Emergency Medicine

Theme:Breathing
AIntubation
BIV coamoxiclav
CIV penicillin
DMask ventilation
EOral erythromycin
FOropharyngeal airway
GOral penicillin V
HOxygen via facemask
IOxygen via headbox
For each scenario choose the most
appropriate mode of immediate
management:
A 3 month old boy presents with a 3d
history of coryza, cough and progressive
difficulty in feeding. Respiratory rate is
60/min with moderate recession, wheeze
and crackles. Heart rate is 150/min, good
peripheral perfusion. Oxygen saturation
is 88% on air.
Correct
The 3 month old child has bronchiolitis,
is hypoxic and requires oxygen. This is
best provided by headbox or nasal
prongs.
A 6 week old boy presents with bilateral

purulent conjunctivitis and difficulty in
breathing. Respiratory rate is 50/min,
mild recession. Heart rate is 120/min.
Osygen saturation is 94% on air.
Correct
The 6 week old boy has chlamydia
pneumonitis and conjunctivitis, is not
hypoxic, and requires erythromycin.
A 3-year-old boy presents with fever and

breathing difficulty. On examination he
has a respiratory rate of 45/min, painful
inspiration, and crackles at the right base.
Oxygen saturations are 93% on air and
temperature is 38.9oC.
Correct
The 3-year-old boy has bacterial
pneumonia with focal consolidation,
most likely pneumococcal. IV penicillin
is the treatment of choice.
Theme:Blood gas analysis

AMetabolic acidosis - acute, normal
oxygenation
BMetabolic acidosis - acute with
hypoxaemia
CMetabolic acidosis - compensated,
normal oxygenation
DMetabolic alkalosis - acute, normal
oxygenation
EMetabolic alkalosis - acute with
hypoxaemia
FMetabolic alkalosis - compensated,
normal oxygenation
GNormal blood gases
HNormal ventilation with hypoxaemia
IRespiratory failure - acute
JRespiratory failure - compensated,
normal oxygenation
KRespiratory failure - compensated with
hypoxaemia
For each of the following blood gas
results, select the most appropriate
designation from the list of options. The
line labelled Oxygen concentration
represents the concentration of oxygen
that each individual is inhaling; Normal
values are:
PaO2 kPa 12.0 - 14.7
PaO2 mmHg 90 - 110
PaCO2 kPa 4.5 - 6.0
PaCO2 mmHg 34 - 45
pH 7.36 - 7.44
H + molarity nmol/l 35 - 45
Bicarbonate mmol/l 24 30
pO2 10.0 kPa(80 mmHg); pCO2 5.8kPa
(44mmHg); pH 7.24; H+ molarity
57nmol/l Bicarbonate 18mmol/l; Base
Excess -7mmol/l; Oxygen concentration
40%
Correct
The low pH with low bicarbonate
indicates a metabolic acidosis, and the
low normal O2 on inspired [O2]
indicates hypooxaemia. This may occur
with poisoning and associated respiratory
failure.
pO2 6.7kPa( 50mmHg); pCO2 10.1kPa

42nmol/l Bicarbonate 42.4mmol/l; Base
Excess +14mmol/l; Oxygen
concentration 21%
Correct
This is the typical feature of a corrected
respiratory failure with hypoxaemia. The
PaO2 is low, the PaCO2 is high, with
raised bicarbonate indicating renal
correction and a high base excess

30nmol/l Bicarbonate 39mmol/l; Base
Excess +14mmol/l; Oxygen
concentration 30%
Incorrect - The correct answer is

Metabolic alkalosis - acute, normal
oxygenation
Metabolic alkalosis, for example in a
patient with severe vomiting, is
characterised by a high pH, high
bicarbonate and a raised base excess.

76nmol/l; Bicarbonate 29.5mmol/l; Base
21%
Correct
There is a type 2 respiratory failure with
Hypoxia, hypercapnia and acidosis with
a normal bicarbonate, indicating an acute
respiratory failure, for example in severe
asthma or pneumonia. .
pO2 16.3 kPa( 122mmHg); pCO2 7.5

kPa (56mmHg); pH 7.26; H+ molarity
55nmol/l Bicarbonate 24.1mmol/l; Base
75%
Correct
There is an acidosis with a normal

bicarbonate, and hypercapnia, on high
flow O2. This is the picture of acute
respiratory failure often found in patients
with chronic obstructive airways disease
who have lost their hypoxic drive and
have been given high concentrations of
O2.
Theme:Trauma management
ACT Scan head
BEndotracheal intubation
CIntercostal drain
DLaparotomy
ELarge bore IV Access and fluid
resuscitation
FLog roll and rectal examination
GNeedle Cricothyroidotomy
HNeedle decompression
IPressure dressing
JThoracotomy
Select the most appropriate management
step from the list above for the following
patients:
A 25-year-old male was brought into the

A and E following a motorbike accident.
He was found unconscious lying prone
about 25 meters from the bike. He had
been intubated at the site. His neck was
protected with a collar. He was being
mechanically ventilated with 100%
oxygen in A and E. He had a thready
pulse of 100/min, Blood pressure of
70/50, SaO2 of 90%. Trachea is central
but air entry is decreased on the left side
with a tympanic note on percussion.
Correct
A 20-year-old female horse rider was

brought into A and E on a spinal board
having fallen of her horse. She was
complaining bitterly about being
restrained on the spinal board because
her back was hurting. On examination,
she had a pulse of 120/min, blood
pressure of 84/30 mmHg, normal chest
examination. Abdominal examination
showed a bruise and tenderness on her
left hypochondrium and lumbar regions.
She had a decreased sensation below her
knees and she couldnt move her toes.

Large bore IV Access and fluid
resuscitation
A 55-year-old male was admitted after

having a high speed accident in his car.
He was found with his head on the
steering wheel. His airway was patent,
neck protected with appropriate collar
and IV access secured. His primary
survey revealed severe facial injuries,
Glasgow Coma Scale of 13/15 and
probable pelvic and bilateral femoral
fractures. During secondary survey, his
respiration was noted to be laboured with
gurgling sounds and GCS suddenly
dropped to 6/15.

Endotracheal intubation
In situations of trauma, it will help to remember ABCDE. UNDER ALL CIRCUMSTANCES
MANAGEMENT OF AIRWAY COMES BEFORE BREATHING; BREATHING BEFORE
CIRCULATION; CIRCULATION BEFORE DYSFUNCTION/ DISABILITY. The answers to above
scenarios are based on this principle.
Clinically this young male in an RTA has a pneumothorax on the left side. The immediate treatment of
this is needle thoracotomy/decompression buying time for a more definitive insertion of an intercostal
drain. The female involved in a horse riding accident probably has a spinal injury and may also have a
splenic haemorrhage but before proceeding further she needs venous access and fluid resuscitation. The
55-year-old male has developed an airway problem and so needs definitive airway management prior to
urgent CT headscan.
Theme:Oxygen therapy
A24% oxygen
B24% oxygen and antibiotics
C24% oxygen and intravenous
furosemide
D24% oxygen and nebulised
bronchodilators
E24% oxygen, antibiotics and nebulised
bronchodilators
F24% oxygen, diamorphine and
intravenous furosemide
G60% oxygen
H60% oxygen and antibiotics
I60% oxygen and intravenous
furosemide
J60% oxygen and nebulised
bronchodilators
K60% oxygen, antibiotics and nebulised
bronchodilators
L60% oxygen, diamorphine and
intravenous furosemide
For each of the following clinical
situations, select the most appropriate
option for immediate management from
the list above
An 18-year-old woman with a previous

history of asthma develops acute
dyspnoea following a row with her
boyfriend. On examination she is
tachypnoeic and distressed, with
widespread wheezes.
Correct
This young woman has severe asthma

and needs nebulisers and high
concentration of oxygen.
A previously healthy 24-year-old man

presents with acute dyspnoea, left sided
and and cough productive of green
sputum tinged with blood. On
examination he is pyrexial and looks ill,
with signs of consolidation at the left
lung base but no wheezes.

60% oxygen and antibiotics
This is a young man with a lobar
pneumonia with systemic sepsis. He
should receive high flow oxygen and
intravenous antibiotics.
A 68-year-old smoker presents with

acute shortness of breath, on a
background of chronic productive cough.
On examination he is centrally cyanosed
and pyrexial, with widespread crackles
and wheezes

24% oxygen, antibiotics and nebulised
bronchodilators
The history suggests chronic bronchitis
with acute exacerbation and chronic CO2
retention should be suspected.. This man
may have Type 2 respiratory failure with
CO2 retention. High flow Oxygen may
suppress his respiratory drive. Nebulisers
and antibiotics should be standard given
the pyrexia and chest signs.
A 55-year-old man develops sudden

onset of right sided chest pain and
dyspnoea in Terminal 2 of Manchester
Airport on arrival from Hong Kong. On
examination he is ill, cyanosed and
apyrexial. There are no localising signs
on chest examination
Correct
The history is suggestive of Pulmonary
Embolism. The immediate management
would be high flow O2. Heparin should
be commenced whilst a definitive
diagnosis is being sought. 5 The history
of coronary artery disease, and
presentation with pink frothy sputum,
would suggest left ventricular failure and
pulmonary oedema. Diamorphine, IV
diuretic and high dose O2 is the
immediate treatment. IV Nitrates (or
sublingual GTN) are also an option.
A 57-year-old man is on the waiting list

for coronary artery bypass grafting; he
develops acute dyspnoea and cough with
frothy pink sputum. On examination he
is tachypnoeic and distressed, with
profuse basal crackles but no wheeze.
Correct
Acute Asthma requires high dose O2 and
bronchodilators, along with IV
hydrocortisone.
Principle of oxygen therapy in

respiratory failure...
Theme:Complications of fractures
AAvascular necrosis
BCompartment syndrome
CFat emboli
DGangrene
EHaemorrhagic Shock
FMal-union
GOsteoarthritis
HOsteomyelitis
IRhabdomyolysis
JTetraparesis
KVenous thromboembolism
From the above list, select the most
likely complication that accounts for
each of the following cases:
A 26-year-old male receives lower leg
injuries playing rugby. On examination,
he has a pulse of 120 bpm, a blood
pressure of 90/60 mmHg and he has a
compound fracture of both tibias.
Correct
This case has features of shock with
tachycardia and hypotension a
consequence of large quantities of blood
loss associated with the fracture.
A 24-year-old male sustains a forearm

injury but fails to attend for medical
attention until the following day when he
presents with forearm pain, swelling and
an inability to flex the wrist.

Compartment syndrome
The patient has developed a forearm
compartment syndrome as a consequence
of swelling and increased pressure of the
muscles within the fascial compartment.
A 40-year-old male receives a compound

fracture of his left tibia after falling from
a ladder. He undergoes internal fixation.
However, several months after discharge
from hospital, the patient is aware of a
breakdown of skin overlying the tibia
and a persistent discharge.

Osteomyelitis
This case has a discharging sinus months
after a compound fracture. This would
suggest an underlying osteomyelitis.
A 33-year-old male injures his hand

whilst playing rugby. He attends casualty
but leaves after waiting 2 hours without
obtaining medical advice. He represents
three months later with pain at the base
of the thumb and painful movements of
the thumb.

Avascular necrosis
The patient has fractured his scaphoid
and has developed avascular necrosis of
the scaphoid.
A 55-year-old male is admitted after

falling from his horse. Examination and
investigations confirm a fractured pelvis.
Hours later he becomes dyspnoeic, with
a pulse of 120 beats per minute and a
blood pressure of 100/70 mmHg and a
fall in oxygen saturation to 86%. He is
aware of small petechiae.
Correct
This case has developed dyspnoea hours
after sustaining a pelvis fracture. This is
too early for thromboembolism but, in
the presence of the petechiae would
suggest fat embolism.
Theme:Back pain
AAbdominal aortic aneurysm
BAchalasia of the oesophagus
CAcute prolapsed intervertebral disc
DAnkylosing spondylitis
EChronic low back pain
FChronic pancreatitis
GCostochondritis
HDissection of thoracic aorta
IMetastatic prostatic carcinoma
JMultiple myeloma
KMyelomeningocoele
LNeurofibroma
MOsteomalacia
NOsteoporotic vertebral collapse
OPaget s disease of bone
PPleural effusion
QPsoriatic arthropathy
RStaghorn calculi
SSyringomyelia
TTuberculosis
UUric acid arthropathy
The following patients present to the
casualty department with back pain.
What is the most likely diagnosis from
the list of options given above?
Normal values: serum corrected calcium
2.15 - 2.65mmol/l, creatinine
<110mol/l
A previously healthy 75-year-old white
woman presents with acute onset of
severe pain over the mid-thoracic spine.
Examination reveals localised tenderness
over T5. Serum calcium and alkaline
phosphatase are normal, and ESR is

20mm in the first hour.
Correct
The most likely diagnosis is an
osteoporotic vertebral collapse in a
female of this age with a normal calcium
and alkaline phosphatase, with only a
mildly raised ESR, which may be normal
for this age group.
A 30-year-old Asian woman complains

of poorly localised pain in the shoulders
and pelvis. Examination reveals no
localising signs. Serum corrected
calcium is 2.1mmol/l, the alkaline
phosphatase is raised, and ESR is 10mm
in the first hour
Correct
Osteomalacia is relatively common in
Asian females. The alkaline phosphatase
is raised, the calcium low or normal,
with a low serum phosphate. Bone pain
can be due to subclinical fractures.
A 68-year old white man has been

unwell for 3 months and develops pain
over the thoracic spine. On examination
there is evidence of recent weight loss;
there is tenderness over T10. Serum
corrected calcium is 3.3mmol/l,
creatinine is 350mol/l, and ESR is

Multiple myeloma
Multiple Myeloma presents commonly in

this age group, and slightly more
commonly in males. Tenderness over
T10 indicates vertebral collapse
secondary to lytic bone lesions. Renal
failure may be secondary to
hypercalcaemia, hyperuricaemia or
dehydration. A markedly elevated ESR is
common, due to the presence of
paraprotein in the serum.
A 30-year old white man complains of

chronic pain in the lumbosacral region.
Examination reveals tenderness over the
sacro-iliac joints and restricted range of
spinal movements. Serum corrected
calcium is 2.3mmol/l, alkaline
phosphatase is normal, and ESR is
Correct
Serum calcium and alkaline phosphatase
are normal in Ankylosing spondylitis.
The ESR is often elevated. Restricted
range of lumbar lateral flexion is often
an early feature, and ankylosing
spondylitis usually presents below the
age of 40.
A 66-year-old man presents with a

fracture of the right hip after suffering a
fall in the kitchen at home. In addition to
the fracture, the hip X-ray shows
multiple well-defined lytic lesions in the
pelvic bones and the femur. Urinalysis
shows heavy proteinuria.
Correct
Again Myeloma is the most likely

diagnosis in this case. Metastatic prostate
carcinoma may present with lytic lesions
and pathological fractures, but would not
cause proteinuria, which in this case is
likely to indicate Bence-Jones protein.
Read up about back pain...
Theme:Treatment of cardiological
patients
AAspirin
BDigoxin
CDC cardioversion
DIntravenous morphine
EIntravenous naloxone
FIntravenous verapamil
GInsertion of chest drain
HOxygen therapy only
IPulmonary embolectomy
JPericardial drainage
KWarfarin
For each patient, what is the most
appropriate treatment?
A 72-year old man with ischaemic heart
disease complains of feeling faint for the
past hour. He is pale, sweaty and
hypotensive. His ECG shows a regular
tachycardia of 180 beats/min with QRS
duration 0.20 secs.
Correct
The first case has underlying IHD with a
regular tachycardia of 180 and shows
evidence of distress this suggests VT
and the most appropriate treatment
would be DC cardioversion.
A 64-year old woman with known atrial

fibrillation treated with digoxin attends
your surgery complaining of transient
loss of vision in the left eye which
recovered spontaneously.
Correct
The second case has had amaurosis
fugax and requires anticoagulation in the
form of warfarin.
A 73-year old man with known

carcinoma of the bronchus becomes
increasingly short of breath over the past
few days. The chest x-ray shows an
enlarged heart shadow but no pulmonary
oedema.
Correct
The third case has a bronchial carcinoma
with a pericardial effusion.
Pericardiocentesis would be most
appropriate.
A 23-year old man is seen in the

Emergency Department with 20%
pneumothorax of the right lung. His
blood pressure and pulse are stable.

Oxygen therapy only
The fourth case has a stable
pneumothorax and observation with
Oxygen therapy is all that is required.
A 75-year old woman with chronic

obstructive pulmonary disease is brought
to the Emergency Department, semiconscious and cyanosed. One week ago
she was given a new drug relief of
symptoms from osteoarthritis. She has
bilateral pin-point pupils.
Correct
The history in the final case suggests
opiate use and naloxone would be
appropriate.
Theme:Signs of life
ABarbiturate coma
BBrain stem death
CCardiac arrest with agonal rhythm
DClinical diagnosis of death
EPulseless Electrical Activity
FHypothermia
GHypoxic cerebral depression
HRigor mortis
ISudden cardiac arrest
JVentricular tachycardia
You are called to a cardiac arrest on the
medical admissions unit. For each of the
given situations, indicate the most
appropriate diagnosis from the list of
options:
A patient on a medical ward is known to
have carcinomatosis; there are no signs
of life

Clinical diagnosis of death
A patient has been pulled out of a lake,

and has a deep body temperature of 28.1
o C; the femoral pulses are not palpable
Correct
A patient has been found in bed with a

deep body temperature of 22.1 o C; the
arms and legs are stiff
Correct
A patient has been in cardiac arrest for

15 minutes; the ECG appears to show a
relatively normal sinus rhythm

Pulseless Electrical Activity
A patient has been in cardiac arrest for

10 minutes; the ECG shows wide regular
complexes at a fast rate.

Ventricular tachycardia
The patient with carcinomatosis, when all other options to this question are considered is most likely to
have a clinical diagnosis of death. Drowning is associated with hypothermia and the femoral pulses are
not palpable due to pulseless electrical activity. A patient found with no vital signs of life with stiff
limbs,i.e. rigor mortis, is likely to have been dead for some considerable time. When a relatively normal
rhythm is present on the monitor in a cardiac arrest situation, pulseless electrical activity must be
considered. The most likely cause of wide, regular complexes in a patient in cardiac arrest is ventricular
tachycardia. Other causes of wide complexes in this situation could be hyperkalaemia, Bundle Branch
Block (e.g. in presence of myocardial infarction) or ST elevation giving the appearance of widened QRS
complex
Theme:Substance abuse
AAspirin
BBarbiturates
CBenzodiazepines
DCannabis
ECocaine
FEcstasy
GHallucinogenic Mushrooms
HMethanol
IOpiates
JSolvent abuse
KTricyclic antidepressants
From the above list select the drug that is
most likely to be responsible for the
presentation of the following cases:
An 18-year-old female is brought to
casualty after collapsing in a night club.
Her friends state that she has taken
unknown substances during the night and
has been hyperactive. She is
hallucinating and has a Glasgow Coma
Scale of 15. Her temperature is 38.5C,
she appears dehydrated, she has a pulse
of 110 beats per minute and a blood
pressure of 110/70 mmHg. Respiratory
rate is 22/minute and she has saturations
of 99%.
Correct
This young girl has been out clubbing
and presents with hyperactvity,
dehydration together with generally nonspecific signs but slight hypertension
suggest amphetamine use. This is most
likely to be ecstasy - MDMA. Ecstasy
may also cause arrhythmias and seizures
and has been connected with some
fatalities associated with water

intoxication and acute hyponatraemia.
A 33-year-old female is brought to

casualty unconscious. Examination
reveals a Glasgow Coma Scale of 6, a
blood pressure of 120/70, a pulse of 52
beats per minute a respiratory rate of 10
per minute with saturations of 85
percent. She has small pupils.
Correct
The features are of respiratory
depression and pin-point pupils which
are suggestive of opiates.
A 26-year-old female presents to

casualty in distress. She is agitated and
has had a haemetemesis. Examination
reveals a temperature of 40C, a pulse of
120 beats per minute and a blood
pressure of 110/80 mmHg. She has a
respiratory rate of 38/minute and has
saturations of 100%. Her pupils are
normal in size.
Correct
This case has hyperventialtion, a pyrexia
and has had a haemetemesis suggestive
of a gastirc irritant - aspirin. This causes
a metabolic acidosis with hyperpyrexia
in overdose. Haemetemsis due to gastirc
irritation is a feature and coagulation
may be deranged.
A 42-year-old female presents

unconscious. She has a Glasgow Coma
Scale of 7, a temperature of 37.5C, a

pulse of 134 beats per minute, a blood
pressure of 130/60 mmHg and a
respiratory rate of 22 with saturations of
95%. Examination of the pupils reveals
dilated pupils. A bladder is palpable on
examination of the abdomen.
Correct
This case has reduced concious level,
irritability a tachycarida, urinary
retention and dilated pupils. These
features suggest an anticholinergic
toxicity and from the above list, tricyclic
antidepressants fit. Fits and ventricular
arrhythmias are a another feature.
A 17-year-old male is brought to casualty

after being found collapsed in the street.
Examination reveals a Glasgow Coma
Scale of 7, a temperature of 36.5C, a
blood pressure of 145/85 mmHg with a
pulse of 70 beats per minute. His pupil
size is normal and he has a respiratory
rate of 15 with saturations of 96%.
Correct
This patient to all intents and purposes is
unrouseable and asleep. This is most
likely to be due to benzodiazepines.
Theme:CAUSES OF
BREATHLESSNESS
AAcute blood loss

BAsthma
CAtypical pneumonia
DBronchiectasis
EBronchopneumonia
FCarcinoma of the bronchus
GCentrilobular emphysema
HExtrinsic allergic alveolitis
IMesothelioma
JChronic anaemia
KSarcoidosis
Each patient described below presents
with breathlessness, For each one,
choose the single most likely diagnosis
from the list of options. Each option may
be used once, more than once, or not at
all
A 60-year-old builder has smoked 30

cigarettes each day for 40 years. He has
recently developed breathlessness
associated with cough and haemoptysis.
There is clubbing of the fingers and toes.
On percussion, there is stony dullness
over the left side of the chest
Correct
Cigarette smoking is the major risk of
bronchial cancer. The risk is dependent
on the number of cigarettes and duration
of smoking. 80% of patients present with
chronic cough, 70% with haemoptysis,
15% with recurrent or slowly resolving
pneumonia. Intrathoracic complications
include pleural effusions, recurrent
laryngeal nerve palsies, SVC obstruction
and Horner's syndrome.
A 64-year-old former shipyard worker, a

lifelong non-smoker, complains of
increasing difficulty with breathing;
there is a persistent dull ache in the left

chest, exacerbated on deep inspiration.
On examination, there is reduction in
respiratory movement on the left; a chest
x-ray shows lobular pleural thickening
Correct
Mesothelioma is a pleural based lung
malignancy which is related to earlier
asbestos exposure usually from
workplace, for example shipbuilding.
Clinical features include chest pain,
dypsnoea and blood stained pleural
effusions. Diagnosis is by pleural biopsy.
Prognosis is poor and treatment is
symptomatic.
A 42-year-old crop farmer complains of

persistent breathlessness that has
developed over several years. He has
exacerbations of breathlessness when he
handles hay, associated with fever and
malaise
Correct
Farmer's lung is due to a hypersensitivity
reaction to Micropolyspora faeni.
Clinical features occur 4-8 hours after
exposure; fever, malaise, dry cough and
dypsnoea are usual. Chronic disease may
follow acute symptoms or occur
independently. In the acute stage:
neutrophilia, high ESR, and positive
serum preciptins are usual. Chronic
disease shows upper zone shadowing due
to fibrosis. Prednisolone is the treatment
is the treatment of choice.
An 18-year-old cystic fibrosis sufferer

has persistent cough productive of
purulent sputum. He has finger clubbing
and low-pitched inspiratory and
expiratory crackles on auscultation.
Correct
Cystic fibrosis is a cause of a
bronchiectasis. Clinical features of
bronchiectasis include persistent
productive cough especially in winter
months, haemoptysis, clubbing and lowpitched inspiratory and expiratory
crackles on auscultation. CXR shows
cystic shadows, fluid levels, and tram
-line or ring shadows.
A 48-year-old woman of Caribbean

origin complains of progressive
shortness of breath and painful lesions on
her shins. He has a history of
hypertension and of joint pain. A blood
test shows hypercalcaemia.
Correct
Sarcoidosis is of unknown cause
characterized by non-caseating
granulomas. It is commoner in AfroCaribbean people and it may affect any
organ or age group.
Theme:Acute poisoning
ABenzodiazepines
BDigoxin
Cecstasy
DOpioids
EOrganophosphorus compounds
FParaquat
Gparacetamol
HSalicylates.
IWarfarin
For each of the patients below choose the
single most likely cause of their
presentation from the options above.
Each option may be used once, more
than once or not at all.
A 60-year-old farmer is rushed into A&E

unconscious, sweating profusely and
with copious secretions drooling from
his mouth. His pupils are small
Correct
Organophosphorus compounds used as
insecticides or military nerve gases act
by inhibiting acetylcholinesterase.
Clinical features include miosis, blurred
vision, hypersalivation, expectoration of
frothy secretions, nausea, vomiting ,
abdominal cramps, diarrhoea,
bronchospasm. Diagnosis can be
confirmed by measuring the plasma or
RBC cholinesterase activity. Treatment is
supportive. Specific antidotes to
organophosphate poisoning are atropine
and cholinesterase reactivators (e.g.
oximes such as pralidoxime).
A 28-year-old is brought to the A&E on

Friday night, Examination reveals
hyperthermia, hyperglycaemia and
hypertension.

ecstasy
3,4- methylenedioxymethamphethamine
(MDMA), commonly known as
ecstasy. Clinical features in most cases
of mild abuse are characterized by
agitation, tachycardia, hypertension,
widely dilated pupils, trismus and
sweating. In more severe cases,
hyperthermia, disseminated intravascular
coagulation, rhabdomyolysis and acute
renal failure predominate. Treatment in
severe cases involves the use of
intravenous fluids and, if necessary,
dantrolene, 1 mg/kg body weight
intravenously,should be administered and
repeated as necessary to reduce
hyperthermia.
A 74-year-old woman is brought into

Accidents and emergency with melaena
and bruising. She is semi conscious.
Correct
Management of severe warfarin toxicity
involves use of whole blood, fresh frozen
plasma or clotting factor concentrates
may be required in severe acute
haemorrhage, but vitamin K given until
clotting returns to normal is usually
sufficient.
An 18-year-old male, brought with

history of consumption of unknown
substance. Investigation reveals, He is
unconscious, barely breathing, normal
pulse and small pupils.
Correct
Opiod toxicity may manifest as coma,

very low respiratory rate and pin-point
pupils. Other complications include
convulsions, hypotension, peripheral
circulatory failure, cardiac arrhythmias
and conduction defects, hypothermia,
pulmonary oedema, renal failure and
rhabdomyolysis. Resuscitation comprises
establishing a clear airway, giving
oxygen, placing the patient in a semiprone position to reduce the risk of
aspiration in the event of vomiting, and
immediate intravenous injection of an
adequate dose of naloxone. Assisted
ventilation may be required if naloxone
is not immediately available or if very
large doses are required.
An 80-year-old man who has a history of

heart disease has nausea, vomiting,
hypokalaemia and cardiac arrhythmias.
Correct
Binding of digoxin to the Na+/K+ATPase transport system is inhibited by
high levels of potassium and the level of
activity of this enzyme is increased by
the presence of magnesium. Thus both
hypokalaemia and hypomagnesaemia
increase digoxin toxicity. Digoxin
toxicity is more common in patients than
other drugs eg. Beta blockers, verapamil
and quinidine. Hypothyroid patients are
more sensitive to the effects of digoxin.
Cardiac monitoring should be
undertaken. Normal saline is the
intravenous fluid of choice
Hypokalaemia and hypomagnesaemia
should be corrected. Administration of
digoxin Fab is the primary treatment for
all the major cardiac complications of
heart block, arrhythmias, hyperkalaemia
of more than 6mmol/l or digoxin level of
more than 10nmol/L (six hours after
ingestion). If this is unavailable, heart
block should be treated with pacing and

tachyarrhythmias may be treated with
magnesium.
Theme:CNS PROBLEMS
ABacterial meningitis
BCryptococcal meningitis
CGuillian-Barre syndrome
DHuman immunodeficiency virus (HIV)
infection
EListeriosis
FMultiple sclerosis
GEncephalitis
HSubarachnoid haemorrhage
ISecondary cancer
JViral meningitis
All the patients described below have
had a lumbar puncture. For each one,
choose the single most likely diagnosis
from the list of options. Each option may
be used once, more than once, or not at
all
A 32-year-old doctor with a family
history of polycystic disease of the
kidney collapsed suddenly after a sudden
persistent occipital headache. A sample
of cerebrospinal fluid obtained 12 hours
later was reported as xanthochromic.
Correct
The incidence of subarachnoid
haemorrhage is 15/10000. Age range is
typically 35-65yrs. Common causes are
rupture of congenital berry aneurysms in
70% of patients, and arterovenous
malformations in 15% of patients.
Recognised associations include
polycystic kidney disease, Ehlers-Danlos
syndrome and coarctation of the aorta.
Sudden severe occipital headache is the

most striking clinical feature and may be
associated with focal neurological signs.
CT Brain scan is indicated and if no
bleed is identified a Lumbar Puncture
may uniformly blood stained fluid or
xanthochromia.
A 28-year-old woman presents with

urinary incontinence and pain on
movement of right eye with rapid
deterioration in central vision. On
examination she has impaired coordination on heel-shin test. She has
nystagmus and an internuclear
opthalmoplegia. The cerebrospinal fluid
shows a slight increase in lymphocyte
count, raised total proteins and raised
immunoglobulins
Correct
Multiple sclerosis is a chronic relapsing
and remitting disorder characterized by
demyelinating plaques within the CNS.
Clinical features may be wide ranging
including CNS defects such as spastic
paraparesis, cerebellar signs, optic
atrophy, nystagmus internuclear
opthalmoplegia as urinary incontinence.
CSF examination shows raised protein
and lymphocyte count, oligoclonal bands
of IgG on CSF electrophoresis and
delayed visual, auditory and
somatosensory evoked potentials. MRI is
sensitive but not specific for plaque
detection.
An 18-year-old student presents with

headache, neck stiffness and
photophobia. The cerebrospinal fluid
examination shows 100 lymphocytes,
CSF glucose is more than 2/3 blood
glucose value and CSF protein is

0.60g/L. Gram stain was negative.
Correct
This patient has viral meningitis.
Causative viruses include herpes
simplex, varicella zoster, coxsackie,
echo, mumps and influenza viruses.
A 56-year-old woman has a history of

headaches for several weeks. More
recently she has had several convulsions.
She was a heavy smoker until six years
ago. There has recently been moderate
weight loss. Cerebrospinal fluid shows
increased lymphocytes, with clumps of
irregular cells which have deeply
hyperchromatic nuclei and scanty
cytoplasm
Correct
Secondary carcinomas form
approximately 25% of all CNS
malignancies. These commonly originate
from the bronchi, breasts, stomach,
prostate, thyroid or kidney.
A 24-year-old student has a 24 hour

history of an ear infection, with
photophobia, neck stiffness and a
headache. Cerebrospinal fluid shows a
white cell count of 500/mm3, almost all
of which are polymorphs.
Correct
Bacterial meningitis usually has a rapid

onset on less than 48 hours.
Meningococcus, pnumococcus and
Haemophilus are the common causes of
pyogenic infection.
Theme:Abdominal pain
AAcute cystitis
BAddison's disease
CAppendicitis
DCancer of the colon
EChronic inflammatory bowel disease
FDiverticular disease
GEctopic pregnancy
HEndometriosis
IInguinal hernia
JLead poisoning
KPelvic inflammatory disease
LPrimary spasmodic dysmenorrhoea
MPseudo-obstruction
NRuptured follicular cyst
OToxic megacolon
PUrinary retention
QVesical calculus
RVolvulus
Each of the subjects below is a woman
presenting with lower abdominal pain.
Select the most likely diagnosis from the
list of options.
A 23-year-old woman presents with a
three day history of low abdominal pain,
frequency of micturition and a yellow,
offensive vaginal discharge. Her bowel
actions are regular and her weight is
steady. Her last period was three weeks
previously and she is on no contraception

Pelvic inflammatory disease
, is associated with a malodorous, green
or yellow discharge. It may be associated
with STDs such as chlamydia but may

occur in a sexually inactive female.
A 24-year-old woman presents with a

four month history of right-sided lower
abdominal pain, watery diarrhoea and a
loss of weight of 6Kg. Her periods are
regular taking the oral contraceptive pill.
Correct
The most likely answer in this case is
chronic inflammatory bowel disease
given the weight loss, abdominal pain
and diarrhoea. Addison's disease would
present insidiously, and typically without
bowel symptoms.
A 65-year-old with a ten year history

constipation, and of left-sided lower
abdominal pain which is worse on
defecation. Her weight is steady and she
has normal micturition, She has had no
periods for 15 years.

Diverticular disease
In a patient of this age, Diverticular
disease is common and would present in
this fashion. The fact that weight loss is
not present suggests that malignancy is
not present.
A 30-year-old woman presents with a six

hour history of severe pain in the lower
abdomen. She has had a normal bowel
motion this morning and her weight is
steady. Her last period was six weeks ago
and she has an IUCD for

contraception.BP 90/60 mmHg and HR
100 bpm
Correct
This patient has a short, acute history of
abdominal pain and has features of early
shock. She has missed her last period and
has normal bowel motions, with no
weight loss. The IUCD is associated with
a small risk of ectopic pregnancy, and
this is the most likely diagnosis from the
above list.
A 15-year-old girl presents with

agonising pain in the right lower
abdomen for four hours. She has vomited
once but not had a bowel motion since
the previous day. Her weight is steady.
Her periods started 12 months ago and
are still irregular, but the last was three
weeks ago. She denies being sexually
active.
Correct
This patient has an acute history of right
lower abdominal pain, vomiting and
relative constipation. Appendicitis is
relatively common at this age, and is the
most likely diagnosis in this scenario
Everything about abdominal pain...
Theme:Investigation of Emergencies
AArterial blood gases
BBlood Glucose
CBlood Urea electrolytes and creatinine

DCT scan of Brain
EFull blood count and group and cross
match
FMRI scan of Knees
GThyroid function tests
HToxicology Screen
ISkull Xray
For each patient below, choose the single
most essential diagnostic investigation
from the above list of options. Each
option may be used once, more than once
or not at all.
21-year-old Female found
unconsciousness next to her 22-year-old
husband, who was found dead. Her ECG
shows evidence of Acute MI.
Correct
Severe cases of cocaine intoxication may
result in acute myocardial infarction,
aortic dissection, myocarditis, ventricular
arrhytmias and cardiorespiratory arrest.
24-year-old Female, admitted to the

Accidents and Emergency department
with a Pneumonia is now barely
conscious with poor respiration despite
high flow oxygen therapy.
Correct
This patient needs urgent arterial blood
gas estimation and should be considered
for artificial ventilation.
21-year-old rugby player, had suffered

from an episode of brief
unconsciousness. He is rushed into A&E

the next day with unconsciousness.
Correct
Extra dural haemorrhage is suggested as
complicating a head injury, period of
unconsciousness is followed by a period
of alertness and the rapid deterioration
into unconsciousness.
A 72-year-old woman is admitted

unconscious with a core temperature of
35.6oC. She has a heart rate of 42 beats
per minute and slowly relaxing reflexes.
Correct
Drowsiness, bradycardia, slowly relaxing
reflexes and would suggest the diagnosis
of hypothyroid coma. Urgent thyroid
function tests will confirm the diagnosis.
A 24-year-old school teacher who is a

very well controlled diabetic is found
unconscious by her students after lunch.
On her desk is a pile of partly marked
papers and an uneaten sandwich
Correct
Urgent blood glucose estimation by
sampling capillary blood would confirm
the diagnosis of hypoglycaemic coma.
However she requires urgent
administration of 50% dextrose or a
glucagon injection.
Theme:Emergency medicine
ABoerhaave's syndrome
BCardiac tamponade
CDiaphramatic rupture
DDissecting thoracic aorta
EFlail chest
FMallory-Weiss syndrome
GRuptured thoracic aorta
HTension pneumothorax
ITraumatic haemothorax
Select the most likely diagnosis in the
following cases:
A 25-year-old man who was involved in

a high-speed motorbike crash is brought
to the Accident and Emergency
department with respiratory distress and
left-sided chest pain. On examination, he
has distended neck veins and there is
decreased air-entry on the left side of the
chest. His blood pressure is 100/72
mmHg, pulse rare 110/min and
respiratory rate 20/min
Correct
Tension pneumothorax is a lifethreatening surgical emergency since
failure to relieve the tension may result
in a cardio-respiratory arrest. It usually
occurs following penetrating or blunt
injuries to the chest, frequently following
major traumas. In tension pneumothorax,
the air is drawn into the pleural space
with each inspiration but has no route to
escape; thus acting as a one-way valve.
Patients present with respiratory distress,
tachycardia, hypotension, distended neck
veins, decreased air-entry in the affected
lung, and deviation of trachea and

mediastinum to the opposite side,
although all these signs and symptoms
may not always be present.
A 56-year-old man who is known to

consume large amounts of alcohol
presents to the Accident and Emergency
department with severe pain over the
retro-sternal/epigastric region. He gives a
history of vomiting large amounts of
blood following a bout of heavy
drinking. On examination, he is
manifesting signs of shock. Chest X-ray
reveals gas in the mediastinum and in the
subcutaneous tissues.

Boerhaave's syndrome
Mallory-Weiss syndrome is arterial
bleeding in the upper gastrointestinal
tract, caused by a mucosal tear at or near
the point where the oesophagus joins the
stomach. It is thought that the tear or
laceration occurs when there is a sudden
increase in intra-abdominal pressure as
in violent episodes of vomiting following
heavy drinking. The condition is more
common in alcoholics with or without
portal hypertension. Mallory-Weiss
syndrome is the cause for nearly 5% of
all upper GI haemorrhage. The patient
may present with severe epigastric/retrosternal pain and signs of shock. The
severity of shock depends on the amount
of blood loss and pain. When associated
with a rupture of the oesophagus, the
condition is termed . Chest X-ray may
reveal gas in the mediastinum and in the
subcutaneous tissues from the ruptured
oesophagus
A 37-year-old man is brought into to the

Accident and Emergency department
with penetrating injury to the left side of
his chest wall following a road traffic
accident. He complains of severe leftsided chest pain, and on examination, his
JVP is raised and the heart sounds are
muffled. His blood pressure is 98/74
mmHg and his Chest X-ray reveals a
globular heart.
Correct
Cardiac tamponade may occur following
penetrating or blunt injuries to the chest
wall and/or heart, lung or breast
carcinomas, pericarditis, and
myocardical infarction. The classical
signs of cardiac tamponade include a
rising JVP, falling BP and muffled heart
sounds (Becks triad). The other
recognised features include a rising JVP
with inspiration (Kussmals sign),
tachycardia and hypotension. Chest Xray reveals a globular heart and the left
heart border may be convex or straight
with the right cardiophrenic angle
reduced to less than 90.
Theme:Overdosages/ poisoning
ADigoxin
BIron
COrganophosphates
DParacetamol
EParaquat
FSalicylate
GSodium hypochlorite (bleach)
HTricyclics
For each patient below, choose from the
list above the single most likely
causative agent responsible for their

presentation.
A 7-year-old child with nausea vomiting

and features of heart block.
Correct
Digoxin toxicity. features include nausea,
vomiting impaired cognition and
arrhythmias. Treatment involves
correction of hypokalaemia and digoxin
specific antibody fragments are indicated
to treat serious arrhythmias
A 45-year-old farmer presents with

excessive sweating, abdominal pain and
diarrhoea.
Correct
Organophosphate insecticides inactivate
cholinesterase resulting in increased
cholinergic symptoms of salivation,
lacrimation, small pupils, sweating,
urination and diarrhoea, coma and
respiratory failure. Treatment is with the
anticholinergic atropine.
A 17-year-old girl is admitted with

hyperventilation and is noted to be in
metabolic acidosis.
Correct
Salicylate (present in aspirin

preparations) causes hyperventilation
which may result in a respiratory
alkalosis. Massive overdose may cause a
metabolic acidosis.
A 32 year Farm labourer with sore

mouth, pulmonary oedema & renal
failure
Correct
Paraquat is found in weed-killers.This
causes Diarrhoea and vomiting, painful
oral ulcers, alveolitis (pulmonary
oedema)and renal failure.
A 16-year-old girl presents with right

upper quadrant pain and has deranged
liver function tests.
Correct
Paracetamol poisoning may cause
vomiting, right upper quadrant pain.
Later Liver failure with encephalopathy
and renal failure may issue. Treatment
with N-acetyl cysteine (NAC) is given
according to a standard nomogram. NAC
may be useful up to 36 hours following
ingestion. The occasional patient may
require liver transplantation..
Theme:Upper gastrointestinal
haemorrhage
Apeptic ulcer
Bacute erosive gastritis
Coesophageal varices
DMallory-Weiss tear
EGastric leiomyoma
FAorto-enteric fistula
Goesophagitis
Hduodenal lymphoma
For each case below, choose the
SINGLE most appropriate diagnosis
from the above list of options. Each
option may be used once, more than
once, or not at all.
A 47-year-old alcoholic presents to
casualty with a profuse haematemesis.
He is found on examination to be
jaundiced, mildy confused with ascites
and a liver flap. His serum albumin is
markedly low.
Correct
The alcoholism and profuse
haematemesis are suggestive of varices.
Plus, this patient has evidence of portal
hypertension.
A 21-year-old student is brought into the

casualty department with severe
vomiting and diarrhoea. He has just
returned from a holiday in Sri Lanka and
is dehydrated. He continues to vomit and
then complains of severe retrosternal
pain and has a haematemesis.

Mallory-Weiss tear
Typical history of recurrent vomiting
then blood.
A warden in a block of flats is called to

see a 62-year-old with a massive
haematemesis. He has a midline
laparotomy scar from an aortic aneurysm
repair and is vomiting large quantities of
fresh blood.
Correct
The midline laparotomy and massive
haematemesis after AAA repair are
highly suggestive of aorto-enteric fistula.
A possiblity is peptic ulceratio/stress
ulcer but under the circumstances, the
examiner is probably seeking the former
answer.
A 70 year man is taken to theatre with a

massive upper GI bleed. At laparotomy
he is found to have a large mass in the
gastric body which is rubbery in nature
and is bleeding profusely.
Correct
The rubbery large mass suggests
leiomyoma. These are prone to
haemorrhage.
A 42-year-old man who is previously fit

and well presents with a sudden onset of
haematemesis. He has noticed malaena
stool during the day and is on no
medication.
Correct
This patient has been previously fit and

well and taking no medication. Of the
options offered it seems most likely that
this is due to an acute peptic ulceration.
Patients with severe upper GI haemorrhage require resuscitation with respect to their airway, breathing,
and circulation. A history should be gained contemporaneously. The underlying cause should then be
treated. Bleeding ulcers are injected with adrenalin or underrun, varices may be injected or banded.
Which of the following is not a

recognised effect of chronic cocaine
abuse?
(Please select 1 option)
Hallucinations
Hypersomnia
Hyponatraemia Correct
Severe anxiety and paranoid ideation
Sexual dysfunction in men
Chronic users of cocaine often feel that
they perform better in many areas when
intoxicated. This misperception probably
results from the overriding effects of
euphoria and stimulation caused by the
drug. Chronic cocaine use can result in
erectile dysfunction, ejaculatory
dysfunction, hypersomnia. Severe
anxiety and paranoid hallucinations
increase with more frequent use.
A 64-year-old woman presented 10 hours

after ingestion of 12g of Quinine
Sulphate.
Which of the following is the most
common characteristic clinical feature in
this situation?
Blindness Correct
Bradycardia
Hyperacusis
Hyperglycaemia
Hypotension
A tachycardia is seen in overdose, not a
bradycardia. Quinine may cause tinnitus
and deafness, but not hyperacusis.
Blindness is a characteristic feature of
quinine overdose. Blurred vision may
proceed to complete blindness within a
few hours.
As vision is lost the pupils become
dilated and unresponsive to light.
Initially only narrowing of the retinal
arterioles may be seen on fundoscopy but
after 3 days retinal oedema may appear.
Hypotension may be a feature, especially
in the context of dysryhthmia, but I feel
that blindness is the common
characteristic feature.
Which of the following is associated
with a prolonged QT interval?
Digoxin
Hyperkalaemia
Hyperthermia
Hypocalcemia Correct
Hypokalemia
Causes of QT prolongation include
Congenital Long-QT syndromes; Drugs:
Class I and Class III antiarrhythmic
drugs; Tricyclic antidepressants,
phenothiazines, non-sedating
antihistamines; Hypocalcaemia;
Hypothermia; Severe bradycardia.
Causes of a short QT interval include
Hypercalcemia; Administration of
Magnesium; Digitalis toxicity. Potassium
alterations do not commonly affect the
QT interval. Hypokalaemia produces
flattening of the T wave and a

pronounced U wave.
Question: 4 of 30 /
Overall score: 100%
A 22-year-old male is admitted wheezing
with a respiratory rate of 35/min, a pulse
of 120 beats per min, blood pressure
110/70 mmHg, Peak Expiratory Flow
rate < 50% predicted. The Emergency
Medical Services have administered
salbutamol 5mg (twice), Ipratroprium
0.5mg and face mask oxygen.
His arterial blood gas reveals:
pH
7.42
PaCO2 5.0 kPa
PaO2
22 kPa
Base excess -2 mmol/L
SpO2
98
(7.36-7.44)
(4.7-6.0)
(11.3-12.6)
(+/-2)

appropriate action for this man?
Chest X-ray
Intensive care referral Correct
Ipratroprium
Magnesium 1-2 g
Oxygen 35 %
In this case the patient is showing signs
of respiratory decompensation. A normal
or raised PaCO2 in an asthmatic is a
warning of impending respiratory failure
as the patient becomes too tired to
ventilate adequately and ITU need to be
notified. Administration of magnesium
would be the next therapeutic measure. A
chest x-ray will be helpful but should not
delay in treatment and referral. 35 %
oxygen is inadequate.
Question: 5 of 30 /
Overall score: 100%
A 17-year-old male presents to A+E after
an overdose of alcohol and paracetamol.
He complained of abdominal discomfort
and an intravenous infusion of NAcetylcysteine was commenced. 15
minutes later he developed
breathlessness, reported feeling flushed
and developed a tachycardia.
A disulfiram-like (antabuse) reaction has occurred

The patient has had a panic attack
The patient has developed pulmonary oedema
The patient has received an overdose of N-Acetylcysteine
The patient has received N-Acetylcysteine previously Correct
This patient is having an acute
hypersensitivity reaction the most
common, dose independent adverse drug
reaction. It is caused by previous
exposure and being sensitised to the
drug. The initial exposure induces the
production of antibodies of Ig E class,
subsequent exposue induces an
immunological reaction anaphylaxis.
Some drugs can produce an similar
pseudoallergic reaction on first exposure.
An 80-year-old retired haulier with a past

history of controlled hypertension
presents with acute onset weakness of his
left arm, that resolved over 12 hours. He
had suffered two similar episodes over
the last three months. Examination
reveals a blood pressure of 132/82

mmHg and he is in atrial fibrillation with
a ventricular rate of 85 per minute. CT
brain scan is normal. What is the most
appropriate management?
Amiodarone
Aspirin
Digoxin
Dipyridamole
Warfarin Correct
It seems that this patient has had three
transient ischaemic attacks due to atrial
fibrillation. The most appropriate
therapeutic strategy would be warfarin.
Studies reveal that warfarin would be
therapeutically superior than aspirin in
such a patient's case, provided he is not
at risk of falls, when the risk of a
traumatic bleed may outweigh the
benefits of anticoagulation.
A 41-year-old female is brought into

A&E after taking an uncertain quantity
of paracetamol two hours previously and
trying to hang herself. She becomes
agitated and insists that she wants to go
home immediately. You judge that she is
at high risk of suicide. Which of the
following is the most appropriate course
of action for this patient?
Call the duty psychiatrist, and with other staff in the A&E
department attempt to restrain her under Common Law until they
arrive. Correct
Ask her to sign a discharge against medical advice form and let
her go.
Call the duty psychiatrist, but let the patient go if she insists and the
duty psychiatrist does not arrive in time to see her.
Detain her under section 5(2) of the Mental Health Act.
Call the hospital security services, restrain her and sedate her.
In an A&E department the suicidal
patient who declines to be admitted for
observation and treatment should be
managed as follows: Ensure that a
member of staff stays with them at all
times Call the duty psychiatrist If they
attempt to abscond before or during
psychiatric assessment, the staff of the
A&E department have a duty under
Common Law to restrain the patient. If a
patient who is already being nursed on
medical, surgical or obstetric ward, or in
a high dependency or intensive care unit,
develops a mental illness (or has an
exacerbation of a pre-existing disorder),
their physician or surgeon can authorise
their compulsory detention for up to 72
hours under section 5(2) of the Mental
Health Act.
Question: 1 of 30 /
Overall score: 100%
A 22-year-old female is admitted very
distressed and short of breath.
Examination reveals a respiratory rate of
35/min, a pulse of 120 beats per min, a
blood pressure 110/70 mmHg, oxygen
saturations of 90% and a Peak Expiratory
Flow rate < 50% predicted. The
Emergency Medical Services have
administered salbutamol 5mg (twice) and
face mask oxygen.
appropriate next action in this patient?
Arterial blood gas analysis

Intensive care referral
Oxygen 35%
Prednisolone 40mg
Salbutamol 5mg and ipratroprium bromide 0.5mg Correct
According to British Thoracic Society
guidelines addition of ipratroprium
would be the next step in the case of this
lady with acute severe asthma.
Prednisolone would be administered
shortly thereafter. 35% oxygen is
inadequate and a maximal concentration
should be used. A blood gas is not
essential for management particularly
with the oxygen saturations of 90%
although these will be performed.
Intensive care referral may well be
appropriate if this lady does not improve.
Managment of Acute severe Asthma...
A 59-year-old man is admitted with chest

pain of 8 hours duration and has ST
elevation inn the inferior leads on his
admission ECG. An electrocardiogram
from a previous clinic visit shows sinus
rhythm two months ago. He has insulin
dependent diabetes mellitus and chronic
renal failure. Investigations reveal:
Fasting plasma glucose 7.4 mmol/L
Sodium
137 mmol/L
Potassium
4.4 mmol/L
Urea
10 mmol/L
Creatinine
200 mol/L
(3.0-6.0)
(137-144)
(3.5-4.9)
(2.5-7.5)
(60-110)
Which of the following which represent

an absolute contraindication to the use of
thrombolysis?
Allergy to penicillin.
Gastro intestinal bleeding in last 3 months.
History of haemorrhagic stroke. This is the correct answer
Ischaemic stroke 12 months ago
On warfarin therapy Incorrect answer selected
Absolute contraindications to
thrombolysis include:
Previous haemorrhagic stroke

Ischaemic stroke in last 6 months
Central nervous system damage
or neoplasm
Within 3 weeks of major surgery,
head injury or major trauma
Active internal bleeding (menses
excluded) or gastro-intestinal
bleeding within the past month.
Known or suspected aortic
dissection
Known bleeding disorder
Proliferative diabetic retinopathy
Allergy and oral anticoagulants are relative contraindications.
A 27-year-old female presents to the

surgical intake with abdominal pain and
5 day history of vomiting. Over the last 3
months she has also been aware of a 6kg
weight loss. On examination, she is pale,
has a temperature of 38.5oC, blood
pressure of 90/60 mmHg and pulse rate
of 130 in sinus rhythm. The chest is clear
on auscultation but she has a diffusely
tender abdomen with no guarding. Her
BM reading is 2.5.
Initial biochemistry is as follows:
Sodium 124 mmol/L
Potassium 6.0 mmol/L
Urea
7.5 mmol/L
Creatinine 78 mol/L
Glucose 2.0 mmol/L
(137-144)
(3.5-4.9)
(2.5-7.5)
(60-110)
(3.0-6.0)
What is the probable diagnosis?

Abdominal migraine
Acute appendicitis
Acute cholecystitis
Addison's disease Correct

Insulinoma
This patient has clinical features of
hypoadrenal crisis with abdominal pain
and vomiting and shock with
hypoglycaemia, hyponatremia and
hyperkalaemia in keeping with
hypoadrenalism. She needs emergency
fluid resuscitation, steroid
administration, (prior to this urgent
cortisol measurement), and careful
search for occult infection. One may
expect to find features of addisons
disease such as oral pigmentation or
other autoimmune disease.
A 49-year-old postwoman with a long

standing diagnosis of acute intermittent
porphyria is referred by her GP for
advice on drug therapy. She is a
longstanding poorly-controlled
hypertensive, and the GP has provided
two ECGs, from consecutive weeks, both
of which demonstrate atrial fibrillation.
She has not had an acute exacerbation of
AIP for over 7 years. Which of the
following drugs would be unsuitable for
use in her treatment?
Aspirin
Atenolol
Bumetanide
Digoxin
Methyldopa Correct
AIP is often associated with
hypertension. Centrally acting drugs
such as methyldopa and clonidine, ACE
inhibitors, calcium channel blockers and
furosemide are contra-indicated. Among
the diuretics, amiloride, bumetanide,
acetazolamide, cyclopenthiazide, and
triamterene have been used safely.

Digoxin, beta-blockers, heparin, and
warfarin are also thought to be safe.
An 8 month old child presents with spots

on the legs. He is well and feeding well.
39+6/40 3.5kg, no neonatal problems.
No drugs nor medications, fully
immunised. No FH/SH of note.
On examination temperature 37.4C
(tympanic), RR 30/min, HR 110/min.
Well perfused, capillary refill time of 1
second. 20- 30 1-2mm non-blanching
purpuric spots over the shins.
What is the most likely diagnosis?
Child physical abuse

Cough petechiae
Enteroviral infection This is the correct answer
Henoch Schoenlein purpura Incorrect answer selected
Idiopathic Thrombocytopaenic purpura
This child is well, and presents with
purpuric spots and a low-grade fever.
Although about 20% of such children
have serious bacterial infection and 710% have meningitis/ septicaemia, this
still leaves 70% who have some sort of
viral infection. A large number of viruses
(eg Varicella and EBV) can present in
this way, although in clinical practice the
specific cause is rarely found.
A 78-year-old male is brought to A+E

and has a witnessed seizure in the
resuscitation room. His blood glucose is
recorded as 1.0mmol/l. He is not
diabetic, and has no other significant past
medical history. He is given 50ml of

50% dextrose and he slowly recovers
over the next 1 hour. A serum cortisol
concentration later returns as 800 nmol/L
(120-600).
Which of the following would be the
most relevant investigation for this man?
Chest x-ray
CT head scan
Electrocardiogram
Prolonged 72 hour fast Correct
Short synacthen test
The historical and biochemical evidence
here suggests a diagnosis of spontaneous
hypoglycaemia and the most likely cause
would be an insulinoma. However, one
would wish to exclude possible drug
administration and although not
mentioned here, a sulphonylurea screen
should be undertaken. He has presented
with symptomatic hypoglycaemia, is not
diabetic therefore should not have
received insulin or a sulphonylurea.
There is nothing to suggest alcohol or
drug misuse. Similarly, there is nothing
to suggest sepsis. However, to prove a
diagnosis of spontaneous hypoglycaemia
a prolonged fast is required and should
be develop hypogluycaemia,
measurement of insulin and C-peptide
will be needed to confirm the diagnosis.
The appropriate cortisol response during
his hypoglycaemic episode (cortisol 800)
excludes hypoadrenalism.
Which of the following investigations

would contribute the most to acute risk
stratification in a patient with unstable
angina?
Coronary angiography
Echocardiography
Electrocardiography
Myocardial perfusion scanning
Troponin testing Correct
The adverse prognostic factors in
unstable angina are labile ECG changes,
persistent angina in spite of maximal
medical therapy or clinical evidence of
heart failure. However, the most
important adverse prognostic factor is
Troponin elevation. These are the
patients who should be referred for
urgent coronary revascularization.
Which of the following is not a

recognised cause of a dominant R in lead
V1 on the ECG?
Dextrocardia
Duchenne Muscular Dystrophy Incorrect answer selected
Ebstein's anomaly
Myotonic dystrophy This is the correct answer
Primary Pulmonary Hypertension
A dominant R wave in V1 has few
causes- RVH as in Eisenmenger's
syndrome; primary pulmonary HT;
RBBB as in Ebstein's anomaly; WolfParkinson-White syndrome Type A;
Dextrocardia; True posterior MI;
Duchenne Muscular Dystrophy.
Reversed splitting of the second heart

sound is found in which one of the
following?
Atrial septal defect

Left bundle branch block (LBBB) Correct
Mild aortic stenosis (AS)
Right bundle branch block (RBBB)
Ventricular septal defect (VSD)
Reversed splitting of the 2nd heart sound
occurs with reversal of the normal A2,P2
pattern. Thus A2 may be delayed as with
severe AS (not mild), and LBBB. P2
may be early as with Wolff-ParkinsonWhite type B and Persistent Ductus
Arteriosus. Atrial septal defects show
wide fixed splitting, and RBBB has
wide, but not fixed splitting.
Abdominal pain is a feature of all of the

following except:
Acute arsenic poisoning

Acute iron poisoning
Acute lead poisoning
Methanol toxicity
Typhoid fever Correct
Lead toxicity acutely leads to colicky
abdominal pains, fatigue, paralysis and
encephalopathy.
Arsenic chronically causes
hyperkeratosis, tranverse nail bed lines
(Mees' lines) and chronic vasospasm
causing blackfoot disease. Acute toxicity
causes severe abdominal pain,
haemorrhagic gastroenteritis and hepatic
necrosis. Capillary leaking can lead to
pulmonary oedema, and shock. Later a
peripheral neuropathy develops.

Methanol toxicity causes a metabolic
acidosis, optic atrophy and peripheral
neuropathy. After a delay of 4-36 hours,
nausea, vomiting and abdominal pain are
seen.pain is not a dominant feature of
typhoid fever. The most constant
accompaniment of the fever in typhoid is
headache. Along with this go nonspecific symptoms, to be expected of a
significant infection (malaise, lassitude,
myalgia, arthralgia, and anorexia).
In classical typhoid, constipation is a
frequent early symptom though the
majority of patients will experience loose
motions at some time. Bloody diarrhoea
may be seen. Nausea and vomiting are
relatively infrequent in uncomplicated
typhoid but are seen with abdominal
distention in more severe cases. Other
symptoms of early typhoid are cough,
sore throat, and a tendency to epistaxes
A patient has just received intravenous

ceftazidime. They immediately become
flushed and wheezy, with a blood
pressure of 80/40 mmHg.
appropriate immediate management for
this patient?
Chlorphenamine 10mg IV
Epinephrine 0.2mls of 1:1000 IV
Epinephrine 0.5mg IV
Epinephrine 0.5mg i.m. This is the correct answer
Hydrocortisone 100mg i.v. Incorrect answer selected
Immediate treatment of anaphylaxis
includes cessation of whatever caused it.
Oxygen, fluids and
adrenaline/epinephrine 0.5mg i.m or
subcutaneously. (checking
concentrations of adrenaline is very
important especially in high pressure
situations). Intravenous adrenaline is
potentially hazardous unless diluted
appropriately.
A 15-year-old girl attends as an

emergency to A+E with her mother. Her
mother provides a 30 minute history of
deteriorating breathlessness and facial
puffiness. She has otherwise been well
except for eczema and she takes the oral
contraceptive. She is in obvious distress,
her breathing is laboured and noisy.
What is the SINGLE most likely cause
of breathlessness?
Acute epiglottitis
Angioneurotic oedema Correct
Asthma
Pneumothorax
Pulmonary embolism
The history of noisy breathing is
suggestive of stridor, which can be
triggered by an allergic reaction in an
otherwise well adolescent and the history
of atopy is supportive of a diagnosis of
angioedema. Similarly, the rather abrupt
history is again suggestive. The main
differential diagnosis is asthma where
one would expect expiratory wheeze,
however the silent chest is an ominous
feature in acute severe asthma
A 27-year-old lady collapses in the

Emergency Room after being admitted
with numerous seizures. You obtain
information from her husband that she
has a past history of seizures, but has not
had any for the last two years, and is well
controlled on valproate. He also informs
you that she has been gaining weight
recently and has also had erratic menses
which the neurology clinic attribute to
the valproate.
Pulse
110/min
Blood pressure 160/90 mmHg
Urinalysis 3+ proteinuria
After Airway, Breathing and circulation, the immediate drug therapy should be:
Diazepam 10mg
Lorazepam 2mg
Magnesium 2 grams Correct
Nil
Phenytoin 1000mg
This lady may well be having an
epileptic fit, but why should a young
woman have an elevated BP and
proteinuria? In a woman of this age with
raised blood pressure and proteinuria, a
diagnosis of eclampsia has to be
considered and the primary treatment of
eclampsia is the administration of
magnesium.
An 18 year-old college student is

admitted with a two week history of
paraesthesia and weakness affecting all
four limbs. Examination shows mild
distal weakness, absent reflexes, and
glove and stocking sensory loss. FVC is
900mls. CT head is normal. Lumbar
puncture reveals 5 lymphocytes, 1 red
cell, glucose 4.5 and protein of 0.9 g/l.
What is the next management step?
Intravenous immunoglobulin Incorrect answer selected

Intubation and ventilation This is the correct answer
MRI brain
Plasma exchange
Serum lead levels
The clinical features and CSF findings
are typical of Guillain-Barre syndrome.
An FVC below 1 litre (or about 15 mls
per kilogram body weight) is indicative
of severe respiratory weakness and is an
indication for urgent intubation and
ventilation. The specific treatment is
either intravenous immunoglobulin or
plasma exchange.
A 51-year-old politician experiences

palpitations, and when he receives an
ECG it demonstrates a regular narrow
complex tachycardia of 180 bpm. Which
of the following is not a recognised
problem with the use of intravenous
adenosine in this patient?
The need for dose reduction if the patient is on theophylline

Correct
The need for dose reduction if the patient is on disopyramide
Bronchospasm if the patient is asthmatic
Production of chest pain even if this patient has normal coronary
arteries
Possible worsening of re-entry tachycardia if this patient has WolffParkinson-White syndrome
The action of adenosine is blocked by
theophylline, and enhanced by
disopyramide. The patient should be
warned about chest tightness and
dizziness, and a defibrillator should be at
hand in case the tachycardia accelerates,
as may happen with the WolffParkinson-White syndrome. Adenosine
can produce profound bronchospasm and

should be avoided in asthmatics.
A 39 year-old female escort attends her

local GU clinic with a fever, malaise and
arthralgia. She has a widespread maculopapular rash, but no other abnormalities.
Investigations
HIV p24 antigen
negative
Cold agglutinin IgM antibody 1:32
FT-ABS
negative
VDRL
positive
CRP
137
The patient recovers but four weeks later
presents to A&E with double vision and
difficulty walking. Deep tendon reflexes
are absent. Which is the most important
test to arrange next?
MRI head scan Incorrect answer selected

Lumbar puncture
Spirometry This is the correct answer
Tensilon test
Nerve conduction studies
The most likely cause of the presenting
illness is Mycoplasma pneumoniae
infection. This can cause fever,
arthralgia, maculopapular rash and a
raised CRP. It is also a cause of false
positive VDRL and +ve cold agglutinins.
Neurological syndromes post infection
include meningoencephilitis, transverse
myelitis and Guillain Barre syndrome.
MRI, lumbar puncture and nerve
conduction studies are all indicated but
the most important investigation is
measurement of vital capacity to monitor
any evolving respiratory paralysis
A 17-year-old male presents to A+E after

an overdose of alcohol and paracetamol.
He complained of abdominal discomfort
and an intravenous infusion of NAcetylcysteine was commenced. 15
minutes later he developed
breathlessness, reported feeling flushed
and developed a tachycardia.
What is the most likely explanation for
this reaction?
A disulfiram-like (antabuse) reaction has occurred

The patient has had a panic attack
The patient has developed pulmonary oedema
The patient has received an overdose of N-Acetylcysteine
The patient has received N-Acetylcysteine previously Correct
This patient is having an acute
hypersensitivity reaction the most
common, dose independent adverse drug
reaction. It is caused by previous
exposure and being sensitised to the
drug. The initial exposure induces the
production of antibodies of Ig E class,
subsequent exposue induces an
immunological reaction anaphylaxis.
Some drugs can produce an similar
pseudoallergic reaction on first exposure.
A 61-year-old West Indian presents to

casualty with sudden onset of leg
weakness associated with back pain. On
examination there is flaccid paraplegia
with absent reflexes and silent plantars,
and a sensory level at T10 with
preservation of dorsal column
modalities. MRI of the spine performed
the morning after admission is normal.

appropriate next investigation?
CSF analysis
CT chest with contrast Correct
CT head
Serum B12 estimation
Spirometry
The clinical picture here is that of acute
anterior cord syndrome (dorsal columns
preserved), and is often caused by cord
infarction. Occasionally, especially in
hypertensive Afro-Carribean patients,
and in the presence of chest or back pain,
this is caused by thoracic aortic
dissection interrupting the anterior spinal
artery. This possibility needs to be
pursued with a chest CT scan
A 40-year-old male presents to the A&E

department. Routine admission bloods
reveal a Triglyceride level of 20mmol/l
(0.45-1.69). Which of the following
conditions is least likely to be
associated?
Acute pancreatitis
Hypothyroidism Correct
Nephrotic syndrome
Thiazide therapy
Von Gierke's
Hypothyroidism is more likely to present
with a pronounced
hypercholesterolaemia and a smaller rise
in triglyceride. We aren't told about pain,
clearly complete absence of abdominal
pain would make acute pancreatitis

rather unlikely.
In the treatment of a type one diabetic

who presents in DKA (diabetic
ketoacidosis) with a pH of 7.1, which of
the following statements is correct?
Bicarbonate should be given immediately

DKA in pregnancy carries a significant mortality to the to the fetus
Correct
Hyperphosphataemia occurs following treatment
Serum osmolality will not help in monitoring response to treatment
The glucose level correlates well with the degree of acidosis
Diabetic ketoacidosis in pregnancy
carries an increased mortality to both
mother and foetus. Serum osmolality is
more reliable than glucose. Phosphate
and potassium fall with treatment. The
use of bicarbonate is not evidence based
in any robust way, there is no threshold
at which there is evidence for its use, and
if given at all, it should be given with
care, with close monitoring of the
patient.
Ventricular rather than supraventricular

tachycardia is suggested by?
A pre-excitation pattern on the ECG after reversion to sinus rhythm

A variable intensity of the first heart sound Correct
An rSR' pattern on the ECG in lead V1
Irregular QRS complexes on the ECG
Slowing of the heart with carotid sinus massage
Ventricular tachycardia produces AV

dissociation which gives rise to
diagnostic clinical signs (variable
intensity of the first heart sound, cannon
waves in JVP) and ECG features
( capture beats and fusion beats).
Vagal manoeuvres such as carotid sinus
massage slow down AV nodal
conduction SVTs that rely on the AV
node for propagation will be affected
while VT will not. Pre-excitation
suggests WPW, which can cause a broad
complex tachycardia (anterograde
conduction via bundle of Kent) although
a narrow complex tachycardia is more
common. When RBBB occurs in VT, it
is usually an Rsr' pattern, while an rsR'
pattern suggests SVT with ratedependent bundle branch block. VT is
regular consider AF with aberrant
conduction if irregular.
You are called to the delivery of a 41+4

gestation infant, who is being delivered
by emergency caesarian section. Mother
is a healthy Caucasian of 27 years, who
smokes 15/d. There have been concerns
about fetal growth on serial ultrasound
scans.
Labour commenced 18 hours ago, and
mother has been in Stage 2 for the past
90 minutes. There have been 3
bradycardias with delayed recovery, and
the liquor is thickly meconium stained.
The baby is given to you. She is floppy,
pale and covered in thick meconium.
Group B Strep septicaemia

Holoprosencephaly
Hypoxic ischaemic encephalopathy

Meconium aspiration Correct
Surfactant deficient lung disease
This child is growth retarded and has had
significant fetal distress (birth asphyxia).
A cord gas may help judge the severity
of the perinatal insult.
She should be quickly wiped and
wrapped in a warm towel, then placed
head down on the resuscitation trolley. If
vigorous no further action is required. If
flat, her oropharynx and cords should be
inspected and suction applied to the
trachea if there is suspicion that there is
some meconium between them. She
should then be intubated and ventilated.
Depending on her response she may
require ECM or a bolus of fluid (eg
given via the UVC).
A 16-year-old girl presents with an acute

exacerbation of asthma. On examination
her respiratory rate was 30 per minute,
her heart rate was 120 beats per minute
and a peak expiratory flow rate(PEFR)
was 30% of the predicted value.
Her blood gas analysis on air shows:
PaO2 9 kPa (11.3-12.6)
PaCO2 3.5 kPa (4.7-6.0)
After the administration of oxygen and
corticosteroids what is the most
appropriate next step in management?
Intravenous Aminophylline
Intravenous Salbutamol
Ipratropium Bromide via oxygen-driven nebuliser
Salbutamol via oxygen-driven nebuliser Correct
Salmeterol via breath-actuated inhaler

This patient has severe asthma as
revealed by the low PEFR, low P02 and
signs.
The next stage in the management is the
administration of nebulised beta 2
agonists with supplementation of high
flow oxygen (minimum of 6L/minute).
Beta 2 agonists can be administered in
15-30 minute intervals if required.
Intravenous therapy with beta 2 agonists
should only be used if inhaled therapies
cannot be reliably administered.
A 45-year-old man attends Emergency

Department with symptoms suggestive
of community acquired pneumonia. On
examination he is pyrexial at 38.0oC and
has a respiratory rate of 32/min, with a
blood pressure of 85/55mmHg.
Which of the following combination of
features are not necessarily an indication
for urgent hospital admission?
BP of 85/55 mmHg and respiratory rate of 32/min

Confusion and BP of 85/55mmHg
Pyrexia of 38.0oC and serum urea of 7.5 mmol/l Correct
Respiratory rate of 32 and blood urea of 7.5 mmol/l
BP of 85/55 mmHg and urea of 7.5 mmol/l
This patient has community acquired
pneumonia. The CURB score can be
used in the assessment of severity using
Core Adverse Prognostic Features which
are 2 from 4 of:
1.Confusion abbreviated mental test
score < 8
2.Urea > 7mmol/l

3.Respiratory rate > 30/min
4.Blood Pressure Systolic BP < 90 or
diastolic BP <60.
Clinical judgement must still however be
used particularly if only one feature is
present or if there is co-morbidity such
as age >50 years, chronic cardiac,
respiratory or renal disease.
A 16-year-old female presents with

shortness of breath. She is known to
suffer from asthma and her usual best
PEFR is 410L/min. Which of the
following features would suggest that
this is a severe asthma attack?
Blood pressure of 156/80 mmHg

Pulse of 100 beats per minute
PEFR 200L/min Correct
Respiratory rate of 22 per minute
Temperature of 39oC
BTS guidelines suggest Inability to
complete sentences, a tacchycardia in
excess of 110 bpm, a respiratory rate
above 25/minute and a PEFR 33-50% of
the predicted value is suggestive of acute
severe asthma. Life threatening asthma
would include silent chest, bradycardia,
hypotension and hypoxia.
An 18 month old girl presents with

stridor at 1 am. She has had a cold for 48
hours, with low-grade fever, but went to
bed as usual at 7.30pm. She awoke 4
hours later crying and distressed, with a
barking cough.

Aspiration of foreign body

Asthma
Bacterial tracheitis
Croup Correct
Epiglottitis
Classical history of viral croup. Most of
these episodes are one-off and settle
rapidly without treatment or with
dexamethasone orally.
A 4 month old boy is brought in dead to

hospital. He had had a cold for 3 days,
with crusty nose and mild fever. He went
to bed at 7 pm as usual. Mother checked
him at 11pm before going to bed. In the
morning she found him stiff and cold. He
was brought to A and E by ambulance,
but resuscitation was unsuccessful.
Mother is single 19 years and smokes
20/d.
He was born at 39/40 weighing 3.25 kg,
and there were no neonatal problems. He
had been growing along the 50th centile
for height and weight.
Acute life-threatening event

Cardiac dysrhythmias
Seizures
Sudden infant death syndrome Correct
This is a typical history of SIDS. The
official definition is: "The sudden death
of an infant under 1 year of age that
remains unexplained after a thorough
case investigation, including
performance of a complete autopsy,

examination of the death scene, and a
review of the clinical history."
Risk factors include: maternal smoking,
prematurity, over-wrapping, intercurrent
infection, prone sleeping position, low
social class
The Back to Sleep campaign seems to have reduced the incidence, although the rate had already started
to decline prior to it.
A 14-year-old girl was found

unconscious at the roadside by a passerby, who called an ambulance.
On examination she was unkempt, had
slurred speech and an ataxic gait. Her
core temperature was 34.5C, but there
were no other specific abnormalities to
find. Her BM stix result was 2.9 mmol/l.
Alcohol ingestion Correct

Complex partial seizure
Encephalitis
Insulin overdose
Migraine
The picture suggests acute alcohol
ingestion. This is often accompanied by
hypothermia and hypoglycaemia.
It is important to exclude other
ingestions and to look for coexisting
social problems.
A 22-Year-old Golf course groundsman

develops sudden onset of breathlessness
and right-sided chest pain whilst
maintaining the 18th hole. He is rushed
to hospital but his condtion worsens
when being examined by a junior doctor
who reported hearing very distant breath
sounds over his right lung. Following the
intervention of a senior doctor his
condition improves rapidly. What was
the most probable diagnosis?
Myocardial infarction
Pericarditis
Pneumonia
Pulmonary embolism
Tension Pneumothorax Correct
Sudden onset of chest pain and
respiratory distress in previously fit
young man should alert one to the
diagnosis of pneumothorax. He
developed Clinically obvious Tension
pneumothorax in hospital.
An 18-Year-old male is rushed into

Casualty department by a group of
friends who abscond before they are
questioned by the medical staff. He is
semiconscious, has a respiratory rate of
8/min, blood pressure was 120/70mmHg
and pulse 60/min. He is noted to have
suspicious marks on his arms and his
pupils are small. What single initial
treatment would you administer?
Adrenaline
Aspirin
Atropine
Dextrose
Naloxone Correct
The features of unconsciousness,

respiratory depression plus small pupils
suggest opiate induced respiratory
depression from street drug abuse. This
should be relieved promptly with
naloxone which is an opiate receptor
antagonist.
A 13-year-old girl is rushed into hospital,

having become rapidly drowsy after
running the 1500 metres in the school
atheletics competition. She has been on
insulin for diabetes for 3 years. Her latest
HbA1C is 7.8%.
On examination she responds to pain,
and is pale and sweaty. Her temperature
is 36.5C, Respiratory rate 12/min and
heart rate 80/min. There are no focal
neurological findings.
Hypoglycaemia Correct
Postural hypotension
Substance abuse
Vasovagal episode
Viral encephalitis
The history suggests tight diabetic
control, with neurological deterioration
following exercise. Hypoglycaemic
coma is most likely, and the sweatiness
and pallor are suggestive. The BM stix in
this case was 1.2 mmol/l and she
recovered rapidly with IV 10% dextrose
5 ml/kg.

Emergency Medicine

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Theme:Breathing

A 6 week old boy presents with bilateral

A 3-year-old boy presents with fever and

Theme:Blood gas analysis

pO2 6.7kPa( 50mmHg); pCO2 10.1kPa

pO2 14.3kPa( 108mmHg); pCO2 6.3kPa

Incorrect - The correct answer is

pO2 4.7kPa( 35mmHg); pCO2 12.7kPa

pO2 16.3 kPa( 122mmHg); pCO2 7.5

There is an acidosis with a normal

A 25-year-old male was brought into the

A 20-year-old female horse rider was

Incorrect - The correct answer is

A 55-year-old male was admitted after

Incorrect - The correct answer is

An 18-year-old woman with a previous

This young woman has severe asthma

A previously healthy 24-year-old man

Incorrect - The correct answer is

A 68-year-old smoker presents with

Incorrect - The correct answer is

A 55-year-old man develops sudden

A 57-year-old man is on the waiting list

Principle of oxygen therapy in

A 24-year-old male sustains a forearm

Incorrect - The correct answer is

A 40-year-old male receives a compound

Incorrect - The correct answer is

A 33-year-old male injures his hand

Incorrect - The correct answer is

A 55-year-old male is admitted after

phosphatase are normal, and ESR is

A 30-year-old Asian woman complains

A 68-year old white man has been

Incorrect - The correct answer is

Multiple Myeloma presents commonly in

A 30-year old white man complains of

A 66-year-old man presents with a

Again Myeloma is the most likely

Read up about back pain...

A 64-year old woman with known atrial

A 73-year old man with known

A 23-year old man is seen in the

Incorrect - The correct answer is

A 75-year old woman with chronic

Incorrect - The correct answer is

A patient has been pulled out of a lake,

A patient has been found in bed with a

A patient has been in cardiac arrest for

Incorrect - The correct answer is

A patient has been in cardiac arrest for

Incorrect - The correct answer is

fatalities associated with water

A 33-year-old female is brought to

A 26-year-old female presents to

A 42-year-old female presents

Scale of 7, a temperature of 37.5C, a

A 17-year-old male is brought to casualty

AAcute blood loss

A 60-year-old builder has smoked 30

A 64-year-old former shipyard worker, a

there is a persistent dull ache in the left

A 42-year-old crop farmer complains of

An 18-year-old cystic fibrosis sufferer