A 44-year-old man presents with chest pain. His ECG shows ST-segment elevation in leads II, III, and aVF with ST-segment depression in leads I and aVL. He is haemodynamically stable. Primary PCI is being arranged. Right ventricular infarction is suspected. Prior to transfer, which medication should be used with extreme caution or avoided?
Q172
A 63-year-old man is admitted with suspected sepsis secondary to pneumonia. He is started on empirical antibiotics and intravenous fluids. Despite receiving 30 mL/kg crystalloid over 3 hours, his blood pressure remains 88/54 mmHg with a lactate of 3.8 mmol/L. His heart rate is 108 bpm and urine output has been 15 mL in the past hour. Central venous access is obtained. Which vasopressor should be commenced as first-line treatment?
Q173
A 38-year-old woman is brought to the Emergency Department by ambulance with suspected anaphylaxis. She received intramuscular adrenaline 500 micrograms from paramedics 10 minutes ago. On arrival, she remains hypotensive at 82/48 mmHg despite receiving 500 mL of intravenous crystalloid. Heart rate is 124 bpm and she has ongoing stridor. What is the most appropriate next step in management?
Q174
A 51-year-old woman presents to the Emergency Department with a 4-hour history of severe epigastric pain radiating to her back. She has vomited multiple times. She has a history of gallstones. On examination, she is tachycardic at 112 bpm, blood pressure 105/68 mmHg, temperature 37.8°C, and is tender in the epigastrium. Blood tests show: amylase 1240 U/L, CRP 28 mg/L, white cell count 13.5 × 10⁹/L, calcium 2.15 mmol/L, albumin 38 g/L, ALT 180 U/L, bilirubin 42 μmol/L, and creatinine 95 μmol/L. What is her modified Glasgow score for acute pancreatitis severity?
Q175
A 75-year-old man with atrial fibrillation on warfarin presents after a collapse. He struck his head during the fall. He has a Glasgow Coma Scale score of 15 and no focal neurological deficit. His INR is 3.8. He complains of mild headache but appears well. According to NICE head injury guidelines, what is the most appropriate management?
Q176
A 29-year-old woman collapses while running a marathon. Bystanders report she had a brief tonic-clonic seizure lasting approximately 30 seconds. She is now conscious but confused. She has no known epilepsy. On arrival, her temperature is 39.8°C, heart rate 118 bpm, blood pressure 108/72 mmHg, and she appears disorientated. Her skin feels hot and dry. Blood glucose is 5.2 mmol/L. What is the most likely diagnosis and immediate management priority?
Q177
A 67-year-old man presents with central chest pain lasting 90 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and T-wave inversion in leads I and aVL. His troponin I taken on arrival is 45 ng/L (normal <14 ng/L). He has been given aspirin 300 mg, ticagrelor 180 mg, and fondaparinux 2.5 mg subcutaneously. His pain has settled with GTN spray and morphine. His GRACE score is calculated as 142. What is the most appropriate management strategy?
Q178
A 58-year-old woman with type 2 diabetes presents with a 36-hour history of feeling generally unwell. She has been taking oral antibiotics for a urinary tract infection prescribed by her GP 3 days ago. On examination, temperature is 37.2°C, heart rate 94 bpm, blood pressure 118/74 mmHg, respiratory rate 18/min, and oxygen saturation 97% on room air. Blood tests show: white cell count 16.2 × 10⁹/L, C-reactive protein 145 mg/L, lactate 1.4 mmol/L, creatinine 98 μmol/L. What is the most appropriate immediate management?
Q179
A 42-year-old woman is brought to the Emergency Department 15 minutes after eating prawns at a restaurant. She has facial flushing, generalised urticaria, and reports feeling breathless. Her blood pressure is 102/68 mmHg, heart rate 108 bpm, respiratory rate 24/min, and oxygen saturation 94% on room air. She has widespread wheeze on chest auscultation. After administering intramuscular adrenaline 500 micrograms, which of the following additional treatments should be given?
Q180
A 33-year-old man collapses at a wedding reception. Witnesses report he stood up quickly from his seat, appeared pale, and lost consciousness for approximately 10 seconds. He recovered quickly without confusion and denies chest pain or palpitations. He has no significant past medical history. On examination, his cardiovascular and neurological examinations are normal. His ECG shows normal sinus rhythm with no abnormalities. What is the most likely diagnosis?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 171: A 44-year-old man presents with chest pain. His ECG shows ST-segment elevation in leads II, III, and aVF with ST-segment depression in leads I and aVL. He is haemodynamically stable. Primary PCI is being arranged. Right ventricular infarction is suspected. Prior to transfer, which medication should be used with extreme caution or avoided?
A. Aspirin 300 mg oral loading dose
B. Morphine 5-10 mg intravenous for pain relief
C. GTN sublingual spray for chest pain (Correct Answer)
D. Ticagrelor 180 mg oral loading dose
E. Unfractionated heparin intravenous bolus
Explanation: ***GTN sublingual spray for chest pain***- In **Right Ventricular (RV) infarction**, the infarcted ventricle is highly **preload-dependent** to maintain cardiac output through the lungs.- **Nitrates** like GTN cause significant **venodilation**, which reduces venous return (preload) and can precipitate **profound hypotension** and cardiogenic shock.*Aspirin 300 mg oral loading dose*- This is a standard **antiplatelet agent** required for all patients with **STEMI** to reduce mortality and prevent further thrombus propagation.- It does not significantly affect **hemodynamics** or preload, making it safe and necessary in the setting of an RV MI.*Morphine 5-10 mg intravenous for pain relief*- While **morphine** can cause some mild vasodilation and hypotension, it is often necessary for severe pain and to reduce **sympathetic drive**.- It is used with caution but is not contraindicated like **nitrates**, which have a much more aggressive effect on preload reduction.*Ticagrelor 180 mg oral loading dose*- This is a potent **P2Y12 inhibitor** used as part of **dual antiplatelet therapy (DAPT)** prior to primary PCI.- It has no effect on **ventricular preload** or systemic blood pressure and is a critical component of the management of acute coronary syndromes.*Unfractionated heparin intravenous bolus*- Heparin provides essential **anticoagulation** to prevent further clot formation until the vessel can be mechanically reopened via **primary PCI**.- It does not impact **right ventricular filling pressures** or exacerbate the hemodynamic vulnerability of an RV infarction.
Question 172: A 63-year-old man is admitted with suspected sepsis secondary to pneumonia. He is started on empirical antibiotics and intravenous fluids. Despite receiving 30 mL/kg crystalloid over 3 hours, his blood pressure remains 88/54 mmHg with a lactate of 3.8 mmol/L. His heart rate is 108 bpm and urine output has been 15 mL in the past hour. Central venous access is obtained. Which vasopressor should be commenced as first-line treatment?
A. Noradrenaline targeting mean arterial pressure ≥65 mmHg (Correct Answer)
B. Dopamine targeting systolic blood pressure >90 mmHg
C. Adrenaline with incremental dose titration
D. Vasopressin as primary vasopressor agent
E. Dobutamine to improve cardiac output
Explanation: ***Noradrenaline targeting mean arterial pressure ≥65 mmHg***- According to the **Surviving Sepsis Campaign guidelines**, **Noradrenaline** is the first-choice vasopressor for septic shock because it effectively increases blood pressure via **alpha-1 adrenergic receptor** stimulation with minimal risk of tachycardia.- A **Mean Arterial Pressure (MAP) target of ≥65 mmHg** is the standard benchmark for ensuring adequate organ perfusion while minimizing the adverse effects of excessive vasoconstriction.*Dopamine targeting systolic blood pressure >90 mmHg*- **Dopamine** is no longer recommended as a first-line agent because it is associated with a significantly higher risk of **tachyarrhythmias** compared to noradrenaline.- Clinical outcomes are better when targeting **MAP** rather than **systolic blood pressure**, as MAP is a better indicator of tissue perfusion.*Adrenaline with incremental dose titration*- **Adrenaline** is typically considered a **second-line** or third-line agent to be added to noradrenaline if the initial response is inadequate.- It may lead to increased **lactate levels** via stimulation of skeletal muscle glycolysis, which can complicate the clinical assessment of shock resolution.*Vasopressin as primary vasopressor agent*- **Vasopressin** is not recommended as a monotherapy or primary agent; instead, it is used as an **adjunct** to noradrenaline to either raise MAP or reduce the noradrenaline dose.- Evidence suggests that starting vasopressin as the **sole primary agent** does not provide a survival benefit over noradrenaline.*Dobutamine to improve cardiac output*- **Dobutamine** is a pure **inotrope** (beta-1 agonist) and should only be used if there is evidence of myocardial dysfunction or persistent hypoperfusion after an adequate MAP is achieved.- It has **vasodilatory** properties and could potentially worsen hypotension if used as a primary agent in distributive shock without adequate pressor support.
Question 173: A 38-year-old woman is brought to the Emergency Department by ambulance with suspected anaphylaxis. She received intramuscular adrenaline 500 micrograms from paramedics 10 minutes ago. On arrival, she remains hypotensive at 82/48 mmHg despite receiving 500 mL of intravenous crystalloid. Heart rate is 124 bpm and she has ongoing stridor. What is the most appropriate next step in management?
A. Repeat intramuscular adrenaline 500 micrograms immediately (Correct Answer)
B. Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min
C. Give further 1000 mL intravenous fluid bolus and reassess
D. Administer intravenous hydrocortisone 200 mg and chlorphenamine 10 mg
E. Give nebulised adrenaline 5 mg for upper airway obstruction
Explanation: ***Repeat intramuscular adrenaline 500 micrograms immediately***
- For cases of **refractory anaphylaxis** where symptoms like **hypotension** and **stridor** persist 5 minutes after the first dose, the immediate priority is to repeat the **intramuscular (IM) adrenaline**.
- IM adrenaline can be safely repeated every **5 minutes** as needed; most patients respond to 1-2 doses, and this remains the first-line intervention over more invasive routes.
*Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min*
- **Intravenous adrenaline infusions** are reserved for cases that have failed multiple IM doses and are typically managed only by **specialists** in critical care settings.
- Initiating IV adrenaline too early carries significant risks of **arrhythmias**, **myocardial ischaemia**, and hypertensive crisis if not carefully monitored.
*Give further 1000 mL intravenous fluid bolus and reassess*
- While **intravenous fluid resuscitation** is crucial for distributive shock, it should occur concurrently with, rather than instead of, repeated **adrenaline doses**.
- Relying solely on fluids does not address the **bronchospasm** or **airway edema** indicated by the patient's ongoing **stridor**.
*Administer intravenous hydrocortisone 200 mg and chlorphenamine 10 mg*
- These are **adjunctive treatments** used to prevent biphasic reactions or treat skin symptoms; they do not address the acute **life-threatening** airway or circulatory collapse.
- Both **corticosteroids** and **antihistamines** have a slow onset of action and are never a substitute for primary **adrenaline** administration.
*Give nebulised adrenaline 5 mg for upper airway obstruction*
- While **nebulised adrenaline** may be used for specific conditions like croup, it is not the standard of care for treating systemic **anaphylactic stridor**.
- Systemic administration via the **IM route** is required to provide the necessary alpha-1 effect to reduce total airway **mucosal edema** and restore blood pressure.
Question 174: A 51-year-old woman presents to the Emergency Department with a 4-hour history of severe epigastric pain radiating to her back. She has vomited multiple times. She has a history of gallstones. On examination, she is tachycardic at 112 bpm, blood pressure 105/68 mmHg, temperature 37.8°C, and is tender in the epigastrium. Blood tests show: amylase 1240 U/L, CRP 28 mg/L, white cell count 13.5 × 10⁹/L, calcium 2.15 mmol/L, albumin 38 g/L, ALT 180 U/L, bilirubin 42 μmol/L, and creatinine 95 μmol/L. What is her modified Glasgow score for acute pancreatitis severity?
A. 0 - indicating mild pancreatitis
B. 1 - indicating mild pancreatitis (Correct Answer)
C. 2 - indicating moderately severe pancreatitis
D. 3 - indicating severe pancreatitis
E. 4 - indicating severe pancreatitis
Explanation: ***1 - indicating mild pancreatitis***
- The **modified Glasgow (Imrie) score** assesses **acute pancreatitis** severity. The patient's age (51 years), WCC (13.5 × 10⁹/L), calcium (2.15 mmol/L), and albumin (38 g/L) do not meet the typical scoring thresholds for these individual criteria.
- However, the **elevated ALT of 180 U/L** is significantly above the normal range and strongly suggests a **biliary etiology** due to gallstones. While the standard Glasgow threshold for liver enzymes is >200 U/L, this significant elevation may be considered one point in some clinical interpretations of severity, leading to a score of 1, which typically indicates **mild pancreatitis**.
*0 - indicating mild pancreatitis*
- While a score of 0 can indicate mild pancreatitis, the presence of significant **ALT elevation (180 U/L)** points towards a potential risk factor that might warrant at least one point in a comprehensive assessment.
- A score of 0 might underestimate the initial severity in a patient with a known history of **gallstones** and associated enzyme derangements.
*2 - indicating moderately severe pancreatitis*
- A score of 2 requires two positive criteria from the **modified Glasgow score**, and based on the provided data, the patient does not meet two distinct thresholds.
- Moderately severe pancreatitis is typically associated with **transient organ failure** (lasting <48 hours), which is not indicated by her current vital signs or creatinine.
*3 - indicating severe pancreatitis*
- **Severe pancreatitis** is defined by a Glasgow score of **≥ 3**, which implies multiple systemic derangements or organ failure.
- This patient's clinical and biochemical parameters, such as stable blood pressure and normal creatinine, do not meet enough criteria to reach a score of 3 or higher.
*4 - indicating severe pancreatitis*
- A score of 4 would indicate a very high risk of **pancreatic necrosis** and multi-organ failure.
- The patient's presentation, while acute, does not show the profound systemic inflammatory response or organ dysfunction expected for such a high severity score.
Question 175: A 75-year-old man with atrial fibrillation on warfarin presents after a collapse. He struck his head during the fall. He has a Glasgow Coma Scale score of 15 and no focal neurological deficit. His INR is 3.8. He complains of mild headache but appears well. According to NICE head injury guidelines, what is the most appropriate management?
A. Discharge home with head injury advice if CT head is normal
B. Perform CT head within 1 hour and admit for neurological observations
C. Perform CT head within 8 hours and consider admission (Correct Answer)
D. Reverse anticoagulation immediately before CT head
E. Observe for 4 hours and perform CT only if symptoms develop
Explanation: ***Perform CT head within 8 hours and consider admission***
- According to **NICE guidelines**, patients on **anticoagulation** (like warfarin) who have sustained a head injury require a **CT head within 8 hours** of the injury.
- This applies even with a **GCS of 15** and no focal deficits, as anticoagulation significantly increases the risk of **delayed intracranial hemorrhage**.
*Discharge home with head injury advice if CT head is normal*
- While discharge is often possible after a normal CT, the primary immediate management step required is the **scheduling of the scan** itself.
- Discharge requires a normal scan and a reliable adult to supervise the patient, which must be assessed **after investigation**.
*Perform CT head within 1 hour and admit for neurological observations*
- A CT within **1 hour** is reserved for high-risk features such as **GCS <13**, focal neurological deficits, suspected **skull fracture**, or persistent vomiting.
- This patient is hemodynamically stable and neurologically intact, so the urgent 1-hour window is not mandated by **NICE criteria**.
*Reverse anticoagulation immediately before CT head*
- Immediate **reversal of anticoagulation** is indicated only if there is confirmed **intracranial hemorrhage** or clinically significant active bleeding.
- Prophylactic reversal before imaging is not recommended for a patient with a **GCS of 15** and no focal signs.
*Observe for 4 hours and perform CT only if symptoms develop*
- Observation alone is insufficient for patients on **warfarin** or other anticoagulants; they must receive **neuroimaging** regardless of symptom progression.
- Waiting for symptoms to develop could lead to a delay in diagnosing a **life-threatening bleed** enabled by the patient's elevated **INR**.
Question 176: A 29-year-old woman collapses while running a marathon. Bystanders report she had a brief tonic-clonic seizure lasting approximately 30 seconds. She is now conscious but confused. She has no known epilepsy. On arrival, her temperature is 39.8°C, heart rate 118 bpm, blood pressure 108/72 mmHg, and she appears disorientated. Her skin feels hot and dry. Blood glucose is 5.2 mmol/L. What is the most likely diagnosis and immediate management priority?
A. First seizure secondary to structural brain lesion; arrange urgent CT head
B. Heat stroke; commence active cooling and intravenous fluid resuscitation (Correct Answer)
C. Hyponatraemia-induced seizure; give hypertonic saline urgently
D. Cardiac arrhythmia causing syncope; arrange urgent echocardiography
E. Hypoglycaemia-induced seizure; administer intravenous dextrose
Explanation: ***Heat stroke; commence active cooling and intravenous fluid resuscitation***
- The patient's presentation with a **tonic-clonic seizure**, **confusion**, and severe **hyperthermia** (39.8°C) following extreme physical exertion (marathon) is diagnostic of **exertional heat stroke**.
- Immediate management focuses on **rapid active cooling** to reduce core body temperature and **intravenous fluid resuscitation** to manage dehydration and prevent multi-organ dysfunction.
*First seizure secondary to structural brain lesion; arrange urgent CT head*
- While a first seizure always warrants investigation, the clear precipitating factors of **extreme exertion** and profound **hyperthermia** make heat stroke the primary and most urgent diagnosis.
- Urgent imaging like a CT head is secondary to life-saving interventions for heat stroke, as immediate cooling takes precedence over detailed structural evaluation in this acute setting.
*Hyponatraemia-induced seizure; give hypertonic saline urgently*
- Although **exercise-associated hyponatraemia** can occur in endurance athletes and cause seizures, the prominent **hyperthermia** and hot, dry skin strongly point away from it as the primary immediate concern.
- **Hypertonic saline** is indicated only for confirmed severe symptomatic hyponatraemia, whereas cooling for heat stroke must be initiated empirically and without delay.
*Cardiac arrhythmia causing syncope; arrange urgent echocardiography*
- A **tonic-clonic seizure** followed by prolonged **post-ictal confusion** is not characteristic of simple syncope, which typically involves a rapid return to baseline consciousness.
- The observed **tachycardia** is more likely a physiological response to **hyperthermia** and dehydration, rather than the primary etiology for the collapse and neurological symptoms.
*Hypoglycaemia-induced seizure; administer intravenous dextrose*
- This diagnosis is directly contradicted by the patient's **normal blood glucose level of 5.2 mmol/L** on arrival.
- Administering intravenous dextrose without evidence of hypoglycemia is inappropriate and would not address the life-threatening core issue of **hyperthermia**.
Question 177: A 67-year-old man presents with central chest pain lasting 90 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and T-wave inversion in leads I and aVL. His troponin I taken on arrival is 45 ng/L (normal <14 ng/L). He has been given aspirin 300 mg, ticagrelor 180 mg, and fondaparinux 2.5 mg subcutaneously. His pain has settled with GTN spray and morphine. His GRACE score is calculated as 142. What is the most appropriate management strategy?
A. Arrange immediate coronary angiography within 2 hours
B. Arrange early coronary angiography within 72 hours (Correct Answer)
C. Continue medical management and arrange outpatient stress testing
D. Administer thrombolysis immediately
E. Arrange CT coronary angiography as outpatient
Explanation: ***Arrange early coronary angiography within 72 hours***- This patient presents with an **NSTEMI**, indicated by **elevated troponin I** (45 ng/L) and **ischemic ECG changes** (ST depression, T-wave inversion) without ST elevation.- A **GRACE score of 142** signifies an intermediate-to-high risk NSTEMI, for which an **early invasive strategy** (angiography within 72 hours) is the recommended management to identify and revascularize culprit lesions.*Arrange immediate coronary angiography within 2 hours*- Immediate angiography (<2 hours) is reserved for **very high-risk** NSTEMI patients, such as those with **hemodynamic instability**, cardiogenic shock, or **refractory chest pain** despite optimal medical therapy.- This patient's pain has settled, and he is not described as unstable, therefore he does not meet criteria for this urgent pathway.*Continue medical management and arrange outpatient stress testing*- This conservative approach is typically reserved for **low-risk NSTEMI/UA patients** (e.g., GRACE score <108) or those with contraindications to invasive procedures.- Given the elevated troponin and a GRACE score of 142, an **invasive strategy** is necessary to diagnose and manage the underlying coronary artery disease.*Administer thrombolysis immediately*- **Thrombolysis (fibrinolytic therapy)** is primarily indicated for **STEMI** when primary percutaneous coronary intervention (PCI) cannot be performed within recommended timeframes.- It is **contraindicated in NSTEMI/UA** due to an increased risk of adverse outcomes and lack of benefit compared to an invasive strategy.*Arrange CT coronary angiography as outpatient*- **CT coronary angiography (CTCA)** is a non-invasive diagnostic tool used for **stable patients** with suspected coronary artery disease or for risk stratification in lower-risk individuals.- In the setting of an acute **NSTEMI**, invasive coronary angiography is required to precisely identify the culprit lesion and proceed with **revascularization** (e.g., PCI or CABG) if indicated.
Question 178: A 58-year-old woman with type 2 diabetes presents with a 36-hour history of feeling generally unwell. She has been taking oral antibiotics for a urinary tract infection prescribed by her GP 3 days ago. On examination, temperature is 37.2°C, heart rate 94 bpm, blood pressure 118/74 mmHg, respiratory rate 18/min, and oxygen saturation 97% on room air. Blood tests show: white cell count 16.2 × 10⁹/L, C-reactive protein 145 mg/L, lactate 1.4 mmol/L, creatinine 98 μmol/L. What is the most appropriate immediate management?
A. Commence intravenous broad-spectrum antibiotics and fluid resuscitation immediately
B. Continue oral antibiotics and arrange outpatient follow-up (Correct Answer)
C. Admit for observation and repeat blood tests in 6 hours
D. Switch to alternative oral antibiotics and arrange review in 48 hours
E. Obtain urine and blood cultures, then continue current oral antibiotics
Explanation: ***Continue oral antibiotics and arrange outpatient follow-up***
- This patient is clinically stable with normal vital signs (low **NEWS2** score) and no signs of **organ dysfunction**, such as normal **lactate** and **creatinine**. Her **qSOFA** score is 0.
- Despite elevated inflammatory markers (**WCC** and **CRP**), the absence of **sepsis criteria** or clinical deterioration after 3 days of oral antibiotics suggests the current regimen is likely effective, and she can be managed in an outpatient setting.
*Commence intravenous broad-spectrum antibiotics and fluid resuscitation immediately*
- These aggressive interventions are reserved for patients with **sepsis** or **septic shock**, evidenced by signs of **organ dysfunction** or **hemodynamic instability**, which are absent in this patient.
- The patient has normal **blood pressure**, **heart rate**, and **lactate**, indicating stable hemodynamics and no immediate need for **intravenous fluids** or broad-spectrum IV antibiotics.
*Admit for observation and repeat blood tests in 6 hours*
- Admission is not warranted given her **clinical stability**, normal **vitals**, and absence of **sepsis** criteria. Close observation in a hospital setting is for patients at higher risk of deterioration.
- While inflammatory markers are elevated, her overall clinical picture does not suggest a need for urgent re-evaluation with repeat blood tests within 6 hours, which is typically for unstable or rapidly deteriorating patients.
*Switch to alternative oral antibiotics and arrange review in 48 hours*
- There is no evidence of **treatment failure** or clinical worsening after 3 days on the current antibiotics, as she remains clinically stable with normal vital signs.
- Switching antibiotics empirically without evidence of resistance or worsening infection is generally discouraged and can contribute to **antimicrobial resistance** without clear benefit.
*Obtain urine and blood cultures, then continue current oral antibiotics*
- **Blood cultures** are typically indicated in patients with suspected **bacteremia**, severe sepsis, or those who are immunocompromised or have persistent fever, none of which apply to this clinically stable, afebrile patient.
- While a **urine culture** is often obtained for UTIs, changing immediate management based on this is not necessary in a stable patient already on appropriate oral antibiotics, especially if her symptoms are likely to improve.
Question 179: A 42-year-old woman is brought to the Emergency Department 15 minutes after eating prawns at a restaurant. She has facial flushing, generalised urticaria, and reports feeling breathless. Her blood pressure is 102/68 mmHg, heart rate 108 bpm, respiratory rate 24/min, and oxygen saturation 94% on room air. She has widespread wheeze on chest auscultation. After administering intramuscular adrenaline 500 micrograms, which of the following additional treatments should be given?
A. Intravenous chlorphenamine and hydrocortisone only
B. Nebulised salbutamol and intravenous fluids
C. Intravenous chlorphenamine, hydrocortisone, and nebulised salbutamol (Correct Answer)
D. Intravenous hydrocortisone and subcutaneous adrenaline
E. Nebulised adrenaline and intravenous antihistamine
Explanation: ***Intravenous chlorphenamine, hydrocortisone, and nebulised salbutamol***- The initial management of **anaphylaxis** is **intramuscular adrenaline**. After this, **adjunctive therapies** are crucial to manage the systemic reaction.- **Intravenous chlorphenamine** targets histamine-mediated symptoms like urticaria, **hydrocortisone** helps prevent biphasic reactions and reduces inflammation, and **nebulised salbutamol** is specifically indicated for the patient's **widespread wheeze** and breathlessness.*Intravenous chlorphenamine and hydrocortisone only*- While these are important adjunctive treatments for anaphylaxis, this option fails to address the patient's significant **respiratory distress** and **widespread wheeze**.- A bronchodilator like **nebulised salbutamol** is essential for managing bronchospasm and improving oxygenation in this clinical scenario.*Nebulised salbutamol and intravenous fluids*- Though **salbutamol** addresses respiratory distress and **intravenous fluids** support blood pressure, this combination lacks the necessary antihistamines and corticosteroids for a complete systemic anaphylactic reaction.- **Antihistamines** are crucial for reducing **urticaria** and flushing, and **corticosteroids** are vital for preventing a biphasic reaction and reducing inflammation.*Intravenous hydrocortisone and subcutaneous adrenaline*- **Subcutaneous adrenaline** is not the recommended route for acute anaphylaxis; **intramuscular adrenaline** is preferred due to faster absorption and more reliable pharmacokinetics.- This option also omits **antihistamines** for skin symptoms and **bronchodilators** for the active **wheeze**, leaving significant aspects of the anaphylaxis undertreated.*Nebulised adrenaline and intravenous antihistamine*- **Nebulised adrenaline** is primarily used for **upper airway obstruction** (e.g., stridor due to laryngeal edema), not for lower airway bronchospasm (**wheeze**), where salbutamol is more appropriate.- This regimen excludes **corticosteroids** (like hydrocortisone), which are vital for preventing late-phase reactions and managing systemic inflammation in anaphylaxis.
Question 180: A 33-year-old man collapses at a wedding reception. Witnesses report he stood up quickly from his seat, appeared pale, and lost consciousness for approximately 10 seconds. He recovered quickly without confusion and denies chest pain or palpitations. He has no significant past medical history. On examination, his cardiovascular and neurological examinations are normal. His ECG shows normal sinus rhythm with no abnormalities. What is the most likely diagnosis?
A. Vasovagal syncope (Correct Answer)
B. Cardiac arrhythmia
C. Postural orthostatic tachycardia syndrome
D. Hypertrophic cardiomyopathy
E. Transient ischaemic attack
Explanation: ***Vasovagal syncope***
- This presentation features a **clear trigger** (standing up quickly), **prodromal symptoms** (pallor), and a brief loss of consciousness followed by **rapid, complete recovery** without confusion.
- It is a reflex-mediated event leading to **transient autonomic dysfunction**, causing bradycardia and vasodilation, typically seen in young adults with **normal ECGs**.
*Cardiac arrhythmia*
- Arrhythmic syncope typically occurs **suddenly without a prodrome** and is often independent of postural changes or volume status.
- The absence of **palpitations** and a completely **normal ECG** makes a primary electrical cardiac cause less likely in this patient.
*Postural orthostatic tachycardia syndrome*
- POTS typically presents with a **sustained increase in heart rate** upon standing without a significant drop in blood pressure.
- While it causes dizziness and **pre-syncope**, it rarely results in a complete **loss of consciousness** as observed in this scenario.
*Hypertrophic cardiomyopathy*
- This condition usually presents with syncope during or immediately after **strenuous exertion**, rather than simple postural changes at a social event.
- Patients with HCM typically exhibit **ECG abnormalities** (e.g., LVH or deep Q waves) and may have a detectable **systolic murmur** on examination.
*Transient ischaemic attack*
- A TIA involves **focal neurological deficits** (e.g., hemiparesis or aphasia) rather than a generalized loss of consciousness.
- **Syncope** is not a typical manifestation of TIA unless there is bilateral involvement of the **posterior circulation**, which is rare and accompanied by other brainstem signs.
