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{ "rows": [ { "id": "q1a", "premiseSound": false, "correction": "INR 2.5 is not above range. For the vast majority of warfarin indications (VTE, atrial fibrillation, most mechanical valves) the therapeutic target is 2.0–3.0, so 2.5 is mid-range and therapeutic.", "correctValue": "Therapeutic INR range 2.0–3.0 for most indications; 2.5 is within range.", "answer": "No vitamin K is indicated. Continue the current warfarin dose and recheck INR in the usual interval. If the indication is a mechanical mitral valve (target 2.5–3.5), 2.5 is at the lower boundary and you would still not give vitamin K.", "note": "If the INR were truly supratherapeutic (e.g., >4.5 without bleeding, or >10), the route and dose of vitamin K would depend on bleeding risk, but that is not the situation here." }, { "id": "q2b", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Agree. IV calcium gluconate 10 mL of 10 % over 2–3 minutes is the correct first step to stabilise the myocardium. Follow immediately with 10 units regular insulin + 50 mL D50W to shift potassium intracellularly, and arrange definitive removal (dialysis, loop diuretic, or cation-exchange resin).", "note": "Calcium chloride is an acceptable alternative but is more caustic to veins; prefer gluconate unless a central line is in place. Recheck ECG and potassium in 30 minutes." }, { "id": "q3c", "premiseSound": false, "correction": "A potassium of 3.9 mEq/L is not hypokalemic. It falls squarely within the normal reference range.", "correctValue": "Normal serum potassium 3.5–5.0 mEq/L; 3.9 mEq/L is within range.", "answer": "No potassium replacement is needed. 3.9 is a normal value. Recheck only if there is a clinical reason (diuretics, GI losses, arrhythmia), but do not give oral or IV potassium for this number.", "note": "If he is on a loop or thiazide diuretic and you are concerned about a downward trend, a repeat level in 24 hours is reasonable, but a single 3.9 does not trigger replacement." }, { "id": "q4d", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, start N-acetylcysteine now. IV 21-hour protocol (150 mg/kg over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h) is standard in hospital. Do not wait for a second level.", "note": "Confirm the ingestion was truly a single acute event and the time of ingestion is reliable. If either is uncertain, treat as above the line. Check a baseline LFT and coagulation panel before the first bag." }, { "id": "q5e", "premiseSound": false, "correction": "HbA1c 5.9 % is not diabetes. It falls in the prediabetes range. Diabetes is diagnosed at HbA1c ≥ 6.5 %.", "correctValue": "Diabetes threshold HbA1c ≥ 6.5 %; prediabetes 5.7–6.4 %; normal < 5.7 %.", "answer": "Do not start metformin for diabetes. At 5.9 % this is prediabetes: the intervention is lifestyle modification (caloric reduction, ≥150 min/week moderate activity, weight management). Recheck HbA1c in 6–12 months.", "note": "Metformin may be considered in selected high-risk prediabetic patients (BMI > 35, age < 60, prior gestational diabetes) per ADA, but it is not indicated on the basis of a 5.9 % A1c alone." }, { "id": "q6f", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Correct—you cannot switch to another ACE inhibitor. Angioedema is a bradykinin-mediated class effect, and cross-reactivity between ACE inhibitors is high. Choose a different antihypertensive class (calcium-channel blocker, thiazide, or beta-blocker as appropriate).", "note": "ARBs carry a small residual risk (~1–2 %) of angioedema in patients with prior ACE-I angioedema; most guidelines advise avoiding ARBs as well, though the risk is far lower than with a second ACE-I. Document the reaction clearly in the chart." }, { "id": "q7g", "premiseSound": false, "correction": "Antibiotics do not shorten acute bronchitis. Over 90 % of acute bronchitis episodes are viral, and multiple meta-analyses (including Cochrane) show no clinically meaningful reduction in cough duration or complications from antibiotics in otherwise healthy adults.", "correctValue": "Cochrane review: no significant reduction in cough duration or complications with antibiotics for acute bronchitis in immunocompetent adults.", "answer": "No antibiotic. This is acute bronchitis, almost certainly viral. Treat symptomatically (NSAIDs, cough suppressant, fluids, humidified air) and advise return if fever > 38.5 °C develops, dyspnea worsens, or symptoms persist beyond three weeks.", "note": "The calculus changes if there are signs of a secondary bacterial process (focal consolidation, purulent sputum with fever > 3 days, immunocompromise, or comorbid COPD/heart failure), but a healthy 34-year-old with a clear chest and no fever does not meet that threshold." }, { "id": "q8h", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "0.3 mg IM (0.01 mg/kg × 30 kg) of 1:1,000 epinephrine into the anterolateral thigh. That is 0.3 mL of the 1 mg/mL ampoule. Repeat in 5–15 minutes if there is no clinical improvement.", "note": "Use the 1:1,000 (1 mg/mL) concentration, not the 1:10,000. If there is no response after two or three IM doses, escalate to IV epinephrine infusion with continuous cardiac monitoring and consider an anaesthesia/ICU call." }, { "id": "q9i", "premiseSound": false, "correction": "In a COPD exacerbation the oxygen target is 88–92 % SpO2, not 100 %. Aiming for 100 % risks worsening hypercapnia by increasing V/Q mismatch and blunting hypoxic ventilatory drive.", "correctValue": "Target SpO2 88–92 % in COPD exacerbation (BTS/NICE guideline).", "answer": "Do not increase the oxygen. 91 % on 2 L nasal cannula is within the 88–92 % target. Keep her at 2 L and obtain an ABG to assess for hypercapnia and acidosis.", "note": "If the ABG shows a rising pCO2 with pH < 7.35, initiate NIV (BiPAP). The 91 % is the number you want; chasing a higher saturation in a CO2-retainer can precipitate respiratory failure." }, { "id": "q10j", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, that is the correct order. Draw blood cultures first, then give dexamethasone 10 mg IV immediately before or concurrently with the first antibiotic dose (e.g., ceftriaxone + vancomycin). Do not delay antibiotics for a lumbar puncture if there is any concern for herniation or delay.", "note": "Dexamethasone is only effective if administered before or with the first antibiotic dose; once antibiotics have been given, do not start it. It is specifically indicated for suspected pneumococcal meningitis—stop it if cultures return a different organism or if the diagnosis is revised." }, { "id": "q11k", "premiseSound": false, "correction": "A single negative troponin at presentation does not rule out MI. Troponin typically begins to rise 3–6 hours after the onset of myocardial injury, so a value drawn at 4 hours may still be in the window before detectable elevation.", "correctValue": "Troponin rise begins 3–6 h after symptom onset; a single negative value at 4 h does not exclude evolving MI. Serial troponins (0 h and 3 h with high-sensitivity assay, or 0 h and 6 h with conventional) are required.", "answer": "No, do not discharge. Repeat the troponin at 3 hours (high-sensitivity) or 6 hours (conventional assay) and obtain a 12-lead ECG now. If serial troponins are negative and the ECG shows no ischaemic changes, discharge with a low threshold for re-evaluation is reasonable.", "note": "If the initial ECG shows ST-segment deviation, the pain is ongoing, or there are high-risk features (diabetes, prior MI, heart failure), the threshold to admit for observation is lower regardless of a single negative troponin." }, { "id": "q12l", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, synchronized cardioversion now. This is a haemodynamically unstable tachyarrhythmia (SBP 78, ischaemic chest pain, poor peripheral perfusion). Start at 200 J biphasic for atrial fibrillation. Do not delay for rate-control drugs.", "note": "If the patient becomes pulseless or severely obtunded, switch to unsynchronized defibrillation. Although the thromboembolic risk of cardioverting AF of unknown duration is real, instability takes priority; start therapeutic anticoagulation as soon as feasible after the procedure." } ] }