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A 63-year-old man is brought to hospital after being found
unconscious in his caravan. He is drowsy but rousable
Test Analysis
and complains
of a severe headache and nausea.

On examination his temperature is 36.5°C but appears flushed.


Neck is supple and there is no palpable
lymphadenopathy. His BP is
110/65 mmHg. Heart sounds normal with no murmurs or added sounds,
and his
chest is clear to auscultation. The remainder of the
examination is unremarkable.

His son reported that his father, usually a skilled model-maker,


had appeared clumsy lately and had been
confused at times when
talking on the telephone.

Investigations show
Haemoglobin 158 g/L (130-180)

White cell count 10.1 ×109/L (4-11)

Platelets 401 ×109/L (150-400)

Serum sodium 140 mmol/L (137-144)

Serum potassium 4.4 mmol/L (3.5-4.9) Score:


Serum urea 5.8 mmol/L (2.5-7.5)
Total Answered:
Serum creatinine 110 µmol/L (60-110)

Serum glucose 4.5 mmol/L (3.0-6.0) Question Navigator


CSF opening pressure 150 mmH2O (50-180)

<3 mL-1
Tags
CSF cell count (≤5)

CSF protein 0.4 g/L (0.15-0.45)

CSF glucose 3.3 mmol/L (3.3-4.4)

Arterial blood gases breathing air:


PaO2 11.6 kPa (11.3-12.6)

PaCO2 4.3 kPa (4.7-6.0)

HCO3 20 mmol/L (20-28)

pH 7.33 (7.36-7.44)

Based on the information available to you, which investigation


would you like to do?

(Please select 1 option)



Carboxyhaemoglobin level


CT scan head


Estimation of carbon monoxide diffusion factor (KCO)


Methaemoglobin level


Mini mental state examination


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A 63-year-old man is brought to hospital after being found
unconscious in his caravan. He is drowsy but rousable
Answer Statistics
and complains
of a severe headache and nausea.

On examination his temperature is 36.5°C but appears flushed.


Neck is supple and there is no palpable Test Analysis
lymphadenopathy. His BP is
110/65 mmHg. Heart sounds normal with no murmurs or added sounds,
and his
chest is clear to auscultation. The remainder of the
examination is unremarkable.

His son reported that his father, usually a skilled model-maker,


had appeared clumsy lately and had been
confused at times when
talking on the telephone.

Investigations show
Haemoglobin 158 g/L (130-180)

White cell count 10.1 ×109/L (4-11)

Platelets 401 ×109/L (150-400)

Serum sodium 140 mmol/L (137-144)

Serum potassium 4.4 mmol/L (3.5-4.9)

Serum urea 5.8 mmol/L (2.5-7.5)

Serum creatinine 110 µmol/L (60-110) Score:

Serum glucose 4.5 mmol/L (3.0-6.0) Total Answered:

CSF opening pressure 150 mmH2O (50-180)

<3 mL-1
Feedback
CSF cell count (≤5)

CSF protein 0.4 g/L (0.15-0.45)


Question Navigator
CSF glucose 3.3 mmol/L (3.3-4.4)

Arterial blood gases breathing air: Revision Notes


PaO2 11.6 kPa (11.3-12.6)
Tags
PaCO2 4.3 kPa (4.7-6.0)

HCO3 20 mmol/L (20-28)

pH 7.33 (7.36-7.44)

Based on the information available to you, which investigation


would you like to do?

(Please select 1 option)


Carboxyhaemoglobin level
Correct


CT scan head


Estimation of carbon monoxide diffusion factor (KCO)


Methaemoglobin level


Mini mental state examination

The history is suggestive of carbon monoxide (CO) poisoning due


to poor ventilation in his caravan.
CO binds with high affinity to haemoglobin, forming
carboxyhaemoglobin. CO also binds myoglobin and
mitochondrial
cytochrome oxidase.

CO poisoning causes tissue hypoxia, anaerobic metabolism and


lactic acidosis.

Elevated carboxyhaemoglobin levels document exposure, but do not


correlate with severity.

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A late middle-aged homeless man is brought to the emergency
department with a six hour history of profuse
Test Analysis
vomiting. He
complains of nausea and headache.

The history available is sketchy. He is of no fixed abode and


denies having any previous medical problems. He
appears unkempt and
is confused - oriented to person but not time or place. He is
afebrile. His breath smells of
ketones.

Twelve hours after admission his condition deteriorates. He


complains of blurred vision and his pupils are fixed
and dilated;
his respiratory rate increases sharply over the next few minutes
and he becomes unconscious.

Investigations show:

Hb 138 g/L (130-180)

WCC 7.1 ×109/L (4-11)

Platelets 401 ×109/L (150-400)

Plasma sodium 135 mmol/L (137-144)


Score:
Plasma potassium 5.0 mmol/L (3.5-4.9)

Plasma urea 5.8 mmol/L (2.5-7.5) Total Answered:

Plasma creatinine 110 µmol/L (60-110)

Plasma chloride 100 mmol/L (95-107)


Question Navigator
Plasma bicarbonate 12 mmol/L (20-28)
Tags
Plasma glucose 5.5 mmol/L (3.0-6.0)

Plasma lactate 4.1 mmol/L (0.6-1.7)

PaO2 12 kPa (11.3-12.6)

PaCO2 4.2 kPa (4.7-6.0)

pH 7.22 (7.36-7.44)

Urine microscopy Crystals seen

The anion gap is calculated as which of the following?

(Please select 1 option)



12 mmol/L


28 mmol/L


88 mmol/L


112 mmol/L


140 mmol/L

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A late middle-aged homeless man is brought to the emergency
department with a six hour history of profuse
Answer Statistics
vomiting. He
complains of nausea and headache.

The history available is sketchy. He is of no fixed abode and


denies having any previous medical problems. He Test Analysis
appears unkempt and
is confused - oriented to person but not time or place. He is
afebrile. His breath smells of
ketones.

Twelve hours after admission his condition deteriorates. He


complains of blurred vision and his pupils are fixed
and dilated;
his respiratory rate increases sharply over the next few minutes
and he becomes unconscious.

Investigations show:

Hb 138 g/L (130-180)

WCC 7.1 ×109/L (4-11)

Platelets 401 ×109/L (150-400)

Plasma sodium 135 mmol/L (137-144)

Plasma potassium 5.0 mmol/L (3.5-4.9)

Plasma urea 5.8 mmol/L (2.5-7.5)


Score:
Plasma creatinine 110 µmol/L (60-110)
Total Answered:
Plasma chloride 100 mmol/L (95-107)

Plasma bicarbonate 12 mmol/L (20-28)


Feedback
Plasma glucose 5.5 mmol/L (3.0-6.0)

Plasma lactate 4.1 mmol/L (0.6-1.7)


Question Navigator
PaO2 12 kPa (11.3-12.6)

PaCO2 4.2 kPa (4.7-6.0) Revision Notes


pH 7.22 (7.36-7.44)
Tags
Urine microscopy Crystals seen

The anion gap is calculated as which of the following?

(Please select 1 option)


12 mmol/L
Incorrect answer selected

28 mmol/L
This is the correct answer


88 mmol/L


112 mmol/L


140 mmol/L

The most likely diagnosis is methanol toxicity.

Early signs of toxicity are due to methanol. Later signs are due
to its metabolite, formic acid.

Early signs include:


Nausea
Vomiting
Headache, and
Confusion.

Formic acid later produces a metabolic acidosis and retinal


injury.

The laboratory data show a high gap metabolic acidosis.

Anion gap = (Na + K) − (Cl + HCO3); normal range 7-17


mmol/L.

Although elevated, the lactate level does not account for the
anion gap. The diagnosis can be made early by
measuring the serum
methanol and serum formate levels.

Treatment is aimed at:


1. Eliminating formic acid (alkaline diuresis or
haemodialysis).
2. Correcting acidosis with IV bicarbonate.
3. Preventing metabolism of methanol to formic acid by
administering IV ethanol.

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A 15-year-old girl is brought to the Emergency department by her
parents. She has no past medical history of
Test Analysis
note.

In her parents' absence, she says that she and her boyfriend
had an argument several days previously and that
as a result she
took a number of paracetamol tablets, but did not intend to kill
herself.

Which of the following is the best indicator of the degree of


hepatocellular damage?

(Please select 1 option)



Aspartate transaminase level


Bilirubin level


INR


Paracetamol level


Quantity of paracetamol ingested

Score:

Total Answered:
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A 15-year-old girl is brought to the Emergency department by her
parents. She has no past medical history of
Answer Statistics
note.

In her parents' absence, she says that she and her boyfriend
had an argument several days previously and that Test Analysis
as a result she
took a number of paracetamol tablets, but did not intend to kill
herself.

Which of the following is the best indicator of the degree of


hepatocellular damage?

(Please select 1 option)


Aspartate transaminase level
Incorrect answer selected


Bilirubin level

INR
This is the correct answer


Paracetamol level


Quantity of paracetamol ingested

Paracetamol overdose is a common question.

The essentials of management are: Score:


1. Check paracetamol level four hours after ingestion, check
levels against the Rumack-Matthew nomogram.
Total Answered:
2. Gastric lavage if large dose ingested (more than 7.5 g) and/or
presenting within eight hours of ingestion;
consider oral
charcoal.
3. Give N-acetylcysteine or methionine. Feedback
4. Hourly BMs monitored.
5. Check INR 12 hourly.
Question Navigator
Signs associated with poor prognosis (and indicating need for
transfer to a liver unit) include:
INR greater than 2.0 within 48 hours or greater than 3.5 within
72 hours of ingestion Revision Notes
Creatinine greater than 200 umol/l
Blood pH less than 7.3
Signs of encephalopathy
Tags
Hypotension (SBP less than 80 mmHg).

Liver enzymes are a poor marker of the degree of hepatocellular


damage; synthetic function (as determined by
INR or PT) is the best
indicator.

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A 19-year-old male is brought to casualty after having a
generalised seizure in a nightclub.
Test Analysis
Some friends, who are accompanying him, state that he has a
known history of epilepsy. They also report that he
has consumed
approximately 10 pints of lager during the evening and that he
vomited while having the seizure.

On examination the patient is drowsy but responsive to verbal


commands. His clothing is covered in vomitus. He
is febrile,
37.5°C. On auscultation of his chest, there are coarse crackles in
the right upper and mid zones. His
chest radiograph shows diffuse
right upper lobar airway shadowing.

Which of the following combinations of antibiotics should be


started?

(Please select 1 option)



Amoxicillin + metronidazole


Ceftazidime + erythromycin


Co-trimoxazole


Erythromycin + rifampicin
Score:

Penicillin + gentamicin
Total Answered:

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A 19-year-old male is brought to casualty after having a
generalised seizure in a nightclub.
Answer Statistics
Some friends, who are accompanying him, state that he has a
known history of epilepsy. They also report that he
has consumed
approximately 10 pints of lager during the evening and that he
vomited while having the seizure. Test Analysis
On examination the patient is drowsy but responsive to verbal
commands. His clothing is covered in vomitus. He
is febrile,
37.5°C. On auscultation of his chest, there are coarse crackles in
the right upper and mid zones. His
chest radiograph shows diffuse
right upper lobar airway shadowing.

Which of the following combinations of antibiotics should be


started?

(Please select 1 option)


Amoxicillin + metronidazole
Correct


Ceftazidime + erythromycin


Co-trimoxazole


Erythromycin + rifampicin


Penicillin + gentamicin

Score:
This patient clearly has aspiration pneumonia and the only
appropriate treatment would be amoxicillin and
Total Answered:
metronidazole.

Monotherapy would be insufficient in a case of aspiration


pneumonia. The amoxicillin is used primarily to cover
Feedback
aerobes and
facultative aerobes, and the metronidazole targets anaerobes.

They are required in conjunction to offer optimal cover. In


cases of serious side effects, the regime would need to Question Navigator
be
re-considered

Revision Notes

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What is the diagnosis?
Test Analysis

(Please select 1 option) Score:



Anterior uveitis Total Answered:

Dendritic ulcer


Episcleritis Question Navigator

Rubeosis iridis
Tags

Scleromalacia perforans

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What is the diagnosis?
Answer Statistics

Test Analysis

(Please select 1 option)


Anterior uveitis
Incorrect answer selected

Dendritic ulcer
This is the correct answer
Score:


Episcleritis
Total Answered:


Rubeosis iridis
Feedback

Scleromalacia perforans

Question Navigator
Dendritic ulcers are caused by herpes simplex virus.
Revision Notes
Presentation is usually with:
Pain
Photophobia Tags
Blurred vision
Conjunctivitis
Chemosis.

Steroid eye drops are contraindicated as they may induce massive


amoeboid ulceration and blindness.

Diagnosis is by instillation of fluorescein eye drops which


stain the ulcer (shown in slide).

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A 42-year-old Zimbabwean man was admitted to the emergency
department after becoming unconscious at
Test Analysis
Heathrow airport shortly
after his arrival in the United Kingdom.

His wife said that he had been unwell for several weeks, but had
complained of a high fever associated with neck
stiffness for the
past 24 hours. Microscopy of his CSF is pictured.

Score:

Total Answered:

Question Navigator
What organism is shown?

(Please select 1 option)


Tags

Candida albicans


Cryptococcus neoformans


Listeria monocytogenes


Pneumocystis jirovecii


Toxoplasma gondii

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A 42-year-old Zimbabwean man was admitted to the emergency
department after becoming unconscious at
Answer Statistics
Heathrow airport shortly
after his arrival in the United Kingdom.

His wife said that he had been unwell for several weeks, but had
complained of a high fever associated with neck Test Analysis
stiffness for the
past 24 hours. Microscopy of his CSF is pictured.

Score:

Total Answered:
What organism is shown?

(Please select 1 option)


Feedback
Candida albicans
Incorrect answer selected

Cryptococcus neoformans
This is the correct answer Question Navigator

Listeria monocytogenes
Revision Notes

Pneumocystis jirovecii


Toxoplasma gondii
Tags

Diagnosis is by demonstration of C. neoformans in the


cerebrospinal fluid - shown on an India ink stain: the thick

polysaccharide capsule is highlighted around the cell (shown in


slide).

Cryptococcal meningitis is an AIDS-defining illness occurring


when CD4 less than 50 cells/mm3 and may be
associated
with a pneumonitis.

Cryptococcus can also cause papular skin lesions that


resemble molluscum contagiosum.

The disease is commoner in African populations.

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Work Smart MRCP Part 2 Written July 2011

A 58-year-old male was seen in the neurology clinic having been


referred with weakness of both hands and
Test Analysis
wrists. In the preceding
week he had been having several falls and his mother, who had
accompanied him, felt
he was dragging his feet whilst walking.

He had recently been to see his GP because of weight loss and


had been diagnosed with impaired glucose
tolerance. Otherwise he
suffered occasional palpitations, but had no known medical history
and did not take any
regular medication.

Score:

Total Answered:

Question Navigator

Tags

On examination the patient had a monotonous, nasal voice. His


general appearance is shown in the picture.
Cranial nerve
examination revealed bilateral ptosis, but pupils and fundoscopy
were intact. There was marked
bilateral facial weakness and also
some weakness of neck flexion and extension.

Upper limb inspection revealed marked distal wasting of the


hands and forearm musculature. There was reduced
tone and supinator
jerks bilaterally with weakness of finger flexion and extension and
also wrist extension. There
was some mild weakness of shoulder
abduction bilaterally.

Lower limb examination revealed wasting around the ankles, with


reduced ankle tone and reflexes and
weakness of dorsiflexion and
plantarflexion. Sensory examination was intact.

Investigations revealed:

Haemoglobin 152 g/L (130-180)

Mean cell volume 93 fL (80-96)

White cell count 5.1 ×109/L (4-11)

Platelets 221 ×109/L (150-400)

Serum sodium 137 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 6.6 mmol/L (2.5-7.5)

Serum creatinine 61 mol/L (60-110)

Serum creatine kinase 170 U/L (24-170)


Plasma lactate 1.2 mmol/L (0.6-1.2)

Fasting plasma glucose 8.2 mmol/L (3-6)

Plasma TSH 4.2 mU/L (0.5-5.0)

Plasma T4 62 nmol/L (58-174)

Plasma T3 1.99 nmol/L (1.07-3.18)

His electrocardiogram is shown below:

How would you investigate this patient?

(Please select 1 option)



DNA analysis for mitochondrial mutations


DNA analysis for mutations in the dystrophin gene


EMG


Tensilon test


Trial of Sinemet

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Work Smart MRCP Part 2 Written July 2011

A 58-year-old male was seen in the neurology clinic having been


referred with weakness of both hands and
Answer Statistics
wrists. In the preceding
week he had been having several falls and his mother, who had
accompanied him, felt
he was dragging his feet whilst walking.
Test Analysis
He had recently been to see his GP because of weight loss and
had been diagnosed with impaired glucose
tolerance. Otherwise he
suffered occasional palpitations, but had no known medical history
and did not take any
regular medication.

Score:

Total Answered:

Feedback

On examination the patient had a monotonous, nasal voice. His


general appearance is shown in the picture.
Question Navigator
Cranial nerve
examination revealed bilateral ptosis, but pupils and fundoscopy
were intact. There was marked
bilateral facial weakness and also
some weakness of neck flexion and extension.
Revision Notes
Upper limb inspection revealed marked distal wasting of the
hands and forearm musculature. There was reduced
tone and supinator
jerks bilaterally with weakness of finger flexion and extension and
also wrist extension. There
was some mild weakness of shoulder
abduction bilaterally. Tags

Lower limb examination revealed wasting around the ankles, with


reduced ankle tone and reflexes and
weakness of dorsiflexion and
plantarflexion. Sensory examination was intact.

Investigations revealed:

Haemoglobin 152 g/L (130-180)

Mean cell volume 93 fL (80-96)

White cell count 5.1 ×109/L (4-11)

Platelets 221 ×109/L (150-400)

Serum sodium 137 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 6.6 mmol/L (2.5-7.5)

Serum creatinine 61 mol/L (60-110)

Serum creatine kinase 170 U/L (24-170)


Plasma lactate 1.2 mmol/L (0.6-1.2)

Fasting plasma glucose 8.2 mmol/L (3-6)

Plasma TSH 4.2 mU/L (0.5-5.0)

Plasma T4 62 nmol/L (58-174)

Plasma T3 1.99 nmol/L (1.07-3.18)

His electrocardiogram is shown below:

How would you investigate this patient?

(Please select 1 option)


DNA analysis for mitochondrial mutations
Incorrect answer selected


DNA analysis for mutations in the dystrophin gene

EMG
This is the correct answer


Tensilon test


Trial of Sinemet

This patient has a history and clinical features in keeping with


a diagnosis of myotonic dystrophy, which is the
most common adult
muscular dystrophy.

Features include:
Frontal baldness in men
Atrophy of temporalis, masseters, facial muscle, and
Bilateral ptosis.

Neck muscles, including sternocleidomastoid, are involved early


in the course of disease.

Cardiac abnormalities are common and include first degree heart


block (shown above) and complete heart block.

Myotonic dystrophy is also associated with:


Intellectual impairment
Gonadal atrophy, and
Insulin resistance.

Diagnosis can be made on electromyogram (EMG) and muscle


biopsy.

Mutations in the dystrophin gene are found in patients with


Duchenne and Becker muscular dystrophy. There is
no maternal
history or elevated lactate to suggest a mitochondrial
disorder.

There is clearly systemic involvement, which is not found in


patients with myasthenia gravis. The history and
clinical signs are
not in keeping with Parkinson's disease.

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Work Smart MRCP Part 2 Written 2007 April

A 23-year-old obese woman presented to the casualty department


with a four day history of progressively
Test Analysis
worsening generalised
headache associated with a buzzing in her ears.

In the last few days she had noticed some blurring of her vision
and reduction in her visual field. She had started
to feel
nauseated particularly early in the morning and on the morning of
admission had vomited several times.
She had a history of severe
acne which was treated with long-term oral doxycycline and smoked
35 cigarettes a
day.

On examination she was orientated with a Glasgow coma scale of


15/15. Visual acuity was recorded as 6/18 in
both eyes. There was
reduction in peripheral visual fields bilaterally and enlargement
of the blind spot bilaterally.
The rest of the neurological
examination was entirely normal.

The fundoscopic appearance is shown below:

Score:

Total Answered:

Question Navigator

Tags

An MRI scan of the brain was normal.

A lumbar puncture was performed and yielded the following


data:

Opening pressure 33 cm H2O (6-18)

CSF protein 0.42 g/L (0.15-0.45)

CSF white cell count 2 cells per mL (<5)

CSF red cell count 2 cells per mL (<5)

CSF oligoclonal bands Negative -

Given the above clinical account, what is the likely cause for
this patient's visual disturbance?

(Please select 1 option)



Benign intracranial hypertension


Central retinal vein occlusion


Optic nerve meningioma


Optic papillitis

Pseudopapilloedema

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Work Smart MRCP Part 2 Written 2007 April

A 23-year-old obese woman presented to the casualty department


with a four day history of progressively
Answer Statistics
worsening generalised
headache associated with a buzzing in her ears.

In the last few days she had noticed some blurring of her vision
and reduction in her visual field. She had started Test Analysis
to feel
nauseated particularly early in the morning and on the morning of
admission had vomited several times.
She had a history of severe
acne which was treated with long-term oral doxycycline and smoked
35 cigarettes a
day.

On examination she was orientated with a Glasgow coma scale of


15/15. Visual acuity was recorded as 6/18 in
both eyes. There was
reduction in peripheral visual fields bilaterally and enlargement
of the blind spot bilaterally.
The rest of the neurological
examination was entirely normal.

The fundoscopic appearance is shown below:

Score:

Total Answered:

Feedback

Question Navigator

Revision Notes

An MRI scan of the brain was normal.


Tags
A lumbar puncture was performed and yielded the following
data:

Opening pressure 33 cm H2O (6-18)

CSF protein 0.42 g/L (0.15-0.45)

CSF white cell count 2 cells per mL (<5)

CSF red cell count 2 cells per mL (<5)

CSF oligoclonal bands Negative -

Given the above clinical account, what is the likely cause for
this patient's visual disturbance?

(Please select 1 option)


Benign intracranial hypertension
Correct


Central retinal vein occlusion


Optic nerve meningioma


Optic papillitis

Pseudopapilloedema

The slide shows papilloedema.

Management of optic disc oedema begins with a correct


diagnosis.

Most importantly, it is crucial to distinguish between


papilloedema and the many other forms of optic disc
oedema,
including 'masqueraders' such as buried optic disc
drusen.

Consider the acuity, visual fields, ophthalmoscopy findings and


especially the laterality of presentation carefully
in the initial
work-up.

Drug induced causes of BIH include vitamin A toxicity, long term


use of tetracyclines, hormone treatments
(contraception most
commonly).

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Work Smart
What is the diagnosis?
Test Analysis

Score:

Total Answered:

Question Navigator

Tags
(Please select 1 option)

Anterior uveitis


Dislocation of the lens


Hyphaema


Hypopyon


Malignant melanoma of the iris

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What is the diagnosis?
Answer Statistics

Test Analysis

Score:

Total Answered:

Feedback
(Please select 1 option)
Anterior uveitis
Incorrect answer selected
Question Navigator

Dislocation of the lens

Hyphaema
This is the correct answer Revision Notes

Hypopyon
Tags

Malignant melanoma of the iris

The slide shows hyphaema: blood in the anterior chamber.

It is usually caused by trauma - often small objects (champagne


corks, squash balls) hitting the eye.

Aspiration may be required to prevent loss of vision.

Reference:

MacEwen CJ. Ocular Injuries. J R Coll Surg Edinb.


1999;44(5):317-23

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A 25-year-old man presents with vague chest pain and cough. He
is a non smoker with no significant PMH.
Test Analysis
His chest x ray, taken in the Emergency department, is
shown.

Score:

Total Answered:

Question Navigator

Tags

What is the most appropriate treatment for this condition?

(Please select 1 option)



Amoxicillin/clavulanate and clarithromycin


Manage by observation, advice and review in 1 week


Intercostal chest drain insertion


Low molecular weight heparin and CTPA


Nebulised salbutamol

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Work Smart
A 25-year-old man presents with vague chest pain and cough. He
is a non smoker with no significant PMH.
Answer Statistics
His chest x ray, taken in the Emergency department, is
shown.
Test Analysis

Score:

Total Answered:

Feedback

Question Navigator

Revision Notes

Tags

What is the most appropriate treatment for this condition?

(Please select 1 option)


Amoxicillin/clavulanate and clarithromycin
Incorrect answer selected

Manage by observation, advice and review in 1 week


This is the correct answer


Intercostal chest drain insertion


Low molecular weight heparin and CTPA


Nebulised salbutamol

The slide shows a small right apical pneumothorax less than 2cm
in size.

Given there is no actual breathlessness careful observation,


advice to return if symptoms deteriorate and call
back to clinic is
sufficient treatment; neither aspiration nor chest drain insertion
is required.

Reference:

MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British


Thoracic Society Pleural
Disease Guideline 2010.
Thorax. 2010;65 Suppl 2:ii18-31.

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A 19-year-old male presented with pleuritic chest pain which
occurred suddenly while playing football. He
Test Analysis
presented to the
Emergency department complaining of dyspnoea. His chest x ray is
shown.

Score:

Total Answered:

Question Navigator

Tags
Which of the following would be the definitive treatment for
this condition?

(Please select 1 option)



High-flow inspired oxygen


Intercostal chest drain insertion


Intravenous amoxicillin + clarithromycin


Low molecular weight heparin


Nebulised salbutamol

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A 19-year-old male presented with pleuritic chest pain which
occurred suddenly while playing football. He
Answer Statistics
presented to the
Emergency department complaining of dyspnoea. His chest x ray is
shown.

Test Analysis

Score:

Total Answered:

Feedback
Which of the following would be the definitive treatment for
this condition?

(Please select 1 option)


Question Navigator
High-flow inspired oxygen
Incorrect answer selected

Intercostal chest drain insertion


This is the correct answer Revision Notes

Intravenous amoxicillin + clarithromycin
Tags

Low molecular weight heparin


Nebulised salbutamol

The slide shows a large left-sided tension pneumothorax.

The left hemithorax is hyperinflated with loss of lung markings


peripherally. This is particularly noticeable in the
left lower
zone. There is also a mediastinal shift away from the midline
towards the right.

This is a classical presentation of pneumothorax: young fit male


(often tall) who develops chest pain and
shortness of breath while
exercising.

What are the alternatives presented here?


This would be an unusual presentation of PE
There is no history of wheeze to suggest
bronchoconstriction
There is no consolidation on the CXR
Nor any suggestion in the history that suggests infection.

Having ruled out these alternatives you have two options that
might be used to treat pneumothorax (oxygen or
chest tube).
If you realise that this is a pneumothorax, the question tries
to establish whether you are aware of the
circumstances in which
oxygen alone is adequate versus those in which chest tube insertion
is necessary.

Where there is a tension pneumothorax neither oxygen alone nor


needle aspiration would be appropriate and a
chest tube must be
inserted.

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This patient was brought in to hospital unresponsive.
Test Analysis

Score:

Total Answered:
Which of the following is the most appropriate initial step in
management?

(Please select 1 option) Question Navigator



Administration of intravenous cefotaxime


Blood glucose Tags

CT head scan


Full blood count


Lumbar puncture

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This patient was brought in to hospital unresponsive.
Answer Statistics

Test Analysis

Which of the following is the most appropriate initial step in


management? Score:

(Please select 1 option) Total Answered:


Administration of intravenous cefotaxime
Correct


Blood glucose Feedback

CT head scan
Question Navigator

Full blood count


Lumbar puncture Revision Notes

Tags
The picture shows a purpuric rash of meningococcal
septicaemia.

All the options are relevant in the overall management of a


patient with meningococcal disease. However,
administration of
intravenous antibiotics is the greatest priority - regardless of
whether cultures have been sent.

Further Reading:

Meningitis Research Foundation. Early Management of Suspected Bacterial Meningitis


and Meningococcal
Septicaemia in Immunocompetent Adults

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This patient was admitted to hospital with severe central
abdominal pain.
Test Analysis

Score:

Total Answered:

Question Navigator

What name is given to this appearance?


Tags
(Please select 1 option)

Adenoma sebaceum


Chickenpox


Condyloma acuminatum


Eruptive xanthomata


Tophaceous gout

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This patient was admitted to hospital with severe central
abdominal pain.
Answer Statistics

Test Analysis

Score:

Total Answered:

What name is given to this appearance?


Feedback
(Please select 1 option)
Adenoma sebaceum
Incorrect answer selected Question Navigator

Chickenpox
Revision Notes

Condyloma acuminatum

Eruptive xanthomata
This is the correct answer
Tags

Tophaceous gout

Typical lesions of eruptive xanthomata are shown: raised


lesions, typically occurring on extensor surfaces.

Eruptive xanthomata occur in hyperlipidaemic states associated


with hypertriglyceridaemia.

Well-recognised associations of hypertriglyceridaemia include


acute pancreatitis and lipaemia retinalis.

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Work Smart MRCP Part 2 Written 2006 December

Test Analysis

Score:

What is the diagnosis? Total Answered:

(Please select 1 option)



Central retinal artery occlusion Question Navigator

Central retinal vein occlusion
Tags

Cytmegalovirus retinitis


Retinal detachment


Toxoplasma retinitis

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Work Smart MRCP Part 2 Written 2006 December

Answer Statistics

Test Analysis

What is the diagnosis?


Score:
(Please select 1 option)
Total Answered:
Central retinal artery occlusion
Incorrect answer selected

Central retinal vein occlusion


This is the correct answer
Feedback

Cytmegalovirus retinitis


Retinal detachment Question Navigator

Toxoplasma retinitis
Revision Notes

The slide shows the typical appearance of central retinal vein


occlusion.
Tags
"Patients usually present with painless loss of vision and
are found to have diffuse retinal hemorrhages in all four
quadrants
of the retina as well as dilated, tortuous veins, cotton-wool
spots, disc edema, optociliary shunt
vessels and neovessels might
also be present. Multiple etiologies should be considered
including: hypertension,
glaucoma, optic disc edema,
hypercoagulable states, vasculitis, drug-induced, and retrobulbar
compression by
tumors or grave's
opthalmopathy."1

Reference:

1. Zein W. Retinal Vein Occlusion. http://www.eyeweb.org/rvo.htm (accessed 28


September 2012)

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Work Smart MRCP Part 2 Written 2007 April

This 80-year-old lady presented with congestive cardiac


failure.
Test Analysis

Score:

Total Answered:

Question Navigator

Tags

What is the diagnosis?

(Please select 1 option)



Achondroplasia


Paget's disease of bone


Rickets


Scurvy


Syphilis
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Work Smart MRCP Part 2 Written 2007 April

This 80-year-old lady presented with congestive cardiac


failure.
Answer Statistics

Test Analysis

Score:

Total Answered:

Feedback

Question Navigator

Revision Notes

Tags

What is the diagnosis?

(Please select 1 option)


Achondroplasia
Incorrect answer selected

Paget's disease of bone


This is the correct answer


Rickets


Scurvy


Syphilis
Typical appearance of pagetic tibiae is shown, with
characteristic bowing.

Complications of Paget's disease include:


Bone pain
Pathological fractures
Nerve deafness
Spinal cord compression
High-output cardiac failure and
Osteosarcoma.

The latter affects ~1% of patients who have had the disease for
over 10 years.

Bowing of the tibia may also be a feature of rickets, syphilis


and achondroplasia.

Further Reading:

NHS Choices. Paget's disease.

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A 47-year-old woman was seen in general medical clinic
complaining of a three month history of progressive
Test Analysis
diffuse myalgia
and weakness.

The weakness appeared to affect her shoulder muscles and thighs,


and she had noticed she was experiencing
great difficulty in
walking up and down stairs. She had not noticed any weakness of
ocular muscles or any
swallowing, speech or breathing problems. She
had a past medical history of hypertension and hyperlipidaemia
and
took regular atenolol and simvastatin. She was a smoker of 10
cigarettes per day and did not drink alcohol.

On examination her blood pressure was 135/85 mmHg, pulse 67


beats per minute and regular with a
temperature 36.1°C.
Auscultation of the chest and heart revealed normal heart sounds
with some bilateral
expiratory wheeze. Examination of the cranial
nerves revealed no abnormalities and there was no detectable
neck
weakness.

On upper limb examination there was general myalgia, but no


evidence of wasting. Tone, reflexes and sensation
were all normal,
but there was proximal weakness of 3/5 with preserved distal power.
There was a similar
pattern of weakness in the lower limb with
preserved tone, reflexes and sensation.

Investigations showed:
Score:
Haemoglobin 124 g/L (130-180) Total Answered:
White cell count 6.0 ×109/L (4-11)

Platelets 267 ×109/L (150-400) Question Navigator

ESR (Westergren) 15 mm/1st hour (0-15)


Tags
Serum sodium 135 mmol/L (137-144)

Serum potassium 4.8 mmol/L (3.5-4.9)

Serum urea 6.2 mmol/L (2.5-7.5)

Serum creatinine 120 µmol/L (60-110)

Plasma lactate 1.2 mmol/L (0.6-1.8)

Serum creatine kinase 599 U/L (24-170)

Fasting plasma glucose 4.6 mmol/L (3-6)

Serum cholesterol 3.6 mmol/L (<5.2)

Plasma TSH 4.1 mU/L (0.5-5.0)

Plasma T4 63 nmol/L (58-174)

Plasma T3 2.6 nmol/L (1.07-3.18)

Urinalysis was normal.

What is the likely diagnosis?

(Please select 1 option)



Inclusion body myositis


McArdle's disease


Mitochondrial myopathy


Neuroleptic malignant syndrome

Statin-induced myopathy

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A 47-year-old woman was seen in general medical clinic
complaining of a three month history of progressive
Answer Statistics
diffuse myalgia
and weakness.

The weakness appeared to affect her shoulder muscles and thighs,


and she had noticed she was experiencing Test Analysis
great difficulty in
walking up and down stairs. She had not noticed any weakness of
ocular muscles or any
swallowing, speech or breathing problems. She
had a past medical history of hypertension and hyperlipidaemia
and
took regular atenolol and simvastatin. She was a smoker of 10
cigarettes per day and did not drink alcohol.

On examination her blood pressure was 135/85 mmHg, pulse 67


beats per minute and regular with a
temperature 36.1°C.
Auscultation of the chest and heart revealed normal heart sounds
with some bilateral
expiratory wheeze. Examination of the cranial
nerves revealed no abnormalities and there was no detectable
neck
weakness.

On upper limb examination there was general myalgia, but no


evidence of wasting. Tone, reflexes and sensation
were all normal,
but there was proximal weakness of 3/5 with preserved distal power.
There was a similar
pattern of weakness in the lower limb with
preserved tone, reflexes and sensation.

Investigations showed:

Haemoglobin 124 g/L (130-180)

White cell count 6.0 ×109/L (4-11)


Score:

267 ×109/L Total Answered:


Platelets (150-400)

ESR (Westergren) 15 mm/1st hour (0-15)


Feedback
Serum sodium 135 mmol/L (137-144)

Serum potassium 4.8 mmol/L (3.5-4.9) Question Navigator


Serum urea 6.2 mmol/L (2.5-7.5)

Serum creatinine 120 µmol/L (60-110) Revision Notes


Plasma lactate 1.2 mmol/L (0.6-1.8)
Tags
Serum creatine kinase 599 U/L (24-170)

Fasting plasma glucose 4.6 mmol/L (3-6)

Serum cholesterol 3.6 mmol/L (<5.2)

Plasma TSH 4.1 mU/L (0.5-5.0)

Plasma T4 63 nmol/L (58-174)

Plasma T3 2.6 nmol/L (1.07-3.18)

Urinalysis was normal.

What is the likely diagnosis?

(Please select 1 option)


Inclusion body myositis
Incorrect answer selected


McArdle's disease


Mitochondrial myopathy


Neuroleptic malignant syndrome
Statin-induced myopathy
This is the correct answer

Myalgia, myositis and myopathy are all recognised effects of


HMG-CoA reductase inhibitors (statins). There is an
increased
incidence when statins are co-administered with a fibrate or when
given to patients on
immunosuppressants. Unless therapy is
withdrawn, rhabdomyolysis may ensue often associated with acute

renal failure secondary to myoglobinuria.

Inclusion body myositis is an inflammatory myopathy producing


distal and asymmetric weakness.

McArdle's disease tends to present in children with painful


muscle cramps and myoglobinuria after intense
exercise. It is an
autosomal recessive condition resulting myophosphorylase deficiency
which leads to an
inability to utilise glucose.

There are no extra neurological features to suggest a


mitochondrial disorder and the plasma lactate is normal.

Neuroleptic malignant syndrome is caused by anti-psychotic


medication.

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The following arterial blood gases (ABGs) were taken from an
unconscious 45-year-old man in the Emergency
Test Analysis
department:

pH 7.36 (7.36-7.44)

pO2 13.0 kPa (11.3-12.6)

pCO2 3.7 kPa (4.7-6.0)

HCO3− 15 mmol/L (20-28)

Which is the correct interpretation of the ABG result?

(Please select 1 option)



Compensated metabolic acidosis


Compensated metabolic alkalosis


Compensated respiratory acidosis
Score:

Compensated respiratory alkalosis
Total Answered:

Delayed analysis of ABG sample

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The following arterial blood gases (ABGs) were taken from an
unconscious 45-year-old man in the Emergency
Answer Statistics
department:

pH 7.36 (7.36-7.44) Test Analysis


pO2 13.0 kPa (11.3-12.6)

pCO2 3.7 kPa (4.7-6.0)

HCO3− 15 mmol/L (20-28)

Which is the correct interpretation of the ABG result?

(Please select 1 option)


Compensated metabolic acidosis
Correct


Compensated metabolic alkalosis


Compensated respiratory acidosis


Compensated respiratory alkalosis


Delayed analysis of ABG sample
Score:

Total Answered:
The pH and bicarbonate results suggest that there is an
acidosis. In a respiratory acidosis one would expect the
carbon
dioxide to be high. In this case the CO2 is low,
favouring metabolic acidosis.
Feedback
Some degree of respiratory compensation of the acidosis is seen.
Typically, a patient's respiratory rate increases
with
increased respiratory effort. This allows some of the excess
H+ to be excreted as CO2 helping to prevent Question Navigator

large variations in pH.

H+ + HCO3−  → H2O +
CO2 Revision Notes
This deep and rapid breathing can lead to oxygen levels which
are high or high-normal. An alternative
explanation for the high
oxygen levels here is that the patient may be receiving oxygen
therapy in the Tags
Emergency department.

Delayed analysis of an ABG sample can result in a spuriously low


pO2. There is no reason to suspect this has
occurred in
this case.

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A 62-year-old female is referred with mild confusion.
Test Analysis
She has a history of depression, type 2 diabetes mellitus and
angina for which she takes a variety of
medications.

Investigations reveal:

Sodium concentration 123 mmol/L (137-144)

Potassium 3.4 mmol/L (3.5-4.9)

Urea 5.2 mmol/L (2.5-7.5)

Creatinine 70 µmol/L (60-110)

Plasma osmolality 260 mosmol/L

Urine osmolality 650 mosmol/L

Urine sodium concentration 38 mmol/L

What agent may be responsible for her presentation?


Score:
(Please select 1 option)
Total Answered:

Fluoxetine


Lisinopril Question Navigator

Lithium


Metformin
Tags


Pioglitazone

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A 62-year-old female is referred with mild confusion.
Answer Statistics
She has a history of depression, type 2 diabetes mellitus and
angina for which she takes a variety of
medications. Test Analysis
Investigations reveal:

Sodium concentration 123 mmol/L (137-144)

Potassium 3.4 mmol/L (3.5-4.9)

Urea 5.2 mmol/L (2.5-7.5)

Creatinine 70 µmol/L (60-110)

Plasma osmolality 260 mosmol/L

Urine osmolality 650 mosmol/L

Urine sodium concentration 38 mmol/L

What agent may be responsible for her presentation?

(Please select 1 option)


Fluoxetine
Correct Score:


Lisinopril Total Answered:


Lithium


Metformin
Feedback


Pioglitazone
Question Navigator

This patient has syndrome of inappropriate antidiuretic hormone


(SIADH) as suggested by the hyponatraemia Revision Notes
with high urine sodium
and osmolality.

Drugs that may cause SIADH include: Tags


Selective serotonin reuptake inhibitors (SSRIs)
(fluoxetine)
Tricyclic antidepressants
Sulphonylureas
Thiazides, and
Carbamazepine.

Other causes of SIADH include:


Pneumonias
Meningitis Guillain-Barré
Trauma, and
Malignancy.

Lithium would cause diabetes insipidus (DI).

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A 34-year-old male presents on the neurology ward with headache
and breathlessness. He has a tetraplegia due
Test Analysis
to trauma to the
cervical spine at level C5 which he sustained approximately two
weeks ago in a rugby match.

Examination reveals a flushed appearance, a temperature of


37.5°C, a blood pressure of 220/110 mmHg and a
pulse of 60 bpm
regular. His JVP is not elevated and chest and heart examinations
are normal. Examination of
the abdomen reveals no specific
abnormality with a urinary catheter in situ although this appears
to have
become blocked over the last two hours.

From the following list, what is the most likely explanation for
his current symptoms?

(Please select 1 option)



Acute renal failure


Autonomic dysreflexia


Phaeochromocytoma


Pulmonary embolism


Reflex sympathetic dystrophy Score:

Total Answered:

Submit answer
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A 34-year-old male presents on the neurology ward with headache
and breathlessness. He has a tetraplegia due
Answer Statistics
to trauma to the
cervical spine at level C5 which he sustained approximately two
weeks ago in a rugby match.

Examination reveals a flushed appearance, a temperature of


37.5°C, a blood pressure of 220/110 mmHg and a Test Analysis
pulse of 60 bpm
regular. His JVP is not elevated and chest and heart examinations
are normal. Examination of
the abdomen reveals no specific
abnormality with a urinary catheter in situ although this appears
to have
become blocked over the last two hours.

From the following list, what is the most likely explanation for
his current symptoms?

(Please select 1 option)


Acute renal failure
Incorrect answer selected

Autonomic dysreflexia
This is the correct answer


Phaeochromocytoma


Pulmonary embolism


Reflex sympathetic dystrophy

Score:
This patient has autonomic dysreflexia which is a poorly
understood condition associated with abnormal control
of the
autonomic nervous system in quadriplegic patients. Total Answered:

It affects approximately 85% of patients with a lesion above C6


and may be triggered by cystitis, retention of
urine or a blocked
catheter as in this case, or constipation. Feedback

The increased sympathetic activity results in vasoconstriction


and hypertension with stimulation of the carotid
and aortic
baroreceptors. These in turn respond via the vasomotor centre with
increased vagal tone resulting in
Question Navigator
a bradycardia but reduced
sympathetic tone with vasodilatation not possible due to the cord
damage.
Revision Notes
Treatment relies upon recognition and removal of the noxious
stimulus.

Vasodilators such as calcium antagonists may be used to treat


the hypertension. Tags

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A 28-year-old lady presents with a three day history of a
painful swollen right calf.
Test Analysis
Her coagulation screen shows:

Prothrombin time 13 s (11.5-15.5)

Thrombin time 13 s (13)

Activated partial thromboplastin time 78 s (30-40)

The APTT was not corrected when mixed with normal plasma.

What is the cause of the clotting abnormality?

(Please select 1 option)



Chronic liver disease


Disseminated intravascular coagulation


Haemophilia
Score:

Lupus anticoagulant
Total Answered:

von Willebrand disease

Question Navigator

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A 28-year-old lady presents with a three day history of a
painful swollen right calf.
Answer Statistics
Her coagulation screen shows:

Prothrombin time 13 s (11.5-15.5)


Test Analysis

Thrombin time 13 s (13)

Activated partial thromboplastin time 78 s (30-40)

The APTT was not corrected when mixed with normal plasma.

What is the cause of the clotting abnormality?

(Please select 1 option)


Chronic liver disease
Incorrect answer selected


Disseminated intravascular coagulation


Haemophilia

Lupus anticoagulant
This is the correct answer


von Willebrand disease
Score:

Total Answered:
The abnormality shown is a prolonged APTT.

Chronic liver disease would cause a prolonged prothrombin time


(PT) so this can be excluded immediately. Feedback
All the other options are causes of prolonged APTT but it is
only lupus anticoagulant that does not correct when
mixed with
normal plasma. Question Navigator

Also the clues in the case history are young female and
suspected DVT, which with recurrent miscarriages,
Revision Notes
strokes and
thrombocytopenia, are features of the antiphospholipid
syndrome.

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You are called to see a 58-year-old lady on the ward because the
nursing staff have noticed the following
Test Analysis
abnormality of her
eye.

She is an inpatient with a history of paroxysmal atrial


fibrillation and rheumatoid arthritis. The lady complains only
of a
minor ache in the eye.

Score:

Total Answered:

Question Navigator

Tags

Which of her medication is a likely cause of the lesion?

(Please select 1 option)



Amiodarone


Aspirin


Folic acid


Meloxicam


Methotrexate

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You are called to see a 58-year-old lady on the ward because the
nursing staff have noticed the following
Answer Statistics
abnormality of her
eye.

She is an inpatient with a history of paroxysmal atrial


fibrillation and rheumatoid arthritis. The lady complains only Test Analysis
of a
minor ache in the eye.

Score:

Total Answered:

Feedback

Question Navigator

Revision Notes
Which of her medication is a likely cause of the lesion?
Tags
(Please select 1 option)
Amiodarone
Incorrect answer selected

Aspirin
This is the correct answer


Folic acid


Meloxicam


Methotrexate

The picture shows a subconjunctival haemorrhage which is an


alarming adverse effect of aspirin therapy (and
other
antiplatelets).

It usually resolves over 10-14 days.

If the haematoma is large it may be worth considering


prophylactic antibiotic eyedrops.

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These are the shins of a 73-year-old female who is admitted as a
consequence of increasing confusion and
Test Analysis
inability to look after
herself.

Which one of the following investigations would be most likely


to confirm the underlying diagnosis? Score:

(Please select 1 option) Total Answered:



CT head scan


Plasma glucose concentration Question Navigator

Thyroid function tests
Tags

Urea and electrolytes


Vitamin B12

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These are the shins of a 73-year-old female who is admitted as a
consequence of increasing confusion and
Answer Statistics
inability to look after
herself.

Test Analysis

Which one of the following investigations would be most likely


to confirm the underlying diagnosis?

(Please select 1 option)


CT head scan
Incorrect answer selected Score:


Plasma glucose concentration Total Answered:

Thyroid function tests


This is the correct answer
Feedback

Urea and electrolytes


Vitamin B12 Question Navigator

Revision Notes
The diagnosis is erythema ab igne and this is due to sitting too
close to a fire. It frequently occurs on the front of
the shins or
lower back, the latter especially associated with the use of a hot
water bottle.
Tags
In this patient's case the confusion and coldness with
erythema ab igne suggest a diagnosis of hypothyroidism.

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A 65-year-old male is admitted after being found by the police
collapsed in the centre of town. He is a known
Test Analysis
alcoholic and is
dishevelled and dirty.

Examination reveals a confused male with a Glasgow coma scale of


13, a temperature of 37°C, a pulse of 110
bpm regular and a blood
pressure of 138/96 mmHg with oxygen saturations of 98%. There are
no specific
abnormalities on examination, with normal reflexes,
tone and down going plantars. He has a respiratory rate of
30 per
minute.

Investigations show:

Haemoglobin 115 g/L (130-180)

MCV 102 fL (80-96)

White cell count 8.2 ×109/L (4-11)

Platelets 150 ×109/L (150-400)

Serum sodium 136 mmol/L (137-144)

Serum potassium 3.6 mmol/L (3.5-4.9) Score:

Serum urea 7.0 mmol/L (2.5-7.5) Total Answered:


Serum creatinine 120 µmol/L (60-110)

Plasma glucose 5.2 mmol/L (3.0-6.0) Question Navigator

Arterial blood gas analysis shows:


Tags
pH 7.24 (7.36-7.44)

pO2 14.7 kPa / 110 mmHg (11.3-12.6)

pCO2 4.0 kPa / 30 mmHg (4.7-6.0)

Standard HCO3 17 mmol/L (20-28)

Which investigation is most likely to assist with a


diagnosis?

(Please select 1 option)



Ammonia concentration


Benzodiazepine concentration


Methanol concentration


Salicylate concentration


Vitamin B12 levels

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A 65-year-old male is admitted after being found by the police
collapsed in the centre of town. He is a known
Answer Statistics
alcoholic and is
dishevelled and dirty.

Examination reveals a confused male with a Glasgow coma scale of


13, a temperature of 37°C, a pulse of 110 Test Analysis
bpm regular and a blood
pressure of 138/96 mmHg with oxygen saturations of 98%. There are
no specific
abnormalities on examination, with normal reflexes,
tone and down going plantars. He has a respiratory rate of
30 per
minute.

Investigations show:

Haemoglobin 115 g/L (130-180)

MCV 102 fL (80-96)

White cell count 8.2 ×109/L (4-11)

Platelets 150 ×109/L (150-400)

Serum sodium 136 mmol/L (137-144)

Serum potassium 3.6 mmol/L (3.5-4.9)

Serum urea 7.0 mmol/L (2.5-7.5)


Score:
Serum creatinine 120 µmol/L (60-110)

Plasma glucose 5.2 mmol/L (3.0-6.0) Total Answered:

Arterial blood gas analysis shows:


Feedback
pH 7.24 (7.36-7.44)

pO2 14.7 kPa / 110 mmHg (11.3-12.6) Question Navigator


pCO2 4.0 kPa / 30 mmHg (4.7-6.0)
Revision Notes
Standard HCO3 17 mmol/L (20-28)

Tags
Which investigation is most likely to assist with a
diagnosis?

(Please select 1 option)


Ammonia concentration
Incorrect answer selected


Benzodiazepine concentration

Methanol concentration
This is the correct answer


Salicylate concentration


Vitamin B12 levels

This patient has a metabolic acidosis and reduced conscious


level that exceeds the metabolic derangement.

His alcohol history and appearance suggests consumption of


methanol which is a weak acid and would account
for this clinical
picture and the biochemical abnormalities.

Salicylate overdose is another possibility but less likely.

Benzodiazepines would be expected to cause respiratory


depression and respiratory acidosis.
His increased mean corpuscular volume (MCV) is more than likely
due to his alcohol abuse and B12
concentrations would not be
helpful.

This presentation is not typical of hepatic encephalopathy as


flapping tremor is expected and extensor plantar
responses.

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Test Analysis

Which of the following agents is the most appropriate to treat


this lesion?

(Please select 1 option) Score:



Aciclovir eye drops Total Answered:

Ganciclovir ocular implant


Gentamicin eye drops Question Navigator

Steroid eye drops
Tags

Systemic glucocorticoids

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Answer Statistics

Test Analysis

Which of the following agents is the most appropriate to treat


this lesion?

(Please select 1 option)


Aciclovir eye drops
Correct


Ganciclovir ocular implant
Score:


Gentamicin eye drops
Total Answered:


Steroid eye drops
Feedback

Systemic glucocorticoids

Question Navigator
Dendritic ulcers are caused by herpes simplex virus.
Revision Notes
Presentation is usually with pain, photophobia, blurred vision,
conjunctivitis and chemosis.

Steroid eye drops are contraindicated as they may induce massive


amoeboid ulceration and blindness. Tags
They are treated with aciclovir eye drops, which should be
continued for three days after the ulcer has healed.

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A 30-year-old male HIV positive patient is admitted with


Pneumocystis jirovici pneumonia (PCP). He stopped
Test Analysis
taking
co-trimoxazole therapy three weeks previously due to a rash.

Blood gases reveal:

pH 7.02 (7.36-7.44)

pCO2 5.3 kPa (4.7-6.0)

pO2 7.3 kPa (11.3-12.6)

Which of the following drug combinations would you select as


treatment for this patient?

(Please select 1 option)



Ciprofloxacin, metronidazole and nebulised pentamidine


Clindamycin, primaquine and prednisolone


High dose Co-trimoxazole and prednisolone
Score:

Infliximab, Ticarcillin and iv pentamidine
Total Answered:

Rifampicin and isoniazid

Question Navigator

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Work Smart MRCP Part 2 Written 2007 July

A 30-year-old male HIV positive patient is admitted with


Pneumocystis jirovici pneumonia (PCP). He stopped
Answer Statistics
taking
co-trimoxazole therapy three weeks previously due to a rash.

Blood gases reveal: Test Analysis


pH 7.02 (7.36-7.44)

pCO2 5.3 kPa (4.7-6.0)

pO2 7.3 kPa (11.3-12.6)

Which of the following drug combinations would you select as


treatment for this patient?

(Please select 1 option)


Ciprofloxacin, metronidazole and nebulised pentamidine
Incorrect answer selected

Clindamycin, primaquine and prednisolone


This is the correct answer


High dose Co-trimoxazole and prednisolone


Infliximab, Ticarcillin and iv pentamidine


Rifampicin and isoniazid
Score:

Total Answered:
This patient has severe PCP suggested by the pO2
below 10.

As he is allergic to co-trimoxazole alternative therapy would be


IV pentamidine or clindamycin with primaquine. Feedback
Steroids have been shown to reduce mortality and prevent lung
damage in people with moderate-to-severe PCP.
(The severity is
determined on the basis of arterial blood gas results. Question Navigator

These agents are used as adjunctive initial therapy only in


patients with HIV infection who have severe PCP as
Revision Notes
defined by a
room air arterial oxygen pressure of less than 70 mmHg or an
arterial-alveolar O2 gradient that
exceeds 35 mmHg.
Tags
It is important that steroids be started right away if they are
indicated, because their purpose is to keep people
stable during
those first few days of treatment. While it is true that long term
steroid use is immunosuppressive a
21 day tapering course has been
shown to be safe and effective.

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A 16-year-old girl is brought to casualty by her parents.
Test Analysis
She has a two day history of general malaise, vomiting and vague
abdominal discomfort. Over the past twelve
hours she has become
increasingly drowsy.

On examination she was unresponsive to verbal commands. Her


temperature 36.5°C, BP 74/48 mmHg.

Investigations revealed:
Sodium 121 mmol/L (137-144)

Potassium 6.2 mmol/L (3.5-4.9)

Urea 11.6 mmol/L (2.5-7.5)

Creatinine 162 µmol/L (60-110)

Glucose 1.1 mmol/L (3.0-6.0)

Chloride 91 mmol/L (95-107)

Bicarbonate 14 mmol/L (20-28)


Score:
After giving emergency treatment, what single investigation
would be of most value in confirming the diagnosis?
Total Answered:
(Please select 1 option)

Autoantibody screen
Question Navigator

CT scan abdomen


Fasting blood glucose Tags

Insulin + C peptide levels


Tetracosactrin (Synacthen) test

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A 16-year-old girl is brought to casualty by her parents.
Answer Statistics
She has a two day history of general malaise, vomiting and vague
abdominal discomfort. Over the past twelve
hours she has become
increasingly drowsy. Test Analysis
On examination she was unresponsive to verbal commands. Her
temperature 36.5°C, BP 74/48 mmHg.

Investigations revealed:
Sodium 121 mmol/L (137-144)

Potassium 6.2 mmol/L (3.5-4.9)

Urea 11.6 mmol/L (2.5-7.5)

Creatinine 162 µmol/L (60-110)

Glucose 1.1 mmol/L (3.0-6.0)

Chloride 91 mmol/L (95-107)

Bicarbonate 14 mmol/L (20-28)

After giving emergency treatment, what single investigation


would be of most value in confirming the diagnosis?

(Please select 1 option) Score:


Autoantibody screen
Incorrect answer selected
Total Answered:

CT scan abdomen


Fasting blood glucose Feedback

Insulin + C peptide levels
Question Navigator
Tetracosactrin (Synacthen) test
This is the correct answer

Revision Notes
The patient has presented with an addisonian crisis.

A definitive diagnosis is made with a Synacthen test. Tags

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A 76-year-old lady had a GI bleed 10 months ago related to NSAID
use for osteoarthritis. At that time an
Test Analysis
endoscopy showed a duodenal
ulcer which was treated. She now represents with an acute
haematemesis
following re-prescription of diclofenac with
misoprostol.

Her haemoglobin on admission is 56 g/L. OGD is performed,


showing a single bleeding vessel on the posterior
wall of the
duodenum. Adrenaline injection and clipping fail to control the
bleeding.

What is the next step in her management?

(Please select 1 option)



IV Omeprazole


Octreotide


Repeat endscopy the next day


Terlipressin


Urgent referral to on-call surgeons
Score:

Total Answered:

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A 76-year-old lady had a GI bleed 10 months ago related to NSAID
use for osteoarthritis. At that time an
Answer Statistics
endoscopy showed a duodenal
ulcer which was treated. She now represents with an acute
haematemesis
following re-prescription of diclofenac with
misoprostol.
Test Analysis
Her haemoglobin on admission is 56 g/L. OGD is performed,
showing a single bleeding vessel on the posterior
wall of the
duodenum. Adrenaline injection and clipping fail to control the
bleeding.

What is the next step in her management?

(Please select 1 option)


IV Omeprazole
Incorrect answer selected


Octreotide


Repeat endscopy the next day


Terlipressin

Urgent referral to on-call surgeons


This is the correct answer

This lady has lost a lot of blood and has ongoing bleeding
despite endoscopic intervention. She requires urgent
Score:
surgery and
oversewing of the bleeding vessel. Interventional radiology for
embolisation of the vessel would be
a potential alternative route
that could be considered depending upon availability of the service
and the patient's Total Answered:
operative risk.

It would be appropriate to use omeprazole postoperatively to


promote ulcer healing. Omeprazole will not stop Feedback
bleeding from a
visible vessel.

Terlipressin and octreotide decrease portal blood pressure and


have an established role in variceal
Question Navigator
haemorrhage, but not in peptic
ulcer disease.
Revision Notes

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Four politicians are rushed into the Emergency department. They
were set upon by an individual as they left a
Test Analysis
meeting. The
individual had two aerosol cans which he sprayed in front of their
faces.

On presentation, all of the men had profuse lacrimation,


chemosis, pain around the eyes and injected cornea.
Slit-lamp
examination revealed severe corneal injuries. There was no
demonstrable neurological deficit in any of
the patients, but all
four men complained of shortness of breath, cough and wheeze. All
the men were pyrexic,
nauseated, and all developed diarrhoea within
two hours of admission.

Initially, blood gases were normal, but after two hours,


arterial blood gases in the most severely affected man
showed:

On FiO2 35% -

pO2 8.0 kPa (11.3-12.6)

pCO2 6.5 kPa (4.7-6.0)

HCO3 30 mmol/L -
Score:
Base Excess −2 mmol/L (+/− 2)
Total Answered:
Within 18 hours, the two men who had received the greatest
exposure to the spray had developed haemoptysis
and progressive
dyspnoea. Chest x ray at this time showed bilateral pleural
effusions, with widespread alveolar
shadowing. The severely
affected patients were intubated and ventilated but, with maximal
supportive care, they Question Navigator
died; one 36 hours later, the other at 40
hours.

The two surviving patients received full supportive care, but


also required intubation and ventilation. Both men Tags
required
treatment for pulmonary oedema, and severe dehydration secondary to
profuse, blood stained
diarrhoea. One of the men had an OGD after
an episode of melaena which showed widespread, severe,
inflammatory
gastritis. Both men eventually recovered after a prolonged hospital
stay.

What was the substance present in the aerosol that is most


likely to have caused the described syndrome in
these patients?

(Please select 1 option)



Anthrax


Paraquat


Pepper spray


Ricin


Sarin

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Work Smart
Four politicians are rushed into the Emergency department. They
were set upon by an individual as they left a
Answer Statistics
meeting. The
individual had two aerosol cans which he sprayed in front of their
faces.

On presentation, all of the men had profuse lacrimation,


chemosis, pain around the eyes and injected cornea. Test Analysis
Slit-lamp
examination revealed severe corneal injuries. There was no
demonstrable neurological deficit in any of
the patients, but all
four men complained of shortness of breath, cough and wheeze. All
the men were pyrexic,
nauseated, and all developed diarrhoea within
two hours of admission.

Initially, blood gases were normal, but after two hours,


arterial blood gases in the most severely affected man
showed:

On FiO2 35% -

pO2 8.0 kPa (11.3-12.6)

pCO2 6.5 kPa (4.7-6.0)

HCO3 30 mmol/L -

Base Excess −2 mmol/L (+/− 2)

Within 18 hours, the two men who had received the greatest
exposure to the spray had developed haemoptysis Score:
and progressive
dyspnoea. Chest x ray at this time showed bilateral pleural
effusions, with widespread alveolar
shadowing. The severely
affected patients were intubated and ventilated but, with maximal
supportive care, they Total Answered:
died; one 36 hours later, the other at 40
hours.

The two surviving patients received full supportive care, but


also required intubation and ventilation. Both men Feedback
required
treatment for pulmonary oedema, and severe dehydration secondary to
profuse, blood stained
diarrhoea. One of the men had an OGD after
an episode of melaena which showed widespread, severe, Question Navigator
inflammatory
gastritis. Both men eventually recovered after a prolonged hospital
stay.

What was the substance present in the aerosol that is most


likely to have caused the described syndrome in Revision Notes
these patients?

(Please select 1 option)


Tags
Anthrax
Incorrect answer selected


Paraquat


Pepper spray

Ricin
This is the correct answer


Sarin

Given the circumstances, the current political climate, and the


rising risk of bioterrorism, vigilance is required in
the emergency
department.

The arterial blood gases show acute respiratory failure. In this


case, the rapid time course to severe symptoms
and death would be
unusual for infectious agents. Anthrax is therefore unlikely.

Pepper spray gives symptoms which last for approximately 40


minutes and is not associated with death, unless it
leads to
exacerbation of asthma/chronic obstructive pulmonary disease.

Paraquat usually requires ingestion to be fatal, but it can be


absorbed through mucous membranes. Usually,
inhalation of spray is
unlikely to cause systemic toxicity because of its low vapour
pressure and the large
droplets that are formed.

Sarin has muscarinic and nicotinic effects.

Muscarinic effects:
Paralysis
Fasciculations
Hyperglycaemia, and
Ketosis.

Nicotinic effects:
Hypotension
Meiosis
Dyspnoea, and
GI disturbance.

There is not a great deal of evidence of how ricin poisoning


inhalation may present, but animal studies and
anecdotal reports of
deaths caused by ricin poisoning give us a good idea.

The above clinical situation accurately describes the symptoms


of ricin poisoning. Laboratory findings in ricin
inhalation are
non-specific but similar to other pulmonary irritants which cause
pulmonary oedema. When
inhaled as a small particle aerosol, this
toxin may produce pathologic changes within eight hours and severe

respiratory symptoms followed by acute hypoxic respiratory failure


in 36-72 hours. An affected patient may have
massive bleeding from
the stomach and intestines. The patient is most likely to die from
multiple organ failure.

Ricin's toxicity lies in its ability to inhibit protein


synthesis, via the endonuclease activity of its A-chain.

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A 29-year-old man presents with a six month history of nasal
congestion. He was seen by an ENT consultant
Test Analysis
who diagnosed
sinusitis. He presents now with a two day history of right
periorbital swelling and diplopia.

Examination reveals him to be unwell, although he has no neck


stiffness or photophobia; his temperature is
37.4°C. He has marked
drooping of the right eyelid with the right eye congested and
deviated to the right with an
enlarged right pupil. Left eye
appears normal. Fundoscopy is normal. There is also loss of
sensation of the right
forehead.

What is the likely diagnosis?

(Please select 1 option)



Cavernous sinus thrombosis


Epidural abscess


Meningitis


Pituitary adenoma


Tolosa-Hunt syndrome Score:

Total Answered:

Submit answer
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Work Smart
A 29-year-old man presents with a six month history of nasal
congestion. He was seen by an ENT consultant
Answer Statistics
who diagnosed
sinusitis. He presents now with a two day history of right
periorbital swelling and diplopia.

Examination reveals him to be unwell, although he has no neck


stiffness or photophobia; his temperature is Test Analysis
37.4°C. He has marked
drooping of the right eyelid with the right eye congested and
deviated to the right with an
enlarged right pupil. Left eye
appears normal. Fundoscopy is normal. There is also loss of
sensation of the right
forehead.

What is the likely diagnosis?

(Please select 1 option)


Cavernous sinus thrombosis Correct


Epidural abscess


Meningitis


Pituitary adenoma


Tolosa-Hunt syndrome

Score:
The history is typical for cavernous sinus thrombosis possibly
secondary to sinusitis. This is a life threatening
condition. Total Answered:

Urgent CT brain and antibiotics are needed.


Feedback

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Work Smart MRCP Part 2 Written 2001 July

A 52-year-old man presented with acute dyspnoea. His past


medical history includes three vessel coronary
Test Analysis
artery bypass
surgery for ischaemic heart disease.

Examination revealed widespread inspiratory crackles with chest


x ray confirming pulmonary oedema. He was
treated with intravenous
nitrates and furosemide with symptomatic improvement.
Investigations at this stage
revealed:

Serum sodium 138 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 8.7 mmol/L (2.5-7.5)

Serum creatinine 170 µmol/L (60-110)

Random plasma glucose 10.1 mmol/L (<11.1)

Urinalysis Protein ++

The following day he was switched to oral furosemide at a dose


of 80 mg daily and began captopril 12.5 mg
twice daily, increased
to 25 mg twice daily. Repeat investigations one week later
revealed: Score:

Serum sodium 134 mmol/L (137-144) Total Answered:


Serum potassium 5.1 mmol/L (3.5-4.9)

Serum urea 20.7 mmol/L (2.5-7.5) Question Navigator


Serum creatinine 270 µmol/L (60-110)
Tags
Fasting plasma glucose 6.0 mmol/L (3.0-6.0)

Which is the next best investigation after emergency treatment


in determining the cause of his renal failure?

(Please select 1 option)



Captopril renogram


Doppler of the renal arteries


Renal angiography


Renal biopsy


Renal isotope scan

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Work Smart MRCP Part 2 Written 2001 July

A 52-year-old man presented with acute dyspnoea. His past


medical history includes three vessel coronary
Answer Statistics
artery bypass
surgery for ischaemic heart disease.

Examination revealed widespread inspiratory crackles with chest


x ray confirming pulmonary oedema. He was Test Analysis
treated with intravenous
nitrates and furosemide with symptomatic improvement.
Investigations at this stage
revealed:

Serum sodium 138 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 8.7 mmol/L (2.5-7.5)

Serum creatinine 170 µmol/L (60-110)

Random plasma glucose 10.1 mmol/L (<11.1)

Urinalysis Protein ++

The following day he was switched to oral furosemide at a dose


of 80 mg daily and began captopril 12.5 mg
twice daily, increased
to 25 mg twice daily. Repeat investigations one week later
revealed:

Serum sodium 134 mmol/L (137-144)


Score:
Serum potassium 5.1 mmol/L (3.5-4.9)

Serum urea 20.7 mmol/L (2.5-7.5)


Total Answered:

Serum creatinine 270 µmol/L (60-110)


Feedback
Fasting plasma glucose 6.0 mmol/L (3.0-6.0)

Which is the next best investigation after emergency treatment


in determining the cause of his renal failure? Question Navigator
(Please select 1 option)
Captopril renogram
Incorrect answer selected Revision Notes

Doppler of the renal arteries
Tags
Renal angiography
This is the correct answer


Renal biopsy


Renal isotope scan

This patient has coronary heart disease.

Renal function deteriorated in the presence of an


angiotensin-converting enzyme inhibitor (ACEI) and it is
important
to exclude atheroma of the renal arteries causing renal artery
stenosis. Renal angiography,
particularly MR angiography is a good
way to diagnose renovascular disease without having to administer

nephrotoxic contrast. This does not have to be performed as an


emergency, but after stopping the ACE-inhibitor
and rehydrating the
patient. At this point, the risk of gandoilinium-induced
complications will be decreased.

As gold standard, percutaneous angiography is the investigation


of choice, and also enables angioplasty, if
indicated.

Renal artery Doppler is prone to more false negative results


than angiography.
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Work Smart MRCP Part 2 Written 2001 July

A 52-year-old man presented with acute dyspnoea.


Test Analysis
His past medical history includes three vessel coronary artery
bypass surgery for ischaemic heart disease and
hypertension.

Examination revealed widespread expiratory crackles with chest x


ray confirming pulmonary oedema. He was
treated with intravenous
nitrates and furosemide with symptomatic improvement.

Investigations at this stage revealed:

Serum sodium 138 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 8.7 mmol/L (2.5-7.5)

Serum creatinine 170 µmol/L (60-110)

Random plasma glucose 10.1 mmol/L (<11.1)

Urinalysis Protein++
Score:
The following day he was switched to oral furosemide at a dose
of 80 mg daily and began captopril 12.5 mg
Total Answered:
twice daily, increased
to 25 mg twice daily. Repeat investigations one week later
revealed:

Serum sodium 134 mmol/L (137-144)


Question Navigator
Serum potassium 5.1 mmol/L (3.5-4.9)

Serum urea 15.7 mmol/L (2.5-7.5) Tags


Serum creatinine 220 µmol/L (60-110)

Fasting plasma glucose 6.0 mmol/L (3.0-6.0)

Which of the following is most likely to be responsible for the


deterioration in renal function?

(Please select 1 option)



Captopril


Cholesterol emboli


Diabetic nephropathy


Furosemide


Hypertension

Submit answer
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Work Smart Work Hard Mock Tests Group Learning  1 Revision Advice Tags Learning Journal

Work Smart MRCP Part 2 Written 2001 July

A 52-year-old man presented with acute dyspnoea.


Answer Statistics
His past medical history includes three vessel coronary artery
bypass surgery for ischaemic heart disease and
hypertension. Test Analysis
Examination revealed widespread expiratory crackles with chest x
ray confirming pulmonary oedema. He was
treated with intravenous
nitrates and furosemide with symptomatic improvement.

Investigations at this stage revealed:

Serum sodium 138 mmol/L (137-144)

Serum potassium 4.2 mmol/L (3.5-4.9)

Serum urea 8.7 mmol/L (2.5-7.5)

Serum creatinine 170 µmol/L (60-110)

Random plasma glucose 10.1 mmol/L (<11.1)

Urinalysis Protein++

The following day he was switched to oral furosemide at a dose


of 80 mg daily and began captopril 12.5 mg
twice daily, increased
to 25 mg twice daily. Repeat investigations one week later
revealed:
Score:
Serum sodium 134 mmol/L (137-144)
Total Answered:
Serum potassium 5.1 mmol/L (3.5-4.9)

Serum urea 15.7 mmol/L (2.5-7.5) Feedback


Serum creatinine 220 µmol/L (60-110)

Fasting plasma glucose 6.0 mmol/L (3.0-6.0) Question Navigator

Which of the following is most likely to be responsible for the


deterioration in renal function?
Revision Notes
(Please select 1 option)
Captopril
Correct Tags

Cholesterol emboli


Diabetic nephropathy


Furosemide


Hypertension

This patient has coronary artery atheroma and therefore could


have a renal artery stenosis by the same
pathophysiological
mechanism.

A rise in serum creatinine more than 20% above the baseline


after starting an angiotensin-converting enzyme
inhibitor (ACEI)
should prompt the clinician to hold the drug,  monitor renal
function and investigate for renal
artery stenosis.

The patient does not have diabetes based upon a fasting plasma
glucose of only 6 mmol/L (3.0-6.0).

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Work Smart MRCP Part 2 Written 2001 July

A 14-year-old girl is admitted with headache, nausea and


vomiting. She had previously been well but her
Test Analysis
symptoms
deteriorated over the last 12 hours.

On admission, she is noted to be slightly confused with a


temperature of 39 degrees centigrade, stiff neck
positive
Kernig's sign and a faint purpuric rash on the knees. Her blood
pressure is 90/60 mmHg with a pulse of
120 beats per minute.

A diagnosis of meningococcal meningitis is confirmed following


CT head scan and lumbar puncture. She is
admitted to ITU and
treated with IV cefotaxime 2 g tds and benzylpenicillin 2.4 g qds.
She has a rather stormy
admission requiring intubation, ventilation
and hypotensive episodes. On day two of her admission, her urine

output falls with hourly urine output of approximately 10


ml/hr.

Investigations reveal:

Haemoglobin 167 g/L (115-165)

White cell count 16.8 ×109/L (4-11)

Platelets 100 ×109/L (150-400)


Score:
Serum sodium 125 mmol/L (137-144)
Total Answered:
Serum potassium 5 mmol/L (3.5-4.9)

Serum urea 6.7 mmol/L (2.5-7.5) Question Navigator


Serum creatinine 100 µmol/L (60-110)

Plasma osmolality 300 mosmol/Kg (278-305) Tags


Urine osmolality 285 mosmol/Kg (350-1000)

Urine urea 120 mmol/L

Urine sodium 75 mmol/L

Why is this acute tubular necrosis and not pre-renal


failure?

(Please select 1 option)



Her blood pressure is low


Her serum sodium is 125 mmol/L


Her urine output falls


Her urine:plasma osmolality ratio is >1:1


Her urine:plasma urea ratio is elevated

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Work Smart MRCP Part 2 Written 2001 July

A 14-year-old girl is admitted with headache, nausea and


vomiting. She had previously been well but her
Answer Statistics
symptoms
deteriorated over the last 12 hours.

On admission, she is noted to be slightly confused with a


temperature of 39 degrees centigrade, stiff neck Test Analysis
positive
Kernig's sign and a faint purpuric rash on the knees. Her blood
pressure is 90/60 mmHg with a pulse of
120 beats per minute.

A diagnosis of meningococcal meningitis is confirmed following


CT head scan and lumbar puncture. She is
admitted to ITU and
treated with IV cefotaxime 2 g tds and benzylpenicillin 2.4 g qds.
She has a rather stormy
admission requiring intubation, ventilation
and hypotensive episodes. On day two of her admission, her urine

output falls with hourly urine output of approximately 10


ml/hr.

Investigations reveal:

Haemoglobin 167 g/L (115-165)

White cell count 16.8 ×109/L (4-11)

Platelets 100 ×109/L (150-400)

Serum sodium 125 mmol/L (137-144)

Serum potassium 5 mmol/L (3.5-4.9) Score:

Serum urea 6.7 mmol/L (2.5-7.5) Total Answered:


Serum creatinine 100 µmol/L (60-110)

Plasma osmolality 300 mosmol/Kg (278-305) Feedback


Urine osmolality 285 mosmol/Kg (350-1000)

Urine urea 120 mmol/L Question Navigator


Urine sodium 75 mmol/L
Revision Notes
Why is this acute tubular necrosis and not pre-renal
failure?

(Please select 1 option) Tags


Her blood pressure is low
Incorrect answer selected

Her serum sodium is 125 mmol/L


This is the correct answer


Her urine output falls


Her urine:plasma osmolality ratio is >1:1


Her urine:plasma urea ratio is elevated

In acute tubular necrosis (ATN), urine to plasma osmolality


should be less than 1.1, urinary sodium excretion is
typically more
than 60 mmol/L and urinary urea excretion less than 160 mmol/L.

If this patient had a physiological oliguria, there would still


be preservation of urine concentration, with low urinary

sodium.

Both ATN and pre-renal failure can present with a fall in urine
output. There is such a marked variation in urine
urea
concentration, that it is seldom used as a clinical guide.

Further Reading:
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A 40-year-old man with chronic alcohol abuse presented in the
Emergency department with confusion, agitation
Test Analysis
and ataxia. He had
been found wandering the streets at 2 am and was brought in by the
police. He had been
admitted on numerous occasions previously
related to alcohol abuse.

On examination he appeared dishevelled, confused and smelt of


alcohol. He was disoriented in time and place
with a mini-mental
score of 16/30. He was apyrexial with a blood pressure of 138/90
mmHg. He had bilateral
sixth nerve palsies, gaze-evoked nystagmus
and gait ataxia.

What treatment should this patient receive?

(Please select 1 option)



Diazepam


Immunoglobulins


Penicillin


Steroids


Thiamine Score:

Total Answered:

Submit answer
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Work Smart
A 40-year-old man with chronic alcohol abuse presented in the
Emergency department with confusion, agitation
Answer Statistics
and ataxia. He had
been found wandering the streets at 2 am and was brought in by the
police. He had been
admitted on numerous occasions previously
related to alcohol abuse.
Test Analysis
On examination he appeared dishevelled, confused and smelt of
alcohol. He was disoriented in time and place
with a mini-mental
score of 16/30. He was apyrexial with a blood pressure of 138/90
mmHg. He had bilateral
sixth nerve palsies, gaze-evoked nystagmus
and gait ataxia.

What treatment should this patient receive?

(Please select 1 option)


Diazepam Incorrect answer selected


Immunoglobulins


Penicillin


Steroids

Thiamine
This is the correct answer

Score:
The most likely diagnosis is Wernicke's encephalopathy. It
is characterised by
Confusion Total Answered:
Ataxia
Gaze palsies.
Feedback
Intravenous thiamine should be given immediately in those
situations.

Wernicke's should be considered in the setting of


malnutrition or in patients lacking a well-rounded diet. Question Navigator

The commonest cause is chronic alcohol abuse.


Revision Notes

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A 45-year-old man presented with a six month history of
agitation and delusions.
Test Analysis
He had seen a psychiatrist who had made a diagnosis of paranoid
schizophrenia and started depot haloperidol.
His psychosis had
improved considerably following this therapy and he had been
well.

However, he was admitted by his GP following a three day history


of confusion and increasing drowsiness.

On examination, he was agitated, with a temperature of 38.5°C


and blood pressure of 190/110 mmHg. His
cardiovascular and chest
examination were normal and no enlarged liver, spleen or kidneys
were noted. He had
bilateral severe rigidity but no tremor.

Septic screen was normal.

What is the most likely diagnosis?

(Please select 1 option)



Herpes simplex encephalopathy


Hysteria
Score:

Meningitis
Total Answered:

Neuroleptic malignant syndrome


Non-convulsive status epilepticus
Question Navigator

Tags
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A 45-year-old man presented with a six month history of
agitation and delusions.
Answer Statistics
He had seen a psychiatrist who had made a diagnosis of paranoid
schizophrenia and started depot haloperidol.
His psychosis had
improved considerably following this therapy and he had been
well. Test Analysis
However, he was admitted by his GP following a three day history
of confusion and increasing drowsiness.

On examination, he was agitated, with a temperature of 38.5°C


and blood pressure of 190/110 mmHg. His
cardiovascular and chest
examination were normal and no enlarged liver, spleen or kidneys
were noted. He had
bilateral severe rigidity but no tremor.

Septic screen was normal.

What is the most likely diagnosis?

(Please select 1 option)


Herpes simplex encephalopathy
Incorrect answer selected


Hysteria


Meningitis

Neuroleptic malignant syndrome


This is the correct answer
Score:

Non-convulsive status epilepticus
Total Answered:

The following characterise neuroleptic malignant syndrome: Feedback


Confusion/drowsiness
Autonomic dysfunction Question Navigator
Pyrexia and
Extrapyramidal signs.
Revision Notes
Discontinuation of the neuroleptic and initiation of fluids
and anti-pyretics are essential.

Dantrolene and dopamine agonists should be considered in severe


cases. Tags

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Work Smart MRCP Part 2 Written 2003 August

A 17-year-old female presents with a two day history of


vomiting, general lethargy and giddiness.
Test Analysis
Over the last six months she had lost 5 kg in weight, had a
reduced appetite and had been feeling increasingly
lethargic. She
had no past medical history of note, was a non-smoker and took the
combined oral contraceptive
pill for contraception. Her elder
brother was well and there was a family history of thyroid disease
with both her
mother and maternal grandmother taking thyroxine.

On examination, she was comfortable at rest, appeared slightly


dehydrated was apyrexial, had a body mass
index of 18.5
kg/m2 and oxygen saturations on air of 99%. Her blood
pressure was 102/64 mmHg and fell to
86/60 mmHg on standing. Her
pulse was 90 beats per minute regular and auscultation of the heart
and chest
were normal. No abnormalities were detected on abdominal
or CNS examination.

Investigations revealed:

Haemoglobin 105 g/L (115-165)

Mean cell volume 88 fL (80-96)

White cell count 8.8 ×109/L (4-11)


Score:
Neutrophils 4.4 ×109/L (1.5-7)
Total Answered:
Lymphocytes 2.8 ×109/L (1.5-4)

Eosinophils 0.8 ×109/L (0.04-0.4) Question Navigator


Serum sodium 130 mmol/L (137-144)
Tags
Serum potassium 5.8 mmol/L (3.5-4.9)

Serum urea 12.8 mmol/L (2.5-7.5)

Serum creatinine 135 µmol/L (60-110)

Plasma glucose 3.8 mmol/L (3.0-6.0)

Free T4 8.8 pmol/L (10-22)

TSH 1.2 mu/L (0.4-5)

Urinalysis Ketones +

Which of the following is the most appropriate investigation for


this patient?

(Please select 1 option)



Adrenal autoantibodies


CT adrenals


MRI pituitary


Short Synacthen test


Thyroid autoantibodies

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Work Smart MRCP Part 2 Written 2003 August

A 17-year-old female presents with a two day history of


vomiting, general lethargy and giddiness.
Answer Statistics
Over the last six months she had lost 5 kg in weight, had a
reduced appetite and had been feeling increasingly
lethargic. She
had no past medical history of note, was a non-smoker and took the
combined oral contraceptive Test Analysis
pill for contraception. Her elder
brother was well and there was a family history of thyroid disease
with both her
mother and maternal grandmother taking thyroxine.

On examination, she was comfortable at rest, appeared slightly


dehydrated was apyrexial, had a body mass
index of 18.5
kg/m2 and oxygen saturations on air of 99%. Her blood
pressure was 102/64 mmHg and fell to
86/60 mmHg on standing. Her
pulse was 90 beats per minute regular and auscultation of the heart
and chest
were normal. No abnormalities were detected on abdominal
or CNS examination.

Investigations revealed:

Haemoglobin 105 g/L (115-165)

Mean cell volume 88 fL (80-96)

White cell count 8.8 ×109/L (4-11)

Neutrophils 4.4 ×109/L (1.5-7)

Lymphocytes 2.8 ×109/L (1.5-4) Score:

Eosinophils 0.8 ×109/L (0.04-0.4) Total Answered:

Serum sodium 130 mmol/L (137-144)


Feedback
Serum potassium 5.8 mmol/L (3.5-4.9)

Serum urea 12.8 mmol/L (2.5-7.5)


Question Navigator
Serum creatinine 135 µmol/L (60-110)

Plasma glucose 3.8 mmol/L (3.0-6.0) Revision Notes


Free T4 8.8 pmol/L (10-22)

TSH 1.2 mu/L (0.4-5) Tags


Urinalysis Ketones +

Which of the following is the most appropriate investigation for


this patient?

(Please select 1 option)


Adrenal autoantibodies
Incorrect answer selected


CT adrenals


MRI pituitary

Short Synacthen test


This is the correct answer


Thyroid autoantibodies

The salient features in this young patient's case are the


longstanding asthenia with weight loss and the sudden
episode of
vomiting.

She appears clinically dehydrated as demonstrated by the


postural hypotension but her results reveal a
hyponatraemia,
hyperkalaemia and hyperuricaemia. Her full blood count shows an
eosinophilia.

The most likely diagnosis is acute hypoadrenalism due probably


to Addison's disease in view of the strong family
history of
autoimmune disease. The diagnosis should be confirmed with a short
Synacthen test and a cortisol
response less than 550 nmol/L is
confirmatory.

Abnormal thyroid function tests with low thyroxine (T4) and


normal thyroid-stimulating hormone are quite
commonly associated
with Addison's and do not reflect secondary hypothyroidism but
sick euthyroidism.

Thyroxine replacement must not be given to these patients as it


can exacerbate the adrenal crisis. The thyroid
function tests will
normalise with hydrocortisone therapy.

Even if this were hypopituitarism an MRI of the pituitary would


not diagnose hypoadrenalism and again this could
be confirmed with
a short Synacthen test.

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Work Smart MRCP Part 2 Written 2003 August

A 55-year-old male previously diagnosed with alcoholic liver


disease was admitted with increasing confusion. He
Test Analysis
consumed at
least 40 units of alcohol weekly.

On examination he was confused with a Glasgow coma scale of 14


and had a slight flap of the outstretched
hands. His temperature
was 36.8°C and he had a blood pressure of 122/88 mmHg. He was noted
to be
jaundiced with spider naevi and palmar erythema. Abdominal
examination revealed slight distension but no
organomegaly.

Investigations revealed:
Serum sodium 139 mmol/l (137-144)

Serum potassium 3.6 mmol/l (3.5-4.9)

Serum urea 2.7 mmol/l (2.5-7.5)

Serum creatinine 65 µmol/l (60-110)

Serum bilirubin 65 µmol/l (1-22)

Serum aspartate aminotransferase 150 U/l (1-31)


Score:
Serum alanine aminotransferase 110 U/l (5-35)

Serum alkaline phosphatase 450 U/l (30-100)


Total Answered:

Serum gamma glutamyl transferase 500 U/l (<50)


Question Navigator
At that stage he was commenced on the rapid detoxification
programme consisting of diazepam 20 mg at a
minimum interval of two
hourly (maximum dose 200 mg on 24 hours, standard regime). The
following day, he
Tags
was found collapsed in the bathroom on ward.

Which of the following agents is administered is most likely to


lead to an improvement in his conscious level?

(Please select 1 option)



Cefotaxime


Flumazenil


Naloxone


Thiamine


Vitamin K

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Work Smart MRCP Part 2 Written 2003 August

A 55-year-old male previously diagnosed with alcoholic liver


disease was admitted with increasing confusion. He
Answer Statistics
consumed at
least 40 units of alcohol weekly.

On examination he was confused with a Glasgow coma scale of 14


and had a slight flap of the outstretched Test Analysis
hands. His temperature
was 36.8°C and he had a blood pressure of 122/88 mmHg. He was noted
to be
jaundiced with spider naevi and palmar erythema. Abdominal
examination revealed slight distension but no
organomegaly.

Investigations revealed:
Serum sodium 139 mmol/l (137-144)

Serum potassium 3.6 mmol/l (3.5-4.9)

Serum urea 2.7 mmol/l (2.5-7.5)

Serum creatinine 65 µmol/l (60-110)

Serum bilirubin 65 µmol/l (1-22)

Serum aspartate aminotransferase 150 U/l (1-31)

Serum alanine aminotransferase 110 U/l (5-35)

Serum alkaline phosphatase 450 U/l (30-100)


Score:
Serum gamma glutamyl transferase 500 U/l (<50)
Total Answered:
At that stage he was commenced on the rapid detoxification
programme consisting of diazepam 20 mg at a
minimum interval of two
hourly (maximum dose 200 mg on 24 hours, standard regime). The
following day, he
Feedback
was found collapsed in the bathroom on ward.

Which of the following agents is administered is most likely to


lead to an improvement in his conscious level? Question Navigator
(Please select 1 option)
Cefotaxime
Incorrect answer selected Revision Notes
Flumazenil
This is the correct answer
Tags

Naloxone


Thiamine


Vitamin K

The dramatic decline in conscious level associated with


institution of an aggressive alcohol detoxification
regimen in a
patient with impaired hepatic function (therefore reduced hepatic
clearance) makes benzodiazepine
toxicity the most likely
diagnosis.

The rapid detoxification programmes now used are excellent for


acute withdrawal from alcohol but should not be
used in patients
who are encephalopathic (as suggested by his confusion and flapping
tremor). 

Flumazenil reverses the effects of benzodiazepines but care must


taken in its usage due to a relatively short half
life when
compared to benzodiazepines and the risk of provoking seizures when
administered.

Causes of his encephalopathy should be sought, for example,


spontaneous bacterial peritonitis, GI bleed or
infection.
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Work Smart MRCP Part 2 Written 2003 December

A 23-year-old female presents acutely unwell. She has a three


month history of weight loss, tiredness and
Test Analysis
lethargy which has
deteriorated over the last week. Six weeks previously she had been
diagnosed with
hypothyroidism by her general practitioner.

Investigations at that time showed:

Free T4 8.8 pmol/L (10-22)

Plasma TSH 5.5 mU/L (0.4-5)

She had started thyroxine 50 µg daily but had deteriorated over


the last two weeks.

She is a non-smoker, drinks no alcohol and takes the oral


contraceptive pill. Her mother and maternal
grandmother have both
been diagnosed with hypothyroidism and take thyroxine.

On examination she appears unwell and mildly dehydrated. She has


a temperature of 37.5°C and has a BMI of
21.3 kg/m2. Her
blood pressure is 72/44 mmHg, with a pulse of 100 beats per minute.
Examination of the
cardiovascular system is otherwise normal. No
abnormalities are encountered on respiratory or abdominal

examination. Brief neurological examination is normal and both


plantars are flexor. Score:
As yet, the investigations requested by the house officer are
unavailable. Total Answered:
In the meantime what is the most appropriate immediate
management of this patient?

(Please select 1 option) Question Navigator



Intravenous cefotaxime
Tags

Intravenous glucose


Intravenous fluids and hydrocortisone


Intravenous thyroxine (T4)


Intravenous thyronine (T3)

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Work Smart MRCP Part 2 Written 2003 December

A 23-year-old female presents acutely unwell. She has a three


month history of weight loss, tiredness and
Answer Statistics
lethargy which has
deteriorated over the last week. Six weeks previously she had been
diagnosed with
hypothyroidism by her general practitioner.
Test Analysis
Investigations at that time showed:

Free T4 8.8 pmol/L (10-22)

Plasma TSH 5.5 mU/L (0.4-5)

She had started thyroxine 50 µg daily but had deteriorated over


the last two weeks.

She is a non-smoker, drinks no alcohol and takes the oral


contraceptive pill. Her mother and maternal
grandmother have both
been diagnosed with hypothyroidism and take thyroxine.

On examination she appears unwell and mildly dehydrated. She has


a temperature of 37.5°C and has a BMI of
21.3 kg/m2. Her
blood pressure is 72/44 mmHg, with a pulse of 100 beats per minute.
Examination of the
cardiovascular system is otherwise normal. No
abnormalities are encountered on respiratory or abdominal

examination. Brief neurological examination is normal and both


plantars are flexor.

As yet, the investigations requested by the house officer are


unavailable.
Score:
In the meantime what is the most appropriate immediate
management of this patient?
Total Answered:
(Please select 1 option)
Intravenous cefotaxime
Incorrect answer selected
Feedback

Intravenous glucose

Intravenous fluids and hydrocortisone


This is the correct answer
Question Navigator

Intravenous thyroxine (T4)


Intravenous thyronine (T3) Revision Notes

Tags
The patient has had a long history of weight loss and fatigue
and was diagnosed with hypothyroidism based
upon a slightly low T4
and slightly high TSH. Thyroxine was prescribed but this has
precipitated a deterioration
of the underlying condition such that
the patient presents with features suggesting an addisonian
crisis.

Thus is a medical emergency and should be treated with


intravenous fluids and hydrocortisone. An appropriate
test would be
a short Synacthen test which could be completed in 30 minutes.
Adrenal autoantibodies are likely
to be positive in over 80% of
cases.

Sick euthyroidism is a recognised feature of Addison's


disease and treatment with thyroxine may exacerbate the
condition
and precipitate acute hypoadrenalism.

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Work Smart MRCP Part 2 Written 2003 December

An 80-year-old female presents to the Emergency Department


acutely unwell after being found unresponsive, on
Test Analysis
the floor of her
house, by her son. She had a past history of hypothyroidism and of
taking thyroxine daily.
However, her compliance with treatment is
questionable.

On examination she was unrousable with a Glasgow Coma Scale of


6/15, had a central temperature of 34°C,
oxygen saturations of 95%
on air, a pulse of 44 beats per minute and a blood pressure of
100/80 mmHg. There
were no specific localising signs on
neurological examination, but both plantars were extensor.

Prior to results of her emergency blood tests being available,


what is the most appropriate immediate treatment
for this
patient?

(Please select 1 option)



Intravenous 50% glucose


Intravenous hydrocortisone


Intravenous normal saline


Intravenous thyronine (T3) and hydrocortisone
Score:

Oral thyroxine via NG tube
Total Answered:

Question Navigator
Submit answer
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Work Smart MRCP Part 2 Written 2003 December

An 80-year-old female presents to the Emergency Department


acutely unwell after being found unresponsive, on
Answer Statistics
the floor of her
house, by her son. She had a past history of hypothyroidism and of
taking thyroxine daily.
However, her compliance with treatment is
questionable.
Test Analysis
On examination she was unrousable with a Glasgow Coma Scale of
6/15, had a central temperature of 34°C,
oxygen saturations of 95%
on air, a pulse of 44 beats per minute and a blood pressure of
100/80 mmHg. There
were no specific localising signs on
neurological examination, but both plantars were extensor.

Prior to results of her emergency blood tests being available,


what is the most appropriate immediate treatment
for this
patient?

(Please select 1 option)


Intravenous 50% glucose
Incorrect answer selected


Intravenous hydrocortisone


Intravenous normal saline

Intravenous thyronine (T3) and hydrocortisone


This is the correct answer


Oral thyroxine via NG tube

Score:

This patient has typical features of myxoedema coma, which usually occurs in the
elderly who are typically non- Total Answered:
compliant. It carries a high
mortality and should initially be treated with IV thyroid hormone -
either T4 or T3 - and
IV hydrocortisone even before results are
obtained. Feedback
Other treatment includes rewarming. IV fluids should be used
cautiously, as these patients are typically fluid
overloaded. Question Navigator

Revision Notes
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Work Smart MRCP Part 2 Written 2003 December

A 45-year-old man presented with diplopia, dysarthria and


difficulty with swallowing.
Test Analysis
Over the next few days he developed weakness of the upper and
lower limbs. On day four he was unable to walk
unaided. He denied
any sensory symptoms or bladder disturbances. His previous medical
history is
unremarkable. He is a non-smoker, does not drink alcohol
excessively. He does not take any drugs.

On examination he was apyrexial. His general medical examination


was normal. His higher mental function was
unremarkable. There were
no signs of meningism. Cranial nerve examination showed bilateral
dilated and fixed
pupils. He had binocular diplopia but no obvious
ophthalmoplegia. He was dysarthric with weak cough. His vital

capacity was 3.15 standing and 2.00 lying flat. He had lower motor
neurone tetraparesis of power 3/5. He was
hyporeflexic with normal
sensation and was unable to walk unaided.

Investigations including full blood count, urea and


electrolytes, liver function tests, serum calcium, thyroid
function
tests, autoantibody screen, erythrocyte sedimentation rate and
serum C reactive protein were normal.

His electrocardiogram and chest radiograph were normal. A CT


scan of his brain was normal, as were nerve
conduction studies and
an electromyogram (EMG).

What is the most likely diagnosis? Score:

(Please select 1 option) Total Answered:



Botulism


Guillain-Barré syndrome Question Navigator


Lyme disease
Tags

Myasthenia gravis


Vasculitis

Submit answer
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Work Smart MRCP Part 2 Written 2003 December

A 45-year-old man presented with diplopia, dysarthria and


difficulty with swallowing.
Answer Statistics
Over the next few days he developed weakness of the upper and
lower limbs. On day four he was unable to walk
unaided. He denied
any sensory symptoms or bladder disturbances. His previous medical
history is Test Analysis
unremarkable. He is a non-smoker, does not drink alcohol
excessively. He does not take any drugs.

On examination he was apyrexial. His general medical examination


was normal. His higher mental function was
unremarkable. There were
no signs of meningism. Cranial nerve examination showed bilateral
dilated and fixed
pupils. He had binocular diplopia but no obvious
ophthalmoplegia. He was dysarthric with weak cough. His vital

capacity was 3.15 standing and 2.00 lying flat. He had lower motor
neurone tetraparesis of power 3/5. He was
hyporeflexic with normal
sensation and was unable to walk unaided.

Investigations including full blood count, urea and


electrolytes, liver function tests, serum calcium, thyroid
function
tests, autoantibody screen, erythrocyte sedimentation rate and
serum C reactive protein were normal.

His electrocardiogram and chest radiograph were normal. A CT


scan of his brain was normal, as were nerve
conduction studies and
an electromyogram (EMG).

What is the most likely diagnosis?

(Please select 1 option)


Score:
Botulism
Correct
Total Answered:

Guillain-Barré syndrome


Lyme disease
Feedback

Myasthenia gravis


Vasculitis Question Navigator

Revision Notes
The clinical presentation of descending weakness with autonomic
dysfunction (fixed dilated pupils) is typical of
botulism.
Tags
It is a neuromuscular junction disorder and therefore nerve
conduction studies and EMG are normal.

Repetitive nerve stimulation shows incremental responses, which


is diagnostic of botulism.

Cerebrospinal fluid analysis is usually normal.

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Work Smart MRCP Part 2 Written 2003 December

A 60-year-old woman presented with a three month history of


diplopia and blurred vision of left eye. She denied
Test Analysis
any pain or
other neurological symptoms. Her previous medical history is
unremarkable. She smokes 20
cigarettes per day and drinks alcohol
in moderation.

Her general medical examination is normal. Her visual acuity on


the right is 6/6 and on the left 6/36. There is left
partial ptosis
and mild proptosis with conjunctival injection. The left pupil is
smaller than the right but reacting
normally to light. There is
some limitation of abduction of the left eye. Fundoscopy showed a
pale left optic disc.
The left corneal reflex is reduced. The
remainder of the neurological examination is normal.

Routine blood tests including full blood count, urea and


electrolytes, liver function tests, thyroid function, serum

calcium, serum creatine kinase, and autoantibody screen were


normal. Her electrocardiogram and chest
radiograph showed no
abnormalities.

Slit lamp examination was normal and intraocular pressures were


within normal range.

Where is the most likely site of the lesion causing her


symptoms?

(Please select 1 option)



Brain stem Score:


Cavernous sinus Total Answered:


Optic chiasm
Question Navigator

Orbital apex syndrome


Superior orbital fissure Tags

Submit answer
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Work Smart MRCP Part 2 Written 2003 December

A 60-year-old woman presented with a three month history of


diplopia and blurred vision of left eye. She denied
Answer Statistics
any pain or
other neurological symptoms. Her previous medical history is
unremarkable. She smokes 20
cigarettes per day and drinks alcohol
in moderation.
Test Analysis
Her general medical examination is normal. Her visual acuity on
the right is 6/6 and on the left 6/36. There is left
partial ptosis
and mild proptosis with conjunctival injection. The left pupil is
smaller than the right but reacting
normally to light. There is
some limitation of abduction of the left eye. Fundoscopy showed a
pale left optic disc.
The left corneal reflex is reduced. The
remainder of the neurological examination is normal.

Routine blood tests including full blood count, urea and


electrolytes, liver function tests, thyroid function, serum

calcium, serum creatine kinase, and autoantibody screen were


normal. Her electrocardiogram and chest
radiograph showed no
abnormalities.

Slit lamp examination was normal and intraocular pressures were


within normal range.

Where is the most likely site of the lesion causing her


symptoms?

(Please select 1 option)


Brain stem
Incorrect answer selected


Cavernous sinus
Score:

Optic chiasm
Total Answered:
Orbital apex syndrome
This is the correct answer


Superior orbital fissure Feedback

The combination of optic neuropathy, proptosis, chemosis,


Horner's syndrome, ophthalmoplegia (in this case due
Question Navigator
to sixth
nerve palsy) and involvement of the first branch of the trigeminal
nerve is typical of orbital apex
syndrome. Revision Notes
There is some disease process (causing the orbital apex
syndrome) causing partial defects in the nerves. It is
not the
presence or absence of function in a particular nerve that makes
the diagnosis, it is the pattern of Tags
involvement.

Further Reading:

Yeh S, Foroozan R. Orbital apex syndrome. Curr Opin


Ophthalmol. 2004;15(6):490-8.

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Work Smart
A 55-year-old male is admitted with a large haematemesis. Three
weeks ago he underwent bilateral inguinal
Test Analysis
hernia repair and has
been taking analgesia. The following image was noted on
endoscopy.

Score:

Total Answered:

Question Navigator

Tags
What is the most appropriate next step in the management of this
patient?

(Please select 1 option)



Endoscopic adrenaline injection


Intravenous proton pump inhibitor therapy


Intravenous glypressin therapy


Oral proton pump inhibitor therapy


Surgery

Submit answer
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Work Smart
A 55-year-old male is admitted with a large haematemesis. Three
weeks ago he underwent bilateral inguinal
Answer Statistics
hernia repair and has
been taking analgesia. The following image was noted on
endoscopy.

Test Analysis

Score:

Total Answered:

Feedback
What is the most appropriate next step in the management of this
patient?

(Please select 1 option)


Question Navigator
Endoscopic adrenaline injection
Correct


Intravenous proton pump inhibitor therapy Revision Notes

Intravenous glypressin therapy
Tags

Oral proton pump inhibitor therapy


Surgery

The endoscopy shows a bleeding duodenal ulcer (approximately in


the 9 o'clock position). The most appropriate
initial step in
the management of this patient is adrenaline injection.

Studies have suggested that optimal treatment would now be to


commence IV PPI for 72 hours post injection of
ulcer. In
particular, Lau et al. showed a decrease in recurrent bleeding,
although no decrease in mortality.

Reference:

Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent
bleeding after endoscopic
treatment of bleeding peptic ulcers.
N Engl J Med. 2000;343(5):310-6.

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Work Smart MRCP Part 2 Written 2003 August

A 42-year-old homeless man is brought into accident and


Emergency department at approximately 11:00 pm by
Test Analysis
the emergency
ambulance crew. He is known to have a history of alcohol abuse and
on this occasion he was
found by a group of passers-by outside a
nightclub having sustained a laceration to his forehead following a
fall
onto the pavement.

On arrival at the Emergency department he was described as being


unkempt with a strong odour of alcohol. He
appeared to be
moderately intoxicated with alcohol and on examination he was found
to have a superficial
laceration over his left forehead, which
required no suturing. His Glasgow coma scale was 14/15. No
localising
signs were found on examination of the central nervous
system. He was admitted overnight for observations.

He took his own discharge at approximately 9:00 am the next day


but returned to the ward later on the same day
complaining
shortness of breath and blurred vision. In addition, he had
developed abdominal pain associated
with vomiting and
diarrhoea.

On examination, he had a respiratory rate of 30/min. Pulse rate


of 100/min regular, blood pressure of 110/60
mmHg and heart sounds
normal. There were occasional coarse crepitations in both lung
fields which cleared on
coughing. Examination of the abdomen
revealed generalised tenderness with no masses or
hepato-
splenomegaly. Rectal examination was normal. The only other
positive findings were hyperaemia and blurring of Score:
the optic discs
bilaterally.
Total Answered:
Initial investigations showed:

pH 7.25 (7.36-7.44) Question Navigator


pO2 14.3 kPa (11.3-12.6)
Tags
pCO2 3.7 kPa (4.7-6.0)

Bicarbonate 12 mmol/L (20-28)

Base excess −12 mmol/L (+/-2)

Serum sodium 132 mmol/L (137-144)

Serum potassium 4.1 mmol/L (3.5-4.9)

Serum urea 7.2 mmol/L (2.5-7.5)

Serum creatinine 113 µmol/L (60-110)

Serum chloride 96 mmol/L (95-107)

Serum glucose 5.4 mmol/L (3.0-6.0)

What is the most likely cause for his abnormal


investigations?

(Please select 1 option)



Diabetic ketoacidosis


Ecstasy ingestion


Ethylene glycol ingestion


Methanol ingestion


Pancreatitis

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Work Smart MRCP Part 2 Written 2003 August

A 42-year-old homeless man is brought into accident and


Emergency department at approximately 11:00 pm by
Answer Statistics
the emergency
ambulance crew. He is known to have a history of alcohol abuse and
on this occasion he was
found by a group of passers-by outside a
nightclub having sustained a laceration to his forehead following a
fall
onto the pavement. Test Analysis

On arrival at the Emergency department he was described as being


unkempt with a strong odour of alcohol. He
appeared to be
moderately intoxicated with alcohol and on examination he was found
to have a superficial
laceration over his left forehead, which
required no suturing. His Glasgow coma scale was 14/15. No
localising
signs were found on examination of the central nervous
system. He was admitted overnight for observations.

He took his own discharge at approximately 9:00 am the next day


but returned to the ward later on the same day
complaining
shortness of breath and blurred vision. In addition, he had
developed abdominal pain associated
with vomiting and
diarrhoea.

On examination, he had a respiratory rate of 30/min. Pulse rate


of 100/min regular, blood pressure of 110/60
mmHg and heart sounds
normal. There were occasional coarse crepitations in both lung
fields which cleared on
coughing. Examination of the abdomen
revealed generalised tenderness with no masses or
hepato-
splenomegaly. Rectal examination was normal. The only other
positive findings were hyperaemia and blurring of
the optic discs
bilaterally.

Initial investigations showed: Score:

Total Answered:
pH 7.25 (7.36-7.44)

pO2 14.3 kPa (11.3-12.6)


Feedback
pCO2 3.7 kPa (4.7-6.0)

Bicarbonate 12 mmol/L (20-28) Question Navigator


Base excess −12 mmol/L (+/-2)

Serum sodium 132 mmol/L (137-144)


Revision Notes
Serum potassium 4.1 mmol/L (3.5-4.9)
Tags
Serum urea 7.2 mmol/L (2.5-7.5)

Serum creatinine 113 µmol/L (60-110)

Serum chloride 96 mmol/L (95-107)

Serum glucose 5.4 mmol/L (3.0-6.0)

What is the most likely cause for his abnormal


investigations?

(Please select 1 option)


Diabetic ketoacidosis
Incorrect answer selected


Ecstasy ingestion


Ethylene glycol ingestion

Methanol ingestion
This is the correct answer


Pancreatitis

The most obvious abnormality is a metabolic acidosis with


respiratory compensation. He also has a large anion
gap of 29.1,
which indicates the presence of a large concentrations of
cations.

Anion gap = (Na + K) − (chloride + HCO3), normally


10-18.

Possible diagnoses includes ethylene glycol or methanol


ingestion and diabetic ketoacidosis.

The absence of an elevated glucose makes diabetic ketoacidosis


unlikely.

Ethylene glycol is antifreeze, usually consumed by those with


suicidal intent or history of deliberate self harm.

Methanol is pure distilled alcohol, more likely to be consumed


by those with a history of alcohol abuse.

Visual impairment typically occurs with methanol and in severe


cases result in permanent blindness. Initial
presentation of
methanol or ethylene glycol mimics those of ethanol ingestion and
when co-ingested, protects
the patient from the toxic effects of
methanol and ethylene glycol (possibly delaying the diagnosis).

This is because alcohol dehydrogenase has a higher affinity for


ethanol, hence methanol and ethylene glycol are
excreted unchanged
in the kidneys, preventing the formation of toxic metabolites
formate (methanol) and oxalic
acid (ethylene glycol).

Severe pancreatitis can give rise to a lactic acidosis but does


not give rise to hyperaemia or blurring of the optic
discs.

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Work Smart MRCP Part 2 Written 2003 December

A 52-year-old woman is referred by an orthopaedic surgeon for


advice following a Colles' fracture eight weeks
Test Analysis
ago. At the
time of her fracture, the radiologist had reported 'significant
osteopaenia'. A dual-energy x ray
absorptiometry (DEXA) scan
was carried out and her T score was -2.6 at the hip and -1.9 at the
lumbar spine.

She smokes approximately 15 cigarettes per day and has a body


mass index of 21 kg/m2. She has been post-
menopausal for
two years, is unaware of any menopausal symptoms and has had a
benign breast lump removed
18 months ago. She is currently taking
aspirin, atenolol and glyceryl trinitrate (GTN) spray for her
angina, which
she uses only occasionally.

What would be the most appropriate treatment?

(Please select 1 option)



Alendronate


Calcitonin


Calcium and vitamin D supplements


Hormone replacement therapy
Score:

Raloxifene
Total Answered:

Question Navigator
Submit answer
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Work Smart MRCP Part 2 Written 2003 December

A 52-year-old woman is referred by an orthopaedic surgeon for


advice following a Colles' fracture eight weeks
Answer Statistics
ago. At the
time of her fracture, the radiologist had reported 'significant
osteopaenia'. A dual-energy x ray
absorptiometry (DEXA) scan
was carried out and her T score was -2.6 at the hip and -1.9 at the
lumbar spine.
Test Analysis
She smokes approximately 15 cigarettes per day and has a body
mass index of 21 kg/m2. She has been post-
menopausal for
two years, is unaware of any menopausal symptoms and has had a
benign breast lump removed
18 months ago. She is currently taking
aspirin, atenolol and glyceryl trinitrate (GTN) spray for her
angina, which
she uses only occasionally.

What would be the most appropriate treatment?

(Please select 1 option)


Alendronate
Correct


Calcitonin


Calcium and vitamin D supplements


Hormone replacement therapy


Raloxifene

Score:

Bisphosphonates (for example, alendronate and risedronate) act


as a potent inhibitors of bone resorption by Total Answered:
decreasing osteoclast
recruitment, activity, and life span. Treatment with
bisphosphonates has been shown to
increase bone mineral density
(BMD) significantly in osteoporotic patients and thus reduce
fractures. Problems Feedback
with adverse effects (mainly GI upset) can be
reduced by a weekly administration of bisphosphonates. It is the

drug of choice for treatment of osteoporosis.


Question Navigator
Calcium and vitamin D supplements are more likely to benefit
women who are more than five years post
menopause, as their intake
is likely to be low. Post menopausal women who wish to reduce the
risk of
Revision Notes
osteoporosis should consume 1000-1500 mg of elemental
calcium and 400-800 IU of vitamin D daily, ideally
through calcium
containing foods. Excessive intake of calcium and vitamin D may
cause adverse effects such as
hypercalcaemia and
hypercalciuria.
Tags

The use of hormone replacement therapy (HRT) is controversial


and should be reserved for those with
menopausal symptoms and
without overt cardiovascular disease, as studies suggest increased
cardiovascular
risk although it is still a good agent in preventing
fractures.

Reference:

1. Beral V. Breast cancer and hormone-replacement therapy in


the Million Women Study. Lancet.

2003;362(9382):419-27.

2. NICE. Osteoporosis - primary prevention (TA160).

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Work Smart MRCP Part 2 Written 2003 December

A 45-year-old man with a past medical history of multiple


sclerosis was admitted to hospital following an
Test Analysis
overdose of
baclofen. He was diagnosed with relapsing and remitting multiple
sclerosis 20 years ago and is
usually mobile with two sticks. He
performs intermittent self-catheterisation and his only medication
is baclofen
20 mg three times a day.

He was found surrounded by empty packets previously containing


baclofen by his son after returning from a
night out with his
friends. Earlier that evening, the patient and his partner had an
argument and this was thought
to have precipitated his actions.
According to his partner, there were approximately 20 tablets left
in the packet,
each containing 10 mg of baclofen. (150 mg of
baclofen is associated with severe toxicity.)

He is a non-smoker and is teetotal. The only other past medical


history of note is a previous admission 18
months ago with severe
community acquired pneumonia, for which he needed mechanical
ventilation.

On examination, he was drowsy with a respiratory rate of 5/min.


He had a Glasgow coma scale (GCS) of 8/15
(eye = 2, verbal = 2,
motor = 4) and neurological examination revealed generalised
hyporeflexia. Pulse rate was
60/min and blood pressure was 95
systolic and 60 diastolic. Examination of respiratory,
cardiovascular and
abdominal system was unremarkable.
Score:
His arterial gases on 50% inspired O2 were as
follows:
Total Answered:
pH 7.34 (7.36-7.44)

PO2 24.0 kPa (11.3-12.6) Question Navigator


PCO2 7.2 kPa (4.7-6.0)

HCO3
Tags
27 mmol/L (20-28)

Base excess 0.3 mmol/L (+/-2)

What would be your next step in the management of this


patient?

(Please select 1 option)



Increase concentration of inspired oxygen


Intravenous doxapram infusion


Intubation and mechanical ventilation


Non-invasive positive pressure ventilation (NIPPV)


Reduce concentration of inspired oxygen

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Work Smart MRCP Part 2 Written 2003 December

A 45-year-old man with a past medical history of multiple


sclerosis was admitted to hospital following an
Answer Statistics
overdose of
baclofen. He was diagnosed with relapsing and remitting multiple
sclerosis 20 years ago and is
usually mobile with two sticks. He
performs intermittent self-catheterisation and his only medication
is baclofen
20 mg three times a day. Test Analysis

He was found surrounded by empty packets previously containing


baclofen by his son after returning from a
night out with his
friends. Earlier that evening, the patient and his partner had an
argument and this was thought
to have precipitated his actions.
According to his partner, there were approximately 20 tablets left
in the packet,
each containing 10 mg of baclofen. (150 mg of
baclofen is associated with severe toxicity.)

He is a non-smoker and is teetotal. The only other past medical


history of note is a previous admission 18
months ago with severe
community acquired pneumonia, for which he needed mechanical
ventilation.

On examination, he was drowsy with a respiratory rate of 5/min.


He had a Glasgow coma scale (GCS) of 8/15
(eye = 2, verbal = 2,
motor = 4) and neurological examination revealed generalised
hyporeflexia. Pulse rate was
60/min and blood pressure was 95
systolic and 60 diastolic. Examination of respiratory,
cardiovascular and
abdominal system was unremarkable.

His arterial gases on 50% inspired O2 were as


follows:

pH 7.34 (7.36-7.44) Score:


PO2 24.0 kPa (11.3-12.6) Total Answered:
PCO2 7.2 kPa (4.7-6.0)

HCO3
Feedback
27 mmol/L (20-28)

Base excess 0.3 mmol/L (+/-2)


Question Navigator
What would be your next step in the management of this
patient?
Revision Notes
(Please select 1 option)
Increase concentration of inspired oxygen
Incorrect answer selected
Tags

Intravenous doxapram infusion

Intubation and mechanical ventilation


This is the correct answer


Non-invasive positive pressure ventilation (NIPPV)


Reduce concentration of inspired oxygen

His CO2 retention is likely to be due to central


nervous system depression and reduction in diaphragmatic

contraction secondary to baclofen toxicity. Onset of toxicity is


rapid and its effect can last up to 35-40 hours post
ingestion.

Features include:
Drowsiness
Coma
Respiratory depression
Hyporeflexia
Hypotonia
Hypothermia, and
Hypotension.

Bradycardia with first degree heart block and prolongation of


Q-T interval can occur.

Treatment is usually supportive and often requires intensive


care.

The presence of hypoxic drive is unlikely as the patient is a


non-smoker thus a reduction in inspired oxygen
would not increase
his respiratory drive.

NIPPV would be an option but not in a patient with a GCS


8/15.

Patients with a high risk of aspiration pneumonia are a


contraindication to non-invasive ventilation.

Doxapram has no place in the treatment of baclofen toxicity.

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Work Smart MRCP Part 2 Written July 2011

A 56-year-old lady presents with sudden onset occipital


headache, vomiting and depressed conscious level.
Test Analysis
She was previously well with no significant past medical
history. In particular there is no history of exertional
chest
pain, asthma or diabetes. She is a non-smoker.

Examination reveals neck stiffness, equal pupils and a GCS of


12. Pulse is 84 bpm, BP 140/90 mmHg. Chest is
clear to
auscultation.

Laboratory findings are normal.

An urgent CT brain scan reveals an acute subarachnoid


haemorrhage and she is transferred to neurosurgery.

After conducting further investigations the neurosurgery team


plan to take her to theatre for clipping of an
aneurysm. The
anaesthetic team are concerned about her ECG shown below.

Score:

Total Answered:

Question Navigator

Tags

What is the most likely explanation from the list of


options?

(Please select 1 option)



Acute myocardial infarction


ECG changes due to intracranial haemorrhage


Left bundle branch block


Pulmonary embolism


Ventricular pre-excitation

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Work Smart MRCP Part 2 Written July 2011

A 56-year-old lady presents with sudden onset occipital


headache, vomiting and depressed conscious level.
Answer Statistics
She was previously well with no significant past medical
history. In particular there is no history of exertional
chest
pain, asthma or diabetes. She is a non-smoker. Test Analysis
Examination reveals neck stiffness, equal pupils and a GCS of
12. Pulse is 84 bpm, BP 140/90 mmHg. Chest is
clear to
auscultation.

Laboratory findings are normal.

An urgent CT brain scan reveals an acute subarachnoid


haemorrhage and she is transferred to neurosurgery.

After conducting further investigations the neurosurgery team


plan to take her to theatre for clipping of an
aneurysm. The
anaesthetic team are concerned about her ECG shown below.

Score:

Total Answered:

Feedback

Question Navigator
What is the most likely explanation from the list of
options?
Revision Notes
(Please select 1 option)
Acute myocardial infarction
Incorrect answer selected
Tags

ECG changes due to intracranial haemorrhage


Left bundle branch block


Pulmonary embolism

Ventricular pre-excitation
This is the correct answer

The ECG shows a shortened PR interval (in this case the PR


interval is approximately 0.08 s - two small squares
NR 0.12-0.2 s)
and a delta wave. In this case it is probably best seen in the
lateral chest leads V3 - V6.

Ventricular pre-excitation (if there were a history of


tachycardia it would be Wolff-Parkinson-White syndrome)
commonly
masquerades as other conditions, such as bundle branch block or
ischaemia.

Intracranial haemorrhage can cause changes in the ECG which are


typically deep symmetrical T-wave inversion
and prolonged QT
interval.

Acute pulmonary embolism is unlikely, as there are none of the


transient features that one would expect to see
(S1Q3T3 pattern, RV
strain and tachycardia).
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Work Smart MRCP Part 2 Written July 2011

A 48-year-old man is admitted with an episode of syncope.


Test Analysis
Whilst gardening he experienced chest pain lasting about 40
minutes. The pain eased but he felt light-headed,
had nausea and,
according to his wife went very pale. He slumped to the floor
unconscious but woke up
spontaneously in less than a minute.

Previously he was known to be hypertensive and was taking


aspirin 75 mg OD, captopril 25 mg BD and
bendroflumethiazide 2.5 mg
OD. He is an electrical engineer and does not smoke.

The ambulance crew brought him to the Emergency department.

His ECG is shown:

Score:

Total Answered:

Question Navigator

Tags

What does the ECG show?

(Please select 1 option)



Accelerated idioventricular rhythm


Acute myocardial infarction


Agonal rhythm


Complete heart block


Mobitz type II heart block

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Work Smart MRCP Part 2 Written July 2011

A 48-year-old man is admitted with an episode of syncope.


Answer Statistics
Whilst gardening he experienced chest pain lasting about 40
minutes. The pain eased but he felt light-headed,
had nausea and,
according to his wife went very pale. He slumped to the floor
unconscious but woke up Test Analysis
spontaneously in less than a minute.

Previously he was known to be hypertensive and was taking


aspirin 75 mg OD, captopril 25 mg BD and
bendroflumethiazide 2.5 mg
OD. He is an electrical engineer and does not smoke.

The ambulance crew brought him to the Emergency department.

His ECG is shown:

Score:

Total Answered:

Feedback

Question Navigator

What does the ECG show? Revision Notes


(Please select 1 option)
Accelerated idioventricular rhythm
Incorrect answer selected Tags

Acute myocardial infarction


Agonal rhythm

Complete heart block


This is the correct answer


Mobitz type II heart block

The ECG shows complete heart block.

There are P waves which show no relation to the QRS


complexes.

The QRS complexes are wide, regular and represent a ventricular


escape rhythm.

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A 30-year-old gentleman is admitted to the Emergency department
after a motor vehicle accident. You are asked
Test Analysis
to review the
patient.

He is fully oriented to time, place and person. On questioning,


the patient cannot provide any information about
the accident; the
last he remembers was getting into the car in order to attend a
meeting. The paramedics who
attended the emergency call describe
that the patient has had a frontal car accident and was found
outside the
car, he was initially 'dazed' but recovered
after a few minutes.

He had only a few superficial scratches and contusions on his


face, elbows and knees and a small haematoma
on his forehead. The
patient is fully oriented to time, place and person, with a GCS of
15. He is up and about
and demands when he can leave hospital.

What course of management would you advise?

(Please select 1 option)



Admit the patient for observation and consciousness charting


CT scan head
Score:

Discharge home with advice to return if any deterioration
Total Answered:

MRI head


Plain x ray skull and C-spine
Question Navigator

Tags
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Work Smart
A 30-year-old gentleman is admitted to the Emergency department
after a motor vehicle accident. You are asked
Answer Statistics
to review the
patient.

He is fully oriented to time, place and person. On questioning,


the patient cannot provide any information about Test Analysis
the accident; the
last he remembers was getting into the car in order to attend a
meeting. The paramedics who
attended the emergency call describe
that the patient has had a frontal car accident and was found
outside the
car, he was initially 'dazed' but recovered
after a few minutes.

He had only a few superficial scratches and contusions on his


face, elbows and knees and a small haematoma
on his forehead. The
patient is fully oriented to time, place and person, with a GCS of
15. He is up and about
and demands when he can leave hospital.

What course of management would you advise?

(Please select 1 option)


Admit the patient for observation and consciousness charting
Incorrect answer selected

CT scan head
This is the correct answer


Discharge home with advice to return if any deterioration


MRI head Score:

Plain x ray skull and C-spine Total Answered:

NICE have issued clear guidelines on the management of Head injury


(CG56). Feedback

In the following cases, NICE recommends a CT scan to evaluate


cases of head injury:
GCS less than 13 at any point since the injury Question Navigator
GCS equal to 13 or 14 at two hours after the injury
Suspected open or depressed skull fracture Revision Notes
Any sign of basal skull fracture (haemotympanum,
'panda' eyes, cerebrospinal fluid otorrhoea, Battle's

sign)
Tags
Post traumatic seizure
Focal neurological deficit
More than one episode of vomiting
Amnesia for greater than 30 minutes of events before
impact.

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A 63-year-old man was admitted to hospital with eight hours'
duration of severe chest pain.
Test Analysis
He had a history of hypertension and hypercholesterolaemia but
no previous history of ischaemic heart disease.
His
electrocardiogram showed inferior ST segment elevation myocardial
infarction (STEMI) and he was
thrombolysed in the cardiac care
unit. He made a good recovery but three days later became acutely
breathless.

On examination he had a respiratory rate of 36 per minute and a


pulse of 128 beats per minute and regular. His
blood pressure was
80/45 mmHg and oxygen saturations were 85% on room air.
Auscultation revealed a gallop
rhythm and a harsh systolic murmur
at the apex. Chest examination revealed widespread crackles and

wheezes.

His chest radiograph is shown below.

Score:

Total Answered:

Question Navigator

Tags

What is the most likely explanation for these findings?

(Please select 1 option)



Aortic stenosis


Cardiac tamponade


Papillary muscle rupture


Pulmonary embolism


Ventricular wall aneurysm

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Work Smart
A 63-year-old man was admitted to hospital with eight hours'
duration of severe chest pain.
Answer Statistics
He had a history of hypertension and hypercholesterolaemia but
no previous history of ischaemic heart disease.
His
electrocardiogram showed inferior ST segment elevation myocardial
infarction (STEMI) and he was Test Analysis
thrombolysed in the cardiac care
unit. He made a good recovery but three days later became acutely
breathless.

On examination he had a respiratory rate of 36 per minute and a


pulse of 128 beats per minute and regular. His
blood pressure was
80/45 mmHg and oxygen saturations were 85% on room air.
Auscultation revealed a gallop
rhythm and a harsh systolic murmur
at the apex. Chest examination revealed widespread crackles and

wheezes.

His chest radiograph is shown below.

Score:

Total Answered:

Feedback

Question Navigator

Revision Notes

Tags

What is the most likely explanation for these findings?

(Please select 1 option)


Aortic stenosis
Incorrect answer selected


Cardiac tamponade

Papillary muscle rupture


This is the correct answer


Pulmonary embolism


Ventricular wall aneurysm

This patient presents with features of acute left ventricular


failure and has a chest x ray which shows pulmonary
oedema as
reflected by Kerley B lines and interstitial oedema.
The examination findings indicate a harsh systolic murmur at the
apex which, in association with acute
pulmonary oedema, would be
most in keeping with a papillary muscle rupture in association with
myocardial
infarction.

The posteromedial papillary muscle is twice as likely to rupture


as is the anterolateral papillary muscle. This is
because the
anterolateral papillary muscle is more often supplied by two
arterial systems (left anterior
descending and left circumflex
coronary arteries), whereas the posteromedial papillary muscle is
frequently
supplied by only one coronary artery (usually the right)
system.

Occlusion of the right coronary artery (posterior descending


branch) is usually implicated in inferior myocardial

infarction.

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A 75-year-old woman is admitted with a pre-syncopal episode.
Test Analysis
She had felt as though she were going to 'black out'
whilst out shopping and an ambulance was called. She
denies chest
pain and shortness of breath. She has a past history of
hypertension for which she has been taking
a diuretic.

On examination she is conscious and has a BP of 85/40 mmHg. Her


ECG is shown below:

Score:

Total Answered:

Question Navigator

Tags

What is the immediate management?

(Please select 1 option)



DC cardioversion


IV amiodarone


IV flecainide


IV lidocaine


Sotalol

Submit answer
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Work Smart
A 75-year-old woman is admitted with a pre-syncopal episode.
Answer Statistics
She had felt as though she were going to 'black out'
whilst out shopping and an ambulance was called. She
denies chest
pain and shortness of breath. She has a past history of
hypertension for which she has been taking Test Analysis
a diuretic.

On examination she is conscious and has a BP of 85/40 mmHg. Her


ECG is shown below:

Score:

Total Answered:

Feedback

Question Navigator
What is the immediate management?

(Please select 1 option)


Revision Notes
DC cardioversion
Correct


IV amiodarone Tags

IV flecainide


IV lidocaine


Sotalol

The electrocardiogram (ECG) shows a wide complex tachycardia


with a rate of about 200 with marked left axis
deviation.

On careful examination of the rhythm strip there is evidence of


independent atrial activity - P waves can be seen
'marching
through' the QRS complexes. Even without demonstrating
independent P waves the QRS width, axis
deviation and rate all
suggest a ventricular origin rather than a supraventricular
origin.

This is not torsades, as there is no characteristic twisting


about the isoelectric line, and it is not ventricular
fibrillation
(VF) since there is a regular pattern to the QRS complexes.

Another possibility (not listed here) is ventricular flutter but


this would normally have an even higher rate.

Since this lady is elderly and compromised with a low blood


pressure, even though she is asymptomatic, the
treatment of choice
is DC cardioversion.

An anaesthetist needs to be called to assist with direct current


cardioversion (DCCV) which should be
'synchronised' to
limit the risk of conversion to VF.

Should she deteriorate in the meantime and become pulseless,


then a praecordial thump should be given,
followed immediately by
DCCV if not successful.

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An 82-year-old lady was admitted to hospital with fever and
confusion. She had been found collapsed at home
Test Analysis
by her son, who
reported that she was usually fit and well and coped well on her
own at home.

She had a past history of angina, which was well-controlled on a


beta-blocker and oral nitrate and she also
suffered from
osteoarthritis.

On examination she looked pale and unwell and smelled strongly


of stale urine. Her temperature was 38.1°C.
She was disoriented in
time, place and person. Her blood pressure was 80/45 mmHg with
pulse 110 beats per
minute and regular.

There were widespread petechiae on the limbs. Her respiratory


rate was measured at 28 breaths per minute. Her
heart sounds were
normal and the chest clear. Her abdomen was soft, but she was very
tender in the
suprapubic region and a mass was felt rising from the
pelvic brim.

After taking blood, it was noted that there was continued


bleeding from the venous puncture site. A urinary
catheter was
inserted and yielded 1500 ml of cloudy yellow offensive-smelling
urine.

Which of the following statements is true?


Score:
(Please select 1 option)

Circulating levels of activated protein C (aPC) will be reduced Total Answered:


Levels of D-dimer will be reduced
Question Navigator

Levels of fibrin degradation products (FDPs) will be reduced


The activated partial thromboplastin time (APTT) will be below the normal range Tags

The platelet count is likely to be elevated

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Work Smart
An 82-year-old lady was admitted to hospital with fever and
confusion. She had been found collapsed at home
Answer Statistics
by her son, who
reported that she was usually fit and well and coped well on her
own at home.

She had a past history of angina, which was well-controlled on a


beta-blocker and oral nitrate and she also Test Analysis
suffered from
osteoarthritis.

On examination she looked pale and unwell and smelled strongly


of stale urine. Her temperature was 38.1°C.
She was disoriented in
time, place and person. Her blood pressure was 80/45 mmHg with
pulse 110 beats per
minute and regular.

There were widespread petechiae on the limbs. Her respiratory


rate was measured at 28 breaths per minute. Her
heart sounds were
normal and the chest clear. Her abdomen was soft, but she was very
tender in the
suprapubic region and a mass was felt rising from the
pelvic brim.

After taking blood, it was noted that there was continued


bleeding from the venous puncture site. A urinary
catheter was
inserted and yielded 1500 ml of cloudy yellow offensive-smelling
urine.

Which of the following statements is true?

(Please select 1 option)


Circulating levels of activated protein C (aPC) will be reduced
Correct
Score:

Levels of D-dimer will be reduced
Total Answered:

Levels of fibrin degradation products (FDPs) will be reduced


The activated partial thromboplastin time (APTT) will be below the normal range Feedback

The platelet count is likely to be elevated
Question Navigator

The patient has disseminated intravascular coagulation (DIC)


secondary to sepsis. Given the history, the most
Revision Notes
likely source is
the urinary tract.

Several coagulation abnormalities which may be seen in severe


sepsis include: Tags
APTT - elevated
PT - elevated
FDPs - elevated
D-dimers - elevated
Platelets - reduced
Fibrinogen - reduced
Protein C - reduced
Antithrombin - reduced.

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A 67-year-old woman was admitted to hospital with a tender, hot,
right calf.
Test Analysis
She had a longstanding history of congestive cardiac failure and
was known to have chronic oedema of her left
leg. The admitting
doctor recorded a differential diagnosis of either deep vein
thrombosis or cellulitis and started
the patient on a treatment
dose of low molecular weight heparin and booked a Doppler
ultrasound scan of the
affected leg.

While on the ward overnight, the nurses asked the senior house
officer to review the patient as they felt that she
was not well.
On reviewing her, the SHO found that the patient was confused,
febrile 39.0°C, blood pressure
85/60 mmHg, pulse 120 beats per
minute and regular, and respiratory rate 32 breaths per minute.

The area of erythema that had been present on the right lower
leg on admission had extended to the mid-thigh.

In recognition of the acutely sick patient, which of the


following is correct?

(Please select 1 option)



A blood lactate level of >1.5 mmol/l is associated with an
increased mortality


Arterial blood gas pH is superior to base excess in evaluating metabolic acidosis
Score:

The commonest clinical signs preceding cardiac arrest are tachycardia and hypotension
Total Answered:

The degree of base excess disturbance correlates with intravascular fluid requirement


The respiratory rate is a highly specific sign predicting underlying physiological disturbance Question Navigator

Tags

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Work Smart
A 67-year-old woman was admitted to hospital with a tender, hot,
right calf.
Answer Statistics
She had a longstanding history of congestive cardiac failure and
was known to have chronic oedema of her left
leg. The admitting
doctor recorded a differential diagnosis of either deep vein
thrombosis or cellulitis and started Test Analysis
the patient on a treatment
dose of low molecular weight heparin and booked a Doppler
ultrasound scan of the
affected leg.

While on the ward overnight, the nurses asked the senior house
officer to review the patient as they felt that she
was not well.
On reviewing her, the SHO found that the patient was confused,
febrile 39.0°C, blood pressure
85/60 mmHg, pulse 120 beats per
minute and regular, and respiratory rate 32 breaths per minute.

The area of erythema that had been present on the right lower
leg on admission had extended to the mid-thigh.

In recognition of the acutely sick patient, which of the


following is correct?

(Please select 1 option)


A blood lactate level of >1.5 mmol/l is associated with an
increased mortality
Correct


Arterial blood gas pH is superior to base excess in evaluating metabolic acidosis


The commonest clinical signs preceding cardiac arrest are tachycardia and hypotension


The degree of base excess disturbance correlates with intravascular fluid requirement Score:


The respiratory rate is a highly specific sign predicting underlying physiological disturbance Total Answered:

Abnormalities in heart rate Feedback


Temperature
Respiratory rate Question Navigator
Urine output
Conscious level
Revision Notes
can all be used to predict critical illness.

All of these have a low specificity but a high sensitivity in


detecting underlying physiological disturbance. Tags
Most critically ill patients have signs of organ dysfunction
that are usually due to underlying tissue hypoxia. The
most common
clinical signs prior to a cardiac arrest are respiratory distress
(RR >25/min) and altered mental
state.

Over 50% of patients requiring ICU present with with metabolic


acidosis many with a raised blood lactate
concentration. A raised
lactate in associated with a higher mortality.

Base excess has been shown to be superior to pH in evaluating


metabolic acidosis and in predicting subsequent
complications.

A base excess of <-4 mmol/L has been associated with a


mortality of 50-60%.

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A 75-year-old woman is admitted with a pre-syncopal episode.
Test Analysis
She had felt as though she were going to 'black out'
whilst out shopping and an ambulance was called. She
denies any
history of chest pain or shortness of breath. She has a past
history of hypertension for which she has
been taking a
diuretic.

On examination she is conscious and has a BP of 85/50 mmHg. Her


ECG is shown below.

Score:

Total Answered:

Question Navigator

Tags

Which of the following is the most likely diagnosis?

(Please select 1 option)



Atrial tachycardia with aberrant conduction


SVT with aberrant conduction


Torsades de pointes


Ventricular fibrillation


Ventricular tachycardia

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Work Smart
A 75-year-old woman is admitted with a pre-syncopal episode.
Answer Statistics
She had felt as though she were going to 'black out'
whilst out shopping and an ambulance was called. She
denies any
history of chest pain or shortness of breath. She has a past
history of hypertension for which she has Test Analysis
been taking a
diuretic.

On examination she is conscious and has a BP of 85/50 mmHg. Her


ECG is shown below.

Score:

Total Answered:

Feedback

Question Navigator
Which of the following is the most likely diagnosis?

(Please select 1 option)


Revision Notes
Atrial tachycardia with aberrant conduction
Incorrect answer selected


SVT with aberrant conduction Tags

Torsades de pointes


Ventricular fibrillation

Ventricular tachycardia
This is the correct answer

The ECG shows a wide complex tachycardia with a rate of about


200 with marked left axis deviation.

On careful examination of the rhythm strip there is evidence of


independent atrial activity; P waves can be seen
'marching
through' the QRS complexes.

Even without demonstrating independent P waves, the QRS width,


axis deviation and rate all suggest a
ventricular origin rather
than a supraventricular origin.

This is not torsades as there is no characteristic twisting


about the isoelectric line, and it is not VF since there is a

regular pattern to the QRS complexes.

Another possibility (not listed here) is ventricular flutter but


this would normally have an even higher rate.
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This 52-year-old man was found collapsed on a golf course.
Test Analysis
Cardiopulmonary resuscitation was initiated. On arrival of the
paramedics, he was noted to be in ventricular
fibrillation.

What was the cause of his collapse?

(Please select 1 option) Score:



Acute myocardial infarction
Total Answered:

Acute rheumatic fever


Bacterial endocarditis Question Navigator

Cardiac Lyme disease
Tags

Lightning strike

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This 52-year-old man was found collapsed on a golf course.
Answer Statistics
Cardiopulmonary resuscitation was initiated. On arrival of the
paramedics, he was noted to be in ventricular
fibrillation. Test Analysis

What was the cause of his collapse?

(Please select 1 option)


Acute myocardial infarction
Incorrect answer selected


Acute rheumatic fever Score:


Bacterial endocarditis Total Answered:


Cardiac Lyme disease
Feedback
Lightning strike
This is the correct answer

Question Navigator
The figure shows a 'ferning' or 'arborescent'
rash pathognomonic of a lightning strike, also known as Lichtenberg

figures. Revision Notes


"The pathology of lightning, or keraunopathy, is known only
to a few specialists."1
Tags
Reference:

1. NASA Science. Human Voltage: What happens when people and


lightning converge.

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A 35-year-old woman with alcoholic cirrhosis is admitted with
deteriorating confusion and deteriorating ascites.
Test Analysis
On examination, she is mildly jaundiced, has a temperature of
37.5°C, is agitated and confused and has a
flapping tremor of the
outstretched hands. Abdominal examination reveals tense
ascites.

Investigations reveal:
FBC Mild leucocytosis

Sodium 142 mmol/l (134-144)

Potassium 4.2 mmol/l (3.5 - 5.5)

Urea 4.4 mmol/l (3-8)

Creatinine 110 µmol/l (50-100)

Glucose 5.4 mmol/l (3.5-6)

Bilirubin 78 µmol/l (0-18)

AST 110 iu/l (5-40)

Alkaline phosphatase 550 iu/l (50-110) Score:

Ascitic tap polymorphonuclear cell count of 350 cells per


mm3. Total Answered:

Which of the following is the most appropriate treatment for


this patient?
Question Navigator
(Please select 1 option)

Intravenous cefotaxime
Tags

Intravenous lorazepam


Intravenous metronidazole


IV glypressin


Oral neomycin

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A 35-year-old woman with alcoholic cirrhosis is admitted with
deteriorating confusion and deteriorating ascites.
Answer Statistics
On examination, she is mildly jaundiced, has a temperature of
37.5°C, is agitated and confused and has a
flapping tremor of the
outstretched hands. Abdominal examination reveals tense
ascites. Test Analysis
Investigations reveal:
FBC Mild leucocytosis

Sodium 142 mmol/l (134-144)

Potassium 4.2 mmol/l (3.5 - 5.5)

Urea 4.4 mmol/l (3-8)

Creatinine 110 µmol/l (50-100)

Glucose 5.4 mmol/l (3.5-6)

Bilirubin 78 µmol/l (0-18)

AST 110 iu/l (5-40)

Alkaline phosphatase 550 iu/l (50-110)

Ascitic tap polymorphonuclear cell count of 350 cells per


mm3.
Score:
Which of the following is the most appropriate treatment for
this patient?
Total Answered:
(Please select 1 option)
Intravenous cefotaxime
Correct
Feedback

Intravenous lorazepam


Intravenous metronidazole Question Navigator


IV glypressin
Revision Notes

Oral neomycin

Tags
This patient has spontaneous bacterial peritonitis (SBP) as
suggested by the typical history, ascites and raised

polymorphonuclear count within the ascitic tap, which appears to


have precipitated the hepatic encephalopathy.

It is most commonly seen in alcoholic cirrhosis and the


causative organism is usually Escherichia
coli, Klebsiella,
Streptococcus
pneumoniae or Enterococci. (Compare this
with the mixed growth seen in other forms of
peritonitis.)

Sending some ascitic fluid in blood culture bottles increases


the yield.

Initial treatment is with broad spectrum antibiotics such as


cefotaxime.

Norfloxacin is recommended for short term prophylaxis.

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Work Smart MRCP Part 2 Written July 2011

A 26-year-old woman presented at 35 weeks of pregnancy with


profuse vaginal bleeding. She had suffered two
Test Analysis
previous
miscarriages.

She had a pulse of 95 beats per minute, blood pressure of 110/84


mmHg and no fetal heart sounds were
audible.

Investigations revealed:

Haemoglobin 98 g/L (115 - 165)

Platelets 66 ×109/L (150 - 400)

Prothrombin time 21 sec (11.5-15.5)

APTT 52 sec (30-40)

Fibrinogen 0.5 g/L (2-4)

What is the most appropriate next step in management?

(Please select 1 option) Score:



Antithrombin III infusion
Total Answered:

Fibrinogen replacement infusion (cryoprecipitate)


Intravenous heparin Question Navigator

Platelet transfusion
Tags

Transfusion of two units group O rhesus D negative blood

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Work Smart MRCP Part 2 Written July 2011

A 26-year-old woman presented at 35 weeks of pregnancy with


profuse vaginal bleeding. She had suffered two
Answer Statistics
previous
miscarriages.

She had a pulse of 95 beats per minute, blood pressure of 110/84


mmHg and no fetal heart sounds were Test Analysis
audible.

Investigations revealed:

Haemoglobin 98 g/L (115 - 165)

Platelets 66 ×109/L (150 - 400)

Prothrombin time 21 sec (11.5-15.5)

APTT 52 sec (30-40)

Fibrinogen 0.5 g/L (2-4)

What is the most appropriate next step in management?

(Please select 1 option)


Antithrombin III infusion
Incorrect answer selected

Fibrinogen replacement infusion (cryoprecipitate)


This is the correct answer Score:


Intravenous heparin Total Answered:


Platelet transfusion
Feedback

Transfusion of two units group O rhesus D negative blood

Question Navigator
The clinical picture is disseminated intravascular
coagulation.

When bleeding is the major problem, the aim is to maintain the


prothrombin and activated thromboplastin time at Revision Notes
a ratio of 1.5
times of the control and the fibrinogen level above 1 g/L.
Tags
Platelet transfusion is recommended if the count is less than 50
×109/L.

Anaemia is not very severe so in this case fibrinogen


replacement would be the appropriate first choice with
blood
transfusion an addition if bleeding continues and patient develops
hypovolaemic shock.

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A 78-year-old male patient is brought to the emergency
department with a history of breathlessness. He has a
Test Analysis
background of
ischaemic heart disease and diabetes.

He was brought to the resuscitation department and IV access was


gained, oxygen administered and he was put
on a cardiac
monitor.

His initial observations were:

Respiratory rate 26

Heart rate 145

Blood pressure 105/69

Oxygen saturations 99% on 5 L via non-rebreather mask

On further questioning he had noted increased swelling of ankles


and required more pillows to sleep. There was
no history of chest
pain.

On examination the patient was alert and orientated. A focused


clinical examination revealed an elevated venous
pressure, normal
heart sounds and crackles to the mid bases. ECG demonstrated an
irregular narrow-complex Score:
tachycardia. Total Answered:
What is the most appropriate initial management choice of this
patient's arrhythmia?

(Please select 1 option) Question Navigator



Adenosine 6 mg IV
Tags

Amiodarone 300 mg IV stat


Digoxin 500 mcg orally


DC cardiovert


Verapamil 5 mg IV

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A 78-year-old male patient is brought to the emergency
department with a history of breathlessness. He has a
Answer Statistics
background of
ischaemic heart disease and diabetes.

He was brought to the resuscitation department and IV access was


gained, oxygen administered and he was put Test Analysis
on a cardiac
monitor.

His initial observations were:

Respiratory rate 26

Heart rate 145

Blood pressure 105/69

Oxygen saturations 99% on 5 L via non-rebreather mask

On further questioning he had noted increased swelling of ankles


and required more pillows to sleep. There was
no history of chest
pain.

On examination the patient was alert and orientated. A focused


clinical examination revealed an elevated venous
pressure, normal
heart sounds and crackles to the mid bases. ECG demonstrated an
irregular narrow-complex
tachycardia.
Score:
What is the most appropriate initial management choice of this
patient's arrhythmia?
Total Answered:
(Please select 1 option)
Adenosine 6 mg IV Incorrect answer selected
Feedback

Amiodarone 300 mg IV stat

Digoxin 500 mcg orally This is the correct answer Question Navigator

DC cardiovert


Verapamil 5 mg IV
Revision Notes

Tags
This question focuses on the acute management of patients with
tachyarrhythmia in a potentially peri-arrest
situation. It tests
knowledge of current UK resuscitation counsel guidelines.

The guidelines provide an algorithm to approach patients with a


narrow-complex tachycardia who are unwell.
The key to the
appropriate management of these patients is the identification of
adverse factors.

The patient in this scenario presents with symptoms and signs


suggesting heart failure, with a narrow complex
tachycardia,
probably atrial fibrillation (AF).

The key to managing this patient is the control of the heart


rate.

If you consider the patient to be unstable/in shock,


synchronised DC shock is advised. However, this requires
sedation
and can lead to unnecessary complications. The patient here does
have some concerning features, but
is alert and orientated. The
slightly low BP may be normal for him.

Amiodarone is not ideal as it would need to be given via a


central line and chemical cardioversion may not be
safe given the
unknown duration of AF and risk of stroke associated with
cardioversion.

Oral digoxin is the most appropriate choice for ventricular rate


control.

DC shock would only be indicated for acute haemodynamic


compromise/shock.
Verapamil is negatively inotropic and so should not be used if
there is evidence of acute heart failure.

Adenosine could be used for diagnosis and/or treatment of some


regular narrow complex tachycardias, but is not
effective in
treating AF.

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A 37-year-old lady is brought to the Emergency department with
rapidly increasing breathlessness and chest
Test Analysis
pain over the preceding
48 hours.

She had been under the care of rheumatologists for joint


symptoms and has been diagnosed with systemic lupus
erythematosus
(SLE). There is no history of recent travel or symptoms to suggest
infection.

On examination the patient is short of breath with a respiratory


rate of 26. Oxygen saturations are 97% on room
air. Pulse is 130
regular and blood pressure is 80/60 mmHg. Cardiac examination is
unremarkable but the
venous pressure is elevated. There is no
peripheral oedema.

A 12 lead ECG reveals a sinus tachycardia only. A chest x ray


demonstrates a slightly enlarged heart but clear
lung fields.

Which is the most appropriate next step in this patient's


management, from the list below?

(Please select 1 option)



Full dose low molecular weight heparin


Intravenous furosemide
Score:

Start ionotropic agents
Total Answered:

Urgent CT pulmonary angiogram


Urgent transthoracic echocardiogram Question Navigator

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A 37-year-old lady is brought to the Emergency department with
rapidly increasing breathlessness and chest
Answer Statistics
pain over the preceding
48 hours.

She had been under the care of rheumatologists for joint


symptoms and has been diagnosed with systemic lupus Test Analysis
erythematosus
(SLE). There is no history of recent travel or symptoms to suggest
infection.

On examination the patient is short of breath with a respiratory


rate of 26. Oxygen saturations are 97% on room
air. Pulse is 130
regular and blood pressure is 80/60 mmHg. Cardiac examination is
unremarkable but the
venous pressure is elevated. There is no
peripheral oedema.

A 12 lead ECG reveals a sinus tachycardia only. A chest x ray


demonstrates a slightly enlarged heart but clear
lung fields.

Which is the most appropriate next step in this patient's


management, from the list below?

(Please select 1 option)


Full dose low molecular weight heparin
Incorrect answer selected


Intravenous furosemide


Start ionotropic agents


Urgent CT pulmonary angiogram Score:

Urgent transthoracic echocardiogram


This is the correct answer Total Answered:

Feedback
This question is difficult.

The case describes a patient with lupus and acute


breathlessness. The symptoms and haemodynamic Question Navigator
parameters are a
worry - urgent diagnosis and management are essential.

The features of the history could be due to pericardial effusion


or pulmonary embolism (PE) (both increased risk Revision Notes
with SLE). The
normal oxygen saturations and slightly enlarged heart point away
from PE, and make pericardial
effusion more likely. We are not told
if pulsus paradoxus is present. Tags
Cardiac examination can be normal with a pericardial effusion.
An urgent echo will exclude a significant
pericardial effusion. It
will also provide information on evidence of tamponade
physiology.

It is rare to diagnose PE with an echo, but it is useful in


detecting right heart dilatation/impairment and pulmonary

hypertension which can be strongly suggestive of a diagnosis of


PE.

Therefore, from this list, an urgent echo is the most


appropriate. A computed tomography pulmonary angiogram
(CTPA) would
rule out PE and could demonstrate an effusion, but would not reveal
tamponade changes.

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A 26-year-old male attends the Emergency department following
sudden onset palpitations at home. He is under
Test Analysis
the cardiologist for
a "heart problem" but he is unsure of the details.

On arrival his initial pulse rate is 202 irregularly irregular


but reverts intermittently to sinus rhythm 70 beats per
minute. He
is attached to a cardiac monitor which continues to show frequent
paroxysms of tachycardia.

His blood pressure is 105/60 mmHg. A 12 lead ECG during


tachycardia shows an irregular rhythm with broad
QRS complex and in
sinus rhythm shows a short PR interval with 'slurred'
upstroke to the QRS complex.

On further questioning there is no breathlessness or chest


pain.

From the list below which is the most appropriate next


management step?

(Please select 1 option)



Direct current cardioversion during tachycardia


Intravenous adenosine


Intravenous digoxin
Score:

Intravenous flecainide
Total Answered:

Intravenous verapamil

Question Navigator

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A 26-year-old male attends the Emergency department following
sudden onset palpitations at home. He is under
Answer Statistics
the cardiologist for
a "heart problem" but he is unsure of the details.

On arrival his initial pulse rate is 202 irregularly irregular


but reverts intermittently to sinus rhythm 70 beats per Test Analysis
minute. He
is attached to a cardiac monitor which continues to show frequent
paroxysms of tachycardia.

His blood pressure is 105/60 mmHg. A 12 lead ECG during


tachycardia shows an irregular rhythm with broad
QRS complex and in
sinus rhythm shows a short PR interval with 'slurred'
upstroke to the QRS complex.

On further questioning there is no breathlessness or chest


pain.

From the list below which is the most appropriate next


management step?

(Please select 1 option)


Direct current cardioversion during tachycardia
Incorrect answer selected


Intravenous adenosine


Intravenous digoxin

Intravenous flecainide
This is the correct answer


Intravenous verapamil
Score:

Total Answered:
This patient's resting ECG suggests ventricular
pre-excitation.

When patients with pre-excitation develop atrial fibrillation


(AF) this will result in a broad complex, irregular Feedback
tachycardia. If
these patients are given medications which block the
atrioventricular (AV) node (for example,
adenosine, verapamil,
digoxin) this can result in worsening of the tachycardia (as all
the atrial depolarisations Question Navigator
will be conducted to the ventricles)
with potentially catastrophic results.

The drug of choice in this setting is flecainide, hence from the


above intravenous flecainide is correct and Revision Notes
adenosine, digoxin and
verapamil are incorrect.

DC cardioversion is not appropriate for a paroxysmal tachycardia


but could be considered if the episode was Tags
sustained and
haemodynamically compromising.

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A 78-year-old female patient is under the care of your
supervising consultant on the coronary care unit.
Test Analysis
She was admitted 24 hours ago with an acute anterior myocardial
infarction. She underwent a primary
percutaneous intervention with
a good initial result. Post percutaneous coronary intervention the
patient has
remained haemodynamically stable.

However, the CCU sister calls you to see the patient as she
noticed the heart rate was "slow" on the monitor.
The
patient had started to feel light headed and her blood pressure was
105/60 mmHg.

A 12 lead ECG reveals a bradycardia with a rate of 46 beats per


minute with narrow QRS morphology. There are
some non-conducted P
waves and you note the PR remains unchanged prior to the
non-conducted beat.

From the list below, which is the most appropriate next


management step?

(Please select 1 option)



Atropine 500 micrograms


Isoprenaline infusion


Monitor and observe Score:


Transcutaneous cardiac pacing Total Answered:


Transvenous cardiac pacing
Question Navigator

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Work Smart
A 78-year-old female patient is under the care of your
supervising consultant on the coronary care unit.
Answer Statistics
She was admitted 24 hours ago with an acute anterior myocardial
infarction. She underwent a primary
percutaneous intervention with
a good initial result. Post percutaneous coronary intervention the
patient has Test Analysis
remained haemodynamically stable.

However, the CCU sister calls you to see the patient as she
noticed the heart rate was "slow" on the monitor.
The
patient had started to feel light headed and her blood pressure was
105/60 mmHg.

A 12 lead ECG reveals a bradycardia with a rate of 46 beats per


minute with narrow QRS morphology. There are
some non-conducted P
waves and you note the PR remains unchanged prior to the
non-conducted beat.

From the list below, which is the most appropriate next


management step?

(Please select 1 option)


Atropine 500 micrograms
Incorrect answer selected


Isoprenaline infusion


Monitor and observe


Transcutaneous cardiac pacing
Score:
Transvenous cardiac pacing
This is the correct answer
Total Answered:

The ECG findings are consistent with Mobitz type II second


degree heart block.
Feedback
There is a significant risk of asystole or complete heart block
so temporary cardiac pacing is indicated in the first
instance. Question Navigator
Mobitz type II or complete heart block does not respond to
atropine. Atropine may be useful for sinus or
junctional
bradycardia. Revision Notes
Transcutaneous is the same as external pacing (via pads); it is
terrible for the patient and should only be used as
a holding
measure in emergency. Transvenous is via the femoral or internal
jugular vein. Tags

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A 67-year-old lady is admitted, via the Emergency department  to
the coronary care unit. She complained of
Test Analysis
sudden onset palpitations
and chest pain. On arrival in CCU she was in atrial fibrillation.
The on-call doctor
prescribed intravenous amiodarone. This
cardioverted to normal sinus rhythm.

Three hours later the patient complains of some chest


discomfort. Her blood pressure has remained at 110/70
mmHg and
heart rate increased to 190 The 12 lead ECG shows torsade de
pointes.

You call for immediate help from the cardiology registrar. She
asks you to initiate which of the following treatment
options
before she arrives to help?

(Please select 1 option)



Amiodarone intravenously


DC cardioversion


Flecainide intravenously


Magnesium sulphate intravenously


Transcutaneous overdrive pacing Score:

Total Answered:

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A 67-year-old lady is admitted, via the Emergency department  to
the coronary care unit. She complained of
Answer Statistics
sudden onset palpitations
and chest pain. On arrival in CCU she was in atrial fibrillation.
The on-call doctor
prescribed intravenous amiodarone. This
cardioverted to normal sinus rhythm.
Test Analysis
Three hours later the patient complains of some chest
discomfort. Her blood pressure has remained at 110/70
mmHg and
heart rate increased to 190 The 12 lead ECG shows torsade de
pointes.

You call for immediate help from the cardiology registrar. She
asks you to initiate which of the following treatment
options
before she arrives to help?

(Please select 1 option)


Amiodarone intravenously
Incorrect answer selected


DC cardioversion


Flecainide intravenously

Magnesium sulphate intravenously


This is the correct answer


Transcutaneous overdrive pacing

Score:
Drugs which prolong the QT interval (including amiodarone) can
lead to torsade. This is a malignant arrhythmia
with a significant
risk of deteriorating into ventricular fibrillation (VF) and needs
prompt treatment. Total Answered:

If any adverse features are present, synchronised DCCV is the


treatment of choice. In this case, the patient is
stable and may
need DCCV. Feedback

The initial management of torsade with no adverse features


present is:
Stop all drugs which prolong QT Question Navigator
Correct any electrolyte abnormalities
Give IV magnesium (2 g IV over 10 minutes) Revision Notes
The patient may need transvenous overdrive pacing, but expert
help is needed for this.
Tags
Therefore, the correct answer is magnesium sulphate
intravenously.

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A 28-year-old woman, who is 24 weeks pregnant with her first
child is referred to the medical assessment unit
Test Analysis
with six hour
history of palpitations. These started suddenly and are causing the
patient to feel uncomfortable.
On arrival she looks anxious. Her
blood pressure is 125/80 mmHg. Her pulse is 140 bpm and
regular.

A 12 lead ECG reveals a regular, narrow complex tachycardia,


rate 140. On further questioning the patient has
noticed a few
brief episodes of palpitations over the last year.

You begin to discuss the management options and the patient


becomes tearful because she is concerned about
the effects on her
baby.

Which is the most appropriate management plan for this


patient?

(Please select 1 option)



Vagal manoeuvres followed by adenosine


Vagal manoeuvres followed by amiodarone


Vagal manoeuvres followed by atenolol


Vagal manoeuvres followed by DC cardioversion Score:


Vagal manoeuvres followed by verapamil Total Answered:

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Work Smart
A 28-year-old woman, who is 24 weeks pregnant with her first
child is referred to the medical assessment unit
Answer Statistics
with six hour
history of palpitations. These started suddenly and are causing the
patient to feel uncomfortable.
On arrival she looks anxious. Her
blood pressure is 125/80 mmHg. Her pulse is 140 bpm and
regular.
Test Analysis
A 12 lead ECG reveals a regular, narrow complex tachycardia,
rate 140. On further questioning the patient has
noticed a few
brief episodes of palpitations over the last year.

You begin to discuss the management options and the patient


becomes tearful because she is concerned about
the effects on her
baby.

Which is the most appropriate management plan for this


patient?

(Please select 1 option)


Vagal manoeuvres followed by adenosine
Correct


Vagal manoeuvres followed by amiodarone


Vagal manoeuvres followed by atenolol


Vagal manoeuvres followed by DC cardioversion


Vagal manoeuvres followed by verapamil
Score:

Total Answered:
This question tests knowledge of the management of
tachyarrhythmia in pregnancy.

The most common tachyarrhythmias in pregnancy are AV nodal


re-entrant tachycardia, and the ECG described
Feedback
here is consistent
with that. Often pregnant patients are extremely anxious regarding
the effects of medications
on their babies.
Question Navigator
As in the non-pregnant population, vagal manoeuvres should be
tried first. If these are unsuccessful, as in
approximately 75% of
cases, adenosine in the next step. Adenosine is safe in pregnancy
(this fact can be
Revision Notes
explained to the patient for reassurance).

Verapamil should not be used in the first trimester. Tags


Some beta blockers can be used in pregnancy - there is small
risk of fetal bradycardia and intrauterine growth
retardation.

Amiodarone should be avoided unless no alternative.

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As the medical CT2 on call, you are bleeped to attend the
Emergency department urgently to assist in a cardiac
Test Analysis
arrest
situation.

A 75-year-old man was brought to the Emergency department after


he called 999 complaining of shortness of
breath and chest pain. He
was brought immediately to the Emergency department by paramedics
but became
unconscious while he was in the ambulance. As the
paramedics were just outside the hospital they brought him
straight
in.

On arrival, he was unconscious and had no cardiac output. A


monitor was attached, venous access gained and
he was intubated.
The monitor showed his rhythm to be asystole.

As you arrive the emergency nurse is performing chest


compressions. The team leader asks you to prepare
drugs.

Regarding asystole, which of the following drug regimes is


recommended for a cardiac arrest situation?

(Please select 1 option)



Adrenaline alone - repeated doses every three to five minutes
Score:

Atropine and adrenaline - repeated doses of both
Total Answered:

Isoprenaline infusion


No drug treatment
Question Navigator

Single dose of atropine followed by repeated doses of adrenaline

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As the medical CT2 on call, you are bleeped to attend the
Emergency department urgently to assist in a cardiac
Answer Statistics
arrest
situation.

A 75-year-old man was brought to the Emergency department after


he called 999 complaining of shortness of Test Analysis
breath and chest pain. He
was brought immediately to the Emergency department by paramedics
but became
unconscious while he was in the ambulance. As the
paramedics were just outside the hospital they brought him
straight
in.

On arrival, he was unconscious and had no cardiac output. A


monitor was attached, venous access gained and
he was intubated.
The monitor showed his rhythm to be asystole.

As you arrive the emergency nurse is performing chest


compressions. The team leader asks you to prepare
drugs.

Regarding asystole, which of the following drug regimes is


recommended for a cardiac arrest situation?

(Please select 1 option)


Adrenaline alone - repeated doses every three to five minutes
Correct


Atropine and adrenaline - repeated doses of both


Isoprenaline infusion Score:

No drug treatment Total Answered:

Single dose of atropine followed by repeated doses of adrenaline

Feedback

2005 UK resuscitation guidelines recommended a single dose (3


mg) of atropine for asystolic (or slow rate PEA)
cardiac
arrest.
Question Navigator

However, asystolic cardiac arrests are usually due to primary


cardiac pathology (rather than increased vagal
Revision Notes
tone) so
physiologically, atropine is unlikely to be useful in this
situation.

This has been confirmed in recent studies and subsequently the


updated 2010 UK resuscitation guidelines no Tags
longer recommend
atropine in these scenarios.

Adrenaline should be given every three to five minutes.

Isoprenaline has no role in asystolic cardiac arrests.

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A 76-year-old man is brought to the Emergency department.He has
a history of left ventricular dysfunction
Test Analysis
secondary to ischaemic
heart disease.

That morning he had developed sudden onset rapid, irregular


palpitations, and felt breathless so he called the
emergency
services. On arrival at the Emergency department he was connected
to a monitor, venous access
was gained and a 12 lead ECG was
recorded.

On examination he looked unwell; he was sweaty and his venous


pressure was elevated. His pulse was 185
irregularly irregular.
Heart sounds were normal. Auscultation of his lungs revealed
crackles to mid-zones
bilaterally. Blood pressure was recorded at
85/52 mmHg.

The 12 lead ECG showed a fast, irregular narrow complex


tachycardia with absent P waves.

From this list, which is the treatment of choice for this


patient?

(Please select 1 option)



Adenosine


Atenolol intravenously
Score:

Amiodarone intravenously
Total Answered:

Digoxin intravenously


Direct current cardioversion (DCCV) Question Navigator

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A 76-year-old man is brought to the Emergency department.He has
a history of left ventricular dysfunction
Answer Statistics
secondary to ischaemic
heart disease.

That morning he had developed sudden onset rapid, irregular


palpitations, and felt breathless so he called the Test Analysis
emergency
services. On arrival at the Emergency department he was connected
to a monitor, venous access
was gained and a 12 lead ECG was
recorded.

On examination he looked unwell; he was sweaty and his venous


pressure was elevated. His pulse was 185
irregularly irregular.
Heart sounds were normal. Auscultation of his lungs revealed
crackles to mid-zones
bilaterally. Blood pressure was recorded at
85/52 mmHg.

The 12 lead ECG showed a fast, irregular narrow complex


tachycardia with absent P waves.

From this list, which is the treatment of choice for this


patient?

(Please select 1 option)


Adenosine
Incorrect answer selected


Atenolol intravenously


Amiodarone intravenously


Digoxin intravenously Score:

Direct current cardioversion (DCCV)


This is the correct answer Total Answered:

Feedback
The management of tachyarrhythmias is dependent on the presence
of adverse features. These include
Myocardial ischaemia
Shock Question Navigator
Syncope and
Heart failure. Revision Notes
When adverse features are present, synchronised DCCV under GA or
conscious sedation is the treatment of
choice. Tags
This patient has a tachyarrhythmia (probable atrial fibrillation
[AF]) with signs of heart failure therefore the most
appropriate
management is DCCV.

If adverse features are not present, it is appropriate to try


drugs first.

For AF (complicated by heart failure) digoxin or amiodarone are


indicated.

Therefore the correct answer is Direct current cardioversion


(DCCV).

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A 37-year-old male is brought to the Emergency department having
suffered a collapse at home.
Test Analysis
Whilst cooking breakfast he had become dizzy and collapsed to
the floor. He lost consciousness for 20 seconds.
His wife called
the ambulance. On arrival his GCS was 15/15, pulse 37 regular, BP
105/60 mmHg.

On arrival at the Emergency department he started to feel dizzy


and his BP dropped to 92/65 mmHg. His pulse
was 35 BPM and regular.
An ECG demonstrated a narrow complex regular bradycardia with no P
waves visible.

The Emergency department doctor administered 500 micrograms of


atropine with no improvement. He remained
alert and orientated. He
had a large, well healed sternotomy scar and was on powerful
immunosuppressants,
his wife informs you he had a cardiac
transplant three years previously.

You called the cardiology registrar who was busy for another 15
minutes with a primary PCI call.

The cardiology registrar asked to try another treatment before


he came down to see the patient.

What is the most likely treatment suggested by the cardiology


registrar?

(Please select 1 option)



Glucagon Score:


Glycopyrrolate Total Answered:


Repeated doses of atropine at 500 mcg per dose
Question Navigator

Repeated doses of atropine at 1 mg per dose


Slow intravenous infusion of theophylline
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A 37-year-old male is brought to the Emergency department having
suffered a collapse at home.
Answer Statistics
Whilst cooking breakfast he had become dizzy and collapsed to
the floor. He lost consciousness for 20 seconds.
His wife called
the ambulance. On arrival his GCS was 15/15, pulse 37 regular, BP
105/60 mmHg. Test Analysis
On arrival at the Emergency department he started to feel dizzy
and his BP dropped to 92/65 mmHg. His pulse
was 35 BPM and regular.
An ECG demonstrated a narrow complex regular bradycardia with no P
waves visible.

The Emergency department doctor administered 500 micrograms of


atropine with no improvement. He remained
alert and orientated. He
had a large, well healed sternotomy scar and was on powerful
immunosuppressants,
his wife informs you he had a cardiac
transplant three years previously.

You called the cardiology registrar who was busy for another 15
minutes with a primary PCI call.

The cardiology registrar asked to try another treatment before


he came down to see the patient.

What is the most likely treatment suggested by the cardiology


registrar?

(Please select 1 option)


Glucagon
Incorrect answer selected


Glycopyrrolate
Score:

Repeated doses of atropine at 500 mcg per dose
Total Answered:

Repeated doses of atropine at 1 mg per dose

Slow intravenous infusion of theophylline


This is the correct answer
Feedback

This question is designed to test knowledge of the management of


bradycardias. Question Navigator

The scenario describes a typical history of a syncopal event


secondary to a bradycardia. The key to its
Revision Notes
management is the
recognition of any adverse factors (shock, syncope, heart failure
or ischaemia). If none are
present and patient is not at risk of
asystole, the patient should be observed in the first instance.
Tags
The key part of this scernario is history of a cardiac
transplant The pharmacotherapy of bradycardias is different
for
this group of patients. This is because the transplanted heart is
denervated.

Therefore there is no place for atropine, even at higher doses,


hence repeated doses of atropine at 500 mcg per
dose or at 1 mg per
dose are incorrect.

Glycopyrrolate is an antimuscirinc agent and has a similar


mechanism of action to atropine, hence glycopyrrolate
is
incorrect.

Glucagon can be useful if there is a suggestion of betablocker


overdose, this could be the case here but we are
not told the
patient is on a beta-blocker.

The Resuscitation Council (UK) guidelines suggest


using theophylline as a slow intravenous infusion (100-200
mg).

Temporary pacing would also be an appropriate course of action


but only if there is little delay. The patient is
alert and
therefore medical treatment could be tried first.

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A 64-year-old man with a history of depression self presents to
the Emergency department four hours after
Test Analysis
taking an overdose of his
antihypertensive medication, which he thinks is a beta-blocker. He
states he has been
feeling light headed for a few hours but has not
noted any other symptoms.

His blood pressure is recorded as 96/60 mmHg and his pulse is


45. A 12 lead ECG reveals a regular rhythm with
normal QRS
morphology. The PR interval is prolonged but there are no
non-conducted P waves.

From the options below, which is the first step in this


patient's management?

(Please select 1 option)



Activated charcoal


Atropine


Glucagon


Observation


Temporal transvenous cardiac pacing
Score:

Total Answered:

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A 64-year-old man with a history of depression self presents to
the Emergency department four hours after
Answer Statistics
taking an overdose of his
antihypertensive medication, which he thinks is a beta-blocker. He
states he has been
feeling light headed for a few hours but has not
noted any other symptoms.
Test Analysis
His blood pressure is recorded as 96/60 mmHg and his pulse is
45. A 12 lead ECG reveals a regular rhythm with
normal QRS
morphology. The PR interval is prolonged but there are no
non-conducted P waves.

From the options below, which is the first step in this


patient's management?

(Please select 1 option)


Activated charcoal
Incorrect answer selected

Atropine
This is the correct answer


Glucagon


Observation


Temporal transvenous cardiac pacing

Overdose of beta-blockers or calcium channel blocker can lead to


significant bradycardia.
Score:
If taken within one hour of presentation, activated charcoal
should be tried.
Total Answered:
If there is symptomatic bradycardia atropine should be used in
the first instance.

Glucagon can be effective but this should be tried after


atropine. Feedback
Pacing may be necessary if these drug treatments fail.
Question Navigator
Therefore the correct answer here, in a patient who has
symptomatic bradycardia more than one hour after a
probable
beta-blocker overdose is atropine.
Revision Notes

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A 50-year-old male patient is brought to the emergency
department having sustained a witnessed cardiac arrest.
Test Analysis
He has a
history of coronary artery disease and diabetes.

On arrival he is intubated and having chest compressions


performed by the paramedics. He has one "blue"
cannula
inserted in his right antecubital fossa. The paramedics hand over
that he has had two cycles of the
current ALS protocol. He is
coming to the end of another cycle of advanced life support.

The team leader asks to stop chest compressions and the monitor
is reviewed and the rhythm is consistent with
VF. Meanwhile the
defibrillator is being charged for a shock, according to the most
up-to-date advanced life
support guidelines.

What is the correct course of action?

(Please select 1 option)



Continue chest compressions


Leave the oxygen running to the patient


Perform a bedside echocardiogram
Score:

Stop chest compressions
Total Answered:

Try to secure an IV line

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A 50-year-old male patient is brought to the emergency
department having sustained a witnessed cardiac arrest.
Answer Statistics
He has a
history of coronary artery disease and diabetes.

On arrival he is intubated and having chest compressions


performed by the paramedics. He has one "blue" Test Analysis
cannula
inserted in his right antecubital fossa. The paramedics hand over
that he has had two cycles of the
current ALS protocol. He is
coming to the end of another cycle of advanced life support.

The team leader asks to stop chest compressions and the monitor
is reviewed and the rhythm is consistent with
VF. Meanwhile the
defibrillator is being charged for a shock, according to the most
up-to-date advanced life
support guidelines.

What is the correct course of action?

(Please select 1 option)


Continue chest compressions
Correct


Leave the oxygen running to the patient


Perform a bedside echocardiogram


Stop chest compressions


Try to secure an IV line Score:

Total Answered:

The UK Resuscitation Council published updated clinical


guidelines for adult advanced life support in 2010.
Feedback
There are a number of changes to the guidelines. One of the most
significant is the concentration on the
importance of good chest
compressions for as long as possible during resuscitation.
Question Navigator
The new guidelines state that chest compressions should now
continue while the defibrillator is being charged.

While this occurs, the oxygen supply to the patient should be


removed. Revision Notes
Although the patient in this scenario is likely to need better
intravenous access, the new guidelines state that only
the team
member performing chest compressions should be touching the patient
while the defibrillator is Tags
charging, hence leaving the oxygen
running to the patient and trying to secure an IV line are
incorrect.

The new guidelines recognise the potential use of ultrasound


during cardiopulmonary resuscitation; it should be
performed at a
different stage (for example, while the pulse is being
checked).

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A 60-year-old female patient was brought to the emergency
department by paramedics following a witnessed
Test Analysis
collapse at
home.

When the paramedics arrived there was no response from the


patient, no pulse and no recordable blood
pressure. On arrival at
the Emergency department her GCS was 3/15. She had been intubated
by the
paramedics. She had IV access.

A defibrillator was attached and she was having chest


compressions. She was in VF and had had two DC
shocks by the crew,
at appropriate energy levels.

As she was transferred to the Emergency department trolley, the


second cycle had completed. Chest
compressions were halted, no
pulse was palpable and VF was confirmed on the monitor. A third
shock was
delivered to the patient.

What is the most appropriate immediate next action?

(Please select 1 option)



Give adrenaline 1 mg after the chest compressions have restarted
Score:

Give adrenaline 1 mg before the chest compressions have restarted
Total Answered:

Give adrenaline after the next assessment of rhythm


Give 300 mg IV amiodarone
Question Navigator

Medications are not recommended at this point in advanced life
support

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A 60-year-old female patient was brought to the emergency
department by paramedics following a witnessed
Answer Statistics
collapse at
home.

When the paramedics arrived there was no response from the


patient, no pulse and no recordable blood Test Analysis
pressure. On arrival at
the Emergency department her GCS was 3/15. She had been intubated
by the
paramedics. She had IV access.

A defibrillator was attached and she was having chest


compressions. She was in VF and had had two DC
shocks by the crew,
at appropriate energy levels.

As she was transferred to the Emergency department trolley, the


second cycle had completed. Chest
compressions were halted, no
pulse was palpable and VF was confirmed on the monitor. A third
shock was
delivered to the patient.

What is the most appropriate immediate next action?

(Please select 1 option)


Give adrenaline 1 mg after the chest compressions have restarted
Correct


Give adrenaline 1 mg before the chest compressions have restarted


Give adrenaline after the next assessment of rhythm Score:

Give 300 mg IV amiodarone Total Answered:

Medications are not recommended at this point in advanced life
support

Feedback

The Resuscitation UK guidelines on Advanced Life Support emphasise the importance


of minimal interruption to
chest compressions. This follows an
increasing body of evidence that minimal interruption of chest
Question Navigator

compressions is associated with improved outcomes.


Revision Notes
The guidelines recommend the first dose of adrenaline (1 mg)
after the third shock, but after chest compressions
have restarted
immediately.
Tags
This differs from the 2005 guidelines which recommended
administering adrenaline immediately after the third
shock. This
was considered to introduce an extra delay in chest compressions.
Although this seems a minor
point, it illustrates one of the main
changes to the new guidelines that chest compressions should be
interrupted
for as short a time as possible.

1 mg of adrenaline should be given after the third shock.

Although 300 mg amiodarone should be given after the third


shock, it should be after adrenaline has been
administered.

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A 73-year-old woman is brought to hospital in cardiac arrest.
She has a history of breast cancer and coronary
Test Analysis
artery disease and
was found by her husband on the floor at home.

He called the emergency services, and when the paramedics


arrived the patient was unconscious with no
respiratory effort or
cardiac output. She was cannulated and intubated while automated
defibrillator paddles
were attached. She is brought immediately to
the Emergency department.

The patient is transferred onto the Emergency department trolley


in the resuscitation area. The monitor is
reattached and the
patient remains in VF. The Emergency department nurse is providing
good chest
compressions.

The paramedics hand over that they have not yet administered any
shocks. As the team leader, you instruct one
shock to be given,
after confirming the rhythm.

After the shock is given, which is the next immediate management


step this resuscitation situation?

(Please select 1 option)



Adrenaline IV
Score:

Amiodarone IV
Total Answered:

Check for a pulse


Immediately restart chest compressions
Question Navigator

Start chest compressions after giving IV adrenaline

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A 73-year-old woman is brought to hospital in cardiac arrest.
She has a history of breast cancer and coronary
Answer Statistics
artery disease and
was found by her husband on the floor at home.

He called the emergency services, and when the paramedics


arrived the patient was unconscious with no Test Analysis
respiratory effort or
cardiac output. She was cannulated and intubated while automated
defibrillator paddles
were attached. She is brought immediately to
the Emergency department.

The patient is transferred onto the Emergency department trolley


in the resuscitation area. The monitor is
reattached and the
patient remains in VF. The Emergency department nurse is providing
good chest
compressions.

The paramedics hand over that they have not yet administered any
shocks. As the team leader, you instruct one
shock to be given,
after confirming the rhythm.

After the shock is given, which is the next immediate management


step this resuscitation situation?

(Please select 1 option)


Adrenaline IV
Incorrect answer selected


Amiodarone IV


Check for a pulse Score:
Immediately restart chest compressions
This is the correct answer Total Answered:

Start chest compressions after giving IV adrenaline

Feedback

This question tests knowledge on the current UK Resuscitation


Council guidelines.
Question Navigator
New guidelines were published in 2010 but the ALS shockable
rhythm algorithms are broadly in line with the
2005 guidelines they
replaced.
Revision Notes
It is currently believed that the best chance of survival is
with rapid defibrillation (when appropriate) and minimal

interruption of chest compressions. Immediately after the first


shock (and each subsequent shock) chest Tags
compressions should be
restarted immediately and pulse and rhythm reassessed after two
minutes.

Adrenaline is given after the third shock (and then every three
to five minutes).

Amiodarone is given after the third shock.

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A 57-year-old former user of intravenous drugs is brought to
hospital in cardiac arrest. As part of the cardiac
Test Analysis
arrest team, you
are called urgently to the Emergency department to assist.

On arrival the patient is intubated and the nurse is providing


chest compressions. The patient has already
received two shocks for
VF. The paramedics and the Emergency department team have not yet
been able to
gain any venous access, despite numerous attempts.
Adrenaline is indicated on the next cycle.

In order to given adrenaline, which the recommended next


step?

(Please select 1 option)



Give adrenaline via the endotracheal tube at normal dose


Give adrenaline via the endotracheal tube at higher dose


Manage cardiac arrest without medications


Obtain intraosseous access


Perform a cut down procedure to gain venous access
Score:

Total Answered:

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A 57-year-old former user of intravenous drugs is brought to
hospital in cardiac arrest. As part of the cardiac
Answer Statistics
arrest team, you
are called urgently to the Emergency department to assist.

On arrival the patient is intubated and the nurse is providing


chest compressions. The patient has already Test Analysis
received two shocks for
VF. The paramedics and the Emergency department team have not yet
been able to
gain any venous access, despite numerous attempts.
Adrenaline is indicated on the next cycle.

In order to given adrenaline, which the recommended next


step?

(Please select 1 option)


Give adrenaline via the endotracheal tube at normal dose
Incorrect answer selected


Give adrenaline via the endotracheal tube at higher dose


Manage cardiac arrest without medications

Obtain intraosseous access


This is the correct answer


Perform a cut down procedure to gain venous access

Endotracheal tube administration of drugs provides unreliable


plasma drug levels and can impair gaseous
Score:
exchange.
Total Answered:
Therefore, in the recent (2010) UK Resuscitation Council
guidelines, endotracheal administration of drugs is no
longer
recommended.
Feedback
Intraosseous access has been traditionally used in children.
However it is a safe and effective method of
administering drugs in
cardiac arrest; it provides adequate plasma levels of drugs and
allows equivalent flow
rates to IV access.
Question Navigator

Therefore if IV access cannot be gained within two minutes, IO


access should be attempted (if trained). Tibial or
Revision Notes
humeral sites
should be tried first.

Central venous access is recommended (as long as it does not


interfere with chest compressions). Tags

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A 73-year-old man is brought to the Emergency department  in
cardiac arrest. He was found by his carer
Test Analysis
unconscious on the
floor.

On arrival of the paramedics he was in VF and received two


shocks prior to arriving at hospital. He is intubated
and has good
IV access.

While in the Emergency department he has had a further five


shocks at the recommended energy and the
appropriate doses of
adrenaline and amiodarone but despite this he remains in VF.

As part of the cardiac arrest team you are called to help. You
look through his medications and find he is on

bendroflumethiazide.

Regarding the management of this patient's cardiac arrest,


which is the next most appropriate management
option?

(Please select 1 option)



Increase dose of adrenaline


Increase shock energy
Score:

Lidocaine IV
Total Answered:

Magnesium sulphate IV


Repeat dose of amiodarone, at increased dose Question Navigator

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A 73-year-old man is brought to the Emergency department  in
cardiac arrest. He was found by his carer
Answer Statistics
unconscious on the
floor.

On arrival of the paramedics he was in VF and received two


shocks prior to arriving at hospital. He is intubated Test Analysis
and has good
IV access.

While in the Emergency department he has had a further five


shocks at the recommended energy and the
appropriate doses of
adrenaline and amiodarone but despite this he remains in VF.

As part of the cardiac arrest team you are called to help. You
look through his medications and find he is on

bendroflumethiazide.

Regarding the management of this patient's cardiac arrest,


which is the next most appropriate management
option?

(Please select 1 option)


Increase dose of adrenaline
Incorrect answer selected


Increase shock energy


Lidocaine IV

Magnesium sulphate IV
This is the correct answer Score:


Repeat dose of amiodarone, at increased dose Total Answered:

Feedback
Refractory VF is, of course, a worrying sign in a cardiac arrest
situation.

It is worth considering other management options if repeated


shocks are ineffective. Also it is always worth Question Navigator
repeatedly
reviewing the "4 Hs and 4 Ts" for any possible reversible
causes.

Magnesium sulphate IV is recommended for the treatment of


refractory VF, if there is anything to suggest the Revision Notes
patient may be
hypomagnesaemic (such as on medications which might cause this,
that is, thiazides).

There is no indication for increasing doses of adrenaline or


amiodarone, or increasing shock energy. Tags

Amiodarone can be given again but this should be at the reduced


dose of 150 mg.

Lidocaine is only recommended if amiodarone is unavailable,


and/or has not already been given.

Therefore the most appropriate response here is magnesium


sulphate IV.

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As part of the cardiac arrest team, you are called urgently to
attend an emergency situation at the psychiatric unit
Test Analysis
attached to
the hospital you work in.

One of the porters has picked up an emergency pack containing


the main cardiac arrest medications. The ward
has a defibrillator.
You are informed a 23-year-old male has been found unconscious on
his bed. The psychiatric
nurse also informs you a large box of
lofepramine is missing from the drug trolley and has been found
empty
under the patient's bed.

Anticipating the situation, which drug should you ensure is


available in the cardiac arrest pack?

(Please select 1 option)



Bicarbonate


Calcium chloride


Glucagon


Lidocaine


Verapamil Score:

Total Answered:

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As part of the cardiac arrest team, you are called urgently to
attend an emergency situation at the psychiatric unit
Answer Statistics
attached to
the hospital you work in.

One of the porters has picked up an emergency pack containing


the main cardiac arrest medications. The ward Test Analysis
has a defibrillator.
You are informed a 23-year-old male has been found unconscious on
his bed. The psychiatric
nurse also informs you a large box of
lofepramine is missing from the drug trolley and has been found
empty
under the patient's bed.

Anticipating the situation, which drug should you ensure is


available in the cardiac arrest pack?

(Please select 1 option)


Bicarbonate
Correct


Calcium chloride


Glucagon


Lidocaine


Verapamil

Score:
This question tests knowledge of management of cardiac arrest in
certain situations. The scenario describes a
probable tricyclic
overdose. Total Answered:

Bicarbonate is not recommended for routine use in cardiac


arrests but is indicated for tricyclic overdose (and
cardiac arrest
due to hyperkalaemia). Feedback

The other medications listed here are not indicated for


tricyclic overdoses.
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An 83-year-old previously fit and well male patient is brought
to the Emergency department after feeling unwell
Test Analysis
for some time.
While in the waiting room he collapses to the floor and is
unresponsive.

He is rushed to the resuscitation area and attached to a


defibrillator. IV access is gained and an airway secured.
The
monitor shows VF and he is given a shock. Chest compressions are
continued and after he remains in VF.
He is shocked for the second
time and chest compressions continue for two minutes. After this,
the monitor is
checked and remains in VF

According the current resuscitation guidelines, what is the


immediate next management step?

(Please select 1 option)



Adrenaline


One shock and check pulse


One shock and immediately restart chest compressions


Ten seconds of echocardiography


Three shocks and check pulse Score:

Total Answered:

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An 83-year-old previously fit and well male patient is brought
to the Emergency department after feeling unwell
Answer Statistics
for some time.
While in the waiting room he collapses to the floor and is
unresponsive.

He is rushed to the resuscitation area and attached to a


defibrillator. IV access is gained and an airway secured. Test Analysis
The
monitor shows VF and he is given a shock. Chest compressions are
continued and after he remains in VF.
He is shocked for the second
time and chest compressions continue for two minutes. After this,
the monitor is
checked and remains in VF

According the current resuscitation guidelines, what is the


immediate next management step?

(Please select 1 option)


Adrenaline
Incorrect answer selected


One shock and check pulse

One shock and immediately restart chest compressions


This is the correct answer


Ten seconds of echocardiography


Three shocks and check pulse

Score:
Current UK resuscitation guidelines emphasise the importance of
minimising breaks in chest compressions in a
cardiac arrest
situation. After each shock chest compressions should be restarted
immediately before anything Total Answered:
else is done. The rhythm assessment
(and pulse check) should happen after two minutes of chest

compressions. Current guidelines also recommend single shock


strategy. Feedback
Adrenaline is indicated after the second shock, and after chest
compressions have recommenced.

The use of brief periods of echo (10 seconds) is now supported


in an arrest situation (but should be performed at
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the end of two
minutes of compressions).
Revision Notes
Therefore the most appropriate immediate step is one shock and
immediately restart chest compressions

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A 53-year-old man is brought to the Emergency department in
cardiac arrest.
Test Analysis
After 26 minutes of full advanced life support, the team leader
notes a change in rhythm and a pulse is detected.
The patient has a
history of type II diabetes but no other past medical history and
his usual state of health is
excellent.

The cardiac arrest team leader arranges for ITU admission for
post-resuscitation care.

Regarding the management of a patient post cardiac arrest, which


of the therapeutic measures in the list should
be used for this
patient?

(Please select 1 option)



Maintain glucose 4-6.5 mmol 1-1


Maintain glucose <10 mmol 1-1


Oxygen to obtain saturations of 100%


Prophylactic antiepileptic medications
Score:

Regular IV paracetamol
Total Answered:

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A 53-year-old man is brought to the Emergency department in
cardiac arrest.
Answer Statistics
After 26 minutes of full advanced life support, the team leader
notes a change in rhythm and a pulse is detected.
The patient has a
history of type II diabetes but no other past medical history and
his usual state of health is Test Analysis
excellent.

The cardiac arrest team leader arranges for ITU admission for
post-resuscitation care.

Regarding the management of a patient post cardiac arrest, which


of the therapeutic measures in the list should
be used for this
patient?

(Please select 1 option)


Maintain glucose 4-6.5 mmol 1-1
Incorrect answer selected

Maintain glucose <10 mmol 1-1


This is the correct answer


Oxygen to obtain saturations of 100%


Prophylactic antiepileptic medications


Regular IV paracetamol

Score:
The current 2010 UK resuscitation guidelines describe in detail
the importance of patient care after a successful Total Answered:
cardiac arrest,
and how to minimise the complications of the "post-cardiac
arrest syndrome".

Of the list of options, the only recommended treatment is to


maintain glucose <10 mmol 1-. Feedback
Hyperglycaemia and hypoglycaemia are both associated with
adverse outcomes and should be actively avoided.
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Trials investigating tight sugar control (4.5-6.0 mmol
1-1) demonstrated worse outcomes (due to increased

hypoglycaemia).
Revision Notes
Hyperoxaemia (and hypoxia) is also associated with poor
outcomes, so oxygen saturations should be kept at 94-
98%, not
100%.
Tags
Hyperpyrexia is a poor sign but this should be treated
reactively, not prophylactically. This is also the case for

seizures.

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A 45-year-old man with no past medical history attends the
Emergency department with an episode of acute
Test Analysis
onset breathlessness
and chest pain. While in the toilet in the Emergency department he
collapses and is found
unconscious.

He is moved immediately to the resuscitation area and advanced


adult life support is started. There is no
respiratory effort and
the monitor shows a sinus tachycardia with no pulse palpable.

His wife attends and informs you he has recently returned from a
business trip in Hong Kong and had been
complaining of a painful,
swollen left leg. After 10 minutes of unsuccessful advanced life
support, the patient
remains in pulseless electrical activity
(PEA).

For this cardiac arrest scenario, which is an appropriate next


step?

(Please select 1 option)



FAST scan


Intra-arterial thrombolysis


Intravenous thrombolysis followed by CPR for 90 minutes
Score:

Intravenous thrombolysis followed by CPR for 30 minutes
Total Answered:

Transthoracic echocardiography to image the right ventricle

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A 45-year-old man with no past medical history attends the
Emergency department with an episode of acute
Answer Statistics
onset breathlessness
and chest pain. While in the toilet in the Emergency department he
collapses and is found
unconscious.
Test Analysis
He is moved immediately to the resuscitation area and advanced
adult life support is started. There is no
respiratory effort and
the monitor shows a sinus tachycardia with no pulse palpable.

His wife attends and informs you he has recently returned from a
business trip in Hong Kong and had been
complaining of a painful,
swollen left leg. After 10 minutes of unsuccessful advanced life
support, the patient
remains in pulseless electrical activity
(PEA).

For this cardiac arrest scenario, which is an appropriate next


step?

(Please select 1 option)


FAST scan
Incorrect answer selected


Intra-arterial thrombolysis

Intravenous thrombolysis followed by CPR for 90 minutes


This is the correct answer


Intravenous thrombolysis followed by CPR for 30 minutes


Transthoracic echocardiography to image the right ventricle Score:

Total Answered:

Thromboembolic disease is a potentially reversible cause of


cardiac arrest.
Feedback
Massive PE can lead to PEA and can be treated with thrombolysis.
Thrombolysis is indicated in the cardiac
arrest situation for
suspected PEs. However, it can take 90 minutes to be effective and
therefore must only be
used if it is appropriate to continue CPR
for this duration.
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Brief echo (less than 10 seconds) is appropriate in cardiac


arrest, but it is unlikely right ventricular abnormalities
Revision Notes
(which
may indirectly support the diagnosis) can be demonstrated in that
brief time.

FAST scan is not specifically indicated in this scenario. Tags


Intra-arterial thrombolysis is not indicated.

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