation:

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

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      6.8
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  • Question 28 - A 60 year old female comes to the emergency department complaining of sudden...

    Correct

    • A 60 year old female comes to the emergency department complaining of sudden difficulty in breathing. Upon examination, it is observed that the patient has had a tracheostomy for a prolonged period due to being on a ventilator after a severe head injury. Following the emergency tracheostomy algorithm, the tracheostomy is removed, but the patient's condition does not improve. What should be the next course of action in managing this patient?

      Your Answer: Cover the stoma and begin bag valve mask ventilation

      Explanation:

      When attempting to ventilate a patient with a tracheostomy, the first approach is usually through the mouth. If this is not successful, ventilation through the tracheostomy stoma is appropriate. After removing the tracheostomy, the doctor should begin ventilating the patient through the mouth by performing standard oral manoeuvres and covering the stoma with a hand or swab. If these measures fail, the clinician should then proceed to ventilate through the tracheostomy stoma using a bag valve mask and appropriate adjuncts such as oral or nasal adjuncts or an LMA.

      Further Reading:

      Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

      When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

      Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      11.3
      Seconds
  • Question 29 - A 70 year old male who underwent aortic valve replacement 2 months ago...

    Correct

    • A 70 year old male who underwent aortic valve replacement 2 months ago presents to the emergency department with a 4 day history of fever, fatigue, and overall malaise. The initial observations are as follows:

      Temperature: 38.7ºC
      Pulse rate: 126 bpm
      Blood pressure: 132/76 mmHg
      Respiration rate: 24 bpm
      Oxygen saturation: 96% on room air

      During the examination, splinter hemorrhages are observed on the patient's fingernails, leading to a suspicion of infective endocarditis. What is the most likely causative organism in this particular case?

      Your Answer: Staphylococcus

      Explanation:

      In this case, a 70-year-old male who recently underwent aortic valve replacement is presenting with symptoms of fever, fatigue, and overall malaise. Upon examination, splinter hemorrhages are observed on the patient’s fingernails, which raises suspicion of infective endocarditis. Given the patient’s history and symptoms, the most likely causative organism in this particular case is Staphylococcus.

      Further Reading:

      Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.

      The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.

      Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.

      The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.

      In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.

    • This question is part of the following fields:

      • Infectious Diseases
      19.1
      Seconds
  • Question 30 - 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
      8.8
      Seconds
  • Question 31 - A 65-year-old man comes in with a sudden onset of right-sided weakness and...

    Correct

    • A 65-year-old man comes in with a sudden onset of right-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage and he is being prepared for thrombolysis. His blood pressure is currently elevated at 190/100 mmHg.
      What would be the most suitable next course of action in managing his condition?

      Your Answer: Labetalol 10 mg IV

      Explanation:

      Severe hypertension, defined as blood pressure greater than 180/120 mmHg, is a condition that prevents the use of thrombolysis. In order to proceed with thrombolysis, it is necessary to lower the patient’s blood pressure to below this level within the designated time frame. Oral medications are unlikely to work quickly enough, so an intravenous antihypertensive agent is required.

      One commonly used agent in these situations is labetalol, which is administered intravenously at a dose of 10 mg over 1-2 minutes. This dose can be repeated if necessary, or an infusion can be set up to deliver a continuous dose of 2-8 mg per minute. Once the blood pressure is reduced to less than 180/105 mmHg, thrombolysis can be safely performed.

      Alternatively, a nitrate infusion, such as Isoket, can be used in patients who cannot tolerate beta-blockers due to contraindications like asthma, heart block, or cardiac failure. This provides an alternative option for lowering blood pressure in these individuals.

    • This question is part of the following fields:

      • Neurology
      6.3
      Seconds
  • Question 32 - A 28 year old male presents to the emergency department after experiencing 4...

    Correct

    • A 28 year old male presents to the emergency department after experiencing 4 days of severe vomiting and diarrhea. A peripheral cannula is inserted, and blood samples are taken, revealing the following results:

      Na+ 135 mmol/L
      K+ 2.3 mmol/L
      Ur 8.8 mmol/L
      Cr 123 umol/L

      The medical team decides to administer intravenous fluids. They plan to infuse a 1 liter bag of 0.9% saline with 40 mmol of potassium chloride. What would be the most appropriate duration for this infusion?

      Your Answer: 4 hours

      Explanation:

      The recommended maximum infusion rate for IV fluids containing potassium is 10 mmol/hr in normal circumstances outside of the HDU/ICU setting, according to NHS SPS. However, in certain situations, higher infusion rates may be used. The BNF advises a maximum infusion rate of 20 mmol/hr for saline containing KCl, which is commonly administered to patients with DKA. If infusion rates exceed 10 mmol/hr, it is recommended to administer the fluids ideally in a HDU/level 2/ICU setting, through a central line, using an infusion pump, and with cardiac monitoring in place.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      6.7
      Seconds
  • Question 33 - A 60-year-old individual arrives at the emergency department complaining of a nosebleed. The...

    Correct

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

      Your Answer: Insert bilateral nasal tampons

      Explanation:

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

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      11.6
      Seconds
  • Question 34 - You are reviewing a 35-year-old man after receiving his most recent blood results....

    Incorrect

    • You are reviewing a 35-year-old man after receiving his most recent blood results. He is currently taking ramipril for his blood pressure, which is well controlled. He used to consume 30 units of alcohol per week until three months ago when he was advised to reduce his intake following his last set of blood tests. He has since remained completely abstinent. He has no identifiable risk factors for chronic liver disease. On examination, you can palpate a 1 cm liver edge below the right costal margin. His most recent two sets of blood results are provided below.

      Blood results today:
      Bilirubin: 19 µmol/L (3-20)
      ALT: 98 IU/L (5-40)
      AST: 46 IU/L (5-40)
      ALP: 126 IU/L (20-140)
      GGT: 225 IU/L (5-40)

      Blood results 3 months ago:
      Bilirubin: 19 µmol/L (3-20)
      ALT: 126 IU/L (5-40)
      AST: 39 IU/L (5-40)
      ALP: 118 IU/L (20-140)
      GGT: 35 IU/L (5-40)

      What is the SINGLE most likely diagnosis?

      Your Answer: Alcohol excess

      Correct Answer: Non-alcoholic steatohepatitis

      Explanation:

      The diagnosis in this case is non-alcoholic steatohepatitis (NASH), which is characterized by fatty infiltration of the liver and is commonly associated with obesity. It is the most frequent cause of persistently elevated ALT levels in patients without risk factors for chronic liver disease.

      Risk factors for developing NASH include obesity, particularly truncal obesity, diabetes mellitus, and hypercholesterolemia.

      The clinical features of NASH can vary, with many patients being completely asymptomatic. However, some may experience right upper quadrant pain, nausea and vomiting, and hepatomegaly (enlarged liver).

      The typical biochemical profile seen in NASH includes elevated transaminases, with an AST:ALT ratio of less than 1. Often, there is an isolated elevation of ALT, and gamma-GT levels may be mildly elevated. In about one-third of patients, non-organ specific autoantibodies may be present. The presence of antinuclear antibodies (ANA) is associated with insulin resistance and indicates a higher risk of rapid progression to advanced liver disease.

      If the AST level is significantly elevated or if the gamma-GT level is markedly elevated, further investigation for other potential causes should be considered. A markedly elevated gamma-GT level may suggest alcohol abuse, although it can also be elevated in NASH alone.

      Diagnosis of NASH is confirmed through a liver biopsy, which will reveal increased fat deposition and a necro-inflammatory response within the hepatocytes.

      Currently, there is no specific treatment for NASH. However, weight loss and medications that improve insulin resistance, such as metformin, may help slow down the progression of the disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      30.5
      Seconds
  • Question 35 - You assess a 68-year-old woman with chronic lymphocytic leukemia (CLL).
    Which ONE of the...

    Correct

    • You assess a 68-year-old woman with chronic lymphocytic leukemia (CLL).
      Which ONE of the following statements about CLL is accurate?

      Your Answer: It is most commonly discovered as an incidental finding

      Explanation:

      Chronic lymphocytic leukaemia (CLL) is the most common form of leukaemia in adults. It occurs when mature lymphocytes multiply uncontrollably. B-cell lineage accounts for about 95% of cases. CLL is typically slow-growing and is often discovered incidentally during routine blood tests. As the disease progresses, patients may experience swollen lymph nodes, enlarged liver and spleen, low red blood cell count, and increased susceptibility to infections. This condition primarily affects adult males, with over 75% of CLL patients being men over the age of 50.

    • This question is part of the following fields:

      • Haematology
      14
      Seconds
  • Question 36 - A 3-year-old girl is brought to the Emergency Department by ambulance following an...

    Correct

    • A 3-year-old girl is brought to the Emergency Department by ambulance following an episode of fainting at home. The parents noticed that the girl suddenly collapsed and appeared pale. After lifting her up, she quickly regained consciousness and her color returned. After a thorough examination and investigation by the pediatric team, a diagnosis of a brief resolved unexplained event (BRUE) is made.
      Which of the following is NOT a recognized risk factor for a BRUE?

      Your Answer: High birth weight

      Explanation:

      The term Apparent Life-Threatening Event (ALTE) has traditionally been used to describe a specific type of event. However, in 2016, the American Academy of Paediatrics (AAP) recommended replacing ALTE with a new term called Brief Resolved Unexplained Event (BRUE).

      An ALTE is defined as an episode that is frightening to the observer and is characterized by a combination of symptoms such as apnoea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), significant change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer may even fear that the infant has died.

      On the other hand, BRUE has stricter criteria and is only applicable to episodes that occur in infants under 12 months old. A BRUE is characterized by being brief (lasting less than 1 minute, typically 2-30 seconds), resolved (the infant must have returned to their baseline state), and not explained by any identifiable medical condition. It must also exhibit at least one of the following symptoms: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in muscle tone (hyper- or hypotonia), or altered level of responsiveness.

      To diagnose a BRUE, a thorough history and physical examination of the infant must be conducted, and no explanation for the event should be found. Additionally, there are several risk factors associated with the development of a BRUE, including prematurity, age less than ten weeks, recent anesthesia, airway or maxillofacial abnormalities, history of gastro-oesophageal reflux disease, previous apnoeic episode, recent upper respiratory tract infection. Low birth weight may also be a risk factor, while high birth weight has no recognized association with BRUEs.

    • This question is part of the following fields:

      • Paediatric Emergencies
      13.9
      Seconds
  • Question 37 - A 70-year-old man with atrial fibrillation comes to the Emergency Department with an...

    Correct

    • A 70-year-old man with atrial fibrillation comes to the Emergency Department with an unrelated medical issue. While reviewing his medications, you find out that he is taking warfarin as part of his treatment.
      Which ONE of the following beverages should he avoid?

      Your Answer: Cranberry juice

      Explanation:

      Warfarin has been found to heighten the likelihood of bleeding events when consumed alongside specific juices, such as cranberry juice and grapefruit juice. As a result, individuals who are taking warfarin should be cautioned against consuming these beverages. For more information on this topic, please refer to the BNF section on warfarin interactions and the interaction between warfarin and cranberry juice.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      5
      Seconds
  • Question 38 - A 57 year old male presents to the emergency department with sudden onset...

    Correct

    • A 57 year old male presents to the emergency department with sudden onset dizziness in the past 24 hours. The patient describes a sensation of the room spinning even when at rest. The patient also complains of feeling nauseated and has vomited a few times. The patient states that they do not take any regular medications and are generally healthy, aside from a recent cold. There is no reported hearing loss or ringing in the ears. Upon observation, the patient appears unsteady while attempting to walk and tends to veer to the left side. The head impulse test yields positive results. All vital signs are within normal range.

      What is the most appropriate course of treatment for this patient?

      Your Answer: Prochlorperazine

      Explanation:

      First-line treatments for nausea and vomiting in patients with vestibular neuronitis include prochlorperazine, cinnarizine, cyclizine, and promethazine. According to NICE guidelines, the following treatment options are recommended: buccal or intramuscular administration of prochlorperazine, intramuscular administration of cyclizine, or oral administration of prochlorperazine, cinnarizine, cyclizine, or promethazine teoclate (if the nausea and vomiting are mild and the patient can tolerate oral medication). Betahistine is specifically used to treat Meniere’s disease, which is characterized by hearing loss and tinnitus. The Epley maneuver is a treatment option for benign paroxysmal positional vertigo (BPPV). Haloperidol and levomepromazine are indicated for postoperative nausea and vomiting, as well as nausea and vomiting in palliative care, but they are not recommended for treating patients with vestibular neuronitis.

      Further Reading:

      Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

      Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

      Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

      The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

    • This question is part of the following fields:

      • Ear, Nose & Throat
      33.4
      Seconds
  • Question 39 - A patient is experiencing lower gastrointestinal bleeding following the administration of heparin. You...

    Incorrect

    • A patient is experiencing lower gastrointestinal bleeding following the administration of heparin. You choose to utilize protamine sulfate to reverse the anticoagulation.

      Which ONE statement about protamine sulfate is NOT true?

      Your Answer: It has an anticoagulant effect

      Correct Answer: It is administered subcutaneously

      Explanation:

      Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex is inactive and is used to counteract the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.

      Apart from its ability to neutralize heparin, protamine sulphate also possesses a weak intrinsic anticoagulant effect. This is believed to be due to its inhibition of the formation and activity of thromboplastin.

      To administer protamine sulphate, it is slowly injected intravenously. The dosage should be adjusted based on the amount of heparin to be neutralized, the time elapsed since heparin administration, and the aPTT. For every 100 IU of heparin, 1 mg of protamine is required for neutralization. However, the maximum adult dose within a 10-minute period should not exceed 50 mg.

      It is important to note that protamine sulphate has additional effects on the body. It acts as a depressant on the heart muscle and may lead to bradycardia and hypotension. These effects are caused by complement activation and the release of leukotrienes.

    • This question is part of the following fields:

      • Haematology
      12.8
      Seconds
  • Question 40 - A 45-year-old man presents with generalized weakness and palpitations. Upon reviewing his blood...

    Correct

    • A 45-year-old man presents with generalized weakness and palpitations. Upon reviewing his blood results, you note that his potassium level is significantly elevated. His ECG shows a broad QRS and peaked T waves. As part of his treatment, you administer a dose of calcium chloride.

      How does calcium chloride work in the treatment of hyperkalemia?

      Your Answer: Stabilisation of the cell membrane

      Explanation:

      Calcium is effective in treating hyperkalaemia by counteracting the harmful effects on the heart caused by high levels of potassium. It achieves this by stabilizing the cardiac cell membrane and preventing unwanted depolarization. The onset of action is rapid, typically within 15 minutes, but the effects do not last for a long duration. Calcium is considered the first-line treatment for severe hyperkalaemia (potassium levels above 7 mmol/l) and when significant ECG abnormalities are present, such as widened QRS interval, loss of P wave, or cardiac arrhythmias. However, if the ECG only shows peaked T waves, calcium is usually not recommended.

      It is important to note that calcium does not directly affect the serum potassium levels. Therefore, when administering calcium, it should be accompanied by other therapies that actively lower the serum potassium levels, such as insulin and salbutamol.

      When hyperkalaemia is accompanied by hemodynamic compromise, calcium chloride is preferred over calcium gluconate. This is because calcium chloride contains approximately three times more elemental calcium than an equal volume of calcium gluconate.

    • This question is part of the following fields:

      • Nephrology
      8.4
      Seconds
  • Question 41 - A 68 year old patient with dementia is brought into the emergency department...

    Correct

    • A 68 year old patient with dementia is brought into the emergency department by a caregiver due to a suspected accidental overdose. The caregiver reports finding several of the patient's medication bottles with multiple tablets missing. An ECG is conducted and reveals a prolonged QT interval. The caregiver presents you with the medication containers. Which of the following medications is the most probable culprit for the prolonged QT interval?

      Your Answer: Citalopram

      Explanation:

      Antipsychotics and antidepressants are drugs that are known to cause QT prolongation, which is a potentially dangerous heart rhythm abnormality. Similarly, SSRIs and other antidepressants are also associated with QT prolongation. On the other hand, beta-blockers like bisoprolol are used to shorten the QT interval and are considered as a treatment option for long QT syndrome. However, it’s important to note that sotalol, although classified as a beta blocker, acts differently by blocking potassium channels. This unique mechanism of action makes sotalol a class III anti-arrhythmic agent and may result in QT interval prolongation.

      Further Reading:

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      8.4
      Seconds
  • Question 42 - A 48 year old woman comes to the emergency department complaining of episodes...

    Incorrect

    • A 48 year old woman comes to the emergency department complaining of episodes of lightheadedness. She mentions that she is an avid jogger and noticed on her fitness tracker that her heart rate had dropped to 48 beats per minute. Which of the following characteristics would warrant drug intervention or transcutaneous pacing in a patient with bradycardia?

      Your Answer: Presyncope

      Correct Answer: Myocardial ischaemia

      Explanation:

      Indications for drug treatment or pacing in patients with bradycardia include shock, syncope, myocardial ischemia, heart failure, and the presence of risk factors for asystole. If any of these adverse features are present, it is important to consider drug treatment or pacing. However, even if none of these adverse features are present, patients may still require drug treatment or pacing if they have risk factors for developing asystole, such as recent asystole, Mobitz II AV block, complete heart block with broad QRS, or a ventricular pause longer than 3 seconds.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      12.6
      Seconds
  • Question 43 - A 45-year-old woman comes in with a history of fatigue, excessive thirst, and...

    Correct

    • A 45-year-old woman comes in with a history of fatigue, excessive thirst, and frequent urination. A urine dipstick test is done, which shows the presence of glucose in the urine.
      Which ONE result would be INCONSISTENT with a diagnosis of diabetes mellitus in this patient?

      Your Answer: An HbA1c of 40 mmol/mol

      Explanation:

      According to the 2011 recommendations from the World Health Organization (WHO), HbA1c can now be used as a diagnostic test for diabetes. However, this is only applicable if stringent quality assurance tests are in place and the assays are standardized to criteria aligned with international reference values. Additionally, accurate measurement of HbA1c is only possible if there are no conditions present that could hinder its accuracy.

      To diagnose diabetes using HbA1c, a value of 48 mmol/mol (6.5%) is recommended as the cut-off point. It’s important to note that a value lower than 48 mmol/mol (6.5%) does not exclude the possibility of diabetes, as glucose tests are still necessary for a definitive diagnosis.

      When using glucose tests, the following criteria are considered diagnostic for diabetes mellitus:
      – A random venous plasma glucose concentration greater than 11.1 mmol/l
      – A fasting plasma glucose concentration greater than 7.0 mmol/l
      – A two-hour plasma glucose concentration greater than 11.1 mmol/l, two hours after consuming 75g of anhydrous glucose in an oral glucose tolerance test (OGTT)

      However, there are certain circumstances where HbA1c is not appropriate for diagnosing diabetes mellitus. These include:
      – ALL children and young people
      – Patients of any age suspected of having Type 1 diabetes
      – Patients with symptoms of diabetes for less than two months
      – Patients at high risk of diabetes who are acutely ill, such as those requiring hospital admission
      – Patients taking medication that may cause a rapid rise in glucose levels, such as steroids or antipsychotics
      – Patients with acute pancreatic damage, including those who have undergone pancreatic surgery
      – Pregnant individuals
      – Presence of genetic, hematologic, and illness-related factors that can influence HbA1c and its measurement.

    • This question is part of the following fields:

      • Endocrinology
      62.6
      Seconds
  • Question 44 - You are managing a 35-year-old woman with a presumed diagnosis of anaphylaxis. A...

    Correct

    • You are managing a 35-year-old woman with a presumed diagnosis of anaphylaxis. A tryptase level is obtained shortly after initiating treatment, which leads to an improvement in the patient's condition. You decide to request a follow-up tryptase level to further support the diagnosis of anaphylaxis. When would be the appropriate time to obtain the repeat level?

      Your Answer: 1 to 2 hours from the onset of symptoms

      Explanation:

      Tryptase levels can be a valuable tool in diagnosing anaphylaxis. During an anaphylactic reaction, mast cell tryptase is released and can be measured in the blood. Research suggests that tryptase levels reach their highest point in the blood within 1 minute to 6 hours after the reaction begins, typically peaking around 1-2 hours after the onset of symptoms. This information is crucial for diagnosing and treating anaphylaxis, especially in cases where the diagnosis is uncertain. It’s important to note that tryptase levels may return to normal within 6 hours, so the timing of blood samples is crucial. The current recommendation is to take three tryptase level measurements: one as soon as resuscitation begins, another 1-2 hours after symptoms start, and a third 24 hours later or during the recovery period. It’s worth mentioning that some individuals may have elevated baseline tryptase levels, which should be taken into consideration during the diagnosis process.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Allergy
      8.4
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  • Question 45 - You receive a call from the paramedics notifying you that they are bringing...

    Correct

    • You receive a call from the paramedics notifying you that they are bringing a 45-year-old male patient to the emergency department (ED) who experienced a cardiac arrest. What is the survival rate to hospital discharge for patients who suffer an out-of-hospital cardiac arrest?

      Your Answer: 7-8%

      Explanation:

      The percentage of patients who survive to hospital discharge after experiencing an out of hospital cardiac arrest.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      11.6
      Seconds
  • Question 46 - A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during...

    Incorrect

    • A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during their gap year.
      Which of the following is NOT a viral haemorrhagic fever?

      Your Answer: Hantavirus

      Correct Answer: Chagas disease

      Explanation:

      The viral hemorrhagic fevers (VHFs) are a group of infectious diseases caused by four distinct types of RNA viruses. These include Filoviruses (such as Marburg virus and Ebola), Arenaviruses (like Lassa fever and Argentine haemorrhagic fever), Bunyaviruses (including Hantavirus and Rift Valley fever), and Flavivirus (such as Yellow fever and dengue fever). VHFs are serious multi-system disorders that can be potentially fatal. Each type of VHF has a natural reservoir, which is an animal or insect host, and they are typically found in the areas where these host species reside. Outbreaks of these hemorrhagic fevers occur sporadically and irregularly, making them difficult to predict.

      The typical clinical features of VHFs include fever, headache, myalgia, fatigue, bloody diarrhea, haematemesis, petechial rashes and ecchymoses, edema, confusion and agitation, as well as hypotension and circulatory collapse.

      On the other hand, Chagas disease is not classified as a VHF. It is a tropical disease caused by the protozoan Trypanosoma cruzi. This disease is transmitted by Triatomine insects, commonly known as kissing bugs. Initially, Chagas disease causes a mild acute illness that resembles flu. However, around 10% of individuals develop chronic Chagas disease, which can lead to various complications. These complications include cardiac issues like dilated cardiomyopathy, neurological problems such as neuritis, and gastrointestinal complications like megacolon.

    • This question is part of the following fields:

      • Infectious Diseases
      9.8
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  • Question 47 - A 35-year-old woman has experienced a fracture of the left humerus. During examination,...

    Correct

    • A 35-year-old woman has experienced a fracture of the left humerus. During examination, it is found that she has weakness in extending her wrist and metacarpophalangeal joints, leading to wrist drop and an inability to grip with her left hand. However, she still has preserved extension of the elbow. Additionally, there is a loss of sensation over the dorsal aspect of the forearm from below the elbow to the 1st dorsal interosseous.
      Which nerve has been damaged in this particular case?

      Your Answer: Radial nerve

      Explanation:

      Radial nerve injuries often occur in conjunction with fractures of the humerus. The most common cause of a radial nerve palsy is external compression or trauma to the radial nerve as it passes through the spiral groove in the middle of the humerus.

      There are several factors that can lead to damage of the radial nerve in the spiral groove. These include trauma, such as a fracture in the middle of the humerus, compression known as Saturday night palsy, and iatrogenic causes like injections.

      When the radial nerve is injured within the spiral groove, it results in weakness of the wrist and metacarpophalangeal joints. However, elbow extension is not affected because the branches to the triceps and anconeus muscles originate before the spiral groove. The interphalangeal joints remain unaffected as well, as they are supplied by the median and ulnar nerves. Sensory loss will be experienced over the dorsal aspect of the forearm, extending from below the elbow to the 1st dorsal interosseous.

      In contrast, injury to the radial nerve in the axilla will also cause weakness of elbow extension and sensory loss in the distribution of the more proximal cutaneous branches. This helps distinguish it from injury in the spiral groove.

      In the forearm, the posterior interosseous branch of the radial nerve can also be damaged. This can occur due to injury to the radial head or entrapment in the supinator muscle under the arcade of Frohse. However, this type of injury can be easily distinguished from injury in the spiral groove because there is no sensory involvement and no wrist drop, thanks to the preservation of the extensor carpi radialis longus. Nonetheless, there will still be weakness in the wrist and fingers.

    • This question is part of the following fields:

      • Neurology
      14.7
      Seconds
  • Question 48 - A 35-year-old woman with a background of mental health issues is behaving strangely...

    Correct

    • A 35-year-old woman with a background of mental health issues is behaving strangely and making threats to harm herself and those nearby in the shopping district. The authorities are contacted and determine the necessity to relocate the woman to a secure location.
      Which section of the 2007 Mental Health Act (MHA) permits a police officer to transfer an individual displaying signs of a mental health disorder to a place of safety?

      Your Answer: Section 136

      Explanation:

      Section 136 of the Mental Health Act (MHA) grants authority to a police officer to relocate an individual who seems to be experiencing a mental health disorder to a secure location. This provision permits detention for a period of 72 hours, during which time the patient can undergo evaluation by a medical professional.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      7.4
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  • Question 49 - A 32 year old female has been brought into the ED during the...

    Correct

    • A 32 year old female has been brought into the ED during the early hours of the morning after being found unresponsive on a park bench by a police patrol. The ambulance crew started Cardiopulmonary resuscitation which has continued after the patient's arrival in the ED. You are concerned about hypothermia given recent frosts and outdoor temperatures near freezing. Which of the following methods is most suitable for evaluating the patient's core temperature?

      Your Answer: Oesophageal temperature probe

      Explanation:

      In patients with hypothermia, it is important to use a low reading thermometer such as an oesophageal temperature probe or vascular temperature probe. Skin surface thermometers are not effective in hypothermia cases, and rectal and tympanic thermometers may not provide accurate readings. Therefore, it is recommended to use oesophageal temperature or vascular temperature probes. However, it is worth noting that oesophageal probes may not be accurate if the patient is receiving warmed inhaled air.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      196.5
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  • Question 50 - A 35-year-old dairy farmer presents with a flu-like illness that has been worsening...

    Incorrect

    • A 35-year-old dairy farmer presents with a flu-like illness that has been worsening for the past two weeks. He has high fevers, a pounding headache, and muscle aches. He has now also developed a dry cough, stomach pain, and diarrhea. During the examination, there are no notable chest signs, but a liver edge can be felt 4 cm below the costal margin.

      Today, his blood tests show the following results:
      - Hemoglobin (Hb): 13.4 g/dl (normal range: 13-17 g/dl)
      - White blood cell count (WCC): 21.5 x 109/l (normal range: 4-11 x 109/l)
      - Neutrophils: 17.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Platelets: 567 x 109/l (normal range: 150-400 x 109/l)
      - C-reactive protein (CRP): 187 mg/l (normal range: < 5 mg/l)
      - Sodium (Na): 127 mmol/l (normal range: 133-147 mmol/l)
      - Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      - Creatinine (Creat): 122 micromol/l (normal range: 60-120 micromol/l)
      - Urea: 7.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      - Aspartate aminotransferase (AST): 121 IU/l (normal range: 8-40 IU/l)
      - Alkaline phosphatase (ALP): 296 IU/l (normal range: 30-200 IU/l)
      - Bilirubin: 14 micromol/l (normal range: 3-17 micromol/l)

      What is the SINGLE most likely causative organism?

      Your Answer: Chlamydia psittaci

      Correct Answer: Coxiella burnetii

      Explanation:

      Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.

      In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.

      It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.

    • This question is part of the following fields:

      • Respiratory
      18.8
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  • Question 51 - A young woman with a previous case of urethritis has a urethral swab...

    Correct

    • A young woman with a previous case of urethritis has a urethral swab sent to the laboratory for examination. Neisseria gonorrhoeae is identified in the sample, confirming a diagnosis of gonorrhea.

      Which ONE statement about Neisseria gonorrhoeae is accurate?

      Your Answer: It adheres to the genitourinary epithelium via pili

      Explanation:

      Neisseria gonorrhoeae is a type of bacteria that causes the sexually transmitted infection known as gonorrhoea. It is a Gram-negative diplococcus, meaning it appears as pairs of bacteria under a microscope. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important characteristic of Neisseria gonorrhoeae is its ability to undergo antigenic variation, which means that recovering from an infection does not provide immunity and reinfection is possible.

      When Neisseria gonorrhoeae infects the body, it first attaches to the genitourinary epithelium using pili, which are hair-like structures on the surface of the bacteria. It then invades the epithelial layer and triggers a local acute inflammatory response. In men, the clinical features of gonorrhoea often include urethritis (inflammation of the urethra) in about 80% of cases, dysuria (painful urination) in around 50% of cases, and mucopurulent discharge. Rectal infection may also occur, usually without symptoms, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is usually asymptomatic in men.

      In women, the clinical features of gonorrhoea commonly include vaginal discharge in about 50% of cases, lower abdominal pain in around 25% of cases, dysuria in 10-15% of cases, and pelvic/lower abdominal tenderness in less than 5% of cases. Endocervical discharge and/or bleeding may also be present. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge, and pharyngitis is usually asymptomatic in women as well.

      Complications of Neisseria gonorrhoeae infection can be serious and include pelvic inflammatory disease (PID) in women, epididymo-orchitis or prostatitis in men, arthritis, dermatitis, pericarditis and/or myocarditis, hepatitis, and meningitis.

      To diagnose gonorrhoea, samples of pus from the urethra, cervix, rectum, or throat should be collected and promptly sent to the laboratory in specialized transport medium. Traditionally, diagnosis has been made using Gram-stain and culture techniques, but newer PCR testing methods are becoming more commonly used.

    • This question is part of the following fields:

      • Sexual Health
      11.7
      Seconds
  • Question 52 - A 7 year old male is brought into the emergency department by concerned...

    Correct

    • A 7 year old male is brought into the emergency department by concerned parents. The child has been feeling unwell for the past 2-3 days, complaining of stomach pain and feeling nauseous. The parents have also noticed that the child has been drinking more than usual and constantly feels thirsty. Tests confirm a diagnosis of diabetic ketoacidosis (DKA) and appropriate treatment is initiated. About 4 hours after starting treatment, one of the nursing staff asks you to assess the patient as he has been experiencing headaches and has started vomiting. The following repeat observations are recorded:

      Pulse: 58 bpm
      Respiration rate: 28 bpm
      Temperature: 37.2ºC

      What is the most appropriate course of action?

      Your Answer: Administer mannitol (20%) 0.5-1 g/kg over 10-15 minutes

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      9.1
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  • Question 53 - A 30-year-old woman is injured in a car crash and sustains severe facial...

    Correct

    • A 30-year-old woman is injured in a car crash and sustains severe facial injuries. X-rays and CT scans of her face show that she has a Le Fort II fracture.
      What is the most accurate description of a Le Fort II fracture?

      Your Answer: ‘Floating maxilla’

      Explanation:

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

      The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.

      Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.

      Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.

      Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      5.4
      Seconds
  • Question 54 - You are requested to evaluate a teenager who is in resus with a...

    Incorrect

    • You are requested to evaluate a teenager who is in resus with a supraventricular tachycardia. The patient is stable hemodynamically but has already received 3 doses of IV adenosine and vagal maneuvers. However, there has been no improvement in their condition.
      Based on the current APLS guidelines, what would be the most suitable next course of action in managing this patient?

      Your Answer: 4 J/kg DC unsynchronised shock

      Correct Answer: Give IV amiodarone 5-10 mg/kg

      Explanation:

      Supraventricular tachycardia (SVT) is the most common arrhythmia that occurs in children and infants, causing cardiovascular instability. According to the current APLS guidelines, if a patient with SVT shows no signs of shock and remains stable, initial attempts should be made to use vagal maneuvers. If these maneuvers are unsuccessful, the following steps are recommended:

      – Administer an initial dose of 100 mcg/kg of adenosine.
      – After two minutes, if the child is still in stable SVT, administer another dose of 200 mcg/kg of adenosine.
      – After an additional two minutes, if the child remains in stable SVT, administer another dose of 300 mcg/kg of adenosine.

      If these measures do not resolve the SVT, the guidelines suggest considering the following options:

      – Administer adenosine at a dose of 400-500 mcg/kg.
      – Perform a synchronous DC shock.
      – Administer amiodarone.

      When using amiodarone, the initial dose should be 5-10 mg/kg given over a period of 20 minutes to 2 hours. This should be followed by a continuous infusion of 300 mcg/kg/hour, with adjustments made based on the response, increasing by 1.5 mg/kg/hour. The total infusion rate should not exceed 1.2 g in a 24-hour period.

      If defibrillation is necessary for the treatment of SVT in children, it should be performed as a DC synchronous shock at a dosage of 1-2 J/kg.

    • This question is part of the following fields:

      • Cardiology
      8.3
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  • Question 55 - A 65-year-old man presents with short episodes of vertigo that worsen in the...

    Incorrect

    • A 65-year-old man presents with short episodes of vertigo that worsen in the morning and are triggered by head movement. You suspect a diagnosis of benign paroxysmal positional vertigo (BPPV).
      Which straightforward bedside test can be conducted to confirm the diagnosis?

      Your Answer:

      Correct Answer: The Dix-Hallpike test

      Explanation:

      The Dix-Hallpike test is a straightforward examination that can be utilized to verify the diagnosis of benign paroxysmal positional vertigo (BPPV).

      To conduct the Dix-Hallpike test, the patient is swiftly brought down to a supine position with the neck extended by the clinician executing the maneuver. The test yields a positive result if the patient experiences a recurrence of their vertigo symptoms and the clinician performing the test observes nystagmus.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      0
      Seconds
  • Question 56 - You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple...

    Incorrect

    • You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple administrations of atropine, there has been no improvement in the patient's condition. Which two medications would be the most suitable options to consider next for treating this rhythm?

      Your Answer:

      Correct Answer: Adrenaline/Isoprenaline

      Explanation:

      Adrenaline and isoprenaline are considered as second-line medications for the treatment of bradycardia. If atropine fails to improve the condition, transcutaneous pacing is recommended. However, if pacing is not available, the administration of second-line drugs becomes necessary. Adrenaline is typically given intravenously at a dosage of 2-10 mcg/minute, while isoprenaline is given at a dosage of 5 mcg/minute. It is important to note that glucagon is not mentioned as a treatment option for this patient’s bradycardia, as the cause of the condition is not specified as a beta-blocker overdose.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 57 - You are asked to evaluate a 62-year-old patient who has come in with...

    Incorrect

    • You are asked to evaluate a 62-year-old patient who has come in with complaints of chest discomfort. The nurse has handed you the ECG report, which states 'unspecified age septal infarction' in the comments section.

      Which leads would you anticipate observing ST elevation in an acute septal STEMI?

      Your Answer:

      Correct Answer: V1, V2

      Explanation:

      The septum, which is a part of the heart, can be best identified by examining leads V1 and V2. The septum receives its blood supply from the proximal left anterior descending artery (LAD). The LAD is responsible for supplying blood to the anterior myocardium and also contributes to the blood supply of the lateral myocardium. If the LAD becomes blocked, it can result in ST elevation in all the chest leads.

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 58 - A 21 year old female is brought to the emergency department by her...

    Incorrect

    • A 21 year old female is brought to the emergency department by her parents and admits to ingesting 36 paracetamol tablets. You determine that the patient fulfills the requirements for receiving activated charcoal. What would be the appropriate dosage to administer?

      Your Answer:

      Correct Answer: 50 g

      Explanation:

      The recommended dose of activated charcoal for adults and children aged 12 or over to prevent the absorption of poisons in the gastrointestinal tract is 50g.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 59 - You assess a patient who is currently undergoing systemic anticancer treatment. She presents...

    Incorrect

    • You assess a patient who is currently undergoing systemic anticancer treatment. She presents with a high fever, and you have concerns about the potential occurrence of neutropenic sepsis.

      Which of the following statements about neutropenic sepsis is NOT true?

      Your Answer:

      Correct Answer: Dual therapy with Tazocin and an aminoglycoside is the recommended first-line treatment for confirmed neutropenic sepsis

      Explanation:

      Neutropenic sepsis is a serious condition that can occur when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is often caused by factors such as chemotherapy, immunosuppressive drugs, infections, and bone marrow disorders. Mortality rates can be as high as 20% in adults.

      To diagnose neutropenic sepsis, doctors look for a neutrophil count of 0.5 x 109 per litre or lower in patients undergoing cancer treatment. Additionally, if a patient has a temperature higher than 38°C or other signs of significant sepsis, they may be diagnosed with neutropenic sepsis.

      Cancer treatments, particularly chemotherapy, can weaken the bone marrow ability to fight off infections, making patients more susceptible to neutropenic sepsis. This risk can also be present with radiotherapy.

      According to the current guidelines from the National Institute for Health and Care Excellence (NICE), adult patients with acute leukemia, stem cell transplants, or solid tumors should be offered prophylaxis with a fluoroquinolone antibiotic during periods of expected neutropenia.

      When managing neutropenic sepsis, it is important to follow the UK Sepsis Trust Sepsis Six bundle, which includes specific actions to be taken within the first hour of recognizing sepsis.

      For initial empiric antibiotic therapy in suspected cases of neutropenic sepsis, the NICE guidelines recommend using piperacillin with tazobactam as monotherapy. Aminoglycosides should not be used unless there are specific patient or local microbiological indications.

      Reference:
      NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 60 - A 30-year-old man comes in with a cough and wheezing.
    What ONE clinical...

    Incorrect

    • A 30-year-old man comes in with a cough and wheezing.
      What ONE clinical feature would indicate a potential diagnosis of severe asthma?

      Your Answer:

      Correct Answer: Normal PaCO2

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

    • This question is part of the following fields:

      • Respiratory
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  • Question 61 - A 5 year old female is brought to the emergency department by concerned...

    Incorrect

    • A 5 year old female is brought to the emergency department by concerned parents. The child started experiencing episodes of diarrhea and vomiting 2 days ago which have continued today. They are worried as the patient appears more lethargic and is not urinating as frequently as usual. Upon assessment, the patient is slow to respond to verbal stimuli and has mottled skin, cold extremities, and a capillary refill time of 4 to 5 seconds. The patient's vital signs are as follows:

      Pulse: 142 bpm
      Respiration rate: 35 bpm
      Temperature: 37.6ºC

      What is the most appropriate next course of action for this patient?

      Your Answer:

      Correct Answer: Rapid intravenous infusion of 10 ml/kg of 0.9% sodium chloride solution

      Explanation:

      The most appropriate next step in managing this patient is to rapidly infuse 10 ml/kg of 0.9% sodium chloride solution intravenously. This is because the girl is showing signs of severe dehydration, such as lethargy, decreased urine output, mottled skin, and prolonged capillary refill time. Rapid intravenous fluid administration is necessary to quickly restore her fluid volume and prevent further complications.

      Further Reading:

      Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

      Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

      When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

      In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

      Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

      Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

    • This question is part of the following fields:

      • Paediatric Emergencies
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  • Question 62 - A 35-year-old man is brought in by ambulance following a car crash. A...

    Incorrect

    • A 35-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to assess for the presence of a haemoperitoneum.
      Where is free fluid most likely to be observed if a haemoperitoneum is present?

      Your Answer:

      Correct Answer: Liver

      Explanation:

      A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information is crucial for making decisions regarding further management of the patient.

      The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.

      During a standard FAST scan, four regions are examined. The subxiphoid transverse view is used to assess for pericardial effusion and left lobe liver injuries. The longitudinal view of the right upper quadrant helps identify right liver injuries, right kidney injury, and fluid in the hepatorenal recess (Morison’s pouch). The longitudinal view of the left upper quadrant is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are used to examine the bladder and fluid in the pouch of Douglas.

      In addition to the standard FAST scan, an extended FAST or eFAST may be performed to assess the left and right thoracic regions. This helps determine the presence of pneumothorax and haemothorax.

      The hepatorenal recess is the deepest part of the peritoneal cavity when the patient is lying flat. Consequently, it is the most likely area for fluid to accumulate.

    • This question is part of the following fields:

      • Trauma
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  • Question 63 - A 38 year old is participating in a charity mountain trek up Mount...

    Incorrect

    • A 38 year old is participating in a charity mountain trek up Mount Kilimanjaro but falls ill at an elevation of 3800m. What clinical feature helps differentiate high altitude cerebral edema from acute mountain sickness?

      Your Answer:

      Correct Answer: Ataxia

      Explanation:

      High Altitude Cerebral Edema (HACE) is a condition that develops from acute mountain sickness (AMS). Ataxia, which refers to a lack of coordination, is the primary early indication of HACE. The mentioned symptoms are typical characteristics of AMS.

      Further Reading:

      High Altitude Illnesses

      Altitude & Hypoxia:
      – As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
      – Hypoxia occurs at altitude due to decreased inspired oxygen.
      – At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.

      Acute Mountain Sickness (AMS):
      – AMS is a clinical syndrome caused by hypoxia at altitude.
      – Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
      – Symptoms usually occur after 6-12 hours above 2500m.
      – Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
      – The Lake Louise AMS score is used to assess the severity of AMS.
      – Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
      – Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
      – Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.

      High Altitude Pulmonary Edema (HAPE):
      – HAPE is a progression of AMS but can occur without AMS symptoms.
      – It is the leading cause of death related to altitude illness.
      – Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
      – Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
      – Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.

      High Altitude Cerebral Edema (HACE):
      – HACE is thought to result from vasogenic edema and increased vascular pressure.
      – It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
      – Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
      – Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
      – Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis.

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 64 - A 35-year-old woman comes in with a worsening of her asthma symptoms. She...

    Incorrect

    • A 35-year-old woman comes in with a worsening of her asthma symptoms. She has been experiencing heart palpitations and decided to self-medicate with one of her sister's heart medications. Shortly after taking the medication, her asthma symptoms worsened.
      Which of the following medications is most likely to have caused her asthma exacerbation?

      Your Answer:

      Correct Answer: Propranolol

      Explanation:

      Non-selective beta-blockers, like propranolol, can cause severe bronchospasm in individuals with asthma, particularly when taken in high doses. The current guidelines from the British Thoracic Society (BTS) recommend avoiding the use of beta-blockers in asthma patients. However, there is some evidence suggesting that the long-term use of cardioselective beta-blockers does not appear to trigger asthma attacks in individuals with mild or moderate asthma.

      Beta-blockers play a crucial role in the treatment of patients who have a history of previous myocardial infarction or systolic dysfunction. In individuals with asthma and one of these diagnoses, it is unlikely that the potential benefits of beta-blockers outweigh the risks of worsening asthma symptoms.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 65 - A 2 year old toddler is brought into the resuscitation bay after collapsing...

    Incorrect

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

      Your Answer:

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

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 66 - A middle-aged patient experiences a stroke that leads to impairment in Wernicke’s area.
    What...

    Incorrect

    • A middle-aged patient experiences a stroke that leads to impairment in Wernicke’s area.
      What consequences can be expected from damage to Wernicke’s area?

      Your Answer:

      Correct Answer: Receptive aphasia

      Explanation:

      Wernicke’s area is situated in the dominant cerebral hemisphere temporal lobe. Specifically, it can be found in the posterior section of the superior temporal gyrus.

      This area is responsible for comprehending both written and spoken language. It allows individuals to read a sentence, understand its meaning, and articulate it verbally.

      When Wernicke’s area is damaged, patients may be able to string words together fluently, but the resulting phrases lack coherence and meaning. This condition is known as receptive aphasia or Wernicke’s aphasia.

    • This question is part of the following fields:

      • Neurology
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  • Question 67 - A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30...

    Incorrect

    • A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30 minutes ago. She is currently showing no symptoms and her vital signs are stable. The attending physician recommends administering a dose of activated charcoal.
      Which of the following substances or toxins is activated charcoal NOT effective in decontaminating?

      Your Answer:

      Correct Answer: Lithium

      Explanation:

      Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. It is produced by subjecting carbonaceous matter to high temperatures, a process known as pyrolysis, and then concentrating it with a zinc chloride solution. This creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This porous structure helps prevent the absorption of the harmful toxin by up to 50%.

      The usual dosage of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to give the charcoal within one hour of ingestion, and it may be repeated after one hour if necessary.

      However, there are certain situations where activated charcoal should not be used. If the patient is unconscious or in a coma, there is a risk of aspiration, so the charcoal should not be given. Similarly, if seizures are likely to occur, there is a risk of aspiration and the charcoal should be avoided. Additionally, if there is reduced gastrointestinal motility, there is a risk of obstruction, so activated charcoal should not be used in such cases.

      Activated charcoal is effective in treating overdose with various drugs and toxins, including aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in treating overdose with substances such as iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.

      There are some potential adverse effects associated with activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhaling the charcoal into the lungs), and impaired absorption of oral medications or antidotes.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 68 - A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest...

    Incorrect

    • A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest and back. She recently returned from her vacation in Ibiza and the areas have become more noticeable after sun exposure. What is the most suitable treatment for her condition?

      Your Answer:

      Correct Answer: Ketoconazole shampoo (Nizoral)

      Explanation:

      Pityriasis versicolor, also known as tinea versicolor, is a common skin condition caused by an infection with the yeasts Malassezia furfur and Malassezia globosa. It typically presents as multiple patches of altered pigmentation, primarily on the trunk. In individuals with fair skin, these patches are usually darker in color, while in those with darker skin or a tan, they may appear lighter (known as pityriasis versicolor alba). It is not uncommon for the rash to cause itching.

      The recommended treatment for pityriasis versicolor involves the use of antifungal agents. One particularly effective option is ketoconazole shampoo, which is sold under the brand name Nizoral. To use this shampoo, it should be applied to the affected areas and left on for approximately five minutes before being rinsed off. This process should be repeated daily for a total of five days.

    • This question is part of the following fields:

      • Dermatology
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  • Question 69 - A 42-year-old woman with a long history of anxiety presents having taken a...

    Incorrect

    • A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the medication she takes for a thyroid condition. She informs you that the medication she takes for this condition is levothyroxine 100 mcg. She consumed the medication approximately 30 minutes ago but was promptly discovered by her husband, who quickly brought her to the Emergency Department.

      Which of the following tests will be most beneficial initially?

      Your Answer:

      Correct Answer: Arterial blood gas

      Explanation:

      Calcium-channel blocker overdose is a serious condition that should always be taken seriously as it can be potentially life-threatening. The two most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

      Significant toxicity can occur with the ingestion of more than 10 tablets of verapamil (160 mg or 240 mg immediate or sustained-release capsules) or diltiazem (180 mg, 240 mg or 360 mg immediate or sustained-release capsules). In children, even 1-2 tablets of immediate or sustained-release verapamil or diltiazem can be harmful. Symptoms usually appear within 1-2 hours of taking standard preparations, but with slow-release versions, the onset of severe toxicity may be delayed by 12-16 hours, with peak effects occurring after 24 hours.

      The main clinical manifestations of calcium-channel blocker overdose include nausea and vomiting, low blood pressure, slow heart rate and first-degree heart block, heart muscle ischemia and stroke, kidney failure, pulmonary edema, and high blood sugar levels.

      When managing a patient with calcium-channel blocker overdose, certain bedside investigations are crucial. These include checking blood glucose levels, performing an electrocardiogram (ECG), and obtaining an arterial blood gas sample. Additional investigations that can provide helpful information include assessing urea and electrolyte levels, conducting a chest X-ray to check for pulmonary edema, and performing an echocardiography.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 70 - You assess a patient who has a confirmed diagnosis of Parkinson's disease. She...

    Incorrect

    • You assess a patient who has a confirmed diagnosis of Parkinson's disease. She has been living with the disease for several years and is currently in the advanced stages of the condition.
      Which of the following clinical manifestations is typically observed only in the later stages of Parkinson's disease?

      Your Answer:

      Correct Answer: Cognitive impairment

      Explanation:

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

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

      Other commonly observed clinical features include:

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

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

      – Postural instability
      – Cognitive impairment
      – Orthostatic hypotension

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

    • This question is part of the following fields:

      • Neurology
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  • Question 71 - A 65-year-old man presents with unintentional weight loss and a noticeable lump in...

    Incorrect

    • A 65-year-old man presents with unintentional weight loss and a noticeable lump in his abdomen. A CT scan reveals a sizable tumor in the sigmoid colon.
      Where is the mass most likely to be felt when palpating the surface marking?

      Your Answer:

      Correct Answer: Left iliac fossa

      Explanation:

      The sigmoid colon is the last segment of the colon and is primarily situated in the left iliac fossa.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 72 - A patient currently undergoing treatment for a malignant condition comes in with a...

    Incorrect

    • A patient currently undergoing treatment for a malignant condition comes in with a recent weight increase, puffiness in the face, high blood pressure, and acne. Blood tests show high sodium levels, low potassium levels, and metabolic alkalosis.

      Which of the following is the most probable location of this tumor?

      Your Answer:

      Correct Answer: Lung

      Explanation:

      Small cell lung cancer (SCLC) that originates from neuroendocrine tissue can lead to the development of paraneoplastic endocrine syndromes, such as Cushing syndrome. This occurs due to the inappropriate secretion of ectopic adrenocorticotropic hormone (ACTH). In this case, it is highly likely that the patient has a neuroendocrine tumor within the lung that is secreting ACTH.

      The signs and symptoms of Cushing syndrome may be minimal in cases of ectopic ACTH-secreting tumors, and the onset of symptoms may be sudden, especially in rapidly growing SCLCs. The typical biochemical profile observed in these cases includes elevated sodium levels, low potassium levels, and a metabolic alkalosis.

      The tumors associated with the production of ectopic ACTH are as follows:
      – Small cell lung cancer (SCLC) – 50%
      – Bronchial carcinoid tumors – 10%
      – Thymic carcinoma – 10%
      – Pancreatic islet cell tumors – 5%
      – Phaeochromocytoma – 5%
      – Medullary thyroid carcinoma – 5%

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 73 - A 28 year old male comes to the emergency department complaining of a...

    Incorrect

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

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

      Your Answer:

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

      Explanation:

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

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 74 - A 60-year-old man has accidentally consumed an excessive amount of amitriptyline tablets and...

    Incorrect

    • A 60-year-old man has accidentally consumed an excessive amount of amitriptyline tablets and is currently experiencing toxic side effects.

      Which of the following mechanisms is NOT involved in mediating these toxic effects?

      Your Answer:

      Correct Answer: Opening of potassium channels

      Explanation:

      Tricyclic antidepressant (TCA) overdose is a significant problem in cases of drug overdose and is one of the most common causes of fatal drug poisoning. Any overdose of amitriptyline that exceeds 10 mg/kg has the potential to be life-threatening. If the overdose surpasses 30 mg/kg, it will lead to severe toxicity, cardiotoxicity, and coma.

      The toxic effects of TCAs are caused by various pharmacological actions. These include anticholinergic effects, direct blocking of alpha-adrenergic receptors, inhibition of noradrenaline reuptake at the preganglionic synapse, blockade of sodium channels, and blockade of potassium channels.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 75 - A 6-year-old boy has been brought into the Emergency Department having seizures that...

    Incorrect

    • A 6-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
      What dose of rectal diazepam is recommended for the treatment of the convulsing child?

      Your Answer:

      Correct Answer: 0.5 mg/kg

      Explanation:

      The recommended dose of rectal diazepam for treating a child experiencing convulsions is 0.5 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
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  • Question 76 - A 6-year-old child is experiencing an anaphylactic reaction after being stung by a...

    Incorrect

    • A 6-year-old child is experiencing an anaphylactic reaction after being stung by a bee. What is the appropriate dosage of IM adrenaline to administer?

      Your Answer:

      Correct Answer: 0.3 mL of 1:1000

      Explanation:

      The management of anaphylaxis involves several important steps. First and foremost, it is crucial to ensure proper airway management. Additionally, early administration of adrenaline is essential, preferably in the anterolateral aspect of the middle third of the thigh. Aggressive fluid resuscitation is also necessary. In severe cases, intubation may be required. However, it is important to note that the administration of chlorpheniramine and hydrocortisone should only be considered after early resuscitation has taken place.

      Adrenaline is the most vital medication for treating anaphylactic reactions. It acts as an alpha-adrenergic receptor agonist, which helps reverse peripheral vasodilatation and reduce oedema. Furthermore, its beta-adrenergic effects aid in dilating the bronchial airways, increasing the force of myocardial contraction, and suppressing histamine and leukotriene release. Administering adrenaline as the first drug is crucial, and the intramuscular (IM) route is generally the most effective for most individuals.

      The recommended doses of IM adrenaline for different age groups during anaphylaxis are as follows:

      – Children under 6 years: 150 mcg (0.15 mL of 1:1000)
      – Children aged 6-12 years: 300 mcg (0.3 mL of 1:1000)
      – Children older than 12 years: 500 mcg (0.5 mL of 1:1000)
      – Adults: 500 mcg (0.5 mL of 1:1000)

    • This question is part of the following fields:

      • Allergy
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  • Question 77 - A 35-year-old woman comes in with a femoral shaft fracture sustained in a...

    Incorrect

    • A 35-year-old woman comes in with a femoral shaft fracture sustained in a car accident. You have been requested to administer a femoral nerve block.
      Which of the following two landmarks should be utilized?

      Your Answer:

      Correct Answer: The anterior superior iliac spine and the pubic symphysis

      Explanation:

      To perform a landmark guided femoral nerve block, first locate the inguinal ligament. This can be done by drawing an imaginary line between the anterior superior iliac spine (ASIS) and the pubic symphysis. The femoral nerve passes through the center of this line and is most superficial at the level of the inguinal crease.

      Next, palpate the femoral pulse at the level of the inguinal ligament. The femoral nerve is located approximately 1-1.5 cm lateral to this point. This is where the needle entry point should be.

      By following these steps and using the landmarks provided, you can accurately perform a femoral nerve block.

    • This question is part of the following fields:

      • Pain & Sedation
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  • Question 78 - A 45-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 45-year-old woman was involved in a car accident where her car collided with a tree at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. Her chest X-ray in the resuscitation room shows potential signs of a traumatic aortic injury, but it is uncertain.

      Which investigation should be prioritized for further examination?

      Your Answer:

      Correct Answer: Contrast-enhanced CT scan of the chest

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

    • This question is part of the following fields:

      • Trauma
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  • Question 79 - A 25-year-old man has had discoloured teeth since taking a medication in his...

    Incorrect

    • A 25-year-old man has had discoloured teeth since taking a medication in his youth. Upon examination, visible greyish-brown horizontal stripes can be observed across all of his teeth.
      Which SINGLE medication is most likely responsible for this?

      Your Answer:

      Correct Answer: Doxycycline

      Explanation:

      Tetracycline antibiotics, such as tetracycline and doxycycline, have the potential to cause staining on permanent teeth while they are still forming beneath the gum line. This staining occurs when the drug becomes calcified within the tooth during its development. It is important to note that children are vulnerable to tetracycline-related tooth staining until approximately the age of 8. Additionally, pregnant women should avoid taking tetracycline as it can affect the development of teeth in the unborn child.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 80 - A 48 year old female presents to the emergency department complaining of palpitations....

    Incorrect

    • A 48 year old female presents to the emergency department complaining of palpitations. She reports experiencing brief episodes of palpitations over the past week, which typically resolve on their own after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. The patient's vital signs are as follows:

      Blood pressure: 110/70 mmHg
      Pulse: 120 bpm
      Respiration rate: 17 bpm
      Temperature: 36.5ºC
      Oxygen saturations: 97% on room air

      An electrocardiogram (ECG) is performed and reveals atrial fibrillation. What is the most appropriate initial management for this patient?

      Your Answer:

      Correct Answer: Administer 50 mg atenolol

      Explanation:

      When managing newly diagnosed atrial fibrillation, a rate control strategy is often used. In this approach, beta blockers are typically the first line of treatment. However, sotalol is not recommended, and instead, other beta blockers like atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are preferred. Among these options, atenolol is commonly chosen in NHS trusts due to its cost-effectiveness.

      For patients with signs of hemodynamic instability or adverse features, rhythm control (cardioversion) may be considered if they present within 48 hours of likely onset. However, in the case of this patient, their symptoms started a week ago, and there are no indications of hemodynamic instability or adverse features.

      Digoxin monotherapy is typically reserved for individuals who have limited physical activity or are unable to take other first-line rate control medications due to other health conditions or contraindications.

      Further Reading:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
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  • Question 81 - You review a 6-year-old boy with a fever, rash, photophobia, and conjunctivitis for...

    Incorrect

    • You review a 6-year-old boy with a fever, rash, photophobia, and conjunctivitis for the past 24 hours. On examining his mouth, you observe Koplik’s spots on the buccal mucosa. The parents of the child would like to know how long he should stay home from school.
      What is the recommended duration for keeping this infection away from school?

      Your Answer:

      Correct Answer: 4 days from onset of rash

      Explanation:

      This child has been clinically diagnosed with measles. The typical presentation includes a high fever accompanied by symptoms of a runny nose and sensitivity to light. Conjunctivitis, or pink eye, is often present as well. The associated rash is a widespread red rash with raised bumps. Koplik spots, which are white lesions on the inside of the cheeks, are a telltale sign of measles.

      According to Public Health England, it is recommended that children with measles stay away from school, nursery, or childminders for four days starting from when the rash first appears.

      For more information, you can refer to the Guidance on Infection Control in Schools and other Childcare Settings.
      https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf

    • This question is part of the following fields:

      • Dermatology
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  • Question 82 - A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to...

    Incorrect

    • A 35-year-old woman with a history of paroxysmal supraventricular tachycardia is found to have a diagnosis of Lown-Ganong-Levine (LGL) syndrome.
      Which of the following statements about LGL syndrome is NOT true?

      Your Answer:

      Correct Answer: It is caused by an accessory pathway for conduction

      Explanation:

      Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.

      When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.

      It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.

    • This question is part of the following fields:

      • Cardiology
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  • Question 83 - A 60-year-old woman comes in sweating and in distress, complaining of abdominal discomfort...

    Incorrect

    • A 60-year-old woman comes in sweating and in distress, complaining of abdominal discomfort and feeling nauseous. She has a history of excessive alcohol consumption and has just completed a weekend of heavy drinking. During the examination, there is significant tenderness in her abdomen, particularly in the upper middle area, and bruising is noticeable around her belly button and on the sides of her abdomen.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Acute pancreatitis

      Explanation:

      Acute pancreatitis is a common and serious cause of acute abdominal pain. It occurs when the pancreas becomes inflamed, leading to the release of enzymes that cause self-digestion of the organ.

      The most common causes of acute pancreatitis are gallstones and alcohol consumption. Many cases are also of unknown origin. To remember the various causes, the mnemonic ‘I GET SMASHED’ can be helpful:

      – I: Idiopathic
      – G: Gallstones
      – E: Ethanol
      – T: Trauma
      – S: Steroids
      – M: Mumps
      – A: Autoimmune
      – S: Scorpion stings
      – H: Hyperlipidemia/hypercalcemia
      – E: ERCP
      – D: Drugs

      The clinical features of acute pancreatitis include severe epigastric pain, nausea and vomiting, referral of pain to specific dermatomes (or shoulder tip via the phrenic nerve), fever/sepsis, epigastric tenderness, jaundice, and signs such as Gray-Turner sign (ecchymosis of the flank) and Cullen sign (ecchymosis of the peri-umbilical area).

      The stimulation of the thoracic splanchnic nerves is responsible for the referred pain to the T6-10 dermatomes that is sometimes observed in pancreatitis and other pancreatic disorders.

      When investigating acute pancreatitis in the emergency department, it is important to perform blood glucose testing, a full blood count (which often shows an elevated white cell count), urea and electrolyte testing, calcium testing, liver function tests, coagulation screening, serum amylase testing (which should be more than 5 times the normal limit), an ECG, arterial blood gas analysis, and an abdominal X-ray.

      Treatment for acute pancreatitis involves providing the patient with oxygen, adequate pain relief (including antiemetics), and fluid resuscitation. A nasogastric tube and urinary catheter should be inserted, and fluid balance should be carefully monitored. Most patients require management in a high dependency unit (HDU) or intensive care unit (ICU) setting.

      Acute pancreatitis has a significant mortality rate, and complications are common. Early complications may include severe sepsis and circulatory shock, acute renal failure, disseminated intravascular coagulation, hypocalcemia, acute respiratory distress syndrome and pancreatic encephalopathy.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 84 - You are requested to standby in the resuscitation bay as the paramedics are...

    Incorrect

    • You are requested to standby in the resuscitation bay as the paramedics are transporting a 70-year-old male who has experienced cardiac arrest at a shopping mall. What is the primary cause for the majority of out-of-hospital cardiac arrests?

      Your Answer:

      Correct Answer: Cardiovascular disease

      Explanation:

      The primary cause for the majority of out-of-hospital cardiac arrests is cardiovascular disease. This refers to conditions that affect the heart and blood vessels, such as coronary artery disease, heart attacks, and arrhythmias. These conditions can lead to sudden cardiac arrest.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
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  • Question 85 - You evaluate a 3-year-old who has been brought to the emergency department due...

    Incorrect

    • You evaluate a 3-year-old who has been brought to the emergency department due to difficulty feeding, irritability, and a high fever. During the examination, you observe a red post-auricular lump, which raises concerns for mastoiditis. What is a commonly known complication associated with mastoiditis?

      Your Answer:

      Correct Answer: Facial nerve palsy

      Explanation:

      Mastoiditis can lead to the development of cranial nerve palsies, specifically affecting the trigeminal (CN V), abducens (CN VI), and facial (CN VII) nerves. This occurs when the infection spreads to the petrous apex of the temporal bone, where these nerves are located. The close proximity of the sixth cranial nerve and the trigeminal ganglion, separated only by the dura mater, can result in inflammation and subsequent nerve damage. Additionally, the facial nerve is at risk as it passes through the mastoid via the facial canal.

      Further Reading:

      Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.

      Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.

      Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.

      Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).

      Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 86 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Incorrect

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

      Your Answer:

      Correct Answer: Unfractionated heparin

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
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  • Question 87 - You evaluate a 56-year-old individual who arrives at the ER complaining of chest...

    Incorrect

    • You evaluate a 56-year-old individual who arrives at the ER complaining of chest discomfort and increasing swelling. Upon reviewing the patient's medical history, you discover that they underwent an echocardiogram a year ago, which revealed moderate-severe tricuspid regurgitation. Which of the following heart murmurs is commonly associated with tricuspid regurgitation?

      Your Answer:

      Correct Answer: Low-frequency pansystolic murmur

      Explanation:

      Tricuspid regurgitation is characterized by a continuous murmur that spans the entire systolic phase of the cardiac cycle. This murmur is best audible at the lower left sternal edge and has a low frequency. Interestingly, the intensity of the murmur increases during inspiration and decreases during expiration, a phenomenon referred to as Carvallo’s sign.

      Further Reading:

      Tricuspid regurgitation (TR) is a condition where blood flows backwards through the tricuspid valve in the heart. It is classified as either primary or secondary, with primary TR being caused by abnormalities in the tricuspid valve itself and secondary TR being the result of other conditions outside of the valve. Mild TR is common, especially in young adults, and often does not cause symptoms. However, severe TR can lead to right-sided heart failure and the development of symptoms such as ascites, peripheral edema, and hepatomegaly.

      The causes of TR can vary. Primary TR can be caused by conditions such as rheumatic heart disease, myxomatous valve disease, or Ebstein anomaly. Secondary TR is often the result of right ventricular dilatation due to left heart failure or pulmonary hypertension. Other causes include endocarditis, traumatic chest injury, left ventricular systolic dysfunction, chronic lung disease, pulmonary thromboembolism, myocardial disease, left to right shunts, and carcinoid heart disease. In some cases, TR can occur as a result of infective endocarditis in IV drug abusers.

      Clinical features of TR can include a pansystolic murmur that is best heard at the lower left sternal edge, Carvallo’s sign (murmur increases with inspiration and decreases with expiration), an S3 heart sound, and the presence of atrial arrhythmias such as flutter or fibrillation. Other signs can include giant C-V waves in the jugular pulse, hepatomegaly (often pulsatile), and edema with lung crepitations or pleural effusions.

      The management of TR depends on the underlying cause and the severity of the condition. In severe cases, valve repair or replacement surgery may be necessary. Treatment may also involve addressing the underlying conditions contributing to TR, such as managing left heart failure or pulmonary hypertension.

    • This question is part of the following fields:

      • Cardiology
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  • Question 88 - A 6-month-old infant develops jaundice and is found to have a diagnosis of...

    Incorrect

    • A 6-month-old infant develops jaundice and is found to have a diagnosis of haemolytic disease of infancy.
      Which immunoglobulins mediate haemolytic disease of infancy?

      Your Answer:

      Correct Answer: IgG

      Explanation:

      Haemolytic disease of the newborn is a condition that occurs in the fetus when IgG antibodies from the mother pass through the placenta. This is classified as a type II hypersensitivity reaction, also known as cytotoxic hypersensitivity. In this type of reaction, antibodies produced by the immune response attach to antigens on the patient’s own cell surfaces.

      The rhesus gene is composed of three parts, which can be C or c, D or d, and E or e. Approximately 15% of the population consists of rhesus negative women who are homozygous for d. When rhesus-positive fetal cells enter the bloodstream of a rhesus-negative mother, maternal anti-D IgG antibodies may be produced. This commonly occurs during delivery, but can also happen after fetal-maternal hemorrhage and certain medical procedures.

      Some other examples of type II hypersensitivity reactions include autoimmune hemolytic anemia, ANCA-associated vasculitides, Goodpasture’s syndrome, myasthenia gravis, and rhesus incompatibility.

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 89 - Following the case of a 45 year old male who was treated in...

    Incorrect

    • Following the case of a 45 year old male who was treated in the resuscitation bay for hypovolaemic shock following a secondary post-tonsillectomy haemorrhage, your consultant requests you to prepare a teaching session for the junior doctors on the topic.

      Concerning secondary post-tonsillectomy bleeding, at what age does this usually occur?

      Your Answer:

      Correct Answer: 5-10 days post procedure

      Explanation:

      Secondary post-tonsillectomy hemorrhage commonly happens between 5 to 10 days after the procedure. This type of bleeding is usually caused by the shedding of the eschar, injury from eating solid foods, infection in the tonsil bed, use of nonsteroidal anti-inflammatory drugs (NSAIDs) after surgery, or unknown reasons.

      Further Reading:

      Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.

      Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.

      Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.

      The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.

      Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.

      Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.

      If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 90 - A 30-year-old woman on treatment for a urinary tract infection returns after 48...

    Incorrect

    • A 30-year-old woman on treatment for a urinary tract infection returns after 48 hours because her symptoms have not improved. She is currently 20 weeks pregnant. Unfortunately, the sensitivities from the urine sample that was sent to the lab are still unavailable. Her blood tests today show that her eGFR is >60 ml/minute. She has been taking nitrofurantoin 100 mg modified-release PO BD for the past two days.
      Which of the following antibiotics is the most suitable to prescribe in this situation?

      Your Answer:

      Correct Answer: Cefalexin

      Explanation:

      For the treatment of pregnant women with lower urinary tract infections (UTIs), it is recommended to provide them with an immediate prescription for antibiotics. It is important to consider their previous urine culture and susceptibility results, as well as any prior use of antibiotics that may have contributed to the development of resistant bacteria. Before starting antibiotics, it is advised to obtain a midstream urine sample from pregnant women and send it for culture and susceptibility testing.

      Once the microbiological results are available, it is necessary to review the choice of antibiotic. If the bacteria are found to be resistant, it is recommended to switch to a narrow-spectrum antibiotic whenever possible. The choice of antibiotics for pregnant women aged 12 years and over is summarized below:

      First-choice:
      – Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days, if the estimated glomerular filtration rate (eGFR) is above 45 ml/minute.

      Second-choice (if there is no improvement in lower UTI symptoms with the first-choice antibiotic for at least 48 hours, or if the first-choice is not suitable):
      – Amoxicillin 500 mg taken orally three times daily for 7 days (only if culture results are available and show susceptibility).
      – Cefalexin 500 mg taken twice daily for 7 days.

      For alternative second-choice antibiotics, it is recommended to consult a local microbiologist and choose the appropriate antibiotics based on the culture and sensitivity results.

    • This question is part of the following fields:

      • Urology
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  • Question 91 - A 35-year-old male comes to the Emergency Department seeking treatment for a wound...

    Incorrect

    • A 35-year-old male comes to the Emergency Department seeking treatment for a wound on his right arm. He mentions during triage that he sustained the injury while being attacked by a group of individuals in the neighborhood who have been causing trouble. He suspects that he may have been shot with a low-caliber firearm. Despite the nursing staff's attempts to involve the authorities, he has adamantly refused to allow them to contact the police. In addition to providing the necessary wound care, what other steps should you take?

      Your Answer:

      Correct Answer: Advise him that it is your statutory duty to report this incident to the police whether he consents or not, and contact them with his demographic details only.

      Explanation:

      Confidentiality is a crucial aspect of the doctor-patient relationship and plays a vital role in upholding trust within the medical profession. However, there are certain situations, such as cases involving gun and knife crimes, where the safety of the wider public may be at risk. In such circumstances, it may be necessary to breach this relationship and provide the police with information, even if the patient refuses to consent.

      It is important to make every effort to obtain the patient’s consent, while also explaining the legal obligation to report such incidents. When sharing information with the police, it is essential to disclose only the minimum amount of information required. Typically, this would involve providing the patient’s demographic details and informing the police that they have sought medical attention for a non-self-inflicted deliberate knife wound.

      However, there are instances where contacting the police may not be necessary. For example, if it is evident that the injury was sustained accidentally or as a result of deliberate self-harm due to a mental health condition, there may be no need to involve law enforcement. In such cases, the patient should still receive the necessary medical treatment for their wound, as long as they provide consent.

      For more information on this topic, please refer to the GMC Guidance on Reporting Gunshot and Knife Wounds.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
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  • Question 92 - You evaluate an infant with bluish skin discoloration. The possibility of congenital cyanotic...

    Incorrect

    • You evaluate an infant with bluish skin discoloration. The possibility of congenital cyanotic heart disease is being considered.
      What is one of the potential causes of congenital cyanotic heart disease?

      Your Answer:

      Correct Answer: Tricuspid atresia

      Explanation:

      It is crucial to be able to distinguish between the underlying causes of congenital cyanotic and acyanotic heart disease. Tricuspid atresia is one of the causes of congenital cyanotic heart disease. Other causes in this category include Ebstein’s anomaly, Hypoplastic left heart syndrome, Tetralogy of Fallot, and Transposition of the great vessels.

      On the other hand, congenital acyanotic heart disease has different causes. These include Ventricular septal defect, Patent ductus arteriosus, Atrial septal defect, Atrioventricular septal defect, Pulmonary stenosis, Aortic stenosis, and Coarctation of the aorta.

      By understanding the distinctions between these causes, healthcare professionals can provide appropriate diagnosis and treatment for patients with congenital heart disease.

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 93 - A 28-year-old individual presents to the emergency department with burns on their hands....

    Incorrect

    • A 28-year-old individual presents to the emergency department with burns on their hands. After evaluation, it is determined that the patient has superficial partial thickness burns on the entire palmar surfaces of both hands. The burns do not extend beyond the wrist joint due to the patient wearing a thick jacket.

      To document the extent of the burns on a Lund and Browder chart, what percentage of the total body surface area is affected by this burn injury?

      Your Answer:

      Correct Answer: 2-3%

      Explanation:

      Based on the Lund and Browder chart, the total percentage of burns is calculated as 3 since it affects one side of both hands.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
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  • Question 94 - A 45-year-old woman is brought to the hospital with a high temperature, cough,...

    Incorrect

    • A 45-year-old woman is brought to the hospital with a high temperature, cough, and difficulty breathing. After conducting additional tests, she is diagnosed with a reportable illness. You fill out the notification form and reach out to the local health protection team.

      What is the most probable diagnosis in this case?

      Your Answer:

      Correct Answer: Legionnaires’ disease

      Explanation:

      Public Health England (PHE) has the primary goal of promptly identifying potential disease outbreaks and epidemics. While accuracy of diagnosis is not the main focus, clinical suspicion of a notifiable infection has been sufficient since 1968.

      Registered medical practitioners (RMPs) are legally obligated to inform the designated proper officer at their local council or local health protection team (HPT) about suspected cases of specific infectious diseases.

      The Health Protection (Notification) Regulations 2010 outline the diseases that RMPs must report to the proper officers at local authorities. These diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever (typhoid or paratyphoid fever), food poisoning, haemolytic uraemic syndrome (HUS), infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires’ disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, severe acute respiratory syndrome (SARS), scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever (VHF), whooping cough, and yellow fever.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 95 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Incorrect

    • A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
      What is the most probable underlying diagnosis?

      Your Answer:

      Correct Answer: Liver disease

      Explanation:

      Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).

      On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.

      Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.

      It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Haematology
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  • Question 96 - A 42 year old female is brought to the emergency department with a...

    Incorrect

    • A 42 year old female is brought to the emergency department with a 15cm long laceration to her arm which occurred when she tripped and fell onto a sharp object. You are suturing the laceration under local anesthesia when the patient mentions experiencing numbness in her lips and feeling lightheaded. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Local anaesthetic toxicity

      Explanation:

      Early signs of local anaesthetic systemic toxicity (LAST) can include numbness around the mouth and tongue, a metallic taste in the mouth, feeling lightheaded or dizzy, and experiencing visual and auditory disturbances. LAST is a rare but serious complication that can occur when administering anesthesia. It is important for healthcare providers to be aware of the signs and symptoms of LAST, as early recognition can lead to better outcomes. Additionally, hyperventilation can temporarily lower calcium levels, which can cause numbness around the mouth.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 97 - A 25 year old female comes to the emergency department with a stab...

    Incorrect

    • A 25 year old female comes to the emergency department with a stab wound to her thigh. She explains that she was in a confrontation with a group of individuals, and one of them attacked her with a knife. She specifically requests that her information remains confidential and insists that the police not be involved. She expresses her fear of retaliation and emphasizes that she does not want to be seen as a snitch. How should you respond in this situation?

      Your Answer:

      Correct Answer: Inform the police about this incident

      Explanation:

      It is important to inform the police in cases of gunshot and deliberate knife wounds. Deliberate stabbings pose a risk of further attacks in the area and can endanger both the patient and the staff in the department. The General Medical Council (GMC) provides clear guidance supporting the need to involve the police in such situations.

      According to the GMC, it is usually necessary to inform the police when a person presents with a gunshot wound. Even accidental shootings involving legally held firearms raise important issues for the police, such as firearms licensing. Similarly, the police should generally be informed when a person has been wounded in an attack involving a knife, blade, or any other sharp instrument. However, if a knife or blade injury appears to be accidental or a result of self-harm, it is not usually necessary to involve the police.

      In cases where seeking consent to disclose personal information is not practical or appropriate, or if a patient refuses consent, it may be justified to disclose the information in the public interest. This is particularly true if failure to do so could expose others to a risk of death or serious harm.

      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
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  • Question 98 - A 25-year-old hairdresser is brought into the emergency department after collapsing at work....

    Incorrect

    • A 25-year-old hairdresser is brought into the emergency department after collapsing at work. The patient's coworker presents you with security camera footage of the incident, where the patient is observed falling to the floor just before experiencing involuntary jerking movements in all four limbs. The patient remained unconscious for approximately one minute and also lost control of their bladder during the episode. A diagnosis of tonic-clonic seizure is made, and there is no prior history of seizures or epilepsy. Despite no identifiable cause, what advice should be given to this patient regarding their ability to drive a car?

      Your Answer:

      Correct Answer: Must not drive for 6 months

      Explanation:

      Patients who experience a seizure(s) should be informed about their ability to drive. There are two important instructions to follow in this regard. Firstly, they must refrain from driving for a period of 6 months. Secondly, they must notify the appropriate authority, such as the DVLA or DVA in Northern Ireland. In the case of a single seizure, driving should be suspended for 6 months from the date of the seizure. However, if an underlying cause that increases the risk of seizures is identified, driving should be halted for 12 months. In the case of multiple seizures or epilepsy, driving should be ceased for 12 months from the most recent seizure.

      Further Reading:

      Blackouts are a common occurrence in the emergency department and can have serious consequences if they happen while a person is driving. It is crucial for doctors in the ED to be familiar with the guidelines set by the DVLA (Driver and Vehicle Licensing Agency) regarding driving restrictions for patients who have experienced a blackout.

      The DVLA has specific rules for different types of conditions that may cause syncope (loss of consciousness). For group 1 license holders (car/motorcycle use), if a person has had a first unprovoked isolated seizure, they must refrain from driving for 6 months or 12 months if there is an underlying causative factor that may increase the risk. They must also notify the DVLA. For group 2 license holders (bus and heavy goods vehicles), the restrictions are more stringent, with a requirement of 12 months off driving for a first unprovoked isolated seizure and 5 years off driving if there is an underlying causative factor.

      For epilepsy or multiple seizures, both group 1 and group 2 license holders must remain seizure-free for 12 months before their license can be considered. They must also notify the DVLA. In the case of a stroke or isolated transient ischemic attack (TIA), group 1 license holders need to refrain from driving for 1 month, while group 2 license holders must wait for 12 months before being re-licensed subject to medical evaluation. Multiple TIAs require 3 months off driving for both groups.

      Isolated vasovagal syncope requires no driving restriction for group 1 license holders, but group 2 license holders must refrain from driving for 3 months. Both groups must notify the DVLA. If syncope is caused by a reversible and treated condition, group 1 license holders need 4 weeks off driving, while group 2 license holders require 3 months. In the case of an isolated syncopal episode with an unknown cause, group 1 license holders must refrain from driving for 6 months, while group 2 license holders will have their license refused or revoked for 12 months.

      For patients who continue to drive against medical advice, the GMC (General Medical Council) has provided guidance on how doctors should manage the situation. Doctors should explain to the patient why they are not allowed to drive and inform them of their legal duty to notify the DVLA or DVA (Driver and Vehicle Agency in Northern Ireland). Doctors should also record the advice given to the patient in their medical record

    • This question is part of the following fields:

      • Neurology
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  • Question 99 - A 35-year-old woman with a past medical history of recurrent episodes of profuse...

    Incorrect

    • A 35-year-old woman with a past medical history of recurrent episodes of profuse sweating, rapid heartbeat, and sudden high blood pressure is found to have a phaeochromocytoma. What is the most suitable initial treatment for this patient?

      Your Answer:

      Correct Answer: Alpha-blocker

      Explanation:

      A phaeochromocytoma is a rare functional tumor that develops from chromaffin cells in the adrenal medulla. Extra-adrenal paragangliomas, also known as extra-adrenal pheochromocytomas, are similar tumors that originate in the ganglia of the sympathetic nervous system but are less common. These tumors secrete catecholamines and cause a range of symptoms and signs related to hyperactivity of the sympathetic nervous system.

      The most common initial symptom is high blood pressure, which can be either sustained or sporadic. Symptoms tend to come and go, occurring multiple times a day or very infrequently. As the disease progresses, the symptoms usually become more severe and frequent.

      Surgical removal is the preferred and definitive treatment option. If the tumor is completely removed without any spread to other parts of the body, it often leads to a cure for hypertension.

      Before surgery, it is crucial to manage the condition medically to reduce the risk of hypertensive crises during the operation. This is typically done by using a combination of non-competitive alpha-blockers (such as phenoxybenzamine) and beta-blockers. Alpha-blockade should be started first, at least 7-10 days before the surgery, to allow for expansion of blood volume. Once this is achieved, beta-blockade can be initiated to help control rapid heart rate and certain irregular heart rhythms. Starting beta-blockade too early can trigger a hypertensive crisis.

      Genetic counseling should also be provided, and any associated conditions should be identified and managed appropriately.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 100 - A 45 year old female comes to the emergency department 2 weeks after...

    Incorrect

    • A 45 year old female comes to the emergency department 2 weeks after having a tracheostomy placed, complaining of bleeding around the tracheostomy site and experiencing small amounts of blood in her cough. What is the primary concern for the clinician regarding the underlying cause?

      Your Answer:

      Correct Answer: Tracheo-innominate fistula

      Explanation:

      Tracheo-innominate fistula (TIF) should be considered as a possible diagnosis in patients experiencing bleeding after a tracheostomy. This bleeding, occurring between 3 days and 6 weeks after the tracheostomy procedure, should be treated as TIF until ruled out. While this complication is uncommon, it is extremely dangerous and often leads to death if not promptly addressed through surgical intervention. Therefore, any bleeding from a tracheostomy tube should be regarded as potentially life-threatening.

      Further Reading:

      Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

      When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

      Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (4/8) 50%
Cardiology (1/4) 25%
Pharmacology & Poisoning (4/7) 57%
Gastroenterology & Hepatology (2/4) 50%
Haematology (2/4) 50%