Pre-course test

Question 1

The most common mechanism underlying hypoxaemic respiratory failure in the critically ill is:
Select one:
a. Low inspired oxygen concentration
b. Increased dead space
c. Hypoventilation
d. Diffusion abnormality
e. Shunting

Answer 1

E

In critically ill patients, this is frequently caused by conditions such as pneumonia, acute respiratory distress syndrome (ARDS), or pulmonary edema, where alveoli are filled with fluid, pus, or collapsed, preventing gas exchange.

Because blood bypasses these non-ventilated or poorly ventilated alveoli, it results in hypoxaemia that is resistant to increased inspired oxygen.

Question 2

Question 2
Haemodynamic support of a hypotensive patient with a massive pulmonary embolus should include:
Select one:
a. Large volume fluid resuscitation
b. Intravenous nitrate infusion
c. Norepinephrine infusion
d. Dobutamine infusion
e. Isoprenaline infusion

Answer 2

C
Explanation: increase MAP -> increase right ventricular coronary perfusion

Question 3

Question 3
Which of the following is not a recommended method of reducing sharps injuries:
Select one:
a. re-sheath needles after use
b. bring the sharps bin to the point at which sharps are being used
c. use safety cannulae
d. double glove while suturing
e. avoid picking up used sharps with your hands

Answer 3

A

Question 4

Question 4
A 78 year old male smoker presents with an acute exacerbation of COPD. His initial arterial blood gas on 28% oxygen shows pH 7.32, PaCO2 8.2 kPa (61 mmHg), PaO2 6.5 (49 mmHg), SaO2 80%. One hour later is arterial blood gas shows pH 7.18, PaCO2 12 kPa (90 mmHg), PaO2 10 kPa (75 mmHg), SaO2 92% on 35% of oyxgen The most appropriate immediate change to his oxygen therapy is to:
Select one:
a. reduce the oxygen concentration to 28%
b. increase the oxygen concentration to 40%
c. give oxygen 15 l/min via a reservoir face mask
d. start non-invasive ventilation (as pH<7.25)
e. no change is necessary

Answer 4

D

The increase in oxygen therapy has improved oxygenation but may also risk worsening hypercapnia due to Haldane effect and reduction of hypoxic drive.

The primary concern is ventilatory failure; oxygen therapy alone may not be sufficient.

The risk of CO2 retention and respiratory fatigue suggests the need for ventilatory support.

Question 5

Question 5
You are looking after a patient admitted with urinary tract infection. Which of the following would suggest that he has sepsis rather than simple infection
Select one or more:
a. Oliguria
b. Fever
c. Decreased consciousness
d. Leucocytosis
e. Desaturation

Answer 5

A,C,E

Question 6

Question 6
In a patient with status epilepticus immediate treatment priorities are:
Select one or more:
a. Lateral position
b. Ensure patent airway
c. Detect and correct hypoglycaemia
d. Ensure adequate breathing
e. Lorazepam 0.1 mg/kg IV

Answer 6

A,B,C,D

Question 7

Question 7
A 60 year old patient has the following arterial blood gas result on air: pH 7.34, PaCO2 8.0 kPa (60 mmHg), PaO2 7.5 kPa (56 mmHg), HCO3- 32.1 mmol/L, BE 8. His acid-base abnormality is:
Select one or more:
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Significantly raised A-a gradient
e. Respiratory acidosis

Answer 7

E

Question 8

Question 8
A 24 year old trauma victim has normal capillary refill, blood pressure 115/40 mmHg and respiratory rate 14/min. He is anxious. His estimated blood loss is:
Select one:
a. <15%
b. 15-20%
c. 21-25%
d. 26-30%
e. >30%

Answer 8

A

Question 9

Question 9
A patient on oxygen 15L/min via reservoir facemask has the following arterial blood gas result: pH 6.9, PaCO2 7.2 kPa (54 mmHg), PaO2 10 kPa (75 mmHg), HCO3- 10 mmol/L. His acid base abnormality is typical of:
Select one:
a. Diabetic ketoacidosis
b. Severe acute pulmonary oedema
c. Hepatic and renal failure
d. Renal tubular acidosis
e. A patient with chronic obstructive pulmonary disease who has been treated with diuretics

Answer 9

B

Question 10

Question 10
A 55 year old man with known hepatitis B cirrhosis has been managed in the medical ward for hematemesis. He has been receiving packed cell, fresh frozen plasma and normal saline. He acutely developed wheezing and shortness of breath. His SpO2 is 92% on room air breathing with a respiratory rate of 22 breaths/minute. His blood pressure is 120/80, pulse regular at a rate of 100 beats/minute. He can speak in full sentences and there is no stridor. He had an urticarial rash on his face and neck. What should be the next step of your management? (P. 142)
Select one:
a. Give inhalational bronchodilator
b. Stop blood product transfusion
c. Give steroid
d. Give adrenaline 0.5mg im
e. Give antihistamine

Answer 10

B

Question 11

Question 11
Which of the following statements is false?
Select one:
a. Loop diuretics do not increase creatinine clearance
b. The part of the kidney that is most susceptible to hypoxia is the renal cortex
c. Urea and creatinine are insensitive markers of glomerular filtration rate
d. Patients undergoing abdominal aortic aneurysm surgery are at increased risk of developing acute renal failure
e. Oliguria in adults can be defined as urine output of less than 400 mls/day

Answer 11

B

a. Loop diuretics do not increase creatinine clearance
True. Loop diuretics (like furosemide) increase urine output but do not directly enhance glomerular filtration rate (GFR); often, they may cause a transient decrease in renal function, thereby not increasing creatinine clearance.

b. The part of the kidney most susceptible to hypoxia is the renal cortex
False. The renal medulla, particularly the inner medulla, is more susceptible to hypoxia because it operates under relatively low oxygen tension and has a higher metabolic demand. The cortex receives more blood flow and is less vulnerable.

c. Urea and creatinine are insensitive markers of glomerular filtration rate
True. Both are affected by factors other than GFR (e.g., hydration status, muscle mass), making them insensitive as precise markers, especially in acute changes.

d. Patients undergoing abdominal aortic aneurysm surgery are at increased risk of developing acute renal failure
True. Such surgeries can involve significant hemodynamic changes and potential ischemia, increasing the risk of acute kidney injury (AKI).

e. Oliguria in adults can be defined as urine output of less than 400 mls/day
True. Oliguria is commonly defined as urine output less than 400 mL/day in adults.

Question 12

(Lack explanation)

Question 13
A patient with sepsis has a BP 100/40 (mean arterial pressure 60 mmHg) before and 110/40 after passive leg raising, CVP 4 mmHg, heart rate 120/min and oxygen saturation 97% (on FiO2 0.3). He is acidotic, oliguric and confused. He is in positive fluid balance of 3L over the first 12 h of his hospital admission. The most appropriate next step in his resuscitation is: (P. 50)
Select one:
a. 1 L crystalloid over 30 minutes
b. Start dobutamine infusion
c. Start norepinephrine infusion
d. No further resuscitation is required
e. Start dopamine infusion

Answer 12

A

Question 13

Question 15
In the determining priority for admission to an ICU with limited resources the overriding ethical principle is:
Select one:
a. distributive justice
b. autonomy
c. beneficence
d. non-maleficence
e. veracity

Answer 13

A

Question 14

Question 16
You have witnessed a man suddenly collapse on the street. He is unconscious and pulseless, but you witness a gasping effort. There is no one nearby and your mobile phone battery is flat. There are no safety issues. The correct immediate management is:
Select one:
a. Call for help, but if no one is near, do not leave the patient to get help, and immediately start chest compressions
b. Immediately start mouth-to-mouth rescue breathing
c. You call for help, but there is nobody near and no one comes. You should leave the patient to find someone to call an ambulance, and only then start chest compressions
d. The patient has gasping efforts and so has not arrested and can be observed in the recovery position
e. Leave the patient and search for an automated external defibrillator

Answer 14

C

Question 15

Question 17
A patient with end stage renal failure who is receiving regular haemodialysis is admitted to hospital for an elective cholecystectomy. Two days later he develops a hospital acquired pneumonia. Which of the following antibiotic regimes would be appropriate?
Select one:
a. Ceftriaxone
b. Gentamicin
c. Amoxycillin-clavulanate
d. Piperacillin-tazobactam
e. Benzylpenicillin and metronidazole

Answer 15

D

Question 16

Question 18
A patient presents with a history of a bee sting. He complains of shortness of breath and an itchy rash. On examination he has an urticarial rash, swelling of his lips and tongue, stridor and dyspnoea, BP 130/60, heart rate 120/min. Immediate treatment should include:
Select one:
a. intravenous epinephrine 0.1 mg
b. intravenous epinephrine 1 mg
c. intravenous ranitidine 50 mg
d. intravenous hydrocortisone 100 mg
e. intramuscular epinephrine 0.5 mg

Answer 16

E

Question 17

Question 19
Which of the following are common causes of breathlessness coming on over minutes?
Select one or more:
a. Pneumothorax
b. Pulmonary embolism
c. Pulmonary oedema
d. Pneumonia
e. Asthma

Answer 17

A,B,C

(Why not ACE?)

Question 18

Question 20
Pacing is indicated for: (P.89)
Select one or more:
a. Bilateral bundle branch block
b. Mobitz type II second degree heart block
c. Newly acquired bifascicular block with 1st degree AV block (trifascicular block)
d. Third degree heart block
e. Mobitz type I second degree heart block

Answer 18

A,B,C,D

Question 19

Question 21
You are asked to see a shocked patient. He has a BP 90/50 with a sinus tachycardia of 120/min. Which of the following suggest that the patient will respond to fluid resuscitation:
Select one:
a. CVP 7 mmHg
b. Rise in CVP of 1 mmHg after a fluid challenge
c. Rise in pulse pressure of 14% on passive leg raising
d. CVP 10 mmHg
e. CVP 14 mmHg

Answer 19

C

Question 20

Question 22
Which of the following statements regarding airway obstruction is/are true: (P.8)
Select one or more:
a. Chest movement can occur even in the presence of complete airway obstruction
b. The absence of stridor makes severe airway obstruction unlikely
c. Drooling and gagging are features of airway obstruction
d. Airway obstruction is an indication for urgent referral to an ENT surgeon and anaesthetist
e. Bradycardia indicates impending cardiac arrest

Answer 20

A,C,D,E

E: Bradycardia can be a sign of severe hypoxia or impending cardiac arrest, but it is not always predictive. In airway obstruction, hypoxia can lead to bradycardia (the “vagal response”). It warrants urgent intervention.

Question 21

(lack explanation)

Question 23
A patient admitted with asthma has been treated for the past day with 4 hourly inhaled salbutamol and ipratropium bromide and 6 hourly intravenous hydrocortisone 100 mg. She cannot speak but she has no wheeze and her arterial saturation is 98% on 15 l/min oxygen via a reservoir face mask. Her heart rate is 160/min and her peak flow is 60 l/min. The appropriate immediate course of action is: Select one:
a. increase the inhaled salbutamol to hourly
b. increase the hydrocortisone to 200 mg 6 hourly
c. give verapamil
d. start IV salbutamol
e. call ICU

Answer 21

E

(not sure btw D and E)

Question 22

Question 24
The first priority in managing a severely head injured patient is: (P. 107)
Select one:
a. Perform a CT scan of the brain
b. Exclude cervical spine injury
c. Reduce the intracranial pressure with mannitol
d. Restore a normal blood pressure and oxygen saturation
e. Sedate the patient to prevent a rise in intracranial pressure due to agitation or coughing

Answer 22

D

Question 23

Question 25
Rear impact motor vehicle accidents are particularly associated with:
Select one:
a. Acetabular fracture
b. Flail chest
c. Aortic dissection
d. Head injury
e. Cervical spine injury

Answer 23

E

Question 24

(lack explanation)

Question 26
A patient is complaining of pain a few hours after a laparotomy for intestinal obstruction. He has a coagulopathy. The most appropriate form of analgesia is:
Select one:
a. parenteral morphine
b. non-steroidal anti-inflammatory agent
c. epidural analgesia
d. tramadol
e. intravenous fentanyl

Answer 24

A

(not sure btw ADE)

Question 25

Question 27 An elderly patient presents comatose. Results of investigations were: plasma sodium 112 mmol/l, potassium 3.5 mmol/l, serum osmolality 245 mOsm/l, urine osmolality 302 mOsml/l, urine sodium 72 mmol/l. Her jugular venous pressure was 8 cm above her sternal angle but she has no peripheral oedema. The most appropriate initial treatment is: Select one: a. Steroid replacement b. 3% saline infusion c. Normal saline infusion d. Fluid restriction e. Arginine vasopressin

Answer 25

B The high urine sodium with low serum osmolality suggests SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) or other causes leading to water retention and hyponatremia. The absence of edema suggests that her hyponatremia is not due to heart failure or cirrhosis. Correct hyponatremia carefully to avoid central pontine myelinolysis. In acute severe hyponatremia with neurological symptoms, initial treatment is hypertonic saline (3%) infusion. The goal is to raise serum sodium by no more than 8-10 mmol/L in 24 hours.

Question 26

Question 28 You are asked to see a 75 year old 60 kg patient. Which of the following are warning signs of a severely ill patient? Select one or more: a. Respiratory rate 12/min b. Mean arterial pressure 65 mmHg c. Glasgow coma score 14 d. Urine output 75 ml in the past 4 hours e. Serum sodium 132 mmol/l

Answer 26

B,D

Question 27

Question 29 A fit tested N95 mask or equivalent should be worn when caring for patients infected with: (P. 154) Select one: a. Neisseria meningitides b. influenza (non-epidemic) c. Streptococcus pneumoniae d. newly diagnosed smear positive tuberculosis e. cytomegalovirus

Answer 27

D

Question 28

Question 30 These are the results from a 65 year old 50 kg patient with urinary tract infection: BP 110/45 (mean 65) mmHg, JVP 0 cm, urine output 40 ml/hr, pH 7.4. The patient is alert and has warm peripheries. The most appropriate haemodynamic intervention is: Select one: a. IV bolus of 250 ml 5% glucose b. No intervention is required c. Low dose dopamine infusion d. IV bolus of 250 ml colloid e. Dobutamine infusion

Answer 28

B Patient is alert with warm peripheries: suggests no significant hypovolemia or shock. BP is borderline low but not critically hypotensive. Urinary output is maintained. JVP is normal, indicating no overt volume overload or right-sided failure. pH 7.4: normal acid-base status. The patient appears clinically stable with no signs of hypoperfusion or shock.

Question 29

Question 31 A post operative patient with a blood pressure of 70/40 has cold peripheries and a jugular venous pressure 0 cm above the sternal angle. The most likely cause of shock is: Select one: a. Cardiogenic shock b. Tension pneumothorax c. Hypovolaemic shock d. Septic shock e. Massive pulmonary embolus

Answer 29

C

Question 30

Question 33 You have several patients under your care that require your attention. Match each patient with the order in which you would deal with him/her. Patient A: 20 year old man admitted with stridor due to acute epiglottitis. His initial respiratory rate was 30/min but has now fallen to 6/min and his stridor has disappeared. He appears to be sleeping Patient B: 52 year old man admitted by your MO with sepsis due to pneumonia. He has been resuscitated and now has the following observations: conscious and orientated, urine output 45 ml over the past hour, pulse 110/min, BP 100/50, pH 7.38, PaCO2 4.8 kPa (36 mmHg), PaO2 13 kPa (98 mm Hg) on FiO2 0.5. The nurse rings you because he is waiting for you to take blood cultures before giving antibiotics Patient C: 34 year old woman admitted with an acute asthmatic attack 5 hours ago. She is now deteriorating. Current observations: peak flow 150 l/min, respiratory rate 28/min, heart rate 105/min, BP 130/80, pulsus paradoxus 5 mm Hg, PaCO2 5 kPa (26 mm Hg), PaO2 12 kPa (mm Hg) on FiO2 0.4. You have been asked to reassess her Patient D: 45 year old man admitted with drowsiness and suspected community acquired meningitis. He has had a CT scan which shows no evidence of raised intracranial pressure and he has been started on high dose ceftriaxone. He is waiting for you to perform a lumbar puncture.

Answer 30

A,C,B,D

Question 31

Question 34 Which of the following statements is/are correct? Select one or more: a. Vasopressin should be used in preference to epinephrine b. Amiodarone is recommended for unstable, shock-resistant VF/VT c. Early defibrillation is the goal in VT/VF arrests d. The initial energy for monophasic defibrillation depends on the manufacturer of the defibrillator e. Successful resuscitation requires team work

Answer 31

B,C,D,E

Question 32

Question 35 A patient with pneumonia becomes oliguric with a urine output of 20 ml/h for the past 3 hours. His BP is 130/70 before and 140/70 after passive leg raising. Urea is 10 mmol/l, creatinine 110 mcmol/l. The most appropriate treatment for his oliguria is Select one: a. mannitol b. no treatment is necessary c. frusemide d. dopamine e. fluid bolus

Answer 32

E Explanation: for pneumonia complicated with oliguria, it is important to give fluid before blood pressure drops

Question 33

Question 36 Adverse effects of non steroidal anti-inflammatory drugs include all of the following except: Select one: a. renal impairment b. acute exacerbation of asthma c. gastrointestinal bleeding d. peptic ulceration e. respiratory depression  

Answer 33

E

Question 34

(Lack explanation) You are asked to see a shocked patient. He has a BP 90/50 with a sinus tachycardia of 120/min. Which of the following suggest that the patient will respond to fluid resuscitation: Select one or more: a. Pulse pressure of 100/50 after passive leg raising b. Pulse pressure of 95/35 after passive leg raising c. Pulse pressure of 90/45 after passive leg raising d. Invisible JVP e. JVP 8 cm above sternal angle

Answer 34

B, D