Best of five mcqs for the acute medicine sce.pdf

1. A 74-year-old man suffered a cardiorespiratory arrest on a surgical ward four days after an elective sigmoid colectomy (with primary anastomosis) for cancer. His past medical history included hypertension and hypercholesterolaemia for which he took lisinopril, atenolol, and atorvastatin. He had been seen by the surgical foundation year 1 doctor (in the UK) eight hours prior to his cardiorespiratory arrest after an episode of nausea and vomiting. On examination at that time his temperature was 38.0°C, pulse 105 beats per minute, blood pressure 95/40 mmHg, and respiratory rate 28 breaths per minute, with peripheral oxygen saturation of 94% on air. The doctor had noted abdominal tenderness, prescribed intravenous fluids, paracetamol and ondansetron, and performed peripheral blood cultures. Which is the most likely cause of the cardiorespiratory arrest? A. Anaphylaxis B. Hyperkalaemia C. Myocardial infarction D. Peritonitis E. Pulmonary embolus 2. A 69-year-old man was successfully defibrillated after an episode of ventricular fibrillation secondary to an ST elevation myocardial infarction (STEMI) and transferred to the cardiac catheter laboratory for primary coronary intervention. After the procedure began he had a further episode of ventricular fibrillation. Regarding defibrillation, which is true? A. A single direct current shock of 360 joules with a biphasic waveform is the most likely to restore spontaneous circulation B. Defibrillation is no more likely to be successful than a properly delivered praecordial thump C. It is safe to continue with the coronary angiogram while the shock is delivered to the patient D. Three shocks delivered with minimal interruptions should be given before any other intervention E. Two minutes of chest compressions before defibrillation is recommended to optimize coronary perfusion chapter 1 CARDIORESPIRATORY ARREST AND SHOCK QUESTIONS 2 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 3. A 75-year-old man was admitted via the emergency department with a two-day history of shortness of breath with a productive cough and 12 hours of nausea and vomiting. He had a history of chronic obstructive pulmonary disease and usually took salmeterol and tiotropium inhalers. His temperature was 39.3°C, heart rate 112 beats per minute, blood pressure 116/72 mmHg, and respiratory rate 24 breaths per minute. His oxygen saturation was 91% on 2 litres per minute of oxygen via nasal cannulae. A venous lactate was measured at 3.3 mmol per litre. Which of the following is true? A. Elevated lactate always represents tissue ischaemia B. Elevated venous lactate identifies a high risk of death C. Hyperlactataemia is diagnostic of severe sepsis D. Venous and arterial lactate measurements are interchangeable E. Venous lactate is not a suitable target for goal directed therapy 4. An 80-year-old woman was admitted to hospital for management of chronic venous leg ulcers. While on the medical ward, she had an asystolic cardiorespiratory arrest. Following resuscitation according to Advanced Life Support guidelines ventricular fibrillation was seen and defibrillation successfully restored spontaneous circulation after 15 minutes. What is the patient’s chance of having a good neurological outcome? A. 5% B. 10% C. 15% D. 20% E. 25% 5. A 49-year-old woman was admitted to the intensive care unit after suffering a massive subarachnoid haemorrhage. One week after admission she remained unresponsive and the decision to perform brainstem death tests was made. What preconditions must be met before the tests are performed? A. Coroner’s approval, known irreversible aetiology of coma, exclusion of reversible causes of apnoea B. Exclusion of reversible causes of apnoea, known irreversible aetiology of coma, exclusion of reversible causes of coma C. Exclusion of reversible causes of coma, 48 hours since onset of coma, structural brain damage on CT scan D. Known irreversible aetiology of coma, coroner’s approval, evidence of absence of cerebral blood flow (e.g. with angiography) E. Twenty-four hours since onset of coma, exclusion of reversible causes of apnoea, absence of contraindications to organ donation CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 3 6. A 55-year-old man was admitted to the acute medical unit with a fourday history of increasing shortness of breath and cough productive of green sputum. He was a smoker who took amlodipine for hypertension. On examination his temperature was 35.8°C, pulse rate 85 beats per minute, blood pressure 112/50 mmHg, and respiratory rate 26 breaths per minute. Bronchial breath sounds were heard at the base of his right lung. His capillary refill time was 4 seconds. Investigations: haemoglobin 143 g/L (130–180) white cell count 13.9 × 109/L (4–11) neutrophil count 10.1 × 109/L (1.5–7.0) platelets 122 × 109/L (150–400) serum sodium 144 mmol/L (137–144) serum potassium 3.9 mmol/L (3.5–4.9) serum urea 10.5 mmol/L (2.5–7.0) serum creatinine 119 μmol/L (60–110) arterial PO2 (air) 9.9 kPa (11.3–12.6) arterial PCO2 4.5 kPa (4.7–6.0) pH 7.33 (7.35–7.45) lactate 3.3 mmol/L (0.5–1.6) Which clinical syndrome does he have? A. Acute kidney injury B. Acute lung injury C. Sepsis D. Septic shock E. Severe sepsis 4 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS What is your first action in this situation? A. Activate the massive haemorrhage protocol B. Call ICU to arrange intubation C. Give 1 mg of terlipressin intravenously D. Give 2 litres of 0.9% saline stat E. Insert a Sengstaken–Blakemore tube 7. A 40-year-old man known to have alcoholic liver disease presented with upper gastrointestinal bleeding. While on the medical ward he had a large haematemesis associated with a reduction in conscious level. He had previously had banding of oesophageal varices. On examination his temperature was 36.1°C, pulse rate 135 beats per minute, blood pressure 73/43 mmHg, and respiratory rate 32 breaths per minute. His Glasgow Coma Score was 9 (E3, V2, M5). Investigations: haemoglobin 59 g/L (130–180) white cell count 14.2 × 109/L (4–11) platelets 99 × 109/L (150–400) international normalized ratio 1.5 (<1.4) activated partial thromboplastin time 42 s (30–40) fibrinogen 2.9 g/L (1.8–5.4) lactate 5.7 mmol/L (0.5–1.6) CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 5 What is your action based on these results? A. Insert arterial catheter B. Repeat fluid challenge C. Start dobutamine D. Start furosemide E. Take the central venous catheter out 8. A 60-year-old woman was admitted to the coronary care unit with acute coronary syndrome for which she underwent percutaneous coronary intervention. Her past medical history included type 2 diabetes mellitus, hypertension, osteoarthritis, and a femoro-popliteal bypass six years ago. She was taking metformin, ramipril, amlodipine, paracetamol, codeine phosphate, and aspirin. A urinary catheter was inserted during the procedure and over the next 12 hours she passed a total of 140 mL of urine. On examination her pulse rate was 84 beats per minute, blood pressure 145/85 mmHg, jugular venous pressure 3 cm above the sternal notch, respiratory rate 18 breaths per minute, and oxygen saturation 96% on air. Auscultation of her chest revealed normal breath sounds with occasional fine inspiratory crackles and heart sounds were dual with no murmurs. There was no peripheral oedema and capillary refill time was 2 seconds. A central venous catheter was inserted and the response to 250 mL of 0.9% saline was assessed: Investigations: Central venous pressure (mmHg): Pre-treatment 5 Post-treatment 9 6 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS What is the problem with the intra-aortic balloon pump? A. Early deflation B. Early inflation C. IABP kinked D. Late deflation E. Slow gas leak 9. A 62-year-old man suffered an out-of-hospital cardiac arrest. He was successfully resuscitated in the emergency department and transferred for percutaneous coronary intervention. Following stenting of the left anterior descending artery an intra-aortic balloon pump (IABP) was inserted and he was moved to the coronary care unit. Two hours after the procedure the patient reported his breathing had become more difficult. The nursing staff had noted that his oxygen saturation had fallen from 96% to 91% on 2 litres per minute of oxygen and that the waveform displayed on the IABP had changed (Figure 1.1). It was switched from a 1:1 to 1:2 ratio for analysis. Unassisted Systole Diastolic Augmentation Assisted Systole Assisted Aortic End Diastolic Pressure Figure 1.1 Intra-aortic balloon pump (IABP) waveform. CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 7 10. An 18-year-old woman was admitted to the acute medical unit after having a generalized seizure. While on the ward, she continued to have fits at least hourly despite treatment with lorazepam, phenytoin, and levetiracetam. Between seizures her Glasgow Coma Score ranged from 9 (E2, V2, M5) to 13 (E3, V4, M6). Transfer to the intensive care unit via the CT scanner was arranged. Which one of the following would not be considered essential for safe transfer of this patient? A. Adrenaline (epinephrine) B. Intravenous access C. Intubation D. Pulse oximetry E. Self-inflating bag 11. A 73-year-old man had a cardiac arrest. The rhythm was pulseless electrical activity. Cardiopulmonary resuscitation was started at a rate of 30 chest compressions to 2 ventilations. What is the correct rate of chest compressions? A. 80–100 per minute B. 90–110 per minute C. 100–120 per minute D. 110–130 per minute E. 120–140 per minute 12. A 64-year-old man had a cardiac arrest. The initial rhythm was pulseless electrical activity. During cardiopulmonary resuscitation the rhythm on the monitor was noted to change to VF. What is the correct course of action? A. Continue cardiopulmonary resuscitation until the two-minute period is completed B. Deliver a DC shock then continue chest compressions until the two-minute period is completed C. Stop chest compressions and assess the rhythm D. Stop chest compressions and check for a pulse E. Stop chest compressions and deliver a DC shock 8 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS ECG showed sinus tachycardia. The appropriate course of action is: A. Focused echocardiography and thrombolysis if right ventricular dysfunction B. Give low molecular weight heparin and arrange urgent coronary angiography C. Measure D-dimer and troponin and start intravenous heparin D. Start intravenous heparin and arrange urgent CT pulmonary angiography E. Thrombolysis pending CT pulmonary angiography 13. A 45-year-old man had a cardiac arrest. Chest compressions were in progress. The anaesthetic trainee intubated the patient, secured the tube at 27 cm at the teeth, and was ventilating the patient using a self-inflating bag with high-flow oxygen. Waveform capnography was attached to the tracheal tube but no end-tidal CO2 was detected. What is the next step in airway management? A. Auscultate the chest to check the tube position B. Continue ventilation via the endo-tracheal tube C. Remove the endo-tracheal tube and establish face-mask ventilation D. Replace the waveform capnography with a new monitor E. Withdraw the tube by 3 cm then re-secure and continue ventilation 14. A 45-year-old woman collapsed on the neurosurgical ward four days after an elective craniotomy for a meningioma. She had no significant past medical history and was taking paracetamol regularly for post-operative analgesia. On the arrival of the medical emergency team her temperature was 37.1°C, pulse rate 119 beats per minute, blood pressure 95/60 mmHg, jugular venous pressure 4 cm above the sternal notch, and respiratory rate 32 breaths per minute. Her Glasgow Coma Score was 13 (E3, V4, M6) and her peripheries were cold. She was complaining of chest pain. Investigations: pH 7.19 (7.35–7.45) PO2 8.5 kPa (11.3–12.6) PCO2 2.9 kPa (4.7–6.0) base excess –10.4 mmol/L (±2) lactate 5.0 mmol/L (0.5–1.6) oxygen saturation 91% (94–98) Arterial blood gas analysis (15 litres per minute oxygen via face mask): CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 9 15. An 18-year-old man was brought to the emergency department on New Year’s Eve after an unwitnessed fall into a river on the way home from a nightclub. His temperature (rectal) was 28.1°C, pulse rate 31 beats per minute with an irregular rhythm, blood pressure 60/45 mmHg, and respiratory rate 9 breaths per minute. His Glasgow Coma Score was 3. There were no injuries. Which of the following is not appropriate for rewarming? A. Continuous renal replacement therapy (CRRT) B. Extracorporeal membrane oxygenation C. Forced air warming blanket D. Intravascular cooling device E. Warmed humidified oxygen 16. A 75-year-old man was admitted to hospital for an elective revision of a total knee replacement. He had type 2 diabetes and stage 2 chronic kidney disease, and was taking gliclazide. On the orthopaedic ward eight hours after the uneventful procedure he became suddenly unwell with shortness of breath and agitation. His temperature was 37.8°C, heart rate 142 beats per minute, blood pressure 70/30 mmHg, and respiratory rate 30 breaths per minute. On auscultation of his chest there were occasional wheezes heard. His peripheries were warm and the capillary refill time was not prolonged. Attached to his intravenous cannula was a 100 mL bag of 0.9% saline containing flucloxacillin. On the bedside table was an empty bag of cellsaver blood. Investigations: ECG: sinus tachycardia CXR: normal Which diagnosis and therapy is most likely and appropriate? A. Anaphylaxis–adrenaline B. Myocardial infarction–percutaneous coronary intervention C. Pulmonary embolus–heparin D. Sepsis–gentamicin E. Transfusion reaction–hydrocortisone 10 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 17. A 49-year-old man presented to hospital with a two-day history of sore throat and progressive dyspnoea. He was a heavy smoker but had no other past medical history and took no regular medication. On examination his temperature was 39.0°C, pulse rate 117 beats per minute, blood pressure 155/84 mmHg, and respiratory rate 27 breaths per minute. Oxygen saturations were 88% on room air. He appeared distressed and was drooling. Inspiratory stridor was audible from the end of the bed. Which of the following is true: A. Antibiotics should be given after tracheostomy B. Immediate tracheostomy may be life-saving C. Intubation is best attempted before transfer D. Oxygen should not be given before intubation E. Steroids and antibiotics are first-line therapy 18. A 45-year-old man with a history of idiopathic dilated cardiomyopathy was admitted after a cardiac arrest at home. The initial rhythm recorded by the ambulance crew was ventricular fibrillation. There was return of spontaneous circulation after 25 minutes of resuscitation following Advanced Life Support guidelines and he was admitted to the intensive care unit for further management including temperature control and haemodynamic support. Which of the following does not apply to the post-cardiac arrest syndrome? A. Intra-aortic balloon pumps may be used to support a failing myocardium B. Intravascular volume depletion and vasodilatation mimic severe sepsis C. Ischaemia-reperfusion injury leads to immunosuppression and coagulopathy D. Oxygen saturations of 94% are acceptable to prevent secondary brain injury E. Prophylactic phenytoin will reduce the incidence of seizures in the first week CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 11 Which of the following is the most likely cause of his acute confusional state? A. Alcohol withdrawal B. Electrolyte disturbance C. Hepatic encephalopathy D. Infection E. Non-compliance with medication at home 19. An 83-year-old man was admitted to hospital after being unable to cope alone at home with an episode of diarrhoea and vomiting. His past medical history included hypertension, bilateral total hip replacements, and early dementia. He did not smoke but drank 30–40 units of alcohol each week. His medication on admission was amlodipine and donepezil. He improved with 48 hours of intravenous fluids, at which point the cannula was removed because pus was noticed at the insertion site. His discharge home was delayed because he became increasingly confused. His temperature was 35.9°C, heart rate 95 beats per minute, blood pressure 105/60 mmHg (having been previously 150/80 mmHg), and respiratory rate 22 breaths per minute. His feet were cold with pitting oedema around his ankles. Investigations: Hb 113 g/L (130–180) WBC 3.8 × 109/L (4–11) platelets 98 × 109/L (150–400) INR 1.6 (<1.4) serum sodium 134 mmol/L (137–144) serum potassium 3.2 mmol/L (3.5–4.9) serum urea 10.1 mmol/L (2.5–7.0) serum creatinine 89 μmol/L (60–110) serum total bilirubin 29 μmol/L (1–22) plasma glucose 8.0 mmol/L 12 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS Which of the following is the most likely cause of coma in this case? A. Brainstem infarction B. Infective endocarditis C. Pontine myelinolysis D. Status epilepticus E. Venous sinus thrombosis 20. A 70-year-old woman had recently been discharged to a medical ward from the intensive care unit after treatment for septic shock secondary to staphylococcal intervertebral disciitis. She was given piperacillintazobactam to treat the staphylococcus and a pseudomonas ventilatorassociated pneumonia. A call for the medical emergency team was put out after she became apnoeic and unresponsive. Prior to this current acute illness she had been well. On arrival of the medical emergency team she had a temperature of 38.4°C, a heart rate of 160 beats per minute, a blood pressure of 155/95 mmHg, and a respiratory rate of 39 breaths per minute. Her Glasgow Coma Score was 3 with bilaterally reactive pupils and disconjugate gaze. Shortly after the arrival of the team she had a further apnoeic episode that resolved spontaneously after 20 seconds and was associated with a bradycardia of 35 beats per minute. She remained unresponsive except for facial grimacing during and after painful stimulation and was readmitted to the ICU for further investigation and treatment. Investigations: Hb 104 g/L (130–180) WBC 11.7 × 109/L (4–11) platelets 433 × 109/L (150–400) serum sodium 150 mmol/L (137–144) serum potassium 2.9 mmol/L (3.5–4.9) serum urea 19.2 mmol/L (2.5–7.0) serum creatinine 90 μmol/L (60–110) serum CRP 30 mg/L (<10) ECG: normal CXR: bibasal atelectasis CT scan of head: normal MR scan of brain: normal CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 13 Which of the following is recommended by the Surviving Sepsis Campaign Guidelines of 2012? A. Give further fluid challenge to exclude occult hypovolaemia B. Give regular hydrocortisone to spare vasopressors C. Start dobutamine to increase cardiac output D. Start low-dose dopamine for renal protection E. Start low-dose vasopressin to increase mean arterial pressure 22. An 80-year-old woman was admitted to the coronary care unit following primary coronary intervention (PCI) for an ST elevation myocardial infarction. On arrival on the coronary care unit she had stopped talking and the attached defibrillator showed a heart rate of 155 beats per minute. Which is not an adverse feature for adult tachyarrhythmia according to the 2015 Advanced Life Support guidelines? A. Chest pain B. Heart rate >150 bpm C. Hypotension D. Pulmonary oedema E. Unconsciousness 21. A 72-year-old man was admitted to the acute medical unit with a diagnosis of sepsis. One week prior to his admission he had undergone a cystoscopy to investigate haematuria. Past medical history included hypertension, obstructive sleep apnoea, and morbid obesity (with an actual body weight of 120 kg). His medication included ramipril and bendroflumethiazide, and had been started on amoxicillin, clarithromycin, and gentamicin intravenously. Twelve hours after admission his urine output was noted to be low at 40 mL over the past six hours. His blood pressure was 85/45 mmHg initially but had increased to 115/60 mmHg after administration of 1500 mL of sodium chloride 0.9%. Investigations: Lactate 2.2 mmol/L (0.5–1.6) serum creatinine 211 μmol/L (60–110) serum bilirubin 37 μmol/L (1–22) 14 CARDIORESPIRATORY ARREST AND SHOCK | QUESTIONS 23. A 36-year-old woman was admitted to the emergency department with a two-day history of fever, malaise, and confusion. She had no past medical history, was allergic to penicillin, and worked as a teacher. On examination her temperature was 39.5°C, pulse 122 beats per minute, blood pressure 75/30 mmHg, and respiratory rate 36 breaths per minute. A purpuric rash was evident on her trunk. Arterial lactate was 6.9 mmol/L (0.6–1.8 mmol/L). What would you do next? A. Fluid challenge with crystalloid, insert a central venous catheter, and start vasopressor therapy B. Give intravenous broad-spectrum antibiotics, fluid challenge with colloid, and insert a central venous catheter C. Take peripheral blood cultures, give intravenous broad-spectrum antibiotics, and call the intensive care unit D. Take peripheral blood cultures, give intravenous broad-spectrum antibiotics, and fluid challenge with crystalloid E. Take peripheral blood cultures, insert a central venous catheter, and start vasopressor therapy