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  • Question 1 - A 40-year-old man presents with a sudden worsening of his asthma symptoms. His...

    Incorrect

    • A 40-year-old man presents with a sudden worsening of his asthma symptoms. His heart rate is 110 bpm, respiratory rate 30/min, and his oxygen levels are 88% on room air. He is feeling fatigued and his breathing is labored, with no audible sounds in his chest. He has already received consecutive salbutamol nebulizers, a single ipratropium bromide nebulizer, and 40 mg of prednisolone orally. The ICU outreach team has been notified and will arrive soon.
      Which of the following medications would be most appropriate to administer while waiting for the ICU outreach team to arrive?

      Your Answer: IV ketamine

      Correct Answer: IV aminophylline

      Explanation:

      This patient exhibits signs of potentially life-threatening asthma. In adults, acute severe asthma is characterized by a peak expiratory flow (PEF) of 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, and an inability to complete sentences in one breath. On the other hand, life-threatening asthma is indicated by a PEF below 33% of the best or predicted value, a blood oxygen saturation (SpO2) below 92%, a partial pressure of oxygen (PaO2) below 8 kPA, a normal partial pressure of carbon dioxide (PaCO2) within the range of 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness, and hypotension.

      To address acute asthma in adults, the recommended drug doses include administering 5 mg of salbutamol through an oxygen-driven nebulizer, delivering 500 mcg of ipratropium bromide via an oxygen-driven nebulizer, providing 40-50 mg of prednisolone orally, administering 100 mg of hydrocortisone intravenously, and infusing 1.2-2 g of magnesium sulfate intravenously over a period of 20 minutes.

      According to the current Advanced Life Support (ALS) guidelines, it is advisable to seek senior advice before considering the use of intravenous aminophylline in cases of severe or life-threatening asthma. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by a continuous infusion of 500-700 mcg/kg/hour. To prevent toxicity, it is important to maintain serum theophylline levels below 20 mcg/ml.

      In situations where inhaled therapy is not feasible, intravenous salbutamol can be considered, with a slow administration of 250 mcg. However, it should only be used when a patient is receiving bag-mask ventilation.

      It is worth noting that there is currently no evidence supporting the use of leukotriene receptor antagonists, such as montelukast, or Heliox in the management of acute severe or life-threatening asthma.

    • This question is part of the following fields:

      • Respiratory
      25.1
      Seconds
  • Question 2 - You assess a 65-year-old woman with a history of progressively increasing shortness of...

    Incorrect

    • You assess a 65-year-old woman with a history of progressively increasing shortness of breath. As part of the patient's treatment plan, your supervisor requests that you carry out a pleural aspiration.
      Based on the BTS guidelines, what is one of the indications for performing a pleural aspiration?

      Your Answer: Unilateral transudative pleural effusion

      Correct Answer: Unilateral exudative pleural effusion

      Explanation:

      A pleural effusion refers to an excess accumulation of fluid in the pleural cavity, which is the space between the parietal and visceral pleura. Normally, this cavity contains a small amount of lubricating fluid, around 5-10 ml, that allows the pleurae to slide smoothly over each other. This fluid also creates surface tension, bringing the two membranes together and ensuring that as the thorax expands, the lungs expand and fill with air. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons. Firstly, it is used to investigate pleural effusion, particularly when it is unilateral and exudative in nature. Secondly, it provides symptomatic relief for breathlessness caused by pleural effusion. However, the British Thoracic Society (BTS) guidelines recommend that pleural aspiration should not be carried out if there is suspicion of unilateral or bilateral transudative effusion, unless there are atypical features or failure of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line, about 10 cm lateral to the spine, and one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

    • This question is part of the following fields:

      • Respiratory
      45.9
      Seconds
  • Question 3 - A 45-year-old woman is brought into resus by blue light ambulance following a...

    Correct

    • A 45-year-old woman is brought into resus by blue light ambulance following a car accident. She was hit by a truck while crossing the road and has a suspected pelvic injury. She is currently on a backboard with cervical spine protection and a pelvic binder in place. The massive transfusion protocol is activated.
      According to the ATLS guidelines, what other medication should be administered?

      Your Answer: Tranexamic acid

      Explanation:

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

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

    • This question is part of the following fields:

      • Trauma
      14.5
      Seconds
  • Question 4 - A teenager is diagnosed with a condition that you identify as a notifiable...

    Correct

    • A teenager is diagnosed with a condition that you identify as a notifiable infection. You fill out the notification form and reach out to the local health protection team.
      Which of the following is the LEAST probable diagnosis?

      Your Answer: Ophthalmia neonatorum

      Explanation:

      Public Health England (PHE) has a primary goal of promptly identifying potential disease outbreaks and epidemics. While accuracy of diagnosis is important, it is not the main focus. Since 1968, clinical suspicion of a notifiable infection has been sufficient for reporting.
      Registered medical practitioners (RMPs) are legally obligated to notify the designated proper officer at their local council or local health protection team (HPT) if they suspect cases of certain infectious diseases.
      The Health Protection (Notification) Regulations 2010 specify the diseases that RMPs must report to the proper officers at local authorities. These diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever (typhoid or paratyphoid fever), food poisoning, haemolytic uraemic syndrome (HUS), infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires’ disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, severe acute respiratory syndrome (SARS), scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever (VHF), whooping cough, and yellow fever. However, as of April 2010, ophthalmia neonatorum is no longer considered a notifiable disease in the UK.

    • This question is part of the following fields:

      • Infectious Diseases
      18.3
      Seconds
  • Question 5 - A 32 year old individual presents to the emergency department with swollen and...

    Correct

    • A 32 year old individual presents to the emergency department with swollen and numb fingertips after spending the night outdoors in freezing temperatures due to excessive alcohol consumption during a New Year's celebration. You suspect that the patient is experiencing second degree frostbite. What is the most accurate description of second degree frostbite?

      Your Answer: Skin necrosis affecting the epidermis and a variable depth of the dermis

      Explanation:

      Second degree frostbite is characterized by tissue necrosis that affects both the epidermis and a variable depth of the dermis. However, there is still some healthy dermis present, which allows for regeneration and recovery of the skin. This type of frostbite is often referred to as partial thickness. Clinically, it is observed as the formation of blisters filled with clear or milky fluid on the surface of the skin, accompanied by redness and swelling.

      Further Reading:

      Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

      In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

      Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

      Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

    • This question is part of the following fields:

      • Dermatology
      35.8
      Seconds
  • Question 6 - You examine the X-ray of a 65 year old male who has tripped...

    Correct

    • You examine the X-ray of a 65 year old male who has tripped and landed on his extended right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. You intend to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). How many healthcare professionals should be present during the entire procedure?

      Your Answer: 2

      Explanation:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      10.1
      Seconds
  • Question 7 - A 60-year-old woman presents with recent weight loss, difficulty breathing, and chest pain....

    Correct

    • A 60-year-old woman presents with recent weight loss, difficulty breathing, and chest pain. She has a long history of smoking and has been diagnosed with COPD. A chest X-ray reveals a large mass in the left lung consistent with cancer. You recommend that she be referred to a specialist for further evaluation and treatment, but she refuses and does not want her family to know about her condition. She also states that she does not want to hear any negative news. After assessing her mental capacity and determining that she is competent and has capacity, which of the following statements is true regarding her ongoing care?

      Your Answer: You should document that the patient has declined information

      Explanation:

      There is no indication for an independent psychiatric evaluation of this patient. However, it is important to clearly document in his medical records that you have assessed his mental capacity and determined that he is capable of making decisions. It would not be appropriate in this case to refer him to a specialist against his wishes or to breach confidentiality by discussing his illness with his family or next of kin. According to the guidelines set by the General Medical Council (GMC), it is necessary to document the fact that the patient has declined relevant information. It is also important to avoid pressuring the patient to change their mind in these circumstances.

      For further information, please refer to the GMC guidelines on treatment and care towards the end of life: good practice in decision making.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      30.5
      Seconds
  • Question 8 - A 65-year-old man comes in with a painful swelling in his right groin....

    Incorrect

    • A 65-year-old man comes in with a painful swelling in his right groin. He had an appendicectomy 25 years ago and has no other medical history. You suspect it may be a hernia. The swelling gradually appears when he stands and can be pushed back in a upward and outward direction. It extends into his scrotum and is located above and towards the center of the pubic tubercle.
      What is the MOST likely diagnosis?

      Your Answer: Femoral hernia

      Correct Answer: Indirect inguinal hernia

      Explanation:

      An inguinal hernia occurs when the contents of the abdominal cavity protrude through the inguinal canal. There are two main types of inguinal hernias: indirect and direct. Indirect hernias, which account for 75% of cases, originate lateral to the inferior epigastric artery and follow the path of the spermatic cord or round ligament through the internal inguinal ring and along the inguinal canal. On the other hand, direct hernias, which make up 25% of cases, originate medial to the inferior epigastric artery and protrude through the posterior wall of the inguinal canal.

      Indirect inguinal hernias can be distinguished from direct hernias by several features. They have an elliptical shape, unlike the round shape of direct hernias. They are also less likely to be easily reducible and reduce spontaneously on reclining. Additionally, indirect hernias take longer to appear when standing compared to direct hernias, which appear immediately. They can be reduced superiorly then superolaterally, while direct hernias reduce superiorly and posteriorly. Pressure over the deep inguinal ring can control indirect hernias. However, they are more prone to strangulation due to the narrow neck of the deep inguinal ring and can extend into the scrotum.

      In contrast, a femoral hernia occurs when the abdominal cavity contents protrude through the femoral canal. These hernias occur below and lateral to the pubic tubercle, whereas inguinal hernias occur above and medial to the pubic tubercle. Femoral hernias are more easily visible when the patient is lying supine.

      A sports hernia, also known as athletic pubalgia, is characterized by chronic groin pain in athletes and the presence of a dilated superficial inguinal ring. However, there is no palpable hernia during examination.

      It is important to note that the hernia described here is not located near any scars, making it unlikely to be an incisional hernia.

    • This question is part of the following fields:

      • Surgical Emergencies
      52.5
      Seconds
  • Question 9 - A 30-year-old woman is brought into resus following a car accident. She is...

    Correct

    • A 30-year-old woman is brought into resus following a car accident. She is experiencing difficulty breathing, and you are unable to hear breath sounds on the left-hand side. Her trachea is deviated to the right, and her neck veins are distended. You make a clinical diagnosis of a tension pneumothorax and decide to perform a needle thoracocentesis.
      At which anatomical landmark should this procedure be performed?

      Your Answer: 5th intercostal space midaxillary line

      Explanation:

      A tension pneumothorax occurs when there is an air leak from the lung or chest wall that acts like a one-way valve. This causes air to build up in the pleural space without any way to escape. As a result, pressure in the pleural space increases and pushes the mediastinum into the opposite hemithorax. If left untreated, this can lead to cardiovascular instability, shock, and cardiac arrest.

      The clinical features of tension pneumothorax include respiratory distress and cardiovascular instability. Tracheal deviation away from the side of the injury, unilateral absence of breath sounds on the affected side, and a hyper-resonant percussion note are also characteristic. Other signs include distended neck veins and cyanosis, which is a late sign. It’s important to note that both tension pneumothorax and massive haemothorax can cause decreased breath sounds on auscultation. However, percussion can help differentiate between the two conditions. Hyper-resonance suggests tension pneumothorax, while dullness suggests a massive haemothorax.

      Tension pneumothorax is a clinical diagnosis and should not be delayed for radiological confirmation. Requesting a chest X-ray in this situation can delay treatment and put the patient at risk. Immediate decompression through needle thoracocentesis is the recommended treatment. Traditionally, a large-bore needle or cannula is inserted into the 2nd intercostal space in the midclavicular line of the affected hemithorax. However, studies on cadavers have shown better success in reaching the thoracic cavity when the 4th or 5th intercostal space in the midaxillary line is used in adult patients. ATLS now recommends this location for needle decompression in adults. The site for needle thoracocentesis in children remains the same, using the 2nd intercostal space in the midclavicular line. It’s important to remember that needle thoracocentesis is a temporary measure, and the insertion of a chest drain is the definitive treatment.

    • This question is part of the following fields:

      • Resus
      12
      Seconds
  • Question 10 - A child with a skin infection that is not improving with initial antibiotics...

    Correct

    • A child with a skin infection that is not improving with initial antibiotics comes back for a follow-up. Upon reviewing the culture results, it is found that Methicillin-resistant Staphylococcus aureus has been identified.
      Which of the following antibiotics is typically ineffective against Methicillin-resistant Staphylococcus aureus?

      Your Answer: Imipenem

      Explanation:

      Methicillin-resistant Staphylococcus aureus (MRSA) has become a significant issue in hospitals and other healthcare facilities in recent years. MRSA refers to any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics, such as penicillins and cephalosporins. This resistance is caused by the presence of the mecA gene, which produces a penicillin-binding protein with low affinity. Fortunately, MRSA is typically susceptible to teicoplanin, vancomycin, daptomycin, and linezolid. On the other hand, imipenem is an intravenous beta-lactam antibiotic that belongs to the carbapenem subgroup.

    • This question is part of the following fields:

      • Dermatology
      13.7
      Seconds
  • Question 11 - You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of...

    Incorrect

    • You evaluate a 55-year-old woman with chest discomfort and suspect a diagnosis of an acute coronary syndrome (ACS).
      Which ONE statement about ACS is NOT TRUE?

      Your Answer: Creatine kinase starts to rise at 4-8 hours after cardiac damage

      Correct Answer: Cardiac enzymes are usually elevated in unstable angina

      Explanation:

      Cardiac enzymes do not increase in unstable angina. However, if cardiac markers do rise, it is classified as a non-ST elevation myocardial infarction (NSTEMI). Both unstable angina and NSTEMI can have a normal ECG. An extended ventricular activation time indicates damage to the heart muscle. This occurs because infarcting myocardium conducts electrical impulses at a slower pace, resulting in a prolonged interval between the start of the QRS complex and the apex of the R wave. A positive troponin test indicates the presence of necrosis in cardiac myocytes.

      Summary:
      Marker | Initial Rise | Peak | Normal at
      Creatine kinase | 4-8 hours | 18 hours 2-3 days | CK-MB = main cardiac isoenzyme
      Myoglobin | 1-4 hours | 6-7 hours | 24 hours | Low specificity due to skeletal muscle damage
      Troponin I | 3-12 hours | 24 hours | 3-10 days | Appears to be the most sensitive and specific
      HFABP | 1-2 hours | 5-10 hours | 24 hours | HFABP = heart fatty acid binding protein
      LDH | 10 hours | 24-48 hours | 14 days | Cardiac muscle mainly contains LDH

    • This question is part of the following fields:

      • Cardiology
      44.7
      Seconds
  • Question 12 - A 25-year-old patient arrives at the emergency department from working in a radiation...

    Correct

    • A 25-year-old patient arrives at the emergency department from working in a radiation lab. He informs you that he may have been exposed to dangerous radiation. The patient mentions that it has been less than 24 hours since he left lab. Which of the following tests provides the most accurate prognosis for the severity of radiation sickness?

      Your Answer: Lymphocyte count

      Explanation:

      The count of lymphocytes, a type of white blood cell, can serve as an early indication of the level of radiation exposure. The severity of the exposure can be determined by observing the decrease in lymphocyte count, which is directly related to the amount of radiation absorbed by the body. Ideally, the count is measured 12 hours after exposure and then repeated every 4 hours initially to track the rate of decrease.

      Further Reading:

      Radiation exposure refers to the emission or transmission of energy in the form of waves or particles through space or a material medium. There are two types of radiation: ionizing and non-ionizing. Non-ionizing radiation, such as radio waves and visible light, has enough energy to move atoms within a molecule but not enough to remove electrons from atoms. Ionizing radiation, on the other hand, has enough energy to ionize atoms or molecules by detaching electrons from them.

      There are different types of ionizing radiation, including alpha particles, beta particles, gamma rays, and X-rays. Alpha particles are positively charged and consist of 2 protons and 2 neutrons from the atom’s nucleus. They are emitted from the decay of heavy radioactive elements and do not travel far from the source atom. Beta particles are small, fast-moving particles with a negative electrical charge that are emitted from an atom’s nucleus during radioactive decay. They are more penetrating than alpha particles but less damaging to living tissue. Gamma rays and X-rays are weightless packets of energy called photons. Gamma rays are often emitted along with alpha or beta particles during radioactive decay and can easily penetrate barriers. X-rays, on the other hand, are generally lower in energy and less penetrating than gamma rays.

      Exposure to ionizing radiation can damage tissue cells by dislodging orbital electrons, leading to the generation of highly reactive ion pairs. This can result in DNA damage and an increased risk of future malignant change. The extent of cell damage depends on factors such as the type of radiation, time duration of exposure, distance from the source, and extent of shielding.

      The absorbed dose of radiation is directly proportional to time, so it is important to minimize the amount of time spent in the vicinity of a radioactive source. A lethal dose of radiation without medical management is 4.5 sieverts (Sv) to kill 50% of the population at 60 days. With medical management, the lethal dose is 5-6 Sv. The immediate effects of ionizing radiation can range from radiation burns to radiation sickness, which is divided into three main syndromes: hematopoietic, gastrointestinal, and neurovascular. Long-term effects can include hematopoietic cancers and solid tumor formation.

      In terms of management, support is mainly supportive and includes IV fluids, antiemetics, analgesia, nutritional support, antibiotics, blood component substitution, and reduction of brain edema.

    • This question is part of the following fields:

      • Environmental Emergencies
      21.9
      Seconds
  • Question 13 - You are managing a 72-year-old patient with type 2 respiratory failure. It has...

    Incorrect

    • You are managing a 72-year-old patient with type 2 respiratory failure. It has been decided to initiate BiPAP therapy. What initial EPAP and IPAP pressure settings would you recommend?

      Your Answer: EPAP 3-5 cmH2O / IPAP 10-15 cmH2O

      Correct Answer:

      Explanation:

      When determining the initial EPAP and IPAP pressure settings for this patient, it is important to consider their specific needs and condition. In general, the EPAP pressure should be set between 3-5 cmH2O, which helps to maintain positive pressure in the airways during exhalation, preventing them from collapsing. This can improve oxygenation and reduce the work of breathing.

      The IPAP pressure, on the other hand, should be set between 10-15 cmH2O. This higher pressure during inhalation helps to overcome any resistance in the airways and ensures adequate ventilation. It also assists in improving the patient’s tidal volume and reducing carbon dioxide levels.

      Therefore, the recommended initial EPAP and IPAP pressure settings for this patient would be EPAP 3-5 cmH2O / IPAP 10-15 cmH2O. These settings provide a balance between maintaining airway patency during exhalation and ensuring sufficient ventilation during inhalation. However, it is important to regularly assess the patient’s response to therapy and adjust the settings as needed to optimize their respiratory function.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

    • This question is part of the following fields:

      • Respiratory
      18.5
      Seconds
  • Question 14 - You are working in the pediatric emergency department and are asked to review...

    Correct

    • You are working in the pediatric emergency department and are asked to review a child's blood gas results by the resident. What is the typical range for partial pressure of carbon dioxide (pCO2)?

      Your Answer: 4.4-6.4 kPa

      Explanation:

      The typical range for the partial pressure of carbon dioxide (pCO2) is 4.4-6.4 kilopascals (kPa). In terms of arterial blood gas (ABG) results, the normal range for pO2 (partial pressure of oxygen) is 10-14.4 kPa or 70-100 millimeters of mercury (mmHg). The normal range for pCO2 is 4.4-6.4 kPa or 35-45 mmHg. Additionally, the normal range for bicarbonate levels is 23-28 millimoles per liter (mmol/L).

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      6
      Seconds
  • Question 15 - After managing a patient with frontotemporal dementia, your consultant believes that the foundation...

    Correct

    • After managing a patient with frontotemporal dementia, your consultant believes that the foundation doctors would benefit from additional education on the topic. They request you to prepare a teaching session for the junior doctors. Which of the following statements is accurate?

      Your Answer: Personality change, speech disturbance and behavioural change are predominant features in frontotemporal dementia

      Explanation:

      In the UK, not all dementia cases are suitable for treatment with acetylcholinesterase inhibitors and memantine. Specifically, patients with frontotemporal dementia should not be prescribed these medications. If a patient experiences visual hallucinations, it may indicate that they have dementia with Lewy bodies.

      Further Reading:

      Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

      To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

      The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

      There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

      Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

      Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

      Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

      In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

    • This question is part of the following fields:

      • Neurology
      22.5
      Seconds
  • Question 16 - A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination...

    Correct

    • A 60-year-old woman presents with worsening symptoms of shortness of breath. Upon examination of her cardiovascular system, you find a collapsing pulse. Her apex beat is hyperkinetic and displaced to the side. During auscultation, you detect an early diastolic murmur that is most pronounced when the patient is sitting forward and exhaling.

      What is the SINGLE most probable diagnosis?

      Your Answer: Aortic regurgitation

      Explanation:

      Aortic regurgitation is a condition where the aortic valve fails to close tightly, resulting in the backflow of blood from the aorta into the left ventricle during ventricular diastole. This valvular lesion presents with various clinical symptoms and signs.

      The clinical symptoms of aortic regurgitation include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. These symptoms are experienced by patients during physical activity, while lying flat, and during episodes of sudden nighttime breathlessness, respectively.

      On the other hand, the clinical signs of aortic regurgitation can be observed during physical examination. These signs include a collapsing pulse, widened pulse pressure, hyperkinetic laterally displaced apex beat, and a thrill in the aortic area. Additionally, an early diastolic murmur can be heard, which is loudest at the lower left sternal edge when the patient is sitting forward and exhaling.

      Aortic regurgitation is also associated with several eponymous signs, which are named after the physicians who first described them. These signs include Corrigan’s sign, which is characterized by visible and forceful neck pulsation. De Musset’s sign refers to head nodding in time with the heartbeat. Quincke’s sign is the observation of visible nail bed capillary pulsation. Duroziez’s sign is the presence of a diastolic murmur heard proximal to femoral artery compression. Traube’s sign is the perception of a pistol shot sound over the femoral arteries. The Lighthouse sign is the blanching and flushing of the forehead. Becker’s sign is the pulsation seen in retinal vessels. Rosenbach’s sign is the presence of a pulsatile liver. Lastly, Muller’s sign refers to pulsations of the uvula.

      In summary, aortic regurgitation is a valvular lesion that leads to the incomplete closure of the aortic valve. It manifests with various clinical symptoms, signs, and eponymous findings, which can be identified through careful examination and observation.

    • This question is part of the following fields:

      • Cardiology
      32.4
      Seconds
  • Question 17 - A 25-year-old woman arrives at the emergency department with complaints of palpitations and...

    Correct

    • A 25-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During triage, the patient reveals that she was previously diagnosed with narrow complex tachycardia a couple of years ago after experiencing palpitations during a night out. You order an ECG. What are the specific criteria used to define narrow complex tachycardia?

      Your Answer: Pulse rate greater than 100 beats per minute and QRS duration less than 0.12 seconds

      Explanation:

      Narrow QRS complex tachycardia is a term used to describe a fast heart rhythm with a pulse rate over 100 bpm and a QRS duration shorter than 120 ms.

      Further Reading:

      Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.

      SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.

      Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.

      Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.

    • This question is part of the following fields:

      • Cardiology
      27
      Seconds
  • Question 18 - A 52-year-old woman comes in with a persistent sore throat that has lasted...

    Incorrect

    • A 52-year-old woman comes in with a persistent sore throat that has lasted for five days. She has also been dealing with cold symptoms for the past few days and has a bothersome dry cough. She denies having a fever and her temperature is normal today. During the examination, there are no noticeable swollen lymph nodes in her neck and her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.

      What is her FeverPAIN score?

      Your Answer: 2

      Correct Answer: 0

      Explanation:

      The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

      If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

      The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

      Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      29.5
      Seconds
  • Question 19 - You observe that a patient's temperature has risen to 41.5ºC after rapid sequence...

    Correct

    • You observe that a patient's temperature has risen to 41.5ºC after rapid sequence induction. You are worried that the patient might be experiencing malignant hyperthermia. What is typically the earliest and most frequent clinical manifestation of malignant hyperthermia?

      Your Answer: Increasing end tidal CO2

      Explanation:

      The earliest and most common clinical indication of malignant hyperthermia is typically an increase in end tidal CO2 levels.

      Further Reading:

      Malignant hyperthermia is a rare and life-threatening syndrome that can be triggered by certain medications in individuals who are genetically susceptible. The most common triggers are suxamethonium and inhalational anaesthetic agents. The syndrome is caused by the release of stored calcium ions from skeletal muscle cells, leading to uncontrolled muscle contraction and excessive heat production. This results in symptoms such as high fever, sweating, flushed skin, rapid heartbeat, and muscle rigidity. It can also lead to complications such as acute kidney injury, rhabdomyolysis, and metabolic acidosis. Treatment involves discontinuing the trigger medication, administering dantrolene to inhibit calcium release and promote muscle relaxation, and managing any associated complications such as hyperkalemia and acidosis. Referral to a malignant hyperthermia center for further investigation is also recommended.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.3
      Seconds
  • Question 20 - With freezing temperatures anticipated, your consultant requests that you organize a teaching session...

    Correct

    • With freezing temperatures anticipated, your consultant requests that you organize a teaching session for the junior physicians regarding the management of frostbite. What imaging modality is preferred for evaluating perfusion abnormalities in extremities impacted by frostbite?

      Your Answer: Technetium 99 (Tc-99) pertechnetate scintigraphy

      Explanation:

      Technetium 99 (Tc-99) pertechnetate scintigraphy is the preferred imaging method for evaluating frostbite. This technique is highly accurate in detecting tissue damage and provides both sensitivity and specificity.

      Further Reading:

      Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

      In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

      Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

      Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

    • This question is part of the following fields:

      • Dermatology
      14.5
      Seconds
  • Question 21 - A 45-year-old man is brought into the Emergency Department by his wife after...

    Correct

    • A 45-year-old man is brought into the Emergency Department by his wife after taking an overdose of paracetamol. The patient states that he “wants to end it all” and refuses to stay in hospital and receive treatment. His wife insists that he must be treated because “he is not thinking clearly”.

      Which blood test is the earliest and most sensitive indicator of liver damage in paracetamol overdose?

      Your Answer: INR

      Explanation:

      Paracetamol overdose is the most common overdose in the U.K. and is also the leading cause of acute liver failure. The liver damage occurs due to a metabolite of paracetamol called N-acetyl-p-benzoquinoneimine (NAPQI), which depletes the liver’s glutathione stores and directly harms liver cells. Severe liver damage and even death can result from an overdose of more than 12 g or > 150 mg/kg body weight.

      The clinical manifestations of paracetamol overdose can be divided into four stages:

      Stage 1 (0-24 hours): Patients may not show any symptoms, but common signs include nausea, vomiting, and abdominal discomfort.

      Stage 2 (24-48 hours): Right upper quadrant pain and tenderness develop, along with the possibility of hypoglycemia and reduced consciousness.

      Stage 3 (48-96 hours): Hepatic failure begins, characterized by jaundice, coagulopathy, and encephalopathy. Loin pain, haematuria, and proteinuria may indicate early renal failure.

      Stage 4 (> 96 hours): Hepatic failure worsens progressively, leading to cerebral edema, disseminated intravascular coagulation (DIC), and ultimately death.

      The earliest and most sensitive indicator of liver damage is a prolonged INR, which starts to rise approximately 24 hours after the overdose. Liver function tests (LFTs) typically remain normal until 18 hours after the overdose. However, AST and ALT levels then sharply increase and can exceed 10,000 units/L by 72-96 hours. Bilirubin levels rise more slowly and peak around 5 days.

      The primary treatment for paracetamol overdose is acetylcysteine. Acetylcysteine is a highly effective antidote, but its efficacy diminishes rapidly if administered more than 8 hours after a significant ingestion. Ingestions exceeding 75 mg/kg are considered significant.

      Acetylcysteine should be given based on a 4-hour level or administered empirically if the presentation occurs more than 8 hours after a significant overdose. If the overdose is staggered or the timing is uncertain, empirical treatment is also recommended. The treatment regimen is as follows:

      – First dose: 150 mg/kg in 200 mL 5% glucose over 1 hour
      – Second dose 50 mg/kg in 500 mL 5% glucose over 4 hours
      – Third dose 100 mg/kg in 1000 mL 5% glucose over 16 hours

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      15.1
      Seconds
  • Question 22 - A 45 year old female with a history of alcohol-related visits to the...

    Correct

    • A 45 year old female with a history of alcohol-related visits to the emergency department is currently in the emergency department after tripping while intoxicated. She has a 7 cm laceration on the frontal area of the scalp. You examine the wound using local anesthesia. What tissue layer lies directly beneath the scalp skin?

      Your Answer: Dense connective tissue

      Explanation:

      The scalp is composed of five layers, starting from the outermost layer, which is the skin, and moving towards the deepest layer, which is the periosteum of the skull. These layers can be remembered using the mnemonic: SCALP – Skin, Connective tissue, Aponeurosis, Loose areolar connective tissue, and Periosteum.

      Further Reading:

      The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.

      The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.

      The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.

      In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.

    • This question is part of the following fields:

      • Dermatology
      17.4
      Seconds
  • Question 23 - A 22-year-old presents to the emergency department with a nosebleed. You observe that...

    Correct

    • A 22-year-old presents to the emergency department with a nosebleed. You observe that they have blood-soaked tissue paper held against the nose, blocking the opening of the left nostril, and blood stains on the front of their shirt. What is the most appropriate initial management for this patient?

      Your Answer: Advise the patient to sit forward and pinch just in front of the bony septum firmly and hold it for 15 minutes

      Explanation:

      To control epistaxis, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Firmly pinch the cartilaginous part of the nose, specifically in front of the bony septum, and maintain pressure for 10-15 minutes without releasing it.

      Further Reading:

      Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

      The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

      If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

      Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

      In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      38.2
      Seconds
  • Question 24 - A 28-year-old woman is brought into the emergency room by an ambulance with...

    Correct

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

      Your Answer: 1 g IV over 10 minutes

      Explanation:

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

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

    • This question is part of the following fields:

      • Trauma
      29
      Seconds
  • Question 25 - A 35-year-old is brought into the resuscitation bay by ambulance after being found...

    Correct

    • A 35-year-old is brought into the resuscitation bay by ambulance after being found unconscious at home. You observe that the patient has a medical history of hyperthyroidism and suspect thyroid storm after conducting a thorough assessment. Which of the following should NOT be administered immediately?

      Your Answer: Lugol’s iodine

      Explanation:

      When treating thyroid storm, it is important to administer certain drugs immediately. These include a beta blocker like propranolol or a calcium channel blocker if a beta blocker cannot be used. Corticosteroids like hydrocortisone or dexamethasone are also given. Additionally, antithyroid drugs like propylthiouracil are administered. However, it is crucial to wait at least one hour after giving the antithyroid drugs before administering iodine solution such as Lugol’s iodine. This is because iodine can worsen thyrotoxicosis by stimulating thyroid hormone synthesis. Propylthiouracil, on the other hand, inhibits the normal interactions of iodine and peroxidase with thyroglobulin, which is why it is given first and allowed time to take effect.

      Further Reading:

      The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.

      Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.

      The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.

      Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.

      Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.

    • This question is part of the following fields:

      • Endocrinology
      20.8
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  • Question 26 - A 52-year-old man presents with ataxia, left-sided loss of pain and temperature sense...

    Incorrect

    • A 52-year-old man presents with ataxia, left-sided loss of pain and temperature sense on the face, left-sided paralysis of the facial muscles and right-sided sensory loss to the body. He is also complaining of severe vertigo, nausea and tinnitus. CT and MRI head scans are undertaken, and he is discovered to have suffered a left-sided stroke. He is subsequently admitted under the stroke team.
      What is the SINGLE most likely diagnosis?

      Your Answer: Lateral medullary syndrome

      Correct Answer: Lateral pontine syndrome

      Explanation:

      Obstruction of the long circumferential branches of the basilar artery leads to the lateral pontine syndrome. This condition is characterized by several symptoms. Firstly, there is ataxia, which is caused by damage to the cerebral peduncles. Additionally, there is ipsilateral loss of pain and temperature sense on the face, resulting from damage to CN V. Another symptom is ipsilateral paralysis of the upper and lower face, which occurs due to damage to CN VII. Furthermore, vertigo, nystagmus, tinnitus, deafness, and vomiting are present, all of which are caused by damage to CN VIII. Lastly, there is contralateral sensory loss to the body, which is a result of damage to the spinothalamic tracts.

    • This question is part of the following fields:

      • Neurology
      68.1
      Seconds
  • Question 27 - A 60-year-old woman presents with a persistent cough and increasing difficulty breathing. She...

    Correct

    • A 60-year-old woman presents with a persistent cough and increasing difficulty breathing. She also complains of muscle aches and occasional joint pain, particularly in her knees and hips. She has a 40-pack-year smoking history. During the examination, you observe fine crackling sounds in the lower parts of her lungs when she exhales. Lung function testing reveals a decrease in the forced vital capacity (FVC) and the forced expiratory volume in one second (FEV1), but a preserved FEV1/FVC ratio. A photo of her hands is provided below:
      What is the SINGLE most likely underlying diagnosis?

      Your Answer: Idiopathic pulmonary fibrosis

      Explanation:

      This patient’s clinical presentation is consistent with a diagnosis of idiopathic pulmonary fibrosis. The typical symptoms of idiopathic pulmonary fibrosis include a dry cough, progressive breathlessness, arthralgia and muscle pain, finger clubbing (seen in 50% of cases), cyanosis, fine end-expiratory bibasal crepitations, and right heart failure and cor pulmonale in later stages.

      Finger clubbing, which is prominent in this patient, can also be caused by bronchiectasis and tuberculosis. However, these conditions would not result in a raised FEV1/FVC ratio, which is a characteristic feature of a restrictive lung disorder.

      In restrictive lung disease, the FEV1/FVC ratio is typically normal, around 70% predicted, while the FVC is reduced to less than 80% predicted. Both the FVC and FEV1 are generally reduced in this condition. The ratio can also be elevated if the FVC is reduced to a greater extent.

      It is important to note that smoking is a risk factor for developing idiopathic pulmonary fibrosis, particularly in individuals with a history of smoking greater than 20 pack-years.

    • This question is part of the following fields:

      • Respiratory
      17.1
      Seconds
  • Question 28 - A 2 year old toddler is brought into the resuscitation bay after collapsing...

    Correct

    • A 2 year old toddler is brought into the resuscitation bay after collapsing and having a seizure. A capillary blood glucose test shows a reading of 0.9 mmol/L. Your consultant instructs you to initiate an intravenous glucose infusion. What is the most suitable dosage?

      Your Answer: 5 mL/kg/hour of 10% dextrose

      Explanation:

      Diabetes Mellitus:
      – Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
      – Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
      – Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
      – Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.

      Hypoglycemia:
      – Definition: lower than normal blood glucose concentration.
      – Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
      – Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
      – Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
      – Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.

      Treatment of neonatal hypoglycemia:
      – Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
      – Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
      – Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
      – If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.

      Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.

    • This question is part of the following fields:

      • Neonatal Emergencies
      13
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  • Question 29 - You assess a patient with a significantly elevated potassium level.
    What is the most...

    Correct

    • You assess a patient with a significantly elevated potassium level.
      What is the most probable cause of this finding?

      Your Answer: Congenital adrenal hyperplasia

      Explanation:

      Hyperkalaemia, or high levels of potassium in the blood, can be caused by various factors that are not related to drug use. These include conditions such as renal failure, where the kidneys are unable to properly regulate potassium levels, and excess potassium supplementation. Other non-drug causes include Addison’s disease, a condition characterized by adrenal insufficiency, and congenital adrenal hyperplasia. Renal tubular acidosis, specifically type 4, can also lead to hyperkalaemia. Additionally, conditions like rhabdomyolysis, burns and trauma, and tumour lysis syndrome can contribute to elevated potassium levels. Acidosis, an imbalance in the body’s pH levels, is another non-drug cause of hyperkalaemia.

      On the other hand, certain medications have been associated with hyperkalaemia. These include ACE inhibitors, angiotensin receptor blockers, NSAIDs, beta-blockers, digoxin, and suxamethonium. These drugs can interfere with the body’s potassium regulation mechanisms and lead to increased levels of potassium in the blood.

      In contrast, there are also conditions that result in low levels of potassium, known as hypokalaemia. Bartter’s syndrome, a rare inherited defect in the ascending limb of the loop of Henle, is characterized by hypokalaemic alkalosis and normal to low blood pressure. Type 1 and 2 renal tubular acidosis are other conditions that cause hypokalaemia. On the other hand, type 4 renal tubular acidosis leads to hyperkalaemia. Gitelman’s syndrome, another rare inherited defect, affects the distal convoluted tubule of the kidney and causes a metabolic alkalosis with hypokalaemia and hypomagnesaemia.

      Lastly, excessive consumption of liquorice can result in a condition called hypermineralocorticoidism, which can lead to hypokalaemia.

    • This question is part of the following fields:

      • Nephrology
      21
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  • Question 30 - A 32-year-old man with a known history of asthma presents with a headache,...

    Correct

    • A 32-year-old man with a known history of asthma presents with a headache, vomiting, and dizziness. His heart rate is elevated at 116 bpm. He currently takes a salbutamol inhaler and theophylline for his asthma. He had visited the Emergency Department a few days earlier and was prescribed an antibiotic.
      Which antibiotic was most likely prescribed to this patient?

      Your Answer: Erythromycin

      Explanation:

      Theophylline is a medication used to treat severe asthma. It is a bronchodilator that comes in modified-release forms, which can maintain therapeutic levels in the blood for 12 hours. Theophylline works by inhibiting phosphodiesterase and blocking the breakdown of cyclic AMP. It also competes with adenosine on A1 and A2 receptors.

      Achieving the right dose of theophylline can be challenging because there is a narrow range between therapeutic and toxic levels. The half-life of theophylline can be influenced by various factors, further complicating dosage adjustments. It is recommended to aim for serum levels of 10-20 mg/l six to eight hours after the last dose.

      Unlike many other medications, the specific brand of theophylline can significantly impact its effects. Therefore, it is important to prescribe theophylline by both its brand name and generic name.

      Several factors can increase the half-life of theophylline, including heart failure, cirrhosis, viral infections, and certain drugs. Conversely, smoking, heavy drinking, and certain medications can decrease the half-life of theophylline.

      There are several drugs that can either increase or decrease the plasma concentration of theophylline. Calcium channel blockers, cimetidine, fluconazole, macrolides, methotrexate, and quinolones can increase the concentration. On the other hand, carbamazepine, phenobarbitol, phenytoin, rifampicin, and St. John’s wort can decrease the concentration.

      The clinical symptoms of theophylline toxicity are more closely associated with acute overdose rather than chronic overexposure. Common symptoms include headache, dizziness, nausea, vomiting, abdominal pain, rapid heartbeat, dysrhythmias, seizures, mild metabolic acidosis, low potassium, low magnesium, low phosphates, abnormal calcium levels, and high blood sugar.

      Seizures are more prevalent in acute overdose cases, while chronic overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more common in chronic overdose situations compared to acute overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      19.7
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  • Question 31 - A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose...

    Incorrect

    • A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose of paracetamol tablets 45 minutes ago. He is currently showing no symptoms and is stable in terms of his blood circulation. The attending physician recommends administering a dose of activated charcoal.
      What is the appropriate dosage of activated charcoal to administer?

      Your Answer: 50 g orally

      Correct Answer:

      Explanation:

      Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.

      The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.7
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  • Question 32 - A 35-year-old individual goes to the emergency room feeling sick for the past...

    Correct

    • A 35-year-old individual goes to the emergency room feeling sick for the past 48 hours after moving into a new apartment. Earlier today, a boiler technician came to conduct the gas safety inspection for the landlord and advised the patient to go to the A&E department due to high carbon monoxide levels and a faulty boiler. You suspect the presence of carbon monoxide poisoning. What is the primary symptom typically associated with carbon monoxide poisoning?

      Your Answer: Headache

      Explanation:

      The primary symptom typically associated with carbon monoxide poisoning is a headache.

      Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.

      When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.

      The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.

      To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.

      Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.

      When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24.1
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  • Question 33 - A 35-year-old male comes to the Emergency Department seeking treatment for a wound...

    Correct

    • A 35-year-old male comes to the Emergency Department seeking treatment for a wound on his right arm. He mentions during triage that he sustained the injury while being attacked by a group of individuals in the neighborhood who have been causing trouble. He suspects that he may have been shot with a low-caliber firearm. Despite the nursing staff's attempts to involve the authorities, he has adamantly refused to allow them to contact the police. In addition to providing the necessary wound care, what other steps should you take?

      Your Answer: Advise him that it is your statutory duty to report this incident to the police whether he consents or not, and contact them with his demographic details only.

      Explanation:

      Confidentiality is a crucial aspect of the doctor-patient relationship and plays a vital role in upholding trust within the medical profession. However, there are certain situations, such as cases involving gun and knife crimes, where the safety of the wider public may be at risk. In such circumstances, it may be necessary to breach this relationship and provide the police with information, even if the patient refuses to consent.

      It is important to make every effort to obtain the patient’s consent, while also explaining the legal obligation to report such incidents. When sharing information with the police, it is essential to disclose only the minimum amount of information required. Typically, this would involve providing the patient’s demographic details and informing the police that they have sought medical attention for a non-self-inflicted deliberate knife wound.

      However, there are instances where contacting the police may not be necessary. For example, if it is evident that the injury was sustained accidentally or as a result of deliberate self-harm due to a mental health condition, there may be no need to involve law enforcement. In such cases, the patient should still receive the necessary medical treatment for their wound, as long as they provide consent.

      For more information on this topic, please refer to the GMC Guidance on Reporting Gunshot and Knife Wounds.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      78.9
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  • Question 34 - A 65-year-old male patient is brought into the emergency department with suspected sepsis....

    Incorrect

    • A 65-year-old male patient is brought into the emergency department with suspected sepsis. It is decided to intubate the patient pending transfer to the intensive care unit (ICU). Your consultant requests you to prepare propofol and suxamethonium for rapid sequence intubation. What is the mechanism of action of suxamethonium?

      Your Answer: Non-competitive agonist of gamma-aminobutyric acid (GABA) receptors at the neuromuscular junction

      Correct Answer: Non-competitive agonist of acetylcholine receptors at the neuromuscular junction

      Explanation:

      Suxamethonium, also called succinylcholine, is a type of drug used to block neuromuscular transmission. It acts as an agonist by binding to acetylcholine receptors at the neuromuscular junction. Unlike acetylcholine, suxamethonium is not broken down by acetylcholinesterase, which means it stays bound to the receptors for a longer time, leading to prolonged inhibition of neuromuscular transmission. Eventually, suxamethonium is metabolized by plasma cholinesterase.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      79.4
      Seconds
  • Question 35 - A 45 year old hiker becomes ill on his third day at Mount...

    Incorrect

    • A 45 year old hiker becomes ill on his third day at Mount Kilimanjaro base camp (altitude of 5895m). The patient experiences severe shortness of breath while at rest and is diagnosed with high altitude pulmonary edema. If left untreated, what is the mortality rate associated with this condition?

      Your Answer: 10%

      Correct Answer: 50%

      Explanation:

      HAPE is a form of noncardiogenic pulmonary edema that occurs secondary to hypoxia. It is a clinical diagnosis characterized by fatigue, dyspnea, and dry cough with exertion. If left untreated, it can progress to dyspnea at rest, rales, cyanosis, and a mortality rate of up to 50%.

      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
      17.5
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  • Question 36 - A 25 year old female comes to the emergency department with a stab...

    Incorrect

    • A 25 year old female comes to the emergency department with a stab wound to her thigh. She explains that she was in a confrontation with a group of individuals, and one of them attacked her with a knife. She specifically requests that her information remains confidential and insists that the police not be involved. She expresses her fear of retaliation and emphasizes that she does not want to be seen as a snitch. How should you respond in this situation?

      Your Answer: Seek consent from the patient to inform hospital security & inform them if consent is granted

      Correct Answer: Inform the police about this incident

      Explanation:

      It is important to inform the police in cases of gunshot and deliberate knife wounds. Deliberate stabbings pose a risk of further attacks in the area and can endanger both the patient and the staff in the department. The General Medical Council (GMC) provides clear guidance supporting the need to involve the police in such situations.

      According to the GMC, it is usually necessary to inform the police when a person presents with a gunshot wound. Even accidental shootings involving legally held firearms raise important issues for the police, such as firearms licensing. Similarly, the police should generally be informed when a person has been wounded in an attack involving a knife, blade, or any other sharp instrument. However, if a knife or blade injury appears to be accidental or a result of self-harm, it is not usually necessary to involve the police.

      In cases where seeking consent to disclose personal information is not practical or appropriate, or if a patient refuses consent, it may be justified to disclose the information in the public interest. This is particularly true if failure to do so could expose others to a risk of death or serious harm.

      Further Reading:

      Principles of Medical Ethics:

      1. Autonomy: Competent adults have the right to make informed decisions about their own medical care.
      2. Beneficence: Healthcare professionals should take actions that serve the best interests of patients.
      3. Non-maleficence: Healthcare professionals should not take actions that may injure or harm patients.
      4. Justice: Healthcare professionals should take actions that are fair and equitable to both the individual and society as a whole.

      Confidentiality:

      1. Use minimum necessary personal information and consider anonymizing information if possible.
      2. Manage and protect personal information to prevent improper access, disclosure, or loss.
      3. Understand and adhere to information governance appropriate to your role.
      4. Comply with the law when handling personal information.
      5. Share relevant information for direct care unless the patient objects.
      6. Obtain explicit consent to disclose identifiable information for purposes other than care or local clinical audit, unless required by law or justified in the public interest.
      7. Inform patients about disclosures of personal information they would not reasonably expect, unless not practicable or undermines the purpose of the disclosure.
      8. Support patients in accessing their information and respecting their legal rights.

      Obtaining Patient’s Consent for Disclosure:

      – Consent should be obtained for disclosing personal information for purposes other than direct care or local clinical audit, unless required by law or not appropriate or practicable.

      Situations Where Patient Consent is Not Required for Disclosure:

      – Adults at risk of or suffering abuse or neglect, as required by law.
      – Adults lacking capacity, if neglect or harm is suspected, unless not overall beneficial to the patient.
      – When required by law or approved through a statutory process.
      – When justified in the public interest, such as for the prevention, detection, or prosecution of serious crime, patient’s fitness to drive, serious communicable disease, or posing a serious risk to others through being unfit for work.

      Confidentiality Following a Patient’s Death:

      – Respect the patient’s confidentiality even after their death.
      – If the patient previously requested not to share personal information with those close to them, abide by their wishes.
      – Be considerate, sensitive, and responsive to those close to the patient, providing as much information as possible.

      The Law & Caldicott Guardians:

      Data Protection Act:
      – Sets rules and standards for the use and handling of personal data by organizations.
      – Personal data must be used fairly, lawfully, transparently, and for specified purposes.
      – Individuals have rights

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      81
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  • Question 37 - A 15 year old male is brought to the emergency department by his...

    Incorrect

    • A 15 year old male is brought to the emergency department by his parents and admits to taking 32 paracetamol tablets 6 hours ago. Blood tests are conducted, including paracetamol levels. What is the paracetamol level threshold above which the ingestion is deemed 'significant'?

      Your Answer: 10 mg/kg/24 hours

      Correct Answer: 75 mg/kg/24 hours

      Explanation:

      If someone consumes at least 75 mg of paracetamol per kilogram of body weight within a 24-hour period, it is considered to be a significant ingestion. Ingesting more than 150 mg of paracetamol per kilogram of body weight within 24 hours poses a serious risk of harm.

      Further Reading:

      Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.

      Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.

      The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.

      In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.

      The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 38 - A 21-year-old student comes in with a sore throat, low-grade fever, and feeling...

    Correct

    • A 21-year-old student comes in with a sore throat, low-grade fever, and feeling unwell for the past week. She mentions having a faint rash all over her body that disappeared quickly. During the examination, you observe mild splenomegaly. The heterophile antibody test comes back positive.
      What is the most probable organism responsible for this case?

      Your Answer: Epstein-Barr virus

      Explanation:

      Infectious mononucleosis is typically a self-limiting infection that is primarily caused by the Epstein-Barr virus (EBV), a member of the human herpesvirus family. About 10% of cases are caused by cytomegalovirus (CMV) infection.

      This clinical infection is most commonly observed in populations with a large number of young adults, such as university students and active-duty military personnel.

      The main clinical features of infectious mononucleosis include a low-grade fever, fatigue, prolonged malaise, sore throat (often accompanied by tonsillar enlargement and exudate), a transient, fine, non-itchy rash, lymphadenopathy (most commonly in the cervical region), arthralgia and myalgia, mild enlargement of the liver and spleen, and jaundice (which is less common in young adults but more prevalent in the elderly).

      To diagnose EBV infectious mononucleosis, a variety of unrelated non-EBV heterophile antibodies and specific EBV antibodies can be used.

      1. Heterophile antibodies:
      Around 70-90% of patients with EBV infectious mononucleosis produce heterophile antibodies, which are antibodies that react against antigens from other species. False positives can occur with hepatitis, malaria, toxoplasmosis, rubella, systemic lupus erythematosus (SLE), lymphoma, and leukemia. Two main screening tests can detect these antibodies and provide rapid results within a day:
      – Paul-Bunnell test: Sheep red blood cells agglutinate in the presence of heterophile antibodies.
      – Monospot test: Horse red blood cells agglutinate in the presence of heterophile antibodies.

      2. EBV-specific antibodies:
      Patients who remain heterophile-negative after six weeks are considered heterophile-negative and should be tested for EBV-specific antibodies. These antibodies are also useful in cases where a false positive heterophile antibody test is suspected.

      Other useful investigations include a full blood count, which often shows a raised white cell count with lymphocytosis and atypical lymphocytes in more than 20% of cases, an elevated erythrocyte sedimentation rate (ESR) in most patients, liver function tests (LFTs) that may show mild elevation of serum transaminases, throat swabs to rule out group A streptococci pharyngitis as a differential diagnosis, and abdominal ultrasound if splenomegaly is present.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      12.9
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  • Question 39 - A 25-year-old traveler comes to the clinic complaining of a fever, cough, and...

    Correct

    • A 25-year-old traveler comes to the clinic complaining of a fever, cough, and headache that have persisted for the last week. He recently returned from a backpacking adventure in India. Additionally, he started experiencing diarrhea a few days ago, and a stool sample was sent for testing, which revealed the presence of Salmonella typhi. Which antibacterial medication would be the most suitable to prescribe for this patient?

      Your Answer: Cefotaxime

      Explanation:

      According to the latest guidelines from NICE and the BNF, the recommended initial treatment for typhoid fever is cefotaxime. It is important to note that infections originating from the Middle-East, South Asia, and South-East Asia may have multiple antibiotic resistance, so it is advisable to test for sensitivity. In cases where the microorganism is found to be sensitive, ciprofloxacin can be considered as a suitable alternative.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      22.1
      Seconds
  • Question 40 - A toddler is brought in with a rash and a high fever. You...

    Correct

    • A toddler is brought in with a rash and a high fever. You suspect a potential diagnosis of bacterial meningitis.
      Based on the current NICE guidelines, which of the following features is LEAST indicative of this condition?

      Your Answer: Focal seizures

      Explanation:

      NICE has emphasized that certain indications and manifestations may indicate specific diseases as the underlying cause of fever. For instance, symptoms such as neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus are suggestive of bacterial meningitis. On the other hand, NICE has identified focal seizures and focal neurological signs as the most indicative of herpes simplex encephalitis. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Neurology
      21.5
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  • Question 41 - A 32-year-old woman is brought to the Emergency Department by ambulance due to...

    Correct

    • A 32-year-old woman is brought to the Emergency Department by ambulance due to 'severe palpitations.' Her heart rate is 180 bpm, and her rhythm strip is suggestive of supraventricular tachycardia. You plan to administer adenosine.
      Which of the following is NOT a contraindication to the use of adenosine?

      Your Answer: History of heart transplant

      Explanation:

      Adenosine is a type of purine nucleoside that is primarily utilized in the diagnosis and treatment of paroxysmal supraventricular tachycardia. Its main mechanism of action involves stimulating A1-adenosine receptors and opening acetylcholine-sensitive potassium channels. This leads to hyperpolarization of the cell membrane in the atrioventricular (AV) node and slows down conduction in the AV node by inhibiting calcium channels.

      When administering adenosine, it is given rapidly through an intravenous bolus, followed by a saline flush. The initial dose for adults is 6 mg, and if necessary, additional doses of 12 mg or 18 mg can be given at 1-2 minute intervals until the desired effect is observed. It is important to note that the latest ALS guidelines recommend 18 mg for the third dose, while the BNF/NICE guidelines suggest 12 mg.

      One of the advantages of adenosine is its very short half-life, which is less than 10 seconds. This means that its effects are rapid, typically occurring within 10 seconds. However, the duration of action is also short, lasting only 10-20 seconds. Due to its short half-life, any side effects experienced are usually brief. These side effects may include a sense of impending doom, facial flushing, dyspnea, chest discomfort, and a metallic taste.

      There are certain contraindications to the use of adenosine. These include 2nd or 3rd degree AV block, sick sinus syndrome, long QT syndrome, severe hypotension, decompensated heart failure, chronic obstructive lung disease, and asthma. It is important to exercise caution when administering adenosine to patients with a heart transplant, as they are particularly sensitive to its effects. In these cases, a reduced initial dose of 3 mg is recommended, followed by 6 mg and then 12 mg.

      It is worth noting that the effects of adenosine can be potentiated by dipyridamole, a medication commonly used in combination with adenosine. Therefore, the dose of adenosine should be adjusted and reduced in patients who are also taking dipyridamole.

    • This question is part of the following fields:

      • Cardiology
      12
      Seconds
  • Question 42 - A 30-year-old man comes in with swelling of his face, particularly his upper...

    Incorrect

    • A 30-year-old man comes in with swelling of his face, particularly his upper lip, and his hands. He has a confirmed diagnosis of hereditary angioedema.
      What is the pattern of inheritance for this disorder?

      Your Answer: Autosomal recessive

      Correct Answer: Autosomal dominant

      Explanation:

      Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.

      Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.

    • This question is part of the following fields:

      • Allergy
      8.7
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  • Question 43 - You are caring for a pediatric patient in the resuscitation bay. Your attending...

    Incorrect

    • You are caring for a pediatric patient in the resuscitation bay. Your attending physician notices you selecting an oropharyngeal airway adjunct (OPA) and recommends using a laryngeal mask airway (LMA) instead. Which of the following statements about the advantages and disadvantages of using a laryngeal mask airway (LMA) is correct?

      Your Answer: There is a high risk of aspiration when using an LMA

      Correct Answer: Greater risk of inducing laryngospasm using LMA compared to endotracheal intubation

      Explanation:

      The use of a laryngeal mask airway (LMA) carries a higher risk of inducing laryngospasm compared to endotracheal intubation. However, LMAs are still considered excellent alternatives to bag masks as they reduce the risk of gastric inflation and aspiration. While they do decrease the risk of aspiration, they are not as protective as endotracheal tubes. Complications associated with LMA use include laryngospasm, nausea and vomiting, and a low risk of aspiration. LMAs have advantages over bag-mask ventilation, such as more effective ventilation, less gastric inflation, and a lower risk of aspiration. However, they also have disadvantages, including the risk of hypoventilation due to air leak around the cuff, greater gastric inflation compared to endotracheal intubation, and a very low risk of aspiration.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      30.4
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  • Question 44 - A 70-year-old woman presents with an acute episode of gout. She has a...

    Correct

    • A 70-year-old woman presents with an acute episode of gout. She has a history of chronic heart failure and hypertension. Her current medications include lisinopril and hydrochlorothiazide.

      Which SINGLE statement regarding the treatment of gout is true?

      Your Answer: Colchicine has a role in prophylactic treatment

      Explanation:

      In cases where there are no reasons to avoid them, high-dose NSAIDs are the first choice for treating acute gout. A commonly used and effective regimen is to take Naproxen 750 mg as a single dose, followed by 250 mg three times a day. Aspirin should not be used for gout because it reduces the clearance of urate in the urine and interferes with the action of uricosuric agents. Instead, Naproxen, diclofenac, or indomethacin are more suitable options.

      Allopurinol is used as a preventive measure to reduce future gout attacks by lowering the levels of uric acid in the blood. However, it should not be started during an acute gout episode as it can worsen the severity and duration of symptoms. Colchicine works by affecting neutrophils, binding to tubulin to prevent their migration into the affected joint. It is equally effective as NSAIDs in relieving acute gout attacks and can also be used for prophylactic treatment if a patient cannot tolerate allopurinol.

      NSAIDs should not be used in patients with heart failure as they can lead to fluid retention and congestive cardiac failure. In such cases, colchicine is the preferred treatment option. Colchicine is also recommended for patients who cannot tolerate NSAIDs. Febuxostat (Uloric) is an alternative to allopurinol and is used for managing chronic gout.

      Corticosteroids are an effective alternative for managing acute gout in patients who cannot take NSAIDs or colchicine. They can be administered orally, intramuscularly, intravenously, or directly into the affected joint.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      20.9
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  • Question 45 - A 35-year-old weightlifter who acknowledges frequent use of anabolic steroids presents with extremely...

    Incorrect

    • A 35-year-old weightlifter who acknowledges frequent use of anabolic steroids presents with extremely severe acne. He has numerous disfiguring, ulcerated, nodular lesions covering his face, back, and chest. Many of the lesions have bleeding crusts, and he has significant scarring present. Several have also connected and formed sinuses. He is also experiencing overall discomfort with joint pains and a sensation of fever. You measure his temperature, and it is currently 39°C.
      What is the MOST LIKELY single diagnosis?

      Your Answer: Acne conglobata

      Correct Answer: Acne fulminans

      Explanation:

      Acne conglobata is an extremely severe form of acne where acne nodules come together and create sinuses. Acne fulminans, on the other hand, is a rare and severe complication of acne conglobata that is accompanied by systemic symptoms. It is linked to elevated levels of androgenic hormones, specific autoimmune conditions, and a genetic predisposition.

      The typical clinical characteristics of acne fulminans are as follows:

      – Sudden and abrupt onset
      – Inflammatory and ulcerated nodular acne primarily found on the chest and back
      – Often painful lesions
      – Ulcers on the upper trunk covered with bleeding crusts
      – Severe acne scarring
      – Fluctuating fever
      – Painful joints and arthropathy
      – General feeling of illness (malaise)
      – Loss of appetite and weight loss
      – Enlarged liver and spleen (hepatosplenomegaly)

      It is crucial to refer patients immediately for a specialist evaluation and hospital admission. Treatment options for acne fulminans include systemic corticosteroids, dapsone, ciclosporin, and high-dose intravenous antibiotics.

    • This question is part of the following fields:

      • Dermatology
      20.8
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  • Question 46 - A one-week-old infant presents with eyelid swelling and a mucopurulent discharge from both...

    Correct

    • A one-week-old infant presents with eyelid swelling and a mucopurulent discharge from both eyes shortly after birth. The diagnosis of ophthalmia neonatorum is made. What is the most probable causative organism in this case?

      Your Answer: Chlamydia trachomatis

      Explanation:

      Ophthalmia neonatorum refers to any cause of conjunctivitis during the newborn period, regardless of the specific organism responsible.

      Conjunctivitis is the most frequent occurrence of Chlamydia trachomatis infection in newborns. Chlamydia is now the leading cause, accounting for up to 40% of cases. Neisseria gonorrhoea, on the other hand, only accounts for less than 1% of reported cases. The remaining cases are caused by non-sexually transmitted bacteria like Staphylococcus, Streptococcus, Haemophilus species, and viruses.

      Gonorrhoeal ophthalmia neonatorum typically presents within 1 to 5 days after birth. It is characterized by intense redness and swelling of the conjunctiva, eyelid swelling, and a severe discharge of pus. Corneal ulceration and perforation may also be present.

      Chlamydial ophthalmia neonatorum, on the other hand, usually appears between 5 to 14 days after birth. It is characterized by a gradually increasing watery discharge that eventually becomes purulent. The inflammation in the eyes is usually less severe compared to gonococcal infection, and there is a lower risk of corneal ulceration and perforation.

      The second most common manifestation of Chlamydia trachomatis infection in newborns is pneumonia. Approximately 5-30% of infected neonates will develop pneumonia. About half of these infants will also have a history of ophthalmia neonatorum.

    • This question is part of the following fields:

      • Ophthalmology
      7.9
      Seconds
  • Question 47 - A 16 year old girl arrives at the emergency department with her friend...

    Correct

    • A 16 year old girl arrives at the emergency department with her friend following a fall from her skateboard. An X-ray reveals a dislocated shoulder. You inform the patient that the shoulder will require sedation for reduction. At what age is it generally assumed that a patient has the capacity to provide consent for treatment?

      Your Answer: 16

      Explanation:

      Patients who are 16 years old and above are presumed to have the ability to make decisions about their treatment.

      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
      14.2
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  • Question 48 - A 25 year old patient is brought into the resuscitation bay by paramedics...

    Correct

    • A 25 year old patient is brought into the resuscitation bay by paramedics after being pulled from a lake. The patient initially had a core temperature of 29.2ºC. CPR is underway. The patient's core temperature is rechecked after warming measures are introduced and the core temperature has increased to 32.5ºC. What changes, if any, would you make to administration of adrenaline during CPR in a patient with a core temperature of 32.5ºC compared to someone with a normal core temperature?

      Your Answer: Interval between doses doubled

      Explanation:

      When performing CPR on patients with a core temperature of 30-35°C, it is recommended to double the interval between IV drug doses compared to what is used for normothermic patients. However, if the core temperature is above 35°C, standard drug protocols should be followed.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      23
      Seconds
  • Question 49 - A 68-year-old woman presents with a 4-month history of easy bruising and fatigue....

    Incorrect

    • A 68-year-old woman presents with a 4-month history of easy bruising and fatigue. She has also experienced frequent nosebleeds over the past few weeks. She has had two respiratory infections and a urinary tract infection in the recent months and reports feeling unwell. You have arranged for her to undergo a series of blood tests, and the results of her complete blood count are as follows:

      Hemoglobin (Hb): 7.4 g/dl (13-17 g/dl)
      Mean Corpuscular Volume (MCV): 103 fl (80-100 fl)
      Platelets: 46 x 109/l (150-400 x 109/l)
      White Blood Cell Count (WCC): 4.4 x 109/l (4-11 x 109/l)
      Neutrophils: 0.8 x 109/l (2.5-7.5 x 109/l)
      Lymphocytes: 3.4 x 109/l (1.3-3.5 x 109/l)
      Monocytes: 0.4 x 109/l (0.2-0.8 x 109/l)
      Reticulocytes: 70 x 109/l (50-100 x 109/l)

      What is the SINGLE most likely diagnosis?

      Your Answer: Vitamin B12 deficiency

      Correct Answer: Myelodysplastic syndrome

      Explanation:

      Myelodysplastic syndromes are a group of disorders affecting the haemopoietic stem cell, leading to ineffective production of myeloid blood cells. These conditions typically manifest between the ages of 60 and 75 and are more prevalent in men than women.

      The clinical features of myelodysplastic syndromes include tiredness due to anaemia (the most common presentation), easy bruising, and a tendency to bleed. Laboratory findings often reveal anaemia (usually macrocytic or normocytic), neutropenia, thrombocytopenia, and abnormal cell morphology with oddly shaped macrocytes.

      Chronic lymphocytic leukaemia (CLL) is the most common form of adult leukaemia, primarily affecting B-lymphocytes. It often presents asymptomatically in patients who undergo routine blood tests revealing elevated white cell counts and lymphocytosis. Men over the age of 50 account for over 75% of CLL cases. Blood films typically show a predominance of mature-looking lymphocytes and smear cells.

      Iron deficiency anaemia is characterized by hypochromic microcytic anaemia and a reduced red blood cell count. Peripheral blood smears in iron deficiency anaemia may exhibit poikilocytosis (varying shapes) and anisocytosis (varying sizes). Pencil cells are also observed in this condition.

      Vitamin B12 and folate deficiency can also cause macrocytic anaemia. However, the severity of anaemia and macrocytosis would generally need to be much more pronounced to result in neutropenia and thrombocytopenia. Therefore, a myelodysplastic syndrome is more likely in such cases.

    • This question is part of the following fields:

      • Haematology
      46.7
      Seconds
  • Question 50 - A 25-year-old woman visits your office expressing concern about a recent unprotected sexual...

    Correct

    • A 25-year-old woman visits your office expressing concern about a recent unprotected sexual encounter that occurred three days ago. She is extremely anxious and determined to prevent pregnancy. The patient has a history of asthma and currently takes Clenil Modulite. Her BMI is 30.

      What is the most appropriate choice for her in this situation?

      Your Answer: Copper IUD

      Explanation:

      Women have three options when requesting emergency contraception. The first option is Levonelle 1.5 mg, which contains levonorgestrel and can be used up to 72 hours after unprotected sexual intercourse (UPSI). If vomiting occurs within 2 hours of taking the tablet, another one should be given. Levonelle mainly works by preventing ovulation.

      The second option is ulipristal acetate, the newest treatment available. It can be used up to 120 hours after UPSI. If vomiting occurs within 3 hours of ingestion, another tablet should be given. Ulipristal acetate also works by inhibiting ovulation. However, it should be avoided in patients taking enzyme-inducing drugs, those with severe hepatic impairment, or those with severe asthma requiring oral steroids.

      The third option is the copper IUD, which can be fitted up to 5 days after UPSI or ovulation, whichever is longer. The failure rate of the copper IUD is less than 1 in 1000, making it 10-20 times more effective than oral emergency contraceptive options. It is important to note that Levonelle and ulipristal may be less effective in women with higher BMIs.

    • This question is part of the following fields:

      • Sexual Health
      16.9
      Seconds
  • Question 51 - A 68-year-old woman presents with severe diarrhea one week after having a total...

    Correct

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

      Your Answer: Oral vancomycin

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      13.3
      Seconds
  • Question 52 - A 45-year-old woman experiences excessive bleeding after a minor surgical procedure. Her blood...

    Correct

    • A 45-year-old woman experiences excessive bleeding after a minor surgical procedure. Her blood test results are as follows:
      Hemoglobin (Hb): 11.6 g/dl (12-15 g/dl)
      Mean Corpuscular Volume (MCV): 80 fl (80-100 fl)
      Platelets: 246 x 109/l (150-400 x 109/l)
      Bleeding time: 9 minutes (2-7 minutes)
      Prothrombin time: 12 seconds (10-14 seconds)
      Thrombin time: 16 seconds (15-19 seconds)
      Activated Partial Thromboplastin Time (APTT): 64 seconds (35-45 seconds)

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Von Willebrand disease

      Explanation:

      Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects approximately 1 in 100 individuals. It occurs due to a deficiency in Von Willebrand factor (vWF), which plays a crucial role in blood clotting. vWF not only binds to factor VIII to protect it from rapid breakdown, but it is also necessary for proper platelet adhesion. When vWF is lacking, both factor VIII levels and platelet function are affected, leading to prolonged APTT and bleeding time. However, the platelet count and thrombin time remain unaffected.

      While some individuals with vWD may not experience any symptoms and are diagnosed incidentally during a clotting profile check, others may present with easy bruising, nosebleeds (epistaxis), and heavy menstrual bleeding (menorrhagia). In severe cases, more significant bleeding and joint bleeding (haemarthrosis) can occur.

      For mild cases of von Willebrand disease, bleeding can be managed with desmopressin. This medication works by stimulating the release of vWF stored in the Weibel-Palade bodies, which are storage granules found in the endothelial cells lining the blood vessels and heart. By increasing the patient’s own levels of vWF, desmopressin helps improve clotting. In more severe cases, replacement therapy is necessary. This involves infusing cryoprecipitate or Factor VIII concentrate to provide the missing vWF. Replacement therapy is particularly recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

    • This question is part of the following fields:

      • Haematology
      38.3
      Seconds
  • Question 53 - A 72 year old female presents to the emergency department with a 3...

    Correct

    • A 72 year old female presents to the emergency department with a 3 day history of watery diarrhea. She reports having approximately 4-5 episodes of diarrhea accompanied by lower abdominal cramping pain each day. The patient mentions that she visited her primary care physician 2 days ago, who requested a stool sample. The patient's vital signs are as follows:

      Temperature: 37.6ºC
      Blood pressure: 138/82 mmHg
      Pulse: 90 bpm
      Respiration rate: 16

      Upon reviewing the pathology results, it is noted that the stool sample has tested positive for clostridium difficile. Additionally, the patient's complete blood count, which was sent by the triage nurse, has been received and is shown below:

      Hemoglobin: 13.5 g/l
      Platelets: 288 * 109/l
      White blood cells: 13.9 * 109/l

      How would you classify the severity of this patient's clostridium difficile infection?

      Your Answer: Moderate

      Explanation:

      Clostridium difficile infections can range in severity from mild to life-threatening. Mild or moderate severity infections are determined by the frequency of stool and white blood cell count. Severe or life-threatening infections are characterized by high fever, radiological signs, and evidence of organ dysfunction or sepsis.

      In this case, the patient’s clinical features indicate a moderate severity C.diff infection. Moderate severity infections typically have an increased white blood cell count but less than 15 x 109/l. They are typically associated with 3-5 loose stools per day.

      Further Reading:

      Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.

      Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.

      Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.

      Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      25.5
      Seconds
  • Question 54 - A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As...

    Incorrect

    • A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As a result of this medication, the newborn develops a defect.
      What is the most probable defect that will occur as a result of using this drug during pregnancy?

      Your Answer: Grey baby syndrome

      Correct Answer: Haemorrhagic disease of the newborn

      Explanation:

      There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.

      Below is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.

      Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.

      Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.

      Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.

      Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.1
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  • Question 55 - A 48-year-old woman, who has recently been diagnosed with hypertension, presents with weakness,...

    Incorrect

    • A 48-year-old woman, who has recently been diagnosed with hypertension, presents with weakness, stiffness, and aching of her arms that are most pronounced around her shoulders and upper arms. On examination, she has reduced tone in her arms and a reduced biceps reflex. She finds lifting objects somewhat difficult. There is no apparent sensory deficit. She has recently been started on a medication for her hypertension.
      A recent check of her U&Es reveals the following biochemical picture:
      K+ 6.9 mmol/L
      Na+ 138 mmol/L
      eGFR 50 ml/min/1.73m2
      Which antihypertensive is she most likely to have been prescribed?

      Your Answer: Atenolol

      Correct Answer: Ramipril

      Explanation:

      This patient has presented with symptoms and signs consistent with myopathy. Myopathy is characterized by muscle weakness, muscle atrophy, and reduced tone and reflexes. Hyperkalemia is a known biochemical cause for myopathy, while other metabolic causes include hypokalemia, hypercalcemia, hypomagnesemia, hyperthyroidism, hypothyroidism, diabetes mellitus, Cushing’s disease, and Conn’s syndrome. In this case, ACE inhibitors, such as ramipril, are a well-recognized cause of hyperkalemia and are likely responsible.

      Commonly encountered side effects of ACE inhibitors include renal impairment, persistent dry cough, angioedema (with delayed onset), rashes, upper respiratory tract symptoms (such as a sore throat), and gastrointestinal upset.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      48.4
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  • Question 56 - A 6-month-old infant is referred by the community pediatrician following a well-child visit...

    Incorrect

    • A 6-month-old infant is referred by the community pediatrician following a well-child visit with a rash. After an assessment by the dermatology team and subsequent investigations, the infant is discovered to have a localized skin infection. The underlying cause is thought to be bacterial in nature.

      Which of the following is the SINGLE most likely diagnosis?

      Your Answer: Rhesus disease

      Correct Answer: Alpha 1-antitrypsin deficiency

      Explanation:

      Neonatal jaundice is a complex subject, and it is crucial for candidates to have knowledge about the different causes, presentations, and management of conditions that lead to jaundice in newborns. Neonatal jaundice can be divided into two groups: unconjugated hyperbilirubinemia, which can be either physiological or pathological, and conjugated hyperbilirubinemia, which is always pathological.

      The causes of neonatal jaundice can be categorized as follows:

      Haemolytic unconjugated hyperbilirubinemia:
      – Intrinsic causes of haemolysis include hereditary spherocytosis, G6PD deficiency, sickle-cell disease, and pyruvate kinase deficiency.
      – Extrinsic causes of haemolysis include haemolytic disease of the newborn and Rhesus disease.

      Non-haemolytic unconjugated hyperbilirubinemia:
      – Breastmilk jaundice, cephalhaematoma, polycythemia, infection (particularly urinary tract infections), Gilbert syndrome.

      Hepatic conjugated hyperbilirubinemia:
      – Hepatitis A and B, TORCH infections, galactosaemia, alpha 1-antitrypsin deficiency, drugs.

      Post-hepatic conjugated hyperbilirubinemia:
      – Biliary atresia, bile duct obstruction, choledochal cysts.

      By understanding these different categories and their respective examples, candidates will be better equipped to handle neonatal jaundice cases.

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 57 - A 45 year old patient is brought to the emergency department (ED) by...

    Correct

    • A 45 year old patient is brought to the emergency department (ED) by a family member. The patient began experiencing coughing symptoms ten days ago, but within the past 48 hours, they have developed a high fever, difficulty breathing during mild exertion, and the family reports that the patient appears confused. It is noted that the patient is currently taking azathioprine for the treatment of rheumatoid arthritis.

      Upon assessing the patient's vital signs, you decide to initiate the sepsis 6 pathway. What is the recommended timeframe for implementing the 'sepsis six'?

      Your Answer: 1 hour

      Explanation:

      The sepsis 6 pathway is a time-sensitive protocol that should be started promptly and all 6 initial steps should be completed within 1 hour. It is important not to confuse the sepsis 6 pathway with the 6 hour care bundle. Time is of the essence when managing septic patients, and initiating the sepsis 6 pathway immediately has been proven to enhance survival rates in sepsis patients.

      Further Reading:

      There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.

      The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.

      To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.

      There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.

      NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.

    • This question is part of the following fields:

      • Infectious Diseases
      18.4
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  • Question 58 - You are treating an 82-year-old patient who is unable to bear weight after...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      16.4
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  • Question 59 - A 32-year-old musician is currently participating in a community withdrawal program for a...

    Correct

    • A 32-year-old musician is currently participating in a community withdrawal program for a substance misuse issue. He has been attempting to quit for more than a year and consistently attends a community support group for his problem. The healthcare team in charge of his treatment have prescribed him Acamprosate to aid with his withdrawal.
      What substance is he most likely trying to withdraw from?

      Your Answer: Alcohol

      Explanation:

      Acamprosate, also known as Campral, is a medication used in the treatment of alcohol dependence. It is believed to work by stabilizing a chemical pathway in the brain that is disrupted during alcohol withdrawal. For optimal results, Acamprosate should be used alongside psychosocial support, as it helps reduce alcohol consumption and promote abstinence.

      When starting treatment with Acamprosate, it is important to begin as soon as possible after assisted withdrawal. The typical dosage is 1998 mg (666 mg three times a day), unless the patient weighs less than 60 kg, in which case a maximum of 1332 mg per day should be prescribed.

      Generally, Acamprosate is prescribed for up to 6 months. However, for those who benefit from the medication and wish to continue, it can be taken for a longer duration. If drinking persists 4-6 weeks after starting the drug, it should be discontinued.

      Patients who are prescribed Acamprosate should be closely monitored, with regular check-ins at least once a month for the first six months. If the medication is continued beyond six months, the frequency of check-ins can be reduced but should still occur at regular intervals.

      While routine blood tests are not mandatory, they can be considered if there is a need to monitor liver function recovery or as a motivational tool to show patients their progress.

    • This question is part of the following fields:

      • Mental Health
      16.7
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  • Question 60 - A 55-year-old woman with no permanent residence experiences a head injury after a...

    Correct

    • A 55-year-old woman with no permanent residence experiences a head injury after a fall. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.

      During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.

      Which treatment is most likely responsible for causing these symptoms?

      Your Answer: Intravenous glucose

      Explanation:

      This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.

      Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.

      This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.

      Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.

    • This question is part of the following fields:

      • Neurology
      28.8
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  • Question 61 - A 45-year-old woman comes in with a one-week history of fatigue, fever, headache,...

    Incorrect

    • A 45-year-old woman comes in with a one-week history of fatigue, fever, headache, muscle aches, and a dry cough that has now started to produce a small amount of sputum. She has also been experiencing occasional episodes of diarrhea for the past two days. During the examination, audible crackles are heard at the base of her lungs. Her blood test results today show evidence of hemolytic anemia and the presence of cold agglutinins.

      What is the SINGLE most appropriate antibiotic to prescribe for this patient?

      Your Answer: Doxycycline

      Correct Answer: Clarithromycin

      Explanation:

      This patient presents with symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection with Mycoplasma pneumoniae. The clinical features of Mycoplasma pneumoniae infection include a flu-like illness that precedes respiratory symptoms, along with fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness.

      Mycoplasma pneumoniae infection is commonly associated with the development of erythema multiforme, a rash characterized by multiple red lesions on the limbs that evolve into target lesions a few days after the rash appears. Additionally, this infection can also cause Steven-Johnson syndrome. It is worth noting that haemolytic anaemia with cold agglutinins can complicate Mycoplasma pneumoniae infections, providing further evidence for the diagnosis.

      The recommended first-line antibiotic for treating this case would be a macrolide, such as clarithromycin. Doxycycline can also be used but is generally considered a second-line option.

    • This question is part of the following fields:

      • Respiratory
      19.9
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  • Question 62 - A 35-year-old woman is injured in a car crash and sustains severe facial...

    Correct

    • A 35-year-old woman is injured in a car crash and sustains severe facial trauma. Imaging studies show that she has a Le Fort I fracture.
      What is the characteristic injury pattern of a Le Fort I fracture?

      Your Answer: Horizontal fracture across the inferior aspect of the maxilla

      Explanation:

      Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.

      The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.

      Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.

      Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.

      Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      10.1
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  • Question 63 - A 65-year-old man comes in with a sudden onset of right-sided weakness and...

    Correct

    • A 65-year-old man comes in with a sudden onset of right-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage and he is being prepared for thrombolysis. His blood pressure is currently elevated at 190/100 mmHg.
      What would be the most suitable next course of action in managing his condition?

      Your Answer: Labetalol 10 mg IV

      Explanation:

      Severe hypertension, defined as blood pressure greater than 180/120 mmHg, is a condition that prevents the use of thrombolysis. In order to proceed with thrombolysis, it is necessary to lower the patient’s blood pressure to below this level within the designated time frame. Oral medications are unlikely to work quickly enough, so an intravenous antihypertensive agent is required.

      One commonly used agent in these situations is labetalol, which is administered intravenously at a dose of 10 mg over 1-2 minutes. This dose can be repeated if necessary, or an infusion can be set up to deliver a continuous dose of 2-8 mg per minute. Once the blood pressure is reduced to less than 180/105 mmHg, thrombolysis can be safely performed.

      Alternatively, a nitrate infusion, such as Isoket, can be used in patients who cannot tolerate beta-blockers due to contraindications like asthma, heart block, or cardiac failure. This provides an alternative option for lowering blood pressure in these individuals.

    • This question is part of the following fields:

      • Neurology
      19.9
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  • Question 64 - A child presents with a severe acute asthma attack. After a poor response...

    Incorrect

    • A child presents with a severe acute asthma attack. After a poor response to the initial salbutamol nebulizer, you administer another nebulizer that also contains ipratropium bromide.
      What is the most common side effect experienced with ipratropium bromide?

      Your Answer: Urinary retention

      Correct Answer: Dry mouth

      Explanation:

      Ipratropium bromide commonly leads to dry mouth as a side effect. Additionally, it may result in constipation, cough, sudden bronchospasm, headache, nausea, and palpitations. In patients with prostatic hyperplasia and bladder outflow obstruction, it can cause urinary retention. Furthermore, susceptible individuals may experience acute closed-angle glaucoma as a result of using this medication.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      57.2
      Seconds
  • Question 65 - A 45-year-old patient arrives at the Emergency Department complaining of a severe headache....

    Correct

    • A 45-year-old patient arrives at the Emergency Department complaining of a severe headache. This individual is a known heavy drinker, consuming 15-20 units of alcohol daily. It is currently 3 pm, and the patient is visibly intoxicated. Despite the need for assessment, the patient adamantly refuses and insists on leaving.
      What course of action would be most suitable in this situation?

      Your Answer: Suggest a referral to the community drug and alcohol team

      Explanation:

      When considering the management of long-term conditions and promoting patient self-care, it is important to explore various factors. However, out of the given options, the only safe and viable choice is to refer the patient to the community drug and alcohol team. Without further information about the patient’s headache, a CT scan is not necessary. It would be unwise to advise the patient to stop drinking or to allow them to leave the department without assessing their capacity and obtaining their signature on a self-discharge form. At this point, there is insufficient information to make a referral to the medical team.

    • This question is part of the following fields:

      • Mental Health
      39.6
      Seconds
  • Question 66 - A 22-year-old woman is brought in by ambulance. She has a decreased level...

    Correct

    • A 22-year-old woman is brought in by ambulance. She has a decreased level of consciousness and is challenging to awaken. She has a history of anxiety and depression and was discovered at home next to an empty bottle of diazepam tablets.

      Which acid-base disorder would you anticipate being caused by a substantial benzodiazepine overdose?

      Your Answer: Respiratory acidosis

      Explanation:

      Common causes for different acid-base disorders.

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

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. It can also occur due to pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.

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

      Metabolic acidosis with a raised anion gap can occur due to lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction) or ketoacidosis (such as in diabetes, starvation, or alcohol excess). It can also be a result of renal failure or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11.9
      Seconds
  • Question 67 - Whilst assessing a patient in the Emergency Department, you observe a diastolic murmur.
    Which...

    Incorrect

    • Whilst assessing a patient in the Emergency Department, you observe a diastolic murmur.
      Which of the following is NOT a potential cause of a diastolic murmur?

      Your Answer: Atrial myxoma

      Correct Answer: Tricuspid regurgitation

      Explanation:

      Tricuspid regurgitation leads to a pansystolic murmur that is most pronounced in the tricuspid area during inhalation. The primary cause of tricuspid regurgitation is right ventricular failure.

      Other clinical signs that may be present in tricuspid regurgitation include a raised jugular venous pressure (JVP) and giant C-V waves. Additionally, features of increased right atrial pressure, such as ascites and dependent edema, may be observed. Pulsatile hepatomegaly and a thrill at the left sternal edge are also possible indicators. Reverse splitting of the second heart sound, due to early closure of the pulmonary valve, and a third heart sound, caused by rapid right ventricular filling, may be heard as well.

      Aortic regurgitation, on the other hand, produces an early diastolic murmur that is most audible at the lower left sternal edge when the patient is sitting forward and exhaling.

      In the case of mitral stenosis, a rumbling mid-diastolic murmur is best heard at the apex while the patient is in the left lateral position and exhaling, using the bell of the stethoscope.

      Atrial myxomas are benign tumors that can develop in the heart. Most commonly found on the left side, they may obstruct the mitral valve, resulting in a mid-diastolic murmur similar to that of mitral stenosis.

      Lastly, left anterior descending artery stenosis can cause an early diastolic murmur, also known as Dock’s murmur. This murmur is similar to that of aortic regurgitation and is best heard at the left 2nd or 3rd intercostal space.

    • This question is part of the following fields:

      • Cardiology
      15.7
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  • Question 68 - A 68 year old female visits the emergency department with complaints of lower...

    Correct

    • A 68 year old female visits the emergency department with complaints of lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable and a diagnosis of acute urinary retention is made. To determine if any medications may be contributing to the condition, you inquire about the patient's drug history. Which of the following drug classes is NOT known to cause urinary retention?

      Your Answer: 5α-reductase inhibitors

      Explanation:

      Urinary retention can be caused by various drug classes. One such class is 5α-reductase inhibitors like finasteride, which are prescribed to alleviate obstructive symptoms caused by an enlarged prostate. Some commonly known drugs that can lead to urinary retention include alcohol, anticholinergics, decongestants (such as phenylephrine and pseudoephedrine), disopyramide, antihistamines (like diphenhydramine and phenergan), and amphetamines.

      Further Reading:

      Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.

      There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.

      The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.

    • This question is part of the following fields:

      • Urology
      35.5
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  • Question 69 - A 35-year-old woman with a history of sickle cell disease undergoes a blood...

    Correct

    • A 35-year-old woman with a history of sickle cell disease undergoes a blood transfusion. After one week, she experiences a slight fever and notices dark urine. Blood tests are ordered, revealing elevated bilirubin and LDH levels, as well as a positive Direct Antiglobulin Test (DAT).
      What is the most suitable course of treatment for this patient?

      Your Answer: Monitor renal function and haemoglobin

      Explanation:

      Blood transfusion is a crucial treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there have been improvements in safety procedures and a reduction in transfusion use, errors and adverse reactions still occur.

      Delayed haemolytic transfusion reactions (DHTRs) typically occur 4-8 days after a blood transfusion, but can sometimes manifest up to a month later. The symptoms are similar to acute haemolytic transfusion reactions but are usually less severe. Patients may experience fever, inadequate rise in haemoglobin, jaundice, reticulocytosis, positive antibody screen, and positive Direct Antiglobulin Test (Coombs test). DHTRs are more common in patients with sickle cell disease who have received frequent transfusions.

      These reactions are caused by the presence of a low titre antibody that is too weak to be detected during cross-match and unable to cause lysis at the time of transfusion. The severity of DHTRs depends on the immunogenicity or dose of the antigen. Blood group antibodies associated with DHTRs include those of the Kidd, Duffy, Kell, and MNS systems. Most DHTRs have a benign course and do not require treatment. However, severe haemolysis with anaemia and renal failure can occur, so monitoring of haemoglobin levels and renal function is necessary. If an antibody is detected, antigen-negative blood can be requested for future transfusions.

      Here is a summary of the main transfusion reactions and complications:

      1. Febrile transfusion reaction: Presents with a 1-degree rise in temperature from baseline, along with chills and malaise. It is the most common reaction and is usually caused by cytokines from leukocytes in transfused red cell or platelet components. Supportive treatment with paracetamol is helpful.

      2. Acute haemolytic reaction: Symptoms include fever, chills, pain at the transfusion site, nausea, vomiting, and dark urine. It is the most serious type of reaction and often occurs due to ABO incompatibility from administration errors. The transfusion should be stopped, and IV fluids should be administered. Diuretics may be required.

      3. Delayed haemolytic reaction: This reaction typically occurs 4-8 days after a blood transfusion and presents with fever, anaemia, jaundice and haemoglobuinuria. Direct antiglobulin (Coombs) test positive. Due to low titre antibody too weak to detect in cross-match and unable to cause lysis at time of transfusion. Most delayed haemolytic reactions have a benign course and require no treatment. Monitor anaemia and renal function and treat as required.

    • This question is part of the following fields:

      • Haematology
      43.1
      Seconds
  • Question 70 - 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
      5.5
      Seconds
  • Question 71 - A 45-year-old man comes in with a high temperature, shivering, aching head, cough,...

    Correct

    • A 45-year-old man comes in with a high temperature, shivering, aching head, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the birdhouse. During the examination, a red rash is noticed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.
      What is the BEST antibiotic to prescribe for this patient?

      Your Answer: Doxycycline

      Explanation:

      Psittacosis is a type of infection that can be transmitted from animals to humans, known as a zoonotic infection. It is caused by a bacterium called Chlamydia psittaci. This infection is most commonly seen in people who own domestic birds, but it can also affect those who work in pet shops or zoos.

      The typical presentation of psittacosis includes symptoms similar to those of pneumonia that is acquired within the community. People may experience flu-like symptoms along with severe headaches and sensitivity to light. In about two-thirds of patients, an enlargement of the spleen, known as splenomegaly, can be observed.

      Infected individuals often develop a reddish rash with flat spots on their face, known as Horder’s spots. Additionally, they may experience skin conditions such as erythema nodosum or erythema multiforme.

      The recommended treatment for psittacosis is a course of tetracycline or doxycycline, which should be taken for a period of 2-3 weeks.

    • This question is part of the following fields:

      • Respiratory
      31.7
      Seconds
  • Question 72 - A 32-year-old woman was involved in a car accident where her car collided...

    Correct

    • A 32-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. A helical contrast-enhanced CT scan of the chest reveals a traumatic aortic injury. After receiving analgesia, which has effectively controlled her pain, her vital signs are as follows: HR 95, BP 128/88, SaO2 97% on room air, temperature is 37.4ºC.
      Which of the following medications would be most appropriate to administer next?

      Your Answer: Esmolol

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

    • This question is part of the following fields:

      • Trauma
      31.8
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  • Question 73 - A 60-year-old man presents with visible jaundice, fatigue, and intense itching. He has...

    Correct

    • A 60-year-old man presents with visible jaundice, fatigue, and intense itching. He has noticed that his stools float and that they have become pale, foul-smelling, and oily in appearance. He has no history of abdominal pain. He has a past medical history of Crohn's disease, which has been controlled with mesalazine. On examination, you notice yellowish pigmentation of the skin, sclerae, and mucous membranes. His abdomen is soft but can palpate a firm liver edge 5 cm below the costal margin. He also has numerous scratch marks covering his abdomen and upper thighs. His liver function tests are shown below:
      Bilirubin 102 mmol (3-20)
      ALT 235 IU/L (5-40)
      ALP: 1501 IU/L (20-140)
      pANCA: positive
      cANCA: negative
      ANA: negative
      SMA: negative
      What is the SINGLE most likely diagnosis?

      Your Answer: Primary sclerosing cholangitis

      Explanation:

      This woman is showing signs of obstructive jaundice along with a history of ulcerative colitis. The most probable diagnosis in this case is primary sclerosing cholangitis (PSC). PSC is a condition that causes inflammation and blockage of the bile ducts, leading to progressive damage. It is characterized by recurrent episodes of cholangitis and the development of scar tissue in the bile ducts. In severe cases, it can lead to liver cirrhosis, liver failure, and even liver cancer. PSC is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis.

      The underlying cause of PSC is believed to be autoimmune in nature. Around 80% of patients with PSC test positive for p-ANCA antibodies, which are associated with autoimmune diseases. Other antibodies such as antinuclear antibodies (ANA) and anti-smooth muscle antibodies may also be present, but they are only found in about one-third of PSC patients.

      Autoimmune hepatitis, on the other hand, is a liver inflammation caused by a decrease in regulatory T-cells (Treg cells), leading to the production of autoantibodies against hepatocyte surface antigens. It primarily affects women (70%) between the ages of 15 and 40. The condition causes chronic and progressive hepatitis, often presenting in the later stages when the patient is severely unwell and jaundiced. Liver function tests typically show significantly elevated levels of transaminases (ALT and AST), often more than ten times the normal range. Alkaline phosphatase (ALP) levels may be normal or slightly elevated. Antinuclear antibodies (ANA) are positive in approximately 80% of cases, while smooth muscle antibodies (SMA) are positive in about 70% of cases. Antimitochondrial antibodies are usually low or absent.

      Primary biliary cirrhosis is another autoimmune liver disease that leads to the progressive destruction of the small bile ducts in the liver, primarily affecting the intralobular ducts. This results in cholestatic jaundice, liver fibrosis, and eventually cirrhosis. The condition is more common in women (90%) and typically occurs between the ages of 30 and 65. Liver function tests show predominantly elevated levels of alkaline phosphatase (ALP), often before any symptoms or signs of the disease appear.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 74 - A 7-year-old boy is brought to the Emergency Department with lower abdominal pain...

    Correct

    • A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a preliminary diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip, and when you attempt to extend it passively, his abdominal pain intensifies.
      Which muscle is most likely in contact with the inflamed structure causing these symptoms?

      Your Answer: Psoas major

      Explanation:

      This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.

      The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.

      The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 75 - A 36 year old male comes to the emergency department complaining of increased...

    Correct

    • A 36 year old male comes to the emergency department complaining of increased thirst and frequent urination. During the assessment, you order blood and urine samples to measure osmolality. The results reveal an elevated plasma osmolality of 320 mOSm/Kg and a decreased urine osmolality of 198 mOSm/Kg. What is the most probable diagnosis?

      Your Answer: Diabetes insipidus

      Explanation:

      Diabetes insipidus (DI) is characterized by specific biochemical markers. One of these markers is a low urine osmolality, meaning that the concentration of solutes in the urine is lower than normal. In contrast, the serum osmolality, which measures the concentration of solutes in the blood, is high in individuals with DI. This combination of low urine osmolality and high serum osmolality is indicative of DI. Other common biochemical disturbances associated with DI include elevated plasma osmolality, polyuria (excessive urine production), and hypernatremia (high sodium levels in the blood). However, it is important to note that sodium levels can sometimes be within the normal range in individuals with DI. It is worth mentioning that conditions such as Addison’s disease, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and primary polydipsia are associated with low serum osmolality and hyponatremia. Additionally, the use of selective serotonin reuptake inhibitors (SSRIs) can also lead to hyponatremia as a side effect.

      Further Reading:

      Diabetes insipidus (DI) is a condition characterized by either a decrease in the secretion of antidiuretic hormone (cranial DI) or insensitivity to antidiuretic hormone (nephrogenic DI). Antidiuretic hormone, also known as arginine vasopressin, is produced in the hypothalamus and released from the posterior pituitary. The typical biochemical disturbances seen in DI include elevated plasma osmolality, low urine osmolality, polyuria, and hypernatraemia.

      Cranial DI can be caused by various factors such as head injury, CNS infections, pituitary tumors, and pituitary surgery. Nephrogenic DI, on the other hand, can be genetic or result from electrolyte disturbances or the use of certain drugs. Symptoms of DI include polyuria, polydipsia, nocturia, signs of dehydration, and in children, irritability, failure to thrive, and fatigue.

      To diagnose DI, a 24-hour urine collection is done to confirm polyuria, and U&Es will typically show hypernatraemia. High plasma osmolality with low urine osmolality is also observed. Imaging studies such as MRI of the pituitary, hypothalamus, and surrounding tissues may be done, as well as a fluid deprivation test to evaluate the response to desmopressin.

      Management of cranial DI involves supplementation with desmopressin, a synthetic form of arginine vasopressin. However, hyponatraemia is a common side effect that needs to be monitored. In nephrogenic DI, desmopressin supplementation is usually not effective, and management focuses on ensuring adequate fluid intake to offset water loss and monitoring electrolyte levels. Causative drugs need to be stopped, and there is a risk of developing complications such as hydroureteronephrosis and an overdistended bladder.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 76 - A 32-year-old individual arrives at the emergency department complaining of bloody diarrhea that...

    Correct

    • A 32-year-old individual arrives at the emergency department complaining of bloody diarrhea that has been ongoing for two days. The patient mentions experiencing a similar episode six months ago, although it was less severe and resolved within a week. The possibility of inflammatory bowel disease (IBD) crosses your mind. Which of the following statements about IBD is accurate?

      Your Answer: The terminal ileum is the most common site affected by Crohn's

      Explanation:

      Crohn’s disease is characterized by skip lesions, which are not present in ulcerative colitis. Unlike ulcerative colitis, Crohn’s disease causes inflammation throughout the entire thickness of the intestinal wall, not just the mucosa. Interestingly, smoking increases the risk of developing Crohn’s disease but decreases the risk of ulcerative colitis. Additionally, having an appendicectomy before adulthood is believed to protect against ulcerative colitis, whereas it actually increases the risk of developing Crohn’s disease for about 5 years after the surgery.

      Further Reading:

      Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation of the intestinal tract and an imbalance of the intestinal microbiota. The two main forms of IBD are Crohn’s disease and ulcerative colitis (UC). In some cases, it is not possible to differentiate between Crohn’s disease and UC, and the term inflammatory bowel disease type-unclassified may be used.

      Crohn’s disease is a chronic, relapsing-remitting inflammatory disease that can affect any part of the gastrointestinal tract, from the mouth to the anus. It most commonly involves the ileum and colon. The inflammation in Crohn’s disease affects all layers of the intestinal wall, leading to complications such as strictures, fistulas, and adhesions. Risk factors for developing Crohn’s disease include a family history, smoking, infectious gastroenteritis, appendicectomy, and the use of NSAIDs and oral contraceptive drugs. Symptoms of Crohn’s disease can vary but often include diarrhea, abdominal pain, weight loss, and perianal disease. Extraintestinal features, such as arthritis, erythema nodosum, and uveitis, can also occur.

      Ulcerative colitis is a chronic, relapsing-remitting inflammatory disease that primarily affects the large bowel. The inflammation in UC is limited to the intestinal mucosa and does not involve skip lesions like in Crohn’s disease. Risk factors for developing UC include a family history, not smoking, and no appendix. Symptoms of UC include bloody diarrhea, urgency, tenesmus, and abdominal pain. Extraintestinal features, such as arthritis and uveitis, can also occur. Complications of UC include toxic megacolon, bowel obstruction, bowel perforation, strictures, fistula formation, anemia, malnutrition, and colorectal cancer.

      Diagnosing IBD involves various investigations, including blood tests, stool microscopy and culture, fecal calprotectin testing, endoscopy with biopsy, and imaging modalities such as CT and MR enterography. The management of Crohn’s disease and UC is complex and may involve corticosteroids, immunosuppressive drugs, biologic therapy, surgery, and nutritional support. Patients with IBD should also be monitored for nutritional deficiencies, colorectal cancer, and osteoporosis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 77 - A 60-year-old man comes in with decreased visual acuity and 'floaters' in his...

    Correct

    • A 60-year-old man comes in with decreased visual acuity and 'floaters' in his right eye. Upon conducting fundoscopy, you observe a sheet of sensory retina bulging towards the center of the eye.
      What is the MOST LIKELY diagnosis?

      Your Answer: Retinal detachment

      Explanation:

      Retinal detachment is a condition where the retina separates from the retinal pigment epithelium, resulting in a fluid-filled space between them. This case presents a classic description of retinal detachment. Several risk factors increase the likelihood of developing this condition, including myopia, being male, having a family history of retinal detachment, previous episodes of retinal detachment, blunt ocular trauma, previous cataract surgery, diabetes mellitus (especially if proliferative retinopathy is present), glaucoma, and cataracts.

      The clinical features commonly associated with retinal detachment include flashes of light, particularly at the edges of vision (known as photopsia), a dense shadow in the peripheral vision that spreads towards the center, a sensation of a curtain drawing across the eye, and central visual loss. Fundoscopy, a procedure to examine the back of the eye, reveals a sheet of sensory retina billowing towards the center of the eye. Additionally, a positive Amsler grid test, where straight lines appear curved or wavy, may indicate retinal detachment.

      Other possible causes of floaters include posterior vitreous detachment, retinal tears, vitreous hemorrhage, and migraine with aura. However, in this case, the retinal appearance described is consistent with retinal detachment.

      It is crucial to arrange an urgent same-day ophthalmology referral for this patient. Fortunately, approximately 90% of retinal detachments can be successfully repaired with one operation, and an additional 6% can be salvaged with subsequent procedures. If the retina remains fixed six months after surgery, the likelihood of it becoming detached again is low.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 78 - A 67 year old male is brought into the emergency department by concerned...

    Correct

    • A 67 year old male is brought into the emergency department by concerned neighbors. They inform you that the patient is frequently intoxicated, but this morning they discovered him wandering in the street and he appeared extremely disoriented and unstable, which is out of character for him. Upon reviewing the patient's medical records, you observe that he has been experiencing abnormal liver function tests for several years and a history of alcohol abuse has been documented. You suspect that the underlying cause of his condition is Wernicke's encephalopathy.

      Your Answer: Vitamin B1 deficiency

      Explanation:

      Wernicke’s encephalopathy is a sudden neurological condition that occurs due to a lack of thiamine (vitamin B1). It is characterized by symptoms such as confusion, difficulty with coordination, low body temperature, low blood pressure, involuntary eye movements, and vomiting.

      Further Reading:

      Alcoholic liver disease (ALD) is a spectrum of disease that ranges from fatty liver at one end to alcoholic cirrhosis at the other. Fatty liver is generally benign and reversible with alcohol abstinence, while alcoholic cirrhosis is a more advanced and irreversible form of the disease. Alcoholic hepatitis, which involves inflammation of the liver, can lead to the development of fibrotic tissue and cirrhosis.

      Several factors can increase the risk of progression of ALD, including female sex, genetics, advanced age, induction of liver enzymes by drugs, and co-existent viral hepatitis, especially hepatitis C.

      The development of ALD is multifactorial and involves the metabolism of alcohol in the liver. Alcohol is metabolized to acetaldehyde and then acetate, which can result in the production of damaging reactive oxygen species. Genetic polymorphisms and co-existing hepatitis C infection can enhance the pathological effects of alcohol metabolism.

      Patients with ALD may be asymptomatic or present with non-specific symptoms such as abdominal discomfort, vomiting, or anxiety. Those with alcoholic hepatitis may have fever, anorexia, and deranged liver function tests. Advanced liver disease can manifest with signs of portal hypertension and cirrhosis, such as ascites, varices, jaundice, and encephalopathy.

      Screening tools such as the AUDIT questionnaire can be used to assess alcohol consumption and identify hazardous or harmful drinking patterns. Liver function tests, FBC, and imaging studies such as ultrasound or liver biopsy may be performed to evaluate liver damage.

      Management of ALD involves providing advice on reducing alcohol intake, administering thiamine to prevent Wernicke’s encephalopathy, and addressing withdrawal symptoms with benzodiazepines. Complications of ALD, such as intoxication, encephalopathy, variceal bleeding, ascites, hypoglycemia, and coagulopathy, require specialized interventions.

      Heavy alcohol use can also lead to thiamine deficiency and the development of Wernicke Korsakoff’s syndrome, characterized by confusion, ataxia, hypothermia, hypotension, nystagmus, and vomiting. Prompt treatment is necessary to prevent progression to Korsakoff’s psychosis.

      In summary, alcoholic liver disease is a spectrum of disease that can range from benign fatty liver to irreversible cirrhosis. Risk factors for progression include female sex, genetics, advanced age, drug-induced liver enzyme induction, and co-existing liver conditions.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 79 - You are reviewing a 35-year-old man after receiving his most recent blood results....

    Correct

    • You are reviewing a 35-year-old man after receiving his most recent blood results. He is currently taking ramipril for his blood pressure, which is well controlled. He used to consume 30 units of alcohol per week until three months ago when he was advised to reduce his intake following his last set of blood tests. He has since remained completely abstinent. He has no identifiable risk factors for chronic liver disease. On examination, you can palpate a 1 cm liver edge below the right costal margin. His most recent two sets of blood results are provided below.

      Blood results today:
      Bilirubin: 19 µmol/L (3-20)
      ALT: 98 IU/L (5-40)
      AST: 46 IU/L (5-40)
      ALP: 126 IU/L (20-140)
      GGT: 225 IU/L (5-40)

      Blood results 3 months ago:
      Bilirubin: 19 µmol/L (3-20)
      ALT: 126 IU/L (5-40)
      AST: 39 IU/L (5-40)
      ALP: 118 IU/L (20-140)
      GGT: 35 IU/L (5-40)

      What is the SINGLE most likely diagnosis?

      Your Answer: Non-alcoholic steatohepatitis

      Explanation:

      The diagnosis in this case is non-alcoholic steatohepatitis (NASH), which is characterized by fatty infiltration of the liver and is commonly associated with obesity. It is the most frequent cause of persistently elevated ALT levels in patients without risk factors for chronic liver disease.

      Risk factors for developing NASH include obesity, particularly truncal obesity, diabetes mellitus, and hypercholesterolemia.

      The clinical features of NASH can vary, with many patients being completely asymptomatic. However, some may experience right upper quadrant pain, nausea and vomiting, and hepatomegaly (enlarged liver).

      The typical biochemical profile seen in NASH includes elevated transaminases, with an AST:ALT ratio of less than 1. Often, there is an isolated elevation of ALT, and gamma-GT levels may be mildly elevated. In about one-third of patients, non-organ specific autoantibodies may be present. The presence of antinuclear antibodies (ANA) is associated with insulin resistance and indicates a higher risk of rapid progression to advanced liver disease.

      If the AST level is significantly elevated or if the gamma-GT level is markedly elevated, further investigation for other potential causes should be considered. A markedly elevated gamma-GT level may suggest alcohol abuse, although it can also be elevated in NASH alone.

      Diagnosis of NASH is confirmed through a liver biopsy, which will reveal increased fat deposition and a necro-inflammatory response within the hepatocytes.

      Currently, there is no specific treatment for NASH. However, weight loss and medications that improve insulin resistance, such as metformin, may help slow down the progression of the disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 80 - You assess a patient who complained of chest discomfort and difficulty breathing. Upon...

    Correct

    • You assess a patient who complained of chest discomfort and difficulty breathing. Upon examination, it is determined that the patient has developed a spontaneous pneumothorax on the right side, and an unsuccessful pleural aspiration was attempted. The pneumothorax remains significant in size, and the patient continues to experience breathlessness. A Seldinger chest tube is inserted, but shortly after, it begins to drain bright red blood.

      Which complication is the most probable cause of this occurrence?

      Your Answer: Intercostal artery laceration

      Explanation:

      Intercostal artery laceration during the insertion of a chest drain is a potentially life-threatening complication. Although rare, it occurs more frequently than other complications mentioned. To minimize the risk of damage to underlying structures and unsightly scarring, the British Thoracic Society (BTS) recommends inserting chest drains within the safe triangle. This triangle is defined by the base of the axilla, the lateral border of the latissimus dorsi, the lateral border of the pectoralis major, and the 5th intercostal space.

      Possible complications associated with the insertion of small-bore chest drains include puncture of the intercostal artery, organ perforation due to over-introduction of the dilator into the chest cavity, hospital-acquired pleural infection from non-aseptic techniques, inadequate stay suture leading to the chest tube falling out, and tube blockage, which may be more common with smaller bore Argyle drains.

      When using an intercostal approach, it is important to place the chest drain closer to the superior border of the rib below in the intercostal space. This positioning helps avoid injury to the intercostal neurovascular bundle located under the costal groove of the rib above.

      For more information, refer to the British Thoracic Society pleural disease guidelines.

    • This question is part of the following fields:

      • Respiratory
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  • Question 81 - A 45-year-old man comes in with vomiting, disorientation, and decreased urine production. His...

    Correct

    • A 45-year-old man comes in with vomiting, disorientation, and decreased urine production. His creatinine levels have increased by 150% compared to his usual levels over the past week. After conducting additional tests, the patient is diagnosed with acute kidney injury (AKI).
      What stage of AKI does he fall under?

      Your Answer: Stage 2

      Explanation:

      Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This leads to the accumulation of urea and other waste products in the body, as well as disturbances in fluid balance and electrolyte levels. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.

      AKI is categorized into three stages based on specific criteria. In stage 1, there is a rise in creatinine levels of 26 micromol/L or more within 48 hours, or a rise of 50-99% from baseline within 7 days (1.5-1.99 times the baseline). Additionally, a urine output of less than 0.5 mL/kg/hour for more than 6 hours is indicative of stage 1 AKI.

      Stage 2 AKI is characterized by a creatinine rise of 100-199% from baseline within 7 days (2.0-2.99 times the baseline), or a urine output of less than 0.5 mL/kg/hour for more than 12 hours.

      In stage 3 AKI, there is a creatinine rise of 200% or more from baseline within 7 days (3.0 or more times the baseline). Alternatively, a creatinine rise to 354 micromol/L or more with an acute rise of 26 micromol/L or more within 48 hours, or a rise of 50% or more within 7 days, is indicative of stage 3 AKI. Additionally, a urine output of less than 0.3 mL/kg/hour for 24 hours or anuria (no urine output) for 12 hours also falls under stage 3 AKI.

    • This question is part of the following fields:

      • Nephrology
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  • Question 82 - A 45-year-old woman with no permanent address sustains a head injury after falling....

    Incorrect

    • A 45-year-old woman with no permanent address sustains a head injury after falling. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.

      During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.

      Which medication should be urgently administered to this patient?

      Your Answer: Oral thiamine

      Correct Answer: Intravenous Pabrinex

      Explanation:

      This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.

      Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.

      This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.

      Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.

    • This question is part of the following fields:

      • Neurology
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  • Question 83 - A 45-year-old woman presents with increasing shortness of breath at rest and severe...

    Correct

    • A 45-year-old woman presents with increasing shortness of breath at rest and severe left shoulder pain. The pain travels down the inner side of her left arm and into her ring and little finger. She has a long history of smoking, having smoked 30 packs of cigarettes per year. During the examination, her voice sounds hoarse and there is muscle wasting in her left hand and forearm. Additionally, she has a left-sided ptosis and miosis.

      What is the MOST suitable initial test to perform?

      Your Answer: Chest X-ray

      Explanation:

      This individual, who has been smoking for a long time, is likely to have squamous cell carcinoma of the lung located at the right apex. This particular type of cancer is causing Pancoast’s syndrome. Pancoast’s syndrome typically presents with rib erosion, leading to severe shoulder pain, as well as Horner’s syndrome due to the infiltration of the lower part of the brachial plexus. Additionally, there may be hoarseness of the voice and a ‘bovine cough’ due to a concurrent recurrent laryngeal nerve palsy.

      The classic description of Horner’s syndrome includes the following clinical features on the same side as the tumor: miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (lack of sweating), and enophthalmos (sunken appearance of the eye). A chest X-ray would be able to detect the presence of the apical tumor and confirm the diagnosis.

    • This question is part of the following fields:

      • Respiratory
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  • Question 84 - A 75-year-old man is brought to the resuscitation area of your Emergency Department...

    Correct

    • A 75-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few weeks with vomiting and diarrhea. His wife tells you that he was started on a medication by his GP six months ago for pain and stiffness around his shoulders, upper arms, and hips. She describes this medication as being '6 small blue tablets.' He has been unable to take these tablets for the past few days. On examination, he is pale and sweaty and appears confused. His observations are as follows: temperature 37.2°C, HR 130 bpm, BP 90/50, RR 22, SaO2 97% on 2 L oxygen, GCS 13. He has intravenous access in situ, and his BM stick glucose is 2.5.
      What is the SINGLE most likely diagnosis?

      Your Answer: Addisonian crisis

      Explanation:

      This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. The most likely underlying rheumatological diagnosis in this case is polymyalgia rheumatica, and it is likely that the GP started the patient on prednisolone medication.

      Addison’s disease occurs when the adrenal glands underproduce steroid hormones, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.

      An Addisonian crisis is most commonly triggered by the deliberate or accidental withdrawal of steroid therapy in patients with Addison’s disease. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.

      The clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main features are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and coma.

      Biochemically, Addison’s disease is characterized by increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may include the Synacthen test, plasma ACTH level, plasma renin level, and adrenocortical antibodies.

      Management of Addison’s disease should be overseen by an Endocrinologist. Typically, patients require hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet, being aware of the possibility of an Addisonian crisis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 85 - A 45-year-old woman who is originally from Brazil has recently developed dilated cardiomyopathy...

    Correct

    • A 45-year-old woman who is originally from Brazil has recently developed dilated cardiomyopathy and difficulty swallowing. She remembers being bitten by an insect approximately 10 years ago, which resulted in a fever and flu-like symptoms. On her ankle, where the bite occurred, she now has a firm, violet-colored lump.
      What is the SINGLE most probable diagnosis?

      Your Answer: Chagas disease

      Explanation:

      Chagas disease, also known as American Trypanosomiasis, is a tropical illness caused by the protozoan Trypanosoma cruzi. It is transmitted by Triatomine insects, commonly known as kissing bugs, which belong to the Reduviidae family. This zoonotic disease is prevalent in Central and South America, with an estimated 8 million people infected in the region. In Brazil alone, there are approximately 120,000 new cases reported each year.

      The disease progresses through two stages: the acute stage and the chronic stage. During the acute stage, many patients may not experience any symptoms, and the infection can go unnoticed. However, some individuals may exhibit symptoms such as fever, malaise, muscle pain, loss of appetite, and occasionally vomiting and diarrhea. Clinical signs may include swollen lymph nodes and enlargement of the liver and spleen. At the site of the insect bite, an inflammatory response called a chagoma can occur. This is characterized by a swollen, violet-colored nodule that can last up to 8 weeks. Another distinctive sign of acute Chagas disease is Romaña’s sign, which is eyelid swelling caused by accidentally rubbing bug feces into the eyes.

      Following the acute stage, an estimated 10-30% of individuals progress to the chronic stage of Chagas disease. There is typically a latent phase between the acute and chronic phases, which can last for as long as 20-30 years. The chronic phase is associated with various complications, including cardiovascular problems such as dilated cardiomyopathy, heart failure, and arrhythmias. Gastrointestinal issues like megacolon, megaesophagus, and secondary achalasia can also arise. Neurological complications, such as neuritis, sensory and motor deficits, and encephalopathy, may occur. Additionally, psychiatric symptoms, including dementia, can manifest in some cases.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 86 - A 5 year old boy is brought into the emergency department by worried...

    Incorrect

    • A 5 year old boy is brought into the emergency department by worried parents. The child's parents inform you that the patient has had a cough and a runny nose for about 2-3 days, but in the past 24 hours, he has developed a fever and started coughing up large quantities of green mucus. You suspect bacterial tracheitis. What is the most probable causative agent?

      Your Answer: Pseudomonas aeruginosa

      Correct Answer: Staphylococcus aureus

      Explanation:

      Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

      The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

      In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

      Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

      When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

    • This question is part of the following fields:

      • Paediatric Emergencies
      25.4
      Seconds
  • Question 87 - A 7-year-old girl presents with a 4-day history of blurred vision in her...

    Correct

    • A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.

      What is the SINGLE most likely causative organism?

      Your Answer: Toxocara canis

      Explanation:

      Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.

      The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.

    • This question is part of the following fields:

      • Ophthalmology
      17.4
      Seconds
  • Question 88 - A 45-year-old male patient comes in with loss of appetite, vomiting, fatigue, and...

    Incorrect

    • A 45-year-old male patient comes in with loss of appetite, vomiting, fatigue, and disorientation. His blood tests show low sodium levels, and after further examination, he is diagnosed with drug-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH).
      Which of the following medications is most likely causing this presentation?

      Your Answer: Chloramphenicol

      Correct Answer: Amitriptyline

      Explanation:

      The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by the presence of low sodium levels and low osmolality due to the inappropriate and continuous release or action of the hormone, despite normal or increased blood volume. This leads to a decreased ability to excrete water.
      There are several factors that can cause SIADH, with carbamazepine being a well-known example. These causes can be grouped into different categories. One category is CNS damage, which includes conditions like meningitis and subarachnoid hemorrhage. Another category is malignancy, with small-cell lung cancer being a common cause. Certain drugs, such as carbamazepine, SSRIs, amitriptyline, and morphine, can also trigger SIADH. Infections, such as pneumonia, lung abscess, and brain abscess, are another potential cause. Lastly, endocrine disorders like hypothyroidism can contribute to the development of SIADH.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      16.8
      Seconds
  • Question 89 - A 60-year-old woman comes in sweating and in distress, complaining of abdominal discomfort...

    Correct

    • A 60-year-old woman comes in sweating and in distress, complaining of abdominal discomfort and feeling nauseous. She has a history of excessive alcohol consumption and has just completed a weekend of heavy drinking. During the examination, there is significant tenderness in her abdomen, particularly in the upper middle area, and bruising is noticeable around her belly button and on the sides of her abdomen.

      What is the SINGLE most probable diagnosis?

      Your Answer: Acute pancreatitis

      Explanation:

      Acute pancreatitis is a common and serious cause of acute abdominal pain. It occurs when the pancreas becomes inflamed, leading to the release of enzymes that cause self-digestion of the organ.

      The most common causes of acute pancreatitis are gallstones and alcohol consumption. Many cases are also of unknown origin. To remember the various causes, the mnemonic ‘I GET SMASHED’ can be helpful:

      – I: Idiopathic
      – G: Gallstones
      – E: Ethanol
      – T: Trauma
      – S: Steroids
      – M: Mumps
      – A: Autoimmune
      – S: Scorpion stings
      – H: Hyperlipidemia/hypercalcemia
      – E: ERCP
      – D: Drugs

      The clinical features of acute pancreatitis include severe epigastric pain, nausea and vomiting, referral of pain to specific dermatomes (or shoulder tip via the phrenic nerve), fever/sepsis, epigastric tenderness, jaundice, and signs such as Gray-Turner sign (ecchymosis of the flank) and Cullen sign (ecchymosis of the peri-umbilical area).

      The stimulation of the thoracic splanchnic nerves is responsible for the referred pain to the T6-10 dermatomes that is sometimes observed in pancreatitis and other pancreatic disorders.

      When investigating acute pancreatitis in the emergency department, it is important to perform blood glucose testing, a full blood count (which often shows an elevated white cell count), urea and electrolyte testing, calcium testing, liver function tests, coagulation screening, serum amylase testing (which should be more than 5 times the normal limit), an ECG, arterial blood gas analysis, and an abdominal X-ray.

      Treatment for acute pancreatitis involves providing the patient with oxygen, adequate pain relief (including antiemetics), and fluid resuscitation. A nasogastric tube and urinary catheter should be inserted, and fluid balance should be carefully monitored. Most patients require management in a high dependency unit (HDU) or intensive care unit (ICU) setting.

      Acute pancreatitis has a significant mortality rate, and complications are common. Early complications may include severe sepsis and circulatory shock, acute renal failure, disseminated intravascular coagulation, hypocalcemia, acute respiratory distress syndrome and pancreatic encephalopathy.

    • This question is part of the following fields:

      • Surgical Emergencies
      13.2
      Seconds
  • Question 90 - A 68 year old male is brought into the emergency department with a...

    Incorrect

    • A 68 year old male is brought into the emergency department with a two week history of worsening nausea, muscle aches, fatigue, and weakness. You send urine and blood samples for analysis. The results are shown below:

      Na+ 126 mmol/l
      K+ 5.3 mmol/l
      Urea 7.0 mmol/l
      Creatinine 90 µmol/l
      Glucose 6.0 mmol/l
      Urine osmolality 880 mosmol/kg

      You review the patient's medications. Which drug is most likely responsible for this patient's symptoms?

      Your Answer: Lithium

      Correct Answer: Sertraline

      Explanation:

      This patient is experiencing hyponatremia, which is characterized by low plasma osmolality and high urine osmolality, indicating syndrome of inappropriate antidiuretic hormone secretion (SIADH). One of the most common causes of SIADH is the use of SSRIs. On the other hand, lithium, sodium bicarbonate, and corticosteroids are known to cause hypernatremia. Plasma osmolality can be calculated using the formula (2 x Na) + Glucose + Urea. In this patient, the calculated osmolality is 265 mosmol/kg, which falls within the normal range of 275-295 mosmol/kg.

      Further Reading:

      Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.

      There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.

      The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.

      Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.

      It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.

    • This question is part of the following fields:

      • Nephrology
      25.4
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SESSION STATS - PERFORMANCE PER SPECIALTY

Respiratory (5/9) 56%
Trauma (3/3) 100%
Infectious Diseases (3/3) 100%
Dermatology (4/5) 80%
Basic Anaesthetics (1/3) 33%
Palliative & End Of Life Care (1/1) 100%
Surgical Emergencies (2/3) 67%
Resus (1/1) 100%
Cardiology (3/5) 60%
Environmental Emergencies (2/3) 67%
Neurology (5/7) 71%
Ear, Nose & Throat (2/3) 67%
Pharmacology & Poisoning (5/11) 45%
Endocrinology (2/2) 100%
Neonatal Emergencies (1/2) 50%
Nephrology (2/3) 67%
Safeguarding & Psychosocial Emergencies (2/3) 67%
Gastroenterology & Hepatology (8/8) 100%
Allergy (0/1) 0%
Musculoskeletal (non-traumatic) (1/1) 100%
Ophthalmology (3/3) 100%
Haematology (2/3) 67%
Sexual Health (1/1) 100%
Elderly Care / Frailty (1/1) 100%
Mental Health (2/2) 100%
Maxillofacial & Dental (1/1) 100%
Urology (1/1) 100%
Paediatric Emergencies (0/1) 0%
Passmed