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  • Question 1 - You assess a patient who has a confirmed diagnosis of Parkinson's disease. She...

    Correct

    • You assess a patient who has a confirmed diagnosis of Parkinson's disease. She has been living with the disease for several years and is currently in the advanced stages of the condition.
      Which of the following clinical manifestations is typically observed only in the later stages of Parkinson's disease?

      Your Answer: Cognitive impairment

      Explanation:

      Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:

      – Hypokinesia (reduced movement)
      – Bradykinesia (slow movement)
      – Rest tremor (usually occurring at a rate of 4-6 cycles per second)
      – Rigidity (increased muscle tone and ‘cogwheel rigidity’)

      Other commonly observed clinical features include:

      – Gait disturbance (characterized by a shuffling gait and loss of arm swing)
      – Loss of facial expression
      – Monotonous, slurred speech
      – Micrographia (small, cramped handwriting)
      – Increased salivation and dribbling
      – Difficulty with fine movements

      Initially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:

      – Postural instability
      – Cognitive impairment
      – Orthostatic hypotension

      Although PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.

    • This question is part of the following fields:

      • Neurology
      7
      Seconds
  • Question 2 - A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her...

    Correct

    • A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her left loin. During the examination, she experiences tenderness over the left renal angle, and her temperature is 38.6°C. The triage nurse has already inserted a cannula, and a complete set of blood tests has been sent to the lab.

      What is the SINGLE most probable diagnosis?

      Your Answer: Pyelonephritis

      Explanation:

      This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.

      According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.

      NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).

      For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.

      For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.

    • This question is part of the following fields:

      • Urology
      7.5
      Seconds
  • Question 3 - A 58 year old male comes to the emergency department complaining of palpitations,...

    Correct

    • A 58 year old male comes to the emergency department complaining of palpitations, swollen legs, and excessive sweating. Thyroid function tests are requested and reveal low TSH and elevated free T4 levels. Which of the following medications is most likely responsible for these symptoms?

      Your Answer: Amiodarone

      Explanation:

      Amiodarone, a medication used to treat heart rhythm problems, can have effects on the thyroid gland. It can either cause hypothyroidism (low thyroid hormone levels) or hyperthyroidism (high thyroid hormone levels). Amiodarone is a highly fat-soluble drug that accumulates in various tissues, including the thyroid. Even after stopping the medication, its effects can still be seen due to its long elimination half-life of around 100 days.

      The reason behind amiodarone impact on the thyroid is believed to be its high iodine content. In patients with sufficient iodine levels, amiodarone-induced hypothyroidism is more likely to occur. On the other hand, in populations with low iodine levels, amiodarone can lead to a condition called iodine-induced thyrotoxicosis, which is characterized by hyperthyroidism.

      The mechanism of amiodarone-induced hypothyroidism involves the release of iodide from the drug, which blocks the uptake of further iodide by the thyroid gland and hampers the production of thyroid hormones. Additionally, amiodarone inhibits the conversion of the inactive thyroid hormone T4 to the active form T3.

      Amiodarone-induced hyperthyroidism, on the other hand, is thought to occur in individuals with abnormal thyroid glands, such as those with nodular goiters, autonomous nodules, or latent Graves’ disease. In these cases, the excess iodine from amiodarone overwhelms the thyroid’s normal regulatory mechanisms, leading to hyperthyroidism.

      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. hypotension, hypoventilation, altered mental state, seizures and/or coma.

    • This question is part of the following fields:

      • Endocrinology
      9.3
      Seconds
  • Question 4 - A 32-year-old woman is admitted to the department after ingesting an excessive amount...

    Correct

    • A 32-year-old woman is admitted to the department after ingesting an excessive amount of tricyclic antidepressants (TCAs) four hours ago.
      Which of the following ECG findings is most frequently observed in cases of TCA overdose?

      Your Answer: Sinus tachycardia

      Explanation:

      The most commonly observed change in the electrocardiogram (ECG) during a tricyclic antidepressant (TCA) overdose is sinus tachycardia. Additionally, other ECG changes that can be seen in TCA overdose include prolongation of the PR interval, broadening of the QRS complex, prolongation of the QT interval, and the occurrence of ventricular arrhythmias in cases of severe toxicity. The cardiotoxic effects of TCAs are caused by the blocking of sodium channels, which leads to broadening of the QRS complex, and the blocking of potassium channels, which results in prolongation of the QT interval. The severity of the QRS broadening is associated with adverse events: a QRS duration greater than 100 ms is predictive of seizures, while a QRS duration greater than 160 ms is predictive of ventricular arrhythmias.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.5
      Seconds
  • Question 5 - A 55-year-old man with a history of hypertension arrived at the emergency department...

    Correct

    • A 55-year-old man with a history of hypertension arrived at the emergency department with a sudden and severe occipital headache accompanied by vomiting and neck stiffness. There is no reported head injury. Upon clinical examination, the patient has a temperature of 37ºC, a respiratory rate of 18 per minute, a pulse of 88 beats per minute, and a blood pressure of 160/100. The physician observes a lateral and inferior deviation of the left eye with a dilated pupil and drooping of the left upper eyelid.

      What is the SINGLE most likely diagnosis?

      Your Answer: Subarachnoid haemorrhage

      Explanation:

      The most probable diagnosis in this case is a subarachnoid haemorrhage (SAH).

      When assessing patients who present with an SAH, they may exhibit focal neurological signs, which can indicate the potential location of the aneurysm. Common areas where aneurysms occur include the bifurcation of the middle cerebral artery, the junction of the anterior communicating cerebral artery, and the junction of the posterior communicating artery with the internal carotid artery. If there is complete or partial paralysis of the oculomotor nerve, it suggests the rupture of a posterior communicating artery aneurysm.

      While hypertension is a risk factor for SAH, a significant increase in blood pressure may occur as a reflex response following the haemorrhage.

    • This question is part of the following fields:

      • Neurology
      13.3
      Seconds
  • Question 6 - You are with a hiking group and have ascended from an elevation of...

    Correct

    • You are with a hiking group and have ascended from an elevation of 2800m to 3400 meters over the past two days. One of your group members is experiencing difficulty breathing while at rest and has developed a dry cough. The individual's vital signs are as follows:

      Blood pressure: 150/92 mmHg
      Pulse: 126 bpm
      Respiration rate: 28 bpm
      Oxygen saturations: 86% on air

      Which of the following medications would be most appropriate to administer to this individual?

      Your Answer: Nifedipine

      Explanation:

      Nifedipine is the preferred medication for treating high altitude pulmonary edema (HAPE). When a patient shows signs of HAPE, the best course of action is to immediately descend to a lower altitude while receiving supplemental oxygen. However, if descent is not possible, nifedipine can be used to alleviate symptoms and assist with descent. Nifedipine works by reducing the pressure in the pulmonary artery. On the other hand, dexamethasone is the preferred medication for treating acute mountain sickness and high altitude cerebral edema (HACE).

      Further Reading:

      High Altitude Illnesses

      Altitude & Hypoxia:
      – As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
      – Hypoxia occurs at altitude due to decreased inspired oxygen.
      – At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.

      Acute Mountain Sickness (AMS):
      – AMS is a clinical syndrome caused by hypoxia at altitude.
      – Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
      – Symptoms usually occur after 6-12 hours above 2500m.
      – Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
      – The Lake Louise AMS score is used to assess the severity of AMS.
      – Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
      – Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
      – Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.

      High Altitude Pulmonary Edema (HAPE):
      – HAPE is a progression of AMS but can occur without AMS symptoms.
      – It is the leading cause of death related to altitude illness.
      – Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
      – Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
      – Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.

      High Altitude Cerebral Edema (HACE):
      – HACE is thought to result from vasogenic edema and increased vascular pressure.
      – It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
      – Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
      – Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
      – Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis.

    • This question is part of the following fields:

      • Environmental Emergencies
      11.4
      Seconds
  • Question 7 - A 35-year-old woman comes in with intense one-sided abdominal pain starting in the...

    Correct

    • A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. You suspect she may have ureteric colic.
      According to NICE, which of the following painkillers is recommended as the initial treatment for rapid relief of severe pain in ureteric colic?

      Your Answer: Intramuscular diclofenac

      Explanation:

      The term renal colic is commonly used to describe a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. However, a more accurate term is ureteric colic, as the pain usually arises from a blockage in the ureter itself.

      Renal or ureteric colic typically presents with a sudden onset of severe abdominal pain on one side, starting in the lower back or flank and radiating to the genital area in women or to the groin or testicle in men.

      The pain usually:
      – Lasts for minutes to hours and comes in spasms, with periods of no pain or a dull ache
      – Is often accompanied by nausea, vomiting, and blood in the urine
      – Is often described as the most intense pain a person has ever experienced (many women describe it as worse than childbirth).

      People with renal or ureteric colic:
      – Are restless and unable to find relief by lying still (which helps distinguish it from peritonitis)
      – May have a history of previous episodes
      – May have a fever and sweating if there is a urinary tract infection present
      – May complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and bladder (due to irritation of the bladder muscle).

      If possible, a urine dipstick test should be done to support the diagnosis and check for signs of a urinary tract infection.

      Checking for blood in the urine can also support the diagnosis of renal or ureteric colic. However, the absence of blood does not rule out the diagnosis and other causes of pain should be considered.

      Checking for nitrite and leukocyte esterase in the urine can indicate an infection.

      Pain management:
      – Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic.
      – Intravenous paracetamol can be given to adults, children, and young people if NSAIDs are not suitable or not providing enough pain relief.
      – Opioids may be considered if both NSAIDs and intravenous paracetamol are not suitable or not providing enough pain relief.
      – Antispasmodics should not be given to adults, children, and young people with suspected renal colic.

    • This question is part of the following fields:

      • Urology
      8.4
      Seconds
  • Question 8 - A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and...

    Incorrect

    • A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and vaginal bleeding. During the examination, her cervix is found to be open. A local early pregnancy assessment unit (EPAU) performs an ultrasound scan. The scan is unable to detect a fetal heartbeat but does show the presence of retained products of conception.

      What is the SINGLE most probable diagnosis?

      Your Answer: Inevitable miscarriage

      Correct Answer: Incomplete miscarriage

      Explanation:

      An incomplete miscarriage occurs when a miscarriage occurs, but the products of conception have not been fully expelled from the uterus. This commonly happens between weeks 8 and 14 of pregnancy.

      Symptoms of an incomplete miscarriage include pain and bleeding, and the cervix is usually open. A diagnosis can be confirmed through an ultrasound scan, which will show the absence of a fetal heartbeat and retained products.

      Treatment for an incomplete miscarriage can be done medically, such as using misoprostol, or surgically, like undergoing an ERPC procedure.

      There are potential complications that can arise from an incomplete miscarriage, including endometritis, myometritis, septic shock, and disseminated intravascular coagulation (DIC).

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      27.4
      Seconds
  • Question 9 - A 65-year-old patient arrives after an acute overdose of digoxin. She is experiencing...

    Correct

    • A 65-year-old patient arrives after an acute overdose of digoxin. She is experiencing nausea and is expressing concerns about palpitations.
      What is the indication for administering DigiFab to this patient?

      Your Answer: Ventricular tachycardia

      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/ml

      Chronic 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
      10.2
      Seconds
  • Question 10 - You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician...

    Correct

    • You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician requests you to insert a femoral central venous line. How should the patient be positioned for this procedure?

      Your Answer: Patient supine with slight abduction and external rotation of thigh/hip

      Explanation:

      To insert a femoral line, the patient should be lying on their back with a pillow placed under their buttocks to elevate the groin area. The thigh should be slightly moved away from the body and rotated outward.

      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
      18.2
      Seconds
  • Question 11 - You evaluate a 62-year-old man with a painful swollen left big toe. The...

    Incorrect

    • You evaluate a 62-year-old man with a painful swollen left big toe. The pain began this morning and is described as the most severe pain he has ever experienced. It has gradually worsened over the past 8 hours. He is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The skin over the affected area appears red and shiny.

      His only significant medical history is hypertension, which has been challenging to control. He is currently taking amlodipine 10 mg and ramipril 10 mg daily for this condition and is awaiting a medication review for his antihypertensive treatment. His blood pressure today measures 165/94 mmHg.
      What is the SINGLE most appropriate next step in management?

      Your Answer: Commence naproxen

      Correct Answer: Commence colchicine

      Explanation:

      The diagnosis in this case is clearly gout. According to the guidelines from the European League Against Rheumatism (EULAR), the symptoms of acute pain, joint swelling, tenderness, and redness that worsen over a 6-12 hour period strongly suggest crystal arthropathy.

      Checking serum urate levels to confirm hyperuricemia before starting treatment for acute gout attacks has little benefit 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 the 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. Therefore, it is the most suitable choice for this patient.

      During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute episode. However, in patients already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs or colchicine as appropriate.

      Febuxostat (Uloric) is another option for managing chronic gout, but like allopurinol, it should not be used for acute episodes.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      18.6
      Seconds
  • Question 12 - A 6-year-old boy has been brought into the Emergency Department having seizures that...

    Correct

    • A 6-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
      What dose of rectal diazepam is recommended for the treatment of the convulsing child?

      Your Answer: 0.5 mg/kg

      Explanation:

      The recommended dose of rectal diazepam for treating a child experiencing convulsions is 0.5 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
      10.9
      Seconds
  • Question 13 - A 22 year old female comes to the emergency department complaining of pleuritic...

    Incorrect

    • A 22 year old female comes to the emergency department complaining of pleuritic chest pain that has been present for 2 days. She is not currently taking any medications. A chest X-ray reveals no abnormalities and her D-dimer test is negative. An ECG shows sinus rhythm, but a prolonged QTc of 500 ms is observed. The patient is diagnosed with costochondritis and an incidental finding of long QT syndrome (LQTS). What is the primary treatment approach for LQTS?

      Your Answer: Calcium channel blockers

      Correct Answer: Beta blockers

      Explanation:

      Beta blockers are the primary treatment for long QT syndrome (LQTS). This patient probably has an undiagnosed congenital LQTS because there is no obvious cause. If there is a known cause of LQTS that can be removed, removing it may be the only necessary treatment. However, in all other cases, beta blockers are usually needed to prevent ventricular arrhythmias. Ventricular arrhythmias happen because of increased adrenergic activity. Beta blockers reduce the effects of adrenergic stimulation.

      Further Reading:

      Long QT syndrome (LQTS) is a condition characterized by a prolonged QT interval on an electrocardiogram (ECG), which represents abnormal repolarization of the heart. LQTS can be either acquired or congenital. Congenital LQTS is typically caused by gene abnormalities that affect ion channels responsible for potassium or sodium flow in the heart. There are 15 identified genes associated with congenital LQTS, with three genes accounting for the majority of cases. Acquired LQTS can be caused by various factors such as certain medications, electrolyte imbalances, hypothermia, hypothyroidism, and bradycardia from other causes.

      The normal QTc values, which represent the corrected QT interval for heart rate, are typically less than 450 ms for men and less than 460ms for women. Prolonged QTc intervals are considered to be greater than these values. It is important to be aware of drugs that can cause QT prolongation, as this can lead to potentially fatal arrhythmias. Some commonly used drugs that can cause QT prolongation include antimicrobials, antiarrhythmics, antipsychotics, antidepressants, antiemetics, and others.

      Management of long QT syndrome involves addressing any underlying causes and using beta blockers. In some cases, an implantable cardiac defibrillator (ICD) may be recommended for patients who have experienced recurrent arrhythmic syncope, documented torsades de pointes, previous ventricular tachyarrhythmias or torsades de pointes, previous cardiac arrest, or persistent syncope. Permanent pacing may be used in patients with bradycardia or atrioventricular nodal block and prolonged QT. Mexiletine is a treatment option for those with LQT3. Cervicothoracic sympathetic denervation may be considered in patients with recurrent syncope despite beta-blockade or in those who are not ideal candidates for an ICD. The specific treatment options for LQTS depend on the type and severity of the condition.

    • This question is part of the following fields:

      • Cardiology
      40.2
      Seconds
  • Question 14 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Correct

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is accurate?

      Your Answer: It increases the duration of the action potential

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
      27.4
      Seconds
  • Question 15 - A 65 year old type 2 diabetic with recently diagnosed dementia is brought...

    Incorrect

    • A 65 year old type 2 diabetic with recently diagnosed dementia is brought into the emergency department by the caregiver from her assisted living facility due to concern that her foot ulcer is worsening. The doctor had started antibiotics a week earlier as an ulcer to the big toe appeared infected. An X-ray reveals bone erosion and reactive bone sclerosis consistent with osteomyelitis. You refer the patient to the orthopedic resident on-call. You overhear the resident discussing toe amputation and requesting the patient sign a consent form. You are worried because you are unsure if the patient has the capacity to give consent. Which of the following is NOT one of the criteria a patient must meet to be considered to have capacity?

      Your Answer: Demonstrate they can weigh up the pros and cons of the decision to be made

      Correct Answer: Patient must be adequately informed about the proposed treatment

      Explanation:

      In order for a patient to be considered to have capacity, they must meet four criteria. Firstly, they must be able to comprehend the decision that needs to be made and understand the information that has been provided to them. Secondly, they should be able to retain the information in order to make an informed decision. Thirdly, they must demonstrate the ability to evaluate the advantages and disadvantages of the decision at hand. Lastly, they should be able to effectively communicate their decision.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      29.3
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  • Question 16 - A 10-year-old girl is brought into the Emergency Department with stomach pain and...

    Correct

    • A 10-year-old girl is brought into the Emergency Department with stomach pain and throwing up. Her mom tells you that she has been losing weight lately and seems to be drinking a lot and peeing a lot. During the examination, she appears tired and you notice that she is dehydrated. She is breathing deeply and quickly. Her blood sugar levels are found to be very high when her blood is tested.
      Which of the following tests will be most useful in confirming the diagnosis?

      Your Answer: Urine dipstick

      Explanation:

      The most probable diagnosis in this case is diabetic ketoacidosis (DKA). To confirm the diagnosis, it is important to establish that his blood glucose levels are high, he has significant ketonuria or ketonaemia, and that he is experiencing acidosis. Therefore, out of the options provided, a urine dipstick test will be the most useful.

      DKA is a life-threatening condition that occurs when there is a lack of insulin, leading to an inability to metabolize glucose. This results in hyperglycemia and an osmotic diuresis, causing excessive thirst and increased urine production. If the urine output exceeds the patient’s ability to drink, dehydration becomes inevitable. Additionally, without insulin, fat becomes the primary energy source, leading to the production of large amounts of ketones and metabolic acidosis.

      DKA is characterized by three main factors:
      1. Hyperglycemia (blood glucose > 11 mmol/l)
      2. Ketonaemia (> 3 mmol/l) or significant ketonuria (> 2+ on urine dipstick)
      3. Acidosis (bicarbonate < 15 mmol/l and/or venous pH < 7.3) The clinical features of DKA include nausea, vomiting, excessive thirst, excessive urine production, abdominal pain, signs of dehydration, a smell of ketones on the breath (similar to pear drops), deep and rapid respiration (Kussmaul breathing), confusion or reduced consciousness, and tachycardia, hypotension, and shock. The following investigations should be performed:
      – Blood glucose measurement
      – Urine dipstick test (will show marked glycosuria and ketonuria)
      – Blood ketone assay (more sensitive and specific than urine dipstick)
      – Blood tests including full blood count (FBC) and urea and electrolytes (U&Es)
      – Arterial or venous blood gas analysis (to assess for metabolic acidosis)

      The principles of managing DKA are as follows:
      – Fluid boluses should only be given to reverse signs of shock and should be administered slowly in 10 ml/kg aliquots. If there are no signs of shock, fluid boluses should not be given, and specialist advice should be sought if a second bolus is required.
      – Rehydration should be done with replacement therapy over 48 hours after signs of shock have been reversed.
      – The first 20 ml/kg of fluid resuscitation should be given in addition

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      19.7
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  • Question 17 - A 30-year-old man comes in with a cough and wheezing.
    What ONE clinical...

    Incorrect

    • A 30-year-old man comes in with a cough and wheezing.
      What ONE clinical feature would indicate a potential diagnosis of severe asthma?

      Your Answer: Heart rate of 120 bpm

      Correct Answer: Normal PaCO2

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

    • This question is part of the following fields:

      • Respiratory
      43.2
      Seconds
  • Question 18 - You assess a 30-year-old woman with a background of bipolar disorder and prior...

    Correct

    • You assess a 30-year-old woman with a background of bipolar disorder and prior instances of hostile and aggressive conduct.
      What SINGLE factor has been demonstrated to heighten the likelihood of aggression?

      Your Answer: Coercive behaviour

      Explanation:

      There are several factors that are known to increase the risk of violence from patients. These include being male, being young (under 40 years old), having poor levels of self-care, exhibiting coercive behavior, having a history of prior violent episodes, making multiple attendances to the hospital, being intoxicated with alcohol, and experiencing organic psychosis.

    • This question is part of the following fields:

      • Mental Health
      33
      Seconds
  • Question 19 - A healthy and active 45-year-old woman comes in with paralysis of the facial...

    Correct

    • A healthy and active 45-year-old woman comes in with paralysis of the facial muscles on the right side. She is unable to frown or raise her eyebrow on the right side. When instructed to close her eyes and bare her teeth, the right eyeball rolls up and outwards. These symptoms began 24 hours ago. She has no significant medical history, and the rest of her examination appears normal.

      What is the most probable diagnosis in this case?

      Your Answer: Bell’s palsy

      Explanation:

      The patient has presented with a facial palsy that affects only the left side and involves the lower motor neurons. This can be distinguished from an upper motor neuron lesion because the patient is unable to raise their eyebrow and the upper facial muscles are also affected. Additionally, the patient demonstrates a phenomenon known as Bell’s phenomenon, where the eye on the affected side rolls upwards and outwards when attempting to close the eye and bare the teeth.

      Approximately 80% of sudden onset lower motor neuron facial palsies are attributed to Bell’s palsy. It is believed that this condition is caused by swelling of the facial nerve within the petrous temporal bone, which is secondary to a latent herpesvirus, specifically HSV-1 and HZV.

      There are other potential causes for an isolated lower motor neuron facial nerve palsy, including Ramsay-Hunt syndrome (caused by the herpes zoster virus), trauma, parotid gland tumor, cerebellopontine angle tumor (such as an acoustic neuroma), middle ear infection, cholesteatoma, and sarcoidosis.

      However, Ramsay-Hunt syndrome is unlikely in this case since there is no presence of pain or pustular lesions in and around the ear. An acoustic neuroma is also less likely, especially without any symptoms of sensorineural deafness or tinnitus. Furthermore, there are no clinical features consistent with an inner ear infection.

      The recommended treatment for this patient is the administration of steroids, and appropriate follow-up should be organized.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      13.4
      Seconds
  • Question 20 - You are requested to evaluate a 6 year old girl. She was playing...

    Incorrect

    • You are requested to evaluate a 6 year old girl. She was playing in the backyard when she suddenly burst into tears. Her mother suspects she stepped on a bee. Shortly after, her face began to swell and her breathing became rapid and noisy. Your diagnosis is anaphylaxis. What is the appropriate dosage of adrenaline to administer?

      Your Answer: 300 micrograms by IM injection

      Correct Answer: 150 micrograms by IM injection

      Explanation:

      The appropriate dose of adrenaline for treating anaphylaxis in children under 6 years old is 150 micrograms, which is equivalent to 0.15 ml of a 1 in 1,000 solution.

      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
      13.1
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SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (3/3) 100%
Urology (2/2) 100%
Endocrinology (1/1) 100%
Pharmacology & Poisoning (2/2) 100%
Environmental Emergencies (1/1) 100%
Obstetrics & Gynaecology (0/1) 0%
Resus (1/1) 100%
Musculoskeletal (non-traumatic) (0/1) 0%
Cardiology (1/2) 50%
Safeguarding & Psychosocial Emergencies (0/1) 0%
Gastroenterology & Hepatology (1/1) 100%
Respiratory (0/1) 0%
Mental Health (1/1) 100%
Ear, Nose & Throat (1/1) 100%
Paediatric Emergencies (0/1) 0%
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