Day 4 A&E

Question 1

A 53-year-old lady presents to the A&E Department with a 2-hour history of chest pain and difficulty breathing.

The pain feels sharp and feels worse when she takes a deep breath in.

She also noticed some streaks of blood in her sputum.

She has a past medical history of breast cancer diagnosed 2 months ago.

She also noticed some swelling of her right calf.

Her basic observations are as follows:

HR 110, RR 25, BP 135/90, T 37.0, SO2 92%

On examination, you note that she is tachypnoeic.

Auscultation of her heart and lungs are normal.

On examination of her peripheries, you note that her right leg is about 5 cm larger than her left leg.

There is pitting oedema of the right leg and her calf is tender to palpation.

An ECG shows sinus tachycardia and a CXR is normal.

The consultant mentions that she has a high Well’s score and needs immediate treatment.

What is the next best investigation?

Answer 1

CT Pulmonary Angiogram (CTPA)

This lady has obvious clinical features of a PE supported by a high Well’s score. Her increased age, features of a deep vein thrombosis (DVT) in her right leg and current malignancy are risk factors for a PE.

A CT-pulmonary angiogram (CTPA) is the next best and most useful investigation to confirm her diagnosis.

Question 2

A 37 year old lady presents with

• sweating
• palpitations
• tachycardia
• acute confusion

On examination she is warm to touch, has an irregular pulse, a heaving apex, evidence of pulmonary oedema and a smooth symmetrical swelling of the anterior neck.

What is the diagnosis?

What is the most appropriate initial management of this patient?

Answer 2

IV propanolol

This is important to control cardiovascular symptoms and other peripheral symptoms because these are what will lead to the most immediate complications of thyroid storm

Question 3

A 24 year old female presents to the emergency department, having taken a significant overdose of amitriptyline, friends who witnessed the overdose state the patient did not take any other drugs or any alcohol.

On initial assessment, the patient is confused and drowsy.

There is no abnormality noted on assessment of the patient’s airway, breath and heart sounds are normal, and the pulse is regular.

The blood pressure is 127/68, heart rate is 87, respiratory rate is 21, and oxygen saturations are 96% on air.

Which of the following is the single most important initial investigation?

Answer 3

12-lead ECG

This patient has taken an overdose of a tricyclic anti-depressant, which can be fatal, and she is already showing adverse effects with confusion and drowsiness.

The most important adverse effect of tricyclic overdose is QRS prolongation and PR and QT interval prolongation, which can easily progress to heart blocks and ventricular arrhythmias.

As such, the most important investigation is a 12-lead ECG, as abnormalities may require urgent treatment.

Question 4

A 49-year-old man with known epilepsy has a generalised seizure on the ward which self terminates after 2 minutes.

Shortly afterwards, and without regaining consciousness in the interim, the generalised seizure returns.

His airway is secured, intravenous access gained, high-flow oxygen administered, and resuscitation commenced.

Which of the following is the most appropriate management at this stage?

Answer 4

Lorazepam 4 mg IV

Repeat seizure without intervening consciousness is classified as status epilepticus, and treatment with anti-epileptic drugs must be commenced.

In a hospital setting, with intravenous access, Lorazepam is the agent of choice.

This is usually given as a 4 mg bolus and repeated once after 5-10 minutes if the seizure does not terminate.

Question 5

A 19-year-old man presents to the emergency department with:

• sudden-onset difficulty in breathing
• facial swelling
• stridor

One dose of adrenaline was administered 5 minutes ago, along with a 500ml 0.9% sodium chloride fluid challenge, but symptoms are persistent.

What is the single best next step?

Answer 5

Adrenaline 500 micrograms (1:1000) IM

This is the dose to treat anaphylaxis in adults. If the initial dose is ineffective (as in this scenario), it can be repeated every five minutes, several times if necessary.

Question 6

A 19-year-old lady is brought into the Emergency Department (ED).

She reports worsening abdominal pain and vomiting over the last 3 days.

Additionally, she notes feeling more weak and drowsy over the last 24 hours.

Investigations reveal a random blood glucose level of 24 mmol/L (4-11 mmol/L) and a serum ketone level of 3 mmol/L (<0.1 mmol/L).

An arterial blood gas reveals a raised anion gap metabolic acidosis.

The patient is started on a fixed rate insulin infusion (FRII).

The doctor prescribes 50U of Actrapid in 50mls of 0.9% sodium chloride.

Given that the patient weighs 50kg, over how many hours should the infusion be set to run? (2)

Answer 6

10 hours

This patient has diabetic ketoacidosis (DKA) which is characterised by hyperglycaemia, ketonaemia and a raised anion gap metabolic acidosis.

Initial management consists of restoring the circulating volume by giving 0.9% saline and starting a fixed rate insulin infusion (FRII).

Insulin should be given at a rate of 0.1 Units/kg/hour.

As this patient weights 50kg, the rate should 5 Units per hour.

Standard protocol is to prescribe 50U of Actrapid meaning that this infusion would have to run over 10 hours in order to maintain a rate of 5 Units per hour.

The rate may need to be changed depending on repeat measurements of glucose, ketones and bicarbonate.

The infusion does not necessarily have to run the full 10 hours and can be stopped if criteria for DKA resolution are met (venous pH > 7.3; ketones < 0.6 mmol/L).

Question 7

At what rate is insulin infused in DKA patients?

Answer 7

Insulin should be given at a rate of 0.1 Units/kg/hour.

Question 8

A 64 year old woman presents to her GP with nausea and vomiting. The vomiting is productive of blood-stained gastric contents. She complains of pain after swallowing.

She has a past medical history of Paget’s disease, hypertension, and hypercholesterolaemia.

She takes simvastatin, amlodipine and risedronate.

These are all once daily, which she takes before bed each night.

She does not smoke and drinks very little alcohol.

What is the most likely diagnosis?

Answer 8

Oesophagitis

By the blood-stained vomit, it is highly suggestive that this patient has an upper GI bleed.

She is taking risedronate, which is a bisphosphonate. Bisphosphonates should be taken in a particular manner - take with a full glass of water, on an empty stomach, and stand/sit for at least 30 minutes after taking.

This is because bisphosphonates are known to cause oesophagitis. A

s this patient has been incorrectly taking her risedronate, this is the most likely diagnosis.

Question 9

How does Mallory-Weiss syndrome syndrome present?

Answer 9

This presents with haematemesis which classically occurs following one or multiple episodes of retching or vomiting.

Question 10

A 56 year old man presents to A&E with vomiting with blood-stained contents.

A digital rectal examination reveals melaena.

Observations and bloods are taken, including a cross-match.

Which of the following scores is most appropriate to use?

• Rockall score
• Gleason score
• Glasgow-Blatchford score
• MELD score
• Child-Pugh score

Answer 10

Glasgow-Blatchford score

Both the Glasgow-Blatchford score and the Rockall score are used to assess the risk of patients who present with a presentation suggestive of an upper GI bleed.

The main difference between being whether endoscopy findings are included.

As this patient is yet to have an endoscopy, then the Glasgow-Blatchford score is most appropriate.

Question 11

What is a MELD score?

What is a Child-Pugh score?

Answer 11

MELD score​​

• The MELD score is used to calculate the severity of the end-stage liver disease.
• The final score can be used for transplant planning.

Child-Pugh score

• The Child-Pugh score is used to assess risk of mortality in patients with cirrhosis.

Question 12

An 84-year old woman presents to the emergency department.

She has been feeling generally unwell, with a fever and vomiting for the past week.

• Sodium 132 mmol/L (135-145mmol/L)
• Potassium 5.9mmol/L (3.5-5.3mmol/L)
• Urea 54mmol/L (2.5-7.6mmol/L)
• Creatinine 483micromol/L (70-100micromol/L)

Given the diagnosis of an acute kidney injury (AKI), which single factor would most urgently indicate the need for a referral for haemofiltration?

Answer 12

Refractory pulmonary oedema

It is clear from the stem that this patient has Acute Kidney Injury (AKI). Even without any baseline results to compare with, the urea and creatinine values are grossly abnormal.

There are several possible causes for AKI in geriatric patients, e.g. - falls, infection, etc., and the history of their presentations can often be vague and general.

This question requires a good knowledge of the management of AKI, especially with regards to escalating the management from ward-based treatment to receiving haemofiltration in the Intensive Care Unit (ICU).

The acronym to remember for this referral is AEIOU BLAST:

Acidosis (pH <7.2 or bicarbonate <10mmol/L)

Electrolyte (persistent hyperkalaemia, i.e. >7mmol/L)

Intoxication (overdose of barbiturates, lithium, * alcohol, salicylates, theophylline)

Oedema (pulmonary that is refractory)

Uraemia (urea >40 or complications e.g. encephalitis)

Question 13

Indications for haemofiltration/dialysis

(10)

Answer 13

The acronym to remember for this referral is AEIOU BLAST:

Acidosis (pH <7.2 or bicarbonate <10mmol/L)

Electrolyte (persistent hyperkalaemia, i.e. >7mmol/L)

Intoxication (overdose of barbiturates, lithium, * alcohol, salicylates, theophylline)

Oedema (pulmonary that is refractory)

Uraemia (urea >40 or complications e.g. encephalitis)

DRUGS

Barbiturates

Lithium

Salicylates

Theophylline

Question 14

A 24 year old female presents with tinnitus, nausea, vomiting and fever following a deliberate drug overdose 6 hours ago.

She is unable to specify the quantity or nature of the pills she took. An initial VBG is done which returns as follows:

• pH 7.49 (7.35-7.45)
• pO2 14.9kPa (>10.6)
• pCO2 3.3kPa (4.7-6)
• HCO3 24mmol/L (22-26)

A repeat VBG is done 2 hours later which shows:

• pH 7.31 (7.35-7.45)
• pO2 14.9kPa (>10.6)
• pCO2 2.4kPa (4.7-6)
• HCO3 16mmol/L (22-26)

What is the most appropriate management of this patient?

Answer 14

IV sodium bicarbonate

Urinary alkalisation (with IV sodium bicarbonate) is the treatment of choice for aspirin overdose because it helps clear the aspirin from the bloodstream.

Question 15

What is Digibind used to treat?

Answer 15

Digibind

This presentation does not fit with digoxin toxicity (i.e. there is no colour vision disturbance, evidence of electrolyte abnormalities).

Question 16

What is Flumazenil used to treat?

Answer 16

Flumazenil

benzodiazepine overdose (i.e. decreased consciousness, ataxia, slurred speech, respiratory depression) in this presentation.

Question 17

A 55-year-old Indian lady presents to the A&E Department with a 2-hour history of chest pain. The pain feels sharp, and it came on suddenly while she was lying in bed. She notes that the pain felt worse when she coughs, and she also recently noticed some streaks of blood in her sputum. She does not complain of any night sweats or weight loss.

She has a family history of DM and lung cancer. She smokes about 10 cigarettes a day for the past 5 years, and drinks alcohol occasionally. She has a past medical history of HTN, asthma and DM. She travels to India every year to visit her family, and recently returned from her annual trip a few days ago. She has no drug allergies and takes regular atorvastatin, ramipril, amlodipine and metformin. Her basic observations are as follows:

HR 110, RR 25, BP 135/90, T 37.6, SO2 94%

On examination, you note that she is tachypnoeic and restless. On auscultation of her chest, you hear vesicular breath sounds and no added sounds. Heart sounds are normal with no murmurs present. Her abdomen is soft and non-tender without organomegaly. On examination of her peripheries, you do note some redness and swelling of her right leg.

What is the most likely underlying diagnosis?

Answer 17

Pulmonary Embolism

This lady experienced acute onset pleuritic chest pain with haemoptysis and some difficulty breathing. Her recent travel is a risk factor for developing PE. She is also tachycardic with a mild temperature, which can occur in PE. More importantly, the swelling of her right leg can indicate a recent DVT, which could have caused the PE. This is the most likely diagnosis.

Question 18

A 62 year old male patient is recovering on the ward from a myocardial infarction.

Whilst sitting in bed he notes sudden onset palpitations and dizziness.

30 seconds later he turns grey and loses consciousness.

There are no signs of life and CPR is commenced for 2 minutes.

The electrocardiogram (ECG) monitor shows irregular broad complex tachycardia.

What is the diagnosis?

Which of the following is the next appropriate management step?

Answer 18

Unsynchronised direct current (DC) cardioversion

An irregular broad complex tachycardia is assumed to be ventricular fibrillation.

The patient should be managed according to the Advanced Life Support guidelines.

If there are no signs of life, the resuscitation team should be called and CPR commenced.

Shockable rhythms (VF or VT) are managed with unsynchronised DC cardioversion.

Question 19

A 74 year old lady is found unresponsive in her bed on the acute medical unit.

This lady has been admitted for treatment of a lower respiratory tract infection, but no other background is available.

The patient has an absent central pulse and does not appear to be making any respiratory effort.

The bedside cardiac monitor shows disorganised electrical activity.

What is the single best initial treatment?

Answer 19

Commence chest compressions

This patient is in cardiac arrest as evidenced by an absent central pulse, no respiratory effort and disorganised electrical activity on the monitor (likely representing ventricular fibrillation).

The first measure that contributes to good outcomes in cardiac arrest is starting early, good-quality chest compressions.

Chest compressions will keep some blood circulating to the vital organs while preparations are made for other interventions, giving the patient the best chance of not only surviving, but also having a good neurological outcome.

If the patient was witnessed going into cardiac arrest, with an initial shockable rhythm, then it would be appropriate to deliver up to three shocks immediately.

Question 20

A 27 year old is brought into the emergency department by her partner, having taken an intentional overdose.

The patient is tearful and unwilling to give a full history, but confirms she has taken paracetamol-containing tablets.

She also consents to being assessed and treated as required.

The patient’s partner reports she has taken an overdose of co-dydramol and paracetamol tablets, he is unsure when they were taken or exactly how many were taken, although he has found empty packets of 32 tablets of each medication.

On examination the patient is alert, there is no abnormality on respiratory or cardiovascular examination.

There is no focal neurological deficit.

Observations are all within normal parameters.

The patient has IV access.

Which of the following is the single next best step in managing this patient?

Answer 20

Commence an IV N-acetylcysteine infusion

This patient appears to have taken a significant overdose of paracetamol.

As the exact dose and timing of the overdose is not readily apparent, standard treatment protocols advocate starting a N-acetylcysteine infusion (NAC), which is the antidote for paracetamol overdose.

The rationale is that it is safest to assume the patient has toxic levels of paracetamol within their circulation and to start treatment, rather than to delay and try and establish further details or measure serum paracetamol levels.

In cases of staggered overdose or where timings/dosages are unclear, a NAC infusion should be started within one hour of assessment.

Question 21

Calcium channel blockers

(2)

Answer 21

Calcium channel blockers are medications used to lower blood pressure.

They work by preventing calcium from entering the cells of the heart and arteries.

Question 22

A 78-year-old woman on the stroke ward chokes on a piece of toast while eating her breakfast.

She is clutching her neck and appears distressed.

Which of the following is the best initial management?

Answer 22

Encourage the patient to cough

According to the UK Resuscitation Council, the first step in the management of suspected choking is to encourage the person to cough. If the cough is effective, they are encouraged to continue coughing. If ineffective, five back blows are delivered followed by five abdominal thrusts, and this is repeated. If the person becomes unconscious, CPR is commenced.

Question 23

A 35-year-old lady presents to the Emergency Department with a 12-hour history of central chest pain.

The pain came on quite suddenly when she woke up.

She describes a central pain that eases when she exhales.

It does not radiate to her arms or jaw and the pain has a severity of 8/10.

She recalls having a bit of a runny nose a few days ago, but reports no symptoms of nausea, dyspnoea or fevers.

She has a past medical history of seasonal asthma as a child.

She takes no medication or inhalers for this.

Clinical examination is unremarkable.

HR 110, T 37.0, RR 16, S02 95% RA, BP 120/75.

An ECG shows sinus tachycardia. There is ST elevation in anterior, inferior and lateral leads. There are no T wave changes. The axis is normal and she is in sinus rhythm.

• Hb: 13 (12 - 15.5)
• MCV: 92 (80 - 100)
• WCC: 9 (3 - 11)
• Plat: 200 (150 - 400)
• Na: 143 mmol/l (135 - 145)
• K: 4.5 mmol/l (3.5 - 5)
• Urea: 4.3 mmol/l (2.5 - 7)
• Cr: 70 umol/l (45 - 90)
• Trop T: 0.6 ng/mL (<0.2 ng/mL)

What is the underlying diagnosis?

What is the most appropriate treatment for this lady?

Answer 23

Naproxen and advise bed rest

This lady has features of pericarditis.

She had flu-like symptoms and describe a pleuritic type of chest pain - that is exacerbated on inhalation and cough.

ECG features of pericarditis typically include PR depression and a widespread saddle-shaped ST elevation.

Troponin levels may also be slightly elevated in pericarditis.

The most appropriate treatment for pericarditis would be NSAIDs and bed rest .

Question 24

A 34-year-old man with a background of cirrhosis presents to the Emergency Department (ED) with haematemesis.

He is resuscitated with high flow oxygen and IV fluids.

As a variceal bleed is suspected, he is also given IV terlipressin and broad-spectrum antibiotics.

His pulse rate is 95 bpm and his blood pressure 110/80 mmHg.

His GCS is 8.

Investigation results reveal:

Hb - 85 g/L (135- 185 g/L)
Platelets - 95 X 10^9 /L (150-450 x10^9 /L)
INR - 1.5 (1.2-1.4)

Which of the following is the next best step in immediate management?

Answer 24

Call the anaesthetist

This patient is likely to have a reduced GCS due to hepatic encephalopathy.

With a GCS of 8, the patient is at risk of airway compromise.

Therefore, the next step would be to call an anaesthetist who would be able to intubate the patient and secure the airway.

After this, the patient should proceed for an oesophagogastroduodenoscopy (OGD) in order to isolate and treat the cause of bleeding.

Even if there is a less severe degree of encephalopathy, often the preference is to secure the airway before endoscopy due to the increased risk of aspiration in this group of patients.

Question 25

A 59-year-old man on the ward is initiated on treatment for hospital-acquired pneumonia.

He suddenly develops a widespread rash and swelling of his lips.

An expiratory wheeze can be heard from the end of the bed.

Which of the following is the next best step in the management of this patient?

Answer 25

Give IM Adrenaline 500 micrograms (0.5 mL of 1:1000)

This is the correct answer. The patient has features of anaphylaxis, likely due to antibiotics given to treat his hospital-acquired pneumonia. The most important step in the management of anaphylaxis is the administration of Adrenaline as this is a fast-acting treatment of the life-threatening airway obstruction. This can be repeated after five minutes if the patient has not improved.

Question 26

A 36 year old man presents with new onset confusion, nausea and vomiting.

On examination he has cherry red skin, his oxygen saturations are 100% on room air and he is tachycardic.

He has no focal neurology or signs of meningism.

What is the most appropriate management of this patient?

Answer 26

Hyperbaric oxygen

Giving oxygen is essentially the only effective management of these patients.

Whether it should be hyperbaric is contentious but many consider this gold standard management.

Question 27

A 19 year old female presents with abdominal pain and nausea.

She says she took thirty-six 500mg tablets of paracetamol 5 hours ago.

Which is likely to be the best prognostic marker for this patient?

Answer 27

Prothrombin time

The prothrombin time gives an indication of clotting ability. S

ince this reflects the synthetic function of the liver, it is the best marker of prognosis in this patient.

The King’s College Criteria (of which INR is a component) can be used in patients with acute liver failure in order to assess their prognosis and facilitate assessment for consideration of a hepatic transplant.

Paracetamol levels - This is the incorrect answer.

• The amount of paracetamol ingested and the levels in the blood do not necessarily correlate to the extent of liver damage.

Question 28

What does serum AST measure?

Answer 28

Although the serum AST can be raised in liver disease, it is non-specific and is also found in cardiac and skeletal muscle, the brain and kidneys.

Question 29

What does raised Serum ALP indicate?

(5)

Answer 29

Serum ALP may be elevated in cases of:

• cirrhosis
• hepatitis
• obstructive jaundice

but can also be raised

• bone malignancy
• pregnancy due to its presence in the placenta and bone.

Question 30

What are the serum markers for:

Liver Damage?

Obstructive Cholecystasis?

Answer 30

Question 31

Match the markers to the disease

ALT

GGT

ALP

AST

Answer 31

Liver Damage:

• AST
• ALT

Obstructive Cholecystasis:

• GGT
• ALP

Question 32

A 46 year old female who suffers from type two diabetes mellitus presents to the emergency department feeling generally unwell, with a fever and pain and swelling over her right thigh.

There is no history of trauma except for a recent insect bite on the right thigh.

On assessment, the patient looks unwell, although she is alert and orientated.

Breath and heart sounds are normal, and the abdomen is soft and non-tender.

There is a tense, erythematous, tender swelling with palpable crepitus over the right anterior thigh.

The area has a deep purple discolouration, distal pulses are palpable.

Observations reveal a

• respiratory rate of 22
• oxygen saturations of 94% on room air
• blood pressure of 92/47
• heart rate of 119
• temperature of 39.7 celsius

X-ray of the right femur demonstrates no bony pathology but subcutaneous gas is visible.

What is the most likely diagnosis?

What is the single most important treatment?

Answer 32

Surgical debridement and washout of the right thigh

This patient has necrotising fasciitis of the right thigh;

A clinical picture consistent with cellulitis but the patient appears critically unwell, and has signs of subcutaneous gas on the x-ray which suggests deep-seated infection, in addition to the purple colour which develops as a result of thrombosis within the local blood vessels.

~70% of necrotising fasciitis occur in people with some form of immunosuppression or a significant chronic disease such as diabetes.

The most important treatment is early and aggressive surgical debridement and washout of the affected area, and patients often require multiple trips to theatre.

Question 33

An 18-year-old woman presents to the emergency department with sudden onset dyspnoea.

Due to exhaustion, she is unable to give further history.

On examination, she is leaning forward, with use of accessory muscles of breathing.

There is a blue tinge to her lips and an audible wheeze.

Trachea is central, and chest expansion is bilaterally reduced.

The chest is resonant to percussion.

Auscultation is difficult due to bilaterally quiet breath sounds.

Her observations are below:

• HR 80
• BP102/75
• RR 8
• SaO2 88%
• T 37.3

Her ABG (on room air) is below

• pH 7.3 (7.35-7.45)
• pCO2 5.9 kPa (4.7-6)
• pO2 8 kPa (>10.6)
• HCO3- 25 mmol/L (22-26)

What is the most likely diagnosis? (5)

How should she be treated? (4)

Which features would make this life-threatening? (4)

Answer 33

Life-threatening asthma:

• exhaustion
• cyanosis
• feeble respiratory effort (leading to a ‘quiet’ chest and ‘normal’ respiratory rate)
• oxygen saturations less than 92%
• ‘normal’ PaCO2

This should warrant immediate treatment with:

• Oxygen
• Salbutamol
• Ipratropium Bromide nebulisers
• steroids

Other signs of life-threatening asthma include:

• altered conscious level
• hypotension
• peak flow < 33% best or predicted
• PaO2 < 8kPa

Question 34

A 72 year old man presents to A&E resus with after collapsing.

He has haematemesis and is also passing fresh blood from the back passage.

He has a past medical history of hypertension and aortic aneurysm repair.

He observations show HR 120, BP 72/41, respiratory rate 18, saturations 96% on room air, apyrexia, GCS 13/15.

He has received 3 litres of normal saline and is still hypotensive.

What is the most appropriate management?

Answer 34

Activate the major haemorrhage protocol

Major haemorrhage protocol is used when a patient has a large haemorrhage making them haemodynamically unstable and requiring urgent resuscitation with blood.

It is used to supply group 0 blood (universal blood).

Major haemorrhage is variously defined as:

• Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5 litres in a 70 kg adult)
• 50% of total blood volume lost in less than 3 hours
• Bleeding in excess of 150 mL/minute.

Question 35

Major haemorrhage is variously defined as:

(3)

Answer 35

• Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5 litres in a 70 kg adult)
• 50% of total blood volume lost in less than 3 hours
• Bleeding in excess of 150 mL/minute.

Question 36

A 22-year-old gentleman presents to the Emergency Department with an 8-hour history of diffuse abdominal pain and vomiting.

He is breathing heavily and appears quite drowsy. You are unable to take a proper history from him.

His mother, who came along with him mentioned that has been a healthy boy since young, with no significant past medical history.

He went out with his friends the night before and had a few pints of beer. There was no mention of any trauma.

His observations are as follows: T 37.3, HR 105, RR 25, SO2 97% RA, BP 100/70.

You quickly do an ABG and it shows the following:

• pH: 7.2 (7.35 - 7.45)
• PO2: 11.5 kPa (10 - 15)
• PCO2: 4.3 kPa (4.5 - 6)
• HCO3: 15 mmol/l (22 - 26)
• PO4: 2.8 (2.5 - 4.5)
• Cl: 105 (95 - 105)
• Na: 133 mmol/l (135 - 145)
• K: 5.4 mmol/l (3.5 - 5)
• Lac: 2.6 mmol/l (0.5 - 1.0)
• Glucose: 19 mmol/l
• Anion Gap: 18.4 (normal = <12)

Which test is most appropriate investigation to confirm the underlying diagnosis?

Answer 36

Blood ketones

Ketones should be measured if DKA is suspected. The high anion gap metabolic acidosis and hyperglycaemia in the setting of an acute abdomen can point to DKA. Lactate may be slightly raised in DKA. Hyponatraemia can occur as a pseudo-hyponatraemia due to the large amounts of glucose. This is the best answer for this question.

Question 37

A 34 year old man presents to the emergency department having fallen off his bicycle at low speed and hit his head, he was not wearing a helmet.

The patient is currently alert and orientated, but is not sure whether he lost consciousness as “it all happened so fast” and he cannot recall why he was cycling or where he was going.

He reports he vomited once shortly after the injury.

On examination there is no focal neurological deficit, Glasgow coma scale score is 15/15, pupils are equal and reactive to light, and there is a 4cm haematoma over the left fronto-temporal region.

What is the single best course of action for managing this patient?

Answer 37

CT head within eight hours

This patient does not meet any of the NICE criteria for CT imaging within one hour of presentation, but given the patient is not sure whether he lost consciousness and appears to have some retrograde amnesia (he is unsure why he was cycling or where he was going), it would be safest to arrange a CT head within the next eight hours - practically it would probably be done as soon as possible, as a normal CT head would mean the patient could potentially be discharged.

Question 38

Describe the mechanism of action of aminophylline

Answer 38

Non-selective adenosine receptor antagonist and phosphodiesterase inhibitor

This is the correct answer. Aminophylline is a combination drug with Theophylline and Ethylenediamine. Side effects include headache, nausea, palpitations and seizures.

Question 39

Which drug is a non-selective adenosine receptor antagonist and phosphodiesterase inhibitor?

Answer 39

aminophylline

Question 40

What are of beta-2 agonists used to manage?

(3)

How do beta-2 agonists work?

(1)

Answer 40

This is an important group of drugs used in the management of:

• COPD
• asthma
• hyperkalaemia.

Beta-2 adrenoreceptors are found in the smooth muscle of the bronchi, activation of which leads to relaxation.

Salbutamol is an example of short-acting beta-2 agonist.

Question 41

Which drug class is used to treat COPD, asthma and hyperkalemia?

Answer 41

beta-2 agonists

Question 42

How do corticosteroids work?

(2)

Answer 42

Down-regulation of

• pro-inflammatory interleukins
• cytokines

This is the mechanism of action of inhaled corticosteroids in the management of COPD. This reduces inflammation and mucus secretion, to alleviate the airway obstruction and provide symptomatic relief.

Question 43

What is the mechanism of action of ipratropium? (3)

What is it used to treat?

Answer 43

Muscarinic acetylcholine receptor antagonist

Activation of the parasympathetic nervous system leads to:

• bronchial constriction
• production of bronchial secretions

Ipratropium works by inhibiting these and is therefore used in the management of acute exacerbation of COPD.

Question 44

What is the mechanism of action of magnesium sulfate?

(2)

Answer 44

Enhances calcium uptake in sarcoplasmic reticulum

Enhanced uptake of calcium in the sarcoplasmic reticulum leads to smooth muscle relaxation and thus bronchodilation.

Magnesium Sulphate is sometimes given in acute life-threatening asthma; however, is not routinely used in COPD.

Question 45

Which medication enhances calcium uptake in sarcoplasmic reticulum?

Answer 45

magnesium sulfate

Question 46

A 7 year old boy presents to A&E with weakness, vomiting and abdominal pain.

He has a two week history of feeling very thirsty and urinating frequently, and his mother is concerned that he has lost weight.

He is drowsy and responds to pain.

• respiratory rate is 18
• saturations are 96% on air
• heart rate is 96.

What blood gas abnormality would you expect in this patient?

What is the mechanism behind his symptoms?

Answer 46

Metabolic acidosis with partial respiratory compensation

This child with recent

• polyuria
• polydipsia
• weight loss presenting
• acute abdominal pain
• vomiting
• is experiencing an episode of diabetic ketoacidosis.

Diabetic ketoacidosis presents with a blood gas abnormality of metabolic acidosis with partial respiratory compensation.

What is the mechanism behind his symptoms?

This is from build up of acidic ketones in the blood, and hyperventilation in an attempt to compensate (partial respiratory compensation).

Question 47

What is the mechanism behind partially compensated diabetic metabolic acidosis?

Answer 47

What is the mechanism behind the symptoms?

This is from build up of acidic ketones in the blood, and hyperventilation in an attempt to compensate (partial respiratory compensation).

Question 48

A 70-year old gentleman presents to the A&E Department with worsening dyspnoea and productive cough over the last two days.

He has a past medical history of COPD and has a 40 pack year smoking history.

His regular medications include PRN salbutamol and a regular seretide inhaler.

His observations are as follows:

HR 100, RR 24, BP 140/90, T 37.9, SO2 82%

He is given 60% oxygen via a green Venturi mask.

He was also started on ipratropium nebulisers, prednisolone and amoxicillin.

About half an hour later, you come back to reassess the patient and the nurse states that he has become drowsy and slightly confused.

He also complains of a slight headache.

On auscultation, you note there is less wheeze than before.

You note that his O2 sats have improved to 98%.

What is the most appropriate next management step?

What is the cause of his drowsiness?

Which test would you do to confirm?

Answer 48

Reduce oxygen supply to 24%

This patient has started to become more drowsy, confused and developed a headache about half an hour after being started on 60% oxygen.

In the context of a COPD patient, this must be treated as hypercapnia.

The oxygen supply should be reduced immediately.

You may also need to do an ABG to assess his arterial pH and pCO2, which will allow you to consider further management options such as NIV.

Question 49

An 84 year old female presents with:

• nausea
• vomiting
• disturbance in her colour vision
• palpitations

Her background includes chronic back pain, IHD, heart failure, diabetes and hypertension.

Her medications include oral morphine solution, amlodipine, atenolol, digoxin, metformin, ramipril and furosemide.

An ECG shows tall tented T waves and a VBG demonstrated hyperkalaemia.

Her ramipril is suspended and she is initiated on insulin + dextrose.

What is the most appropriate further management of this patient’s likely diagnosis?

Answer 49

Give Digibind

The patient has evidence of digoxin toxicity. This is a treatment option for symptomatic/life-threatening digoxin toxicity. It is a digoxin specific antibody which binds to digoxin preventing it from acting on ion pumps.

Question 50

What are the effects of ACE inhibitors on electrolytes?

(2)

Answer 50

increase in serum potassium

causing tall-tented-t-waves

Question 51

How to treat hyperkalaemia

(4)

Answer 51

Question 52

You are crash-bleeped to attend to a patient in the emergency department.

Other members of the team have arrived and CPR has already been commenced.

The defibrillator pads have already been attached and the ECG shows:

• rapid chaotic waves of varying amplitudes
• with no discernible P waves, QRS complexes or T waves.
• The carotid pulse is not palpable.

What is the diagnosis?

What is the single best next step?

Answer 52

This patient is in ventricular fibrillation, which falls under the ‘shockable rhythm’ branch of the adult advanced life support algorithm.

• Deliver one shock
• It is important to recommence CPR immediately after this

Question 53

The medical foundation doctor is called to review an 87 year old gentleman on the acute medical unit.

The patient has been complaining of palpitations, but has no other symptoms.

He is on IV antibiotics for a chest infection and has not been eating and drinking much recently.

The medication history includes furosemide, spironolactone, ramipril, bisoprolol, apixaban, and atorvastatin.

On assessment, the patient is alert and orientated, there are coarse crackles at the right lung base, and the pulse is irregularly irregular (this rhythm is confirmed on bedside three-lead ECG).

The heart rate is 141, respiratory rate is 22, oxygen saturations 94% on air, blood pressure 96/44, and temperature 37.2.

Which of the following is the single best initial treatment for this patient?

Answer 53

Give 250ml IV normal saline over 15 minutes

This patient appears to be in fast atrial fibrillation (AF), as evidenced by the irregularly irregular tachycardia, and medication history including bisoprolol (most likely being used as a rate control measure for the patient’s AF) and apixaban (thromboprophylaxis for the increased risk of stroke in AF).

Given the background of infection, reduced oral intake, and two diuretic medications, this patient is most likely hypovolaemic, which has most probably precipitated this episode of fast AF (it is hard to interpret the tachycardia and hypotension in this patient without knowing a baseline and considering his medication history).

As such the best initial treatment is an IV fluid bolus - given the patient’s age and the fact he is on multiple diuretics, a cautious approach is sensible - hence 250ml initially, rather than 500ml - more fluid can always be given if required.

Question 54

What is Atrial fibrillation

(3)

Answer 54

Atrial fibrillation is a supraventricular tachyarrhythmia characterised electrocardiographically by

• replacement of consistent P waves
• by rapid, irregular
• fibrillatory waves

Question 55

An 85 year old man presents to A&E with chest pain which radiates to the jaw and left arm.

He has a past medical history of autosomal dominant polycystic kidney disease, type 2 diabetes.

He has had one previous admission for a subarachnoid haemorrhage.

O2 saturations are 97% on room air.

An ECG is done which identifies ST-elevation in several leads.

Troponin is raised.

Transfer to the nearest percutaneous coronary intervention centre will take 2 hours.

What is the most appropriate management?

Answer 55

Percutaneous coronary intervention

If percutaneous coronary intervention (PCI) can be performed within 120 minutes of initial medical contact then it is preferred over fibrinolysis in the majority of patients.

In this case the patient cannot get PCI in this window.

However, they have a previous intracranial haemorrhage which is an absolute contra-indication for fibrinolysis so PCI is the best option even if outside of the typical window.

Question 56

A 65-year-old man presents to the Emergency Department with a 5-hour history of palpitations.

He has a past medical history of Ischaemic Heart Disease, and he had an MI 2 years ago.

His basic observations are as follows:

HR 150, RR 25, BP 125/80, T 37.3, SO2 96% RA.

On examination, JVP was not visible and there was no peripheral oedema. He has palpable peripheral pulses.

Auscultation of his heart and lungs were normal.

What does his ECG show?

What is the most appropriate management for this patient?

Answer 56

IV Amiodarone

This patient has developed a monomorphic broad complex tachycardia on his ECG.

This is also known as a ventricular tachycardia (VT).

• The most appropriate management of VT in a haemodynamically stable patient is IV Amiodarone.

Question 57

What is Magnesium sulfate used to treat?

Answer 57

IV Magnesium Sulphate can be used in the treatment of torsades de pointes, a type of polymorphic broad complex tachycardia.

Question 58

What is IV Adenosine used to treat?

(2)

Answer 58

In the treatment of narrow complex tachycardias,

• if vagal manoeuvres do not work
• IV Adenosine can be used

Question 59

When is DC Cardioversion used?

(4)

Answer 59

DC Cardioversion should only be performed on patients who have features of:

• heart failure
• ischaemia
• syncope
• hypotension

Question 60

When are Vagal Manoeuvres used?

(2)

Answer 60

Vagal manoeuvres such as carotid sinus massage and Valsalva can be used as the

• first line management in stable patients
• narrow complex tachycardia

Question 61

An 18 year old male presents to the emergency department with nausea and abdominal pain.

On physical examination he has dry mucous membranes and reduced skin turgor. Vital signs are: heart rate 110 bpm, respiratory rate 24/min, blood pressure 80/60 mmHg, temperature 38’C, and oxygen saturations 99% on room air. Urine dipstick shows 3+ ketones.

ABG shows a

• sodium of 150 mmol/L
• potassium of 5.8 mmol/L
• bicarbonate of 17 mmol/L
• chloride of 101 mmol/L

What is the most likely diagnosis,

What is the most appropriate first step in the management?

Answer 61

500ml bolus intravenous 0.9% sodium chloride stat

The patient presents with clinical features consistent with diabetic ketoacidosis (causing a raised anion gap metabolic acidosis)

The most important initial management step is fluids.

This patient is severely dehydrated, however, and the systolic blood pressure is <90 mmHg, so an initial fluid bolus is more appropriate.

Question 62

A 78 year old man presents to A&E with central chest pain. He feels short of breath and slightly clammy.

He has a past medical history of diabetes and hypertension.

He has an ECG which shows;

• ST depression
• broad R waves
• upright T waves in leads V1-3

What investigation is most likely to confirm the diagnosis?

Answer 62

ECG with leads V7-9 on the back

The ECG changes are typical of those which appear in a posterior myocardial infarction.

If a STEMI occurs then in the posterior area of the heart then reciprocal changes are seen in the anterior and septal leads of V1-3.

In order to investigate the posterior aspect of the heart directly leads must be placed on the back - these are leads V7-9.

Posterior MI is suggested by the following changes in V1-3:

• Horizontal ST depression
• Tall, broad R waves (>30ms)
• Upright T waves
• Dominant R wave (R/S ratio > 1) in V2

Question 63

How should posterior MI be detected

(4)

Answer 63

Posterior MI is suggested by the following changes in V1-3:

• Horizontal ST depression
• Tall, broad R waves (>30ms)
• Upright T waves
• Dominant R wave (R/S ratio > 1) in V2

Question 64

HHS diagnostic criteria

(3)

Answer 64

It is characterised by:

severe hyperglycaemia (>=30mmol/L)

hypotension

hyperosmolality (usually >320 mosmol/kg).

Question 65

A 65-year-old lady comes to A&E complaining of a painful right-sided headache with nausea and vomiting.

The pain originates from the eye and has been increasing over the past 2 hours.

Her vision has also become blurry and she is seeing haloes around lights.

On examination the eye appears blood-shot with a hazy cornea.

Give the likely diagnosis

What is the definitive treatment for this condition?

Answer 65

Peripheral iridotomy

This patient has had acute angle-closure glaucoma, where intra-ocular pressure has suddenly increased due to a blockage drainage of aqueous humour.

Question 66

How do Pilocarpine eye drops work?

(3)

Answer 66

This is used to increase drainage of aqueous humour through the trabecular network by causing pupillary constriction.

It is a muscarinic antagonist.

This is used in the acute setting but is not the definitive treatment for acute angle-closure glaucoma.

Question 67

How do Timolol eye drops work?

(2)

Answer 67

This is used to reduce production of aqueous humour to prevent intraocular pressure from increasing further.

This is used in the acute setting but is not the definitive treatment for acute angle-closure glaucoma.

Question 68

How does Acetazolamide work?

(2)

Answer 68

Acetazolamide is a carbonic anhydrase inhibitor, hence causing the accumulation of carbonic acid.

It may be used long term for the treatment of open-angle glaucoma and short term for acute angle-closure glaucoma until surgery can be carried out.

Question 69

A 68-year-old man presents to A&E with a drooping eyelid.

On examination, there is partial ptosis and miosis on the right side.

He reports that this has progressed over the last week or two.

A full neurological examination is performed.

There is no slurring of his speech and no other cranial nerve abnormalities.

He reports some right-sided shoulder pain radiating down his arm, and motor weakness of the intrinsic hand muscles are elicited on the right side.

He has no significant past medical history but he has been a heavy smoker for the last 30 years.

Which of the following is the most likely explanation for this patient’s presentation?

Answer 69

Pancoast tumour

The presentation of ipsilateral Horner’s syndrome in combination with thoracic outlet syndrome can be explained by an invasive apical lung cancer invading the sympathetic plexus and brachial plexus.

Pancoast tumours can also cause a hoarse voice and bovine cough if it is affecting the laryngeal nerve.

The patient’s history of heavy smoking would also be in keeping with a diagnosis of lung cancer.

Question 70

What is Lateral medullary syndrome??

Answer 70

symptoms such as

• ipsilateral vestibular nuclei deficits (nystagmus, vertigo, vomiting)
• ipsilateral cerebellar signs (eg. ataxia)

Question 71

A 24 year old male who is unresponsive to painful stimuli and is making a gurgling sound is brought into the emergency department by paramedics.

No observations or further history is available, however a fully-equipped emergency trolley is at the bedside.

What is the next most appropriate action?

Answer 71

Inspect the patient’s mouth for any causes of airway obstruction

The first step in managing a patient’s airway is to assess for any cause of obstruction.

This may be due to the patient’s position or conscious level (their own anatomy obstructing their airway) or due to an external obstruction such as a foreign body, saliva, vomit, or blood.

It is important to identify if the cause of airway compromise is due to an external obstruction, as this should be removed if possible before performing airway manoeuvres.

There is a risk moving the foreign body further into the airway if the airway is opened before removing it.

Question 72

A 28 year old lady presents after taking a paracetamol overdose 5 hours ago.

Her serum paracetamol level is found to be above the treatment threshold when plotted on the nomogram and she is commenced on N-acetylcysteine (NAC).

30 minutes into the infusion, she develops flushing and complains of chest discomfort.

What is the next best step in management?

Answer 72

Stop the infusion and give IV chlorphenamine

This patient has developed an anaphylactoid reaction which is an important side-effect of NAC.

In an anaphylactoid reaction, there is release of immune mediators such as histamine from mast cells.

However, unlike in anaphylaxis, the process is not thought to be antibody (IgE) mediated but rather a direct consequence of the drug itself.

The appropriate management is to stop the infusion, give 10 mg of IV chlorphenamine and re-start the infusion at a slower rate once the symptoms settle.

If the patient is wheezy (due to bronchospasm), salbutamol nebulisers can also be considered.

Question 73

A 73 year old female patient with known heart failure presents to the Emergency Department with a 4 day history of progressive shortness of breath and pitting oedema, which now extends up to the knees bilaterally.

Her chest x-ray reveals bilateral pulmonary infiltrates in a “bats wing” distribution in-keeping with pulmonary oedema.

Her observations are as follows:

• Heart rate (HR): 74
• Respiratory rate (RR): 22
• Oxygen saturations (SATS): 89% on room air
• Blood pressure (BP): 87/62
• Temperature: 37.1

Which of the following is the next best step in the management of this patient? (2)

Answer 73

• Sit the patient up and give high flow oxygen
• This is the first step you should take with any hypoxic patient.

You should aim to be correcting/ improving their hypoxaemia as a priority using your Airway, Breathing, Circulation algorithm.

Patient posture can have a big impact on oxygen levels.

Sitting a patient up and encouraging deep breaths can avoid use of oxygen at all in patients with borderline saturations, however here with saturations of 89% on room the patient is likely to need both here.

Question 74

A 35-year-old lady presents to the A&E Department with a 12-hour history of central chest pain.

The pain came on quite suddenly when she woke up.

She describes a central pain that eases when she exhales.

It does not radiate to her arms or jaw and the pain has a severity of 8/10.

She recalls having a bit of a runny nose a few days ago, but reports no symptoms of nausea, dyspnoea or fevers.

She has a past medical history of seasonal asthma but takes no inhalers. Clinical examination is unremarkable.

Her observations are as follows:

HR: 110, T: 37.0, RR: 16, S02: 95%, BP: 120/75

An ECG shows sinus tachycardia. There is ST elevation in anterior, inferior and lateral leads. There are no T wave changes. The axis is normal and she is in sinus rhythm.

Her blood results show the following:

Hb: 13 (12 - 15.5)
MCV: 92 (80 - 100)
WCC: 9 (3 - 11)
Plat: 200 (150 - 400)

Na: 143 mmol/l (135 - 145)
K: 4.5 mmol/l (3.5 - 5)
Urea: 4.3 mmol/l (2.5 - 7)
Cr: 70 umol/l (45 - 90)

Trop T: 0.6 ng/mL (<0.2 ng/mL)

What is the diagnosis?

What is the treatment?

What else would you see in her ECG?

Answer 74

Naproxen and advise bed rest

This lady has features of pericarditis.

She had flu-like symptoms and describe a pleuritic type of chest pain - that is exacerbated on inhalation and cough.

ECG features of pericarditis typically include PR depression and a widespread saddle-shaped ST elevation.

Troponin levels may also be slightly elevated in pericarditis.

The most appropriate treatment for pericarditis would be NSAIDs and bed rest

Question 75

A 78-year-old man presents to A&E via ambulance after sustaining a head injury from falling at home.

This was a mechanical fall with no preceding symptoms.

He hit his head on the tiled floor, falling from a standing height.

He reports that he briefly lost consciousness after the impact, but is able to recall all events thereafter.

On the ambulance, his GCS was calculated to be 14.

Two hours following the injury, in A&E, his GCS was 15/15.

He had one episode of vomiting on the ambulance.

On examination, a large bruise is noted on the left forehead, but there are no focal neurological deficits, no evidence of open or depressed skull fracture, and no signs of basal skull fracture.

Which of the following features in the history above warrants a CT head for this man?

Answer 75

Loss of consciousness and age

In adults with head injuries, a CT head within 8 hours is indicated if there is loss of consciousness associated with any of the following risk factors:

• age ≥ 65 years
• coagulopathy
• dangerous mechanism of injury
• more than 30 minutes of retrograde amnesia of events immediately before the head injury

If the patient is anticoagulated, this is another indication for CT head within 8 hours, without the need for loss of consciousness or risk factors.

Question 76

Criteria for performing a CT head scan within 8 hours following head injury

(4)

Answer 76

In adults with head injuries, a CT head within 8 hours is indicated if there is loss of consciousness associated with any of the following risk factors:

• age ≥ 65 years
• coagulopathy
• dangerous mechanism of injury
• more than 30 minutes of retrograde amnesia of events immediately before the head injury

Question 77

Criteria for performing a CT head scan within 1 hour of head injury

(8)

Answer 77

For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:

• GCS less than 13 on initial assessment in the emergency department.
• GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
• Suspected open or depressed skull fracture.
• Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
• Post-traumatic seizure.
• Focal neurological deficit.
• More than 1 episode of vomiting.
• A provisional written radiology report should be made available within 1 hour of the scan being performed.

Question 78

An 74 year old man is being treated for chest sepsis with IV amoxicillin.

His past medical history includes hypertension, for which he is on ramipril and amlodipine.

He is normotensive. His blood tests come back as follows:

• Na 142 (135-145)
• K 5.4 (3.5-5.5)
• Ur 10.4 (2.5-6.7)
• Cr 203 (70-150) - baseline 120

He is initiated on IV fluids and is currently producing some concentrated urine.

What is the most appropriate next step in managing this patient?

Answer 78

Stop ramipril

Ramipril may worsen pre-renal AKI by reducing renal perfusion through dilation of renal arterioles. It is therefore imperative to stop it.

Question 79

Drugs to discontinue in AKI

(6)

Answer 79

Diuretics

ACE inhibitors (ramipril)

ARBs (losartan)

NSAIDS (ibuprofen)

Cyclosporins

interferon

Question 80

A 79 year old man presents to A&E with shortness of breath.

On examination his legs have pitting oedema to the knees.

His JVP is raised. Auscultation of the chest reveals widespread crackles.

He has a past medical history of ischaemic heart disease, hypertension, and heart failure.

What is the most appropriate initial management?

Answer 80

IV furosemide

This man has presented with decompensated heart failure.

The symptoms and signs are indicative of both left and right cardiac failure.

Patients with heart failure and overload should be treated early with intravenous diuretics as part of their initial management, regardless of the underlying cause.

Question 81

A 55-year-old Indian lady presents to the Emergency Department with a 2-hour history of chest pain. The pain feels sharp, and it came on suddenly while she was lying in bed. She notes that the pain felt worse when she coughs, and she also recently noticed some streaks of blood in her sputum. She does not complain of any night sweats or weight loss. She has a family history of DM and lung cancer. She smokes about 10 cigarettes a day for the past 5 years, and drinks alcohol occasionally.

She has a past medical history of HTN, asthma and DM. She travels to India every year to visit her family, and recently returned from her annual trip a few days ago. She has no drug allergies and takes regular atorvastatin, ramipril, amlodipine and metformin. Her basic observations are as follows: HR 110, RR 25, BP 135/90, T 37.6, SO2 94% RA.

On examination, you note that she is tachypnoeic and restless. On auscultation of her chest, you hear vesicular breath sounds and no added sounds. Heart sounds are normal with no murmurs present. Her abdomen is soft and non-tender without organomegaly. On examination of her peripheries, you do note some redness and swelling of her right leg.

What is the most likely underlying diagnosis?

Answer 81

Pulmonary Embolism

This lady experienced acute onset pleuritic chest pain with haemoptysis and some difficulty breathing. Her recent travel is a risk factor for developing PE. She is also tachycardic with a mild temperature, which can occur in PE. More importantly, the swelling of her right leg can indicate a recent DVT, which could have caused the PE. This is the most likely diagnosis.

Question 82

A 26-year-old woman presents to A&E with a widespread rash.

She appears well at rest, with no swelling of the lips or tongue, and no evidence of respiratory compromise.

On examination, an erythematous, maculopapular rash is noted affecting the face, all four limbs and torso.

She denies nausea, vomiting and diarrhoea.

She has no significant past medical history of note but was recently treated by her GP for suspected bacterial pharyngitis with Amoxicillin.

Observations are as follows:

• respiratory rate 10/min
• SpO2 96% on room air
• pulse rate 100/min
• blood pressure 124/83
• temperature 37.9.

Which of the following is the most likely diagnosis?

• HIV seroconversion
• Anaphylaxis
• Infectious mononucleosis
• Steven-Johnson syndrome
• Jarisch-Herxheimer reaction

Answer 82

Infectious mononucleosis

This is a classic history of a patient with infectious mononucleosis (glandular fever) who has been treated with Amoxicillin for bacterial pharyngitis and re-present with Amoxicillin-related rash.

The pathophysiology of this rash is unknown.

The widespread rash settles after Amoxicillin is stopped and with supportive management.

Question 83

What is Steven-Johnson syndrome?

Answer 83

This is a rare, life-threatening skin condition that is most commonly due to a drug reaction.

The main drug groups include;

• beta-lactam antibiotics
• sulfa- drugs
• antiepileptic drugs
• Allopurinol

Question 84

What is HIV seroconversion?

Answer 84

HIV is an important diagnosis to exclude in a patient presenting with widespread maculopapular rash.

HIV seroconversion presents similarly to glandular fever, up to 3 months after exposure, with symptoms such as:

• fever
• myalgia
• sore throat
• diarrhoea
• rash
• lymphadenopathy

Question 85

A 67 year old lady presents to the emergency department with acute breathlessness, having had a myocardial infarction two weeks ago.

On initial assessment, the airway is patent, the patient is markedly tachypnoeic with bi-basal crepitations on auscultation, oxygen saturations are 93% on high-flow oxygen, heart sounds are normal and the radial pulse has a rate of 118, blood pressure is 127/74, IV access is in situ, on exposure there is pitting oedema of both legs up to the knee.

What is the single best initial treatment for this patient?

Answer 85

IV furosemide 40mg

This patient is in acute cardiogenic pulmonary oedema, as evidenced by the respiratory distress, bibasal crepitations, hypoxia, and history of recent MI.

This episode has likely been brought on by acute cardiac failure, as a result of the impaired cardiac function caused by the MI.

Oxygen is already being given, and as IV access is available, giving an IV diuretic should be the next priority.

Diuretics reduce preload by their vasodilatory action and they also increase fluid excretion to decrease the hydrostatic pressure in the pulmonary circulation and allow fluid to move out of the lungs back into the circulation.

Question 86

What is dobatamine?

Answer 86

Dobutamine is an intotropic (contraction) medication, and should only be used in a high-dependency/intensive care setting, with input of senior intensive care/medical doctors.

It may be an appropriate treatment in patients with pulmonary oedema who have hypotension, and signs/symptoms that are not responding to IV diuretics and nitrates.

Question 87

A 46 year old man is reviewed on the orthopaedic ward, he is awaiting surgery for a fractured left tibia and fibula, following a motorcycle accident.

The patient is complaining of severe pain in his left leg, and has recently received 10mg of oral morphine, having already had 20mg before this.

On examination, the patient is alert and orientated but visibly in pain. Respiratory and cardiovascular examination is unremarkable.

The left leg has an above knee back slab in place, on removal of the bandaging the left lower leg is tense, swollen, and tender.

Passive ankle plantarflexion causes the patient severe pain, and sensation is decreased in the left foot compared to the right.

Distal pulses are intact in both legs.

Which is the single best definitive action in managing this patient?

Answer 87

Fasciotomy of the left lower leg

The history is highly suspicious for a developing acute compartment syndrome in the left lower leg - suspicion is raised by the history of trauma with a tibial and fibular fracture, disproportionate levels of pain, a limb that is swollen, tense, and tender, and pain on passive stretch of muscles suggests oedema/increased pressure in the compartment they run through.

Altered sensation is also a concerning feature; loss of distal pulses is a very late sign.

Acute compartment syndrome is an emergency and requries urgent reduction of compartment pressures in order to save the affected limb; fasciotomy is the definitive treatment.

Question 88

A 75-year-old woman is brought into the emergency department by ambulance due to severe back pain.

The pain is in the thoracic region and is described as a ‘band’ around the chest.

It came on suddenly three hours ago whilst she was eating breakfast and has rapidly become ‘unbearable’.

It is worsened by movement and coughing.

She has a history of breast cancer, for which she is receiving palliative radiotherapy.

On examination, she is unable to walk due to pain and leg weakness.

Muscle tone and power of the lower limbs is bilaterally reduced, with MRC grading 2/5 in all muscle groups.

Lower limb reflexes are bilaterally reduced. Anal tone is normal on PR examination, and the bladder is not palpable.

There is reduced pin-prick, fine touch and vibration sense from the level of the umbilicus onwards.

Proprioceptive sense is lost up to the hip joint.

Upper limb neurological examination and cardiorespiratory examination are normal.

• HR 89
• BP 150/94 (right arm) 151/92 (left arm)
• RR 22
• SaO2 97%
• T 36.8

Give the most likely diagnosis.

What is the single most important investigation?

Which spinal level is affected?

Answer 88

MRI whole spine

This patient has acute spinal cord compression secondary to metastatic spinal disease from breast cancer.

s there may be metastatic deposits anywhere along the spine, an urgent whole spine MRI is necessary to look for disease along the whole spine.

Examination findings suggest disease in the thoracic spinal cord at the level of T10 due to the presence of a sensory level.

In acute spinal cord compression, tone and reflexes may be initially reduced despite this being an upper motor neurone lesion.

The lack of bladder and bowel symptoms does not rule out acute spinal cord compression as these are late signs and can herald irreversible damage.

Question 89

A 74-year-old man with Stage IV Chronic Kidney Disease presents to A&E with palpitations and shortness of breath.

Whilst waiting to be seen in the department, he starts to become drowsy and confused. The patient is assessed using an ABCDE method.

• Heart rate 98 beats per minute
• Blood pressure 110/70
• Respiratory rate 22 breaths per minute
• SpO2 93% on room air
• Temperature 36.4

Physical examination reveals bi-basal lung crepitations, a pericardial rub, and pitting oedema up to the mid-calves.

An arterial blood gas shows

• pH 7.22 (normal: 7.35-7.45)
• lactate 1.2 (normal: 0.5-1 mmol/L)
• PaO2 10.0 (normal: >10.6 kPa)
• PaCO2 5.3 (normal: 4.7-6.0 kPa)
• Potassium 7.0 (3.5-5.0 mmol/L)
• Sodium 150 (135-145 mmol/L)

An electrocardiogram shows the following:

Which of the following is the most appropriate first step in managing this patient?

Answer 89

Intravenous Calcium gluconate

This patient is presenting with clinical features suggestive of complications arising from acute-on-chronic renal failure.

These include hyperkalaemia (tented T-waves on ECG, best seen in precordial leads), acute pulmonary oedema (bi-basal crepitations and Type I respiratory failure on an ABG) and uraemia (confusion and uremic pericarditis).

These complications will need to be immediately addressed as this patient is very unwell.

As this patient has a very high potassium level and has ECG changes associated with hyperkalaemia, it would be most important to start an intravenous infusion of Calcium gluconate, which stabilises the myocardium and prevents the development of ventricular tachyarrhythmias.

Question 90

An 82-year-old woman is on the ward, two days after a neck of femur fracture repair. She reports sudden-onset shortness of breath and sharp chest pain exacerbated by breathing.

Observations are as follows: respiratory rate 22/min, SpO2 93% on high flow oxygen, pulse rate 125/min, blood pressure 88/54, temperature 37.3.

A 12-lead ECG is performed which shows sinus tachycardia.

Wells’ score is calculated as 4, and D-dimer is 1200 ng/mL. A CTPA is ordered.

A diagnosis of massive pulmonary embolism (PE) is suspected.

Which of the following features indicate that the PE is massive?

Answer 90

Systolic blood pressure < 90 mmH

Massive pulmonary embolism is characterised by hypotension (systolic blood pressure < 90 mmHg or a drop in systolic blood pressure of ≥ 40 mmHg for ≥ 15 minutes) or signs of shock.

It is associated with significantly higher mortality rates than non-massive PE.

Question 91

A 32-year-old man presents to A&E with chest pain.

He describes a two-day history of severe, sharp, central chest pain that is worse on inspiration.

He has no past medical history of note.

Observations are as follows:

• respiratory rate 12/min
• SpO2 96% on room air
• pulse rate 112/min
• blood pressure 128/89
• temperature 37.7

A 12-lead ECG is performed which shows global concave ST-elevation.

Which of the following is the most likely diagnosis?

Answer 91

Acute pericarditis

The history of a young man with pleuritic chest pain and low-grade fever is highly suspicious of acute pericarditis (acute inflammation of the pericardium).

This is confirmed by the characteristic global concave ST elevation seen on the 12-lead ECG.

PR depression and T wave changes may also be seen. Acute pericarditis may be idiopathic or caused by infection (most commonly viral), inflammatory disorders, cardiac surgery, or drugs.

Question 92

A 67-year-old woman on the Oncology ward being treated for meningioma reports worsening headache.

On examination, she appears drowsy and is irritable. Her pupils are non-reactive.

Raised intracranial pressure (ICP) is suspected.

Which of the following clinical features are associated with raised ICP?

Answer 92

• Increased blood pressure
• bradycardia
• irregular breathing

This is the Cushing’s triad, which is the physiological response that can be seen in the context of raised ICP.

Increased blood pressure is an attempt to maintain adequate cerebral blood flow, while the bradycardia is a baroreceptor reflex in response to hypertension.

The respiratory centre is located in the brainstem. Increased ICP leads to increased pressure on the brainstem, leading to irregular breathing patterns.

Question 93

What is Cushing’s triad?

Answer 93

Increased blood pressure

bradycardia

irregular breathing

This is the Cushing’s triad, which is the physiological response that can be seen in the context of raised ICP.

Question 94

A 19 year old male, who is known to abuse alcohol, arrives in the emergency department having a generalised tonic-clonic seizure which has been on-going for the past 15 minutes.

The patient has received one dose of rectal diazepam.

The airway is maintained with an oropharyngeal airway in situ and high-flow oxygen via a non-rebreathe mask is running.

There is no abnormality on examination of the chest.

IV access has been established.

There is not past history of seizures and the patient is not on any regular medication.

Which of the following is the single best next treatment?

Answer 94

Give IV lorazepam 4mg

In the treatment of seizures, the standard ABCDE approach applies.

With regard to treatment, benzodiazepines are the first line, with options of giving initial treatment via the buccal or rectal route if IV access is not available.

It is appropriate to give up to two doses of benzodiazepines to terminate the seizure, and as this patient has already received a dose of rectal diazepam, the patient should be given a further dose; IV access is available so IV lorazepam is appropriate.

Question 95

A 21-year-old patient presents to General Practice after having a seizure.

Whilst undergoing an initial assessment, he has another seizure that lasts more than five minutes.

A nurse has attempted to obtain intravenous access but has had a number of unsuccessful attempts.

What is the most appropriate initial treatment?

Answer 95

Buccal midazolam

The first line treatment for seizures and status epilepticus is benzodiazepines.

Since intravenous access is yet to be obtained, the most appropriate initial treatment in this patient is buccal midazolam (which works more quickly than rectal treatment).

This is in keeping with recommendations by NICE.

Question 96

A 48 year old man presents to hospital with a right upper quadrant pain, jaundice and rigors.

• His heart rate is 105bpm
• blood pressure 88/63
• respiratory rate 28/min
• Temperature 38.4°C
• Oxygen saturations 98% on room air

On examination he is Murphy’s sign positive.

What is Murpy’s sign?

A VBG lactate is perform which returns as 5mmol/L.

What is the most appropriate immediate management of this patient?

Answer 96

Murphy’s sign is elicited in patients with acute cholecystitis

• If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.

Fluid challenge with crystalloid

A fluid challenge is recommended by NICE for any patient with suspected sepsis who displays the signs of shock (SBP<90mmHg) or has a lactate above 4mmol/L.

This is because these patients are at high risk of failing to adequately perfuse their organs.

Question 97

The medical foundation doctor is called to the cardiac care unit to review an 76 year old lady has just had a witnessed loss of consciousness.

On arrival patient is alert but complaining of feeling dizzy and breathless, no airway or breathing issue is identified.

On assessment of circulation, the patient has a

• weak radial pulse with a rate of around 40,
• blood pressure is 98/47
• cardiac monitor shows complete heart-block.

There is an IV cannula in situ.

The patient’s medication history includes atenolol, ramipril, and amlodipine.

What is the single best initial treatment for this patient?

Answer 97

IV atropine 500 micrograms

This patient has symptomatic bradycardia caused by complete heart-block.

In an unstable patient with bradycardia, the first line treatment is atropine IV.

It works as an anticholinergic agent, decreasing the parasympathetic input to the heart and thereby causing increased sinoatrial node firing and increased heart rate.

Atropine can be given in 500 micrograms to 1mg boluses, up to a total of 3mg.

Question 98

A 78-year-old patient on the ward complains of palpitations and dizziness.

She has an extensive past medical history and is currently being treated for community-acquired pneumonia.

A 12-lead ECG is performed and a diagnosis of torsades de pointes is made.

Which of the following drugs has most likely contributed to the patient developing this abnormal heart rhythm?

(2)

Answer 98

Erythromycin

Macrolide antibiotics can cause QT prolongation, which increases the risk of developing torsades de pointes. She has likely been started on this for the treatment of pneumonia.

Question 99

Causes of TDPs

Answer 99

Causes of a long QT interval which may predispose a patient to developing TDP include the following. This can be remembered by a useful mnemonic - TIMMES:

1. Toxins: drugs including anti-arrhythmics, anti-psychotics and tricyclic antidepressants
2. Inherited: congenital long QT syndromes such as Romano-Ward and Jervell and Lange-Nielson syndromes.
3. Ischaemia
4. Myocarditis
5. Mitral valve prolapse
6. Electrolyte abnormalities, such as hypokalaemia and hypocalcaemia
7. Subarachnoid Haemorrhage

Question 100

Causes of cardiac arrest

(8)

Answer 100

Question 101

Ways to treat hyper-kalaemia

Answer 101

Question 102

A 33-year-old Afro-Caribbean lady complains of painful loss of vision in her right eye over the last three days.

She reports that she has an irregular shaped area missing towards the middle of her vision.

She also complains of abnormal perception of colours with reds appearing less distinct than normal.

She is otherwise healthy with no significant past medical history.

She does not take any regular medications and has no allergies.

Given the underlying diagnosis, which of the following findings would you most likely find on examination of her eyes?

Answer 102

A relatively dilated pupil on the right when the torch is swung towards it

This lady has features in keeping with a diagnosis of optic neuritis which may be secondary to a demyelinating condition such as multiple sclerosis.

This option describes a relative afferent pupillary defect (RAPD) of the right eye, which commonly occurs in patients affected by MS (secondary to optic neuritis)

Optic neuritis is a condition that affects the eye and your vision. It occurs when your optic nerve is inflamed..

Question 103

A 30-year old woman presents to the Emergency Department with shortness of breath. She has recently returned from holiday in America.

Clinical examination is unremarkable.

A diagnosis of pulmonary embolism is suspected.

What is the most common ECG finding in a pulmonary embolus?

Answer 103

Sinus tachycardia

Other features include

• right heart strain (RBBB, right axis deviation T wave inversion and ST segment changes)
• rare S1Q3T3 feature (S wave in lead I, Q wave T wave inversion in lead III).

The most common ECG finding in patients with pulmonary embolism is sinus tachycardia. Other features such as the right axis deviation and right ventricular strain pattern may also be seen.

These ECG changes occur due to the dilatation of the right atrium and ventricle, as well as right ventricular ischaemia.

Tachycardia can also be secondary to fever and pain.

Question 104

A 65-year-old woman presents to the emergency department with sudden-onset shortness of breath and chest pain.

She has just returned from a trip to South Africa.

On examination chest expansion is symmetrical, trachea is central and breath sounds are vesicular.

Her observations are below:

• HR 120
• BP 80/40
• RR 20
• SaO2 88%
• T 37.50C

Given the likely diagnosis, what is the most appropriate initial treatment?

Answer 104

15L of Oxygen therapy via non-rebreathe mask

This woman likely has a PE following a long haul flight back from South Africa. Following the ABCDE approach, her low oxygen saturations should be treated first with high flow oxygen.

Anticoagulation with LWMH following a PE is necessary, but only after the patient has been resucitated.

Question 105

A 47 year old man with a known adrenal mass presents complaining of severe headache and sweating.

He is mildly pyrexial and his BP is 231/143mmHg.

An ECG shows some sub-criteria ST elevation in the lateral leads.

What is the most appropriate initial management?

Answer 105

Phentolamine

This is the ideal initial management of a symptomatic phaeochromocytoma because it blocks mainly alpha adrenergic receptors leading to vasodilation and reduction in blood pressure.

BETA BLOCKERS cannot be given as the first drug because there is a significant risk of reflex vasoconstriction leading to worsening hypertension if the alpha adrenergic receptors are not already blocked.

Question 106

A 40-year-old man is brought into the Emergency Department (ED) after being found poorly rousable at home.

He has been unwell for the last few weeks complaining of tiredness, weakness, excess thirst and nausea.

On examination, he has a GCS of 10 and is haemodynamically stable.

His initial investigation results are as follows:

• Blood glucose: 65 mmol/L (4-11 mmol/L)
• Urine glucose: 4+
• Urine ketones: +
• Sodium: 154 mmol/L (135-145 mmol/L)
• Potassium: 5.0 mmol/L (3.5-5.0 mmol/L)
• Urea: 35 mmol/L (2.5-6.7 mmol/L)
• Creatinine: 240 µmol/L (70-130 µmol/L)

Which of the following is the next best step in management?

(2)

Answer 106

1L of 0.9% saline over 1 hour

This patient has Hyperosmolar Hyperglycaemic State (HHS).

It is characterised by marked hyperglycaemia (above 30 mmol/L); absent or mild ketonaemia and raised serum osmolality (> 320 mOSm/kg).

Osmolality, in this case, should be formally requested but can be estimated by the formula: (2 X sodium) + urea + glucose. In this case: (2 x 154) + 35 + 65 = 408 mOsm/kg.

Compared to diabetic ketoacidosis (DKA), HHS has a more insidious onset and is associated with higher blood glucose levels.

It is also more common in Type 2 diabetics and not usually associated with heavy ketonuria. In this case, mild ketonuria is likely due to starvation.

First-line treatment for HHS is to hydrate the patient with 0.9% saline. At least 1L should be given in the first hour.

Question 107

A 50-year-old lady presents to the Emergency Department with a 1-day history of pleuritic chest pain.

She has a past medical history of COPD. Her observations are as follows:

HR 88

RR 20,

BP 120/85

T 37.0

SO2 89% RA

On examination, she is comfortable at rest.

On palpation, there is no tracheal deviation or crepitus over the chest.

On auscultation, there is decreased air entry over her right lung.

A chest X-ray is ordered which shows evidence of reduced lung markings on the right side with no other findings.

What is the best management option for this patient?

Answer 107

Chest drain insertion

This patient has features of a secondary spontaneous pneumothorax of the right lung, most likely secondary to her underlying COPD.

Patients who have a secondary pneumothorax who are symptomatic or have a pneumothorax measuring >2 cm from the chest rim on radiographs should be offered a chest drain.

Question 108

Describes the immediate emergency treatment of a tension pneumothorax.

Answer 108

Immediate needle decompression with a large-bore needle in the 2nd intercostal space mid-clavicular line

Question 109

A 63-year-old man on the Respiratory ward develops sudden respiratory distress. He is haemodynamically unstable with hypotension and tachycardia. The trachea is deviated to the right side of the chest.

A tension pneumothorax is suspected.

Which of the following is the next best step in the management of this patient?

Answer 109

Insert a 14-16G needle into the 2nd intercostal space, midclavicular line of the left side

A needle thoracostomy is the best initial management for tension pneumothorax while awaiting chest x-ray to confirm the diagnosis, and chest drain insertion as definitive management.

In tension pneumothorax the trachea is deviated away from the affected side, therefore in this man, the needle should be inserted into the left lung.

Question 110

A 67-year-old man is brought into the Emergency Department (ED) after collapsing whilst out shopping.

His wife reports that he suddenly ‘blacked out’ for about 30 seconds.

He initially went pale and then appeared flushed on regaining consciousness.

On assessment, he is unresponsive.

His blood pressure is 90/65 mmHg and an ECG shows a heart rate of 35 bpm with complete dissociation between the p waves and QRS complexes.

Which of the following is the next best step in management?

What is the definitive treatment?

Answer 110

IV Atropine 500mgs

This man’s blackout has characteristics of cardiogenic syncope due to bradycardia (also known as a Stokes-Adams attack).

These include sudden onset, short duration and associated facial colour change (due to oxygenated blood in the pulmonary capillaries accumulating and then being released into the systemic circulation during recovery, leading to flushing).

His ECG findings and slow heart rate are indicative of third-degree (complete) heart block.

Following initial assessment, in the presence of adverse features (myocardial ischaemia, heart failure, syncope or shock), the initial management of bradycardia is to administer 500 micrograms of atropine IV if the patient is unstable.

The definitive management for complete heart block is the insertion of a permanent pacemaker.

Question 111

An 89 year old Type 2 diabetic is being treated for a urinary tract infection with IV gentamicin.

He has a small peripheral cannula placed in the back of his hand.

During his admission his capillary blood glucose measurements are repeatedly >15mmol/L.

His gliclazide is therefore increased from 80mg BD to 160mg BD.

The next evening he is noted to become significantly more agitated and confused.

A capillary blood glucose measurement returns at 2.9mmol/L.

What is the most appropriate initial management of this patient?

Answer 111

Carton of fruit juice

• This is an ideal choice for mild hypoglycaemia because it contains plenty of short chain carbohydrates which will rapidly increase blood glucose.

50ml 50% glucose - This is inappropriate for several reasons.

Firstly, IV glucose is not necessary in a patient who is only exhibiting the signs of mild hypoglycaemia.

Secondly, the IV glucose regimen of choice is usually 10-20%. 50% glucose is extremely venotoxic therefore cannot be given through the small cannula in the back of the hand.

Instead, it will require a large bore cannula in a large vein. It is for this reason that 50% glucose is no longer recommended as the glucose fluid of choice in hypoglycaemia.

Question 112

A 45 year old man presents to the emergency department, he is vomiting large amounts of blood.

The patient is known to misuse alcohol, but has no other significant past medical history.

On assessment, the patient is alert but vomiting, breath and heart sounds are normal.

Observations show a blood pressure of 86/41, heart rate of 127, respiratory rate of 22, oxygen saturations of 96% on 2L/min via nasal cannula, and a temperature of 36.8 celsius.

Two large bore IV cannulae are in situ.

The major haemorrhage protocol has been activated.

What is the single best initial treatment?

Answer 112

Give a 500ml normal saline bolus IV

This patient is in haemorrhagic shock secondary to a significant upper GI bleed (likely variceal, in the context of profuse haematemesis and history of alcohol misuse) and as such current evidence and guidance suggests that initial resuscitation is done with IV crystalloids, while awaiting blood for transfusion (if required).

A restrictive blood transfusion strategy is advocated in these patients based on available evidence, as this reduces the risk of both on-going and re-bleeding.

Question 113

A 28 year old man collapses outside the GP surgery.

The receptionist immediately calls you to come and assess the patient.

On assessing the patient you see that he has a rash on his arms and legs, there is an audible wheeze and his lips are swollen.

His temperature is 36.6, HR is 110, RR is 36, sats 92% blood pressure 82/60.

You make the diagnosis of anaphylaxis, place the patient in the recovery position, attach high flow oxygen and call 999.

Which of the following medication is the most appropriate to administer immediately?

Answer 113

• Adrenaline 1:1000
• IM
• 500micrograms
• (0.5ml)

This is the correct dose of adrenaline, a life saving medication in anaphylaxis.