A 51-year-old woman with metastatic ovarian cancer on chemotherapy presents to the Emergency Department with a 24-hour history of fever and general malaise. Her temperature is 38.7°C, heart rate 105 bpm, blood pressure 102/65 mmHg, and respiratory rate 18 breaths/min. Blood tests show: white cell count 0.8 × 10⁹/L, neutrophils 0.3 × 10⁹/L, haemoglobin 95 g/L, platelets 142 × 10⁹/L. Which empirical antibiotic regimen is most appropriate for this patient?
Q22
A 75-year-old man with atrial fibrillation, for which he takes apixaban, is brought to the Emergency Department after collapsing while shopping. He has no recollection of the event. His wife states he suddenly fell to the ground without warning and regained consciousness within seconds. Examination reveals a heart rate of 38 bpm (irregular), blood pressure 168/92 mmHg, and a systolic murmur loudest at the right upper sternal edge radiating to the carotids. ECG confirms atrial fibrillation with slow ventricular response. What is the most likely cause of his syncope?
Q23
A 67-year-old woman with a history of hypertension and chronic kidney disease stage 3 presents with sudden-onset tearing chest pain radiating to her back. Her blood pressure is 172/95 mmHg in the right arm and 138/82 mmHg in the left arm. ECG shows left ventricular hypertrophy with no acute ischaemic changes. Chest X-ray demonstrates a widened mediastinum. What is the target systolic blood pressure in the acute management of this patient?
Q24
A 42-year-old man with a known allergy to penicillin is brought to the Emergency Department 10 minutes after developing facial swelling and difficulty breathing following administration of co-amoxiclav for a dental infection. Despite two doses of intramuscular adrenaline 500 micrograms, he remains hypotensive at 78/45 mmHg with stridor and widespread urticaria. After securing the airway and establishing intravenous access, what is the most appropriate next step in management?
Q25
A 32-year-old pregnant woman at 36 weeks gestation collapses at home. Her partner reports she suddenly complained of severe chest pain and shortness of breath before losing consciousness. On arrival to the Emergency Department, she is alert but extremely distressed, with blood pressure 85/50 mmHg, heart rate 132 bpm, respiratory rate 34 breaths/min, and oxygen saturation 88% on high-flow oxygen. Her ECG shows sinus tachycardia and right axis deviation. What is the most likely underlying mechanism for her collapse?
Q26
A 58-year-old man with a history of type 2 diabetes presents to the Emergency Department with 2 hours of central chest pain. His ECG shows sinus rhythm with ST-segment depression of 2 mm in leads V3-V6. His troponin I at presentation is 45 ng/L (normal <14 ng/L). His blood pressure is 145/88 mmHg and heart rate is 78 bpm. He has been given aspirin 300 mg, ticagrelor 180 mg, and subcutaneous fondaparinux. Which scoring system is most appropriate for risk stratification in this patient?
Q27
A 45-year-old woman presents to the Emergency Department with a 36-hour history of fever, productive cough, and increasing shortness of breath. On examination, her temperature is 38.9°C, heart rate 118 bpm, blood pressure 94/58 mmHg, respiratory rate 28 breaths/min, and oxygen saturation 91% on room air. Blood tests show lactate 3.2 mmol/L and white cell count 18.5 × 10⁹/L. According to the Sepsis Six bundle, which intervention should be completed within the first hour?
Q28
A 35-year-old woman with a known allergy to shellfish attends a dinner party and consumes a soup that she later discovers contained shrimp stock. Within 15 minutes, she develops mild lip tingling and a few hives on her arms but no other symptoms. She remains haemodynamically stable with blood pressure 128/78 mmHg, heart rate 76/min, respiratory rate 14/min, oxygen saturation 99% on air, and no respiratory distress. She has her adrenaline auto-injector with her. What is the most appropriate immediate management?
Q29
A 78-year-old woman is brought to the Emergency Department after being found collapsed at home. She is drowsy but responsive to voice. Her daughter reports she has been increasingly unwell over the past 72 hours with productive cough and reduced oral intake. Observations: temperature 36.1°C, heart rate 118/min, blood pressure 88/56 mmHg, respiratory rate 32/min, oxygen saturation 91% on 15 litres oxygen via non-rebreathing mask. Blood tests show: white cell count 24.5 × 10⁹/L, lactate 4.8 mmol/L, creatinine 198 μmol/L (baseline 85 μmol/L), albumin 28 g/L. She has received 2 litres of crystalloid over 45 minutes. Her blood pressure is now 90/54 mmHg. Chest radiograph confirms right middle and lower lobe consolidation. In addition to antibiotics and ongoing resuscitation, what intervention has been demonstrated to provide mortality benefit in severe community-acquired pneumonia with septic shock?
Q30
A 52-year-old man with known ischaemic heart disease presents with 90 minutes of central crushing chest pain radiating to his left arm. His ECG shows ST-segment depression of 2 mm in leads V3-V6 and T wave inversion in leads I, aVL, V4-V6. His high-sensitivity troponin I at presentation is 245 ng/L (normal <14 ng/L). Blood pressure is 138/82 mmHg, heart rate 88/min, oxygen saturation 96% on air. He has received aspirin, ticagrelor, morphine, and GTN. His pain has partially settled. What is his GRACE risk score category and recommended management timeframe for coronary angiography?
Acute Medical Presentations UK Medical PG Practice Questions and MCQs
Question 21: A 51-year-old woman with metastatic ovarian cancer on chemotherapy presents to the Emergency Department with a 24-hour history of fever and general malaise. Her temperature is 38.7°C, heart rate 105 bpm, blood pressure 102/65 mmHg, and respiratory rate 18 breaths/min. Blood tests show: white cell count 0.8 × 10⁹/L, neutrophils 0.3 × 10⁹/L, haemoglobin 95 g/L, platelets 142 × 10⁹/L. Which empirical antibiotic regimen is most appropriate for this patient?
A. Oral co-amoxiclav 625 mg three times daily
B. Intravenous benzylpenicillin 2.4 g four times daily
C. Intravenous piperacillin-tazobactam 4.5 g three times daily (Correct Answer)
D. Intravenous gentamicin 5 mg/kg once daily
E. Oral ciprofloxacin 500 mg twice daily
Explanation: ***Intravenous piperacillin-tazobactam 4.5 g three times daily***
- The patient has **febrile neutropenia**, defined by a fever >38°C and a **neutrophil count <0.5 × 10⁹/L** in a patient on chemotherapy. This is a medical emergency requiring urgent broad-spectrum intravenous antibiotics.
- **Piperacillin-tazobactam** (Tazocin) is a first-line empirical monotherapy for febrile neutropenia as it provides broad coverage against common pathogens, including **Pseudomonas aeruginosa**, Gram-positive bacteria, and many Gram-negative organisms.
*Oral co-amoxiclav 625 mg three times daily*
- **Oral antibiotics** are generally insufficient for the initial treatment of high-risk febrile neutropenia, especially in a patient with signs of systemic illness (tachycardia, hypotension risk).
- **Co-amoxiclav** lacks adequate coverage against **Pseudomonas aeruginosa**, a critical opportunistic pathogen in neutropenic patients with high mortality.
*Intravenous benzylpenicillin 2.4 g four times daily*
- **Benzylpenicillin** has a narrow spectrum primarily targeting Gram-positive cocci and is ineffective against a broad range of Gram-negative bacteria that are significant causes of infection in neutropenic patients.
- It notably fails to cover **Pseudomonas aeruginosa**, which is a high-risk pathogen in this patient population.
*Intravenous gentamicin 5 mg/kg once daily*
- While **gentamicin** provides excellent Gram-negative coverage, it is not suitable as **monotherapy** for febrile neutropenia due to its lack of coverage against Gram-positive bacteria and anaerobes.
- It is typically used as an **adjunct** in combination with a beta-lactam for broader coverage or in specific scenarios, not as a standalone empirical agent.
*Oral ciprofloxacin 500 mg twice daily*
- **Oral ciprofloxacin** is inappropriate for the initial empirical treatment of high-risk febrile neutropenia, which requires immediate and reliable **intravenous antibiotic administration**.
- While sometimes used for prophylaxis or very low-risk febrile neutropenia, it is insufficient for a patient presenting acutely with systemic signs of infection and significant neutropenia.
Question 22: A 75-year-old man with atrial fibrillation, for which he takes apixaban, is brought to the Emergency Department after collapsing while shopping. He has no recollection of the event. His wife states he suddenly fell to the ground without warning and regained consciousness within seconds. Examination reveals a heart rate of 38 bpm (irregular), blood pressure 168/92 mmHg, and a systolic murmur loudest at the right upper sternal edge radiating to the carotids. ECG confirms atrial fibrillation with slow ventricular response. What is the most likely cause of his syncope?
A. Ventricular tachycardia causing haemodynamic compromise
B. Critical aortic stenosis with reduced cardiac output on exertion (Correct Answer)
C. Carotid sinus hypersensitivity causing profound bradycardia
D. Transient ischaemic attack affecting the brainstem
E. Postural hypotension secondary to anticoagulation therapy
Explanation: ***Critical aortic stenosis with reduced cardiac output on exertion***- The patient presents with **exertional syncope** (collapsed while shopping) and a classic **systolic murmur** loudest at the **right upper sternal edge radiating to the carotids**, which is highly suggestive of **aortic stenosis**.- Syncope occurs because the **fixed cardiac output** cannot adequately increase to meet the metabolic demands of exertion, leading to **transient cerebral hypoperfusion**.*Ventricular tachycardia causing haemodynamic compromise*- While **ventricular tachycardia** can cause syncope due to haemodynamic compromise, the presence of a distinct **ejection systolic murmur** makes a structural cardiac cause (like aortic stenosis) more likely.- The ECG shows atrial fibrillation with a slow ventricular response (bradycardia), not ventricular tachycardia.*Carotid sinus hypersensitivity causing profound bradycardia*- **Carotid sinus hypersensitivity** typically involves a clear trigger such as **neck movement**, wearing tight collars, or **direct pressure** on the carotid sinus, which is not described in this scenario.- Although the patient has bradycardia (38 bpm), the exertional nature of the syncope and the characteristic murmur point away from this diagnosis.*Transient ischaemic attack affecting the brainstem*- A **TIA** involving the brainstem would likely present with other **focal neurological deficits** such as diplopia, vertigo, ataxia, or dysarthria.- The patient's immediate and full recovery within seconds, with no residual neurological signs, is characteristic of **cardiac syncope** rather than a cerebrovascular event.*Postural hypotension secondary to anticoagulation therapy*- **Postural hypotension** typically occurs upon changing positions (e.g., standing up) and is characterized by a significant drop in blood pressure, not usually during sustained activity like shopping.- **Apixaban** is an anticoagulant and does not directly cause hypotension or affect **autonomic vascular tone**; its primary effect is on coagulation.
Question 23: A 67-year-old woman with a history of hypertension and chronic kidney disease stage 3 presents with sudden-onset tearing chest pain radiating to her back. Her blood pressure is 172/95 mmHg in the right arm and 138/82 mmHg in the left arm. ECG shows left ventricular hypertrophy with no acute ischaemic changes. Chest X-ray demonstrates a widened mediastinum. What is the target systolic blood pressure in the acute management of this patient?
A. Maintain systolic blood pressure below 100-120 mmHg within 20 minutes (Correct Answer)
B. Gradual reduction of systolic blood pressure to below 140 mmHg over 24 hours
C. Maintain systolic blood pressure at current level to ensure organ perfusion
D. Reduce systolic blood pressure to below 160 mmHg within the first hour
E. Aggressive reduction to systolic blood pressure below 90 mmHg immediately
Explanation: ***Maintain systolic blood pressure below 100-120 mmHg within 20 minutes***- Rapid, aggressive reduction of systolic blood pressure to **100-120 mmHg** is critical in **acute aortic dissection** to decrease the shear stress (dP/dt) on the aortic wall and prevent propagation.- This target should be achieved quickly, typically within **20 minutes**, usually alongside heart rate control to **<60 bpm** using IV beta-blockers like **labetalol** or **esmolol**.*Gradual reduction of systolic blood pressure to below 140 mmHg over 24 hours*- This approach is appropriate for a **hypertensive urgency**, but it is too slow and the target is too high for a life-threatening **aortic dissection**.- Delaying blood pressure control in this scenario significantly increases the risk of **aortic rupture** and mortality.*Maintain systolic blood pressure at current level to ensure organ perfusion*- While organ perfusion is important, the high shear stress from a pressure of **172 mmHg** will likely cause the **intimal tear** to propagate further.- The immediate risk of **catastrophic rupture** outweighs the risk of temporary hypoperfusion, making this a dangerous and inappropriate management strategy.*Reduce systolic blood pressure to below 160 mmHg within the first hour*- A target of **160 mmHg** is insufficient for acute aortic dissection management, as the goal is to reach the **lowest possible pressure** compatible with adequate organ perfusion.- Waiting an hour is too long; immediate and rapid intervention is required to stabilize the **aortic wall stress** and prevent further damage.*Aggressive reduction to systolic blood pressure below 90 mmHg immediately*- Reducing SBP to **below 90 mmHg** may lead to **critical hypoperfusion** of vital organs, including the brain, kidneys, and heart.- Over-aggressive reduction can cause complications such as **ischemic stroke**, **acute kidney injury** (worsening existing CKD), or **myocardial ischemia**.
Question 24: A 42-year-old man with a known allergy to penicillin is brought to the Emergency Department 10 minutes after developing facial swelling and difficulty breathing following administration of co-amoxiclav for a dental infection. Despite two doses of intramuscular adrenaline 500 micrograms, he remains hypotensive at 78/45 mmHg with stridor and widespread urticaria. After securing the airway and establishing intravenous access, what is the most appropriate next step in management?
A. Give intravenous hydrocortisone 200 mg and chlorphenamine 10 mg only
B. Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min (Correct Answer)
C. Administer further intramuscular adrenaline 500 micrograms and reassess
D. Give intravenous fluid bolus 500-1000 mL crystalloid rapidly and reassess
E. Arrange urgent transfer to intensive care unit for vasopressor support
Explanation: ***Commence intravenous adrenaline infusion at 0.05-0.1 micrograms/kg/min*** - This patient has **refractory anaphylaxis**, indicated by persistent **hypotension** (78/45 mmHg) and airway compromise (stridor) despite two doses of **intramuscular (IM) adrenaline**. - An **intravenous adrenaline infusion** provides continuous, titratable support, crucial for reversing profound **vasodilation** and **bronchospasm** in severe, unresponsive cases. *Give intravenous hydrocortisone 200 mg and chlorphenamine 10 mg only* - These are **adjunctive therapies** for anaphylaxis, primarily aimed at reducing prolonged symptoms and preventing biphasic reactions, not immediate life support. - **Steroids** and **antihistamines** have a delayed onset of action and should never replace or delay immediate **adrenaline** administration, especially in a critical, unstable patient. *Administer further intramuscular adrenaline 500 micrograms and reassess* - While IM adrenaline is first-line, repeating it a third time after two failed doses in a persistently hypotensive patient indicates a need to escalate to a more effective route and continuous delivery. - The patient's condition (persistent hypotension, stridor) suggests that IM absorption might be compromised or insufficient, necessitating **intravenous administration** for better control. *Give intravenous fluid bolus 500-1000 mL crystalloid rapidly and reassess* - **Intravenous fluids** are vital for managing the **distributive shock** associated with anaphylaxis and should be given promptly. - However, fluids alone will not counteract the profound **vasodilation** or **bronchospasm** and must be administered *concurrently* with or immediately after initiating an **adrenaline infusion** in such a refractory case. *Arrange urgent transfer to intensive care unit for vasopressor support* - While this patient will ultimately require **intensive care** for ongoing management and monitoring, immediate life-saving interventions, such as initiating an **adrenaline infusion**, must occur in the Emergency Department. - Delaying critical treatment by transferring an **unstable patient** without adequate stabilization (i.e., commencing an adrenaline infusion) is inappropriate and potentially dangerous.
Question 25: A 32-year-old pregnant woman at 36 weeks gestation collapses at home. Her partner reports she suddenly complained of severe chest pain and shortness of breath before losing consciousness. On arrival to the Emergency Department, she is alert but extremely distressed, with blood pressure 85/50 mmHg, heart rate 132 bpm, respiratory rate 34 breaths/min, and oxygen saturation 88% on high-flow oxygen. Her ECG shows sinus tachycardia and right axis deviation. What is the most likely underlying mechanism for her collapse?
A. Reduced venous return due to inferior vena cava compression by the gravid uterus
B. Acute massive pulmonary embolism causing obstructive shock (Correct Answer)
C. Amniotic fluid embolism causing distributive shock
D. Peripartum cardiomyopathy causing cardiogenic shock
E. Vasovagal syncope related to anxiety about imminent delivery
Explanation: ***Acute massive pulmonary embolism causing obstructive shock***
- Sudden onset of **chest pain**, **dyspnea**, **hypotension**, and **tachycardia** in a pregnant woman (a **hypercoagulable state**) is highly suggestive of a massive **pulmonary embolism** (PE).
- The **hypoxia**, **right axis deviation** on ECG, and signs of **shock** (BP 85/50 mmHg, HR 132 bpm) indicate acute **right ventricular strain** and **obstructive shock** due to severe pulmonary vascular obstruction.
*Reduced venous return due to inferior vena cava compression by the gravid uterus*
- While **supine hypotensive syndrome** can cause symptoms like lightheadedness or syncope in late pregnancy, it typically resolves with a change in position (e.g., **left lateral recumbent**).
- This condition does not explain the severe **chest pain**, **persistent hypoxia** (88% on high-flow O2), or **ECG changes (right axis deviation)** indicative of acute right heart strain.
*Amniotic fluid embolism causing distributive shock*
- Amniotic fluid embolism is a rare and catastrophic event, but it classically occurs during **active labor**, **cesarean delivery**, or immediately **postpartum**, not typically at home at 36 weeks before labor.
- It is often characterized by a triad of acute **hypoxia**, **hypotension**, and **coagulopathy** (disseminated intravascular coagulation), with neurologic changes like seizures, which are not explicitly reported here as the primary mechanism for collapse.
*Peripartum cardiomyopathy causing cardiogenic shock*
- **Peripartum cardiomyopathy** typically presents with symptoms of **heart failure** (e.g., dyspnea, edema, orthopnea) developing **gradually** during the last month of pregnancy or within five months postpartum.
- The **sudden, acute collapse** with severe chest pain and the specific ECG finding of **right axis deviation** are less consistent with a primary left ventricular failure cause of cardiogenic shock.
*Vasovagal syncope related to anxiety about imminent delivery*
- **Vasovagal syncope** typically involves a transient loss of consciousness, often triggered by stress or pain, with **rapid and complete recovery** without ongoing severe hemodynamic instability.
- It would not account for the profound and sustained **hypotension**, **severe hypoxia** (SpO2 88% on high-flow O2), severe chest pain, or the **right axis deviation** on the ECG.
Question 26: A 58-year-old man with a history of type 2 diabetes presents to the Emergency Department with 2 hours of central chest pain. His ECG shows sinus rhythm with ST-segment depression of 2 mm in leads V3-V6. His troponin I at presentation is 45 ng/L (normal <14 ng/L). His blood pressure is 145/88 mmHg and heart rate is 78 bpm. He has been given aspirin 300 mg, ticagrelor 180 mg, and subcutaneous fondaparinux. Which scoring system is most appropriate for risk stratification in this patient?
A. HEART score
B. GRACE score (Correct Answer)
C. Wells score
D. CHA₂DS₂-VASc score
E. Rockall score
Explanation: ***GRACE score***
- The **GRACE (Global Registry of Acute Coronary Events)** score is the gold standard for predicting **in-hospital and 6-month mortality** in patients with confirmed **Acute Coronary Syndrome (ACS)**.
- It uses parameters like age, heart rate, systolic BP, renal function, and cardiac markers to determine the necessity and timing of **invasive coronary angiography**.
*HEART score*
- Primarily used in the Emergency Department as a **triage tool** to identify low-risk patients with **undifferentiated chest pain** who can be safely discharged.
- While useful for initial screening, it is less comprehensive than GRACE for secondary risk stratification once an **NSTEMI** is confirmed by elevated troponin.
*Wells score*
- A clinical prediction rule used to estimate the pre-test probability of **Pulmonary Embolism (PE)** or **Deep Vein Thrombosis (DVT)**.
- It does not have a role in the management or risk assessment of **coronary artery disease** or myocardial infarction.
*CHA₂DS₂-VASc score*
- Used to determine the annual **stroke risk** in patients with **atrial fibrillation** to guide anticoagulation therapy.
- Although this patient is in sinus rhythm, this score is unrelated to the acute management of **myocardial ischemia**.
*Rockall score*
- Used to calculate the risk of adverse outcomes, such as rebleeding or death, following an **upper gastrointestinal bleed**.
- It incorporates clinical data and **endoscopic findings**, which is irrelevant to the presentation of an acute **NSTEMI**.
Question 27: A 45-year-old woman presents to the Emergency Department with a 36-hour history of fever, productive cough, and increasing shortness of breath. On examination, her temperature is 38.9°C, heart rate 118 bpm, blood pressure 94/58 mmHg, respiratory rate 28 breaths/min, and oxygen saturation 91% on room air. Blood tests show lactate 3.2 mmol/L and white cell count 18.5 × 10⁹/L. According to the Sepsis Six bundle, which intervention should be completed within the first hour?
A. Arrange urgent chest X-ray and await results before starting treatment
B. Administer high-flow oxygen, take blood cultures, give intravenous antibiotics, give intravenous fluid challenge, measure lactate, and monitor urine output (Correct Answer)
C. Start broad-spectrum antibiotics only after microbiological samples are obtained
D. Insert central venous catheter for accurate fluid monitoring before fluid resuscitation
E. Obtain arterial blood gas, venous blood gas, and chest X-ray before initiating treatment
Explanation: ***Administer high-flow oxygen, take blood cultures, give intravenous antibiotics, give intravenous fluid challenge, measure lactate, and monitor urine output***- This option correctly lists all six components of the **Sepsis Six bundle** ("three in and three out") which must be completed within **60 minutes** of recognition.- Early and rapid implementation of these interventions is crucial to reverse **organ dysfunction** and manage **hypotension** in patients with severe sepsis and **septic shock**.*Arrange urgent chest X-ray and await results before starting treatment*- Diagnostic imaging, such as a **chest X-ray**, should not delay the immediate and life-saving interventions of the **Sepsis Six bundle**.- Delaying treatment, especially **antibiotics**, in sepsis significantly increases **mortality**, making rapid intervention paramount.*Start broad-spectrum antibiotics only after microbiological samples are obtained*- While it's ideal to obtain **blood cultures** before administering antibiotics, delaying antibiotics to await samples is not acceptable if it causes a significant delay.- The **"golden hour"** for antibiotic administration in sepsis is critical; antibiotics should be given within 60 minutes, even if cultures are slightly delayed.*Insert central venous catheter for accurate fluid monitoring before fluid resuscitation*- **Central venous catheter (CVC)** insertion is an invasive procedure and is not a component of the initial **Sepsis Six bundle** to be completed within the first hour.- Initial fluid challenges for **hypotension** should be initiated promptly via **peripheral intravenous access**, typically a large-bore cannula.*Obtain arterial blood gas, venous blood gas, and chest X-ray before initiating treatment*- Awaiting multiple advanced investigations like **ABG/VBG** and **chest X-ray** before starting any treatment goes against the principle of rapid intervention in sepsis.- A **venous lactate** is sufficient for the Sepsis Six bundle, and critical treatment should not be postponed for extensive diagnostic work-up.
Question 28: A 35-year-old woman with a known allergy to shellfish attends a dinner party and consumes a soup that she later discovers contained shrimp stock. Within 15 minutes, she develops mild lip tingling and a few hives on her arms but no other symptoms. She remains haemodynamically stable with blood pressure 128/78 mmHg, heart rate 76/min, respiratory rate 14/min, oxygen saturation 99% on air, and no respiratory distress. She has her adrenaline auto-injector with her. What is the most appropriate immediate management?
A. Administer intramuscular adrenaline 500 micrograms immediately as per anaphylaxis protocol
B. Give oral antihistamine and observe for 2 hours in Emergency Department
C. Administer oral antihistamine and corticosteroid then discharge with safety-netting advice
D. Arrange immediate hospital admission for 24-hour observation
E. Give oral antihistamine, observe for minimum 6-8 hours, and ensure emergency action plan in place (Correct Answer)
Explanation: ***Give oral antihistamine, observe for minimum 6-8 hours, and ensure emergency action plan in place***- The patient presents with a **minor allergic reaction** without signs of airway, breathing, or circular dysfunction (no **anaphylaxis**), so **oral antihistamines** are the first-line symptomatic treatment.- Extended observation of **6-8 hours** is recommended because food-triggered reactions can progress or exhibit a **biphasic response**, necessitating monitoring before safe discharge.*Administer intramuscular adrenaline 500 micrograms immediately as per anaphylaxis protocol*- **Adrenaline** is indicated only for **anaphylaxis**, which requires systemic involvement such as **respiratory distress** or **hypotension**, neither of which are present here.- Using adrenaline for a localized skin reaction is inappropriate and can cause unnecessary **tachycardia** and hypertension.*Give oral antihistamine and observe for 2 hours in Emergency Department*- A **2-hour observation** period is clinically insufficient for food allergies, as the risk of a late-phase or **biphasic reaction** remains high beyond this window.- Guidelines generally suggest a longer period of monitoring to ensure the patient does not develop **delayed systemic symptoms**.*Administer oral antihistamine and corticosteroid then discharge with safety-netting advice*- Routine use of **corticosteroids** is no longer recommended for preventing biphasic reactions and does not replace the need for an adequate **observation period**.- Discharging the patient immediately after medication without observation is unsafe given the known **potent allergen** (shrimp) and previous history of allergy.*Arrange immediate hospital admission for 24-hour observation*- **Inpatient admission** for 24 hours is overly cautious for a patient who is currently **haemodynamically stable** with only mild cutaneous symptoms.- Most stable allergic reactions can be managed safely in an **Emergency Department observation unit** or clinical decision unit rather than a formal ward bed.
Question 29: A 78-year-old woman is brought to the Emergency Department after being found collapsed at home. She is drowsy but responsive to voice. Her daughter reports she has been increasingly unwell over the past 72 hours with productive cough and reduced oral intake. Observations: temperature 36.1°C, heart rate 118/min, blood pressure 88/56 mmHg, respiratory rate 32/min, oxygen saturation 91% on 15 litres oxygen via non-rebreathing mask. Blood tests show: white cell count 24.5 × 10⁹/L, lactate 4.8 mmol/L, creatinine 198 μmol/L (baseline 85 μmol/L), albumin 28 g/L. She has received 2 litres of crystalloid over 45 minutes. Her blood pressure is now 90/54 mmHg. Chest radiograph confirms right middle and lower lobe consolidation. In addition to antibiotics and ongoing resuscitation, what intervention has been demonstrated to provide mortality benefit in severe community-acquired pneumonia with septic shock?
A. High-dose intravenous vitamin C (1.5 g every 6 hours) combined with thiamine and hydrocortisone
B. Intravenous immunoglobulin therapy 0.5 g/kg daily for 3 days
C. Intravenous hydrocortisone 50 mg every 6 hours for 7 days or until ICU discharge (Correct Answer)
D. Early goal-directed therapy with protocolized fluid and vasopressor administration targeting ScvO₂ >70%
E. Activated protein C infusion at 24 micrograms/kg/hour for 96 hours
Explanation: ***Intravenous hydrocortisone 50 mg every 6 hours for 7 days or until ICU discharge*** - Recent evidence from trials like **CAPE COD** and **APROCCHSS** demonstrates that early use of **low-dose corticosteroids** reduces 28-day mortality in patients with **severe community-acquired pneumonia** and septic shock. - It helps stabilize hemodynamics, reduces the **duration of vasopressor support**, and modulates the overwhelming systemic **inflammatory response** seen in severe sepsis. *High-dose intravenous vitamin C (1.5 g every 6 hours) combined with thiamine and hydrocortisone* - Frequently referred to as the **Hatari protocol**, Large RCTs like **LOVIT** and **VICTAS** failed to show any survival benefit or improvement in organ-free days. - Current guidelines recommend **against** the routine use of vitamin C in septic shock as it does not improve outcomes compared to standard care. *Intravenous immunoglobulin therapy 0.5 g/kg daily for 3 days* - **IVIG** is not recommended by the **Surviving Sepsis Campaign** due to a lack of evidence for mortality benefit and high cost. - It is generally reserved for specific cases like **toxic shock syndrome** caused by Group A Streptococcus, rather than standard bacterial pneumonia. *Early goal-directed therapy with protocolized fluid and vasopressor administration targeting ScvO₂ >70%* - Although initially promising in the **Rivers trial**, subsequent multicentered trials (**ProCESS, ARISE, and ProMISe**) showed no mortality benefit over **usual care**. - Rigid protocolization of **ScvO2 monitoring** and aggressive fluid/transfusion targets can lead to complications like **fluid overload** without improving survival. *Activated protein C infusion at 24 micrograms/kg/hour for 96 hours* - **Activated protein C (Drotrecogin alfa)** was formerly used but was **withdrawn from the market** worldwide in 2011. - The **PROWESS-SHOCK** trial determined it provided no mortality benefit and significantly increased the risk of **major bleeding events**.
Question 30: A 52-year-old man with known ischaemic heart disease presents with 90 minutes of central crushing chest pain radiating to his left arm. His ECG shows ST-segment depression of 2 mm in leads V3-V6 and T wave inversion in leads I, aVL, V4-V6. His high-sensitivity troponin I at presentation is 245 ng/L (normal <14 ng/L). Blood pressure is 138/82 mmHg, heart rate 88/min, oxygen saturation 96% on air. He has received aspirin, ticagrelor, morphine, and GTN. His pain has partially settled. What is his GRACE risk score category and recommended management timeframe for coronary angiography?
A. High risk (>140); coronary angiography within 72 hours (Correct Answer)
B. Very high risk; emergency coronary angiography within 120 minutes
C. Low risk (<109); conservative management with coronary angiography only if recurrent symptoms
D. Intermediate risk (109-140); coronary angiography within 72 hours
E. High risk (>140); immediate coronary angiography within 2 hours
Explanation: ***High risk (>140); coronary angiography within 72 hours***
- This patient has **NSTEMI** due to ischaemic chest pain, **ST-segment depression**, and a significantly **elevated troponin I** (245 ng/L), placing him in the high-risk category.
- According to **NICE and ESC guidelines**, patients with high-risk NSTE-ACS (including a GRACE score >140 or presence of high-risk features) should receive **coronary angiography within 72 hours** of presentation.
*Very high risk; emergency coronary angiography within 120 minutes*
- **Very high risk** criteria for NSTE-ACS include features such as **haemodynamic instability**, cardiogenic shock, recurrent/refractory chest pain despite maximal medical therapy, or life-threatening arrhythmias.
- This patient is currently **haemodynamically stable** and his pain has partially settled, thus he does not meet the criteria for emergency angiography within **120 minutes**.
*Low risk (<109); conservative management with coronary angiography only if recurrent symptoms*
- A **low-risk** classification is inappropriate here as the patient has objective evidence of **myocardial necrosis** (elevated troponins) and **ST-segment deviation** on ECG.
- Conservative management is typically reserved for patients with no ongoing ischaemia, no elevated cardiac biomarkers, and absence of other **high-risk indicators**.
*Intermediate risk (109-140); coronary angiography within 72 hours*
- While the management timeframe of **72 hours** is appropriate for intermediate risk, the patient's clinical picture with significant **ST-segment depression** and high **troponin elevation** indicates a **high-risk** category, which usually corresponds to a GRACE score **>140**.
- The distinction between intermediate and high risk is important for overall prognosis and specific risk factor modification, even if the revascularization window is similar.
*High risk (>140); immediate coronary angiography within 2 hours*
- Immediate coronary angiography (within **2 hours**) is reserved for **very high-risk** NSTE-ACS patients who present with **refractory angina**, **haemodynamic instability**, or life-threatening arrhythmias.
- Although this patient is high risk, he does not exhibit these **critical emergency indications** that necessitate angiography within such a rapid timeframe.
