An 18 year old woman has blurred vision for 24 hours and is seen in the Emergency Department. She has increased thirst and drinks 4 litres of water a day. She has lost 10 Kgs in weight in 6 weeks. Her temperature is 37.2°C, pulse rate 100 bpm, BP 90/50 mmHg, respiratory rate 30 breaths per minute and oxygen saturation 98% breathing air. Which is the most important initial investigation?

Correct Answer: C

Rationale: The most important initial investigation in this case is option C) Capillary glucose. This choice is correct because the patient presents with symptoms suggestive of diabetic ketoacidosis (DKA), a life-threatening complication of diabetes. The symptoms of blurred vision, polydipsia, weight loss, and vital signs such as tachycardia, hypotension, and tachypnea are all indicative of DKA. Measuring capillary glucose levels will help confirm the diagnosis of hyperglycemia, which is essential for prompt initiation of treatment to stabilize the patient's condition. Option A) Arterial blood gases could be considered to assess the acid-base status and electrolyte abnormalities associated with DKA, but capillary glucose is more specific and crucial for the initial diagnosis. Option B) Blood cultures are not indicated as the primary concern in this scenario is the management of DKA, and blood cultures are not typically the first-line investigation for this condition. Option D) Full blood count is not the most pertinent investigation in this case as it does not directly address the urgent need to confirm hyperglycemia and initiate appropriate treatment for DKA. In an educational context, understanding the importance of prompt and accurate diagnosis in psychiatric emergencies like DKA is crucial for healthcare providers. This case highlights the significance of recognizing and managing medical conditions that can present with psychiatric symptoms, emphasizing the need for a comprehensive approach to patient care in emergency settings. This rationale underscores the critical role of clinical reasoning and prioritization of investigations to ensure timely and effective interventions for patients in psychiatric emergencies.

Correct Answer: A

Rationale: In this scenario, the most appropriate initial drug to prescribe to a 50-year-old man admitted for alcohol detoxification is option A) Chlordiazepoxide. Chlordiazepoxide is a benzodiazepine that helps manage alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures that can occur during detoxification. Benzodiazepines are the first-line treatment for alcohol withdrawal due to their effectiveness in managing symptoms and preventing complications. Option B) Clomethiazole is not commonly used for alcohol withdrawal and has a more limited role in clinical practice compared to benzodiazepines like Chlordiazepoxide. Option C) Disulfiram is used as a deterrent to alcohol consumption rather than for managing withdrawal symptoms. Option D) Fluoxetine is an antidepressant and is not indicated as the initial drug for alcohol detoxification. In an educational context, understanding the appropriate pharmacological management of alcohol withdrawal is crucial for healthcare professionals working in psychiatric emergency settings. Benzodiazepines like Chlordiazepoxide play a key role in the safe and effective management of alcohol withdrawal, helping to prevent severe complications and ensuring the patient's safety during detoxification. It is important to consider the individual patient's needs, medical history, and risk factors when selecting the most appropriate drug for alcohol detoxification.

Correct Answer: D

Rationale: The correct answer is D) Reflex anoxic seizure. In this scenario, the 5-year-old boy experienced unconsciousness after a painful stimulus (running into the school desk). Reflex anoxic seizures are commonly triggered by sudden pain or fright, leading to a brief loss of consciousness. This type of seizure is more common in young children and is often mistaken for other conditions due to its sudden onset and association with specific triggers. Option A) Absence seizure is unlikely in this case because absence seizures typically present as brief staring spells without any preceding injury or pain. Option B) Febrile convulsion is less likely as it is usually associated with fever and occurs in younger children, typically between 6 months to 5 years of age, with a peak incidence around 18 months. Option C) Hyperventilation does not fit the presentation described and is more commonly associated with anxiety or panic attacks rather than sudden unconsciousness following a painful event. Educationally, understanding the different types of seizures and their triggers is crucial for healthcare professionals, especially in the emergency setting. Recognizing the specific characteristics of reflex anoxic seizures helps in accurate diagnosis and appropriate management, ensuring the child receives the necessary care promptly. It also highlights the importance of taking a detailed history, including the events leading up to the episode, to differentiate between seizure types and provide optimal care for the patient.

Correct Answer: C

Rationale: The most appropriate next management step for the 9-year-old boy with asthma who presents with a cough, worsening breathlessness, and is seen in the Emergency Department is option C: Intravenous magnesium sulfate infusion. Magnesium sulfate is a bronchodilator that can be effective in acute severe asthma exacerbations. It works by relaxing the smooth muscles in the airways, helping to open up the air passages and improve breathing. In this scenario, where the child is experiencing worsening breathlessness, administering magnesium sulfate intravenously can help alleviate the respiratory distress. Option A, intravenous aminophylline infusion, is not the best choice in this situation because aminophylline can have narrow therapeutic windows and may lead to toxicity if not carefully monitored. It is also not the first-line treatment for acute asthma exacerbations in children. Option B, intravenous hydrocortisone bolus, is an important treatment in asthma exacerbations, but it is typically used in conjunction with bronchodilators like magnesium sulfate. Corticosteroids help reduce airway inflammation and improve lung function over a longer period, whereas magnesium sulfate acts more quickly to relieve bronchospasm. Option D, intubate and ventilate, is a drastic measure that should only be considered if the patient's condition deteriorates to the point where they are unable to maintain adequate oxygenation despite other interventions. It is not the initial management step for a child with asthma presenting with cough and worsening breathlessness. In an educational context, understanding the appropriate management steps in a psychiatric emergency is crucial for healthcare providers working in Emergency Departments or urgent care settings. Proper assessment, timely intervention, and knowledge of evidence-based treatments are essential to ensure positive outcomes for patients experiencing acute asthma exacerbations.

Correct Answer: C

Rationale: In this scenario, the most appropriate next step in management is option C) Discuss the concerns of the intensive care team with the family. This option is the correct choice because it emphasizes the importance of open communication and collaboration with the patient's family in a psychiatric emergency situation involving status epilepticus and pneumonia. Discussing the concerns of the intensive care team with the family is crucial for several reasons. Firstly, it ensures that the family is informed about the patient's condition, treatment plan, and prognosis, which can help them make decisions in the best interest of the patient. Secondly, involving the family in the decision-making process fosters a sense of partnership and trust between healthcare providers and the patient's support system. Options A) Apply for a court order to withdraw treatment and B) Complete a Do Not Resuscitate (DNR) form are incorrect because they both involve making significant decisions about the patient's care without engaging the family or considering their perspectives. In a psychiatric emergency, it is important to involve the family as they can provide valuable information about the patient's medical history, preferences, and values. Option D) Follow the advice of the intensive care team is also not the most appropriate next step because it overlooks the importance of family involvement in decision-making. In psychiatric emergencies, collaborating with the patient's family can lead to more holistic and patient-centered care. Educationally, this question highlights the significance of family-centered care in psychiatric emergencies. It underscores the importance of communication, collaboration, and shared decision-making in providing optimal care for patients in critical situations. By selecting option C, healthcare providers can ensure that the patient receives comprehensive care that considers not only their medical needs but also their social and emotional well-being.