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Work SmartQuestion 1 of 22
Which of the following does not have a role in the management of chronic cancer pain?
(Please select 1 option)
Carbamazepine
Clodronate
Dexamethasone
Nifedipine Incorrect answer selected
Pinaverium This is the correct answer
Pinaverium is used to reduce the pain duration in irritable bowel syndrome (IBS).
Carbamazepine is in use for the treatment of neuropathic pain of malignancy, diabetes and otherdisorders.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and theassociated hypercalcaemia.
The corticosteroids are used to treat pain from central nervous system tumours. Reducing theinflammation and oedema relieves the pain caused by neural compression.
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinaltumours.
Painful bladder spasm may be relieved by oxybutynin.
1 11%2 8%3 7%4 56%5 18%
Answer Statistics
Times answered: 8539
Test Analysis
Score: 0%
Total Answered: 1
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Work SmartQuestion 2 of 22
An 18-year-old woman sustains severe head injuries in a road traffic accident.
The following day her investigations show:
Sodium 160 mmol/L (137-144)
Potassium 3.7 mmol/L (3.5-4.9)
Chloride 120 mmol/L (95-107)
Urea 3.0 mmol/L (2.5-7.5)
Creatinine 90 µmol/L (60- 110)
Which one of the following statements is correct?
(Please select 1 option)
Rapid rehydration with 5% dextrose is indicated
She has the syndrome of inappropriate antidiuretic hormone secretion (SIADH)
She should be treated with sodium restriction
She will have a hypercholraemic acidosis
Urine osmolality will be low Correct
There is a marked hypernatraemia with elevated chloride but normal potassium and urea in a patient
with severe head injuries.
The likely cause of this presentation is diabetes insipidus. Urine osmolality is therefore likely to below.
You cannot say that she has a hyperchloraemic acidosis as you do not have her bicarbonateconcentration but if you assume that the anion gap would be normal, that is 10-12, then this wouldsuggest that the bicarbonate is elevated, suggesting either a metabolic alkalosis or respiratoryacidosis with compensation.
Although restoration of normal volaemia and osmolality is required, giving 5% dextrose mayexacerbate any cerebral oedema and so correction should be gradual.
1 12%2 19%3 16%4 16%5 37%
Answer Statistics
Times answered: 9704
Test Analysis
CorrectIncorrectPartiallyCorrect
Score: 50%
Total Answered: 2
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Work SmartQuestion 3 of 22
A 14-year-old boy bangs heads with an opponent during an unofficial football game. He is knockedout for 30 seconds and is amnesic for the event. He recovers quickly and continues playing.
Two hours later he complains of headache, begins vomiting, then loses consciousness. He had a fullterm normal delivery with no neonatal complications. His immunisations are up to date. There is noFH/SH of note.
On examination he responds only to deep pain. He is apyrexial with respiratory rate of 10/min(irregular), pulse of 40/min. He has a large bruise in the right temporal area.
Which is the most likely diagnosis?
(Please select 1 option)
Cerebral contusion
Contrecoup injury
Extradural haematoma Correct
Subdural haematoma
Tonsillar herniation
The history is of a closed head injury, followed by a lucid period followed by decreasing level ofconsciousness.
The time course suggests an extradural haematoma, where there is arterial bleeding whichaccumulates rapidly outside the dura causing raised intracranial pressure.
Subdural haematoma in infants may accompany massive axon injury in 'shaken baby syndrome', andpresents acutely. Retinal haemorrages are often present. (Chronic subdurals due to birth trauma canpresent much later due to the open fontanelle.)
Epidural haematoma, typically from a torn middle meningeal artery and associated with skull fracture,accumulates much more rapidly.
There may be apparent recovery from the initial concussion, but deterioration is usually within 15-30minutes.
© Colin Melville 2012
1 5%2 5%3 56%4 26%5 9%
Answer Statistics
Times answered: 6274
Test Analysis
CorrectIncorrectPartiallyCorrect
Score: 66.67%
Total Answered: 3
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Work SmartQuestion 4 of 22
A 56-year-old man is admitted with epigastric pain after drinking heavily.
He has a temperature of 36.9°C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and arespiratory rate of 32/min.
Investigations reveal:
Haemoglobin 126 g/L (130-180)
Platelets 169 ×10 /L (150-400)
White cell count 3.9 ×10 /L (4-11)
Which of the following is the diagnosis?
(Please select 1 option)
Leaking aortic aneurysm
Multiple organ dysfunction syndrome (MODS) Incorrect answer selected
Severe sepsis
Septic shock
Systemic inflammatory response syndrome (SIRS) This is the correct answer
This patient has features of pancreatitis. He also has hypotension, and leucopenia. He therefore fulfils
9
9
the criteria for systemic inflammatory response syndrome. This is equivalent to sepsis, but occurs inthe absence of infection (e.g. in pancreatitis).
SIRS is defined as two or more of the following:
Temperature more than 38°C or less than 36°CHeart rate more than 90 beats/minRespiratory rate more than 20 breaths/min or PaCO2 less than 4.3 kPaWBC count 12,000/mm , less than 4000/mm , or more than 10% immature (bands) form.
A leaking aortic aneurysm is still a possibility, however a decreased white cell count would not beexpected.
We do not have enough information to diagnose multiple organ dysfunction. There is no evidence ofinfection to make a diagnosis of septic shock or severe sepsis. For information, sepsis is defined asthe association of systemic inflammatory responses with evidence of microbial origin. Severe sepsisalso has hypoperfusion or dysfunction of at least one organ system, and septic shock is this plushypotension refractory to fluid resuscitation.
3 3
1 18%2 6%3 23%4 9%5 44%
Answer Statistics
Times answered: 7975
Test Analysis
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Score: 50%
Total Answered: 4
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Work SmartQuestion 5 of 22
A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary topancreatitis is admitted to the High Dependency Unit.
He has a pulse of 109 beats/min and a blood pressure of 89/74 mmHg despite receiving IV fluids andurine output of 25 ml/hour after catheterisation.
Which of the following is the most appropriate course of action for this patient?
(Please select 1 option)
A central line Correct
A CT abdomen
A surgical referral
An arterial line
Broad spectrum antibiotics
Early goal-directed therapy (EGDT) in cases of SIRS or septic shock is becoming increasinglyrecognised as potentially beneficial. If fluids are not achieving haemodynamic stability, and there isindication of hypoperfusion as indicated by oliguria or lactataemia, then vigorous resuscitation isindicated.
EGDT aims to increase organ perfusion through restoration of mean arterial pressure using inotropesif necessary, maintaining central venous pressure (CVP), maintaining oxygenation, and using SjVO(jugular venous oxygen saturation) as a guide to oxygen utilisation at the tissue level. SjVO higher
2
2
than 70% is indicative of organ hypoperfusion, as oxygen is not being extracted.
Insertion of a central line above allows measurement of CVP, SjVO and the use of inotropes.2
1 57%2 8%3 6%4 7%5 23%
Answer Statistics
Times answered: 7642
Test Analysis
Score: 60%
Total Answered: 5
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Work SmartQuestion 6 of 22
A 64-year-old man is admitted with severe epigastric pain. He has had the pain for 36 hours. Anabdominal x ray shows a central, dilated small bowel loop.
His temperature is 37.0°C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min,SpO2 85% on air.
His full blood count reveals:
Haemoglobin 130 g/L (130-180)
White cell count 3.2 ×10 /L (4-11)
Platelets 108 ×10 /L (150-400)
MCV 105 fL (80-96)
Which of the following is the most appropriate initial treatment of this patient?
(Please select 1 option)
Administer high-flow oxygen This is the correct answer
Insert 2 × 14 gauge venflons and give 2 litres Hartmann's solution Incorrect answerselected
Intensive care
Intubation and ventilation
Invasive monitoring
9
9
This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitisgiven the finding of an isolated dilated loop of small bowel on abdominal radiograph. However, theinitial treatment is the same independent of the underlying cause.
All of the above answers are reasonable, however resuscitation of the sick patient still follows theABC algorithm:
AirwayBreathingCirculation.
Airway control and oxygen to maintain normal saturations is the first part of that algorithm.Subsequent fluid resuscitation and treatment of the underlying cause can then be initiated. The needfor invasive monitoring and intensive care is then assessed, depending on the response to initialtreatment.
1 32%2 50%3 13%4 3%5 2%
Answer Statistics
Times answered: 8113
Test Analysis
CorrectIncorrectPartiallyCorrect
Score: 50%
Total Answered: 6
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Work SmartQuestion 7 of 22
A 64-year-old man is admitted with 12 hours of central and epigastric pain.
An abdominal x ray shows a central, dilated small bowel loop. His temperature is 37.2°C, pulseregular at 130 beats per min, blood pressure 95/55 mmHg, respiratory rate 29/min, and SpO2 90% onair.
His admission full blood count is:
Haemoglobin 120 g/L (130-180)
White cell count 13.6 ×10 /L (4-11)
Platelets 96 ×10 /L (150-400)
MCV 105 fL (80-96)
Which of the following is the most likely diagnosis?
(Please select 1 option)
Gall stone ileus
Ischaemic bowel
Pancreatitis Correct
Perforated duodenal ulcer
Small bowel obstruction
9
9
Ischaemic bowel and perforated duodenal ulcer would be high in the differential list. However, thehistory and raised mean corpuscular volume (MCV) suggests chronic high alcohol use and theseverity of his observations would suggest a systemic inflammatory response which is more commonwith pancreatitis.
Acute pancreatitis has a mortality of 7-10%, often due to sepsis or multiorgan failure. There are anumber of scoring systems which can be used to guide prognosis, but they are unreliable within thefirst 48 hours o f the illness. Gallstones account for 50% of cases, with the majority of the rest beingassociated with alcohol.
Patients typically present with severe epigastric pain which radiates to the back, and vomiting. Asseen in this example, there is often a systemic inflammatory response (SIRS), Amylase is markedlyraised, often in excess of four times the normal value. Early complications include ARDS (adultrespiratory distress syndrome), acute kidney injury and disseminated intravascular coagulation (DIC).
Treatment is essentially supportive, and high levels of monitoring are usually required (often in theintensive care unit). Those patients who are found to have gallstones should be considered for urgentERCP when stable. All should have a cholecystectomy either during the same admission or withinfour weeks depending on their clinical progress.
1 6%2 14%3 41%4 14%5 25%
Answer Statistics
Times answered: 8068
Test Analysis
CorrectIncorrectPartiallyCorrect
Score: 57.14%
Total Answered: 7
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Work SmartQuestion 8 of 22
A 74-year-old man with ischaemic heart disease is in the surgical high dependency unit following aHartmann's procedure completed 12 hours previously.
He is in pain. He has drained 100/200/300 mls of blood into his drains in each of the last three hours.His blood pressure is 110/80 mmHg, his pulse 105/min. He has a respiratory rate 32/min, SpO2100% on oxygen by face mask.
Crossmatched blood is available.
Haemoglobin 81 g/L (130-180)
White cell count 4.5 ×10 /L (4-11)
Platelets 132 ×10 /L (150-400)
Which of the following actions would be undertake as your initial priority?
(Please select 1 option)
Give 1000 ml of colloid stat
Give 1000 ml of crystalloid stat
Morphine 5 mg intravenously Incorrect answer selected
Return to theatre
Transfuse 2 units of packed red blood cells stat This is the correct answer
9
9
He is still actively bleeding and haemodilution will not have been achieved so his Hb will be lowerthan the result given. It will take at least 30-60 minutes before he is back in theatre and anaesthetized(CEPOD lists/emergency sections/crash calls/no porter etc). With IHD he is at at high risk of aperioperative MI. He should have the blood first as crossmatched blood is available.
His observations could be caused by pain. However in the face of a falling haemoglobin, a risingpulse rate, and an increasing loss into his drains this patient needs to return to theatre.
His blood pressure is not critically low and although many would give crystalloid or colloid, it isreasonable in an elderly man with ischaemic heart disease to give blood if it is easily available.Overload with non-oxygen carrying fluid should be avoided (although the red cells are not functionalfor a while).
1 25%2 11%3 10%4 16%5 38%
Answer Statistics
Times answered: 5838
Test Analysis
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Score: 50%
Total Answered: 8
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Work SmartQuestion 9 of 22
You are asked to see a 75-year-old man post-oversew of a duodenal ulcer. He is confused.
His SpO2 is 97 on oxygen. Pulse 110 beats per min, blood pressure 100/50 mmHg, respiratory rate32/min and his urine output is 10 ml in the last hour.
Which of the following is the most appropriate treatment for this man?
(Please select 1 option)
100% oxygen via face mask
Central line and arterial line
Haloperidol 2.5 mg intravenously
Noradrenaline via central line
Normal saline 500 ml stat Correct
Postoperative confusion is common in the elderly. However this can be caused by a low perfusionstate.
His observations are indicative of underfilling/dehydration. (He could also have atelectais or havedeveloped a chest infection. Post-operative problems are often multifactorial.)
Of the options given a fluid bolus is appropriate. This is what you would expect your FY1 to do whilewaiting for the blood test results and before calling you.
Some would argue that 100% oxygen comes before fluids but with an SpO2 of 97 it is unlikely thathypoxia is contributing to his problems (nonetheless oxygen therapy would be recommended).
The other options would come further down the line if initial interventions were unsuccessful and hedeteriorated.
1 7%2 14%3 2%4 2%5 76%
Answer Statistics
Times answered: 7800
Test Analysis
Score: 55.56%
Total Answered: 9
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Work SmartQuestion 10 of 22
A 67-year-old man is three days post-operation for a sigmoid colectomy. He has insulin dependentdiabetes mellitus. He complains of dizziness, upper abdominal discomfort, and faintness.
His blood pressure is 110/75 mmHg, his pulse is 95 bpm, he has a respiratory rate 24/min, and hehas SpO2 99% on air. His blood glucose is 18 mmol/l.
His electrocardiogram shows ST depression of 2 mm in leads II, III and AVF.
Which of the following is the initial drug therapy for this patient?
(Please select 1 option)
Aspirin 300 mg Correct
Clexane 1 mg/kg subcutaneously
Clopidogrel 75 mg
Diamorphine 2.5 mg
Glycerol trinitrate 800 mcg sublingually
Initial treatment of an acute coronary syndrome is aspirin 300 mg. This should be safe in the post-surgical patient with no signs of bleeding at three days post operation. Clexane would have also beengiven pre- and post-operation.
The dose of clopidogrel is 300 mg in an acute coronary syndrome.
Diamorphine is used to treat anxiety and pain, neither of which is commented upon.
GTN would be reasonable to try, however the blood pressure is low.
Remember that in the diabetic, chest pain may not be a feature of acute coronary syndrome due toautonomic dysfunction, and in most post surgical patients myocardial infarct is silent.
1 59%2 15%3 3%4 6%5 17%
Answer Statistics
Times answered: 7592
Test Analysis
Score: 60%
Total Answered: 10
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Work SmartQuestion 11 of 22
A 56-year-old man with severe brain damage is apnoeic, unsedated, and temperature 36.9°C.
He is intubated and ventilated. His biochemistry is normal.
The combination of which of the following specialists would be able to confirm brain stem death?
(Please select 1 option)
Consultant/specialist trainee with one years experience Incorrect answer selected
Consultant/specialist trainee with three years experience
Consultant/specialist trainee with four years experience
Consultant/specialist trainee with five years experience This is the correct answer
Consultant/specialist trainee with two years experience
The conventional criteria previously established for clinical death were based upon lack ofcardiorespiratory function.
The development of organ transplantation highlighted patients who had conditions incompatible withlife, but who continued to have some form of cardiorespiratory function with artificial support. This ledto a code of practice for the diagnosis of brain stem death.
This is based on the knowledge that when the brain stem is damaged to such a degree that itsfunctions are irreversibly destroyed, the heart will inevitably stop beating shortly afterwards. Whenthis occurs, therefore, the patient is dead even though respiration and circulation can be artificiallymaintained. Brain stem function is checked through set criteria, and the findings must be agreed by at
least two senior doctors. One should be a consultant, and the other must have at least five years postregistration who has experience in the testing of brain stem death.
Life support should be withdrawn at this point, but consideration should be taken as to whether theperson would be a suitable organ donor.
Reference:
Department of Health. A code of practice for the diagnosis of brain stem death, including guidelinesfor the identification and management of potential organ and tissue donors.
1 10%2 28%3 13%4 36%5 13%
Answer Statistics
Times answered: 8765
Test Analysis
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Score: 54.55%
Total Answered: 11
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Work SmartQuestion 12 of 22
An 18-year-old male is admitted with a history of diarrhoea and vomiting associated with weaknessand lethargy.
His motor power in the distal arms and legs is decreased and he describes difficulty swallowing. Hisforced vital capacity (FVC) is 1.5 litres.
Which of the following is the most appropriate immediate treatment for this condition?
(Please select 1 option)
Cyclophosphamide
Intravenous immunoglobulin therapy (IgG) 0.5 g/kg This is the correct answer
Intubation and ventilation Incorrect answer selected
Plasmapheresis
Prednisolone 60 mg
This scenario is suggestive of Guillain-Barré syndrome (GBS).
Dysphagia is a dangerous symptom suggestive of bulbar involvement. However a FVC of 1.5 litres isnot an indication for immediate ventilation (a FVC of less than 1 litre would be an indication).
First line therapy is intravenous IgG. Plasmapheresis can also be used but requires specialistequipment.
Steroids are of no benefit.
Cyclophosphamide, although an immune suppressant, is a red herring.
1 1%2 44%3 32%4 15%5 8%
Answer Statistics
Times answered: 7872
Test Analysis
Score: 50%
Total Answered: 12
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Work SmartQuestion 13 of 22
A 21-year-old male is admitted with acute onset headache and is drowsy.
He is opening his eyes spontaneously, is disoriented but is localising to painful stimuli.
Which of the following is the investigation of choice for this man?
(Please select 1 option)
Computed tomography (CT) Correct
Lumbar puncture (LP)
Magnetic resonance angiography (MRA)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Urgent CT will confirm diagnosis in 95% of patients with subarachnoid haemorrhage.
Lumbar puncture is not usually required unless the history is suggestive and the CT is normal.
Blood will be present in the cerebro-spinal fluid (if a bloody tap is suspected the number of red bloodcells should fall with each successive sample).
If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined forxanthochromia after centrifugation.
1 77%2 12%3 5%4 5%5 1%
Answer Statistics
Times answered: 9870
Test Analysis
Score: 53.85%
Total Answered: 13
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Work SmartQuestion 14 of 22
A 21-year-old male is admitted with acute onset headache and is drowsy.
He is opening his eyes spontaneously, is disoriented and is localising painful stimuli. He has a normalcomputed tomography (CT) scan.
Which of the following is the most appropriate next investigation for this patient?
(Please select 1 option)
Cerebral angiography
Lumbar puncture Correct
Magnetic resonance angiography
Magnetic resonance imaging
No further investigations necessary
Lumbar puncture (LP) is not usually required unless the history is suggestive and the CT is normal asin this case.
Blood will be present in the CSF (if a bloody tap is suspected the number of red blood cells should fallwith each successive sample).
If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined forxanthochromia after centrifugation.
1 3%2 81%3 6%4 6%5 4%
Answer Statistics
Times answered: 9335
Test Analysis
Score: 57.14%
Total Answered: 14
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Work SmartQuestion 15 of 22
A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperablecarcinoma of the distal oesophagus. Oesophageal spasm causes food to stick after swallowing whichcauses odynophagia.
Which drug would be most helpful in relieving his chronic pain?
(Please select 1 option)
Clodronate
Dexamethasone
Nifedipine Correct
Oxybutynin
Pinaverium
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinaltumours and could be used to relieve his odynophagia.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and theassociated hypercalcaemia.
Pinaverium is used to reduce the pain duration associated with irritable bowel syndrome (IBS).
Corticosteroids are used to treat pain from central nervous system tumours and painful bladderspasm may be relieved by oxybutynin.
1 3%2 10%3 63%4 16%5 7%
Answer Statistics
Times answered: 7890
Test Analysis
Score: 60%
Total Answered: 15
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Work SmartQuestion 16 of 22
Exam Themes January 2007
Which of the following statements regarding the subclavian vein and its relations is correct?
(Please select 1 option)
Begins at the lateral border of the first rib This is the correct answer
Forms the axillary vein
Joins the superior vena cava Incorrect answer selected
The thoracic duct joins the right subclavian
The subclavian vein passes posterior to scalenus anterior
The subclavian vein is a continuation of the axillary vein, beginning at the lateral border of the first rib.
It passes anterior to scalenus anterior.
The subclavian and internal jugular vein unite to form the brachiocephalic vein, subsequently the leftand right brachiocephalic veins unite to form the superior vena cava.
The thoracic duct enters the left subclavian.
The brachiocephalic trunk is a branch of the aortic arch, which divides to form the right subclavianand right common carotid arteries.
1 20%2 12%3 22%4 34%5 11%
Answer Statistics
Times answered: 9599
Test Analysis
Score: 56.25%
Total Answered: 16
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Work SmartQuestion 17 of 22
Which of the following statements regarding the internal jugular vein and relations is true?
(Please select 1 option)
Lies lateral to the common carotid artery This is the correct answer
Originates at the carotid canal
Passes behind the clavicle to join the superior vena cava
Passes posterior to the subclavian artery
Receives a lymphatic trunk at its union with the external jugular vein Incorrect answerselected
The internal jugular vein originates at the jugular foramen.
It initially lies posterior to the carotid artery, as it descends in the carotid sheath it lies lateral first tothe internal then the common carotid artery within the carotid sheath.
It passes anterior to the subclavian artery to join the subclavian vein and then form thebrachiocephalic vein; the left and right brachiocephalic veins unite to form the superior vena cava.
The internal jugular vein receives a lymphatic trunk at its union with the subclavian vein.
The external jugular vein drains into the subclavian vein.
1 50%2 3%3 22%4 13%5 12%
Answer Statistics
Times answered: 8634
Test Analysis
Score: 52.94%
Total Answered: 17
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Work SmartQuestion 18 of 22
A 67-year-old man complains of dizziness and faintness. He has insulin dependent diabetes mellitusand he had a sigmoid colectomy three days previously.
His blood pressure is 80/50 mmHg, his pulse 110 beats per min, his respiratory rate 24/min, and hehas SpO2 99% on air. His plasma glucose concentration is 18 mmol/L (3.0-6.0 fasting)
Which of the following is the most appropriate investigation for this patient?
(Please select 1 option)
Arterial blood gas Incorrect answer selected
Chest x ray
Electrocardiogram This is the correct answer
Serum lactate
Urine ketones
This man may have a cardiac cause for his dizziness.
The highest prevalence of myocardial infarction is 72 hours post operation. Patients with diabetesmay not have chest pain due to autonomic dysfunction.
The differential diagnosis would include pulmonary embolus. It may also include diabeticketoacidosis, but this would be unlikely with his glucose at 18 mmol/l and would not directly explainhis hypotension. Also, he would be expected to have a slightly higher respiratory rate than 24/min.Sepsis is also a possibility, but you would expect there to be a temperature abnormality.
The most appropriate immediate investigation in this scenario would be ECG. This would help toconfirm or exclude a cardiac cause. Sinus tachycardia may make the differential diagnoses morelikely.
If the scenario involved a shorter postoperative time frame (up to 48 hours), exclusion ofhaemorrhage would take high priority.
1 32%2 3%3 23%4 15%5 27%
Answer Statistics
Times answered: 7969
Test Analysis
Score: 50%
Total Answered: 18
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Work SmartQuestion 19 of 22
A patient needs central venous access for total parenteral nutrition (TPN).
Which of the following is the cleanest site for placement?
(Please select 1 option)
Left femoral
Left internal jugular
Right femoral Incorrect answer selected
Right internal jugular
Right subclavian This is the correct answer
Right or left subclavian is regarded as the cleanest site for central venous access. It also the mosttolerated by patients.
However the incidence of subclinical pneumothorax even in the hands of experienced clinicians hasled to it falling out of favour.
Answer Statistics
1 1%2 8%3 2%4 40%5 49%
Times answered: 7994
Test Analysis
Score: 47.37%
Total Answered: 19
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Work SmartQuestion 20 of 22
A 26-year-old female is admitted to ICU with severe asthma.
She is ventilated for one week and receives IV co-amoxiclav/clarithromycin, magnesium,prednisolone, sedatives and muscle relaxants.
She improves gradually but two days after stopping muscle relaxants she still is unable to be weanedfrom ventilatory support.
On examination, she is alert but has flaccid weakness of all limbs.
Which of the following is the likely diagnosis?
(Please select 1 option)
Critical illness polyneuropathy Incorrect answer selected
Guillain-Barré syndrome
Hypermagnesaemia
Prolonged neuromuscular blockade This is the correct answer
Steroid induced myopathy
The history suggests prolonged neuromuscular junction (NMJ) blockade which may be exacerbatedby both corticosteroids and magnesium.
This condition was originally described with suxamethonium due to hereditary reductions in plasmacholinesterase activity.
However, drugs and electrolyte abnormalities may exacerbate this.
1 28%2 16%3 13%4 34%5 8%
Answer Statistics
Times answered: 8941
Test Analysis
Score: 45%
Total Answered: 20
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Work SmartQuestion 21 of 22
A 58-year-old man with known alcoholism is admitted to the Emergency Department following a largeupper GI haemorrhage. As far as you are, aware he has no other significant past medical history andis non compliant with medications for his liver disease, including propranolol which was started afterhis last admission to the Gastroenterology ward. On admission to the Emergency Department, he isdrunk and aggressive
Which of the following is the likely initial reaction to blood loss in this patient?
(Please select 1 option)
Aldosterone release
Angiotensin 2 production
Hypotension
Increased aquaporin 2 expression Incorrect answer selected
Tachycardia This is the correct answer
The answer is Tachycardia. Increased output of noradrenaline, coupled with decreased vagal tonepost acute blood loss is responsible for the initial tachycardia seen. These changes also driveincreased myocardial contractility and vasoconstriction, preserving blood pressure at least in theinitial period after blood loss. Blood pressure generally only falls if the amount of blood loss exceedsthese compensatory mechanisms (increased cardiac output, tachycardia, and increased arterialtone).
Aldosterone release and angiotensin 2 production are incorrect. The renin system is activated by
blood loss, but the resultant angiotensin 2 production with subsequent aldosterone release is lessrapid. Aquaporin 2 expression is increased in response to more chronic hypovolaemia, improving theaction of ADH and promoting greater reabsorption of water in the kidney.
1 4%2 7%3 15%4 4%5 71%
Answer Statistics
Times answered: 2408
Test Analysis
Score: 42.86%
Total Answered: 21
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Work SmartQuestion 22 of 22
Core Questions
A 24-year-old man presents with rash, lip and eye swelling, and tachypnoea 15 minutes following ameal at his local Chinese restaurant. On auscultation of his chest there is widespread wheeze.
Which treatment should be given immediately?
(Please select 1 option)
IM adrenaline Correct
IM chlorphenamine
IV adrenaline
IV atropine
IV hydrocortisone
This presentation is classical for anaphylaxis, which should be treated immediately with IMadrenaline. Patients known to have a severe allergy might carry this in the form of an Epipen.
IV adrenaline should only be used in the setting of cardiac arrest, unless in a critical care setting withexpert supervision.
IV atropine is indicated in the management of unstable patients with bradycardia.
Hydrocortisone and chlorphenamine are indicated in the subsequent management of anaphylaxis, butadrenaline should be used first in patients with respiratory compromise.
1 80%2 3%3 6%4 0%5 11%
Answer Statistics
Times answered: 1623
Test Analysis
Score: 45.45%
Total Answered: 22
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