Run Detail

{ "rows": [ { "id": "q1a", "premiseSound": false, "correction": "An INR of 2.5 is not above range. The standard therapeutic target for warfarin (AF, VTE, most indications) is INR 2.0 to 3.0; only mechanical mitral valves and some high-risk states use 2.5 to 3.5. Vitamin K is not indicated for a therapeutic INR.", "correctValue": "Therapeutic INR target 2.0-3.0 (2.5-3.5 for mechanical mitral valve); vitamin K generally reserved for INR >10 without bleeding, or any INR with significant bleeding", "answer": "Do nothing to the dose. INR 2.5 is mid-therapeutic, and giving vitamin K would drop him subtherapeutic and make him hard to re-anticoagulate for days. Continue current dosing and recheck at the usual interval.", "note": "If he is bleeding, that changes management regardless of INR, but the treatment is then hold warfarin plus vitamin K and four-factor PCC, not vitamin K for the number alone." }, { "id": "q2b", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, agree. Give 10 mL of 10% calcium gluconate IV over 2 to 5 minutes for membrane stabilization, repeat in 5 to 10 minutes if ECG changes persist. Then shift potassium with 10 units IV insulin plus 25 g dextrose and nebulized salbutamol, and arrange removal (loop diuretic, binder, or dialysis depending on renal function).", "note": "Calcium does not lower potassium at all, so it buys minutes only; the insulin/dextrose must follow immediately, with glucose checks for the next few hours." }, { "id": "q3c", "premiseSound": false, "correction": "A potassium of 3.9 mmol/L is normal, not hypokalemic. The reference range is roughly 3.5 to 5.0 mmol/L; hypokalemia is below 3.5.", "correctValue": "Normal serum potassium 3.5-5.0 mmol/L; hypokalemia <3.5 mmol/L (severe <2.5)", "answer": "No replacement needed, oral or IV. Recheck only if there is a clinical reason such as diuretic titration or arrhythmia.", "note": "In an acute MI or on high-dose loop diuretics some teams target 4.0 or higher, but that is still a modest oral top-up, never IV for a level of 3.9." }, { "id": "q4d", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, start acetylcysteine now. At 8 hours post single acute ingestion the Rumack-Matthew nomogram is valid, and a level above the treatment line is a clear indication; do not wait for repeat labs. Start the standard IV regimen (150 mg/kg loading over 60 minutes, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours) and send LFTs, INR, and renal function.", "note": "The nomogram only applies to single acute ingestions with a known time between 4 and 24 hours; for staggered ingestions, unknown timing, or presentation after 8 hours with any doubt, treat empirically." }, { "id": "q5e", "premiseSound": false, "correction": "An HbA1c of 5.9% is not diabetes. The diagnostic threshold is 6.5% or higher (confirmed on repeat unless symptomatic with hyperglycemia); 5.7 to 6.4% is prediabetes.", "correctValue": "HbA1c ≥6.5% diagnoses diabetes; 5.7-6.4% is prediabetes; <5.7% normal", "answer": "Do not start metformin on this result and do not label him diabetic. Counsel on diet, weight, and exercise, and recheck HbA1c in 6 to 12 months or sooner if symptoms appear. Consider a fasting glucose or OGTT if you want a second measure now.", "note": "Metformin for prediabetes is a reasonable option in high-risk people (BMI ≥35, age under 60, prior gestational diabetes) but that is a shared decision, not a diagnosis of diabetes." }, { "id": "q6f", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Correct, you cannot. ACE inhibitor angioedema is a bradykinin-mediated class effect, so all ACE inhibitors are contraindicated for life after an episode. Document it as an allergy and switch to a different class.", "note": "ARBs are usually acceptable if there is a strong indication, with a small residual risk (a few percent) of recurrent angioedema; avoid neprilysin inhibitors (sacubitril) entirely." }, { "id": "q7g", "premiseSound": false, "correction": "Antibiotics do not meaningfully shorten uncomplicated acute bronchitis in healthy adults. The Cochrane review shows roughly half a day less cough on average, no reduction in activity limitation, and a higher rate of adverse effects; guidelines recommend against antibiotics in this setting.", "correctValue": "Cochrane meta-analysis: about 0.5 day shorter cough with antibiotics, no clinically meaningful benefit, NNH for adverse effects about 5; acute bronchitis cough typically lasts 2-3 weeks", "answer": "Neither. Tell her the cough will likely last two to three weeks, offer symptomatic relief (fluids, honey, antitussive if needed), and give clear return advice for fever, dyspnea, or worsening after day 10. No antibiotic.", "note": "Reconsider if she develops fever, focal chest signs, hypoxia, or has COPD, immunosuppression, or age over 65 with comorbidities, at which point pneumonia rather than bronchitis is the question." }, { "id": "q8h", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "0.3 mg IM, which is 0.01 mg/kg of 1 mg/mL (1:1000) epinephrine, so 0.3 mL. Repeat every 5 to 15 minutes if no improvement. If using an autoinjector, the 0.3 mg device is appropriate for a 30 kg child.", "note": "Maximum single dose is 0.5 mg; place the child supine or semi-recumbent with legs raised, give oxygen and fluids, and do not substitute antihistamines or steroids for epinephrine." }, { "id": "q9i", "premiseSound": false, "correction": "The target for a COPD exacerbation is not 100%. Patients with COPD are at risk of hypercapnic respiratory failure with liberal oxygen, and the target saturation is 88 to 92% (BTS, GOLD, and ATS/ERS guidance). Aiming for 100% worsens hypercapnia and acidosis and increases mortality.", "correctValue": "Target SpO2 88-92% in COPD exacerbation (versus 94-98% for patients not at risk of hypercapnia)", "answer": "Give no more oxygen. 91% on 2 L is within target, so leave the flow where it is and get an arterial or venous gas to check pCO2 and pH. If the saturation drifts below 88%, increase in small steps; if he is acidotic and hypercapnic despite controlled oxygen, escalate to non-invasive ventilation.", "note": "If a prior gas has shown he does not retain CO2, some teams relax the target to 94-98%, but the default on a ward without that information is 88-92%." }, { "id": "q10j", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Right order. Draw blood cultures immediately, then give dexamethasone 10 mg IV (0.15 mg/kg) with or just before the first dose of ceftriaxone 2 g plus vancomycin (add ampicillin if over 50 or immunocompromised). Do not delay antibiotics for imaging or LP; the LP can follow if there is no contraindication.", "note": "Continue dexamethasone every 6 hours for 4 days only if the organism is Streptococcus pneumoniae, and stop it if another cause is found; if antibiotics have already been given, starting steroids late adds little." }, { "id": "q11k", "premiseSound": false, "correction": "A single negative troponin at 4 hours from symptom onset does not rule out MI. Troponin rises over several hours, so rule-out requires serial measurements: 0 and 3 hours (or 0 and 6 hours) with conventional assays, or a validated 0/1-hour or 0/2-hour high-sensitivity pathway, plus a non-ischemic ECG and a low clinical risk score.", "correctValue": "Rule-out requires serial troponin at 0 and 3 h (conventional) or 0/1 h or 0/2 h (high-sensitivity) below assay-specific thresholds; single early value sensitivity is well below 100%", "answer": "Do not discharge yet. Repeat the troponin at the interval your assay's pathway specifies, repeat the ECG, and calculate a risk score such as HEART; discharge only if both troponins are negative, the ECG is non-ischemic, and the score is low.", "note": "A very-low single hs-troponin drawn 3 or more hours after onset with a normal ECG can be enough under some validated pathways, but at 4 hours with a conventional assay you still need the second sample." }, { "id": "q12l", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, cardiovert now. Hypotension, ongoing ischemic chest pain, and poor perfusion attributable to the tachycardia make this unstable AF, and synchronized DC cardioversion is first line: start at 120 to 200 J biphasic with sedation if time allows, and escalate if the first shock fails. Do not delay for rate-control drugs or anticoagulation.", "note": "Ask quickly whether the AF is actually the cause or a consequence of shock (sepsis, bleeding, tamponade) since cardioverting compensatory AF may not help, and give heparin as soon as feasible afterward." } ] }