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Question 1
Correct
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A 65-year-old woman presents with a history of frequent falls, difficulty with walking, and bladder control problems. After a thorough evaluation and tests, a diagnosis of normal-pressure hydrocephalus is made.
What is the most common underlying factor leading to NPH?Your Answer: Idiopathic – no cause found
Explanation:This patient is displaying symptoms that are characteristic of normal-pressure hydrocephalus (NPH). NPH is a type of communicating hydrocephalus where the pressure inside the skull, as measured through a lumbar puncture, is either normal or occasionally elevated. It primarily affects elderly individuals, and the likelihood of developing NPH increases with age.
Around 50% of NPH cases are considered idiopathic, meaning there is no identifiable cause. The remaining cases are secondary to various conditions such as head injury, meningitis, subarachnoid hemorrhage, central nervous system tumors, and radiotherapy.
The typical presentation of NPH includes a classic triad of symptoms: gait disturbance (often characterized by a broad-based and shuffling gait), sphincter disturbance leading to incontinence (usually urinary incontinence), and progressive dementia with memory loss, inattention, inertia, and bradyphrenia.
Diagnosing NPH primarily relies on identifying the classic clinical triad mentioned above. Additional investigations can provide supportive evidence, including CT and MRI scans that reveal enlarged ventricles and periventricular lucency. Lumbar puncture may also be performed, with the cerebrospinal fluid (CSF) typically appearing normal or intermittently elevated. Intraventricular monitoring may show beta waves for more than 5% of a 24-hour period.
NPH is one of the few reversible causes of dementia, making early recognition and treatment crucial. Medical treatment options such as carbonic anhydrase inhibitors (e.g., acetazolamide) and repeated lumbar punctures can provide temporary relief. However, the definitive treatment for NPH involves surgically inserting a cerebrospinal fluid (CSF) shunt. This procedure has shown lasting clinical benefits in 70% to 90% of patients compared to their pre-operative state.
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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 25-year-old patient arrives at the emergency department from working in a radiation lab. He informs you that he may have been exposed to dangerous radiation. The patient mentions that it has been less than 24 hours since he left lab. Which of the following tests provides the most accurate prognosis for the severity of radiation sickness?
Your Answer: Lymphocyte count
Explanation:The count of lymphocytes, a type of white blood cell, can serve as an early indication of the level of radiation exposure. The severity of the exposure can be determined by observing the decrease in lymphocyte count, which is directly related to the amount of radiation absorbed by the body. Ideally, the count is measured 12 hours after exposure and then repeated every 4 hours initially to track the rate of decrease.
Further Reading:
Radiation exposure refers to the emission or transmission of energy in the form of waves or particles through space or a material medium. There are two types of radiation: ionizing and non-ionizing. Non-ionizing radiation, such as radio waves and visible light, has enough energy to move atoms within a molecule but not enough to remove electrons from atoms. Ionizing radiation, on the other hand, has enough energy to ionize atoms or molecules by detaching electrons from them.
There are different types of ionizing radiation, including alpha particles, beta particles, gamma rays, and X-rays. Alpha particles are positively charged and consist of 2 protons and 2 neutrons from the atom’s nucleus. They are emitted from the decay of heavy radioactive elements and do not travel far from the source atom. Beta particles are small, fast-moving particles with a negative electrical charge that are emitted from an atom’s nucleus during radioactive decay. They are more penetrating than alpha particles but less damaging to living tissue. Gamma rays and X-rays are weightless packets of energy called photons. Gamma rays are often emitted along with alpha or beta particles during radioactive decay and can easily penetrate barriers. X-rays, on the other hand, are generally lower in energy and less penetrating than gamma rays.
Exposure to ionizing radiation can damage tissue cells by dislodging orbital electrons, leading to the generation of highly reactive ion pairs. This can result in DNA damage and an increased risk of future malignant change. The extent of cell damage depends on factors such as the type of radiation, time duration of exposure, distance from the source, and extent of shielding.
The absorbed dose of radiation is directly proportional to time, so it is important to minimize the amount of time spent in the vicinity of a radioactive source. A lethal dose of radiation without medical management is 4.5 sieverts (Sv) to kill 50% of the population at 60 days. With medical management, the lethal dose is 5-6 Sv. The immediate effects of ionizing radiation can range from radiation burns to radiation sickness, which is divided into three main syndromes: hematopoietic, gastrointestinal, and neurovascular. Long-term effects can include hematopoietic cancers and solid tumor formation.
In terms of management, support is mainly supportive and includes IV fluids, antiemetics, analgesia, nutritional support, antibiotics, blood component substitution, and reduction of brain edema.
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This question is part of the following fields:
- Environmental Emergencies
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Question 3
Correct
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A 45-year-old woman is about to begin taking warfarin for the treatment of her atrial fibrillation. She is currently on multiple other medications.
Which ONE medication will counteract the effects of warfarin?Your Answer: Phenytoin
Explanation:Cytochrome p450 enzyme inducers have the ability to hinder the effects of warfarin, leading to a decrease in INR levels. To remember the commonly encountered cytochrome p450 enzyme inducers, the mnemonic PC BRASS can be utilized. Each letter in the mnemonic represents a specific inducer: P for Phenytoin, C for Carbamazepine, B for Barbiturates, R for Rifampicin, A for Alcohol (chronic ingestion), S for Sulphonylureas, and S for Smoking. These inducers can have an impact on the effectiveness of warfarin and should be taken into consideration when prescribing or using this medication.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 4
Correct
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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: 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.
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This question is part of the following fields:
- Cardiology
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Question 5
Correct
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A 40-year-old male patient presents with a history of dizziness and fainting episodes. He has also been suffering from a mild flu-like illness for the past few days. He had a syncopal episode in the department and was moved into the resuscitation area. His observations are as follows: Temperature 38.4°C, HR 112, BP 78/44, oxygen saturation 98% on high-flow oxygen, GCS 14/15, BM 1.5.
His initial blood results are shown below:
Na+: 118 mmol/l
K+: 6.1 mmol/l
Urea: 11.6 mmol/l
Creatinine: 132 mmol/l
Which of the following investigations is most appropriate to confirm the underlying diagnosis?Your Answer: Synacthen test
Explanation:This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. It is more commonly seen in women than men and typically occurs between the ages of 30 and 50.
Addison’s disease is caused by insufficient production of steroid hormones by the adrenal glands, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.
The most common trigger for an Addisonian crisis in patients with Addison’s disease is the intentional or accidental withdrawal of steroid therapy. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.
Clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main symptoms are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and even coma.
Biochemical markers of Addison’s disease typically include increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Confirmatory investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and testing for adrenocortical antibodies.
Management of Addison’s disease should be overseen by an Endocrinologist. Treatment usually involves the administration of hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also require thyroxine if there is concurrent hypothalamic-pituitary disease. Treatment is lifelong, and patients should carry a steroid card and MedicAlert bracelet to alert healthcare professionals about their condition and the potential for an Addisonian crisis.
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This question is part of the following fields:
- Endocrinology
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Question 6
Correct
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A 14-year-old girl with a background of mental health issues is brought to the Emergency Department by law enforcement. She is currently being restrained and needs immediate sedation.
According to the NICE guidelines for short-term management of violent and aggressive patients, what should be the first-line choice for rapid sedation in this patient?Your Answer: Lorazepam
Explanation:Rapid tranquillisation involves administering medication through injection (typically into the muscle) when oral medication is not feasible or appropriate and immediate sedation is necessary. The current guidelines from NICE regarding the short-term management of violent and aggressive patients recommend the use of intramuscular lorazepam for rapid tranquillisation in children and young individuals. The dosage should be adjusted based on their age and weight. If there is only a partial response to intramuscular lorazepam, the dosage should be assessed according to the child or young person’s age and weight, and an additional dose may be considered.
For more information, please refer to the NICE guidance on violence and aggression: short-term management in mental health, health, and community settings.
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This question is part of the following fields:
- Mental Health
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Question 7
Correct
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You are present at a child cardiac arrest scene. The blood gas shows that the patient is extremely acidotic and has a high potassium level. The attending physician suggests that sodium bicarbonate is administered.
What dose of sodium bicarbonate should be given in this case?Your Answer: 1 ml/kg 8.4%
Explanation:The regular use of sodium bicarbonate in pediatric cardiac arrest is not commonly advised. However, it may be considered in cases of prolonged arrests, and it serves a specific purpose in treating hyperkalemia and the arrhythmias caused by tricyclic antidepressant overdose.
When sodium bicarbonate is administered, the appropriate dosage is 1 ml per kilogram of 8.4% sodium bicarbonate.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 8
Correct
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A 35 year old epileptic is brought into the emergency department after experiencing a grand mal seizure. The patient is unable to close their mouth. You suspect temporomandibular joint dislocation. What is the initial imaging test recommended for diagnosing this condition?
Your Answer: Orthopantomogram
Explanation:The recommended first-line diagnostic test for TMJ dislocation is an OPG. The Royal College of Emergency Medicine suggests that an OPG is the most effective initial imaging technique for diagnosing TMJ dislocation. However, mandibular series X-ray views and CT scans can also be used as alternative imaging methods.
Further Reading:
TMJ dislocation occurs when the mandibular condyle is displaced from its normal position in the mandibular fossa of the temporal bone. The most common type of dislocation is bilateral anterior dislocation. This occurs when the mandible is dislocated forward and the masseter and pterygoid muscles spasm, locking the condyle in place.
The temporomandibular joint is unique because it has an articular disc that separates the joint into upper and lower compartments. Dislocation can be caused by trauma, such as a direct blow to the open mouth, or by traumatic events like excessive mouth opening during yawning, laughing, shouting, or eating. It can also occur during dental work.
Signs and symptoms of TMJ dislocation include difficulty fully opening or closing the mouth, pain or tenderness in the TMJ region, jaw pain, ear pain, difficulty chewing, and facial pain. Connective tissue disorders like Marfan’s and Ehlers-Danlos syndrome can increase the likelihood of dislocation.
If TMJ dislocation is suspected, X-rays may be done to confirm the diagnosis. The best initial imaging technique is an orthopantomogram (OPG) or a standard mandibular series.
Management of anterior dislocations involves reducing the dislocated mandible, which is usually done in the emergency department. Dislocations to the posterior, medial, or lateral side are usually associated with a mandibular fracture and should be referred to a maxillofacial surgeon.
Reduction of an anterior dislocation involves applying distraction forces to the mandible. This can be done by gripping the mandible externally or intra-orally. In some cases, procedural sedation or local anesthesia may be used, and in rare cases, reduction may be done under general anesthesia.
After reduction, a post-reduction X-ray is done to confirm adequate reduction and rule out any fractures caused by the procedure. Discharge advice includes following a soft diet for at least 48 hours, avoiding wide mouth opening for at least 2 weeks, and supporting the mouth with the hand during yawning or laughing. A Barton bandage may be used to support the mandible if the patient is unable to comply with the discharge advice. Referral to a maxillofacial surgeon as an outpatient is also recommended.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 9
Correct
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A 35-year-old man comes to the clinic complaining of increasing numbness and weakness in his legs over the past 4 days. The symptoms seem to be spreading upwards towards his thighs, and he has also noticed some weakness in his hands. He mentions that he had a bad bout of diarrhea about three weeks ago, but otherwise, he has been healthy. What is the most likely organism responsible for his symptoms?
Your Answer: Campylobacter jejuni
Explanation:This patient’s medical history suggests a diagnosis of Guillain-Barré syndrome (GBS). GBS typically presents with initial symptoms of sensory changes or pain, accompanied by muscle weakness in the hands and/or feet. This weakness often spreads to the arms and upper body, affecting both sides. During the acute phase, GBS can be life-threatening, with around 15% of patients experiencing respiratory muscle weakness and requiring mechanical ventilation.
The exact cause of GBS is unknown, but it is believed to involve an autoimmune response where the body’s immune system attacks the myelin sheath surrounding the peripheral nerves. In about 75% of cases, there is a preceding infection, commonly affecting the gastrointestinal or respiratory tracts.
In this particular case, the most likely underlying cause is Campylobacter jejuni, a gastrointestinal pathogen. This is supported by the recent history of a severe diarrheal illness.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 65 year old male is brought to the emergency department following a fall which occurred while the patient was getting out of bed. The patient complains of feeling dizzy as he got out of bed before experiencing tunnel vision and briefly losing consciousness. The patient is certain he only blacked out for a few seconds as the time on the bedside clock had not changed. The patient informs you that he has had several similar episodes over the past few months when getting out of bed, but most of the time he only feels dizzy and doesn't faint. He denies any loss of bladder or bowel control or biting his tongue. An ECG is performed which shows normal sinus rhythm. You note the patient takes the following medication:
Lisinopril 10 mg OD
Fluoxetine 20 mg OD
What is the most likely diagnosis?Your Answer: Orthostatic hypotension
Explanation:Orthostatic hypotension is a condition where patients feel lightheaded and may experience tunnel vision when they stand up from a lying down position. These symptoms are often worse in the morning. The patient’s history of recurrent episodes after being in a supine position for a long time strongly suggests orthostatic hypotension. There are no signs of epilepsy, such as deja-vu or jambs vu prodrome, tongue biting, loss of bladder or bowel control, or postictal confusion. The normal ECG and consistent timing of symptoms make postural orthostatic tachycardia syndrome (PAF) less likely. There are no neurological deficits to suggest a transient ischemic attack (TIA). The prodromal symptoms, such as tunnel vision and lightheadedness, align more with orthostatic hypotension rather than vasovagal syncope, which typically occurs after long periods of standing and is characterized by feeling hot and sweaty. Although carotid sinus syndrome could be considered as a differential diagnosis, as the patient’s head turning on getting out of bed may trigger symptoms, it is not one of the options.
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:
- Cardiology
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Question 11
Correct
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A 45 year old male is brought into the emergency department by a family member with a 2 day history of nausea and vomiting. On initial assessment the patient appears disoriented. Observations reveal the patient to have a heart rate of 140 beats per minute and blood pressure of 90/60 mmHg. You contemplate the possibility of Addison's disease. What is the primary cause of Addison's disease in the United Kingdom?
Your Answer: Autoimmune adrenalitis
Explanation:Addison’s disease is primarily caused by tuberculosis, making it the most prevalent factor worldwide.
Further Reading:
Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.
The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.
The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.
Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.
There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.
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This question is part of the following fields:
- Endocrinology
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Question 12
Correct
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A 25-year-old woman presents to the emergency department with a complaint of progressive lip swelling that began 1 hour ago. Upon reviewing her medical history, it is noted that she has a previous diagnosis of hereditary angioedema (HAE). The following findings have been documented:
- Blood pressure: 120/80 mmHg
- Pulse rate: 90 beats per minute
- Respiratory rate: 16 breaths per minute
- Temperature: 37.5 degrees Celsius
What is the primary concern regarding this patient?Your Answer: Airway obstruction
Explanation:The primary concern regarding this patient is airway obstruction. The patient’s complaint of progressive lip swelling, along with her previous diagnosis of hereditary angioedema (HAE), suggests that she may be experiencing an allergic reaction. Angioedema can cause swelling in various parts of the body, including the lips, tongue, and throat. If the swelling progresses and affects the airway, it can lead to difficulty breathing and potentially block the airway completely. This can be a life-threatening emergency and requires immediate intervention to ensure the patient’s airway remains open and they can breathe properly.
Further Reading:
Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.
Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.
HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.
The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.
The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.
In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.
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This question is part of the following fields:
- Respiratory
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Question 13
Incorrect
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A toddler develops a palsy of his left leg following a fall. On examination, there is a loss of hip abduction, external rotation and knee flexion. The leg is noticeably dragging with the knee extended and the foot turned inward.
What is the SINGLE most likely diagnosis?Your Answer: Klumpke’s palsy
Correct Answer: Erb’s palsy
Explanation:Erb’s palsy, also known as Erb-Duchenne palsy, is a condition where the arm becomes paralyzed due to an injury to the upper roots of the brachial plexus. The primary root affected is usually C5, although C6 may also be involved in some cases. The main cause of Erb’s palsy is when the arm experiences excessive force during a difficult childbirth, but it can also occur in adults as a result of shoulder trauma.
Clinically, the affected arm will hang by the side with the elbow extended and the forearm turned inward (known as the waiter’s tip sign). Upon examination, there will be a loss of certain movements:
– Shoulder abduction (involving the deltoid and supraspinatus muscles)
– Shoulder external rotation (infraspinatus muscle)
– Elbow flexion (biceps and brachialis muscles)It is important to differentiate Erb’s palsy from Klumpke’s palsy, which affects the lower roots of the brachial plexus (C8 and T1). Klumpke’s palsy presents with a claw hand due to paralysis of the intrinsic hand muscles, along with sensory loss along the ulnar side of the forearm and hand. If T1 is affected, there may also be the presence of Horner’s syndrome.
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This question is part of the following fields:
- Neurology
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Question 14
Incorrect
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A 6-year-old girl is brought in by her parents with wheezing and difficulty breathing. Over the past few days, she has been feeling sick and has had a decreased appetite. Her parents have noticed that she seems to struggle with breathing, especially when she is playing or exerting herself. Her oxygen levels are at 90% on room air, but all her other vital signs are normal. A chest X-ray is taken, which is shows left lung appears overinflated and hyperlucent, with concomitant rib flaring and a depressed ipsilateral hemidiaphragm. What is the MOST likely diagnosis for this patient?
Your Answer: Asthma
Correct Answer: Inhaled foreign body
Explanation:This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.
Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.
Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.
While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.
To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.
Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.
Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).
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This question is part of the following fields:
- Respiratory
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Question 15
Incorrect
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A 7-year-old child experiences an anaphylactic reaction after being stung by a bee.
What dosage of IV hydrocortisone should be administered in this situation?Your Answer: 50 mg
Correct Answer: 100 mg
Explanation:Corticosteroids can be beneficial in preventing or reducing prolonged reactions. According to the current APLS guidelines, the recommended doses of hydrocortisone for different age groups are as follows:
– Children under 6 months: 25 mg administered slowly via intramuscular (IM) or intravenous (IV) route.
– Children aged 6 months to 6 years: 50 mg administered slowly via IM or IV route.
– Children aged 6 to 12 years: 100 mg administered slowly via IM or IV route.
– Children over 12 years: 200 mg administered slowly via IM or IV route.
– Adults: 200 mg administered slowly via IM or IV route.It is important to note that the most recent ALS guidelines do not recommend the routine use of corticosteroids for treating anaphylaxis in adults. However, the current APLS guidelines still advocate for the use of corticosteroids in children to manage anaphylaxis.
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This question is part of the following fields:
- Allergy
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Question 16
Correct
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A 25-year-old presents to the emergency department with a complaint of haematemesis and haemoptysis that started 45 minutes ago. The patient had a tonsillectomy 5 days ago. The patient's vital signs are as follows:
Blood pressure: 120/70 mmHg
Pulse: 80 bpm
Respiration rate: 16 bpm
Temperature: 36.8ºC
During the examination, fresh clotted blood is observed in the left tonsillar fossa, but there is no active bleeding. The patient reports that they no longer feel blood dripping down their throat and does not cough up any blood in the next 45 minutes. What is the most appropriate management for this patient?Your Answer: Admit under ENT
Explanation:Patients who experience post-tonsillectomy bleeding, even if it stops, should be closely monitored and assessed by an ear, nose, and throat specialist before being discharged. It is important to note that minor bleeding episodes may occur before a more severe hemorrhage. Therefore, patients with post-tonsillectomy bleeds, even if they seem to have resolved, should be admitted to the hospital under the care of an ENT specialist.
Further Reading:
Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.
Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.
Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.
The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.
Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.
Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.
If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 17
Correct
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A 45-year-old man is brought into the Emergency Department by his wife after taking an overdose of paracetamol. The patient states that he “wants to end it all” and refuses to stay in hospital and receive treatment. His wife insists that he must be treated because “he is not thinking clearly”.
Which blood test is the earliest and most sensitive indicator of liver damage in paracetamol overdose?Your Answer: INR
Explanation:Paracetamol overdose is the most common overdose in the U.K. and is also the leading cause of acute liver failure. The liver damage occurs due to a metabolite of paracetamol called N-acetyl-p-benzoquinoneimine (NAPQI), which depletes the liver’s glutathione stores and directly harms liver cells. Severe liver damage and even death can result from an overdose of more than 12 g or > 150 mg/kg body weight.
The clinical manifestations of paracetamol overdose can be divided into four stages:
Stage 1 (0-24 hours): Patients may not show any symptoms, but common signs include nausea, vomiting, and abdominal discomfort.
Stage 2 (24-48 hours): Right upper quadrant pain and tenderness develop, along with the possibility of hypoglycemia and reduced consciousness.
Stage 3 (48-96 hours): Hepatic failure begins, characterized by jaundice, coagulopathy, and encephalopathy. Loin pain, haematuria, and proteinuria may indicate early renal failure.
Stage 4 (> 96 hours): Hepatic failure worsens progressively, leading to cerebral edema, disseminated intravascular coagulation (DIC), and ultimately death.
The earliest and most sensitive indicator of liver damage is a prolonged INR, which starts to rise approximately 24 hours after the overdose. Liver function tests (LFTs) typically remain normal until 18 hours after the overdose. However, AST and ALT levels then sharply increase and can exceed 10,000 units/L by 72-96 hours. Bilirubin levels rise more slowly and peak around 5 days.
The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is a highly effective antidote, but its efficacy diminishes rapidly if administered more than 8 hours after a significant ingestion. Ingestions exceeding 75 mg/kg are considered significant.
Acetylcysteine should be given based on a 4-hour level or administered empirically if the presentation occurs more than 8 hours after a significant overdose. If the overdose is staggered or the timing is uncertain, empirical treatment is also recommended. The treatment regimen is as follows:
– First dose: 150 mg/kg in 200 mL 5% glucose over 1 hour
– Second dose 50 mg/kg in 500 mL 5% glucose over 4 hours
– Third dose 100 mg/kg in 1000 mL 5% glucose over 16 hours -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 18
Correct
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A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby bar and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?
Your Answer: Osborne Waves (J waves)
Explanation:Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, shivering artifact, ventricular ectopics (abnormal heartbeats originating from the ventricles), and even cardiac arrest (ventricular tachycardia, ventricular fibrillation, or asystole) may occur.
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:
- Cardiology
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Question 19
Correct
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A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a known history of lung cancer.
What is the most probable diagnosis in this case?Your Answer: Superior vena cava syndrome
Explanation:This patient has come in with worsening breathlessness and coughing, along with coughing up blood, all of which are occurring on top of their existing lung cancer. The diagnosis in this case is superior vena cava obstruction, which is being caused by the primary bronchial neoplasm.
The typical clinical presentation of superior vena cava obstruction includes breathlessness and coughing, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.
Given the urgency of the situation, this man will require immediate treatment. Upon initial presentation, it is important to elevate his head and provide supplemental oxygen to alleviate symptoms. Additionally, corticosteroids and diuretics may be administered. Further investigation will be necessary through CT scanning, and radiotherapy may be recommended as a potential course of action.
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This question is part of the following fields:
- Oncological Emergencies
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Question 20
Correct
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A 62 year old male comes to the emergency department with a chief complaint of experiencing dizziness upon movement. The patient states that the symptoms began today when he got up from bed. He describes the dizzy spells as a sensation of the room spinning and they typically last for around 30 seconds. The patient also mentions feeling nauseous during these episodes. There are no reported issues with hearing loss or tinnitus.
What is the most probable diagnosis?Your Answer: Benign paroxysmal positional vertigo
Explanation:BPPV is a condition where dizziness and vertigo occur suddenly when the position of the head is changed. This is a common symptom of benign paroxysmal positional vertigo, which is characterized by episodes of vertigo triggered by head movements.
Further Reading:
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.
The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.
Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 21
Correct
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A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. After conducting a comprehensive examination and measuring the intraocular pressure, you diagnose her with acute closed-angle glaucoma.
Which of the following statements about acute closed-angle glaucoma is correct?Your Answer: intraocular pressures are often greater than 30 mmHg
Explanation:This patient has presented with acute closed-angle glaucoma, which is a medical emergency in the field of ophthalmology. It occurs when the iris bows forward and blocks the fluid access to the trabecular meshwork, which is located at the entrance to Schlemm’s canal. As a result, the intraocular pressure rises and leads to glaucomatous optic neuropathy.
The main clinical features of acute closed-angle glaucoma include severe eye pain, loss of vision or decreased visual acuity, congestion and redness around the cornea, corneal swelling, a fixed semi-dilated oval-shaped pupil, nausea and vomiting, and preceding episodes of blurred vision or seeing haloes.
The diagnosis can be confirmed by tonometry, which measures the pressure inside the eye. The normal range of intraocular pressure is 10-21 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 should include providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous administration of acetazolamide 500 mg is recommended to reduce intraocular pressure. Treatment with a topical miotic, like pilocarpine 1% or 2%, should be initiated approximately one hour after starting other measures, as the pupil may initially be paralyzed and unresponsive.
On the other hand, chronic open-angle glaucoma is a more common presentation than acute closed-angle glaucoma. It affects approximately 1 in 50 people over the age of 40 and 1 in 10 people over the age of 75. In this condition, there is a partial blockage within the trabecular meshwork, which hinders the drainage of aqueous humor and gradually increases intraocular pressure, leading to optic neuropathy. Unlike acute closed-angle glaucoma, chronic open-angle glaucoma does not cause eye pain or redness. It presents gradually with a progressive loss of peripheral vision, while central vision is relatively preserved.
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This question is part of the following fields:
- Ophthalmology
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Question 22
Correct
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A 32-year-old woman comes in seeking contraceptive advice. She is currently 48 hours behind schedule in starting the first pill of her new packet. She took all of her pills consistently last month before her pill-free interval. She engaged in unprotected sexual intercourse last night and wants to know the best course of action.
What is the MOST suitable advice to provide her?Your Answer: She should take the most recent missed pill, the remaining pills should be continued at the usual time, but no emergency contraception is required
Explanation:If you have missed one pill, which means it has been 48-72 hours since you took the last pill in your current packet or you started the first pill in a new packet 24-48 hours late, you need to take the missed pill as soon as you remember. Make sure to continue taking the remaining pills at your usual time. Emergency contraception is generally not necessary in this situation, but it may be worth considering if you have missed pills earlier in the packet or during the last week of the previous packet.
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This question is part of the following fields:
- Sexual Health
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Question 23
Correct
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A 4 year old is brought into the emergency department by worried parents. The child has been pulling at his right ear and has been fussy and crying for the past day. During the examination, you observe that the child has a temperature of 38.9ºC and there is redness over the mastoid. You suspect mastoiditis. What is the most probable causative bacteria?
Your Answer: Streptococcus pneumoniae
Explanation:The most commonly found organism in patients with mastoiditis is Streptococcus pneumoniae.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 24
Correct
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You intend to utilize plain 1% lidocaine for a ring block on a finger that requires suturing. How much lidocaine hydrochloride is present in every 1 ml of plain 1% lidocaine solution?
Your Answer: 10 mg lidocaine hydrochloride
Explanation:Each milliliter of plain 1% lidocaine solution contains 10 milligrams of lidocaine hydrochloride.
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This question is part of the following fields:
- Pain & Sedation
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Question 25
Correct
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A 65-year-old man comes in with a sudden onset of right-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage and he is being prepared for thrombolysis. His blood pressure is currently elevated at 190/100 mmHg.
What would be the most suitable next course of action in managing his condition?Your Answer: Labetalol 10 mg IV
Explanation:Severe hypertension, defined as blood pressure greater than 180/120 mmHg, is a condition that prevents the use of thrombolysis. In order to proceed with thrombolysis, it is necessary to lower the patient’s blood pressure to below this level within the designated time frame. Oral medications are unlikely to work quickly enough, so an intravenous antihypertensive agent is required.
One commonly used agent in these situations is labetalol, which is administered intravenously at a dose of 10 mg over 1-2 minutes. This dose can be repeated if necessary, or an infusion can be set up to deliver a continuous dose of 2-8 mg per minute. Once the blood pressure is reduced to less than 180/105 mmHg, thrombolysis can be safely performed.
Alternatively, a nitrate infusion, such as Isoket, can be used in patients who cannot tolerate beta-blockers due to contraindications like asthma, heart block, or cardiac failure. This provides an alternative option for lowering blood pressure in these individuals.
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This question is part of the following fields:
- Neurology
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Question 26
Correct
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A 30-year-old woman is injured in a car crash and sustains severe facial injuries. X-rays and CT scans of her face show that she has a Le Fort II fracture.
What is the most accurate description of a Le Fort II fracture?Your Answer: ‘Floating maxilla’
Explanation:Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.
The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.
Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.
Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.
Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 27
Correct
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A 6-year-old boy comes in with a headache, stiffness in his neck, and sensitivity to light. He has a known allergy to penicillin and had to spend some time in the ICU because of it. He has also recently developed a rash of small red or purple spots on his arms and legs.
What is the MOST suitable next course of action in managing his condition?Your Answer: Chloramphenicol
Explanation:This girl is displaying symptoms and signs that are consistent with a diagnosis of meningococcal septicaemia. It is crucial that she receives urgent antibiotic treatment. If a patient has a penicillin allergy, but not anaphylaxis, a third-generation cephalosporin like cefotaxime may be administered. However, in this particular case, the girl has a documented history of anaphylaxis to penicillin. It is important to note that up to 10% of patients who are allergic to penicillin may experience an adverse reaction to cephalosporins. In situations where there is a true anaphylactic reaction to penicillins, the British National Formulary (BNF) recommends the use of chloramphenicol as an alternative treatment option.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A patient is experiencing lower gastrointestinal bleeding following the administration of heparin. You choose to utilize protamine sulfate to reverse the anticoagulation.
Which ONE statement about protamine sulfate is NOT true?Your Answer: It has an anticoagulant effect
Correct Answer: It is administered subcutaneously
Explanation:Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex is inactive and is used to counteract the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.
Apart from its ability to neutralize heparin, protamine sulphate also possesses a weak intrinsic anticoagulant effect. This is believed to be due to its inhibition of the formation and activity of thromboplastin.
To administer protamine sulphate, it is slowly injected intravenously. The dosage should be adjusted based on the amount of heparin to be neutralized, the time elapsed since heparin administration, and the aPTT. For every 100 IU of heparin, 1 mg of protamine is required for neutralization. However, the maximum adult dose within a 10-minute period should not exceed 50 mg.
It is important to note that protamine sulphate has additional effects on the body. It acts as a depressant on the heart muscle and may lead to bradycardia and hypotension. These effects are caused by complement activation and the release of leukotrienes.
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This question is part of the following fields:
- Haematology
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Question 29
Correct
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You review a patient with sickle-cell disease and a history of multiple previous painful episodes. The patient informs you that two other individuals in his family also have sickle-cell disease.
What is the mode of inheritance for sickle-cell disease?Your Answer: Autosomal recessive
Explanation:Sickle-cell disease is a blood disorder that is inherited in an autosomal recessive manner. It is characterized by the production of abnormal red blood cells that have a sickle shape. These abnormal cells are triggered by various factors such as low oxygen levels, dehydration, stress, and infection. The disease is caused by a specific mutation in the beta-globin chain of hemoglobin, resulting in the substitution of glutamic acid with valine at the sixth position. The gene responsible for this mutation is located on chromosome 11.
On the other hand, sickle-cell trait refers to the carrier state of the disease. Individuals with sickle-cell trait have one normal allele and one abnormal allele. Both alleles are co-dominant, meaning that both normal and abnormal hemoglobin are produced. As a result, individuals with sickle-cell trait do not experience the same severity of symptoms as those with sickle-cell disease.
When both parents are carriers of the sickle-cell trait, there is a 50% chance that their child will also be an unaffected carrier, a 25% chance that the child will be unaffected, and a 25% chance that the child will develop sickle-cell disease. This is because the inheritance of the disease follows the principles of autosomal recessive inheritance.
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This question is part of the following fields:
- Haematology
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Question 30
Incorrect
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A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.
What is the SINGLE most likely causative organism?Your Answer: Pasteurella canis
Correct Answer: Toxocara canis
Explanation:Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.
The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.
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This question is part of the following fields:
- Ophthalmology
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Question 31
Correct
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With freezing temperatures anticipated, your consultant requests that you organize a teaching session for the junior physicians regarding the management of frostbite. What imaging modality is preferred for evaluating perfusion abnormalities in extremities impacted by frostbite?
Your Answer: Technetium 99 (Tc-99) pertechnetate scintigraphy
Explanation:Technetium 99 (Tc-99) pertechnetate scintigraphy is the preferred imaging method for evaluating frostbite. This technique is highly accurate in detecting tissue damage and provides both sensitivity and specificity.
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 decreased 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.
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This question is part of the following fields:
- Dermatology
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Question 32
Correct
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You are overseeing the care of a trauma patient in the resuscitation bay. A chest tube has been inserted through thoracostomy to drain the hemothorax. The initial amount of blood drained is documented, and there are plans to monitor the additional blood volume drained every hour. What would be an indication for thoracotomy in this patient?
Your Answer: 250 ml blood drained from pleural cavity (in addition to previous volumes) between hours 2 and 3 post insertion
Explanation:The main indications for thoracotomy in patients with haemothorax are prompt drainage of at least 1500 ml of blood, ongoing blood loss of more than 200 ml per hour for 2-4 hours, and the need for continued blood transfusion. Option 3 in the given choices meets these criteria as the blood loss remains above 200 ml per hour for more than 2 hours after the drain is inserted. Option 1 does not meet the criteria as the blood volume is below 1500 ml. Option 2 does not meet the criteria as the blood loss has not been ongoing for at least 2 hours. Option 4 does not meet the criteria as there is no information indicating the need for ongoing blood transfusion.
Further Reading:
Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.
The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.
In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.
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This question is part of the following fields:
- Trauma
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Question 33
Correct
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You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You plan on administering atropine to address the patient's bradyarrhythmia.
According to the resuscitation council, what is the maximum recommended total dose of atropine that should be administered?Your Answer: 3mg
Explanation:When treating adults with bradycardia, a maximum of 6 doses of atropine 500 mcg can be administered. Each dose is given intravenously every 3-5 minutes. The total dose should not exceed 3mg.
Further Reading:
Causes of Bradycardia:
– Physiological: Athletes, sleeping
– Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
– Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
– Hypothermia
– Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
– Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
– Head injury: Cushing’s response
– Infections: Endocarditis
– Other: Sarcoidosis, amyloidosisPresenting symptoms of Bradycardia:
– Presyncope (dizziness, lightheadedness)
– Syncope
– Breathlessness
– Weakness
– Chest pain
– NauseaManagement of Bradycardia:
– Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
– Treat reversible causes of bradycardia
– Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
– Transcutaneous pacing if atropine is ineffective
– Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolateBradycardia Algorithm:
– Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf -
This question is part of the following fields:
- Cardiology
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Question 34
Correct
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A 35 year old female presents to the emergency department complaining of sudden abdominal pain. She mentions that she has been consuming alcohol excessively for the past 48 hours and suspects it may be the cause of her discomfort. After a thorough evaluation and necessary tests, the patient is deemed stable enough to be discharged. You counsel her on the importance of consuming alcohol within safe limits.
According to the department of health, what is the recommended maximum number of units per week for women in order to minimize health risks?Your Answer: 14
Explanation:The UK chief medical officer and Department of Health recommend that both men and women should limit their alcohol consumption to no more than 14 units per week in order to minimize health risks. It is advised that individuals who consume up to 14 units per week should spread this amount over at least 3 days. Pregnant women are advised to completely avoid alcohol for the safest approach. Hazardous drinking refers to a pattern of alcohol consumption that increases the risk of harm. This includes consuming more than 14 units per week, but less than 35 units per week for women.
Further Reading:
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.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 35
Correct
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A 65-year-old woman with a history of Parkinson's disease and depression has experienced a gradual decline in her cognitive abilities over the past year. Her memory and ability to focus have been noticeably impaired recently. Additionally, she has experienced a few episodes of unexplained temporary loss of consciousness and occasional visual hallucinations.
What is the SINGLE most probable diagnosis?Your Answer: Dementia with Lewy bodies (DLB)
Explanation:Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative condition that is closely linked to Parkinson’s disease (PD). It is the third most common cause of dementia in older individuals, following Alzheimer’s disease and vascular dementia.
DLB is characterized by several clinical features, including the presence of Parkinsonism or co-existing PD, a gradual decline in cognitive function, fluctuations in cognition, alertness, and attention span, episodes of temporary loss of consciousness, recurrent falls, visual hallucinations, depression, and complex, systematized delusions. The level of cognitive impairment can vary from hour to hour and day to day.
Pathologically, DLB is marked by the formation of abnormal protein collections called Lewy bodies within the cytoplasm of neurons. These intracellular protein collections share similar structural characteristics with the classic Lewy bodies observed in Parkinson’s disease.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 36
Correct
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A 25-year-old male arrives at the Emergency Department in evident distress. He woke up this morning with sudden and intense pain in his right testicle. He also experiences some discomfort in his right iliac fossa. He reports feeling nauseous and has vomited twice while waiting. Upon examination, his right testicle is firm, highly sensitive, and positioned slightly higher than the left side.
What is the MOST probable diagnosis in this case?Your Answer: Testicular torsion
Explanation:Testicular torsion is a condition where the spermatic cord twists, leading to a lack of blood flow to the testis. It is a surgical emergency and prompt action is necessary to save the testis. It is most commonly seen in individuals aged 15-30 years.
Varicocele refers to the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more frequently observed in the left testis and may be associated with infertility. This is believed to be due to the increased temperature caused by the varicose veins. Symptoms include a dull ache in the testis, which is often worse after exercise or at the end of the day. Standing examination can reveal the presence of Varicocele. Treatment is usually conservative, with surgery reserved for severe cases.
Hydrocoele can occur at any age and is characterized by the accumulation of fluid in the tunica vaginalis. It presents as scrotal swelling, which can be palpated above. The surface of the hydrocoele is smooth and it can be transilluminated. The testis is contained within the swelling and cannot be felt separately. Primary or secondary causes can lead to hydrocoele, and in adults, an ultrasound is performed to rule out underlying pathology such as tumors. Conservative management is often sufficient unless the hydrocoele is large.
Testicular cancer is the most common cancer in men aged 20-34 years. Awareness campaigns have emphasized the importance of self-examination for early detection. Risk factors include undescended testes, which increase the risk by 10-fold if bilateral. A previous history of testicular cancer carries a 4% risk of developing a second cancer. The usual presentation is a painless lump in the testis, which can also manifest as a secondary hydrocoele. Seminomas account for 60% of cases and are slow-growing, usually confined to the testis upon diagnosis. Stage 1 seminomas have a 98% 5-year survival rate. Teratomas, which can grow faster, make up 40% of cases and can occur within seminomas. Mixed type tumors are treated as teratomas due to their more aggressive nature. Surgical treatment, with or without chemotherapy and radiotherapy, is the primary approach.
Epididymo-orchitis is inflammation of the testis and epididymis caused by infection.
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This question is part of the following fields:
- Urology
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Question 37
Incorrect
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A 32-year-old man with a long-standing history of ulcerative colitis presents with a complication of his illness.
What is the SINGLE least likely complication that he has developed?Your Answer: Vitamin B12 deficiency
Correct Answer: Perianal fistula
Explanation:Ulcerative colitis can lead to various complications, although the development of fistulae is rare and less likely compared to other complications. Perianal complications associated with ulcerative colitis are uncommon and typically occur in cases with more extensive inflammation and a severe disease course.
The complications of ulcerative colitis can be categorized into localized and systemic complications. Localized complications include bleeding, electrolyte imbalance, toxic megacolon, perforation, an increased risk of colonic carcinoma, an increased risk of lymphoma, and the rare occurrence of stricture and fistula formation.
On the other hand, systemic complications of ulcerative colitis involve malnutrition and weight loss, iron-deficiency anemia, vitamin B12 deficiency, hypoproteinaemia, primary sclerosing cholangitis, primary biliary cirrhosis, chronic active hepatitis, joint pain or arthropathy, ankylosing spondylitis, pyoderma gangrenosum, and erythema nodosum. Additionally, ulcerative colitis can also lead to complications affecting the eyes, such as iritis, episcleritis, and uveitis.
Overall, while ulcerative colitis can present with various complications, the development of fistulae is rare and less likely compared to other complications. Perianal complications are infrequent and typically associated with more extensive inflammation and a severe disease course.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 38
Correct
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You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a traumatic brain injury. What should be included in the initial management of a patient with elevated intracranial pressure (ICP)?
Your Answer: Maintain systolic blood pressure >90 mmHg
Explanation:Maintaining adequate blood pressure is crucial in managing increased intracranial pressure (ICP). The recommended blood pressure targets may vary depending on the source. The Scottish Intercollegiate Guidelines Network (SIGN) suggests maintaining an adequate blood pressure, while the 4th edition of the Brain Trauma Foundation recommends maintaining a systolic blood pressure (SBP) above 100 mm Hg for individuals aged 50-69 years (or above 110 mm Hg for those aged 15-49 years) to reduce mortality and improve outcomes.
When managing a patient with increased ICP, the initial steps should include maintaining normal body temperature to prevent fever, positioning the patient with a 30º head-up tilt, and administering analgesia and sedation as needed. It is important to monitor and maintain blood pressure, using inotropes if necessary to achieve the target. Additionally, preparations should be made to use medications such as Mannitol or hypertonic saline to lower ICP if required. Hyperventilation may also be considered, although it carries the risk of inducing ischemia and requires monitoring of carbon dioxide levels.
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.
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This question is part of the following fields:
- Neurology
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Question 39
Correct
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A 42-year-old woman presents with a skin condition that has occurred secondary to a systemic illness that she suffers from.
Which skin condition is NOT correctly paired with its associated systemic illness?Your Answer: Vitiligo and Cushing’s disease
Explanation:Many systemic illnesses have distinct dermatological associations. Some of these are listed below:
Addison’s disease is characterized by pigmentation and vitiligo.
Cushing’s disease is associated with pigmentation, striae, hirsutism, and acne.
Diabetes mellitus can cause necrobiosis lipoidica, which presents as shiny, yellowish plaques on the shin. It can also lead to xanthoma, a condition characterized by yellowish lipid deposits in the skin, and granuloma annulare, which manifests as palpable ring lesions on the hands, face, or feet.
Hyperlipidemia is linked to xanthoma and xanthomata, which are yellowish plaques on the eyelids.
Crohn’s disease is associated with erythema nodosum.
Ulcerative colitis can cause pyoderma gangrenosum and erythema nodosum.
Liver disease often presents with pruritus, spider naevi, and erythema.
Malignancy can lead to mycosis fungoides, a type of lymphoma that affects the skin. It is also associated with acanthosis nigricans, which is often seen in gastrointestinal malignancies.
Hypothyroidism is linked to alopecia, while thyrotoxicosis can cause both alopecia and pretibial myxedema.
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This question is part of the following fields:
- Dermatology
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Question 40
Correct
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You consult with your supervisor for a case-based discussion following a case where you treated a pediatric patient with a peritonsillar abscess. Your supervisor suggests that you take the lead in conducting a teaching session on peritonsillar abscess in children.
Which of the following statements about peritonsillar abscess in pediatric patients is accurate?Your Answer: Most commonly presents in adolescents and young adults aged 20-40 years
Explanation:Peritonsillar abscess, also known as quinsy, is most commonly seen in adolescents and young adults between the ages of 20 and 40. Risk factors for developing quinsy include being male and smoking. It is a relatively common condition, with studies showing an incidence rate of 10 to 30 cases per 100,000 population. When treating quinsy, it is important to use a broader range of antibiotics compared to standard treatment for pharyngotonsillitis, as the causative organisms may not be limited to Group A Streptococcus. Common antibiotic choices include intravenous amoxicillin with clindamycin or metronidazole, although the specific antibiotic used may vary depending on local antimicrobial policies.
Further Reading:
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.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 41
Correct
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A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given isoniazid as part of her medication. As a result of this treatment, the newborn develops a defect.
Which of the following defects is the most probable outcome due to the use of this medication during pregnancy?Your Answer: Neuropathy
Explanation:The standard drug regimen for tuberculosis is generally safe to use during pregnancy, with the exception of streptomycin which should be avoided. However, the use of isoniazid during pregnancy has been associated with potential risks such as liver damage in the mother and the possibility of neuropathy and seizures in the newborn.
Here is a list outlining some commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If taken during the second and third trimesters, these medications can lead to reduced blood flow, kidney failure, and a condition called oligohydramnios.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity, resulting in hearing loss in the baby.
Aspirin: High doses of aspirin can increase the risk of first trimester abortions, delayed labor, premature closure of the fetal ductus arteriosus, and a condition called fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When taken late in pregnancy, these medications can cause respiratory depression in the baby and lead to a withdrawal syndrome.
Calcium-channel blockers: If taken during the first trimester, these drugs can cause abnormalities in the fingers and toes. If taken during the second and third trimesters, they may result in fetal growth retardation.
Carbamazepine: This medication can increase the risk of hemorrhagic disease in the newborn and neural tube defects.
Chloramphenicol: Use of this drug in newborns can lead to a condition known as grey baby syndrome.
Corticosteroids: If taken during the first trimester, corticosteroids may increase the risk of orofacial clefts in the baby.
Danazol: When taken during the first trimester, this medication can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect the development of male sex organs in the baby.
Haloperidol: If taken during the first trimester, this medication may increase the risk of limb malformations. If taken during the third trimester, it can lead to an increased risk of extrapyramidal symptoms in the newborn.
Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 42
Correct
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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: 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.
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This question is part of the following fields:
- Endocrinology
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Question 43
Correct
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A 60-year-old woman presents with a gradual decline in her hearing. She struggles to understand her husband's words at times and describes his voice as muffled. Both of her ears are affected, and her hearing worsens in noisy settings. During the examination, both of her eardrums appear normal, and Rinne's test yields normal results.
What is the MOST LIKELY diagnosis for this patient?Your Answer: Presbycusis
Explanation:Presbycusis is a type of hearing loss that occurs gradually as a person gets older. It affects both ears and is caused by the gradual deterioration of the hair cells in the cochlea and the cochlear nerve. The most noticeable hearing loss is at higher frequencies, and it worsens over time. People with presbycusis often have difficulty hearing speech clearly, and they may describe words as sounding muffled or blending together. A test called Rinne’s test will show normal results in cases of presbycusis. If a patient has presbycusis, it is recommended that they be referred for a hearing aid fitting.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 44
Correct
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A 32-year-old man receives a blood transfusion and experiences a severe transfusion reaction. His condition quickly worsens, and he ultimately succumbs to this reaction. His death is reported to Serious Hazards of Transfusion (SHOT).
Which of the following is the SECOND most common cause of transfusion-related fatalities in the UK?Your Answer: TACO
Explanation:Transfusion-related lung injury (TRALI) is responsible for about one-third of all transfusion-related deaths, making it the leading cause. On the other hand, transfusion-associated circulatory overload (TACO) accounts for approximately 20% of these fatalities, making it the second leading cause. TACO occurs when a large volume of blood is rapidly infused, particularly in patients with limited cardiac reserve or chronic anemia. Elderly individuals, infants, and severely anemic patients are especially vulnerable to this reaction.
The typical signs of TACO include acute respiratory distress, rapid heart rate, high blood pressure, the appearance of acute or worsening pulmonary edema on a chest X-ray, and evidence of excessive fluid accumulation. In many cases, simply reducing the transfusion rate, positioning the patient upright, and administering diuretics will be sufficient to manage the condition. However, in more severe cases, it is necessary to halt the transfusion and consider non-invasive ventilation.
Transfusion-related acute lung injury (TRALI) is defined as new acute lung injury (ALI) that occurs during or within six hours of transfusion, not explained by another ALI risk factor. Transfusion of part of one unit of any blood product can cause TRALI.
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This question is part of the following fields:
- Haematology
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Question 45
Correct
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A 6 year old male is brought to the emergency department due to a rash on the flexural surfaces of both elbows. Dad informs you that there is usually some dry skin here but the redness has increased and the child has been scratching the area a lot over the past few days. You diagnose a moderate severity eczema flare.
What is the most suitable course of action?Your Answer: Advise regular use of emollients and twice daily clobetasone butyrate
Explanation:Dermovate (Clobetasol propionate) is a strong steroid used for treating skin conditions. It is important to continue using emollients alongside steroid treatment. If the flare-ups are not effectively controlled by steroids, Tacrolimus can be considered as a secondary treatment option.
Further Reading:
Eczema is a chronic inflammatory skin disease characterized by dry, itchy skin with eczematous lesions. It often follows a chronic relapsing course and can lead to chronic skin changes such as lichenification and pigment changes. The term eczema is often used interchangeably with dermatitis, but strictly speaking, dermatitis refers to inflammation of the skin while eczema refers to specific conditions where skin inflammation is a feature.
Atopic eczema, also known as atopic dermatitis, is the most common type of eczema. It is usually first diagnosed in young children, with 90% of cases diagnosed before the age of 5. However, it can affect individuals of any age. Symptoms often improve as patients progress into their teens and adulthood. Around 10-20% of children are affected by atopic eczema, but only 3% of adults experience symptoms.
The exact cause of atopic eczema is not fully understood, but it is believed to be multifactorial, with both genetic and environmental factors playing a role. Genetic defects in genes that aid in the functioning of the skin barrier have been identified, which may predispose individuals to breaks in the skin barrier and increased exposure to antigens. Environmental factors such as pollution, allergen exposure, climate, and others also contribute to the development of the disease.
Diagnosing atopic eczema involves assessing the presence of key clinical features, such as pruritus (itching), eczema/dermatitis in a pattern appropriate for age, early age of onset, and personal or family history of atopy. Various diagnostic criteria have been established to aid in the diagnosis, including those set out by the American Academy of Dermatology and the UK working party.
The severity of atopic eczema can vary, and treatment options depend on the severity. Mild cases may be managed with emollients (moisturizers) and mild potency topical corticosteroids. Moderate cases may require moderate potency topical corticosteroids, topical calcineurin inhibitors, and bandages. Severe cases may necessitate the use of potent topical corticosteroids, topical calcineurin inhibitors, bandages, phototherapy, and systemic therapy.
In addition to medical treatment, identifying and avoiding triggers is an important aspect of managing atopic eczema. Common triggers include irritants, contact allergens, certain foods, skin infections, inhalant triggers, stress and infection.
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This question is part of the following fields:
- Dermatology
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Question 46
Correct
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A 45 year old male attends the emergency department and complains about fatigue, muscle spasms and frequent urination. A capillary blood glucose is normal at 4.4 mmol/l. You review his medication list and suspect the patient may have acquired diabetes insipidus. Which medication is most likely to be responsible?
Your Answer: Lithium
Explanation:Nephrogenic diabetes insipidus may develop in a certain percentage of individuals who take lithium.
Further Reading:
Diabetes insipidus (DI) is a condition characterized by either a decrease in the secretion of antidiuretic hormone (cranial DI) or insensitivity to antidiuretic hormone (nephrogenic DI). Antidiuretic hormone, also known as arginine vasopressin, is produced in the hypothalamus and released from the posterior pituitary. The typical biochemical disturbances seen in DI include elevated plasma osmolality, low urine osmolality, polyuria, and hypernatraemia.
Cranial DI can be caused by various factors such as head injury, CNS infections, pituitary tumors, and pituitary surgery. Nephrogenic DI, on the other hand, can be genetic or result from electrolyte disturbances or the use of certain drugs. Symptoms of DI include polyuria, polydipsia, nocturia, signs of dehydration, and in children, irritability, failure to thrive, and fatigue.
To diagnose DI, a 24-hour urine collection is done to confirm polyuria, and U&Es will typically show hypernatraemia. High plasma osmolality with low urine osmolality is also observed. Imaging studies such as MRI of the pituitary, hypothalamus, and surrounding tissues may be done, as well as a fluid deprivation test to evaluate the response to desmopressin.
Management of cranial DI involves supplementation with desmopressin, a synthetic form of arginine vasopressin. However, hyponatraemia is a common side effect that needs to be monitored. In nephrogenic DI, desmopressin supplementation is usually not effective, and management focuses on ensuring adequate fluid intake to offset water loss and monitoring electrolyte levels. Causative drugs need to be stopped, and there is a risk of developing complications such as hydroureteronephrosis and an overdistended bladder.
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This question is part of the following fields:
- Endocrinology
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Question 47
Correct
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A 45-year-old man presents with generalized weakness and palpitations. Upon reviewing his blood results, you note that his potassium level is significantly elevated. His ECG shows a broad QRS and peaked T waves. As part of his treatment, you administer a dose of calcium chloride.
How does calcium chloride work in the treatment of hyperkalemia?Your Answer: Stabilisation of the cell membrane
Explanation:Calcium is effective in treating hyperkalaemia by counteracting the harmful effects on the heart caused by high levels of potassium. It achieves this by stabilizing the cardiac cell membrane and preventing unwanted depolarization. The onset of action is rapid, typically within 15 minutes, but the effects do not last for a long duration. Calcium is considered the first-line treatment for severe hyperkalaemia (potassium levels above 7 mmol/l) and when significant ECG abnormalities are present, such as widened QRS interval, loss of P wave, or cardiac arrhythmias. However, if the ECG only shows peaked T waves, calcium is usually not recommended.
It is important to note that calcium does not directly affect the serum potassium levels. Therefore, when administering calcium, it should be accompanied by other therapies that actively lower the serum potassium levels, such as insulin and salbutamol.
When hyperkalaemia is accompanied by hemodynamic compromise, calcium chloride is preferred over calcium gluconate. This is because calcium chloride contains approximately three times more elemental calcium than an equal volume of calcium gluconate.
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This question is part of the following fields:
- Nephrology
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Question 48
Correct
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A 32-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctor diagnosed her with pelvic inflammatory disease and started her on antibiotics. She initially got better but now she is back with intense pain in her lower abdomen and a temperature of 39.5°C.
What is the MOST suitable first test to perform?Your Answer: Ultrasound scan
Explanation:This patient is highly likely to have developed a tubo-ovarian abscess (TOA), which is a complication of pelvic inflammatory disease. TOA occurs when a pocket of pus forms in the fallopian tube and/or ovary. If the abscess ruptures, it can lead to sepsis and become life-threatening.
The initial imaging modality of choice is transabdominal and endovaginal ultrasound. This imaging technique often reveals multilocular complex retro-uterine/adnexal masses with debris, septations, and irregular thick walls. These masses can be present on both sides.
Urgent hospital admission is necessary, and the usual management involves draining the abscess and administering intravenous antibiotics. The abscess drainage can be guided by ultrasound or CT scanning.
In some cases, laparotomy or laparoscopy may be required to drain the abscess.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 49
Correct
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A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose 45 minutes ago. He is currently showing no symptoms and is stable in terms of blood flow. The attending physician recommends administering a dose of activated charcoal.
Which of the following substances or toxins is activated charcoal effective in decontaminating?Your Answer: Aspirin
Explanation:Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the molecules of the ingested toxin onto its surface.
Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. It is produced by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then treating it with a zinc chloride solution to increase its concentration. This process creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This allows it to effectively inhibit the absorption of toxins by up to 50%.
The usual dose of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to administer it within one hour of ingestion, and it may be repeated after one hour if necessary.
However, there are certain situations where activated charcoal should not be used. These include cases where the patient is unconscious or in a coma, as there is a risk of aspiration. It should also be avoided if seizures are imminent, as there is a risk of aspiration. Additionally, if there is reduced gastrointestinal motility, activated charcoal should not be used to prevent the risk of obstruction.
Activated charcoal is effective in treating overdose with certain drugs and toxins, such as aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in cases of overdose with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.
There are potential adverse effects associated with the use of activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhalation of charcoal into the lungs), and impaired absorption of oral medications or antidotes.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 50
Correct
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You evaluate a teenager with tetralogy of Fallot in a pediatric cardiology clinic.
Which of the following is NOT a characteristic of tetralogy of Fallot?Your Answer: Left ventricular hypertrophy
Explanation:Tetralogy of Fallot (TOF) is the most prevalent cause of cyanotic congenital heart disease. It is characterized by four distinct features: pulmonary infundibular stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. TOF is often associated with various congenital syndromes, including DiGeorge syndrome (22q11 microdeletion syndrome), Trisomy 21, Foetal alcohol syndrome, and Maternal phenylketonuria.
Nowadays, many cases of TOF are identified during antenatal screening or early postnatal assessment due to the presence of a heart murmur. Initially, severe cyanosis is uncommon shortly after birth because the patent ductus arteriosus provides additional blood flow to the lungs. However, once the ductus arteriosus closes, typically a few days after birth, cyanosis can develop.
In cases where TOF goes undetected, the clinical manifestations may include severe cyanosis, poor feeding, breathlessness, dyspnea on exertion (such as prolonged crying), hypercyanotic spells triggered by activity, agitation, developmental delay, and failure to thrive. A cardiac examination may reveal a loud, long ejection systolic murmur caused by pulmonary stenosis, a systolic thrill at the lower left sternal edge, an aortic ejection click, and digital clubbing. Radiologically, a characteristic finding in TOF is a ‘boot-shaped’ heart (Coeur en sabot).
Treatment for TOF often involves two stages. Initially, a palliative procedure is performed to alleviate symptoms, followed by a total repair at a later stage.
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This question is part of the following fields:
- Neonatal Emergencies
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Question 51
Incorrect
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You review a 30-year-old woman with a known diagnosis of HIV. She asks you some questions about her diagnosis.
What is the median incubation period from HIV infection until the development of advanced HIV disease (also referred to as AIDS)?Your Answer: 6 months
Correct Answer: 10 years
Explanation:The estimated median incubation period from HIV infection to the onset of advanced HIV disease, also known as AIDS, is around ten years.
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This question is part of the following fields:
- Infectious Diseases
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Question 52
Correct
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A 32-year-old woman comes in with left-sided flank pain and nausea. A urine dipstick shows microscopic blood in the urine. She is later diagnosed with renal colic.
What is the most frequently occurring type of kidney stone?Your Answer: Calcium containing stones
Explanation:Urinary tract stones form when the concentration of salt and minerals in the urine becomes too high. These stones can be classified into five types based on their mineral composition and how they develop.
The most common type of stone is the calcium stone, which can be further divided into calcium oxalate and calcium phosphate stones. These account for 60-80% of all urinary tract stones.
Another type is the struvite or magnesium ammonium phosphate stone, making up about 10-15% of cases. Uric acid stones, also known as urate stones, occur in 3-10% of cases.
Cystine stones are less common, accounting for less than 2% of urinary tract stones. Finally, there are drug-induced stones, which are caused by certain medications such as triamterene, protease inhibitors like indinavir sulphate, and sulfa drugs. These account for approximately 1% of cases.
By understanding the different types of urinary tract stones, healthcare professionals can better diagnose and treat patients with this condition.
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This question is part of the following fields:
- Urology
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Question 53
Incorrect
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A 72-year-old man presents to the Emergency Department anxious, confused, and agitated. He has also vomited several times. He has recently been prescribed a course of amoxicillin for a suspected chest infection by his primary care physician. You are unable to obtain a coherent medical history from him, but he has brought his regular medications with him, which include: aspirin, simvastatin, and carbimazole. His friend who accompanied him states that he stopped taking his medications a few days ago. His vital signs are as follows: temperature 38.9°C, heart rate 138, respiratory rate 23, blood pressure 173/96, and oxygen saturation 97% on room air.
Which of the following medications would be most appropriate to prescribe in this case?Your Answer: Levothyroxine
Correct Answer: Potassium iodide
Explanation:Thyroid storm is a rare condition that affects only 1-2% of patients with hyperthyroidism. However, it is crucial to diagnose it promptly because it has a high mortality rate of approximately 10%. Thyroid storm is often triggered by a physiological stressor, such as stopping antithyroid therapy prematurely, recent surgery or radio-iodine treatment, infections (especially chest infections), trauma, diabetic ketoacidosis or hyperosmolar diabetic crisis, thyroid hormone overdose, pre-eclampsia. It typically occurs in patients with Graves’ disease or toxic multinodular goitre and presents with sudden and severe hyperthyroidism. Symptoms include high fever (over 41°C), dehydration, rapid heart rate (greater than 140 beats per minute) with or without irregular heart rhythms, low blood pressure, congestive heart failure, nausea, jaundice, vomiting, diarrhea, abdominal pain, confusion, agitation, delirium, psychosis, seizures, or coma.
To diagnose thyroid storm, various blood tests should be conducted, including a full blood count, urea and electrolytes, blood glucose, coagulation screen, CRP, and thyroid profile (T4/T3 and TSH). A bone profile/calcium test should also be done as 10% of patients develop hypocalcemia. Blood cultures should be taken as well. Other important investigations include a urine dipstick/MC&S, chest X-ray, and ECG.
The management of thyroid storm involves several steps. Intravenous fluids, such as 1-2 liters of 0.9% saline, should be administered. Airway support and management should be provided as necessary. A nasogastric tube should be inserted if the patient is vomiting. Urgent referral for inpatient management is essential. Paracetamol (1 g PO/IV) can be given to reduce fever. Benzodiazepines, such as diazepam (5-20 mg PO/IV), can be used for sedation. Steroids, like hydrocortisone (100 mg IV), may be necessary if there is co-existing adrenal suppression. Antibiotics should be prescribed if there is an intercurrent infection. Beta-blockers, such as propranolol (80 mg PO), can help control heart rate. High-dose carbimazole (45-60 mg/day) is recommended.
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This question is part of the following fields:
- Endocrinology
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Question 54
Correct
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A 60-year-old man presents with decreased visual acuity and 'floaters' in his right eye. You conduct a fundoscopy and observe a sheet of sensory retina bulging towards the center of the eye. A diagnosis of retinal detachment is made.
Which of the following statements about retinal detachment is NOT true?Your Answer: Hypermetropia is a significant risk factor
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.
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This question is part of the following fields:
- Ophthalmology
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Question 55
Incorrect
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You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department. The patient is experiencing ventricular fibrillation, and adrenaline is being administered as part of the cardiac arrest protocol.
Which ONE statement is accurate regarding the utilization of adrenaline in this arrest?Your Answer: It should be administered every 2-3 minutes
Correct Answer: There is no evidence of long-term benefit from its use
Explanation:Adrenaline is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) once chest compressions have been resumed. The recommended dose is 1 mg, which can be administered as either 10 mL of 1:10,000 or 1 mL of 1:1000 concentration. Subsequently, adrenaline should be given every 3-5 minutes, alternating with chest compressions, and it should be administered without interrupting the compressions. While there is no evidence of long-term benefit from the use of adrenaline in cardiac arrest, some studies have shown improved short-term survival, which justifies its continued use.
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This question is part of the following fields:
- Cardiology
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Question 56
Correct
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A 32-year-old patient presents to the emergency department with a 6 cm leg laceration. After assessing the wound, it is determined that suturing under anesthesia is necessary. You intend to supervise one of the medical students in closing the wound. Before beginning the procedure, you have a discussion about the risks associated with local anesthesia. Methemoglobinemia is primarily associated with which type of anesthetic agent?
Your Answer: Prilocaine
Explanation:Methaemoglobinaemia is a condition that can occur when prilocaine is used, particularly when administered at doses higher than 16 mg/kg.
Further Reading:
Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.
However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.
The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.
If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.
It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 57
Correct
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A 35-year-old patient comes in with acute severe asthma and is currently receiving regular salbutamol nebulizers. Her potassium level is tested and is found to be 2.8 mmol/l. She is also taking another medication prescribed by her primary care physician, but she cannot remember the name.
Which of the following medications is the LEAST likely to have caused her hypokalemia?Your Answer: Spironolactone
Explanation:Potentially, there can be a serious condition called hypokalaemia, which is characterized by low levels of potassium in the body. This condition should be taken seriously, especially in cases of severe asthma, as it can be made worse by certain medications like theophyllines (such as aminophylline and Uniphyllin Continus), corticosteroids, and low oxygen levels. Additionally, the use of thiazide and loop diuretics can also worsen hypokalaemia. Therefore, it is important to regularly monitor the levels of potassium in the blood of individuals with severe asthma.
It is worth noting that spironolactone, a type of diuretic, is known as a potassium-sparing medication. This means that it does not typically contribute to hypokalaemia.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 58
Correct
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You are overseeing the care of a 72-year-old patient who is experiencing a peri-arrest arrhythmia. Laboratory results indicate that the patient has a significant deficiency of magnesium in their blood. After careful consideration, you determine that administering magnesium sulfate is necessary. What is the appropriate dosage regimen for this treatment?
Your Answer: 2g IV given over 10-15 minutes
Explanation:To treat serious arrhythmia caused by hypomagnesaemia, it is recommended to administer 2 g of magnesium sulphate intravenously over a period of 10-15 minutes.
Further Reading:
In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.
Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.
Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.
Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.
Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.
Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.
It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 59
Incorrect
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A 45-year-old man presents with a red, painful right eye. He describes the pain as being excruciating, and it radiates to his forehead. His eyes are excessively watery, and he prefers to stay in a dark room at home because light exacerbates the pain. On examination, his eye appears very red, and there is tenderness upon palpation of the eyeball. His visual acuity is decreased. He was recently diagnosed with ankylosing spondylitis.
What is the SINGLE MOST likely diagnosis?Your Answer: Anterior uveitis
Correct Answer: Scleritis
Explanation:Scleritis is a serious condition characterized by inflammation of the sclera, the white outer layer of the eye. It often affects both eyes, with bilateral involvement seen in about half of the cases. While the cause of scleritis can be unknown (idiopathic), it is associated with systemic inflammatory diseases like rheumatoid arthritis in approximately one-third of patients. In fact, scleritis can sometimes be the initial manifestation of these inflammatory conditions.
The clinical features of scleritis include moderate to severe pain, which can be felt in the brow or jaw. The pain worsens with eye movement and may disrupt sleep. The onset of symptoms is typically gradual. Other common symptoms include sensitivity to light (photophobia), excessive tearing (epiphora), and redness of both the superficial and deep episcleral vessels. The affected eye may also be tender to touch, and there may be a decrease in visual acuity. Some individuals may have a history of previous episodes of scleritis.
In summary, scleritis is a serious inflammatory disease of the sclera that can be associated with systemic inflammatory conditions. It presents with significant pain, often referred to the brow or jaw, and worsened by eye movement. Other symptoms include photophobia, excessive tearing, and redness of the episcleral vessels. It is important to recognize scleritis as it can be the first sign of underlying inflammatory diseases.
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This question is part of the following fields:
- Ophthalmology
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Question 60
Correct
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A 6-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
What dose of rectal diazepam is recommended for the treatment of the convulsing child?Your Answer: 0.5 mg/kg
Explanation:The recommended dose of rectal diazepam for treating a child experiencing convulsions is 0.5 mg per kilogram of body weight.
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This question is part of the following fields:
- Neurology
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Question 61
Correct
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A 70-year-old woman presents with an acute episode of gout. She has a history of chronic heart failure and hypertension. Her current medications include lisinopril and hydrochlorothiazide.
Which SINGLE statement regarding the treatment of gout is true?Your Answer: Colchicine has a role in prophylactic treatment
Explanation:In cases where there are no reasons to avoid them, high-dose NSAIDs are the first choice for treating acute gout. A commonly used and effective regimen is to take Naproxen 750 mg as a single dose, followed by 250 mg three times a day. Aspirin should not be used for gout because it reduces the clearance of urate in the urine and interferes with the action of uricosuric agents. Instead, Naproxen, diclofenac, or indomethacin are more suitable options.
Allopurinol is used as a preventive measure to reduce future gout attacks by lowering the levels of uric acid in the blood. However, it should not be started during an acute gout episode as it can worsen the severity and duration of symptoms. Colchicine works by affecting neutrophils, binding to tubulin to prevent their migration into the affected joint. It is equally effective as NSAIDs in relieving acute gout attacks and can also be used for prophylactic treatment if a patient cannot tolerate allopurinol.
NSAIDs should not be used in patients with heart failure as they can lead to fluid retention and congestive cardiac failure. In such cases, colchicine is the preferred treatment option. Colchicine is also recommended for patients who cannot tolerate NSAIDs. Febuxostat (Uloric) is an alternative to allopurinol and is used for managing chronic gout.
Corticosteroids are an effective alternative for managing acute gout in patients who cannot take NSAIDs or colchicine. They can be administered orally, intramuscularly, intravenously, or directly into the affected joint.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 62
Correct
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A 68 year old male is brought into the emergency department from his nursing home due to the sudden onset of profuse foul smelling diarrhea over the past 2 days that has not improved. The patient has been feeling slightly unwell for the past few weeks and was prescribed a week-long course of amoxicillin by his GP for a chest infection, which he completed. He then started taking clindamycin for lower limb cellulitis five days ago, which he is still taking. Which of the following tests would be most helpful in determining the underlying cause of this patient's symptoms?
Your Answer: Stool cytotoxin assay
Explanation:C. difficile diarrhoea is typically diagnosed by testing a stool sample for the presence of its toxin using the cytotoxin assay. This patient has several risk factors for developing c.diff diarrhoea, including recent use of broad spectrum antibiotics, being over the age of 65, and residing in a nursing home. The gold standard for diagnosing c.diff diarrhoea is the detection of exotoxin in the stool using the cytotoxin assay. The C13 urea breath test is used to detect h.pylori infection, while stool antigen testing is commonly used to detect h.pylori as well as rotavirus and other viral causes of gastroenteritis. Stool microscopy is utilized to identify the presence of parasitic organisms such as protozoa and helminths.
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.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 63
Correct
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A 65-year-old patient presents with sudden-onset spontaneous epistaxis. You are struggling to control the bleeding and decide to insert bilateral ‘Rapid Rhino’ nasal packs. The patient informs you that he has von Willebrand disease.
What is dysfunctional in von Willebrand disease?Your Answer: Platelet adhesion
Explanation:Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects about 1 in 100 people. It occurs due to a deficiency in Von Willebrand factor (vWF), which is responsible for protecting factor VIII from breaking down too quickly in the blood. Additionally, vWF is necessary for proper platelet adhesion, so a lack of it can lead to abnormal platelet function. As a result, both the APTT and bleeding time are prolonged, while the platelet count and thrombin time remain unaffected.
In many cases, vWD goes unnoticed as patients do not experience any symptoms. It is often diagnosed incidentally during a routine clotting profile check. However, if symptoms do occur, the most common ones are easy bruising, nosebleeds, and heavy menstrual bleeding. In severe cases, more serious bleeding and joint bleeds can occur.
For mild cases of von Willebrand disease, bleeding can be treated with desmopressin. This medication helps increase the patient’s own levels of vWF by releasing stored vWF from the Weibel-Palade bodies in the endothelial cells. These bodies are storage granules found in the inner lining of blood vessels and the heart. In more severe cases, replacement therapy is necessary, which involves infusing cryoprecipitate or Factor VIII concentrate. Replacement therapy is recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.
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This question is part of the following fields:
- Haematology
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Question 64
Correct
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You assess a 7-year-old girl who has been brought to the ER by her parents due to concerns about her health. They report that she has had a fever and a sore throat for the past few days, but now she has developed a red rash all over her body. After diagnosing scarlet fever, you prescribe antibiotics. What guidance would you provide to the parents regarding their child's attendance at school?
Your Answer: Exclusion from school until 24 hours after starting antibiotic treatment
Explanation:Patients who have been diagnosed with Scarlet fever should be instructed to stay away from school or work until at least 24 hours after they have started taking antibiotics. It is also important for them to practice good hygiene habits.
Further Reading:
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the peak incidence at 4 years. The typical presentation of scarlet fever includes fever, malaise, sore throat (tonsillitis), and a rash. The rash appears 1-2 days after the fever and sore throat symptoms and consists of fine punctate erythema that first appears on the torso and spares the face. The rash has a rough ‘sandpaper’ texture and desquamation occurs later, particularly around the fingers and toes. Another characteristic feature is the ‘strawberry tongue’, which initially has a white coating and swollen, reddened papillae, and later becomes red and inflamed. Diagnosis is usually made by a throat swab, but antibiotic treatment should be started immediately without waiting for the results. The recommended treatment is oral penicillin V, but patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics. Scarlet fever is a notifiable disease. Complications of scarlet fever include otitis media, rheumatic fever, and acute glomerulonephritis.
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This question is part of the following fields:
- Infectious Diseases
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Question 65
Incorrect
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A 10 year old female is brought to the emergency department by her father due to frequent nosebleeds from the left nostril. The father informs you that this is the fourth nosebleed in the past week. After removing blood-soaked tissue paper from the left nostril, you observe clotted blood on the septum and floor of the left nostril. The right nostril appears normal.
What is the most suitable course of action for this patient?Your Answer: Apply silver nitrate stick to the right anterior nasal septum
Correct Answer: Discharge with prescription for Naseptin cream to be applied to the nostrils four times daily for 10 days and give written epistaxis advice
Explanation:Naseptin, a topical antiseptic cream containing chlorhexidine and neomycin, has been found to be just as effective as silver nitrate cautery in treating recurrent nosebleeds in children. This means that using Naseptin can help prevent future nosebleeds in children with this condition. It is important to note that silver nitrate cautery can cause more pain and should only be used if a specific bleeding vessel can be identified.
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 66
Correct
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You are resuscitating a trauma patient who is 42 years old and your consultant asks you to perform a central venous catheter insertion. During your discussion, you consider which approach carries the greatest risk of pneumothorax.
Your Answer: Subclavian
Explanation:The subclavian approach for central lines carries the highest risk of pneumothorax. However, it does have advantages such as being accessible during airway control and having easily identifiable landmarks for insertion, even in obese patients. It is important to note that the carotid is not used for CVC’s.
Further Reading:
A central venous catheter (CVC) is a type of catheter that is inserted into a large vein in the body, typically in the neck, chest, or groin. It has several important uses, including CVP monitoring, pulmonary artery pressure monitoring, repeated blood sampling, IV access for large volumes of fluids or drugs, TPN administration, dialysis, pacing, and other procedures such as placement of IVC filters or venous stents.
When inserting a central line, it is ideal to use ultrasound guidance to ensure accurate placement. However, there are certain contraindications to central line insertion, including infection or injury to the planned access site, coagulopathy, thrombosis or stenosis of the intended vein, a combative patient, or raised intracranial pressure for jugular venous lines.
The most common approaches for central line insertion are the internal jugular, subclavian, femoral, and PICC (peripherally inserted central catheter) veins. The internal jugular vein is often chosen due to its proximity to the carotid artery, but variations in anatomy can occur. Ultrasound can be used to identify the vessels and guide catheter placement, with the IJV typically lying superficial and lateral to the carotid artery. Compression and Valsalva maneuvers can help distinguish between arterial and venous structures, and doppler color flow can highlight the direction of flow.
In terms of choosing a side for central line insertion, the right side is usually preferred to avoid the risk of injury to the thoracic duct and potential chylothorax. However, the left side can also be used depending on the clinical situation.
Femoral central lines are another option for central venous access, with the catheter being inserted into the femoral vein in the groin. Local anesthesia is typically used to establish a field block, with lidocaine being the most commonly used agent. Lidocaine works by blocking sodium channels and preventing the propagation of action potentials.
In summary, central venous catheters have various important uses and should ideally be inserted using ultrasound guidance. There are contraindications to their insertion, and different approaches can be used depending on the clinical situation. Local anesthesia is commonly used for central line insertion, with lidocaine being the preferred agent.
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This question is part of the following fields:
- Resus
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Question 67
Correct
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You assess a patient with airway obstruction in the resuscitation area of the Emergency Department at your hospital.
Which of the following is the LEAST probable cause?Your Answer: GCS score of 9
Explanation:The airway is deemed at risk when the Glasgow Coma Scale (GCS) falls below 8. There are various factors that can lead to airway obstruction, including the presence of blood or vomit in the airway, a foreign object such as a tooth or food blocking the passage, direct injury to the face or throat, inflammation of the epiglottis (epiglottitis), involuntary closure of the larynx (laryngospasm), constriction of the bronchial tubes (bronchospasm), swelling in the pharynx due to infection or fluid accumulation (oedema), excessive bronchial secretions, and blockage of a tracheostomy tube.
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This question is part of the following fields:
- Trauma
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Question 68
Correct
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While examining a 68-year-old man, you detect an ejection systolic murmur. The murmur does not radiate, and his pulse character is normal.
What is the SINGLE most likely diagnosis?Your Answer: Aortic sclerosis
Explanation:Aortic sclerosis is a condition that occurs when the aortic valve undergoes senile degeneration. Unlike aortic stenosis, it does not result in any obstruction of the left ventricular outflow tract. To differentiate between aortic stenosis and aortic sclerosis, the following can be used:
Feature: Aortic stenosis
– Symptoms: Can be asymptomatic, but may cause angina, breathlessness, and syncope if severe.
– Pulse: Slow rising, low volume pulse.
– Apex beat: Sustained, heaving apex beat.
– Thrill: Palpable thrill in the aortic area can be felt.
– Murmur: Ejection systolic murmur loudest in the aortic area.
– Radiation: Radiates to carotids.Feature: Aortic sclerosis
– Symptoms: Always asymptomatic.
– Pulse: Normal pulse character.
– Apex beat: Normal apex beat.
– Thrill: No thrill.
– Murmur: Ejection systolic murmur loudest in the aortic area.
– Radiation: No radiation. -
This question is part of the following fields:
- Cardiology
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Question 69
Correct
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A 45-year-old woman presents with a painful, swollen right calf following a recent flight from New York. You assess her for a possible deep vein thrombosis (DVT).
Which scoring system does NICE recommend for assessing the likelihood of DVT?Your Answer: Two-level Wells score
Explanation:The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.
Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.
To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.
When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.
Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.
To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.
For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.
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This question is part of the following fields:
- Vascular
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Question 70
Correct
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You evaluate a 45-year-old woman with a swollen and red left calf and thigh. Her D-dimer level is elevated, and you schedule an ultrasound examination, which shows a proximal vein clot (DVT). She has no significant medical history and no known drug allergies.
According to the current NICE guidelines, which anticoagulant is recommended as the initial treatment for DVT?Your Answer: Rivaroxaban
Explanation:The current guidelines from NICE recommend that the first-line treatment for confirmed deep-vein thrombosis (DVT) or pulmonary embolism (PE) should be either apixaban or rivaroxaban, which are direct oral anticoagulants.
If neither of these options is suitable, the following alternatives should be considered:
1. LMWH (low molecular weight heparin) should be administered for at least 5 days, followed by dabigatran or edoxaban.
2. LMWH should be combined with a vitamin K antagonist (VKA), such as warfarin, for at least 5 days or until the international normalized ratio (INR) reaches at least 2.0 on 2 consecutive readings. Afterward, the VKA can be continued alone.
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This question is part of the following fields:
- Vascular
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Question 71
Correct
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A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER score is 3. She weighs 60 kg.
What is the appropriate dosage of alteplase to give?Your Answer: 63mg
Explanation:Alteplase (rt-pA) is recommended for the treatment of acute ischaemic stroke in adults if it is administered as soon as possible within 4.5 hours of the onset of stroke symptoms. It is important to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. This dose should be given intravenously over a period of 60 minutes. The first 10% of the dose should be administered through intravenous injection, while the remaining dose should be given through intravenous infusion. For a patient weighing 70 kg, the recommended dose would be 63 mg. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.
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This question is part of the following fields:
- Neurology
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Question 72
Correct
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A 45-year-old presents to the emergency department complaining of occasional right-sided facial swelling over the past 3 days. The patient describes the swelling as uncomfortable and it occurs after eating a meal, but then goes away within an hour or so. The patient mentions that the swelling has gone down since arriving at the department. Upon examination, there is no visible redness or tenderness when the face is touched. The patient's vital signs are as follows:
Blood pressure: 142/82 mmHg
Pulse rate: 86 bpm
Respiration rate: 15 bpm
Temperature: 36.5ºC
What is the probable diagnosis?Your Answer: Sialolithiasis
Explanation:Salivary gland stones often cause intermittent swelling that tends to worsen during meal times. This pattern of symptoms is indicative of Sialolithiasis, which refers to the presence of stones in the salivary glands. In cases of acute sialadenitis, the affected gland or duct would typically be enlarged and tender to touch, accompanied by signs of infection such as redness or fever. While mucoepidermoid carcinoma is the most common type of salivary gland cancer, malignant salivary gland tumors are rare. On the other hand, pleomorphic adenoma is the most common benign neoplasm of the salivary glands, with an incidence rate of approximately 2-3.5 cases per 100,000 population. However, it is important to note that salivary gland stones are much more common than tumors, with an annual incidence rate that is 10 times higher.
Further Reading:
Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.
There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.
Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.
Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 73
Correct
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A 35-year-old weightlifter who admits to heavy use of anabolic steroids presents with extremely severe acne. He has numerous disfiguring, ulcerated, nodular lesions covering his face, back, and chest. Many of the lesions have bleeding crusts, and he has significant scarring. Some of the lesions have also connected and formed sinuses. He is also experiencing general malaise, joint pain, and a feverish feeling. You take his temperature and it is currently 39°C.
What is the MOST appropriate course of action for managing this patient?Your Answer: Refer for hospital admission
Explanation:Acne conglobata is an extremely severe form of acne where acne nodules come together and create sinuses. Acne fulminans, on the other hand, is a rare and severe complication of acne conglobata that is accompanied by systemic symptoms. It is linked to elevated levels of androgenic hormones, specific autoimmune conditions, and a genetic predisposition.
The typical clinical characteristics of acne fulminans are as follows:
– Sudden and abrupt onset
– Inflammatory and ulcerated nodular acne primarily found on the chest and back
– Often painful lesions
– Ulcers on the upper trunk covered with bleeding crusts
– Severe acne scarring
– Fluctuating fever
– Painful joints and arthropathy
– General feeling of illness (malaise)
– Loss of appetite and weight loss
– Enlarged liver and spleen (hepatosplenomegaly)It is crucial to refer patients immediately for a specialist evaluation and hospital admission. Treatment options for acne fulminans include systemic corticosteroids, dapsone, ciclosporin, and high-dose intravenous antibiotics.
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This question is part of the following fields:
- Dermatology
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Question 74
Correct
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You are requested to evaluate a 7-year-old girl who is feeling sick in the Pediatric Emergency Department. Upon reviewing her urea & electrolytes, you observe that her potassium level is elevated at 6.6 mmol/l. Her ECG appears normal, and she is in stable condition.
As per the APLS guidelines, which medication should be administered promptly?Your Answer: Nebulised salbutamol
Explanation:Hyperkalaemia is a condition where the level of potassium in the blood is higher than normal, specifically greater than 5.5 mmol/l. It can be categorized as mild, moderate, or severe depending on the specific potassium levels. Mild hyperkalaemia is when the potassium level is between 5.5-5.9 mmol/l, moderate hyperkalaemia is between 6.0-6.4 mmol/l, and severe hyperkalaemia is when the potassium level exceeds 6.5 mmol/l. The most common cause of hyperkalaemia in renal failure, which can be either acute or chronic. Other causes include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.
If the patient’s life is not immediately at risk due to an arrhythmia, the initial treatment for hyperkalaemia should involve the use of a beta-2 agonist, such as salbutamol (2.5-10 mg). Salbutamol activates cAMP, which stimulates the Na+/K+ ATPase pump. This action helps shift potassium into the intracellular compartment. The effects of salbutamol are rapid, typically occurring within 30 minutes. With the recommended dose, a decrease in the serum potassium level of approximately 1 mmol can be expected.
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This question is part of the following fields:
- Nephrology
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Question 75
Correct
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A 23-year-old arrives at the emergency department complaining of fatigue, a severe sore throat, and swollen neck glands that have persisted for more than a week. He visited his primary care physician yesterday and was prescribed amoxicillin. However, today he woke up with a rash all over his body and his throat has not improved. During the examination, a widespread non-blanching maculopapular rash is observed.
What is the probable underlying cause of the patient's symptoms?Your Answer: Epstein-Barr virus
Explanation:In cases of acute glandular fever, certain antibiotics like ampicillin and amoxicillin can potentially cause severe rashes that affect the entire body and specifically the extremities. The exact cause of these rashes is still unknown. If there is uncertainty in the diagnosis and the clinician wants to cover the possibility of streptococcal tonsillitis, it is recommended to use phenoxymethylpenicillin (penicillin V) as the preferred treatment.
Further Reading:
Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 76
Correct
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A 35 year old male comes to the emergency department with a 3 hour history of nosebleed. You administer cautery to the right nostril which successfully stops the bleeding. You intend to release the patient. Which of the following medications would be the most suitable to prescribe?
Your Answer: Prescribe naseptin cream four times daily for 10 days
Explanation:After undergoing nasal cautery, it is recommended to follow these steps for proper treatment:
1. Gently dab the cauterized area with a clean cotton bud to remove any excess chemical or blood.
2. Apply a topical antiseptic preparation to the area.
3. As the first line of treatment, prescribe Naseptin® cream (containing chlorhexidine and neomycin) to be applied to the nostrils four times daily for a duration of 10 days. However, if the patient has allergies to neomycin, peanut, or soya, prescribe mupirocin nasal ointment instead. This should be applied to the nostrils two to three times a day for 5-7 days.
4. Advise the patient to avoid blowing their nose for a few hours.These steps will help ensure proper healing and minimize any potential complications after nasal cautery.
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 77
Correct
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A 65-year-old man has experienced a stroke affecting the blood vessels in his brain. Testing of his visual field reveals that he has a quadrantanopia in the lower left side of his vision.
Where in the visual pathway has this injury occurred?Your Answer: Upper optic radiation
Explanation:Homonymous quadrantanopia occur when there are lesions in the optic radiation. The optic tract passes through the posterolateral angle of the optic chiasm, running alongside the cerebral peduncle and inside the uncus of the temporal lobe. Eventually, it reaches the lateral geniculate body (LGN) in the thalamus. Acting as a relay center, the LGN sends axons through the optic radiation to the primary visual cortex in the occipital lobe. The upper optic radiation carries fibers from the superior retinal quadrants (which corresponds to the lower half of the visual field) and travels through the parietal lobe. On the other hand, the lower optic radiation carries fibers from the inferior retinal quadrants (which corresponds to the upper half of the visual field) and travels through the temporal lobe. Consequently, lesions in the temporal lobe can lead to superior homonymous quadrantanopia, while lesions in the parietal lobe can cause inferior homonymous quadrantanopia. The diagram below provides a summary of the different visual field defects resulting from lesions at various points in the visual pathway.
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This question is part of the following fields:
- Ophthalmology
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Question 78
Incorrect
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A 5-year-old child weighing 20 kg shows clinical signs of shock and is 10% dehydrated due to gastroenteritis. An initial fluid bolus of 20 ml/kg is given. How much fluid should be given in the next 24 hours?
Your Answer: 1600 ml
Correct Answer: 3100 ml
Explanation:To determine the amount of fluid that should be given to the 5-year-old child over the next 24 hours, we need to account for the following components of fluid therapy:
- Deficit Replacement: The fluid lost due to dehydration.
- Maintenance Fluid: The fluid needed for normal physiological needs.
- Ongoing Losses: Any additional fluid loss (e.g., continued diarrhea or vomiting), which may need to be estimated and added if applicable.
Calculation Steps
1. Calculate the Fluid Deficit
The child is 10% dehydrated. This means that the child has lost 10% of their body weight in fluids.
- Body Weight: 20 kg
- Percentage Dehydration: 10%
Fluid Deficit=Body Weight×Percentage Dehydration
Fluid Deficit=20 kg×0.10=2 kg=2 liters=2000 ml
2. Calculate the Maintenance Fluid Requirement
Use the standard maintenance fluid calculation for children (the Holliday-Segar method):
- First 10 kg: 100 ml/kg/day
- Next 10 kg: 50 ml/kg/day
For a 20 kg child:
- First 10 kg: 10 kg×100 ml/kg/day=1000 ml/day
- Next 10 kg: 10 kg×50 ml/kg/day=500 ml/day
Total maintenance fluid requirement:
Maintenance Fluid=1000 ml+500 ml=1500 ml/day
3. Subtract the Initial Fluid Bolus
An initial fluid bolus of 20 ml/kg was given to treat shock:
- Fluid Bolus Given: 20 ml/kg×20 kg=400 ml
This amount should be subtracted from the deficit to avoid overhydration:
Remaining Deficit=2000 ml−400 ml=1600 ml
4. Total Fluid Requirement for 24 Hours
The total fluid requirement for the next 24 hours is the sum of the remaining deficit and the maintenance fluid:
Total Fluid for 24 hours=Remaining Deficit+Maintenance Fluid
Total Fluid for 24 hours=1600 ml+1500 ml=3100 ml
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This question is part of the following fields:
- Nephrology
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Question 79
Incorrect
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A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18 kg.
As per the BTS guidelines, what dosage of prednisolone should be prescribed for him?Your Answer: 22 mg
Correct Answer: 30 mg
Explanation:The BTS guidelines for acute asthma in children recommend administering oral steroids early in the treatment of asthma attacks. It is advised to give a dose of 20 mg prednisolone for children aged 2–5 years and a dose of 30–40 mg for children over 5 years old. If a child is already taking maintenance steroid tablets, they should receive 2 mg/kg prednisolone, up to a maximum dose of 60 mg. If a child vomits after taking the medication, the dose of prednisolone should be repeated. In cases where a child is unable to keep down orally ingested medication, intravenous steroids should be considered. Typically, treatment for up to three days is sufficient, but the duration of the course should be adjusted based on the time needed for recovery. Tapering off the medication is not necessary unless the steroid course exceeds 14 days. For more information, refer to the BTS/SIGN Guideline on the Management of Asthma.
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This question is part of the following fields:
- Respiratory
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Question 80
Incorrect
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A 28 year old male is brought into the ED after being discovered in a collapsed state. The patient is making minimal effort to breathe. The patient is a known IV drug user. The attending physician requests that you obtain an arterial blood gas sample from the radial artery. The blood gas is collected and the results are as follows:
pH 7.30
pO2 8.8 kPa
pCO2 7.4 kPa
Bicarbonate 26 mmol/L
Chloride 98 mmol/L
Potassium 5.6 mmol/L
Sodium 135 mmol/L
What type of acid-base abnormality is indicated?Your Answer: Metabolic acidosis
Correct Answer: Respiratory acidosis
Explanation:Respiratory acidosis occurs when the respiratory system is unable to effectively remove carbon dioxide from the body, leading to an increase in acidity. This is often seen in cases of opioid overdose, where respiratory depression can occur. In respiratory acidosis, the bicarbonate levels may rise as the body’s metabolic system tries to compensate for the increased acidity.
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 81
Correct
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A 45-year-old woman returns from a recent vacation on a cruise ship with a persistent cough and a high temperature. Today she has also experienced frequent episodes of diarrhea and has developed sharp chest pain on both sides. She reports feeling short of breath, especially when she exerts herself. The cruise ship doctor had prescribed her amoxicillin a few days ago, but she has not seen any improvement.
Her blood test results today are as follows:
Hemoglobin (Hb): 14.4 g/dl (normal range: 13-17 g/dl)
White blood cell count (WCC): 13.5 x 109/l (normal range: 4-11 x 109/l)
Neutrophils: 10.2 x 109/l (normal range: 2.5-7.5 x 109/l)
Lymphocytes: 0.6 x 109/l (normal range: 1.3-3.5 x 109/l)
Eosinophils: 0.35 x 109/l (normal range: 0.04-0.44 x 109/l)
C-reactive protein (CRP): 87 mg/l (normal range: <5 mg/l)
Sodium (Na): 122 mmol/l (normal range: 133-147 mmol/l)
Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Creat): 112 micromol/l (normal range: 60-120 micromol/l)
Urea: 6.8 mmol/l (normal range: 2.5-7.5 mmol/l)
What is the SINGLE most likely causative organism?Your Answer: Legionella pneumophila
Explanation:Legionella pneumophila is a type of Gram-negative bacterium that 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. In the past, there have been instances of Legionnaires’ disease outbreaks on cruise ships due to inadequate maintenance of air conditioning and shower units.
The pneumonic form of Legionnaires’ disease presents with certain clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A persistent cough, which is usually non-productive and occurs in approximately 90% of cases, is also common. Other symptoms include pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia. Additionally, some individuals may experience a condition called syndrome of inappropriate antidiuretic hormone secretion (SIADH), which can lead to hyponatraemia.
It is important to note that infections caused by Legionella pneumophila are resistant to amoxicillin. However, they can be effectively treated with macrolide antibiotics like erythromycin or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used for treatment.
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This question is part of the following fields:
- Respiratory
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Question 82
Correct
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A 68 year old female visits the emergency department with complaints of lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable and a diagnosis of acute urinary retention is made. To determine if any medications may be contributing to the condition, you inquire about the patient's drug history. Which of the following drug classes is NOT known to cause urinary retention?
Your Answer: 5α-reductase inhibitors
Explanation:Urinary retention can be caused by various drug classes. One such class is 5α-reductase inhibitors like finasteride, which are prescribed to alleviate obstructive symptoms caused by an enlarged prostate. Some commonly known drugs that can lead to urinary retention include alcohol, anticholinergics, decongestants (such as phenylephrine and pseudoephedrine), disopyramide, antihistamines (like diphenhydramine and phenergan), and amphetamines.
Further Reading:
Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.
There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.
The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.
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This question is part of the following fields:
- Urology
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Question 83
Correct
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A 35-year-old patient arrives at the emergency department with a 2-hour history of sporadic coffee ground vomiting. You determine that a formal risk assessment is necessary. Which tool would be the most suitable for the initial evaluation?
Your Answer: Blatchford score
Explanation:The Blatchford score, also known as the Glasgow-Blatchford Bleeding Score, is a commonly used tool to evaluate individuals who present with an acute upper gastrointestinal bleed. It is recommended by NICE (National Institute for Health and Care Excellence) that healthcare professionals use specific risk assessment scores for patients with this condition. The Blatchford score is used for initial assessment, while the full Rockall score is used after endoscopy.
The Blatchford score consists of 9 criteria, including gender, urea levels, hemoglobin levels, systolic blood pressure, pulse rate, presence of melena (black, tarry stools) at presentation, syncope (fainting) at presentation, presence of hepatic disease, and presence of cardiac failure. These criteria are used to determine the patient’s risk level. A calculator for the Blatchford score can be found in the links section.
Further Reading:
Peptic ulcer disease (PUD) is a condition characterized by a break in the mucosal lining of the stomach or duodenum. It is caused by an imbalance between factors that promote mucosal damage, such as gastric acid, pepsin, Helicobacter pylori infection, and NSAID drug use, and factors that maintain mucosal integrity, such as prostaglandins, mucus lining, bicarbonate, and mucosal blood flow.
The most common causes of peptic ulcers are H. pylori infection and NSAID use. Other factors that can contribute to the development of ulcers include smoking, alcohol consumption, certain medications (such as steroids), stress, autoimmune conditions, and tumors.
Diagnosis of peptic ulcers involves screening for H. pylori infection through breath or stool antigen tests, as well as upper gastrointestinal endoscopy. Complications of PUD include bleeding, perforation, and obstruction. Acute massive hemorrhage has a case fatality rate of 5-10%, while perforation can lead to peritonitis with a mortality rate of up to 20%.
The symptoms of peptic ulcers vary depending on their location. Duodenal ulcers typically cause pain that is relieved by eating, occurs 2-3 hours after eating and at night, and may be accompanied by nausea and vomiting. Gastric ulcers, on the other hand, cause pain that occurs 30 minutes after eating and may be associated with nausea and vomiting.
Management of peptic ulcers depends on the underlying cause and presentation. Patients with active gastrointestinal bleeding require risk stratification, volume resuscitation, endoscopy, and proton pump inhibitor (PPI) therapy. Those with perforated ulcers require resuscitation, antibiotic treatment, analgesia, PPI therapy, and urgent surgical review.
For stable patients with peptic ulcers, lifestyle modifications such as weight loss, avoiding trigger foods, eating smaller meals, quitting smoking, reducing alcohol consumption, and managing stress and anxiety are recommended. Medication review should be done to stop causative drugs if possible. PPI therapy, with or without H. pylori eradication therapy, is also prescribed. H. pylori testing is typically done using a carbon-13 urea breath test or stool antigen test, and eradication therapy involves a 7-day triple therapy regimen of antibiotics and PPI.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 84
Correct
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A 45-year-old man presents with brief episodes of vertigo that are worse in the evening and is triggered by head movement and turning in bed. Each episode lasts only a couple of minutes. He experiences nausea during the attacks but has not vomited. He has no previous history of hearing loss or tinnitus.
What is the SINGLE most probable diagnosis?Your Answer: Benign paroxysmal positional vertigo (BPPV)
Explanation:Benign paroxysmal positional vertigo (BPPV) occurs when there is dysfunction in the inner ear. This dysfunction causes the otoliths, which are located in the utricle, to become dislodged from their normal position and migrate into one of the semicircular canals over time. As a result, these detached otoliths continue to move even after head movement has stopped, leading to vertigo due to the conflicting sensation of ongoing movement with other sensory inputs.
While the majority of BPPV cases have no identifiable cause (idiopathic), approximately 40% of cases can be attributed to factors such as head injury, spontaneous labyrinthine degeneration, post-viral illness, middle ear surgery, or chronic middle ear disease.
The main clinical features of BPPV include symptoms that are provoked by head movement, rolling over, and upward gaze. These episodes are typically brief, lasting less than 5 minutes, and are often worse in the mornings. Unlike other inner ear disorders, BPPV does not cause hearing loss or tinnitus. Nausea is a common symptom, while vomiting is rare. The Dix-Hallpike test can be used to confirm the diagnosis of BPPV.
It is important to note that vestibular suppressant medications have not been proven to be beneficial in managing BPPV. These medications do not improve symptoms or reduce the duration of the disease.
The treatment of choice for BPPV is the Epley manoeuvre. This maneuver aims to reposition the dislodged otoliths back into the utricles from the semicircular canals. A 2014 Cochrane review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with a number needed to treat of 2-4.
Referral to an ENT specialist is recommended for patients with BPPV in the following situations: if the treating clinician is unable to perform or access the Epley manoeuvre, if the Epley manoeuvre has not been beneficial after repeated attempts (minimum two), if the patient has been symptomatic for more than 4 weeks, or if the patient has experienced more than 3 episodes of BPPV.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 85
Correct
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect she may have ureteric colic.
What are the two types of drugs that can be used for conservative treatment as medical expulsive therapy?Your Answer: Alpha-blocker and calcium-channel blocker
Explanation:Conservative management of ureteric stones may involve the use of medical expulsive therapy (MET), which can be achieved through the administration of either an alpha-blocker or a calcium-channel blocker. This treatment aims to facilitate the natural passage of the stone during the observation period.
Research has shown that in adults, both alpha-blockers and calcium channel blockers have been effective in improving the passage of distal ureteric stones that are less than 10 mm in size, when compared to no treatment. Additionally, alpha-blockers have shown to be more effective than placebo in promoting stone passage. Alpha-blockers have also demonstrated more benefits than calcium channel blockers in terms of stone passage, as well as some advantages in terms of hospital stay and pain management. However, there was no significant difference in the time it took for the stone to pass or the overall quality of life.
Currently, the National Institute for Health and Care Excellence (NICE) recommends alpha-blockers as the preferred choice for medical expulsive therapy. 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 86
Correct
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You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
Which tuning fork should be utilized to conduct a Weber's test on this individual?Your Answer: 512 Hz
Explanation:A 512 Hz tuning fork is recommended for conducting both the Rinne’s and Weber’s tests. However, a lower-pitched 128 Hz tuning fork is commonly used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for both tests, it is considered less reliable.
To perform the Weber’s test, the 512 Hz tuning fork should be set in motion and then placed on the center of the patient’s forehead. The patient should be asked if they perceive the sound in the middle of their forehead or if it is heard more on one side.
If the sound is heard more on one side, it may indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 87
Correct
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A 28-year-old woman presents after experiencing a syncopal episode earlier in the day. She fainted while jogging on the treadmill at her local gym. She regained consciousness quickly and currently feels completely fine. Upon examination, she has a slim physique, normal heart sounds without any additional sounds or murmurs, clear lungs, and a soft abdomen. She is originally from Thailand and mentions that her mother passed away suddenly in her 30s.
Her ECG reveals:
- Right bundle branch block pattern
- Downward-sloping 'coved' ST elevation in leads V1-V3
- Widespread upward-sloping ST depression in other leads
What is the SINGLE most likely diagnosis?Your Answer: Brugada syndrome
Explanation:Brugada syndrome is a genetic disorder that is passed down from one generation to another in an autosomal dominant manner. It is characterized by abnormal findings on an electrocardiogram (ECG) and can lead to sudden cardiac death. The cause of death in individuals with Brugada syndrome is typically ventricular fibrillation, which occurs as a result of specific defects in ion channels that are determined by our genes. Interestingly, this syndrome is more commonly observed in South East Asia and is actually the leading cause of sudden unexplained cardiac death in Thailand.
One of the key features seen on an ECG that is consistent with Type 1 Brugada syndrome is a pattern known as right bundle branch block. Additionally, there is a distinct downward sloping coved ST elevation observed in leads V1-V3. These specific ECG findings help to identify individuals who may be at risk for developing Brugada syndrome and experiencing its potentially fatal consequences.
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This question is part of the following fields:
- Cardiology
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Question 88
Correct
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You are reviewing a 35-year-old man after receiving his most recent blood results. He is currently taking ramipril for his blood pressure, which is well controlled. He used to consume 30 units of alcohol per week until three months ago when he was advised to reduce his intake following his last set of blood tests. He has since remained completely abstinent. He has no identifiable risk factors for chronic liver disease. On examination, you can palpate a 1 cm liver edge below the right costal margin. His most recent two sets of blood results are provided below.
Blood results today:
Bilirubin: 19 µmol/L (3-20)
ALT: 98 IU/L (5-40)
AST: 46 IU/L (5-40)
ALP: 126 IU/L (20-140)
GGT: 225 IU/L (5-40)
Blood results 3 months ago:
Bilirubin: 19 µmol/L (3-20)
ALT: 126 IU/L (5-40)
AST: 39 IU/L (5-40)
ALP: 118 IU/L (20-140)
GGT: 35 IU/L (5-40)
What is the SINGLE most likely diagnosis?Your Answer: Non-alcoholic steatohepatitis
Explanation:The diagnosis in this case is non-alcoholic steatohepatitis (NASH), which is characterized by fatty infiltration of the liver and is commonly associated with obesity. It is the most frequent cause of persistently elevated ALT levels in patients without risk factors for chronic liver disease.
Risk factors for developing NASH include obesity, particularly truncal obesity, diabetes mellitus, and hypercholesterolemia.
The clinical features of NASH can vary, with many patients being completely asymptomatic. However, some may experience right upper quadrant pain, nausea and vomiting, and hepatomegaly (enlarged liver).
The typical biochemical profile seen in NASH includes elevated transaminases, with an AST:ALT ratio of less than 1. Often, there is an isolated elevation of ALT, and gamma-GT levels may be mildly elevated. In about one-third of patients, non-organ specific autoantibodies may be present. The presence of antinuclear antibodies (ANA) is associated with insulin resistance and indicates a higher risk of rapid progression to advanced liver disease.
If the AST level is significantly elevated or if the gamma-GT level is markedly elevated, further investigation for other potential causes should be considered. A markedly elevated gamma-GT level may suggest alcohol abuse, although it can also be elevated in NASH alone.
Diagnosis of NASH is confirmed through a liver biopsy, which will reveal increased fat deposition and a necro-inflammatory response within the hepatocytes.
Currently, there is no specific treatment for NASH. However, weight loss and medications that improve insulin resistance, such as metformin, may help slow down the progression of the disease.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 89
Correct
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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: 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.
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This question is part of the following fields:
- Trauma
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Question 90
Correct
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A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only passed a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
What is a potential pre-renal cause of AKI in this patient?Your Answer: Cardiac failure
Explanation:Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of waste products and disturbances in fluid and electrolyte balance. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.
The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases in the community are due to pre-renal causes, accounting for 90% of cases. These are often associated with conditions such as hypotension from sepsis or fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated in AKI.
The table below summarizes the most common causes of AKI:
Pre-renal:
– Volume depletion (e.g., hemorrhage, severe vomiting or diarrhea, burns)
– Oedematous states (e.g., cardiac failure, liver cirrhosis, nephrotic syndrome)
– Hypotension (e.g., cardiogenic shock, sepsis, anaphylaxis)
– Cardiovascular conditions (e.g., severe cardiac failure, arrhythmias)
– Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, Abdominal aortic aneurysm
– Renal artery stenosis
– Hepatorenal syndromeIntrinsic renal:
– Glomerular disease (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
– Tubular injury: acute tubular necrosis (ATN) following prolonged ischemia
– Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
– Vascular disease (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
– EclampsiaPost-renal:
– Renal stones
– Blood clot
– Papillary necrosis
– Urethral stricture
– Prostatic hypertrophy or malignancy
– Bladder tumor
– Radiation fibrosis
– Pelvic malignancy
– Retroperitoneal fibrosis -
This question is part of the following fields:
- Nephrology
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Question 91
Correct
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A 65 year old female presents to the emergency department complaining of severe abdominal pain. You note previous attendances with alcohol related injuries. On taking the history the patient admits to being a heavy drinker and estimates her weekly alcohol consumption at 80-100 units. She tells you her abdomen feels more swollen than usual and she feels nauseated. On examination of the abdomen you note it is visibly distended, tender to palpate and shifting dullness is detected on percussion. The patient's observations are shown below:
Blood pressure 112/74 mmHg
Pulse 102 bpm
Respiration rate 22 bpm
Temperature 38.6ºC
What is the most likely diagnosis?Your Answer: Spontaneous bacterial peritonitis
Explanation:Spontaneous bacterial peritonitis (SBP) is a condition that occurs as a complication of ascites, which is the accumulation of fluid in the abdomen. SBP typically presents with various symptoms such as fevers, chills, nausea, vomiting, abdominal pain, general malaise, altered mental status, and worsening ascites. This patient is at risk of developing alcoholic liver disease and cirrhosis due to their harmful levels of alcohol consumption. Harmful drinking is defined as drinking ≥ 35 units a week for women or drinking ≥ 50 units a week for men. The presence of shifting dullness and a distended abdomen are consistent with the presence of ascites. SBP is an acute bacterial infection of the ascitic fluid that occurs without an obvious identifiable cause. It is one of the most commonly encountered bacterial infections in patients with cirrhosis. Signs and symptoms of SBP include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 92
Correct
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A 25-year-old woman comes to the clinic with a swollen and red right knee. She recently returned from a trip to Bangkok. During the examination, her temperature is 38.6°C and she has a rash with small blisters on her trunk. The knee feels warm to touch and is immobile. Attempts to flex or extend the knee are unsuccessful. A joint aspiration is done, and Gram-negative diplococci are observed.
Which of the following antibiotics would be the most suitable to prescribe for this patient?Your Answer: Cefotaxime
Explanation:The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The patient’s recent travel to Bangkok, presence of a vesicular rash on the trunk, and the identification of Gram-negative diplococci support this diagnosis.
Septic arthritis is characterized by several clinical features. These include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and systemic upset.
The most common cause of septic arthritis is Staphylococcus aureus. Other bacteria that can lead to this condition include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).
According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves the following approaches. Flucloxacillin is the first-line antibiotic. In cases of penicillin allergy, clindamycin is recommended. If there is suspicion of MRSA (methicillin-resistant Staphylococcus aureus), vancomycin should be used. For suspected gonococcal arthritis or Gram-negative infection, cefotaxime is the preferred choice. The suggested duration of treatment is 4-6 weeks, although it may be longer if the infection is complicated.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 93
Correct
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A 5 year old girl is brought into the emergency room. Her father entered the room as she was about to eat a cashew. Within a few minutes, her face began to swell. You determine that she is experiencing anaphylaxis. After administering the necessary medication, you decide to administer an IV fluid challenge. How much crystalloid would you administer to a child in this scenario?
Your Answer: 10 ml/kg
Explanation:According to the 2021 resus council guidelines, when administering an IV fluid challenge to a child with anaphylaxis, the recommended dose is 10 ml/kg. It is important to note that prior to the update, the advised dose was 20 ml/kg. In an exam, if you are provided with the child’s weight, you may be required to calculate the volume requirement.
Further Reading:
Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.
When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.
The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.
In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.
Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 94
Correct
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A 52 year old male is brought into the emergency department acutely ill and is transferred to resus. Your consultant suspects thyrotoxic crisis and instructs you to prepare the necessary medication. What drugs are typically administered during the initial treatment of thyrotoxic crisis?
Your Answer: Antithyroid drug, beta blocker, corticosteroids and iodine solution
Explanation:Thyroid storm, also known as thyrotoxic crisis, is a rare and dangerous complication of hyperthyroidism. The initial management of this condition involves the use of specific medications. These medications include a beta blocker, a corticosteroid, an antithyroid drug, and an iodine solution.
The beta blocker used is typically propranolol, which is administered intravenously at a dose of 1 mg over 1 minute. If a beta blocker is contraindicated, a calcium channel blocker such as diltiazem may be used instead, at a dose of 0.25 mg/kg over 2 minutes.
For corticosteroids, hydrocortisone is commonly used and given intravenously at a dose of 200 mg. Alternatively, dexamethasone can be used at a dose of 2 mg intravenously.
The antithyroid drug used is usually propylthiouracil, which is given orally, through a nasogastric tube, or rectally, at a dose of 200 mg.
An iodine solution, specifically Lugol’s iodine, is also part of the initial management. However, it should not be administered until at least 1 hour after the antithyroid drug has been given. This is because iodine can exacerbate thyrotoxicosis by stimulating thyroid hormone synthesis. Propylthiouracil, on the other hand, inhibits the normal interactions of iodine and peroxidase with thyroglobulin, preventing the formation of T4 and T3. Therefore, it is given first and allowed time to take effect before iodine is administered.
Further Reading:
The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.
Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.
The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.
Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.
Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.
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This question is part of the following fields:
- Endocrinology
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Question 95
Incorrect
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A middle-aged woman presents with symptoms that can be associated with sexually transmitted infection (STI). Following her investigations, she is diagnosed with the most common cause of STI in the UK.
Which of the following is the SINGLE most likely diagnosis?Your Answer: Genital herpes
Correct Answer: Chlamydia
Explanation:Chlamydia trachomatis is a type of Gram-negative bacteria that is responsible for causing the sexually transmitted infection known as chlamydia. This bacterium is typically either coccoid or rod-shaped in its appearance.
There are various serological variants of C. trachomatis, and each variant is associated with different patterns of disease. Specifically, types D-K are responsible for causing genitourinary infections.
In the United Kingdom, chlamydia is the most commonly diagnosed sexually transmitted infection (STI). It is also the leading preventable cause of infertility worldwide. Interestingly, around 50% of men infected with chlamydia do not experience any symptoms, while at least 70% of infected women are asymptomatic.
If left untreated, chlamydia can lead to various complications. In women, these complications may include pelvic inflammatory disease (PID), ectopic pregnancy, and tubal infertility. Men, on the other hand, may experience complications such as proctitis, epididymitis, and epididymo-orchitis.
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This question is part of the following fields:
- Sexual Health
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Question 96
Correct
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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: 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.
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This question is part of the following fields:
- Surgical Emergencies
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Question 97
Correct
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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: 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.
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This question is part of the following fields:
- Respiratory
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Question 98
Correct
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You review a patient with chronic severe back pain with a medical student that has examined the patient. He feels the most likely diagnosis is lumbar disc herniation. He explains that all five features of Reynold’s pentad are present.
Which of the following does NOT form part of Reynold’s pentad?Your Answer: Raised white cell count
Explanation:Ascending cholangitis occurs when there is an infection in the common bile duct, usually caused by a stone that has led to a blockage of bile flow. This condition is known as choledocholithiasis. The typical symptoms of ascending cholangitis are jaundice, fever (often accompanied by chills), and pain in the upper right quadrant of the abdomen. It is important to note that ascending cholangitis is a serious medical emergency that can be life-threatening, as patients often develop sepsis. Approximately 10-20% of patients may also experience altered mental status and low blood pressure due to septic shock. When these additional symptoms are present along with the classic triad of symptoms (Charcot’s triad), it is referred to as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis. While a high white blood cell count is commonly seen in this condition, it is not considered part of Reynold’s pentad.
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This question is part of the following fields:
- Surgical Emergencies
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Question 99
Correct
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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: 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.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 100
Correct
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A 45-year-old woman with a history of chronic heart failure presents to the Emergency Department with an infection. Upon reviewing her medications, you discover that she is taking furosemide as part of her management.
Which ONE of the following antibiotics should be avoided?Your Answer: Gentamicin
Explanation:When furosemide and gentamicin are prescribed together, there is a higher chance of experiencing ototoxicity and deafness. It is recommended to avoid co-prescribing these medications. For more information, you can refer to the BNF section on furosemide interactions.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 101
Correct
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A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
Which of the following conditions is NOT linked to Crohn's disease?Your Answer: Primary sclerosing cholangitis
Explanation:Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing inflammation and blockage over time. This leads to recurrent episodes of cholangitis and progressive scarring of the bile ducts. Ultimately, PSC can result in liver cirrhosis, liver failure, and even hepatocellular carcinoma. It is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis. However, there is no association between PSC and Crohn’s disease.
On the other hand, Crohn’s disease has its own set of recognized associations. For instance, there is an increased incidence of Crohn’s disease among smokers, with approximately 50-60% of Crohn’s patients being smokers. Other associations include the presence of aphthous ulcers, uveitis and episcleritis (eye inflammation), seronegative spondyloarthropathies (inflammatory joint diseases), erythema nodosum (painful skin nodules), pyoderma gangrenosum (skin ulceration), finger clubbing, autoimmune hemolytic anemia, cholelithiasis (gallstones), and osteoporosis.
It is important to note the distinct associations and characteristics of these two conditions, as they have different implications for diagnosis, treatment, and management.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 102
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A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
Which of the following will be visible on her X-ray?Your Answer: Fracture of the zygomatic arch
Explanation:Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.
These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:
1. Widening of the zygomaticofrontal suture
2. Fracture of the zygomatic arch
3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
4. Fracture of the lateral orbital rim. -
This question is part of the following fields:
- Maxillofacial & Dental
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Question 103
Correct
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A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently undergoing radiation therapy. His observations are as follows: HR 92 bpm, BP 126/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
Which validated scoring system can be used to assess the risk of developing serious complications in adults with febrile neutropenia?Your Answer: MASCC Risk Index Score
Explanation:The MASCC Risk Index Score, developed by the Multinational Association of Supportive Care in Cancer, is a tool that can be utilized to identify patients who are at low risk for experiencing serious complications of febrile neutropenia. This score takes into account various characteristics of the patient to determine their risk level. For example, patients who have a minimal burden of febrile neutropenia with no or mild symptoms, no hypotension (with a systolic blood pressure above 90 mmHg), and no chronic obstructive pulmonary disease are assigned higher scores. Additionally, patients with a solid tumor or hematological malignancy and no previous fungal infection, as well as those who do not require parental fluids for dehydration, are also given higher scores. On the other hand, patients with a moderate burden of febrile neutropenia symptoms, those in an outpatient setting at the onset of fever, and those under the age of 60 receive lower scores. It is important to note that the qSOFA Score, CURB-65 Score, SCAP Score, and qCSI Score are different tools used for assessing different conditions and are not specifically used in the context of febrile neutropenia.
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This question is part of the following fields:
- Oncological Emergencies
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Question 104
Correct
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A 10-year-old girl is brought into the Emergency Department with stomach pain and throwing up. Her mom tells you that she has been losing weight lately and seems to be drinking a lot and peeing a lot. During the examination, she appears tired and you notice that she is dehydrated. She is breathing deeply and quickly. Her blood sugar levels are found to be very high when her blood is tested.
Which of the following tests will be most useful in confirming the diagnosis?Your Answer: Urine dipstick
Explanation:The most probable diagnosis in this case is diabetic ketoacidosis (DKA). To confirm the diagnosis, it is important to establish that his blood glucose levels are high, he has significant ketonuria or ketonaemia, and that he is experiencing acidosis. Therefore, out of the options provided, a urine dipstick test will be the most useful.
DKA is a life-threatening condition that occurs when there is a lack of insulin, leading to an inability to metabolize glucose. This results in hyperglycemia and an osmotic diuresis, causing excessive thirst and increased urine production. If the urine output exceeds the patient’s ability to drink, dehydration becomes inevitable. Additionally, without insulin, fat becomes the primary energy source, leading to the production of large amounts of ketones and metabolic acidosis.
DKA is characterized by three main factors:
1. Hyperglycemia (blood glucose > 11 mmol/l)
2. Ketonaemia (> 3 mmol/l) or significant ketonuria (> 2+ on urine dipstick)
3. Acidosis (bicarbonate < 15 mmol/l and/or venous pH < 7.3) The clinical features of DKA include nausea, vomiting, excessive thirst, excessive urine production, abdominal pain, signs of dehydration, a smell of ketones on the breath (similar to pear drops), deep and rapid respiration (Kussmaul breathing), confusion or reduced consciousness, and tachycardia, hypotension, and shock. The following investigations should be performed:
– Blood glucose measurement
– Urine dipstick test (will show marked glycosuria and ketonuria)
– Blood ketone assay (more sensitive and specific than urine dipstick)
– Blood tests including full blood count (FBC) and urea and electrolytes (U&Es)
– Arterial or venous blood gas analysis (to assess for metabolic acidosis)The principles of managing DKA are as follows:
– Fluid boluses should only be given to reverse signs of shock and should be administered slowly in 10 ml/kg aliquots. If there are no signs of shock, fluid boluses should not be given, and specialist advice should be sought if a second bolus is required.
– Rehydration should be done with replacement therapy over 48 hours after signs of shock have been reversed.
– The first 20 ml/kg of fluid resuscitation should be given in addition -
This question is part of the following fields:
- Gastroenterology & Hepatology
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