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  • Question 1 - A 45-year-old man presents with a severe exacerbation of his COPD. He has...

    Incorrect

    • A 45-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
      What is the appropriate maintenance infusion rate for him?

      Your Answer: 15 mg/hour

      Correct Answer: 30 mg/hour

      Explanation:

      The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 60 kg patient, the appropriate infusion rate would be 30 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.

    • This question is part of the following fields:

      • Respiratory
      27
      Seconds
  • Question 2 - A 42-year-old woman is brought in by ambulance following a severe car accident....

    Incorrect

    • A 42-year-old woman is brought in by ambulance following a severe car accident. There was a prolonged extraction at the scene, and a complete trauma call is initiated. She is disoriented and slightly restless. Her vital signs are as follows: heart rate 125, blood pressure 83/45, oxygen saturation 98% on high-flow oxygen, respiratory rate 31, temperature 36.1°C. Her capillary refill time is 5 seconds, and her extremities appear pale and cool to the touch. Her cervical spine is immobilized with triple precautions. The airway is clear, and her chest examination is normal. Two large-bore cannulas have been inserted in her antecubital fossa, and a comprehensive set of blood tests, including a request for a cross-match, has been sent to the laboratory. She experiences significant tenderness in the suprapubic area upon abdominal palpation, and noticeable bruising is evident around her pelvis. A pelvic X-ray reveals a vertical shear type pelvic fracture.
      Approximately how much blood has she lost?

      Your Answer: 2000-2500 mL

      Correct Answer: 1500-2000 mL

      Explanation:

      This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.

      Hemorrhage can be categorized into four different classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.

      In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.

      In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure remains normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.

      The patient in this case is in class III hemorrhage, with a blood loss of 1500-2000 mL or 30-40% of the blood volume. The pulse rate is elevated, ranging from 120-140 beats per minute, and the systolic blood pressure is decreased. The pulse pressure is also decreased, and the respiratory rate is elevated to 30-40 breaths per minute. The urine output decreases significantly to 5-15 mL per hour, and the patient may experience anxiety and confusion.

      Class IV hemorrhage represents the most severe level of blood loss, with a loss of over 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is decreased, and the respiratory rate is over 40 breaths per minute. The urine output becomes negligible, and the patient may become confused and lethargic.

    • This question is part of the following fields:

      • Trauma
      74
      Seconds
  • Question 3 - A patient with a known history of asthma presents with symptoms of theophylline...

    Incorrect

    • A patient with a known history of asthma presents with symptoms of theophylline toxicity after starting a new medication.
      Which of the following drugs is most likely causing this interaction?

      Your Answer: Carbamazepine

      Correct Answer: Fluconazole

      Explanation:

      Theophylline, a medication commonly used to treat respiratory conditions, can be affected by certain drugs, either increasing or decreasing its plasma concentration and half-life. Drugs that can increase the plasma concentration of theophylline include calcium channel blockers like verapamil, cimetidine, fluconazole, macrolides such as erythromycin, methotrexate, and quinolones like ciprofloxacin. On the other hand, drugs like carbamazepine, phenobarbitol, phenytoin (and fosphenytoin), rifampicin, and St. John’s wort can decrease the plasma concentration of theophylline. It is important to be aware of these interactions when prescribing or taking theophylline to ensure its effectiveness and avoid potential side effects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      20.6
      Seconds
  • Question 4 - You assess a patient who has experienced a minor antepartum bleeding. You have...

    Incorrect

    • You assess a patient who has experienced a minor antepartum bleeding. You have a conversation with the obstetric team about the necessity of rhesus-D prophylaxis.
      Which ONE statement about anti-D is accurate?

      Your Answer: Anti-D is an IgM class antibody directed against the Rhesus D (RhD) antigen

      Correct Answer: Routine antenatal prophylaxis is recommended for RhD negative women at 28 and 34 weeks

      Explanation:

      Anti-D is an antibody of the IgG class that targets the Rhesus D (RhD) antigen. It is specifically administered to women who are RhD negative, meaning they do not have the RhD antigen on their red blood cells. When a RhD negative woman is exposed to the blood of a RhD positive fetus, she may develop antibodies against RhD that can cross the placenta and attack the red blood cells of the fetus, leading to a condition called hemolytic disease of the newborn. Anti-D is given to bind to the fetal red blood cells in the mother’s circulation and neutralize them before an immune response is triggered.

      RhD should be administered in the event of a sensitizing event, which can include childbirth, antepartum hemorrhage, miscarriage, ectopic pregnancy, intrauterine death, amniocentesis, chorionic villus sampling, or abdominal trauma. It is important to administer Anti-D as soon as possible after a sensitizing event, but it can still provide some benefit even if given outside of the recommended 72-hour window, according to the British National Formulary (BNF).

      For RhD negative women, routine antenatal prophylaxis with Anti-D is recommended at 28 and 34 weeks of pregnancy, regardless of whether they have already received Anti-D earlier in the same pregnancy due to a sensitizing event.

      In cases of uncomplicated miscarriage before 12 weeks of gestation, confirmed by ultrasound, or mild and painless vaginal bleeding, prophylactic Anti-D is not necessary because the risk of feto-maternal hemorrhage is extremely low. However, in cases of therapeutic termination of pregnancy, whether through surgical or medical methods, confirmed RhD negative women who are not known to be sensitized to RhD should receive 250 IU of prophylactic Anti-D immunoglobulin.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      43.4
      Seconds
  • Question 5 - A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain....

    Correct

    • A 40-year-old businessman presents with sudden onset breathlessness and right-sided pleuritic chest pain. He has recently returned from a trip to Australia. He has no past medical history of note and suffers no known allergies. His observations are as follows: temperature 38.2°C, oxygen saturations 93% on air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, he has a tender, swollen left calf, and his chest is clear.

      What is the SINGLE investigation most likely to confirm the diagnosis?

      Your Answer: CT pulmonary angiogram

      Explanation:

      The clinical history and examination strongly suggest that the patient has a pulmonary embolism caused by a deep vein thrombosis in his right leg.

      The typical symptoms of a pulmonary embolism include shortness of breath, chest pain that worsens with breathing, coughing, and/or coughing up blood. There may also be symptoms indicating the presence of a deep vein thrombosis. Other signs include rapid breathing and heart rate, fever, and in severe cases, signs of shock, an abnormal heart rhythm, and increased pressure in the jugular veins.

      Given the patient’s high probability Wells score, it is recommended that an immediate CT pulmonary angiogram (CPTA) be performed. This test is considered the most reliable method for diagnosing a pulmonary embolism. A d-dimer test would not provide any additional benefit in this case. While a chest X-ray and ECG may provide useful information, they alone cannot confirm the diagnosis.

      For patients who have an allergy to contrast media, renal impairment, or are at high risk from radiation exposure, a ventilation/perfusion single-photon emission computed tomography (V/Q SPECT) scan or a V/Q planar scan can be offered as an alternative to CTPA.

    • This question is part of the following fields:

      • Respiratory
      63.5
      Seconds
  • Question 6 - A 30-year-old man has ingested an excessive amount of paracetamol. He consumed the...

    Incorrect

    • A 30-year-old man has ingested an excessive amount of paracetamol. He consumed the overdose 12 hours ago and is unsure of the number of tablets he has taken.
      Which of the following substances can be utilized as an antidote for paracetamol overdose?

      Your Answer: Desferrioxamine

      Correct Answer: Methionine

      Explanation:

      The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is an extremely effective antidote, but its effectiveness decreases quickly if administered more than a few hours after a significant ingestion. Ingestions that exceed 75 mg/kg are considered to be significant.

      For patients who decline treatment, methionine is a helpful alternative. It is taken orally in a dosage of 2.5 g every 4 hours, with a total dose of 10 g.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      36.6
      Seconds
  • Question 7 - A 45-year-old man with a long history of type 2 diabetes mellitus presents...

    Correct

    • A 45-year-old man with a long history of type 2 diabetes mellitus presents with pain in his left buttock, hip, and thigh. The pain started suddenly a few weeks ago, and he cannot recall any previous injury. During the examination, he shows wasting of his left quadriceps, struggles to stand up from a seated position, and has an absent knee jerk on the left side. Muscle fasciculations are observed in his left thigh. His BMI is 30, and he is a smoker.

      What is the SINGLE most beneficial management measure for this patient?

      Your Answer: Good glycaemic control

      Explanation:

      Diabetic amyotrophy, also referred to as proximal diabetic neuropathy, is the second most prevalent form of diabetic neuropathy. It typically manifests with pain in the buttocks, hips, or thighs and is often initially experienced on one side of the body. The pain may start off as mild and gradually progress or it can suddenly appear, as seen in this particular case. Subsequently, weakness and wasting of the proximal muscles in the lower limbs occur, potentially leading to the patient requiring assistance when transitioning from a seated to a standing position. Reflexes in the affected areas can also be impacted. Fortunately, diabetic amyotrophy can be reversed through effective management of blood sugar levels, physiotherapy, and adopting a healthy lifestyle.

    • This question is part of the following fields:

      • Endocrinology
      39.1
      Seconds
  • Question 8 - You requested an evaluation of a 50-year-old individual who has come in with...

    Correct

    • You requested an evaluation of a 50-year-old individual who has come in with a two-day history of dizziness. The medical student has examined the patient and provided a tentative diagnosis of vestibular neuritis. What characteristics would typically be observed in a patient with vestibular neuritis?

      Your Answer: Recent viral infection

      Explanation:

      Vestibular neuronitis is believed to occur when the vestibular nerve becomes inflamed, often following a viral infection like a cold. This condition causes a constant feeling of dizziness, which can worsen with head movements. On the other hand, BPPV (benign paroxysmal positional vertigo) is characterized by brief episodes of vertigo lasting around 10-20 seconds, triggered by specific head movements. To diagnose BPPV, the Dix-Hallpike test is performed, and a positive result is indicated by a specific type of eye movement called nystagmus. In contrast, vestibular neuritis typically presents with horizontal nystagmus that only occurs in one direction.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      162.8
      Seconds
  • Question 9 - A 32 year old female presents to the emergency department with a painful...

    Correct

    • A 32 year old female presents to the emergency department with a painful burning skin rash. She has been feeling unwell for the past 2 to 3 days, experiencing a mild fever, headache, cough, and lethargy before the rash appeared. The patient recently started taking sulfasalazine one week ago for the treatment of ulcerative colitis.

      Upon examination, the patient exhibits dark centred macules and blisters primarily on the face, neck, and upper body. The conjunctiva of her eyes appear red, and there are ulcers on her tongue. What is the probable diagnosis?

      Your Answer: Stevens-Johnson syndrome

      Explanation:

      The initial stage of SJS is characterized by a rash on the skin, specifically on the macular area. As the condition progresses, the rash transforms into blisters, known as bullae, which eventually detach from the skin.

      Further Reading:

      Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous immune reactions characterized by blistering skin rash and erosions/ulceration of mucous membranes. SJS has less than 10% total body surface area (TBSA) involvement, SJS/TEN overlap has 10% to 30% TBSA involvement, and TEN has more than 30% TBSA involvement. The exact cause of SJS and TEN is not well understood, but it is believed to be a T-cell–mediated cytotoxic reaction triggered by drugs, infections, or vaccinations. Drugs are responsible for 50% of SJS cases and up to 95% of TEN cases, with antibiotics and anticonvulsants being the most common culprits.

      The clinical features of SJS and TEN include a prodrome of malaise, fever, headache, and cough, followed by the appearance of small pink-red macules with darker centers. These macules can coalesce and develop into larger blisters (bullae) that eventually break and cause the epidermis to slough off. Painful mucosal erosions can also occur, affecting various parts of the body and leading to complications such as renal failure, hepatitis, pneumonia, and urethritis. Nikolsky’s sign, which refers to the easy sloughing off of the epidermal layer with pressure, is a characteristic feature of SJS and TEN.

      The diagnosis of SJS, SJS/TEN overlap, and TEN can be confirmed through a skin biopsy, which typically shows desquamation at the epidermal-papillary dermal junction and the presence of necrotic epithelium and lymphocytes. Management of SJS and TEN involves supportive care, withdrawal of the causative agent if drug-related, monitoring for metabolic derangement and infection, maintaining the airway, treating respiratory function and pneumonia, fluid resuscitation, wound care, analgesia, and nutritional support. Ophthalmology consultation is also recommended. Intravenous immunoglobulin, ciclosporin, corticosteroids, and plasmapheresis may be used in treatment, but there is limited evidence supporting their effectiveness.

      The prognosis of SJS and TEN can be assessed using the SCORTEN score, which comprises of 7 clinical and biological parameters, with the predicted probability of mortality ranging from 3.2% to 90.0%.

    • This question is part of the following fields:

      • Dermatology
      51.8
      Seconds
  • Question 10 - You are requested to standby in the resuscitation bay as the paramedics are...

    Correct

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

      Your Answer: Cardiovascular disease

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      15.2
      Seconds
  • Question 11 - A 65-year-old diabetic man presents with a gradual decrease in consciousness and confusion...

    Incorrect

    • A 65-year-old diabetic man presents with a gradual decrease in consciousness and confusion over the past week. His diabetes is typically controlled with metformin 500 mg twice daily. He recently received treatment for a urinary tract infection from his primary care physician, and his family reports that he has been experiencing excessive thirst. He has vomited multiple times today. A urine dipstick test shows a small amount of white blood cells and 1+ ketones. The results of his arterial blood gas analysis are as follows:

      pH: 7.29
      pO2: 11.1 kPa
      pCO2: 4.6 kPa
      HCO3-: 22 mmol/l
      Na+: 154 mmol/l
      K+: 3.2 mmol/l
      Cl-: 100 mmol/l
      Urea: 17.6 mmol/l
      Glucose: 32 mmol/l

      Which SINGLE statement is true regarding this case?

      Your Answer: She does not require insulin

      Correct Answer: Anticoagulation should be given

      Explanation:

      In an elderly patient with a history of gradual decline accompanied by high blood sugar levels, excessive thirst, and recent infection, the most likely diagnosis is hyperosmolar hyperglycemic state (HHS). This condition can be life-threatening, with a mortality rate of approximately 50%. Common symptoms include dehydration, elevated blood sugar levels, altered mental status, and electrolyte imbalances. About half of the patients with HHS also experience hypernatremia.

      To calculate the serum osmolality, the formula is 2(K+ + Na+) + urea + glucose. In this case, the serum osmolality is 364 mmol/l, indicating a high level. It is important to discontinue the use of metformin in this patient due to the risk of metformin-associated lactic acidosis (MALA). Additionally, an intravenous infusion of insulin should be initiated.

      The treatment goals for HHS are to address the underlying cause and gradually and safely:
      – Normalize the osmolality
      – Replace fluid and electrolyte losses
      – Normalize blood glucose levels

      If significant ketonaemia is present (3β-hydroxybutyrate is more than 1 mmol/L), it indicates a relative lack of insulin, and insulin should be administered immediately. However, if significant ketonaemia is not present, insulin should not be started.

      Patients with HHS are at a high risk of thromboembolism, and it is recommended to routinely administer low molecular weight heparin. In cases where the serum osmolality exceeds 350 mmol/l, full heparinization should be considered.

    • This question is part of the following fields:

      • Endocrinology
      143.3
      Seconds
  • Question 12 - A 40-year-old woman with Marfan syndrome presents with a severe tearing chest pain...

    Correct

    • A 40-year-old woman with Marfan syndrome presents with a severe tearing chest pain that spreads to her back. A diagnosis of aortic dissection is suspected.
      Which SINGLE statement regarding aortic dissection is FALSE?

      Your Answer: An inter-arm blood pressure differential of greater than 10 mmHg is a highly sensitive predictor

      Explanation:

      Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.

      Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.

      A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.

      Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.

      Aortic dissection can be classified according to the Stanford classification system:
      – Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
      – Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure.

    • This question is part of the following fields:

      • Cardiology
      37.1
      Seconds
  • Question 13 - A 72 year old male is brought to the emergency department by ambulance...

    Incorrect

    • A 72 year old male is brought to the emergency department by ambulance after experiencing severe chest pain while walking his dog. The patient complains of feeling nauseated and states that the pain spreads to his neck. An ECG is conducted, revealing ST elevation in leads I and AVL. Which coronary artery is most likely blocked?

      Your Answer: Distal left anterior descending

      Correct Answer: Left circumflex artery

      Explanation:

      Patients who have a STEMI caused by a blockage in the left circumflex artery (LCX) will usually show ST elevation in leads I and AVL. These leads correspond to the high lateral area of the heart, which is supplied by the LCX artery.

      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
      46.6
      Seconds
  • Question 14 - A 35-year-old woman comes to the clinic complaining of a persistent dry cough...

    Correct

    • A 35-year-old woman comes to the clinic complaining of a persistent dry cough and fever for the past few days. She has noticed that her cough does not produce any phlegm. Today, she has also experienced multiple episodes of diarrhea and has developed sharp chest pain on both sides. She mentions feeling short of breath, especially when she exerts herself. She works as a Jacuzzi and whirlpool installer and smokes 10 cigarettes per day.

      What is the SINGLE most probable causative organism in this scenario?

      Your Answer: Legionella pneumophila

      Explanation:

      Legionella pneumophila, a Gram-negative bacterium, can be found in natural water supplies and soil. It is responsible for causing Legionnaires’ disease, a serious illness. Outbreaks of this disease have been associated with poorly maintained air conditioning systems, whirlpool spas, and hot tubs.

      The pneumonic form of Legionnaires’ disease presents with specific clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A non-productive cough, occurring in approximately 90% of cases, is also common. Pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia are other symptoms that may be experienced.

      Fortunately, Legionella pneumophila infections can be effectively treated with macrolide antibiotics like erythromycin, or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used as a treatment option.

      While the majority of Legionnaires’ disease cases are caused by Legionella pneumophila, there are several other species of Legionella that have been identified. One such species is Legionella longbeachae, which is less commonly encountered. It is primarily found in soil and potting compost and has been associated with outbreaks of Pontiac fever, a milder variant of Legionnaires’ disease that does not primarily affect the respiratory system.

    • This question is part of the following fields:

      • Respiratory
      33
      Seconds
  • Question 15 - A 65 year old male is brought to the emergency department after experiencing...

    Correct

    • A 65 year old male is brought to the emergency department after experiencing a sudden decline in health over the past 72 hours. The patient appears slightly confused and restless. Here are the observations:

      Blood pressure: 178/94 mmHg
      Pulse: 122 bpm
      Respiration rate: 24 bpm
      Temperature: 39.5ºC

      An ECG is conducted, revealing rapid atrial fibrillation. During the examination, the patient exhibits crackling sounds in the lower parts of the lungs, pitting edema in both legs below the knee, and a mild yellowish tint in the sclera. The patient's GP office is contacted to obtain further information about their medical history. The patient is prescribed carbimazole and bisoprolol, but they have not renewed their prescription on time. What is the most probable diagnosis?

      Your Answer: Thyroid storm

      Explanation:

      The patient is showing signs of confusion and restlessness. Upon examination, it is found that the patient has high blood pressure, a rapid pulse rate, increased respiration rate, and a high temperature. An ECG reveals rapid atrial fibrillation. Additionally, the patient exhibits crackling sounds in the lower parts of the lungs, pitting edema in both legs below the knee, and a mild yellowish tint in the sclera. The patient’s medical history is obtained from their GP office, which reveals that they have not renewed their prescription for carbimazole and bisoprolol on time. Based on these findings, the most probable diagnosis is a thyroid storm.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      49
      Seconds
  • Question 16 - A 35-year-old man is diagnosed with anterior uveitis.
    Which SINGLE statement regarding this condition...

    Incorrect

    • A 35-year-old man is diagnosed with anterior uveitis.
      Which SINGLE statement regarding this condition is FALSE?

      Your Answer: There is a strong association between the HLA-B27 genotype

      Correct Answer: It most commonly involves the posterior chamber

      Explanation:

      Anterior uveitis refers to the inflammation of the iris and is characterized by a painful and red eye. It is often accompanied by symptoms such as sensitivity to light, excessive tearing, and a decrease in visual clarity. In less than 10% of cases, the inflammation may extend to the posterior chamber. The condition can also lead to the formation of adhesions between the iris and the lens or cornea, resulting in an irregularly shaped pupil known as synechia. In severe cases, pus may accumulate in the front part of the eye, specifically the anterior chamber, causing a condition called hypopyon.

      There are various factors that can cause anterior uveitis, including idiopathic cases where no specific cause can be identified. Other causes include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, ankylosing spondylitis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). It is worth noting that approximately 50% of patients with anterior uveitis have a strong association with the HLA-B27 genotype.

      Complications that can arise from uveitis include the development of cataracts, glaucoma, band keratopathy (a condition where calcium deposits form on the cornea), and even blindness.

    • This question is part of the following fields:

      • Ophthalmology
      25.6
      Seconds
  • Question 17 - A 21-year-old man comes in with a suddenly painful and swollen right testis...

    Correct

    • A 21-year-old man comes in with a suddenly painful and swollen right testis and intense abdominal pain. The pain started while he was asleep, and he has experienced multiple episodes of vomiting. His cremasteric reflex is not present, and the testis is too sensitive to touch.
      What is the SINGLE most probable diagnosis?

      Your Answer: Testicular torsion

      Explanation:

      Testicular torsion is the correct diagnosis in this case. When a patient presents with sudden, severe, and acute testicular pain, testicular torsion should be assumed until proven otherwise. There are several historical factors that support this diagnosis. These include the pain occurring suddenly, being accompanied by vomiting, happening during sleep (as half of torsions occur during sleep), a previous history of torsion in the other testis, previous episodes that have resolved recently, and a history of undescended testis.

      On examination, there are certain findings that further suggest testicular torsion. The testis may be positioned high in the scrotum and too tender to touch. The opposite testis may lie horizontally (known as Angell’s sign). Pain is not relieved by elevating the testis (negative Prehn’s sign), and the cremasteric reflex may be absent.

      It is important to recognize that testicular torsion is a surgical emergency that requires immediate assessment and intervention to restore blood flow. Irreversible damage can occur within six hours of onset, so prompt treatment is crucial in this patient.

    • This question is part of the following fields:

      • Urology
      40.5
      Seconds
  • Question 18 - A 37 year old male is brought into the emergency department with severe...

    Incorrect

    • A 37 year old male is brought into the emergency department with severe chest injuries following a car accident. FAST scanning shows the presence of around 100 ml of fluid in the pericardium. The patient's blood pressure is 118/78 mmHg and pulse rate is 92. What is the recommended course of action for managing this patient?

      Your Answer: Repeat FAST scan hourly to assess change in effusion volume

      Correct Answer: Transfer to theatre for thoracotomy

      Explanation:

      For individuals with traumatic cardiac tamponade, thoracotomy is the recommended treatment. In the case of a trauma patient with a significant buildup of fluid around the heart and the potential for tamponade, it is advised to transfer stable patients to the operating room for thoracotomy instead of performing pericardiocentesis. Pericardiocentesis, when done correctly, is likely to be unsuccessful due to the presence of clotted blood in the pericardium. Additionally, performing pericardiocentesis would cause a delay in the thoracotomy procedure. If access to the operating room is not possible, pericardiocentesis may be considered as a temporary solution.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      51.8
      Seconds
  • Question 19 - A 60-year-old woman comes in with severe left eye pain and loss of...

    Correct

    • A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. She has experienced vomiting multiple times. During the examination, there is noticeable left-sided circumcorneal erythema, and the left pupil is mid-dilated and unresponsive to light.

      What would be the most suitable initial investigation in this case?

      Your Answer: Applanation tonometry

      Explanation:

      This patient has presented with acute closed-angle glaucoma, which is a serious eye condition requiring immediate medical attention. It occurs when the iris pushes forward and blocks the fluid access to the trabecular meshwork, leading to increased pressure within the eye and damage to the optic nerve.

      The main symptoms of acute closed-angle glaucoma include severe eye pain, decreased vision, redness around the cornea, swelling of the cornea, a fixed semi-dilated pupil, nausea, vomiting, and episodes of blurred vision or seeing haloes.

      To confirm the diagnosis, tonometry is performed to measure the intraocular pressure. Normal pressure ranges from 10 to 21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.

      Management of acute closed-angle glaucoma involves providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous acetazolamide is administered to reduce intraocular pressure. Additionally, a topical miotic medication like pilocarpine is started about an hour after initiating other treatments to help constrict the pupil, as it may initially be paralyzed and unresponsive.

      Overall, acute closed-angle glaucoma is a medical emergency that requires prompt intervention to alleviate symptoms and prevent further damage to the eye.

    • This question is part of the following fields:

      • Ophthalmology
      37.8
      Seconds
  • Question 20 - A 45-year-old woman presents with a severe headache that has been ongoing for...

    Correct

    • A 45-year-old woman presents with a severe headache that has been ongoing for the past 3 hours. She describes it as the 'most intense headache she has ever experienced'. She also complains of sensitivity to light and stiffness in her neck. There is no history of any head injury. Initially, she was treated conservatively and her symptoms improved. However, on the third day, she had a seizure and lost the ability to move her left arm. Physical examination reveals weakness in the left arm but normal sensation. A CT scan of her head shows a localized area of decreased density in the right frontal lobe, with a loss of distinction between grey and white matter and surrounding swelling.

      What is the most likely cause of her current condition?

      Your Answer: Cerebral vasospasm

      Explanation:

      Intracranial hemorrhages can be categorized based on their location into epidural, subdural, subarachnoid, or intracerebral hemorrhages. The patient in this case is experiencing a severe headache accompanied by signs of meningismus, which strongly suggests a diagnosis of subarachnoid hemorrhage. Additionally, there is no history of trauma, and most cases of subarachnoid hemorrhage are caused by the rupture of a berry aneurysm located in the circle of Willis. Hypertension is a significant risk factor for the rupture of an aneurysm.

      During the patient’s hospital stay, they develop an ischemic stroke, which is confirmed by a CT scan. This is most likely a result of cerebral vasospasm secondary to the subarachnoid hemorrhage. To prevent this complication, patients are often treated with the cerebral selective calcium channel blocker Nimodipine.

      Another potential complication of this condition is rebleeding, with the highest risk occurring in the first few days. Rebleeding can be potentially fatal, so it is crucial to repair the aneurysm as soon as possible. The presence of blood in the subarachnoid space can also disrupt the production and drainage of cerebrospinal fluid, leading to hydrocephalus.

      Long-term complications of subarachnoid hemorrhage include epilepsy, with most patients experiencing their first seizure within a year after the hemorrhage. However, the risk of epilepsy decreases over time. Cognitive dysfunction is also a common long-term complication and can manifest as memory loss, difficulty concentrating, or challenges in performing regular tasks. Emotional problems, such as depression and anxiety, are frequently observed as well.

    • This question is part of the following fields:

      • Neurology
      60.8
      Seconds
  • Question 21 - A 45-year-old man with a long-standing history of benign prostatic hyperplasia dribbling presents...

    Correct

    • A 45-year-old man with a long-standing history of benign prostatic hyperplasia dribbling presents with a fever, chills, and muscle aches. After taking a detailed history and conducting an examination, you diagnose acute bacterial prostatitis and decide to start antibiotics.
      What is the recommended duration of treatment for this condition?

      Your Answer: 14 days

      Explanation:

      Acute bacterial prostatitis is a sudden inflammation of the prostate gland, which can be either focal or diffuse and is characterized by the presence of pus. The most common organisms that cause this condition include Escherichia coli, Streptococcus faecalis, Staphylococcus aureus, and Neisseria gonorrhoea. The infection usually reaches the prostate through direct extension from the posterior urethra or urinary bladder, but it can also spread through the blood or lymphatics. In some cases, the infection may originate from the rectum.

      According to the National Institute for Health and Care Excellence (NICE), acute prostatitis should be suspected in men who present with a sudden onset of feverish illness, which may be accompanied by rigors, arthralgia, or myalgia. Irritative urinary symptoms like dysuria, frequency, urgency, or acute urinary retention are also common. Perineal or suprapubic pain, as well as penile pain, low back pain, pain during ejaculation, and pain during bowel movements, can occur. A rectal examination may reveal an exquisitely tender prostate. A urine dipstick test showing white blood cells and a urine culture confirming urinary infection are also indicative of acute prostatitis.

      The current recommendations by NICE and the British National Formulary (BNF) for the treatment of acute prostatitis involve prescribing an oral antibiotic for a duration of 14 days, taking into consideration local antimicrobial resistance data. The first-line antibiotics recommended are Ciprofloxacin 500 mg twice daily or Ofloxacin 200 mg twice daily. If these are not suitable, Trimethoprim 200 mg twice daily can be used. Second-line options include Levofloxacin 500 mg once daily or Co-trimoxazole 960 mg twice daily, but only when there is bacteriological evidence of sensitivity and valid reasons to prefer this combination over a single antibiotic.

      For more information, you can refer to the NICE Clinical Knowledge Summary on acute prostatitis.

    • This question is part of the following fields:

      • Urology
      35.5
      Seconds
  • Question 22 - A 57 year old male presents to the emergency department with a 24...

    Correct

    • A 57 year old male presents to the emergency department with a 24 hour history of worsening pain on the left side of the mouth and jaw. Upon examination, there is noticeable swelling of the gum around the 1st and 2nd upper left molar teeth, indicative of a dental abscess. Which of the following signs would warrant hospitalization?

      Your Answer: Swelling of sublingual space

      Explanation:

      Patients with dental abscess should be evaluated for signs of spread into deep fascial planes. Infection of the sublingual space can lead to serious complications that can be life-threatening. Swelling in this area can cause the tongue to elevate, potentially obstructing the airway. Other complications include infections such as mediastinitis, necrotizing fasciitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre’s syndrome, cerebral abscess, orbital abscess, and osteomyelitis.

      There are certain indications that may require admission to the hospital for dental abscess. These include evidence of significant systemic disturbance, inability to control the infection with antibiotics, rapid spread of infection, stridor or compromised airway, swelling of the sublingual space or pharynx, difficulty swallowing or speaking, immunocompromised patients, abscess requiring drainage under general anesthesia.

      Fever and pain are common symptoms of dental abscess but by themselves are not enough to warrant admission. Ideally, dental abscess should be managed through urgent dental review. However, if immediate dental review is not available, the patient may be treated with antibiotics as long as there are no signs of more severe infection.

      Further Reading:

      Dental abscess is a condition that usually occurs as a result of dental caries or following a dental procedure or trauma. Dental caries refers to the loss of enamel caused by acids produced by bacteria in the mouth. This allows bacteria to enter the pulp, root, and local tissues, leading to infection. The infection can then spread to surrounding tissues, causing conditions such as gingivitis or dental abscess. In severe cases, the infection can spread to deep fascial planes, resulting in conditions like retropharyngeal abscess or Ludwig’s angina.

      A dental abscess is typically caused by a combination of gram-positive and gram-negative bacteria, such as Streptococcus, Staphylococcus, and Prevotella. When assessing a patient with a suspected dental abscess, a thorough history and inspection of the mouth, face, and neck are necessary. This helps confirm the diagnosis and assess the risk of serious complications, such as airway compromise or deep/spreading infection.

      Some concerning features on history or examination include systemic upset (e.g., fever, vomiting), sublingual or pharyngeal swelling, stridor, dysphagia, dysphonia, dyspnea, and progression of illness despite current antibiotic treatment. It’s important to consider non-dental causes of mouth and jaw pain, such as trauma, referred sinus pain, cardiac pain radiating to the jaw, trigeminal neuralgia, otalgia radiating to the jaw, and parotid gland swelling.

      Management of a dental abscess typically involves providing analgesia (NSAIDs and paracetamol) and facilitating early dental review. Antibiotics may be prescribed in certain cases, such as when the patient does not have immediate access to a dentist and is systemically unwell, shows signs of severe infection, or is a high-risk individual (e.g., immunocompromised or diabetic). The choice of antibiotics includes amoxicillin, phenoxymethylpenicillin, or clarithromycin (if penicillin allergic). In severe or spreading infections, metronidazole may be added. The typical course of antibiotics is 5 days.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      34.6
      Seconds
  • Question 23 - A 6-year-old girl presents with a history of a persistent cough that has...

    Correct

    • A 6-year-old girl presents with a history of a persistent cough that has been present for the past four weeks. The cough occurs in quick bursts with a deep breath in followed by a series of forceful coughs. She occasionally vomits after coughing. Her mother reports that the cough is more severe at night.

      During the examination, her chest sounds clear, but you observe two small subconjunctival hemorrhages and some tiny red spots on her face.

      What is the MOST suitable test to perform in this case?

      Your Answer: Serology for anti-pertussis toxin IgG antibody levels

      Explanation:

      This presentation strongly suggests a diagnosis of whooping cough, which is an infection of the upper respiratory tract caused by the bacteria Bordetella pertussis. The disease is highly contagious and is transmitted through respiratory droplets. The incubation period is typically 7-21 days, and it is estimated that about 90% of close household contacts will become infected.

      The clinical course of whooping cough can be divided into two stages. The first stage, known as the catarrhal stage, is similar to a mild respiratory infection with symptoms such as low-grade fever and a runny nose. A cough may be present, but it is usually not as severe as in the second stage. This phase typically lasts about a week.

      The second stage, called the paroxysmal stage, is characterized by the development of a distinctive cough. The coughing occurs in spasms, often preceded by an inspiratory whoop sound. These spasms are followed by a series of rapid, hacking coughs. Patients may also experience vomiting and develop subconjunctival hemorrhages and petechiae. Between spasms, patients generally feel well and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over this period. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) has specific recommendations for testing for whooping cough based on the age of the patient, the time since onset of illness, and the severity of the presentation.

      For infants under 12 months of age, hospitalized patients should be tested using PCR testing. Non-hospitalized patients within two weeks of onset should be investigated with culture of a nasopharyngeal swab or aspirate. Non-hospitalized patients presenting over two weeks after onset should be tested using serology for anti-pertussis toxin IgG antibody levels.

      For children over 12 months of age and adults, patients within two weeks of onset should be tested using culture of a nasopharyngeal swab or aspirate. Patients aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after onset should have oral fluid testing for anti-pertussis toxin IgG antibody levels.

    • This question is part of the following fields:

      • Respiratory
      36.5
      Seconds
  • Question 24 - A 38-year-old man from East Africa comes in with a fever, night sweats,...

    Correct

    • A 38-year-old man from East Africa comes in with a fever, night sweats, a cough, and haemoptysis. He has a confirmed diagnosis of HIV and a CD4 count of 115 cells/mm3.

      What is the SINGLE most probable causative organism in this scenario?

      Your Answer: Mycobacterium tuberculosis

      Explanation:

      The co-epidemic of tuberculosis and HIV is a significant global health challenge at present. According to the WHO, there were 10 million new cases of tuberculosis in 2019, with approximately 11% of these cases being co-infected with HIV. Tuberculosis is the most common contagious infection in individuals with compromised immune systems due to HIV, often leading to death.

      Tuberculosis is caused by an infection with the bacterium Mycobacterium tuberculosis. While it primarily affects the lungs, it can also impact various other parts of the body. The disease is spread through aerosol transmission, meaning it is transmitted through droplets in the air.

      The primary symptoms of tuberculosis infection include a chronic cough, coughing up blood (haemoptysis), fever, night sweats, and weight loss. In individuals who have not been previously affected, tuberculosis can cause a primary lesion known as the Ghon focus. This lesion typically develops in the upper lobes of the lungs.

      In 15-20% of cases, the infection spreads to extrapulmonary sites such as the pleura, central nervous system, lymphatics, bones, joints, and genitourinary system. Extrapulmonary tuberculosis that affects the spine is known as Pott’s disease, primarily affecting the lower thoracic and upper lumbar vertebrae. Cervical tuberculous lymphadenopathy, also known as scrofula, is characterized by cold abscesses without erythema or warmth.

      Only a small percentage of patients, around 5-10%, go on to develop post-primary tuberculosis, also known as reactivation tuberculosis. This typically occurs a year or two after the primary infection and is more likely to happen in individuals with a weakened immune system. Reactivation tuberculosis often involves the lung apex.

    • This question is part of the following fields:

      • Infectious Diseases
      10.7
      Seconds
  • Question 25 - A 21 year old male presents to the emergency department with a 3...

    Correct

    • A 21 year old male presents to the emergency department with a 3 day history of a sore throat and fever. The patient denies having a cough. On examination, the patient's temperature is 37.9°C, blood pressure is 120/80 mmHg, and pulse rate is 90 bpm. There is visible white exudate on both tonsils, which are severely inflamed, and tenderness on palpation of the lymph nodes around the sternocleidomastoid muscles bilaterally.

      What is this patient's FeverPAIN score?

      Your Answer: 4

      Explanation:

      The FeverPAIN score is a clinical scoring system that helps determine the likelihood of a streptococcal infection and whether antibiotic treatment is necessary. It consists of several criteria that are assessed to assign a score.

      Firstly, if the patient has a fever higher than 38°C, they score 0 or 1 depending on the presence or absence of this symptom.

      Secondly, the presence of purulence, such as pharyngeal or tonsillar exudate, results in a score of 1.

      Thirdly, if the patient sought medical attention within 3 days or less, they score 1.

      Fourthly, if the patient has severely inflamed tonsils, they score 1.

      Lastly, if the patient does not have a cough or coryza (nasal congestion), they score 1.

      By adding up the scores from each criterion, the FeverPAIN score can help healthcare professionals determine the likelihood of a streptococcal infection and guide the decision on whether antibiotic treatment is necessary. In this particular case, the patient has a score of 4.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      61.4
      Seconds
  • Question 26 - A 10 year old boy is brought into the emergency department after falling...

    Incorrect

    • 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: Severe hypothermia

      Correct 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
      49.1
      Seconds
  • Question 27 - A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates...

    Correct

    • A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates an acute myocardial infarction, and he is immediately taken to the catheterization laboratory. Angiography reveals a blockage in the left anterior descending artery.
      Which area of the heart is most likely affected in this scenario?

      Your Answer: Anteroseptal

      Explanation:

      A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.

      For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.

      In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.

      Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.

      In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.

    • This question is part of the following fields:

      • Cardiology
      28.3
      Seconds
  • Question 28 - A 35-year-old man is brought in by ambulance following a car crash. A...

    Incorrect

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

      Your Answer: Spleen

      Correct Answer: Liver

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      36.7
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  • Question 29 - A 68-year-old diabetic man presents with a gradual decrease in consciousness and confusion...

    Correct

    • A 68-year-old diabetic man presents with a gradual decrease in consciousness and confusion over the past week. He normally controls his diabetes with metformin 500 mg twice a day. He recently received treatment for a urinary tract infection from his GP, and his family reports that he has been excessively thirsty. He has vomited multiple times today. A urine dipstick test shows a trace of leukocytes and 2+ ketones. The results of his arterial blood gas analysis are as follows:
      pH: 7.29
      pO2: 11.1 kPa
      pCO2: 4.6 kPa
      HCO3-: 22 mmol/l
      Na+: 154 mmol/l
      K+: 3.2 mmol/l
      Cl-: 100 mmol/l
      Urea: 17.6 mmol/l
      Glucose: 32 mmol/l
      Which investigation would be most helpful in guiding his management?

      Your Answer: Serum 3β-hydroxybutyrate

      Explanation:

      In an elderly patient with a history of gradual decline accompanied by symptoms of hyperglycemia, excessive thirst, recent infection, and very high blood sugar levels, the most likely diagnosis is a hyperosmolar hyperglycemic state (HHS). This condition can be life-threatening, with a mortality rate of approximately 50%. Common symptoms include high blood sugar levels, dehydration, altered mental status, and electrolyte imbalances. About 50% of patients with HHS also experience hypernatremia, an elevated sodium level in the blood.

      To calculate the serum osmolality, the following formula can be used: 2 (K+ + Na+) + urea + glucose. In this particular case, the calculation would be 2 (3.2 + 154) + 17.6 + 32 = 364 mmol/l. Patients with HHS typically have a serum osmolality greater than 350 mmol/l.

      In order to manage HHS, it is important to address the underlying cause and gradually and safely achieve the following goals:
      1. Normalize the osmolality
      2. Replace fluid and electrolyte losses
      3. Normalize blood glucose levels

      Given the presence of 1+ ketones in the patient’s urine, which is likely due to vomiting and a mild acidosis, it is recommended to discontinue the use of metformin due to the risk of metformin-associated lactic acidosis (MALA). Additionally, an intravenous infusion of insulin should be initiated in this case.

      If significant ketonaemia is present (3β-hydroxybutyrate is more than 1 mmol/L), it indicates a relative deficiency of insulin, and insulin treatment should be started immediately. However, if significant ketonaemia is not present, insulin should not be initiated.

      Patients with HHS are at a high risk of developing thromboembolism, and therefore, routine administration of low molecular weight heparin is recommended. In cases where the serum osmolality exceeds 350 mmol/l, full heparinization should be considered.

    • This question is part of the following fields:

      • Endocrinology
      92.8
      Seconds
  • Question 30 - A 65 year old is brought to the emergency department due to confusion...

    Incorrect

    • A 65 year old is brought to the emergency department due to confusion and mild fever. It is suspected that the patient has a urinary tract infection. The patient's family member informs you that the patient takes warfarin for atrial fibrillation but is unsure if they have taken it correctly due to confusion. An INR test is conducted and the result comes back as 8.2.

      What would be the most suitable course of action?

      Your Answer: Give intravenous vitamin K 5 mg

      Correct Answer: Give vitamin K 1 mg by mouth

      Explanation:

      When the INR (International Normalized Ratio) is above 8 but there is no sign of bleeding, the usual approach is to stop administering warfarin and instead provide oral vitamin K. If the INR is below 8 and there is no evidence of bleeding, it is appropriate to discontinue warfarin. However, if there is evidence of bleeding or the INR exceeds 8, reversal agents are administered. In cases where the INR is greater than 8 without any bleeding, oral vitamin K is typically prescribed at a dosage of 1-5 mg.

      Further Reading:

      Management of High INR with Warfarin

      Major Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 5 mg.
      – Administer 25-50 u/kg four-factor prothrombin complex concentrate.
      – If prothrombin complex concentrate is not available, consider using fresh frozen plasma (FFP).
      – Seek medical attention promptly.

      INR > 8.0 with Minor Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 1-3mg.
      – Repeat vitamin K dose if INR remains high after 24 hours.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if bleeding worsens or persists.

      INR > 8.0 without Bleeding:
      – Stop warfarin immediately.
      – Administer oral vitamin K 1-5 mg using the intravenous preparation orally.
      – Repeat vitamin K dose if INR remains high after 24 hours.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if any symptoms or concerns arise.

      INR 5.0-8.0 with Minor Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 1-3mg.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if bleeding worsens or persists.

      INR 5.0-8.0 without Bleeding:
      – Withhold 1 or 2 doses of warfarin.
      – Reduce subsequent maintenance dose.
      – Monitor INR closely and seek medical advice if any concerns arise.

      Note: In cases of intracranial hemorrhage, prothrombin complex concentrate should be considered as it is faster acting than fresh frozen plasma (FFP).

    • This question is part of the following fields:

      • Haematology
      89
      Seconds
  • Question 31 - You assess a patient who has been brought into the resuscitation room in...

    Correct

    • You assess a patient who has been brought into the resuscitation room in an obtunded state. The patient is wearing a MedicAlert bracelet, indicating a diagnosis of Addison's disease.
      Which ONE statement accurately describes this condition?

      Your Answer: ACTH levels are usually elevated

      Explanation:

      Addison’s disease occurs when the adrenal glands do not produce enough steroid hormones. This includes glucocorticoids, mineralocorticoids, and sex steroids. The most common cause is autoimmune adrenalitis, which accounts for about 70-80% of cases. It is more prevalent in women and typically occurs between the ages of 30 and 50.

      The clinical symptoms of Addison’s disease include weakness, lethargy, low blood pressure (especially when standing up), nausea, vomiting, weight loss, reduced hair in the armpits and pubic area, depression, and hyperpigmentation (darkening of the skin in certain areas like the palms, mouth, and exposed skin).

      Biochemically, Addison’s disease is characterized by increased levels of ACTH (a hormone that tries to stimulate the adrenal glands), low sodium levels, high potassium levels, high calcium levels, low blood sugar, and metabolic acidosis.

      People with Addison’s disease have a higher risk of developing type 1 diabetes, Hashimoto’s thyroiditis, Grave’s disease, premature ovarian failure, pernicious anemia, vitiligo, and alopecia.

      Management of Addison’s disease should be overseen by an Endocrinologist. Treatment typically involves taking hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet in case of an Addisonian crisis.

    • This question is part of the following fields:

      • Endocrinology
      40.2
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  • Question 32 - A 72-year-old male visits the emergency department on a weekend complaining of colicky...

    Correct

    • A 72-year-old male visits the emergency department on a weekend complaining of colicky abdominal pain and frequent episodes of diarrhea. The patient mentions that he had given a stool sample to his GP earlier in the week, but he is worried because the diarrhea has worsened. The pathology report confirms the presence of clostridium difficile toxin in the stool sample. Which of the medications the patient regularly takes are known to increase the risk of clostridium difficile diarrhea?

      Your Answer: Lansoprazole

      Explanation:

      Regular use of medications that decrease gastric acid secretion, such as proton pump inhibitors (esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) and H2 receptor antagonists like ranitidine, can increase the risk of developing clostridium difficile diarrhoea. However, it is important to note that antibiotics are the most common cause of this condition.

      Further Reading:

      Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.

      Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.

      Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.

      Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      26.5
      Seconds
  • Question 33 - A 42-year-old patient comes in with a 3-day history of urgency, increased frequency...

    Correct

    • A 42-year-old patient comes in with a 3-day history of urgency, increased frequency of urination, and discomfort while urinating. Upon examination, she has no fever, mild tenderness in the suprapubic area, and no tenderness in the flank region. Her pregnancy test is negative and she has no medication allergies.

      What is the MOST suitable course of action for management?

      Your Answer: The patient should be started on a 3-day course of oral trimethoprim

      Explanation:

      Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. The Scottish Intercollegiate Guidelines Network (SIGN) has developed comprehensive guidelines for the management of UTIs. According to these guidelines, if a patient presents with three or more classical UTI symptoms and is not pregnant, it is recommended to initiate empirical treatment with a three-day course of either trimethoprim or nitrofurantoin. For more detailed information, you can refer to the SIGN guidelines on the management of suspected bacterial urinary tract infection in adults.

    • This question is part of the following fields:

      • Urology
      36.4
      Seconds
  • Question 34 - A child develops a palsy of their right arm following a traumatic birth....

    Incorrect

    • A child develops a palsy of their right arm following a traumatic birth. During the examination, there is a deformity known as 'claw hand' and sensory loss on the ulnar side of the forearm and hand.
      What is the SINGLE most probable diagnosis?

      Your Answer: Erb’s palsy

      Correct Answer: Klumpke’s palsy

      Explanation:

      Klumpke’s palsy, also known as Dejerine-Klumpke palsy, is a condition where the arm becomes paralyzed due to an injury to the lower roots of the brachial plexus. The most commonly affected root is C8, but T1 can also be involved. The main cause of Klumpke’s palsy is when the arm is pulled forcefully in an outward position during a difficult childbirth. It can also occur in adults with apical lung carcinoma (Pancoast’s syndrome).

      Clinically, Klumpke’s palsy is characterized by a deformity known as ‘claw hand’, which is caused by the paralysis of the intrinsic hand muscles. There is also a loss of sensation along the ulnar side of the forearm and hand. In some cases where T1 is affected, a condition called Horner’s syndrome may also be present.

      Klumpke’s palsy can be distinguished from Erb’s palsy, which affects the upper roots of the brachial plexus (C5 and sometimes C6). In Erb’s palsy, the arm hangs by the side with the elbow extended and the forearm turned inward (known as the ‘waiter’s tip sign’). Additionally, there is a loss of shoulder abduction, external rotation, and elbow flexion.

    • This question is part of the following fields:

      • Neurology
      15.6
      Seconds
  • Question 35 - A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
    Which of the following statements...

    Correct

    • A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
      Which of the following statements is accurate regarding subarachnoid hemorrhage?

      Your Answer: SAH is associated with polycystic kidneys

      Explanation:

      A subarachnoid haemorrhage (SAH) occurs when there is spontaneous bleeding into the subarachnoid space and is often a catastrophic event. The incidence of SAH is 9 cases per 100,000 people per year, and it typically affects individuals between the ages of 35 and 65.

      The majority of SAH cases (80%) are caused by the rupture of berry (saccular) aneurysms, while 15% are caused by arteriovenous malformations (AVM). In less than 5% of cases, no specific cause can be found. Berry aneurysms are associated with polycystic kidneys, Ehlers-Danlos Syndrome, and coarctation of the aorta.

      There are several risk factors for SAH, including smoking, hypertension, bleeding disorders, alcohol misuse, mycotic aneurysm, and a family history of the condition.

      Patients with SAH typically experience a sudden and severe occipital headache, often described as the worst headache of my life. This may be accompanied by vomiting, collapse, seizures, and coma. Clinical signs of SAH include neck stiffness, a positive Kernig’s sign, and focal neurological abnormalities. Fundoscopy may reveal subhyaloid retinal haemorrhages in approximately 25% of patients.

      Re-bleeding occurs in 30-40% of patients who survive the initial episode, with the highest risk occurring between 7 and 14 days after the initial event.

      Untreated SAH has a mortality rate of nearly 50% within the first eight weeks following presentation. Prolonged coma is associated with a 100% mortality rate.

      The first-line investigation for SAH is a CT head scan, which can detect over 95% of cases if performed within the first 24 hours. The sensitivity of the CT scan increases to nearly 100% if performed within 6 hours of symptom onset. If the CT scan is negative and there are no contraindications, a lumbar puncture (LP) should be performed at least 12 hours after the onset of headache to diagnose SAH. Approximately 3% of patients with a negative CT scan will be confirmed to have had an SAH following an LP.

    • This question is part of the following fields:

      • Neurology
      64.6
      Seconds
  • Question 36 - You are examining the facial X-rays of a young patient who was involved...

    Incorrect

    • You are examining the facial X-rays of a young patient who was involved in a physical altercation and sustained multiple facial injuries. What tools or techniques are utilized to aid in the interpretation of facial radiographs and facilitate the identification of facial fractures?

      Your Answer: Le Fort lines

      Correct Answer: Dolan lines

      Explanation:

      The interpretation of facial X-rays is often assisted by the use of McGrigor-Campbell lines and Dolan lines. These lines, along with accompanying notes and images, provide additional information for a more accurate analysis.

      Further Reading:

      Facial X-rays are commonly used to assess and diagnose facial fractures. Two standard views are typically performed: the Occipitomental view and the Occipitomental 30º view. The Occipitomental view provides a comprehensive look at the upper and middle thirds of the face, including the orbital margins, frontal sinuses, zygomatic arches, and maxillary antra. On the other hand, the Occipitomental 30º view uses a 30-degree caudal angulation to better visualize the zygomatic arches and walls of the maxillary antra, although it may compromise the clear view of the orbital margins.

      To assist in the interpretation of facial X-rays, imaginary lines are often drawn across the images to highlight any asymmetry or disruption. Two commonly used sets of lines are the McGrigor-Campbell lines and Dolan’s lines. McGrigor-Campbell lines are used to aid in the interpretation of both the Occipitomental and Occipitomental 30º views. These lines include an upper line that passes through the zygomatico-frontal sutures and the upper edge of the orbits, a middle line that follows the zygomatic arch and crosses the zygomatic bone, and a lower line that passes through the condyle and coronoid process of the mandible and the walls of the maxillary antra.

      Dolan’s lines, described by Dolan and Jacoby, are often used in conjunction with McGrigor-Campbell lines. These lines include the orbital line, which traces the inner margins of the orbital walls and the nasal arch, the zygomatic line, which traces the superior margin of the zygomatic arch and body, and the maxillary line, which traces the inferior margin of the zygomatic arch, body, and buttress, as well as the lateral wall of the maxillary sinus. Together, the zygomatic and maxillary lines resemble the profile of an elephant’s head and are referred to as Dolan’s elephant. These lines help provide additional information and aid in the interpretation of facial X-rays.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      25.3
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  • Question 37 - A 32 year old female presents to the emergency department with a one...

    Correct

    • A 32 year old female presents to the emergency department with a one day history of gradually worsening suprapubic pain, increased urinary frequency, and foul-smelling urine. The patient has a temperature of 37.2ºC and her vital signs are within normal limits. Urine dipstick testing reveals the presence of nitrites, leukocytes, and blood. The patient reports no regular medication use and the last time she took any acute medication was approximately 6 months ago when she was prescribed antihistamines for hayfever symptoms. Based on these findings, the most likely cause of her symptoms is a urinary tract infection. What is the most probable causative organism?

      Your Answer: Escherichia coli

      Explanation:

      Based on the patient’s symptoms of suprapubic pain, increased urinary frequency, and foul-smelling urine, along with the presence of nitrites, leukocytes, and blood in the urine dipstick test, the most likely cause of her symptoms is a urinary tract infection (UTI). The most probable causative organism for UTIs is Escherichia coli.

      Further Reading:

      A urinary tract infection (UTI) is an infection that occurs in any part of the urinary system, from the kidneys to the bladder. It is characterized by symptoms such as dysuria, nocturia, polyuria, urgency, incontinence, and changes in urine appearance and odor. UTIs can be classified as lower UTIs, which affect the bladder, or upper UTIs, which involve the kidneys. Recurrent UTIs can be due to relapse or re-infection, and the number of recurrences considered significant depends on age and sex. Uncomplicated UTIs occur in individuals with a normal urinary tract and kidney function, while complicated UTIs are caused by anatomical, functional, or pharmacological factors that make the infection persistent, recurrent, or resistant to treatment.

      The most common cause of UTIs is Escherichia coli, accounting for 70-95% of cases. Other causative organisms include Staphylococcus saprophyticus, Proteus mirabilis, and Klebsiella species. UTIs are typically caused by bacteria from the gastrointestinal tract entering the urinary tract through the urethra. Other less common mechanisms of entry include direct spread via the bloodstream or instrumentation of the urinary tract, such as catheter insertion.

      Diagnosis of UTIs involves urine dipstick testing and urine culture. A urine culture should be sent in certain circumstances, such as in male patients, pregnant patients, women aged 65 years or older, patients with persistent or unresolved symptoms, recurrent UTIs, patients with urinary catheters, and those with risk factors for resistance or complicated UTIs. Further investigations, such as cystoscopy and imaging, may be required in cases of recurrent UTIs or suspected underlying causes.

      Management of UTIs includes simple analgesia, advice on adequate fluid intake, and the prescription of appropriate antibiotics. The choice of antibiotic depends on the patient’s gender and risk factors. For women, first-line antibiotics include nitrofurantoin or trimethoprim, while second-line options include nitrofurantoin (if not used as first-line), pivmecillinam, or fosfomycin. For men, trimethoprim or nitrofurantoin are the recommended antibiotics. In cases of suspected acute prostatitis, fluoroquinolone antibiotics such as ciprofloxacin or ofloxacin may be prescribed for a 4-week course.

    • This question is part of the following fields:

      • Urology
      50.6
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  • Question 38 - A 60-year-old man comes in with decreased visual acuity and 'floaters' in his...

    Correct

    • A 60-year-old man comes in with decreased visual acuity and 'floaters' in his right eye. Upon conducting fundoscopy, you observe a sheet of sensory retina bulging towards the center of the eye.
      What is the MOST LIKELY diagnosis?

      Your Answer: Retinal detachment

      Explanation:

      Retinal detachment is a condition where the retina separates from the retinal pigment epithelium, resulting in a fluid-filled space between them. This case presents a classic description of retinal detachment. Several risk factors increase the likelihood of developing this condition, including myopia, being male, having a family history of retinal detachment, previous episodes of retinal detachment, blunt ocular trauma, previous cataract surgery, diabetes mellitus (especially if proliferative retinopathy is present), glaucoma, and cataracts.

      The clinical features commonly associated with retinal detachment include flashes of light, particularly at the edges of vision (known as photopsia), a dense shadow in the peripheral vision that spreads towards the center, a sensation of a curtain drawing across the eye, and central visual loss. Fundoscopy, a procedure to examine the back of the eye, reveals a sheet of sensory retina billowing towards the center of the eye. Additionally, a positive Amsler grid test, where straight lines appear curved or wavy, may indicate retinal detachment.

      Other possible causes of floaters include posterior vitreous detachment, retinal tears, vitreous hemorrhage, and migraine with aura. However, in this case, the retinal appearance described is consistent with retinal detachment.

      It is crucial to arrange an urgent same-day ophthalmology referral for this patient. Fortunately, approximately 90% of retinal detachments can be successfully repaired with one operation, and an additional 6% can be salvaged with subsequent procedures. If the retina remains fixed six months after surgery, the likelihood of it becoming detached again is low.

    • This question is part of the following fields:

      • Ophthalmology
      31.1
      Seconds
  • Question 39 - A 35 year old male is brought to the emergency department by his...

    Correct

    • A 35 year old male is brought to the emergency department by his wife with a 24 hour history of vomiting and increasing fatigue over the past 1-2 hours. Initial tests confirm a diagnosis of diabetic ketoacidosis and the patient is started on intravenous fluids and an insulin infusion. You are reminded by your attending physician to monitor the bicarbonate level and adjust the insulin infusion rate if it is not improving as anticipated. What is the minimum desired change in bicarbonate that should be aimed for?

      Your Answer: Venous bicarbonate rising by at least 3 mmol/L/hr

      Explanation:

      When patients with diabetic ketoacidosis (DKA) are treated with insulin infusion, it is expected that their plasma bicarbonate levels will increase by at least 3 mmol/L per hour. Insulin therapy is aimed at correcting both hyperglycemia and ketoacidosis. However, if capillary ketones are not decreasing by at least 0.5 mmol/L per hour, venous bicarbonate is not rising by at least 3 mmol/L per hour, or plasma glucose is not decreasing by at least 3 mmol/L per hour, the insulin infusion rate should be reevaluated.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      75.1
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  • Question 40 - A 45-year-old man with atrial fibrillation presents to the Emergency Department with an...

    Correct

    • A 45-year-old man with atrial fibrillation presents to the Emergency Department with an unrelated medical condition. Upon reviewing his medications, you discover that he is taking warfarin as part of his management.

      Which ONE of the following supplements should be avoided?

      Your Answer: St. John’s Wort

      Explanation:

      St. John’s wort can reduce the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for patients who are taking warfarin to be aware that they should avoid using St. John’s wort as a supplement. For more information on this interaction, you can refer to the BNF section on warfarin interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      23.4
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  • Question 41 - You review a patient with a history of renal failure that has presented...

    Correct

    • You review a patient with a history of renal failure that has presented to the Emergency Department with problems relating to their renal replacement therapy. You note that they are currently receiving peritoneal dialysis.

      In which of the following patient groups with end-stage renal failure should peritoneal dialysis be considered as the initial treatment option, instead of hemodialysis?

      Your Answer: Children aged two years old or younger

      Explanation:

      All individuals diagnosed with stage 5 chronic kidney disease should be given the option to choose between haemodialysis or peritoneal dialysis. Peritoneal dialysis should be prioritized as the preferred treatment for the following groups of patients: those who still have some remaining kidney function, adult patients without major additional health conditions, and children who are two years old or younger.

    • This question is part of the following fields:

      • Nephrology
      63.2
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  • Question 42 - A patient currently undergoing treatment for a malignant condition comes in with a...

    Correct

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

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

      Your Answer: Lung

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Oncological Emergencies
      34.4
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  • Question 43 - A 45 year old patient presents to the emergency department with a head...

    Incorrect

    • A 45 year old patient presents to the emergency department with a head laceration sustained following a fall while under the influence of alcohol. You determine to evaluate the patient's alcohol consumption. Which screening tool does NICE (National Institute for Health and Care Excellence) recommend for assessing risky drinking?

      Your Answer: Child-Pugh

      Correct Answer: AUDIT

      Explanation:

      The AUDIT screening tool is recommended by NICE for identifying patients who may be at risk of hazardous drinking.

      Alcoholic liver disease (ALD) is a spectrum of disease that ranges from fatty liver at one end to alcoholic cirrhosis at the other. Fatty liver is generally benign and reversible with alcohol abstinence, while alcoholic cirrhosis is a more advanced and irreversible form of the disease. Alcoholic hepatitis, which involves inflammation of the liver, can lead to the development of fibrotic tissue and cirrhosis.

      Several factors can increase the risk of progression of ALD, including female sex, genetics, advanced age, induction of liver enzymes by drugs, and co-existent viral hepatitis, especially hepatitis C.

      The development of ALD is multifactorial and involves the metabolism of alcohol in the liver. Alcohol is metabolized to acetaldehyde and then acetate, which can result in the production of damaging reactive oxygen species. Genetic polymorphisms and co-existing hepatitis C infection can enhance the pathological effects of alcohol metabolism.

      Patients with ALD may be asymptomatic or present with non-specific symptoms such as abdominal discomfort, vomiting, or anxiety. Those with alcoholic hepatitis may have fever, anorexia, and deranged liver function tests. Advanced liver disease can manifest with signs of portal hypertension and cirrhosis, such as ascites, varices, jaundice, and encephalopathy.

      Screening tools such as the AUDIT questionnaire can be used to assess alcohol consumption and identify hazardous or harmful drinking patterns. Liver function tests, FBC, and imaging studies such as ultrasound or liver biopsy may be performed to evaluate liver damage.

      Management of ALD involves providing advice on reducing alcohol intake, administering thiamine to prevent Wernicke’s encephalopathy, and addressing withdrawal symptoms with benzodiazepines. Complications of ALD, such as intoxication, encephalopathy, variceal bleeding, ascites, hypoglycemia, and coagulopathy, require specialized interventions.

      Heavy alcohol use can also lead to thiamine deficiency and the development of Wernicke Korsakoff’s syndrome, characterized by confusion, ataxia, hypothermia, hypotension, nystagmus, and vomiting. Prompt treatment is necessary to prevent progression to Korsakoff’s psychosis.

      In summary, alcoholic liver disease is a spectrum of disease that can range from benign fatty liver to irreversible cirrhosis. Risk factors for progression include female sex, genetics, advanced age, drug-induced liver enzyme induction, and co-existing liver conditions.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      38.9
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  • Question 44 - A 32-year-old woman with a history of alcoholic liver disease comes in with...

    Correct

    • A 32-year-old woman with a history of alcoholic liver disease comes in with a fever, abdominal pain, ascites, and worsening hepatic encephalopathy. The doctor suspects spontaneous bacterial peritonitis. Which ONE statement is correct regarding this diagnosis?

      Your Answer: Patients should be administered broad-spectrum antibiotics

      Explanation:

      Spontaneous bacterial peritonitis (SBP) is a sudden bacterial infection of the fluid in the abdomen. It typically occurs in patients with high blood pressure in the portal vein, and about 70% of cases are seen in patients with severe liver disease. In any given year, around 30% of patients with fluid buildup in the abdomen will develop SBP.

      SBP can present with a wide range of symptoms, so it’s important to be vigilant when caring for patients with fluid buildup in the abdomen, especially if there is a sudden decline in their condition. Some patients may not show any symptoms at all.

      Common clinical features of SBP include fever (80% of cases), abdominal pain (70% of cases), worsening or unexplained confusion due to liver dysfunction, diarrhea, nausea and vomiting, and bowel obstruction.

      There are several factors that increase the risk of developing SBP, including severe liver disease (Child-Pugh class C), gastrointestinal bleeding, urinary tract infection, excessive growth of bacteria in the intestines, presence of indwelling lines such as central venous catheters or urinary catheters, previous episodes of SBP, and low levels of protein in the fluid buildup in the abdomen.

      To diagnose SBP, a procedure called abdominal paracentesis is performed to collect fluid from the abdomen. The following findings on fluid analysis strongly suggest SBP: total white blood cell count in the fluid greater than 500 cells/µL, total neutrophil count in the fluid greater than 250 cells/µL, lactate level in the fluid higher than 25 mg/dL, pH of the fluid below 7.35, and presence of bacteria on Gram-stain.

      Patients with SBP should be admitted to the hospital and treated with broad-spectrum antibiotics. The preferred antibiotic is an intravenous third-generation cephalosporin, such as Ceftriaxone. If the patient is allergic to beta-lactam antibiotics, ciprofloxacin can be considered as an alternative. Administration of intravenous albumin has been shown to reduce the risk of kidney failure and death.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      90.2
      Seconds
  • Question 45 - A 45-year-old man presents with palpitations and is found to have atrial fibrillation....

    Correct

    • A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
      Which of the following statements is correct regarding the ECG findings in atrial fibrillation?

      Your Answer: Some impulses are filtered out by the AV node

      Explanation:

      The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.

      In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.

      The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.

    • This question is part of the following fields:

      • Cardiology
      49.8
      Seconds
  • Question 46 - A 5-year-old child develops jaundice and is found to have a diagnosis of...

    Incorrect

    • A 5-year-old child develops jaundice and is found to have a diagnosis of haemolytic disease of the child.
      Which type of hypersensitivity reaction has occurred in this situation?

      Your Answer: Type I hypersensitivity reaction

      Correct Answer: Type II hypersensitivity reaction

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Neonatal Emergencies
      16.3
      Seconds
  • Question 47 - A 5 year old girl is brought into the emergency department after stepping...

    Incorrect

    • A 5 year old girl is brought into the emergency department after stepping on a sharp object while playing barefoot in the backyard. The wound needs to be stitched under anesthesia. While obtaining parental consent from the accompanying adult, you notice that the adult has a different last name than the child. When asking about their relationship to the child, the adult states that they are the child's like a mother and is the partner of the girl's father. What is the term used to describe a parent or guardian who can provide consent on behalf of a child?

      Your Answer: Parental authority

      Correct Answer: Parental responsibility

      Explanation:

      Parental responsibility encompasses the legal rights, duties, powers, responsibilities, and authority that a parent holds for their child. This includes the ability to provide consent for medical treatment on behalf of the child. Any individual with parental responsibility has the authority to give consent for their child. If a father meets any of the aforementioned criteria, he is considered to have parental responsibility. On the other hand, a mother is automatically granted parental responsibility for her child from the moment of birth.

      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
      99.2
      Seconds
  • Question 48 - A 45 year old patient is brought to the emergency department (ED) by...

    Correct

    • A 45 year old patient is brought to the emergency department (ED) by a family member. The patient began experiencing coughing symptoms ten days ago, but within the past 48 hours, they have developed a high fever, difficulty breathing during mild exertion, and the family reports that the patient appears confused. It is noted that the patient is currently taking azathioprine for the treatment of rheumatoid arthritis.

      Upon assessing the patient's vital signs, you decide to initiate the sepsis 6 pathway. What is the recommended timeframe for implementing the 'sepsis six'?

      Your Answer: 1 hour

      Explanation:

      The sepsis 6 pathway is a time-sensitive protocol that should be started promptly and all 6 initial steps should be completed within 1 hour. It is important not to confuse the sepsis 6 pathway with the 6 hour care bundle. Time is of the essence when managing septic patients, and initiating the sepsis 6 pathway immediately has been proven to enhance survival rates in sepsis patients.

      Further Reading:

      There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.

      The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.

      To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.

      There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.

      NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.

    • This question is part of the following fields:

      • Infectious Diseases
      37.8
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  • Question 49 - A 45-year-old male smoker comes in with a severe episode of chest pain...

    Incorrect

    • 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:

      Correct 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
      0
      Seconds
  • Question 50 - You are called into the pediatric resuscitation room to assist with a child...

    Incorrect

    • You are called into the pediatric resuscitation room to assist with a child who has arrested. The team have just started the first cycle of chest compressions and have attached monitoring. You suggest briefly pausing chest compressions to check if the rhythm is shockable.

      How long should the brief pause in chest compressions last?

      Your Answer:

      Correct Answer: ≤ 5 seconds

      Explanation:

      The duration of the pause in chest compressions should be kept short, not exceeding 5 seconds. This applies to both pausing to assess the rhythm and pausing to administer a shock if the rhythm is deemed shockable. It is important to note that a pulse check lasting less than two seconds may fail to detect a palpable pulse, particularly in individuals with a slow heart rate (bradycardia).

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      0
      Seconds
  • Question 51 - A 25-year-old woman with a known history of generalized anxiety disorder presents hyperventilating....

    Incorrect

    • A 25-year-old woman with a known history of generalized anxiety disorder presents hyperventilating. You suspect that she is experiencing a panic attack. She was seen by a resident physician shortly before your assessment, and an arterial blood gas was taken.
      What type of acid-base disorder would you anticipate being caused by hyperventilation secondary to anxiety?

      Your Answer:

      Correct Answer: Respiratory alkalosis

      Explanation:

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

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.

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

      Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).

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

    • This question is part of the following fields:

      • Mental Health
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  • Question 52 - A 45-year-old woman comes in with central chest pain that is spreading to...

    Incorrect

    • A 45-year-old woman comes in with central chest pain that is spreading to her left arm for the past 30 minutes. Her vital signs are as follows: heart rate of 80 beats per minute, blood pressure of 118/72, and oxygen saturation of 98% on room air. The ECG shows the following findings:
      ST depression in leads V1-V4 and aVR
      ST elevation in V5-V6, II, III, and aVF
      Positive R wave in V1 and V2
      What is the most likely diagnosis in this case?

      Your Answer:

      Correct Answer: Acute inferoposterior myocardial infarction

      Explanation:

      The ECG shows the following findings:
      – There is ST depression in leads V1-V4 and aVR.
      – There is ST elevation in leads V5-V6, II, III, and aVF.
      – There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
      These ECG changes indicate that there is an acute inferoposterior myocardial infarction.

    • This question is part of the following fields:

      • Cardiology
      0
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  • Question 53 - A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated...

    Incorrect

    • A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
      Which of the following conditions is associated with ulcerative colitis?

      Your Answer:

      Correct Answer: Cholelithiasis

      Explanation:

      Cholelithiasis is a common occurrence in individuals with Crohn’s disease. There are several other conditions that are known to be associated with Crohn’s disease. These include a higher prevalence in smokers, with approximately 50-60% of patients being smokers. Additionally, individuals with Crohn’s disease may experience aphthous ulcers, uveitis, episcleritis, seronegative spondyloarthropathies, erythema nodosum, pyoderma gangrenosum, finger clubbing, autoimmune hemolytic anemia, and osteoporosis. However, it is important to note that primary biliary cirrhosis, primary sclerosing cholangitis, and chronic active hepatitis are associations commonly seen in ulcerative colitis rather than Crohn’s disease. Lastly, dermatitis herpetiformis is a condition that is associated with coeliac disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      0
      Seconds
  • Question 54 - A 72-year-old man with a known history of heart disease presents due to...

    Incorrect

    • A 72-year-old man with a known history of heart disease presents due to a general decline in his health. He complains of feeling extremely tired and has been experiencing occasional heart palpitations over the past few days. A complete set of blood tests, including a venous gas, have been sent to the laboratory, revealing a potassium level of 7.3 mmol/l. An ECG is performed, which shows abnormal, wide QRS complexes.
      What is the initial treatment that should be administered first?

      Your Answer:

      Correct Answer: IV calcium chloride

      Explanation:

      This patient has been diagnosed with severe hyperkalemia and is showing significant ECG changes. The top priority in this situation is to protect the heart. It is recommended to administer 10 ml of 10% calcium chloride immediately over a period of 2-5 minutes. Calcium helps counteract the harmful effects of hyperkalemia on the heart by stabilizing the cardiac cell membrane and preventing unwanted depolarization.

      Hyperkalemia is a commonly encountered electrolyte disorder, affecting up to 10% of hospitalized patients. It is typically caused by an increase in potassium release from cells or impaired excretion by the kidneys. The main causes of hyperkalemia include renal failure, certain medications (such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs), tissue breakdown (as seen in conditions like tumor lysis, rhabdomyolysis, and hemolysis), metabolic acidosis (often associated with renal failure or diabetic ketoacidosis), and endocrine disorders like Addison’s disease.

      ECG changes that may be observed in hyperkalemia include a prolonged PR interval, peaked T-waves, widening of the QRS complex, reduced or absent P wave, sine wave pattern, AV dissociation, asystole, and bradycardia. It is important to note that the severity of ECG changes may not always correlate with the actual serum potassium levels in a patient.

      The treatment approach for hyperkalemia depends on its severity. Mild hyperkalemia is defined as a potassium level of 5.5-5.9 mmol/L, moderate hyperkalemia as 6.0-6.4 mmol/L, and severe hyperkalemia as >6.5 mmol/L.

      For mild hyperkalemia, the focus should be on addressing the underlying cause and preventing further increase in serum potassium levels. This may involve adjusting medications or dietary changes. If treatment is necessary, potassium exchange resins like calcium resonium can be used to remove potassium from the body.

      In cases of moderate hyperkalemia, the goal is to shift potassium from the extracellular space into the cells. This can be achieved by administering insulin and glucose intravenously. Monitoring blood glucose levels is crucial in this situation. Potassium exchange resins should also be considered, and dialysis may be necessary.

      Severe hyperkalemia without ECG changes requires immediate medical attention.

    • This question is part of the following fields:

      • Nephrology
      0
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  • Question 55 - A 70-year-old man presents to the Emergency Department acutely ill with abdominal and...

    Incorrect

    • A 70-year-old man presents to the Emergency Department acutely ill with abdominal and lower limb pain. He had a syncopal episode in the department and was transferred to the resuscitation area.

      His initial blood results are as follows:
      Na+: 114 mmol/l
      K+: 7.1 mmol/l
      Urea: 17.6 mmol/l
      Creatinine: 150 mmol/l

      What is the most frequent cause of the underlying diagnosis in this scenario?

      Your Answer:

      Correct Answer: Autoimmune adrenalitis

      Explanation:

      Acute adrenal insufficiency, also known as Addisonian crisis, is a rare condition that can have catastrophic consequences if not diagnosed in a timely manner. It is more prevalent in women and typically occurs between the ages of 30 and 50.

      Addison’s disease is caused by a deficiency in the production of steroid hormones by the adrenal glands, affecting glucocorticoid, mineralocorticoid, and sex steroid production. The main causes of Addison’s disease include autoimmune adrenalitis, bilateral adrenalectomy, Waterhouse-Friderichsen syndrome, tuberculosis, and congenital adrenal hyperplasia.

      An Addisonian crisis can be triggered by the intentional or accidental withdrawal of steroid therapy, as well as factors such as infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.

      The 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 in areas such as palmar creases, buccal mucosa, and exposed skin.

      During an Addisonian crisis, the main symptoms are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and even coma.

      Biochemical features that can confirm the diagnosis of Addison’s disease include increased ACTH levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and adrenocortical antibody testing.

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 56 - You intend to administer Midazolam to sedate a patient before reducing a dislocated...

    Incorrect

    • You intend to administer Midazolam to sedate a patient before reducing a dislocated shoulder. Where does the metabolism of Midazolam occur?

      Your Answer:

      Correct Answer: Liver

      Explanation:

      When administering treatment to patients with hepatic impairment, it is crucial to consider that midazolam is metabolized in the liver.

      Further Reading:

      Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.

      There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.

      Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.

      The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.

      Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.

      After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.

    • This question is part of the following fields:

      • Basic Anaesthetics
      0
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  • Question 57 - A 25 year old female comes to the emergency department complaining of a...

    Incorrect

    • A 25 year old female comes to the emergency department complaining of a sore throat that has been bothering her for the past 2 days. She denies having any cough or runny nose. During the examination, her temperature is measured at 37.7°C, blood pressure at 120/68 mmHg, and pulse rate at 88 bpm. The oropharynx and tonsils show signs of redness. The patient's neck is not tender and there are no palpable masses.

      What is the CENTOR score for this patient?

      Your Answer:

      Correct Answer: 1

      Explanation:

      The CENTOR score is a tool used to assess the likelihood of a patient having a streptococcal infection, which is a common cause of sore throat. It is based on four clinical criteria: presence of tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. Each criterion is assigned one point, with a maximum score of four.

      In this case, the patient has a sore throat without cough or runny nose, and her temperature is slightly elevated at 37.7°C. The examination reveals redness in the oropharynx and tonsils, but no tender neck or palpable masses. Based on this information, the patient would score one point on the CENTOR score.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 58 - You evaluate a 82 year old who has been admitted to the emergency...

    Incorrect

    • You evaluate a 82 year old who has been admitted to the emergency department due to high fever and worsening disorientation in the past few days. During chest examination, you observe left basal crackles. A chest X-ray confirms the presence of pneumonia. Your diagnosis is pneumonia with suspected sepsis. What is the mortality rate linked to sepsis?

      Your Answer:

      Correct Answer: 30%

      Explanation:

      The mortality rate linked to sepsis can vary depending on various factors such as the patient’s age, overall health, and the severity of the infection. However, on average, the mortality rate for sepsis is estimated to be around 30%.

      Further Reading:

      There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.

      The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.

      To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.

      There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.

      NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 59 - A 45-year-old woman presents with a history of passing fresh red blood mixed...

    Incorrect

    • A 45-year-old woman presents with a history of passing fresh red blood mixed in with her last two bowel movements. She has had her bowels open three times in the past 24 hours. On examination, she is haemodynamically stable with a pulse of 85 bpm and a BP of 110/70. Her abdomen is soft and nontender, and there is no obvious source of anorectal bleeding on rectal examination.
      Which investigation is recommended first-line for haemodynamically stable patients with lower gastrointestinal bleeds that require hospitalization?

      Your Answer:

      Correct Answer: Colonoscopy

      Explanation:

      The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.

      When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).

      For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.

      Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.

      Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.

      If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.

      If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.

      If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.

      Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.

      In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 60 - A 2-year-old child is diagnosed with a condition that you identify as a...

    Incorrect

    • A 2-year-old child is diagnosed with a condition that you identify as a reportable infection. You fill out the notification form and reach out to the local health protection team.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Mumps

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 61 - A 32-year-old woman comes in with left-sided flank pain and nausea. A urine...

    Incorrect

    • 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:

      Correct 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
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  • Question 62 - A 35 year old man presents to the emergency department complaining of worsening...

    Incorrect

    • A 35 year old man presents to the emergency department complaining of worsening difficulty breathing that has been developing over the last 2 days. His partner mentioned that he looked pale. He informs you that he usually doesn't take any medications but started taking chloroquine for malaria prevention 5 days ago as he is planning to travel to Kenya next week. His oxygen saturation is 89% on room air and you observe that he appears bluish in color. Upon obtaining a blood gas, you notice that his blood has a chocolate-like hue. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Methaemoglobinaemia

      Explanation:

      Methaemoglobinaemia is a condition characterized by various symptoms such as headache, anxiety, acidosis, arrhythmia, seizure activity, reduced consciousness or coma. One notable feature is the presence of brown or chocolate coloured blood. It is important to note that the patient is taking chloroquine, which is a known trigger for methaemoglobinaemia. Additionally, despite the condition, the patient’s arterial blood gas analysis shows a normal partial pressure of oxygen.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Haematology
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  • Question 63 - A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position...

    Incorrect

    • A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position sense, vibratory sense and discriminatory touch. She also complains of blurred vision, and on further examination, you notice that she is unable to move her left eye outward and is tilting her head to the left side. A CT head scan is performed, and she is found to have experienced a left-sided stroke. She is subsequently admitted under the care of the stroke team.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Medial pontine syndrome

      Explanation:

      When the paramedian branches of the basilar artery are blocked, it leads to a condition known as medial pontine syndrome. This syndrome is characterized by several symptoms. Firstly, there is contralateral hemiplegia, which refers to paralysis on the opposite side of the body due to damage to the pyramidal tracts. Additionally, there is contralateral loss of joint position sense, vibratory sense, and discriminatory touch, which occurs as a result of damage to the medial lemniscus. Lastly, individuals with medial pontine syndrome may experience double vision caused by paralysis of the lateral rectus muscle, which is due to damage to the sixth cranial nerve.

    • This question is part of the following fields:

      • Neurology
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  • Question 64 - A child presents with a thermal burn affecting her left hand that occurred...

    Incorrect

    • A child presents with a thermal burn affecting her left hand that occurred in the kitchen while baking. You evaluate the burn and observe that it is a deep partial-thickness burn.
      Which of the following statements about deep partial-thickness burns is accurate?

      Your Answer:

      Correct Answer: They do not blanch with pressure

      Explanation:

      Assessing the depth of a burn is crucial for determining the severity of the injury and planning appropriate wound care. Burns are typically classified as first-, second-, or third-degree, depending on how deeply they penetrate the skin’s surface.

      First-degree burns, also known as superficial burns, only affect the outer layer of skin called the epidermis. These burns are characterized by redness and pain, with dry skin and no blistering. An example of a first-degree burn is mild sunburn. They usually do not require intravenous fluid replacement and are not included in the assessment of the burn’s extent. Long-term tissue damage is rare with these burns.

      Second-degree burns, also called partial-thickness burns, involve both the epidermis and part of the dermis layer of skin. They can be further categorized as superficial partial-thickness or deep partial-thickness burns. Superficial partial-thickness burns are moist, hypersensitive, potentially blistered, uniformly pink, and blanch when touched. Deep partial-thickness burns are drier, less painful, potentially blistered, red or mottled in appearance, and do not blanch when touched.

      Third-degree burns, also known as full-thickness burns, destroy both the epidermis and dermis layers of skin and extend into the subcutaneous tissue. These burns may also damage underlying bones, muscles, and tendons. The burn site appears translucent or waxy white, or it can be charred. Once the epidermis is removed, the underlying dermis may initially appear red but does not blanch under pressure. This dermis is typically dry and does not produce any fluid. Since the nerve endings are destroyed, there is no sensation in the affected area.

    • This question is part of the following fields:

      • Trauma
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  • Question 65 - A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of...

    Incorrect

    • A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of Parkinson's disease is determined.
      Parkinson's disease primarily occurs due to a loss of dopaminergic cells in which anatomical regions?

      Your Answer:

      Correct Answer: Midbrain

      Explanation:

      Parkinson’s disease is primarily characterized by the degeneration of cells in the substantia nigra, a region located in the midbrain. The most severely affected part is the pars compacta, which plays a crucial role in motor control. As a result, there is a significant decrease in the activity of cells that secrete dopamine.

      The main symptoms of Parkinson’s disease include tremors that occur when the body is at rest, rigidity in the muscles, and bradykinesia, which refers to a slowness in movement. These symptoms can greatly impact a person’s ability to perform everyday tasks and can progressively worsen over time.

    • This question is part of the following fields:

      • Neurology
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  • Question 66 - A 45-year-old man presents with severe nausea and recurrent vomiting. The vomiting episodes...

    Incorrect

    • A 45-year-old man presents with severe nausea and recurrent vomiting. The vomiting episodes occur every few weeks and are accompanied by colicky abdominal pain. However, his bowel movements are normal. He reports that the only relief he gets during these episodes is by taking hot baths. He has no significant medical history but admits to being a heavy and regular cannabis user. A complete set of blood tests and an abdominal X-ray are performed, both of which come back normal.
      What is the most probable diagnosis in this case?

      Your Answer:

      Correct Answer: Cannabinoid hyperemesis syndrome

      Explanation:

      Cannabinoid hyperemesis syndrome (CHS) is an extremely rare form of cannabinoid toxicity that occurs in chronic smokers. It is characterized by recurring episodes of severe nausea and vomiting. One distinctive feature of this syndrome is that individuals who suffer from it often find relief from their symptoms by taking hot baths or showers, and they may compulsively bathe during episodes of nausea and vomiting.

      CHS typically develops in heavy, long-term cannabis users who consume the drug multiple times a day for many years. On average, symptoms appear after about 16 years of cannabis use, although some patients may experience symptoms after as little as three years.

      In 2009, Sontineni and colleagues established criteria for diagnosing cannabinoid hyperemesis syndrome. These criteria include essential factors such as long-term cannabis use, major factors like severe nausea and vomiting that occur in a cyclic pattern over months, and resolution of symptoms after discontinuing cannabis use. Supportive criteria include compulsive hot baths with symptom relief, colicky abdominal pain, and no evidence of inflammation in the gallbladder or pancreas.

      The exact cause of CHS is not fully understood, but there are two main theories. One theory suggests that the syndrome is a result of a build-up of cannabinoids in the body, which leads to toxicity. Another theory proposes that the functionality of cannabinoid receptors in the brain, particularly in the hypothalamus, is affected, resulting in CHS.

      Most conventional anti-emetic drugs are effective in treating the vomiting phase of CHS. During acute episodes, it is important to monitor the patient’s hydration status as the combination of hot baths and prolonged vomiting can lead to cannabinoid hyperemesis acute renal failure (CHARF). This can be easily prevented and treated with intravenous fluids.

      Once the acute episode of vomiting and dehydration has been addressed, the condition can be easily cured by discontinuing cannabis consumption.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 67 - A 32-year-old male patient complains of a painless, solid lump in the body...

    Incorrect

    • A 32-year-old male patient complains of a painless, solid lump in the body of his left testis. Upon examination, the lump is firm, located within the testis, and does not show transillumination.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer:

      Correct Answer: Testicular cancer

      Explanation:

      Testicular cancer is the most common form of cancer that affects men between the ages of 20 and 34. In recent times, there have been campaigns aimed at raising awareness about the importance of self-examination for early detection. Some risk factors for this type of cancer include having undescended testes, especially if it affects both testicles, which increases the risk by ten times. Additionally, individuals who have had testicular cancer in the past have a 4% chance of developing a second cancer.

      The typical presentation of testicular cancer is a painless swelling in the testicles. When examined, the swelling feels hard and is located within the testis. It cannot be illuminated when light is shone through it. Approximately 60% of cases are seminomas, which are slow-growing and usually confined to the testis at the time of diagnosis. If seminomas are diagnosed at stage 1 (confined to the testis only), the 5-year survival rate is 98%. The remaining 40% of cases are teratomas, which can grow at a faster rate and often coexist with seminomas. In cases where the tumors are of mixed type, they are treated as teratomas due to their more aggressive nature. The main treatment for testicular cancer is surgery, with the possibility of additional chemotherapy and radiotherapy.

    • This question is part of the following fields:

      • Urology
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  • Question 68 - A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing,...

    Incorrect

    • A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing, and wheezing. Blood tests reveal an elevated packed cell volume (PCV). A chest X-ray shows more than 6 ribs visible above the diaphragm in the midclavicular line. An arterial blood gas indicates slightly low pO2 levels.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: COPD

      Explanation:

      Based on the provided information, it is highly probable that this patient is suffering from chronic obstructive pulmonary disease (COPD). This conclusion is supported by several factors. Firstly, the patient has a history of chronic productive cough and wheezing, which are common symptoms of COPD. Additionally, the patient has a long-term smoking history, which is a major risk factor for developing this condition.

      Furthermore, the patient’s raised packed cell volume (PCV) is likely a result of chronic hypoxemia, a common complication of COPD. This indicates that the patient’s body is trying to compensate for the low oxygen levels in their blood.

      Moreover, the chest X-ray reveals evidence of hyperinflation, which is a characteristic finding in patients with COPD. This suggests that the patient’s lungs are overinflated and not functioning optimally.

      Lastly, the arterial blood gas analysis shows hypoxemia, indicating that the patient has low levels of oxygen in their blood. This is another significant finding that aligns with a diagnosis of COPD.

      In summary, based on the patient’s history, smoking habits, raised PCV, chest X-ray findings, and arterial blood gas results, it is highly likely that they have COPD.

    • This question is part of the following fields:

      • Respiratory
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  • Question 69 - You review a patient with Sheehan’s syndrome following a postpartum hemorrhage. She would...

    Incorrect

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

      Your Answer:

      Correct Answer: Diabetes insipidus may occur

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 70 - A 37 year old woman presents to the emergency department with complaints of...

    Incorrect

    • A 37 year old woman presents to the emergency department with complaints of headache, profuse sweating, and heart palpitations. Upon examination, her blood pressure is measured at 228/114 mmHg. The possibility of phaeochromocytoma crosses your mind. Where do phaeochromocytomas typically originate within the adrenal tissue?

      Your Answer:

      Correct Answer: Medulla

      Explanation:

      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
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  • Question 71 - A 60-year-old woman comes in with a nosebleed that began after blowing her...

    Incorrect

    • A 60-year-old woman comes in with a nosebleed that began after blowing her nose an hour ago. You assessed her when she arrived 30 minutes ago and recommended that she try to stop the bleeding by pinching the soft, cartilaginous part of her nose. She has been doing this since then, but her nose is still bleeding. During the examination, you notice a small and easily visible bleeding spot in her right nostril.
      What is the most suitable next step to take?

      Your Answer:

      Correct Answer: Perform nasal cautery

      Explanation:

      When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s airway and circulation.

      If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated. Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula and collect blood samples for tests such as full blood count, urea and electrolytes, clotting studies, and blood typing and crossmatching (depending on the amount of blood loss). These patients should be closely monitored in a majors area or a designated observation area, as dislodgement of a blood clot can lead to severe bleeding.

      First aid measures to control bleeding include the following steps:
      1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there are signs of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the back of the throat.
      2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
      3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
      4. If the patient is unable to comply with pinching their own nose, an alternative technique is to ask a relative or staff member to apply external pressure using a device like a swimmer’s nose clip.
      5. It is important to dispel the misconception that compressing the bones of the nose will help stop the bleeding. Applying ice to the neck or forehead has not been proven to affect nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may help reduce nasal blood flow.

      If bleeding stops with first aid measures, it may be beneficial to apply a topical antiseptic preparation to reduce crusting and inflammation. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 72 - A 10-year-old girl comes in with sudden abdominal pain. She has a high...

    Incorrect

    • A 10-year-old girl comes in with sudden abdominal pain. She has a high temperature and feels very nauseous. During the examination, she experiences tenderness in the right iliac fossa. You suspect she may have acute appendicitis.
      What is the surface marking for McBurney's point in this case?

      Your Answer:

      Correct Answer: One-third of the distance from the anterior superior iliac spine to the umbilicus

      Explanation:

      Appendicitis is a condition characterized by the acute inflammation of the appendix. It is a common cause of the acute abdomen, particularly affecting children and young adults in their 20s and 30s. The typical presentation of appendicitis involves experiencing poorly localized periumbilical pain, which is pain originating from the visceral peritoneum. Within a day or two, this pain tends to localize to a specific point known as McBurney’s point, which is associated with pain from the parietal peritoneum. Alongside the pain, individuals with appendicitis often experience symptoms such as fever, loss of appetite, and nausea.

      McBurney’s point is defined as the point that lies one-third of the distance from the anterior superior iliac spine to the umbilicus. This point roughly corresponds to the most common position where the base of the appendix attaches to the caecum.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 73 - A 68 year old man has been kept on the observation ward overnight...

    Incorrect

    • A 68 year old man has been kept on the observation ward overnight due to a head injury and is scheduled for discharge. While eating a sandwich, he starts coughing violently. His face is turning cyanosed and he is having difficulty breathing. The cough seems ineffective at clearing his throat. He remains conscious, coughing, and exhibits noticeable stridor. What is the most suitable immediate course of action?

      Your Answer:

      Correct Answer: Give 5 back blows or 5 abdominal thrusts

      Explanation:

      When an adult patient is choking and unable to clear the obstruction by coughing, the next step is to deliver either 5 back blows or abdominal thrusts. The appropriate action depends on the severity of the airway obstruction. If the choking is mild and not causing significant difficulty in breathing, it is recommended to encourage the patient to cough and closely monitor for any worsening symptoms. However, if the choking is severe and causing a complete blockage of the airway, it is necessary to administer either back blows or abdominal thrusts to dislodge the obstruction. In the event that the patient loses consciousness, immediate CPR should be initiated.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 74 - A 45-year-old patient presents with a painful, swollen left knee. His symptoms started...

    Incorrect

    • A 45-year-old patient presents with a painful, swollen left knee. His symptoms started three days ago. He has no history of injury, and a joint aspirate is sent for laboratory testing. The aspirate reveals pus cells, negatively birefringent crystals, and no presence of organisms.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Gout

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 75 - A 65-year-old man presents with unintentional weight loss and a noticeable lump in...

    Incorrect

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

      Your Answer:

      Correct Answer: Left iliac fossa

      Explanation:

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

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 76 - You are participating in expedition medicine training organized by your emergency department. The...

    Incorrect

    • You are participating in expedition medicine training organized by your emergency department. The training session is centered on identifying and handling altitude illnesses. At what elevation does altitude sickness usually begin to manifest?

      Your Answer:

      Correct Answer: 2500 metres

      Explanation:

      Altitude sickness is usually experienced at altitudes above 2,500 meters (8,000 ft), although some individuals may be affected at lower altitudes. It is important to note that climbers in the UK, where the highest peak is Ben Nevis at 1,345 meters, do not need to worry about altitude sickness.

      Further Reading:

      High Altitude Illnesses

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 77 - You are summoned to the resuscitation bay to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a head injury. A fellow healthcare provider informs you that the patient is exhibiting Cushing's triad of symptoms. What is the most accurate description of Cushing's triad?

      Your Answer:

      Correct Answer: Widened pulse pressure, bradycardia and bradypnoea

      Explanation:

      Cushing’s triad is a combination of widened pulse pressure, bradycardia, and reduced respirations. It is a physiological response of the nervous system to acute increases in intracranial pressure (ICP). This response, known as the Cushing reflex, can cause the symptoms of Cushing’s triad. These symptoms include an increase in systolic blood pressure and a decrease in diastolic blood pressure, a slower heart rate, and irregular or reduced breathing. Additionally, raised ICP can also lead to other symptoms such as headache, papilloedema, and vomiting.

      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:

      • Endocrinology
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  • Question 78 - 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, yellowish vaginal discharge. A pregnancy test done today is negative. She has a temperature of 39.1°C, and there is tenderness in her abdomen during the examination.

      What is the MOST suitable treatment plan?

      Your Answer:

      Correct Answer: IV ceftriaxone and metronidazole plus oral doxycycline

      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
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  • Question 79 - A young hiker who got stranded while hiking in freezing temperatures is brought...

    Incorrect

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

      Your Answer:

      Correct Answer: 50%

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 80 - A 52-year-old woman comes in with a history of two episodes of atrial...

    Incorrect

    • A 52-year-old woman comes in with a history of two episodes of atrial fibrillation (AF). The most recent episode lasted for six days before resolving on its own. How would you classify the type of AF she has experienced?

      Your Answer:

      Correct Answer: Paroxysmal

      Explanation:

      In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.

      Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.

      Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.

      Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.

      By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.

    • This question is part of the following fields:

      • Cardiology
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  • Question 81 - A 32-year-old woman is given trimethoprim for a urinary tract infection while in...

    Incorrect

    • A 32-year-old woman is given trimethoprim for a urinary tract infection while in her second trimester of pregnancy. As a result of this medication, the baby develops a birth defect.
      What is the most probable abnormality that will occur as a result of using this drug during pregnancy?

      Your Answer:

      Correct Answer: Neural tube defect

      Explanation:

      During the first trimester of pregnancy, the use of trimethoprim is linked to an increased risk of neural tube defects because it antagonizes folate. If it is not possible to use an alternative antibiotic, it is recommended that pregnant women taking trimethoprim also take high-dose folic acid. However, the use of trimethoprim in the second and third trimesters of pregnancy is considered safe.

      Below is a list outlining the commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If given in the second and third trimesters, they can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): They can cause ototoxicity and deafness.

      Aspirin: High doses can lead to 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 (e.g. diazepam): When given late in pregnancy, they can cause respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, they can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.

      Carbamazepine: It can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: It can cause grey baby syndrome.

      Corticosteroids: If given in the first trimester, they may cause orofacial clefts.

      Danazol: If given in the first trimester, it can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol: If given in the first trimester, it may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: It can cause maternal bleeding and thrombocytopenia.

      Isoniazid: It can lead to maternal liver damage and neuropathy and seizures in the neonate.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 82 - A 62 year old female presents to the emergency department 1 hour after...

    Incorrect

    • A 62 year old female presents to the emergency department 1 hour after experiencing intense tearing chest pain that radiates to the back. The patient reports the pain as being extremely severe, rating it as 10/10. It is noted that the patient is prescribed medication for high blood pressure but admits to rarely taking the tablets. The patient's vital signs are as follows:

      Blood pressure: 188/92 mmHg
      Pulse rate: 96 bpm
      Respiration rate: 23 rpm
      Oxygen saturation: 98% on room air
      Temperature: 37.1ºC

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Aortic dissection

      Explanation:

      The majority of dissections happen in individuals between the ages of 40 and 70, with the highest occurrence observed in the age group of 50 to 65.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
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  • Question 83 - A 68-year-old woman presents with a 4-month history of easy bruising and fatigue....

    Incorrect

    • A 68-year-old woman presents with a 4-month history of easy bruising and fatigue. She has also experienced frequent nosebleeds over the past few weeks. She has had two respiratory infections and a urinary tract infection in the recent months and reports feeling unwell. You have arranged for her to undergo a series of blood tests, and the results of her complete blood count are as follows:

      Hemoglobin (Hb): 7.4 g/dl (13-17 g/dl)
      Mean Corpuscular Volume (MCV): 103 fl (80-100 fl)
      Platelets: 46 x 109/l (150-400 x 109/l)
      White Blood Cell Count (WCC): 4.4 x 109/l (4-11 x 109/l)
      Neutrophils: 0.8 x 109/l (2.5-7.5 x 109/l)
      Lymphocytes: 3.4 x 109/l (1.3-3.5 x 109/l)
      Monocytes: 0.4 x 109/l (0.2-0.8 x 109/l)
      Reticulocytes: 70 x 109/l (50-100 x 109/l)

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Myelodysplastic syndrome

      Explanation:

      Myelodysplastic syndromes are a group of disorders affecting the haemopoietic stem cell, leading to ineffective production of myeloid blood cells. These conditions typically manifest between the ages of 60 and 75 and are more prevalent in men than women.

      The clinical features of myelodysplastic syndromes include tiredness due to anaemia (the most common presentation), easy bruising, and a tendency to bleed. Laboratory findings often reveal anaemia (usually macrocytic or normocytic), neutropenia, thrombocytopenia, and abnormal cell morphology with oddly shaped macrocytes.

      Chronic lymphocytic leukaemia (CLL) is the most common form of adult leukaemia, primarily affecting B-lymphocytes. It often presents asymptomatically in patients who undergo routine blood tests revealing elevated white cell counts and lymphocytosis. Men over the age of 50 account for over 75% of CLL cases. Blood films typically show a predominance of mature-looking lymphocytes and smear cells.

      Iron deficiency anaemia is characterized by hypochromic microcytic anaemia and a reduced red blood cell count. Peripheral blood smears in iron deficiency anaemia may exhibit poikilocytosis (varying shapes) and anisocytosis (varying sizes). Pencil cells are also observed in this condition.

      Vitamin B12 and folate deficiency can also cause macrocytic anaemia. However, the severity of anaemia and macrocytosis would generally need to be much more pronounced to result in neutropenia and thrombocytopenia. Therefore, a myelodysplastic syndrome is more likely in such cases.

    • This question is part of the following fields:

      • Haematology
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  • Question 84 - A 28 year old male arrives at the emergency department with a complaint...

    Incorrect

    • A 28 year old male arrives at the emergency department with a complaint of a painful throat that began 5 days ago but has worsened significantly in the last 24 hours. The patient is experiencing difficulty in opening his mouth due to the pain. Upon examination, you determine that the patient is suffering from a peritonsillar abscess. What is the most probable causative organism in this case?

      Your Answer:

      Correct Answer: Streptococcus pyogenes

      Explanation:

      The most probable causative organism in a case of peritonsillar abscess is Streptococcus pyogenes.

      A peritonsillar abscess, also known as quinsy, is a collection of pus that forms between the palatine tonsil and the pharyngeal muscles. It is often a complication of acute tonsillitis and is most commonly seen in adolescents and young adults. The exact cause of a peritonsillar abscess is not fully understood, but it is believed to occur when infection spreads beyond the tonsillar capsule or when small salivary glands in the supratonsillar space become blocked.

      The most common causative organisms for a peritonsillar abscess include Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and anaerobic organisms. Risk factors for developing a peritonsillar abscess include smoking, periodontal disease, male sex, and a previous episode of the condition.

      Clinical features of a peritonsillar abscess include severe throat pain, difficulty opening the mouth (trismus), fever, headache, drooling of saliva, bad breath, painful swallowing, altered voice, ear pain on the same side, neck stiffness, and swelling of the soft palate. Diagnosis is usually made based on clinical presentation, but imaging scans such as CT or ultrasound may be used to assess for complications or determine the best site for drainage.

      Treatment for a peritonsillar abscess involves pain relief, intravenous antibiotics to cover for both aerobic and anaerobic organisms, intravenous fluids if swallowing is difficult, and drainage of the abscess either through needle aspiration or incision and drainage. Tonsillectomy may be recommended to prevent recurrence. Complications of a peritonsillar abscess can include sepsis, spread to deeper neck tissues leading to necrotizing fasciitis or retropharyngeal abscess, airway compromise, recurrence of the abscess, aspiration pneumonia, erosion into major blood vessels, and complications related to the causative organism. All patients with a peritonsillar abscess should be referred to an ear, nose, and throat specialist for further management.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 85 - You are evaluating a patient in the Emergency Department who has been treated...

    Incorrect

    • You are evaluating a patient in the Emergency Department who has been treated for a head injury. He has recently been advised by his doctor to cease driving, but his daughter informs you that he is still driving.
      What would be the initial course of action to take in this situation?

      Your Answer:

      Correct Answer: Talk to the patient and ascertain whether he understands the risks to himself and others and see if you can help him realise that he should stop driving

      Explanation:

      This question evaluates your ability to effectively communicate while promoting patient self-care and understanding of managing long-term conditions.

      The most appropriate answer would be to initially talk to the patient himself. This approach allows for an assessment of the patient’s capacity to make decisions on his own. It is a gentle approach that respects his ability to make safe and sensible decisions.

      In some cases, it can be helpful to include other close family members or friends when explaining a situation to a patient. However, it is important to avoid being coercive. While this option may be a good choice, it is not the best first step to take.

      If all reasonable means have been tried and the patient continues to drive, there may come a time when it is necessary to contact the DVLA. However, this should be expressed in a less confrontational manner.

      Suggesting to the patient’s wife to sell the car is not appropriate as it is not your place to make such a suggestion. Additionally, his wife may still need to use the car even if he cannot drive. This is not a suggestion that should be made by you.

      It is not necessary to inform the DVLA immediately, as this could negatively impact the doctor-patient relationship in the future.

      For more information, you can refer to the DVLA guidance on medical conditions affecting driving.

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 86 - A 14-year-old girl comes in with a sudden onset of a painful throat...

    Incorrect

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

      Your Answer:

      Correct Answer: 5

      Explanation:

      Two scoring systems are suggested by NICE to aid in the evaluation of sore throat: The Centor Clinical Prediction Score and The FeverPAIN Score.

      The FeverPAIN score was developed from a study involving 1760 adults and children aged three and above. The score was tested in a trial that compared three prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, or a combination of the score with the use of a near-patient test (NPT) for streptococcus. Utilizing the score resulted in faster symptom resolution and a reduction in the prescription of antibiotics (both reduced by one third). The inclusion of the NPT did not provide any additional benefit.

      The score comprises of five factors, each of which is assigned one point: Fever (Temp >38°C) in the last 24 hours, Purulence, Attended rapidly in under three days, Inflamed tonsils, and No cough or coryza.

      Based on the score, the recommendations are as follows:
      – Score 0-1 = 13-18% likelihood of streptococcus infection, antibiotics are not recommended.
      – Score 2-3 = 34-40% likelihood of streptococcus infection, consider delayed prescribing of antibiotics (3-5 day ‘backup prescription’).
      – Score 4-5 = 62-65% likelihood of streptococcus infection, use immediate antibiotics if severe, or a 48-hour short ‘backup prescription.’

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 87 - You are requested to standby in the resuscitation bay for a 28-year-old patient...

    Incorrect

    • You are requested to standby in the resuscitation bay for a 28-year-old patient who is being transported to the emergency department after being hit in the face by the side mirror of a passing truck. The paramedics inform you that the patient is suspected to have a Le Fort III fracture. What characteristic differentiates a Le Fort III fracture from a Le Fort II fracture?

      Your Answer:

      Correct Answer: Involvement of the zygomatic arch

      Explanation:

      Le Fort III fractures can be distinguished from Le Fort II fractures by the presence of damage to the zygomatic arch.

      Further Reading:

      The Le Fort fracture classification describes three fracture patterns seen in midface fractures, all involving the maxilla and pterygoid plate disruption. As the classification grading increases, the anatomic level of the maxillary fracture ascends from inferior to superior.

      Le Fort I fractures, also known as floating palate fractures, typically result from a downward blow struck above the upper dental row. Signs include swelling of the upper lip, bruising to the upper buccal sulcus, malocclusion, and mobile upper teeth.

      Le Fort II fractures, also known as floating maxilla fractures, are typically the result of a forceful blow to the midaxillary area. Signs include a step deformity at the infraorbital margin, oedema over the middle third of the face, sensory disturbance of the cheek, and bilateral circumorbital ecchymosis.

      Le Fort III fractures, also known as craniofacial dislocation or floating face fractures, are typically the result of high force blows to the nasal bridge or upper maxilla. These fractures involve the zygomatic arch and extend through various structures in the face. Signs include tenderness at the frontozygomatic suture, lengthening of the face, enophthalmos, and bilateral circumorbital ecchymosis.

      Management of Le Fort fractures involves securing the airway as a priority, following the ABCDE approach, and identifying and managing other injuries, especially cervical spine injuries. Severe bleeding may occur and should be addressed appropriately. Surgery is almost always required, and patients should be referred to maxillofacial surgeons. Other specialties, such as neurosurgery and ophthalmology, may need to be involved depending on the specific case.

    • This question is part of the following fields:

      • Maxillofacial & Dental
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  • Question 88 - Your supervisor requests you to arrange a training session for the new medical...

    Incorrect

    • Your supervisor requests you to arrange a training session for the new medical interns on diabetes mellitus and hypoglycemia. Which of the following statements is accurate?

      Your Answer:

      Correct Answer: Glucose levels should be checked 10-15 minutes after administering glucagon

      Explanation:

      After administering any treatment for hypoglycemia, it is important to re-check glucose levels within 10-15 minutes. This allows for a reassessment of the effectiveness of the treatment and the possibility of administering additional treatment if needed. Obesity is a significant risk factor for developing type 2 diabetes, while most individuals with type 1 diabetes have a body mass index (BMI) below 25 kg/m2. It is crucial to provide carbohydrates promptly after treating hypoglycemia. The correct dose of glucagon for treating hypoglycemia in adults is 1 mg, and the same dose can be used for children aged 9 and above who weigh more than 25kg. HbA1c results between 42 and 47 indicate pre-diabetes.

      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
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  • Question 89 - You review a 65-year-old woman who is on the clinical decision unit (CDU)...

    Incorrect

    • You review a 65-year-old woman who is on the clinical decision unit (CDU) following a fall. Her son is present, and he is concerned about recent problems she has had with memory loss. He is very worried that she may be showing signs of developing dementia.

      Which of the following is the most prevalent type of dementia?

      Your Answer:

      Correct Answer: Alzheimer’s disease

      Explanation:

      Alzheimer’s disease is the most prevalent type of dementia, making up around 55-60% of all cases. In the UK, the occurrence of Alzheimer’s disease is approximately 5 per 1000 person-years, and the likelihood of developing it increases with age.

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 90 - A 7-year-old boy presents with a sore throat and a dry cough that...

    Incorrect

    • A 7-year-old boy presents with a sore throat and a dry cough that has been present for five days. He has no medical history of note, takes no medication and reports no known drug allergies. On examination, he is febrile with a temperature of 38.5°C and has a few tender anterior cervical lymph nodes. His throat and tonsils appear red and inflamed, and you can see copious exudate on his right tonsil.
      Using the FeverPAIN Score to assess his sore throat, which of the following would be the MOST APPROPRIATE management for him at this stage?

      Your Answer:

      Correct Answer: She should be offered a 'back-up prescription' for penicillin V

      Explanation:

      The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

      The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

      According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 91 - A 35-year-old female smoker presents with an episode of acute right-sided chest pain....

    Incorrect

    • A 35-year-old female smoker presents with an episode of acute right-sided chest pain. She describes the pain as being ‘extremely severe’, and it is aggravated by movement and coughing. The pain radiates to her neck and shoulder on the affected side. Her vital signs are within normal limits, and her oxygen saturation is 98% on room air. On examination, she exhibits localized tenderness around the 4th rib on the right-hand side. Her lung fields are clear, and her heart sounds are normal.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Tietze’s syndrome

      Explanation:

      Tietze’s syndrome is an uncommon condition that leads to localized pain and tenderness in one or more of the upper four ribs, with the second and third ribs being the most commonly affected. The exact cause of this syndrome is still unknown, although it has been suggested that it may be linked to repeated small injuries to the chest wall.

      The pain experienced in Tietze’s syndrome is typically aggravated by movement, sneezing, and coughing, and it can also extend to the neck or shoulder on the affected side. In some cases, a firm swelling can be felt over the cartilage of the affected rib. While the pain usually diminishes after a few weeks or months, the swelling may persist.

      Treatment for Tietze’s syndrome involves the use of pain-relieving medications, such as NSAIDs. In more severe or persistent cases, local steroid injections may be beneficial.

    • This question is part of the following fields:

      • Cardiology
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  • Question 92 - A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has...

    Incorrect

    • A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has been feeling extremely tired and has been experiencing worsening nausea over the past few days. She also complains of intermittent chest pain. The patient mentions that her urine has been dark in color. She has no significant medical history and smokes 10 cigarettes per day. On examination, she appears pale and has inspiratory crackles at both bases. Her blood pressure is elevated at 175/94 mmHg. Urinalysis reveals proteinuria and microscopic haematuria.

      Her blood results today are as follows:
      Hb 8.4 g/dl (13-17 g/dl)
      MCV 69 fl (76-96 fl)
      WCC 21.5 x 109/l (4-11 x 109/l)
      Neutrophils 17.2 x 109/l (2.5-7.5 x 109/l)
      Na 134 mmol/l (133-147 mmol/l)
      K 4.2 mmol/l (3.5-5.0 mmol/l)
      Creat 232 micromol/l (60-120 micromol/l)
      Urea 12.8 mmol/l (2.5-7.5 mmol/l)

      Which SINGLE investigation will confirm the diagnosis in this case?

      Your Answer:

      Correct Answer: Renal biopsy

      Explanation:

      The most probable diagnosis in this situation is Goodpasture’s syndrome, a rare autoimmune vasculitic disorder characterized by three main symptoms: pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more prevalent in men, particularly in smokers. It is also associated with HLA-B7 and HLA-DRw2.

      The clinical manifestations of Goodpasture’s syndrome include constitutional symptoms like fever, fatigue, nausea, and weight loss. Patients may also experience hemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to bleeding within the lungs, arthralgia, rapidly progressive glomerulonephritis, hematuria, hypertension, and rarely hepatosplenomegaly may also be present.

      Blood tests will reveal iron deficiency anemia, an elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis, which also cause renal impairment and pulmonary hemorrhage.

      Diagnosis is typically confirmed through a renal biopsy, which can detect the presence of anti-GBM antibodies. This would be the most appropriate investigation to confirm the diagnosis in this case.

      The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.

    • This question is part of the following fields:

      • Respiratory
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  • Question 93 - You evaluate a 35-year-old male patient who has been diagnosed with an anal...

    Incorrect

    • You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
      What would be the most suitable next step in managing this patient's condition?

      Your Answer:

      Correct Answer: Botulinum toxin injection

      Explanation:

      An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.

      Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.

      The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)

      Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 94 - A 35-year-old woman presents with a swollen, red, and warm right knee. She...

    Incorrect

    • A 35-year-old woman presents with a swollen, red, and warm right knee. She has recently returned from a trip to Tokyo. During examination, her temperature is 38.6°C, and she has a rash with small blisters on her chest. The knee feels warm to touch and is immobile. Attempts to bend or straighten the knee are unsuccessful. A joint fluid sample is taken, revealing the presence of Gram-negative diplococci.
      What is the most likely organism responsible for this condition?

      Your Answer:

      Correct Answer: Neisseria gonorrhoea

      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 symptoms.

      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 infection, vancomycin should be used. For 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)
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  • Question 95 - A 25 year old male presents to the emergency department complaining of a...

    Incorrect

    • A 25 year old male presents to the emergency department complaining of a sore throat and fever that has been bothering him for the past 2 days. The patient is specifically asking for a prescription for antibiotics. Which scoring system would be the most suitable for evaluating the patient's requirement for antibiotics?

      Your Answer:

      Correct Answer: FeverPAIN

      Explanation:

      The FeverPAIN score is a clinical scoring system that helps determine the probability of streptococcal infection and the necessity of antibiotic treatment. NICE recommends using either the CENTOR or FeverPAIN clinical scoring systems to assess the likelihood of streptococcal infection and the need for antibiotics. The RSI score is utilized to evaluate laryngopharyngeal reflux, while the CSMCPI is employed to predict clinical outcomes in patients with upper gastrointestinal bleeding. Lastly, the Mallampati score is used to assess the oropharyngeal space and predict the difficulty of endotracheal intubation.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 96 - A 35-year-old man is brought into the emergency room by an ambulance with...

    Incorrect

    • A 35-year-old man is brought into the emergency room by an ambulance with flashing lights. He has been involved in a building fire and has sustained severe burns. You evaluate his airway and have concerns about potential airway blockage. You decide to perform intubation on the patient and begin preparing the required equipment.
      Which of the following is NOT a reason for performing early intubation in a burn patient?

      Your Answer:

      Correct Answer: Superficial partial-thickness circumferential neck burns

      Explanation:

      Early assessment of the airway is a critical aspect of managing a burned patient. Airway obstruction can occur rapidly due to direct injury or swelling from the burn. If there is a history of trauma, the airway should be evaluated while maintaining cervical spine control.

      There are several risk factors for airway obstruction in burned patients, including inhalation injury, soot in the mouth or nostrils, singed nasal hairs, burns to the head, face, and neck, burns inside the mouth, large burn area and increasing burn depth, associated trauma, and a carboxyhemoglobin level above 10%.

      In cases where significant swelling is anticipated, it may be necessary to urgently secure the airway with an uncut endotracheal tube before the swelling becomes severe. Delaying recognition of impending airway obstruction can make intubation difficult, and a surgical airway may be required.

      The American Burn Life Support (ABLS) guidelines recommend early intubation in certain situations. These include signs of airway obstruction, extensive burns, deep facial burns, burns inside the mouth, significant swelling or risk of swelling, difficulty swallowing, respiratory compromise, decreased level of consciousness, and anticipated transfer of a patient with a large burn and airway issues without qualified personnel to intubate during transport.

      Circumferential burns of the neck can cause tissue swelling around the airway, making early intubation necessary in these cases as well.

    • This question is part of the following fields:

      • Trauma
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  • Question 97 - A 32 year old woman arrives at the emergency department complaining of abdominal...

    Incorrect

    • A 32 year old woman arrives at the emergency department complaining of abdominal pain, fever, and yellowing of her skin and eyes. Upon examination, it is evident that she is clinically jaundiced. The patient has a history of intravenous drug use. You suspect she may have acute hepatitis B infection. Which of the following serology results would best support this diagnosis?

      Your Answer:

      Correct Answer: HBsAg positive and anti-HBc IgM positive

      Explanation:

      The presence of serum HBsAg for more than 6 months indicates chronic HBV infection. HBeAg can be detected in the serum during the early stages of acute infection and some chronic infections. Higher levels of virus replication are usually associated with the presence of HBeAg, making individuals with chronic HBV more infectious. If HBeAg is cleared, anti-HBe is typically detected, indicating lower infectivity. The presence of anti-HBe, along with a decline in HBV-DNA, suggests control of viral replication and the likelihood of resolving acute hepatitis B. The presence of anti-HBc indicates current or past HBV infection, appearing at the onset of symptoms in acute infection and persisting for life. However, it may be absent in the early stages of acute infection. Anti-HBc IgM indicates recent HBV infection within the last six months and can help differentiate between acute and chronic infection. Over time, it is gradually replaced by IgG anti-HBc. IgG anti-HBc generally persists for life and indicates past infection. Anti-HBs indicates recovery from and immunity to HBV. If anti-HBs is present without anti-HBc, it suggests immunization. The quantification of anti-HBs is used to measure the response to vaccination.

      Further Reading:

      Hepatitis B is a viral infection that is transmitted through exposure to infected blood or body fluids. It can also be passed from mother to child during childbirth. The incubation period for hepatitis B is typically 6-20 weeks. Common symptoms of hepatitis B include fever, jaundice, and elevated liver transaminases.

      Complications of hepatitis B infection can include chronic hepatitis, which occurs in 5-10% of cases, fulminant liver failure, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa, and cryoglobulinemia.

      Immunization against hepatitis B is recommended for various at-risk groups, including healthcare workers, intravenous drug users, sex workers, close family contacts of infected individuals, and those with chronic liver disease or kidney disease. The vaccine contains HBsAg adsorbed onto an aluminum hydroxide adjuvant and is prepared using recombinant DNA technology. Most vaccination schedules involve three doses of the vaccine, with a booster recommended after 5 years.

      Around 10-15% of adults may not respond adequately to the vaccine. Risk factors for poor response include age over 40, obesity, smoking, alcohol excess, and immunosuppression. Testing for anti-HBs levels is recommended for healthcare workers and patients with chronic kidney disease. Interpretation of anti-HBs levels can help determine the need for further vaccination or testing for infection.

      In terms of serology, the presence of HBsAg indicates acute disease if present for 1-6 months, and chronic disease if present for more than 6 months. Anti-HBs indicates immunity, either through exposure or immunization. Anti-HBc indicates previous or current infection, with IgM anti-HBc appearing during acute or recent infection and IgG anti-HBc persisting. HbeAg is a marker of infectivity.

      Management of hepatitis B involves notifying the Health Protection Unit for surveillance and contact tracing. Patients should be advised to avoid alcohol and take precautions to minimize transmission to partners and contacts. Referral to a gastroenterologist or hepatologist is recommended for all patients. Symptoms such as pain, nausea, and itch can be managed with appropriate drug treatment. Pegylated interferon-alpha and other antiviral medications like tenofovir and entecavir may be used to suppress viral replication in chronic carriers.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 98 - A 35 year old female presents to the emergency department following a motor...

    Incorrect

    • A 35 year old female presents to the emergency department following a motor vehicle collision. Which system should be utilized to evaluate the potential for cervical spine injury?

      Your Answer:

      Correct Answer: Canadian C-spine rules

      Explanation:

      When a 35-year-old female comes to the emergency department after a motor vehicle collision, it is important to assess the potential for cervical spine injury. To do this, the Canadian C-spine rules should be utilized. These rules provide a systematic approach to determine whether imaging, such as X-rays, is necessary to evaluate the cervical spine. The Canadian C-spine rules take into account various factors such as the patient’s age, mechanism of injury, and presence of certain symptoms or physical findings. By following these rules, healthcare professionals can effectively evaluate the potential for cervical spine injury and determine the appropriate course of action for further assessment and management.

      Further Reading:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

    • This question is part of the following fields:

      • Trauma
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  • Question 99 - A 65 year old male is brought into the emergency department following a...

    Incorrect

    • A 65 year old male is brought into the emergency department following a fall with a suspected fracture of the hip. You gather a 20 gauge cannula for administration of IV fluids and pain relief. What would be considered the best approach for preparing the skin before cannulation?

      Your Answer:

      Correct Answer: Skin cleaned for 30 seconds with 2% chlorhexidine gluconate in 70% alcohol

      Explanation:

      To minimize the risk of infection and promote proper healing, the best approach for preparing the skin would be to clean it for 30 seconds with 2% chlorhexidine gluconate in 70% alcohol. This solution has been shown to effectively kill bacteria and reduce the risk of infection. Other options such as povidone-iodine, 90% isopropyl alcohol, and 30% isopropyl alcohol may also have some antimicrobial properties, but they are not as effective as chlorhexidine gluconate.

      Further Reading:

      Peripheral venous cannulation is a procedure that should be performed following established guidelines to minimize the risk of infection, injury, extravasation, and early failure of the cannula. It is important to maintain good hand hygiene, use personal protective equipment, ensure sharps safety, and employ an aseptic non-touch technique during the procedure.

      According to the National Institute for Health and Care Excellence (NICE), the skin should be disinfected with a solution of 2% chlorhexidine gluconate and 70% alcohol before inserting the catheter. It is crucial to allow the disinfectant to completely dry before inserting the cannula.

      The flow rates of IV cannulas can vary depending on factors such as the gauge, color, type of fluid used, presence of a bio-connector, length of the cannula, and whether the fluid is drained under gravity or pumped under pressure. However, the following are typical flow rates for different gauge sizes: 14 gauge (orange) has a flow rate of 270 ml/minute, 16 gauge (grey) has a flow rate of 180 ml/minute, 18 gauge (green) has a flow rate of 90 ml/minute, 20 gauge (pink) has a flow rate of 60 ml/minute, and 22 gauge (blue) has a flow rate of 36 ml/minute. These flow rates are based on infusing 1000 ml of normal saline under ideal circumstances, but they may vary in practice.

    • This question is part of the following fields:

      • Resus
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  • Question 100 - You are currently evaluating a patient who has presented with fatigue and decreased...

    Incorrect

    • You are currently evaluating a patient who has presented with fatigue and decreased urine output. Upon reviewing his blood results, you discover that he is experiencing acute renal failure. Your plan is to refer him to the medical on-call team for admission. However, during the discussion of his test results, he becomes agitated and expresses a desire to leave the hospital against medical advice, as he feels neglected. It is important to note that he has the capacity to make decisions for himself. How should you effectively handle this situation?

      Your Answer:

      Correct Answer: Try and explain the reasons why he should stay and what his further management plan would be

      Explanation:

      In this scenario, it is crucial to evaluate whether the patient possesses the ability to make decisions regarding his medical care. The question indicates that he has the capacity to do so, making him competent in making these decisions. Therefore, it would be prudent to inform him about the potential management options if he chooses to stay, as well as the potential consequences if he decides to self-discharge. Since he is competent and capable of weighing the risks, the next step would be to have him sign a self-discharge form.

      It is important to note that taking his bloods without his consent could be considered battery, and the patient would have every right to file a serious complaint against you. Additionally, arranging an ultrasound scan may not provide any further valuable information at this moment.

      Asking a nurse to keep an eye on the patient may not be practical, as the nurse could be extremely busy, and finding your consultant quickly may not be feasible. Furthermore, telling the patient that he must stay would not allow him the opportunity to make an informed decision on his own. It is important to emphasize that in this case, the patient is deemed to have the capacity to make decisions, and therefore, the medical team cannot act in his best interests without his consent.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
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  • Question 101 - A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris...

    Incorrect

    • A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris and bullous pemphigoid.
      Which of the following features would indicate a diagnosis of bullous pemphigoid?

      Your Answer:

      Correct Answer: Prominent pruritus

      Explanation:

      Bullous pemphigoid (BP) is a chronic autoimmune disorder that affects the skin, causing blistering. It occurs when the immune system mistakenly attacks the basement membrane of the epidermis. This attack is carried out by immunoglobulins (IgG and sometimes IgE) and activated T lymphocytes. The autoantibodies bind to proteins and release cytokines, leading to complement activation, neutrophil recruitment, and the release of enzymes that destroy the hemidesmosomes. As a result, subepidermal blisters form.

      Pemphigus, on the other hand, is a group of autoimmune disorders characterized by blistering of the skin and mucosal surfaces. The most common type, pemphigus vulgaris (PV), accounts for about 70% of cases worldwide. PV is also autoimmune in nature, with autoantibodies targeting cell surface antigens on keratinocytes (desmogleins 1 and 3). This leads to a loss of adhesion between cells and their separation.

      Here is a comparison of the key differences between pemphigus vulgaris and bullous pemphigoid:

      Pemphigus vulgaris:
      – Age: Middle-aged people (average 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 (average 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
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  • Question 102 - A child has arrived at the Emergency Department with facial swelling and difficulty...

    Incorrect

    • A child has arrived at the Emergency Department with facial swelling and difficulty breathing. The child has been given adrenaline, corticosteroids, and chlorpheniramine and subsequently shows improvement. Your attending physician is uncertain if this was an anaphylactic reaction and suspects it may have been angioedema.
      What SINGLE test could confirm a diagnosis of anaphylaxis in this situation?

      Your Answer:

      Correct Answer: Mast cell tryptase

      Explanation:

      The mast cell tryptase test, also known as the tryptase test, is a valuable tool for detecting mast cell activation and confirming the diagnosis of anaphylaxis in cases where there is uncertainty. Tryptase is the primary protein found in mast cells. During anaphylaxis, mast cells release their contents, leading to an increase in blood tryptase levels. Typically, these levels start to rise approximately 30 minutes after symptoms begin, reach their peak at 1-2 hours, and return to normal within 6-8 hours.

      For optimal results, it is recommended to collect three timed samples. The first sample should be taken as soon as possible after resuscitation efforts have commenced. The second sample should be obtained 1-2 hours after the onset of symptoms. Lastly, a third sample should be collected at the 24-hour mark to establish a baseline level.

      While skin allergy tests, like the patch test, and blood tests for specific IgE can help identify the trigger of an allergic reaction, they alone cannot confirm the occurrence of anaphylaxis. The mast cell tryptase test, on the other hand, provides valuable information in confirming the diagnosis.

    • This question is part of the following fields:

      • Allergy