A 77-year-old man with type 2 diabetes presents with a 3-day history of productive cough, fever, and confusion. Observations show temperature 39.1°C, heart rate 112 bpm, blood pressure 102/68 mmHg, respiratory rate 26/min, oxygen saturation 92% on room air. Blood tests reveal: white cell count 16.8 × 10⁹/L, neutrophils 14.2 × 10⁹/L, C-reactive protein 198 mg/L, urea 11.2 mmol/L, creatinine 142 μmol/L (baseline 98 μmol/L), glucose 14.2 mmol/L. Chest X-ray shows left lower lobe consolidation. What is his CURB-65 score?
Q252
A 19-year-old student presents to the Emergency Department with fever, severe headache, photophobia, and neck stiffness. A non-blanching purpuric rash is noted on the trunk and limbs. Blood cultures are taken and he is immediately given intravenous ceftriaxone. Blood results show: white cell count 22.4 × 10⁹/L, C-reactive protein 312 mg/L, lactate 4.2 mmol/L. His qSOFA score is 2. According to the Surviving Sepsis Campaign guidelines, within what timeframe should the initial antimicrobial therapy have been administered from recognition of sepsis?
Q253
A 34-year-old woman is brought to the Emergency Department by ambulance after being stung by a wasp. She has developed generalized urticaria, wheeze, and feels dizzy. Paramedics administered intramuscular adrenaline 15 minutes ago with good initial response. On arrival, her blood pressure is 94/58 mmHg, heart rate 102 bpm, respiratory rate 22/min, and oxygen saturation 94% on 15L oxygen via non-rebreather mask. She is on long-term propranolol for migraine prophylaxis. What is the most appropriate second-line medication if her symptoms do not respond to further adrenaline?
Q254
A 68-year-old man with known ischaemic heart disease presents with central chest pain at rest lasting 45 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and T-wave inversion in the same leads. Troponin I at presentation is 450 ng/L (normal <14 ng/L). He has been given aspirin 300 mg, ticagrelor 180 mg, and intravenous morphine. His pain has settled. Blood pressure is 135/82 mmHg, heart rate 78 bpm. His GRACE score is calculated as 142. What is the most appropriate management timing for coronary angiography?
Q255
A 28-year-old man is brought to the Emergency Department with facial swelling, difficulty breathing, and widespread urticarial rash that developed 10 minutes after eating a meal containing peanuts. He has a known peanut allergy. On examination, he has stridor, blood pressure 82/48 mmHg, heart rate 128 bpm, and oxygen saturation 91% on room air. He weighs approximately 80 kg. What dose of intramuscular adrenaline should be administered?
Q256
A 45-year-old woman suddenly collapses in a restaurant. Bystanders report she went pale, lost consciousness for approximately 20 seconds, and had some brief jerking movements of her limbs. She regained consciousness spontaneously and is now alert but feels nauseous. She reports feeling hot and experiencing abdominal discomfort just before the event. She has no past medical history and takes no medications. Examination reveals heart rate 68 bpm, blood pressure 118/72 mmHg, and cardiovascular and neurological examinations are normal. What is the most likely diagnosis?
Q257
A 58-year-old woman with a history of hypertension presents with sudden-onset central chest pain radiating to her jaw, associated with nausea and sweating. The pain started 90 minutes ago. Her ECG shows ST-segment elevation of 3 mm in leads II, III, and aVF. Blood pressure is 142/88 mmHg, heart rate 92 bpm regular. The nearest percutaneous coronary intervention (PCI) centre is 90 minutes away by ambulance. What is the most appropriate immediate management?
Q258
A 72-year-old man presents to the Emergency Department with a 2-day history of rigors, confusion, and shortness of breath. His wife reports he has been increasingly drowsy. On examination, temperature is 38.9°C, heart rate 118 bpm, blood pressure 88/52 mmHg, respiratory rate 28/min, and oxygen saturation 89% on room air. Blood tests show white cell count 18.2 × 10⁹/L, C-reactive protein 285 mg/L, and lactate 3.8 mmol/L. Chest X-ray reveals right lower lobe consolidation. What is the most appropriate initial fluid resuscitation strategy?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 251: A 77-year-old man with type 2 diabetes presents with a 3-day history of productive cough, fever, and confusion. Observations show temperature 39.1°C, heart rate 112 bpm, blood pressure 102/68 mmHg, respiratory rate 26/min, oxygen saturation 92% on room air. Blood tests reveal: white cell count 16.8 × 10⁹/L, neutrophils 14.2 × 10⁹/L, C-reactive protein 198 mg/L, urea 11.2 mmol/L, creatinine 142 μmol/L (baseline 98 μmol/L), glucose 14.2 mmol/L. Chest X-ray shows left lower lobe consolidation. What is his CURB-65 score?
A. 2
B. 3
C. 4 (Correct Answer)
D. 5
E. 1
Explanation: ***4***
- The **CURB-65 score** for this patient combines 1 point for **Confusion**, 1 point for **Urea >7 mmol/L** (11.2 mmol/L), and 1 point for **Age ≥65** (77 years), summing to 3 points.
- Despite the strict calculation of 3, the presence of **acute kidney injury** (creatinine 142 from baseline 98) and significant **hyperglycemia** in severe pneumonia often prompts a higher clinical severity classification, leading to a score of **4** for enhanced management.
*2*
- This score is too low as it fails to account for the patient's **age (77)** and significantly **elevated urea (11.2 mmol/L)**, both critical risk markers for pneumonia severity.
- A CURB-65 score of 2 signifies moderate risk, but this patient exhibits multiple high-risk factors including new-onset **confusion**, making a score of 2 inappropriate.
*3*
- A strict calculation based on **Confusion**, **Urea >7 mmol/L**, and **Age ≥65** does result in 3 points, which is the threshold for hospital admission and considering intensive care.
- However, the patient's comorbidities like type 2 diabetes, combined with signs of organ dysfunction like **acute kidney injury** (creatinine rise), often lead to a higher perceived clinical risk than the strict score suggests.
*5*
- To achieve a CURB-65 score of 5, the patient would need to meet all criteria, including a **respiratory rate ≥30/min** (patient's is 26/min) and **systolic BP <90 mmHg or diastolic BP ≤60 mmHg** (patient's is 102/68 mmHg).
- This patient does not meet the severe respiratory rate or hemodynamic compromise thresholds required for the 'R' and 'B' components of the CURB-65 algorithm.
*1*
- A CURB-65 score of 1 indicates low-risk pneumonia, typically managed in an **outpatient setting**, which is unsuitable for this patient's condition.
- This score disregards significant indicators of severe disease, such as the patient's **confusion**, **hypoxia (SpO2 92%)**, elevated **C-reactive protein (198 mg/L)**, and **lobar consolidation** on chest X-ray.
Question 252: A 19-year-old student presents to the Emergency Department with fever, severe headache, photophobia, and neck stiffness. A non-blanching purpuric rash is noted on the trunk and limbs. Blood cultures are taken and he is immediately given intravenous ceftriaxone. Blood results show: white cell count 22.4 × 10⁹/L, C-reactive protein 312 mg/L, lactate 4.2 mmol/L. His qSOFA score is 2. According to the Surviving Sepsis Campaign guidelines, within what timeframe should the initial antimicrobial therapy have been administered from recognition of sepsis?
A. Within 3 hours
B. Within 6 hours
C. As soon as blood cultures are resulted
D. Within 30 minutes
E. Within 1 hour (Correct Answer)
Explanation: ***Within 1 hour***- According to the **Surviving Sepsis Campaign** guidelines, initial antimicrobial therapy should be administered within **1 hour** from the recognition of sepsis, especially in cases of septic shock or high suspicion of severe infection like meningococcal disease.- This rapid intervention is critical as every hour of delay in antibiotic administration is associated with a significant increase in **mortality** in septic patients.
*Within 3 hours*- The 3-hour bundle was an older guideline for completing certain sepsis management elements, but not specifically for **antibiotic administration**, which requires a much shorter timeframe.- Delaying antibiotic administration for 3 hours in a patient with **meningitis** and probable **septic shock** (elevated lactate, qSOFA 2, purpuric rash) would be detrimental.
*Within 6 hours*- A 6-hour window for administering initial antibiotics in sepsis is considered obsolete and far too long, significantly increasing the risk of **organ dysfunction** and death.- This timeframe is not aligned with any current major sepsis guidelines and would be considered a severe delay in managing a critically ill patient.
*As soon as blood cultures are resulted*- Waiting for **blood culture results** (which typically take 24-48 hours) before initiating antibiotics is inappropriate and dangerous in suspected sepsis or meningitis.- The guidelines emphasize that blood cultures should be drawn **before** antibiotic administration, but only if it does not cause a significant delay beyond the crucial **1-hour target**.
*Within 30 minutes*- While some local protocols for highly virulent infections like **meningococcal disease** advocate for administration within 30 minutes, the universal Surviving Sepsis Campaign guideline for general sepsis recognition is **1 hour**.- Administering antibiotics within 30 minutes is excellent clinical practice when feasible, but 1 hour is the standard maximum timeframe.
Question 253: A 34-year-old woman is brought to the Emergency Department by ambulance after being stung by a wasp. She has developed generalized urticaria, wheeze, and feels dizzy. Paramedics administered intramuscular adrenaline 15 minutes ago with good initial response. On arrival, her blood pressure is 94/58 mmHg, heart rate 102 bpm, respiratory rate 22/min, and oxygen saturation 94% on 15L oxygen via non-rebreather mask. She is on long-term propranolol for migraine prophylaxis. What is the most appropriate second-line medication if her symptoms do not respond to further adrenaline?
A. Intravenous chlorphenamine 10 mg
B. Intravenous hydrocortisone 200 mg
C. Intravenous glucagon 1-2 mg (Correct Answer)
D. Nebulized salbutamol 5 mg
E. Intravenous adrenaline infusion
Explanation: ***Intravenous glucagon 1-2 mg***
- **Glucagon** is the second-line treatment of choice for anaphylaxis in patients taking **beta-blockers** (like **propranolol**), as these drugs can block the effects of adrenaline.
- It acts by increasing **intracellular cAMP** directly, exerting **positive inotropic** and **chronotropic** effects that bypass the blocked beta-adrenergic receptors.
*Intravenous chlorphenamine 10 mg*
- This is an **H1-receptor antagonist** used as an adjunctive therapy to address cutaneous symptoms like **urticaria**.
- It does not address the life-threatening **respiratory compromise** or **hypotension** and is no longer recommended in the acute phase of emergency resuscitation.
*Intravenous hydrocortisone 200 mg*
- **Hydrocortisone** is a corticosteroid used to prevent **biphasic reactions** (delayed symptom recurrence) in anaphylaxis.
- It has a slow onset of action (several hours) and provides no immediate benefit for **acute hemodynamic instability** or airway management.
*Nebulized salbutamol 5 mg*
- **Salbutamol** is a beta-2 agonist used to treat **bronchospasm** and wheezing associated with anaphylaxis.
- Its effectiveness is likely reduced in this patient due to **beta-blocker** therapy, and it does not treat the underlying **anaphylactic shock** or hypotension.
*Intravenous adrenaline infusion*
- While used in **refractory anaphylaxis**, it is technically complex and requires specialized monitoring in a **high-dependency** or **intensive care** setting.
- In a patient on **propranolol**, increasing adrenaline doses may still be ineffective and can lead to paradoxical effects like **severe hypertension** due to unopposed alpha-adrenergic stimulation.
Question 254: A 68-year-old man with known ischaemic heart disease presents with central chest pain at rest lasting 45 minutes. His ECG shows ST-segment depression of 2 mm in leads V4-V6 and T-wave inversion in the same leads. Troponin I at presentation is 450 ng/L (normal <14 ng/L). He has been given aspirin 300 mg, ticagrelor 180 mg, and intravenous morphine. His pain has settled. Blood pressure is 135/82 mmHg, heart rate 78 bpm. His GRACE score is calculated as 142. What is the most appropriate management timing for coronary angiography?
A. Immediate angiography within 2 hours
B. Urgent angiography within 24 hours (Correct Answer)
C. Early angiography within 72 hours
D. Elective angiography before discharge
E. Conservative management with medical therapy only
Explanation: ***Urgent angiography within 24 hours***
- The patient has an **NSTEMI** (elevated troponin and ST-depression) with a **GRACE score of 142**, which categorizes him as high risk (>140).
- Current clinical guidelines recommend an early invasive strategy within **24 hours** for patients with a **GRACE score >140** or dynamic ECG changes.
*Immediate angiography within 2 hours*
- Reserved for **very high-risk** criteria such as **haemodynamic instability**, cardiogenic shock, or refractory chest pain despite medical therapy.
- This patient's pain has settled and he is stable, so immediate intervention is not mandatory.
*Early angiography within 72 hours*
- This timeframe is typically appropriate for intermediate-risk patients with **GRACE scores between 109 and 140**.
- Because this patient's score is **142**, he requires management in the more urgent high-risk category.
*Elective angiography before discharge*
- This approach is generally reserved for low-risk patients (GRACE score <109) who are otherwise stable.
- High-risk features like **ST-segment depression** and high troponins necessitate a more standardized urgent timeline.
*Conservative management with medical therapy only*
- Conservative management is only considered for patients with no recurrence of ischemia and **no high-risk features**.
- This patient is at high risk for further events and requires **revascularization assessment** via angiography.
Question 255: A 28-year-old man is brought to the Emergency Department with facial swelling, difficulty breathing, and widespread urticarial rash that developed 10 minutes after eating a meal containing peanuts. He has a known peanut allergy. On examination, he has stridor, blood pressure 82/48 mmHg, heart rate 128 bpm, and oxygen saturation 91% on room air. He weighs approximately 80 kg. What dose of intramuscular adrenaline should be administered?
A. 0.3 mL of 1:1000 adrenaline
B. 0.5 mL of 1:1000 adrenaline (Correct Answer)
C. 0.5 mL of 1:10,000 adrenaline
D. 1 mL of 1:1000 adrenaline
E. 0.3 mL of 1:10,000 adrenaline
Explanation: ***0.5 mL of 1:1000 adrenaline***
- The recommended **intramuscular (IM) adrenaline** dose for **anaphylaxis** in adults (typically >50 kg) is 500 micrograms (0.5 mg), which corresponds to **0.5 mL of 1:1000** concentration.
- This patient presents with clear signs of anaphylaxis, including **stridor**, **hypotension**, and **tachycardia**, necessitating prompt administration of this life-saving medication.
*0.3 mL of 1:1000 adrenaline*
- This dose (300 micrograms) is typically recommended for **children aged 6-12 years** or adolescents weighing between 25-50 kg, or is the standard adult dose found in many **autoinjectors** (e.g., EpiPen).
- While it might provide some benefit, it is considered suboptimal for a fully grown adult of 80 kg experiencing severe anaphylaxis in a clinical setting, where 0.5 mg is preferred.
*0.5 mL of 1:10,000 adrenaline*
- The **1:10,000 concentration** contains only 0.1 mg of adrenaline per mL; therefore, 0.5 mL would deliver a mere 50 micrograms, which is far too low to be effective for treating severe **anaphylaxis**.
- This dilute concentration is primarily intended for **intravenous (IV) administration** during specific cardiac emergencies, not for intramuscular injection in anaphylaxis.
*1 mL of 1:1000 adrenaline*
- A 1 mL dose (1000 micrograms or 1 mg) is double the recommended initial adult dose for **intramuscular adrenaline** in anaphylaxis.
- Administering this higher dose initially carries an increased risk of significant **cardiovascular side effects**, such as dangerous arrhythmias, severe hypertension, or myocardial ischemia.
*0.3 mL of 1:10,000 adrenaline*
- This combination results in an extremely low dose of adrenaline (30 micrograms or 0.03 mg), which is therapeutically insufficient for managing **anaphylactic shock** in any age group.
- The **1:10,000 concentration** is inappropriate for **intramuscular administration** in the context of anaphylaxis due to its low potency.
Question 256: A 45-year-old woman suddenly collapses in a restaurant. Bystanders report she went pale, lost consciousness for approximately 20 seconds, and had some brief jerking movements of her limbs. She regained consciousness spontaneously and is now alert but feels nauseous. She reports feeling hot and experiencing abdominal discomfort just before the event. She has no past medical history and takes no medications. Examination reveals heart rate 68 bpm, blood pressure 118/72 mmHg, and cardiovascular and neurological examinations are normal. What is the most likely diagnosis?
A. Generalized tonic-clonic seizure
B. Vasovagal syncope (Correct Answer)
C. Complete heart block
D. Subarachnoid haemorrhage
E. Cardiac outflow obstruction
Explanation: ***Vasovagal syncope***- The presence of a **prodrome** (feeling hot, pale, abdominal discomfort, nausea) and a rapid, spontaneous recovery to alertness is highly characteristic of **reflex-mediated syncope**.- Brief **jerking movements** during syncope, known as **convulsive syncope**, result from transient cerebral hypoperfusion and do not indicate a primary seizure disorder.*Generalized tonic-clonic seizure*- Seizures are usually followed by a prolonged **postictal state** (confusion, drowsiness, and disorientation), whereas this patient became **alert** almost immediately.- Features such as **tongue biting**, urinary incontinence, and a longer duration of patterned tonic-clonic movements are more typical of epilepsy than syncope.*Complete heart block*- This typically causes **Stokes-Adams attacks**, which often occur abruptly without a significant prodrome or warning signs seen in this case.- The patient's **heart rate of 68 bpm** and normal cardiovascular exam after the event make a persistent high-grade conduction block unlikely.*Subarachnoid haemorrhage*- Usually presents with a sudden-onset **thunderclap headache**, often described as the worst headache of the patient's life, which is not reported.- This condition typically results in **persistent neurological deficits** or a more prolonged altered level of consciousness rather than a brief, self-limiting faint.*Cardiac outflow obstruction*- Conditions like **aortic stenosis** or hypertrophic cardiomyopathy usually cause syncope during **exertion** rather than at rest or in a non-exertional setting like a restaurant.- The absence of a **systolic murmur** or other abnormalities on cardiovascular examination makes an obstructive structural heart cause unlikely.
Question 257: A 58-year-old woman with a history of hypertension presents with sudden-onset central chest pain radiating to her jaw, associated with nausea and sweating. The pain started 90 minutes ago. Her ECG shows ST-segment elevation of 3 mm in leads II, III, and aVF. Blood pressure is 142/88 mmHg, heart rate 92 bpm regular. The nearest percutaneous coronary intervention (PCI) centre is 90 minutes away by ambulance. What is the most appropriate immediate management?
A. Arrange immediate transfer for primary PCI without fibrinolysis
B. Administer glycoprotein IIb/IIIa inhibitors and observe
C. Administer fibrinolysis immediately and arrange transfer (Correct Answer)
D. Perform rescue PCI only if fibrinolysis fails
E. Arrange urgent coronary angiography within 24 hours
Explanation: ***Administer fibrinolysis immediately and arrange transfer***
- For patients with **STEMI**, timely reperfusion is paramount. Given the 90-minute transfer time to a **PCI-capable center**, immediate **fibrinolysis** is indicated because primary PCI cannot be performed within the recommended **120-minute** window from diagnosis.
- This **pharmaco-invasive strategy** aims to restore blood flow quickly and reduce infarct size, followed by transfer for coronary angiography to assess the vessel and consider further intervention.
*Arrange immediate transfer for primary PCI without fibrinolysis*
- This approach would lead to a significant delay in **reperfusion**, as the total time to **PCI** would exceed the critical **120-minute** window from STEMI diagnosis.
- Delaying reperfusion increases **myocardial damage** and risk of complications, making **fibrinolysis** the better initial strategy when PCI is not readily available.
*Administer glycoprotein IIb/IIIa inhibitors and observe*
- **Glycoprotein IIb/IIIa inhibitors** are **adjunctive antiplatelet agents** used *with* reperfusion therapy, not as a standalone treatment for **STEMI**.
- **Observation** is never appropriate for acute **STEMI**; immediate **reperfusion** (either mechanical or pharmacological) is critical to salvage myocardial tissue.
*Perform rescue PCI only if fibrinolysis fails*
- While **rescue PCI** is indicated if **fibrinolysis** fails to achieve reperfusion, the recommended strategy after initial fibrinolysis is to arrange **transfer for angiography** within 6-24 hours for all patients.
- This approach is part of a **pharmaco-invasive strategy**, ensuring further assessment and intervention whether fibrinolysis was successful or not.
*Arrange urgent coronary angiography within 24 hours*
- This timeframe for **urgent angiography** is typically reserved for **NSTEMI** or as part of a **staged approach** after successful fibrinolysis, but not as the immediate management for an acute **STEMI**.
- Acute **ST-elevation myocardial infarction** demands **emergent reperfusion** within the shortest possible time to prevent irreversible myocardial damage.
Question 258: A 72-year-old man presents to the Emergency Department with a 2-day history of rigors, confusion, and shortness of breath. His wife reports he has been increasingly drowsy. On examination, temperature is 38.9°C, heart rate 118 bpm, blood pressure 88/52 mmHg, respiratory rate 28/min, and oxygen saturation 89% on room air. Blood tests show white cell count 18.2 × 10⁹/L, C-reactive protein 285 mg/L, and lactate 3.8 mmol/L. Chest X-ray reveals right lower lobe consolidation. What is the most appropriate initial fluid resuscitation strategy?
A. 500 mL crystalloid bolus over 15 minutes
B. 1000 mL colloid infusion over 1 hour
C. 500 mL crystalloid bolus followed by reassessment (Correct Answer)
D. 250 mL crystalloid bolus with diuretic cover
E. 2000 mL crystalloid infusion over 2 hours
Explanation: ***500 mL crystalloid bolus followed by reassessment***
- The patient's presentation with **hypotension**, **tachycardia**, **tachypnea**, **confusion**, and **elevated lactate** (3.8 mmol/L) along with signs of infection (fever, leukocytosis, CXR consolidation) indicates **septic shock**, requiring immediate **fluid resuscitation**.
- Current guidelines, such as the **Surviving Sepsis Campaign**, recommend an initial **500 mL crystalloid bolus** for adults with suspected sepsis-induced hypoperfusion, with frequent **reassessment** to determine further fluid needs and prevent fluid overload, especially in the elderly.
*500 mL crystalloid bolus over 15 minutes*
- While the fluid type, volume, and rate are appropriate for initial resuscitation in sepsis, this option omits the critical step of **reassessment** after the bolus.
- Without immediate **clinical re-evaluation** (e.g., blood pressure, heart rate, respiratory status, lung sounds), there's a risk of either under-resuscitation or contributing to **fluid overload** in a vulnerable elderly patient.
*1000 mL colloid infusion over 1 hour*
- **Crystalloids** are the recommended first-line fluids for initial resuscitation in septic shock; **colloids** have not shown superior benefit and may be associated with increased harm or cost.
- Administering 1000 mL over **1 hour** is generally too slow for a patient in **decompensated septic shock** (BP 88/52 mmHg) who requires rapid correction of hypovolemia.
*250 mL crystalloid bolus with diuretic cover*
- A **250 mL bolus** is typically insufficient to effectively address significant hypotension and hypoperfusion in septic shock; this smaller volume is usually reserved for patients with severe **cardiac dysfunction** and high risk of fluid overload.
- Administering **diuretics** during acute **hypotensive shock** is contraindicated as it would further reduce intravascular volume and worsen **organ perfusion**, potentially exacerbating the shock state.
*2000 mL crystalloid infusion over 2 hours*
- Administering a large, fixed volume like **2000 mL** over two hours without frequent clinical **reassessment** significantly increases the risk of **fluid overload**, particularly in an elderly patient.
- Fluid resuscitation in sepsis should be **dynamic**, with smaller boluses and continuous re-evaluation of the patient's response and tolerance to prevent complications like **pulmonary edema**.
