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Question 1
Correct
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A 65 year old female is brought to the emergency department by her son. The son informs you that he visited his mother at the assisted living facility and noticed a decline in her alertness and mental state since his last visit 2 weeks ago. He expresses dissatisfaction with the facility staff, who made excuses about several caregivers being absent due to illness or vacation.
Upon assessment, the patient opens her eyes and makes incomprehensible sounds when spoken to, but is unable to speak coherently or form words. The patient exhibits localized response to painful stimuli.
What is this patient's Glasgow Coma Score?Your Answer: 10
Explanation:The GCS scoring system evaluates a patient’s level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each criterion is assigned a score, and the total score determines the patient’s GCS score. For example, if a patient has a GCS score of 10 (E3 V2 M5), it means they scored 3 out of 4 in eye opening, 2 out of 5 in verbal response, and 5 out of 6 in motor response.
Further Reading:
A subdural hematoma (SDH) is a condition where there is a collection of blood between the dura mater and the arachnoid mater of the brain. It occurs when the cortical bridging veins tear and bleed into the subdural space. Risk factors for SDH include head trauma, cerebral atrophy, advancing age, alcohol misuse, and certain medications or bleeding disorders. SDH can be classified as acute, subacute, or chronic depending on its age or speed of onset. Acute SDH is typically the result of head trauma and can progress to become chronic if left untreated.
The clinical presentation of SDH can vary depending on the nature of the condition. In acute SDH, patients may initially feel well after a head injury but develop more serious neurological symptoms later on. Chronic SDH may be detected after a CT scan is ordered to investigate confusion or cognitive decline. Symptoms of SDH can include increasing confusion, progressive decline in neurological function, seizures, headache, loss of consciousness, and even death.
Management of SDH involves an ABCDE approach, seizure management, confirming the diagnosis with CT or MRI, checking clotting and correcting coagulation abnormalities, managing raised intracranial pressure, and seeking neurosurgical opinion. Some SDHs may be managed conservatively if they are small, chronic, the patient is not a good surgical candidate, and there are no neurological symptoms. Neurosurgical intervention typically involves a burr hole craniotomy to decompress the hematoma. In severe cases with high intracranial pressure and significant brain swelling, a craniectomy may be performed, where a larger section of the skull is removed and replaced in a separate cranioplasty procedure.
CT imaging can help differentiate between subdural hematoma and other conditions like extradural hematoma. SDH appears as a crescent-shaped lesion on CT scans.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 2
Correct
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A 60-year-old woman presents with a persistent cough and increasing difficulty breathing. She also complains of muscle aches and occasional joint pain, particularly in her knees and hips. She has a 40-pack-year smoking history. During the examination, you observe fine crackling sounds in the lower parts of her lungs when she exhales. Lung function testing reveals a decrease in the forced vital capacity (FVC) and the forced expiratory volume in one second (FEV1), but a preserved FEV1/FVC ratio. A photo of her hands is provided below:
What is the SINGLE most likely underlying diagnosis?Your Answer: Idiopathic pulmonary fibrosis
Explanation:This patient’s clinical presentation is consistent with a diagnosis of idiopathic pulmonary fibrosis. The typical symptoms of idiopathic pulmonary fibrosis include a dry cough, progressive breathlessness, arthralgia and muscle pain, finger clubbing (seen in 50% of cases), cyanosis, fine end-expiratory bibasal crepitations, and right heart failure and cor pulmonale in later stages.
Finger clubbing, which is prominent in this patient, can also be caused by bronchiectasis and tuberculosis. However, these conditions would not result in a raised FEV1/FVC ratio, which is a characteristic feature of a restrictive lung disorder.
In restrictive lung disease, the FEV1/FVC ratio is typically normal, around 70% predicted, while the FVC is reduced to less than 80% predicted. Both the FVC and FEV1 are generally reduced in this condition. The ratio can also be elevated if the FVC is reduced to a greater extent.
It is important to note that smoking is a risk factor for developing idiopathic pulmonary fibrosis, particularly in individuals with a history of smoking greater than 20 pack-years.
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This question is part of the following fields:
- Respiratory
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Question 3
Correct
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You evaluate a 56-year-old individual who arrives at the ER complaining of chest discomfort and increasing swelling. Upon reviewing the patient's medical history, you discover that they underwent an echocardiogram a year ago, which revealed moderate-severe tricuspid regurgitation. Which of the following heart murmurs is commonly associated with tricuspid regurgitation?
Your Answer: Low-frequency pansystolic murmur
Explanation:Tricuspid regurgitation is characterized by a continuous murmur that spans the entire systolic phase of the cardiac cycle. This murmur is best audible at the lower left sternal edge and has a low frequency. Interestingly, the intensity of the murmur increases during inspiration and decreases during expiration, a phenomenon referred to as Carvallo’s sign.
Further Reading:
Tricuspid regurgitation (TR) is a condition where blood flows backwards through the tricuspid valve in the heart. It is classified as either primary or secondary, with primary TR being caused by abnormalities in the tricuspid valve itself and secondary TR being the result of other conditions outside of the valve. Mild TR is common, especially in young adults, and often does not cause symptoms. However, severe TR can lead to right-sided heart failure and the development of symptoms such as ascites, peripheral edema, and hepatomegaly.
The causes of TR can vary. Primary TR can be caused by conditions such as rheumatic heart disease, myxomatous valve disease, or Ebstein anomaly. Secondary TR is often the result of right ventricular dilatation due to left heart failure or pulmonary hypertension. Other causes include endocarditis, traumatic chest injury, left ventricular systolic dysfunction, chronic lung disease, pulmonary thromboembolism, myocardial disease, left to right shunts, and carcinoid heart disease. In some cases, TR can occur as a result of infective endocarditis in IV drug abusers.
Clinical features of TR can include a pansystolic murmur that is best heard at the lower left sternal edge, Carvallo’s sign (murmur increases with inspiration and decreases with expiration), an S3 heart sound, and the presence of atrial arrhythmias such as flutter or fibrillation. Other signs can include giant C-V waves in the jugular pulse, hepatomegaly (often pulsatile), and edema with lung crepitations or pleural effusions.
The management of TR depends on the underlying cause and the severity of the condition. In severe cases, valve repair or replacement surgery may be necessary. Treatment may also involve addressing the underlying conditions contributing to TR, such as managing left heart failure or pulmonary hypertension.
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This question is part of the following fields:
- Cardiology
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Question 4
Incorrect
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A 60-year-old man presents with visible jaundice, fatigue, and intense itching. He has noticed that his stools float and that they have become pale, foul-smelling, and oily in appearance. He has no history of abdominal pain. He has a past medical history of Crohn's disease, which has been controlled with mesalazine. On examination, you notice yellowish pigmentation of the skin, sclerae, and mucous membranes. His abdomen is soft but can palpate a firm liver edge 5 cm below the costal margin. He also has numerous scratch marks covering his abdomen and upper thighs. His liver function tests are shown below:
Bilirubin 102 mmol (3-20)
ALT 235 IU/L (5-40)
ALP: 1501 IU/L (20-140)
pANCA: positive
cANCA: negative
ANA: negative
SMA: negative
What is the SINGLE most likely diagnosis?Your Answer: Primary biliary cirrhosis
Correct Answer: Primary sclerosing cholangitis
Explanation:This woman is showing signs of obstructive jaundice along with a history of ulcerative colitis. The most probable diagnosis in this case is primary sclerosing cholangitis (PSC). PSC is a condition that causes inflammation and blockage of the bile ducts, leading to progressive damage. It is characterized by recurrent episodes of cholangitis and the development of scar tissue in the bile ducts. In severe cases, it can lead to liver cirrhosis, liver failure, and even liver cancer. PSC is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis.
The underlying cause of PSC is believed to be autoimmune in nature. Around 80% of patients with PSC test positive for p-ANCA antibodies, which are associated with autoimmune diseases. Other antibodies such as antinuclear antibodies (ANA) and anti-smooth muscle antibodies may also be present, but they are only found in about one-third of PSC patients.
Autoimmune hepatitis, on the other hand, is a liver inflammation caused by a decrease in regulatory T-cells (Treg cells), leading to the production of autoantibodies against hepatocyte surface antigens. It primarily affects women (70%) between the ages of 15 and 40. The condition causes chronic and progressive hepatitis, often presenting in the later stages when the patient is severely unwell and jaundiced. Liver function tests typically show significantly elevated levels of transaminases (ALT and AST), often more than ten times the normal range. Alkaline phosphatase (ALP) levels may be normal or slightly elevated. Antinuclear antibodies (ANA) are positive in approximately 80% of cases, while smooth muscle antibodies (SMA) are positive in about 70% of cases. Antimitochondrial antibodies are usually low or absent.
Primary biliary cirrhosis is another autoimmune liver disease that leads to the progressive destruction of the small bile ducts in the liver, primarily affecting the intralobular ducts. This results in cholestatic jaundice, liver fibrosis, and eventually cirrhosis. The condition is more common in women (90%) and typically occurs between the ages of 30 and 65. Liver function tests show predominantly elevated levels of alkaline phosphatase (ALP), often before any symptoms or signs of the disease appear.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 5
Correct
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You intend to utilize 1% lidocaine with adrenaline 1:200,000 for a peripheral nerve block on a 60 kg healthy young female. What is the maximum amount of lidocaine that can be administered in this scenario?
Your Answer: 420 mg lidocaine hydrochloride
Explanation:The maximum safe dose of plain lidocaine is 3 mg per kilogram of body weight, with a maximum limit of 200 mg. However, when lidocaine is administered with adrenaline in a 1:200,000 ratio, the maximum safe dose increases to 7 mg per kilogram of body weight, with a maximum limit of 500 mg.
In this particular case, the patient weighs 60 kg, so the maximum safe dose of lidocaine hydrochloride would be 60 multiplied by 7 mg, resulting in a total of 420 mg.
For more detailed information on lidocaine hydrochloride, you can refer to the BNF section dedicated to this topic.
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This question is part of the following fields:
- Pain & Sedation
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Question 6
Correct
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You are overseeing the care of a 70-year-old male who suffered extensive burns in a residential fire. After careful calculation, you have determined that the patient's fluid requirement for the next 24 hours is 6 liters. How would you prescribe this amount?
Your Answer: 50% (3 litres in this case) over first 8 hours then remaining 50% (3 litres in this case) over following 16 hours
Explanation:Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.
When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.
Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.
The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.
Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.
Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.
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This question is part of the following fields:
- Trauma
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Question 7
Incorrect
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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: Antineutrophilic cytoplasmic antibodies (ANCAs)
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.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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A 4-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
What dose of IV lorazepam is recommended for the treatment of the convulsing child?Your Answer: 0.1 mg/kg
Explanation:The recommended dosage of intravenous lorazepam for treating a child experiencing seizures is 0.1 mg per kilogram of body weight.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 42-year-old woman was in a car crash where her vehicle collided with a wall at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel. She has bruising on her front chest wall and is experiencing chest pain. The chest X-ray taken in the emergency room shows signs of a traumatic aortic injury.
Which of the following chest X-ray findings is most indicative of this injury?Your Answer: Leftward shift of right mainstem bronchus
Correct Answer: Presence of a pleural cap
Explanation:Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.
The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.
Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.
A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.
Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic
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This question is part of the following fields:
- Trauma
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Question 10
Correct
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A 45-year-old woman comes in with a swollen, red, and painful left knee. The doctor suspects septic arthritis and sends a joint aspirate to the lab.
What is the most common organism that causes septic arthritis?Your Answer: Staphylococcus aureus
Explanation:Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.
According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 11
Correct
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You are evaluating a 68-year-old patient with a known history of COPD who has come to the emergency department due to worsening shortness of breath and a cough producing green sputum. An arterial blood gas is obtained and the results are as follows:
Parameter Result
pH 7.31
pO2 9.1 kPa
pCO2 6.5 kPa
Bicarbonate 32 mmol/l
Base Excess +4
The patient is given immediate doses of prednisone and amoxicillin, and nebulized salbutamol is administered. After one hour of treatment, a repeat blood gas is obtained with the patient receiving 40% inspired oxygen via venturi. The results are as follows:
Parameter Result
pH 7.27
pO2 9.0 kPa
pCO2 7.2 kPa
Bicarbonate 33 mmol/l
Base Excess +5
Which of the following interventions would be the most appropriate to implement next?Your Answer: Non-invasive ventilation
Explanation:According to the brit-thoracic guidelines, if a patient with COPD continues to experience respiratory acidosis even after receiving standard medical therapy for one hour, it is recommended to consider using non-invasive ventilation (NIV). This is especially important if the patient’s hypoxia and hypercapnia are worsening despite the initial treatment.
Further Reading:
Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.
To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.
Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.
The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.
The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.
The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.
Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.
The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.
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This question is part of the following fields:
- Respiratory
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Question 12
Incorrect
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You evaluate a 52-year-old man with a painful swollen left big toe. He has a known history of gout and states that this pain is similar to previous flare-ups. He is currently on a daily dose of allopurinol 200 mg and has been taking it for the past year. This is his second episode of acute gout during this time period. He has no significant medical history and is not taking any other medications. He has no known allergies.
What is the MOST suitable next step in management?Your Answer: Continue with the allopurinol and commence colchicine
Correct Answer: Continue with the allopurinol and commence naproxen
Explanation:Allopurinol should not be started during an acute gout attack as it can make the attack last longer and even trigger another one. However, if a patient is already taking allopurinol, they should continue taking it and treat the acute attack with NSAIDs or colchicine as usual.
The first choice for treating acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. Colchicine can be used if NSAIDs are not suitable, for example, in patients with high blood pressure or a history of peptic ulcer disease. In this case, the patient has no reason to avoid NSAIDs, so naproxen would still be the preferred option.
Once the acute attack has subsided, it would be reasonable to gradually increase the dose of allopurinol, aiming for urate levels in the blood of less than 6 mg/dl (<360 µmol/l). Febuxostat (Uloric) is an alternative to allopurinol that can be used for long-term management of gout.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 13
Correct
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A 60-year-old individual arrives at the emergency department complaining of a nosebleed. The patient informs you that they have been applying pressure to the soft part of their nose for 10 minutes. You request the patient to release the pressure for examination purposes, but upon doing so, bleeding commences from both nostrils, and the bleeding point remains unseen. What would be the most suitable course of action for managing this patient?
Your Answer: Insert bilateral nasal tampons
Explanation:Nasal packing is recommended for cases of bilateral epistaxis (nosebleeds on both sides) and when it is difficult to locate the source of bleeding. If initial first aid measures, such as applying pressure to the soft part of the nose, do not stop the bleeding or if there is no visible bleeding point, nasal packing is necessary. In the UK, the most commonly used methods for nasal packing are Merocel nasal tampons and rapid-rhino inflatable nasal packs. If anterior nasal packing fails to control the bleeding, posterior nasal packing with a Foley catheter may be considered. Ideally, this procedure should be performed by an ENT surgeon, but if specialist input is not immediately available, a trained clinician in the emergency department can carry it out.
Further Reading:
Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.
The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.
If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.
Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.
In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 14
Incorrect
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A 5-year-old girl is brought to the Emergency Department by her parents. For the past two days, she has had severe diarrhoea and vomiting. She has not passed urine so far today. She normally weighs 20 kg. On examination, she has sunken eyes and dry mucous membranes. She is tachycardia and tachypnoeic and has cool peripheries. Her capillary refill time is prolonged.
What is her estimated percentage dehydration?Your Answer: 5%
Correct Answer: 10%
Explanation:Generally speaking, if a child shows clinical signs of dehydration but does not exhibit shock, it can be assumed that they are 5% dehydrated. On the other hand, if shock is also present, it can be assumed that the child is 10% dehydrated or more. To put it in simpler terms, 5% dehydration means that the body has lost 5 grams of fluid per 100 grams of body weight, which is equivalent to 50 milliliters per kilogram of fluid. Similarly, 10% dehydration implies a loss of 100 milliliters per kilogram of fluid.
The clinical features of dehydration and shock are summarized below:
Dehydration (5%):
– The child appears unwell
– The heart rate may be normal or increased (tachycardia)
– The respiratory rate may be normal or increased (tachypnea)
– Peripheral pulses are normal
– Capillary refill time (CRT) is normal or slightly prolonged
– Blood pressure is normal
– Extremities feel warm
– Decreased urine output
– Reduced skin turgor
– Sunken eyes
– Depressed fontanelle
– Dry mucous membranesClinical shock (10%):
– The child appears pale, lethargic, and mottled
– Tachycardia (increased heart rate)
– Tachypnea (increased respiratory rate)
– Weak peripheral pulses
– Prolonged CRT
– Hypotension (low blood pressure)
– Extremities feel cold
– Decreased urine output
– Decreased level of consciousness -
This question is part of the following fields:
- Nephrology
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Question 15
Incorrect
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A 5-year-old boy is brought to the Emergency Department by his mother. He is known to have eczema and has recently experienced a worsening of his symptoms with some of the affected areas having weeping and crusting lesions. Upon examining his skin, you observe multiple flexural areas involved with numerous weeping lesions. He has no known allergies to any medications.
What is the MOST suitable course of action for management?Your Answer: Topical fucidin cream
Correct Answer: Oral flucloxacillin
Explanation:Based on the child’s medical history, it appears that they have multiple areas of infected eczema. In such cases, the NICE guidelines recommend starting treatment with flucloxacillin as the first-line option for bacterial infections. This is because staphylococcus and/or streptococcus bacteria are the most common causes of these infections. Swabs should only be taken if there is a likelihood of antibiotic resistance or if a different pathogen is suspected. In cases where the child is allergic to flucloxacillin, erythromycin can be used as an alternative. If the child cannot tolerate erythromycin, clarithromycin is the recommended option. For more information, you can refer to the NICE Clinical Knowledge Summary on the management of infected eczema.
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This question is part of the following fields:
- Dermatology
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Question 16
Correct
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You are managing a 62-year-old woman with a dorsally displaced fracture of the distal radius. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). Following the administration of the local anesthetic, you observe a change in the patient's skin color to a grayish-blue hue. What complication is most likely to have occurred?
Your Answer: Methaemoglobinaemia
Explanation:In this case, the administration of the local anesthetic used for the Bier’s block may have caused the patient’s blood to convert hemoglobin into methemoglobin, resulting in the observed skin color change.
Further Reading:
Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.
Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.
During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.
There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 17
Correct
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A 75-year-old is brought to the emergency department by her daughter. The patient has been feeling sick for the past day. The patient's daughter suspects she may have taken an excessive amount of digoxin tablets in the past few days. You are worried about digoxin toxicity. What antidote should be readily accessible in the emergency department for the treatment of digoxin toxicity?
Your Answer: Digoxin specific antibody fragments
Explanation:Digoxin-specific antibody fragments, known as Digibind or Digifab, are utilized for the treatment of digoxin toxicity. These antibody fragments should be readily available in all hospital pharmacies across the UK and accessible within a maximum of one hour.
Further Reading:
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, digoxin toxicity can occur, and plasma concentration alone does not determine if a patient has developed toxicity. Symptoms of digoxin toxicity include feeling generally unwell, lethargy, nausea and vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia.
ECG changes seen in digoxin toxicity include downsloping ST depression with a characteristic Salvador Dali sagging appearance, flattened, inverted, or biphasic T waves, shortened QT interval, mild PR interval prolongation, and prominent U waves. There are several precipitating factors for digoxin toxicity, including hypokalaemia, increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, verapamil, and diltiazem.
Management of digoxin toxicity involves the use of digoxin specific antibody fragments, also known as Digibind or digifab. Arrhythmias should be treated, and electrolyte disturbances should be corrected with close monitoring of potassium levels. It is important to note that digoxin toxicity can be precipitated by hypokalaemia, and toxicity can then lead to hyperkalaemia.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 18
Incorrect
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A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after going into labor. An ambulance is called, and she is ‘blue lighted’ into the resus area of your Emergency Department. She appears cyanosed and states that her heart feels like it is ‘beating very quickly’. Shortly after arriving in the Emergency Department, she becomes unresponsive. You notice a change in rhythm to ventricular fibrillation on the cardiac monitor and are unable to detect a pulse or any signs of life. She receives three stacked shocks and is managed according to the ALS algorithm, but initial attempts at resuscitation are unsuccessful.
Which of the following management options is most likely to improve his likelihood of successful resuscitation?Your Answer: Thrombolysis
Correct Answer: Peri-mortem Caesarean section
Explanation:Based on her presentation, the most probable cause of the cardiac arrest in this case is either a pulmonary embolism or amniotic fluid embolism.
When dealing with a cardiac arrest during pregnancy, there are several adjustments that need to be made compared to a regular cardiac arrest situation. These adjustments include:
– Ensuring the presence of an obstetrician
– Having a paediatrician or neonatologist available
– Manually displacing the uterus to the left in order to relieve caval compression
– Tilting the table to the left side, ideally at a 15-30 degree angle
– Performing early tracheal intubation to reduce the risk of aspiration (it is recommended to seek expert anaesthetic assistance for this)
– Initiating preparations for an emergency Caesarean sectionIn the event of a cardiac arrest, a perimortem Caesarean section should be performed within 5 minutes of the onset. This procedure is crucial as it relieves caval compression, improves the chances of successful resuscitation by increasing venous return during CPR, and maximizes the likelihood of the infant’s survival. The best survival rate for the infant occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 19
Incorrect
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A 62-year-old man presents with depressive symptoms, mood swings, difficulty writing, memory impairment, and difficulty generating ideas.
Which of the following is the SINGLE MOST likely diagnosis?Your Answer: Parkinson’s Disease
Correct Answer: Alzheimer’s Disease
Explanation:Alzheimer’s disease is characterized by various clinical features. These include memory loss, mood swings, apathy, and the presence of depressive or paranoid symptoms. Additionally, individuals with Alzheimer’s may experience Parkinsonism, a condition that affects movement, as well as a syndrome associated with the parietal lobe. Other symptoms may include difficulties with tasks such as copying 2D drawings, dressing properly, and carrying out a sequence of actions. Furthermore, individuals may struggle with copying gestures and may exhibit denial of their disorder, known as anosognosia. Topographical agnosia, or getting lost in familiar surroundings, may also be present, along with sensory inattention and astereognosis, which is the inability to identify objects when placed in the hand. Ultimately, Alzheimer’s disease is characterized by a relentless progression of personality and intellectual deterioration.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 20
Incorrect
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You review a 52-year-old woman who has recently been prescribed antibiotics for a urinary tract infection (UTI). She has a history of COPD and is currently taking salbutamol and Seretide inhalers and Phyllocontin Continus. Since starting the antibiotics, she has been experiencing nausea, vomiting, and abdominal pain.
Which SINGLE antibiotic is she most likely to have been prescribed for her UTI?Your Answer:
Correct Answer: Ciprofloxacin
Explanation:Phyllocontin Continus contains aminophylline, which is a combination of theophylline and ethylenediamine. It is a bronchodilator that is commonly used to manage COPD and asthma.
In this case, the woman is showing symptoms of theophylline toxicity, which may have been triggered by the antibiotic prescribed for her urinary tract infection. Quinolone antibiotics, like ciprofloxacin, can increase the concentration of theophyllines in the blood, leading to toxicity.
There are other medications that can also interact with theophyllines. These include macrolide antibiotics such as clarithromycin, allopurinol, antifungals like ketoconazole, and calcium-channel blockers such as amlodipine. It is important to be aware of these interactions to prevent any potential complications.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 21
Incorrect
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There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological and nuclear) incident, with a high likelihood of sarin gas being the responsible agent. In the management of this situation, certain casualties are administered pralidoxime as an antidote.
What is the mode of action of pralidoxime?Your Answer:
Correct Answer: Reactivating acetylcholinesterase
Explanation:The primary approach to managing nerve gas exposure through medication involves the repeated administration of antidotes. The two antidotes utilized for this purpose are atropine and pralidoxime.
Atropine is the standard anticholinergic medication employed to address the symptoms associated with nerve agent poisoning. It functions as an antagonist for muscarinic acetylcholine receptors, effectively blocking the effects caused by excessive acetylcholine. Initially, a 1.2 mg intravenous bolus of atropine is administered. This dosage is then repeated and doubled every 2-3 minutes until excessive bronchial secretion ceases and miosis (excessive constriction of the pupil) resolves. In some cases, as much as 100 mg of atropine may be necessary.
Pralidoxime (2-PAMCl) is the standard oxime used in the treatment of nerve agent poisoning. Its mechanism of action involves reactivating acetylcholinesterase by scavenging the phosphoryl group attached to the functional hydroxyl group of the enzyme, thereby counteracting the effects of the nerve agent itself. For patients who are moderately or severely poisoned, pralidoxime should be administered intravenously at a dosage of 30 mg/kg of body weight (or 2 g in the case of an adult) over a period of four minutes.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 22
Incorrect
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You review a 72-year-old woman with a diagnosis of lung cancer. You can see from her notes that she has an advanced decision in place.
Which SINGLE statement is true regarding an advanced decision?Your Answer:
Correct Answer: It can be used by Jehovah’s witnesses to refuse blood transfusions
Explanation:An advance decision, also known as an advance directive in Scotland, is a statement made by a patient expressing their desire to refuse certain types of medical treatment or care in the event that they become unable to make or communicate decisions for themselves. These statements serve as a means of effectively communicating the patient’s wishes to healthcare professionals and family members, helping to avoid any confusion that may arise. If a patient reaches a point where they are no longer capable of making informed decisions about their care, an advance decision can provide clarity and guidance.
An advance decision can typically be utilized in the following situations: making decisions regarding CPR, determining the use of IV fluids and parenteral nutrition, deciding on specific procedures, and addressing the use of blood products for Jehovah’s Witnesses. However, it is important to note that advance decisions have their limitations and cannot be used to grant a relative lasting power of attorney, appoint a spokesperson to make decisions on the patient’s behalf, request a specific medical treatment, advocate for something illegal (such as assisted suicide), refuse treatment for a mental health condition, or authorize treatments that are not in the patient’s best interests.
A doctor is legally obligated to adhere to an advance decision unless certain circumstances arise. These circumstances include changes that invalidate the decision, advances or changes in treatment that alter the circumstances, ambiguity in the wording of the decision, or if the decision is unsigned or its authenticity is in doubt. If there are any doubts about the validity of an advance decision, it is advisable to seek legal advice. Unfortunately, there have been instances where advance decisions have been forged or signed under duress, and any suspicions of this nature should be raised.
It is important to note that there is no specific time period for which an advance decision remains valid.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 23
Incorrect
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A 68 year old male presents to the emergency department complaining of dizziness and palpitations that have been occurring for the past 2 hours. An ECG confirms the presence of atrial fibrillation. The patient has no previous history of atrial fibrillation but was diagnosed with mild aortic valve stenosis 8 months ago during an echocardiogram ordered by his primary care physician. The patient reports that the echocardiogram was done because he was experiencing shortness of breath, which resolved after 2-3 months and was attributed to a recent bout of pneumonia. The decision is made to attempt pharmacological cardioversion. What is the most appropriate medication to use for this purpose in this patient?
Your Answer:
Correct Answer: Amiodarone
Explanation:According to NICE guidelines, amiodarone is recommended as the initial choice for pharmacological cardioversion of atrial fibrillation (AF) in individuals who have evidence of structural heart disease.
Further Reading:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.
AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.
Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.
Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.
Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.
Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 68 year old female is brought into the emergency department after a fall. The patient is accompanied by her children who inform you that there have been several falls in recent weeks. These falls tend to happen in the morning when the patient gets out of bed and appear to have worsened since the GP altered the patient's usual medication. You suspect orthostatic hypotension. What is the minimum blood pressure drop upon standing that is necessary to confirm the diagnosis?
Your Answer:
Correct Answer: 20 mmHg systolic or 10 mmHg diastolic
Explanation:To diagnose orthostatic hypotension, there needs to be a decrease in systolic blood pressure of at least 20 mmHg (or 30 mmHg for individuals with hypertension) and/or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing. This confirms the presence of orthostatic hypotension.
Further Reading:
Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.
When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.
During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.
There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 25
Incorrect
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Whilst assessing a patient in the Emergency Department, you observe a pansystolic murmur.
Which of the following is NOT a potential cause of a pansystolic murmur?Your Answer:
Correct Answer: Aortic stenosis
Explanation:Aortic stenosis leads to the presence of a murmur during the ejection phase of the cardiac cycle. This murmur is most audible at the right second intercostal space and can be heard extending into the right neck.
Mitral regurgitation, on the other hand, produces a high-pitched murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the apex of the heart and can be heard radiating into the axilla.
Tricuspid regurgitation is characterized by a blowing murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is most clearly heard at the lower left sternal edge.
Ventricular septal defect results in a harsh murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the third or fourth left intercostal space and can be heard radiating throughout the praecordium.
Aortopulmonary shunts are an extremely rare cause of a murmur that occurs throughout the entire systolic phase of the cardiac cycle.
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This question is part of the following fields:
- Cardiology
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Question 26
Incorrect
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A 35-year-old male comes to the Emergency Department seeking treatment for a wound on his right arm. He mentions during triage that he sustained the injury while being attacked by a group of individuals in the neighborhood who have been causing trouble. He suspects that he may have been shot with a low-caliber firearm. Despite the nursing staff's attempts to involve the authorities, he has adamantly refused to allow them to contact the police. In addition to providing the necessary wound care, what other steps should you take?
Your Answer:
Correct Answer: Advise him that it is your statutory duty to report this incident to the police whether he consents or not, and contact them with his demographic details only.
Explanation:Confidentiality is a crucial aspect of the doctor-patient relationship and plays a vital role in upholding trust within the medical profession. However, there are certain situations, such as cases involving gun and knife crimes, where the safety of the wider public may be at risk. In such circumstances, it may be necessary to breach this relationship and provide the police with information, even if the patient refuses to consent.
It is important to make every effort to obtain the patient’s consent, while also explaining the legal obligation to report such incidents. When sharing information with the police, it is essential to disclose only the minimum amount of information required. Typically, this would involve providing the patient’s demographic details and informing the police that they have sought medical attention for a non-self-inflicted deliberate knife wound.
However, there are instances where contacting the police may not be necessary. For example, if it is evident that the injury was sustained accidentally or as a result of deliberate self-harm due to a mental health condition, there may be no need to involve law enforcement. In such cases, the patient should still receive the necessary medical treatment for their wound, as long as they provide consent.
For more information on this topic, please refer to the GMC Guidance on Reporting Gunshot and Knife Wounds.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 27
Incorrect
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A 4-week-old baby girl is brought in by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen.
What is the first test to be done in this case?Your Answer:
Correct Answer: Abdominal ultrasound scan
Explanation:Infantile hypertrophic pyloric stenosis is a condition characterized by the thickening and enlargement of the smooth muscle in the antrum of the stomach, leading to the narrowing of the pyloric canal. This narrowing can easily cause obstruction. It is a relatively common condition, occurring in about 1 in 500 live births, and is more frequently seen in males than females, with a ratio of 4 to 1. It is most commonly observed in first-born male children, although it can rarely occur in adults as well.
The main symptom of infantile hypertrophic pyloric stenosis is vomiting, which typically begins between 2 to 8 weeks of age. The vomit is usually non-bilious and forcefully expelled. It tends to occur around 30 to 60 minutes after feeding, leaving the baby hungry despite the vomiting. In some cases, there may be blood in the vomit. Other clinical features include persistent hunger, dehydration, weight loss, and constipation. An enlarged pylorus, often described as olive-shaped, can be felt in the right upper quadrant or epigastric in approximately 95% of cases. This is most noticeable at the beginning of a feed.
The typical acid-base disturbance seen in this condition is hypochloremic metabolic alkalosis. This occurs due to the loss of hydrogen and chloride ions in the vomit, as well as decreased secretion of pancreatic bicarbonate. The increased bicarbonate ions in the distal tubule of the kidney lead to the production of alkaline urine. Hyponatremia and hypokalemia are also commonly present.
Ultrasound scanning is the preferred diagnostic tool for infantile hypertrophic pyloric stenosis, as it is reliable and easy to perform. It has replaced barium studies as the investigation of choice.
Initial management involves fluid resuscitation, which should be tailored to the weight and degree of dehydration. Any electrolyte imbalances should also be corrected.
The definitive treatment for this condition is surgical intervention, with the Ramstedt pyloromyotomy being the procedure of choice. Laparoscopic pyloromyotomy is also an effective alternative if suitable facilities are available. The prognosis for infants with this condition is excellent, as long as there is no delay in diagnosis and treatment initiation.
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This question is part of the following fields:
- Neonatal Emergencies
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Question 28
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. Her urine test shows blood. A CT scan is scheduled and confirms a diagnosis of ureteric colic. She was given diclofenac through an intramuscular injection, but her pain is still not well managed.
According to the latest NICE guidelines, what is the recommended next option for pain relief in this patient?Your Answer:
Correct Answer: Intravenous paracetamol
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 29
Incorrect
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A 25 year old is brought into the emergency department after being found unresponsive in a park. It is believed the patient had been drinking alcohol at a nearby bar and decided to walk home in the freezing weather. The patient's temperature is recorded as 27.8ºC. What grade of hypothermia is this?
Your Answer:
Correct Answer: Severe hypothermia
Explanation:Severe hypothermia is defined as having a core body temperature below 28ºC. The Royal College of Emergency Medicine (RCEM) also uses the term profound hypothermia to describe individuals with a core temperature below 20ºC.
Further Reading:
Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.
ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.
Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.
Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.
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This question is part of the following fields:
- Environmental Emergencies
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Question 30
Incorrect
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A 32-year-old woman comes in with a history of urgency, bloody diarrhea, and crampy abdominal pain for the past 8 weeks. She occasionally experiences pain before having a bowel movement, but it is relieved once the stool is passed. A sigmoidoscopy is conducted, and a rectal biopsy reveals the presence of inflammatory cell infiltrate and crypt abscesses.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Ulcerative colitis
Explanation:In a young patient who has been experiencing bloody diarrhea for more than 6 weeks, it is important to consider inflammatory bowel disease as a possible diagnosis. The challenge lies in distinguishing between ulcerative colitis and Crohn’s disease. In this case, a biopsy was performed and the results showed the presence of inflammatory cell infiltrate and crypt abscesses, which strongly suggests a diagnosis of ulcerative colitis.
Ulcerative colitis:
– Typically affects only the rectum and colon
– The terminal ileum may be affected if backwash ileitis occurs
– Does not have skip lesions (areas of normal mucosa between affected areas)
– Decreased incidence in smokers
– Common associations include liver conditions such as primary biliary cirrhosis, chronic active hepatitis, and primary sclerosing cholangitis
– Other systemic manifestations are less common compared to Crohn’s disease
– Pathological features include primarily affecting the mucosa and submucosa, presence of mucosal ulcers, inflammatory cell infiltrate, and crypt abscesses
– Clinical features include less prominent abdominal pain, bloody diarrhea in 90% of cases, passage of mucus, and possible fever
– Barium studies may show a granular appearance, button-shaped ulcers, and loss of normal haustral markings
– Complications include a 20-fold increase in the 20-year risk of colonic carcinoma, iron deficiency anemia, and rare occurrence of fistulaeCrohn’s disease:
– Can affect any part of the gastrointestinal tract from the mouth to the anus
– May have skip lesions of normal mucosa between affected areas
– Increased incidence in smokers
– Systemic manifestations are more common compared to ulcerative colitis, including erythema nodosum, pyoderma gangrenosum, iritis/uveitis, cholelithiasis, and joint pain/arthropathy
– Pathological features include transmural inflammation, presence of lymphoid aggregates and neutrophil infiltrates, and non-caseating granulomas seen in 30% of cases
– Clinical features include more prominent abdominal pain, common occurrence of diarrhea (which can also be bloody), frequent and oral lesions, and possible fever
– Barium studies may show severe mucosal ulcers -
This question is part of the following fields:
- Gastroenterology & Hepatology
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