00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 7-year-old child experiences an anaphylactic reaction after being stung by a bee....

    Incorrect

    • A 7-year-old child experiences an anaphylactic reaction after being stung by a bee.
      What dosage of IV hydrocortisone should be administered in this situation?

      Your Answer: 50 mg

      Correct Answer: 100 mg

      Explanation:

      Corticosteroids can be beneficial in preventing or reducing prolonged reactions. According to the current APLS guidelines, the recommended doses of hydrocortisone for different age groups are as follows:

      – Children under 6 months: 25 mg administered slowly via intramuscular (IM) or intravenous (IV) route.
      – Children aged 6 months to 6 years: 50 mg administered slowly via IM or IV route.
      – Children aged 6 to 12 years: 100 mg administered slowly via IM or IV route.
      – Children over 12 years: 200 mg administered slowly via IM or IV route.
      – Adults: 200 mg administered slowly via IM or IV route.

      It is important to note that the most recent ALS guidelines do not recommend the routine use of corticosteroids for treating anaphylaxis in adults. However, the current APLS guidelines still advocate for the use of corticosteroids in children to manage anaphylaxis.

    • This question is part of the following fields:

      • Allergy
      6.5
      Seconds
  • Question 2 - A new Emergency Department nurse is required to verify her immunity to hepatitis...

    Correct

    • A new Emergency Department nurse is required to verify her immunity to hepatitis B before starting her position. She has received a hepatitis B vaccination series in the past but cannot remember the specific dates.
      What ONE blood test result would indicate that she has developed immunity as a result of her hepatitis B vaccination?

      Your Answer: HBsAg negative, anti-HBs positive

      Explanation:

      Hepatitis B surface antigen (HBsAg) is a protein found on the surface of the hepatitis B virus. It can be detected in high levels in the blood during both acute and chronic hepatitis B virus infections. The presence of HBsAg indicates that the person is capable of spreading the infection to others. Normally, the body produces antibodies to HBsAg as part of the immune response to the infection. HBsAg is also used to create the hepatitis B vaccine.

      Hepatitis B surface antibody (anti-HBs) indicates that a person has recovered from the hepatitis B virus infection and is now immune to it. This antibody can also develop in individuals who have been successfully vaccinated against hepatitis B.

      Total hepatitis B core antibody (anti-HBc) appears when symptoms of acute hepatitis B begin and remains present for life. The presence of anti-HBc indicates that a person has either had a previous or ongoing infection with the hepatitis B virus, although the exact time frame cannot be determined. This antibody is not present in individuals who have received the hepatitis B vaccine.

      IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates a recent infection or acute hepatitis B. If this antibody is present, it suggests that the infection occurred within the past six months.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      8.9
      Seconds
  • Question 3 - A 42-year-old woman with a long-standing history of ulcerative colitis presents with a...

    Correct

    • A 42-year-old woman with a long-standing history of ulcerative colitis presents with a fever, itching, and yellowing of the skin. An ERCP is scheduled, which reveals a characteristic beads-on-a-string appearance.

      What is the SINGLE most probable diagnosis?

      Your Answer: Primary sclerosing cholangitis

      Explanation:

      Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing inflammation and blockage over time. It is more commonly seen in men than women, with a ratio of 3 to 1, and is typically diagnosed around the age of 40. PSC is characterized by recurring episodes of cholangitis and progressive scarring of the bile ducts. If left untreated, it can lead to liver cirrhosis, liver failure, and even hepatocellular carcinoma. PSC is often associated with ulcerative colitis, with more than 80% of PSC patients also having this condition. Other associations include fibrosis in the retroperitoneal and mediastinal areas.

      When performing an endoscopic retrograde cholangiopancreatography (ERCP) to diagnose PSC, certain findings are typically observed. These include ulceration of the common bile duct, irregular narrowing with saccular dilatation above the structured ducts (resembling beads-on-a-string or a beaded appearance), and involvement of both the intra- and extrahepatic ducts simultaneously.

      Complications that can arise from PSC include liver cirrhosis, portal hypertension, liver failure, and cholangiocarcinoma. Treatment options for PSC include the use of ursodeoxycholic acid to improve symptoms and liver function (although it does not affect the overall prognosis), cholestyramine to alleviate itching, and correction of deficiencies in fat-soluble vitamins. In some cases, endoscopic dilatation of strictures may be necessary.

      Liver transplantation is the definitive treatment for PSC. The 10-year survival rate after transplantation is approximately 65%, and the average survival time from the time of diagnosis is around seven years. Patients with PSC often succumb to complications such as secondary biliary cirrhosis, portal hypertension, or cholangitis. Additionally, about 10% of PSC patients will develop cholangiocarcinoma.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      7.5
      Seconds
  • Question 4 - A child with a history of stomach pain and loose stools is diagnosed...

    Correct

    • A child with a history of stomach pain and loose stools is diagnosed with a tapeworm infection after finding eggs in their stool.
      What is the most suitable treatment for this infection?

      Your Answer: Praziquantel

      Explanation:

      Two types of tapeworms, Taenia solium and Taenia saginata, can infest humans. Infestation occurs when people consume meat from intermediate hosts that contain the parasite’s tissue stages. Tapeworms compete for nutrients and infestation is often without symptoms. However, in more severe cases, individuals may experience epigastric pain, diarrhea, and vomiting. Diagnosis involves identifying characteristic eggs in the patient’s stool.

      Taenia solium infestation can also lead to a condition called cysticercosis. This occurs when larval cysts infiltrate and spread throughout the lung, liver, eye, or brain. Cysticercosis presents with neurological symptoms, seizures, and impaired vision. Confirmation of cysticercosis involves the presence of antibodies and imaging tests such as chest X-rays and CT brain scans.

      The treatment for tapeworm infestation is highly effective and involves the use of medications like niclosamide or praziquantel. However, it is important to seek specialist advice when managing Taenia infections in the central nervous system, as severe inflammatory reactions can occur.

    • This question is part of the following fields:

      • Infectious Diseases
      3.1
      Seconds
  • Question 5 - A 45 year old comes to the emergency department with swelling of the...

    Correct

    • A 45 year old comes to the emergency department with swelling of the lips and tongue that developed slowly over the past 3 hours. There is no accompanying rash. The patient denies consuming anything unusual and has no known allergies. The patient recently began taking multiple new medications after experiencing a heart attack one month ago. You suspect that the patient is experiencing non-allergic drug induced angioedema. What is the most probable cause of the patient's symptoms?

      Your Answer: Ramipril

      Explanation:

      The most frequent cause of non-allergic drug induced angioedema is ACE inhibitors. Symptoms usually appear several days to weeks after beginning the medication. It is important to note that penicillin and NSAIDs are the primary drug culprits for angioedema, but they trigger it through an IgE mediated allergic mechanism, resulting in both angioedema and urticaria. The onset of symptoms in these cases typically occurs within minutes to hours after exposure.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      114.8
      Seconds
  • Question 6 - A 65 year old is brought into the emergency department by two members...

    Correct

    • A 65 year old is brought into the emergency department by two members of the public after collapsing in a nearby park. The patient appears confused, looking around the room but not responding to questions or commands. Verbal output is limited to grunting and coughing. Observations are taken and are shown below:

      Blood pressure 148/76 mmHg
      Pulse 90 bpm
      Respirations 18 bpm
      Temperature 36.8ºC
      Oxygen Saturations 98% on air
      Capillary glucose 1.2 mmol/l

      What is the most appropriate next step in this patient's management?

      Your Answer: Give glucagon 1 mg via intramuscular injection

      Explanation:

      The use of glucose infusion is not recommended due to its hypertonic nature, which can potentially increase the risk of extravasation injury.

      Further Reading:

      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:

      • Endocrinology
      11.8
      Seconds
  • Question 7 - You conduct an evaluation on a 25-year-old individual who has arrived at the...

    Correct

    • You conduct an evaluation on a 25-year-old individual who has arrived at the emergency department with a suspected jaw fracture after a bicycle incident. During the assessment, you observe diminished sensation in the front of the chin and lower lip on the right side. Which nerve is most likely to have been damaged?

      Your Answer: Mental nerve

      Explanation:

      Fractures in the body of the mandible pose a potential risk of injury to the mental nerve. This nerve is responsible for providing sensation to the lower lip, front of the chin, and the labial gingiva of the mandibular front teeth and premolars. Specifically, fractures involving the mental foramen increase the likelihood of damaging the mental nerve.

      Further Reading:

      Mandibular fractures are a common type of facial fracture that often present to the emergency department. The mandible, or lower jaw, is formed by the fusion of two hemimandibles and articulates with the temporomandibular joints. Fractures of the mandible are typically caused by direct lateral force and often involve multiple fracture sites, including the body, condylar head and neck, and ramus.

      When assessing for mandibular fractures, clinicians should use a look, feel, move method similar to musculoskeletal examination. However, it is important to note that TMJ effusion, muscle spasm, and pain can make moving the mandible difficult. Key signs of mandibular fracture include malocclusion, trismus (limited mouth opening), pain with the mouth closed, broken teeth, step deformity, hematoma in the sublingual space, lacerations to the gum mucosa, and bleeding from the ear.

      The Manchester Mandibular Fracture Decision Rule uses the absence of five exam findings (malocclusion, trismus, broken teeth, pain with closed mouth, and step deformity) to exclude mandibular fracture. This rule has been found to be 100% sensitive and 39% specific in detecting mandibular fractures. Imaging is an important tool in diagnosing mandibular fractures, with an OPG X-ray considered the best initial imaging for TMJ dislocation and mandibular fracture. CT may be used if the OPG is technically difficult or if a CT is being performed for other reasons, such as a head injury.

      It is important to note that head injury often accompanies mandibular fractures, so a thorough head injury assessment should be performed. Additionally, about a quarter of patients with mandibular fractures will also have a fracture of at least one other facial bone.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      5.1
      Seconds
  • Question 8 - A 25-year-old male presents to the emergency department with notable facial swelling following...

    Correct

    • A 25-year-old male presents to the emergency department with notable facial swelling following an assault. A facial fracture is suspected due to the patient losing consciousness during the incident. As a precaution, the decision is made to send him for CT scans of the brain and facial views. The CT results confirm a zygomaticomaxillary complex (ZMC) fracture, but no mandible fracture is observed. Upon examination, it is observed that the patient is experiencing difficulty fully opening or closing their mouth. What is the probable cause of this issue?

      Your Answer: Temporalis muscle entrapment

      Explanation:

      Injuries to the zygomatic arch that result in limited mouth opening or closing can occur when the temporalis muscle or mandibular condyle becomes trapped. If this happens, it is important to seek immediate medical attention. It is worth noting that the muscles responsible for chewing (masseter, temporalis, medial pterygoid, and lateral pterygoid) are innervated by the mandibular nerve (V3).

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Maxillofacial & Dental
      11.9
      Seconds
  • Question 9 - A 72-year-old man comes with his wife due to worries about his memory....

    Correct

    • A 72-year-old man comes with his wife due to worries about his memory. After gathering information, you observe a gradual decrease in his cognitive abilities. The only significant medical history he has is a heart attack he had 8 years ago.
      What is the MOST PROBABLE diagnosis?

      Your Answer: Vascular dementia

      Explanation:

      Vascular dementia is the second most common form of dementia, accounting for approximately 25% of all cases. It occurs when the brain is damaged due to various factors, such as major strokes, multiple smaller strokes that go unnoticed (known as multi-infarct), or chronic changes in smaller blood vessels (referred to as subcortical dementia). The term vascular cognitive impairment (VCI) is increasingly used to encompass this range of diseases.

      Unlike Alzheimer’s disease, which has a gradual and subtle onset, vascular dementia can occur suddenly and typically shows a series of stepwise increases in symptom severity. The presentation and progression of the disease can vary significantly.

      There are certain features that suggest a vascular cause of dementia. These include a history of transient ischemic attacks (TIAs) or cardiovascular disease, the presence of focal neurological abnormalities, prominent memory impairment in the early stages of the disease, early onset of gait disturbance and unsteadiness, frequent unprovoked falls in the early stages, bladder symptoms (such as incontinence) without any identifiable urological condition in the early stages, and seizures.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      9.2
      Seconds
  • Question 10 - You assess a patient with a decreased calcium level.
    What is a known factor...

    Incorrect

    • You assess a patient with a decreased calcium level.
      What is a known factor that can cause hypocalcemia?

      Your Answer: Thiazide diuretics

      Correct Answer: Rhabdomyolysis

      Explanation:

      Rhabdomyolysis leads to an increase in phosphate levels in the blood, which in turn causes a decrease in the levels of ionized calcium. On the other hand, conditions such as Addison’s disease, hyperthyroidism, the use of thiazide diuretics, and lithium can all contribute to an elevation in calcium levels. There are also other factors that can result in low calcium levels, including hypoparathyroidism, a deficiency of vitamin D, sepsis, fluoride poisoning, a lack of magnesium, renal failure, tumor lysis syndrome, pancreatitis, and the administration of EDTA infusions.

    • This question is part of the following fields:

      • Nephrology
      6.2
      Seconds
  • Question 11 - You are evaluating a 4-year-old girl who has been diagnosed with diabetic ketoacidosis...

    Correct

    • You are evaluating a 4-year-old girl who has been diagnosed with diabetic ketoacidosis (DKA). She had initially improved after receiving fluids, but her condition has worsened in the past hour. She is now expressing discomfort due to a headache and is displaying irritability. She has also started vomiting again, and the nursing staff has observed an increase in her blood pressure and a decrease in her heart rate.

      What would be the most suitable course of treatment for this patient?

      Your Answer: Mannitol

      Explanation:

      Cerebral edema is the most significant complication of diabetic ketoacidosis (DKA), leading to death in many cases. It occurs in approximately 0.2-1% of DKA cases. The high blood glucose levels cause an osmolar gradient, resulting in the movement of water from the intracellular fluid (ICF) to the extracellular fluid (ECF) space and a decrease in cell volume. When insulin and intravenous fluids are administered to correct the condition, the effective osmolarity decreases rapidly, causing a reversal of the fluid shift and the development of cerebral edema.

      Cerebral edema is associated with a higher mortality rate and poor neurological outcomes. To prevent its occurrence, it is important to slowly normalize osmolarity over a period of 48 hours, paying attention to glucose and sodium levels, as well as ensuring proper hydration. Monitoring the child for symptoms such as headache, recurrent vomiting, irritability, changes in Glasgow Coma Scale (GCS), abnormal slowing of heart rate, and increasing blood pressure is crucial.

      If cerebral edema does occur, it should be treated with either a hypertonic (3%) saline solution at a dosage of 3 ml/kg or a mannitol infusion at a dosage of 250-500 mg/kg over a 20-minute period.

      In addition to cerebral edema, there are other complications associated with DKA in children, including cardiac arrhythmias, pulmonary edema, and acute renal failure.

    • This question is part of the following fields:

      • Endocrinology
      10.6
      Seconds
  • Question 12 - You are requested to evaluate a 75-year-old male who has been referred to...

    Correct

    • You are requested to evaluate a 75-year-old male who has been referred to the emergency department after visiting his local Bootsâ„¢ store for a hearing assessment. The patient reports experiencing pain and hearing impairment on the right side a few days prior to the examination. The nurse who examined the patient's ears before conducting the audiogram expressed concerns regarding malignant otitis externa.

      What is the primary cause of malignant otitis externa?

      Your Answer: Pseudomonas aeruginosa

      Explanation:

      Malignant otitis externa, also known as necrotising otitis externa, is a severe infection that affects the external auditory canal and spreads to the temporal bone and nearby tissues, leading to skull base osteomyelitis. The primary cause of this condition is usually an infection by Pseudomonas aeruginosa. It is commonly observed in older individuals with diabetes.

      Further Reading:

      Otitis externa is inflammation of the skin and subdermis of the external ear canal. It can be acute, lasting less than 6 weeks, or chronic, lasting more than 3 months. Malignant otitis externa, also known as necrotising otitis externa, is a severe and potentially life-threatening infection that can spread to the bones and surrounding structures of the ear. It is most commonly caused by Pseudomonas aeruginosa.

      Symptoms of malignant otitis externa include severe and persistent ear pain, headache, discharge from the ear, fever, malaise, vertigo, and profound hearing loss. It can also lead to facial nerve palsy and other cranial nerve palsies. In severe cases, the infection can spread to the central nervous system, causing meningitis, brain abscess, and sepsis.

      Acute otitis externa is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus, while chronic otitis externa can be caused by fungal infections such as Aspergillus or Candida albicans. Risk factors for otitis externa include eczema, psoriasis, dermatitis, acute otitis media, trauma to the ear canal, foreign bodies in the ear, water exposure, ear canal obstruction, and long-term antibiotic or steroid use.

      Clinical features of otitis externa include itching of the ear canal, ear pain, tenderness of the tragus and/or pinna, ear discharge, hearing loss if the ear canal is completely blocked, redness and swelling of the ear canal, debris in the ear canal, and cellulitis of the pinna and adjacent skin. Tender regional lymphadenitis is uncommon.

      Management of acute otitis externa involves general ear care measures, optimizing any underlying medical or skin conditions that are risk factors, avoiding the use of hearing aids or ear plugs if there is a suspected contact allergy, and avoiding the use of ear drops if there is a suspected allergy to any of its ingredients. Treatment options include over-the-counter acetic acid 2% ear drops or spray, aural toileting via dry swabbing, irrigation, or microsuction, and prescribing topical antibiotics with or without a topical corticosteroid. Oral antibiotics may be prescribed in severe cases or for immunocompromised individuals.

      Follow-up is advised if symptoms do not improve within 48-72 hours of starting treatment, if symptoms have not fully resolved

    • This question is part of the following fields:

      • Ear, Nose & Throat
      13.8
      Seconds
  • Question 13 - A 42-year-old woman with a lengthy background of depression arrives at the hospital...

    Correct

    • A 42-year-old woman with a lengthy background of depression arrives at the hospital after intentionally overdosing on the medication she takes for her heart condition. She informs you that the medication she takes for this condition is verapamil immediate-release 240 mg. She ingested the tablets approximately half an hour ago but was promptly discovered by her husband, who quickly brought her to the Emergency Department.

      What is one of the effects of verapamil?

      Your Answer: Negative dromotropy

      Explanation:

      Calcium-channel blocker overdose is a serious matter and should always be treated as 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 cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

      The toxic effects of calcium-channel blockers can be summarized as follows:

      Cardiac effects:
      – Excessive negative inotropy: causing myocardial depression
      – Negative chronotropy: leading to sinus bradycardia
      – Negative dromotropy: resulting in atrioventricular node blockade

      Vascular smooth muscle tone effects:
      – Decreased afterload: causing systemic hypotension
      – Coronary vasodilation: leading to widened blood vessels in the heart

      Metabolic effects:
      – Hypoinsulinaemia: insulin release depends on calcium influx through L-type calcium channels in islet beta-cells
      – Calcium channel blocker-induced insulin resistance: causing reduced responsiveness to insulin.

      It is important to be aware of these effects and take appropriate action in cases of calcium-channel blocker overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      29.7
      Seconds
  • Question 14 - In the aftermath of a suspected CBRN (chemical, biological, radiological, and nuclear) incident,...

    Incorrect

    • In the aftermath of a suspected CBRN (chemical, biological, radiological, and nuclear) incident, where sarin gas is believed to be the responsible agent, healthcare workers are faced with a significant number of casualties. What is the primary focus for healthcare workers when responding to the scene of a CBRN event?

      Your Answer: Removal of the clothing of the casualties

      Correct Answer: The wearing of adequate personal protective equipment

      Explanation:

      Healthcare workers responding to contaminated casualties must prioritize their own safety by wearing appropriate personal protective equipment. This is crucial because secondary contamination can occur. Additionally, if working in contaminated areas, healthcare workers should maximize ventilation and use breathing equipment. Ensuring the safety of healthcare workers is essential as they cannot effectively help the casualties without it.

      The first step in managing contaminated casualties is early skin decontamination. It is important to move the casualties to a safe area and remove all contaminated clothing to minimize further exposure. The skin should then be thoroughly rinsed with water to physically remove the nerve agent. After rinsing, it should be washed with an alkaline solution of soap and water or a 0.5% hypochlorite solution to chemically neutralize the nerve agent. To prevent ongoing absorption through the eyes, contact lenses should be removed and the eyes irrigated.

      Resuscitation should be initiated using an ABCDE approach, and casualties should be supported and transferred to the hospital as quickly as possible. Ventilation may be necessary in some cases. Nerve agent antidote autoinjectors can be utilized, and the use of these should be guided by local policy for prehospital personnel.

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      13.3
      Seconds
  • Question 15 - A 45-year-old patient has been diagnosed with gonorrhea. You are preparing to initiate...

    Correct

    • A 45-year-old patient has been diagnosed with gonorrhea. You are preparing to initiate antibiotic treatment.
      Which of the following antibiotic combinations would be the most suitable?

      Your Answer: Ceftriaxone and azithromycin

      Explanation:

      Ceftriaxone is currently one of the limited antibiotics that effectively treats gonorrhoea. It is typically administered alongside azithromycin or doxycycline to enhance its effectiveness.

    • This question is part of the following fields:

      • Sexual Health
      15.3
      Seconds
  • Question 16 - A 25-year-old male medical student presents with intense vomiting that began a couple...

    Correct

    • A 25-year-old male medical student presents with intense vomiting that began a couple of hours after consuming a microwaved Chinese takeout.
      What is the MOST LIKELY single causative organism?

      Your Answer: Bacillus cereus

      Explanation:

      Bacillus cereus is a type of bacterium that is Gram-positive, rod-shaped, and beta-haemolytic. It is responsible for causing a condition known as ‘fried rice syndrome’.

      The bacterium forms hardy spores that can withstand boiling temperatures and remain viable even when rice is left at room temperature for extended periods before being fried. When these spores germinate, they can lead to the development of the syndrome.

      There are two types of strains associated with Bacillus cereus. The first type produces an emetic enterotoxin, which results in symptoms such as nausea and vomiting. These symptoms typically occur within 1 to 6 hours after consuming contaminated food and can be quite severe, lasting for about 6 to 24 hours.

      The second type of strain produces a diarrheagenic enterotoxin. This strain is commonly associated with the ingestion of meat, vegetables, and dairy products. Symptoms of this type of infection include abdominal pain and vomiting, which usually begin 8 to 12 hours after ingestion and resolve within 12 to 24 hours.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      6.2
      Seconds
  • Question 17 - A 68 year old male with dementia is brought into the emergency department...

    Correct

    • A 68 year old male with dementia is brought into the emergency department by his daughter due to a sudden decline in cognitive function over the past week. The daughter suspects that the patient's medication may have been altered recently. She presents you with the tablets she discovered in the patient's room. Which medication is most likely responsible for the decline in the patient's cognitive abilities?

      Your Answer: Oxybutynin

      Explanation:

      Anticholinergic drugs have been found to worsen cognitive impairment in individuals with dementia. Certain commonly prescribed medications are associated with a higher anticholinergic burden, which can lead to increased cognitive decline. Examples of drugs with high anticholinergic potency include tricyclic antidepressants like amitriptyline hydrochloride, paroxetine, first-generation antihistamines such as chlorpheniramine maleate and promethazine hydrochloride, certain antipsychotics like olanzapine, clozapine, and quetiapine, urinary antispasmodics like solifenacin, oxybutynin, and tolterodine, and antimuscarinics like ipratropium, tiotropium, atropine, and cyclopentolate. However, it’s important to note that rivastigmine and memantine are recommended as first-line treatments for Alzheimer’s and DLB, while haloperidol, despite being an antipsychotic, has low anticholinergic potency.

      Further Reading:

      Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

      To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

      The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

      There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

      Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

      Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

      Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

      In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.3
      Seconds
  • Question 18 - A 37 year old male presents to the emergency department complaining of sudden...

    Correct

    • A 37 year old male presents to the emergency department complaining of sudden onset headache, tremor, and palpitations. During triage, his blood pressure is measured at 220/110 mmHg. You start considering the likelihood of secondary causes of hypertension, including the possibility of extra-adrenal phaeochromocytoma. What percentage of phaeochromocytoma cases are extra-adrenal?

      Your Answer: 10-15%

      Explanation:

      The correct answer is 10-15%. This means that out of all phaeochromocytoma cases, approximately 10-15% occur outside of the adrenal glands.

      Further Reading:

      Phaeochromocytoma is a rare neuroendocrine tumor that secretes catecholamines. It typically arises from chromaffin tissue in the adrenal medulla, but can also occur in extra-adrenal chromaffin tissue. The majority of cases are spontaneous and occur in individuals aged 40-50 years. However, up to 30% of cases are hereditary and associated with genetic mutations. About 10% of phaeochromocytomas are metastatic, with extra-adrenal tumors more likely to be metastatic.

      The clinical features of phaeochromocytoma are a result of excessive catecholamine production. Symptoms are typically paroxysmal and include hypertension, headaches, palpitations, sweating, anxiety, tremor, abdominal and flank pain, and nausea. Catecholamines have various metabolic effects, including glycogenolysis, mobilization of free fatty acids, increased serum lactate, increased metabolic rate, increased myocardial force and rate of contraction, and decreased systemic vascular resistance.

      Diagnosis of phaeochromocytoma involves measuring plasma and urine levels of metanephrines, catecholamines, and urine vanillylmandelic acid. Imaging studies such as abdominal CT or MRI are used to determine the location of the tumor. If these fail to find the site, a scan with metaiodobenzylguanidine (MIBG) labeled with radioactive iodine is performed. The highest sensitivity and specificity for diagnosis is achieved with plasma metanephrine assay.

      The definitive treatment for phaeochromocytoma is surgery. However, before surgery, the patient must be stabilized with medical management. This typically involves alpha-blockade with medications such as phenoxybenzamine or phentolamine, followed by beta-blockade with medications like propranolol. Alpha blockade is started before beta blockade to allow for expansion of blood volume and to prevent a hypertensive crisis.

    • This question is part of the following fields:

      • Endocrinology
      5.5
      Seconds
  • Question 19 - A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency...

    Correct

    • A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency Department after experiencing sudden difficulty breathing. Shortly after her arrival, she loses consciousness. The cardiac monitor displays ventricular fibrillation, confirming cardiac arrest.
      Which of the following statements about cardiac arrest during pregnancy is correct?

      Your Answer: Early tracheal intubation should be performed

      Explanation:

      Cardiac arrest during pregnancy is a rare occurrence, happening in approximately 16 out of every 100,000 live births. It is crucial to consider both the mother and the fetus when dealing with cardiac arrest in pregnancy, as the best way to ensure a positive outcome for the fetus is by effectively resuscitating the mother.

      The main causes of cardiac arrest during pregnancy include pre-existing cardiac disease, pulmonary embolism, hemorrhage, ectopic pregnancy, hypertensive disorders of pregnancy, amniotic fluid embolism, and suicide. Many cardiovascular problems associated with pregnancy are caused by compression of the inferior vena cava.

      To prevent decompensation or potential cardiac arrest during pregnancy, it is important to follow these steps when dealing with a distressed or compromised pregnant patient:

      – Place the patient in the left lateral position or manually displace the uterus to the left.
      – Administer high-flow oxygen, guided by pulse oximetry.
      – Give a fluid bolus if there is low blood pressure or signs of hypovolemia.
      – Re-evaluate the need for any medications currently being administered.
      – Seek expert help and involve obstetric and neonatal specialists early.
      – Identify and treat the underlying cause.

      In the event of cardiac arrest during pregnancy, in addition to following the standard guidelines for basic and advanced life support, the following modifications should be made:

      – Immediately call for expert help, including an obstetrician, anesthetist, and neonatologist.
      – Start CPR according to the standard ALS guidelines, but adjust the hand position slightly higher on the sternum.
      – Ideally establish IV or IO access above the diaphragm to account for potential compression of the inferior vena cava.
      – Manually displace the uterus to the left to relieve caval compression.
      – Tilt the table to the left side (around 15-30 degrees of tilt).
      – Perform early tracheal intubation to reduce the risk of aspiration (seek assistance from an expert anesthetist).
      – Begin preparations for an emergency Caesarean section.

      A perimortem Caesarean section should be performed within 5 minutes of the onset of cardiac arrest. This delivery will alleviate caval compression and increase the chances of successful resuscitation by improving venous return during CPR. It will also maximize the chances of the infant’s survival, as the best survival rate occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      15
      Seconds
  • Question 20 - A 5 year old girl is brought into the emergency room. Her father...

    Correct

    • A 5 year old girl is brought into the emergency room. Her father entered the room as she was about to eat a cashew. Within a few minutes, her face began to swell. You determine that she is experiencing anaphylaxis. After administering the necessary medication, you decide to administer an IV fluid challenge. How much crystalloid would you administer to a child in this scenario?

      Your Answer: 10 ml/kg

      Explanation:

      According to the 2021 resus council guidelines, when administering an IV fluid challenge to a child with anaphylaxis, the recommended dose is 10 ml/kg. It is important to note that prior to the update, the advised dose was 20 ml/kg. In an exam, if you are provided with the child’s weight, you may be required to calculate the volume requirement.

      Further Reading:

      Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.

      When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.

      The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.

      In some cases, 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. This can help confirm the diagnosis and guide further management.

      Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.

    • This question is part of the following fields:

      • Paediatric Emergencies
      10.1
      Seconds
  • Question 21 - A father brings his 3-year-old daughter to the Emergency Department. They have previously...

    Incorrect

    • A father brings his 3-year-old daughter to the Emergency Department. They have previously presented 8 times over the past nine months and on each occasion have been discharged. She has previously been investigated for multiple episodes of abdominal pain, and no cause found. Investigations have included routine blood tests, a negative ultrasound for appendicitis, and a negative CT scan. Four weeks ago, she presented with dad being concerned about the possibility of a urinary tract infection but was discharged without treatment, and dad had been reassured. Today she has presented having had several alleged episodes of diarrhea and vomiting at home. She has not been eating or drinking and has been spiking fevers. She appears undistressed and has had no witnessed vomiting episodes in the department. Her observations today are: temperature: 37.0°C, heart rate 110 bpm, SaO2 99% on air, RR 30, capillary refill time <2 seconds.
      What is the SINGLE most likely diagnosis?

      Your Answer: Somatic symptom disorder

      Correct Answer: Meadow syndrome

      Explanation:

      Meadow syndrome, formerly known as Munchausen syndrome by proxy, is the most likely diagnosis in this case. It involves a caregiver intentionally creating the appearance of health problems in another person, usually their own child. This can involve causing harm to the child or manipulating test results to make it seem like the child is sick or injured.

      There are several features that support a diagnosis of Meadow syndrome. These include symptoms or signs that only appear when the parent or guardian is present, symptoms that are only observed by the parent or guardian, and symptoms that do not respond to treatment or medication. Additionally, there may be a history of unlikely illnesses, such as a significant amount of blood loss without any change in physiological data. The parent or guardian may also seek multiple clinical opinions despite already receiving a definitive opinion, and they may persistently disagree with the clinical opinion.

      Another characteristic of Meadow syndrome is the significant impact it has on the child’s normal activities, such as frequent school absenteeism. The child may also use aids to daily living that are seemingly unnecessary, like a wheelchair. It is important to note that a principal risk factor for this condition is the parent having experienced a negative event or trauma during their own childhood, such as the death of a parent or being a victim of child abuse or neglect.

      It is crucial not to confuse Meadow syndrome with Munchausen syndrome, where an individual pretends to be ill or deliberately produces symptoms in themselves. Hypochondriasis is another condition where a person excessively worries about having a serious illness. Somatic symptom disorder, previously known as somatisation disorder, is characterized by an intense focus on physical symptoms that causes significant emotional distress and impairs functioning. Lastly, Ganser syndrome is a rare dissociative disorder that involves giving nonsensical or incorrect answers to questions and experiencing other dissociative symptoms like fugue, amnesia, or conversion disorder, often accompanied by visual pseudohallucinations and a decreased state of consciousness.

    • This question is part of the following fields:

      • Mental Health
      96
      Seconds
  • Question 22 - A 35-year-old woman is given a medication during the advanced stages of pregnancy....

    Correct

    • A 35-year-old woman is given a medication during the advanced stages of pregnancy. As a result, the newborn experiences respiratory depression and develops a neonatal withdrawal syndrome.

      Which of the following medications is the most probable cause of these abnormalities?

      Your Answer: Diazepam

      Explanation:

      During the later stages of pregnancy, the use of diazepam has been linked to respiratory depression in newborns and a withdrawal syndrome. There are several drugs that can have adverse effects during pregnancy, and the list below outlines the most commonly encountered ones.

      ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the second and third trimesters. Aminoglycosides, like gentamicin, can lead to ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g., 75 mg) do not pose significant risks.

      Benzodiazepines, including diazepam, can cause respiratory depression and a neonatal withdrawal syndrome when administered late in pregnancy. Calcium-channel blockers can cause phalangeal abnormalities if given in the first trimester and fetal growth retardation if given in the second and third trimesters. Carbamazepine can lead to hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol is associated with grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, when administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride as it can affect male sex organ development.

      Haloperidol, if given in the first trimester, may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.

      Lithium, if given in the first trimester, poses a risk of fetal cardiac malformations. In the second and third trimesters, it can result in hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus in the neonate.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      14.6
      Seconds
  • Question 23 - A 45-year-old male smoker comes in with a severe episode of chest pain...

    Correct

    • A 45-year-old male smoker comes in with a severe episode of chest pain that spreads to his left arm and jaw. The pain lasted for about half an hour before being relieved by GTN spray and aspirin. A troponin test is done 12 hours later, which comes back positive. His ECG at the time of presentation reveals widespread ST depression.

      What is the MOST LIKELY diagnosis in this case?

      Your Answer: Non-ST-elevation myocardial infarction

      Explanation:

      This patient has developed a non-ST elevation myocardial infarction (NSTEMI). The electrocardiogram (ECG) reveals widespread ST depression, indicating widespread subendocardial ischemia. Additionally, the troponin test results are positive, indicating myocyte necrosis.

      The acute coronary syndromes consist of unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).

      Unstable angina is characterized by one or more of the following: angina of effort occurring over a few days with increasing frequency, angina episodes occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The ECG may show T-wave/ST-segment changes, similar to this case. Cardiac enzymes are typically normal, and the troponin test is negative in unstable angina.

      Non-ST elevation myocardial infarction (NSTEMI) typically presents with sustained cardiac chest pain lasting more than 20 minutes. The ECG often shows abnormalities in T-waves or ST-segments. Cardiac enzymes are elevated, and the troponin test is positive.

      ST-elevation myocardial infarction (STEMI) usually presents with typical cardiac chest pain suggestive of an acute myocardial infarction. The ECG reveals ST-segment elevation and the development of Q waves. Cardiac enzymes are elevated, and the troponin test is positive.

    • This question is part of the following fields:

      • Cardiology
      30.3
      Seconds
  • Question 24 - A 25-year-old woman comes to the clinic with a swollen and red right...

    Correct

    • A 25-year-old woman comes to the clinic with a swollen and red right knee. She recently returned from a trip to Bangkok. During the examination, her temperature is 38.6°C and she has a rash with small blisters on her trunk. The knee feels warm to touch and is immobile. Attempts to flex or extend the knee are unsuccessful. A joint aspiration is done, and Gram-negative diplococci are observed.
      Which of the following antibiotics would be the most suitable to prescribe for this patient?

      Your Answer: Cefotaxime

      Explanation:

      The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The patient’s recent travel to Bangkok, presence of a vesicular rash on the trunk, and the identification of Gram-negative diplococci support this diagnosis.

      Septic arthritis is characterized by several clinical features. These include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and systemic upset.

      The most common cause of septic arthritis is Staphylococcus aureus. Other bacteria that can lead to this condition include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).

      According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves the following approaches. Flucloxacillin is the first-line antibiotic. In cases of penicillin allergy, clindamycin is recommended. If there is suspicion of MRSA (methicillin-resistant Staphylococcus aureus), vancomycin should be used. For suspected gonococcal arthritis or Gram-negative infection, cefotaxime is the preferred choice. The suggested duration of treatment is 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      6.6
      Seconds
  • Question 25 - A 42-year-old man has recently taken an antibiotic for a skin infection. He...

    Correct

    • A 42-year-old man has recently taken an antibiotic for a skin infection. He has been experiencing palpitations and had an ECG performed, which shows the presence of new QT prolongation.
      Which of the following antibiotics is he most likely to have taken?

      Your Answer: Erythromycin

      Explanation:

      Prolongation of the QT interval can lead to a dangerous ventricular arrhythmia called torsades de pointes, which can result in sudden cardiac death. There are several commonly used medications that are known to cause QT prolongation.

      Low levels of potassium (hypokalaemia) and magnesium (hypomagnesaemia) can increase the risk of QT prolongation. For example, diuretics can interact with QT-prolonging drugs by causing hypokalaemia.

      The QT interval varies with heart rate, and formulas are used to correct the QT interval for heart rate. Once corrected, it is referred to as the QTc interval. The QTc interval is typically reported on the ECG printout. A normal QTc interval is less than 440 ms.

      If the QTc interval is greater than 440 ms but less than 500 ms, it is considered borderline. Although there may be some variation in the literature, a QTc interval within these values is generally considered borderline prolonged. In such cases, it is important to consider reducing the dose of QT-prolonging drugs or switching to an alternative medication that does not prolong the QT interval.

      A prolonged QTc interval exceeding 500 ms is clinically significant and is likely to increase the risk of arrhythmia. Any medications that prolong the QT interval should be reviewed immediately.

      Here are some commonly encountered drugs that are known to prolong the QT interval:

      Antimicrobials:
      – Erythromycin
      – Clarithromycin
      – Moxifloxacin
      – Fluconazole
      – Ketoconazole

      Antiarrhythmics:
      – Dronedarone
      – Sotalol
      – Quinidine
      – Amiodarone
      – Flecainide

      Antipsychotics:
      – Risperidone
      – Fluphenazine
      – Haloperidol
      – Pimozide
      – Chlorpromazine
      – Quetiapine
      – Clozapine

      Antidepressants:
      – Citalopram/escitalopram
      – Amitriptyline
      – Clomipramine
      – Dosulepin
      – Doxepin
      – Imipramine
      – Lofepramine

      Antiemetics:
      – Domperidone
      – Droperidol
      – Ondansetron/Granisetron

      Others:
      – Methadone
      – Protein kinase inhibitors (e.g. sunitinib)

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      6.2
      Seconds
  • Question 26 - A 68 year old male is brought into the emergency department with burns...

    Correct

    • A 68 year old male is brought into the emergency department with burns sustained in a house fire. You evaluate the extent of the burns to the patient's body. According to the Jackson's Burn wound model, what is the term used to describe the most peripheral area of the burn?

      Your Answer: Zone of hyperaemia

      Explanation:

      The zone of hyperaemia, located at the outermost part of the burn, experiences heightened tissue perfusion. Typically, this area will return to its normal tissue state.

      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:

      • Surgical Emergencies
      10
      Seconds
  • Question 27 - A 72 year old male comes to the emergency department complaining of central...

    Correct

    • A 72 year old male comes to the emergency department complaining of central chest pain. An ECG is performed to check for signs of ischemic changes. Which of the following results is most indicative of a non ST elevation myocardial infarction (NSTEMI)?

      Your Answer: Q wave in lead V2

      Explanation:

      Q waves in V2 and V3 are typically abnormal and indicate a pathological condition. Q waves are negative deflections that occur before an R wave. They can be either normal or abnormal. Small normal Q waves, which are less than 1mm deep, may be present in most leads. Deeper normal Q waves are commonly seen in lead III, as long as they are not present in the adjacent leads II and AVF. On the other hand, pathological Q waves are usually deeper and wider. In particular, Q waves should not be observed in V2 and V3. The specific criteria for identifying pathological Q waves are as follows: any Q wave in leads V2-V3 that is greater than 0.02s in duration or a QS complex in leads V2-V3; a Q wave that is greater than 0.03s in duration and deeper than 1mm, or a QS complex, in leads I, II, aVL, aVF, or V4-V6 in any two leads of a contiguous lead grouping; an R wave that is greater than 0.04s in duration in V1-V2 and has an R/S ratio greater than 1, along with a concordant positive T wave, in the absence of a conduction defect. In healthy individuals, the T-wave is normally inverted in aVR and inverted or flat in V1. T-wave inversion in III is also considered a normal variation. If there is ST elevation in lead V1, it would suggest a ST-elevation myocardial infarction (STEMI) rather than a non-ST-elevation myocardial infarction (NSTEMI).

      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
      3.6
      Seconds
  • Question 28 - You are suturing a young patient with a significant laceration. While performing the...

    Correct

    • You are suturing a young patient with a significant laceration. While performing the procedure, the patient begins to express discomfort. You observe that the patient seems restless and their muscles are experiencing spasms. You suspect that the patient is displaying symptoms of local anesthetic toxicity. Apart from following standard ALS protocols, what intravenous medication can be administered in case of a cardiac arrest?

      Your Answer: Intralipid

      Explanation:

      Intralipid is a lipid emulsion that is commonly used as a source of nutrition in parenteral nutrition. However, it has also been found to be effective in treating local anesthetic toxicity. When administered intravenously, Intralipid acts as a lipid sink, meaning it can bind to the local anesthetic agent and remove it from the affected tissues, thereby reversing the toxic effects.

      In cases of cardiac arrest related to local anesthetic toxicity, Intralipid can be administered as a bolus followed by an infusion. The recommended dose is typically 1.5 mL/kg bolus over 1 minute, followed by an infusion of 0.25 mL/kg/minute for 10 minutes. This can be repeated if necessary.

      It is important to note that while Intralipid has shown promising results in treating local anesthetic toxicity, it should not replace standard ALS protocols. Basic life support (BLS) measures, such as cardiopulmonary resuscitation (CPR), should still be initiated immediately, and advanced cardiac life support (ACLS) protocols should be followed.

      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:

      • Pharmacology & Poisoning
      16.3
      Seconds
  • Question 29 - There has been a car accident involving multiple individuals near the school where...

    Correct

    • There has been a car accident involving multiple individuals near the school where you are currently teaching. The school administration has been notified, and an emergency situation has been declared.

      Which of the following statements about the coordination at the site of an emergency situation is accurate?

      Your Answer: Gold command is located at a distant location

      Explanation:

      The Gold-Silver-bronze Hierarchy is utilized to establish the chain of command at the site of a significant incident in the United Kingdom.

      Gold (Strategic):
      The Gold Commander assumes overall control of their organization’s resources at the incident. They are situated at a remote location known as the Gold Command. Ideally, the Gold Commanders for each organization should be co-located, but if that is not feasible, they must maintain constant communication with each other.

      Silver (Tactical):
      The Silver Commander for each organization is the highest-ranking member of each service present at the scene of the major incident. Their responsibility is to manage the available resources at the scene in order to achieve the strategic objectives set by the Gold Commander. They work closely with the Silver Commanders of other organizations and are not directly involved in dealing with the incident itself.

      Bronze (Operational):
      The Bronze Commander directly oversees their organization’s resources at the incident. They collaborate with their staff on the scene of the incident. In cases where the incident is geographically widespread, multiple Bronze commanders may assume responsibility for different areas. In complex incidents, Bronze commanders may share tasks or responsibilities.

      At the scene of the major incident, the Police and Fire Service establish a cordon to restrict access, requiring permission from the appropriate officer to enter. The Silver and Bronze areas are designated within the scene.

      The Silver area is situated within an outer cordon that surrounds the inner cordon. It houses the Casualty Clearing Station (CCS), Ambulance Parking Point, and the service incident commanders for each organization. Medical personnel are only allowed to enter the Silver area if instructed to do so by the MIO (Medical Incident Officer) and if authorized by the service responsible for safety at the scene, typically the Fire Service. Primary triage, evacuation of casualties, and treatment of trapped casualties take place in this area.

      The Bronze area is located within an inner cordon that surrounds the scene of the incident. All medical activities within the Bronze area are directed by the MIO and AIO (Ambulance Incident Officer), who work together. Doctors operate under the command of the MIO, while ambulance personnel are under the command of the AIO.

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      15.1
      Seconds
  • Question 30 - A 25-year-old woman is brought to the Emergency Department by her younger brother....

    Incorrect

    • A 25-year-old woman is brought to the Emergency Department by her younger brother. He states her behavior has been strange lately and that he is extremely concerned about her. She is exhibiting signs of acute psychosis.
      Which ONE of the following would indicate a diagnosis of schizophrenia?

      Your Answer: Grandiose delusions

      Correct Answer: Emotional incongruity

      Explanation:

      Emotional incongruity, although not a primary symptom, is one of the negative symptoms that define chronic schizophrenia. These symptoms, as described by Kurt Schneider, are known as first-rank symptoms. They include auditory hallucinations such as hearing third-person voices discussing the patient, thought echo, and commentary on actions. Passivity phenomena, such as thought insertion, thought withdrawal, thought broadcast, and feelings of thoughts and actions being under external control, are also considered first-rank symptoms. Delusions, which can be primary or secondary, are another characteristic of schizophrenia.

      Chronic schizophrenia is primarily characterized by negative symptoms. These symptoms include poor motivation and self-care, social withdrawal, depression, flat and blunted affect, emotional incongruity, decreased activity, poverty of thought and speech. On the other hand, symptoms like loss of inhibitions, pressure of speech, and grandiose delusions are more indicative of mania. Increased anxiety in social circumstances is often associated with social anxiety disorder.

      In summary, emotional incongruity is a negative symptom of chronic schizophrenia, while the first-rank symptoms described by Kurt Schneider encompass auditory hallucinations, passivity phenomena, and delusions. It is important to differentiate these symptoms from those associated with mania or social anxiety disorder.

    • This question is part of the following fields:

      • Mental Health
      8.1
      Seconds
  • Question 31 - A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse,...

    Incorrect

    • A 28-year-old woman comes in with lower abdominal pain, painful urination, painful intercourse, and thick vaginal discharge. A pregnancy test done today is negative. She has no fever and her vital signs are normal. During the exam, her abdomen feels soft, but she experiences cervical motion tenderness during a pelvic examination.

      What is the MOST suitable treatment plan?

      Your Answer: IV ceftriaxone and metronidazole plus oral doxycycline

      Correct Answer: IM ceftriaxone plus oral doxycycline and metronidazole

      Explanation:

      Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

      PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

      To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

      Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

      For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      4.7
      Seconds
  • Question 32 - A 35-year-old woman is brought into the emergency department after being hit by...

    Correct

    • A 35-year-old woman is brought into the emergency department after being hit by a car while riding her bike. The patient was not wearing a helmet and suffered a head injury from hitting the pavement. She has a significant scalp contusion and appears drowsy. There is a suspicion of increased intracranial pressure. How does intracranial pressure affect cerebral perfusion pressure?

      Your Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP)

      Explanation:

      Cerebral perfusion pressure (CPP) is calculated by adding the intracranial pressure (ICP) to the diastolic blood pressure (DBP).

      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
      6.8
      Seconds
  • Question 33 - A 70-year-old man with a known history of Alzheimer's disease and a previous...

    Correct

    • A 70-year-old man with a known history of Alzheimer's disease and a previous heart attack experiences urinary incontinence and a sudden decline in his cognitive function. He denies experiencing any abdominal pain or discomfort while urinating.

      What is the SINGLE most probable diagnosis?

      Your Answer: Urinary tract infection

      Explanation:

      Symptoms of urinary tract infection (UTI) can be difficult to detect in elderly patients, especially those with dementia. Common signs like painful urination and abdominal discomfort may be absent. Instead, these patients often experience increased confusion, restlessness, and a decline in cognitive abilities. Therefore, if an elderly patient suddenly develops urinary incontinence and experiences a rapid deterioration in cognitive function, it is highly likely that they have a UTI.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      24.6
      Seconds
  • Question 34 - A 45-year-old woman develops hypothyroidism secondary to the administration of a medication for...

    Correct

    • A 45-year-old woman develops hypothyroidism secondary to the administration of a medication for a thyroid condition.

      Which of the following medications is most likely to be responsible?

      Your Answer: Amiodarone

      Explanation:

      Amiodarone has a chemical structure that is similar to thyroxine and has the ability to bind to the nuclear thyroid receptor. This medication has the potential to cause both hypothyroidism and hyperthyroidism, although hypothyroidism is more commonly observed, affecting around 5-10% of patients.

      There are several side effects associated with the use of amiodarone. These include the formation of microdeposits in the cornea, increased sensitivity to sunlight resulting in photosensitivity, feelings of nausea, disturbances in sleep patterns, and the development of either hyperthyroidism or hypothyroidism. In addition, there have been reported cases of acute hepatitis and jaundice, peripheral neuropathy, lung fibrosis, and QT prolongation.

      It is important to be aware of these potential side effects when considering the use of amiodarone as a treatment option. Regular monitoring and close medical supervision are necessary to detect and manage any adverse reactions that may occur.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11.4
      Seconds
  • Question 35 - A 25-year-old patient arrives at the emergency department from working in a radiation...

    Correct

    • A 25-year-old patient arrives at the emergency department from working in a radiation lab. He informs you that he may have been exposed to dangerous radiation. The patient mentions that it has been less than 24 hours since he left lab. Which of the following tests provides the most accurate prognosis for the severity of radiation sickness?

      Your Answer: Lymphocyte count

      Explanation:

      The count of lymphocytes, a type of white blood cell, can serve as an early indication of the level of radiation exposure. The severity of the exposure can be determined by observing the decrease in lymphocyte count, which is directly related to the amount of radiation absorbed by the body. Ideally, the count is measured 12 hours after exposure and then repeated every 4 hours initially to track the rate of decrease.

      Further Reading:

      Radiation exposure refers to the emission or transmission of energy in the form of waves or particles through space or a material medium. There are two types of radiation: ionizing and non-ionizing. Non-ionizing radiation, such as radio waves and visible light, has enough energy to move atoms within a molecule but not enough to remove electrons from atoms. Ionizing radiation, on the other hand, has enough energy to ionize atoms or molecules by detaching electrons from them.

      There are different types of ionizing radiation, including alpha particles, beta particles, gamma rays, and X-rays. Alpha particles are positively charged and consist of 2 protons and 2 neutrons from the atom’s nucleus. They are emitted from the decay of heavy radioactive elements and do not travel far from the source atom. Beta particles are small, fast-moving particles with a negative electrical charge that are emitted from an atom’s nucleus during radioactive decay. They are more penetrating than alpha particles but less damaging to living tissue. Gamma rays and X-rays are weightless packets of energy called photons. Gamma rays are often emitted along with alpha or beta particles during radioactive decay and can easily penetrate barriers. X-rays, on the other hand, are generally lower in energy and less penetrating than gamma rays.

      Exposure to ionizing radiation can damage tissue cells by dislodging orbital electrons, leading to the generation of highly reactive ion pairs. This can result in DNA damage and an increased risk of future malignant change. The extent of cell damage depends on factors such as the type of radiation, time duration of exposure, distance from the source, and extent of shielding.

      The absorbed dose of radiation is directly proportional to time, so it is important to minimize the amount of time spent in the vicinity of a radioactive source. A lethal dose of radiation without medical management is 4.5 sieverts (Sv) to kill 50% of the population at 60 days. With medical management, the lethal dose is 5-6 Sv. The immediate effects of ionizing radiation can range from radiation burns to radiation sickness, which is divided into three main syndromes: hematopoietic, gastrointestinal, and neurovascular. Long-term effects can include hematopoietic cancers and solid tumor formation.

      In terms of management, support is mainly supportive and includes IV fluids, antiemetics, analgesia, nutritional support, antibiotics, blood component substitution, and reduction of brain edema.

    • This question is part of the following fields:

      • Environmental Emergencies
      17.3
      Seconds
  • Question 36 - A 35-year-old woman currently nursing her baby has developed a painful, red lump...

    Correct

    • A 35-year-old woman currently nursing her baby has developed a painful, red lump in her left breast. She feels chilled and generally not well and has a temperature of 38.6°C. During examination, she has a significant red area on the outer side of the nipple on her left breast. The entire breast seems swollen and inflamed.

      What is the SINGLE most probable diagnosis?

      Your Answer: Breast abscess

      Explanation:

      This patient is experiencing a breast abscess that has developed as a result of lactational mastitis. When milk is not properly drained, it can lead to an overgrowth of bacteria and subsequently cause an infection in the breast. If left untreated, this infection can lead to the accumulation of pus in a specific area of the breast. It is estimated that around 5-10% of women with infectious mastitis will develop a breast abscess. The recommended treatment involves a combination of antibiotics, such as flucloxacillin or co-amoxiclav, along with either aspiration or incision and drainage of the abscess.

    • This question is part of the following fields:

      • Surgical Emergencies
      4.6
      Seconds
  • Question 37 - A 45 year old presents to the emergency department due to increasing fatigue...

    Correct

    • A 45 year old presents to the emergency department due to increasing fatigue and occasional confusion over the past few days. The patient has type 2 diabetes mellitus. A capillary blood glucose is taken at triage and reads 'hi'. Bloods are collected and sent for analysis. The results are as follows:

      Na+ 146 mmol/l
      K+ 5.7 mmol/l
      Urea 21 mmol/l
      Creatinine 138 µmol/l
      Glucose 38 mmol/l
      pH 7.35
      Bicarbonate 19 mmol/l

      What is the calculated plasma osmolality for this patient?

      Your Answer: 351 mOsm/kg

      Explanation:

      The plasma osmolality for this patient can be calculated by multiplying the sodium concentration by 2, adding the glucose concentration, and then adding the urea concentration. In this case, the calculation would be (2 x 146) + 38 + 21.

      Further Reading:

      Hyperosmolar hyperglycaemic state (HHS) is a syndrome that occurs in people with type 2 diabetes and is characterized by extremely high blood glucose levels, dehydration, and hyperosmolarity without significant ketosis. It can develop over days or weeks and has a mortality rate of 5-20%, which is higher than that of diabetic ketoacidosis (DKA). HHS is often precipitated by factors such as infection, inadequate diabetic treatment, physiological stress, or certain medications.

      Clinical features of HHS include polyuria, polydipsia, nausea, signs of dehydration (hypotension, tachycardia, poor skin turgor), lethargy, confusion, and weakness. Initial investigations for HHS include measuring capillary blood glucose, venous blood gas, urinalysis, and an ECG to assess for any potential complications such as myocardial infarction. Osmolality should also be calculated to monitor the severity of the condition.

      The management of HHS aims to correct dehydration, hyperglycaemia, hyperosmolarity, and electrolyte disturbances, as well as identify and treat any underlying causes. Intravenous 0.9% sodium chloride solution is the principal fluid used to restore circulating volume and reverse dehydration. If the osmolality does not decline despite adequate fluid balance, a switch to 0.45% sodium chloride solution may be considered. Care must be taken in correcting plasma sodium and osmolality to avoid complications such as cerebral edema and osmotic demyelination syndrome.

      The rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours, and the fall in blood glucose should be no more than 5 mmol/L per hour. Low-dose intravenous insulin may be initiated if the blood glucose is not falling with fluids alone or if there is significant ketonaemia. Potassium replacement should be guided by the potassium level, and the patient should be encouraged to drink as soon as it is safe to do so.

      Complications of treatment, such as fluid overload, cerebral edema, or central pontine myelinolysis, should be assessed for, and underlying precipitating factors should be identified and treated. Prophylactic anticoagulation is required in most patients, and all patients should be assumed to be at high risk of foot ulceration, necessitating appropriate foot protection and daily foot checks.

    • This question is part of the following fields:

      • Endocrinology
      12
      Seconds
  • Question 38 - A 28-year-old woman comes in with anxiety. She also exhibits symptoms of dry...

    Correct

    • A 28-year-old woman comes in with anxiety. She also exhibits symptoms of dry mouth, coughing, lower body temperature, altered perception of time and space, and bloodshot eyes. What is the MOST LIKELY diagnosis?

      Your Answer: Cannabis use

      Explanation:

      The clinical manifestations of cannabis use encompass various aspects. Firstly, it can amplify pre-existing mood states, leading to feelings of euphoria, depression, or anxiety. Additionally, cannabis can distort one’s perception of time and space, creating a sense of disorientation. It also enhances the enjoyment of aesthetic experiences, making them more pleasurable. Visual hallucinations may also occur as a result of cannabis use. Physiological effects include dry mouth, coughing, and irritation of the respiratory tract. Furthermore, cannabis use often leads to an increased appetite and a decrease in body temperature. Reddened eyes and respiratory tract irritation are also common symptoms associated with cannabis use.

    • This question is part of the following fields:

      • Mental Health
      6.9
      Seconds
  • Question 39 - A 40-year-old male patient presents with a history of dizziness and fainting episodes....

    Incorrect

    • A 40-year-old male patient presents with a history of dizziness and fainting episodes. He has also been suffering from a mild flu-like illness for the past few days. He had a syncopal episode in the department and was moved into the resuscitation area. His observations are as follows: Temperature 38.4°C, HR 112, BP 78/44, oxygen saturation 98% on high-flow oxygen, GCS 14/15, BM 1.5.
      His initial blood results are shown below:
      Na+: 118 mmol/l
      K+: 6.1 mmol/l
      Urea: 11.6 mmol/l
      Creatinine: 132 mmol/l
      Which of the following investigations is most appropriate to confirm the underlying diagnosis?

      Your Answer: 24-hour urinary cortisol collection

      Correct Answer: Synacthen test

      Explanation:

      This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. It is more commonly seen in women than men and typically occurs between the ages of 30 and 50.

      Addison’s disease is caused by insufficient production of steroid hormones by the adrenal glands, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.

      The most common trigger for an Addisonian crisis in patients with Addison’s disease is the intentional or accidental withdrawal of steroid therapy. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.

      Clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main symptoms are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and even coma.

      Biochemical markers of Addison’s disease typically include increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Confirmatory investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and testing for adrenocortical antibodies.

      Management of Addison’s disease should be overseen by an Endocrinologist. Treatment usually involves the administration of hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also require thyroxine if there is concurrent hypothalamic-pituitary disease. Treatment is lifelong, and patients should carry a steroid card and MedicAlert bracelet to alert healthcare professionals about their condition and the potential for an Addisonian crisis.

    • This question is part of the following fields:

      • Endocrinology
      9.6
      Seconds
  • Question 40 - A 62 year old female presents to the emergency department with a three...

    Correct

    • A 62 year old female presents to the emergency department with a three day history of nausea and upper abdominal pain. The patient is concerned as the nausea became severe enough to cause her to vomit today and she noticed dark blood in the vomitus. The patient takes simvastatin daily for high cholesterol and has recently been taking ibuprofen to treat knee pain. You are able to schedule her for an endoscopy today.

      Upon returning to the ED, you decide to conduct a risk assessment for upper gastrointestinal bleeding. Which of the following tools would be the most appropriate to use?

      Your Answer: Full Rockall score

      Explanation:

      According to NICE guidelines, when evaluating patients with acute upper GI bleeding, it is recommended to use the Blatchford score during the initial assessment and the full Rockall score after endoscopy. The Rockall score is specifically designed to assess the risk of re-bleeding or death in these patients. If a patient’s post-endoscopic Rockall score is less than 3, they are considered to have a low risk of re-bleeding or death and may be eligible for early discharge.

      Further Reading:

      Upper gastrointestinal bleeding (UGIB) refers to the loss of blood from the gastrointestinal tract, occurring in the upper part of the digestive system. It can present as haematemesis (vomiting blood), coffee-ground emesis, bright red blood in the nasogastric tube, or melaena (black, tarry stools). UGIB can lead to significant hemodynamic compromise and is a major health burden, accounting for approximately 70,000 hospital admissions each year in the UK with a mortality rate of 10%.

      The causes of UGIB vary, with peptic ulcer disease being the most common cause, followed by gastritis/erosions, esophagitis, and other less common causes such as varices, Mallory Weiss tears, and malignancy. Swift assessment, hemodynamic resuscitation, and appropriate interventions are essential for the management of UGIB.

      Assessment of patients with UGIB should follow an ABCDE approach, and scoring systems such as the Glasgow-Blatchford bleeding score (GBS) and the Rockall score are recommended to risk stratify patients and determine the urgency of endoscopy. Transfusion may be necessary for patients with massive hemorrhage, and platelet transfusion, fresh frozen plasma (FFP), and prothrombin complex concentrate may be offered based on specific criteria.

      Endoscopy plays a crucial role in the management of UGIB. Unstable patients with severe acute UGIB should undergo endoscopy immediately after resuscitation, while all other patients should undergo endoscopy within 24 hours of admission. Endoscopic treatment of non-variceal bleeding may involve mechanical methods of hemostasis, thermal coagulation, or the use of fibrin or thrombin with adrenaline. Proton pump inhibitors should only be used after endoscopy.

      Variceal bleeding requires specific management, including the use of terlipressin and prophylactic antibiotics. Oesophageal varices can be treated with band ligation or transjugular intrahepatic portosystemic shunts (TIPS), while gastric varices may be treated with endoscopic injection of N-butyl-2-cyanoacrylate or TIPS if bleeding is not controlled.

      For patients taking NSAIDs, aspirin, or clopidogrel, low-dose aspirin can be continued once hemostasis is achieved, NSAIDs should be stopped in patients presenting with UGIB.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      5.6
      Seconds
  • Question 41 - A 35-year-old woman comes in with amenorrhoea for the past six months following...

    Correct

    • A 35-year-old woman comes in with amenorrhoea for the past six months following childbirth. The delivery was complicated by a post-partum haemorrhage that necessitated a blood transfusion. She has been unable to produce breast milk or breastfeed. She has also mentioned a loss of hair in her underarm and pubic regions and a decreased sex drive.
      What is the SINGLE most probable diagnosis?

      Your Answer: Sheehan’s syndrome

      Explanation:

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

      During pregnancy, the anterior pituitary gland undergoes hypertrophy, making it more vulnerable to ischaemia in the later stages. While the posterior pituitary gland is usually unaffected due to its direct arterial supply, there have been rare cases where it is also involved.

      The clinical features of Sheehan’s syndrome include the absence or infrequency of menstrual periods, the inability to produce milk and breastfeed (galactorrhoea), decreased libido, fatigue and tiredness, and loss of pubic and axillary hair. Additionally, secondary hypothyroidism and adrenal insufficiency may also occur.

      Serum prolactin levels are typically low, measuring less than 5ng/ml. An MRI can be helpful in ruling out other pituitary issues, such as a pituitary tumor.

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      7.5
      Seconds
  • Question 42 - A 47 year old male visits the emergency department after injuring his knee....

    Correct

    • A 47 year old male visits the emergency department after injuring his knee. The patient explains that he extended his leg after tripping on a flight of stairs, but experienced intense pain around the knee when he landed on his foot. Walking has become challenging for the patient. The patient experiences tenderness above the patella and upon examination, the patella appears to be positioned lower than normal. An X-ray of the knee is requested. What is used to evaluate the accurate placement (height) of the patella on the X-ray?

      Your Answer: Insall-Salvati ratio

      Explanation:

      The Insall-Salvati ratio is determined by dividing the length of the patellar tendon (TL) by the length of the patella (PL). This ratio is used to compare the relative lengths of these two structures. A normal ratio is typically 1:1.

      Further Reading:

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

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

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

    • This question is part of the following fields:

      • Trauma
      6.9
      Seconds
  • Question 43 - A 22-year-old arrives at the emergency department after ingesting a combination of pills...

    Correct

    • A 22-year-old arrives at the emergency department after ingesting a combination of pills 45 minutes ago following a heated dispute with their partner. The patient reports consuming approximately 30 tablets in total, consisting of four or five different types. These tablets were sourced from their grandparents medication, although the patient is uncertain about their specific names. They mention the possibility of one tablet being called bisoprolol. What is the recommended antidote for beta-blocker toxicity?

      Your Answer: Glucagon

      Explanation:

      Glucagon is the preferred initial treatment for beta-blocker poisoning when there are symptoms of slow heart rate and low blood pressure.

      Further Reading:

      Poisoning in the emergency department is often caused by accidental or intentional overdose of prescribed drugs. Supportive treatment is the primary approach for managing most poisonings. This includes ensuring a clear airway, proper ventilation, maintaining normal fluid levels, temperature, and blood sugar levels, correcting any abnormal blood chemistry, controlling seizures, and assessing and treating any injuries.

      In addition to supportive treatment, clinicians may need to consider strategies for decontamination, elimination, and administration of antidotes. Decontamination involves removing poisons from the skin or gastrointestinal tract. This can be done through rinsing the skin or using methods such as activated charcoal, gastric lavage, induced emesis, or whole bowel irrigation. However, induced emesis is no longer commonly used, while gastric lavage and whole bowel irrigation are rarely used.

      Elimination methods include urinary alkalinization, hemodialysis, and hemoperfusion. These techniques help remove toxins from the body.

      Activated charcoal is a commonly used method for decontamination. It works by binding toxins in the gastrointestinal tract, preventing their absorption. It is most effective if given within one hour of ingestion. However, it is contraindicated in patients with an insecure airway due to the risk of aspiration. Activated charcoal can be used for many drugs, but it is ineffective for certain poisonings, including pesticides (organophosphates), hydrocarbons, strong acids and alkalis, alcohols (ethanol, methanol, ethylene glycol), iron, lithium, and solvents.

      Antidotes are specific treatments for poisoning caused by certain drugs or toxins. For example, cyanide poisoning can be treated with dicobalt edetate, hydroxocobalamin, or sodium nitrite and sodium thiosulphate. Benzodiazepine poisoning can be treated with flumazanil, while opiate poisoning can be treated with naloxone. Other examples include protamine for heparin poisoning, vitamin K or fresh frozen plasma for warfarin poisoning, fomepizole or ethanol for methanol poisoning, and methylene blue for methemoglobinemia caused by benzocaine or nitrates.

      There are many other antidotes available for different types of poisoning, and resources such as TOXBASE and the National Poisons Information Service (NPIS) can provide valuable advice on managing poisonings.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.5
      Seconds
  • Question 44 - A 45-year-old man presents with brief episodes of vertigo that are worse in...

    Correct

    • A 45-year-old man presents with brief episodes of vertigo that are worse in the evening and is triggered by head movement and turning in bed. Each episode lasts only a couple of minutes. He experiences nausea during the attacks but has not vomited. He has no previous history of hearing loss or tinnitus.

      What is the SINGLE most probable diagnosis?

      Your Answer: Benign paroxysmal positional vertigo (BPPV)

      Explanation:

      Benign paroxysmal positional vertigo (BPPV) occurs when there is dysfunction in the inner ear. This dysfunction causes the otoliths, which are located in the utricle, to become dislodged from their normal position and migrate into one of the semicircular canals over time. As a result, these detached otoliths continue to move even after head movement has stopped, leading to vertigo due to the conflicting sensation of ongoing movement with other sensory inputs.

      While the majority of BPPV cases have no identifiable cause (idiopathic), approximately 40% of cases can be attributed to factors such as head injury, spontaneous labyrinthine degeneration, post-viral illness, middle ear surgery, or chronic middle ear disease.

      The main clinical features of BPPV include symptoms that are provoked by head movement, rolling over, and upward gaze. These episodes are typically brief, lasting less than 5 minutes, and are often worse in the mornings. Unlike other inner ear disorders, BPPV does not cause hearing loss or tinnitus. Nausea is a common symptom, while vomiting is rare. The Dix-Hallpike test can be used to confirm the diagnosis of BPPV.

      It is important to note that vestibular suppressant medications have not been proven to be beneficial in managing BPPV. These medications do not improve symptoms or reduce the duration of the disease.

      The treatment of choice for BPPV is the Epley manoeuvre. This maneuver aims to reposition the dislodged otoliths back into the utricles from the semicircular canals. A 2014 Cochrane review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with a number needed to treat of 2-4.

      Referral to an ENT specialist is recommended for patients with BPPV in the following situations: if the treating clinician is unable to perform or access the Epley manoeuvre, if the Epley manoeuvre has not been beneficial after repeated attempts (minimum two), if the patient has been symptomatic for more than 4 weeks, or if the patient has experienced more than 3 episodes of BPPV.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      13
      Seconds
  • Question 45 - A 25-year-old woman comes in seeking the morning after pill. She explains that...

    Correct

    • A 25-year-old woman comes in seeking the morning after pill. She explains that she had unprotected sexual intercourse (UPSI) with her long-term partner within the past 48 hours. She is in good health and is eager to resume taking the oral contraceptive pill after addressing this situation.
      What is the BEST choice for her in this case?

      Your Answer: Levonelle 1.5 mg

      Explanation:

      Women have three options when requesting emergency contraception. The first option is Levonelle 1.5 mg, which contains levonorgestrel and can be used up to 72 hours after unprotected sexual intercourse (UPSI). If vomiting occurs within 2 hours of taking the tablet, another one should be given. Levonelle mainly works by preventing ovulation.

      The second option is ulipristal acetate, the newest treatment available. It can be used up to 120 hours after UPSI. If vomiting occurs within 3 hours of ingestion, another tablet should be given. Ulipristal acetate also works by inhibiting ovulation. However, it should be avoided in patients taking enzyme-inducing drugs, those with severe hepatic impairment, or those with severe asthma requiring oral steroids.

      The third option is the copper IUD, which can be fitted up to 5 days after UPSI or ovulation, whichever is longer. The failure rate of the copper IUD is less than 1 in 1000, making it 10-20 times more effective than oral emergency contraceptive options. It is important to note that Levonelle and ulipristal may be less effective in women with higher BMIs.

    • This question is part of the following fields:

      • Sexual Health
      16.1
      Seconds
  • Question 46 - A 65-year-old woman with a history of smoking and a confirmed diagnosis of...

    Correct

    • A 65-year-old woman with a history of smoking and a confirmed diagnosis of peripheral vascular disease presents with symptoms suggestive of acute limb ischemia. After conducting a series of tests, the medical team suspects that an embolus is the likely cause.
      Which of the following investigations would be the most beneficial in determining the origin of the embolus?

      Your Answer: Popliteal ultrasound

      Explanation:

      Acute limb ischaemia refers to a sudden decrease in blood flow to a limb, which puts the limb at risk of tissue damage. This condition is most commonly caused by either a sudden blockage of a partially blocked artery due to a blood clot or by an embolus that travels from another part of the body. It is considered a surgical emergency, as without prompt surgical intervention, the affected limb may suffer extensive tissue death within six hours.

      The leading cause of acute limb ischaemia is the sudden blockage of a previously narrowed artery segment, accounting for 60% of cases. The second most common cause is an embolus, which makes up 30% of cases. Emboli can originate from sources such as a blood clot in the left atrium of the heart in patients with atrial fibrillation (which accounts for 80% of peripheral emboli), a clot formed on the heart wall after a heart attack, or from prosthetic heart valves. It is crucial to differentiate between these two causes, as the treatment and prognosis differ.

      To properly diagnose acute limb ischaemia, several important investigations should be arranged. These include a hand-held Doppler ultrasound scan, which can help determine if there is any remaining blood flow in the arteries. Blood tests such as a full blood count, erythrocyte sedimentation rate, blood glucose level, and thrombophilia screen should also be conducted. If there is uncertainty in the diagnosis, urgent arteriography may be necessary.

      In cases where an embolus is suspected as the cause, additional investigations are needed to identify its source. These investigations may include an electrocardiogram to detect atrial fibrillation, an echocardiogram to assess the heart’s structure and function, an ultrasound of the aorta, and ultrasounds of the popliteal and femoral arteries.

    • This question is part of the following fields:

      • Vascular
      7.1
      Seconds
  • Question 47 - A 3-month-old boy is brought in by his parents with a history of...

    Correct

    • A 3-month-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having trouble with feeding. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles across his chest.

      What is the SINGLE most likely diagnosis?

      Your Answer: Bronchiolitis

      Explanation:

      Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.

      The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.

      Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.

      However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.

      If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.

    • This question is part of the following fields:

      • Respiratory
      14.6
      Seconds
  • Question 48 - At what age do patients in the UK gain the legal right to...

    Correct

    • At what age do patients in the UK gain the legal right to decline consent, when a 16-year-old attends the emergency department with one of their friends after sustaining a laceration to the foot from stepping on glass? You inform the patient that the wound requires exploration, cleaning, and suturing.

      Your Answer: 18

      Explanation:

      In the UK, patients are granted the legal right to refuse consent when they reach the age of 18. While it may appear peculiar to have varying ages for obtaining consent rights, this is the current situation. If a patient under the age of 18 refuses necessary treatment and demonstrates capacity, it may be necessary to engage in further discussions with the hospital’s legal team, senior medical staff, and/or defense unions to determine the most appropriate course of action.

      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
      9.1
      Seconds
  • Question 49 - A toddler arrives at the Emergency Department with a painful ankle after tripping...

    Incorrect

    • A toddler arrives at the Emergency Department with a painful ankle after tripping in the backyard. Their ankle looks swollen and misshapen, and the triage nurse evaluates their discomfort.
      Which pain scale is the most suitable to use for a toddler?

      Your Answer: Non-verbal pain score (NVPS)

      Correct Answer: Behavioural scale

      Explanation:

      A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.

      To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.

      The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.

      To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.

    • This question is part of the following fields:

      • Pain & Sedation
      24.6
      Seconds
  • Question 50 - A 3-year-old girl is hit by a car while crossing the street. She...

    Incorrect

    • A 3-year-old girl is hit by a car while crossing the street. She is brought to the resus area of your Emergency Department by a blue light ambulance. A trauma call is initiated, and a primary survey is conducted. She is stable hemodynamically, and the only abnormality found is a severely swollen and deformed left thigh area. An X-ray is taken, which shows a fracture in the proximal femoral shaft. The child is experiencing significant pain, and you decide to apply skin traction to immobilize the fracture. You also plan to administer a dose of intranasal diamorphine.
      The child weighs 12 kg. What is the appropriate dose of intranasal diamorphine to administer?

      Your Answer: 0.15 mg

      Correct Answer: 1.5 mg

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Pain & Sedation
      7.3
      Seconds
  • Question 51 - 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
      5.4
      Seconds
  • Question 52 - A 2 year old is brought into resus following rescue from a car...

    Correct

    • A 2 year old is brought into resus following rescue from a car accident. The patient has severe injuries and observations are consistent with shock. Attempts to insert an IV cannula fail three times. You decide to obtain intraosseous (IO) access. Which of the following is a commonly used site for obtaining intraosseous (IO) access in young children?

      Your Answer: Distal femur - 2 cm above condyle in midline

      Explanation:

      The three sites most frequently used for IO access are the proximal tibia, distal tibia, and distal femur. The proximal tibia is located 2 cm below the tibial tuberosity, while the distal tibia is just above the medial malleolus. The distal femur site is situated 2 cm above the condyle in the midline. These sites are commonly chosen for IO access. However, there are also less commonly used sites such as the proximal humerus (above the surgical neck) and the iliac crest. It is important to note that the proximal humerus may be challenging to palpate in children and is typically not used in those under 5 years of age. Additionally, accessing the sternum requires a specialist device.

      Further Reading:

      Intraosseous (IO) cannulation is a technique used to gain urgent intravenous (IV) access in patients where traditional IV access is difficult to obtain. It involves injecting fluid or drugs directly into the medullary cavity of the bone. This procedure can be performed in both adult and pediatric patients and is commonly used in emergency situations.

      There are different types of IO needles available, including manual IO needles and device-powered IO needles such as the EZ-IO. These tools allow healthcare professionals to access the bone and administer necessary medications or fluids quickly and efficiently.

      The most commonly used sites for IO cannulation are the tibia (shinbone) and the femur (thighbone). In some cases, the proximal humerus (upper arm bone) may also be used. However, there are certain contraindications to IO cannulation that should be considered. These include fractures of the bone to be cannulated, overlying skin infections or a high risk of infection (such as burns), conditions like osteogenesis imperfecta or osteoporosis, ipsilateral vascular injury, and coagulopathy.

      While IO cannulation is a valuable technique, there are potential complications that healthcare professionals should be aware of. These include superficial skin infections, osteomyelitis (infection of the bone), skin necrosis, growth plate injury (in pediatric patients), fractures, failure to access or position the needle correctly, extravasation (leakage of fluid or medication into surrounding tissues), and compartment syndrome (a rare but serious condition that can occur if there is an undiagnosed fracture).

      Overall, IO cannulation is a useful method for gaining urgent IV access in patients when traditional methods are challenging. However, it is important for healthcare professionals to be aware of the potential complications and contraindications associated with this procedure.

    • This question is part of the following fields:

      • Paediatric Emergencies
      5.5
      Seconds
  • Question 53 - A 28-year-old with a past of opioid misuse is brought into the ER...

    Incorrect

    • A 28-year-old with a past of opioid misuse is brought into the ER after being discovered in a collapsed state with decreased level of consciousness. You are worried about the patient's airway. Your consultant recommends using a nasopharyngeal airway adjunct instead of an oropharyngeal airway adjunct. Why is a nasopharyngeal airway preferred in this scenario?

      Your Answer: Less likely to provoke laryngospasm

      Correct Answer: Less likely to provoke the gag reflex

      Explanation:

      When a patient is semi-conscious, it is less likely for the nasopharyngeal airway adjuncts (NPA’s) to trigger the gag reflex compared to oropharyngeal airways. Therefore, NPA’s are typically the preferred option in these cases.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      6.6
      Seconds
  • Question 54 - A 35-year-old woman is brought into the emergency room by an ambulance with...

    Correct

    • A 35-year-old woman is brought into the emergency room by an ambulance with flashing lights. She has been in a car accident and has sustained severe burns. You examine her airway and have concerns about potential airway blockage. Your plan is to intubate the patient and begin preparing the required equipment.
      As per the ATLS guidelines, what is the minimum internal diameter of the endotracheal tube that should be utilized?

      Your Answer: 7.5 mm

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

    • This question is part of the following fields:

      • Trauma
      6.3
      Seconds
  • Question 55 - A middle-aged man is brought to the hospital with slurred speech and unusual...

    Correct

    • A middle-aged man is brought to the hospital with slurred speech and unusual behavior. He has been experiencing urinary incontinence and has also noticed weakness in his right arm. A CT scan is conducted, which confirms the diagnosis of a stroke.
      Which of the following blood vessels is most likely to be affected?

      Your 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
      9.8
      Seconds
  • Question 56 - A 10 year old boy is brought into the emergency department after falling...

    Correct

    • A 10 year old boy is brought into the emergency department after falling through the ice while playing on a frozen pond. The child was submerged up to his waist and it took his friends approximately 10-15 minutes to pull him out of the water completely. The child then spent an additional 10 minutes outside in wet clothes with an air temperature of -4ºC before an adult arrived and took him to the emergency department. A core temperature reading is taken and recorded as 29.6ºC. How would you best classify the patient?

      Your Answer: Moderate hypothermia

      Explanation:

      Moderate hypothermia is indicated by core temperatures ranging from 28-32ºC.

      Further Reading:

      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, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in depressed myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

      In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

      Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

      Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

    • This question is part of the following fields:

      • Environmental Emergencies
      6.5
      Seconds
  • Question 57 - A 6 week old female is brought into the emergency department by concerned...

    Correct

    • A 6 week old female is brought into the emergency department by concerned new parents. They inform you that for the past couple of days, the baby has been vomiting forcefully after each feeding and is not urinating as frequently as usual. The parents are anxious as the baby was delivered via C-section at full term and is solely bottle fed. During the examination, you detect a lump in the upper abdomen.

      What is the most probable diagnosis?

      Your Answer: Pyloric stenosis

      Explanation:

      Pyloric stenosis is characterized by recurring episodes of projectile vomiting and the presence of a mass in the upper abdomen, often described as an olive. This patient exhibits clinical features that align with pyloric stenosis and possesses several common risk factors, including being a male, being the firstborn son, being bottle-fed, and being delivered via C-section. It is important to note that intestinal atresia is typically diagnosed either during pregnancy or shortly after birth.

      Further Reading:

      Pyloric stenosis is a condition that primarily affects infants, characterized by the thickening of the muscles in the pylorus, leading to obstruction of the gastric outlet. It typically presents between the 3rd and 12th weeks of life, with recurrent projectile vomiting being the main symptom. The condition is more common in males, with a positive family history and being first-born being additional risk factors. Bottle-fed children and those delivered by c-section are also more likely to develop pyloric stenosis.

      Clinical features of pyloric stenosis include projectile vomiting, usually occurring about 30 minutes after a feed, as well as constipation and dehydration. A palpable mass in the upper abdomen, often described as like an olive, may also be present. The persistent vomiting can lead to electrolyte disturbances, such as hypochloremia, alkalosis, and mild hypokalemia.

      Ultrasound is the preferred diagnostic tool for confirming pyloric stenosis. It can reveal specific criteria, including a pyloric muscle thickness greater than 3 mm, a pylorus longitudinal length greater than 15-17 mm, a pyloric volume greater than 1.5 cm3, and a pyloric transverse diameter greater than 13 mm.

      The definitive treatment for pyloric stenosis is pyloromyotomy, a surgical procedure that involves making an incision in the thickened pyloric muscle to relieve the obstruction. Before surgery, it is important to correct any hypovolemia and electrolyte disturbances with intravenous fluids. Overall, pyloric stenosis is a relatively common condition in infants, but with prompt diagnosis and appropriate management, it can be effectively treated.

    • This question is part of the following fields:

      • Paediatric Emergencies
      5.1
      Seconds
  • Question 58 - A 68-year-old man suffers a fractured neck of femur. He is later diagnosed...

    Correct

    • A 68-year-old man suffers a fractured neck of femur. He is later diagnosed with osteoporosis and is prescribed medication for the secondary prevention of osteoporotic fragility fractures.
      What is the recommended initial treatment for the secondary prevention of osteoporotic fragility fractures?

      Your Answer: Oral bisphosphonate

      Explanation:

      Oral bisphosphonates are the primary choice for treating osteoporotic fragility fractures in individuals who have already experienced such fractures. After a fragility fracture, it is advised to start taking a bisphosphonate, typically alendronic acid, and consider supplementing with calcium and vitamin D.

      There are other treatment options available for preventing fragility fractures after an initial occurrence. These include raloxifene, teriparatide, and denosumab.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      3.3
      Seconds
  • Question 59 - A young patient presents with a blistering rash. The differential diagnosis includes pemphigus...

    Incorrect

    • A young patient presents with a blistering rash. The differential diagnosis includes pemphigus vulgaris and bullous pemphigoid.

      Which of the following features would indicate a diagnosis of pemphigus vulgaris?

      Your Answer: Haemorrhagic blister contents

      Correct Answer: Age 50 at presentation

      Explanation:

      Pemphigus, derived from the Greek word for bubble ‘pemphix’, refers to a group of autoimmune disorders that cause blistering of the skin and/or mucosal surfaces. The most common subset is pemphigus vulgaris (PV), which accounts for approximately 70% of cases worldwide. PV is characterized by an autoimmune response where autoantibodies target cell surface antigens on keratinocytes, specifically desmogleins 1 and 3. This leads to a loss of cell-to-cell adhesion and separation, resulting in blister formation.

      On the other hand, bullous pemphigoid (BP) is a chronic autoimmune blistering skin disorder that affects the subepidermal layer. It occurs when the basement membrane of the epidermis is attacked by IgG and sometimes IgE immunoglobulins, as well as activated T lymphocytes. The binding of autoantibodies to proteins and the release of cytokines from T cells trigger complement activation, neutrophil recruitment, and the release of proteolytic enzymes. These enzymes destroy the hemidesmosomes, leading to the formation of subepidermal blisters.

      To summarize the differences between pemphigus vulgaris and bullous pemphigoid, the following provides a comparison:

      Pemphigus Vulgaris:
      – Age: Middle-aged people (mean age 50)
      – Oral involvement: Common
      – Blister type: Large, flaccid, and painful
      – Blister content: Fluid-filled, often haemorrhagic
      – Areas commonly affected: Initially face and scalp, then spread to the chest and back
      – Nikolsky sign: Usually positive
      – Pruritus: Rare
      – Skin biopsy: Intra-epidermal deposition of IgG between cells throughout the epidermis

      Bullous Pemphigoid:
      – Age: Elderly people (mean age 80)
      – Oral involvement: Rare
      – Blister type: Large and tense
      – Blister content: Fluid-filled
      – Areas commonly affected: Upper arms, thighs, and skin flexures
      – Nikolsky sign: Usually negative
      – Pruritus: Common
      – Skin biopsy: A band of IgG and/or C3 at the dermo-epidermal junction

    • This question is part of the following fields:

      • Dermatology
      5.7
      Seconds
  • Question 60 - You are requested to insert a central venous catheter into the neck using...

    Correct

    • You are requested to insert a central venous catheter into the neck using ultrasound guidance. What characteristic aids in differentiating between a vein and artery when evaluating the neck vessels using ultrasound?

      Your Answer: Veins are obliterated on compression whereas arteries are not

      Explanation:

      Veins and arteries can be differentiated on ultrasound based on their compressibility, response to valsalva, and shape. When compressed, veins are obliterated while arteries remain unaffected. Additionally, when a patient performs a valsalva maneuver, the neck veins expand. In transverse view, arteries appear circular with a muscular wall, whereas veins tend to have an oval shape. It is important to note that the overall size and internal diameter are not reliable indicators for distinguishing between arteries and veins.

      Further Reading:

      A central venous catheter (CVC) is a type of catheter that is inserted into a large vein in the body, typically in the neck, chest, or groin. It has several important uses, including CVP monitoring, pulmonary artery pressure monitoring, repeated blood sampling, IV access for large volumes of fluids or drugs, TPN administration, dialysis, pacing, and other procedures such as placement of IVC filters or venous stents.

      When inserting a central line, it is ideal to use ultrasound guidance to ensure accurate placement. However, there are certain contraindications to central line insertion, including infection or injury to the planned access site, coagulopathy, thrombosis or stenosis of the intended vein, a combative patient, or raised intracranial pressure for jugular venous lines.

      The most common approaches for central line insertion are the internal jugular, subclavian, femoral, and PICC (peripherally inserted central catheter) veins. The internal jugular vein is often chosen due to its proximity to the carotid artery, but variations in anatomy can occur. Ultrasound can be used to identify the vessels and guide catheter placement, with the IJV typically lying superficial and lateral to the carotid artery. Compression and Valsalva maneuvers can help distinguish between arterial and venous structures, and doppler color flow can highlight the direction of flow.

      In terms of choosing a side for central line insertion, the right side is usually preferred to avoid the risk of injury to the thoracic duct and potential chylothorax. However, the left side can also be used depending on the clinical situation.

      Femoral central lines are another option for central venous access, with the catheter being inserted into the femoral vein in the groin. Local anesthesia is typically used to establish a field block, with lidocaine being the most commonly used agent. Lidocaine works by blocking sodium channels and preventing the propagation of action potentials.

      In summary, central venous catheters have various important uses and should ideally be inserted using ultrasound guidance. There are contraindications to their insertion, and different approaches can be used depending on the clinical situation. Local anesthesia is commonly used for central line insertion, with lidocaine being the preferred agent.

    • This question is part of the following fields:

      • Resus
      11.3
      Seconds
  • Question 61 - A 35-year-old woman presents with a two-week history of a persistent cough that...

    Correct

    • A 35-year-old woman presents with a two-week history of a persistent cough that has now started to produce a small amount of sputum. She is also experiencing muscle aches, fatigue, headaches, and has had diarrhea for the past three days. Her vital signs are as follows: temperature 37.8°C, heart rate 88, blood pressure 120/80, respiratory rate 20, oxygen saturation 99% on room air. Upon examination, she has crackling sounds heard on the left side of her chest. A chest X-ray reveals consolidation in the left lower lobe.

      What is the MOST appropriate course of action for management?

      Your Answer: Clarithromycin 500 mg PO BD for 14 days

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection typically include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs may develop later in the illness. Interestingly, the X-ray features of the pneumonia are often more noticeable than the severity of the chest symptoms.

      Treatment for Mycoplasma pneumoniae infection can involve the use of macrolides, such as clarithromycin, or tetracyclines, such as doxycycline. The recommended minimum treatment period is 10-14 days, making clarithromycin a preferable option over doxycycline in this particular case.

    • This question is part of the following fields:

      • Respiratory
      15.8
      Seconds
  • Question 62 - You are caring for a pediatric patient in the resuscitation bay. Your attending...

    Correct

    • You are caring for a pediatric patient in the resuscitation bay. Your attending physician notices you selecting an oropharyngeal airway adjunct (OPA) and recommends using a laryngeal mask airway (LMA) instead. Which of the following statements about the advantages and disadvantages of using a laryngeal mask airway (LMA) is correct?

      Your Answer: Greater risk of inducing laryngospasm using LMA compared to endotracheal intubation

      Explanation:

      The use of a laryngeal mask airway (LMA) carries a higher risk of inducing laryngospasm compared to endotracheal intubation. However, LMAs are still considered excellent alternatives to bag masks as they reduce the risk of gastric inflation and aspiration. While they do decrease the risk of aspiration, they are not as protective as endotracheal tubes. Complications associated with LMA use include laryngospasm, nausea and vomiting, and a low risk of aspiration. LMAs have advantages over bag-mask ventilation, such as more effective ventilation, less gastric inflation, and a lower risk of aspiration. However, they also have disadvantages, including the risk of hypoventilation due to air leak around the cuff, greater gastric inflation compared to endotracheal intubation, and a very low risk of aspiration.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.2
      Seconds
  • Question 63 - A 35-year-old woman presents to the Emergency Department with a brief history of...

    Incorrect

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

      What is the SINGLE most likely diagnosis?

      Your Answer: Venous sinus thrombosis

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      14.4
      Seconds
  • Question 64 - A 68 year old is brought into the emergency department by ambulance after...

    Correct

    • A 68 year old is brought into the emergency department by ambulance after falling down the stairs. The patient typically receives assistance from carers four times a day for bathing, getting dressed, and using the restroom. The ambulance crew informs you that the patient has a poor appetite as they have advanced lung cancer and discontinued chemotherapy 3 months ago due to disease progression and deteriorating health. The ambulance crew also mentions that the patient's palliative care specialist recently estimated their life expectancy to be a matter of weeks during their last consultation. What would be the clinical frailty score for this patient?

      Your Answer: 9

      Explanation:

      The clinical frailty score is a tool used to evaluate frailty and determine the level of safety for a patient’s discharge from the hospital. A higher CFS score indicates a greater likelihood of an extended hospital stay, increased need for support after discharge, and higher risk of mortality. In the case of this patient with terminal cancer and a life expectancy of less than 6 months, they would be classified as having the highest possible frailty score.

      Further Reading:

      Falls are a common occurrence in the elderly population, with a significant number of individuals over the age of 65 experiencing at least one fall per year. These falls are often the result of various risk factors, including impaired balance, muscle weakness, visual impairment, cognitive impairment, depression, alcohol misuse, polypharmacy, and environmental hazards. The more risk factors a person has, the higher their risk of falling.

      Falls can have serious complications, particularly in older individuals. They are a leading cause of injury, injury-related disability, and death in this population. Approximately 50% of falls in the elderly result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people living in the community lead to hospitalization or fractures. Hip fractures, in particular, are commonly caused by falls and have a high mortality rate within one year.

      Complications of falls include fractures, soft tissue injuries, fragility fractures, distress, pain, loss of self-confidence, reduced quality of life, loss of independence, fear of falls and activity avoidance, social isolation, increasing frailty, functional decline, depression, and institutionalization. Additionally, individuals who remain on the floor for more than one hour after a fall are at risk of dehydration, pressure sores, pneumonia, hypothermia, and rhabdomyolysis.

      Assessing falls requires a comprehensive history, including the course of events leading up to the fall, any pre-fall symptoms, and details about the fall itself. A thorough examination is also necessary, including an assessment of injuries, neurological and cardiovascular function, tests for underlying causes, vision assessment, and medication review. Home hazard assessments and frailty assessments are also important components of the assessment process.

      Determining the frailty of older patients is crucial in deciding if they can be safely discharged and what level of care they require. The clinical Frailty Scale (CFS or Rockwood score) is commonly used for this purpose. It helps healthcare professionals evaluate the overall frailty of a patient and make appropriate care decisions.

      In summary, falls are a significant concern in the elderly population, with multiple risk factors contributing to their occurrence. These falls can lead to serious complications and have a negative impact on an individual’s quality of life. Assessing falls requires a comprehensive approach, including a thorough history, examination, and consideration of frailty.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      7.3
      Seconds
  • Question 65 - A 70-year-old woman experiences a sudden rupture of her Achilles tendon after completing...

    Correct

    • A 70-year-old woman experiences a sudden rupture of her Achilles tendon after completing a round of antibiotics.
      Which of the following antibiotics is MOST likely to have caused this rupture?

      Your Answer: Ciprofloxacin

      Explanation:

      Fluoroquinolones are a rare but acknowledged cause of tendinopathy and spontaneous tendon rupture. It is estimated that tendon disorders related to fluoroquinolones occur in approximately 15 to 20 out of every 100,000 patients. These issues are most commonly observed in individuals who are over the age of 60.

      The Achilles tendon is the most frequently affected, although cases involving other tendons such as the quadriceps, peroneus brevis, extensor pollicis longus, the long head of biceps brachii, and rotator cuff tendons have also been reported. The exact underlying mechanism is not fully understood, but it is believed that fluoroquinolone drugs may hinder collagen function and/or disrupt blood supply to the tendon.

      There are other risk factors associated with spontaneous tendon rupture, including corticosteroid therapy, hypercholesterolemia, gout, rheumatoid arthritis, long-term dialysis, and renal transplantation.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      7.1
      Seconds
  • Question 66 - A 32-year-old woman comes in with left-sided flank pain and nausea. A urine...

    Correct

    • A 32-year-old woman comes in with left-sided flank pain and nausea. A urine dipstick shows microscopic blood in the urine. She is later diagnosed with renal colic.
      What is the most frequently occurring type of kidney stone?

      Your Answer: Calcium containing stones

      Explanation:

      Urinary tract stones form when the concentration of salt and minerals in the urine becomes too high. These stones can be classified into five types based on their mineral composition and how they develop.

      The most common type of stone is the calcium stone, which can be further divided into calcium oxalate and calcium phosphate stones. These account for 60-80% of all urinary tract stones.

      Another type is the struvite or magnesium ammonium phosphate stone, making up about 10-15% of cases. Uric acid stones, also known as urate stones, occur in 3-10% of cases.

      Cystine stones are less common, accounting for less than 2% of urinary tract stones. Finally, there are drug-induced stones, which are caused by certain medications such as triamterene, protease inhibitors like indinavir sulphate, and sulfa drugs. These account for approximately 1% of cases.

      By understanding the different types of urinary tract stones, healthcare professionals can better diagnose and treat patients with this condition.

    • This question is part of the following fields:

      • Urology
      8
      Seconds
  • Question 67 - A 3 year old is brought to the emergency department due to concern...

    Correct

    • A 3 year old is brought to the emergency department due to concern that the patient has developed a fever, symptoms of a cold, and a widespread rash with blisters. You diagnose the child with chickenpox and advise the mother on how to manage the condition. The mother informs you that she is 12 weeks pregnant and is worried about the potential consequences of contracting chickenpox during pregnancy.

      What is the most significant complication of chickenpox infection for the mother during pregnancy?

      Your Answer: Pneumonitis

      Explanation:

      Pregnant women who contract chickenpox for the first time are more likely to develop pneumonitis, a condition characterized by inflammation of the lungs. Additionally, these women face a five-fold increased risk of pneumonitis compared to non-pregnant individuals. Furthermore, the fetus is at risk of developing fetal varicella syndrome, a condition associated with chickenpox infection during pregnancy.

      Further Reading:

      Chickenpox exposure during pregnancy poses risks to both the mother and the fetus. The mother has a 5 times greater risk of developing pneumonitis, a potentially serious complication. The fetus is at risk of developing fetal varicella syndrome (FVS) if the maternal exposure occurs before 20 weeks gestation. The risk of FVS is around 1% in these cases and includes features such as skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There have been very few cases of FVS reported between 20-28 weeks gestation and none following 28 weeks.

      Other risks to the fetus include the development of shingles in infancy, which has a 1-2% risk if the maternal exposure occurs in the second or third trimester. There is also a risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth. This condition can be fatal to the newborn child in around 20% of cases.

      In the management of chickenpox exposure during pregnancy, it is important to determine if the mother is immune to varicella. If there is any doubt, maternal blood should be urgently checked for varicella antibodies. If the pregnant woman is not immune, she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. VZIG is considered effective up to 10 days post-exposure. Consensus guidelines also recommend the use of oral aciclovir if the pregnant woman presents with chickenpox within 24 hours of the rash onset.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      32.4
      Seconds
  • Question 68 - 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: Ramipril

      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
      10.5
      Seconds
  • Question 69 - A 28 year old female presents to the emergency department after being struck...

    Correct

    • A 28 year old female presents to the emergency department after being struck in the face during a night out. The patient reports a possible jaw fracture. You assess the patient for signs of mandibular fracture using the Manchester Mandibular Fracture Decision Rule.

      Which of the following signs is NOT included in the Manchester Mandibular Fracture Decision Rule?

      Your Answer: Lacerations to the gum mucosa

      Explanation:

      The Manchester Mandibular Fracture Decision Rule consists of five signs that indicate a possible mandibular fracture: malocclusion, trismus, pain with mouth closed, broken teeth, and step deformity. If none of these signs are present, it is unlikely that a mandibular fracture has occurred. However, if one or more of these signs are present, it is recommended to obtain an X-ray for further evaluation. It is important to note that gum lacerations, although commonly seen in mandibular fractures, are not included in the Manchester Mandibular Fracture Decision Rule.

      Further Reading:

      Mandibular fractures are a common type of facial fracture that often present to the emergency department. The mandible, or lower jaw, is formed by the fusion of two hemimandibles and articulates with the temporomandibular joints. Fractures of the mandible are typically caused by direct lateral force and often involve multiple fracture sites, including the body, condylar head and neck, and ramus.

      When assessing for mandibular fractures, clinicians should use a look, feel, move method similar to musculoskeletal examination. However, it is important to note that TMJ effusion, muscle spasm, and pain can make moving the mandible difficult. Key signs of mandibular fracture include malocclusion, trismus (limited mouth opening), pain with the mouth closed, broken teeth, step deformity, hematoma in the sublingual space, lacerations to the gum mucosa, and bleeding from the ear.

      The Manchester Mandibular Fracture Decision Rule uses the absence of five exam findings (malocclusion, trismus, broken teeth, pain with closed mouth, and step deformity) to exclude mandibular fracture. This rule has been found to be 100% sensitive and 39% specific in detecting mandibular fractures. Imaging is an important tool in diagnosing mandibular fractures, with an OPG X-ray considered the best initial imaging for TMJ dislocation and mandibular fracture. CT may be used if the OPG is technically difficult or if a CT is being performed for other reasons, such as a head injury.

      It is important to note that head injury often accompanies mandibular fractures, so a thorough head injury assessment should be performed. Additionally, about a quarter of patients with mandibular fractures will also have a fracture of at least one other facial bone.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      3.1
      Seconds
  • Question 70 - A 45 year old male is brought into the emergency department by a...

    Correct

    • A 45 year old male is brought into the emergency department by a family member with a 2 day history of nausea and vomiting. On initial assessment the patient appears disoriented. Observations reveal the patient to have a heart rate of 140 beats per minute and blood pressure of 90/60 mmHg. You contemplate the possibility of Addison's disease. What is the primary cause of Addison's disease in the United Kingdom?

      Your Answer: Autoimmune adrenalitis

      Explanation:

      Addison’s disease is primarily caused by tuberculosis, making it the most prevalent factor worldwide.

      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
      5.6
      Seconds
  • Question 71 - A 25 year old female has been brought into the emergency department (ED)...

    Correct

    • A 25 year old female has been brought into the emergency department (ED) in the early hours of the morning after being discovered unresponsive in a parking lot behind a nightclub by the authorities. The paramedics initiated cardiopulmonary resuscitation (CPR) which has been ongoing since the patient's arrival in the ED. The patient's core temperature is recorded at 28ºC. You contemplate the most effective Rewarming strategy to employ. Which method of Rewarming is known for producing a rapid increase in core body temperature?

      Your Answer: Cardiopulmonary bypass

      Explanation:

      Cardiopulmonary bypass (CPB) is the most efficient technique for warming up a patient who is experiencing hypothermia. While other methods may also be suitable and may have already been initiated by the paramedic team, CPB stands out as the most effective approach.

      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
      3.7
      Seconds
  • Question 72 - A patient has been diagnosed with septic arthritis in their left knee. The...

    Correct

    • A patient has been diagnosed with septic arthritis in their left knee. The joint aspirate reveals the presence of Escherichia coli.

      Which of the following patient populations is at the highest risk for developing septic arthritis caused by Escherichia coli?

      Your Answer: Intravenous drug users

      Explanation:

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

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

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      4.6
      Seconds
  • Question 73 - A 40-year-old woman comes in with tremor, anxiety, sweating, and nausea. Her observations...

    Correct

    • A 40-year-old woman comes in with tremor, anxiety, sweating, and nausea. Her observations reveal an elevated heart rate of 119 bpm. She typically consumes 2-3 large bottles of strong cider daily but has recently run out of money and hasn't had an alcoholic drink since the previous night.
      Which assessment scale should be utilized to guide the treatment of this woman's alcohol withdrawal? Select ONE option.

      Your Answer: CIWA scale

      Explanation:

      The CIWA scale, also known as the Clinical Institute Withdrawal Assessment for Alcohol scale, is a scale consisting of ten items that is utilized in the evaluation and management of alcohol withdrawal. It is currently recommended by both NICE and the Royal College of Emergency Medicine for assessing patients experiencing acute alcohol withdrawal. The maximum score on the CIWA scale is 67, with scores indicating the severity of withdrawal symptoms. A score of less than 5 suggests mild withdrawal, while a score between 6 and 20 indicates moderate withdrawal. Any score above 20 is considered severe withdrawal. The ten items evaluated on the scale encompass common symptoms and signs of alcohol withdrawal, such as nausea/vomiting, tremors, sweating, anxiety, agitation, sensory disturbances, and cognitive impairments.

      In addition to the CIWA scale, there are other screening tools available for assessing various conditions. The CAGE questionnaire is commonly used to screen for alcohol-related issues. The STEPI is utilized as a screening tool for early symptoms of the schizophrenia prodrome. The EPDS is an evidence-based questionnaire that can be employed to screen for postnatal depression. Lastly, the SCOFF questionnaire is a screening tool used to identify the possible presence of eating disorders.

      For further information on the assessment and management of acute alcohol withdrawal, the NICE pathway is a valuable resource. The RCEM syllabus also provides relevant information on this topic. Additionally, the MHC1 module on alcohol and substance misuse offers further reading material for those interested in this subject.

    • This question is part of the following fields:

      • Mental Health
      4.8
      Seconds
  • Question 74 - A 35-year-old woman comes in with intense one-sided abdominal pain starting in the...

    Correct

    • A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect a diagnosis of ureteric colic.
      What is the preferred imaging technique for confirming the diagnosis?

      Your Answer: Non-contrast helical computed tomography

      Explanation:

      The term renal colic is commonly used to describe a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. However, a more accurate term is ureteric colic, as the pain usually arises from a blockage in the ureter itself.

      Renal or ureteric colic typically presents with a sudden onset of severe abdominal pain on one side, starting in the lower back or flank and radiating to the genital area in women or to the groin or testicle in men.

      The pain usually:
      – Lasts for minutes to hours and comes in spasms, with periods of no pain or a dull ache
      – Is often accompanied by nausea, vomiting, and blood in the urine
      – Is often described as the most intense pain a person has ever experienced (many women describe it as worse than childbirth).

      People with renal or ureteric colic:
      – Are restless and unable to find relief by lying still (which helps distinguish it from peritonitis)
      – May have a history of previous episodes
      – May have a fever and sweating if there is a urinary tract infection present
      – May complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and bladder (due to irritation of the bladder muscle).

      If possible, a urine dipstick test should be done to support the diagnosis and check for signs of a urinary tract infection.

      Checking for blood in the urine can also support the diagnosis of renal or ureteric colic. However, the absence of blood does not rule out the diagnosis and other causes of pain should be considered.

      Checking for nitrite and leukocyte esterase in the urine can indicate an infection.

      Pain management:
      – Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic.
      – Intravenous paracetamol can be given to adults, children, and young people if NSAIDs are not suitable or not providing enough pain relief.
      – Opioids may be considered if both NSAIDs and intravenous paracetamol are not suitable or not providing enough pain relief.
      – Antispasmodics should not be given to adults, children, and young people with suspected renal colic.

    • This question is part of the following fields:

      • Urology
      3.2
      Seconds
  • Question 75 - A 45-year-old woman comes in with a severe skin rash. After being evaluated...

    Correct

    • A 45-year-old woman comes in with a severe skin rash. After being evaluated by the dermatology consultant on call, she is diagnosed with Stevens-Johnson syndrome.
      Which of the following statements about Stevens-Johnson syndrome is correct?

      Your Answer: Epidermal detachment is seen in less than 10% of the body surface area

      Explanation:

      Stevens-Johnson syndrome is a severe and potentially deadly form of erythema multiforme. It can be triggered by anything that causes erythema multiforme, but it is most commonly seen as a reaction to medication within 1-3 weeks of starting treatment. Initially, there may be symptoms like fever, fatigue, joint pain, and digestive issues, followed by the development of severe mucocutaneous lesions that are blistering and ulcerating.

      Stevens-Johnson syndrome and toxic epidermal necrolysis are considered to be different stages of the same mucocutaneous disease, with toxic epidermal necrolysis being more severe. The extent of epidermal detachment is used to differentiate between the two. In Stevens-Johnson syndrome, less than 10% of the body surface area is affected by epidermal detachment, while in toxic epidermal necrolysis, it is greater than 30%. An overlap syndrome occurs when detachment affects between 10-30% of the body surface area.

      Several drugs can potentially cause Stevens-Johnson syndrome and toxic epidermal necrolysis, including tetracyclines, penicillins, vancomycin, sulphonamides, NSAIDs, and barbiturates.

    • This question is part of the following fields:

      • Dermatology
      2.4
      Seconds
  • Question 76 - A 65 year old male presents to the emergency department with sudden onset...

    Incorrect

    • A 65 year old male presents to the emergency department with sudden onset of central back pain. After evaluation, you order an X-ray which reveals anterior wedging of the L2 vertebra. You suspect the patient may have undiagnosed osteoporosis. Which of the following statements about osteoporosis is correct?

      Your Answer: Osteoporosis is characterised by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase

      Correct Answer: Osteoporosis is defined as a T-score of less than -2.5

      Explanation:

      Osteoporosis is a condition characterized by weak and brittle bones, making them more prone to fractures. In this case, the patient’s sudden onset of central back pain and the X-ray findings of anterior wedging of the L2 vertebra suggest the possibility of undiagnosed osteoporosis.

      One correct statement about osteoporosis is that it is defined as a T-score of less than -2.5. The T-score is a measure of bone density and is used to diagnose osteoporosis. A T-score of -2.5 or lower indicates a significant decrease in bone density and an increased risk of fractures.

      Skeletal scintigraphy is not used to diagnose osteoporosis. Instead, it is commonly used to evaluate for other conditions such as bone infections or tumors.

      The pubic rami is not the most common site for osteoporotic fractures. Osteoporotic fractures commonly occur in the spine (vertebral fractures), hip, and wrist.

      Osteoporosis is not characterized by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase. This description is more consistent with a condition called Paget’s disease of bone.

      The prevalence of osteoporosis is not approximately 10% at 50 years of age. The prevalence of osteoporosis increases with age, and it is estimated that around 50% of women and 25% of men over the age of 50 will experience an osteoporotic fracture in their lifetime.

      Further Reading:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      2.3
      Seconds
  • Question 77 - A 65-year-old woman presents with severe and persistent back pain a few days...

    Correct

    • A 65-year-old woman presents with severe and persistent back pain a few days after spinal surgery. She has a temperature of 38.4°C and is highly sensitive over the area where the surgery was performed. During examination, she exhibits weakness in right knee extension and foot dorsiflexion.

      What is the preferred investigation to confirm the diagnosis?

      Your Answer: MRI spine

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in certain cases, especially in immunocompromised individuals and intravenous drug users. Gram-negative organisms like Escherichia coli and Mycobacterium tuberculosis can also cause discitis, particularly in cases of Pott’s disease.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in about 1-2% of patients post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, a refusal to walk may also be a symptom.

      When diagnosing discitis, magnetic resonance imaging (MRI) is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. Computed tomography (CT) scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves hospital admission for intravenous antibiotics. Before starting the antibiotics, it is recommended to send three sets of blood cultures and a full set of blood tests, including a C-reactive protein (CRP) test, to the laboratory.

      A typical antibiotic regimen for discitis would include intravenous flucloxacillin 2 g every 6 hours as the first-line treatment if there is no penicillin allergy. Intravenous vancomycin may be used if the infection was acquired in the hospital, if there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, or if there is a documented penicillin allergy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      15.5
      Seconds
  • Question 78 - You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric...

    Correct

    • You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric Intensive Care Unit with meningococcal meningitis. She provided close care for her son before his admission and is worried about the potential of contracting the disease herself. She is currently 20 weeks pregnant.
      What is the MOST suitable option for chemoprophylaxis in her situation?

      Your Answer: Ceftriaxone 250 mg IM

      Explanation:

      For individuals who have been in contact with patients diagnosed with Neisseria meningitidis meningitis, the recommended medication to prevent the infection is rifampicin 600 mg taken orally twice a day for two days. Alternatively, a single oral dose of ciprofloxacin 500 mg can also be administered. However, it is important to note that both rifampicin and ciprofloxacin should not be used during pregnancy and are contraindicated in such cases. Therefore, in situations involving pregnant individuals, the preferred option is a single 250 mg dose of ceftriaxone given intramuscularly.

    • This question is part of the following fields:

      • Neurology
      6.5
      Seconds
  • Question 79 - A 40 year old male has been brought into the ED during the...

    Correct

    • A 40 year old male has been brought into the ED during the late hours of the evening after being discovered unresponsive lying on the sidewalk. The paramedics initiated Cardiopulmonary resuscitation which has been ongoing since the patient's arrival in the ED. The patient's core temperature is documented at 28ºC. How frequently would you administer adrenaline to a patient with this core temperature during CPR?

      Your Answer: Withhold adrenaline

      Explanation:

      During CPR of a hypothermic patient, it is important to follow specific guidelines. If the patient’s core temperature is below 30ºC, resuscitation drugs, such as adrenaline, should be withheld. Once the core temperature rises above 30ºC, cardiac arrest drugs can be administered. However, if the patient’s temperature is between 30-35ºC, the interval for administering cardiac arrest drugs should be doubled. For example, adrenaline should be given every 6-10 minutes instead of the usual 3-5 minutes for a normothermic patient.

      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
      9.1
      Seconds
  • Question 80 - A 35-year-old patient comes in with acute severe asthma and is currently receiving...

    Correct

    • A 35-year-old patient comes in with acute severe asthma and is currently receiving regular salbutamol nebulizers. Her potassium level is tested and is found to be 2.8 mmol/l. She is also taking another medication prescribed by her primary care physician, but she cannot remember the name.
      Which of the following medications is the LEAST likely to have caused her hypokalemia?

      Your Answer: Spironolactone

      Explanation:

      Potentially, there can be a serious condition called hypokalaemia, which is characterized by low levels of potassium in the body. This condition should be taken seriously, especially in cases of severe asthma, as it can be made worse by certain medications like theophyllines (such as aminophylline and Uniphyllin Continus), corticosteroids, and low oxygen levels. Additionally, the use of thiazide and loop diuretics can also worsen hypokalaemia. Therefore, it is important to regularly monitor the levels of potassium in the blood of individuals with severe asthma.

      It is worth noting that spironolactone, a type of diuretic, is known as a potassium-sparing medication. This means that it does not typically contribute to hypokalaemia.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.3
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Allergy (0/1) 0%
Gastroenterology & Hepatology (4/4) 100%
Infectious Diseases (1/1) 100%
Pharmacology & Poisoning (11/12) 92%
Endocrinology (5/6) 83%
Maxillofacial & Dental (3/3) 100%
Elderly Care / Frailty (4/5) 80%
Nephrology (0/1) 0%
Ear, Nose & Throat (2/2) 100%
Major Incident Management & PHEM (1/2) 50%
Sexual Health (2/2) 100%
Obstetrics & Gynaecology (3/4) 75%
Paediatric Emergencies (3/3) 100%
Mental Health (2/4) 50%
Cardiology (2/2) 100%
Musculoskeletal (non-traumatic) (3/3) 100%
Surgical Emergencies (2/2) 100%
Neurology (3/4) 75%
Environmental Emergencies (4/4) 100%
Trauma (2/2) 100%
Vascular (1/1) 100%
Respiratory (2/2) 100%
Safeguarding & Psychosocial Emergencies (1/1) 100%
Pain & Sedation (0/2) 0%
Basic Anaesthetics (1/2) 50%
Dermatology (1/2) 50%
Resus (1/1) 100%
Urology (2/2) 100%
Passmed