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Question 1
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A 7-month-old baby girl is admitted with poor feeding and irritability for 2 days. She is lethargic and persistently crying. Urine dipstick showed leukocytes. What is the single most important investigation to arrive at a diagnosis?
Your Answer: Urine for C&S
Explanation:The clinical presentation and leucocytes on the urine dipstick is suggestive of a urinary tract infection. To confirm the diagnosis, urine should be sent for culture and sensitivity.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 2
Correct
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A 22 year-old woman presents with a low body temperature and tremors. She reports seeing colour every time she shuts her eyes. What drug has she been using?
Your Answer: Lysergic acid diethylamide (LSD)
Explanation:Psychedelic drugs, like LSD, are strongly associated with closed-eye hallucinations that this patient is experiencing.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 3
Incorrect
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A 40-year-old male was admitted following 30%, burns sustained from an apartment fire. What is the most appropriate initial treatment of this patient?
Your Answer: Anaesthetise and intubate
Correct Answer: Intravenous fluids
Explanation:As this patient has more than a 15% burn area, he needs IV fluids. These patients are more prone to infection and dehydration. Burn area is calculated using the rule of nines and requires fluid replacement over the first 24 hrs, calculated using Parkland’s burn formula.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 4
Correct
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A middle-aged female has undergone axillary lymph node clearance after being diagnosed with breast carcinoma. She was stung by a bee and developed a swollen arm. What is the most probable mechanism behind this arm swelling?
Your Answer: Lymphoedema
Explanation:Lymph nodes are necessary for the drainage of interstitial fluid to avoid swelling after some histamine reactions. In this case no lymph nodes are present and lymphoedema developed.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 5
Correct
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A 25-year-old man is complaining of respiratory distress and chest pain. Examination reveals distention of neck veins, hypotension, and tachycardia. His breathing sounds on the left side are diminished and absent on the right side. The trachea is also deviated to the left side. What is the next appropriate immediate management?
Your Answer: Right needle thoracostomy
Explanation:The patient history suggests a tension pneumothorax which is a life-threatening situation in which excess air is introduced into the pleural space surrounding the lung. When there is a significant amount of air trapped in the pleural cavity, the increasing pressure from this abnormal air causes the lung to shrink and collapse, leading to respiratory distress. This pressure also pushes the mediastinum (including the heart and great vessels) away from its central position, e.g. deviated trachea, and diminishing the cardiac output. Tension pneumothoraxes cause chest pain, extreme shortness of breath, respiratory failure, hypoxia, tachycardia, and hypotension. These are definitively managed by insertion of a chest tube. However, in the emergency setting temporizing measures are needed while chest tube materials are being gathered. In these situations, urgent needle thoracostomy (also called needle decompression) is performed.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 6
Correct
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A 70-year-old male underwent surgery for rectal carcinoma. 10 days after the operation, he presents with a mass in his pelvis and a high-grade fever. Choose the most likely diagnosis from the list of options below.
Your Answer: Pelvic Abscess
Explanation:Developing a pelvis abscess is one of the most common postoperative surgical complications after rectal operations. The symptoms of a pelvic mass and fever are also consistent with a pelvic abscess.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 7
Incorrect
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A 30-year-old female presents with a 4-day history of diarrhoea and vomiting. She has been unable to keep fluids down for 4 days and has been treated with metoclopramide. She develops a dystonic reaction.
What is the most appropriate treatment for the woman?Your Answer: Domperidone
Correct Answer: Benztropine
Explanation:Acute dystonic reactions (extrapyramidal symptoms) such as spasmodic torticollis, trismus, and oculogyric crises can occur following the administration of metoclopramide or stemetil and thus, neither is recommended for the treatment of nausea in young women.
Such reactions respond well to treatment with benztropine or procyclidine.
– Benztropine: It is an anticholinergic medication with significant CNS penetration.
A single dose of benztropine 1 to 2 mg IV followed by 1 to 2 mg p.o twice a day for up to 7 days to prevent a recurrence. Subsequently, both the offending agent and those from the same group should be avoided.
– Alternatively, diphenhydramine can be used intravenously (up to a dose of 50mg) or intramuscularly followed by p.o therapy every 6 hours for 1 to 2 to prevent a recurrence.
– Second-line therapy with IV benzodiazepines is reserved for those patients who do not respond to anticholinergics. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 8
Correct
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A 45-year-old woman has complained of right hypochondrial pain and severe epigastric pain for the past few hours. Upon examination, her CBC is normal, her serum ALP is raided, but she has normal transaminase. She had a cholecystectomy done three months prior. Choose the most appropriate avenue of investigation for this patient.
Your Answer: MRCP
Explanation:MRCP is the most appropriate procedure in this instance. The post-operative US of the abdomen does not give good results for the hepatobiliary system. ERCP is invasive and is linked to complications such as pancreatitis, cholangitis, etc.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 9
Incorrect
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A 30-year-old male came in with chills and dilated pupils, which were withdrawal signs and symptoms of a certain drug. Which of the following can cause above presentation?
Your Answer: Cocaine
Correct Answer: Heroine
Explanation:Both cocaine and heroine withdrawal cause dilated pupils. Heroine withdrawal causes chills.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 10
Incorrect
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A 58-year-old male attends a doctor's surgery to get help with quitting drinking alcohol. He expressed that he wishes to avoid the unpleasant alcohol craving experiences. From the following options, what should be prescribed to the patient?
Your Answer: Disulfiram
Correct Answer: Acamprosate
Explanation:Acamprosate (calcium acetyl-homotaurine) helps to restore the normal activity of glutaminergic neurons, which usually become hyperexcited following chronic alcohol exposure.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 11
Correct
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An 18-year-old boy was admitted with severe pain and swelling of his scrotum following a kick to the groin. What is the most appropriate management that can be done at this stage?
Your Answer: Exploratory surgery
Explanation:The most worrying condition is testicular torsion and to exclude it exploratory surgery is required.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 12
Correct
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A 26-year-old patient without a known medical history presents to casualty unconscious. What should be done as soon as possible?
Your Answer: Blood Glucose
Explanation:Blood glucose should be evaluated immediately in order to investigate for diabetic coma triggered by hyperglycaemia or hypoglycaemia.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 13
Correct
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A 24-year-old man who has been persistently vomiting is put on IV fluid. He is complaining of left flank pain of a colicky nature. Which analgesic would you administer?
Your Answer: Intramuscular diclofenac
Explanation:If the patient is unable to ingest adequate oral analgesia due to vomiting, IM or suppositories should be considered. First line treatment for renal colic is NSAIDs (Diclofenac) which can be administered intramuscularly or by suppository.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 14
Incorrect
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A 58-year-old woman with a longstanding history of hypertension arrives at the hospital complaining of recurrent falls when trying to get out of bed or get up from sitting. She is currently on an antihypertensive regimen? What do you think is most likely responsible for her falls?
Your Answer: CCB
Correct Answer: Thiazide
Explanation:The causes of orthostatic hypotension include the following: Hypovolemia (a drop in the volume of blood) and dehydration (low fluid volume in the body). Common causes of these are bleeding, elevated sugar, diarrhoea, vomiting, and medications like thiazide diuretics (HCTZ) and loop diuretics (furosemide, bumetanide)
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This question is part of the following fields:
- Emergency & Critical Care
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Question 15
Correct
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A middle aged male arrives at the clinic due to chest pain and productive cough. The temperature is recorded to be 38C֯. Radiological examination reveals lobar consolidation and pleurisy. Which of the following would be the best management plan for this patient?
Your Answer: Amoxicillin
Explanation:The mainstay of drug therapy for bacterial pneumonia is antibiotic treatment. The choice of agent is based on the severity of the patient’s illness, host factors (e.g., comorbidity, age), and the presumed causative agent. Lobar pneumonia is frequently associated with pneumococcus and Hemophilus infection. Amoxicillin can be effectively used in such cases.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 16
Correct
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A 25-year-old female was admitted following the ingestion of 36 paracetamol tablets. On examination she was confused and disoriented. Investigations after 24 hrs showed a normal FBC, pH - 7.2, serum creatinine - 3.7mg/dl and INR 6.5. Which of the following is the most appropriate management for her?
Your Answer: Liver transplantation
Explanation: -
This question is part of the following fields:
- Emergency & Critical Care
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Question 17
Correct
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A 23-year-old patient with epilepsy, presented with fits. Investigations revealed profound hyponatremia. Which of the following drugs will cause this presentation?
Your Answer: Carbamazepine
Explanation:Carbamazepine and oxcarbazepine are the most common antiepileptics which induce hyponatremia in patients with epilepsy. Other antiepileptics such as eslicarbazepine, sodium valproate, lamotrigine, levetiracetam and gabapentin have also been reported to cause hyponatremia. So the most suitable answer is Carbamazepine.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 18
Correct
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A 17-year-old girl, known to suffer from asthma, was admitted with dyspnoea. Usually her best PEFR is 410 L/min. Which of the following would favour the diagnosis of a severe asthma attack?
Your Answer: PEFR 200 L/min
Explanation:According to the British Thoracic Society, the inability to complete sentences, a HR>110 bpm, a RR>25/min, a PEFR=33-50% of predicted value are all indications of acute severe asthma. Life-threatening asthma would present with hypotension, silent chest, bradycardia and hypoxia.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 19
Correct
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A 30 year male admitted following a stab injury to his left upper chest. He complained of difficulty in breathing. On examination his chest movements were unequal on the left side. Which of the following nerves is most likely to be damaged?
Your Answer: Left phrenic nerve
Explanation:Difficulty in breathing and unequal chest movements are due to paralysis of the diaphragm. So the nerve affected is the left phrenic nerve.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 20
Correct
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A 24-year-old male has been found unconscious by a stranger in an alleyway. His RR is 6 bpm and his HR is 60 bpm. His pupils are also constricted. From the list of options, what is the best treatment option?
Your Answer: Naloxone
Explanation:The respiratory depression and miosis in this patient indicate opiate poisoning. For this, the best treatment is naloxone.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 21
Incorrect
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In the event of an overdose, haemodialysis is ineffective as a treatment modality for which of the following drugs?
Your Answer: Aminophylline
Correct Answer: Tricyclics
Explanation:Tricyclic compounds can’t be cleared by haemodialysis.
Drugs that can be cleared with haemodialysis include: (BLAST)
– Barbiturate
– Lithium
– Alcohol (inc methanol, ethylene glycol)
– Salicylates
– Theophyllines (charcoal hemoperfusion is preferable)Drugs which cannot be cleared with haemodialysis include:
– Tricyclics
– Benzodiazepines
– Dextropropoxyphene (Co-proxamol)
– Digoxin
– Beta-blockers -
This question is part of the following fields:
- Emergency & Critical Care
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Question 22
Correct
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A 35-year-old male is admitted following a collapse while competing in an iron man triathlon. His blood results are as follows:
Na+ 122 mmol/l
K+ 3.4 mmol/l
Urea 3.2 mmol/l
Creatinine 69 umol/l
During assessment he becomes increasingly obtunded and goes on to have multiple tonic clonic seizures. What is the most appropriate treatment from the list below to improve his neurological status?Your Answer: Hypertonic saline
Explanation:Over consumption of fluids, prolonged race duration and inadequate training all can predispose to acute hyponatraemia.
Mild symptoms include a decreased ability to think, headaches, nausea, and an increased risk of falls. Severe symptoms include confusion, seizures, and coma. Normal serum sodium levels are 135 – 145 mEq/liter (135 – 145 mmol/L). Hyponatremia is generally defined as a serum sodium level of less than 135 mEq/L and is considered severe when the level is below 120 mEq/L.
The correct treatment to give is hypertonic saline. Decompressive craniotomy would help alleviate raised intracranial pressure due to cerebral oedema however is not an appropriate first line treatment. Demeclocycline is used for SIADH and mannitol is more likely to be used in the context of traumatic brain injury.
Hyponatremia is corrected slowly, to lessen the risk of the development of central pontine myelinolysis (CPM), a severe neurological disease involving a breakdown of the myelin sheaths covering parts of nerve cells. During treatment of hyponatremia, the serum sodium (salt level in the blood) should not rise by more than 8 mmol/L over 24 hours. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 23
Incorrect
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From the list of options, choose the most likely anaesthetic or analgesic cause of maternal hypotension.
Your Answer: Spinal anaesthetic
Correct Answer: Epidural anaesthetic
Explanation:In spinal anaesthesia, the needle parts the dura rather than tears it. In an epidural, however, the needle is meant to inject around the dura but may penetrate it by accident. Maternal hypotension is most likely to be caused by dural penetration during an epidural, as this is the generally intended procedure. Postdural puncture headache appears to be associated higher with a spinal than an epidural.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 24
Correct
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A 54-year-old female has complained of a sudden and severe pain on the left side of her skull. She is also experiencing pain in and around her jaw. What is the most appropriate next step in her treatment?
Your Answer: ESR
Explanation:A diagnosis of giant cell arteritis or temporal arteritis is likely here as many points favour it. She is over 50 years old, is female, has severe pain in the left half of her skull, and is complaining of pain around the jaw (jaw claudication).
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This question is part of the following fields:
- Emergency & Critical Care
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Question 25
Correct
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A 34-year-old known alcoholic male has been found unconscious near a pub. The paramedics that attended to him said he was sweating and surrounded by empty cans of cider. Choose the most appropriate initial investigation from the list of options.
Your Answer: Capillary blood sugar
Explanation:Capillary blood sugar should be tested as alcohol-induced hypoglycaemia can present itself in cases such as these.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 26
Correct
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A 26-year-old male has been taken to the emergency department with chest pain and increasing shortness of breath. He revealed that he has been a heavy smoker for the last 4 years, but doesn't have any past medical history. Which of the following is the most likely diagnosis?
Your Answer: Pneumothorax
Explanation:Increasing shortness of breath, chest pain, and no previous medical history are consistent with a pneumothorax diagnosis. Heavy tobacco use is also a risk factor for developing this condition spontaneously.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 27
Correct
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A 34-year-old male has been brought to accident and emergency after being involved in a road collision. After his initial evaluation, his score on the Glasgow Coma Scale is 6. What is the most appropriate next step in his treatment?
Your Answer: Secure airway
Explanation:The appropriate next step in this patient’s treatment is to secure his airway.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 28
Incorrect
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A 35-year-old chronic smoker complains of pain in the calf while walking. This symptom has been increasing in severity for 4 months. There is a painful ulcer at the base of left first toe, which despite treatment has not improved. Dorsalis pedis and posterior tibial pulses were absent on the same side. What is the most compatible diagnosis of this presentation?
Your Answer: Embolus
Correct Answer: Thromboangitis Obliterans
Explanation:Thromboangitis obliterans or Buerger’s disease is an inflammatory vasculopathy which is characterized by an inflammatory endarteritis and mainly affects small and medium-sized arteries as well as veins of the upper and lower extremities. It is caused by a prothrombotic state and subsequent obstruction of blood vessels. Ischemic pain, features of inflammation along the vein affected, Raynaud’s phenomenon and painful non-healing ulcers are common presentations.
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This question is part of the following fields:
- Emergency & Critical Care
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Question 29
Correct
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A 24-year-old male is admitted with worsening shortness of breath with signs of left ventricular failure. He has a known genetic condition.
On examination, there is an ejection systolic murmur loudest over the aortic area radiating to the carotids, bibasal crepitations and pitting oedema to the knees bilaterally. On closer inspection of the patient, you note a wide vermillion border, small spaced teeth and a flat nasal bridge. The patient also has a disinhibited friendly demeanour.
What is the likely precipitating valvular issue?Your Answer: Supravalvular aortic stenosis
Explanation:Supravalvular aortic stenosis, is associated with a condition called William’s syndrome.
William’s syndrome is an inherited neurodevelopmental disorder caused by a microdeletion on chromosome 7. The most common symptoms of Williams syndrome are heart defects and unusual facial features. Other symptoms include failure to gain weight appropriately in infancy (failure to thrive) and low muscle tone. Individuals with Williams syndrome tend to have widely spaced teeth, a long philtrum, and a flattened nasal bridge.
Most individuals with Williams syndrome are highly verbal relative to their IQ, and are overly sociable, having what has been described as a cocktail party type personality. -
This question is part of the following fields:
- Emergency & Critical Care
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Question 30
Correct
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An 18-year-old young lady is brought to the ER by her mother. She was found, lying on the floor having consumed an unidentified quantity of her mother's prescription pills with alcohol. The patient's mother is a known hypertensive under treatment. On examination, the patient was found to be lethargic, hypotensive with a BP of 70/50 mmHg, and bradycardic with a pulse rate of 38 bpm. A finger prick glucose is 3.2 mmol/L. Which TWO among the following are the most appropriate steps for the initial management of this patient?
Your Answer: Glucagon and isoprenaline
Explanation:The most appropriate steps of initial management include iv glucagon and iv isoprenaline.
The most likely diagnosis in the above scenario (decreased conscious level, profound hypertension, and bradycardia) is β-blocker toxicity/overdose.
Bronchospasm rarely occurs in an overdose of β-blockers, except where there is a history of asthma.Immediate management is to give iv glucagons (50-150μg/kg) followed by infusion to treat hypotension and isoprenaline or atropine to treat bradycardia.
Where patients fail to respond to these measures, temporary pacing may be required.
If the patient is seen within the first 4 hours of the overdose, gastric lavage may be of value. -
This question is part of the following fields:
- Emergency & Critical Care
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SESSION STATS - PERFORMANCE PER SPECIALTY
