SDL Corrections

Question 1

A 79 year old man has been admitted following a fall. He has sustained a fractured neck of femur that requires surgical repair. He is known to have some co-morbidities and his prescription list is as follows:

A) Furosemide
B) GTN
C) Levetiracetam
D) Metformin
E) Paracetamol

Which medication would be classified as time critical?

Answer 1

C) Levetiracetam (as is an anti-epileptic).

Question 2

A 23 year old man with asthma has severe shortness of breath. He is speaking partial sentences. He has significantly increased respiratory effort with a prolonged expiratory time and widespread wheeze. He is alert and his observations are: P 125 bpm (sinus), BP 85/55mmHg, RR 31 and SpO2 94% on high flow oxygen.

Which feature indicates this is a life-threatening exacerbation of his asthma?

A) BP 85/55mmHg
B) High-flow oxygen therapy
C) Pulse 125 bpm
D) Respiratory rate 31
E) SpO2 94%

Answer 2

BP 85/55 mmHg

Question 3

An ambulance has been called to a 34 year man with a sudden onset of breathlessness and facial swelling whilst popcorn in the cinema. He has obvious facial swelling and is agitated. Observations show: P 130 bpm, BP 70/40 mmHg, RR 28, SpO2 88% in air.

Which is the most appropriate initial treatment for this man?

A) Adrenaline
B) Amiodarone
C) Intravenous fluids
D) Oxygen via a non-rebreathe mask
E) Salbutamol

Answer 3

A) Adrenaline

Remember –> give adrenaline ASAP in suspected anaphylaxis.

Question 4

A 49 year old man was found on the ground outside the ED having a generalised seizure. He is well known and regularly presents with issues relating to illicit drug and alcohol use. He has now been taken into the resuscitation room and has a nasopharyngeal airway. He is receiving high-flow oxygen via a non-rebreathe mask. He has been fitting for 5 minutes.

Which is the most appropriate initial management plan to terminate the seizure?

A) Administer intravenous lorazepam
B) Bolus intravenous glucose
C) Contact an anaesthetist for rapid sequence induction and intubation
D) Give naloxone (opioid antidote)
E) Give rectal diazepam

Answer 4

A) Administer IV lorazepam

Question 5

A 50 year old man has just had a cardiac arrest in the MAU. During the event, his airway was managed with positioning and an oropharyngeal airway (OPA). After 15 minutes of CPR, he regained a cardiac output. He has now had a pulse for 10 minutes but he is very agitated. He is on 15L of oxygen via a NRBM and his GCS is E1V2M4.

Which is the most appropriate device to manage his airway now?

A) Endotracheal tube
B) i-Gel® supraglottic airway
C) Laryngeal mask airway
D) Nasopharyngeal airway
E) Oropharyngeal airway

Answer 5

A) Endotracheal tube

Remember - GCS<8, intubate!

Question 6

A 70 year old man with advanced COPD has just had a cardiac arrest in the MAU. He was admitted with severe pneumonia and acute kidney injury. He received 5 minutes of CPR and now has a cardiac output.

Which is the most appropriate oxygen delivery device to use in his initial post- resuscitation care?

A) Nasal cannula
B) No device required
C) Non-rebreathe mask with reservoir
D) Simple face mask
E) Venturi mask

Answer 6

C) NBR with reservoir

For all critically ill patients, high concentration oxygen should be administered immediately until the patient is stable (even in COPD).

Question 7

Which is the most appropriate initial fluid prescription for a patient in DKA?

A) 250ml bolus of 0.9% sodium chloride over 10-15 minutes.
B) 500ml bolus of 0.9% sodium chloride over 10-15 minutes.
C) 500ml bolus of 0.9% sodium chloride over 30 minutes.
D) 1000ml infusion of 0.9% sodium chloride over 60 minutes.
E) 1000ml infusion of 0.9% sodium chloride over 120 minutes.

Answer 7

D) 1000ml infusion of 0.9% saline over 60 mins

Question 8

What are the 4 main principles of maangement of DKA?

Answer 8

1) Fluid replacement

2) Insulin

3) Correction of electrolyte disturbance

4) Long acting insulin should be continued, short-acting insulin should be stopped

Question 9

What type of fluid therapy is given in DKA?

Answer 9

isotonic saline is used initially, even if the patient is severely acidotic

Question 10

Example fluid regime in DKA for patient with a systolic BP on admission 90mmHg and over?

Answer 10

Over 1st hour: 1000ml 0.9% saline

Over next 2 hours: 1000ml 0.9% saline with potassium chloride

Over next 2 hours: 1000ml 0.9% saline with potassium chloride

Over next 4 hours: 1000ml 0.9% saline with potassium chloride

Over next 4 hours: 1000ml 0.9% saline with potassium chloride

Over next 6 hours: 1000ml 0.9% saline with potassium chloride

Question 11

Why may a slower fluid infusion may be indicated in young adults (aged 18-25 years) in DKA?

Answer 11

Due to greater risk of cerebral oedema

Question 12

How is DKA resolution defined?

Answer 12

pH >7.3 and

blood ketones < 0.6 mmol/L and

bicarbonate > 15.0mmol/L

Question 13

How soon should the ketonaemia and acidosis be resolved in DKA?

Answer 13

Within 24 hours - if not, patient requires senior review from an endocrinologist.

Question 14

When can the patient be switched to SC insulin in DKA?

Answer 14

If DKA resolution criteria has been met AND the patient is eating and drinking.

Question 15

What is rate of insulin infusion in DKA?

Answer 15

0.1 unit/kg/hour

Note - once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime

Question 16

When is 10% dextrose infusion started in DKA?

Answer 16

Once blood glucose is < 14 mmol/l

Question 17

A 32 year old woman is in active labour for the first time. She is in delivery suite and is requesting more pain relief. Her pain is uncontrolled despite inhaled Entonox® (nitrous oxide and oxygen mix) and two doses of pethidine (last dose 45 minutes ago). She has just been examined and her cervix is 5 cm dilated.

Which strategy to address her pain is most appropriate at this time?

A) Epidural analgesia
B) Offer a pudendal nerve block
C) Refer the patient for a PCA (patient controlled analgesia)
D) Suggest self-management techniques such as hypnobirthing
E) Supplement the current analgesia with a TENS machine

Answer 17

A) Epidural analgesia

Question 18

A 58 year old man has been diagnosed with a femoral DVT following a long-haul flight and is being counselled about treatment. He is usually well and takes no medication currently. There are no concerns about the need for rapid reversal.

Which is the most appropriate treatment regime to suggest?

A) DOAC
B) Dual antiplatelets
C) Low molecular weight heparin
D) IVC filter
E) Warfarin

Answer 18

A) DOAC

Question 19

A 77 year old man is hypotensive on HDU. He is usually well. He underwent an emergency laparotomy in theatre 4 hours ago for a bleeding duodenal ulcer and required a large blood transfusion. He has cold peripheries and his observations show temperature 36.5◦C, P 170-190 bpm, BP 85/50 mmHg, SpO2 95% on 3L oxygen. His catheter shows a urine output of 100mls per hour.

Which is the most likely cause of his hypotension?

A) Cardiac arrhythmia
B) Hypovolaemia
C) Pulmonary oedema due to fluid overload
D) Sepsis
E) Transfusion reaction

Answer 19

A) Cardiac arrhythmia

The patient is showing signs of cardiogenic shock.

Question 20

A 40 year old man is to undergo general anaesthetic and is having an airway assessment. A visual examination of his pharyngeal structures has just been undertaken.

Which scoring system is it most appropriate to use to document the findings?

A) Cormack-Lehane Grading
B) LEMON
C) Mallampati classification
D) MOANS
E) The 3-3-2 evaluation

Answer 20

C) Mallampati classification

Question 21

A 37 year old woman has presented with sudden-onset, severe, right iliac fossa pain, and a syncopal episode. She has had vague abdominal pain for several days and has had two episodes of diarrhoea today. She also describes feeling ‘dizzy’ whenever she tries to sit up on the trolley. She looks very pale and her lower abdomen is distended. Observations show: Temperature 36.6°C, P 135, BP 90/60mmHg, SpO2 97% in air.

Which underlying diagnosis is the likely cause of her symptoms?

A) Ectopic pregnancy
B) Appendicitis
C) Gastroenteritis
D) Supraventricular tachycardia
E) Urinary sepsis

Answer 21

A) Ectopic pregnancy

Question 22

A 55 year old man has presented with a frontal headache and blurred vision. He describes headaches for the past two months but isn’t entirely sure when they started. He knows they are usually worse in the morning and when he strains to open his bowels or sneezes. He has felt nauseated but has not vomited. He is systemically well and has not experienced any weight loss. He is known to have hypertension controlled by amlodipine.

Which is the most likely cause of his symptoms?

A) Hypertensive encephalopathy
B) Idiopathic intracranial hypertension
C) Migraine
D) Space occupying lesion
E) Tension headache

Answer 22

D) Space occupying lesion

Question 23

A 23 year old man has been found unconscious in a park. He appears unkempt and is cold to touch. His pulse is palpable with normal volume and rate. His respiratory rate is approximately 6 and his breathing pattern is shallow. His pupils are markedly constricted and he has an abrasion to his cheek.

Which is the most likely cause of his current state?

A) Alcohol excess
B) Benzodiazepine usage
C) Hypoglycaemia
D) Intracranial haemorrhage
E) Opioid poisoning

Answer 23

E) Opioid poisoning

Question 24

A 68 year old woman is waiting to go to theatre and has been found to be disorientated and agitated. She is known to have insulin-dependent diabetes. She was started on an appropriate regime but a problem with the pump has meant that she has not received any glucose for some time . She is awake but is clammy to touch. Her capillary blood glucose is 2.8 mmol/L.

Which is the most appropriate treatment for her hypoglycaemia?

A) 10% glucose
B) 50% glucose
C) Glucagon
D) Glucogel
E) Glucose tablets

Answer 24

D) Glucogel

Management of moderate hypoglycaemia.

Question 25

Management of hypoglycaemia in hospital if the patient is unconscious or unable to swallow?

Answer 25

SC injection or IM injection of glucagon.

Alternatively, IV 20% glucose solution can be given.

Question 26

Most appropriate investigation to confirm hyperkalaemia?

Answer 26

VBG

Question 27

A 25 year old woman has been stabbed by her partner in the abdomen and has just arrived in the resuscitation room of the ED. She looks unwell and is pale and agitated. Her observations show P 160 bpm and regular, BP 65/32 mmHg, RR 27 and SpO2 96% in 15L of oxygen. The ambulance service were unable to cannulate her so she has not had any fluid yet.

Which is the most appropriate initial fluid to infuse to manage her hypotension?

A) 0.9% sodium chloride
B) 5% dextrose
C) Cross-matched blood
D) Hartmann’s solution
E) O-negative blood

Answer 27

E) O-negative blood

Major haemorrhage protocol!

Question 28

A 74 year old man is at an evening appointment with his GP for constipation. During questioning, he describes an episode earlier in the day where his speech was slurred and his wife noted that the right side of his face appeared ‘droopy’ for about 10 minutes. The symtoms have now resolved. He is already taking aspirin intermittently and his blood pressure is well controlled with ramipril. He is a non-smoker and is not diabetic.

Which is the most appropriate action to now take in addition to an urgent referral to the TIA clinic?

A) Advise the patient to go to the ED
B) Commence 75mg clopidogrel
C) No other action needed
D) Phone 999
E) Prescribe 300mg aspirin

Answer 28

E) Prescribe 300mg aspirin

Question 29

A 75 year old man who is known to have poorly controlled hypertension has had a collapse. He is known to have a 40 pack year smoking-history but no other co-morbidity. He described experiencing sudden-onset back pain and then had a brief loss of consciousness. He now only has severe left iliac fossa pain which is radiating into his groin. Observations show: temperature 37.3oC, P 110 bpm regular, BP 115/62 mmHg, RR 18 and SpO2 96% in air.

Which is the most likely cause of his loss of consciousness?

A) Cardiac arrhythmia
B) Orthostatic hypotension
C) Perforated duodenal ulcer
D) Renal colic
E) Ruptured abdominal aortic aneurysm

Answer 29

E) Ruptured AAA

Question 30

A 55 year old man who is normally ‘non-verbal’ with learning disability, has been identified as having ‘red-flag sepsis’. He has had a catheter inserted 2 hours ago for monitoring of his urine output and there was no residual volume. Despite 1500mls of fluid, he has not passed any urine and his catheter bag is empty. His observations are: temperature 39.3oC, P 110 bpm regular, BP 95/62 mmHg, RR 18 and SpO2 97% in air. He has now become agitated and aggressive.

Which is the most appropriate action to take to address his low urine output?

A) Administer a fluid bolus
B) Escalate to critical care for inotropic support
C) Flush the urinary catheter
D) Give a small dose of diuretic
E) Increase the rate of his current fluid infusion

Answer 30

C) Flush the catheter

This may help to remove any debris that may be in the bladder, which can lead to blocking the catheter, preventing it from draining.

Question 31

A 72 year old man has presented with hypoxaemia and breathlessness. Observations show that: P 140 irregularly irregular, BP 175/85mmhg, RR 27, SpO2 92% in 15L. He is mottled, cold to touch and is agitated. There are coarse crackles throughout his chest. The working diagnosis is acutely decompensated pulmonary oedema secondary to him omitting his diuretic for several days.

Which is the most appropriate way to initially manage his hypoxaemia?

A) Continue 15L via a non-rebreathe mask
B) CPAP
C) Intravenous furosemide
D) Intravenous GTN
E) Invasive ventilation

Answer 31

B) CPAP

This is the management of cardiogenic pulmonary oedema.

Question 32

A 62 year old man has been admitted with chest pain and ECG changes suspicious for a myocardial infarction. He has now decided that he wants to go home and does not want to wait for blood tests or treatment. He is known to be a lifelong cigarette smoker and takes medication for hypertension. He has no other past medical history and is not under the influence of any drugs or alcohol.

Which is the most appropriate action to now take?

A) Advise him that he cannot leave and that the police to return him to hospital if he leaves.
B) Assess his capacity to self-discharge
C) Contact hospital security to prevent him leaving the ward
D) Offer safety-net advice and allow him to sign a self-discharge form.
E) Refer the patient to the mental health team for immediate review.

Answer 32

D) Offer safety-net advice and allow him to sign a self-discharge form.