Q1. Which shock type characteristically presents with WARM peripheries and low systemic vascular resistance? A. Hypovolaemic B. Cardiogenic C. Distributive D. Obstructive ANSWER: C — Distributive. Why: vasodilation lowers SVR and keeps the peripheries warm and flushed. The other three cause compensatory vasoconstriction, so the patient is cold and clammy. LEARNING POINT: warm-versus-cold is the first and cheapest classifying question at the bedside.

Q2. The earliest reliable clinical sign of shock is: A. Hypotension B. Tachycardia C. Loss of consciousness D. Anuria ANSWER: B — Tachycardia. Why: the baroreceptor reflex raises heart rate first to defend cardiac output. Hypotension appears only once compensation fails. C, D: both indicate advanced, decompensated shock. LEARNING POINT: waiting for hypotension is how shock is missed.

Q3. A 26-year-old after blunt abdominal trauma: pulse 126, BP 114/94, cool peripheries, capillary refill 4 seconds. The most appropriate interpretation is: A. Not shocked — the blood pressure is normal B. Compensated hypovolaemic shock C. Neurogenic shock D. Early septic shock ANSWER: B — Compensated hypovolaemic shock. Why: the narrow pulse pressure (114/94) reflects a rising diastolic from vasoconstriction, alongside tachycardia and delayed capillary refill. Compensation is maintaining the systolic pressure — for now. A: the classic error the question is testing. C: neurogenic shock causes bradycardia and warm skin. D: no infective features, and the skin is cold. LEARNING POINT: a normal systolic with a narrow pulse pressure and tachycardia is shock, not reassurance.

Q4. A 70-year-old with anterior STEMI: BP 80/56, cold, JVP raised, bibasal crackles. Which is most likely to cause harm? A. High-flow oxygen B. A 1-litre crystalloid bolus C. Urgent reperfusion D. Continuous cardiac monitoring ANSWER: B — the fluid bolus. Why: this is cardiogenic shock. The raised JVP and crackles show the ventricle is already overfilled and failing; more volume worsens pulmonary oedema. C: reperfusion is the definitive treatment. A, D: appropriate supportive measures. LEARNING POINT: "shocked → give fluid" is wrong in cardiogenic and unhelpful in obstructive shock. Classify first.

Q5. A 32-year-old thrown from a horse, paraplegic: pulse 48, BP 76/42, warm dry skin. The most likely diagnosis is: A. Haemorrhagic shock B. Neurogenic shock C. Cardiogenic shock D. Septic shock ANSWER: B — Neurogenic shock. Why: loss of sympathetic outflow above ~T6 causes vasodilation with unopposed vagal tone, so the patient is hypotensive but BRADYCARDIC with warm dry skin. A: haemorrhage causes tachycardia and cold skin — but it must still be excluded, since both can coexist. C: would give a raised JVP and cold peripheries. D: requires an infective source and causes tachycardia. LEARNING POINT: hypotension WITH bradycardia after trauma is neurogenic shock until proven otherwise.

Q6. A 60-year-old with septic shock remains hypotensive after adequate fluid resuscitation. The next step is: A. Further large-volume fluid alone B. Start a vasopressor C. Withhold antibiotics until cultures return D. Give a blood transfusion regardless of haemoglobin ANSWER: B — start a vasopressor. Why: septic shock is defined by circulatory failure persisting despite adequate fluid resuscitation, and that is the point at which vasopressor support is indicated. A: continued indiscriminate fluid risks overload without correcting the vasodilation. C: antibiotics must never be delayed for cultures. D: transfusion is guided by haemoglobin and bleeding, not given reflexively. LEARNING POINT: the sepsis / septic shock distinction is what defines escalation.

Q7. A patient with brisk acute gastrointestinal haemorrhage has a haemoglobin of 13.4 g/dL on arrival. This means: A. Significant bleeding is excluded B. The result is unreliable and should be repeated at once C. Haemoglobin may be normal early in acute haemorrhage D. The patient has polycythaemia ANSWER: C — Hb may be normal early. Why: acute haemorrhage loses red cells and plasma in the same proportion, so the CONCENTRATION is initially unchanged. It falls later as fluid shifts and resuscitation dilute what remains. A: the dangerous conclusion this question tests. B: the result is accurate — it is the interpretation that must account for timing. D: unsupported by anything in the stem. LEARNING POINT: a normal haemoglobin never excludes significant acute bleeding.

Q8. A 55-year-old on long-term propranolol has a large upper GI bleed. Pulse 78, BP 92/70, cold peripheries. The heart rate is best explained by: A. The bleed is trivial B. Beta blockade preventing a compensatory tachycardia C. Neurogenic shock D. An accurate reflection of adequate perfusion ANSWER: B — beta blockade blunts the tachycardia. Why: beta-1 blockade prevents the reflex rise in heart rate, so the patient cannot mount the usual compensation. The cold peripheries, narrow pulse pressure and relative hypotension still indicate significant shock. A, D: dangerously wrong — the absent tachycardia is a drug effect, not evidence of stability. C: no spinal injury, and neurogenic shock gives warm skin. LEARNING POINT: medication can erase a cardinal sign. Always ask what the patient is taking before you reassure yourself with a normal heart rate.