plab emergency medicine complete

8/15/2019 Plab Emergency Medicine Complete

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Work Smart

Time taken: 00:23

Theme: Overdose

A Acetylcysteine

B Desferrioxamine

C Dimercaprol

D Ethanol

E Flumazenil

F Gluca on

G !aloxone

H O"servation

I #ralidoxime

J #enicillamine

K $odium nitrite

From the a"ove list of antidotes select the a ent that %ould "e most appropriate in thefollo%in cases:


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A &0'year'old farmer is admitted acutely after in estin an un(no%n overdose) Examination

reveals a particularly anxious male %ho is s%eaty and salivatin ) *is temperature is +0,- and he

has a "lood pressure of .0/ 0 mm* %ith a pulse of 1 "eats per minute)

ncorrect ' he correct ans%er is #ralidoximehe first case has features of or anophosphate poisonin as su ested "y thehypersalivation4 s%eatin and relative "radycardia indicatin increased choliner ic activity)his should "e treated %ith #ralidoxime)

A 5 'year'old irl is admitted after ta(in a paracetamol overdose %ith alcohol + hours

previously) *er plasma paracetamol concentration is 6ust "elo% the nona ram concentration that

%ould su est treatment) *er plasma alcohol concentration is 520 m /l

-orrecthe second case has paracetamol poisonin and althou h the paracetamol concentration is"elo% the level to treat on the nona ram this person has consumed lar e amounts of alcoholand so should "e treated %ith acetylcysteine)

A 12'year'old va rant attends casualty %ith hyperventilation and vomitin ) *e confesses to

havin drun( methanol)

ncorrect ' he correct ans%er is Ethanolhe third case has consumed methanol %hich may cause "lindness4 lactic acidosis and liverfailure) #ro"lems are a result of the "uild up of toxic meta"olites of methanol %hich may "einhi"ited "y the administration of ethanol)

A 'year'old child is admitted after consumin her mothers ferrous sulphate ta"lets) $he has had

one haemetemesis and the iron concentration is excessive)

ncorrect ' he correct ans%er is Desferrioxaminehe fourth case has consumed a lar e amount of ferrous sulphate %hich needs to "e treated%ith desferrioxamine)


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An 57'year'old female is "rou ht to casualty after collapsin in a ni ht clu") *er friends state that

she has ta(en un(no%n su"stances durin the ni ht and has "een hyperactive) $he is

hallucinatin and has a Glas o% coma scale of 51) *er temperature is 37)1,-4 she appears

dehydrated4 she has a pulse of 550 "eats per minute and a "lood pressure of 550/&0 mm* )

;espiratory rate is 22/minute and she has saturations of ..


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I ;ha"domyolysis

J etraparesis

K =enous throm"oem"olism

From the iven list select the most li(ely complication that accounts for each of the follo%in

cases:

A 2 'year'old male receives lo%er le in6uries playin ru "y) On examination4 he has a pulse of

520 "pm4 a "lood pressure of .0/ 0 mm* and he has a compound fracture of "oth ti"ias)

ncorrect ' he correct ans%er is *aemorrha ic shoc(

his case has features of shoc( %ith tachycardia and hypotension a conse8uence of lar e 8uantitiesof "lood loss associated %ith the fracture)

A 2+'year'old male sustains a forearm in6ury "ut fails to attend for medical attention until the

follo%in day %hen he presents %ith forearm pain4 s%ellin and an ina"ility to flex the %rist)

ncorrect ' he correct ans%er is -ompartment syndrome

he patient has developed a forearm compartment syndrome as a conse8uence of s%ellin andincreased pressure of the muscles %ithin the fascial compartment)

A +0'year'old male receives a compound fracture of his left ti"ia after fallin from a ladder) *e

under oes internal fixation) *o%ever4 several months after dischar e from hospital4 the patient is

a%are of a "rea(do%n of s(in overlyin the ti"ia and a persistent dischar e)

ncorrect ' he correct ans%er is Osteomyelitishis case has a dischar in sinus months after a compound fracture) his %ould su est anunderlyin osteomyelitis)

A 33'year'old male in6ures his hand %hilst playin ru "y) *e attends casualty "ut leaves after

%aitin t%o hours %ithout o"tainin medical advice) *e represents three months later %ith pain at

the "ase of the thum" and painful movements of the thum")


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-orrecthe patient has fractured his scaphoid and has developed avascular necrosis of the scaphoid)

A 11'year'old male is admitted after fallin from his horse) Examination and investi ations

confirm a fractured pelvis) *ours later he "ecomes dyspnoeic4 %ith a pulse of 520 "eats per

minute and a "lood pressure of 500/&0 mm* and a fall in oxy en saturation to 7


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From the iven list4 %hich is the most appropriate treatment for each of the follo%in

patients?

A &2'year'old man %ith ischaemic heart disease complains of feelin faint for the past hour) *e is

pale4 s%eaty and hypotensive) *is E-G sho%s a re ular tachycardia of 570 "eats/min %ith @;$duration 0)20 secs)

ncorrect ' he correct ans%er is D- cardioversionhis patient has underlyin *D %ith a re ular tachycardia of 570 and sho%s evidence of distress this su ests = and the most appropriate treatment %ould "e D- cardioversion)

A +'year'old %oman %ith (no%n atrial fi"rillation treated %ith di oxin attends your sur erycomplainin of transient loss of vision in the left eye %hich recovered spontaneously)

ncorrect ' he correct ans%er is >arfarinhis patient has had amaurosis fu ax and re8uires anticoa ulation in the form of %arfarin)

A &3'year'old man %ith (no%n carcinoma of the "ronchus "ecomes increasin ly short of "reath

over the past fe% days) he chest x ray sho%s an enlar ed heart shado% "ut no pulmonary

oedema)

ncorrect ' he correct ans%er is #ericardial draina ehis patient has a "ronchial carcinoma %ith a pericardial effusion) #ericardiocentesis %ould "e mostappropriate)

A 23'year'old man is seen in the Emer ency department %ith 20< pneumothorax of the ri ht

lun ) *is "lood pressure and pulse are sta"le)

ncorrect ' he correct ans%er is Oxy en therapy onlyhis patient has a sta"le pneumothorax and o"servation %ith oxy en therapy is all that is re8uired)


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A &1'year'old %oman %ith chronic o"structive pulmonary disease is "rou ht to the Emer ency

department4 semi'conscious and cyanosed) One %ee( a o she %as iven a ne% dru relief for

symptoms of osteoarthritis) $he has "ilateral pin'point pupils)

ncorrect ' he correct ans%er is ntravenous naloxonehe history of this patient su ests opiate use and naloxone %ould "e appropriate)

Work Smart

Time taken: 00:10

Theme: Advanced Bife $upport

A Adenosine

B Amiodarone

C 9asic life support %ith adrenaline

D -all for the cardiac arrest team

E -hec( for a central pulse

F -hest tu"e %ith an under %ater seal

G Defi"rillation at 200C

H Give a praecordial thump

I Bidocaine

J $ome other specific treatment if the cause of the arrest is (no%n

K $ynchronised D- cardioversion

$elect the most appropriate ans%er from the iven list that descri"es the most appropriate

treatment priority or action in the follo%in scenarios:


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A 2 'year'old (no%n asthmatic has a narro% complex tachycardia %ith a heart rate of 220/min)

*is 9# is 71/10 mm* ) ntravenous access is esta"lished and hi h flo% oxy en is "ein iven "y

mas() =a al manoeuvres are unsuccessful)

ncorrect ' he correct ans%er is $ynchronised D- cardioversionhe first patient is in cardiac arrest and in order to activate the chain of survival4 callin the cardiacarrest team is essential) >hen limited assistance is availa"le4 performin effective "asic life supportta(es second priority over alertin the arrest team)

A +'year'old female %ho 50 days a o had a total hip replacement is found unconscious in the

%ard toilet) $he is unresponsive4 apnoeic and pulseless)

ncorrect ' he correct ans%er is -all for the cardiac arrest team

A 15'year'old male is in refractory fine =F) *e has received defi"rillatory shoc(s and 5 m of

adrenaline intravenously) One minute of -#; is on oin )

ncorrect ' he correct ans%er is Amiodarone Amiodarone should "e considered in shoc( refractory e edicine ;efractory =F or pulseless = ) t can"e iven as early as the "efore the fourth defi"rillatory shoc() Bidocaine can "e used as an alternative%hen amiodarone is unavaila"le)

he third case has a peri'arrest rhythm4 %hich is compromisin his cardiac output) *e needsto "e sedated or anaesthetised prior to "ein iven a synchronised D- shoc( startin at500C) Adenosine can induce "ronchospasm and should "e avoided)

An elderly female has arrested durin the insertion of a ri ht su"clavian central line) he E-G

rhythm sho%s sinus tachycardia) Adrenaline has "een iven and three minutes of "asic life

support is on oin ) As the cardiac arrest team leader you notice that the trachea is deviated to

the left)

ncorrect ' he correct ans%er is $ome other specific treatment if the cause of the arrest is

(no%nhe fourth case is also in cardiac arrest "ut has sinus tachycardia as a rhythm4 thus it is called #EA

pulseless electrical activity ) #reviously it %as (no%n as E D electromechanichal dissociation ) hedeviated trachea su ests a ri ht tension pneumothorax4 %hich re8uires immediate needlethoracocentesis to relieve the pressure) A chest tu"e %ith an under %ater seal can "e inserted later)

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-orrectuscle relaxation is re8uired durin the creation of a pneumoperitoneum4 %hich provides aclear vie% and access to the fallopian tu"es) he anticipated duration of sur ery is 20 to 30

minutes4 thus atracurium is the "est choice) $uxamethonium is too short actin andpancuronium lasts too lon )

A youn male is due to have a lar e lipoma excised from his forearm) >hich a ent %ould "e a

suita"le intravenous induction a ent to allo% placement of an B A?

ncorrect ' he correct ans%er is #ropofol#ropofol is the "est induction a ent %hen plannin to use an B A) t inhi"its the pharyn ealand laryn eal reflexes faster than thiopentone or etomidate4 providin optimal conditions forinsertin the device)

A %ell controlled asthmatic patient presents for a (nee arthroscopy) >hich a ent %ould provide

appropriate intraoperative anal esia?

ncorrect ' he correct ans%er is FentanylDru s that cause "ronchoconstriction or that have the potential to release histamine are "estavoided in asthmatics) herefore diamorphine and diclofenac are not the "est choice)Fentanyl does not release histamine and small doses %ill provide suita"le intraoperativeanal esia)

A +'year'old male presents for a cystoscopy) A hiatus hernia %as dia nosed six months a o)

*is current medication is Gaviscon and he has "een nil "y mouth since midni ht) $elect a

suita"le muscle relaxant to allo% placement of the endotracheal tu"e)

ncorrect ' he correct ans%er is $uxamethonium#atients %ith a hiatus hernia must have their air%ay protected as 8uic(ly as possi"lefollo%in induction of anaesthesia) Failure to protect the air%ay %ith a cuffed endotrachealtu"e may lead to soilin of the trachea from re ur itation of residual astric fluid) hus arapid se8uence induction should "e considered) $uxamethonium is the correct choice as itprovides optimum intu"atin conditions in 30 to +1 seconds)


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A 5 'year'old African male presents %ith a 2'day'old penetratin %ound to his calf) *is main

complaint is pain) #ulse and "lood pressure are normal and a full "lood count reveals a

haemo lo"in of 7)1 /dl) *e is "oo(ed for exploration and de"ridement of the %ound)

ncorrect ' he correct ans%er is *aemo lo"in electrophoresishis needs to "e investi ated as a sic(lin crisis can "e precipitated "y sur ery)

A 3'year'old female is scheduled for a si moid colectomy) %elve months a o she had an

anterior myocardial infarct "ut has made a ood recovery) $he can clim" a fli ht of stairs slo%ly

"ut ets short of "reath) edication includes an A-E inhi"itor) our examination reveals a loud

systolic murmur4 "reath sounds are vesicular)

ncorrect ' he correct ans%er is Echocardio raph$he is under oin a sizea"le procedure and needs appropriate assessment of her leftventricular function)

A 1.'year'old previously healthy male4 presented 52 hours a o %ith "o%el o"struction and has

"ecome increasin ly confused) *e is receivin oxy en "y mas() he pulse oximeter reads500


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A 5.'year'old female %ith dia"etes %ho is insulin dependent has a penetratin in6ury to her left

eye) $he is on t%ice daily insulin and had lunch four hours a o) *er operation is expected to

"e in %ithin the hour)

ncorrect ' he correct ans%er is Glucose concentrationGlucose al%ays needs to "e chec(ed in a dia"etic patient and this youn %oman %ill re8uirea slidin scale insulin re ime for her operation)

$ur ery on anticoa ulated patients can result in excessive intraoperative "lood loss andcomplicate recovery due to haematoma formation)

For elective sur ery %arfarin can "e stopped and sur ery postponed until the !; is lessthan 5)1)

ntravenous heparin should "e su"stituted for the %arfarin if anticoa ulation is essential)Fresh frozen plasma %ill allo% rapid correction of the effect of %arfarin and may "eprefera"le to vitamin I)

n the case of the 33'year'old female her 6o in activity su ests that the pulmonaryem"olism has not si nificantly compromised her as exchan e and so "lood as analysis%ould not have a hi h priority)

Work Smart

Time taken: 05:50

Theme: $tro(e syndromes

A -ere"ral a"scess

B -ere"ral em"olism

C -ere"ral infarction

D -ere"ral oedema

E -ere"ral throm"osis

F ntracere"ral haemorrha e

G $u"arachnoid haemorrha e


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H $u"dural haematoma

I ransient ischaemic attac(

For each of the follo%in patients "elo% choose the sin le most li(ely dia nosis from theiven list of options)

Each option may "e used once4 more than once or not at all)

A 10'year'old %oman %ith thyrotoxicosis and thyroid heart disease complained of palpitations)

$he %as found to have atrial fi"rillation and started on anticoa ulants) he next day she

complained of difficulty in movin her left arm)

ncorrect ' he correct ans%er is -ere"ral em"olismEm"olisation is a ris( associated %ith dysrhythmias4 the commonest "ein atrial fi"rillation)he ris( is reatest in the elderly4 particularly those %ith valvular heart disease4 dia"etes4hypertension or previous sto(es)

A 35'year'old male loses consciousness "riefly and is "rou ht into the emer ency %ard) *e

complains of severe headaches and photopho"ia)

ncorrect ' he correct ans%er is $u"arachnoid haemorrha e$u"arachnoid haemorrha e is caused "y rupture of an aneurysm and the initial headache or coma is caused "y the sudden rise in intracranial pressure)

A 37'year'old man has "een complainin of headaches4 dizziness and poor concentration for

some time) *e is "rou ht into hospital %ith %ea(ness on the left side) *is haemo lo"in is 20 /dl)

ncorrect ' he correct ans%er is -ere"ral throm"osis#olycythaemia vera causes focal neurolo ical si ns as a result of throm"osis from increasedviscosity) here is a paradoxical ris( of haemorrha e)

A 2'year'old male is found drun( outside a pu" in the early hours of the mornin ) *e is

conscious "ut una"le to move the ri ht side of his "ody) *e starts to have partial seizures in

hospital)


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ncorrect ' he correct ans%er is $u"dural haematoma-hronic su"dural haematomas sometimes present as stro(es) A history of previous traumato the head or alcoholic a"use is useful) Alcoholics sometimes have suffered trauma in thepast of %hich they have no recollection)

A 0'year'old hypertensive man loses consciousness) An ur ent head - scan sho%s a lar e

hyperdense lesion in the left fronto'parietal lo"e)

ncorrect ' he correct ans%er is ntracere"ral haemorrha e-linically it can "e difficult to differentiate "et%een haemorrha es and infarcts) ;ecenthaemorrha e is hyperdense and therefore "ri hter than "rain tissue on - scan)

Work Smart

Time taken: 05:5

Theme: $i ns of life

A 9ar"iturate coma

B 9rain stem death

C -ardiac arrest %ith a onal rhythm

D -linical dia nosis of death

E *ypothermia

F *ypoxic cere"ral depression

G #ulseless electrical activity

H ;i or mortis

I $udden cardiac arrest

J =entricular tachycardia

ou are called to a cardiac arrest on the medical admissions unit)


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Dro%nin is associated %ith hypothermia and the femoral pulses are not palpa"le due topulseless electrical activity)

A patient found %ith no vital si ns of life %ith stiff lim"s4 that is4 ri or mortis4 is li(ely to have"een dead for some considera"le time)

>hen a relatively normal rhythm is present on the monitor in a cardiac arrest situation4pulseless electrical activity must "e considered)

he most li(ely cause of %ide4 re ular complexes in a patient in cardiac arrest is ventriculartachycardia) Other causes of %ide complexes in this situation could "e hyper(alaemia4"undle "ranch "loc( for example4 in presence of myocardial infarction or $ elevationivin the appearance of %idened @;$ complex)

Work Smart

Time taken: 05:22

Theme: Oxy en therapy

A 2+< oxy en

B 2+< oxy en and anti"iotics

C 2+< oxy en and intravenous furosemide

D 2+< oxy en and ne"ulised "ronchodilators

E 2+< oxy en4 anti"iotics and ne"ulised "ronchodilators

F 2+< oxy en4 diamorphine and intravenous furosemide

G 0< oxy en

H 0< oxy en and anti"iotics

I 0< oxy en and intravenous furosemide

J 0< oxy en and ne"ulised "ronchodilators

K 0< oxy en4 anti"iotics and ne"ulised "ronchodilators

L 0< oxy en4 diamorphine and intravenous furosemide


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For each of the follo%in clinical situations4 select from the iven list the most appropriate

option for immediate mana ement:

An 57'year'old %oman %ith a previous history of asthma develops acute dyspnoea follo%in a

ro% %ith her "oyfriend) On examination she is tachypnoeic and distressed4 %ith %idespread%heezes)

ncorrect ' he correct ans%er is 0< oxy en and ne"ulised "ronchodilatorshis youn %oman has severe asthma and needs ne"ulisers and hi h concentration ofoxy en)

A previously healthy 2+'year'old man presents %ith acute dyspnoea4 left sided and and cou h

productive of reen sputum tin ed %ith "lood) On examination he is pyrexial and loo(s ill4 %ith

si ns of consolidation at the left lun "ase "ut no %heezes)

ncorrect ' he correct ans%er is 0< oxy en and anti"ioticshis is a youn man %ith a lo"ar pneumonia %ith systemic sepsis) *e should receive hi hflo% oxy en and intravenous anti"iotics)

A 7'year'old smo(er presents %ith acute shortness of "reath4 on a "ac( round of chronic

productive cou h) On examination he is centrally cyanosed and pyrexial4 %ith %idespread

crac(les and %heezes)

ncorrect ' he correct ans%er is 2+< oxy en4 anti"iotics and ne"ulised "ronchodilatorshe history su ests chronic "ronchitis %ith acute exacer"ation and chronic -O 2 retentionshould "e suspected) his man may have type 2 respiratory failure %ith -O 2 retention) *i hflo% oxy en may suppress his respiratory drive) !e"ulisers and anti"iotics should "estandard iven the pyrexia and chest si ns)

A 11'year'old man develops sudden onset of ri ht sided chest pain and dyspnoea in erminal 2

of anchester Airport on arrival from *on Ion ) On examination he is ill4 cyanosed and

apyrexial) here are no localisin si ns on chest examination)

ncorrect ' he correct ans%er is 0< oxy en


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he history is su estive of pulmonary em"olism) he immediate mana ement %ould "ehi h flo% O 2) *eparin should "e commenced %hilst a definitive dia nosis is "ein sou ht)

A 1&'year'old man is on the %aitin list for coronary artery "ypass raftin J he develops acute

dyspnoea and cou h %ith frothy pin( sputum) On examination he is tachypnoeic and distressed4

%ith profuse "asal crac(les "ut no %heeze)

ncorrect ' he correct ans%er is 0< oxy en4 diamorphine and intravenous furosemide Acute asthma re8uires hi h dose O 2 and "ronchodilators4 alon %ith = hydrocortisone) hehistory of coronary artery disease4 and presentation %ith pin( frothy sputum4 %ould su estleft ventricular failure and pulmonary oedema) Diamorphine4 = diuretic and hi h dose O 2 isthe immediate treatment) = nitrates or su"lin ual G ! are also an option)

Work Smart

Time taken: 05:2.

Theme: 9ac( pain

A A"dominal aortic aneurysm

B Achalasia of the oesopha us

C Acute prolapsed interverte"ral disc

D An(ylosin spondylitis

E -hronic lo% "ac( pain

F -hronic pancreatitis

G -ostochondritis

H Dissection of thoracic aorta

I etastatic prostatic carcinoma

J ultiple myeloma


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K yelomenin ocele

L !eurofi"roma

M Osteomalacia

N Osteoporotic verte"ral collapse

O #a etK s disease of "one

P #leural effusion

Q #soriatic arthropathy

R $ta horn calculi

S $yrin omyelia

T u"erculosis

U ric acid arthropathy

he follo%in patients present to the casualty department %ith "ac( pain)

>hat is the most li(ely dia nosis from the iven list of options?!ormal values:

Se !m "# e"te$ "a%"i!m 2)51 ' 2) 1 mmol/B

Se !m " eatinine 0 ' 550 Lmol/B

A previously healthy &1'year'old %hite %oman presents %ith acute onset of severe pain over the

mid'thoracic spine) Examination reveals localised tenderness over 1) $erum calcium andal(aline phosphatase are normal4 and E$; is 20 mm in the first hour)

ncorrect ' he correct ans%er is Osteoporotic verte"ral collapsehe most li(ely dia nosis is an osteoporotic verte"ral collapse in a female of this a e %ith anormal calcium and al(aline phosphatase4 %ith only a mildly raised E$;4 %hich may "enormal for this a e roup)


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A 30'year'old Asian %oman complains of poorly localised pain in the shoulders and pelvis)

Examination reveals no localisin si ns) $erum corrected calcium is 2)5 mmol/l4 the al(aline

phosphatase is raised4 and E$; is 50 mm in the first hour)

ncorrect ' he correct ans%er is OsteomalaciaOsteomalacia is relatively common in Asian females) he al(aline phosphatase is raised4 thecalcium lo% or normal4 %ith a lo% serum phosphate) 9one pain can "e due to su"clinicalfractures)

A 7'year'old %hite man has "een un%ell for three months and develops pain over the thoracic

spine) On examination there is evidence of recent %ei ht lossJ there is tenderness over 50)

$erum corrected calcium is 3)3 mmol/l4 creatinine is 310 Lmol/l4 and E$; is 550 mm in the first

hour)

ncorrect ' he correct ans%er is ultiple myelomaultiple myeloma presents commonly in this a e roup and sli htly more commonly inmales) enderness over 50 indicates verte"ral collapse secondary to lytic "one lesions);enal failure may "e secondary to hypercalcaemia4 hyperuricaemia or dehydration) Amar(edly elevated E$; is common due to the presence of paraprotein in the serum)

A 30'year old %hite man complains of chronic pain in the lum"osacral re ion) Examination

reveals tenderness over the sacro'iliac 6oints and restricted ran e of spinal movements) $erum

corrected calcium is 2)3 mmol/l4 al(aline phosphatase is normal4 and E$; is 30 mm in the first

hour)

ncorrect ' he correct ans%er is An(ylosin spondylitis

$erum calcium and al(aline phosphatase are normal in an(ylosin spondylitis) he E$; isoften elevated) ;estricted ran e of lum"ar lateral flexion is often an early feature andan(ylosin spondylitis usually presents "elo% the a e of +0)

A 'year'old man presents %ith a fracture of the ri ht hip after sufferin a fall in the (itchen at

home) n addition to the fracture4 the hip x ray sho%s multiple %ell'defined lytic lesions in the

pelvic "ones and the femur) rinalysis sho%s heavy proteinuria)

ncorrect ' he correct ans%er is ultiple myeloma


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A ain myeloma is the most li(ely dia nosis in this case) etastatic prostate carcinoma maypresent %ith lytic lesions and patholo ical fractures "ut %ould not cause proteinuria4 %hich inthis case is li(ely to indicate 9ence Cones protein)

Work Smart

Time taken: 05:+5

Theme: Be %ea(ness

A 9rain stem

B -ere"ral hemisphere

C -onus medullaris

D -ommon peroneal nerve

E B1 nerve root

F Bum"osacral plexus

G uscle ie4 a myopathy

H #eripheral nerve ie4 a polyneuropathy

I $ciatic nerve

J $pinal cord

K $ural nerve

L arsal tunnel

Each of the items "elo% is an extract from the medical history and examination findin s of a

patient %ith le %ea(ness)

For each one4 select the most li(ely location of the lesion from the list of options)

M))) %ea(ness and %astin of the ri ht ti"ialis anterior and calf4 a"sent ri ht an(le 6er( and

extensor plantar responsesJ nerve conduction studies sho%ed normal motor conduction velocity

and sensory responses from the ri ht common peroneal nerve)))M


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ncorrect ' he correct ans%er is -onus medullarisGiven normal conduction velocity and sensory responses in the common peroneal nerve4and the extensor plantar response4 %ith muscle %astin an upper motor neurone lesion issu ested e) ) compression of the conus medullaris)

M ))) ri ht le %ea(ness of su"acute onset involvin an(le dorsiflexion4 eversion and inversion4

%ith depression of the ipsilateral an(le 6er( and sensory loss confined to the dorsum of the foot

and the anterior aspect of the le )))M

ncorrect ' he correct ans%er is B1 nerve roothe area of sensory loss ives the site of the lesion4 the most li(ely cause "ein herniation

of the interverte"ral disc "et%een B+ and B1 and compression of the B1 nerve root)

M))) %ea( left le evolvin over a fe% %ee(s %ith tin lin in the foot and4 on direct 8uestionin 4

urinary ur encyJ examination sho%ed increased tone in "oth lo%er lim"s and "ilaterally extensor

plantar responsesJ %ea(ness restricted to left hip flexion and an(le dorsiflexionJ pain sensation

reduced in the ri ht foot "ut 6oint position sense lost in the left foot )))M

ncorrect ' he correct ans%er is $pinal cordhe clinical findin s su est a spastic paraparesis of radual evolution4 the lesion lyin inthe spinal cord e) ) multiple sclerosis)

M))) radually evolvin difficulty risin from a chair and clim"in stairs4 %ithout sensory lossJ

electromyo raphy of the 8uadriceps muscle sho%ed small4 "ro(en up motor unit potentials in

normal num"ers)))M

ncorrect ' he correct ans%er is uscle ie4 a myopathyhe E G findin s are typical of a myopathy4 and the history su ests that it is proximal e) )#olymyal ia ;heumatica4 osteomalacia4 -ushin Hs disease

M))) severe pain in the lo%er "ac( and left thi h and le in a patient on anticoa ulantsJ mar(ed

%ea(ness of hip flexion and (nee extension on the same side %ith impaired sensation on the

anterior aspect of the thi h)))M


26/141

ncorrect ' he correct ans%er is Bum"osacral plexushis history su ests a haematoma in the lum"ar re ion %ith pressure effect on thelum"osacral plexus)

Work Smart

Time taken: 05:+7

Theme: ;adiolo ical nvesti ations

A -hest radio raph

B -omputed tomo raphy of the "rain

C -omputed tomo raphy of the pelvis

D -omputed tomo raphy of the thorax

E -omputed tomo raphy pulmonary an io ram

F Echocardio raphy

G *ysterosalpin o ram

H ntravenous uro raphy

I a netic resonance ima in of the "rain

J ;adionucleotide ventilation/perfusion scan

K $(ull radio raphy

L ranscranial ultrasound

M ltrasound of the a"domen

N ltrasound of the pelvis

Each item "elo% is an extract from the clinical information %ritten on a referral card sent to

the radiolo y department)


27/141

For each su"6ect4 select from the list of options the ima in investi ation most li(ely to "e

informative)

M))) 1'year'old male hypertensiveJ acute central chest painJ a %idened superior mediastinum on

his chest radio raph )))M

ncorrect ' he correct ans%er is -omputed tomo raphy of the thoraxhe presumed dia nosis here must "e aortic dissection4 and this %ill "e revealed usin a -of the thorax and aorta) n the past4 aortic arch an io raphy %as considered the optimaldia nostic tool "ut this has "een superseded "y ima in %ith - or ; )

M))) 2+'year'old female non'smo(erJ pleuritic chest pain and haemoptysisJ a normal chestradio raph )))M

ncorrect ' he correct ans%er is -omputed tomo raphy pulmonary an io ramhese clinical features su est pulmonary em"olism and - #A is re arded as the "est testto dia nose this condition)

M))) 2+'year'old femaleJ 52 %ee(s pre nant4 %ith va inal "leedin )))M

ncorrect ' he correct ans%er is ltrasound of the pelvisltrasound of the pelvis does not deliver any ionisin radiation to the fetus at a critical time inits development4 %hilst investi atin the cause of the va inal "leedin 4 for example4threatened miscarria e)

M))) 22'year'old female4 una"le to conceiveJ history of pelvic inflammatory disease )))M

ncorrect ' he correct ans%er is *ysterosalpin o ramhe hysterosalpin o ram %ill investi ate the anatomy of the uterus and fallopian tu"es)#elvic inflammatory disease is associated %ith infertility4 due to scarrin in the fallopian tu"essecondary to salpin itis)

M))) +'day'old maleJ convulsions and "ul in fontanelles )))M


28/141

ncorrect ' he correct ans%er is ranscranial ultrasoundranscranial ultrasound is an useful tool in the assessment of "rain in6ury in the ne%"orn)

Work Smart

Time taken: 05:11

Theme: -!$ #;O9BE $

A 9acterial menin itis

B -ryptococcal menin itis

C Encephalitis

D Guillian'9arre syndrome

E *uman immunodeficiency virus * = infection

F Bisteriosis

G ultiple sclerosis

H $econdary cancer

I $u"arachnoid haemorrha e

J =iral menin itis

All the patients descri"ed "elo% have had a lum"ar puncture)

For each one4 choose the sin le most li(ely dia nosis from the list of options)

Each option may "e used once4 more than once4 or not at all


29/141

A 32'year'old doctor %ith a family history of polycystic disease of the (idney collapsed suddenly

after a sudden persistent occipital headache) A sample of cere"rospinal fluid o"tained 52 hours

later %as reported as xanthochromic)

ncorrect ' he correct ans%er is $u"arachnoid haemorrha e

A 27'year'old %oman presents %ith urinary incontinence and pain on movement of ri ht eye %ith

rapid deterioration in central vision) On examination she has impaired co'ordination on heel'shin

test) $he has nysta mus and an internuclear ophthalmople ia) he cere"rospinal fluid sho%s a

sli ht increase in lymphocyte count4 raised total proteins and raised immuno lo"ulins)

ncorrect ' he correct ans%er is ultiple sclerosis

An 57'year'old student presents %ith headache4 nec( stiffness and photopho"ia) he

cere"rospinal fluid examination sho%s 500 lymphocytes4 -$F lucose is more than 2/3 "lood

lucose value and -$F protein is 0) 0 /B) Gram stain %as ne ative)

ncorrect ' he correct ans%er is =iral menin itis

A 1 'year'old %oman has a history of headaches for several %ee(s) ore recently she has had

several convulsions) $he %as a heavy smo(er until six years a o) $he has recently experienced

moderate %ei ht loss) -ere"rospinal fluid sho%s increased lymphocytes4 %ith clumps of irre ular cells %hich have deeply hyperchromatic nuclei and scanty cytoplasm)

ncorrect ' he correct ans%er is $econdary cancer

A 2+'year'old student has a 2+ hour history of an ear infection4 %ith photopho"ia4 nec( stiffness

and a headache) -ere"rospinal fluid sho%s a %hite cell count of 100/mm3

4 almost all of %hich arepolymorphs)


30/141

-orrect

he 32'year'old patient has su"arachnoid haemorrha e) he incidence of su"arachnoidhaemorrha e is 51/50000) he a e ran e is typically 31' 1 years) -ommon causes arerupture of con enital "erry aneurysms in &0< of patients4 and arterovenous malformationsin 51< of patients)

;eco nised associations include

#olycystic (idney disease

Ehlers'Danlos syndrome and

-oarctation of the aorta)

$udden severe occipital headache is the most stri(in clinical feature and may "eassociated %ith focal neurolo ical si ns) - "rain scan is indicated and if no "leed isidentified a lum"ar puncture may identify "lood stained fluid or xanthochromia)

he 27'year'old patient has multiple sclerosis) ultiple sclerosis is a chronic relapsin andremittin disorder characterised "y demyelinatin pla8ues %ithin the -!$) -linical features

may "e %ide ran in includin -!$ defects such as

$pastic paraparesis

-ere"ellar si ns

Optic atrophy

!ysta mus

nternuclear ophthalmople ia and

rinary incontinence)

-$F examination sho%s

;aised protein and lymphocyte count

Oli oclonal "ands of G on -$F electrophoresis and

Delayed visual4 auditory and somatosensory evo(ed potentials)

; is sensitive "ut not specific for pla8ue detection)


31/141


32/141

G -entrilo"ular emphysema

H Extrinsic aller ic alveolitis

I esothelioma

J -hronic anaemia

K $arcoidosis

Each patient descri"ed "elo% presents %ith "reathlessness) For each one4 choose the sin lemost li(ely dia nosis from the list of options)

Each option may "e used once4 more than once4 or not at all)

A 0'year'old "uilder has smo(ed 30 ci arettes each day for +0 years) *e has recently

developed "reathlessness associated %ith cou h and haemoptysis) here is clu""in of the

fin ers and toes) On percussion4 there is stony dullness over the left side of the chest)

ncorrect ' he correct ans%er is -arcinoma of the "ronchus

-i arette smo(in is the ma6or ris( of "ronchial cancer) he ris( is dependent on the num"er of ci arettes and duration of smo(in ) 70< of patients present %ith chronic cou h4 &0< %ithhaemoptysis4 and 51< %ith recurrent or slo%ly resolvin pneumonia) ntrathoraciccomplications include pleural effusions4 recurrent laryn eal nerve palsies4 $=- o"structionand *ornerHs syndrome)

A +'year'old former shipyard %or(er4 a lifelon non'smo(er4 complains of increasin difficulty

%ith "reathin ) here is a persistent dull ache in the left chest4 %hich is exacer"ated on deep

inspiration) On examination4 there is reduction in respiratory movement on the leftJ a chest x'ray

sho%s lo"ular pleural thic(enin )

ncorrect ' he correct ans%er is esothelioma

esothelioma is a pleural "ased lun mali nancy %hich is related to earlier as"estos

exposure usually from %or(place4 such as ship yards) -linical features include chest pain4


33/141

dypsnoea and "lood stained pleural effusion) Dia nosis is "y pleural "iopsy) #ro nosis ispoor and treatment is symptomatic)

A +2'year'old crop farmer complains of persistent "reathlessness that has developed over

several years) *e has exacer"ations of "reathlessness %hen he handles hay4 associated %ith

fever and malaise)

ncorrect ' he correct ans%er is Extrinsic aller ic alveolitis

FarmerHs lun is due to a hypersensitivity reaction to icropolyspora faeni) -linical featuresoccur +'7 hours after exposureJ fever4 malaise4 dry cou h and dypsnoea are usual) -hronicdisease may follo% acute symptoms or occur independently) n the acute sta e4 neutrophilia4hi h E$;4 and positive serum preciptins are usual) -hronic disease sho%s upper zoneshado%in due to fi"rosis) #rednisolone is the treatment of choice)

An 57'year'old cystic fi"rosis sufferer has persistent cou h4 %hich is productive of purulent

sputum) *e has fin er clu""in and lo%'pitched inspiratory and expiratory crac(les on

auscultation)

ncorrect ' he correct ans%er is 9ronchiectasis

-ystic fi"rosis is a cause of a "ronchiectasis) -linical features of "ronchiectasis includepersistent productive cou h especially in %inter months 4 haemoptysis4 clu""in and lo%'pitched inspiratory and expiratory crac(les on auscultation) -N; sho%s cystic shado%s4 fluidlevels4 and tramline or rin shado%s)

A +7'year'old %oman of -ari""ean ori in complains of pro ressive shortness of "reath and

painful lesions on her shins) $he has a history of hypertension and of 6oint pain) A "lood test

sho%s hypercalcaemia)

ncorrect ' he correct ans%er is $arcoidosis

$arcoidosis is of un(no%n cause characterised "y non'caseatin ranuloma) t is commoner

in Afro'-ari""ean people and it may affect any or an or a e roup)


34/141

Work Smart

Time taken: 02:55

Theme: nvesti ation of emer encies

A Arterial "lood ases

B 9lood lucose

C 9lood urea electrolytes and creatinine

D - scan of "rain

E Full "lood count and roup and cross match

F ; scan of (nees

G hyroid function tests

H oxicolo y screen

I $(ull x ray

For each patient "elo%4 choose the sin le most essential dia nostic investi ation from the

iven list of options)


A 25'year'old female is found unconscious next to her 22'year'old hus"and4 %ho %as found

dead) *er electrocardio ram E-G sho%s evidence of acute myocardial infarction )

ncorrect ' he correct ans%er is oxicolo y screen$evere cases of cocaine intoxication may result in:

Acute myocardial infarction

Aortic dissection

yocarditis

=entricular arrhythmias


35/141

-ardiorespiratory arrest)

A 2+'year'old female4 admitted to the Emer ency department %ith pneumonia is no% "arelyconscious4 %ith poor respiration4 despite hi h flo% oxy en therapy)

-orrecthis patient needs ur ent arterial "lood as estimation4 and should "e considered forartificial ventilation)

A 25'year'old ru "y player4 %ho had suffered from an episode of "rief unconsciousness) *e isrushed into the Emer ency department4 unconscious4 the next day)

ncorrect ' he correct ans%er is - scan of "rainExtradural haemorrha e is su ested as complicatin a head in6uryJ a period ofunconsciousness is follo%ed "y a period of alertness and the rapid deterioration intounconsciousness)

A &2'year'old %oman is admitted unconscious %ith a core temperature of 31) ,-) $he has a

heart rate of +2 "eats per minute and slo%ly relaxin reflexes)

ncorrect ' he correct ans%er is hyroid function testsDro%siness4 "radycardia and slo%ly relaxin reflexes %ould su est the dia nosis ofhypothyroid coma) r ent thyroid function tests %ill confirm the dia nosis)

A 2+'year'old school teacher4 %ho is a very %ell controlled dia"etic4 is found unconscious "y her

students after lunch) On her des( is a pile of partly mar(ed papers and an uneaten sand%ich)

ncorrect ' he correct ans%er is 9lood lucoser ent "lood lucose estimation "y samplin capillary "lood %ould confirm the dia nosis ofhypo lycaemic coma) *o%ever4 she re8uires ur ent administration of 10< dextrose or aluca on in6ection)


36/141

Work Smart

Time taken: 02:23

Theme: Acute poisonin

A 9enzodiazepines

B Di oxin

C Ecstasy

D Opioids

E Or anophosphorus compounds

F #ara8uat

G #aracetamol

H $alicylates)

I >arfarin

For each of the patients "elo% choose the sin le most li(ely cause of their presentation from

the iven options)


A 0'year'old farmer is rushed into the Emer ency department unconscious4 s%eatin profusely

and %ith copious secretions droolin from his mouth) *is pupils are small)

ncorrect ' he correct ans%er is Or anophosphorus compoundsOr anophosphorus compounds used as insecticides or military Hnerve asesH act "yinhi"itin acetylcholinesterase) -linical features include:

iosis

9lurred vision

*ypersalivation

Expectoration of frothy secretions


37/141


38/141

ncorrect ' he correct ans%er is >arfarinana ement of severe %arfarin toxicity involves use of %hole "lood4 fresh frozen plasma orclottin factor concentrates may "e re8uired in severe acute haemorrha e4 "ut vitamin Iiven until clottin returns to normal is usually sufficient)

An 57'year'old male4 "rou ht %ith history of consumption of un(no%n su"stance) nvesti ation

reveals he is unconscious4 "arely "reathin 4 normal pulse and small pupils)

ncorrect ' he correct ans%er is OpioidsOpiod toxicity may manifest as coma4 very lo% respiratory rate and pin'point pupils) Othercomplications include:

-onvulsions

*ypotension

#eripheral circulatory failure

-ardiac arrhythmias and conduction defects

*ypothermia

#ulmonary oedema

;enal failure

;ha"domyolysis)

;esuscitation comprises esta"lishin a clear air%ay4 ivin oxy en4 placin the patient in asemi'prone position to reduce the ris( of aspiration in the event of vomitin 4 and immediateintravenous in6ection of an ade8uate dose of naloxone) Assisted ventilation may "e re8uiredif naloxone is not immediately availa"le or if very lar e doses are re8uired)

An 70'year'old man %ho has a history of heart disease has nausea4 vomitin 4 hypo(alaemia and

cardiac arrhythmias)

ncorrect ' he correct ans%er is Di oxin9indin of di oxin to the !a /I 'A #ase transport system is inhi"ited "y hi h levels ofpotassium and the level of activity of this enzyme is increased "y the presence ofma nesium) hus "oth hypo(alaemia and hypoma nesaemia increase di oxin toxicity)Di oxin toxicity is more common in patients than other dru s such as "eta "loc(ers4verapamil and 8uinidine) *ypothyroid patients are more sensitive to the effects of di oxin)


39/141


40/141

prematurity

over'%rappin

intercurrent infection

prone sleepin position

lo% social class)

Work Smart

Time taken: 02:35

>hich of the follo%in is an indicator of poor pro nosis in acute pancreatitis?

#lease select 5 option

Al"umin P 31 / B

AB P 530 /B

-alcium P 5).5 mmol/B his is the correct ans%er

-reatinine P 530 mmol/B

#a O 2 P 50 (#a ncorrect ans%er selected

#oor pro nostic indicators in the first +7 hours of acute pancreatitis include:

A e more than 11 years

>hite cell count >-- more than 51

Glucose more than 50

rea more than 5

Al"umin less than 30 /B

Alanine aminotransferase AB more than 200


41/141


42/141

>hich of the follo%in dru s is matched correctly %ith its action?


Amiodarone shortens the action potential ncorrect ans%er selected

Di oxin stimulates !a/I A #ase

$imvastatin inhi"its * G-oA reductase his is the correct ans%er

$otalol has class and class properties

$trepto(inase increases fi"rino en levels

$otalol has class "eta'"loc(er and class amiodarone li(e actions)

Amiodarone prolon s the action potential and the @ interval)

9oth sotalol and amiodarone carry the ris( of precipitatin ventricular arrhythmias)

After throm"olysis4 fi"rino en levels are lo%4 due to consumption durin throm"osis)

Di oxin inhi"its the cardiomyocyte mem"rane !a/I A #ase

Work Smart

Time taken: 02:+.

An 57'year'old colle e student is admitted %ith a t%o %ee( history of paraesthesia and

%ea(ness affectin all four lim"s)

Examination sho%s mild distal %ea(ness4 a"sent reflexes4 and love and stoc(in sensory

loss) F=- is .00 mls) - head is normal) Bum"ar puncture reveals 1 lymphocytes4 5 red cell4

lucose +)1 and protein of 0). /l)

>hat is the next mana ement step?


ntravenous immuno lo"ulin

ntu"ation and ventilation his is the correct ans%er

; "rain

#lasma exchan e


43/141

$erum lead levels ncorrect ans%er selected

he clinical features and -$F findin s are typical of Guillain'9arre syndrome)

An forced vital capacity F=- "elo% 5 litre or a"out 51 mls per (ilo ram "ody %ei ht is

indicative of severe respiratory %ea(ness and is an indication for ur ent intu"ation andventilation)

he specific treatment is either intravenous immuno lo"ulin or plasma exchan e)

Work Smart

Time taken: 02:13

n the treatment of an individual %ith type 5 dia"etes %ho presents in DIA dia"etic

(etoacidosis %ith a p* of &)54 %hich of the follo%in statements is correct?


9icar"onate should "e iven immediately

DIA in pre nancy carries a si nificant mortality to the to the fetus his is the correct ans%er

*yperphosphataemia occurs follo%in treatment

$erum osmolality %ill not help in monitorin response to treatment

he lucose level correlates %ell %ith the de ree of acidosis ncorrect ans%er selected

Dia"etic (etoacidosis in pre nancy carries an increased mortality to "oth mother and fetus)

$erum osmolality is more relia"le than lucose)

#hosphate and potassium fall %ith treatment)

he use of "icar"onate is not evidence "ased in any ro"ust %ay4 there is no threshold at%hich there is evidence for its use4 and if iven at all4 it should "e iven %ith care4 %ith closemonitorin of the patient

Work Smart

Time taken: 03:00


44/141

A +'year'old teacher reaches casualty resuscitation department after experiencin 30

minutes of severe central chest pain radiatin to the left arm)

he initial E-G sho%s 5 mm $ elevation in leads =5 ' =3 only)

*e is iven oxy en and morphine anal esia)

>hich of the follo%in is the most appropriate next step?


Emer ency referral to cardiolo ist for primary an ioplasty

Aspirin4 clopido rel and repeat E-G in 51 minutes his is the correct ans%er

ransfer to coronary care unit immediately

!o further therapy until 52 hour troponin

Aspirin4 clopido rel and throm"olysis ncorrect ans%er selected

he symptoms are suspicious for acute myocardial infarction4 ho%ever4 he does not fulfilcriteria for anterior $ elevation 2 mm $ elevation in conti uous chest leads or ne% left"undle "ranch "loc( QB999R so primary an ioplasty/throm"olysis is not indicated at thissta e)

*e should "e iven aspirin and clopido rel and the E-G repeated in 51 minutes for evolvinchan es) f su"se8uent E-G meets criteria and pain persists4 he should "e referred for

primary an ioplasty)f the second E-G does not meet criteria and he is pain free4 he should "e treated as a non'$ elevation acute coronary syndrome4 %ith clexane4 clopido rel etc) and closely monitoredon coronary care unit)

Work Smart

Time taken: 03:0+

A 5'year'old >est ndian presents to casualty %ith sudden onset of le %ea(ness

associated %ith "ac( pain)

On examination there is flaccid paraple ia %ith a"sent reflexes and silent plantars4 and a

sensory level at 50 %ith preservation of dorsal column modalities)

; of the spine performed the mornin after admission is normal)

>hich of the follo%in is the most appropriate next investi ation?


45/141


-$F analysis

- chest %ith contrast his is the correct ans%er

- head

$erum 952 estimation

$pirometry ncorrect ans%er selected

he clinical picture here is that of acute anterior cord syndrome dorsal columns preserved 4and is often caused "y cord infarction)

Occasionally4 especially in hypertensive Afro'-arri"ean patients4 and in the presence ofchest or "ac( pain4 this is caused "y thoracic aortic dissection interruptin the anterior spinal

artery)his possi"ility needs to "e pursued %ith a chest - scan)

Work Smart

Time taken: 03:0&

>hich of the follo%in is not a reco nised cause of a dominant ; in lead =5 on the E-G?


Dextrocardia

Duchenne muscular dystrophy

E"steinHs anomaly

yotonic dystrophy his is the correct ans%er

#rimary pulmonary hypertension ncorrect ans%er selected

A dominant ; %ave in =5 has fe% causes

;i ht ventricular hypertrophy ;=* as in Eisenmen erHs syndrome


46/141

#rimary pulmonary hypertension *

;i ht "undle "ranch "loc( ;999 as in E"steinHs anomaly

>olff'#ar(inson'>hite syndrome type A

Dextrocardia

rue posterior myocardial infarction

Duchenne muscular dystrophy)

Work SmartTime taken: 03:55

A 5 'year'old A'level student develops deterioration in vision in her left eye over three days)

$he complains of discomfort in the eye and thin(s that difficulty %ith perception of colour %as

the first pro"lem that she noticed4 durin a trip to an art allery)

On examination4 visual acuity on the left is do%n to li ht perception) he pupil appears

dilated and does not constrict to li ht4 althou h does %hen a torch is shone in the ri ht eye)

>hat is the most li(ely dia nosis?


Amaurosis fu ax

Anterior ischaemic optic neuropathy

-entral retinal artery occlusion

- = retinitis

Optic neuritis -orrect

he causes of acute unilateral loss of vision include:


47/141

Open an le laucoma ' other eye is often affected

Giant cell arteritis ' associated %ith headache4 6a% claudication4 scalp tenderness) *i hE$;) sually affects "oth eyes

;etinal artery occlusion ' acute4 %ith maximal deficit at the onset and varia"le resolution4and a spot at the macula

Amaurosis fu ax ' transient "lindness lastin minutes to hours) Associated %ith vascularris( factors as usually em"olic) ay "e descri"ed as a Mcurtain comin do%nM

Anterior optic neuropathy ' painless4 may "e central field defect %ith colour distur"ance aprominent feature) Arteriosclerosis4 hypertension and dia"etes are ris( factors

Optic neuritis ' painful4 colour vision affected) ay not result in complete visual loss) ay"e the first manifestation of $4 therefore re8uires appropriate investi ation

Other causes ' cytome alovirus - = 4 toxoplasmosis in association %ithimmunodeficiency)

Work Smart

Time taken: 03:52

A 5 'year'old female presents %ith shortness of "reath) $he is (no%n to suffer from asthma

and her usual "est #EF; is +50 B/min)

>hich of the follo%in features %ould su est that this is a severe asthma attac(?


9lood pressure of 51 /70 mm*

#EF; 200 B/min his is the correct ans%er

#ulse of 500 "eats per minute

;espiratory rate of 22 per minute


48/141

emperature of 3.,- ncorrect ans%er selected

Guidelines from the 9ritish horacic $ociety su est that the follo%in are su estive ofacute severe asthma:

ina"ility to complete sentences

a tachycardia in excess of 550 "pm

a respiratory rate a"ove 21/minute4 and

a #EF; 33'10< of the predicted value)

Bife'threatenin asthma %ould include:

silent chest

"radycardia

hypotension4 and

hypoxia)


A &'year'old irl presents %ith hi h fever and severe left'sided throat pain)

$he has had difficulty in s%allo%in over the last t%o days4 and has "een findin it

increasin ly uncomforta"le to open her mouth) *er voice is muffled and she

dri""les saliva)$he %as "orn at +5/+0 estation %ei hin +)0 ( and there %ere no neonatal

pro"lems)

On examination she loo(s ill) *er temperature is +0)2,- tympanic 4 ;; 51/min and

*; 500/min) E! examination sho%s left tonsillar enlar ement and exudate4 %ith a

uvula deviated to the ri ht)



Atypical tu"erculosis


49/141

-ervical lymphan itis

Forei n "ody aspiration

#eritonsillar a"scess his is the correct ans%er

;etropharyn eal a"scess ncorrect ans%er selected

he history su ests a peritonsillar a"scess 8uinsy on the left side4 a complicationof Group A streptococcus sore throat)

A fever reater than 3.)+,- is associated %ith severe disease4 and treatment is "ysur ical draina e)


A 5+'year'old irl %as found unconscious at the roadside "y a passer'"y4 %ho called an

am"ulance)

On examination she %as un(empt4 had slurred speech and an ataxic ait) *er core

temperature %as 3+)1,-4 "ut there %ere no other specific a"normalities to find) *er 9 stixresult %as 2). mmol/B)



Alcohol in estion his is the correct ans%er

-omplex partial seizure

Encephalitis

nsulin overdose

i raine ncorrect ans%er selected

he picture su ests acute alcohol in estion) his is often accompanied "y hypothermia andhypo lycaemia)

t is important to exclude other in estions and to loo( for coexistin social pro"lems)

Work Smart


50/141


51/141

An 7 month old child presents %ith spots on the le s) *e is %ell and feedin %ell) 3. /+0

3)1 ( 4 no neonatal pro"lems) !o dru s nor medications4 fully immunised) !o F*/$* of note)

On examination temperature 3&) ,- tympanic 4 ;; 30/min4 *; 550/min) >ell perfused4capillary refill time of 5 second) here are 20'30 5'2 mm non'"lanchin purpuric spots over

the shins)



-hild physical a"use

-ou h petechiae

Enteroviral infection his is the correct ans%er

*enoch'$chSnlein purpura

diopathic hrom"ocytopaenic purpura ncorrect ans%er selected

his child is %ell4 and presents %ith purpuric spots and a lo%' rade fever) Althou h a"out20< of such children have serious "acterial infection and &'50< have menin itis/septicaemia4 this still leaves &0< %ho have some sort of viral infection)

A lar e num"er of viruses e =aricella and E9= can present in this %ay4 althou h in clinical

practice the specific cause is rarely found

Work Smart

Time taken: 03:33

A 5+'day'old "oy is admitted %ith collapse)

*e %as "orn at 37 2/+0 %ei hin 3)+& ( to a healthy -aucasian mother) #re nancy and

delivery had "een uncomplicated)

Follo%in dischar e he had failed to ain %ei ht4 and "e an vomitin three days a o) his

had persisted and %orsened) Over the past t%o days the nappies had "een %et t%ice a day)

On examination temperature 3 )2,- tympanic 4 heart rate 5 0/min thready pulses 4

;espiratory rate +0/min) !o murmur4 chest clinically clear) A"domen soft %ith no enlar ed

liver4 spleen or (idneys) Oxy en saturations are 71< in air)

9lood tests sho%:


52/141

S#$i!m 52& mmol/B 53&'5++

P#ta&&i!m 1)7 mmol/B 3)1'+).

U ea 53)& mmol/B 2)1'&)1

C eatinine &+ Lmol/B 0'550



-on enital adrenal hyperplasia his is the correct ans%er

-ritical aortic stenosis

Galactosaemia

Group 9 streptococcal infection

*ypoplastic left heart syndrome ncorrect ans%er selected

he picture is one of shoc( in a child %ho has "ecome pro ressively dehydrated)

$epsis and con enital heart disease are possi"le4 "ut there is nothin specific to point inthese directions)

he electrolytes ma(e the li(ely dia nosis salt'losin con enital adrenal hyperplasia)

Work Smart

Time taken: 03:3

An 57'month'old irl presents %ith stridor at 5 am) $he has had a cold for +7 hours4 %ith lo%'

rade fever4 "ut %ent to "ed as usual at &)30 pm) $he a%o(e four hours later cryin and

distressed4 %ith a "ar(in cou h)



Aspiration of forei n "ody

Asthma

9acterial tracheitis

-roup his is the correct ans%er


53/141

Epi lottitis ncorrect ans%er selected

his is a classical history of viral croup)

ost of these episodes are one'off and settle rapidly %ithout treatment or %ith

dexamethasone orally

Work Smart

Time taken: 03:+5

A 53'year'old irl is rushed into hospital4 havin "ecome rapidly dro%sy after runnin the

5100 metres in the school athletics competition)

$he has "een on insulin for dia"etes for three years) *er latest *"A 5c is 2 mmol/mol)

On examination she responds to pain4 and is pale and s%eaty) *er temperature is 3 )1,-4

;espiratory rate 52/min and heart rate 70/min) here are no focal neurolo ical findin s)



*ypo lycaemia his is the correct ans%er

#ostural hypotension

$u"stance a"use

=asova al episode

=iral encephalitis ncorrect ans%er selected

he history su ests ti ht dia"etic control4 %ith neurolo ical deterioration follo%in exercise)

*ypo lycaemic coma is most li(ely4 and the s%eatiness and pallor are su estive)

he 9 stix in this case %as 5)2 mmol/B and she recovered rapidly %ith a "olus of = 50<dextrose)

Work Smart

Time taken: 03:+&


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A &'year'old irl %ith cystic fi"rosis s "rou ht "y her mother to the Emer ency department

follo%in a massive haematemesis)

Examination reveals that she is hypotensive and she has a tachycardia)



Aorto'intestinal fistula

9leedin oesopha eal varices his is the correct ans%er

9oerhaaveKs syndrome

allory'>eiss tear

#erforated peptic ulcer ncorrect ans%er selected

he most li(ely cause for this type of lar e upper astrointestinal haemorrha e causinshoc( in a child of & years %ould "e from "leedin oesopha eal varices secondary to portalhypertension)

#erforated ulcer is less li(ely)

allory >eiss tear %ould not cause such catastrophic "leedin )

Aorto'intestinal fistula is seen in older patients %ith aortic a"dominal aneurysm)

9oerhaaveHs syndrome is due to oesopha eal rupture normally after severe vomitin )

Work Smart

Time taken: 03:12

Theme: -hildhood *ypertension

A D $A scan

B Echocardio ram

C #lasma renin and aldosterone

D ;enal an io raphy


55/141

E hyroid function tests

F rine catecholamines

G rine dru screen

H Es4 creatinine

I ltrasound I 9

For each of the follo%in scenarios choose the most specific investi ation:

A 51'year'old irl is "rou ht to the Emer ency department havin collapsed at a party) On

examination she has a dry mouth4 a heart rate of 550/min and "lood pressure of 510/550 mm* )

ncorrect ' he correct ans%er is rine dru screen

n the 51'year'old irl there is acute hypertension4 most li(ely related to dru s) he mostcommon offender these days is pro"a"ly D A ecstasy ) A dru screen %ill confirm this)

A 'year'old "oy presents %ith headache on defecation) On examination his "lood pressure in

the ri ht arm is 5+0/500 mm* and he has a 2/ systolic murmur)

ncorrect ' he correct ans%er is Echocardio ram

he 'year'old "oy has hypertension and a heart murmur) t is important to excludecoarctation) he murmur for this may "e loudest over the scapula) Four lim" 9#s are usuallydia nostic4 "ut echocardio raphy %ill identify the precise structural lesion)

A 2'month'old infant is found to have a "lood pressure of 520/.0 mm* persistently) *e %as

"orn at 21/+0 estation4 %as ventilated for 5+ days and is still on oxy en)


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57/141


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B = coamoxiclav

C = penicillin

D as( ventilation

E Oral erythromycin

F Oropharyn eal air%ay

G Oral penicillin =

H Oxy en via facemas(

I Oxy en via head"ox

For each scenario choose the most appropriate mode of immediate mana ement:

A 3'month'old "oy presents %ith a 3 day history of coryza4 cou h and pro ressive difficulty in

feedin ) ;espiratory rate is 0/min %ith moderate recession4 %heeze and crac(les) *eart rate is

510/min4 ood peripheral perfusion) Oxy en saturation is 77< on air)

ncorrect ' he correct ans%er is Oxy en via head"ox

his child has "ronchiolitis4 is hypoxic and re8uires oxy en) his is "est provided "yhead"ox or nasal pron s)

A '%ee('old "oy presents %ith "ilateral purulent con6unctivitis and difficulty in "reathin )

;espiratory rate is 10/min4 mild recession) *eart rate is 520/min) Oxy en saturation is .+< on

air)

ncorrect ' he correct ans%er is Oral erythromycinhis "oy has chlamydia pneumonitis and con6unctivitis4 is not hypoxic4 and re8uireserythromycin)

A 3'year'old "oy presents %ith fever and "reathin difficulty) On examination he has a respiratory

rate of 11/min4 painful inspiration4 and crac(les at the ri ht "ase) Oxy en saturations are 77< on

air and temperature is 3.).,-)


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ncorrect ' he correct ans%er is = penicillinhis "oy has "acterial pneumonia %ith focal consolidation4 most li(ely pneumococcal) =penicillin is the treatment of choice)

Work Smart

Time taken: 0+:53

A &0'year'old %oman4 %ith metastatic "reast cancer presented %ith a %ee(Hs history of

severe %ea(ness4 o"tundation4 and poor oral inta(e)

One month a o4 - of the head revealed multiple intracere"ral lesions) $he under%entcranial irradiation and received dexamethasone4 52 m orally daily)

On examination she is un%ell and disoriented) emperature is 3 ) ,-4 pulse is 500/min4

respiratory rate is 27/min and "lood pressure is 550/ 0 mm* supine) -hest examination

and heart examination are normal) here is lo%er a"dominal tenderness4 especially in the

suprapu"ic area) Diffuse muscle %ea(ness is noted) !o lateralisin neurolo ic si ns or

a"normal reflexes are noted)

nvesti ations reveal:

'hite "e%% "#!nt 5.)1 T50 . /B +'55

P%a&ma (%!"#&e +0 mmol/B 3)0' )0

U ea 21 mmol/B 2)1'&)1

C eatinine 5 0 Lmol/B 0'550

Ca%"i!m 2)2 mmol/B 2)2'2)

S#$i!m 530 mmol/B 53&'5++

P#ta&&i!m 1)0 mmol/B 3)1'+).

Bi"a )#nate 2+ mmol/B 20'27

U ina%*&i& Glucose

#rotein


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oderate "acteria seen

-ultures of "lood and urine are re8uested and she is treated %ith an intravenous slidin

scale insulin)

>hich of the follo%in = fluids %ould you prescri"e in con6unction %ith the insulin slidin

scale for this patient?


1< Dextrose

Dextrose saline

*aemacel

*alf stren th normal saline

!ormal saline -orrect

his patient has an excessive hyper lycaemia contri"utin to her symptoms and related tohyperosmolarity4 althou h she is dehydrated rather than has hyperosmolar non'(etotic coma*O!I )

Also her normal "icar"onate ar ues a ainst dia"etic (etoacidosis)

$he needs = normal saline to ether %ith insulin for her crystalloid re8uirements s%itchin to

= dextrose %hen the "lood lucose descends to 50 mmol/B)

*er dexamathasone has contri"uted to this mar(ed hyper lycaemia causin mar(ed insulinresistance)

Work Smart

Time taken: 0+:5#BA9 2001 $ept

A 22'year'old olf course roundsman develops sudden onset of "reathlessness and ri ht'

sided chest pain %hilst maintainin the 57th hole) *e is rushed to hospital4 "ut his condition

%orsens %hen "ein examined "y a 6unior doctor)

$he reported findin a trachea that %as deviated to the left4 and hearin very distant "reath

sounds over his ri ht lun ) Follo%in the intervention of a senior doctor4 his condition

improves rapidly)

>hat is the most pro"a"le dia nosis?


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yocardial infarction

#ericarditis

#neumonia

#ulmonary em"olism

ension pneumothorax -orrect

$udden onset of chest pain and respiratory distress in a previously fit youn man shouldalert one to the dia nosis of pneumothorax)

ales of patients %ho developed a clinically o"vious tension pneumothorax in hospital aretold fre8uently4 so it is "est to "e a"le to reco nise one if it occurs %hile you are actually

examinin the patientU

Work Smart

Time taken: 0+:20#BA9 2001 $ept

An 57'year'old male is rushed into the Emer ency department "y a roup of friends %holeave "efore they can "e intervie%ed "y medical staff)

*e is semiconscious4 has a respiratory rate of 7/min4 a "lood pressure of 520/&0 mm* and

a pulse of 0 "pm) *e is noted to have needle trac( mar(s on his arms4 and his pupils are

small)

>hat sin le initial treatment %ould you administer?


Adrenaline

Aspirin

Atropine

Dextrose

!aloxone -orrect

hese features of unconsciousness4 respiratory depression plus small pupils su est opiate

toxicity) his commonly occurs as the result of the a"use of street dru s such as heroin)t should "e relieved promptly %ith naloxone %hich is an opiate receptor anta onist)


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!aloxone has a shorter half life than many opiates4 so more than one dose may "enecessary)

Work Smart

Time taken: 0+:2+

A 51'year'old irl attends %ith her mother as an emer ency to the Emer ency department)

*er mother provides a history of 30 minutes of deterioratin "reathlessness and facial

puffiness) $he has other%ise "een %ell except for eczema and she ta(es the oral

contraceptive) $he is in o"vious distress4 her "reathin is la"oured and noisy)

>hat is the sin le most li(ely cause of "reathlessness?


Acute epi lottitis

An io'oedema his is the correct ans%er

Asthma

#neumothorax

#ulmonary em"olism ncorrect ans%er selected

he history of noisy "reathin is su estive of stridor4 %hich can "e tri ered "y an aller icreaction in an other%ise %ell adolescent4 and the history of atopy is supportive of a dia nosisof an io'oedema) $imilarly4 the rather a"rupt history is a ain su estive)

he main differential dia nosis is asthma %here one %ould expect expiratory %heezeJho%ever the silent chest is an ominous feature in acute severe asthma)

Work Smart

Time taken: 0+:33

Theme: =a inal "leedin in pre nancy/puerperium

A A"ruption


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B -ancer of the cervix

C -oa ulation failure

D Ectopic pre nancy

E *ydatidiform mole

F ncomplete miscarria e

G issed miscarria e

H #lacenta praevia

I ;etained placenta

J $epsis of retained products of conception

K $evere thyrotoxicosis

L hreatened a"ortion

M rethral chemotaxis

N terine fi"roids

n each of the follo%in statements4 select the most li(ely cause of va inal "leedin )

A 5 'year'old school irl %ho recently had a sur ical termination of pre nancy %as re'admitted

%ith a"normal va inal "leedin and severe lo%er a"dominal pain and fever) *er haemo lo"in

%as . m/dl and her %hite cell count %as 204000/mcl)

ncorrect ' he correct ans%er is $epsis of retained products of conceptionhe patientHs fever and raised %hite cell count indicate infection and the a"normal"leedin /anaemia indicate a septic miscarria e follo%in a failed therapeutic a"ortion orsepsis of retained products of conception occurs in approximately 3) < ) ost commonor anisms are Escherichia coli 4Bacteroides 4Streptococci anaero"ic and aero"ic andClostridium perfringens )

An Asian %oman %ho is G3#5 5 %as admitted %ith a history of excessive vomitin 4 va inal

"leedin at 50 %ee(s estation and minimal a"dominal pain) A"dominal examination indicated a


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soft uterus4 5 %ee(sH estation4 and dou hy consistency) An ultrasound scan sho%ed no fetal

parts4 "ut a sno%y pattern) he VhcG %as hi her than the value for 50 %ee(sH estation)

ncorrect ' he correct ans%er is *ydatidiform mole A raised VhcG4 %hich is a (no%n cause of hyperemesis4 should al%ays raise the suspicion of a molar pre nancy) he ultrasound appearances of echoes resem"lin a sno%storm ischaracteristic of hydatidiform mole)

An African %oman %ho had "een investi ated for 50 years primary infertility %as admitted %ith a

history of severe onset lo%er a"dominal pain follo%ed "y sli ht "leedin per va inum) *er

menses %as t%o days overdue) *er "lood pressure %as 70/10 mm* 4 pulse 5+ /m and thready4

haemo lo"in & /dl) #re nancy test %as positive and ultrasound excluded any evidence of a

fetus in the uterine cavity)

ncorrect ' he correct ans%er is Ectopic pre nancy A positive pre nancy test in the a"sence of an intrauterine pre nancy on ultrasound shouldal%ays arouse suspicion of an ectopic pre nancy4 %hich classically presents %ithhaemodynamic compromise) he patientHs infertility is a clue to possi"le tu"al patholo y)9leedin per va inum is often sli ht in ectopic pre nancy4 and does not account for thesevere anaemia) ltrasound examination in this case is li(ely to sho% copious free fluid)

A hypertensive4 haemodynamically sta"le4 3 %ee(s pre nant %oman %as admitted %ith a

history of painless va inal "leedin ) $he had a similar "leed at 20 %ee(sH estation) On

a"dominal examination4 the uterus %as consistent %ith her estational a e4 soft and non' tender)

Fetal lie %as transverse and fetal heart %as audi"le)

ncorrect ' he correct ans%er is #lacenta praevia#lacenta praevia classically presents %ith a painless "leed4 occurrin modally at 3+ %ee(s)9leedin in the second trimester can "e a feature) he lie is transverse "ecause of theposition of the placenta) A soft non'tender uterus excludes ma6or placental a"ruption)

A 33'year'old %oman G1#+ presented %ith sudden a"dominal pain and sli ht va inal "leedin

follo%in a car crash) $he %as pale4 s%eatin 4 hypertensive and her pulse rate %as 520 "pm)

he uterus %as tender and hard4 and fetal parts %ere difficult to define) - G sho%ed si ns of

fetal distress)


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ncorrect ' he correct ans%er is A"ruption Any trauma can cause shearin forces on the placenta and lead to a"ruption or accidentalhaemorrha e) he uterus is characteristically tender and hard4 and fetal parts difficult to

palpate) $eparation of the placenta leads to fetal compromise) 9leedin may "e concealedand can lead to shoc()

Work Smart

Time taken: 0+:+5

Theme: Overdosa es/ poisonin

A Di oxin

B ron

C Or anophosphates

D #aracetamol

E #ara8uat

F $alicylate

G $odium hypochlorite "leach

H ricyclics

For each patient "elo%4 choose from the iven list the sin le most li(ely causative a ent

responsi"le for their presentation:

A &'year'old child %ith nausea vomitin and features of heart "loc()

-orrectDi oxin toxicity) Features include nausea4 vomitin 4 impaired co nition and arrhythmias)reatment involves correction of hypo(alaemiaJ di oxin specific anti"ody fra ments areindicated to treat serious arrhythmias)

A +1'year'old farmer presents %ith excessive s%eatin 4 a"dominal pain and diarrhoea)


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ncorrect ' he correct ans%er is Or anophosphatesOr anophosphate insecticides inactivate cholinesterase resultin in increased choliner icsymptoms of salivation4 lacrimation4 small pupils4 s%eatin 4 urination and diarrhoea4 coma

and respiratory failure) reatment is %ith the anticholiner ic atropine)

A 5&'year'old irl is admitted %ith hyperventilation and is noted to "e in meta"olic acidosis)

ncorrect ' he correct ans%er is $alicylate$alicylate present in aspirin preparations causes hyperventilation %hich may result in arespiratory al(alosis) assive overdose may cause a meta"olic acidosis)

A 32'year'old farm la"ourer %ith sore mouth4 pulmonary oedema and renal failure)

ncorrect ' he correct ans%er is #ara8uat#ara8uat is found in %eed'(illers) his causes diarrhoea and vomitin 4 painful oral ulcers4alveolitis pulmonary oedema and renal failure)

A 5 'year'old irl presents %ith ri ht upper 8uadrant pain and has deran ed liver function tests)

ncorrect ' he correct ans%er is #aracetamol#aracetamol poisonin may cause vomitin 4 ri ht upper 8uadrant pain) Bater liver failure %ithencephalopathy and renal failure may occur) reatment %ith !'acetyl cysteine !A- isiven accordin to a standard nomo ram) !A- may "e useful up to 3 hours follo%inin estion) he occasional patient may re8uire liver transplantation)

Work Smart

Time taken: 0+:+5

An 57'year'old male %ith sic(le cell disease presents %ith severe a"dominal pain) *is "lood

pressure is 570/500 mm* 4 heart rate 550 "pm4 and temperature 37)0,-)

>hat is your first action?


67/141


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!aso astric

$u"cutaneous ncorrect ans%er selected

!aso astric4 and su"cutaneous are too slo% and unrelia"le for emer ency situations

althou h in cardiac arrest the endotracheal route is reco nised ) =enous cut do%n is apossi"ility "ut re8uires s(ill in the procedure)

ntraosseous is still perfectly via"le in the adult patient 2 cm "elo% the ti"ial tu"erosity on theantero'medial side or 2 cm proximal to the medial malleolus)

Work Smart

Time taken: 0+:10

A 21'year'old female %ith a history of palpitations is admitted %ith a pulse of 5 0 "eats per

min4 "lood pressure 501/70 mm* and a respiratory rate 2 /min) $he is a a%a(e4 alert and

oriented and is not distressed) *er electrocardio ram sho%s a re ular @;$ complex of

0)50s duration)

>hich of the follo%in is the most appropriate therapy in this patient?


Adenosine 3 m

D- cardioversion

Diltiazem 51m

=a al manoeuvres his is the correct ans%er

=erapamil 2)1m ncorrect ans%er selected

his is a narro% complex tachycardia %ith normal "lood pressure and an undistressedpatient allo%s the trial of va al manoeuvres "efore dru therapy)

-arotid sinus massa e or valsalva is effective in 21< of cases)

Work Smart

Time taken: 0+:17

http://my.onexamination.com/goto.aspx?url=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCarotid_sinus_reflexhttp://my.onexamination.com/goto.aspx?url=http%3A%2F%2Fen.wikipedia.org%2Fwiki%2FCarotid_sinus_reflex


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Theme: 9lood as analysis

A eta"olic acidosis ' acute4 normal oxy enation

B eta"olic acidosis ' acute %ith hypoxaemia

C eta"olic acidosis ' compensated4 normal oxy enation

D eta"olic al(alosis ' acute4 normal oxy enation

E eta"olic al(alosis ' acute %ith hypoxaemia

F eta"olic al(alosis ' compensated4 normal oxy enation

G !ormal "lood ases

H !ormal ventilation %ith hypoxaemia

I ;espiratory failure ' acute

J ;espiratory failure ' compensated4 normal oxy enation

K ;espiratory failure ' compensated %ith hypoxaemia

For each of the follo%in "lood as results4 select the most appropriate desi nation from the

list of options)

he line la"elled oxy en concentration represents the concentration of oxy en that each

individual is inhalin )

!ormal values are:

PaO + 52)0'5+)& (#a .0'550 mm*

PaCO + +)1' )0 (#a 3+'+1 mm*

,H &)3 '&)++

H - m#%a it* 31'+1 nmol/B

Bi"a )#nate 2+'30 mmol/B

,O+ 50)0 (#a 70 mm*


70/141

,CO+ 1)7( #a ++ mm*

,H &)2+

H- m#%a it* 1& nmol/B

Bi"a )#nate 57 mmol/B

Ba&e E."e&& W& mmol/B

O.*(en "#n"ent ati#n +0<

-orrecthe lo% p* %ith lo% "icar"onate indicates a meta"olic acidosis4 and the lo% normal O 2 oninspired QO 2R indicates hypoxaemia) his may occur %ith poisonin and associatedrespiratory failure)

,O+ )& (#a 10 mm*

,CO+ 50)5 (#a & mm*

,H &)37

H- m#%a it* +2 nmol/B

Bi"a )#nate +2)+ mmol/B

Ba&e e."e&& 5+ mmol/B

O.*(en "#n"ent ati#n 25<

ncorrect ' he correct ans%er is ;espiratory failure ' compensated %ith hypoxaemiahis is the typical feature of a corrected respiratory failure %ith hypoxaemia) he #aO 2 is lo%4the #a-O 2 is hi h4 %ith raised "icar"onate indicatin renal correction and a hi h "aseexcess)

,O+ 5+)3 (#a 507 mm*


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,CO+ )3 (#a +7 mm*

,H &)12

H- m#%a it* 30 nmol/B

Bi"a )#nate 3. mmol/B

Ba&e e."e&& 5+ mmol/B


ncorrect ' he correct ans%er is eta"olic al(alosis ' acute4 normal oxy enationeta"olic al(alosis4 for example in a patient %ith severe vomitin 4 is characterised "y a hi hp*4 hi h "icar"onate and a raised "ase excess)

,O+ +)& (#a 31 mm*

,CO+ 52)& (#a .1 mm*

,H &)52

H- m#%a it* & nmol/B

Bi"a )#nate 2.)1 mmol/B

Ba&e e."e&& W+mmol/B


ncorrect ' he correct ans%er is ;espiratory failure ' acutehere is a type 2 respiratory failure %ith hypoxia4 hypercapnia and acidosis %ith a normal"icar"onate4 indicatin an acute respiratory failure4 for example in severe asthma orpneumonia)

,O+ 5 )3 (#a 522 mm*


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,CO+ &)1 (#a 1 mm*

,H &)2

H- m#%a it* 11 nmol/B

Bi"a )#nate 2+)5 mmol/B

Ba&e e."e&& W2 mmol/B

O.*(en "#n"ent ati#n &1<

ncorrect ' he correct ans%er is ;espiratory failure ' acutehere is an acidosis %ith a normal "icar"onate4 and hypercapnia4 on hi h flo% O 2) his is thepicture of acute respiratory failure often found in patients %ith chronic o"structive air%aysdisease %ho have lost their hypoxic drive and have "een iven hi h concentrations of O 2)

Work Smart

Time taken: 01:05

ou are on call for hospital at ni ht and are ur ently called to a patient on the %ard %ho is

cho(in on a piece of stea( visi"le in his oropharynx) *e is in extremis %ith saturations of

7&hich of the follo%in is the most appropriate immediate mana ement for this patient?


-ricothyroidotomy

Fin er s%eep

*eimlich manoeuvre his is the correct ans%er

*i h flo% oxy en

;emoval %ith forceps ncorrect ans%er selected

A fin er s%eep is more li(ely to push the o"struction further into the air%ay and is no lon eradvocated)


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*i h flo% oxy en is the "reathin part of A4 94 -4 and the air%ay is not clear)

!asopharyn eal air%ays %ill not help in this situation)

;emoval %ith forceps is potentially hazardous)

A *eimlich manoeuvre should "e performed %ith the possi"ility of cricothyroidotomy in mindimmediately thereafter if this procedure fails)

n some countries4 nota"ly Australia4 this procedure is not encoura ed4 mainly "ecauseovervi orous use can cause internal in6ury) *o%ever it is still recommended in the $ andthe I )


Theme: 9lood as analysis

A eta"olic acidosis ' acute4 normal oxy enation

B eta"olic acidosis ' acute %ith hypoxaemia

C eta"olic acidosis ' compensated4 normal oxy enation

D eta"olic al(alosis ' acute4 normal oxy enation

E eta"olic al(alosis ' acute %ith hypoxaemia

F eta"olic al(alosis ' compensated4 normal oxy enation

G !ormal "lood ases

H !ormal ventilation %ith hypoxaemia

I ;espiratory failure ' acute

J ;espiratory failure ' compensated4 normal oxy enation

K ;espiratory failure ' compensated %ith hypoxaemia

For each of the follo%in "lood as results select the most appropriate desi nation from thelist of options)

http://www.deaconess-healthcare.com/Heimlich_Institute/Heimlich_Maneuver/http://www.deaconess-healthcare.com/Heimlich_Institute/Heimlich_Maneuver/


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he line la"elled Hoxy en concentrationH represents the concentration of oxy en that each

individual is inhalin )

!ormal values

PaO + 52)0'5+)& (#a

PaO + .0'550 mm*

PaCO + +)1' )0 (#a

PaCO + 3+'+1 mm*

,H &)3 '&)++

H- m#%a it* 31'+1 nmol/l

Bi"a )#nate 2+'30 mmol/l

,O + 52). (#a .& mm*

,CO + 1)7 (#a ++ mm*

,H &)2+

H- m#%a it* 1& nmol/l

Bi"a )#nate 57 mmol/l

Ba&e e."e&& '& mmol/l

O.*(en "#n"ent ati#n +0<

ncorrect ' he correct ans%er is eta"olic acidosis ' acute %ith hypoxaemiahe lo% p* %ith lo% "icar"onate indicates a meta"olic acidosis4 and the lo% normal O 2 oninspired QO 2R indicates hypoxaemia)

,O + )& (#a 10 mm*

,CO + 50)5 (#a & mm*

,H &)37

H- m#%a it* +2 nmol/l

Bi"a )#nate +2)+ mmol/l

Ba&e e."e&& 5+ mmol/l


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ncorrect ' he correct ans%er is ;espiratory failure ' compensated %ith hypoxaemia

his is the typical feature of a corrected respiratory failure %ith hypoxaemia) he #aO 2 is lo%4the #a-O 2 is hi h4 %ith raised "icar"onate indicatin renal correction and a hi h "aseexcess)

,O + 5+)3 (#a 507 mm*

,CO + )3 (#a +7 mm*

,H &)12

H- m#%a it* 30 nmol/l

Bi"a )#nate 3. mmol/l

Ba&e e."e&& 5+ mmol/l


ncorrect ' he correct ans%er is eta"olic al(alosis ' acute4 normal oxy enationeta"olic al(alosis4 for example in a patient %ith severe vomitin 4 is characterised "y a hi h p*4 hi h

"icar"onate and a raised "ase excess) n an effort to compensate4 the respiratory drive decreasesand hence the #-O 2 "e ins to rise)

,O + +)& (#a 31 mm*

,CO + 52)& (#a .1 mm*

,H &)52

H- m#%a it* & nmol/l

Bi"a )#nate 2.)1 mmol/l

Ba&e e."e&& '+ mmol/l


ncorrect ' he correct ans%er is ;espiratory failure ' acute*ypoxia4 hypercapnia and acidosis %ith a normal "icar"onate4 indicate an acute respiratoryfailure4 for example in massive pulmonary em"olism)


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,O + 5 )3 (#a 522 mm*

,CO + &)1 (#a 1 mm*

,H &)2

H- m#%a it* 11 nmol/l

Bi"a )#nate 2+)5 mmol/l

Ba&e e."e&& '2 mmol/l

O.*(en "#n"

plab emergency medicine complete

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