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  • Question 1 - You are requested to evaluate an older adult patient who has been transported...

    Incorrect

    • You are requested to evaluate an older adult patient who has been transported to the emergency department by ambulance after experiencing a fall overnight. What proportion of falls in the elderly population lead to significant lacerations, traumatic brain injuries, or fractures?

      Your Answer: 15%

      Correct Answer: 50%

      Explanation:

      According to NICE 2019, a significant number of falls in older individuals lead to severe injuries such as major lacerations, traumatic brain injuries, or fractures. Therefore, it is crucial for emergency department clinicians to approach patients over the age of 65 who come in with falls with a heightened level of suspicion.

      Further Reading:

      Falls are a common occurrence in the elderly population, with a significant number of individuals over the age of 65 experiencing at least one fall per year. These falls are often the result of various risk factors, including impaired balance, muscle weakness, visual impairment, cognitive impairment, depression, alcohol misuse, polypharmacy, and environmental hazards. The more risk factors a person has, the higher their risk of falling.

      Falls can have serious complications, particularly in older individuals. They are a leading cause of injury, injury-related disability, and death in this population. Approximately 50% of falls in the elderly result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people living in the community lead to hospitalization or fractures. Hip fractures, in particular, are commonly caused by falls and have a high mortality rate within one year.

      Complications of falls include fractures, soft tissue injuries, fragility fractures, distress, pain, loss of self-confidence, reduced quality of life, loss of independence, fear of falls and activity avoidance, social isolation, increasing frailty, functional decline, depression, and institutionalization. Additionally, individuals who remain on the floor for more than one hour after a fall are at risk of dehydration, pressure sores, pneumonia, hypothermia, and rhabdomyolysis.

      Assessing falls requires a comprehensive history, including the course of events leading up to the fall, any pre-fall symptoms, and details about the fall itself. A thorough examination is also necessary, including an assessment of injuries, neurological and cardiovascular function, tests for underlying causes, vision assessment, and medication review. Home hazard assessments and frailty assessments are also important components of the assessment process.

      Determining the frailty of older patients is crucial in deciding if they can be safely discharged and what level of care they require. The clinical Frailty Scale (CFS or Rockwood score) is commonly used for this purpose. It helps healthcare professionals evaluate the overall frailty of a patient and make appropriate care decisions.

      In summary, falls are a significant concern in the elderly population, with multiple risk factors contributing to their occurrence. These falls can lead to serious complications and have a negative impact on an individual’s quality of life. Assessing falls requires a comprehensive approach, including a thorough history, examination, and consideration of frailty.

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      • Elderly Care / Frailty
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  • Question 2 - A 68 year old female is brought into the emergency department following a...

    Incorrect

    • A 68 year old female is brought into the emergency department following 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 most suitable test to confirm the diagnosis?

      Your Answer:

      Correct Answer: Measure lying and standing blood pressure (BP) with repeated BP measurements while standing for 3 minutes

      Explanation:

      To measure blood pressure while standing, you will need to take repeated measurements for a duration of 3 minutes. This involves measuring both lying and standing blood pressure.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

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  • Question 3 - You admit a 65-year-old woman to the clinical decision unit (CDU) following a...

    Incorrect

    • You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has mild-to-moderate Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
      Which ONE of the following drugs is NOT recommended by NICE to improve cognition in patients suffering from Alzheimer’s disease?

      Your Answer:

      Correct Answer: Moclobemide

      Explanation:

      According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.

      On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.

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  • Question 4 - A 65-year-old woman presents having experienced a minor fall while shopping with her...

    Incorrect

    • A 65-year-old woman presents having experienced a minor fall while shopping with her husband. He has observed that she has been forgetful for quite some time and that her condition has been gradually deteriorating over the past few years. She frequently forgets the names of people and places and struggles to find words for things. Lately, she has also been experiencing increased confusion. She has no significant medical history of note.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Alzheimer’s disease

      Explanation:

      Alzheimer’s disease is the leading cause of dementia, accounting for approximately half of all cases. It involves the gradual degeneration of the cerebral cortex, resulting in cortical atrophy, the formation of neurofibrillary tangles and amyloid plaques, and a decrease in acetylcholine production from affected neurons. The exact cause of this disease is still not fully understood.

      The onset of Alzheimer’s disease is typically slow and subtle, progressing over a span of 7 to 10 years. The symptoms experienced by individuals vary depending on the stage of the disease. In the early stages, family and friends may notice that the patient becomes forgetful, experiencing lapses in memory. They may struggle to recall the names of people and places, as well as have difficulty finding the right words for objects. Recent events and appointments are easily forgotten. As the disease advances, language skills deteriorate, and problems with planning and decision-making arise. The patient may also exhibit apraxia and become more noticeably confused.

      In the later stages of Alzheimer’s disease, symptoms become more severe. The patient may wander aimlessly, become disoriented, and display apathy. Psychiatric symptoms, such as depression, are common during this stage. Hallucinations and delusions may also occur. Behavioral issues, including disinhibition, aggression, and agitation, can be distressing for the patient’s family.

      Considering the absence of a history of transient ischemic attacks (TIAs) or cardiovascular disease, vascular dementia is less likely. Unlike Alzheimer’s disease, vascular dementia typically has a more sudden onset and exhibits stepwise increases in symptom severity.

      Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative disorder closely associated with Parkinson’s disease. It can be distinguished from Alzheimer’s disease by the presence of mild Parkinsonism features, fluctuations in cognition and attention, episodes of transient loss of consciousness, and early occurrence of visual hallucinations and complex delusions.

      Frontotemporal dementia is a progressive form of dementia that primarily affects the frontal and/or temporal lobes. It typically occurs at a younger age than Alzheimer’s disease, usually between 40 and 60 years old. Personality changes often precede memory loss in this condition.

      Pseudodementia, also known as depression-related cognitive dysfunction, is a condition characterized by a temporary decline in cognitive function alongside a functional psychiatric disorder. While depression is the most common cause.

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  • Question 5 - You review a 65-year-old woman who is on the clinical decision unit (CDU)...

    Incorrect

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

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

      Your Answer:

      Correct Answer: Alzheimer’s disease

      Explanation:

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

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  • Question 6 - You evaluate a 72-year-old in the emergency department who has come in with...

    Incorrect

    • You evaluate a 72-year-old in the emergency department who has come in with complaints of back pain. After conducting a thorough assessment, you observe that the patient possesses several risk factors for osteoporosis. You recommend that the patient undergo a formal evaluation to determine their risk of osteoporotic fractures. Which tool is considered the gold standard for this assessment?

      Your Answer:

      Correct Answer: Qfracture

      Explanation:

      QFracture is a highly regarded tool used to predict the risk of osteoporotic fractures and determine if a DXA bone assessment is necessary. It is considered the preferred and gold standard tool by NICE and SIGN. FRAX is another fracture risk assessment tool that is also used to determine the need for a DXA bone assessment. The Rockwood score and electronic frailty Index (eFI) are both frailty scores. The informant questionnaire on cognitive decline in the elderly is a tool used to assess cognitive decline in older individuals.

      Further Reading:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

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  • Question 7 - You admit a 65-year-old woman to the clinical decision unit (CDU) following a...

    Incorrect

    • You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has mild-to-moderate Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
      Which ONE of the following medications can be used as a first-line drug in the management of mild-to-moderate Alzheimer’s disease?

      Your Answer:

      Correct Answer: Rivastigmine

      Explanation:

      According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.

      On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.

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      • Elderly Care / Frailty
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  • Question 8 - A 65 year old female is brought into the emergency department following a...

    Incorrect

    • A 65 year old female is brought into the emergency department following a fall. You observe that the patient has several risk factors for osteoporosis and conduct a Qfractureâ„¢ assessment. What is the threshold for conducting a DXA (DEXA) bone density scan?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

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  • Question 9 - A 65-year-old woman presents with a history of recurrent falls. She is accompanied...

    Incorrect

    • A 65-year-old woman presents with a history of recurrent falls. She is accompanied by her daughter, who tells you that the falls have been getting worse over the past year and that she has also been acting strangely and showing signs of memory loss. Recently, she has also experienced several episodes of urinary incontinence. On examination, you observe that she has a wide-based, shuffling gait.

      What is the definitive treatment for the underlying condition in this scenario?

      Your Answer:

      Correct Answer: Surgical insertion of a CSF shunt

      Explanation:

      This patient is displaying symptoms that are characteristic of normal-pressure hydrocephalus (NPH). NPH is a type of communicating hydrocephalus where the pressure inside the skull, as measured through lumbar puncture, is either normal or occasionally elevated. It primarily affects elderly individuals, and the likelihood of developing NPH increases with age.

      Around 50% of NPH cases are idiopathic, meaning that no clear cause can be identified. The remaining cases are secondary to various conditions such as head injury, meningitis, subarachnoid hemorrhage, central nervous system tumors, and radiotherapy.

      The typical presentation of NPH includes a classic triad of symptoms: gait disturbance (often characterized by a broad-based and shuffling gait), sphincter disturbance leading to incontinence (usually urinary incontinence), and progressive dementia with memory loss, inattention, inertia, and bradyphrenia.

      Diagnosing NPH primarily relies on identifying the classic clinical triad mentioned above. Additional investigations can provide supportive evidence and may involve CT and MRI scans, which reveal enlarged ventricles and periventricular lucency. Lumbar puncture can also be performed to assess cerebrospinal fluid (CSF) levels, which are typically normal or intermittently elevated. Intraventricular monitoring may show beta waves present for more than 5% of a 24-hour period.

      NPH is one of the few reversible causes of dementia, making early recognition and treatment crucial. Medical treatment options include the use of carbonic anhydrase inhibitors (such as acetazolamide) and repeated lumbar punctures as temporary measures. However, the definitive treatment for NPH involves surgically inserting a cerebrospinal fluid (CSF) shunt. This procedure provides lasting clinical benefits for 70% to 90% of patients compared to their pre-operative state.

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  • Question 10 - A 45-year-old woman is brought in by her husband due to issues with...

    Incorrect

    • A 45-year-old woman is brought in by her husband due to issues with her memory. She was fine until a few hours ago but started experiencing symptoms right after engaging in sexual activity. She is currently restless and disoriented, frequently asking the same questions repeatedly. Her neurological exam is normal, and there are no indications of drug use or intoxication.
      What is the MOST LIKELY diagnosis in this case?

      Your Answer:

      Correct Answer: Transient global amnesia

      Explanation:

      Transient global amnesia (TGA) is a neurological condition where individuals experience a temporary loss of short-term memory. This disorder is commonly observed in individuals over the age of 50 and is often associated with migraines.

      The onset of TGA is typically sudden and can occur after engaging in strenuous exercise, sexual activity, or exposure to cold temperatures. These episodes usually last for a few hours and almost always resolve within 24 hours. One distinctive characteristic of TGA is perseveration, where patients repetitively ask the same question. Interestingly, once the episode has passed, individuals are unable to recall it.

      Unlike a transient ischemic attack, TGA does not result in any focal neurological deficits, and the patient’s physical examination will appear normal.

      On the other hand, a fugue state also involves temporary memory loss but presents differently. It is characterized by a loss of personal identity, past memories, and personality traits. Individuals experiencing a fugue state may even adopt entirely new identities and often engage in unplanned travel away from familiar surroundings.

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  • Question 11 - A 65 year old male presents to the emergency department with sudden onset...

    Incorrect

    • A 65 year old male presents to the emergency department with sudden onset of central back pain. After evaluation, you order an X-ray which reveals anterior wedging of the L2 vertebra. You suspect the patient may have undiagnosed osteoporosis. Which of the following statements about osteoporosis is correct?

      Your Answer:

      Correct Answer: Osteoporosis is defined as a T-score of less than -2.5

      Explanation:

      Osteoporosis is a condition characterized by weak and brittle bones, making them more prone to fractures. In this case, the patient’s sudden onset of central back pain and the X-ray findings of anterior wedging of the L2 vertebra suggest the possibility of undiagnosed osteoporosis.

      One correct statement about osteoporosis is that it is defined as a T-score of less than -2.5. The T-score is a measure of bone density and is used to diagnose osteoporosis. A T-score of -2.5 or lower indicates a significant decrease in bone density and an increased risk of fractures.

      Skeletal scintigraphy is not used to diagnose osteoporosis. Instead, it is commonly used to evaluate for other conditions such as bone infections or tumors.

      The pubic rami is not the most common site for osteoporotic fractures. Osteoporotic fractures commonly occur in the spine (vertebral fractures), hip, and wrist.

      Osteoporosis is not characterized by increased bone turnover in focal areas of the axial skeleton with a lytic phase followed by a rapid increase in bone formation by osteoblasts in the sclerotic phase. This description is more consistent with a condition called Paget’s disease of bone.

      The prevalence of osteoporosis is not approximately 10% at 50 years of age. The prevalence of osteoporosis increases with age, and it is estimated that around 50% of women and 25% of men over the age of 50 will experience an osteoporotic fracture in their lifetime.

      Further Reading:

      Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.

      Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.

      The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.

      There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.

      Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.

      Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.

      Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.

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  • Question 12 - A 45-year-old man with a long-standing history of mental health issues, including bipolar...

    Incorrect

    • A 45-year-old man with a long-standing history of mental health issues, including bipolar disorder and anxiety, comes in alone expressing worries about his memory. He reports struggling to recall where he has placed items around his home and occasionally forgetting the names of his acquaintances. This onset occurred abruptly one week ago, and he emphasizes the significant impact it is having on his daily life.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Pseudodementia

      Explanation:

      Pseudodementia, also known as depression-related cognitive dysfunction, is a condition where there is a temporary decline in cognitive function alongside a functional psychiatric disorder. While depression is the most common cause, it can also be observed in various psychiatric conditions such as schizophrenia, bipolar disorder, and hysteria. Fortunately, this condition is reversible with treatment of the underlying psychiatric issue. However, it is important to note that pseudodementia is associated with a relatively high risk of suicide.

      There are several features that are indicative of a diagnosis of pseudodementia. These include a history of a psychiatric condition, a sudden onset of symptoms, the presence of insight into one’s condition, a tendency to emphasize disability, and the absence of changes in cognition during nighttime. By recognizing these characteristics, healthcare professionals can better identify and address this condition.

      Overall, pseudodementia is a temporary decline in cognitive function that occurs alongside a functional psychiatric disorder. It is important to seek appropriate treatment for the underlying psychiatric condition in order to reverse the cognitive decline. Additionally, it is crucial to be aware of the increased risk of suicide associated with this condition.

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  • Question 13 - You are examining the hip X-rays of a 78-year-old woman who slipped while...

    Incorrect

    • You are examining the hip X-rays of a 78-year-old woman who slipped while getting out of bed. What can be helpful in identifying a femoral neck fracture on the anteroposterior X-ray?

      Your Answer:

      Correct Answer: Shenton's line

      Explanation:

      Shenton’s line is a useful tool for identifying hip fractures on radiographs. It is a curved line that is drawn along the bottom edge of the upper pubic bone and the inner lower edge of the femur neck. This line should be smooth and uninterrupted. If there are any breaks or irregularities in the line, it could indicate a fracture, dysplasia, or dislocation.

      Further Reading:

      Fractured neck of femur is a common injury, especially in elderly patients who have experienced a low impact fall. Risk factors for this type of fracture include falls, osteoporosis, and other bone disorders such as metastatic cancers, hyperparathyroidism, and osteomalacia.

      There are different classification systems for hip fractures, but the most important differentiation is between intracapsular and extracapsular fractures. The blood supply to the femoral neck and head is primarily from ascending cervical branches that arise from an arterial anastomosis between the medial and lateral circumflex branches of the femoral arteries. Fractures in the intracapsular region can damage the blood supply and lead to avascular necrosis (AVN), with the risk increasing with displacement. The Garden classification can be used to classify intracapsular neck of femur fractures and determine the risk of AVN. Those at highest risk will typically require hip replacement or arthroplasty.

      Fractures below or distal to the capsule are termed extracapsular and can be further described as intertrochanteric or subtrochanteric depending on their location. The blood supply to the femoral neck and head is usually maintained with these fractures, making them amenable to surgery that preserves the femoral head and neck, such as dynamic hip screw fixation.

      Diagnosing hip fractures can be done through radiographs, with Shenton’s line and assessing the trabecular pattern of the proximal femur being helpful techniques. X-rays should be obtained in both the AP and lateral views, and if an occult fracture is suspected, an MRI or CT scan may be necessary.

      In terms of standards of care, it is important to assess the patient’s pain score within 15 minutes of arrival in the emergency department and provide appropriate analgesia within the recommended timeframes. Patients with moderate or severe pain should have their pain reassessed within 30 minutes of receiving analgesia. X-rays should be obtained within 120 minutes of arrival, and patients should be admitted within 4 hours of arrival.

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  • Question 14 - You admit a 65-year-old woman to the clinical decision unit (CDU) following a...

    Incorrect

    • You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has advanced Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
      Which ONE of the following medications is recommended by NICE for use in the treatment of advanced Alzheimer’s disease?

      Your Answer:

      Correct Answer: Memantine

      Explanation:

      According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.

      On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.

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  • Question 15 - You assess a patient in the clinical decision unit (CDU) who has a...

    Incorrect

    • You assess a patient in the clinical decision unit (CDU) who has a confirmed diagnosis of Pick's disease.
      Which ONE statement about this condition is accurate?

      Your Answer:

      Correct Answer: Personality changes usually occur before memory loss

      Explanation:

      Pick’s disease is a rare neurodegenerative disorder that leads to a gradual decline in cognitive function known as frontotemporal dementia. One of the key features of this condition is the accumulation of tau proteins in neurons, forming silver-staining, spherical aggregations called Pick bodies.

      Typically, Pick’s disease manifests between the ages of 40 and 60. Initially, individuals may experience changes in their personality, such as disinhibition, tactlessness, and vulgarity. They may also exhibit alterations in their moral values and attempt to distance themselves from their family. Concentration problems, over-activity, pacing, and wandering are also common symptoms during this stage.

      What sets Pick’s disease apart from Alzheimer’s disease is that the personality changes occur before memory loss. As the disease progresses, patients will experience deficits in intellect, memory, and language.

      On the other hand, Lewy body dementia (LBD) is characterized by the presence of Lewy bodies, which are different from the Pick bodies seen in Pick’s disease.

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  • Question 16 - A 65 year old female is brought to the emergency department by her...

    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:

      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.

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  • Question 17 - A 72-year-old man comes with his wife due to worries about his memory....

    Incorrect

    • 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:

      Correct 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.

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  • Question 18 - A 62-year-old man presents with depressive symptoms, mood swings, difficulty writing, memory impairment,...

    Incorrect

    • A 62-year-old man presents with depressive symptoms, mood swings, difficulty writing, memory impairment, and difficulty generating ideas.
      Which of the following is the SINGLE MOST likely diagnosis?

      Your Answer:

      Correct Answer: Alzheimer’s Disease

      Explanation:

      Alzheimer’s disease is characterized by various clinical features. These include memory loss, mood swings, apathy, and the presence of depressive or paranoid symptoms. Additionally, individuals with Alzheimer’s may experience Parkinsonism, a condition that affects movement, as well as a syndrome associated with the parietal lobe. Other symptoms may include difficulties with tasks such as copying 2D drawings, dressing properly, and carrying out a sequence of actions. Furthermore, individuals may struggle with copying gestures and may exhibit denial of their disorder, known as anosognosia. Topographical agnosia, or getting lost in familiar surroundings, may also be present, along with sensory inattention and astereognosis, which is the inability to identify objects when placed in the hand. Ultimately, Alzheimer’s disease is characterized by a relentless progression of personality and intellectual deterioration.

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  • Question 19 - A 70-year-old man with a known history of Alzheimer's disease and a previous...

    Incorrect

    • A 70-year-old man with a known history of Alzheimer's disease and a previous heart attack experiences urinary incontinence and a sudden decline in his cognitive function. He denies experiencing any abdominal pain or discomfort while urinating.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Urinary tract infection

      Explanation:

      Symptoms of urinary tract infection (UTI) can be difficult to detect in elderly patients, especially those with dementia. Common signs like painful urination and abdominal discomfort may be absent. Instead, these patients often experience increased confusion, restlessness, and a decline in cognitive abilities. Therefore, if an elderly patient suddenly develops urinary incontinence and experiences a rapid deterioration in cognitive function, it is highly likely that they have a UTI.

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  • Question 20 - A 65-year-old woman presents with a history of frequent falls, difficulty with walking,...

    Incorrect

    • A 65-year-old woman presents with a history of frequent falls, difficulty with walking, and bladder control problems. After a thorough evaluation and tests, a diagnosis of normal-pressure hydrocephalus is made.
      What is the most common underlying factor leading to NPH?

      Your Answer:

      Correct Answer: Idiopathic – no cause found

      Explanation:

      This patient is displaying symptoms that are characteristic of normal-pressure hydrocephalus (NPH). NPH is a type of communicating hydrocephalus where the pressure inside the skull, as measured through a lumbar puncture, is either normal or occasionally elevated. It primarily affects elderly individuals, and the likelihood of developing NPH increases with age.

      Around 50% of NPH cases are considered idiopathic, meaning there is no identifiable cause. The remaining cases are secondary to various conditions such as head injury, meningitis, subarachnoid hemorrhage, central nervous system tumors, and radiotherapy.

      The typical presentation of NPH includes a classic triad of symptoms: gait disturbance (often characterized by a broad-based and shuffling gait), sphincter disturbance leading to incontinence (usually urinary incontinence), and progressive dementia with memory loss, inattention, inertia, and bradyphrenia.

      Diagnosing NPH primarily relies on identifying the classic clinical triad mentioned above. Additional investigations can provide supportive evidence, including CT and MRI scans that reveal enlarged ventricles and periventricular lucency. Lumbar puncture may also be performed, with the cerebrospinal fluid (CSF) typically appearing normal or intermittently elevated. Intraventricular monitoring may show beta waves for more than 5% of a 24-hour period.

      NPH is one of the few reversible causes of dementia, making early recognition and treatment crucial. Medical treatment options such as carbonic anhydrase inhibitors (e.g., acetazolamide) and repeated lumbar punctures can provide temporary relief. However, the definitive treatment for NPH involves surgically inserting a cerebrospinal fluid (CSF) shunt. This procedure has shown lasting clinical benefits in 70% to 90% of patients compared to their pre-operative state.

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  • Question 21 - You review a 72-year-old man that is on the Clinical Decision Unit (CDU)...

    Incorrect

    • You review a 72-year-old man that is on the Clinical Decision Unit (CDU) following the reduction of a hip fracture. His GP recently organized a DEXA scan, and you have managed to access the results on the CDU computer. The results showed a T-score of -2.0 standard deviations. He has no independent risk factors for fractures and no other indicators of low bone mineral density.
      Which SINGLE statement regarding this case is true?

      Your Answer:

      Correct Answer: The patient has osteopenia

      Explanation:

      Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.

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  • Question 22 - A 68 year old is brought into the emergency department by ambulance after...

    Incorrect

    • A 68 year old is brought into the emergency department by ambulance after falling down the stairs. The patient typically receives assistance from carers four times a day for bathing, getting dressed, and using the restroom. The ambulance crew informs you that the patient has a poor appetite as they have advanced lung cancer and discontinued chemotherapy 3 months ago due to disease progression and deteriorating health. The ambulance crew also mentions that the patient's palliative care specialist recently estimated their life expectancy to be a matter of weeks during their last consultation. What would be the clinical frailty score for this patient?

      Your Answer:

      Correct Answer: 9

      Explanation:

      The clinical frailty score is a tool used to evaluate frailty and determine the level of safety for a patient’s discharge from the hospital. A higher CFS score indicates a greater likelihood of an extended hospital stay, increased need for support after discharge, and higher risk of mortality. In the case of this patient with terminal cancer and a life expectancy of less than 6 months, they would be classified as having the highest possible frailty score.

      Further Reading:

      Falls are a common occurrence in the elderly population, with a significant number of individuals over the age of 65 experiencing at least one fall per year. These falls are often the result of various risk factors, including impaired balance, muscle weakness, visual impairment, cognitive impairment, depression, alcohol misuse, polypharmacy, and environmental hazards. The more risk factors a person has, the higher their risk of falling.

      Falls can have serious complications, particularly in older individuals. They are a leading cause of injury, injury-related disability, and death in this population. Approximately 50% of falls in the elderly result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people living in the community lead to hospitalization or fractures. Hip fractures, in particular, are commonly caused by falls and have a high mortality rate within one year.

      Complications of falls include fractures, soft tissue injuries, fragility fractures, distress, pain, loss of self-confidence, reduced quality of life, loss of independence, fear of falls and activity avoidance, social isolation, increasing frailty, functional decline, depression, and institutionalization. Additionally, individuals who remain on the floor for more than one hour after a fall are at risk of dehydration, pressure sores, pneumonia, hypothermia, and rhabdomyolysis.

      Assessing falls requires a comprehensive history, including the course of events leading up to the fall, any pre-fall symptoms, and details about the fall itself. A thorough examination is also necessary, including an assessment of injuries, neurological and cardiovascular function, tests for underlying causes, vision assessment, and medication review. Home hazard assessments and frailty assessments are also important components of the assessment process.

      Determining the frailty of older patients is crucial in deciding if they can be safely discharged and what level of care they require. The clinical Frailty Scale (CFS or Rockwood score) is commonly used for this purpose. It helps healthcare professionals evaluate the overall frailty of a patient and make appropriate care decisions.

      In summary, falls are a significant concern in the elderly population, with multiple risk factors contributing to their occurrence. These falls can lead to serious complications and have a negative impact on an individual’s quality of life. Assessing falls requires a comprehensive approach, including a thorough history, examination, and consideration of frailty.

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  • Question 23 - A 68-year-old man suffers a fractured neck of femur. He is later diagnosed...

    Incorrect

    • 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:

      Correct 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.

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  • Question 24 - You review a 72-year-old woman who is on the clinical decision unit (CDU)...

    Incorrect

    • You review a 72-year-old woman who is on the clinical decision unit (CDU) following a fall. Her son is present, and he is concerned about recent problems she has had with memory loss. He is very worried that she may be showing signs of developing dementia. You perform a mini-mental state examination (MMSE).
      Which of the following scores is indicative of mild dementia?

      Your Answer:

      Correct Answer: 23

      Explanation:

      The mini-mental state examination (MMSE) is a tool consisting of 11 questions that is utilized to evaluate cognitive function. With a maximum score of 30, a score below 24 generally indicates impaired cognitive function. This assessment can be employed to categorize the severity of cognitive impairment in dementia. Mild dementia is typically associated with an MMSE score ranging from 20 to 24, while moderate dementia falls within the MMSE score range of 13 to 20. Severe dementia is characterized by an MMSE score below 12. For more information on testing and assessment for dementia, you can visit the Alzheimer’s Association website. Additionally, the RCEM syllabus references EIP9 for memory loss and EIC4 for dementia and cognitive impairment.

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  • Question 25 - You are evaluating a 70-year-old individual in the emergency department. Laboratory results indicate...

    Incorrect

    • You are evaluating a 70-year-old individual in the emergency department. Laboratory results indicate a serum potassium level of 6.9 mmol/L. An electrocardiogram (ECG) is conducted. Which of the subsequent ECG alterations is linked to hyperkalemia?

      Your Answer:

      Correct Answer: P-wave flattening

      Explanation:

      Hyperkalaemia, a condition characterized by high levels of potassium in the blood, can be identified through specific changes seen on an electrocardiogram (ECG). One of these changes is the tenting of T-waves, where the T-waves become tall and pointed. Additionally, the P-wave, which represents atrial depolarization, may widen and flatten. Other ECG changes associated with hyperkalaemia include a prolonged PR interval, flat P-waves, wide P-waves, widened QRS complex, the appearance of a sine wave pattern, and the possibility of heart block.

      Further Reading:

      Vasoactive drugs can be classified into three categories: inotropes, vasopressors, and unclassified. Inotropes are drugs that alter the force of muscular contraction, particularly in the heart. They primarily stimulate adrenergic receptors and increase myocardial contractility. Commonly used inotropes include adrenaline, dobutamine, dopamine, isoprenaline, and ephedrine.

      Vasopressors, on the other hand, increase systemic vascular resistance (SVR) by stimulating alpha-1 receptors, causing vasoconstriction. This leads to an increase in blood pressure. Commonly used vasopressors include norepinephrine, metaraminol, phenylephrine, and vasopressin.

      Electrolytes, such as potassium, are essential for proper bodily function. Solutions containing potassium are often given to patients to prevent or treat hypokalemia (low potassium levels). However, administering too much potassium can lead to hyperkalemia (high potassium levels), which can cause dangerous arrhythmias. It is important to monitor potassium levels and administer it at a controlled rate to avoid complications.

      Hyperkalemia can be caused by various factors, including excessive potassium intake, decreased renal excretion, endocrine disorders, certain medications, metabolic acidosis, tissue destruction, and massive blood transfusion. It can present with cardiovascular, respiratory, gastrointestinal, and neuromuscular symptoms. ECG changes, such as tall tented T-waves, prolonged PR interval, flat P-waves, widened QRS complex, and sine wave, are also characteristic of hyperkalemia.

      In summary, vasoactive drugs can be categorized as inotropes, vasopressors, or unclassified. Inotropes increase myocardial contractility, while vasopressors increase systemic vascular resistance. Electrolytes, particularly potassium, are important for bodily function, but administering too much can lead to hyperkalemia. Monitoring potassium levels and ECG changes is crucial in managing hyperkalemia.

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  • Question 26 - You review a 72-year-old man who is currently on the Clinical Decision Unit...

    Incorrect

    • You review a 72-year-old man who is currently on the Clinical Decision Unit (CDU) after undergoing surgery for a hip fracture that occurred as a result of a fall. He informs you that he experienced the onset of menopause in his early 50s. His primary care physician recently arranged for a DEXA scan, and you have obtained the results from the CDU computer. The scan reveals a T-score of -3.0 standard deviations. Upon reviewing his medical history and family history, you discover that his father suffered a hip fracture in his early 60s, and the patient himself has a body mass index of 21 kg/m2.

      Which SINGLE statement regarding this case is true?

      Your Answer:

      Correct Answer: She has osteoporosis and ideally should be started on a combination of treatment such as alendronate and calcichew D3 forte

      Explanation:

      Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.

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  • Question 27 - You are treating an 82-year-old patient who is unable to bear weight after...

    Incorrect

    • You are treating an 82-year-old patient who is unable to bear weight after a fall. X-ray results confirm a fractured neck of femur. You inform the patient that they will be referred for surgery. In terms of the blood supply to the femoral neck, which artery is responsible for supplying blood to this area?

      Your Answer:

      Correct Answer: Deep femoral artery

      Explanation:

      The femoral neck receives its blood supply from branches of the deep femoral artery, also known as the profunda femoris artery. The deep femoral artery gives rise to the medial and lateral circumflex branches, which form a network of blood vessels around the femoral neck.

      Further Reading:

      Fractured neck of femur is a common injury, especially in elderly patients who have experienced a low impact fall. Risk factors for this type of fracture include falls, osteoporosis, and other bone disorders such as metastatic cancers, hyperparathyroidism, and osteomalacia.

      There are different classification systems for hip fractures, but the most important differentiation is between intracapsular and extracapsular fractures. The blood supply to the femoral neck and head is primarily from ascending cervical branches that arise from an arterial anastomosis between the medial and lateral circumflex branches of the femoral arteries. Fractures in the intracapsular region can damage the blood supply and lead to avascular necrosis (AVN), with the risk increasing with displacement. The Garden classification can be used to classify intracapsular neck of femur fractures and determine the risk of AVN. Those at highest risk will typically require hip replacement or arthroplasty.

      Fractures below or distal to the capsule are termed extracapsular and can be further described as intertrochanteric or subtrochanteric depending on their location. The blood supply to the femoral neck and head is usually maintained with these fractures, making them amenable to surgery that preserves the femoral head and neck, such as dynamic hip screw fixation.

      Diagnosing hip fractures can be done through radiographs, with Shenton’s line and assessing the trabecular pattern of the proximal femur being helpful techniques. X-rays should be obtained in both the AP and lateral views, and if an occult fracture is suspected, an MRI or CT scan may be necessary.

      In terms of standards of care, it is important to assess the patient’s pain score within 15 minutes of arrival in the emergency department and provide appropriate analgesia within the recommended timeframes. Patients with moderate or severe pain should have their pain reassessed within 30 minutes of receiving analgesia. X-rays should be obtained within 120 minutes of arrival, and patients should be admitted within 4 hours of arrival.

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  • Question 28 - A 68 year old female is brought into the emergency department after a...

    Incorrect

    • A 68 year old female is brought into the emergency department after a fall. The patient is accompanied by her children who inform you that there have been several falls in recent weeks. These falls tend to happen in the morning when the patient gets out of bed and appear to have worsened since the GP altered the patient's usual medication. You suspect orthostatic hypotension. What is the minimum blood pressure drop upon standing that is necessary to confirm the diagnosis?

      Your Answer:

      Correct Answer: 20 mmHg systolic or 10 mmHg diastolic

      Explanation:

      To diagnose orthostatic hypotension, there needs to be a decrease in systolic blood pressure of at least 20 mmHg (or 30 mmHg for individuals with hypertension) and/or a decrease in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing. This confirms the presence of orthostatic hypotension.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

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  • Question 29 - You review a patient on the clinical decision unit (CDU) with a known...

    Incorrect

    • You review a patient on the clinical decision unit (CDU) with a known diagnosis of Alzheimer's disease (AD).
      Which SINGLE statement regarding this condition is true?

      Your Answer:

      Correct Answer: It is the third most common cause of dementia in the elderly

      Explanation:

      Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative condition that is closely linked to Parkinson’s disease (PD). It is the third most common cause of dementia in older individuals, following Alzheimer’s disease and vascular dementia.

      DLB is characterized by several clinical features, including the presence of Parkinsonism or co-existing PD, a gradual decline in cognitive function, fluctuations in cognition, alertness, and attention span, episodes of temporary loss of consciousness, recurrent falls, visual hallucinations, depression, and complex, systematized delusions. The level of cognitive impairment can vary from hour to hour and day to day.

      Pathologically, DLB is marked by the formation of abnormal protein collections called Lewy bodies within the cytoplasm of neurons. These intracellular protein collections share similar structural characteristics with the classic Lewy bodies observed in Parkinson’s disease.

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  • Question 30 - A 68-year-old woman comes in after experiencing an episode of weakness in her...

    Incorrect

    • A 68-year-old woman comes in after experiencing an episode of weakness in her left arm and leg that resolved within a few hours. Her family has noticed a sudden increase in forgetfulness over the past week, with difficulty remembering names of people and places and struggling to find the right words for things.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct 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.

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