Acute Medical Presentations Practice Questions

Q: A 46-year-old man presents with acute onset severe abdominal pain and shock. He takes warfarin for atrial fibrillation. His INR is 6.8. CT shows retroperitoneal hematoma. What is the most appropriate immediate management?

Prothrombin complex concentrate. ***Prothrombin complex concentrate***- This patient presents with **major hemorrhage** (retroperitoneal hematoma) and **shock** due to severe **warfarin coagulopathy** (INR 6.8).- **PCC** provides the fastest and most complete reversal of **Vitamin K antagonist** effects by supplying factors II, VII, IX, and X, crucial for immediate **hemostasis** in life-threatening bleeding.*Vitamin K 10mg IV*- While essential for long-term factor replenishment, **intravenous Vitamin K** has a delayed onset of action, typically taking 6 to 12 hours to significantly reduce the INR.- It is always administered alongside a rapid reversal agent (like PCC) in cases of life-threatening bleeding but is insufficient as the *only* immediate management due to its slow effect.*Fresh frozen plasma*- FFP contains all necessary clotting factors but requires large volumes, is slow to infuse, necessitates **ABO compatibility** testing, and carries a significant risk of **transfusion-associated circulatory overload (TACO)**.- Current guidelines reserve FFP mainly for situations where PCC is unavailable or for specific coagulopathies not covered by PCC.*Stop warfarin only*- Stopping the drug is necessary to prevent further anticoagulation, but the half-lives of the affected clotting factors are long; stopping warfarin alone will not acutely correct the life-threatening coagulopathy needed to stop the active **retroperitoneal hemorrhage**.- Immediate administration of factor concentrates (PCC) or plasma products is required for rapid **hemostatic resuscitation**.*Tranexamic acid*- **Tranexamic acid** is an **antifibrinolytic** agent that works by stabilizing clots by inhibiting plasminogen activation.- It is not the appropriate first-line therapy for reversing the underlying severe **deficiency of Vitamin K-dependent clotting factors** caused by warfarin overdose, which is the primary issue here.

Q: A 46-year-old man presents with acute severe epigastric pain and vomiting. His amylase (1800 U/L). He has a history of alcohol excess. What is the most important initial assessment?

Severity scoring. ***Severity scoring*** - **Initial assessment** in acute pancreatitis focuses on determining severity using tools like the **Ranson criteria**, **APACHE II**, or the **modified Glasgow criteria** to triage care. - Early identification of patients with predicted **severe disease** is crucial for appropriate resource allocation, aggressive fluid resuscitation, and monitoring (often in the ICU). *CT abdomen* - Routine CT is not necessary for the initial diagnosis, which is based on clinical presentation and markedly elevated **amylase/lipase** (Amylase 1800 U/L). - CT imaging is typically reserved for diagnosing complications (e.g., **necrosis** or fluid collections) or if the patient fails to improve clinically after 48-72 hours. *ERCP* - **Endoscopic retrograde cholangiopancreatography (ERCP)** is an intervention, not an initial assessment, primarily indicated for emergent management of acute **biliary obstruction** with concurrent **cholangitis** (infection of bile ducts). - It carries risks, including worsening pancreatitis, and is only performed urgently in a small subset of patients with biliary etiology. *Nutritional assessment* - While important, nutritional assessment is secondary to immediate priorities like **hemodynamic stabilization**, pain control, and severity grading during the first 24-48 hours. - The decision to initiate nutritional support (preferably enteral feeding) is generally based on the predicted **severity score** and the expected duration of the fasting period. *Psychiatric evaluation* - Although the patient has a history of **alcohol excess**, which necessitates later evaluation and counseling, emergent psychiatric evaluation is not the most critical component of the initial medical assessment for acute pancreatitis. - The immediate priority remains stabilization and management of the acute, life-threatening abdominal crisis.

Q: A 39-year-old man presents with acute onset severe headache during sexual intercourse. CT head is normal. What is the most appropriate next investigation?

Lumbar puncture. ***Lumbar puncture***- This presentation with an acute onset severe headache during sexual intercourse (a **thunderclap headache**) is highly suggestive of **subarachnoid hemorrhage (SAH)**, even if the initial **CT head** is normal.- A **lumbar puncture** is the most appropriate next step to look for **xanthochromia** in the CSF, which confirms SAH, especially if performed 6-12 hours after symptom onset.*MRI brain*- While **MRI** with FLAIR sequences can detect subarachnoid blood, it is generally considered less sensitive than a **lumbar puncture** for ruling out SAH after a negative CT scan.- It is often reserved for cases where SAH is strongly suspected but the LP is inconclusive, or for evaluating the cause of SAH once confirmed.*CT angiogram*- **CT angiogram (CTA)** is primarily used to identify the source of bleeding, such as an **aneurysm**, once SAH has been confirmed.- It is not the initial diagnostic test to confirm the presence of **subarachnoid hemorrhage** itself when a non-contrast CT is normal.*Carotid Doppler*- A **Carotid Doppler** ultrasound assesses for **carotid artery stenosis** or dissection in the neck vessels.- This investigation is not relevant for the acute evaluation of a **thunderclap headache**, which indicates an intracranial event like SAH.*EEG*- An **EEG (electroencephalogram)** measures brain electrical activity and is used to diagnose conditions such as **seizures** or certain encephalopathies.- It has no diagnostic value in the acute assessment of a **thunderclap headache** or suspected subarachnoid hemorrhage.

Q: A 67-year-old man with COPD presents with acute confusion and drowsiness. ABG shows pH 7.25, pCO2 8.5 kPa, pO2 7.2 kPa, HCO3- 28 mmol/L. What is the most appropriate immediate management?

Non-invasive ventilation. ***Non-invasive ventilation*** - This patient presents with severe acute hypercapnic respiratory failure (pH 7.25, pCO2 8.5 kPa) and drowsiness, making **Non-invasive ventilation (NIV)** the standard of care to reduce work of breathing. - NIV is specifically indicated in COPD exacerbations when **respiratory acidosis** persists despite medical therapy, significantly reducing the need for invasive intubation. *High-flow oxygen* - Administering high-flow oxygen in a patient with COPD can worsen **hypercapnia** by suppressing the **hypoxic drive** and increasing V/Q mismatch. - It fails to address the primary problem of **hypoventilation**, which is causing the elevated pCO2 and acidosis in this clinical scenario. *Intubation and mechanical ventilation* - While this patient is drowsy, **NIV** should usually be trialed first unless there is a complete loss of airway protection or hemodynamic instability. - **Invasive ventilation** carries a higher risk of complications and difficulty with weaning in patients with chronic lung disease compared to NIV. *IV bicarbonate* - Using IV bicarbonate in **respiratory acidosis** is inappropriate as its reaction results in the further production of **carbon dioxide**, potentially worsening the hypercapnia. - The correct physiological approach is to enhance **alveolar ventilation** to clear CO2 rather than attempting to buffer the pH chemically. *Controlled oxygen therapy* - Controlled oxygen (e.g., via a **Venturi mask**) is used to maintain oxygen saturation between 88-92% but is insufficient on its own when the pH is below 7.35. - In the presence of **CO2 narcosis** and severe acidosis, the patient requires mechanical pressure support (NIV) to improve **minute ventilation** and survive.

Question 1

A 46-year-old man presents with acute onset severe abdominal pain and shock. He takes warfarin for atrial fibrillation. His INR is 6.8. CT shows retroperitoneal hematoma. What is the most appropriate immediate management?

Accepted Answer

Prothrombin complex concentrate

Answer

Vitamin K 10mg IV

Answer

Fresh frozen plasma

Answer

Stop warfarin only

Answer

Tranexamic acid

Question 2

A 46-year-old man presents with acute severe epigastric pain and vomiting. His amylase (1800 U/L). He has a history of alcohol excess. What is the most important initial assessment?

Accepted Answer

Severity scoring

Answer

CT abdomen

Answer

ERCP

Answer

Nutritional assessment

Answer

Psychiatric evaluation

Question 3

A 39-year-old man presents with acute onset severe headache during sexual intercourse. CT head is normal. What is the most appropriate next investigation?

Accepted Answer

Lumbar puncture

Answer

MRI brain

Answer

CT angiogram

Answer

Carotid Doppler

Answer

EEG

Question 4

A 67-year-old man with COPD presents with acute confusion and drowsiness. ABG shows pH 7.25, pCO2 8.5 kPa, pO2 7.2 kPa, HCO3- 28 mmol/L. What is the most appropriate immediate management?

Accepted Answer

Non-invasive ventilation

Answer

High-flow oxygen

Answer

Intubation and mechanical ventilation

Answer

IV bicarbonate

Answer

Controlled oxygen therapy

Question 5

A 70-year-old man presents with sudden onset weakness in his right arm and difficulty speaking. CT head shows acute infarct in the left middle cerebral artery territory. He arrived 2 hours after symptom onset. What is the most appropriate treatment?

Accepted Answer

Alteplase

Answer

Aspirin 300mg

Answer

Clopidogrel

Answer

Warfarin

Answer

Heparin

Acute Medical Presentations — MCQs

Acute Medical Presentations — MCQs

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