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  • Question 1 - A 52-year-old woman with a history of hypertension has ingested an excessive amount...

    Correct

    • A 52-year-old woman with a history of hypertension has ingested an excessive amount of atenolol tablets.

      Which of the following antidotes is appropriate for treating beta-blocker overdose?

      Your Answer: Insulin

      Explanation:

      There are various specific remedies available for different types of poisons and overdoses. The following list provides an outline of some of these antidotes:

      Poison: Benzodiazepines
      Antidote: Flumazenil

      Poison: Beta-blockers
      Antidotes: Atropine, Glucagon, Insulin

      Poison: Carbon monoxide
      Antidote: Oxygen

      Poison: Cyanide
      Antidotes: Hydroxocobalamin, Sodium nitrite, Sodium thiosulphate

      Poison: Ethylene glycol
      Antidotes: Ethanol, Fomepizole

      Poison: Heparin
      Antidote: Protamine sulphate

      Poison: Iron salts
      Antidote: Desferrioxamine

      Poison: Isoniazid
      Antidote: Pyridoxine

      Poison: Methanol
      Antidotes: Ethanol, Fomepizole

      Poison: Opioids
      Antidote: Naloxone

      Poison: Organophosphates
      Antidotes: Atropine, Pralidoxime

      Poison: Paracetamol
      Antidotes: Acetylcysteine, Methionine

      Poison: Sulphonylureas
      Antidotes: Glucose, Octreotide

      Poison: Thallium
      Antidote: Prussian blue

      Poison: Warfarin
      Antidote: Vitamin K, Fresh frozen plasma (FFP)

      By utilizing these specific antidotes, medical professionals can effectively counteract the harmful effects of various poisons and overdoses.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      9.7
      Seconds
  • Question 2 - A 58 year old female presents to the emergency department 2 hours after...

    Incorrect

    • A 58 year old female presents to the emergency department 2 hours after developing severe tearing chest pain that radiates to the back. The patient rates the severity as 10/10 on the visual analogue scale. You note the patient is prescribed medication for hypertension but the patient admits she rarely takes her tablets. The patient's observations are shown below:

      Blood pressure 180/88 mmHg
      Pulse rate 92 bpm
      Respiration rate 22 rpm
      Oxygen sats 97% on air
      Temperature 37.2ÂşC

      Chest X-ray shows a widened mediastinum. You prescribe antihypertensive therapy. What is the target systolic blood pressure in this patient?

      Your Answer: 90-100 mmHg

      Correct Answer: 100-120 mmHg

      Explanation:

      To manage aortic dissection, it is important to lower the systolic blood pressure to a range of 100-120 mmHg. This helps decrease the strain on the damaged artery and minimizes the chances of the dissection spreading further. In this patient, symptoms such as tearing chest pain and a widened mediastinum on the chest X-ray are consistent with aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      27.6
      Seconds
  • Question 3 - A 2-year-old toddler is brought into the emergency department by worried parents. They...

    Incorrect

    • A 2-year-old toddler is brought into the emergency department by worried parents. They inform you that the child has been sick for the past 48 hours, experiencing vomiting and diarrhea. The parents are concerned about the possibility of dehydration. As you evaluate the patient, you look for any red flag signs that may indicate an increased risk of progressing to shock.

      Your Answer: Dry mucous membranes

      Correct Answer: Reduced skin turgor

      Explanation:

      Signs that a child with gastroenteritis may be at risk of progressing to shock include altered responsiveness (such as being irritable or lethargic), sunken eyes, a fast heart rate, rapid breathing, and reduced skin elasticity. In infants aged 3 months or younger, a temperature above 38ÂşC is also a red flag.

      Further Reading:

      Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

      Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

      When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

      In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

      Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

      Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

    • This question is part of the following fields:

      • Paediatric Emergencies
      40.2
      Seconds
  • Question 4 - 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
      19.4
      Seconds
  • Question 5 - A 60-year-old individual comes in with an arthropathy impacting the metatarsophalangeal joint on...

    Correct

    • A 60-year-old individual comes in with an arthropathy impacting the metatarsophalangeal joint on their left foot. Gout is suspected, and a joint aspirate is sent for laboratory analysis.
      What type of crystals would be anticipated in the presence of gout?

      Your Answer: Negatively birefringent needle-shaped crystals

      Explanation:

      Gout and pseudogout are both characterized by the presence of crystal deposits in the joints that are affected. Gout occurs when urate crystals are deposited, while pseudogout occurs when calcium pyrophosphate crystals are deposited. Under a microscope, these crystals can be distinguished by their appearance. Urate crystals are needle-shaped and negatively birefringent, while calcium pyrophosphate crystals are brick-shaped and positively birefringent.

      Gout can affect any joint in the body, but it most commonly manifests in the hallux metatarsophalangeal joint, which is the joint at the base of the big toe. This joint is affected in approximately 50% of gout cases. On the other hand, pseudogout primarily affects the larger joints, such as the knee.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      16.9
      Seconds
  • Question 6 - A 25-year-old patient visits your clinic with concerns about a recent alteration in...

    Incorrect

    • A 25-year-old patient visits your clinic with concerns about a recent alteration in her usual vaginal discharge. She is not sexually active at the moment and has no other health issues. She does not report any itching symptoms but has observed a strong fishy odor in the discharge.
      Which organisms should be the primary target for initial treatment in this scenario?

      Your Answer: Gardnerella vaginalis and Chlamydia trachomatis

      Correct Answer: Gardnerella vaginalis only

      Explanation:

      Bacterial vaginosis (BV) is a common condition that affects up to a third of women during their childbearing years. It occurs when there is an overgrowth of bacteria, specifically Gardnerella vaginalis. This bacterium is anaerobic, meaning it thrives in environments without oxygen. As it multiplies, it disrupts the balance of bacteria in the vagina, leading to a rise in pH levels and a decrease in lactic acid-producing lactobacilli. It’s important to note that BV is not a sexually transmitted infection.

      The main symptom of BV is a greyish discharge with a distinct fishy odor. However, it’s worth mentioning that around 50% of affected women may not experience any symptoms at all.

      To diagnose BV, healthcare providers often use Amsel’s criteria. This involves looking for the presence of three out of four specific criteria: a vaginal pH greater than 4.5, a positive fishy smell test when potassium hydroxide is added, the presence of clue cells on microscopy, and a thin, white, homogeneous discharge.

      The primary treatment for BV is oral metronidazole, typically taken for 5-7 days. This medication has an initial cure rate of about 75%. It’s crucial to provide special care to pregnant patients diagnosed with BV, as it has been linked to an increased risk of late miscarriage, early labor, and chorioamnionitis. Therefore, prompt treatment for these patients is of utmost importance.

    • This question is part of the following fields:

      • Sexual Health
      30.1
      Seconds
  • Question 7 - A 5-year-old girl is brought to the Emergency Department by her father following...

    Correct

    • A 5-year-old girl is brought to the Emergency Department by her father following a fall in the playground at daycare. She has a bruise and a small scrape on her right knee and is walking with a slight limp, but she can put weight on her leg. Her pain is assessed using a numerical rating scale, and the triage nurse informs you that she has 'mild discomfort'.
      According to the RCEM guidance, which of the following analgesics is recommended as a loading dose for the treatment of mild discomfort in a child of this age?

      Your Answer: Oral paracetamol 20 mg/kg

      Explanation:

      A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.

      To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.

      The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.

      To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.

    • This question is part of the following fields:

      • Pain & Sedation
      21.8
      Seconds
  • Question 8 - You evaluate a child with a limp and complaints of hip discomfort. An...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      19.2
      Seconds
  • Question 9 - A 32-year-old construction worker is brought into the emergency department with burns to...

    Correct

    • A 32-year-old construction worker is brought into the emergency department with burns to the right forearm. The patient explains that he was smoking a cigarette while driving back from work when the cigarette accidentally fell onto his arm, igniting his sleeve which might have been soaked in gasoline from work. You observe circumferential burns encompassing the entire right forearm. What would be your primary concern regarding potential complications?

      Your Answer: Compartment syndrome

      Explanation:

      Compartment syndrome can occur when there are circumferential burns on the arms or legs. This typically happens with full thickness burns, where the burnt skin becomes stiff and compresses the compartment, making it difficult for blood to flow out. To treat this condition, escharotomy and possibly fasciotomy may be necessary.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Trauma
      25.2
      Seconds
  • Question 10 - A 70-year-old diabetic smoker presents with central chest pain that radiates to his...

    Incorrect

    • A 70-year-old diabetic smoker presents with central chest pain that radiates to his left shoulder and jaw. He is given 300 mg aspirin and morphine, and his pain subsides. The pain lasted approximately 90 minutes in total. His ECG shows normal sinus rhythm. He is referred to the on-call medical team for admission, and a troponin test is scheduled at the appropriate time. His blood tests today reveal a creatinine level of 298 micromoles per litre.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Fondaparinux

      Correct Answer: Unfractionated heparin

      Explanation:

      This patient’s medical history suggests a diagnosis of acute coronary syndrome. It is important to provide pain relief as soon as possible. This can be achieved by administering GTN (sublingual or buccal), but if there is suspicion of an acute myocardial infarction (MI), intravenous opioids such as morphine should be offered.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a high risk of bleeding or aspirin hypersensitivity. A single loading dose of 300 mg should be given immediately after presentation.

      For patients without a high risk of bleeding and no planned coronary angiography within 24 hours of admission, fondaparinux should be administered. However, if coronary angiography is planned within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. For patients with significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin should be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be given to individuals with an oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for an SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

      Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a potential treatment for adults with STEMI undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
      37.4
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology & Poisoning (1/1) 100%
Cardiology (0/2) 0%
Paediatric Emergencies (0/1) 0%
Respiratory (1/1) 100%
Musculoskeletal (non-traumatic) (2/2) 100%
Sexual Health (0/1) 0%
Pain & Sedation (1/1) 100%
Trauma (1/1) 100%
Passmed