Anaesthetics & ITU

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Which of the following is not a feature of cannabinoids?
Test Analysis
(Please select 1 option)

9-tetrahydrocannabinol is the active constituent of the resin
Bioavailability after oral administration is about 80%
Inhibits eicosanoid synthesis
Lowers intraocular pressure
Naloxone blocks the antinociceptive actions of cannabinoids
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Which of the following is not a feature of cannabinoids?
Answer Statistics

9-tetrahydrocannabinol is the active constituent of the resin
Bioavailability after oral administration is about 80%
Incorrect answer selected
Test Analysis
This is the correct answer
Inhibits eicosanoid synthesis

Lowers intraocular pressure
Naloxone blocks the antinociceptive actions of cannabinoids
Cannabinoids are derived from the resin of cannabis sativa, and 9-tetrahydrocannabinol (9-THC) is its most
important pharmacologically active constituent.
Oral bioavailability of THC, whether given in the pure form or as THC in marijuana, is low and extremely
variable, ranging between 5% and 20%, with effects occurring 0.5-3 hours later. Bioavailability of THC in a
marijuana cigarette or pipe also rarely exceeds 10 - 20%.
Naloxone and other opioid receptor antagonists block the analgesic actions of cannabinoids.
Score:
Synthetic cannabinoids reduce arachidonic acid-induced inflammation by inhibiting eicosanoid production.
Total Answered:
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Any revision notes recorded
here will be automatically
added to a list, and can be
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A patient who is listed for excision of his operable squamous cell lung cancer, suffers a life threatening
Test Analysis
haemoptysis on the ward.

Which of the following is the most appropriate treatment?
Antibiotics
Bronchial embolisation
Conservative care
Radiotherapy
Tranexamic acid
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A patient who is listed for excision of his operable squamous cell lung cancer, suffers a life threatening
Answer Statistics
haemoptysis on the ward.

Which of the following is the most appropriate treatment?
Test Analysis

Antibiotics
Bronchial embolisation
Conservative care
Radiotherapy
Tranexamic acid
Life threatening haemoptysis is a medical emergency that requires prompt action.

Pulmonary angiography will identify the blood supply to the tumour and embolisation of this vessel(s) will
immediately stem the bleeding.
Score:
The other options are also important in the long term management.
Total Answered:
Antibiotics are used to prevent secondary bacterial infection.
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An 82-year-old lady was admitted to hospital with fever and confusion.
Test Analysis
On examination her temperature was 39C, blood pressure was 80/45 mmHg with a pulse of 110 beats per
minute regular with numerous petechiae over the abdomen.
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 is correct concerning this patient?

Circulating levels of activated protein C (aPC) will be reduced
Levels of D dimer will be reduced
Levels of fibrin degradation products (FDPs) will be reduced
The activated partial thromboplastin time (APTT) will be below the normal range
Score:
The platelet count is likely to be elevated
Total Answered:
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An 82-year-old lady was admitted to hospital with fever and confusion.
Answer Statistics
On examination her temperature was 39C, blood pressure was 80/45 mmHg with a pulse of 110 beats per
minute regular with numerous petechiae over the abdomen.
Test Analysis
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 is correct concerning this patient?

Circulating levels of activated protein C (aPC) will be reduced
Correct
Levels of D dimer will be reduced

Levels of fibrin degradation products (FDPs) will be reduced
The activated partial thromboplastin time (APTT) will be below the normal range
The platelet count is likely to be elevated
Score:
Total Answered:
The patient has disseminated intravascular coagulation (DIC) secondary to sepsis.

Given the history, the most likely source is the urinary tract.
Feedback
Several coagulation abnormalities are seen in sepsis including:
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APTT elevated
PT elevated
FDPs elevated
D dimers elevated
Platelets reduced
Fibrinogen reduced
Protein C reduced
Antithrombin reduced.
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A 34-year-old man with a known history of Crohn's disease was admitted to hospital with abdominal pain and
Test Analysis
features of perforation.
He underwent laparotomy and a perforation of the terminal ileum was found with free faecal fluid in the
abdominal cavity. He was transferred to the intensive care unit (ITU).
Together with traditional antimicrobial and supportive ITU therapy, which of the following therapeutic measures
is most likely to improve this patient's outcome?
High-dose intravenous corticosteroids
Low-dose intravenous corticosteroids
Recombinant anti-endotoxin antibody
Recombinant human antithrombin III
Recombinant human tissue-factor pathway inhibitor
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A 34-year-old man with a known history of Crohn's disease was admitted to hospital with abdominal pain and
Answer Statistics
features of perforation.
He underwent laparotomy and a perforation of the terminal ileum was found with free faecal fluid in the
abdominal cavity. He was transferred to the intensive care unit (ITU).
Test Analysis
Together with traditional antimicrobial and supportive ITU therapy, which of the following therapeutic measures
is most likely to improve this patient's outcome?
High-dose intravenous corticosteroids
Low-dose intravenous corticosteroids
Recombinant anti-endotoxin antibody

Recombinant human antithrombin III
Recombinant human tissue-factor pathway inhibitor
The use of corticosteroids in sepsis remains controversial.
Score:
Meta-analyses of all the trials of high-dose steroids (for example, methylprednisolone 1 g) have confirmed that
there is either no benefit, or even that there is an adverse effect in septic patients. However, more recent
Total Answered:
randomised controlled trials have suggested that there is a benefit in sepsis when lower physiological doses of
steroids are given.
The precise mechanism is not fully understood, although it is well known that septic patients have low levels of
endogenous steroids.
The production of recombinant human anticoagulants has gathered pace in recent years and several products
have been tested. There have been randomised clinical trials of recombinant human antithrombin III (Kyber
Sept trial), activated protein C (PROWESS trial) and tissue-factor pathway inhibitor (OPTIMIST trial). Of these,
only recombinant activated protein C has shown any significant survival benefit at 28 days. However,
subsequent studies have failed to demonstrate a survival benefit, and have shown an increased bleeding risk.
Activated protein C is therefore no longer recommended for the treatment of sepsis.
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A 56-year-old man is admitted with epigastric pain after drinking heavily.
Test Analysis
He has a temperature of 36.9C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a respiratory rate of
32/min.
Investigations reveal:
Haemoglobin
12.6 g/dL
10 9 /L
Platelets
169
White cell count
3.9 10 9 /L
(13.0-18.0)
(150-400)
(4-11)
Which of the following is the diagnosis?

Leaking aortic aneurysm
Multi-organ dysfunction syndrome (MODS)
Score:
Severe sepsis
Total Answered:
Septic shock
Systemic inflammatory response syndrome (SIRS)
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A 56-year-old man is admitted with epigastric pain after drinking heavily.
Answer Statistics
He has a temperature of 36.9C, a pulse of 95/min, a blood pressure of 85/60 mmHg, and a respiratory rate of
32/min.
Test Analysis
Investigations reveal:
Haemoglobin
12.6 g/dL
10 9 /L
Platelets
169
White cell count
3.9 10 9 /L
(13.0-18.0)
(150-400)
(4-11)
Which of the following is the diagnosis?

Leaking aortic aneurysm
Multi-organ dysfunction syndrome (MODS)

Severe sepsis
Septic shock
Score:
Systemic inflammatory response syndrome (SIRS)
Total Answered:
This patient has features of pancreatitis. He also has hypotension, and leucopenia. He therefore fulfils the
criteria for systemic inflammatory response syndrome. This is equivalent to sepsis, but occurs in the absence of
infection (e.g. in pancreatitis).
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SIRS is defined as two or more of the following:

Temperature more than 38C or less than 36C.
Heart rate more than 90 beats/min.
Respiratory rate more than 20 breaths/min or PaCO 2 less than 4.3 kPa.
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WBC count 12,000/mm 3 , less than 4000/mm 3 , or more than 10% immature (bands) form.
A leaking aortic aneurysm is still a possibility, however a decreased white cell count would not be expected.
We do not have enough information to diagnose multi-organ dysfunction. There is no evidence of infection to
make a diagnosis of septic shock or severe sepsis. For information, sepsis is defined as the association of
systemic inflammatory responses with evidence of microbial origin. Severe sepsis also has hypoperfusion or
dysfunction of at least one organ system, and septic shock is this plus hypotension refractory to fluid
resuscitation.
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A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to pancreatitis
Test Analysis
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 and urine output of 25 ml/hour after catheterisation.
Which of the following is the most appropriate course of action for this patient?
A central line
A CT abdomen
A surgical referral
An arterial line
Broad spectrum antibiotics
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A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to pancreatitis
Answer Statistics
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 and urine output of 25 ml/hour after catheterisation.
Test Analysis
Which of the following is the most appropriate course of action for this patient?
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 increasingly recognised as
potentially beneficial. If fluids are not achieving haemodynamic stability, and there is indication of hypoperfusion
as indicated by oliguria or lactataemia, then vigorous resuscitation is indicated.
Score:
EGDT aims to increase organ perfusion through restoration of mean arterial pressure using inotropes if
necessary, maintaining central venous pressure (CVP), maintaining oxygenation, and using SjVO2 (jugular
Total Answered:
venous oxygen saturation) as a guide to oxygen utilisation at the tissue level. SjVO2 higher than 70% is
indicative of organ hypoperfusion, as oxygen is not being extracted.
Feedback
Insertion of a central line above allows measurement of CVP, SjVO2 and the use of inotropes.
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A 56-year-old man with septic shock is fully ventilated, on continuous veno-venous haemofiltration receiving
Test Analysis
noradrenaline, vancomycin and ciprofloxacin.

He has a mean arterial pressure (MAP) of 60 mmHg which is then not improved after changing from
noradrenaline to adrenaline. There is no evidence of myocardial dysfunction.
Which of the following would be the most appropriate next step in managing this patient?
ACTH stimulation test
Activated protein C
Change of inotropes
Hydrocortisone
Nitric oxide
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A 56-year-old man with septic shock is fully ventilated, on continuous veno-venous haemofiltration receiving
Answer Statistics
noradrenaline, vancomycin and ciprofloxacin.

He has a mean arterial pressure (MAP) of 60 mmHg which is then not improved after changing from
noradrenaline to adrenaline. There is no evidence of myocardial dysfunction.
Test Analysis
Which of the following would be the most appropriate next step in managing this patient?
ACTH stimulation test
Activated protein C
Change of inotropes
Hydrocortisone
Nitric oxide
The Surviving Sepsis Campaign (a partnership of the Society of Critical Care Medicine, the European Society
of Intensive Care Medicine, and the International Sepsis Forum) has teamed up with the Institute for
Healthcare Improvement to develop severe sepsis bundles. A 'bundle' is a group of interventions related to a
disease process that, when executed together, result in better outcomes than when implemented individually.
Sepsis Resuscitation Bundle:
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Should begin immediately, but must be accomplished within the first six hours of presentation.
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1. Serum lactate measured.
2. Blood cultures obtained prior to antibiotic administration.
3. From the time of presentation, broad-spectrum antibiotics administered within three hours for ED
admissions and one hour for non-ED ICU admissions.
4. In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl):
Deliver an initial minimum of 30 ml/kg of crystalloid (or colloid equivalent).
Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial
pressure (MAP) > 65 mm Hg.
5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l
(36 mg/dl):
Achieve central venous pressure (CVP) of > 8 mm Hg.
Achieve central venous oxygen saturation (ScvO2) of > 70%.
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Sepsis Management Bundle:

To be accomplished as soon as possible may be completed within twenty-four hours of presentation.
1. Steroids administered for septic shock in accordance with a standardised ICU policy. ACTH stimulation test
not required prior to this.
2. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/l).
3. Inspiratory plateau pressures maintained < 30 cm H2O for mechanically ventilated patients.
Drotrectogin alpha (activated protein C) used to be recommended by NICE for the treatment of severe sepsis.
43
Revision Notes
However, in October 2011 the company withdrew this from the market following the results of the PROWESSSHOCK study, which showed there was no statistically significant reduction in 28-day all-cause mortality in
viewed in full on the summary
patients with septic shock.
page.
Nitric oxide is a non-proven therapy in adult respiratory distress syndrome (ARDS), but is less likely to be
effective in this situation.
Reference:
Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management
of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
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A 67-year-old woman is admitted with blackouts.
Test Analysis
Her electrocardiogram shows ventricular escape with complete heart block. As you are standing there she
blacks out once more. Her rhythm strip shows P wave asystole.
Which of the following would be the initial immediate treatment here after airway and breathing?
Adenosine 6 mg
Adrenaline 1 mg
Atropine 0.6 mg
Transcutaneous pacing
Transvenous pacing
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A 67-year-old woman is admitted with blackouts.
Answer Statistics
Her electrocardiogram shows ventricular escape with complete heart block. As you are standing there she
blacks out once more. Her rhythm strip shows P wave asystole.
Test Analysis
Which of the following would be the initial immediate treatment here after airway and breathing?
Adenosine 6 mg
Adrenaline 1 mg
Atropine 0.6 mg
Transcutaneous pacing
Transvenous pacing
Occasionally, atrial electrical activity continues in the absence of ventricular impulses. This is referred to as Pwave asystole and may respond to electrical pacing. This can be achieved by transvenous, transcutaneous or
manual techniques. Transvenous pacing takes longer to instigate, and transcutaneous pacing is therefore the
initial choice here. Manual pacing is an effective holding measure before more definitive pacing is instituted.
Score:
Total Answered:
Atropine can also be used, as can adrenaline, for sustained P wave asystole but pacing is the initial treatment
of choice. All crash trollies within UK hospitals contain the equipment required to externally pace patients.
Feedback
Adenosine can induce asystole, and is only indicated in the treatment of supraventricular tachycardias.
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A 24-year-old female is admitted with palpitations. Her pulse is 220 beats/min, blood pressure 70/50 mmHg
Test Analysis
and she has a respiratory rate 32/min.

She is awake, alert and oriented but dyspnoeic. Her electrocardiogram shows a regular rhythm with QRS
complex width of 0.11s.
What is the most appropriate therapy for this patient?
Adenosine 6 mg/6 mg/12 mg
Amiodarone 300 mg
Atenolol 50 mg
Direct current cardioversion
Verapamil 10 mg
Score:
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A 24-year-old female is admitted with palpitations. Her pulse is 220 beats/min, blood pressure 70/50 mmHg
Answer Statistics
and she has a respiratory rate 32/min.

She is awake, alert and oriented but dyspnoeic. Her electrocardiogram shows a regular rhythm with QRS
complex width of 0.11s.
Test Analysis
What is the most appropriate therapy for this patient?

Adenosine 6 mg/6 mg/12 mg
Amiodarone 300 mg
Atenolol 50 mg
Direct current cardioversion
Verapamil 10 mg
This is highly likely to be a narrow complex tachycardia.

Strictly speaking, as this patient is showing signs of haemodynamic decompromise (that is, systolic blood
pressure less than 90) she should be immediately DC cardioverted under sedation/anaesthesia.
Score:
Total Answered:
In practice, most people would try adenosine first whilst organising a cardioversion.
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A 64-year-old man is admitted with central epigastric pain. Abdominal x ray shows a dilated bowel loop.
Test Analysis
His temperature is 37.0C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min, SpO 2 90% on
air.
His full blood count reveals:
Haemoglobin
130 g/L
(130-180)
White cell count
3.2 10 9 /L
(4-11)
Platelets
108 10 9 /L
(150-400)
MCV
105 fl
(80-96)
Which of the following is the most appropriate initial treatment of this patient?
100% oxygen
Score:
2 14 gauge venflons and 2 litres Hartmann's
Total Answered:
Intensive care
Intubation and ventilation
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Invasive monitoring
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A 64-year-old man is admitted with central epigastric pain. Abdominal x ray shows a dilated bowel loop.
Answer Statistics
His temperature is 37.0C, pulse 130 bpm, blood pressure 80/50 mmHg, respiratory rate 29/min, SpO 2 90% on
air.
Test Analysis

Haemoglobin
130 g/L
(130-180)
White cell count
3.2 10 9 /L
(4-11)
Platelets
108 10 9 /L
(150-400)
MCV
105 fl
(80-96)
Which of the following is the most appropriate initial treatment of this patient?
100% oxygen
Correct
2 14 gauge venflons and 2 litres Hartmann's

Intensive care
Score:
Total Answered:
Invasive monitoring
Feedback
This patient has systemic inflammatory response syndrome, possibly caused by acute pancreatitis given the
finding of an isolated dilated loop of bowel on adbominal radiograph. However, the initial treatment is the same
independent of the underlying cause.
Rate this question

All of the above answers are reasonable, however resuscitation of the sick patient still follows the ABC
algorithm:
Airway
Breathing
Circulation
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 need for invasive monitoring and
intensive care is then assessed, depending on the response to initial treatment.
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A 64-year-old man is admitted with central epigastric pain.
Test Analysis
Abdominal x ray shows a central dilated bowel loop. His temperature is 37.0C, pulse 130 beats per min, blood
pressure 80/50 mmHg, respiratory rate 29/min and SpO 2 90 on air.
Haemoglobin
13.0 g/dL
(13.0-18.0)
White cell count
3.2 10 9 /L
(4-11)
Platelets
108 10 9 /L
(150-400)
MCV
105 fL
(80-96)
Which of the following is the most likely diagnosis?

Gall stone ileus
Ischaemic bowel
Score:
Pancreatitis
Total Answered:
Perforated duodenal ulcer
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Small bowel obstruction
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A 64-year-old man is admitted with central epigastric pain.
Answer Statistics
Abdominal x ray shows a central dilated bowel loop. His temperature is 37.0C, pulse 130 beats per min, blood
pressure 80/50 mmHg, respiratory rate 29/min and SpO 2 90 on air.
Test Analysis

Haemoglobin
13.0 g/dL
(13.0-18.0)
White cell count
3.2 10 9 /L
(4-11)
Platelets
108 10 9 /L
(150-400)
MCV
105 fL
(80-96)
Which of the following is the most likely diagnosis?

Gall stone ileus
Ischaemic bowel
Pancreatitis
Score:
Total Answered:
Small bowel obstruction
Feedback
Ischaemic bowel and perforated duodenal ulcer would be high in the differential list. However the history and
raised mean corpuscular volume (MCV) suggests alcohol use and the severity of his observations would
suggest a systemic inflammatory response which is more common with pancreatitis.
Acute pancreatitis has a mortality of 7-10%, often due to sepsis or multi-organ failure. There are a number of
scoring systems which can be used to guide prognosis, but they are unreliable within the first 48 hours o f the
illness. Gallstones account for 50% of cases, with the majority of the rest being associated with alcohol.
Patients typically present with severe epigastric pain which radiates to the back and vomiting. As seen in this
example, there is often a systemic inflammatory response. Amylase is markedly raised, often in excess of four
times the normal value. Early complications include ARDS (adult respiratory distress syndrome), acute kidney
injury and disseminated intravascular coagulation (DIC).
Treatment is essentially supportive, and high levels of monitoring are usually required (often in the intensive
care unit). Those patients who are found to have gallstones should be considered for emergency ERCP, and
all should have a cholecystectomy during the same admission.
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A 74-year-old man with ischaemic heart disease is in the surgical high dependency unit following a Hartmann's
Test Analysis
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, SpO 2 100% on oxygen by face
mask.
Crossmatched blood is available.
Haemoglobin
8.1 g/dL
(13.0-18.0)
White cell count
4.5 10 9 /L
(4-11)
Platelets
132 10 9 /L
(150-400)
Which of the following is the next most appropriate intervention?

2 units of packed red blood cells
Score:
1000 cmls of crystalloid stat
Total Answered:
1000 ml of colloid stat
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Morphine 5 cmg intravenously
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Return to theatre
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A 74-year-old man with ischaemic heart disease is in the surgical high dependency unit following a Hartmann's
Answer Statistics
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, SpO 2 100% on oxygen by face
Test Analysis
mask.
Crossmatched blood is available.
Haemoglobin
8.1 g/dL
(13.0-18.0)
White cell count
4.5 10 9 /L
(4-11)
Platelets
132 10 9 /L
(150-400)
Which of the following is the next most appropriate intervention?

2 units of packed red blood cells
Correct
1000 cmls of crystalloid stat

1000 ml of colloid stat
Score:
Morphine 5 cmg intravenously
Total Answered:
Return to theatre
Feedback
He is still actively bleeding and haemodilution will not have been achieved so his Hb will be lower than 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 a perioperative 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 rising pulse 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 is reasonable 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 functional for a while).
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You are asked to see a 64-year-old man post-oversew of a duodenal ulcer. He is confused.
Test Analysis
His SpO 2 is 97 on oxygen. Pulse 110 beats per min, blood pressure 100/50 mmHg, respiratory rate 32/min
and his urine output is 10 ml in the last hour.
Which of the following is the most appropriate treatment for this man?
100% oxygen via face mask
Central line and arterial line
Normal saline 500 ml stat
Haloperidol 2.5 mg intravenously
Noradrenaline via central line
Score:
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You are asked to see a 64-year-old man post-oversew of a duodenal ulcer. He is confused.
Answer Statistics
His SpO 2 is 97 on oxygen. Pulse 110 beats per min, blood pressure 100/50 mmHg, respiratory rate 32/min
and his urine output is 10 ml in the last hour.
Test Analysis
Which of the following is the most appropriate treatment for this man?
100% oxygen via face mask
Central line and arterial line

Normal saline 500 ml stat
Haloperidol 2.5 mg intravenously

Noradrenaline via central line
Postoperative confusion is common in the elderly however this can be caused by a low perfusion state.
His observations are indicative of underfilling/dehydration. (He could also have atelectais or have developed a
chest infection. Post-operative problems are often multifactorial.)
Score:
Total Answered:
Of the options given a fluid bolus is appropriate. This is what you would expect your FY1 to do while waiting for
the blood test results and before calling you.
Feedback
Some would argue that 100% oxygen comes before fluids but with an SpO 2 of 97 it is unlikely that hypoxia is
contributing to his problems. (nonetheless oxygen therapy would be recommended).
Rate this question
The other options would come further down the line if initial interventions were unsuccessful and he
deteriorated.
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A 67-year-old man is three days post-operation for a sigmoid colectomy. He has insulin dependent diabetes
Test Analysis
mellitus. He complains of dizziness and faintness.

His blood pressure is 80/50 mmHg, his pulse is 110 bpm, he has a respiratory rate 24/min, and he has SpO 2
99% on air. His blood glucose is 18 mmol/L (3.0-6.0 fasting).
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?
Aspirin 300mg
Clexane 1 mg/kg subcutaneously
Clopidogrel 75 mg
Diamorphine 2.5 mg
Score:
Glycerol tri-nitrate 800 mcg sublingually
Total Answered:
Submit answer
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A 67-year-old man is three days post-operation for a sigmoid colectomy. He has insulin dependent diabetes
Answer Statistics
mellitus. He complains of dizziness and faintness.

His blood pressure is 80/50 mmHg, his pulse is 110 bpm, he has a respiratory rate 24/min, and he has SpO 2
99% on air. His blood glucose is 18 mmol/L (3.0-6.0 fasting).
Test Analysis
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?
Aspirin 300mg
Correct
Clexane 1 mg/kg subcutaneously

Clopidogrel 75 mg
Diamorphine 2.5 mg
Glycerol tri-nitrate 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 also be given, but aspirin initially.
Score:
Total Answered:
The dose of clopidogrel is 300 mg in an acute coronary syndrome.
Feedback
Diamorphine is used to treat anxiety and pain, neither of which is commented upon.
Rate this question
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 to autonomic
dysfunction, and in most post-surgical patients myocardial infarct is silent.
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A 56-year-old man with severe brain damage is apnoeic, unsedated, and temperature 36.9C.
Test Analysis
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?
Consultant/specialist trainee with one years experience
Consultant/specialist trainee with three years experience
Consultant/specialist trainee with four years experience
Consultant/specialist trainee with five years experience
Consultant/specialist trainee with two years experience
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A 56-year-old man with severe brain damage is apnoeic, unsedated, and temperature 36.9C.
Answer Statistics
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?
Test Analysis

Consultant/specialist trainee with one years experience
Consultant/specialist trainee with three years experience

Consultant/specialist trainee with four years experience
Consultant/specialist trainee with five years experience
Consultant/specialist trainee with two years experience
The conventional criteria previously established for clinical death were based upon lack of cardiorespiratory
function.
The development of organ transplantation highlighted patients who had conditions incompatible with life, but
who continued to have some form of cardiorespiratory function with artifical support. This led to a code of
practice for the diagnosis of brainstem death.
Score:
This is based on the knowledge that when the brainstem is damaged to such a degree that its functions are
irreversibly destroyed, the heart will inevitably stop beating shortly afterwards. When this occurs, therefore, the
patient is dead even though respiration and circulation can be artificially maintained. Brain stem function is
Feedback
Total Answered:
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 post registration who has experience in the testing of
Rate this question
brain stem death.
'Life-support' should be withdrawn at this point, but consideration should be taken as to whether the person
would be a suitable organ donor.
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Reference & Further Reading:

A code of practice for the diagnosis of brain stem death, including guidelines for the identification and
management of potential organ and tissue donors. Department of Health. March 1998.
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A 66-year-old male in intensive care has received 2000 mls of colloid in three hours.
Test Analysis
He is receiving an escalating noradrenaline infusion (currently at 0.76 mcg/kg/min), has a blood pressure of
90/50 mmHg, pulse of 90 beats per min, a central venous pressure of 10 mmHg and capillary refill time of 2-3
seconds. His plasma lactate concentration is 2.9 mmol/L (<1.5).
Which of the following is an appropriate method of measuring adequate intravascular filling?
LiDCO (lithium dilution cardiac output)
Oesophageal Doppler monitoring
PiCCO (pulse contour cardiac output)
Pulmonary artery flotation catheter (PAFC)
Transoesophageal echocardiography (TOE)
Score:
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A 66-year-old male in intensive care has received 2000 mls of colloid in three hours.
Answer Statistics
He is receiving an escalating noradrenaline infusion (currently at 0.76 mcg/kg/min), has a blood pressure of
90/50 mmHg, pulse of 90 beats per min, a central venous pressure of 10 mmHg and capillary refill time of 2-3
seconds. His plasma lactate concentration is 2.9 mmol/L (<1.5).
Test Analysis
Which of the following is an appropriate method of measuring adequate intravascular filling?

LiDCO (lithium dilution cardiac output)
Oesophageal Doppler monitoring

PiCCO (pulse contour cardiac output)
Pulmonary artery flotation catheter (PAFC)

Transoesophageal echocardiography (TOE)
PiCCO gives indications of cardiac output, extravascular lung water, intravascular filling and only requires a
central line and a PiCCO femoral arterial line and as such is relatively simple to use.
Score:
It would also not be unreasonable to insert an oesophageal Doppler device; however they have greater
interobserver variation and require a degree of experience to use and are prone to misplacement.
Total Answered:
LiDCO is still not validated or practical to be widely used.
Feedback
PAFC are used widely in the USA however a study has questioned their safety and they have fallen out of
favour in the UK.
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TOE requires considerable expertise to use and is not suitable for cardiac output studies.
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An 18-year-old male is admitted with a history of diarrhoea and vomiting associated with weakness and
Test Analysis
lethargy.
His motor power in the distal arms and legs is decreased and he describes difficulty swallowing. His forced vital
capacity (FVC) is 1.5 litres.
Which of the following is the most appropriate immediate treatment for this condition?
Cyclophosphamide
Intravenous immunoglobulin therapy (IgG) 0.5 g/kg
Plasmapheresis
Prednisolone 60 mg
Score:
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An 18-year-old male is admitted with a history of diarrhoea and vomiting associated with weakness and
Answer Statistics
lethargy.
His motor power in the distal arms and legs is decreased and he describes difficulty swallowing. His forced vital
capacity (FVC) is 1.5 litres.
Test Analysis
Which of the following is the most appropriate immediate treatment for this condition?
Cyclophosphamide
Intravenous immunoglobulin therapy (IgG) 0.5 g/kg

Plasmapheresis
Prednisolone 60 mg
This scenario is suggestive of Guillain-Barre syndrome (GBS).

Dysphagia is a dangerous symptom suggestive of bulbar involvement. However a FVC of 1.5 litres is not an
indication for immediate ventilation (less than 1 litre is).
Score:
Total Answered:
First line therapy is intravenous IgG.
Feedback
Plasmapheresis can also be used but requires specialist equipment.
Rate this question
Steroids are of no benefit.

Cyclophosphamide although an immune suppressant is a red herring.
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A 21-year-old male is admitted with acute onset headache and is drowsy.
Test Analysis
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?
Computed tomography (CT)
Lumbar puncture (LP)
Magnetic resonance angiography (MRA)
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
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Answer Statistics
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?
Test Analysis

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 blood cells
should fall with each successive sample).
If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined for
xanthochromia after centrifugation.
Score:
Total Answered:
Feedback
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Test Analysis
He is opening his eyes spontaneously, is disoriented and is localising painful stimuli. He has a normal
computed tomography (CT) scan.
Which of the following is themost appropriate next investigation for this patient?
Cerebral angiography
Lumbar puncture
Magnetic resonance angiography
Magnetic resonance imaging
No further investigations necessary
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Answer Statistics
He is opening his eyes spontaneously, is disoriented and is localising painful stimuli. He has a normal
computed tomography (CT) scan.
Test Analysis
Which of the following is themost appropriate next investigation for this patient?
Cerebral angiography
Lumbar puncture

Magnetic resonance angiography

Magnetic resonance imaging
No further investigations necessary
Lumbar puncture (LP) is not usually required unless the history is suggestive and theCT is normal as in this
case.
Blood will be present in the CSF (if a bloody tap is suspected the number of red blood cells should fall with
each successive sample).
If the LP is performed six hours after onset of symptoms the supernatant fluid should be examined for
xanthochromia after centrifugation.
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A 67-year-old male is admitted with central chest pain of sudden onset which radiates through to his back.
Test Analysis
His blood pressure is 160/70 mmHg in his right arm and 140/60 mmHg in his left arm. He has
electrocardiographic (ECG) changes in leads II, III and AVF showing ST elevation of 2 mm.
What is the most likely diagnosis?
Coarctation of the aorta
Dissecting thoracic aortic aneurysm
Inferior myocardial infarct
Pancreatitis
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A 67-year-old male is admitted with central chest pain of sudden onset which radiates through to his back.
His blood pressure is 160/70 mmHg in his right arm and 140/60 mmHg in his left arm. He has
electrocardiographic (ECG) changes in leads II, III and AVF showing ST elevation of 2 mm.
Answer Statistics
Test Analysis
What is the most likely diagnosis?

Coarctation of the aorta
Dissecting thoracic aortic aneurysm
Inferior myocardial infarct

Pancreatitis
This history is suggestive of a dissecting thoracic aortic aneurysm.

The ECG changes of inferior myocardial infarct suggest that the aneurysm has dissected the right coronary
artery at its ascending aortic ostium. An ascending aortic dissection needs immediate surgery. Whilst en route
to surgery, beta-blockade to control hypertension is appropriate.
An inferior myocardial infarct is high in the differential - however thrombolysis will kill a patient with an aortic
dissection.
Coarctation can give different blood pressures in either arm but is a chronic condition. Ulcer and pancreatitis
may mimic a heart attack, but with a normal ECG.
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A 27-year-old female with adult respiratory distress syndrome (ARDS) is ventilated on intensive care.
Test Analysis
Her inspired oxygen is 100%, positive end expiratory pressure is 15 cmH2O and peak airway pressure is 40
cmH2O.
Her arterial blood gas shows:
PaO 2
6 kPa
(11.3-12.6)
PaCO2
6.9 kPa
(4.7-6.0)
SpO2
88%
(>92%)
What treatment has been shown to decrease mortality in this patient group?
High frequency oscillatory ventilation (HFOV)
Increasing tidal volume and respiratory rate on the ventilator
Score:
Inhaled nitric oxide therapy
Total Answered:
Prone position
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Extracorporeal membrane oxygenation (ECMO)
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A 27-year-old female with adult respiratory distress syndrome (ARDS) is ventilated on intensive care.
Answer Statistics
Her inspired oxygen is 100%, positive end expiratory pressure is 15 cmH2O and peak airway pressure is 40
cmH2O.
Test Analysis
Her arterial blood gas shows:

PaO 2
6 kPa
(11.3-12.6)
PaCO2
6.9 kPa
(4.7-6.0)
SpO2
88%
(>92%)
What treatment has been shown to decrease mortality in this patient group?
High frequency oscillatory ventilation (HFOV)
Increasing tidal volume and respiratory rate on the ventilator

Inhaled nitric oxide therapy
Prone position
Extracorporeal membrane oxygenation (ECMO)
Score:
This lady is on maximal ventilatory therapy but is still hypoxic. Her high CO2 is a reflection of permissive
Total Answered:
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hypercapnia to prevent overdistension of the lungs with high tidal volumes.
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Treatment of these patients used to be extremely difficult, with no significant improvement in prognosis seen
will any technique. However, in 2010 the CESAR trial demonstrated a significant increase in survival without
significant disability with the use of extracorporeal membrane oxygenation (ECMO).
ECMO involves connecting a patient's circulation to an external oxygenator and pump, via a catheter placed in
the right side of the heart. It requires the continuous infusion of anticoagulant, and as such bleeding is the most
commonly associated complication. Infection and haemolysis are also a risk.
A recent study 1 published in the NEJM concluded that prone positioning improved outcome in severe ARDS.
However, it is only one study in a controversial area. There are a number of studies, including one by the same
group, which have not shown a mortality benefit (and others which show a detrimental effect on mortality).
Prone positioning is therefore not yet widely accepted in clinical practice, although this may change in the
future. For the purpose of the MRCP (where there are single best answers), ECMO remains the correct answer.
Reference:
1. Gurin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N
Engl J Med. 2013;368(23):2159-68.
2. Peek GJ, et al. Randomised controlled trial and parallel economic evaluation of conventional ventilatory
support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Health
Technol Assess. 2010;14(35):1-46.
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MRCP Part 1 2006 May
A 47-year-old man presents with progressive right hand swelling two days after being bitten by a dog.
Test Analysis
On examination there is a puncture wound with pus over the dorsum of the hand, cellulitis, ascending
lymphangitis and tender axillary lymphadenopathy.
What is the most appropriate antibiotics therapy in this case?
Benzylpenicillin and flucloxacillin
Ceftriaxone
Ciprofloxacin
Co-amoxiclav
Erythromycin
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MRCP Part 1 2006 May
A 47-year-old man presents with progressive right hand swelling two days after being bitten by a dog.
On examination there is a puncture wound with pus over the dorsum of the hand, cellulitis, ascending
lymphangitis and tender axillary lymphadenopathy.
Answer Statistics
Test Analysis
What is the most appropriate antibiotics therapy in this case?

Benzylpenicillin and flucloxacillin
Ceftriaxone
Ciprofloxacin
Co-amoxiclav
Erythromycin
Only 15-20% of dog bites become infected, and providing the wound is appropriately cleaned and not
considered at risk (for example,crush or deep wounds) then antibiotic prophylaxis may not be required.
However, this patient has an infected wound, and infective organisms include Pasteurella spp, Staph. aureus
and anaerobes like Corynebacterium.
Score:
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The most appropriate antibiotic therapy in dog bites associated with cellulitis would be co-amoxiclav.
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A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to pneumonia
Test Analysis
is admitted to the high dependency unit.

On examination, he has a temperature of 39C, a respiratory rate of 30/min, has a pulse of 109 beats/min and
a blood pressure of 89/74 mmHg despite receiving IV fluids and urine output of 25 ml/hour after catheterisation.
Which of the following should be instituted immediately and should be accomplished within the first six hours of
presentation?
Administer drotrecogin alfa (activated protein C)
Administer intravenous furosemide
Administer low dose steroids
Institute tight glucose control
Obtain blood cultures prior to antibiotic administration
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A 56-year-old man diagnosed with systemic inflammatory response syndrome (SIRS) secondary to pneumonia
Answer Statistics
is admitted to the high dependency unit.

On examination, he has a temperature of 39C, a respiratory rate of 30/min, has a pulse of 109 beats/min and
a blood pressure of 89/74 mmHg despite receiving IV fluids and urine output of 25 ml/hour after catheterisation.
Test Analysis
Which of the following should be instituted immediately and should be accomplished within the first six hours of
presentation?
Administer drotrecogin alfa (activated protein C)
Administer intravenous furosemide

Administer low dose steroids
Institute tight glucose control
Obtain blood cultures prior to antibiotic administration
The Surviving Sepsis Campaign (a partnership of the Society of Critical Care Medicine, the European Society
of Intensive Care Medicine, and the International Sepsis Forum) has teamed up with the Institute for
Healthcare Improvement to develop severe sepsis bundles. A 'bundle' is a group of interventions related to a
disease process that, when executed together, result in better outcomes than when implemented individually.
Sepsis Resuscitation Bundle
(Should begin immediately, but must be accomplished within the first six hours of presentation.)
1. Serum lactate measured.
2. Blood cultures obtained prior to antibiotic administration.
3. From the time of presentation, broad-spectrum antibiotics administered within three hours for ED
admissions and one hour for non-ED ICU admissions.
4. In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl):
Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent).
Apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial
pressure (MAP) > 65 mm Hg.
5. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l
(36 mg/dl):
Achieve central venous pressure (CVP) of > 8 mm Hg.
Achieve central venous oxygen saturation (ScvO2) of > 70%.
Sepsis Management Bundle
(To be accomplished as soon as possible may be completed within twenty-four hours of presentation.)
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1. Low-dose steroids administered for septic shock in accordance with a standardised ICU policy.
2. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/l).
3. Inspiratory plateau pressures maintained < 30 cm H 2 O for mechanically ventilated patients
Drotrectogin alpha (activated protein C) used to be recommended by NICE for the treatment of severe sepsis.
However, in October 2011 the company withdrew this from the market following the results of the PROWESSSHOCK study, which showed there was no statistically significant reduction in 28-day all-cause mortality in
Revision Notes
patients with septic shock.

page.
Reference:
Dellinger RP, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and
septic shock. Intensive Care Med. 2008;34(1):17-60.
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A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperable carcinoma of the
Test Analysis
distal oesophagus. Oesophageal spasm causes food to stick after swallowing which causes odynophagia.
Which drug would be most helpful in relieving his chronic pain?
Clodronate
Dexamethasone
Nifedipine
Oxybutynin
Pinaverium
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A 78-year-old male who presents with increasing dysphagia is diagnosed with an inoperable carcinoma of the
Answer Statistics
distal oesophagus. Oesophageal spasm causes food to stick after swallowing which causes odynophagia.
Which drug would be most helpful in relieving his chronic pain?
Test Analysis

Clodronate
Dexamethasone
Nifedipine
Oxybutynin
Pinaverium
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours and
could be used to relieve his odynophagia.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated
hypercalcaemia.
Score:
Pinaverium is used to reduce the pain duration associated with irritable bowel syndrome (IBS).
Total Answered:
Corticosteroids are used to treat pain from central nervous system tumours and painful bladder spasm may be
relieved by oxybutynin.
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A 54-year-old obese man with a history of angina and hypertension presents with central crushing chest pain
Test Analysis
of two hours duration.

High flow oxygen, sublingual GTN and aspirin are administered and venous access is obtained. Whilst being
attached to an ECG monitor he collapses, with a doctor present, and the initial rhythm is pulseless ventricular
tachycardia (VT). The external defibrillator is located two minutes away on another ward.
Which of the following is the most appropriate immediate treatment for this man?
A ventilation to compression ratio of 30:2 should commenced
Await arrival of defibrillator, then deliver shock
Continuous chest compressions should be started
He should be given a praecordial thump
Intravenous adrenaline should be given
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A 54-year-old obese man with a history of angina and hypertension presents with central crushing chest pain
Answer Statistics
of two hours duration.

High flow oxygen, sublingual GTN and aspirin are administered and venous access is obtained. Whilst being
attached to an ECG monitor he collapses, with a doctor present, and the initial rhythm is pulseless ventricular
Test Analysis
tachycardia (VT). The external defibrillator is located two minutes away on another ward.
Which of the following is the most appropriate immediate treatment for this man?
A ventilation to compression ratio of 30:2 should commenced
Await arrival of defibrillator, then deliver shock

Continuous chest compressions should be started
He should be given a praecordial thump
Intravenous adrenaline should be given
The 2010 ALS guidelines state that if a patient has a monitored and witnessed VF/VT arrest in hospital, three
quick successive (stacked) shocks should be given. Chest compressions should be started immediately after
the third, with a compression to ventilation ratio of 30:2 for 2 minutes.
A precordial thump can be successful if given within seconds of the onset of a shockable rhythm. Delivery
should not delay calling for help, or accessing a defibrillator, but would be indicated here whilst awaiting the
defibrillator. Chest compressions should start immediately if it is unsuccessful.
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Intravenous adrenaline would be given every 3-5 minutes once chest compressions had started.
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MRCP Part 1 2006 Jan
A 23-year-old man with known peanut allergy presented to the Emergency department with anaphylaxis. He
Test Analysis
has a swollen face and lips.

His BP is 90/60 mmHg, pulse 110 bpm and he is wheezy.
Which of the following formulations of adrenaline should be given?
0.5 ml of 1:10000 adrenaline IM
5 ml of 1:1000 adrenaline IM
10 ml of 1:10000 adrenaline IV
Nebulised adrenaline
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MRCP Part 1 2006 Jan
A 23-year-old man with known peanut allergy presented to the Emergency department with anaphylaxis. He
Answer Statistics
has a swollen face and lips.

His BP is 90/60 mmHg, pulse 110 bpm and he is wheezy.
Test Analysis
Which of the following formulations of adrenaline should be given?


5 ml of 1:1000 adrenaline IM
10 ml of 1:10000 adrenaline IV
Nebulised adrenaline
For adults, a dose of 0.5 mL adrenaline 1:1000 solution (500 micrograms) should be administered
intramuscularly, and repeated after about five minutes in the absence of clinical improvement or if deterioration
occurs after the initial treatment especially if consciousness becomes - or remains - impaired as a result of
hypotension.
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The intramuscular (IM) route for adrenaline is the route of choice for most healthcare providers. There is a
much greater risk of causing harmful side effects by inappropriate dosage or misdiagnosis of anaphylaxis when
using IV adrenaline.
Adult EpiPen which allergy sufferers can carry with them contains 0.3 mg or 0.15 mg adrenaline in a 1:1000
dilution for intramuscular (IM) injection.
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A 67-year-old man complains of dizziness and faintness.
Test Analysis
He has insulin dependent diabetes mellitus and he had a sigmoid colectomy 3 days previously . His blood
pressure is 80/50 mmHg, his pulse 110 beats per min, his respiratory rate 24/min, and he has SpO 2 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?
Arterial blood gas
Chest x ray
Electrocardiogram
Serum Lactate
Urine ketones
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A 67-year-old man complains of dizziness and faintness.
Answer Statistics
He has insulin dependent diabetes mellitus and he had a sigmoid colectomy 3 days previously . His blood
pressure is 80/50 mmHg, his pulse 110 beats per min, his respiratory rate 24/min, and he has SpO 2 99% on
air. His plasma glucose concentration is 18 mmol/L (3.0-6.0 Fasting)
Test Analysis
Which of the following is the most appropriate investigation for this patient?
Arterial blood gas
Chest x ray
Electrocardiogram
Serum Lactate
Urine ketones
This man may have a cardiac cause for his dizziness. The highest prevalence of myocardial infarction (MI) is
72 hours post operation.
Patients with diabetes may not have chest pain due to autonomic dysfunction. The differential diagnosis would
include pulmonary embolus. It may also include diabetic ketoacidosis, but this would be unlikely with his
glucose at 18 mmol/L and would not directly explain his hypotension. Also, he would be expected to have a
slightly higher respiratory rate than 24/min.
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The most appropriate immediate investigation in this scenario would be ECG.

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A patient needs central venous access for total parenteral nutrition (TPN).
Test Analysis
Which of the following is the cleanest site for placement?

Left femoral
Left internal jugular
Right femoral
Right internal jugular
Right subclavian
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A patient needs central venous access for total parenteral nutrition (TPN).
Answer Statistics
Which of the following is the cleanest site for placement?
Test Analysis

Left femoral
Left internal jugular

Right femoral
Right internal jugular
Right subclavian
Right or left subclavian is regarded as the cleanest site for central venous access. It also the most tolerated by
patients.
However the incidence of subclinical pneumothorax even in the hands of experienced clinicians has led to it
falling out of favour.
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An 18-year-old with cerebral palsy is admitted after a respiratory arrest having been intubated by paramedics.
Test Analysis
Nobody can gain intravenous access as the patient is too shut down. A femoral line is not possible due to
contractures. You do not have the experience to perform central venous cannulation.
Which of the following is the best option for administering intravenous fluids/emergency drugs in this situation
of inability to gain venous access?
Down the endotracheal tube
Intramuscular (IM)
Intraosseous
Nasogastric
Subcutaneous
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An 18-year-old with cerebral palsy is admitted after a respiratory arrest having been intubated by paramedics.
Nobody can gain intravenous access as the patient is too shut down. A femoral line is not possible due to
contractures. You do not have the experience to perform central venous cannulation.
Answer Statistics
Test Analysis
Which of the following is the best option for administering intravenous fluids/emergency drugs in this situation
of inability to gain venous access?
Down the endotracheal tube
Intramuscular (IM)
Intraosseous
Nasogastric
Subcutaneous
Nasogastric, IM and subcutaneous are too slow and unreliable for emergency situations (although in cardiac
arrest the endotracheal route is recognised).
Score:
Venous cut down is a possibility but requires skill in the procedure.
Total Answered:
Intraosseous is still perfectly viable in the adult patient 2 cm below the tibial tuberosity on the antero-medial
side or 2 cm proximal to the medial malleolus.
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A 26-year-old female is admitted to ICU with severe asthma.
Test Analysis
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 weaned from
ventilatory support.
On examination, she is alert but has flaccid weakness of all limbs.
Which of the following is the likely diagnosis?
Critical illness polyneuropathy
Guillain-Barr syndrome
Hypermagnesaemia
Prolonged neuromuscular blockade
Score:
Steroid induced myopathy
Total Answered:
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A 26-year-old female is admitted to ICU with severe asthma.
Answer Statistics
She is ventilated for one week and receives IV co-amoxiclav/clarithromycin, magnesium, prednisolone,
sedatives and muscle relaxants.
Test Analysis
She improves gradually but two days after stopping muscle relaxants she still is unable to be weaned from
ventilatory support.
On examination, she is alert but has flaccid weakness of all limbs.
Which of the following is the likely diagnosis?
Critical illness polyneuropathy
Guillain-Barr syndrome
Hypermagnesaemia
Prolonged neuromuscular blockade
Steroid induced myopathy
Score:
The history suggests prolonged neuromuscular junction (NMJ) blockade which may be exacerbated by both
corticosteroids and magnesium.
Total Answered:
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This condition was originally described with suxamethonium due to hereditary reductions in plasma
cholinesterase activity.
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However, drugs and electrolyte abnormalities may exacerbate this.

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A patient post retrosternal thyroidectomy resection has sudden onset shortness of breath.
Test Analysis
On examination, she is talking clearly but has decreased breath sounds on her right side with hyper-resonance
on percussion. Her blood pressure is 110/80 mmHg, pulse 95 beats per minute, respiratory rate 24/min and
SpO 2 92 on air.
Which of the following would be most appropriate for her initially?
Chest x ray
Furosemide 40 mg intravenously
Intercostal chest drain insertion
Needle thoracocentesis
Removal of surgical clips
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A patient post retrosternal thyroidectomy resection has sudden onset shortness of breath.
Answer Statistics
On examination, she is talking clearly but has decreased breath sounds on her right side with hyper-resonance
on percussion. Her blood pressure is 110/80 mmHg, pulse 95 beats per minute, respiratory rate 24/min and
SpO 2 92 on air.
Test Analysis
Which of the following would be most appropriate for her initially?

Chest x ray
Correct
Furosemide 40 mg intravenously
Intercostal chest drain insertion
Needle thoracocentesis
Removal of surgical clips
According to the scenario above this lady has a pneumothorax.

She is not in extremis (suggesting a tension pneumothorax) so needle thoracocentesis is not required.
Score:
Total Answered:
The history and examination are suggestive of a pneumothorax and therefore, with her being relatively stable,
the most appropriate first step would be confirmation with chest x ray followed by chest drain insertion.
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Furosemide would not help.
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A 10-year-old child presents with a respiratory tract infection. You decide to treat him empirically with a broad
Test Analysis
spectrum antibiotic.
The child is taking no other medication, has no other co-morbidity factors and has no known detected allergies.
Which of the following antibiotics is contraindicated in this patient?
Amoxicillin
Clarithromycin
Erythromycin
Flucloxacillin
Minocycline
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A 10-year-old child presents with a respiratory tract infection. You decide to treat him empirically with a broad
Answer Statistics
spectrum antibiotic.
The child is taking no other medication, has no other co-morbidity factors and has no known detected allergies.
Test Analysis
Which of the following antibiotics is contraindicated in this patient?

Amoxicillin
Clarithromycin
Erythromycin
Flucloxacillin
Minocycline
Tetracyclines can bind to calcium and deposit on growing bones and teeth. This may cause staining and
occasionally dental hypoplasia.
Therefore, tetracyclines should not be given to children under the age of 12 or to pregnant or breastfeeding
women.
Score:
Total Answered:
However, doxycycline can be used (unlicenced) for the treatment of anthrax in children.
Feedback
BNF 60
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Mr YB is admitted on your ward with endocarditis and is prescribed vancomycin IV.
Test Analysis
You monitor the patient for signs of toxicity as it has a narrow therapeutic index.
Which of the following is a result of vancomycin toxicity?
Bradycardia
Dry mouth
Erythema multiforme
Hepatoxicity
Ototoxicity
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Mr YB is admitted on your ward with endocarditis and is prescribed vancomycin IV.
Answer Statistics
You monitor the patient for signs of toxicity as it has a narrow therapeutic index.
Which of the following is a result of vancomycin toxicity?
Test Analysis

Bradycardia
Dry mouth
Erythema multiforme
Hepatoxicity
Ototoxicity
Ototoxicity is associated with vancomycin, and is more likely in patients with high plasma concentrations, or
with renal impairment or pre-existing hearing loss.
It may progress after drug withdrawal, and may be irreversible.Hearing loss may be preceded by tinnitus,
which must be regarded as a sign to stop treatment.
The important level to measure here is the trough level as opposed to the peak level with gentamicin.
(Martindale)
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Ms YF is prescribed ciprofloxacin 500 mg twice daily for the treatment of cystitis.
Test Analysis
In which of the following conditions should ciprofloxacin be used with caution?

Asthma
Diabetes
Epilepsy
Glaucoma
Heart failure
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Ms YF is prescribed ciprofloxacin 500 mg twice daily for the treatment of cystitis.
Answer Statistics
In which of the following conditions should ciprofloxacin be used with caution?
Test Analysis

Asthma
Diabetes
Epilepsy
Glaucoma
Heart failure
Quinolones should be used with caution in patients with a history of epilepsy or conditions that predispose to
seizures, in glucose-6-phosphate dehydrogenase (G6PD) deficiency, myasthenia gravis (risk of exacerbation),
and in children or adolescents.
The CSM has warned that quinolones may induce convulsions in patients with or without a history of
convulsions; taking non-steroidal anti-inflammatory drugs (NSAIDs) at the same time may also induce them.
Score:
It should also be noted that ciprofloxacin is contraindicated in pregnancy.
Total Answered:
BNF 60
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Mr UP is taking bendroflumethiazide for hypertension.
Test Analysis
Which of the following is likely to increase whilst on bendroflumethiazide therapy?

Magnesium
Potassium
Sodium
Uric acid
White cell count
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Mr UP is taking bendroflumethiazide for hypertension.
Answer Statistics
Which of the following is likely to increase whilst on bendroflumethiazide therapy?
Test Analysis

Magnesium
Potassium
Sodium
Uric acid
White cell count
Hydrochlorothiazide and other thiazide diuretics may cause metabolic disturbances especially at high doses.
They may provoke hyperglycaemia and glycosuria in diabetic and other susceptible patients. They may cause
hyperuricaemia and precipitate attacks of gout in some patients.
Score:
Thiazide diuretics may be associated with electrolyte imbalances including hypochloraemic alkalosis,
hyponatraemia, and hypokalaemia.
Total Answered:
Hypokalaemia intensifies the effect of digitalis on cardiac muscle and treatment with digitalis or its glycosides
may have to be temporarily suspended. Patients with cirrhosis of the liver are particularly at risk from
hypokalaemia.
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Hyponatraemia may occur in patients with severe heart failure who are very oedematous, particularly with large
doses used with restricted salt in the diet.
The urinary excretion of calcium is reduced.Hypomagnesaemia has also occurred.
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Adverse changes in plasma lipids have also been noted but their clinical significance is unclear.
(Martindale)
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Mrs PL is taking digoxin for heart failure.
Test Analysis
Which of the following drugs, if added to her prescription, would predispose Mrs PL to digoxin toxicity?
Bumetanide
Ibuprofen
Paracetamol
Phenytoin
St. John's wort
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Mrs PL is taking digoxin for heart failure.
Answer Statistics
Which of the following drugs, if added to her prescription, would predispose Mrs PL to digoxin toxicity?
Test Analysis

Bumetanide
Correct
Ibuprofen
Paracetamol
Phenytoin
St. John's wort
Bumetanide is a loop diuretic and may cause hypokalaemia as a side effect. The potassium loss caused by
bumetanide increases the toxicity of digoxin.
A comparative study of the medical records of 418 patients taking digitalis over the period 1950 to 1952, and of
679 patients over the period 1964 to 1966, found that the incidence of digitalis toxicity had more than doubled.1
Of the earlier group 8.6% developed toxicity compared with 17.2% of the latter group (81% taking diuretics,
mainly chlorothiazides, furosemide, ethacrynic acid, chlortalidone). It was concluded that the increased toxicity
was related to the increased usage of potassium-depleting diuretics.
Score:
Total Answered:
Reference:
Feedback
1. Jorgensen AW, Sorensen OH. Digitalis intoxication. A comparative study on the incidence of digitalis
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intoxication during the periods 1950-52 and 1964-66. Acta Med Scand. 1970;188(3):179-83.
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Mrs HV is taking an antidepressant.
Test Analysis
Her husband recently passed away and she was diagnosed as being clinically depressed.
Since taking the antidepressants, she has been complaining of drowsiness, confusion and fatigue.
Depletion of which of the following electrolytes may be causing Mrs HV's symptoms?
Chloride
Magnesium
Phosphate
Potassium
Sodium
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Mrs HV is taking an antidepressant.
Answer Statistics
Her husband recently passed away and she was diagnosed as being clinically depressed.
Since taking the antidepressants, she has been complaining of drowsiness, confusion and fatigue.
Test Analysis
Depletion of which of the following electrolytes may be causing Mrs HV's symptoms?
Chloride
Magnesium
Phosphate
Potassium
Sodium
The Committee on Safety of Medicines (CSM) have reported thathyponatraemia is associated with all types of
antidepressants; however it has been reported more frequently with selective serotonin reuptake inhibitors
(SSRIs) than with other antidepressants.
Hyponatraemia should be considered in all patients who develop drowsiness, confusion or convulsions whilst
taking an antidepressant.
Score:
Total Answered:
Feedback
BNF 60
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You would like to prescribe a selective serotonin reuptake inhibitor (SSRI) for a 14-year-old girl who has been
Test Analysis
diagnosed as being clinically depressed.

After much debate and intervention from various healthcare professionals, it was decided to prescribe her
fluoxetine.
For which one of the following parameters should the patient be closely monitored, especially at the beginning
of treatment?
Coldness of extremities
Hostility
Hyperglycaemia
Prothrombin time
Tachycardia
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Submit answer
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You would like to prescribe a selective serotonin reuptake inhibitor (SSRI) for a 14-year-old girl who has been
Answer Statistics
diagnosed as being clinically depressed.

After much debate and intervention from various healthcare professionals, it was decided to prescribe her
fluoxetine.
Test Analysis
For which one of the following parameters should the patient be closely monitored, especially at the beginning
of treatment?
Coldness of extremities
Hostility
Hyperglycaemia
Prothrombin time
Tachycardia
Children and adolescents need to be monitored carefully. The use of antidepressants has been linked with
suicidal thoughts and behaviour. Where necessary patients should be monitored for suicidal behaviour, self
harm or hostility, particularly at the beginning of treatment or when the dose is changed.
Score:
Total Answered:
The balance of risks and benefits for the treatment of depressive illness in individuals under the age of 18
years is considered unfavourable for citalopram, escitalopram, paroxetine and sertraline.
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Clinical trials have failed to show efficacy and have shown an increase in harmful outcomes.
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Only fluoxetine has shown to be effective in treating depressive illness in children, but careful monitoring for the
above sign is required.
Reference:
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electronic Medicines Compendium (eMC). Fluoxetine 20 mg Capsules

Joint Formulary Committee. British National Formulary 60. London: Pharmaceutical Press, BMJ Group; 2010.
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Mr VU is taking amitriptyline for depressive illness.
Test Analysis
He comes to see you at a routine outpatient appointment and informs you that he has been experiencing some
side effects with his amitriptyline therapy.
Which of the following is the most commonly recognised side effect of this drug?
Gout
Hypokalaemia
Renal stones
Taste disturbances
Urinary retention
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Mr VU is taking amitriptyline for depressive illness.
He comes to see you at a routine outpatient appointment and informs you that he has been experiencing some
side effects with his amitriptyline therapy.
Answer Statistics
Test Analysis
Which of the following is the most commonly recognised side effect of this drug?
Gout
Hypokalaemia
Renal stones
Taste disturbances
Urinary retention
Many adverse effects of amitriptyline and similar tricyclic antidepressants are caused by their antimuscarinic
actions.
Antimuscarinic effects are relatively common and occur before an antidepressant effect is obtained. They
include:
Dry mouth
Constipation occasionally leading to paralytic ileus
Urinary retention
Blurred vision and disturbances in accommodation
Increased intraocular pressure and
Hyperthermia.
Tolerance is often achieved if treatment is continued and adverse effects may be less troublesome if treatment
is begun with small doses and then increased gradually, although this may delay the clinical response.
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Drowsiness may also be common, although a few tricyclic antidepressants possess little or no sedative
potential and may produce nervousness and insomnia.
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Other neurological adverse effects include:
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Headache
Peripheral neuropathy
Tremor
Ataxia
Epileptiform seizures
Tinnitus and
Occasional extrapyramidal symptoms including speech difficulties (dysarthria).
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Confusion, hallucinations, or delirium may occur, particularly in the elderly, and mania or hypomania, and
behavioural disturbances (particularly in children) have been reported.
Revision Notes
Gastrointestinal complaints include:

Sour or metallic taste
Stomatitis and
Gastric irritation with nausea and vomiting.

page.
Orthostatic hypotension and tachycardia can occur in patients without a history of cardiovascular disease, and
may be particularly troublesome in the elderly.
Hypersensitivity reactions, such as urticaria and angioedema, and photosensitisation have been reported and,
rarely, cholestatic jaundice and blood disorders, including:
Eosinophilia
Bone marrow depression
Thrombocytopenia
Leucopenia and
Agranulocytosis.
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Endocrine effects include testicular enlargement, gynaecomastia and breast enlargement, and galactorrhoea.
Sexual dysfunction may also occur.
Changes in blood sugar concentrations may also occur, and, very occasionally, hyponatraemia associated with
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inappropriate secretion of antidiuretic hormone.
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Other adverse effects that have been reported are increased appetite with weight gain (or occasionally
anorexia with weight loss). Sweating may be a problem.
Martindale
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A patient is prescribed warfarin for prophylaxis of DVT.
Test Analysis
Which vitamin does warfarin antagonise?

A
B6
C
D
K
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A patient is prescribed warfarin for prophylaxis of DVT.
Answer Statistics
Which vitamin does warfarin antagonise?
Test Analysis

A
B6
C
D
K
Warfarin inhibits hepatic vitamin K epoxide reductase, which is an enzyme that converts vitamin K to its active
form (hydroquinone).
This results in the impairment of the hepatic synthesis of vitamin K dependent clotting factors (II [prothrombin],
VII, IX, and X).
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A patient on your ward is prescribed warfarin as she has recently been diagnosed with atrial fibrillation. Her
Test Analysis
desired INR is 2.5.

On the morning ward round you take the patient's INR which comes back as 5.2 from the laboratory. There are
no signs of bleeding.
What would be your next course of action?
Decrease the dose of warfarin
Do nothing, as there are no signs of bleeding
Increase the dose of warfarin
Omit the warfarin
Start a heparin infusion
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A patient on your ward is prescribed warfarin as she has recently been diagnosed with atrial fibrillation. Her
Answer Statistics
desired INR is 2.5.

On the morning ward round you take the patient's INR which comes back as 5.2 from the laboratory. There are
no signs of bleeding.
Test Analysis
What would be your next course of action?

Decrease the dose of warfarin
Do nothing, as there are no signs of bleeding

Increase the dose of warfarin
Omit the warfarin
Start a heparin infusion
The main adverse effect of all oral anticoagulants is haemorrhage.

Checking the INR and omitting doses when appropriate is essential; if the anticoagulant is stopped but not
reversed, the INR should be measured two to three days later to ensure that it is falling.
The following recommendations are based on the result of the INR and whether there is major or minor
bleeding; the recommendations apply to patients taking warfarin:
Major bleeding - omit warfarin; give phytomenadione (vitamin K1) 5-10 mg by slow intravenous injection;
give dried prothrombin complex (factors II, VII, IX, and X) 30-50 units/kg (if dried prothrombin complex
unavailable, fresh frozen plasma 15 mL/kg can be given but is less effective).
INR 8.0, no bleeding or minor bleeding - omit warfarin and give phytomenadione (vitamin K1) 2.5-5 mg by
mouth using the intravenous preparation orally [unlicenced use], or 0.5-1 mg by slow intravenous injection
(if complete reversal required 5-10 mg by slow intravenous injection); repeat dose of phytomenadione if
INR still too high after 24 hours; restart warfarin when INR less than 5.0.
INR 5.0-8.0, no bleeding - omit warfarin; minor bleeding - omit warfarin and give phytomenadione (vitamin
K1) 1-2.5 mg by mouth using the intravenous preparation orally [unlicenced use]; restart warfarin when INR
less than 5.0.
Unexpected bleeding at therapeutic levels - always investigate possibility of underlying cause, for example,
unsuspected renal or gastrointestinal tract pathology.
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Mr YB is a patient who regularly attends the anticoagulant clinic.
Test Analysis
He is very concerned as he has been recently started on a new drug by his GP. He asks you whether it would
enhance the anticoagulant effect.
Which of the following may increase the potential for bleeding in patients taking warfarin?
Clopidogrel
Carbamazepine
Griseofulvin
Phenobarbitone
St. John's wort
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Mr YB is a patient who regularly attends the anticoagulant clinic.
Answer Statistics
He is very concerned as he has been recently started on a new drug by his GP. He asks you whether it would
enhance the anticoagulant effect.
Test Analysis
Which of the following may increase the potential for bleeding in patients taking warfarin?
Clopidogrel
Correct
Carbamazepine
Griseofulvin
Phenobarbitone
St. John's wort
Clopidogrel does not appear to have a clinically relevant effect on the pharmacokinetics or pharmacodynamics
of warfarin.
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However, the concurrent use of clopidogrel with warfarin, increases the bleeding risk.
All other drugs in the options are C-P450 enzyme inducers so would decrease the anticoagulant effect
Reference:
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Baxter K, editor. Stockley's Drug Interactions. 9th ed. London: Pharmaceutical Press; 2011.
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Which of the following does not have a role in the management of chronic cancer pain?
Test Analysis

Carbamazepine
Clodronate
Dexamethasone
Nifedipine
Pinaverium
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Which of the following does not have a role in the management of chronic cancer pain?
Answer Statistics

Carbamazepine
Test Analysis
Clodronate
Dexamethasone
Nifedipine
Pinaverium
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 other disorders.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated
hypercalcaemia.
The corticosteroids are used to treat pain from central nervous system tumours. Reducing the inflammation
and oedema relieves the pain caused by neural compression.
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Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours.
Painful bladder spasm may be relieved by oxybutynin.
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Inhibits eicosanoid synthesis

Synthetic cannabinoids reduce arachidonic acid-induced inflammation by inhibiting eicosanoid production.

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haemoptysis on the ward.

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The platelet count is likely to be elevated

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Levels of D dimer will be reduced

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Several coagulation abnormalities are seen in sepsis including:

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Sepsis Management Bundle:

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patients with septic shock.

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