This patient’s investigations have all returned to normal. The clue here is picking up the fact that her symptoms were not relieved by sublingual GTN.

The stem also drops another hint letting you know that she has no medical problems. She therefore does NOT have diabetes, hypertension, hypercholesterolemia, or a smoking history which are risk factors for acute coronary syndrome. Do not get thrown by the slight tachycardia in the stem as it is likely the result of anxiety or chest discomfort.

Costochondritis is the answer here and can sometimes mimic symptoms of an acute coronary syndrome. Movements of the rib cage can produce pain. Costochondritis is inflammation of the costochondral junctions of ribs or chondrosternal joints of the anterior chest wall. It is sometimes called Tietze’s syndrome, but it is not the same thing.

Tietze’s syndrome is the addition of swelling over the affected joints of the anterior chest wall.

The key to this question is trying to figure out what medication this child has taken and try to tie it in with his signs and symptoms.

Amitriptyline: causes drowsiness, hypothermia, hypotension, tachycardia, and dry mouth.

ECG shows arrhythmias, particularly changes in the QRS width, dilated pupils.

The classic features of digoxin toxicity are nausea, vomiting, diarrhea, abdominal pain, headache, dizziness, confusion, delirium, and vision disturbance (blurred or yellow vision). It is also associated with cardiac disturbances including irregular heartbeat, ventricular tachycardia, ventricular fibrillation, sinoatrial block, and AV block.

Metoprolol: bradycardia, hypotension, hypothermia, hypoglycemia (especially in children), and seizures.

Thiazide: hypotension, fever, frequent urination, hypotension, muscle cramps, and twitching.

There is a fine line between Generalised Anxiety Disorder (GAD) and Panic attacks. They both can present similarly.

However, in this question, her symptoms develop rapidly and only last for a few minutes. This is the key phrase that you should look out for that tells you this is a Panic attacks rather than GAD.

PANIC ATTACKS : Period of intense fear characterized by symptoms that include palpitations, sweating shaking, and shortness of breath that develop rapidly.

It peaks around 10 minutes and then gradually resolves over the next 20 minutes.

One may see the extreme where the patient may have feelings of going to die from cardiac or respiratory problems or one may see the usual complaint of dizziness, circumoral paraesthesia, carpopedal spasm, and occasionally sharp or stabbing chest pain. Patients are usually tachycardic.

It is important to rule out secondary causes of tachycardia, chest pain, or shortness of breath thus investigations such as oxygen saturation, ECG, and blood glucose are important initial investigations.

If symptoms do not settle in a few minutes, consider adding on investigations such as a chest X-ray, urea and creatinine, and a full blood count.

Management : Simple breathing exercises like breathing through the nose and reassurance are all that is needed.

Remember that the Parkland formula is calculated from the time of the burn rather than the time of presentation.

PARKLAND FORMULA : We use the Parkland formula to count the fluids required after burns.

This is calculated from the time of the burn rather than the time of presentation. If the presentation is delayed, fluid may need to be given more rapidly.

Fluid requirement = Body area burned (%) x Weight (kg) x 4 mL.

Give 1/2 of the total requirements in 1st 8 hours, then give 2nd half over the next 16 hours.

The area of body burn is calculated by adding the percentage of burns in each area using Wallace’s rule of 9s.

• Head and neck total for front and back: 9%

• Each upper limb total for front and back: 9%

• Thorax and abdomen front: 18%

• Thorax and abdomen back: 18%

• Perineum: 1%

• Each lower limb total for front and back: 18%

There are two options here.

Either index and middle finger of one hand or grip the chest in both hands in such a way that two thumbs can press on the lower third of the sternum.

The patient does not require admission to the hospital for detoxification but does require social support and encouragement. Social services have access to some different services including outpatient detoxification, group therapy sessions, and supportive networks.

In addition, women who are alcohol dependent are at risk of abuse, exploitation, and unwanted pregnancy.

Social services can coordinate a multi-disciplinary approach and create a package of care to facilitate safe detoxification.

Cognitive behavioural therapy (CBT) is a talking therapy aimed at changing the way a person thinks and behaves.

Although at first, it appears CBT would be appropriate for this patient, it must be noted that she has no support network and no package of care in place for her safety. There is no indication to refer to psychology.

Young age and first year in university are likely to point towards drug toxicity.

In this question, the examiners want you to know the basics of life-threatening emergencies.

ABC – airway, breathing, and circulation should always be addressed first. In reality, oxygen by mask, securing venous access, and analgesia would all be done simultaneously.

But for this exam, we should know the steps, thus, securing airways and giving oxygen would come before anything else.

Remember ABC!

FLAIL CHEST : A flail chest occurs as a result of trauma to the chest, leading to at least 3 ribs becoming fractured or broken, close together, with pieces of bone detaching from the chest wall.

These segments of bone start to move independently of the chest wall and in the opposite direction because of lung pressure. The result is a “paradoxical respiration”.

Aetiology :

• Fall (for example, off a bicycle or a horse)

• Blunt trauma to the chest

• Car Accident

Diagnosis: Paradoxical respiration with shortness of breath and chest pain in a patient who has just had blunt chest trauma raises the suspicion of a flail chest.

The diagnosis is usually clinical but with the help of a chest X-ray which would demonstrate rib fractures.

Management:

1. High flow oxygen

2. Analgesia such as paracetamol / NSAIDS / Opiates + splinting of injury

3. Intubation / mechanical ventilation - if worsening RR.

This patient’s pH is abnormal his PaCO2 is abnormal (it is high) AND his HCO3 is abnormal (it is low) therefore, we can conclude that this patient has a mixed acidosis picture.

This is the simplest and best time-saving way to interpret ABG scenarios in the exam. You do not even have to look at the PaO2 value. Increasing ventilation would immediately increase the release of carbon dioxide and help resolve the acidosis.

This is a classic case of opioid overdose. The word “alleyway” already answers away.

Respiratory depression, bradycardia, and miotic pupils support the clinical picture. Naloxone is used to block the effects of opioids, especially in overdose.

ILLICIT DRUGS AND INTOXICATION :

Heroin :

• Respiratory depression

• Pinpoint pupils

• Mild hypotension

• Bradycardia

• Weak pulse

• Constipation

Cocaine :

• Increase respiratory rate and depth

• Mydriasis

• Hypertension

• Tachycardia

• Arrhythmias

• Sweating

• Nausea

• Twitching of small muscles

• Elevated body temperature

• Restlessness and agitation

Ecstasy :

• Uncontrolled body movements

• Hyperthermia

• Increase in blood pressure

• Insomnia

• Trismus

• Tachycardia

• Increase in respiratory rate

LSD (Lysergic acid diethylamide) :

• Mydriasis

• Flushing and sweating   

• Diarrhoea

• Paraesthesias

• Hyperactive reflexes

• Delusions and hallucinations

• Remember the effects of LSD are primarily on the 5 senses:  

Sight – Colours become vivid,

Hearing – Hearing becomes more acute,

Touch – Touch is intensified, 

Smell – May even smell colors, 

Taste – tasting things that aren’t there

CHOKING AND FOREIGN BODY AIRWAY OBSTRUCTION IN INFANTS :

• In a seated position, support the infant in a head-downwards, prone position to let gravity aid the removal of the foreign body

• Deliver up to five sharp blows with the heel of your hand to the middle of the back 

• After five unsuccessful back blows, use chest thrusts: turn the infant into a supine position and deliver five chest thrusts. These are similar to chest compressions for CPR, but sharper and delivered at a slower rate.

She is septic from pneumonia. Sepsis six would need to be performed urgently within the hour. Among the sepsis six is to give intravenous fluids. Oral antibiotics would be inappropriate.

We need a broad-spectrum antibiotic in the bloodstream as soon as possible thus it needs to be given intravenously. Chest X-ray would need to be performed but can be done after performing the sepsis six and stabilizing the patient.

SEPSIS :

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.

'Red Flags' in sepsis -

• Systolic blood pressure < 90 mmHg 

• Heart rate >130 beats/minute

• Oxygen saturations < 91%

• Respiratory rate >25 breaths/minute

• Responds only to voice or pai or unresponsive

• Lactate > 2.0 mmol

• `Reduced urine output.

If 1 or more RED FLAGS are present :

Complete the SEPSIS SIX within 60 minutes. Sepsis Six - Take 3, Give 3

• Take 3 : Blood culture + FBC, urea and electrolytes + clotting & lactate. Start monitoring urine output.

• Give 3 : High flow oxygen, Intravenous fluid challenge, Intravenous antibiotics.

Septic shock is defined as persistently low blood pressure which has failed to respond to the administration of intravenous fluids.

It is well known that chronic alcoholics are at high risk for being deficient in vitamin B1 (thiamine), which is known to put the patient at an increased risk for Wernicke-Korsakoff Syndrome and cerebellar degeneration. Thiamine should be given priority in this stem before administering glucose.

Lorazepam is a benzodiazepine. Respiratory depression is a known effect of benzodiazepine overdose. Amnesia can occur as well, but it will not be life-threatening.

Side effects of benzodiazepines include:

• sedation

• cognitive impairment

• respiratory depression

• hypotension

• anterograde amnesia.

In cases like this where a serious overdose is suspected, give paracetamol antidote N-acetylcysteine immediately. The amount of paracetamol taken is known in this question. N-acetylcysteine infusion should be started if there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration.

The 4-hour figure refers to the time after ingestion at which plasma levels can be interpreted. If levels turn out to be below the treatment line, N-acetylcysteine can be stopped.

Key points to remember for the management of acute upper gastrointestinal bleeding possibly due to varices:

• Always start with fluid resuscitation

• Endoscopy should be undertaken immediately after resuscitation for unstable patients with severe acute upper gastrointestinal bleeding. This allows the bleeding point to be visualized and treated.

* Band ligation is the first choice treatment for all patients with upper gastrointestinal bleeding from oesophageal varices.

• Administer terlipressin at presentation (2 mg intravenously repeated every 4 to 6 hours). Treatment should be stopped after definitive haemostasis has been achieved.

• Avoid omeprazole acutely unless the patient has known peptic ulcer disease. PPIs should not be used before diagnosis by endoscopy

• If INR is prolonged, administer vitamin K

• Administer platelet transfusions to patients who are actively bleeding and have a low platelet count.

• TIPS should be considered only if bleeding from oesophageal varices is not controlled by band ligation.

• Balloon tamponade is only used as a salvage procedure in a patient with massive haemorrhage, at risk of death.

• Administer prophylactic antibiotics e.g. ciprofloxacin or cephalosporin. This can be administered at the presentation. The first four key points are the most important to remember and will get you through the exam.

Please see Q-4

His GCS is less than 15 at 2 hours after the injury on assessment in the emergency department and he has signs of basal skull fracture on top of the additional risk factor which is a dangerous mechanism of injury. He needs an urgent CT head.

This girl is suffering from urticaria. Oral antihistamines would be indicated.

Since this is an allergic reaction, the only two reasonable options are A and C in this question. However, in the context of allergic reactions, IM adrenaline should only be used in an anaphylactic shock whereby the patient would have breathing difficulties.

The following are the indications of adrenaline in anaphylaxis:

1. Hoarseness of voice

2. Wheeze

3. Shortness of breath

4. Shock

5. Stridor

6. Swelling of the tongue and cheek

7. Facial swelling

If you see an urticaria-like allergic reaction, with none of the following indications stated above for adrenaline, then pick the oral antihistamine as the answer.

The pelvic fracture and perineal bruising indicate that there may be a urethral injury. If you suspect a urethral injury, do not attempt to perform urethral catheterization.

In the exam, the option of suprapubic catheterization is usually given. Pick that. Posterior urethral tears are often associated with pelvic fractures. Urethral injury may also result from blows to the perineum.

Look for perineal bruising and blood at the external urethral meatus and perform a rectal examination.

If urethral injury is suspected, do not attempt urethral catheterization, but refer urgently to the urology team. Some urologists perform a retrograde urethrogram to assess urethral injury, but many prefer suprapubic catheterization and subsequent imaging. 

Breathlessness and stridor in a child playing with toys is most likely due to aspiration of a foreign body (e.g. a part of the toy) for which indirect laryngoscopy and/or fiber-optic examination of the pharynx would provide a diagnosis. Remember the ingestion of foreign bodies is most commonly a problem in young children aged 6 months to 5 years.

As this patient is unconscious, we need to intubate and provide IPPV on 100% O2.

For a conscious patient use a tight-fitting mask with an O2 reservoir. The decision for hyperbaric oxygen therapy (HBOT) is a difficult one and there are many debates about the added value provided by hyperbaric oxygen.

In this question, the examiners want you to know the basics of life-threatening emergencies.

ABC – airway, breathing, and circulation should always be addressed first. The patient is in shock.

In reality, high-flow oxygen, securing venous access, and analgesia would all be done simultaneously. But for this exam, we should know the steps.

Thus, securing airways and giving oxygen would come before anything else. Positive pressure ventilation would suffice in most cases of flail chest however this patient needs early intubation as he is acutely deteriorating.

A flail chest like in this stem may require intubation with a double lumen tracheal tube. In a double-lumen endotracheal tube, each lumen may be connected to a different ventilator. With a flail chest, one side of the chest is affected more than the other, so each lung requires different pressures and flows to adequately ventilate.

MANAGEMENT OF SHOCK :

Investigation and treatment should occur simultaneously

Address the priorities

ABC

High flow O2 by mask

Secure adequate venous access and take necessary blood investigation

Resuscitation is usually started with crystalloids, such as normal saline.

TOXIC SHOCK SYNDROME :

Symptoms of toxic shock syndrome vary depending on the underlying cause. Toxic shock syndrome resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise, and confusion, which can rapidly progress to stupor, coma, and multiple organ failure.

The characteristic rash, often seen early in the course of illness, resembles a sunburn and can involve any region of the body, including the lips, mouth, eyes, palms, and soles.

In patients who survive the initial phase of the infection, the rash desquamates, or peels off, after 10–14 days.

WBC is usually increased and platelets are decreased.

Signs and symptoms of toxic shock syndrome:

• Body temperature > 38.9 °C

• Systolic blood pressure < 90 mmHg

• Diffuse macular erythroderma

• Desquamation (especially of the palms and soles) 1–2 weeks after onset.

Involvement of three or more organ systems:

• Gastrointestinal - vomiting, diarrhea

• Muscular: severe myalgia or creatine phosphokinase level elevation

• Mucous membrane hyperemia

• Kidney failure

• Liver inflammation.

A CT head scan should be performed if GCS < 15 at 2 hours post-injury in children.

Primary haemorrhage occurs at the time of surgery. It is bleeding immediately after an injury or operation.

Treatment involves replacing blood. If severe, return to theatre for adequate haemostasis.

The other options given are less likely :

Reactionary haemorrhage - Occurs within the first 24 hours and it is usually due to venous bleeding and is usually caused by slipping of ligatures, dislodgement of clots, and patient warming up after surgery causing vasodilation, on top of normalization of blood pressure.

Secondary haemorrhage - Usually caused by necrosis of an area of the blood vessel, related to the previous repair, and is often precipitated by a wound infection. It occurs 1 to 2 weeks post-op.

Septic shock - There are no signs or symptoms of infection to indicate sepsis.

The patient in the stem was knocked unconscious - there is nothing to indicate that he has stopped breathing and so, CPR is unnecessary.

Primary survey – this follows the ABCDE principle

• Airway maintenance with cervical spine protection

• Breathing and ventilation

• Circulation with haemorrhage control

• Disability with assessment of neurological status

• Exposure / Environmental control.

The most appropriate management here would be FFP as she has a history of liver disease and a high INR.

STAGES OF HYPOVOLAEMIC SHOCK :

For adults, the clinical staging relating to loss of blood volume can be classified as:

Stage 1: Blood loss - 10-15% 

Stage 2: Blood loss - 15-30% 

Stage 3: Blood loss - 30-40% 

Stage 4: Blood loss - Over 40% 

You would need to memorize the amount of blood loss in each stage e.g. 30-40% in stage 3.

In cases of paradoxical rib movement i.e, Flail chest, the most important aspect of treatment is to treat the pain due to rib fractures. Because the pain will lead to hyperventilation and exaggerated movement of rib cage, and we do not want that to occur.

This patient has Mallory-Weiss tears from drinking too much alcohol. As he is vitally stable, and his haemoglobin count is high.

The best plan is to discharge him home with advice. This is a very high-yield question. Occasionally, the option of “discharge with advice” is not there, in which case they would provide other correct options such as

• Repeat FBC

• Observe vital signs for deterioration

Panic attacks usually have a fast onset and resolve quickly as well. They usually take about 10 minutes to peak and then followed by resolution over the next 20 minutes. Some attacks may be situational such as in specific scenarios where attacks have occurred previously whilst other attacks may be spontaneous and described as “out of the blue” which is seen in this stem.

This is a classic presentation of Mallory-Weiss syndrome.

It is characterized by upper gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract, usually at the gastro-oesophageal junction or gastric cardia. Excessive alcohol ingestion is one of the main causes as prolonged or forceful bouts of vomiting can cause a tear in the upper gastrointestinal tract.

Resuscitation is a priority - maintain the airway, provide high-flow oxygen, and correct fluid losses by giving IV fluids.

Intravenous blood can also be given in severe cases. Haemodynamically unstable patients like those in this stem should have an endoscopy immediately after resuscitation. It is the primary diagnostic investigation and can be used to stop the bleeding.

Note, that proton pump inhibitor (PPI) use is not recommended prior to diagnosis by endoscopy.

You should never get a pathophysiology question wrong for the exam. This man has experienced major trauma. The bruises on his abdomen point you toward a possible intra-abdominal bleed.

Here is the mechanism for hypovolaemic shock: Early changes in Loss of blood volume stretch receptors in the atria and baroreceptors in the aorta become activated.

Reactionary Haemorrhage occurs within the first 24 hours following trauma/surgery and it is usually caused by slipping of ligatures, dislodgement of clots, patient warming up after surgery, causing vasodilation, on top of normalization of blood pressure.

Haemostasis appears secure until blood pressure rises to normal then bleeding begins. Treatment usually involves replacing blood and re-exploring the wound.

Hypotension, tense neck, and blood oozing from the drain tell us that the patient is probably bleeding. As the patient is still in the recovery room, the surgery is likely recent (less than 24 hours) thus the diagnosis of reactionary haemorrhage.

The raised level of serum creatinine, bilirubin, and liver enzymes as well as the increased prothrombin time indicates that this patient has taken an overdose of paracetamol. Paracetamol is an antipyretic and analgesic. Patients are usually asymptomatic for the first 24 hours or have nonspecific abdominal symptoms. Hepatic necrosis begins to develop after 24 hours and can progress to acute liver failure.

The liver damage is not usually detectable by routine liver function tests until at least 18 hours after ingestion of paracetamol.

Alanine transferase (ALT), prothrombin time usually peaks 72 to 96 hours after ingestion.

Amitriptyline is a tricyclic antidepressant. TCA’s taken in large amounts can cause excess sedation, and sympathomimetic effects - tachycardia, sweating, dilated pupils.

Aspirin is a potent antiplatelet agent as well as an antipyretic, analgesic, and anti-inflammatory agent. An overdose of aspirin causes ringing in the ears, nausea, abdominal pain, and tachypnoea.

Organophosphates are usually the active ingredients in insecticides. Symptoms include increased saliva and tear production, diarrhoea, vomiting, small pupils, sweating, muscle tremors, and confusion.

In any trauma-associated emergency, including fractures of the shaft of the femur, we should apply Advanced Trauma Life Support principles and attend to the femur only once we are happy with our ABCDEs. As this patient is clinically stable, we should move on to attend to the femur by splinting it.

Intravenous fluids, full blood count, and cross match would also be performed but since in this question, he is clinically stable, we should perform a Thomas’ splint first. Putting a splint will improve alignment and reduce ongoing blood loss.

Bloss loss in a femur shaft fracture is alarming as blood loss is significant. In reality, you would have more than one doctor and health care professional in this scene, thus one would be putting an IV cannula and sending blood while the others would be splinting the leg. Imaging is important but can be done at a later time.

This is a medical emergency. An emergency medical crash call would be appropriate of which the two important teams that should be involved are the anaesthetist and the medical team. The anaesthetist needs to urgently review this patient as intubation would be the first part of management to secure her airways.

Airways, breathing, and circulation would need to be addressed quickly and the patient should be moved into a recovery position whilst waiting for the anesthetist to arrive.

An urgent CT head scan is also important as the likely diagnosis here is a subarachnoid haemorrhage however, the patient would need to be stabilized first by the anaesthetic team prior to moving her to the CT scan room.

The neurosurgical team would also need to be involved but they should only be called once the CT images are made available which shows a brain haemorrhage.

Antihypertensives such as nimodipine are part of the management and are often used by neurosurgeons following aneurysmal subarachnoid haemorrhage however there should be evidence of a subarachnoid on CT head first.

A low respiratory rate, constricted pupils, and semiconscious are features of opioid poisoning.

Naloxone is a specific antagonist for opioids and is used especially in opioid overdose to reverse coma and respiratory depression. When given intravenously, it can begin to work within 2 minutes.

The woman is likely to be suffering from Carbon Monoxide (CO) poisoning caused by inhalation of Methylene Chloride from the paint fumes.

The symptoms of a severe headache, vomiting, and dizziness are suggestive of CO poisoning.

Carboxyhaemolglobin levels are necessary to confirm the diagnosis.

Treatment is with 100% oxygen administered.

Any child with more than 10% of the total body surface area burned requires fluid replacement. Here there is only 6% partial thickness burns.

Cross-match is the most appropriate as he may need a blood transfusion. If IV fluids have not been started and the option for IV fluids is given in this question, then pick IV fluids.

This would be the first initial step together with oxygen.

The other options given in this question are less likely: Fresh frozen plasma is used in replacement of isolated factor deficiency, reversal of warfarin effect, massive blood transfusion and treatment of thrombotic thrombocytopenic purpura and is not indicated here in this question.

Liver enzymes : Have no role in acute management.

Immediate laparotomy : This may well be the last step after all investigations are carried out.

These are the steps that you need to know for the treatment of burns.

Note the order :

1. Large-calibre intravenous lines must be established immediately in a peripheral vein.

Any adult with burns affecting more than 15% of the total body surface area burned or a child with more than 10% of the total body surface area burned requires fluid replacement calculated from the time of the burn.

2. Ensure adequate analgesia: strong opiates should be used

3. Prevent hypothermia.

He is in the ambulance. His oxygen demand has increased due to an increased respiratory rate.

100% oxygen would be a suitable option as part of the initial management. One would not do a needle thoracentesis unless there were clinical features of a tension pneumothorax like a deviated trachea.

Intubate and ventilate all patients with GCS 8 or less. This should be done first before anything else.

After major burns, if there is any evidence of impending airway obstruction (stridor, oropharyngeal swelling, call for senior ED help and a senior anaesthetist immediately. Urgent general anaesthesia and tracheal intubation may be life-saving. Airway, breathing, and circulation are always in this order.

Smoke inhalation injury is a common cause of death in burn victims. Initial assessment may reveal no evidence of injury, but laryngeal oedema can develop suddenly and unexpectedly thus early intubation is warranted if there is evidence of inhalation injury.

Signs and symptoms of smoke inhalation injury :

• Persistent cough

• Stridor

• Wheezing

• Black sputum suggests excessive exposure to soot

• Use of accessory muscles for respiration

• Blistering or edema of the oropharynx

• Hypoxia or hypercapnia.

This patient requires a computed tomography head within 8 hours as per guidelines. There is evidence of retrograde amnesia and also a dangerous mechanism of injury.

Agitation, nervousness, abdominal cramps, sweating, shivering, and arthralgia are all features of heroin withdrawal. The opiates are a group of chemicals that are widely abused for their euphoriant and anxiolytic properties. Heroin is the most frequently abused opiate.

Heroin is most commonly consumed by smoking, but there are so many methods to consume heroin which include taking it orally, snorting it, and through parenteral administrations such as intravenous, intramuscular, or subcutaneous routes. 

36 tablets of paracetamol is 18 g. Remember, 1 tablet is 500 mg.

Generally, if one takes more than 24 tablets (12 g), we admit Paracetamol poisoning is always dealt with in the medical ward. 

In this question, the examiners want you to know the basics of life-threatening emergencies.

ABC – airway, breathing, and circulation should always be addressed first. This patient is in shock. In reality, high-flow oxygen, securing venous access, and analgesia would all be done simultaneously.

Securing airways and giving oxygen would come before anything else.

Management of Shock :

Investigation and treatment should occur simultaneously.

• Get senior help immediately

• Address the priorities - ABC

• Give high flow O2 by mask

• Secure adequate venous access and take necessary blood investigation

• Monitor vital signs, including pulse, BP, SpO2, respiratory rate

• Insert a urinary catheter and monitor urine output hourly

• For shock associated with effective circulating blood volume, give IV crystalloid (0.9% saline) 20 ml/kg as bolus.

The diagnosis here is compartment syndrome given the history of prolonged limb compression. The reason the dorsal pedis pulse is not felt is because arterial blood flow is reduced when pressure exceeds systolic blood pressure. Note that sensory deficit may occur in the distribution of nerves passing through the compartment which explains the reduced sensation in this stem. Muscle tenderness and swelling are also a part of the clinical features seen in compartment syndrome.

Compartment syndrome is a painful and potentially serious condition caused by bleeding or swelling within an enclosed bundle of muscles (a muscle ‘compartment”).

Acute compartment syndrome occurs after a traumatic injury such as a car crash. The trauma causes severe high pressure in the compartment which results in insufficient blood supply to muscles and nerves.

Acute compartment syndrome is a medical emergency that requires surgery to correct. If untreated, the lack of blood supply leads to permanent muscle and nerve damage and can result in the loss of function of the limb.

In panic attacks, perioral paresthesia, tingling, and numbness in the hands can occur due to hyperventilation and CO2 washout leading to low ionic calcium. The description of tightening with palpitations fits with panic attacks.

Her arterial pH is 7.1 which is an indication of liver transplantation; criteria for liver transplantation. Arterial pH < 7.3, 24 hours after ingestion or all of the following:

• Prothrombin time > 100 seconds

• Creatinine > 300 micromol/L

• Grade III or IV encephalopathy

Generally, if one takes more than 24 tablets (12 g), we admit.

Diaphragmatic rupture is a tear of the diaphragm. It is usually secondary to blunt trauma. The usual case would be someonein a car passenger seat involved in a car accident where the seat belt compression causes a burst injury directed to the diaphragm. The pressure within the abdomen rises so quickly with a sudden blow to the abdomen causing a burst in the diaphragm. It is commonly on the left side.

Signs and symptoms include chest and abdominal pain and respiratory distress.

Breath sounds on the side of the rupture may be diminished. Bowel sounds may be heard in the chest. To your knowledge, it is important to remember that chest X-ray to diagnose diaphragmatic rupture is quite unreliable and has low sensitivity and low specificity.

However, there are specific signs detectable on X-ray which should raise suspicion. Diaphragmatic rupture is suspected in any patient with blunt trauma and a raised left hemi diaphragm on a chest X-ray.

Air fluid levels in the chest may also be seen. A nasogastric tube from the stomach may appear on the film in the chest cavity. This particular sign with the NG tube curled into the left chest is pathognomonic for diaphragmatic rupture, but it is rare. A thoracoabdominal CT scan is usually a diagnostic.

This man should be treated for chest sepsis. The oliguria that he has is due to an acute kidney injury secondary to sepsis.

Always remember your sepsis 6. Intravenous fluid such as normal saline or Hartmann’s would be the most appropriate here.

The picture shows a red arm but there are no blisters seen so this can be classified as a superficial burn. Most superficial burns if dressing is required can be managed with a simple non-adherent dressing plus an absorbent layer (e.g. a dressing pad) on top and a bandage to secure the dressing.

He can then be managed as an outpatient with a twice-a-week wound inspection. 

Other things to take note of are checking the tetanus status of the burnt victim and giving tetanus toxoids if required. This is because burns are considered tetanus-prone, especially in cases like this where it involves a barbeque pit in the park.

PARTIAL AND FULL-THICKNESS BURNS :

- Superficial (epidermal) burns are red and painful but do not blister.

- Partial thickness burn ranges from blistering to deep dermal burns.

- The appearance is shiny and the sensation is intact.

- Capillary refill blanches.

- Full-thickness burns have a leathery or waxy appearance. They may be white, brown, or black. There are no blisters and sensation is lost so they do not feel any pain. There is no capillary refill.

Note: that if you were a paediatrician you should be doing a C: V ratio of 15:2 as you potentially need to resuscitate children as part of your role. Note there are two options for chest compression.

Either index and middle finger of one hand or grip the chest in both hands in such a way that two thumbs can press on the lower third of the sternum.

Hereditary angioedema (C1 esterase inhibitor deficiency) :

• Rare genetic condition causing episodes of angioedema which includes life-threatening laryngeal oedema.

The stem would usually include :

• A positive family history

• Onset from childhood of episodes of angioedema affecting the larynx. Sometimes impairing respiration and GI system, causing abdominal pain, and vomiting. Confirmed by:

• Low levels of C-esterase inhibitor and complement studies during the acute episode.

Hyperventilation is an abnormally increased pulmonary ventilation. Patients with hyperventilation syndrome may feel that they are not able to breathe sufficient air. In reality, their oxygenation in the arterial blood is within normal limits.

Due to the rapid breathing, carbon dioxide levels fall which results in respiratory alkalosis. The complaint is usually paroxysmal rather than continuous.

The patient may report breathlessness, followed by paraesthesia and/or tetany in fingers, distal limbs, and mouth. Some patients report chest pain.

Palpitations, wheezing, and sweating are also seen. This may be accompanied by a panic attack. If this becomes more severe, arterial hypocapnia may trigger cerebral vessel vasoconstriction leading to dizziness, faintness, headaches, and loss of consciousness.

After losing consciousness, breathing and blood gases return to normal which restores cerebral blood flow. The patient would shortly recover after that.

Management includes rebreathing into the paper bag to terminate the attack. Other methods include deliberately slowing down the breathing rate. Medications can also be used. Benzodiazepines can be used in acute situations if severe.

This question is testing basic physiology. Acute pain or trauma will activate your body’s sympathetic nervous system. This will cause many of the body’s blood vessels to constrict and will cause the heart to increase the rate and force of contraction.

This patient has just experienced a traumatic accident and is probably bleeding internally, as is evidenced by the abdominal bruising. Excessive blood loss results in a drop in blood pressure.

However, the single most likely cause of his cold and clammy peripheries is the activation of the sympathetic nervous system causing constriction of the blood vessels. This is due to a compensatory mechanism by the body to preserve itself.

Although severe trauma or stressful events can elevate cortisol levels, this is not a direct reason as to why this patient has cold and clammy peripheries.

Coma with slow respiration and pinpoint pupils is typical of opioid poisoning, give naloxone. The other points that point towards an opioid overdose in this question are:

• Friends who did not want to be interviewed by medical staff

• Reduced consciousness

• Low respiratory rate

• Needle track marks on his arm.

Any suspicion of a base of skull fracture should prompt a CT scan of the brain. The bleeding from the ear from the auditory meatus and rhinorrhoea are signs of basilar skull fracture.

SIGNS OF BASILAR SKULL FRACTURE :

Often a clinical diagnosis. One or more of the following may be seen:

• Bilateral orbital bruising confined to the orbital margin (‘Raccoon eyes’)

• Haemotympanum or bleeding from the auditory meatus

• Cerebrospinal fluid otorrhoea or rhinorrhoea

• Battle’s sign : Bruising over the mastoid process without local direct trauma.

The 4-hour paracetamol level is above the treatment line on the nomogram, so intravenous N-acetylcysteine should be given.

Paracetamol tablet = 500 mg, 12 tablets = 6 g of paracetamol. A significant overdose is > 75 mg/kg within 24 hours.

Management of paracetamol poisoning: N-acetylcysteine is the antidote for paracetamol overdose. 

Oral activated charcoal 1 g/kg can be used up to 1-hour post-ingestion of paracetamol if the dose is > 150 mg/kg in 24 hours. It reduces serum levels by limiting gastric absorption.

This patient took the paracetamol overdose 4 hours ago and has a critical level of paracetamol, therefore activated charcoal is not appropriate here. 

Blood to test on admission FBC, U&E, LFT, INR, venous blood gas, glucose, Serum paracetamol level at 4 hours post-ingestion.

N-acetylcysteine should also be started immediately.

Although infection, sepsis, severe sepsis, and SIRS are the correct terms to use, the best term in this case is septic shock. Septic shock is defined as severe sepsis with persistently low blood pressure which has failed to respond to the administration of intravenous fluids.

Adrenaline is by far the most important drug in anaphylaxis and should be given as soon as possible. This girl is 9 years old hence 0.3ml of adrenaline is appropriate for her age (6 to 12 years old).

Once adrenaline is administered, hydrocortisone and chlorpheniramine should follow.

ANAPHYLAXIS ALGORITHM:

1. ABC

2. Give high-flow oxygen

3. Lay the patient flat

4. Adrenaline (epinephrine) intramuscularly in the anterolateral aspect of the middle third of the thigh.

ANAPHYLAXIS FEATURES :

The onset is usually in minutes or hours.

Respiratory:

• Swelling of lips, tongue, pharynx, and epiglottis. The fear here is that it may lead to complete upper airway occlusion

• Lower airway involvement is similar to acute severe asthma e.g. dyspnoea, wheeze (bronchospasm), chest tightness, hypoxia, and hypercapnia

Skin :

• Pruritus, erythema, urticaria, and angioedema

Cardiovascular :

• Peripheral vasodilation and increased permeability cause plasma leakage from the circulation, thus causing hypotension and shock.

This is an orbital blowout fracture. The most common bone affected is the maxilla (orbital floor) followed by the ethmoid (medial wall). The diplopia on upward gaze is caused by impingement of the inferior rectus muscle.

If one takes more than an unknown amount of paracetamol, we admit Serum paracetamol concentration levels are attained at 4 hours post-ingestion if consumed > 150 mg/kg (or an unknown amount).

This patient has a scald.

Scalds and burns are graded and managed in the same way. Analgesia should be the first thing to be prescribed and this patient should then be referred to a specialized burn service.

Most of them would include the following criteria:

• More than 3% of total body surface area partial thickness burn

• Burns involving the face, hands, feet, genitalia, perineum, or major joints

• All deep dermal and full-thickness burns

• All burns associated with electrical shock or chemical burns

• All burns associated with non-accidental injury

• All burns with inhalation injury

His hands are involved and there is a significant amount of body surface area involved, so it would be appropriate to refer to a specialist burn service which is run by experienced burn surgeons. Hand burns are not to be taken lightly because inadequate management can result in a serious disability. 

This elderly woman has biliary sepsis probably due to a bile duct obstruction hence the upper right abdominal pain. As the urine dipstick is negative, it is unlikely that she has a UTI.

As she was never given IV fluids, we are unable to say that she has septic shock given that the term “septic shock” is defined as persistently low blood pressure which has failed to respond to the administration of intravenous fluids.

The very important term to note in this stem is “rigors”. Rigors are episodes of shaking or exaggerated shivering and are classically seen in 2 scenarios:

1. Bacteraemia such as seen in biliary sepsis or sepsis from pyelonephritis.

2. Malaria.

This is a classic case of anaphylaxis.

Administering 0.3 ml in 100U epinephrine intramuscularly would be the most immediate action as she is aged 6 to 12 years old.

From the stem, we can see that she has already been assessed which means the emergency team has already gone through the assessments for Airways, Breathing, and Circulation.

As she is fully conscious, her airway is likely patent and she does not need intubation.

The condition is frequently fatal due to the profuse bleeding that results from the rupture. By far the most common site for tearing in traumatic aortic rupture is the proximal descending aorta.

The classical findings on a chest X-ray of an aortic rupture will be widened mediastinum and a displacement of the trachea. A widened mediastinum occurs when a traumatic pseudoaneurysm changes the contour of the mediastinum or more frequently haemorrhage or haematoma occurs.

In this question, the examiners want you to know the basics of life-threatening emergencies:

ABC – airway, breathing, and circulation should always be addressed first.

This patient’s signs and symptoms fit in with heroin withdrawal. Early signs include a flu-like syndrome like muscle cramps, watering eyes, and a runny nose.

Other symptoms like agitation, sweating, and insomnia are also part of heroin withdrawal. Some may argue that symptoms of cocaine withdrawal may be similar and the runny nose in this stem may be from the persistent post-nasal drip indicating that the user snorts cocaine as their preferred method of ingestion.

This is also a valid explanation but we feel that heroin is still a more appropriate answer.

The history of rheumatoid arthritis tells you that she is more than likely to be taking NSAIDs to manage the pain. This is a risk factor for peptic ulcer which if perforated gives the signs and symptoms that she is describing.

Perforation of a peptic ulcer causes an acute abdomen with epigastric pain that may progress to generalized rigidity. Shoulder tip pain suggest is seen in perforation. A diagnosis is made by taking an erect abdominal/chest X-ray.

Air under the diaphragm gives the diagnosis of a perforation.

Please see Q-33

The most likely diagnosis in this case is likely to be a DVT.

A calf swelling with a positive Homan’s sign (pain when the ankle is dorsiflexed) is commonly seen in deep vein thrombosis (DVT) and popliteal cyst ruptures. Although there is no risk in the stem for a DVT, it is still more common than a popliteal cyst rupture. Popliteal cyst rupture can also cause calf pain and enlargement which is similar to a DVT.

However, popliteal cyst rupture would initially start with swelling and discomfort behind the knee (representing the popliteal cyst) which is then followed by rupture which results in pain and swelling in the calf that mimics DVT. Since there is no evidence of swelling and discomfort behind the knee, pick the more common condition of the two, which would be a DVT.

Imaging such as an ultrasound would differentiate between the two. Baker’s cyst (popliteal cyst) would present as a swelling behind the knee rather than a calf swelling and is generally asymptomatic though it may cause discomfort.

Achilles Tendon rupture would present with the patient giving a history of a ‘popping’ sound at the time of rupture with pain around the ankles and decreased plantar flexion.

The clinical picture here represents metabolic acidosis. This is likely from aspirin poisoning. With aspirin overdose, they initially hyperventilate leading to respiratory alkalosis.

The initial phase could last up to 12 hours. Following that, progressive metabolic acidosis occurs. This usually occurs around the 24-hour mark after ingestion for adults.

Paracetamol overdose may also cause metabolic acidosis in the early and late course of poisoning and thus paracetamol as an answer is not completely wrong.

However, aspirin overdose is a more recognized cause of metabolic acidosis compared to paracetamol.

Overdose of Enalapril (ACE inhibitor) or Diclofenac (NSAIDs) causes metabolic alkalosis and not acidosis.

Overdose of Benzodiazepines would cause respiratory acidosis. If suspecting metabolic acidosis do a blood gas.

N-acetylcysteine infusion should be started if there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration.

Activated charcoal should be considered if the overdose has been taken if the overdose has been taken within 1 hour.

Gastric lavage would always be the wrong answer when dealing with paracetamol poisoning. 

Discharge home only if ingestion of paracetamol is < 150 mg/kg in a patient with no hepatic risk factors.

Haemothorax:

• Blood accumulates in the pleural cavity

Clinical features:

Similar to that seen in traumatic pneumothorax, except for the following:

• Dullness to percussion over the affected lung

• Signs and symptoms of hypovolaemia if massive haemothorax

Investigations:

• Chest X-ray shows an increased shadowing on a supine X-ray, with no visible fluid level

Treatment:

• Oxygen

• Insert 2 large venous cannulas and send blood for cross-matching

• Evacuation of blood may be necessary to prevent the development of empyema; thus, a chest tube is needed and is often placed low.

Usually, the lung will expand and the bleeding will stop after a chest tube is inserted.

• Surgery to stop the bleeding is seldom required. The lung is the usual source of bleeding.

• Since it is a low-pressure system, the bleeding usually stops by itself.

A CT head would be appropriate. The initial GCS of 15 followed by a later GCS of 12 are suggestive of intracranial haemorrhage.

Please see Q-29

15 compressions to 2 breaths with the nose pinched is the answer.

For a child over 1-year-old, pinch the soft part of his nose closed with the index finger and thumb of your hand on his forehead when giving rescue breaths.

Please see Q-59

In case of anaphylaxis, adrenaline is given intramuscularly.

In reality, we would start IV fluids as soon as possible and get a crossmatch for a blood transfusion. Thus, many argue that option A blood transfusion would be correct. Although debatable, the question here does ask for the most appropriate initial management.

IV fluids would be more appropriate given that he is hypotensive and IV fluids would be more appropriate given that he is hypotensive and IV normal saline is readily available in the A&E departments. Packed RBC takes time as staff would need to call the blood transfusion lab and order blood.

This is a case of anaphylaxis.

Treatment should involve discontinuing the antibiotic, giving 100% oxygen, and maintaining the airway. Since there is evidence of shock and respiratory compromise, intramuscular epinephrine (adrenaline) should be administered.

Intravenous antihistamines such as chlorpheniramine 10 mg and hydrocortisone 100-200 mg are commonly prescribed as well as they reduce the severity and duration of symptoms.

If this patient, does not have an acute drop in his blood pressure and does not have airway swelling or evidence of respiratory difficulty, intravenous chlorpheniramine and hydrocortisone would suffice and we could withhold the adrenaline.

The person has suffered a blunt trauma on the left side of his chest and abdomen. When there is a history of road traffic accidents, the presence of bruises (especially over the left chest wall or left upper quadrant), abdominal distention, and cardiovascular compromise,

it is important to consider splenic injury. A splenic injury which includes a ruptured spleen is any injury to the spleen and it occurs commonly after a road traffic accident.

Other features to note in splenic rupture would be the falling blood pressure and the rising pulse. Abdominal tenderness and diminished bowel sounds are also seen.

Plain abdominal X-ray would show a loss of left psoas shadow and this is confirmed by a CT scan.

FAST scans in the emergency department setting have the potential to reveal free peritoneal fluid but while this is helpful, it should not delay CT imaging or surgical intervention.

Please see Q- 46

The question is testing your knowledge of your ABCs and nothing else. Pay attention to the way that the exam gives you a lot of information in the stem; this is designed to ‘waste your time’.

Many people end up failing the exam because of poor time management. This question has nothing to do with the fact that she underwent carotid stenting. All you need to pinpoint for this question is that this post-operative patient is going into shock.

The next most appropriate step would be to apply pressure on the point of swelling as it is most likely that there is a bleed beneath the swelling.

A subcapsular splenic haematoma as diagnosed by the preoperative CT scan is neither a predictor for delayed splenic rupture, nor by itself an indication for operative management of the injured spleen in a haemodynamically stable patient.

Observation would be the most appropriate action.

Focused abdominal sonography (ultrasound) for trauma (FAST) is regarded as the investigation of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma and it is regarded as the investigation of choice for unstable patients.

Free fluid in a haemodynamically unstable patient indicates the need for emergency laparotomy.

However, this patient is stable and does not warrant an immediate laparotomy.

The FAST scans are typically used to enhance the speed of trauma assessment, reduce the number of CT scans, and cut costs.

However, this patient has already had a CT scan, thus an ultrasound scan would not give any added information concerning an acute abdomen.

Solid organ injury in haemodynamically stable patients can often be managed without surgery but would require observation for a while before discharge.

Even though IV access has been established, the best treatment to resolve his hypersensitivity reaction is STILL intramuscular adrenaline.

A continuous generalized seizure lasting for more than 30 minutes has a high risk of cerebral damage. The first part of management is always to establish a clear airway.

Methadone is used to help combat withdrawal effects for opiate misusers. Methadone is an opioid medication and

it reduces withdrawal symptoms in people addicted to heroin. It does not cause the “high” associated with the drug addiction and thus it is especially helpful for opiate addicts to help them quit the drug addiction problem.

Blood taken before 4 hours is unreliable because the drug is still being absorbed and distributed. The N-acetylcysteine infusion does not need to be started unless the time of the overdose is unknown or has been staggered over a few hours. Initial symptoms are often limited to nausea and vomiting.

Activated charcoal should be considered if the overdose has been taken if the overdose has been taken within 1 hour.

Gastric lavage would always be the wrong answer when dealing with paracetamol poisoning.

N-acetylcysteine infusion should not be started until the blood test has been taken at 4 hours and results are above a single treatment line.

As this patient is conscious, we just need a tight-fitting mask with 100% oxygen.

Referral to a psychiatric team would be the most accurate option here. Acute alcohol consumption is an inhibitor of the P-450 enzyme system. Since she has consumed a large amount of alcohol acutely, the risk of fatal effects of paracetamol poisoning would be reduced.

Not to mention that her plasma paracetamol concentration is below the treatment line thus she does not need to start N-acetylcysteine. She does however need a psychiatric evaluation before she leaves the hospital as she was trying to harm herself.

This boy is having anaphylaxis which is a type of allergic reaction.

The other options are far less likely: Aspiration of food. Although this makes sense and many will choose this, aspiration for food will not account for the urticarial rash seen on this boy.

Diffuse Esophageal Spasms usually presents with intermittent chest pain and dysphagia.

The pain can simulate that of a myocardial infarction but bears no relationship with exertion. There is no relationship with eating, ruling out odynophagia. The pain can be precipitated by drinking cold liquids.

Achalasia presents with slowly progressive dysphagia. Initially worse for liquids than solids.

ECG monitoring for TCA overdose is essential.

The important ECG finding suggestive of TCA poisoning is QRS widening. Broad complex tachycardias may occur which are life-threatening.

Please see Q-46

Alcohol-induced hypoglycemia can present in this case.

Methadone is a synthetic opiate primarily used in the detoxification and maintenance of patients who are dependent on opiates—particularly heroin.

Cocaine overdose.

Tachyrhythmia, High fever, and perforated nasal septum are suggestive features of cocaine overdose. Other features include dilated pupils, chest pain, anxiety, delirium, paranoia, etc. Cocaine can even lead to death, which can occur due to a multitude of complications, including heart attack, seizure, and stroke.

This is opiate overdose. Due to their effect on the part of the brain that regulates breathing, opioids in high doses can cause respiratory depression and death.

An opioid overdose can be identified by a combination of three signs and symptoms referred to as the “opioid overdose triad”. The symptoms of the triad are pinpoint pupils, unconsciousness,  and respiratory depression.

Combining opioids with alcohol and sedative medication increases the risk of respiratory depression and death, and combinations of opioids, alcohol, and sedatives are often present in fatal drug overdoses.

Criteria for liver transplantation in paracetamol-induced acute liver failure.

Arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation, OR

If all three of the following occur in a 24-hour period: Creatinine >300 mol/L, PT >100 seconds (INR >6.5), Grade III/IV encephalopathy.

These are features of wernicke’s encephalopathy.

Short-term acute alcohol consumption causes enzyme inhibition as in the present case and even then paracetamol level is under treatment level. So the patient's drug level is on the safe side but simultaneous drug overdose and alcohol consumption needs psychiatric evaluation and hence the option here is A.

He is already alcohol dependent. 

SSRI has a well-known risk of developing suicidal ideation. Arrest and court involvement is also a risk factor and in a neglected person it is also a strong risk factor.

LSD

Wernicke’s encephalopathy. Triad of i) ophthalmoplegia ii) ataxia iii) confusion.

Smoking and alcohol excess can cause palpitation without any recognizable arrhythmia and for this, no treatment is required.

10 tablets of paracetamol is not a life-threatening toxic dose and simultaneous drug overdose and alcohol consumption need psychiatric evaluation.

Vit B complex

Agitation, nervousness, abdominal cramps, sweating, shivering and piloerection, and arthralgia these are features of heroin withdrawal.

Chlordiazepoxide.

The Drug of choice for withdrawal is chlordiazepoxide because of its long action. 
The dose depends on the grade of severity of withdrawal, which is calculated on the basis of the CIWA-Ar score (Not required, just for additional information). A short?acting benzodiazepine such as oxazepam or lorazepam may be used in individuals with impaired liver function.

Alcohol hallucinosis can occur during acute intoxication or withdrawal. It involves auditory and visual hallucinations, most commonly accusatory or threatening voices.

Electrolyte imbalance may cause confusion but not aggressiveness; infection toxicity will cause high fever, low BP, rash, etc which are absent here.

Abstinance from alcohol in the hospital caused delirium tremens (chronic alcoholism is supported by high MCV) here.

Young age and 1st year in university is likely to point towards drug abuse.

Abstinence from alcohol in the hospital leads to delirium tremens. 

Drug abuse with perforated nasal septum indicates cocaine abuse.

Evaluate patient's capacity to refuse treatment.

Withdrawal of alcohol due to hospital admission leads to delirium tremens.

Wernicke’s encephalopathy has a triad of :

i) mental confusion

ii) abnormal eye movements &

iii) unsteady gait.

Korsakoff's syndrome cannot be diagnosed until the person has stopped drinking alcohol for several weeks, to enable the immediate symptoms of alcohol intoxication and withdrawal to subside.

Features of Korsakoffs psychosis :

i) dementia, loss of short-term memory

ii) difficulty in acquiring new information or learning new skills

iii) personality change

iv) confabulation

Dementia, i.e. short term memory loss is seen in korsakoff psychosis.

A case of delirium tremens. Treated with benzodiazepines like chlordiazepoxide or diazepam.

Korsakoff's psychosis.

In Korsakoff psychosis there is confabulation (a memory disturbance is defined as the production of fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive) which may present like this.

This is a case of Wernicke’s encephalopathy which is treated with Vit B complex.

This is a case of Wernicke’s encephalopathy (as hospital admission prevented him from consuming alcohol) and the treatment for this is high potent vitamins.

In young it is unlikely to get oesophageal varices rather than the bleeding is from probable gastric erosion and an endoscopy should be done diagnostic and therapeutic- like sclerotherapy.

Repeated retching and vomiting is a recognized cause of Mallory-Weiss tear which is supported here by vomiting a cupful of blood.

As 4 hour paracetamol level is at critical level start IV N-acety cystiene at once.

Respiratory depression and miosis points towards opiates poisoning for which antidote naloxone is given.

Diagnosis is delirium tremens. So the following chlordiazepoxide thiamine is the appropriate next step.

Refer to social services

Disulfirum is a deterrent that makes alcohol intake unpleasant.

Methadone is an opioid medication.

Methadone reduces withdrawal symptoms in people addicted to heroin or other narcotic drugs without causing the "high" associated with the drug addiction and thus used to help a drug addict to quit from drug addiction.

Diagnosis is delirium tremens. Treatment is with chlordiazepoxide.

Presence of confusion and nystagmus indicates Wernicke’s encephalopathy caused by thiamin (vit. B1) deficiency.

If the patient stops alcohol without any supportive treatment there will occur withdrawal symptoms.

For the presented situation, Acamprosate can help by stopping alcohol without producing withdrawal symptoms by restoring brain chemical derangement caused by alcohol which is responsible for withdrawal symptoms.

Racing heart or palpitation is a common phenomenon in alcoholics which is not serious or harmful. So reassure the patient.

Patient is alcoholic.

On admission abstinence from alcohol caused this withdrawal symptom. Agitation, confusion, and picking at things are suggestive of delirium tremens which is treated with Chlordiazepoxide.

Methadone is a powerful synthetic analgesic drug which is similar to morphine in its effects but less sedative and is used as a substitute drug in the treatment of morphine and heroin addiction.

This is wernicke’s encephalopathy due to alcohol withdrawal, so Vit B complex should be given. This occurs mainly due to thiamine deficiency.

Disulfirum is a deterrent which does not reduce craving. Acramposate by restoring deranged brain chemical reduces craving.

The likely diagnosis is bleeding oesophageal varices which should be diagnosed by endoscopy and if needed stappling can be done with endoscope.

Methadone is eliminated from the body more slowly than naloxone.

chronic alcohol abuse that leads to temporary or permanent cerebellar damage.

Wait for 4h paracetamol level.

Referral for social worker 

If >8–24h and suspicion of large overdose (>7.5g) on the side of caution and start N-acetylcysteine, stopping it if the level is below the treatment line and INR/ALT normal.

Normal GCS makes intracranial lesions less likely. As there is a facial injury to exclude any facial bone fracture we can do a facial X-ray.

It is a case of rhabdomyolysis which is initially treated with IV NS.

Chest is clear, so there is no pneumothorax or pleural effusion.

Muffled heart sound is due to fluid in pericardial space, low BP from reduced chamber expansion due to pericardial fluid’s pressure and restricted right heart expansion causes raised JVP.

The three classic signs (Beck's triad) that indicate cardiac tamponade are: Low pressure in the arteries (hypotension) Bulging (distended) neck veins. Muffled heart sounds.

Secure airway

30-40%

Classification:

Class 1 up to 15% of blood volume lost

Class 2 15%-30% 

Class 3 30%-40% 

Class 4 greater than 40%.

Presence of stridor and wheeze are suggestive of anaphylaxis and the treatment option is IM adrenaline.

Tension pneumothorax.

Points in favour:

i) Stab wound in the back

ii) SOB

iii) Engorged neck vein

iv) Absent breath sound

Iit is also possible that he may have taken the drug, even though first we have to do serum glucose as low blood glucose can be very easily managed and it needs urgent management to save life. If it is excluded then we can look for other causes which may be not fatal in a short time.

Normal vital signs, sweating, and collapse during exercise give suspicion of hypoglycemia which is very easy to treat but fatal if left unrecognized. So the most important next step is to check the blood sugar

In pelvic fracture there is the chance of urethral rupture and hence displacement of the urethral catheter is likely while trying to place it.

As there is no neurological deficit we can exclude any fracture by X-ray first.

Diagonal x-ray means, oblique view of cervical spine. By this view, we can assess facet joint arthopathy. This isn’t related to RTA.

Probable fracture base of the skull.

Blood glucose

Probably impacted food bolus (usually meat) which can be visualized and removed with the aid of endoscopy.

Intubation. [ABC protocol]

Intubation and ventilation [ABC protocol].

Clear airway. [ABC protocol].

In blunt trauma there may be hemopneumothorax but in a sharp wound like stabbing there may occur only hemothorax.

There is no sign of basal fracture.

Panda sign is suggestive of basal fracture, not subconjunctival hemorrhage- unless posterior border of hemorrhage is not visible and no indication of CT scan (there are some criteria for CT scan which are not fulfilled here).

Initial GCS 15 followed by later GCS 12 are suggestive of intracranial hemorrhage. So the best investigation to be done is CT head.

The diagnosis is rhabdomyolysis. So IV fluid is the next appropriate step.

Acute compartment syndrome occurs after a traumatic injury such as a car crash.

The trauma causes severe high pressure in the compartment which results in insufficient blood supply to muscles and nerves.

Acute compartment syndrome is a medical emergency that requires surgery to correct.

If untreated, the lack of blood supply leads to permanent muscle and nerve damage and can result in the loss of function of the limb.

Urgent admission to ITU.

100% oxygen

The likely diagnosis is Rhabdomyolysis where renal failure occurs due to myoglobin (myoglobins are released after the breakdown of skeletal muscles).

IV fluids

Diaphragm rupture

Put airway. [ABC Protocol]

Organic brain damage

Intubation and ventilation

Breathing difficulty with cyanosis may indicate saliva, blood, foreign body (as denture), fall back of tongue etc. for which 1st action is to secure airway.

100% oxygen.

The most appropriate initial management is E. 100% oxygen. Oxygen saturation is low. So we have to give oxygen initially.

Check airway

Sudden onset of dysphagia to both liquid and solid and recent history of fitting denture suggests foreign body (denture) in oesophagus.

Elevate in the high sling for 2 days.

Extravasetion of blood caused this swelling along with inflammation for which the best option is to elevate in the high sling for 2 days which will help improve symptoms by gravitational shift of fluid from hand.

In flial chest multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. Pain, difficulty breathing, tachypnea and tender area of chest wall movement suggest flial chest.

Diaphragmatic rupture.

Bowel sound present on auscultation of the chest following RTA causing lower chest injury is suggestive of diaphragmatic rupture.

Traumatic rupture of the aorta.

A traumatic aortic disruption is caused by a rapid acceleration (or deceleration) causing a tear in the aorta. Normally this is immediately fatal, but those who survive may show a widened mediastinum on CXR.

This can be confirmed with CT scan or angiography of the aorta and requires prompt surgical correction. Stable the haemodynamics and surgical correction.

Haloperidol has autonomic side effects.