A 55-year-old woman with breast cancer on chemotherapy presents with a 24-hour history of fever and general malaise. Temperature is 38.5°C, blood pressure 115/72 mmHg, heart rate 98 bpm. Blood tests show: white cell count 0.6 × 10⁹/L, neutrophils 0.3 × 10⁹/L, haemoglobin 98 g/L, platelets 145 × 10⁹/L. She appears well and is drinking normally. What is the most appropriate initial management?
Q232
A 24-year-old man presents with sudden collapse during a football match. Bystanders initiated CPR immediately. Paramedics found him in ventricular fibrillation and he received one shock from an automated external defibrillator with return of spontaneous circulation. In the Emergency Department, he is alert with no focal neurology. ECG shows right bundle branch block with coved ST elevation in leads V1-V2. His younger brother died suddenly at age 18. What is the most likely underlying diagnosis?
Q233
A 67-year-old woman presents with central chest discomfort lasting 6 hours. She has type 2 diabetes and describes the pain as 'pressure' rather than severe pain. ECG shows sinus rhythm with no acute ST changes. High-sensitivity troponin I at presentation is 8 ng/L (normal <16 ng/L). She remains pain-free. What is the most appropriate next step in management?
Q234
A 50-year-old man with alcohol dependency presents with a 48-hour history of fever, productive cough, and confusion. Blood pressure is 85/55 mmHg, heart rate 125 bpm, respiratory rate 32 breaths/min, temperature 39.1°C, oxygen saturation 88% on room air. Chest examination reveals right lower zone crackles and dullness to percussion. Blood results: white cell count 2.1 × 10⁹/L, neutrophils 0.8 × 10⁹/L, platelets 95 × 10⁹/L, bilirubin 45 μmol/L, INR 1.8, creatinine 198 μmol/L, lactate 4.2 mmol/L. What is his SOFA score?
Q235
A 29-year-old woman with no past medical history presents to the Emergency Department after collapsing while exercising at the gym. She experienced palpitations before losing consciousness for approximately 30 seconds. Bystanders report she looked pale but did not have a seizure. Her father died suddenly aged 35. ECG shows sinus rhythm with deep T-wave inversion in the anterior leads and voltage criteria for left ventricular hypertrophy. Echocardiography shows asymmetric septal hypertrophy with systolic anterior motion of the mitral valve. What is the most likely diagnosis?
Q236
A 58-year-old man presents with central chest pain lasting 45 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and I, aVL. High-sensitivity troponin at presentation is 85 ng/L (normal <14 ng/L). He is pain-free after glyceryl trinitrate and morphine. Blood pressure is 142/88 mmHg, heart rate 76 bpm. He is commenced on dual antiplatelet therapy, fondaparinux, and a beta-blocker. His GRACE score is calculated at 142. What is the most appropriate management timeframe for coronary angiography?
Q237
A 32-year-old woman presents 30 minutes after being stung by a wasp at a picnic. She has developed generalized urticaria and tongue swelling but remains haemodynamically stable with blood pressure 125/78 mmHg, heart rate 88 bpm, and oxygen saturation 98% on room air. She has no stridor or wheeze. She has been given intramuscular adrenaline, intravenous chlorphenamine, and hydrocortisone. She feels better and wishes to go home. What is the most appropriate management?
Q238
A 75-year-old man with a permanent pacemaker presents following a collapse at home. His wife witnessed him lose consciousness suddenly without warning while standing. He was unconscious for approximately 5 seconds and hit his head. He has a history of complete heart block for which the pacemaker was inserted 8 years ago. ECG shows ventricular pacing spikes but no subsequent QRS complexes for several beats, followed by resumption of normal pacemaker function. What is the most likely cause of his collapse?
Q239
A 42-year-old woman presents with sudden-onset severe chest pain that is sharp in nature and worse on inspiration. She returned from Australia 2 days ago after a 24-hour flight. She takes the combined oral contraceptive pill. Vital signs: blood pressure 118/76 mmHg, heart rate 102 bpm, respiratory rate 22 breaths/min, oxygen saturation 93% on room air, temperature 37.2°C. ECG shows sinus tachycardia. D-dimer is 850 ng/mL (normal <500). What is the most appropriate next investigation?
Q240
A 68-year-old man with type 2 diabetes and chronic kidney disease presents with confusion and fever. His wife reports he has been unwell for 2 days with reduced oral intake. Blood pressure is 92/58 mmHg, heart rate 115 bpm, temperature 38.7°C, respiratory rate 26 breaths/min. Blood results show: glucose 18.2 mmol/L, sodium 148 mmol/L, urea 24.5 mmol/L, creatinine 245 μmol/L (baseline 156 μmol/L), lactate 2.8 mmol/L, white cell count 16.8 × 10⁹/L. Urinalysis shows nitrites and leucocytes. What is his qSOFA score?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 231: A 55-year-old woman with breast cancer on chemotherapy presents with a 24-hour history of fever and general malaise. Temperature is 38.5°C, blood pressure 115/72 mmHg, heart rate 98 bpm. Blood tests show: white cell count 0.6 × 10⁹/L, neutrophils 0.3 × 10⁹/L, haemoglobin 98 g/L, platelets 145 × 10⁹/L. She appears well and is drinking normally. What is the most appropriate initial management?
A. Admit for observation and repeat blood tests in 6 hours
B. Commence oral co-amoxiclav and discharge with safety netting
C. Commence intravenous piperacillin-tazobactam immediately (Correct Answer)
D. Arrange urgent haematology review before antibiotics
E. Discharge with advice to return if symptoms worsen
Explanation: ***Commence intravenous piperacillin-tazobactam immediately***- This patient has **neutropenic sepsis**, defined by a temperature ≥38°C and an **absolute neutrophil count (ANC) <0.5 × 10⁹/L** while on chemotherapy.- **Empiric broad-spectrum intravenous antibiotics**, such as piperacillin-tazobactam, must be administered within **one hour** of diagnosis to reduce high mortality risk, regardless of initial clinical appearance.*Admit for observation and repeat blood tests in 6 hours*- Delaying treatment for repeat testing in **neutropenic sepsis** is dangerous, as the condition can rapidly progress to **septic shock** and death.- Observation without active treatment fails to address the underlying severe **bacterial infection** in a critically immunocompromised patient.*Commence oral co-amoxiclav and discharge with safety netting*- **Oral antibiotics** are generally not sufficient for the initial management of confirmed **neutropenic sepsis**, which requires rapid systemic delivery of **IV antibiotics**.- Discharging a patient with **neutropenic sepsis** is unsafe, as they are at high risk of rapid deterioration and require inpatient monitoring and treatment.*Arrange urgent haematology review before antibiotics*- **Antibiotics** for suspected **neutropenic sepsis** should be initiated immediately and **never delayed** for specialist consultations or further non-urgent investigations.- While haematology input is important for overall cancer management, the immediate priority is to administer life-saving **antibiotic therapy** to combat the acute infection.*Discharge with advice to return if symptoms worsen*- Discharging a patient with confirmed **neutropenic sepsis** (fever + ANC 0.3 × 10⁹/L) is a critical management error due to the high risk of severe infection.- These patients require **immediate inpatient admission** for **parenteral antibiotics**, close monitoring, and supportive care.
Question 232: A 24-year-old man presents with sudden collapse during a football match. Bystanders initiated CPR immediately. Paramedics found him in ventricular fibrillation and he received one shock from an automated external defibrillator with return of spontaneous circulation. In the Emergency Department, he is alert with no focal neurology. ECG shows right bundle branch block with coved ST elevation in leads V1-V2. His younger brother died suddenly at age 18. What is the most likely underlying diagnosis?
A. Brugada syndrome (Correct Answer)
B. Long QT syndrome
C. Catecholaminergic polymorphic ventricular tachycardia
D. Arrhythmogenic right ventricular cardiomyopathy
E. Hypertrophic cardiomyopathy
Explanation: ***Brugada syndrome***
- The **ECG pattern** showing a **right bundle branch block (RBBB)** with **coved ST-segment elevation** in leads V1-V2 is classic for Type 1 Brugada syndrome.
- This autosomal dominant condition, often due to **SCN5A mutations**, typically presents with **ventricular fibrillation** or sudden cardiac death and has a strong **family history** component.
*Long QT syndrome*
- This condition is characterized by a **prolonged QT interval** on the ECG, exceeding 440-460 ms, which is not mentioned in this patient’s findings.
- It classically causes **Torsades de Pointes**, a specific form of polymorphic ventricular tachycardia, rather than the coved ST elevation seen here.
*Catecholaminergic polymorphic ventricular tachycardia*
- While it causes exercise-induced arrest, it typically occurs in patients with a **normal resting ECG**, unlike the specific ST changes seen in this case.
- It is characterized by **bidirectional ventricular tachycardia** triggered by high adrenergic states like sports or emotional stress.
*Arrhythmogenic right ventricular cardiomyopathy*
- Diagnostic ECG findings typically include **epsilon waves** and T-wave inversion in V1-V3, rather than the coved ST elevation described.
- It involves the replacement of **myocardium with fibrofatty tissue**, which would be seen on imaging rather than being a pure electrical channelopathy like Brugada.
*Hypertrophic cardiomyopathy*
- ECG findings usually show **left ventricular hypertrophy** (LVH) and **deep T-wave inversions**, rather than an RBBB pattern with ST elevation.
- It is a structural heart disease characterized by profound **septal thickening** that predisposes patients to sudden death, especially during exertion.
Question 233: A 67-year-old woman presents with central chest discomfort lasting 6 hours. She has type 2 diabetes and describes the pain as 'pressure' rather than severe pain. ECG shows sinus rhythm with no acute ST changes. High-sensitivity troponin I at presentation is 8 ng/L (normal <16 ng/L). She remains pain-free. What is the most appropriate next step in management?
A. Discharge with outpatient cardiology follow-up
B. Repeat troponin at 1 hour (Correct Answer)
C. Repeat troponin at 3 hours
D. Perform urgent coronary angiography
E. Commence thrombolysis
Explanation: ***Repeat troponin at 1 hour***
- In a patient with risk factors like **type 2 diabetes** and presenting with chest discomfort, even if atypical and currently pain-free, **high-sensitivity troponin** requires serial measurement to detect potential myocardial injury.
- The **0/1-hour algorithm** using high-sensitivity troponin is the recommended approach (e.g., by ESC guidelines) for rapid and accurate **rule-in or rule-out of NSTEMI**, especially when the initial value is low but not definitively negative.
*Discharge with outpatient cardiology follow-up*
- Discharging the patient based on a single, albeit normal, initial **high-sensitivity troponin** measurement, particularly with a history of chest discomfort and **diabetes**, is premature and unsafe.
- A **serial troponin protocol** is essential to detect a rising trend (delta change) indicative of **acute coronary syndrome (ACS)**, which could still be evolving.
*Repeat troponin at 3 hours*
- While a **0/3-hour algorithm** is an option for troponin measurement, it is less common for **high-sensitivity assays** than the **0/1-hour protocol**, which offers faster and often equally reliable results.
- The **0/1-hour protocol** is generally preferred for improving patient flow and rapid decision-making in the emergency department for patients presenting with chest pain.
*Perform urgent coronary angiography*
- **Urgent coronary angiography** is typically indicated for patients with **ST-elevation myocardial infarction (STEMI)**, refractory angina, **hemodynamic instability**, or life-threatening arrhythmias.
- This patient has no **ST-segment changes** on ECG, is pain-free, and has a normal initial troponin, which does not meet criteria for immediate invasive management.
*Commence thrombolysis*
- **Thrombolysis (fibrinolysis)** is specifically indicated for **STEMI** when primary **percutaneous coronary intervention (PCI)** is not available within the recommended timeframe.
- This patient's ECG shows no **ST-elevation**, making thrombolysis inappropriate and associated with a significant risk of **bleeding complications** without clinical benefit in **NSTE-ACS**.
Question 234: A 50-year-old man with alcohol dependency presents with a 48-hour history of fever, productive cough, and confusion. Blood pressure is 85/55 mmHg, heart rate 125 bpm, respiratory rate 32 breaths/min, temperature 39.1°C, oxygen saturation 88% on room air. Chest examination reveals right lower zone crackles and dullness to percussion. Blood results: white cell count 2.1 × 10⁹/L, neutrophils 0.8 × 10⁹/L, platelets 95 × 10⁹/L, bilirubin 45 μmol/L, INR 1.8, creatinine 198 μmol/L, lactate 4.2 mmol/L. What is his SOFA score?
A. 8
B. 10
C. 12
D. 14 (Correct Answer)
E. 16
Explanation: ***14***
- The patient's clinical picture indicates severe multi-organ dysfunction, contributing to a high SOFA score: **Respiratory** (SpO2 88% on room air = 4 points), **Coagulation** (platelets 95 x 10⁹/L = 2 points), **Liver** (bilirubin 45 µmol/L = 2 points), **Cardiovascular** (hypotension 85/55 mmHg with lactate 4.2 mmol/L suggesting shock requiring vasopressors = 3 points), **CNS** (confusion = 1 point), and **Renal** (creatinine 198 µmol/L = 2 points).
- Summing these individual scores (4+2+2+3+1+2) yields a total SOFA score of **14**, indicating severe illness and a high probability of **ICU mortality**.
*8*
- This score is too low as it significantly underestimates the severity of the patient's **hypotension** and profound **respiratory failure** (SpO2 88% on room air).
- It fails to adequately account for the presence of acute **renal impairment** (creatinine 198 µmol/L) and **thrombocytopenia** (platelets 95 x 10⁹/L).
*10*
- A score of 10 would suggest fewer organ systems involved or less severe **physiological derangement** than what is evident from the patient's vital signs and blood test results.
- It does not fully capture the profound degree of **shock** (MAP 65 mmHg, lactate 4.2) and the combined impact of hepatic and renal dysfunction.
*12*
- While closer, this score likely still undervalues the critical severity of the **hypoxemia** (respiratory component, 4 points) which carries significant weight in the SOFA calculation.
- It may also underrepresent the combined effect of **coagulopathy** (low platelets) and **hyperbilirubinemia** often seen in septic patients with underlying alcohol dependency.
*16*
- A score of 16 would typically require more extreme derangements across multiple systems, such as **platelets <20 x 10⁹/L**, even higher creatinine, or maximal **vasopressor support** levels.
- Although the patient has multi-organ failure, the current clinical data does not meet the maximum point thresholds for all **six organ systems** to reach a score of 16.
Question 235: A 29-year-old woman with no past medical history presents to the Emergency Department after collapsing while exercising at the gym. She experienced palpitations before losing consciousness for approximately 30 seconds. Bystanders report she looked pale but did not have a seizure. Her father died suddenly aged 35. ECG shows sinus rhythm with deep T-wave inversion in the anterior leads and voltage criteria for left ventricular hypertrophy. Echocardiography shows asymmetric septal hypertrophy with systolic anterior motion of the mitral valve. What is the most likely diagnosis?
A. Arrhythmogenic right ventricular cardiomyopathy
B. Hypertrophic obstructive cardiomyopathy (Correct Answer)
C. Long QT syndrome
D. Brugada syndrome
E. Wolff-Parkinson-White syndrome
Explanation: ***Hypertrophic obstructive cardiomyopathy*** - The echocardiography findings of **asymmetric septal hypertrophy** and **systolic anterior motion (SAM)** of the mitral valve are pathognomonic for HOCM. - Clinical features like **exertional syncope**, a strong family history of **sudden cardiac death** (father died at 35), and ECG evidence of **left ventricular hypertrophy** are all highly consistent with this diagnosis. *Arrhythmogenic right ventricular cardiomyopathy* - ARVC primarily involves **fibrofatty replacement** and enlargement of the **right ventricle**, not the left ventricular septal hypertrophy seen here. - ECG typically shows **epsilon waves** and T-wave inversions in the **right precordial leads** (V1-V3), which are distinct from the anterior lead T-wave inversions and LVH criteria described. *Long QT syndrome* - This condition is an electrical disorder characterized by a **prolonged QT interval** on ECG, which predisposes to ventricular arrhythmias like Torsades de Pointes. - It does not cause the **structural cardiac abnormalities** such as asymmetric septal hypertrophy or systolic anterior motion of the mitral valve observed in this patient. *Brugada syndrome* - Brugada syndrome is an inherited channelopathy diagnosed by a specific ECG pattern: **pseudo-right bundle branch block** and persistent **ST-segment elevation in leads V1-V3**. - This is a primary electrical disease and would not present with structural changes like **left ventricular hypertrophy** or asymmetric septal hypertrophy on echocardiography. *Wolff-Parkinson-White syndrome* - WPW syndrome is a pre-excitation disorder identified by a **short PR interval** and a **delta wave** on ECG due to an accessory pathway. - While it can cause palpitations and syncope, it does not involve the **asymmetric septal hypertrophy** or systolic anterior motion of the mitral valve found on echocardiography.
Question 236: A 58-year-old man presents with central chest pain lasting 45 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and I, aVL. High-sensitivity troponin at presentation is 85 ng/L (normal <14 ng/L). He is pain-free after glyceryl trinitrate and morphine. Blood pressure is 142/88 mmHg, heart rate 76 bpm. He is commenced on dual antiplatelet therapy, fondaparinux, and a beta-blocker. His GRACE score is calculated at 142. What is the most appropriate management timeframe for coronary angiography?
A. Immediate (<2 hours)
B. Early (<24 hours)
C. Within 72 hours (Correct Answer)
D. Before discharge from hospital
E. As an outpatient within 6 weeks
Explanation: ***Within 72 hours***- This patient presents with **NSTEMI**, evidenced by ischemic **ST-segment depression** on ECG and an **elevated high-sensitivity troponin** of 85 ng/L. He also has a **GRACE score of 142**.- According to guidelines (e.g., ESC/NICE), patients with a GRACE score >140, or other intermediate-to-high risk features in NSTEMI, should undergo an invasive strategy with coronary angiography **within 72 hours** of presentation.*Immediate (<2 hours)*- This aggressive timeframe is reserved for patients with **very high-risk** features such as **hemodynamic instability**, **cardiogenic shock**, life-threatening arrhythmias, or **refractory chest pain** despite optimal medical therapy.- The patient is currently **pain-free** and hemodynamically stable, indicating he does not meet criteria for immediate angiography.*Early (<24 hours)*- An early invasive strategy within 24 hours is typically recommended for patients with **high-risk** NSTEMI, including those with **dynamic or recurrent ST-T wave changes**, or significant rising/falling troponin. - While the GRACE score is elevated, the patient's current stability and resolved pain place him into the 72-hour window rather than the more urgent 24-hour window, which is for more critically unstable high-risk cases.*Before discharge from hospital*- This approach is generally suitable for patients with **low-risk NSTEMI** (e.g., GRACE score <108) or unstable angina where an initial conservative approach is warranted before deciding on angiography.- Given the patient's **GRACE score of 142** and elevated troponin, a more timely invasive strategy is required than simply waiting until discharge.*As an outpatient within 6 weeks*- This timeframe is only appropriate for the management of **stable angina** or in cases where acute coronary syndrome has been definitively **ruled out**.- The patient has a confirmed NSTEMI, necessitating **in-hospital** invasive assessment to manage risk and prevent further adverse cardiac events.
Question 237: A 32-year-old woman presents 30 minutes after being stung by a wasp at a picnic. She has developed generalized urticaria and tongue swelling but remains haemodynamically stable with blood pressure 125/78 mmHg, heart rate 88 bpm, and oxygen saturation 98% on room air. She has no stridor or wheeze. She has been given intramuscular adrenaline, intravenous chlorphenamine, and hydrocortisone. She feels better and wishes to go home. What is the most appropriate management?
A. Discharge home immediately with advice to return if symptoms recur
B. Observe for 2 hours then discharge if stable
C. Observe for at least 6 hours before considering discharge (Correct Answer)
D. Admit for overnight observation
E. Discharge with oral antihistamines and arrange allergy clinic follow-up in 1 week
Explanation: ***Observe for at least 6 hours before considering discharge***
- NICE and Resuscitation Council (UK) guidelines recommend a minimum **6-hour observation** period for patients who have had **anaphylaxis** that responded well to treatment.
- This observation is critical to monitor for **biphasic reactions**, which are a recurrence of symptoms without further exposure to the allergen, occurring in up to 20% of cases.
*Discharge home immediately with advice to return if symptoms recur*
- Discharging immediately is unsafe due to the risk of **biphasic reactions** and the potential for **late-phase mediators** to cause symptom recurrence.
- Patients require a period of **monitored stability** to ensure the initial treatment has effectively controlled the immune response.
*Observe for 2 hours then discharge if stable*
- A **2-hour observation** is insufficient as biphasic reactions can occur several hours after the initial event, often between **8 to 12 hours**.
- Current guidelines for anaphylaxis management specify a **minimum 6-hour observation** period for patients who have improved.
*Admit for overnight observation*
- **Overnight admission** is generally reserved for patients with more severe anaphylaxis, such as those requiring multiple doses of **adrenaline**, those with persistent symptoms, or those with comorbidities like **asthma**.
- For a patient who is hemodynamically stable and improved with initial treatment, a 6-hour observation is usually sufficient, making overnight admission often unnecessary.
*Discharge with oral antihistamines and arrange allergy clinic follow-up in 1 week*
- While **oral antihistamines** and **allergy clinic follow-up** are important parts of long-term management and discharge planning, they do not negate the need for an acute observation period.
- Crucially, this option omits the essential **observation period** required to ensure stability and rule out a biphasic reaction before discharge.
Question 238: A 75-year-old man with a permanent pacemaker presents following a collapse at home. His wife witnessed him lose consciousness suddenly without warning while standing. He was unconscious for approximately 5 seconds and hit his head. He has a history of complete heart block for which the pacemaker was inserted 8 years ago. ECG shows ventricular pacing spikes but no subsequent QRS complexes for several beats, followed by resumption of normal pacemaker function. What is the most likely cause of his collapse?
A. Vasovagal syncope
B. Pacemaker failure with loss of capture (Correct Answer)
C. Seizure activity
D. Vertebrobasilar insufficiency
E. Postural hypotension
Explanation: ***Pacemaker failure with loss of capture***
- The ECG showing **ventricular pacing spikes** but **no subsequent QRS complexes** for several beats is diagnostic of **loss of capture**, meaning the electrical impulse from the pacemaker failed to stimulate myocardial contraction.
- In a patient with underlying **complete heart block**, loss of capture directly leads to **asystole** or profound **bradycardia**, causing **cerebral hypoperfusion** and sudden **syncope** (Stokes-Adams attack).
*Vasovagal syncope*
- **Vasovagal syncope** typically involves a **prodromal phase** with symptoms like nausea, sweating, lightheadedness, and pallor, which are absent in this "sudden without warning" collapse.
- The specific ECG finding of **pacemaker spikes without QRS complexes** directly points to a cardiac electrical issue rather than a reflex-mediated drop in heart rate or blood pressure.
*Seizure activity*
- A **seizure** usually involves tonic-clonic movements, a longer duration of unconsciousness, and a **post-ictal state** (confusion, drowsiness), none of which are described in the patient's brief (5 seconds) collapse.
- The ECG findings are specific to **pacemaker malfunction** and do not align with the electrophysiological changes seen during a seizure.
*Vertebrobasilar insufficiency*
- **Vertebrobasilar insufficiency** can cause syncope or "drop attacks" but is typically associated with other **neurological symptoms** such as vertigo, diplopia, ataxia, dysarthria, or cranial nerve deficits, which are not mentioned here.
- It would not explain the observed **ECG abnormality** of pacing spikes without capture, which is a clear cardiac electrical event.
*Postural hypotension*
- **Postural hypotension** occurs when a person changes position (e.g., standing up from sitting or lying down) and experiences a significant drop in blood pressure, leading to syncope. This patient collapsed "while standing," indicating he was already upright.
- The ECG finding of **pacemaker loss of capture** is a specific electrical problem and is not a consequence of postural changes or generalized blood pressure drop.
Question 239: A 42-year-old woman presents with sudden-onset severe chest pain that is sharp in nature and worse on inspiration. She returned from Australia 2 days ago after a 24-hour flight. She takes the combined oral contraceptive pill. Vital signs: blood pressure 118/76 mmHg, heart rate 102 bpm, respiratory rate 22 breaths/min, oxygen saturation 93% on room air, temperature 37.2°C. ECG shows sinus tachycardia. D-dimer is 850 ng/mL (normal <500). What is the most appropriate next investigation?
A. Chest X-ray
B. CT pulmonary angiogram (Correct Answer)
C. Ventilation-perfusion (V/Q) scan
D. Echocardiography
E. High-sensitivity troponin
Explanation: ***CT pulmonary angiogram*** - The patient presents with multiple risk factors (**recent long-haul flight**, **combined oral contraceptive pill** use) and symptoms (sudden-onset pleuritic chest pain, **tachycardia**, **hypoxia**) highly suggestive of **pulmonary embolism (PE)**. - Given the high clinical suspicion and stable hemodynamics, **CT pulmonary angiogram (CTPA)** is the gold-standard and most appropriate first-line investigation for definitive diagnosis of PE. *Chest X-ray* - A chest X-ray is useful for ruling out other causes of acute chest pain, such as **pneumothorax** or **pneumonia**, but it cannot definitively diagnose a pulmonary embolism. - While often performed, a normal chest X-ray in a high-suspicion patient does not exclude PE and should not delay definitive imaging like **CTPA**. *Ventilation-perfusion (V/Q) scan* - A **V/Q scan** is a valuable diagnostic tool for PE, typically reserved for patients who have contraindications to CTPA, such as **renal impairment** or severe contrast allergy. - In a patient without such contraindications, **CTPA** is generally preferred due to its higher resolution and faster acquisition time, especially in the emergency setting. *Echocardiography* - **Echocardiography** can show signs of **right ventricular strain** or dysfunction, which may be present in severe PE, but it is not a primary diagnostic test for PE itself. - It is more commonly used in **hemodynamically unstable** patients to assess for right heart failure or to differentiate PE from other cardiac causes of shock. *High-sensitivity troponin* - An elevated **high-sensitivity troponin** can indicate **myocardial injury** or **right ventricular strain** in the context of a PE, but it is not specific for PE and cannot be used for primary diagnosis. - It is primarily used for **risk stratification** and prognosis in confirmed or highly suspected PE, not as an initial diagnostic investigation to confirm the presence of emboli.
Question 240: A 68-year-old man with type 2 diabetes and chronic kidney disease presents with confusion and fever. His wife reports he has been unwell for 2 days with reduced oral intake. Blood pressure is 92/58 mmHg, heart rate 115 bpm, temperature 38.7°C, respiratory rate 26 breaths/min. Blood results show: glucose 18.2 mmol/L, sodium 148 mmol/L, urea 24.5 mmol/L, creatinine 245 μmol/L (baseline 156 μmol/L), lactate 2.8 mmol/L, white cell count 16.8 × 10⁹/L. Urinalysis shows nitrites and leucocytes. What is his qSOFA score?
A. 0
B. 1
C. 2
D. 3 (Correct Answer)
E. 4
Explanation: ***3***- The patient scores 3 points on the **qSOFA scale** because he meets all three clinical criteria: **altered mental status** (confusion), **systolic blood pressure** ≤ 100 mmHg (current BP 92/58), and **respiratory rate** ≥ 22/min (current RR 26).- A **qSOFA score of 2 or more** in a patient with an infection (suggested here by pyuria, nitrites, and fever) indicates a high risk of poor clinical outcomes and likely **sepsis**.*0*- A score of 0 implies that the patient has normal **mental status**, **blood pressure** > 100 mmHg, and **respiratory rate** < 22/min.- This patient is clearly haemodynamically and neurologically compromised, making a score of zero incorrect.*1*- This score would only be applied if only one of the three **qSOFA criteria** was present, such as just the tachypnoea.- It underestimates the severity of this patient who also presents with **hypotension** and **confusion**.*2*- This score would be correct if only two criteria were met; however, this patient exhibits the complete **triad** of qSOFA indicators.- While a score of 2 triggers the same high-risk clinical pathway, it does not accurately reflect his specific **clinical parameters**.*4*- The **qSOFA score** is a 3-point scale based on three specific clinical observations; therefore, a score of 4 is **physiologically impossible**.- Laboratory values like **creatinine**, **lactate**, and **white cell count** are used in the full **SOFA score** but are not included in the quick (qSOFA) bedside tool.
