-
Question 1
Correct
-
A 32-year-old woman presents with a history of increased cough and wheeze over the past two days. She suffers from seasonal allergies in the spring months, which has been worse than usual over recent weeks. When auscultating her chest, you can hear scattered polyphonic wheezes. Her peak flow at presentation was 275 L/min, and her best ever peak flow is 500 L/min. After a single salbutamol nebuliser, her peak flow improves to 455 L/min, and she feels much better.
What is the SINGLE most appropriate next step in her management?Your Answer: Give oral prednisolone 40 mg
Explanation:This man is experiencing an acute asthma episode. His initial peak flow is 55% of his best, indicating a moderate exacerbation. In such cases, it is recommended to administer steroids, specifically a dose of prednisolone 40-50 mg orally.
Chest X-rays are not routinely performed to investigate acute asthma. However, they should be considered in certain situations, including suspected pneumomediastinum, consolidation, life-threatening asthma, inadequate response to treatment, and the need for ventilation.
Nebulised ipratropium bromide is only added to treatment with nebulised salbutamol in patients with acute severe or life-threatening asthma, or those who do not respond well to salbutamol therapy. Therefore, it is not necessary in this particular case.
While it may be reasonable to prescribe an antihistamine for a patient with a history of worsening hay fever, it should not be prioritized over treatment with steroids.
-
This question is part of the following fields:
- Respiratory
-
-
Question 2
Correct
-
A child under your supervision is diagnosed with a reportable illness.
Select from the options below the one condition that is NOT currently a reportable illness.Your Answer: Leptospirosis
Explanation:The Health Protection (Notification) Regulations currently require the reporting of certain diseases. These diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever (typhoid or paratyphoid fever), food poisoning, haemolytic uraemic syndrome (HUS), infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires’ Disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, SARS, scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever (VHF), whooping cough, and yellow fever.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 3
Correct
-
A 23-year-old woman arrives at the Emergency Department after an insect flew into her ear. She is experiencing intense pain and can hear the insect buzzing. The triage nurse has given her pain relief, and she is now comfortable.
What is the most suitable INITIAL course of action?Your Answer: Apply immersion oil to the ear
Explanation:Insect removal from the ear can be quite challenging due to the distress it causes the patient and the inevitable movement of the insect during the process.
To begin, it is important to make the patient comfortable by providing analgesia. In some cases, inhaled Entonox can be helpful, and if the patient is extremely distressed or experiencing significant discomfort, sedation may be necessary.
The first step in the removal process involves immobilizing or killing the insect to prevent further movement and potential damage within the ear. This can be achieved using options such as microscope immersion oil, mineral oil, or lidocaine solution.
Once the insect is confirmed to be dead, the actual removal can be performed using forceps or the highly effective Frazier suction technique. After inspecting the ear and ensuring the insect is no longer alive, connect the Frazier suction device to low continuous suction and slowly insert it into the patient’s external ear canal. By occluding the insufflation port, the contents of the ear canal can be suctioned out. Once no more liquid returns, withdraw the catheter and verify that the insect has been successfully removed.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 4
Correct
-
A 25-year-old arrives at the emergency department after being involved in a car accident. A FAST scan is conducted to assess for abdominal injuries caused by blunt trauma. Which of the following is NOT among the four standard views obtained during a FAST scan?
Your Answer: Umbilical view
Explanation:FAST scans consist of four standard views that are obtained to assess different areas of the body. These views include the right upper quadrant (RUQ), left upper quadrant (LUQ), pericardial sac, and the pelvis.
In the RUQ view, the focus is on the right flank or peri-hepatic area, which includes Morison’s pouch and the right costophrenic pleural recess.
The LUQ view examines the left flank or peri-splenic area, which includes the spleen-renal recess and the left costophrenic pleural space.
The pericardial sac is also assessed to evaluate any abnormalities in this area.
Lastly, the pelvis is examined in two planes to ensure a comprehensive evaluation.
In addition to these four standard views, an anterior pleural view is often performed alongside the others. This view used to be part of the extended FAST (eFAST) scan but is now commonly included routinely.
Further Reading:
Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.
When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.
In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.
In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.
-
This question is part of the following fields:
- Trauma
-
-
Question 5
Correct
-
A 42-year-old woman presents with a history of multiple recent episodes of significant haemoptysis. She reports experiencing haemoptysis and has noticed that her urine appears very dark. During examination, bibasal crepitations are detected. A urine dipstick test reveals positive results for blood and protein.
Her current blood test results are as follows:
Hemoglobin (Hb): 7.9 g/dl (normal range: 13-17 g/dl)
Mean Corpuscular Volume (MCV): 68 fl (normal range: 76-96 fl)
White Cell Count (WCC): 19.5 x 109/l (normal range: 4-11 x 109/l)
Neutrophils: 15.2 x 109/l (normal range: 2.5-7.5 x 109/l)
Lymphocytes: 2.1 x 109/l (normal range: 1.3-3.5 x 109/l)
Eosinophils: 0.21 x 109/l (normal range: 0.04-0.44 x 109/l)
Sodium (Na): 134 mmol/l (normal range: 133-147 mmol/l)
Potassium (K): 4.2 mmol/l (normal range: 3.5-5.0 mmol/l)
Creatinine (Creat): 212 micromol/l (normal range: 60-120 micromol/l)
Urea: 11.8 mmol/l (normal range: 2.5-7.5 mmol/l)
Positive AntiGBM antibodies
Positive c-ANCA
What is the MOST LIKELY diagnosis in this case?Your Answer: Goodpasture’s syndrome
Explanation:The most likely diagnosis in this case is Goodpasture’s syndrome, which is a rare autoimmune vasculitic disorder. It is characterized by a triad of symptoms including pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more commonly seen in men, particularly in smokers. There is also an association with certain HLA types, specifically HLA-B7 and HLA-DRw2.
The clinical features of Goodpasture’s syndrome include constitutional symptoms such as fever, fatigue, nausea, and weight loss. Patients may also experience haemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to intrapulmonary bleeding, arthralgia, rapidly progressive glomerulonephritis, haematuria, hypertension, and hepatosplenomegaly (rarely) may also be present.
Blood tests will reveal an iron deficiency anemia, elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis.
Diagnosis is typically confirmed through renal biopsy, which can detect the presence of anti-GBM antibodies. The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.
It is important to note that this patient’s history is inconsistent with a diagnosis of pulmonary embolism, as renal impairment, haematuria, and the presence of ANCAs and anti-GBM antibodies would not be expected. While pulmonary hemorrhage and renal impairment can occur in systemic lupus erythematosus, these are uncommon presentations, and the presence of ANCAs and anti-GBM antibodies would also be inconsistent with this diagnosis.
Churg-Strauss syndrome can present with pulmonary hemorrhage, and c-ANCA may be present, but patients typically have a history of asthma, sinusitis, and eosinophilia. Wegener’s granulomatosis can present similarly to Goodpasture’s syndrome,
-
This question is part of the following fields:
- Respiratory
-
-
Question 6
Incorrect
-
A 35-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctors 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 SINGLE most probable diagnosis?Your Answer: Pyelonephritis
Correct Answer: Tubo-ovarian abscess
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.
-
This question is part of the following fields:
- Obstetrics & Gynaecology
-
-
Question 7
Correct
-
A 25-year-old woman is brought to the Emergency Department 'resus' area by ambulance after collapsing from heroin use. She has pinpoint pupils, a respiratory rate of 5 per minute, and a GCS of 6/15. As part of her treatment, you administer naloxone.
Which SINGLE statement about the use of naloxone is true?Your Answer: It can be given by a continuous infusion if repeated doses are required
Explanation:Naloxone is a specific antidote for opioid overdose. It effectively reverses respiratory depression and coma when given in sufficient dosage. The initial dose is administered intravenously at 400 micrograms, followed by 800 micrograms for up to 2 doses at 1-minute intervals if there is no response to the preceding dose. If there is still no response, the dosage is increased to 2 mg for one dose. In seriously poisoned patients, a 4 mg dose may be required. If the intravenous route is not feasible, naloxone can also be given by intramuscular injection.
Due to its shorter duration of action compared to most opioids, close monitoring and repeated injections are necessary. The frequency of doses should be based on the respiratory rate and depth of coma, with the dose generally repeated every 2-3 minutes up to a maximum of 10 mg. In cases where repeated doses are needed, naloxone can be administered through a continuous infusion, which should be adjusted according to the vital signs. Initially, the infusion rate can be set at 60% of the initial resuscitative IV dose per hour.
It is important to note that in opioid addicts, the administration of naloxone may trigger a withdrawal syndrome characterized by symptoms such as abdominal cramps, nausea, and diarrhea. However, these symptoms typically subside within 2 hours.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 8
Incorrect
-
A 3-year-old boy comes in with a high temperature and urine that has a strong odor. His mother is worried that he might have a urinary tract infection.
According to NICE, which of the following symptoms is indicative of a UTI in this age group?Your Answer: Fever >39oC
Correct Answer: Poor feeding
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
-
-
Question 9
Incorrect
-
A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, particularly affecting her face and arm more than her leg, as well as sensory loss on the right side. Additionally, she has receptive dysphasia.
Which blood vessel is most likely to be impacted?Your Answer: Anterior cerebral artery
Correct Answer: Middle cerebral artery
Explanation:The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:
Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.
Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.
Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.
It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.
-
This question is part of the following fields:
- Neurology
-
-
Question 10
Incorrect
-
A 4-week-old baby girl is brought in by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen.
What is the first test to be done in this case?Your Answer: Barium studies
Correct Answer: Abdominal ultrasound scan
Explanation:Infantile hypertrophic pyloric stenosis is a condition characterized by the thickening and enlargement of the smooth muscle in the antrum of the stomach, leading to the narrowing of the pyloric canal. This narrowing can easily cause obstruction. It is a relatively common condition, occurring in about 1 in 500 live births, and is more frequently seen in males than females, with a ratio of 4 to 1. It is most commonly observed in first-born male children, although it can rarely occur in adults as well.
The main symptom of infantile hypertrophic pyloric stenosis is vomiting, which typically begins between 2 to 8 weeks of age. The vomit is usually non-bilious and forcefully expelled. It tends to occur around 30 to 60 minutes after feeding, leaving the baby hungry despite the vomiting. In some cases, there may be blood in the vomit. Other clinical features include persistent hunger, dehydration, weight loss, and constipation. An enlarged pylorus, often described as olive-shaped, can be felt in the right upper quadrant or epigastric in approximately 95% of cases. This is most noticeable at the beginning of a feed.
The typical acid-base disturbance seen in this condition is hypochloremic metabolic alkalosis. This occurs due to the loss of hydrogen and chloride ions in the vomit, as well as decreased secretion of pancreatic bicarbonate. The increased bicarbonate ions in the distal tubule of the kidney lead to the production of alkaline urine. Hyponatremia and hypokalemia are also commonly present.
Ultrasound scanning is the preferred diagnostic tool for infantile hypertrophic pyloric stenosis, as it is reliable and easy to perform. It has replaced barium studies as the investigation of choice.
Initial management involves fluid resuscitation, which should be tailored to the weight and degree of dehydration. Any electrolyte imbalances should also be corrected.
The definitive treatment for this condition is surgical intervention, with the Ramstedt pyloromyotomy being the procedure of choice. Laparoscopic pyloromyotomy is also an effective alternative if suitable facilities are available. The prognosis for infants with this condition is excellent, as long as there is no delay in diagnosis and treatment initiation.
-
This question is part of the following fields:
- Neonatal Emergencies
-
-
Question 11
Incorrect
-
A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals that she has normocytic anemia.
What is the most probable underlying diagnosis?Your Answer: Azathioprine usage
Correct Answer: Haemolysis
Explanation:Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).
On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.
Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.
It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.
-
This question is part of the following fields:
- Haematology
-
-
Question 12
Incorrect
-
A 5-year-old girl is brought to the Emergency Department by her father after falling at the park. She has a bruise and a small scrape on her right knee and is walking with a slight limp, but she can put weight on her leg. Her pain is evaluated using a numerical rating scale, and the triage nurse informs you that she has 'mild discomfort'.
According to the RCEM guidance, which of the following analgesics is recommended for managing mild discomfort in a child of this age?Your Answer: Oral diclofenac 0.5 mg/kg
Correct Answer: Oral ibuprofen 10 mg/kg
Explanation:A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.
To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.
The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.
To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.
-
This question is part of the following fields:
- Pain & Sedation
-
-
Question 13
Correct
-
A 45-year-old woman is brought in by her family due to her recent history of strange behavior. She is unable to recall events from a few years ago and also has difficulty answering questions about what has happened over the past few days. She attributes her poor memory to a recent car accident she was involved in. Her family reports that she drinks excessively. She also provides peculiar explanations to some other inquiries but remains friendly and polite during the consultation.
Which of the following is the MOST LIKELY diagnosis?Your Answer: Korsakoff syndrome
Explanation:Korsakoff syndrome is a form of dementia that occurs due to a lack of thiamine (vitamin B1) in the body. This condition is most commonly observed in individuals who have a long history of alcoholism. The main features of Korsakoff syndrome include anterograde amnesia, patchy retrograde amnesia, and confabulation. Additionally, many patients also experience difficulties with language (aphasia), movement (apraxia), recognition (agnosia), or executive functioning. It is important to note that Korsakoff syndrome often coexists with Wernicke’s encephalopathy, which is characterized by a triad of symptoms including ophthalmoplegia, altered mental state, and gait disturbance (ataxia). When both conditions are present, it is referred to as Wernicke-Korsakoff syndrome (WKS).
-
This question is part of the following fields:
- Mental Health
-
-
Question 14
Incorrect
-
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: Central visual loss is commonly seen
Correct 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.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 15
Correct
-
You assess a patient who has recently undergone a localized lung segmentectomy. A few days after the procedure, he presents with feelings of illness, and today's blood results reveal the development of hyponatremia.
What is the most probable cause of this biochemical abnormality?Your Answer: Removal of hormonally active tumour
Explanation:Small cell lung cancer (SCLC) that originates from neuroendocrine tissue has the potential to cause paraneoplastic endocrine syndromes, such as Cushing syndrome. This occurs due to the inappropriate secretion of ectopic adrenocorticotropic hormone (ACTH). In this particular case, it is highly likely that the patient underwent surgery to remove an ACTH-secreting neuroendocrine tumor within the lung.
The tumors associated with the production of ectopic ACTH are as follows:
– SCLC – 50%
– Bronchial carcinoid tumors – 10%
– Thymic carcinoma – 10%
– Pancreatic islet cell tumors – 5%
– Phaeochromocytoma – 5%
– Medullary carcinoma – 5%When ectopic ACTH-secreting tumors are present, the typical signs and symptoms of Cushing syndrome may be minimal. The onset of symptoms can be sudden, especially in rapidly growing SCLCs. The typical biochemical profile observed in these cases includes elevated sodium levels, low potassium levels, and metabolic alkalosis.
The body’s homeostatic mechanism will attempt to compensate for the elevated sodium levels by lowering them. However, after the tumor is removed, a paradoxical period of hyponatremia may occur during the postoperative period. This hyponatremia gradually normalizes until the sodium levels reach a normal range once again.
-
This question is part of the following fields:
- Oncological Emergencies
-
-
Question 16
Incorrect
-
A 35-year-old woman presents with a nosebleed that started after sneezing 20 minutes ago. She is currently using tissues to catch the drips and you have been asked to see her urgently by the triage nurse. Her vital signs are stable, and she has no signs of significant bleeding.
What initial measures should be taken in this case?Your Answer: Compress the nasal bones
Correct Answer: Gain Intravenous access
Explanation:When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.
Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.
First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 17
Incorrect
-
A 35-year-old man comes in with intense tooth pain that has developed 3 days after having a tooth pulled.
What is the MOST LIKELY diagnosis?Your Answer: Periodontal abscess
Correct Answer: Acute alveolar osteitis
Explanation:This patient is experiencing a condition called acute alveolar osteitis, commonly known as ‘dry socket’. It occurs when the blood clot covering the socket gets dislodged, leaving the bone and nerve exposed. This can result in infection and intense pain.
There are several risk factors associated with the development of a dry socket. These include smoking, inadequate dental hygiene, extraction of wisdom teeth, use of oral contraceptive pills, and a previous history of dry socket.
-
This question is part of the following fields:
- Maxillofacial & Dental
-
-
Question 18
Incorrect
-
A 45-year-old man with a long history of type 2 diabetes mellitus presents with pain in his left buttock, hip, and thigh. The pain started suddenly a few weeks ago, and he cannot recall any previous injury. During the examination, he shows wasting of his left quadriceps, struggles to stand up from a seated position, and has an absent knee jerk on the left side. Muscle fasciculations are observed in his left thigh. His BMI is 30, and he is a smoker.
What is the SINGLE most beneficial management measure for this patient?Your Answer: Weight loss
Correct Answer: Good glycaemic control
Explanation:Diabetic amyotrophy, also referred to as proximal diabetic neuropathy, is the second most prevalent form of diabetic neuropathy. It typically manifests with pain in the buttocks, hips, or thighs and is often initially experienced on one side of the body. The pain may start off as mild and gradually progress or it can suddenly appear, as seen in this particular case. Subsequently, weakness and wasting of the proximal muscles in the lower limbs occur, potentially leading to the patient requiring assistance when transitioning from a seated to a standing position. Reflexes in the affected areas can also be impacted. Fortunately, diabetic amyotrophy can be reversed through effective management of blood sugar levels, physiotherapy, and adopting a healthy lifestyle.
-
This question is part of the following fields:
- Endocrinology
-
-
Question 19
Correct
-
A child with a known history of latex allergy arrives at the Emergency Department with a severe allergic reaction caused by accidental exposure.
Which of the following fruits is this child MOST likely to have an allergy to as well?Your Answer: Banana
Explanation:The connection between latex sensitivity and food allergy is commonly known as the latex-fruit syndrome. Foods that have been found to be allergenic in relation to latex are categorized into high, moderate, or low risk groups.
High risk foods include banana, avocado, chestnut, and kiwi fruit.
Moderate risk foods include apple, carrot, celery, melon, papaya, potato, and tomato.
Citrus fruits and pears are considered to have a low risk of causing allergic reactions in individuals with latex sensitivity.
-
This question is part of the following fields:
- Allergy
-
-
Question 20
Incorrect
-
A 35-year-old woman comes in with intense pain five days after a recent tooth extraction. The pain is primarily concentrated in the socket where the tooth was removed. Upon examination, she has no fever and there are no signs of facial or gum swelling.
What is the SINGLE most probable diagnosis?Your Answer: Pulpitis
Correct Answer: Dry socket
Explanation:This patient is experiencing a condition called acute alveolar osteitis, commonly known as ‘dry socket’. It occurs when the blood clot covering the socket gets dislodged, leaving the bone and nerve exposed. This can result in infection and intense pain.
There are several risk factors associated with the development of a dry socket. These include smoking, inadequate dental hygiene, extraction of wisdom teeth, use of oral contraceptive pills, and a previous history of dry socket.
-
This question is part of the following fields:
- Maxillofacial & Dental
-
-
Question 21
Incorrect
-
You are treating a 35-year-old with limb injuries resulting from a rock climbing incident. Your responsibility is to insert a central venous line. The attending physician requests you to place the central venous line in the internal jugular vein. What is the ideal patient positioning for this procedure?
Your Answer: Sim's position
Correct Answer: Trendelenburg position
Explanation:To insert an IJV line, the patient should be positioned in the Trendelenburg position. This means that the patient should lie on their back with their head tilted down by at least 15 degrees. Additionally, the patient’s head should be turned away or laterally rotated from the side where the cannulation will take place. This positioning helps to distend the neck veins, making it easier to access them for the procedure.
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
-
-
Question 22
Correct
-
A 45-year-old woman presents with a 6-month history of lower back pain and rib pain. She has been brought to your clinic today by her husband, who is concerned about her confusion over the past few days. She has also had difficulty passing urine today. On examination, she appears pale and has tenderness over her lumbar spine and lower ribs. Fundoscopy reveals retinal haemorrhages. Her most recent blood results are shown below:
Hb 8.4 g/dl (13-17 g/dl)
MCV 102.6 fl (80-100 fl)
Platelets 114 x 109/l (150-400 x 109/l)
WCC 3.4 x 109/l (4-11 x 109/l)
Normal differential
Sodium 140 mmol/l (135-145 mmol/l)
Potassium 4.6 mmol/l (3.5-5.0 mmol/l)
Calcium 2.94 mmol/l (2.05-2.60 mmol/l)
Creatinine 193 mmol/l (60-110 mmol/l)
Urea 11.2 mmol/l (3-7 mmol/l)
Total protein 88 g/l (60-85 g/l)
Albumin 23 g/l (36-52 g/l)
ESR 132 mm/hr (30 mm/hr)
Which is the SINGLE most likely diagnosis?Your Answer: Multiple myeloma
Explanation:Multiple myeloma is a cancerous growth of plasma cells, a type of white blood cell responsible for producing antibodies. It is more prevalent in men and typically occurs in individuals over the age of 60.
When a patient over 60 presents with an elevated ESR, unexplained anemia, hypercalcemia, renal impairment, and bone pain, the initial diagnosis is usually multiple myeloma until proven otherwise.
The most common symptoms of multiple myeloma include:
1. Anemia: This is caused by the infiltration of the bone marrow and suppression of blood cell production. It is typically normocytic and normochromic, but can also be macrocytic.
2. Bone pain: Approximately 70% of patients experience bone pain, which commonly affects the spine and ribs. Localized pain and tenderness may indicate a pathological fracture, and vertebral fractures can lead to spinal cord compression.
3. Renal failure: Acute or chronic renal failure occurs in about one-third of patients. This is generally due to the effects of light chains on the tubules.
4. Neurological symptoms: Hypercalcemia can cause weakness, lethargy, and confusion, while hyperviscosity can result in headaches and retinopathy. Amyloid infiltration can lead to peripheral neuropathies, with carpal tunnel syndrome being the most common.
5. Infection: The most common infections seen in multiple myeloma patients are pyelonephritis and pneumonia.
In addition to the routine blood tests already conducted, a suspected diagnosis of multiple myeloma should prompt further investigations, including:
– Plasma viscosity measurement
– Urinary protein electrophoresis to detect Bence-Jones proteins
– Serum electrophoresis to identify the type of paraprotein
– Quantitative immunoglobulin level testing
– Skeletal survey to look for lytic lesions
– Bone marrow aspirate and possibly biopsyA diagnosis of multiple myeloma is confirmed by the presence of a monoclonal protein in the serum or urine, lytic lesions on X-ray, and an increased number of plasma cells in the bone marrow.
-
This question is part of the following fields:
- Haematology
-
-
Question 23
Correct
-
A 52-year-old woman presents with high fevers and severe pain in the upper right quadrant that radiates to her back. She is experiencing mild confusion. During examination, she exhibits tenderness in the upper right quadrant, and Murphy's sign is negative. Her vital signs are as follows: temperature is 38°C, heart rate is 114 bpm, and blood pressure is 88/54 mmHg.
Her blood test results are as follows:
- CRP: 134 mg/l (normal range: < 5 mg/l)
- Hb: 11.6 g/dl (normal range: 11.5-16 g/dl)
- WCC: 18.4 x 109/l (normal range: 4-11 x 109/l)
- Neut: 14.0 x 109/l (normal range: 2.5-7.5 x 109/l)
- Bilirubin: 108 mmol (normal range: 3-20)
- ALT: 94 IU/L (normal range: 5-40)
- ALP: 303 IU/L (normal range: 20-140)
What is the SINGLE most likely diagnosis?Your Answer: Ascending cholangitis
Explanation:Ascending cholangitis occurs when there is an infection in the common bile duct, often caused by a stone that has led to a buildup of bile. This condition is characterized by three main symptoms known as Charcot’s triad: jaundice, fever with rigors, and pain in the upper right quadrant of the abdomen. It is a serious medical emergency that can be life-threatening, with some patients also experiencing altered mental status and low blood pressure due to septic shock, known as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis.
In acute cholecystitis, Murphy’s sign is typically positive, indicating inflammation of the gallbladder, while it is negative in biliary colic and ascending cholangitis. The white cell count and C-reactive protein (CRP) levels are usually elevated in ascending cholangitis, and jaundice is often present, along with significantly increased levels of alkaline phosphatase (ALP) and bilirubin.
Hepatocellular carcinoma, on the other hand, presents gradually with symptoms such as fatigue, loss of appetite, jaundice, and an enlarged liver. It often involves features of portal hypertension.
Cholangiocarcinoma is a rare type of cancer that originates from the biliary epithelium. It typically manifests as painless jaundice and itching.
To differentiate between biliary colic, acute cholecystitis, and ascending cholangitis, the following summarizes their key characteristics:
Biliary colic:
– Pain duration: Less than 12 hours
– Fever: Absent
– Murphy’s sign: Negative
– WCC & CRP: Normal
– AST, ALT & ALP: Normal
– Bilirubin: NormalAcute 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 elevatedAscending cholangitis:
– Pain duration: Variable
– Fever: Present
– Murphy’s sign: Negative
– WCC & CRP: Elevated
– AST, ALT & ALP: Elevated
– Bilirubin: Elevated -
This question is part of the following fields:
- Surgical Emergencies
-
-
Question 24
Incorrect
-
A 42-year-old woman is brought to the emergency department after experiencing a sudden and severe headache, which has caused confusion and drowsiness. A CT scan confirms the presence of a subarachnoid hemorrhage. Your consultant instructs you to closely observe for indications of increasing intracranial pressure, such as third cranial nerve palsy. What is the initial manifestation of third cranial nerve palsy in patients with this particular injury?
Your Answer: Nystagmus
Correct Answer: Pupil dilatation
Explanation:The initial indication of progressive compression on the oculomotor nerve is the dilation of the pupil. In cases where the oculomotor nerve is being compressed, the outer parasympathetic fibers are typically affected before the inner motor fibers. These parasympathetic fibers are responsible for stimulating the constriction of the pupil. When they are disrupted, the sympathetic stimulation of the pupil is unopposed, leading to the dilation of the pupil (known as mydriasis or blown pupil). This symptom is usually observed before the drooping of the eyelid (lid ptosis) and the downward and outward positioning of the eye.
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
-
This question is part of the following fields:
- Neurology
-
-
Question 25
Correct
-
A 32-year-old man with a known history of diabetes presents with fatigue, frequent urination, and blurred vision. His blood glucose levels are elevated at 250 mg/dL. He currently takes insulin injections and metformin for his diabetes. You organize for a urine sample to be taken and find that his ketone levels are markedly elevated, and he also has biochemical abnormalities evident.
Which of the following biochemical abnormalities is LEAST likely to be present?Your Answer: Hypoglycaemia
Explanation:The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 26
Correct
-
A 68-year-old man suffers a fractured neck of femur. He is later diagnosed with osteoporosis and is prescribed medication for the secondary prevention of osteoporotic fragility fractures.
What is the recommended initial treatment for the secondary prevention of osteoporotic fragility fractures?Your Answer: Oral bisphosphonate
Explanation:Oral bisphosphonates are the primary choice for treating osteoporotic fragility fractures in individuals who have already experienced such fractures. After a fragility fracture, it is advised to start taking a bisphosphonate, typically alendronic acid, and consider supplementing with calcium and vitamin D.
There are other treatment options available for preventing fragility fractures after an initial occurrence. These include raloxifene, teriparatide, and denosumab.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 27
Correct
-
A 52-year-old man comes in with an acute episode of gout.
Which SINGLE statement regarding the management of acute gout is accurate?Your Answer: A common first-line treatment is Naproxen as a stat dose of 750 mg followed by 250 mg TDS
Explanation:In cases where there are no contraindications, high-dose NSAIDs are the recommended initial treatment for acute gout. A commonly used and effective regimen is to administer a stat dose of Naproxen 750 mg, followed by 250 mg three times a day. It is important to note that Aspirin should not be used in gout as it hinders the urinary clearance of urate and interferes with the action of uricosuric agents. Instead, more appropriate choices include Naproxen, diclofenac, or indomethacin.
Allopurinol is typically used as a prophylactic measure to prevent future gout attacks by reducing serum uric acid levels. However, it should not be initiated during the acute phase of an attack as it can worsen the severity and duration of symptoms.
Colchicine works by binding to tubulin and preventing neutrophil migration into the joint. It is just as effective as NSAIDs in relieving acute gout attacks. Additionally, it has a role in prophylactic treatment if a patient cannot tolerate Allopurinol.
It is important to note that NSAIDs are contraindicated 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 for patients with heart failure or those who cannot tolerate NSAIDs.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 28
Correct
-
A 28-year-old primigravida woman comes in with a slight vaginal bleeding. She describes the bleeding as lighter than her typical menstrual period. She is currently 9 weeks pregnant and her pregnancy test is positive. During the examination, her abdomen is soft and nontender, and the cervical os is closed.
What is the SINGLE most probable diagnosis?Your Answer: Threatened miscarriage
Explanation:A threatened miscarriage is characterized by bleeding in the first trimester of pregnancy, but without the passing of any products of conception and with a closed cervical os. The main features of a threatened miscarriage include vaginal bleeding, often in the form of brown discharge or spotting, minimal abdominal pain, and a positive pregnancy test. It is important for stable patients who are more than 6 weeks pregnant and experiencing bleeding in early pregnancy, without any signs of an ectopic pregnancy, to seek follow-up care at an early pregnancy assessment unit (EPAU).
-
This question is part of the following fields:
- Obstetrics & Gynaecology
-
-
Question 29
Correct
-
A 42-year-old man presents with occasional right upper quadrant pain. The pain typically lasts for 20 to 45 minutes and then goes away on its own. Nausea frequently accompanies the pain. The pain tends to occur following the consumption of a high-fat meal.
What is the SINGLE most probable diagnosis?Your Answer: Gallstones
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of biliary colic. Biliary colic occurs when a gallstone temporarily blocks either the cystic duct or Hartmann’s pouch, leading to contractions in the gallbladder. The blockage is relieved when the stone either falls back into the gallbladder or passes through the duct.
Patients with biliary colic typically experience colicky pain in the upper right quadrant of their abdomen. This pain can last anywhere from 15 minutes to 24 hours and is often accompanied by feelings of nausea and vomiting. It is not uncommon for the pain to radiate into the right scapula area.
Eating fatty foods can exacerbate the pain as they stimulate the release of cholecystokinin, which in turn causes the gallbladder to contract.
-
This question is part of the following fields:
- Surgical Emergencies
-
-
Question 30
Incorrect
-
You evaluate a 45-year-old man with a history of difficult-to-control hypertension. His initial diagnosis was made after ambulatory blood pressure monitoring. He is currently taking Lisinopril 10 mg once daily and Amlodipine 10 mg once daily. Despite this treatment, his blood pressure today is 156/98. On examination, he appears normal and is otherwise in good health. A recent blood test shows the following results:
Sodium: 145 mmol/L (135-147 mmol/L)
Potassium: 3.2 mmol/L (3.5-5.5 mmol/L)
Urea: 6.3 mmol/L (2.0-6.6 mmol/L)
Creatinine: 88 mmol/L (75-125 mmol/L)
What is the MOST LIKELY diagnosis?Your Answer: Phaeochromocytoma
Correct Answer: Primary hyperaldosteronism
Explanation:The most probable diagnosis in this case is primary hyperaldosteronism, which is caused by either an adrenal adenoma (Conn’s syndrome) or bilateral idiopathic adrenal hyperplasia. Conn’s syndrome is likely in a patient who has difficult-to-control hypertension, low levels of potassium (hypokalaemia), and elevated or high normal levels of sodium. If the aldosterone:renin ratio is raised (>30), it further suggests primary hyperaldosteronism. CT scanning can be used to differentiate between an adrenal adenoma and adrenal hyperplasia. Treatment for hyperaldosteronism caused by an adenoma typically involves 4-6 weeks of spironolactone therapy followed by surgical removal of the adenoma. Adrenal hyperplasia usually responds well to potassium-sparing diuretics alone, such as spironolactone or amiloride.
Renal artery stenosis could also be suspected in a case of resistant hypertension, but it would be expected to cause a decline in renal function when taking a full dose of an ACE inhibitor like ramipril. However, in this case, the patient’s renal function is completely normal.
Phaeochromocytoma is associated with symptoms such as headaches, palpitations, tremors, and excessive sweating. The hypertension in phaeochromocytoma tends to occur in episodes. Since these symptoms are absent in this patient, a diagnosis of phaeochromocytoma is unlikely.
Cushing’s syndrome is characterized by various other clinical features, including weight gain, central obesity, a hump-like accumulation of fat on the back (buffalo hump), muscle wasting in the limbs, excessive hair growth (hirsutism), thinning of the skin, easy bruising, acne, and depression. Since this patient does not exhibit any of these features, Cushing’s syndrome is unlikely.
White coat syndrome is an unlikely diagnosis in this case because the initial diagnosis of hypertension was made based on ambulatory blood pressure monitoring.
-
This question is part of the following fields:
- Endocrinology
-
-
Question 31
Incorrect
-
A 32-year-old woman experiences a fracture-dislocation of her forearm after tripping and landing on her outstretched hand. As a result, she has developed weakness in her wrist and finger extensors and experiences pain in her proximal forearm. The weakness in her wrist extensors is only partial, but it is observed that wrist extension causes radial deviation of the wrist. There are no sensory abnormalities.
Which nerve has been affected in this case?Your Answer: Median nerve
Correct Answer: Posterior interosseous nerve
Explanation:The posterior interosseous nerve (PIN) is a motor branch of the radial nerve that is located deep within the body. It emerges above the elbow, between the brachioradialis and brachialis muscles, and then divides into two branches: the superficial radial nerve and the PIN. This division occurs at the lateral epicondyle level. As it travels through the forearm, the PIN passes through the supinator muscle, moving from the front to the back surface. In about 30% of individuals, it also passes through a fibrotendinous structure called the arcade of Frohse, which is located below the supinator muscle. The PIN is responsible for supplying all of the extrinsic wrist extensors, with the exception of the extensor carpi radialis longus muscle.
There are several potential causes of damage to the PIN. Fractures, such as a Monteggia fracture, can lead to injury. Inflammation of the radiocapitellar joint, known as radiocapitellar joint synovitis, can also be a contributing factor. Tumors, such as lipomas, may cause damage as well. Additionally, entrapment of the PIN within the arcade of Frohse can result in a condition known as PIN syndrome.
It is important to note that injury to the PIN can be easily distinguished from injury to the radial nerve in other areas of the arm, such as the spiral groove. This is because there will be no sensory involvement and no wrist drop, as the extensor carpi radialis longus muscle remains unaffected.
The anterior interosseous nerve (AIN) is a branch of the median nerve. It primarily functions as a motor nerve, supplying the flexor pollicis longus muscle, the lateral half of the flexor digitorum profundus muscle, and the pronator quadratus muscle. Damage to the AIN can result in weakness and difficulty moving the index and middle fingers.
-
This question is part of the following fields:
- Neurology
-
-
Question 32
Correct
-
A 35 year old woman arrives at the emergency department with complaints of pain and numbness in her middle finger, index finger, and thumb on the right hand. Upon reviewing her medical history, you discover that she has a previous diagnosis of hypothyroidism. Which of the following clinical features would you expect to find in this patient with hypothyroidism?
Your Answer: Decreased deep tendon reflexes
Explanation:Hypothyroidism often presents with various clinical features. These include weight gain, lethargy, intolerance to cold temperatures, non-pitting edema (such as swelling in the hands and face), dry skin, hair thinning and loss, loss of the outer part of the eyebrows, decreased appetite, constipation, decreased deep tendon reflexes, carpal tunnel syndrome, and menorrhagia.
Further Reading:
The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.
Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.
The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.
Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.
Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.
-
This question is part of the following fields:
- Endocrinology
-
-
Question 33
Correct
-
A 35-year-old woman with no significant medical history complains of chest pain on the right side and difficulty breathing. She does not take any medications regularly and has no known allergies to drugs. She has been a heavy smoker for the past six years.
What is the SINGLE most probable diagnosis?Your Answer: Pneumothorax
Explanation:The risk of primary spontaneous pneumothorax is associated with smoking tobacco and increases as the duration of exposure and daily consumption rise. The changes caused by smoking in the small airways may contribute to the development of local emphysema, leading to the formation of bullae. In this case, the patient does not have any clinical features or significant risk factors for the other conditions mentioned. Therefore, primary spontaneous pneumothorax is the most probable diagnosis.
-
This question is part of the following fields:
- Respiratory
-
-
Question 34
Incorrect
-
A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms of sepsis. The baby was born prematurely at 32 weeks gestation. A diagnosis of neonatal pneumonia is suspected.
What is the SINGLE most probable causative organism?Your Answer: Respiratory syncytial virus
Correct Answer: Escherichia Coli
Explanation:Pneumonia in newborns is typically caused by organisms that inhabit the mother’s genital tract. Despite the widespread use of chemoprophylaxis to prevent maternal carriage, Group B haemolytic Streptococcus remains a common culprit in early-onset infections in full-term and near-term infants aged less than three days. Among very low birth weight infants, Escherichia Coli is the most frequently encountered bacterial strain. Additionally, neonatal pneumonia can be caused by other bacteria such as Chlamydia trachomatis, Listeria monocytogenes, and Haemophilus influenzae.
-
This question is part of the following fields:
- Neonatal Emergencies
-
-
Question 35
Correct
-
A 45-year-old hiker is brought in by air ambulance after being stranded on a mountainside overnight. You conduct an ECG on the patient.
Which of the following ECG alterations is most likely to be observed?Your Answer: Osborn wave
Explanation:Hypothermia can lead to various abnormalities in the electrocardiogram (ECG). These abnormalities include bradyarrhythmias, the presence of a J wave (also known as an Osborn wave), and prolonged intervals such as PR, QRS, and QT. Additionally, shivering artefact and ventricular ectopics may be observed. In severe cases, hypothermia can even result in cardiac arrest, which can manifest as ventricular tachycardia (VT), ventricular fibrillation (VF), or asystole.
One distinctive feature of hypothermia on an ECG is the appearance of a small extra wave immediately following the QRS complex. This wave, known as a J wave or Osborn wave, was named after the individual who first described it. Interestingly, this wave tends to disappear as the body temperature is warmed. Despite its recognition, the exact mechanism behind the presence of the J wave in hypothermia remains unknown.
-
This question is part of the following fields:
- Environmental Emergencies
-
-
Question 36
Correct
-
A 35-year-old construction worker comes in with intense pain in his left eye following an incident at the job site where a significant amount of cement dust entered his left eye.
What would be the initial course of action in managing this case?Your Answer: Irrigate the eye with normal saline
Explanation:Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.
The initial management of a patient with cement or alkali exposure to the eyes should be as follows:
1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.After the initial management, a thorough examination should be conducted, which includes the following steps:
1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.
Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.
-
This question is part of the following fields:
- Ophthalmology
-
-
Question 37
Incorrect
-
A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
Which of the following statements is NOT true regarding the ECG in atrial fibrillation?Your Answer: The disorganized electrical activity usually originates at the root of the pulmonary veins
Correct Answer: Ashman beats have a poor prognosis
Explanation:The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.
In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.
The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.
-
This question is part of the following fields:
- Cardiology
-
-
Question 38
Correct
-
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: 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.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 39
Incorrect
-
A 72 year old female presents to the emergency department with a 3 day history of watery diarrhea. She reports having approximately 4-5 episodes of diarrhea accompanied by lower abdominal cramping pain each day. The patient mentions that she visited her primary care physician 2 days ago, who requested a stool sample. The patient's vital signs are as follows:
Temperature: 37.6ºC
Blood pressure: 138/82 mmHg
Pulse: 90 bpm
Respiration rate: 16
Upon reviewing the pathology results, it is noted that the stool sample has tested positive for clostridium difficile. Additionally, the patient's complete blood count, which was sent by the triage nurse, has been received and is shown below:
Hemoglobin: 13.5 g/l
Platelets: 288 * 109/l
White blood cells: 13.9 * 109/l
How would you classify the severity of this patient's clostridium difficile infection?Your Answer: Mild
Correct Answer: Moderate
Explanation:Clostridium difficile infections can range in severity from mild to life-threatening. Mild or moderate severity infections are determined by the frequency of stool and white blood cell count. Severe or life-threatening infections are characterized by high fever, radiological signs, and evidence of organ dysfunction or sepsis.
In this case, the patient’s clinical features indicate a moderate severity C.diff infection. Moderate severity infections typically have an increased white blood cell count but less than 15 x 109/l. They are typically associated with 3-5 loose stools per day.
Further Reading:
Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.
Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.
Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.
Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.
-
This question is part of the following fields:
- Gastroenterology & Hepatology
-
-
Question 40
Correct
-
A 47-year-old man with a past medical history of alcohol-related visits to the emergency department presents to the ED after falling while intoxicated. He has a 6 cm laceration on the occipital region of his scalp. You examine the wound under local anesthesia. As you remove the dressing and clean away a significant blood clot, you notice pulsatile bleeding from the wound. Which arteries provide blood supply to the posterior scalp?
Your Answer: External carotid
Explanation:The scalp is primarily supplied with blood from branches of the external carotid artery. The posterior half of the scalp is specifically supplied by three branches of the external carotid artery. These branches are the superficial temporal artery, which supplies blood to the frontal and temporal regions of the scalp, the posterior auricular artery, which supplies blood to the area above and behind the external ear, and the occipital artery, which supplies blood to the back of the scalp.
Further Reading:
The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.
The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.
The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.
In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.
-
This question is part of the following fields:
- Trauma
-
-
Question 41
Incorrect
-
A 35 year old male is brought to the emergency department with severe head and chest injuries. As his GCS continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). What is the appropriate dosage of sodium thiopentone for an adult undergoing RSI?
Your Answer: 0.5-1 mg/kg
Correct Answer: 3-5 mg/kg
Explanation:To perform rapid sequence induction in adults, it is recommended to administer a dose of sodium thiopentone ranging from 3 to 5 mg per kilogram of body weight.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
-
This question is part of the following fields:
- Basic Anaesthetics
-
-
Question 42
Incorrect
-
A 40-year-old woman presents with a painful, swollen right ankle following a recent hike in the mountains. You assess her for a possible sprained ankle.
At which of the following locations do the NICE guidelines recommend that you measure the ankle circumference?Your Answer: 10 cm above the lateral malleolus
Correct Answer: 10 cm below the tibial tuberosity
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.
-
This question is part of the following fields:
- Vascular
-
-
Question 43
Incorrect
-
A 35 year old accountant presents to the emergency department with a 3 day history of diarrhea, stomach cramps, and occasional vomiting. After evaluating the patient, you inform them that they are likely experiencing viral gastroenteritis and provide instructions for self-care at home. The patient inquires about when it would be appropriate for them to return to work.
Your Answer: Do NOT attend work or other institutional/social settings until at least 24 hours after the last episode of diarrhoea or vomiting.
Correct Answer: Do NOT attend work or other institutional/social settings until at least 48 hours after the last episode of diarrhoea or vomiting.
Explanation:Individuals who have gastroenteritis should be instructed to refrain from going to work or participating in social activities until at least 48 hours have passed since their last episode of diarrhea or vomiting.
Further Reading:
Gastroenteritis is a transient disorder characterized by the sudden onset of diarrhea, with or without vomiting. It is caused by enteric infections with viruses, bacteria, or parasites. The most common viral causes of gastroenteritis in adults include norovirus, rotavirus, and adenovirus. Bacterial pathogens such as Campylobacter jejuni and coli, Escherichia coli, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, Salmonella typhi and paratyphi, and Shigella dysenteriae, flexneri, boydii, and sonnei can also cause gastroenteritis. Parasites such as Cryptosporidium, Entamoeba histolytica, and Giardia intestinalis or Giardia lamblia can also lead to diarrhea.
Diagnosis of gastroenteritis is usually based on clinical symptoms, and investigations are not required in many cases. However, stool culture may be indicated in certain situations, such as when the patient is systemically unwell or immunocompromised, has acute painful diarrhea or blood in the stool suggesting dysentery, has recently taken antibiotics or acid-suppressing medications, or has not resolved diarrhea by day 7 or has recurrent diarrhea.
Management of gastroenteritis in adults typically involves advice on oral rehydration. Intravenous rehydration and more intensive treatment may be necessary for patients who are systemically unwell, exhibit severe dehydration, or have intractable vomiting or high-output diarrhea. Antibiotics are not routinely required unless a specific organism is identified that requires treatment. Antidiarrheal drugs, antiemetics, and probiotics are not routinely recommended.
Complications of gastroenteritis can occur, particularly in young children, the elderly, pregnant women, and immunocompromised individuals. These complications include dehydration, electrolyte disturbance, acute kidney injury, haemorrhagic colitis, haemolytic uraemic syndrome, reactive arthritis, Reiter’s syndrome, aortitis, osteomyelitis, sepsis, toxic megacolon, pancreatitis, sclerosing cholangitis, liver cirrhosis, weight loss, chronic diarrhea, irritable bowel syndrome, inflammatory bowel disease, acquired lactose intolerance, Guillain-Barré syndrome, meningitis, invasive entamoeba infection, and liver abscesses.
-
This question is part of the following fields:
- Gastroenterology & Hepatology
-
-
Question 44
Correct
-
A 57 year old type 2 diabetic presents to the emergency department with redness on his foot. Upon examination, a foot ulcer measuring 1 cm in diameter is observed, exposing the superficial subcutaneous tissues. There is approximately 1 cm of erythema surrounding the ulcer and some pus at the base. The patient is not running a fever and appears to be in good overall health. It is determined that antibiotics should be initiated. The patient has no known allergies to medications. Which antibiotic would be the most suitable option?
Your Answer: Flucloxacillin 500 mg four times a day for 7 days
Explanation:When treating diabetic foot ulcers that are infected, the severity of the ulcer is used to determine the appropriate antimicrobial therapy. In the case of a mild foot infection (PEDIS 2 grade), the first-line treatment is typically flucloxacillin. Based on the information provided, there is no indication that pseudomonas or MRSA should be suspected. For mild infections, it is reasonable to prescribe flucloxacillin at a dosage of 500 mg-1g four times a day for a duration of 7 days. It is important to reassess the patient at the end of the treatment course.
Further Reading:
Diabetic foot is a complication that can occur in individuals with diabetes due to long-standing high blood sugar levels. This leads to a process called glycation or glycosylation, where glucose binds to proteins and lipids in the body. Abnormal protein glycation can cause cellular dysfunction and various complications.
One of the main problems in diabetic foot is peripheral vascular disease and peripheral neuropathy. These conditions can result in significant foot issues, as trauma to the feet may go unnoticed and untreated. Vascular disease also impairs wound healing and increases the risk of developing ulcers.
Clinical features of diabetic foot include reduced sensation, especially to vibration, non-dermatomal sensory loss, foot deformities such as pes cavus and claw toes, and weak or absent foot pulses. It is important for diabetic patients to have their feet assessed regularly, at least annually, to identify any potential problems. Additional foot assessments should also be conducted during hospital admissions.
During a diabetic foot assessment, the healthcare provider should remove shoes, socks, and any bandages or dressings to examine both feet. They should assess for neuropathy using a 10 g monofilament to test foot sensation and check for limb ischemia by examining pulses and performing ankle brachial pressure index (ABPI) measurements. Any abnormal tissue, such as ulcers, calluses, infections, inflammation, deformities, or gangrene, should be documented. The risk of Charcot arthropathy should also be assessed.
The severity of foot ulcers in diabetic patients can be documented using standardized systems such as SINBAD or the University of Texas classification. The presence and severity of diabetic foot infection can be determined based on criteria such as local swelling, induration, erythema, tenderness, pain, warmth, and purulent discharge.
Management of foot ulcers involves offloading, control of foot infection, control of ischemia, wound debridement, and appropriate wound dressings. Antibiotics may be necessary depending on the severity of the infection. Diabetic patients with foot ulcers should undergo initial investigations including blood tests, wound swabs, and imaging to assess for possible osteomyelitis.
Charcot foot is a serious complication of diabetic peripheral neuropathy that results in progressive destructive arthropathy and foot deformity. Signs of Charcot foot include redness, swelling, warm skin, pain, and deformity. The hallmark deformity is midfoot collapse, known as the rocker-bottom foot.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 45
Correct
-
A 68 year old female is brought into the emergency department after a fall. The patient is accompanied by her children who inform you that there have been several falls in recent weeks. These falls tend to happen in the morning when the patient gets out of bed and appear to have worsened since the GP altered the patient's usual medication. You suspect orthostatic hypotension. What is the minimum blood pressure drop upon standing that is necessary to confirm the diagnosis?
Your Answer: 20 mmHg systolic or 10 mmHg diastolic
Explanation:To diagnose orthostatic hypotension, there needs to be a decrease in systolic blood pressure of at least 20 mmHg (or 30 mmHg for individuals with hypertension) and/or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing. This confirms the presence of orthostatic hypotension.
Further Reading:
Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.
When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.
During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.
There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 46
Correct
-
You evaluate a 35-year-old woman who has recently been diagnosed with epilepsy. She has been initiated on an anti-epileptic drug but has subsequently developed a tremor when assuming a certain posture.
Which INDIVIDUAL anti-epileptic medication is most likely to be accountable for this?Your Answer: Sodium valproate
Explanation:Postural tremor is frequently seen as a neurological side effect in individuals taking sodium valproate. Additionally, a resting tremor may also manifest. It has been observed that around 25% of patients who begin sodium valproate therapy develop a tremor within the first year. Other potential side effects of sodium valproate include gastric irritation, nausea and vomiting, involuntary movements, temporary hair loss, weight gain in females, and impaired liver function.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 47
Correct
-
A 35-year-old woman is given a medication during the advanced stages of pregnancy. As a result, the newborn experiences respiratory depression and develops a neonatal withdrawal syndrome.
Which of the following medications is the most probable cause of these abnormalities?Your Answer: Diazepam
Explanation:During the later stages of pregnancy, the use of diazepam has been linked to respiratory depression in newborns and a withdrawal syndrome. There are several drugs that can have adverse effects during pregnancy, and the list below outlines the most commonly encountered ones.
ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the second and third trimesters. Aminoglycosides, like gentamicin, can lead to ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g., 75 mg) do not pose significant risks.
Benzodiazepines, including diazepam, can cause respiratory depression and a neonatal withdrawal syndrome when administered late in pregnancy. Calcium-channel blockers can cause phalangeal abnormalities if given in the first trimester and fetal growth retardation if given in the second and third trimesters. Carbamazepine can lead to hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol is associated with grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, when administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride as it can affect male sex organ development.
Haloperidol, if given in the first trimester, may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.
Lithium, if given in the first trimester, poses a risk of fetal cardiac malformations. In the second and third trimesters, it can result in hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus in the neonate.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 48
Incorrect
-
A 45-year-old man is brought in to the Emergency Department by his wife. He is experiencing multiple episodes of vertigo, each lasting almost all day, before resolving spontaneously. He usually vomits during the attacks and complains of a sensation of fullness in his ears. He also states that his hearing has been worse than usual recently, and he is also experiencing symptoms of tinnitus.
What is the SINGLE most likely diagnosis?Your Answer: Acoustic neuroma
Correct Answer: Meniere’s disease
Explanation:Meniere’s disease is a condition that affects the inner ear due to changes in fluid volume within the vestibular labyrinth. This leads to the progressive distension of the labyrinth, known as endolymphatic hydrops, which causes damage to the vestibular system and the cochlea. The classic symptoms associated with Meniere’s disease are vertigo, hearing loss, and tinnitus.
The main clinical features of Meniere’s disease include episodes of vertigo that typically last for 2-3 hours. These episodes are usually shorter than 24 hours in duration. Hearing loss, which is often gradual and affects only one ear, is also a common symptom. Tinnitus, a ringing or buzzing sound in the ears, is frequently associated with Meniere’s disease. Other symptoms may include a sensation of fullness or pressure in the ears, as well as nausea and vomiting. Nystagmus, an involuntary eye movement, may occur away from the side of the lesion. Meniere’s disease is more prevalent in individuals who suffer from migraines.
The management of Meniere’s disease aims to alleviate acute attacks, reduce their severity and frequency, and improve hearing while minimizing the impact of tinnitus. If Meniere’s disease is suspected, patients should be referred to an ear, nose, and throat specialist.
During acute attacks, medications such as prochlorperazine, cinnarizine, and cyclizine can help reduce nausea and vertigo symptoms. If vomiting is present, buccal or intramuscular administration of these medications may be necessary. In severe cases, hospital admission may be required to prevent dehydration.
For long-term prevention, lifestyle measures can be beneficial. Avoiding caffeine, chocolate, alcohol, and tobacco is recommended. Excessive fatigue should also be avoided. Following a low-salt diet may be helpful. Betahistine, a medication that initially starts at a dose of 16 mg three times a day, can be used for prophylaxis to reduce the frequency and severity of attacks. Diuretics may also be beneficial, but they are typically not recommended for primary care use.
Overall, the management of Meniere’s disease involves a combination of lifestyle changes and medication to control symptoms and improve the patient’s quality of life.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 49
Correct
-
A 35-year-old woman comes in with complaints of painful urination and frequent urination. A urine dipstick test shows the presence of blood, protein, white blood cells, and nitrites. Based on these findings, you diagnose her with a urinary tract infection and prescribe antibiotics. Her recent blood tests indicate that her estimated glomerular filtration rate (eGFR) is greater than 60 ml/minute.
Which antibiotic would be the most suitable to prescribe for this patient?Your Answer: Nitrofurantoin
Explanation:NICE provides the following recommendations for the treatment of non-pregnant women with lower urinary tract infections (UTIs):
1. Consider prescribing a back-up antibiotic or an immediate antibiotic for women with lower UTIs, taking into account the severity of symptoms, the risk of complications, previous urine culture results, previous antibiotic use, and the woman’s preferences.
2. If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given, review the choice of antibiotic when the microbiological results are available. Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not improving.
3. The first-choice antibiotics for non-pregnant women aged 16 years and over are nitrofurantoin (100 mg modified-release tablets taken twice daily for 3 days) or trimethoprim (200 mg tablets taken twice daily for 3 days), if there is a low risk of resistance.
4. If there is no improvement in lower UTI symptoms after at least 48 hours on the first-choice antibiotic or if the first-choice antibiotic is not suitable, the second-choice options are nitrofurantoin (100 mg modified-release tablets taken twice daily for 3 days), pivmecillinam (400 mg initial dose followed by 200 mg three times daily for 3 days), or fosfomycin (3 g single sachet dose).
5. The risk of resistance to antibiotics may be lower if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility, and in younger people in areas with low resistance rates. The risk of resistance may be higher with recent antibiotic use and in older people in residential facilities.
-
This question is part of the following fields:
- Urology
-
-
Question 50
Correct
-
You review a patient with a history of renal failure that has presented to the Emergency Department with problems relating to their renal replacement therapy. You note that they are currently receiving peritoneal dialysis.
In which of the following patient groups with end-stage renal failure should peritoneal dialysis be considered as the initial treatment option, instead of hemodialysis?Your Answer: Children aged two years old or younger
Explanation:All individuals diagnosed with stage 5 chronic kidney disease should be given the option to choose between haemodialysis or peritoneal dialysis. Peritoneal dialysis should be prioritized as the preferred treatment for the following groups of patients: those who still have some remaining kidney function, adult patients without major additional health conditions, and children who are two years old or younger.
-
This question is part of the following fields:
- Nephrology
-
-
Question 51
Incorrect
-
You are summoned to the resuscitation bay to provide assistance with a patient who has experienced cardiac arrest. The team is getting ready to administer amiodarone. What is the mechanism of action of amiodarone in the context of cardiac arrest?
Your Answer: Blockade of calcium channels
Correct Answer: Blockade of potassium channels
Explanation:Amiodarone functions by inhibiting voltage-gated potassium channels, leading to an extended repolarization period and decreased excitability of the heart muscle.
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.
-
This question is part of the following fields:
- Basic Anaesthetics
-
-
Question 52
Incorrect
-
A 68 year old male is brought into the emergency department with a two week history of worsening nausea, muscle aches, fatigue, and weakness. You send urine and blood samples for analysis. The results are shown below:
Na+ 126 mmol/l
K+ 5.3 mmol/l
Urea 7.0 mmol/l
Creatinine 90 µmol/l
Glucose 6.0 mmol/l
Urine osmolality 880 mosmol/kg
You review the patient's medications. Which drug is most likely responsible for this patient's symptoms?Your Answer: Prednisolone
Correct Answer: Sertraline
Explanation:This patient is experiencing hyponatremia, which is characterized by low plasma osmolality and high urine osmolality, indicating syndrome of inappropriate antidiuretic hormone secretion (SIADH). One of the most common causes of SIADH is the use of SSRIs. On the other hand, lithium, sodium bicarbonate, and corticosteroids are known to cause hypernatremia. Plasma osmolality can be calculated using the formula (2 x Na) + Glucose + Urea. In this patient, the calculated osmolality is 265 mosmol/kg, which falls within the normal range of 275-295 mosmol/kg.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
-
This question is part of the following fields:
- Nephrology
-
-
Question 53
Correct
-
A 72-year-old man comes with his wife due to worries about his memory. After gathering information, you observe a gradual decrease in his cognitive abilities. The only significant medical history he has is a heart attack he had 8 years ago.
What is the MOST PROBABLE diagnosis?Your Answer: Vascular dementia
Explanation:Vascular dementia is the second most common form of dementia, accounting for approximately 25% of all cases. It occurs when the brain is damaged due to various factors, such as major strokes, multiple smaller strokes that go unnoticed (known as multi-infarct), or chronic changes in smaller blood vessels (referred to as subcortical dementia). The term vascular cognitive impairment (VCI) is increasingly used to encompass this range of diseases.
Unlike Alzheimer’s disease, which has a gradual and subtle onset, vascular dementia can occur suddenly and typically shows a series of stepwise increases in symptom severity. The presentation and progression of the disease can vary significantly.
There are certain features that suggest a vascular cause of dementia. These include a history of transient ischemic attacks (TIAs) or cardiovascular disease, the presence of focal neurological abnormalities, prominent memory impairment in the early stages of the disease, early onset of gait disturbance and unsteadiness, frequent unprovoked falls in the early stages, bladder symptoms (such as incontinence) without any identifiable urological condition in the early stages, and seizures.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 54
Incorrect
-
You evaluate a 72-year-old woman with a painful swollen left big toe. The pain started this morning and is described as the most severe pain she has ever experienced. It has gradually worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The overlying skin is red and shiny.
She has a history of hypertension, which has been challenging to control. She is currently taking amlodipine 10 mg and ramipril 10 mg per day for this and is awaiting a review of her antihypertensive medication. Her blood pressure today is 165/94 mmHg.
She has recently also been diagnosed with a myelodysplastic syndrome and requires regular blood transfusions. She is being monitored in a local hematology clinic for a low white cell count and thrombocytopenia.
What is the most appropriate next step in management for this patient?Your Answer: Commence naproxen
Correct Answer: Commence prednisolone
Explanation:The diagnosis in this case is clearly gout. According to the European League Against Rheumatism (EULAR) guidelines, the development of sudden joint pain accompanied by swelling, tenderness, and redness, which worsens over a period of 6-12 hours, strongly suggests crystal arthropathy.
Checking serum urate levels to confirm high levels of uric acid before starting treatment for acute gout attacks is not very beneficial and should not delay treatment. While these levels can be useful for monitoring treatment response, they often decrease during an acute attack and can even be normal. If levels are checked and found to be normal during an attack, they should be rechecked once the attack has resolved.
The first-line treatment for acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. However, caution should be exercised when using NSAIDs in patients with a history of hypertension. Since this patient has had difficulty controlling their blood pressure and remains hypertensive, it would be wise to avoid NSAIDs in this case.
Colchicine is an effective alternative for treating gout, although it may take longer to take effect. It is often used in patients who cannot take NSAIDs due to contraindications, such as hypertension or a history of peptic ulcer disease. It’s important to note that colchicine can also affect the bone marrow, leading to an increase in white blood cells and a decrease in platelets. Therefore, it should not be used in patients with blood disorders, as in this case.
During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute attack. If a patient is already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs, colchicine, or corticosteroids as appropriate.
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. In this patient’s case, using corticosteroids would be the safest and most reasonable treatment option.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 55
Correct
-
A 25-year-old man is given a medication for a medical condition during the 2nd-trimester of his partner's pregnancy. As a result, the newborn experienced delayed onset labor and premature closure of the ductus arteriosus.
Which of the following medications is the most probable cause of these abnormalities?Your Answer: Diclofenac sodium
Explanation:The use of NSAIDs in the third trimester of pregnancy is linked to several risks. These risks include delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus, which is a condition where bilirubin causes brain dysfunction. Additionally, there is a slight increase in the risk of first-trimester abortion if NSAIDs are used early in pregnancy.
Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness.
Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose a significant risk.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimester, they can lead to fetal growth retardation.
Carbamazepine: This drug can cause hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Use of this drug can result in grey baby syndrome.
Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts.
Danazol: If given in the first trimester, this drug can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given in the first trimester, this drug may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: Use of heparin during pregnancy can lead to maternal bleeding and thrombocytopenia.
Isoniazid: This drug can cause maternal liver damage
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 56
Correct
-
A 35-year-old woman presents to the Emergency Department complaining of lower back pain and numbness in both feet. Three days ago, she experienced a sharp, shooting pain in her back after lifting a heavy object at work. The pain has worsened over the past three days, and she has now developed weakness in her right leg. She is also experiencing difficulty with urination. Her medical history includes a previous laminectomy for a herniated lumbar disc four years ago. During the examination, normal power is observed in her left leg, but reduced power is noted in the right leg. Motor strength is reduced to 3 out of 5 in the hamstrings, 2 out of 5 in the ankle and toe plantar flexors, and 0 out of 5 in the ankle dorsiflexors and extensor hallucis longus. The right ankle and Achilles tendon reflexes are absent. Sensory examination reveals reduced sensation in the right calf, right foot, labia, and perianal area. Rectal examination reveals reduced sphincter tone.
What is the SINGLE most likely diagnosis?Your Answer: Cauda equina syndrome
Explanation:Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on the bundle of nerves in the lower back and sacrum. As a result, individuals may experience loss of control over their bladder and bowel functions.
There are certain red flags that may indicate the presence of CES. These include experiencing sciatica on both sides of the body, having severe or worsening neurological issues in both legs (such as significant weakness in knee extension, ankle eversion, or foot dorsiflexion), difficulty starting urination or a decreased sensation of urinary flow, loss of sensation in the rectum, experiencing numbness or tingling in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and having a lax anal sphincter.
Conus medullaris syndrome (CMS) is a condition that affects the conus medullaris, which is located above the cauda equina at the T12-L2 level. Unlike CES, CMS primarily causes back pain and may have less noticeable nerve root pain. The main symptoms of CMS are urinary retention and constipation.
To confirm a diagnosis of CES and determine the level of compression and any underlying causes, an MRI scan is considered the gold-standard investigation. In cases where an MRI is not possible or contraindicated, a CT myelogram or standard CT scans can be helpful. However, plain radiographs have limited value and may only show significant degenerative or traumatic bone diseases.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 57
Incorrect
-
A 35-year-old man with a known history of lumbar radiculopathy causing neuropathic pain presents with an increase in his symptoms. He describes the pain as a severe burning sensation on the right side of his lower back and leg. You discuss his treatment options.
Which of the following pharmacological therapies is recommended by the current NICE guidelines for the management of neuropathic pain? Select ONE option only.Your Answer: Co-dydramol
Correct Answer: Duloxetine
Explanation:The first line of treatment for neuropathic pain includes options such as amitriptyline, duloxetine, gabapentin, or pregabalin. The dosage should be adjusted based on how the individual responds to the medication and their ability to tolerate it. If the initial treatment does not provide relief or is not well tolerated, one of the remaining three medications can be considered as an alternative option.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 58
Incorrect
-
You are part of the team managing a 60 year old patient who has experienced cardiac arrest. What is the appropriate dosage of adrenaline to administer to this patient?
Your Answer: 10 mg IV
Correct Answer: 1 mg IV
Explanation:In cases of cardiac arrest, it is recommended to administer 1 mg of adrenaline intravenously (IV) every 3-5 minutes. According to the 2021 resus council guidelines for adult advanced life support (ALS), the administration of vasopressors should follow these guidelines:
– For adult patients in cardiac arrest with a non-shockable rhythm, administer 1 mg of adrenaline IV (or intraosseous) as soon as possible.
– For adult patients in cardiac arrest with a shockable rhythm, administer 1 mg of adrenaline IV (or intraosseous) after the third shock.
– Continuously repeat the administration of 1 mg of adrenaline IV (or intraosseous) every 3-5 minutes throughout the ALS procedure.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.
-
This question is part of the following fields:
- Basic Anaesthetics
-
-
Question 59
Correct
-
A 65-year-old patient with advanced metastatic lung cancer is experiencing severe pain in his limbs and chest. Despite taking the maximum dose of paracetamol, codeine phosphate, and ibuprofen regularly, his symptoms are no longer being adequately controlled. You decide to discontinue the use of codeine phosphate and initiate stronger opioids.
What is the most suitable course of action at this point?Your Answer: Sustained-release oral morphine
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
-
This question is part of the following fields:
- Palliative & End Of Life Care
-
-
Question 60
Incorrect
-
A 70-year-old woman from a retirement community experiences a sudden collapse. Her blood sugar level is measured and found to be 2.2. She has a medical history of diabetes mellitus.
Which ONE medication is most likely to have caused her episode of hypoglycemia?Your Answer: Sitagliptin
Correct Answer: Pioglitazone
Explanation:Of all the medications mentioned in this question, only pioglitazone is known to be a potential cause of hypoglycemia. Glucagon, on the other hand, is specifically used as a treatment for hypoglycemia. The remaining medications mentioned are antidiabetic drugs that do not typically lead to hypoglycemia when used alone.
-
This question is part of the following fields:
- Endocrinology
-
-
Question 61
Correct
-
a 49-year-old woman with a history of gallstones, presenting with sepsis, right upper quadrant pain, and jaundice is diagnosed with ascending cholangitis. Which SINGLE statement regarding this condition is true?
Your Answer: It occurs when the common bile duct becomes infected
Explanation:Ascending cholangitis occurs when there is an infection in the common bile duct, often caused by a stone that has led to a blockage of bile flow. This condition is characterized by the presence of Charcot’s triad, which includes jaundice, fever with rigors, and pain in the right upper quadrant of the abdomen. It is a serious medical emergency that can be life-threatening, with some patients also experiencing altered mental status and low blood pressure due to septic shock, known as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis.
In acute cholecystitis, Murphy’s sign is typically positive, indicating tenderness in the right upper quadrant when the gallbladder is palpated. However, it is negative in cases of biliary colic and ascending cholangitis. The white cell count and C-reactive protein (CRP) levels are usually elevated in ascending cholangitis, along with the presence of jaundice and significantly increased levels of alkaline phosphatase (ALP) and bilirubin.
To differentiate between biliary colic, acute cholecystitis, and ascending cholangitis, the following 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: NormalAcute 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 elevatedAscending cholangitis:
– Pain duration: Variable
– Fever: Present
– Murphy’s sign: Negative
– WCC & CRP: Elevated
– AST, ALT & ALP: Elevated
– Bilirubin: Elevated -
This question is part of the following fields:
- Surgical Emergencies
-
-
Question 62
Incorrect
-
A 65-year-old patient with advanced metastatic bowel cancer is experiencing symptoms of bowel obstruction and is currently suffering from nausea and vomiting. The patient has been informed that she has only a few days left to live. Upon examination, her abdomen is found to be tender and distended.
What is the most suitable course of action to address her nausea and vomiting in this situation?Your Answer: Prochlorperazine
Correct Answer: Hyoscine butylbromide
Explanation:According to NICE, hyoscine butylbromide is recommended as the initial medication for managing nausea and vomiting in individuals with obstructive bowel disorders who are in the last days of life. NICE provides guidance on how to handle these symptoms in the final days of life, which includes assessing the potential causes of nausea and vomiting in the dying person. This may involve considering factors such as certain medications, recent chemotherapy or radiotherapy, psychological causes, biochemical causes like hypercalcemia, raised intracranial pressure, gastrointestinal motility disorder, ileus, or bowel obstruction.
It is important to discuss the available options for treating nausea and vomiting with the dying person and their loved ones. Non-pharmacological methods should also be considered when managing these symptoms in someone in the last days of life. When selecting medications for nausea and vomiting, factors such as the likely cause and reversibility of the symptoms, potential side effects (including sedation), other symptoms the person may be experiencing, and the desired balancing of effects when managing other symptoms should be taken into account. Additionally, compatibility and potential drug interactions with other medications the person is taking should be considered.
For individuals in the last days of life with obstructive bowel disorders who have nausea or vomiting, hyoscine butylbromide is recommended as the first-line pharmacological treatment. If the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide, octreotide may be considered as an alternative option.
For more information, refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
-
This question is part of the following fields:
- Palliative & End Of Life Care
-
-
Question 63
Correct
-
You are caring for a patient with a declining Glasgow Coma Scale (GCS) that you expect will need rapid sequence induction (RSI). You observe that the patient has a history of asthma. Which of the following induction medications is recognized for its bronchodilatory effects and would be appropriate for use in an asthmatic patient?
Your Answer: Ketamine
Explanation:When caring for a patient with a declining Glasgow Coma Scale (GCS) who may require rapid sequence induction (RSI), it is important to consider their medical history. In this case, the patient has a history of asthma. One of the induction medications that is recognized for its bronchodilatory effects and would be appropriate for use in an asthmatic patient is Ketamine.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
-
This question is part of the following fields:
- Basic Anaesthetics
-
-
Question 64
Incorrect
-
A 28-year-old woman comes in with a severe skin rash. After a consultation with the on-call dermatology consultant, the woman is diagnosed with Stevens-Johnson syndrome.
Which of the following statements about Stevens-Johnson syndrome is NOT true?Your Answer: It can be caused by NSAIDs
Correct Answer: Epidermal detachment is seen in greater than 30% of the body surface area
Explanation:Stevens-Johnson syndrome is a severe and potentially deadly form of erythema multiforme. It can be triggered by anything that causes erythema multiforme, but it is most commonly seen as a reaction to medication within 1-3 weeks of starting treatment. Initially, there may be symptoms like fever, fatigue, joint pain, and digestive issues, followed by the development of severe mucocutaneous lesions that are blistering and ulcerating.
Stevens-Johnson syndrome and toxic epidermal necrolysis are considered to be different stages of the same mucocutaneous disease, with toxic epidermal necrolysis being more severe. The extent of epidermal detachment is used to differentiate between the two. In Stevens-Johnson syndrome, less than 10% of the body surface area is affected by epidermal detachment, while in toxic epidermal necrolysis, it is greater than 30%. An overlap syndrome occurs when detachment affects between 10-30% of the body surface area.
Several drugs can potentially cause Stevens-Johnson syndrome and toxic epidermal necrolysis, including tetracyclines, penicillins, vancomycin, sulphonamides, NSAIDs, and barbiturates.
-
This question is part of the following fields:
- Dermatology
-
-
Question 65
Correct
-
A 35-year-old woman comes in with a 3-day history of mild discomfort while urinating. She also reports increased frequency of urination. She denies any urgency or excessive urination and has not observed any blood in her urine. On physical examination, her abdomen is soft and nontender.
What is the MOST suitable course of action for management?Your Answer: Use a urine dipstick test to help in this patient’s diagnosis
Explanation:Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. To effectively manage UTIs, SIGN has developed excellent guidelines. According to these guidelines, if a patient presents with mild symptoms of a UTI (experiencing two or fewer classical symptoms), it is recommended to use a dipstick test to aid in the diagnosis and treatment process.
-
This question is part of the following fields:
- Urology
-
-
Question 66
Correct
-
A 65 year old female patient has been brought into the department after being hit by a car in a vehicle-pedestrian accident. The patient needs CT imaging to evaluate the complete scope of her injuries. What are the minimum monitoring requirements for transferring a critically ill patient?
Your Answer: ECG, oxygen saturations, blood pressure and temperature monitoring
Explanation:It is crucial to continuously monitor the oxygen saturation, blood pressure, ECG, and temperature of critically ill patients during transfers. If the patient is intubated, monitoring of end-tidal CO2 is also necessary. The minimum standard monitoring requirements for any critically ill patient during transfers include ECG, oxygen saturation, blood pressure, and temperature. Additionally, if the patient is intubated, monitoring of end-tidal CO2 is mandatory. It is important to note that the guidance from ICS/FICM suggests that monitoring protocols for intra-hospital transfers should be similar to those for interhospital transfers.
Further Reading:
Transfer of critically ill patients in the emergency department is a common occurrence and can involve intra-hospital transfers or transfers to another hospital. However, there are several risks associated with these transfers that doctors need to be aware of and manage effectively.
Technical risks include equipment failure or inadequate equipment, unreliable power or oxygen supply, incompatible equipment, restricted positioning, and restricted monitoring equipment. These technical issues can hinder the ability to detect and treat problems with ventilation, blood pressure control, and arrhythmias during the transfer.
Non-technical risks involve limited personal and medical team during the transfer, isolation and lack of resources in the receiving hospital, and problems with communication and liaison between the origin and destination sites.
Organizational risks can be mitigated by having a dedicated consultant lead for transfers who is responsible for producing guidelines, training staff, standardizing protocols, equipment, and documentation, as well as capturing data and conducting audits.
To optimize the patient’s clinical condition before transfer, several key steps should be taken. These include ensuring a low threshold for intubation and anticipating airway and ventilation problems, securing the endotracheal tube (ETT) and verifying its position, calculating oxygen requirements and ensuring an adequate supply, monitoring for circulatory issues and inserting at least two IV accesses, providing ongoing analgesia and sedation, controlling seizures, and addressing any fractures or temperature changes.
It is also important to have the necessary equipment and personnel for the transfer. Standard monitoring equipment should include ECG, oxygen saturation, blood pressure, temperature, and capnographic monitoring for ventilated patients. Additional monitoring may be required depending on the level of care needed by the patient.
In terms of oxygen supply, it is standard practice to calculate the expected oxygen consumption during transfer and multiply it by two to ensure an additional supply in case of delays. The suggested oxygen supply for transfer can be calculated using the minute volume, fraction of inspired oxygen, and estimated transfer time.
Overall, managing the risks associated with patient transfers requires careful planning, communication, and coordination to ensure the safety and well-being of critically ill patients.
-
This question is part of the following fields:
- Basic Anaesthetics
-
-
Question 67
Correct
-
A 35-year-old woman is injured in a car crash and sustains severe facial trauma. Imaging studies show that she has a Le Fort I fracture.
What is the characteristic injury pattern of a Le Fort I fracture?Your Answer: Horizontal fracture across the inferior aspect of the 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.
-
This question is part of the following fields:
- Maxillofacial & Dental
-
-
Question 68
Incorrect
-
A 70-year-old patient comes in after a chronic overdose of digoxin. She has experienced multiple episodes of vomiting, feels extremely tired, and reports that her vision seems to have a yellow tint.
What is the indication for administering DigiFab in this patient?Your Answer: Heart rate of 40 bpm
Correct Answer: Coexistent renal failure
Explanation:Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.
The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:
Acute digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Potassium level >5 mmol/l
– Ingestion of >10 mg of digoxin (in adults)
– Ingestion of >4 mg of digoxin (in children)
– Digoxin level >12 ng/mlChronic digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Significant gastrointestinal symptoms
– Symptoms of digoxin toxicity in the presence of renal failure -
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 69
Incorrect
-
Following the passing of a young patient treated for an extended cardiac arrest after a near-drowning incident, your supervisor requests that you arrange a training session for the junior physicians. Which of the following statements accurately reflects the management of near-drowning patients?
Your Answer: Nebulised bronchodilators are ineffective in treating bronchospasm associated with drowning and should be avoided
Correct Answer: Patients should be extricated from the water in the horizontal position
Explanation:When rescuing drowning patients, it is important to extricate them from the water in a horizontal position whenever possible. This is because the pressure of the water on the body when submerged increases the flow of blood back to the heart, which in turn increases cardiac output. However, when the patient is removed from the water, this pressure effect is lost, which can lead to a sudden drop in blood pressure and circulatory collapse due to the loss of peripheral resistance and pooling of blood in the veins. By extricating the patient in a horizontal position, we can help counteract this effect.
It is worth noting that the amount of water in the lungs after drowning is typically small, usually less than 4 milliliters per kilogram of body weight. Therefore, attempting to drain the water from the lungs is ineffective and not recommended.
In cases of fresh water drowning, pneumonia may occur due to unusual pathogens such as aeromonas spp, burkholderia pseudomallei, chromobacterium spp, pseudomonas species, and leptospirosis.
If the patient experiences bronchospasm, nebulized bronchodilators can be used as a treatment.
To prevent secondary brain injury, it is important to prevent hyperthermia. This can be achieved by maintaining the patient’s core body temperature below 36 degrees Celsius during the rewarming process.
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:
- Respiratory
-
-
Question 70
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
-
-
Question 71
Correct
-
A 45-year-old man comes in with a high temperature, shivering, aching head, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the birdhouse. During the examination, a red rash is noticed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.
What is the BEST antibiotic to prescribe for this patient?Your Answer: Doxycycline
Explanation:Psittacosis is a type of infection that can be transmitted from animals to humans, known as a zoonotic infection. It is caused by a bacterium called Chlamydia psittaci. This infection is most commonly seen in people who own domestic birds, but it can also affect those who work in pet shops or zoos.
The typical presentation of psittacosis includes symptoms similar to those of pneumonia that is acquired within the community. People may experience flu-like symptoms along with severe headaches and sensitivity to light. In about two-thirds of patients, an enlargement of the spleen, known as splenomegaly, can be observed.
Infected individuals often develop a reddish rash with flat spots on their face, known as Horder’s spots. Additionally, they may experience skin conditions such as erythema nodosum or erythema multiforme.
The recommended treatment for psittacosis is a course of tetracycline or doxycycline, which should be taken for a period of 2-3 weeks.
-
This question is part of the following fields:
- Respiratory
-
-
Question 72
Correct
-
A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the pills she takes for insomnia. She informs you that the pill she takes for this condition is zolpidem 10 mg. She consumed the pills approximately 2 hours ago. She is currently hypotensive, with her most recent blood pressure reading being 82/56 mmHg. She weighs 70 kg. You administer a dose of calcium chloride, but there is no improvement in her condition.
Which of the following treatments is LEAST likely to be helpful in supporting her cardiovascular system?Your Answer: Magnesium sulphate
Explanation:Calcium-channel blocker overdose is a serious condition that can be life-threatening. The most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into cells. These channels are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.
The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:
1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.
2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.
3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.
4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.
5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.
6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 73
Correct
-
A 6 year old boy is brought into the emergency department by his father. The boy tugged on the tablecloth and a hot bowl of soup spilled onto his right leg, causing a scald. The boy is in tears and holding onto his right leg. The patient's father mentions that he gave the boy acetaminophen before coming to the emergency department. What is the most suitable additional pain relief to provide?
Your Answer: Rectal diclofenac 1 mg/kg
Explanation:For children experiencing moderate pain, diclofenac (taken orally or rectally), oral codeine, or oral morphine are suitable options for providing relief. The patient has already been given the appropriate initial analgesia for mild pain. Therefore, it is now appropriate to administer analgesia for moderate pain, following the next step on the analgesic ladder. Considering diclofenac, codeine, or oral morphine would be appropriate in this case.
Further Reading:
Assessment and alleviation of pain should be a priority when treating ill and injured children, according to the RCEM QEC standards. These standards state that all children attending the Emergency Department should receive analgesia for moderate and severe pain within 20 minutes of arrival. The effectiveness of the analgesia should be re-evaluated within 60 minutes of receiving the first dose. Additionally, patients in moderate pain should be offered oral analgesia at triage or assessment.
Pain assessment in children should take into account their age. Visual analogue pain scales are commonly used, and the RCEM has developed its own version of this. Other indicators of pain, such as crying, limping, and holding or not-moving limbs, should also be observed and utilized in the pain assessment.
Managing pain in children involves a combination of psychological strategies, non-pharmacological adjuncts, and pharmacological methods. Psychological strategies include involving parents, providing cuddles, and utilizing child-friendly environments with toys. Explanation and reassurance are also important in building trust. Distraction with stories, toys, and activities can help divert the child’s attention from the pain.
Non-pharmacological adjuncts for pain relief in children include limb immobilization with slings, plasters, or splints, as well as dressings and other treatments such as reduction of dislocation or trephine subungual hematoma.
Pharmacological methods for pain relief in children include the use of anesthetics, analgesics, and sedation. Topical anesthetics, such as lidocaine with prilocaine cream, tetracaine gel, or ethyl chloride spray, should be considered for children who are likely to require venesection or placement of an intravenous cannula.
Procedural sedation in children often utilizes either ketamine or midazolam. When administering analgesia, the analgesic ladder should be followed as recommended by the RCEM.
Overall, effective pain management in children requires a comprehensive approach that addresses both the physical and psychological aspects of pain. By prioritizing pain assessment and providing appropriate pain relief, healthcare professionals can help alleviate the suffering of ill and injured children.
-
This question is part of the following fields:
- Paediatric Emergencies
-
-
Question 74
Incorrect
-
You assess a patient in a clinic who has been diagnosed with a neuropathy affecting the muscles around her shoulder joint. During the examination, you observe that she has significant restriction in the abduction of her arm. Your consultant examines the patient and instructs her to raise her arms parallel to the ground in the scapular plane. When rotating the arm internally with the thumbs pointing downwards, she is unable to sustain the position with her left arm when pressure is applied.
Which nerve is most likely to have been affected in this scenario?Your Answer: Axillary nerve
Correct Answer: Suprascapular nerve
Explanation:The supraspinatus muscle is a small muscle located in the upper back. It extends from the supraspinatus fossa of the scapula to the greater tubercle of the humerus. This muscle is part of the rotator cuff, along with three other muscles. The supraspinatus muscle is innervated by the suprascapular nerve, which also innervates the infraspinatus muscle. The suprascapular nerve originates from the upper trunk of the brachial plexus.
The main function of the supraspinatus muscle is to assist the deltoid muscle in abducting the arm at the shoulder joint. Specifically, it is responsible for the initial 15 degrees of arm abduction. Beyond this range, the deltoid muscle takes over as the primary abductor.
In addition to its role in arm movement, the supraspinatus muscle works together with the other rotator cuff muscles to stabilize the shoulder joint. It helps keep the humeral head in the glenoid fossa and counteracts the downward gravitational forces exerted on the shoulder joint by the weight of the arm.
One common test used to assess the supraspinatus muscle is called the empty can test. During this test, the patient is positioned either standing or sitting, with their arms raised parallel to the ground in the scapular plane. The arm is then internally rotated fully, with the thumb facing downward. The clinician applies downward pressure on either the wrists or the elbow, while the patient resists this pressure. If the patient experiences weakness, pain, or both during this resistance, it indicates a possible tear in the supraspinatus tendon or muscle, or a suprascapular nerve neuropathy.
-
This question is part of the following fields:
- Musculoskeletal (non-traumatic)
-
-
Question 75
Incorrect
-
A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his father's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable in terms of blood flow. The attending physician recommends giving a dose of activated charcoal.
What is the appropriate dosage of activated charcoal to administer?Your Answer: 5 g/kg
Correct Answer: 1 g/kg
Explanation:Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind 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. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.
The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 76
Correct
-
A 40 year old man presents to the emergency department after experiencing difficulty swallowing a food bolus. However, the patient successfully swallows the bolus while being evaluated by the triage nurse. During the examination, you observe an enlarged thyroid gland. What is the most appropriate test for evaluating thyroid function?
Your Answer: TSH
Explanation:The best single test to evaluate thyroid function is TSH. Goitres can be associated with either hypothyroidism or hyperthyroidism, although hypothyroidism is more common. According to NICE guidelines, when there is suspicion of hypothyroidism, it is recommended to first check the TSH level. If the TSH level is above the normal range, then the free thyroxine (FT4) should be checked on the same sample. Similarly, in cases of suspected hyperthyroidism, it is advised to first check the TSH level. If the TSH level is below the normal range, then the free thyroxine (FT4) and free triiodothyronine (FT3) should be checked on the same sample.
Further Reading:
The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.
Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.
The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.
Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.
Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.
-
This question is part of the following fields:
- Endocrinology
-
-
Question 77
Correct
-
A 5 year old girl is brought into the emergency room. Her father entered the room as she was about to eat a cashew. Within a few minutes, her face began to swell. You determine that she is experiencing anaphylaxis. After administering the necessary medication, you decide to administer an IV fluid challenge. How much crystalloid would you administer to a child in this scenario?
Your Answer: 10 ml/kg
Explanation:According to the 2021 resus council guidelines, when administering an IV fluid challenge to a child with anaphylaxis, the recommended dose is 10 ml/kg. It is important to note that prior to the update, the advised dose was 20 ml/kg. In an exam, if you are provided with the child’s weight, you may be required to calculate the volume requirement.
Further Reading:
Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.
When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.
The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.
In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.
Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.
-
This question is part of the following fields:
- Paediatric Emergencies
-
-
Question 78
Incorrect
-
You assess a patient with a significantly elevated potassium level.
What is the most probable cause of this finding?Your Answer: Type 1 renal tubular acidosis
Correct Answer: Congenital adrenal hyperplasia
Explanation:Hyperkalaemia, or high levels of potassium in the blood, can be caused by various factors that are not related to drug use. These include conditions such as renal failure, where the kidneys are unable to properly regulate potassium levels, and excess potassium supplementation. Other non-drug causes include Addison’s disease, a condition characterized by adrenal insufficiency, and congenital adrenal hyperplasia. Renal tubular acidosis, specifically type 4, can also lead to hyperkalaemia. Additionally, conditions like rhabdomyolysis, burns and trauma, and tumour lysis syndrome can contribute to elevated potassium levels. Acidosis, an imbalance in the body’s pH levels, is another non-drug cause of hyperkalaemia.
On the other hand, certain medications have been associated with hyperkalaemia. These include ACE inhibitors, angiotensin receptor blockers, NSAIDs, beta-blockers, digoxin, and suxamethonium. These drugs can interfere with the body’s potassium regulation mechanisms and lead to increased levels of potassium in the blood.
In contrast, there are also conditions that result in low levels of potassium, known as hypokalaemia. Bartter’s syndrome, a rare inherited defect in the ascending limb of the loop of Henle, is characterized by hypokalaemic alkalosis and normal to low blood pressure. Type 1 and 2 renal tubular acidosis are other conditions that cause hypokalaemia. On the other hand, type 4 renal tubular acidosis leads to hyperkalaemia. Gitelman’s syndrome, another rare inherited defect, affects the distal convoluted tubule of the kidney and causes a metabolic alkalosis with hypokalaemia and hypomagnesaemia.
Lastly, excessive consumption of liquorice can result in a condition called hypermineralocorticoidism, which can lead to hypokalaemia.
-
This question is part of the following fields:
- Nephrology
-
-
Question 79
Incorrect
-
You assess a patient with a decreased potassium level.
Which of the following is NOT a known factor contributing to hypokalemia?Your Answer: Excessive liquorice ingestion
Correct Answer: Type 4 renal tubular acidosis
Explanation:Hypokalaemia, or low potassium levels, can be caused by various factors. One common cause is inadequate dietary intake, where a person does not consume enough potassium-rich foods. Gastrointestinal loss, such as through diarrhoea, can also lead to hypokalaemia as the body loses potassium through the digestive system. Certain drugs, like diuretics and insulin, can affect potassium levels and contribute to hypokalaemia.
Alkalosis, a condition characterized by an imbalance in the body’s pH levels, can also cause hypokalaemia. Hypomagnesaemia, or low magnesium levels, is another potential cause. Renal artery stenosis, a narrowing of the arteries that supply blood to the kidneys, can lead to hypokalaemia as well.
Renal tubular acidosis, specifically types 1 and 2, can cause hypokalaemia. These conditions affect the kidneys’ ability to regulate acid-base balance, resulting in low potassium levels. Conn’s syndrome, Bartter’s syndrome, and Gitelman’s syndrome are all rare inherited defects that can cause hypokalaemia. Bartter’s syndrome affects the ascending limb of the loop of Henle, while Gitelman’s syndrome affects the distal convoluted tubule of the kidney.
Hypokalaemic periodic paralysis is another condition that can cause low potassium levels. Excessive ingestion of liquorice, a sweet treat made from the root of the liquorice plant, can result in hypokalaemia due to its impact on mineralocorticoid levels.
It is important to note that while type 1 and 2 renal tubular acidosis cause hypokalaemia, type 4 renal tubular acidosis actually causes hyperkalaemia, or high potassium levels.
-
This question is part of the following fields:
- Nephrology
-
-
Question 80
Correct
-
A 35-year-old woman is injured in a car crash and sustains severe facial trauma. Imaging tests show that she has a Le Fort II fracture.
What is the most accurate description of the injury pattern seen in a Le Fort II fracture?Your Answer: Pyramidal-shaped fracture, with the teeth at the base of the pyramid and the nasofrontal suture at the apex
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.
-
This question is part of the following fields:
- Maxillofacial & Dental
-
-
Question 81
Incorrect
-
A 32-year-old triathlete is brought in by ambulance after collapsing during a triathlon event. Due to a summer heatwave, several participants have been admitted with heat-related illnesses. The patient is diagnosed with heat stroke and is in critical condition with a low GCS and signs of organ damage. You decide to transfer the patient to a critical care unit.
Which of the following cooling methods would be the LEAST suitable option for this patient?Your Answer: Intravascular cooling devices
Correct Answer: Cold water immersion
Explanation:There are various cooling techniques that are recommended, but currently, there is limited conclusive evidence on which approach is the most effective. Some possible methods include simple measures such as consuming cold beverages, using fans, applying ice water packs, and spraying tepid water. Cold water immersion therapy can also be beneficial, but it requires the patient to be stable and cooperative, making it impractical for very ill individuals. For patients who are in a more critical condition, advanced cooling techniques like administering cold intravenous fluids, using surface cooling devices (SCD), employing intravascular cooling devices (ICD), or utilizing extracorporeal circuits may be utilized.
-
This question is part of the following fields:
- Environmental Emergencies
-
-
Question 82
Correct
-
A 35-year-old woman with a history of schizophrenia describes a sensation in which her thoughts are heard as if they are being spoken aloud. She states that it feels almost as though her thoughts are ‘being echoed by a voice in her mind’.
Which ONE of the following thought disorders is she displaying?Your Answer: Thought echo
Explanation:Thought echo is a phenomenon where a patient perceives their own thoughts as if they are being spoken out loud. When there is a slight delay in this perception, it is referred to as echo de la pensée. On the other hand, when the thoughts are heard simultaneously, it is known as Gedankenlautwerden.
-
This question is part of the following fields:
- Mental Health
-
-
Question 83
Incorrect
-
A 30-year-old man comes in with swelling of his face, particularly his upper lip, and his hands. He has a confirmed diagnosis of hereditary angioedema.
What is the pattern of inheritance for this disorder?Your Answer: Autosomal recessive
Correct Answer: Autosomal dominant
Explanation:Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.
Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.
-
This question is part of the following fields:
- Allergy
-
-
Question 84
Incorrect
-
A 60-year-old woman presents with recent weight loss, difficulty breathing, and chest pain. She has a long history of smoking and has been diagnosed with COPD. A chest X-ray reveals a large mass in the left lung consistent with cancer. You recommend that she be referred to a specialist for further evaluation and treatment, but she refuses and does not want her family to know about her condition. She also states that she does not want to hear any negative news. After assessing her mental capacity and determining that she is competent and has capacity, which of the following statements is true regarding her ongoing care?
Your Answer: They should be referred to a psychiatrist for an independent assessment of their capacity
Correct Answer: You should document that the patient has declined information
Explanation:There is no indication for an independent psychiatric evaluation of this patient. However, it is important to clearly document in his medical records that you have assessed his mental capacity and determined that he is capable of making decisions. It would not be appropriate in this case to refer him to a specialist against his wishes or to breach confidentiality by discussing his illness with his family or next of kin. According to the guidelines set by the General Medical Council (GMC), it is necessary to document the fact that the patient has declined relevant information. It is also important to avoid pressuring the patient to change their mind in these circumstances.
For further information, please refer to the GMC guidelines on treatment and care towards the end of life: good practice in decision making.
-
This question is part of the following fields:
- Palliative & End Of Life Care
-
-
Question 85
Incorrect
-
A 4-year-old girl is brought in by her father. She is complaining of left-sided ear pain and symptoms of a cold. On examination, she has a red eardrum on the left-hand side. She does not have a fever and appears to be in good health. You determine that she has acute otitis media.
What would be a valid reason to prescribe antibiotics for this child?Your Answer: Hearing loss
Correct Answer: Otorrhoea
Explanation:According to a Cochrane review conducted in 2008, it was discovered that approximately 80% of children experiencing acute otitis media were able to recover within a span of two days. However, the use of antibiotics only resulted in a reduction of pain for about 7% of children after the same two-day period. Furthermore, the administration of antibiotics did not show any significant impact on the rates of hearing loss, recurrence, or perforation. In cases where antibiotics are deemed necessary for children with otitis media, some indications include being under the age of two, experiencing discharge from the ear (otorrhoea), and having bilateral acute otitis media.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 86
Correct
-
A 42 year old male is brought into the ED resuscitation room. The paramedics report the patient was discovered outdoors and unconscious. CPR was initiated in the ambulance. You observe that the patient is hypothermic with a temperature of 30.4ºC. What modifications would you make to the management of cardio-respiratory arrest based on this finding?
Your Answer: Pulse check for up to 1 minute
Explanation:In patients with hypothermia, the pulse check during CPR should be extended to 1 minute. Additionally, several adjustments need to be made to the CPR protocol. Firstly, mechanical ventilation should be used due to the stiffness of the chest wall. Secondly, the dosing or omission of cardiac arrest drugs should be adjusted based on the patient’s temperature. The defibrillation pattern should also be modified, with 3 shocks attempted before re-attempting defibrillation only when the body temperature is above 30ºC. Certain electrolyte disturbances, such as mild hypokalemia, should not be treated as potassium levels typically rise with Rewarming. It is important to plan for prolonged resuscitation in these cases. Lastly, uncorrected ABG results should be used, without adjusting for temperature.
Further Reading:
Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.
ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.
Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.
Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.
-
This question is part of the following fields:
- Resus
-
-
Question 87
Incorrect
-
A 5-year-old girl is brought to the Emergency Department by her parents. For the past two days, she has had severe diarrhoea and vomiting. She has not passed urine so far today. She usually weighs 20 kg. On examination, she has sunken eyes and dry mucous membranes. She is tachycardia and tachypnoeic and has cool peripheries. Her capillary refill time is prolonged.
What volume of fluid would you administer for your initial fluid bolus?Your Answer: 200 ml
Correct Answer: 600 ml
Explanation:Generally speaking, if a child shows clinical signs of dehydration but does not exhibit shock, it can be assumed that they are 5% dehydrated. On the other hand, if shock is also present, it can be assumed that the child is 10% dehydrated or more. When we say 5% dehydration, it means that the body has lost 5 grams per 100 grams of body weight, which is equivalent to 50 milliliters per kilogram of fluid. Similarly, 10% dehydration implies a fluid loss of 100 milliliters per kilogram of fluid.
In the case of this child, they are 10% dehydrated, which means they have lost 100 milliliters per kilogram of fluid. Considering their weight of 30 kilograms, their estimated fluid loss amounts to 100 multiplied by 30, which equals 3000 milliliters.
Since this child is also in shock, they should receive a fluid bolus of 20 milliliters per kilogram. Therefore, the initial volume of fluid to administer would be 20 multiplied by 30 milliliters, resulting in 600 milliliters.
To summarize the clinical features of dehydration and shock, please refer below:
Dehydration (5%):
– The child appears unwell
– Normal heart rate or tachycardia
– Normal respiratory rate or tachypnea
– Normal peripheral pulses
– Normal or mildly prolonged capillary refill time (CRT)
– Normal blood pressure
– Warm extremities
– Decreased urine output
– Reduced skin turgor
– Sunken eyes
– Depressed fontanelle
– Dry mucous membranesClinical shock (10%):
– Pale, lethargic, mottled appearance
– Tachycardia
– Tachypnea
– Weak peripheral pulses
– Prolonged capillary refill time (CRT)
– Hypotension
– Cold extremities
– Decreased urine output
– Decreased level of consciousness -
This question is part of the following fields:
- Nephrology
-
-
Question 88
Incorrect
-
A 65 year old female is brought to the emergency department by her son. The son informs you that he visited his mother at the assisted living facility and noticed a decline in her alertness and mental state since his last visit 2 weeks ago. He expresses dissatisfaction with the facility staff, who made excuses about several caregivers being absent due to illness or vacation.
Upon assessment, the patient opens her eyes and makes incomprehensible sounds when spoken to, but is unable to speak coherently or form words. The patient exhibits localized response to painful stimuli.
What is this patient's Glasgow Coma Score?Your Answer: 12
Correct Answer: 10
Explanation:The GCS scoring system evaluates a patient’s level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each criterion is assigned a score, and the total score determines the patient’s GCS score. For example, if a patient has a GCS score of 10 (E3 V2 M5), it means they scored 3 out of 4 in eye opening, 2 out of 5 in verbal response, and 5 out of 6 in motor response.
Further Reading:
A subdural hematoma (SDH) is a condition where there is a collection of blood between the dura mater and the arachnoid mater of the brain. It occurs when the cortical bridging veins tear and bleed into the subdural space. Risk factors for SDH include head trauma, cerebral atrophy, advancing age, alcohol misuse, and certain medications or bleeding disorders. SDH can be classified as acute, subacute, or chronic depending on its age or speed of onset. Acute SDH is typically the result of head trauma and can progress to become chronic if left untreated.
The clinical presentation of SDH can vary depending on the nature of the condition. In acute SDH, patients may initially feel well after a head injury but develop more serious neurological symptoms later on. Chronic SDH may be detected after a CT scan is ordered to investigate confusion or cognitive decline. Symptoms of SDH can include increasing confusion, progressive decline in neurological function, seizures, headache, loss of consciousness, and even death.
Management of SDH involves an ABCDE approach, seizure management, confirming the diagnosis with CT or MRI, checking clotting and correcting coagulation abnormalities, managing raised intracranial pressure, and seeking neurosurgical opinion. Some SDHs may be managed conservatively if they are small, chronic, the patient is not a good surgical candidate, and there are no neurological symptoms. Neurosurgical intervention typically involves a burr hole craniotomy to decompress the hematoma. In severe cases with high intracranial pressure and significant brain swelling, a craniectomy may be performed, where a larger section of the skull is removed and replaced in a separate cranioplasty procedure.
CT imaging can help differentiate between subdural hematoma and other conditions like extradural hematoma. SDH appears as a crescent-shaped lesion on CT scans.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 89
Correct
-
A 25-year-old man comes in with a persistent sore throat that has lasted for five days. He denies having a cough. During the examination, his temperature is measured at 39°C and a few tender anterior cervical lymph nodes are found. There is a noticeable amount of exudate on his right tonsil, which appears red and inflamed.
What is his FeverPAIN score?Your Answer: 4
Explanation:The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.
If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.
The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.
Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 90
Correct
-
A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:
pH: 7.48
pO2: 7.4 kPa
PCO2: 3.1 kPa
HCO3-: 24.5 mmol/l
Which ONE statement about his ABG is correct?Your Answer: He has a respiratory alkalosis
Explanation:Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.
In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.
By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.
-
This question is part of the following fields:
- Respiratory
-
-
Question 91
Correct
-
A patient currently undergoing treatment for a malignant condition comes in with a recent weight increase, puffiness in the face, high blood pressure, and acne. Blood tests show high sodium levels, low potassium levels, and metabolic alkalosis.
Which of the following is the most probable location of this tumor?Your Answer: Lung
Explanation:Small cell lung cancer (SCLC) that originates from neuroendocrine tissue can lead to the development of paraneoplastic endocrine syndromes, such as Cushing syndrome. This occurs due to the inappropriate secretion of ectopic adrenocorticotropic hormone (ACTH). In this case, it is highly likely that the patient has a neuroendocrine tumor within the lung that is secreting ACTH.
The signs and symptoms of Cushing syndrome may be minimal in cases of ectopic ACTH-secreting tumors, and the onset of symptoms may be sudden, especially in rapidly growing SCLCs. The typical biochemical profile observed in these cases includes elevated sodium levels, low potassium levels, and a metabolic alkalosis.
The tumors associated with the production of ectopic ACTH are as follows:
– Small cell lung cancer (SCLC) – 50%
– Bronchial carcinoid tumors – 10%
– Thymic carcinoma – 10%
– Pancreatic islet cell tumors – 5%
– Phaeochromocytoma – 5%
– Medullary thyroid carcinoma – 5% -
This question is part of the following fields:
- Oncological Emergencies
-
-
Question 92
Incorrect
-
A 2-year-old girl presents with a barking cough. You suspect croup as the diagnosis. She has noticeable stridor at rest and mild chest wall retractions. Her chest examination is normal with good air entry throughout. Her SaO2 is 96% on air at rest but falls to 92% when agitated. Her conscious level is normal.
What is this child’s Westley croup score?Your Answer: 6 points
Correct Answer: 8 points
Explanation:Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually peak within 1-3 days, with the cough being more severe at night. A milder cough may persist for another 7-10 days.
A barking cough is a characteristic symptom of croup, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly used. Nebulized budesonide can be an alternative if the child is experiencing vomiting. However, it’s important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.
Hospitalization for croup is rare and typically reserved for children who are experiencing increasing respiratory distress or showing signs of drowsiness/agitation. The Westley croup score is a useful tool for assessing the child’s condition and making appropriate management decisions. Children with moderate (score 2-7) or severe croup (score >7) may require hospital admission. On the other hand, many children with mild croup (score 0-1) can be safely discharged and treated at home.
The Westley croup score is determined based on the following criteria: the presence of stridor at rest, the severity of retractions, air entry, SaO2 levels below 92% when agitated, and the conscious level of the child. In this particular case, the child’s Westley croup score is 8 points, indicating severe croup.
-
This question is part of the following fields:
- Ear, Nose & Throat
-
-
Question 93
Correct
-
A 35-year-old woman with a long history of heavy alcohol abuse and liver cirrhosis comes in with a fever, abdominal pain, worsening ascites, and confusion. You suspect she may have spontaneous bacterial peritonitis and decide to perform an ascitic tap.
Which of the following is NOT a reason to avoid performing an ascitic tap?Your Answer: Platelet count of 40 x 103/µl
Explanation:Diagnosing spontaneous bacterial peritonitis (SBP) requires an abdominal paracentesis of ascitic tap. Other reasons for performing a diagnostic tap include determining the cause of ascites, distinguishing between transudate and exudate, and detecting cancerous cells. Additionally, a therapeutic paracentesis can be done to alleviate respiratory distress or abdominal pain caused by the ascites.
However, there are certain contraindications to consider. These include having an uncooperative patient, a skin infection at the proposed puncture site, being pregnant, or experiencing severe bowel distension. Relative contraindications involve having severe thrombocytopenia (platelet count less than 20 x 103/μL) or coagulopathy (INR greater than 2.0).
For patients with an INR greater than 2.0, it is recommended to administer fresh frozen plasma (FFP) before the procedure. One approach is to infuse one unit of fresh frozen plasma prior to the procedure and then proceed with the paracentesis while the second unit is being infused.
In the case of patients with a platelet count lower than 20 x 103/μL, it is advisable to provide a platelet infusion before the procedure.
-
This question is part of the following fields:
- Gastroenterology & Hepatology
-
-
Question 94
Incorrect
-
A 25-year-old individual is brought to the emergency department by a companion who discovered the patient in tears next to a bottle of tablets. The patient claims to have ingested about 40 aspirin tablets approximately 1 hour ago. A blood gas sample is collected for testing. Which of the following acid-base imbalances is linked to an overdose of aspirin?
Your Answer: Respiratory acidosis followed by a metabolic alkalosis
Correct Answer: Respiratory alkalosis followed by a metabolic acidosis
Explanation:Salicylate poisoning initially leads to respiratory alkalosis, followed by metabolic acidosis. Salicylates, like aspirin, stimulate the respiratory center in the medulla, causing hyperventilation and respiratory alkalosis. This is usually the first acid-base imbalance observed in salicylate poisoning. As aspirin is metabolized, it disrupts oxidative phosphorylation in the mitochondria, leading to an increase in lactate levels due to anaerobic metabolism. The accumulation of lactic acid and acidic metabolites then causes metabolic acidosis.
Further Reading:
Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.
The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.
To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.
Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.
In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.
-
This question is part of the following fields:
- Pharmacology & Poisoning
-
-
Question 95
Correct
-
A 72 year old female is brought into the emergency department with a history of worsening dizziness, muscle cramps, fatigue, and weakness. Examination reveals the patient to have normal blood pressure, regular heart sounds, and a pulse rate of 88 beats per minute. Respiratory examination shows resonant chest sounds in all areas, normal respiratory rate, and oxygen saturations of 96% with coarse crackles heard at the right base. Neurological examination is unremarkable. You order urine and blood tests for analysis. The results are as follows:
Na+ 122 mmol/l
K+ 5.2 mmol/l
Urea 7.1 mmol/l
Creatinine 98 µmol/l
Glucose 6.4 mmol/l
Urine osmolality 410 mosmol/kg
Which of the following actions should be included in this patient's management plan?Your Answer: Fluid restriction
Explanation:The usual approach to managing SIADH without neurological symptoms is to restrict fluid intake. In this case, the patient has SIADH, as evidenced by low serum osmolality due to low sodium levels. It is important to note that the patient’s urine osmolality is high despite the low serum osmolality.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
-
This question is part of the following fields:
- Nephrology
-
-
Question 96
Correct
-
You are the designated team leader in the resuscitation of a cardiac arrest patient. Your colleague disagrees with the decision to continue with the resuscitation.
What is the most appropriate course of action for you to take?Your Answer: Listen to the reason that they disagree and if their concerns are justified, change your decision accordingly
Explanation:In a resuscitation scenario, problem-solving and teamwork are crucial. The pressure is high, and tough decisions need to be made. As the team leader, it is important to value the opinions of other team members, especially those with more experience. By listening to the registrar’s perspective, you may gain new insights that could impact your decision-making process. Collaboration is key in such situations, and if you find yourself unsure of the best course of action, don’t hesitate to seek assistance.
-
This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
-
-
Question 97
Incorrect
-
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: Pneumothorax
Correct 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
-
-
Question 98
Incorrect
-
John is a 68-year-old man with a history of memory impairment and signs of cognitive decline.
Which ONE of the following signs is MOST indicative of a diagnosis of vascular dementia rather than Alzheimer's disease?Your Answer: Gradual progression
Correct Answer: Sudden onset
Explanation:Vascular dementia is not as common as Alzheimer’s disease, accounting for about 20% of dementia cases compared to 50% for Alzheimer’s. Most individuals with vascular dementia have a history of atherosclerotic cardiovascular disease and/or hypertension.
There are notable differences in how these two diseases present themselves. Vascular dementia often has a sudden onset, while Alzheimer’s disease has a slower onset. The progression of vascular dementia tends to be stepwise, with periods of stability followed by sudden declines, whereas Alzheimer’s disease has a more gradual decline. The course of vascular dementia can also fluctuate, while Alzheimer’s disease shows a steady decline over time.
In terms of personality and insight, individuals with vascular dementia tend to have relatively preserved personality and insight in the early stages, whereas those with Alzheimer’s disease may experience early changes and loss in these areas. Gait is also affected differently, with individuals with vascular dementia taking small steps (known as marche a petit pas), while those with Alzheimer’s disease have a normal gait.
Sleep disturbance is less common in vascular dementia compared to Alzheimer’s disease, which commonly presents with sleep disturbances. Focal neurological signs, such as sensory and motor deficits and pseudobulbar palsy, are more common in vascular dementia, while they are uncommon in Alzheimer’s disease.
To differentiate between Alzheimer’s disease and vascular dementia, the modified Hachinski ischemia scale can be used. This scale assigns scores based on various features, such as abrupt onset, stepwise deterioration, fluctuating course, nocturnal confusion, preservation of personality, depression, somatic complaints, emotional incontinence, history of hypertension, history of strokes, evidence of associated atherosclerosis, focal neurological symptoms, and focal neurological signs. A score of 2 or greater suggests vascular dementia.
Overall, understanding the differences in presentation and using tools like the modified Hachinski ischemia scale can help in distinguishing between Alzheimer’s disease and vascular dementia.
-
This question is part of the following fields:
- Elderly Care / Frailty
-
-
Question 99
Incorrect
-
You review a 6-year-old boy with a fever, rash, photophobia, and conjunctivitis for the past 24 hours. On examining his mouth, you observe Koplik’s spots on the buccal mucosa. The parents of the child would like to know how long he should stay home from school.
What is the recommended duration for keeping this infection away from school?Your Answer: 3 days from onset of rash
Correct Answer: 4 days from onset of rash
Explanation:This child has been clinically diagnosed with measles. The typical presentation includes a high fever accompanied by symptoms of a runny nose and sensitivity to light. Conjunctivitis, or pink eye, is often present as well. The associated rash is a widespread red rash with raised bumps. Koplik spots, which are white lesions on the inside of the cheeks, are a telltale sign of measles.
According to Public Health England, it is recommended that children with measles stay away from school, nursery, or childminders for four days starting from when the rash first appears.
For more information, you can refer to the Guidance on Infection Control in Schools and other Childcare Settings.
https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf -
This question is part of the following fields:
- Dermatology
-
-
Question 100
Incorrect
-
A 35-year-old woman comes in with sharp pain during bowel movements. The pain usually continues for an additional 30-60 minutes afterward. She has also observed spots of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past few weeks.
What is the MOST suitable initial treatment option for this situation?Your Answer: Sphincterotomy
Correct Answer: Topical diltiazem
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.
-
This question is part of the following fields:
- Surgical Emergencies
-
-
Question 101
Incorrect
-
You are requested to aid the team in resuscitating a 42-year-old male who has been admitted to the emergency department with various injuries, including a head injury resulting from a severe assault. The patient shows signs of increased intracranial pressure and has been intubated. The specialist registrar is contemplating the use of hyperventilation. What is the impact of hyperventilation on ICP, and what is its underlying mechanism?
Your Answer: Decreases blood pH which results in arterial vasodilation and increased cerebral blood flow
Correct Answer: Increases blood pH which results in arterial vasoconstriction and reduced cerebral blood flow
Explanation:Hyperventilation leads to the constriction of blood vessels in the brain, which in turn reduces the flow and volume of blood in the brain, ultimately decreasing intracranial pressure (ICP). This is because hyperventilation lowers the levels of carbon dioxide (PaCO2) in the blood, resulting in an increase in pH and causing the arteries in the brain to constrict and reduce blood flow. As a result, cerebral blood volume and ICP decrease. The effects of hyperventilation are immediate, but they gradually diminish over a period of 6-24 hours as the brain adjusts its bicarbonate levels to normalize pH. However, caution must be exercised when discontinuing hyperventilation after a prolonged period, as the sudden increase in PaCO2 can lead to a rapid rise in cerebral blood flow and a detrimental increase in ICP.
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
-
This question is part of the following fields:
- Neurology
-
-
Question 102
Incorrect
-
A student nurse on a clinical rotation in the Emergency Department experiences a needlestick injury from a patient with a history of chronic hepatitis B.
Which ONE statement about hepatitis B prophylaxis is accurate?Your Answer: The hepatitis B vaccine is a live attenuated vaccine
Correct Answer: An accelerated regime is available for post-exposure prophylaxis
Explanation:Hepatitis B vaccination is included in the routine childhood immunisation schedule to provide long-term protection against hepatitis for children under 1 year of age. For these children, the vaccination consists of a primary course that includes the diphtheria with tetanus, pertussis, hepatitis B, poliomyelitis, and Haemophilus influenza type B vaccine. This primary course is given at 4 weekly intervals.
The Hepatitis B vaccine is a conjugate vaccine that contains a surface antigen of the hepatitis virus (HBsAg) and is combined with an aluminium adjuvant to enhance its effectiveness. It is produced using a recombinant DNA technique.
When administering the vaccine to adults and older children, the preferred injection site is the deltoid muscle. However, in younger children, the anterolateral thigh is the preferred site. It is not recommended to inject the vaccine in the gluteal area as it has been found to have reduced efficacy.
The standard vaccination regime for Hepatitis B consists of three primary doses. The initial dose is followed by further doses at one and six months later. A booster dose is recommended at five years if the individual is still at risk.
In cases of post-exposure prophylaxis, an accelerated vaccination regime is used. This involves administering a vaccination at the time of exposure, followed by repeat doses at one and two months later.
In high-risk situations, Hepatitis B immunoglobulin can be given up to 7 days after exposure. Ideally, it should be administered within 12 hours, but according to the BNF, it can still be effective if given within 7 days after exposure.
-
This question is part of the following fields:
- Infectious Diseases
-
-
Question 103
Incorrect
-
A 42-year-old man with systemic lupus erythematosus (SLE) has been diagnosed with anaemia of chronic disease.
Which SINGLE statement regarding anaemia of chronic disease is true?Your Answer: Transferrin saturation is elevated
Correct Answer: Total iron binding capacity is usually reduced
Explanation:Anaemia of chronic disease is a type of anaemia that can occur in various chronic conditions, such as rheumatoid arthritis, systemic lupus erythematosus, tuberculosis, malignancy, malnutrition, hypothyroidism, hypopituitarism, chronic kidney disease, and chronic liver disease. The underlying mechanisms of this type of anaemia are complex and not fully understood, with multiple contributing factors involved. One important mediator in inflammatory diseases like rheumatoid arthritis is interleukin-6 (IL-6). Increased levels of IL-6 lead to the production of hepcidin, a hormone that regulates iron balance. Hepcidin prevents the release of iron from the reticulo-endothelial system and affects other aspects of iron metabolism.
Anaemia of chronic disease typically presents as a normochromic, normocytic anaemia, although it can also be microcytic. It is characterized by reduced serum iron, reduced transferrin saturation, and reduced total iron-binding capacity (TIBC). However, the serum ferritin levels are usually normal or increased. Distinguishing anaemia of chronic disease from iron-deficiency anaemia can be challenging, but in iron-deficiency anaemia, the TIBC is typically elevated, and serum ferritin is usually low.
-
This question is part of the following fields:
- Haematology
-
-
Question 104
Incorrect
-
A 21 year old female is brought to the emergency department by her boyfriend as he is concerned the patient has become drowsy after intermittent vomiting throughout the day. The boyfriend informs you that the patient is a type 1 diabetic. After evaluation, the patient is diagnosed with diabetic ketoacidosis and started on fluids and an insulin infusion. Due to a lack of available beds, the patient is transferred to the A&E observation ward. Several hours later, you are asked about discontinuing the insulin infusion. What criteria must be met before stopping the insulin infusion?
Your Answer: Blood glucose less than 11 mmol/l and venous pH between 7.35 and 7.45
Correct Answer: Ketones less than 0.3 mmol/l and venous pH over 7.3
Explanation:In the treatment of diabetic ketoacidosis (DKA), it is important to continue the infusion of insulin until certain criteria are met. These criteria include ketone levels being less than 0.3 mmol/L and the pH of the blood being above 7.3 or the bicarbonate levels being above 18 mmol/L. Additionally, the patient should feel comfortable enough to eat at this point. It is crucial not to stop the intravenous insulin infusion until at least 30 minutes after administering subcutaneous short-acting insulin.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
-
This question is part of the following fields:
- Endocrinology
30.8
-
00
Correct
00
Incorrect
00
:
00
:
00
Session Time
00
:
00
Average Question Time (
Secs)