CME Acute medicine (113043) self-assessment questionnaire

Mark Holland; Tahseen A Chowdhury

doi:10.7861/clinmedicine.18-1-93

SAQs and answers are ONLINE for RCP fellows and collegiate members

Format

Candidates are asked to choose the best answer from the five possible answers. This best of five format is used in many medical examinations; however, the questions are not intended to be representative of those used in the MRCP(UK) Part 1 or Part 2 Written Examinations.

The answering process

Go to www.rcplondon.ac.uk/SAQ
Log on using your usual RCP username and password
Select the relevant CME question paper
Answer all 10 questions by selecting the best answer from the options provided
Once you have answered all the questions, click on Submit

Registering your external CPD credits

Carrying out this activity allows you to claim two external CPD credits. These will be automatically transferred to your CPD diary, where you can review the activity and claim your points.

A 64-year-old man with anuric end-stage renal failure receiving intermittent haemodialysis was admitted to the emergency department with septic shock. His blood pressure was 76/43 mmHg and his pulse was 127 beats per minute. His jugular venous pressure was not visible and his peripheries were warm and dilated. He had no oedema. After gaining venous access and giving antibiotics, what would be the most appropriate next treatment?
1. 30 mL/kg bolus of crystalloid
2. 250 mL fluid bolus and reassess
3. 1 L fluid bolus and reassess
4. Give 200 mg hydrocortisone intravenously
5. Start norepinephrine to target a MAP of 65 mmHg
A 23-year-old woman presented with a five day history of earache and progressively severe headache and evolving sensorimotor symptoms in the left upper limb. She reported missing her last period. Which one of the following is the best method of identifying a possible cerebral venous sinus thrombosis?
1. CT head
2. CT head and CT venogram combined
3. Digital subtraction angiography
4. MRI head and MR venogram combined
5. Transcranial Doppler ultrasound
Concerning the clinical assessment of an unconscious patient, which one of the following is correct?
1. Cheyne–Stokes breathing provides precise diagnostic information.
2. A CT brain scan is only indicated when there are signs of head trauma.
3. A capillary blood glucose is only useful in patients with a history of diabetes mellitus.
4. When testing motor response to a noxious stimulus, pushing the examiner away is a reflexive motor response.
5. In patients presenting via the emergency department, the history from the paramedic crew and/or their records must be reviewed.
A 28-year-old patient with HIV and sepsis secondary to pneumonia was not responding to treatment. Sputum cultures grew bacteria sensitive to his current antibiotics. His ferritin was >20,000 μg/L (normal range 12–300 μg/mL). Which one of the following should conditions should be considered?
1. Haemochromatosis
2. Haemolysis
3. Haemophagocytic lymphohistiocytosis
4. Iron poisoning
5. Pancreatitis
Which one of the following statements about delirium is correct?
1. Antipsychotics are the cornerstone of treatment.
2. Psychological stressors, such as being in a strange environment, are too trivial to be relevant precipitants.
3. Delirium can present in many ways, but is more likely to be associated with withdrawal and reduced responsiveness than aggression.
4. Delirium characteristically presents as an agitated, overactive state associated with aggression.
5. Delirium generally has a single cause.
Concerning the management of the unconscious patient, which one of the following statements is correct?
1. The first line treatment for hypoglycaemia is intramuscular glucagon.
2. Naloxone is contraindicated in patients with tricyclic antidepressant overdose as it may precipitate a seizure.
3. A pragmatic approach should be taken and an empirical ‘cocktail’ of potential treatments and antidotes should be administered.
4. In epileptic patients with a suspected benzodiazepine overdose, flumazenil should be administered.
5. When the cause of unconsciousness is clinically apparent, an ABCDE approach is still required.
Which one of the following statements about schizophrenia is correct?
1. Delusions tend to be unstable, their focus shifting from hour to hour.
2. Disorientation to place is a common feature.
3. Onset tends to be acute or subacute.
4. Schizophrenia typically presents during adolescence or young adulthood.
5. Visual hallucinations are generally a prominent feature.
A 55-year-old woman presented with left-sided chest pain at 3am. Her husband, who was a GP, had been unable to locate her pulse, at which point she had gone pale, was tachycardic and had felt dizzy, but suffered no loss of consciousness. She had recently sustained a right ankle fracture, and her leg was in a plaster cast. In the ambulance, her blood pressure was 90/60 mmHg and her oxygen saturation was 92% breathing air. On her admission to the emergency department her blood pressure was 110/70 mmHg, pulse rate was 112 beats per minute and oxygen saturation 95% breathing 2 L oxygen. An ECG showed sinus tachycardia. She was given a working diagnosis of a pulmonary embolism (PE) and was treated with low-molecular-weight heparin (LMWH). She was found to be haemodynamically stable, with a D-dimer 5.1 mg/L (<0.5) and serum troponin 93 μg/L (<0.1). CT pulmonary angiography (CTPA) was arranged for the following morning. You have been asked to see the patient because she now feels fine and wants to go home, because she needs to look after her grandchildren. What is the most-appropriate immediate management for this patient?
1. Arrange for urgent CTPA.
2. There is no need for anything further tonight; CTPA can wait until the morning.
3. Arrange an ultrasound scan of both lower limbs.
4. Start novel anticoagulant (NOAC).
5. Carry out thrombolysis.
A 72-year-old man presented to the acute stroke services with two generalised tonic clinic seizures with residual left hemiparesis and gaze preference to the right side. His brain imaging demonstrated parasagittal haemorrhagic infarction and sagittal sinus thrombosis. Which one of the following statements is true with regard to his treatment?
1. Because of the presence of haemorrhage he should not be anticoagulated.
2. Delayed venography after 3 months will help decide on duration of long-term anticoagulation.
3. He should be treated with an appropriate antiepileptic drug.
4. It is appropriate to administer corticosteroids to reduce mass effect from the haemorrhage.
5. The patient should not be treated on a stroke unit.
Concerning prognosis in an unconscious patient, which one of the following statements is correct?
1. Patients presenting with unconsciousness due to epilepsy have relatively better outcomes.
2. The level of consciousness at the time of presentation based on the Glasgow Coma Scale does not influence prognosis.
3. Patients presenting with unconsciousness due to poisoning have relatively poorer outcomes.
4. In unconscious patients with no history of trauma and a confirmed stroke on a CT brain scan the prognosis is very good.
5. The findings from the initial neurological examination and CT brain scan have no prognostic relevance.