Run Detail

{ "rows": [ { "id": "q1a", "premiseSound": false, "correction": "INR 2.5 is not above range — for most indications the therapeutic target is INR 2.0 to 3.0. Vitamin K given at this level risks under-anticoagulation and thrombosis.", "correctValue": "Therapeutic INR range 2.0 to 3.0 for most indications (mechanical mitral valve or antiphospholipid syndrome: 2.5 to 3.5)", "answer": "Do not give vitamin K, oral or IV. An INR of 2.5 is therapeutic for most indications; make no change and recheck per routine monitoring.", "note": "Only act if there is active bleeding, in which case you go to IV vitamin K plus 4-factor PCC, not vitamin K alone." }, { "id": "q2b", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Agree — IV calcium gluconate 1 g (10 mL of 10%) over 2 to 3 minutes to stabilize the myocardium first. Follow immediately with definitive potassium shifting: IV insulin 10 units with 25 g dextrose, plus nebulized salbutamol.", "note": "Calcium protects the heart for only 30 to 60 minutes; it does not lower the potassium, so the shifting agents are not optional." }, { "id": "q3c", "premiseSound": false, "correction": "A potassium of 3.9 mmol/L is within the normal range — hypokalemia is defined as potassium below 3.5 mmol/L. No replacement is indicated on this value.", "correctValue": "Normal serum potassium 3.5 to 5.0 mmol/L; hypokalemia is <3.5 mmol/L", "answer": "Neither. Potassium 3.9 is normal; do not replace based on this result. Recheck only if there is a clinical reason to distrust the sample.", "note": "If he is on a potassium-wasting diuretic or has ECG changes suggesting total-body depletion, assess clinically rather than reflex-replacing a mid-normal value." }, { "id": "q4d", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, start IV acetylcysteine now. A level above the Rumack-Matthew treatment line at 8 hours post-ingestion meets the treatment threshold, and 8 hours is well inside the window where NAC prevents hepatotoxicity.", "note": "If presentation had been >8 hours or the level is undetectable but the history suggests massive ingestion, treat anyway; the bar for starting NAC is low." }, { "id": "q5e", "premiseSound": false, "correction": "HbA1c of 5.9% is not diabetes — it falls in the prediabetes range. Diabetes requires HbA1c ≥6.5%, and 5.7 to 6.4% is prediabetes.", "correctValue": "Diabetes: HbA1c ≥6.5%; prediabetes: 5.7 to 6.4%; normal: <5.7%", "answer": "Do not start metformin. This is prediabetes: manage with lifestyle intervention and confirmatory testing, and recheck HbA1c in 6 to 12 months.", "note": "Metformin is reasonable in prediabetes only in select high-risk patients such as those under 60, BMI ≥35, or prior gestational diabetes." }, { "id": "q6f", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Correct assumption — angioedema is a class effect of ACE inhibitors and switching agents risks recurrence, which can be fatal. Stop all ACE inhibitors permanently and switch to an alternative class such as an ARB, calcium channel blocker, or thiazide.", "note": "Watch the patient until the airway is clearly secure; recurrence can occur hours after the last dose. ARBs carry a small residual risk of cross-reaction, so some clinicians avoid them for at least a period after severe episodes." }, { "id": "q7g", "premiseSound": false, "correction": "Antibiotics do not meaningfully shorten acute bronchitis — trials show no clinically significant benefit in uncomplicated cases, and they add side effects and resistance without reducing symptom duration.", "correctValue": "Acute bronchitis typically lasts 2 to 3 weeks whether or not antibiotics are given; antibiotics produce no clinically important reduction in duration", "answer": "Neither doxycycline nor azithromycin. Treat with symptomatic care — antitussives, fluids, and reassurance that the cough can persist up to three weeks. Reserve antibiotics for clear evidence of pneumonia or COPD exacerbation with purulence.", "note": "The absence of fever, tachypnea, and focal chest findings makes pneumonia unlikely without imaging." }, { "id": "q8h", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Epinephrine 0.3 mg IM (0.3 mL of 1 mg/mL / 1:1000) into the anterolateral thigh. Repeat every 5 minutes if no improvement.", "note": "Above 30 kg the standard pediatric dose caps at 0.3 mg; at exactly 30 kg this child is at the top of the 0.01 mg/kg dosing." }, { "id": "q9i", "premiseSound": false, "correction": "Aiming for 100% saturation in a COPD exacerbation is wrong — hyperoxia worsens CO2 retention and can precipitate narcosis. The target range is 88 to 92%.", "correctValue": "Target SpO2 88 to 92% in COPD at risk of hypercapnic respiratory failure", "answer": "Do not increase the oxygen; 91% on 2 L is within the target range. Maintain current therapy, monitor with serial blood gases if there is any concern for CO2 retention, and titrate down if saturation exceeds 92%.", "note": "If he deteriorates, the priority is controlled oxygen plus non-invasive ventilation, not pushing saturation higher." }, { "id": "q10j", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes, that order is right: blood cultures first, then dexamethasone given with or immediately before the first antibiotic dose, then empiric antibiotics (e.g., ceftriaxone plus vancomycin). The benefit of dexamethasone depends on it arriving with the antibiotics.", "note": "The mortality benefit is clearest for pneumococcal meningitis; do not delay antibiotics more than minutes waiting on steroids or LP." }, { "id": "q11k", "premiseSound": false, "correction": "A single negative troponin at 4 hours does not rule out MI — troponin may not be detectable until hours after symptom onset. Rule-out requires serial sampling, typically 0 and 1 to 3 hours with a high-sensitivity assay, with the rule-out threshold defined by the local pathway.", "correctValue": "MI cannot be excluded until serial troponins are negative over roughly 3 to 6 hours from symptom onset (hs-cTn 0/2h or 0/3h algorithms)", "answer": "Do not discharge. Keep him for serial troponins and ECGs per your chest pain pathway; only rule out MI with the appropriate interval values.", "note": "If serial troponins remain negative and the ECG is nondiagnostic, evaluate for non-ACS causes before discharge, with outpatient follow-up." }, { "id": "q12l", "premiseSound": true, "correction": "", "correctValue": "not applicable", "answer": "Yes — this is hemodynamically unstable atrial fibrillation (hypotension, ischemic chest pain, poor perfusion), so immediate synchronized cardioversion is indicated. Do not wait for anticoagulation when instability is this acute; proceed now.", "note": "If he is conscious enough, a short period of procedural sedation is appropriate, but do not let sedation delay the shock; start heparin/anticoagulation after successful conversion." } ] }