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  • Question 1 - A middle-aged individual with a history of intravenous drug use and unstable housing...

    Correct

    • A middle-aged individual with a history of intravenous drug use and unstable housing presents with extremely intense back pain, elevated body temperature, and weakness in the left leg. The patient has experienced multiple episodes of nighttime pain and is struggling to walk. During the examination, tenderness is noted in the lower lumbar spine, along with weakness in left knee extension and foot dorsiflexion.

      What is the preferred diagnostic test to definitively confirm the diagnosis?

      Your Answer: MRI scan spine

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.

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

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

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

      Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      11.9
      Seconds
  • Question 2 - A 68-year-old man with a history of atrial fibrillation (AF) is found to...

    Correct

    • A 68-year-old man with a history of atrial fibrillation (AF) is found to have an INR of 9.1 during a routine check. He is feeling fine and does not have any signs of bleeding.
      What is the most suitable approach to reverse the effects of warfarin in this patient?

      Your Answer: Stop warfarin and give oral vitamin K

      Explanation:

      The current recommendations from NICE for managing warfarin in the presence of bleeding or an abnormal INR are as follows:

      In cases of major active bleeding, regardless of the INR level, the first step is to stop administering warfarin. Next, 5 mg of vitamin K (phytomenadione) should be given intravenously. Additionally, dried prothrombin complex concentrate, which contains factors II, VII, IX, and X, should be administered. If dried prothrombin complex is not available, fresh frozen plasma can be given at a dose of 15 ml/kg.

      If the INR is greater than 8.0 and there is minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.

      If the INR is greater than 8.0 with no bleeding, warfarin should be stopped. Oral administration of 1-5 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.

      If the INR is between 5.0-8.0 with minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and warfarin can be restarted once the INR is less than 5.0.

      If the INR is between 5.0-8.0 with no bleeding, one or two doses of warfarin should be withheld, and the subsequent maintenance dose should be reduced.

      For more information, please refer to the NICE Clinical Knowledge Summary on the management of warfarin therapy and the BNF guidance on the use of phytomenadione.

    • This question is part of the following fields:

      • Haematology
      22.5
      Seconds
  • Question 3 - A 2-year-old boy presents with a high temperature and foul-smelling urine. His mother...

    Correct

    • A 2-year-old boy presents with a high temperature and foul-smelling urine. His mother is worried that he might have a urinary tract infection.
      Which of the following symptoms is NOT mentioned by NICE as indicative of a UTI in this age range?

      Your Answer: Haematuria

      Explanation:

      According to NICE, the presence of certain clinical features in a child between three months and five years old may indicate a urinary tract infection (UTI). These features include vomiting, poor feeding, lethargy, irritability, abdominal pain or tenderness, and urinary frequency or dysuria. For more information on this topic, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Urology
      7.7
      Seconds
  • Question 4 - A 14-year-old girl presents with a sudden onset of a painful throat that...

    Correct

    • A 14-year-old girl presents with a sudden onset of a painful throat that has been bothering her for the past day. She has no history of a cough and no symptoms of a cold. During the examination, her temperature is measured at 38.5°C, and there is clear evidence of pus on her right tonsil, which also appears to be swollen and red. No swollen lymph nodes are felt in the front of her neck.
      Based on the FeverPAIN Score used to evaluate her sore throat, what is the most appropriate course of action?

      Your Answer: Treat immediately with empiric antibiotics

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      16.3
      Seconds
  • Question 5 - A 5-year-old child presents extremely ill with acute severe asthma. He weighs 18...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Respiratory
      24.9
      Seconds
  • Question 6 - You assess a patient who has been brought into the resuscitation room in...

    Correct

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

      Your Answer: ACTH levels are usually elevated

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      15.4
      Seconds
  • Question 7 - You provide nitrous oxide to a child who has experienced a significant injury...

    Correct

    • You provide nitrous oxide to a child who has experienced a significant injury for temporary pain relief.
      Which of the following is NOT a reason to avoid using nitrous oxide?

      Your Answer: Sepsis

      Explanation:

      The prolonged use of nitrous oxide (Entonox) in patients with sepsis may have a negative impact on DNA synthesis, and it is not recommended to use it in this situation. However, sepsis itself does not prevent the use of nitrous oxide.

      There are several conditions that make the use of nitrous oxide inappropriate. These include a reduced level of consciousness, diving injuries, pneumothorax, middle ear disease, sinus disease, bowel obstruction, a documented allergy to nitrous oxide, hypoxia, and violent or disabled psychiatric patients.

      It is important to note that the use of nitrous oxide should be avoided in patients with sepsis due to its potential effects on DNA synthesis. However, there are other contraindications to its use that should be considered in different clinical scenarios.

    • This question is part of the following fields:

      • Pain & Sedation
      13
      Seconds
  • Question 8 - A 28-year-old woman is brought into the emergency room by an ambulance with...

    Correct

    • A 28-year-old woman is brought into the emergency room by an ambulance with sirens blaring after being involved in a car accident. She was hit by a truck while riding a bicycle and is suspected to have a pelvic injury. Her blood pressure is unstable, and the hospital has activated the massive transfusion protocol. You decide to also give her tranexamic acid.
      What is the appropriate initial dose of tranexamic acid to administer and over what duration of time?

      Your Answer: 1 g IV over 10 minutes

      Explanation:

      ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

      Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

    • This question is part of the following fields:

      • Trauma
      18.8
      Seconds
  • Question 9 - A 32 year old male presents to the emergency department complaining of sudden...

    Correct

    • A 32 year old male presents to the emergency department complaining of sudden shortness of breath. While being assessed by the nurse, the patient mentions that he is currently 28 weeks into his partner's pregnancy. Suddenly, the patient collapses and the nurse urgently calls for your assistance. Upon examination, you find that the patient has no detectable pulse and is not breathing. You make the decision to initiate cardiopulmonary resuscitation (CPR). What is the most likely reversible cause of cardiac arrest that this patient is at a high risk for?

      Your Answer: Thrombosis

      Explanation:

      Pregnant or postpartum women have a significantly higher risk of developing a venous thrombosis compared to women who are not pregnant. In fact, their risk is 10 times greater. Specifically, pregnant or postpartum women have a 1 in 500 chance of developing a venous thrombosis, whereas non-pregnant women have a much lower risk of 1 in 5000. It is important to remember the reversible causes of cardiac arrest, which are categorized as the 4 T’s and the 4 H’s, as mentioned in the notes below the algorithm.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Resus
      31.1
      Seconds
  • Question 10 - A 9-month-old girl comes in with a significant haemarthrosis in her left knee...

    Correct

    • A 9-month-old girl comes in with a significant haemarthrosis in her left knee after falling while trying to stand up using a side table. Her mother mentions that her older sister has a bleeding disorder and has also had haemarthrosis before.
      What is the MOST probable diagnosis?

      Your Answer: Haemophilia A

      Explanation:

      Haemophilia is a collection of genetic disorders that are inherited and lead to impaired blood clotting. Haemophilia A specifically occurs when there is a deficiency of factor VIII and is typically passed down as a recessive trait on the X chromosome.

      The initial signs of haemophilia A usually appear around 6 months of age when infants start crawling, although it can manifest later. Bleeding can occur either spontaneously or as a result of trauma. One key indicator of haemophilia is bleeding into muscles and joints, known as haemarthrosis. While gastrointestinal and cerebral bleeding can also happen, they are less common occurrences.

      Based on the symptoms described, the most likely diagnosis from the given options would be Haemophilia A, especially when there is a combination of haemarthrosis and an older brother with the same disorder.

      Idiopathic thrombocytopenic purpura (ITP) is a condition where the immune system causes a decrease in platelet count. Antibodies target the glycoprotein IIb-IIIa or Ib complex. Acute ITP is more prevalent in children and affects both sexes equally. Chronic ITP, on the other hand, is more common in young to middle-aged women. Unlike haemophilia, ITP typically presents with symptoms such as nosebleeds, oral bleeding, purpura, or petechiae, rather than haemarthrosis. Additionally, ITP is not an inherited disorder.

      Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited disorder that follows an X-linked recessive pattern. It is characterized by a defect in the G6PD enzyme, which plays a crucial role in red blood cell metabolism. Most individuals with G6PD deficiency do not experience symptoms. However, haemolytic crisis can occur in response to factors like illness (especially infection and diabetic ketoacidosis), certain medications (such as specific antibiotics, antimalarials, sulphonamides, and aspirin), or certain foods (notably fava beans).

      Von Willebrand disease (vWD) is the most common hereditary coagulation disorder, affecting approximately 1 in 100 individuals. It arises from a deficiency in Von Willebrand factor (vWF), which leads to reduced levels of factor VIII. vWF is responsible for protecting factor VIII from rapid breakdown in the blood and is also necessary for platelet adhesion.

    • This question is part of the following fields:

      • Haematology
      16.9
      Seconds
  • Question 11 - A 35-year-old man who resides in a Traveller community comes in with a...

    Correct

    • A 35-year-old man who resides in a Traveller community comes in with a severe paroxysmal cough and a fever that has persisted for the last 10 days. He reports not having received any vaccinations. A nasopharyngeal swab for pertussis comes back positive. He is currently 18 weeks into his wife's pregnancy.
      What is the most suitable initial antibiotic to prescribe?

      Your Answer: Erythromycin

      Explanation:

      Pertussis, also known as whooping cough, is a respiratory infection caused by the bacteria Bordetella pertussis. Despite being a bacterial disease, antibiotics do not change the course of the illness once it has taken hold. However, macrolide antibiotics have been proven to shorten the period of contagiousness. Therefore, it is important to administer antibiotics as soon as possible after the onset of symptoms to eliminate the bacteria and reduce further transmission. It is crucial to start antibiotics within three weeks of symptom onset, as they do not affect the progression of the illness or the contagious period.

      First-line treatment for pertussis includes macrolide antibiotics. For babies under one month old, clarithromycin is recommended. For children one month and older, as well as non-pregnant adults, azithromycin or clarithromycin are the preferred options. Pregnant women should be treated with erythromycin. In cases where macrolides are not suitable or well-tolerated, co-trimoxazole can be used off-label.

    • This question is part of the following fields:

      • Respiratory
      15
      Seconds
  • Question 12 - A 55-year-old man receives a blood transfusion. Shortly after the transfusion is started,...

    Incorrect

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

      What is the most suitable course of action for treatment?

      Your Answer: Supportive measures and paracetamol

      Correct Answer: Stop the transfusion and administer antibiotics

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      31.4
      Seconds
  • Question 13 - A 42-year-old woman with a history of gallstones, presents with right upper quadrant...

    Correct

    • A 42-year-old woman with a history of gallstones, presents with right upper quadrant pain and fever. She is diagnosed with acute cholecystitis. Which ONE statement about this condition is accurate?

      Your Answer: The gallbladder fills with pus, which is usually sterile initially

      Explanation:

      Acute cholecystitis occurs when a stone becomes stuck in the outlet of the gallbladder, causing irritation of the wall and resulting in chemical cholecystitis. This leads to the accumulation of pus within the gallbladder, which is typically sterile at first. However, there is a possibility of secondary infection with enteric organisms like Escherichia coli and Klebsiella spp.

      The clinical features of acute cholecystitis include severe pain in the right upper quadrant or epigastrium, which can radiate to the back and lasts for more than 12 hours. Fevers and rigors are often present, along with common symptoms like nausea and vomiting. Murphy’s sign is a useful diagnostic tool, as it has a high sensitivity and positive predictive value for acute cholecystitis. However, its specificity is lower, as it can also be positive in biliary colic and ascending cholangitis.

      In cases of acute cholecystitis, the white cell count and C-reactive protein (CRP) levels are usually elevated. AST, ALT, and ALP may also show elevation, but they can often be within the normal range. Bilirubin levels may be mildly elevated, but they can also be normal. If there is a significant increase in AST, ALT, ALP, and/or bilirubin, it may indicate the presence of other biliary tract conditions such as ascending cholangitis or choledocholithiasis.

      It is important to note that there is some overlap in the presentation of biliary colic, acute cholecystitis, and ascending cholangitis. To differentiate between these diagnoses, the following list can be helpful:

      Biliary colic:
      – Pain duration: Less than 12 hours
      – Fever: Absent
      – Murphy’s sign: Negative
      – WCC & CRP: Normal
      – AST, ALT & ALP: Normal
      – Bilirubin: Normal

      Acute cholecystitis:
      – Pain duration: More than 12 hours
      – Fever: Present
      – Murphy’s sign: Positive
      – WCC & CRP: Elevated
      – AST, ALT & ALP: Normal or mildly elevated
      – Bilirubin: Normal or mildly elevated

      Ascending cholangitis:
      – Pain duration: Variable
      – Fever: Present
      – Murphy’s sign: Negative
      – WCC & CRP: Elevated
      – AST, ALT & ALP: Elevated

    • This question is part of the following fields:

      • Surgical Emergencies
      12.7
      Seconds
  • Question 14 - A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and...

    Correct

    • A 30-year-old pregnant woman who has been receiving treatment for pre-eclampsia deteriorates and arrives at the Emergency Department. Upon evaluating the patient, you decide to admit her due to the development of HELLP syndrome.
      Which of the following signs or symptoms would NOT raise suspicion of HELLP syndrome in a pregnant patient?

      Your Answer: Symptoms occurring around 16 weeks gestation

      Explanation:

      HELLP syndrome is a condition that occurs in approximately 0.5% of pregnancies. It is characterized by haemolysis, elevated liver enzymes, and a low platelet count. While it typically occurs in the late third trimester, it has also been reported in the late second trimester. Around 33% of patients with HELLP syndrome will present shortly after giving birth.

      The initial symptoms of HELLP syndrome can be vague and include nausea, headaches, malaise, and pain in the upper right quadrant of the abdomen. Upon examination, raised blood pressure, proteinuria, and edema may be observed. Further investigations may reveal haemolysis on a blood film, elevated liver enzymes, low platelets, raised LDH, and raised bilirubin.

      Delivery of the baby is the main treatment for HELLP syndrome. However, complications can arise, such as disseminated intravascular coagulation (DIC), renal failure, liver failure, and pulmonary edema. It is crucial to tightly control blood pressure, and magnesium sulfate is often used to reduce the risk of progression to eclampsia. If DIC occurs, treatment with fresh frozen plasma is necessary.

      Without prompt recognition, approximately 25% of individuals with HELLP syndrome may experience severe complications, including placental abruption, liver failure, retinal detachment, and renal failure. With treatment, the mortality rate for the mother is around 1%, while the mortality rate for the baby ranges from 5-10%, depending on the gestational age at the time of delivery.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      8.2
      Seconds
  • Question 15 - A 45-year-old man with a long-standing history of type 2 diabetes mellitus complains...

    Correct

    • A 45-year-old man with a long-standing history of type 2 diabetes mellitus complains of pain in his left buttock, hip, and thigh. The pain began abruptly a couple of months ago, and he cannot recall any previous injury. During the examination, you observe muscle wasting in his left quadriceps, struggles in standing up from a seated position, and an absent knee jerk on the left side. Additionally, you notice muscle fasciculations in his left thigh.

      What is the SINGLE most probable diagnosis?

      Your Answer: Diabetic amyotrophy

      Explanation:

      Diabetic amyotrophy, also referred to as proximal diabetic neuropathy, is the second most prevalent form of diabetic neuropathy. It typically begins with discomfort in the buttocks, hips, or thighs and is often initially experienced on one side. The pain may start off as mild and gradually progress or it can suddenly manifest, as seen in this case. Subsequently, weakness and wasting of the proximal muscles in the lower limbs occur, making it difficult for the patient to transition from sitting to standing without assistance. Reflexes in the affected areas can also be impacted. Good control of blood sugar levels, physiotherapy, and lifestyle adjustments can reverse diabetic amyotrophy.

      Peripheral neuropathy is the most common type of diabetic neuropathy and typically manifests as pain or loss of sensation in the feet or hands.

      Autonomic neuropathy leads to changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the cardiovascular system, resulting in rapid heart rates and orthostatic hypotension.

      Focal neuropathy causes sudden weakness in a single nerve or group of nerves, resulting in pain, sensory loss, or muscle weakness. Any nerve in the body can be affected.

    • This question is part of the following fields:

      • Endocrinology
      7.7
      Seconds
  • Question 16 - You are managing a 68-year-old patient with suspected sepsis, and your attending physician...

    Correct

    • You are managing a 68-year-old patient with suspected sepsis, and your attending physician requests you to place a central line. During your discussion, you both agree to insert a central line into the right internal jugular vein (IJV). What potential complication can be avoided by selecting the right side?

      Your Answer: Thoracic duct injury

      Explanation:

      Inserting an IJV line on the right side of the neck is preferred because it reduces the risk of damaging the thoracic duct. The thoracic duct is where the largest lymphatic vessel in the body connects to the bloodstream. It is situated where the left subclavian and internal jugular veins meet, as well as the beginning of the brachiocephalic vein. Opting for the right side of the neck helps prevent potential harm to the thoracic duct.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      8.3
      Seconds
  • Question 17 - A 45-year-old man presents with brief episodes of vertigo that are worse in...

    Correct

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

      What is the SINGLE most probable diagnosis?

      Your Answer: Benign paroxysmal positional vertigo (BPPV)

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      34.2
      Seconds
  • Question 18 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Correct

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was struck by a truck. She has suffered severe facial injuries and shows signs of airway obstruction. Her neck is immobilized. She has suffered significant midface trauma, and the anesthesiologist decides to secure a definitive airway by intubating the patient. He is unable to pass an endotracheal tube, and he decides to perform a needle cricothyroidotomy.
      Which of the following statements regarding needle cricothyroidotomy is FALSE?

      Your Answer: The cricothyroid membrane is located directly below the cricoid cartilage

      Explanation:

      A needle cricothyroidotomy is a procedure used in emergency situations to provide oxygenation when intubation and oxygenation are not possible. It is typically performed when a patient cannot be intubated or oxygenated. There are certain conditions that make this procedure contraindicated, such as local infection, distorted anatomy, previous failed attempts, and swelling or mass lesions.

      To perform a needle cricothyroidotomy, the necessary equipment should be assembled and prepared. The patient should be positioned supine with their neck in a neutral position. The neck should be cleaned in a sterile manner using antiseptic swabs. If time allows, the area should be anesthetized locally. A 12 or 14 gauge over-the-needle catheter should be assembled to a 10 mL syringe.

      The cricothyroid membrane, located between the thyroid and cricoid cartilage, should be identified anteriorly. The trachea should be stabilized with the thumb and forefinger of one hand. Using the other hand, the skin should be punctured in the midline with the needle over the cricothyroid membrane. The needle should be directed at a 45° angle caudally while negative pressure is applied to the syringe. Needle aspiration should be maintained as the needle is inserted through the lower half of the cricothyroid membrane, with air aspiration indicating entry into the tracheal lumen.

      Once the needle is in place, the syringe and needle should be removed while the catheter is advanced to the hub. The oxygen catheter should be attached and the airway secured. It is important to be aware of possible complications, such as technique failure, cannula obstruction or dislodgement, injury to local structures, and surgical emphysema if high flow oxygen is administered through a malpositioned cannula.

    • This question is part of the following fields:

      • Trauma
      21.3
      Seconds
  • Question 19 - You are asked to review a 7-year-old girl that is feeling sick in...

    Correct

    • You are asked to review a 7-year-old girl that is feeling sick in the Paediatric Emergency Department. You observe from her urea & electrolytes that her potassium is elevated at 6.2 mmol/l.

      What is the most frequent cause of hyperkalaemia in children?

      Your Answer: Renal failure

      Explanation:

      Hyperkalaemia is a condition characterized by a high level of potassium in the blood, specifically a plasma potassium level greater than 5.5 mmol/l. It can be further classified into three categories based on the severity of the condition. Mild hyperkalaemia refers to a potassium level ranging from 5.5-5.9 mmol/l, while moderate hyperkalaemia is defined as a potassium level between 6.0-6.4 mmol/l. Severe hyperkalaemia is indicated by a potassium level exceeding 6.5 mmol/l.

      The most common cause of hyperkalaemia in renal failure, which can occur either acutely or chronically. However, there are other factors that can contribute to this condition as well. These include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.

      Overall, hyperkalaemia is a medical condition that requires attention and management, as it can have significant implications for the body’s normal functioning.

    • This question is part of the following fields:

      • Nephrology
      6
      Seconds
  • Question 20 - A 35-year-old female smoker presents with an episode of acute right-sided chest pain....

    Correct

    • 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.

    • This question is part of the following fields:

      • Cardiology
      7.1
      Seconds
  • Question 21 - A 28 year old female is brought into the emergency department after a...

    Correct

    • A 28 year old female is brought into the emergency department after a jet skiing accident at a local lake. The patient fell off the jet ski but her leg got caught in the handlebars and she was submerged for 2-3 minutes before being freed. The patient's friends started rescue breaths and chest compressions as the patient was unconscious but were stopped after approximately 30 seconds by an off duty lifeguard who assessed the patient and determined she was breathing spontaneously and had a pulse. On examination, the patient is breathing spontaneously with intermittent coughing, oxygen saturation levels are 97% on room air, a few crackling sounds are heard in the lower parts of the lungs, and the patient's Glasgow Coma Scale score is 13 out of 15.

      Which of the following should be included in the initial management of this patient?

      Your Answer: Obtain an arterial blood gas sample for evidence of hypoxia

      Explanation:

      It is recommended to obtain an arterial blood gas (ABG) sample from all patients who have experienced submersion (drowning) as even individuals without symptoms may have a surprising level of hypoxia. Draining the lungs is not effective and not recommended. There is no strong evidence to support the routine use of antibiotics as a preventive measure. Steroids have not been proven to be effective in treating drowning. All drowning patients, except those with normal oxygen levels, normal saturations, and normal lung sounds, should receive supplemental oxygen as significant hypoxia can occur without causing difficulty in breathing.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

    • This question is part of the following fields:

      • Trauma
      25.2
      Seconds
  • Question 22 - A 68-year-old individual reports feeling unwell after having their dislocated shoulder reduced while...

    Correct

    • A 68-year-old individual reports feeling unwell after having their dislocated shoulder reduced while under sedation. You decide to prescribe ondansetron. What is the mechanism of action of ondansetron?

      Your Answer: 5-HT3 receptor antagonist

      Explanation:

      Ondansetron is a medication that works by blocking serotonin receptors in the body. It is commonly used as a first-line treatment for postoperative nausea and vomiting (PONV), which can occur after procedures done under sedation or anesthesia.

      Further Reading:

      postoperative nausea and vomiting (PONV) is a common occurrence following procedures performed under sedation or anesthesia. It can be highly distressing for patients. Several risk factors have been identified for PONV, including female gender, a history of PONV or motion sickness, non-smoking status, patient age, use of volatile anesthetics, longer duration of anesthesia, perioperative opioid use, use of nitrous oxide, and certain types of surgery such as abdominal and gynecological procedures.

      To manage PONV, antiemetics are commonly used. These medications work by targeting different receptors in the body. Cyclizine and promethazine are histamine H1-receptor antagonists, which block the action of histamine and help reduce nausea and vomiting. Ondansetron is a serotonin 5-HT3 receptor antagonist, which blocks the action of serotonin and is effective in preventing and treating PONV. Prochlorperazine is a dopamine D2 receptor antagonist, which blocks the action of dopamine and helps alleviate symptoms of nausea and vomiting. Metoclopramide is also a dopamine D2 receptor antagonist and a 5-HT3 receptor antagonist, providing dual action against PONV. It is also a 5-HT4 receptor agonist, which helps improve gastric emptying and reduces the risk of PONV.

      Assessment and management of PONV involves a comprehensive approach. Healthcare professionals need to assess the patient’s risk factors for PONV and take appropriate measures to prevent its occurrence. This may include selecting the appropriate anesthesia technique, using antiemetics prophylactically, and providing adequate pain control. In cases where PONV does occur, prompt treatment with antiemetics should be initiated to alleviate symptoms and provide relief to the patient. Close monitoring of the patient’s condition and response to treatment is essential to ensure effective management of PONV.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5
      Seconds
  • Question 23 - A 17 year old female presents to the emergency department with a guardian,...

    Incorrect

    • A 17 year old female presents to the emergency department with a guardian, complaining of feeling unwell. She reports experiencing pain in her pelvic and lower abdominal area. The guardian reveals that they suspect she may have a tampon stuck inside her. You request permission to conduct a vaginal examination. In the event that this patient is determined to be incapable of giving consent, who among the following individuals has the authority to provide consent on her behalf?

      Your Answer: Patient's parents

      Correct Answer: Court Appointed Deputy

      Explanation:

      Consent for individuals who lack capacity can be given by the person with lasting power of attorney, a court-appointed deputy, or doctors. Since the patient is an adult (>18), parental consent is not applicable. However, parents or family members can consent on behalf of an adult if they have been granted lasting power of attorney (LPA). The authorized individuals who can provide consent are the person with lasting power of attorney, court-appointed deputies, and doctors in cases involving treatment under best interests or mental health legislation. It is important to note that parental consent is only appropriate if they have LPA.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      27
      Seconds
  • Question 24 - A 72 year old female is brought into the emergency department due to...

    Correct

    • A 72 year old female is brought into the emergency department due to near-fainting. Whilst in the department, the patient loses consciousness and upon examination, no pulse is detected. You begin cardiopulmonary resuscitation (CPR). Which two medications (aside from oxygen) are administered as part of the advanced life support resuscitation protocol?

      Your Answer: Adrenaline and amiodarone

      Explanation:

      According to the ALS algorithm, the main drugs used during CPR are oxygen, adrenaline, and amiodarone. Adrenaline is administered every 3-5 minutes as per the 2021 UK ALS algorithm. Amiodarone is given after 3 shocks.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      13.9
      Seconds
  • Question 25 - You are summoned to the resuscitation bay to aid in the care of...

    Correct

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

      Your Answer: Widened pulse pressure, bradycardia and bradypnoea

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      10.6
      Seconds
  • Question 26 - A 35 year old male presents to the emergency department after twisting his...

    Correct

    • A 35 year old male presents to the emergency department after twisting his right ankle while playing basketball. He reports pain on the outer side of his ankle and foot, and experiences discomfort when putting weight on it.

      After conducting a physical examination, the healthcare provider decides to order ankle and foot X-rays based on the Ottawa foot & ankle rules. According to these guidelines, which of the following scenarios would warrant a foot X-ray?

      Your Answer: Tenderness over navicular

      Explanation:

      An X-ray of the foot is recommended when there is pain in the base of the fifth metatarsal or the navicular bone, as well as an inability to bear weight immediately after an injury or in the emergency department. The Ottawa ankle rules can also be used to determine if an X-ray is necessary for ankle injuries. These rules focus on two specific areas (the malleolar and midfoot zones) to determine if an X-ray of the ankle or foot is needed. More information on these rules can be found in the notes below.

      Further Reading:

      Ankle fractures are traumatic lower limb and joint injuries that involve the articulation between the tibia, fibula, and talus bones. The ankle joint allows for plantar and dorsiflexion of the foot. The key bony prominences of the ankle are called malleoli, with the medial and posterior malleolus being prominences of the distal tibia and the lateral malleolus being a prominence of the distal fibula. The distal fibula and tibia are joined together by the distal tibiofibular joint or syndesmosis, which is comprised of three key ligaments. An ankle X-ray series is often used to guide clinical decision making in patients with ankle injuries, using the Ottawa ankle rules to determine if an X-ray is necessary. Ankle fractures are commonly described by the anatomical fracture pattern seen on X-ray relative to the malleoli involved, such as isolated malleolus fractures, bimalleolar fractures, and trimalleolar fractures. The Weber classification is a commonly used system for distal fibula fractures, categorizing them as Weber A, B, or C based on the level and extent of the fracture.

    • This question is part of the following fields:

      • Trauma
      12.2
      Seconds
  • Question 27 - A 35-year-old woman is diagnosed with meningococcal sepsis. An arterial blood gas is...

    Correct

    • A 35-year-old woman is diagnosed with meningococcal sepsis. An arterial blood gas is performed, and lactic acidosis is detected.
      What type of acid-base disorder would you anticipate in a patient with sepsis-induced lactic acidosis?

      Your Answer: Raised anion gap metabolic acidosis

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      10.8
      Seconds
  • Question 28 - A 68-year-old woman presents with severe diarrhea one week after having a total...

    Correct

    • A 68-year-old woman presents with severe diarrhea one week after having a total knee replacement. The diarrhea has a foul odor and is yellow in color. A stool sample is sent to the laboratory and tests positive for Clostridium difficile toxin.
      What is the MOST suitable course of action for management?

      Your Answer: Oral vancomycin

      Explanation:

      Clostridium difficile is a type of bacteria that is Gram-positive, anaerobic, and capable of forming spores. It is found in the intestines of about 3% of healthy adults, according to estimates from the UK Health Protection Agency in 2012.

      Clostridium difficile associated diarrhea (CDAD) often occurs after the use of broad-spectrum antibiotics, which disrupt the normal bacteria in the gut and allow Clostridium difficile to multiply. This leads to inflammation and bleeding in the lining of the large intestine, resulting in a distinct pseudomembranous appearance. The majority of Clostridium difficile infections are reported in individuals over the age of 65.

      The main symptoms of CDAD include abdominal cramps, severe bloody and/or watery diarrhea, offensive-smelling diarrhea, and fever.

      The gold standard for diagnosing Clostridium difficile colitis is a cytotoxin assay. However, this test can be challenging to perform and results may take up to 48 hours to obtain. The most commonly used laboratory test for diagnosing Clostridium difficile colitis is an enzyme-mediated immunoassay that detects toxins A and B. This test has a specificity of 93-100% and a sensitivity of 63-99%.

      In some cases, patients may develop a condition called toxic megacolon, which can be life-threatening, especially in frail or elderly individuals.

      The current recommended first-line treatment for CDAD is oral vancomycin. For more information, refer to the guidance provided by the National Institute for Health and Care Excellence (NICE) regarding the risk of Clostridium difficile infection associated with the use of broad-spectrum antibiotics.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      17
      Seconds
  • Question 29 - A 62-year-old male patient comes in with a recent onset left-sided headache accompanied...

    Correct

    • A 62-year-old male patient comes in with a recent onset left-sided headache accompanied by feeling generally under the weather and decreased vision in his left eye. He mentioned that brushing his hair on the side of his headache has been painful. He has also been experiencing discomfort around his shoulder girdle for the past few weeks.

      What is the SINGLE most probable diagnosis?

      Your Answer: Temporal arteritis

      Explanation:

      This patient presents with a classic case of temporal arteritis, also known as giant cell arteritis (GCA). Temporal arteritis is a chronic condition characterized by inflammation in the walls of medium and large arteries, specifically granulomatous inflammation. It typically affects individuals who are over 50 years old.

      The clinical features of temporal arteritis include headache, tenderness in the scalp, jaw claudication, and episodes of sudden blindness or amaurosis fugax (usually occurring in one eye). Some patients may also experience systemic symptoms such as fever, fatigue, loss of appetite, weight loss, and depression.

      Temporal arteritis is often associated with polymyalgia rheumatica (PMR) in about 50% of cases. PMR is characterized by stiffness, aching, and tenderness in the upper arms (bilateral) and pain in the pelvic girdle.

      Visual loss is an early and significant complication of temporal arteritis, and once it occurs, it rarely improves. Therefore, early treatment with high-dose corticosteroids is crucial to prevent further visual loss and other ischemic complications. If temporal arteritis is suspected, immediate initiation of high-dose glucocorticosteroid treatment (40 – 60 mg prednisolone daily) is necessary. It is also important to arrange an urgent referral for specialist evaluation, including a same-day ophthalmology assessment for those with visual symptoms, and a temporal artery biopsy.

    • This question is part of the following fields:

      • Neurology
      12.5
      Seconds
  • Question 30 - A 65 year old presents to the emergency department with a 3 week...

    Correct

    • A 65 year old presents to the emergency department with a 3 week history of feeling generally fatigued. You observe that the patient has been undergoing yearly echocardiograms to monitor aortic stenosis. The patient informs you that he had a tooth extraction around 10 days prior to the onset of his symptoms. You suspect that infective endocarditis may be the cause. What organism is most likely responsible for this case?

      Your Answer: Streptococcus viridans

      Explanation:

      Based on the patient’s symptoms and medical history, the most likely organism responsible for this case of infective endocarditis is Streptococcus viridans. This is because the patient has a history of aortic stenosis, which is a risk factor for developing infective endocarditis. Additionally, the patient had a tooth extraction prior to the onset of symptoms, which can introduce bacteria into the bloodstream and increase the risk of infective endocarditis. Streptococcus viridans is a common cause of infective endocarditis, particularly in patients with underlying heart valve disease.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      23.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Musculoskeletal (non-traumatic) (1/1) 100%
Haematology (2/3) 67%
Urology (1/1) 100%
Ear, Nose & Throat (2/2) 100%
Respiratory (2/2) 100%
Endocrinology (3/3) 100%
Pain & Sedation (1/1) 100%
Trauma (4/4) 100%
Resus (3/3) 100%
Surgical Emergencies (1/1) 100%
Obstetrics & Gynaecology (1/1) 100%
Nephrology (1/1) 100%
Cardiology (1/1) 100%
Basic Anaesthetics (1/1) 100%
Safeguarding & Psychosocial Emergencies (0/1) 0%
Infectious Diseases (2/2) 100%
Gastroenterology & Hepatology (1/1) 100%
Neurology (1/1) 100%
Passmed