Acute Medicine

Question 1

A 65 year old man with a history of self-harm presents to A&E with severe nausea and vomiting. He tells you that he took ‘some tablets’ but he didn’t bother to look at what they were. He suffers from stable angina but his PMHx is otherwise unremarkable. His observations are as follows:

HR 110
BP: 110/85
RR: 30
O2 sats: 100%
Temp: 39.0

What is the most likely diagnosis?

A: SSRI toxicity
B: Paracetamol overdose
C: Myocardial infarction
D: Aspirin overdose
E: Panic attack

Answer 1

D) Aspirin overdose

- N/V + elevated resp rate (rasp-irin way of remembering this)

Question 2

A 21 year old woman of average build is brought to A&E by her mother after she ingested 2 packets of paracetamol ~6 hours ago. She says she feels fine at the moment and wishes to be sent home.

What is the next best step in the management of this patient?

A: Send her home with a referral to the Community Mental Health Team
B: Admit her to the local Mental Health Unit
C: Admit her to the renal ward for immediate dialysis
D: Admit her and prescribe activated charcoal
E: Admit her and start IV N-acetyl cysteine

Answer 2

E) N-acetyl-cysteine

Question 3

An 18 year old girl is brought to A&E with difficulty in breathing. On examination, you note swelling of the lips and tongue and an erythematous rash over her face and trunk. Her observations are as follows:

HR 160 
BP: 70/50
RR: 40
O2 sats: 92%
Temp: 37.2

What is the next best step in management of this patient?

A: IV adrenaline 0.5mg
B: IM adrenaline 0.5mg
C: IV adrenaline 0.25mg
D: IM adrenaline 0.25mg
E: Start high-flow oxygen

Answer 3

B) IM adrenaline 0.5mg 1:1000

Question 4

A 35 year old man presents to A&E in respiratory depression with needle track marks on his arms. He has pinpoint pupils on examination. His observations are as follows:

HR 40
BP: 60/30
RR: 8
O2 sats: 90%
Temp: 37.2

What is the next best step in management of this patient?

A: IV naltrexone
B: IV naloxone
C: IV saline 0.9% 1L bolus
D: IV flumazenil
E: IV atropine

Answer 4

B) IV Naloxone

naltrexone = opioid dependence management
saline 0.9% = fluid resus
flumezanil = benzodiazepine overdose
atropine = heart block/beta-blocker overdose/organophosphate overdose

Question 5

A 62yr old gentleman is brought to A&E by his wife who suspects that her husband has been drinking. It is clear that the gentleman is disoriented, and he has a particularly unsteady gate. On examination, you note: spider naevi, gynaecomastia, nystagmus on lateral gaze and mild peripheral neuropathy. His blood results are as follows: 
FBC: 
Hb: 12.5g/dL (13.5-17.5g/dL)
MCV: 105fL (80-96)
HCT: 0.35 (0.4-0.5)
Platelet: 200*10^9/L (150-400*10^9)
WBC: 8,000/mL (4,000-10,000)
U&E: Normal
CRP: Normal
INR: 0.7 (<1.1)

What is the most likely diagnosis?

A) Hepatic Encephalopathy
B) Wernicke’s Encephalopathy
C) Encephalitis
D) Normal Pressure Hydrocephalus
E) Delirium tremens

Answer 5

B) Wernicke’s encephalopathy
Classica WE - disorientation, gynaecomastia, nystagmus, previous alcohol, neuropathy (Vit B deficiency post-alcohol consumption)
- delirium tremens = alcohol withdrawal (48 hrs)
- NPH - gait apraxia, incontinence, dementia
- HE - raised LFTs showing damage
- Encephalitis - fever, headache, altered behaviour, speech, confusion, nausea + raised inflammatory markers