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Question 1
Incorrect
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A 25-year-old type 1 diabetic arrives at the emergency department complaining of a worsening sore throat, fever, and overall feeling of illness. The patient reports that the symptoms began a week ago. During the examination, the patient's temperature is measured at 38.3ºC, bilateral posterior cervical lymphadenopathy is observed, and there is exudate on both tonsils. Additionally, tenderness is noted in the right upper quadrant. Glandular fever is suspected.
What would be the most suitable approach for conducting further investigations?Your Answer: Send throat swab for Epstein-Barr virus (EBV) viral serology
Correct Answer: Send blood for Epstein-Barr virus (EBV) viral serology
Explanation:Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 2
Incorrect
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A 32 year old with a documented peanut allergy is currently receiving treatment for an anaphylactic reaction. What are the most likely cardiovascular manifestations that you would observe in a patient experiencing an episode of anaphylaxis?
Your Answer:
Correct Answer: Hypotension and tachycardia
Explanation:Anaphylaxis, also known as anaphylactic shock, is characterized by certain symptoms similar to other types of shock. These symptoms include low blood pressure (hypotension), rapid heart rate (tachycardia), irregular heart rhythm (arrhythmia), changes in the electrocardiogram (ECG) indicating reduced blood flow to the heart (myocardial ischemia), such as ST elevation, and in severe cases, cardiac arrest.
Further Reading:
Anaphylaxis is a severe and life-threatening hypersensitivity reaction that can have sudden onset and progression. It is characterized by skin or mucosal changes and can lead to life-threatening airway, breathing, or circulatory problems. Anaphylaxis can be allergic or non-allergic in nature.
In allergic anaphylaxis, there is an immediate hypersensitivity reaction where an antigen stimulates the production of IgE antibodies. These antibodies bind to mast cells and basophils. Upon re-exposure to the antigen, the IgE-covered cells release histamine and other inflammatory mediators, causing smooth muscle contraction and vasodilation.
Non-allergic anaphylaxis occurs when mast cells degrade due to a non-immune mediator. The clinical outcome is the same as in allergic anaphylaxis.
The management of anaphylaxis is the same regardless of the cause. Adrenaline is the most important drug and should be administered as soon as possible. The recommended doses for adrenaline vary based on age. Other treatments include high flow oxygen and an IV fluid challenge. Corticosteroids and chlorpheniramine are no longer recommended, while non-sedating antihistamines may be considered as third-line treatment after initial stabilization of airway, breathing, and circulation.
Common causes of anaphylaxis include food (such as nuts, which is the most common cause in children), drugs, and venom (such as wasp stings). Sometimes it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.
The Resuscitation Council (UK) provides guidelines for the management of anaphylaxis, including a visual algorithm that outlines the recommended steps for treatment.
https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf -
This question is part of the following fields:
- Cardiology
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Question 3
Incorrect
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A 45-year-old woman comes in with a history of fatigue, excessive thirst, and frequent urination. A urine dipstick test is done, which shows the presence of glucose in the urine.
Which ONE result would be INCONSISTENT with a diagnosis of diabetes mellitus in this patient?Your Answer:
Correct Answer: An HbA1c of 40 mmol/mol
Explanation:According to the 2011 recommendations from the World Health Organization (WHO), HbA1c can now be used as a diagnostic test for diabetes. However, this is only applicable if stringent quality assurance tests are in place and the assays are standardized to criteria aligned with international reference values. Additionally, accurate measurement of HbA1c is only possible if there are no conditions present that could hinder its accuracy.
To diagnose diabetes using HbA1c, a value of 48 mmol/mol (6.5%) is recommended as the cut-off point. It’s important to note that a value lower than 48 mmol/mol (6.5%) does not exclude the possibility of diabetes, as glucose tests are still necessary for a definitive diagnosis.
When using glucose tests, the following criteria are considered diagnostic for diabetes mellitus:
– A random venous plasma glucose concentration greater than 11.1 mmol/l
– A fasting plasma glucose concentration greater than 7.0 mmol/l
– A two-hour plasma glucose concentration greater than 11.1 mmol/l, two hours after consuming 75g of anhydrous glucose in an oral glucose tolerance test (OGTT)However, there are certain circumstances where HbA1c is not appropriate for diagnosing diabetes mellitus. These include:
– ALL children and young people
– Patients of any age suspected of having Type 1 diabetes
– Patients with symptoms of diabetes for less than two months
– Patients at high risk of diabetes who are acutely ill, such as those requiring hospital admission
– Patients taking medication that may cause a rapid rise in glucose levels, such as steroids or antipsychotics
– Patients with acute pancreatic damage, including those who have undergone pancreatic surgery
– Pregnant individuals
– Presence of genetic, hematologic, and illness-related factors that can influence HbA1c and its measurement. -
This question is part of the following fields:
- Endocrinology
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Question 4
Incorrect
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A child develops a palsy of their right arm following a difficult birth. During the examination, it is observed that there is a lack of shoulder abduction, external rotation, and elbow flexion. The arm is visibly hanging with the elbow extended and the forearm pronated.
Which nerve root is most likely to have been affected in this situation?Your Answer:
Correct Answer: C5
Explanation:Erb’s palsy, also known as Erb-Duchenne palsy, is a condition where the arm becomes paralyzed due to an injury to the upper roots of the brachial plexus. The primary root affected is usually C5, although C6 may also be involved in some cases. The main cause of Erb’s palsy is when the arm experiences excessive force during a difficult childbirth, but it can also occur in adults as a result of shoulder trauma.
Clinically, the affected arm will hang by the side with the elbow extended and the forearm turned inward (known as the waiter’s tip sign). Upon examination, there will be a loss of certain movements:
– Shoulder abduction (involving the deltoid and supraspinatus muscles)
– Shoulder external rotation (infraspinatus muscle)
– Elbow flexion (biceps and brachialis muscles)It is important to differentiate Erb’s palsy from Klumpke’s palsy, which affects the lower roots of the brachial plexus (C8 and T1). Klumpke’s palsy presents with a claw hand due to paralysis of the intrinsic hand muscles, along with sensory loss along the ulnar side of the forearm and hand. If T1 is affected, there may also be the presence of Horner’s syndrome.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 28-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to evaluate for a haemoperitoneum.
Which of the following anatomical regions is NOT examined as part of a typical 4 view FAST scan?Your Answer:
Correct Answer: Parasternal
Explanation:A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information helps healthcare providers make decisions regarding further management of the patient.
The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.
During a standard FAST scan, four regions are assessed. The first is the subxiphoid transverse view, which is used to check for pericardial effusion and left lobe liver injuries. The second is the longitudinal view of the right upper quadrant, which helps identify right liver injuries, right kidney injuries, and fluid in the hepatorenal recess (Morison’s pouch). The third is the longitudinal view of the left upper quadrant, which is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are examined to assess the bladder and fluid in the pouch of Douglas.
In addition to the standard FAST scan, an extended FAST or eFAST may also be performed. This involves examining the left and right thoracic regions to assess for the presence of pneumothorax and haemothorax.
The hepatorenal recess is the deepest part of the peritoneal cavity when a patient is lying flat. Therefore, it is the most likely area for fluid to accumulate in a supine position.
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This question is part of the following fields:
- Trauma
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Question 6
Incorrect
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A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the pills she takes for insomnia. She informs you that the pill she takes for this condition is zolpidem 10 mg. She consumed the pills approximately 2 hours ago. She is currently hypotensive, with her most recent blood pressure reading being 82/56 mmHg. She weighs 70 kg. You administer a dose of calcium chloride, but there is no improvement in her condition.
Which of the following treatments is LEAST likely to be helpful in supporting her cardiovascular system?Your Answer:
Correct Answer: Magnesium sulphate
Explanation:Calcium-channel blocker overdose is a serious condition that can be life-threatening. The most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into cells. These channels are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.
The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:
1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.
2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.
3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.
4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.
5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.
6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 7
Incorrect
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You are present at a trauma call for an elderly pedestrian who has been hit by a vehicle. She exhibits bruising on the right side of her chest. The primary survey has been conducted, and you have been tasked with conducting a secondary survey.
As per the ATLS guidelines, which of the following would be considered a potentially life-threatening chest injury that should be identified and addressed during the SECONDARY survey?Your Answer:
Correct Answer: Traumatic aortic disruption
Explanation:The ATLS guidelines categorize chest injuries in trauma into two groups: life-threatening injuries that require immediate identification and treatment in the primary survey, and potentially life-threatening injuries that should be identified and treated in the secondary survey.
During the primary survey, the focus is on identifying and treating life-threatening thoracic injuries. These include airway obstruction, tracheobronchial tree injury, tension pneumothorax, open pneumothorax, massive haemothorax, and cardiac tamponade. Prompt recognition and intervention are crucial in order to prevent further deterioration and potential fatality.
In the secondary survey, attention is given to potentially life-threatening injuries that may not be immediately apparent. These include simple pneumothorax, haemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, and blunt oesophageal rupture. These injuries may not pose an immediate threat to life, but they still require identification and appropriate management to prevent complications and ensure optimal patient outcomes.
By dividing chest injuries into these two categories and addressing them in a systematic manner, healthcare providers can effectively prioritize and manage trauma patients, ultimately improving their chances of survival and recovery.
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This question is part of the following fields:
- Trauma
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Question 8
Incorrect
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A 47-year-old man with a past medical history of alcohol-related visits to the emergency department presents to the ED after falling while intoxicated. He has a 6 cm laceration on the occipital region of his scalp. You examine the wound under local anesthesia. As you remove the dressing and clean away a significant blood clot, you notice pulsatile bleeding from the wound. Which arteries provide blood supply to the posterior scalp?
Your Answer:
Correct Answer: External carotid
Explanation:The scalp is primarily supplied with blood from branches of the external carotid artery. The posterior half of the scalp is specifically supplied by three branches of the external carotid artery. These branches are the superficial temporal artery, which supplies blood to the frontal and temporal regions of the scalp, the posterior auricular artery, which supplies blood to the area above and behind the external ear, and the occipital artery, which supplies blood to the back of the scalp.
Further Reading:
The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.
The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.
The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.
In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.
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This question is part of the following fields:
- Trauma
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Question 9
Incorrect
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A 40-year-old carpenter comes in with a few weeks of persistent lower back pain. Despite taking the maximum dose of ibuprofen, the pain continues to be significant. What would be the most suitable course of treatment? Choose only ONE option.
Your Answer:
Correct Answer: Low-dose codeine phosphate
Explanation:The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 10
Incorrect
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You are requested to deliver a teaching session on delirium for the incoming medical interns rotating to the emergency department. What is a commonly acknowledged characteristic of delirium?
Your Answer:
Correct Answer: Lucid intervals usually occur during the day
Explanation:Delirium is characterized by fluctuating symptoms of disturbed consciousness that typically develop over hours to days. During the day, lucid intervals may occur, while the worst disturbances are often experienced at night. In contrast, dementia has a gradual onset and does not involve fluctuations in mental state. Stroke, on the other hand, is associated with focal neurological deficits.
Further Reading:
Delirium is an acute syndrome that causes disturbances in consciousness, attention, cognition, and perception. It is also known as an acute confusional state. The DSM-IV criteria for diagnosing delirium include recent onset of fluctuating awareness, impairment of memory and attention, and disorganized thinking. Delirium typically develops over hours to days and may be accompanied by behavioral changes, personality changes, and psychotic features. It often occurs in individuals with predisposing factors, such as advanced age or multiple comorbidities, when exposed to new precipitating factors, such as medications or infection. Symptoms of delirium fluctuate throughout the day, with lucid intervals occurring during the day and worse disturbances at night. Falling and loss of appetite are often warning signs of delirium.
Delirium can be classified into three subtypes based on the person’s symptoms. Hyperactive delirium is characterized by inappropriate behavior, hallucinations, and agitation. Restlessness and wandering are common in this subtype. Hypoactive delirium is characterized by lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn. Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.
The exact pathophysiology of delirium is not fully understood, but it is believed to involve multiple mechanisms, including cholinergic deficiency, dopaminergic excess, and inflammation. The cause of delirium is usually multifactorial, with predisposing factors and precipitating factors playing a role. Predisposing factors include older age, cognitive impairment, frailty, significant injuries, and iatrogenic events. Precipitating factors include infection, metabolic or electrolyte disturbances, cardiovascular disorders, respiratory disorders, neurological disorders, endocrine disorders, urological disorders, gastrointestinal disorders, severe uncontrolled pain, alcohol intoxication or withdrawal, medication use, and psychosocial factors.
Delirium is highly prevalent in hospital settings, affecting up to 50% of inpatients aged over 65 and occurring in 30% of people aged over 65 presenting to the emergency department. Complications of delirium include increased risk of death, high in-hospital mortality rates, higher mortality rates following hospital discharge, increased length of stay in hospital, nosocomial infections, increased risk of admission to long-term care or re-admission to hospital, increased incidence of dementia, increased risk of falls and associated injuries, pressure sores.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 11
Incorrect
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A 68 year old male is brought into the emergency department after a significant episode of haematemesis. The patient is transferred to the resuscitation bay upon arrival, and large bore intravenous access is established while blood samples are sent for analysis and cross matching. You observe that the patient has a medical history of liver cirrhosis and suspect a bleed from oesophageal varices.
Which of the following medications should be prioritized for administration, as it has been proven to enhance survival in patients with gastro-oesophageal variceal bleeding?Your Answer:
Correct Answer: Terlipressin
Explanation:Terlipressin, a vasopressin analogue, has been found to significantly enhance survival rates in cases of acute upper gastrointestinal variceal haemorrhage when compared to a placebo. Alternatively, somatostatin and its analogue octreotide have also demonstrated similar benefits and can be used as alternatives. It is not recommended to administer proton pump inhibitors (PPIs) before endoscopy in cases of acute upper GI bleeds, but they are advised after endoscopy for non-variceal upper GI bleeds. There is no consensus on whether PPIs improve outcomes in variceal bleeding. Recombinant factor Vlla should only be considered if other blood products have failed to correct coagulopathy. Studies indicate that tranexamic acid does not reduce mortality from upper GI bleeding and may actually increase the risk of thromboembolic events.
Further Reading:
Upper gastrointestinal bleeding (UGIB) refers to the loss of blood from the gastrointestinal tract, occurring in the upper part of the digestive system. It can present as haematemesis (vomiting blood), coffee-ground emesis, bright red blood in the nasogastric tube, or melaena (black, tarry stools). UGIB can lead to significant hemodynamic compromise and is a major health burden, accounting for approximately 70,000 hospital admissions each year in the UK with a mortality rate of 10%.
The causes of UGIB vary, with peptic ulcer disease being the most common cause, followed by gastritis/erosions, esophagitis, and other less common causes such as varices, Mallory Weiss tears, and malignancy. Swift assessment, hemodynamic resuscitation, and appropriate interventions are essential for the management of UGIB.
Assessment of patients with UGIB should follow an ABCDE approach, and scoring systems such as the Glasgow-Blatchford bleeding score (GBS) and the Rockall score are recommended to risk stratify patients and determine the urgency of endoscopy. Transfusion may be necessary for patients with massive hemorrhage, and platelet transfusion, fresh frozen plasma (FFP), and prothrombin complex concentrate may be offered based on specific criteria.
Endoscopy plays a crucial role in the management of UGIB. Unstable patients with severe acute UGIB should undergo endoscopy immediately after resuscitation, while all other patients should undergo endoscopy within 24 hours of admission. Endoscopic treatment of non-variceal bleeding may involve mechanical methods of hemostasis, thermal coagulation, or the use of fibrin or thrombin with adrenaline. Proton pump inhibitors should only be used after endoscopy.
Variceal bleeding requires specific management, including the use of terlipressin and prophylactic antibiotics. Oesophageal varices can be treated with band ligation or transjugular intrahepatic portosystemic shunts (TIPS), while gastric varices may be treated with endoscopic injection of N-butyl-2-cyanoacrylate or TIPS if bleeding is not controlled.
For patients taking NSAIDs, aspirin, or clopidogrel, low-dose aspirin can be continued once hemostasis is achieved, NSAIDs should be stopped in patients presenting with UGIB
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 12
Incorrect
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A 2-year-old toddler comes in with a high-grade fever, excessive drooling, and hoarseness. The child is displaying obvious stridor and has an elevated heart rate.
What is the initial step in managing this young patient?Your Answer:
Correct Answer: Call a senior anaesthetist
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 13
Incorrect
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A 35-year-old woman comes in with a red, hot, swollen left knee a few days after returning from a vacation in Thailand. She also reports feeling generally unwell and has a rash on her trunk. Which antibiotic would be the most suitable for this patient?
Your Answer:
Correct Answer: Cefotaxime
Explanation:Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.
According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 14
Incorrect
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A 35-year-old woman comes in with sharp pain while having a bowel movement. The pain usually continues for an additional 30-60 minutes afterward. She has also observed small amounts of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past couple of weeks.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Anal fissure
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.
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This question is part of the following fields:
- Surgical Emergencies
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Question 15
Incorrect
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A 62 year old female is brought to the emergency department by her husband who is concerned that the patient has been experiencing abdominal pain and also appears slightly confused. He informs you that the patient is a heavy drinker and you observe that the patient was diagnosed with liver cirrhosis 8 months ago. The patient has difficulty focusing during the Abbreviated Mental Test Score (AMTS) but scores 7/10. Upon examination, you notice mild ascites. You suspect the patient has moderate (grade 2) hepatic encephalopathy secondary to liver cirrhosis. The patient's initial blood tests are as follows:
Bilirubin 45 µmol/l
ALP 210 u/l
ALT 300 u/l
γGT 160 u/l
Albumin 27 g/l
INR 1.9
What is this patient's Child Pugh score?Your Answer:
Correct Answer: 13
Explanation:This patient’s Child Pugh score is 9. The Child Pugh score is a scoring system used to assess the severity of liver disease and the prognosis of patients with cirrhosis. It takes into account five variables: bilirubin levels, albumin levels, INR (international normalized ratio), ascites, and hepatic encephalopathy. Each variable is assigned a score from 1 to 3, with 3 indicating the most severe impairment.
In this case, the patient’s bilirubin level is 45 µmol/l, which corresponds to a score of 2. The albumin level is 27 g/l, which also corresponds to a score of 3. The INR is 1.9, which corresponds to a score of 2. The presence of moderate ascites indicates a score of 3. Finally, the patient has moderate hepatic encephalopathy, which corresponds to a score of 3.
Adding up the scores for each variable, we get a total score of 13. This indicates that the patient has moderate to severe liver disease and a poorer prognosis.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 16
Incorrect
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A 32-year-old woman with a history of sickle-cell disease undergoes a blood transfusion for severe anemia. Four weeks later, she arrives at the Emergency Department complaining of a skin rash, high temperature, and diarrhea. The medical team orders blood tests, which reveal low levels of all blood cells and abnormal liver function. What is the most probable transfusion reaction that occurred?
Your Answer:
Correct Answer: Graft-vs-host disease
Explanation:Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, immune dilution, and transfusion errors. While there have been improvements in safety procedures and efforts to minimize the use of transfusion, errors and serious adverse reactions still occur and often go unreported.
One rare complication of blood transfusion is transfusion-associated graft-vs-host disease (TA-GVHD). This condition typically presents with fever, rash, and diarrhea 1-4 weeks after the transfusion. Laboratory findings may show pancytopenia and abnormalities in liver function. Unlike GVHD after marrow transplantation, TA-GVHD leads to severe marrow aplasia with a mortality rate exceeding 90%. Unfortunately, there are currently no effective treatments available for this condition, and survival is rare, with death usually occurring within 1-3 weeks of the first symptoms.
During a blood transfusion, viable T lymphocytes from the donor are transfused into the recipient’s body. In TA-GVHD, these lymphocytes engraft and react against the recipient’s tissues. However, the recipient is unable to reject the donor lymphocytes due to factors such as immunodeficiency, severe immunosuppression, or shared HLA antigens. Supportive management is the only option for TA-GVHD.
The following summarizes the main complications and reactions that can occur during a blood transfusion:
Complication Features Management
Febrile transfusion reaction
– Presents with a 1-degree rise in temperature from baseline, along with chills and malaise.
– Most common reaction, occurring in 1 out of 8 transfusions.
– Usually caused by cytokines from leukocytes in transfused red cell or platelet components.
– Supportive management, with the use of paracetamol for symptom relief.Acute haemolytic reaction
– Symptoms include fever, chills, pain at the transfusion site, nausea, vomiting, and dark urine.
– Often accompanied by a feeling of ‘impending doom’.
– Most serious type of reaction, often due to ABO incompatibility caused by administration errors.
– Immediate action required: stop the transfusion, administer IV fluids, and consider diuretics if necessary.Delayed haemolytic reaction
– Typically occurs 4-8 days after a blood transfusion.
– Symptoms include fever, anemia and/or hyperbilirubinemia -
This question is part of the following fields:
- Haematology
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Question 17
Incorrect
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A 35-year-old woman came in ten days ago with a fever, tenderness in the suprapubic area, and discharge from the vagina. The doctors diagnosed her with pelvic inflammatory disease and started her on antibiotics. She initially got better, but now she is back with intense pain in her lower abdomen and a temperature of 39.5°C.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Tubo-ovarian abscess
Explanation:This patient is highly likely to have developed a tubo-ovarian abscess (TOA), which is a complication of pelvic inflammatory disease. TOA occurs when a pocket of pus forms in the fallopian tube and/or ovary. If the abscess ruptures, it can lead to sepsis and become life-threatening.
The initial imaging modality of choice is transabdominal and endovaginal ultrasound. This imaging technique often reveals multilocular complex retro-uterine/adnexal masses with debris, septations, and irregular thick walls. These masses can be present on both sides.
Urgent hospital admission is necessary, and the usual management involves draining the abscess and administering intravenous antibiotics. The abscess drainage can be guided by ultrasound or CT scanning.
In some cases, laparotomy or laparoscopy may be required to drain the abscess.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 18
Incorrect
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A 45-year-old woman comes in with central chest pain that is spreading to her left arm for the past 30 minutes. Her vital signs are as follows: heart rate of 80 beats per minute, blood pressure of 118/72, and oxygen saturation of 98% on room air. The ECG shows the following findings:
ST depression in leads V1-V4 and aVR
ST elevation in V5-V6, II, III, and aVF
Positive R wave in V1 and V2
What is the most likely diagnosis in this case?Your Answer:
Correct Answer: Acute inferoposterior myocardial infarction
Explanation:The ECG shows the following findings:
– There is ST depression in leads V1-V4 and aVR.
– There is ST elevation in leads V5-V6, II, III, and aVF.
– There is a positive R wave in leads V1 and V2, which indicates a reverse Q wave.
These ECG changes indicate that there is an acute inferoposterior myocardial infarction. -
This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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You evaluate a child with a limp and complaints of hip discomfort. An X-ray is conducted, and the diagnosis of Perthes' disease is confirmed.
Which ONE statement about this condition is accurate?Your Answer:
Correct Answer: A positive family history is present in 10-15% of cases
Explanation:Perthes’ disease is a hip disorder that occurs in childhood due to a disruption in the blood supply to the femoral head. This leads to a lack of blood flow, causing the bone to die. The condition typically affects children between the ages of 4 and 10, with boys being more commonly affected than girls. In about 10-15% of cases, there is a family history of the disease, and approximately 15% of patients have the condition in both hips.
The progression of Perthes’ disease can be seen through characteristic changes on X-rays, which can take between 2 and 4 years to fully heal. The earliest sign is an increased density of the epiphysis (the end of the bone) and widening of the medial joint space. As the disease progresses, the epiphysis may fragment and the head of the femur may flatten. Over time, the bone gradually heals, with the dense bone being reabsorbed and replaced by new bone. This process continues until growth stops, and the bone is remodeled.
Children with Perthes’ disease typically present with hip pain and a limp. The pain can vary in severity, and clinical signs may be minor, with only a slight restriction in hip joint movement.
The treatment of Perthes’ disease is a topic of debate. Around 50% of patients can achieve good results with conservative management alone, without the need for surgery. Surgical intervention, such as osteotomy (reshaping the bone), is usually reserved for cases where the disease progresses unfavorably or when conservative treatment fails. Potential complications of Perthes’ disease include permanent hip deformity and secondary arthritis.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 20
Incorrect
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You are with a hiking group and have ascended from an elevation of 2800m to 3400 meters over the past two days. One of your group members is experiencing difficulty breathing while at rest and has developed a dry cough. The individual's vital signs are as follows:
Blood pressure: 150/92 mmHg
Pulse: 126 bpm
Respiration rate: 28 bpm
Oxygen saturations: 86% on air
Which of the following medications would be most appropriate to administer to this individual?Your Answer:
Correct Answer: Nifedipine
Explanation:Nifedipine is the preferred medication for treating high altitude pulmonary edema (HAPE). When a patient shows signs of HAPE, the best course of action is to immediately descend to a lower altitude while receiving supplemental oxygen. However, if descent is not possible, nifedipine can be used to alleviate symptoms and assist with descent. Nifedipine works by reducing the pressure in the pulmonary artery. On the other hand, dexamethasone is the preferred medication for treating acute mountain sickness and high altitude cerebral edema (HACE).
Further Reading:
High Altitude Illnesses
Altitude & Hypoxia:
– As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
– Hypoxia occurs at altitude due to decreased inspired oxygen.
– At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.Acute Mountain Sickness (AMS):
– AMS is a clinical syndrome caused by hypoxia at altitude.
– Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
– Symptoms usually occur after 6-12 hours above 2500m.
– Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
– The Lake Louise AMS score is used to assess the severity of AMS.
– Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
– Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
– Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.High Altitude Pulmonary Edema (HAPE):
– HAPE is a progression of AMS but can occur without AMS symptoms.
– It is the leading cause of death related to altitude illness.
– Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
– Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
– Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.High Altitude Cerebral Edema (HACE):
– HACE is thought to result from vasogenic edema and increased vascular pressure.
– It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
– Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
– Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
– Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis. -
This question is part of the following fields:
- Environmental Emergencies
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Question 21
Incorrect
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You are informed that a 45-year-old individual is en route to the emergency department after inhaling an unidentified gas that was intentionally released on a commuter train. Authorities suspect a potential terrorist attack and recommend checking the patient for signs of organophosphate poisoning. What clinical feature would be anticipated in a case of organophosphate poisoning?
Your Answer:
Correct Answer: Drooling saliva
Explanation:Organophosphate poisoning is characterized by a set of symptoms known as SLUDGE (Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis). Additionally, individuals affected may experience pinpoint pupils, profuse sweating, tremors, and confusion. Organophosphates serve as the foundation for various weaponized nerve agents like Sarin and VX, which were infamously employed by the terrorist group Aum Shinrikyo during multiple attacks in Tokyo in the mid-1990s. While SLUDGE is a commonly used acronym to recall the clinical features, it is important to note that other symptoms such as pinpoint pupils, profuse sweating, tremors, and confusion are not included in the acronym.
Further Reading:
Chemical incidents can occur as a result of leaks, spills, explosions, fires, terrorism, or the use of chemicals during wars. Industrial sites that use chemicals are required to conduct risk assessments and have accident plans in place for such incidents. Health services are responsible for decontamination, unless mass casualties are involved, and all acute health trusts must have major incident plans in place.
When responding to a chemical incident, hospitals prioritize containment of the incident and prevention of secondary contamination, triage with basic first aid, decontamination if not done at the scene, recognition and management of toxidromes (symptoms caused by exposure to specific toxins), appropriate supportive or antidotal treatment, transfer to definitive treatment, a safe end to the hospital response, and continuation of business after the event.
To obtain advice when dealing with chemical incidents, the two main bodies are Toxbase and the National Poisons Information Service. Signage on containers carrying chemicals and material safety data sheets (MSDS) accompanying chemicals also provide information on the chemical contents and their hazards.
Contamination in chemical incidents can occur in three phases: primary contamination from the initial incident, secondary contamination spread via contaminated people leaving the initial scene, and tertiary contamination spread to the environment, including becoming airborne and waterborne. The ideal personal protective equipment (PPE) for chemical incidents is an all-in-one chemical-resistant overall with integral head/visor and hands/feet worn with a mask, gloves, and boots.
Decontamination of contaminated individuals involves the removal and disposal of contaminated clothing, followed by either dry or wet decontamination. Dry decontamination is suitable for patients contaminated with non-caustic chemicals and involves blotting and rubbing exposed skin gently with dry absorbent material. Wet decontamination is suitable for patients contaminated with caustic chemicals and involves a warm water shower while cleaning the body with simple detergent.
After decontamination, the focus shifts to assessing the extent of any possible poisoning and managing it. The patient’s history should establish the chemical the patient was exposed to, the volume and concentration of the chemical, the route of exposure, any protective measures in place, and any treatment given. Most chemical poisonings require supportive care using standard resuscitation principles, while some chemicals have specific antidotes. Identifying toxidromes can be useful in guiding treatment, and specific antidotes may be administered accordingly.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 22
Incorrect
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You are requested to evaluate a teenager who is in resus with a supraventricular tachycardia. The patient is stable hemodynamically but has already received 3 doses of IV adenosine and vagal maneuvers. However, there has been no improvement in their condition.
Based on the current APLS guidelines, what would be the most suitable next course of action in managing this patient?Your Answer:
Correct Answer: Give IV amiodarone 5-10 mg/kg
Explanation:Supraventricular tachycardia (SVT) is the most common arrhythmia that occurs in children and infants, causing cardiovascular instability. According to the current APLS guidelines, if a patient with SVT shows no signs of shock and remains stable, initial attempts should be made to use vagal maneuvers. If these maneuvers are unsuccessful, the following steps are recommended:
– Administer an initial dose of 100 mcg/kg of adenosine.
– After two minutes, if the child is still in stable SVT, administer another dose of 200 mcg/kg of adenosine.
– After an additional two minutes, if the child remains in stable SVT, administer another dose of 300 mcg/kg of adenosine.If these measures do not resolve the SVT, the guidelines suggest considering the following options:
– Administer adenosine at a dose of 400-500 mcg/kg.
– Perform a synchronous DC shock.
– Administer amiodarone.When using amiodarone, the initial dose should be 5-10 mg/kg given over a period of 20 minutes to 2 hours. This should be followed by a continuous infusion of 300 mcg/kg/hour, with adjustments made based on the response, increasing by 1.5 mg/kg/hour. The total infusion rate should not exceed 1.2 g in a 24-hour period.
If defibrillation is necessary for the treatment of SVT in children, it should be performed as a DC synchronous shock at a dosage of 1-2 J/kg.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 42-year-old woman comes in with a suddenly painful right eye and sensitivity to light. The eye feels sandy and is visibly watery. The patient has been experiencing a mild cold for the past few days. You administer fluorescein drops to her eye, and this exposes the existence of a dendritic ulcer.
What is the PRIMARY probable causative organism?Your Answer:
Correct Answer: Herpes simplex virus (type 1)
Explanation:There are two types of infectious agents that can lead to the development of a dendritic ulcer. The majority of cases (80%) are caused by the herpes simplex virus (type I), while the remaining cases (20%) are caused by the herpes zoster virus. To effectively treat this condition, the patient should follow a specific treatment plan. This includes applying aciclovir ointment topically five times a day for a duration of 10 days. Additionally, prednisolone 0.5% drops should be used 2-4 times daily. It is also recommended to take oral high dose vitamin C, as it has been shown to reduce the healing time of dendritic ulcers.
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This question is part of the following fields:
- Ophthalmology
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Question 24
Incorrect
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A 35-year-old male presents to the emergency department complaining of gradual onset sharp chest pain over the past 24 hours. The patient reports that the pain worsens with deep inspiration and feels more comfortable when sitting leaning forward. When asked about pain radiation, the patient confirms that the pain extends to the left side of the neck and points to the ridge of the trapezius. Physical examination reveals clear lung fields, regular rhythm with quiet heart sounds, and no murmurs. The patient's vital signs are as follows:
Blood pressure: 108/66 mmHg
Pulse rate: 94 bpm
Respiratory rate: 18 rpm
Temperature: 37.3ºC
Oxygen saturations: 97% on room air
What is the most likely diagnosis?Your Answer:
Correct Answer: Acute pericarditis
Explanation:Radiation to the trapezius ridge is a distinct symptom of acute pericarditis. The patient in question exhibits characteristics that align with a diagnosis of pericarditis. Pericarditis is a common condition affecting the pericardium, and it is often considered as a potential cause for chest pain. It is worth noting that the specific radiation of pain to the trapezius ridge is highly indicative of pericarditis, as it occurs when the phrenic nerve, which also innervates the trapezius muscle, becomes irritated while passing through the pericardium.
Further Reading:
Pericarditis is an inflammation of the pericardium, which is the protective sac around the heart. It can be acute, lasting less than 6 weeks, and may present with chest pain, cough, dyspnea, flu-like symptoms, and a pericardial rub. The most common causes of pericarditis include viral infections, tuberculosis, bacterial infections, uremia, trauma, and autoimmune diseases. However, in many cases, the cause remains unknown. Diagnosis is based on clinical features, such as chest pain, pericardial friction rub, and electrocardiographic changes. Treatment involves symptom relief with nonsteroidal anti-inflammatory drugs (NSAIDs), and patients should avoid strenuous activity until symptoms improve. Complicated cases may require treatment for the underlying cause, and large pericardial effusions may need urgent drainage. In cases of purulent effusions, antibiotic therapy is necessary, and steroid therapy may be considered for pericarditis related to autoimmune disorders or if NSAIDs alone are ineffective.
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This question is part of the following fields:
- Cardiology
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Question 25
Incorrect
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You examine the X-ray of a 70 year old male who has fallen onto his outstretched right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. Your plan is to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). The patient's blood pressure is 145/90 mmHg and his pulse rate is 75 bpm. What inflation pressure would you use when inflating the cuff?
Your Answer:
Correct Answer: 250 mmHg
Explanation:During Bier’s block, the cuff is inflated to a pressure that is 100 mmHg higher than the patient’s systolic blood pressure. For example, if the systolic blood pressure is 150 mmHg, the cuff would be inflated to 250 mmHg. It is important to note that Bier’s block should not be performed if the systolic blood pressure is greater than 200 mmHg, as this is considered a contraindication. Therefore, the maximum pressure ever used during Bier’s block is 300mmHg.
Further Reading:
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.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 26
Incorrect
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A patient with a known history of asthma presents with symptoms of theophylline toxicity after starting a new medication.
Which of the following drugs is most likely causing this interaction?Your Answer:
Correct Answer: Fluconazole
Explanation:Theophylline, a medication commonly used to treat respiratory conditions, can be affected by certain drugs, either increasing or decreasing its plasma concentration and half-life. Drugs that can increase the plasma concentration of theophylline include calcium channel blockers like verapamil, cimetidine, fluconazole, macrolides such as erythromycin, methotrexate, and quinolones like ciprofloxacin. On the other hand, drugs like carbamazepine, phenobarbitol, phenytoin (and fosphenytoin), rifampicin, and St. John’s wort can decrease the plasma concentration of theophylline. It is important to be aware of these interactions when prescribing or taking theophylline to ensure its effectiveness and avoid potential side effects.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 27
Incorrect
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A young man presents to the Emergency Department with symptoms of acute alcohol withdrawal. He is requesting admission for ‘inpatient detox’ and states he would like some ‘medication to alleviate his symptoms’.
Which of the following is NOT a reason for admitting this patient?Your Answer:
Correct Answer: Previous successful inpatient detox
Explanation:NICE provides a list of reasons for admitting patients with acute alcohol withdrawal. These include individuals who are deemed to be at risk of experiencing withdrawal seizures or delirium tremens. Additionally, young people under the age of 16 who are going through acute alcohol withdrawal may also require admission. Furthermore, vulnerable individuals, such as those who are frail, have cognitive impairment or multiple comorbidities, lack social support, or have learning difficulties, may also benefit from being admitted for acute alcohol withdrawal. For more information, please refer to the NICE pathway for acute alcohol withdrawal.
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This question is part of the following fields:
- Mental Health
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Question 28
Incorrect
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A 65 year old female is brought into the emergency department following a fall. You observe that the patient has several risk factors for osteoporosis and conduct a Qfracture™ assessment. What is the threshold for conducting a DXA (DEXA) bone density scan?
Your Answer:
Correct Answer: 10%
Explanation:Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.
Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.
The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.
There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.
Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.
Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.
Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 29
Incorrect
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A 28-year-old woman is brought in by ambulance after intentionally swallowing 17 tablets of 300 mg aspirin. The overdose occurred three hours ago.
What is true regarding her treatment in the Emergency Department?Your Answer:
Correct Answer: No specific antidote is available in this case
Explanation:Salicylate poisoning is a fairly common form of poisoning that can lead to organ damage and death if not treated promptly. The symptoms of salicylate poisoning include nausea, vomiting, ringing in the ears, hearing loss, excessive sweating, dehydration, rapid breathing, flushed skin, and high fever in children. In severe cases, convulsions, swelling of the brain, coma, kidney failure, fluid in the lungs, and unstable heart function can occur.
The treatment for salicylate poisoning involves stabilizing the patient’s airway, breathing, and circulation as needed, preventing further absorption of the poison, enhancing its elimination from the body, correcting any metabolic abnormalities, and providing supportive care. Unfortunately, there is no specific antidote available for salicylates. If a large amount of salicylate has been ingested within the past hour (more than 4.5 grams in adults or more than 2 grams in children), gastric lavage (stomach pumping) and administration of activated charcoal (50 grams) are recommended to reduce absorption and increase elimination.
Medical investigations for salicylate poisoning should include measuring the level of salicylate in the blood, analyzing arterial blood gases, performing an electrocardiogram (ECG), checking blood glucose levels, assessing kidney function and electrolyte levels, and evaluating blood clotting. ECG abnormalities that may be present include widening of the QRS complex, AV block, and ventricular arrhythmias.
The severity of salicylate poisoning is determined by the level of salicylate in the blood. Mild poisoning is defined as a salicylate level below 450 mg/L, moderate poisoning is between 450-700 mg/L, and severe poisoning is above 700 mg/L. In severe cases, aggressive intravenous fluid therapy is necessary to correct dehydration, and administration of 1.26% sodium bicarbonate can help eliminate the salicylate from the body. It is important to maintain a urine pH of greater than 7.5, ideally between 8.0-8.5. However, forced alkaline diuresis is no longer recommended. Life-threatening cases may require admission to the intensive care unit, intubation and ventilation, and possibly hemodialysis.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 30
Incorrect
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A 32-year-old trauma patient needs procedural sedation for the reduction of an open fracture in his tibia and fibula. Your plan is to use ketamine as the sedative agent.
What type of receptor does ketamine act on to produce its effects?Your Answer:
Correct Answer: N-methyl-D-aspartate (NMDA)
Explanation:Ketamine stands out among other anaesthetic agents due to its unique combination of analgesic, hypnotic, and amnesic properties. This makes it an incredibly valuable and adaptable drug when administered correctly.
The mechanism of action of ketamine involves non-competitive antagonism of the Ca2+ channel pore within the NMDA receptor. Additionally, it inhibits NMDA receptor activity by interacting with the binding site of phencyclidine.
In summary, ketamine’s multifaceted effects and its ability to target specific receptors make it an indispensable tool in the field of anaesthesia.
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This question is part of the following fields:
- Pain & Sedation
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