EMC Practice Questions Flashcards

Question

A teenager trips and falls on her forehead she does not lose consciousness. She responds to her friends at hte scene immediately. But presents to he ED after 2 hours having vomited twice. In the ED she falls asleep but is easily rousable and with a normal neurological examination she has no more episodes of vomiting. Choose the best response: * She needs an immediate CT head to look for a bleed * It's reasonable to wait and watch in this scenario given the history and the normal neurological examination. There is no identified risk in waiting and watching, and there is some risk in CT scans in the young

Answer 1

A teenager trips and falls on her forehead she does not lose consciousness. She responds to her friends at hte scene immediately. But presents to he ED after 2 hours having vomited twice. In the ED she falls asleep but is easily rousable and with a normal neurological examination she has no more episodes of vomiting. Choose the best response: * She needs an immediate CT head to look for a bleed * **_It's reasonable to wait and watch in this scenario given the history and the normal neurological examination. There is no identified risk in waiting and watching, and there is some risk in CT scans in the young_**

Answer 2

All patients with a heart rate of 40-45BPM will need drugs or pacing. * True * **_False_** - some patients may be bradycardiac and asymptomatic.

Answer 3

An infected wound which originated in fresh water swimming pool 3 days ago can be treated with flucloxacillin alone. * True * **_False_**

Answer 4

38 year presents after "rolling the ankle" while playing touch rugby. She kept playing but the ankle remained sore and she presents to the ED. She walks in the ED with a limp. There is no tenderness over the posteior distal fibula the medial malleolus, what do you see in the XR? * The XR shows a # of the fibular which can be managed with a below knee POP slab and ortho follow up * **_The XR is normal and probably should not have been done if the Ottawa ankle rules were applied. She should get referred for PT, advised to mobiliser early, elevate when not mobilising and ICE initially_** * XR is normal and she should get a POP backslab for pain and crutches * She has a # tibia and should be referred to orthopaedic

Answer 5

45M presents with low grade fever and severe lower abdo pain. As he is stable it is better not to mask the signs of peritonism with morphine until he is surgically reviewed. **_False._**

Answer 6

Triage reads: "80 M presents with severe chest pain radiating to back. Vomited once, appears clammy and looks unwell. History of hypertension and AMI. Given antacid in triage." Select one or more correct statements: * This man needs urgent gastroenterology review, and possibly a gastroscopy * **_The most serious diagnosis is thoracic aortic dissection. This, along with ACS, are my most likely diagnoses, therefore I have a red flag_** * **_My list of ddx include peptic ulcer disease, and potentially a perforated duodenal ulcer, I need to exclude the red flag diagnoses, though which apart from dissection and AMI, are bleeding DU_** * No further assessment should be done and he should go straight to CT * **_Initial assessment of ABCDE should be performed; a mobile CXR and ECG will possibly help with diagnosis_**

Answer 7

25 year old woman presents with RLQ pain. 14 weeks pregnant, she has R lower quadrant tenderness and has anorexia and low grade fever. What investigations do you do? * **_Urinalysis_** * **_FBE, EUC, CRP, LFTs, Lipase_** * D-dimer * **_Pelvic ultra sound_** * Abdo XR

Answer 8

High dose frusemide is required to treat acute decompensated pulmonary oedema. True or false? * True * **_False - use nitrate and bipap, then a littel bit of frusemide. High dose of frusemide increases hospital stay length._**

Answer 9

2 year old girl presents with a cough and sudden onset of SOB. She has no fever, a strange sounding cry, and inspiratory stridor and is saturating at 99% RA. Mom tells you she had been well all day, and found her like this when playing in her room. How do you manage this patient? * **_Nebulised adrenaline may help but the history is suggestive of foreign body aspiration, and I would do a mobile CXR in the resuscitation room to assess for airway foreign body, managing ABCDEs_** * Keep her in resus, and keep close eye on her. Neb adrenaline may help improve the airway space.

Answer 10

25 year old presents via ambulance with a grossly deformed ankle. Choose one. * You will most likely reduce this under sedation so in the short term you should withhold medication * With adequate splinting he will not require analgesic medication * **_He should get an IV bolus of morphine 5mg after assessing for allergies and an IV line is placed, then titrate 2.5 mg at a time until analgesia is attained_** * The orthopaedic registrar should assess the patient prior to analgesia

Answer 11

A 4 year old presents to the ED, a tympanic temp reads 37.8, this child has a fever. True or false? * True * **_False_**

Answer 12

Woman fell off her bike, and found to have no injuries other than the one shown in the xr. She is stable has GCS 15 and NV intact and is otherwise well. She has had analgesia and comfortable in a broad arm sling. Choose the one best answer. * She will need immediate surgery for the injury * Broad arm sling and review by GP in a week * **_Discuss the risks and benefits of operative and non operative treatment and base referral on this shared decision making_** * Figure eight bandage to achieve the best result on healing

Answer 13

23 M had URTI symptoms for 4 days. He now has a severe headache, photophobia, and complains of leg pain. He has high fever at 40C. His neurological exam is normal and he has no other physical findings. More than one response may be correct. * Needs urgent CT scan before a LP if the CT is normal * Blood tests should be performed, and if they are normal, he should be treated with analgesia and IV fluids * **_After a full neuro exam and fundoscopy are found to be normal, and he is found to have no clotting abnormalities, an LP can be performed_** * Antibiotics should not be given until after the LP * **_Initial tests performed on the CSF should be protein, glucose, and microscopy for cell count_**

Answer 14

A 2 year old girl found screaming "spider" while playing in the garden. A bite mark could be seen on her foot when presented to the ED after 2 hours. She is vomiting and SOB, looks unwell, is flushed and tachycardic. Her chest reveals moist sounds, and is hypoxic. Select the best statements from the ones below. * **_Envenomation by means other than a spider is possible and your suspicions will depend on the area_** * **_Her initial symptoms sound most like cholinergic symptoms of funnel web spider_** * **_She should be managed in ABCDE in resus_** * Initial pain at bite time indicates more likely a red back spider * **_A lower limb compression bandage should applied immediately while you get further information and give antivenom, which in this case would be 4 vials of funnel web antivenom if indicated by geography and history_**

Answer 15

I cannot use paracetamol and an oral narcotic together. ## Footnote **_False._**

Answer 16

47F known to MH presents with behavioural disturbance. Stable for 5 years with no medication changes. You clear this patient after looking at her psychiatric notes and viewing her from a distance as her vitals signs are normal. Have you have adequately medically assessed this patient? * **_No._** They need full medical assessment. There is a new change.

Answer 17

A 58 year old man has been admitted with sepsis. He has diabetes and known cardiac disease. You are actively fluid resuscitating he remains hypotensive. He gets more confused and pulls his O2 mask off, he complains of SOB, he pulls out one of his IV line sand he looks very diaphoretic. From the list below select the correct statements which reflect what you might do. * **_Move to an area of resuscitation as it appears that we are losing control of this patient, get help, check sugars_** * **_Place a non rebreather mask with 15L of O2 on this man and have someone try and keep it on, and prepare material and staff for intubation_** * **_Make preparation to use pressors and possibly sedate and intubate_** * His behaviour should be managed with a major sedative such as droperidol * Call the surgical team and the physicians as the patient is admitted under them and ask them what they want us to do.

Answer 18

An elderly lady trips and falls 2 days ago, and presents with a headache. She is unstady on her feet. She is on warfarin for AF. She has red flags and needs a CT. **_True._** .

Answer 19

A 45 year old man presents to the ED with his wife, he has tried to hang himself at home but his system of ropes broke. No past psychiatric history but recently lost his job and family finances are not good. He is arguing with his wife, they do not communicate when you observe them. Choose the correct responses. * **_The presence of genuine authentic empathy on the part of early responders in the ED will make subsequent MH assessment easier_** * **_This man has increased risk of suicide because he has recently lost his job and is in financial trouble_** * This man has a wife, family and no past psychiatric history so this means he is not at risk for suicide * **_This man's strained relationship with his wife represents an increased risk for suicide_** * **_This man has an acute and significant risk for suicide, my recommendation is to admit to a mental health facility._**

Answer 20

4 year old, SOB, has a history of asthma and has been sick for 3 days. She has been getting salbutamol puffers Q2H and flixotide. The wheeze has become much quieter over the last hour and she is now very drowsy. There is still respiratory effort there is pulse and the chest is silent. O2 sats are 85%. What do you do, select from the statements below: * **_Resuscitation and advised parents that the child is very ill, get best available assistance, which may be senior ED, paediatric, anaesthetics._** * **_High flow O2 mask and ask for it to be changed to nebulised salbutamol as soon as it is prepared, run the nebulised mask with high flow oxygen._** * **_Get immediate IV access and if this is not available IO._** * **_Keep in mind BIPAP and adrenaline which can be nebulised, IM (if no access at all), and IV in arrest_** * **_IV bolus 50mg/kg of magensium over 20 mins, give 10mcgs/ kg of salbutamol and commence an infusion as per protocol_** * **_Prepare the equipment and get the best staff available for intubation of this patient_**

Answer 21

80 years old, unwell for 3 days, severe lower abdominal pain 1 day. He smells of urine and vitals are normal but he looks unwell. His urine is clear. You find his abdo to be of doughy consistency and tender. The surgical registrar refuses to see the patient stating it's a medical patient and to refer to geriatrics. Which statements from the ones below reflect good practice? * **_Assess in ABCDE system, you need further investigations. Do a bedside BSL and some blood tests including FBE, LFTs, Lipase and VBG_** * **_I would give analgesia and serially assess the patient_** * **_Get a thorough medical and surgical history from the patient including medications_** * **_The elderly with abdo pain are risk patients, I will be very vigilant_** * **_I will re-refer to the surgical registrar and if I am not the senior ED doctor I will ask for assistance with the patient_**

Answer 22

When is the best time to write your clinical notes? 1. After pathology and basic imaging has been done and you have results 2. After you have admitted the patient under the specialist team 3. After you take a history 4. After you have got your basic blood test results 5. **_After you have resuscitated, taken a history and done a secondary survey of the patient, this will usually include placing a cannula and taking bloods._**

Answer 23

An elderly man is brought into the ED complaining of severe abdominal pain. He appears very unwell and diaphorectic. PR 140/min BP 70/45. What are your priorities? * **_This man is very sick! He has a number of worst case diagnoses, but I need to assess and treat in systems-ABCDE_** * I need an urgent CT to clarify the diagnosis and will go straight to CT

Answer 24

Select from the actions below those which will contribute positively to the strategy for dealing with a department which is bed blocked. 1. **_Do a ward round with the NUM and look for patients who will be able to be discharged and may not need to be in a bed any longer_** 2. **_Do a board round with the doctors on the floor and assess at what stage each patient is at and intervene where appropriate if this will facilitate any decision making_** 3. Tell patients in the waiting room that the waiting time will blow out due to lack of beds and they might as well go home if they are not serious 4. **_Revise your admitted patients in the ED and contact the treating physicians if you feel they might be able to be discharged after review from them_** 5. Discharge patients who might be borderline for going home but ensure very close follow up

Answer 25

Tension pneumothorax can lead to obstructive shock. ## Footnote **_True._**

Answer 26

It is essential to remove the bandage to do venom detection. **_False. Undetected venom does not rule out a snake bite, also in some cases polyvalent anti-venom may be indicated anyway._**

Answer 27

Which features below would make the pain more likely to be cardiac? * **_Radiation into the left arm_** * Pain worse on inspiration * **_Radiation into the jaw_** * **_On both the right and left side of the chest_** * **_Worse when exerting myself_**

Answer 28

In many AF patient rate control is a better option acutely and sometimes in the long term. * **_True - don't want to cardiovert them if we don't know how long they've been in AF (can cause them to have an emboli_** * False

Answer 29

An elderly patient presents after a fall from 4 metres and is hypoxic at 85%, this is the xray. The patient should get limited oxygen concentration initiall ybecause they might be a CO2 retainer. **_False._** There is also evidence of consolidation.

Answer 30

It is your responsibility to notify specified groups of diseases such as meningococcal or gonorrhea to which authority? * **_State. Notify first, then will cumulate and send to the federal authority._** * Federal.

Answer 31

The ward clerk gives you the phone and states it is a call for you, the admitting doctor. On taking the phone you find it is a call from a member of the public who is concerned about their fathers breathing. You suggest that they come up to hospital but they state that that's not necessary as he's not that bad. Which is the best statement from the 2 below? 1. **_I would not engage in a thorough history, and strongly advise the caller that most breathing problems should be reviewed straight away in person. If they think their father is unwell they should call an ambulance. I would also ask the ward clerk to advise me in the future who the calls might be from, and to divert medical advice calls to the appropriate number_** 2. I would get a more detailed history and try and ascertain the level of acuity of the patient and assess as to whether they need to come into the hospital.

Answer 32

Antibiotic prophyhlaxis for meningitis should be given to family and carers in which of the following circumstances (more than one) * **_18 month old boy diagnosed with meningitis on PCR testing of CSF_** * **_The husband of a 30 year old woman who has meningitis based on gram stain of CSF_** * The parents of a 6 year old who presents with fever and no focus admitted for empirical treatment and obs * **_A registrar who performed a difficult intubation on a patient with PCR confirmed meningococcus_** * The room mates of student who has elevated WCC in the CSF no confirmed diagnosis * All the classmates of a 12 year old students who has confirmed diagnosis of meningococcus

Answer 33

76M presents with palpitations, and is found to be in rapid AF with ventricular rate of 160bpm. More than one response may be correct. * As long as his SBP remains above 90mmHg then he dose not need immediate treatment * He should get a bolus dose of amiodarone irrespective of other clinical findings and history * **_He should be assessed for stability by ABCDE, and presence or absence of chest pain, SOB, normal mentation and SBP above 90mmHg, then treatment decisions made_** * **_If he assessed as unstable, cardioversion is the best and safest option for him, and this should be performed in the most effective and safest way_** * First priority is a troponin to determine treatment options

Answer 34

Elderly patient presented with 4 days of abdo pain much worse on the day of presentation. She had a respiratory rate of 36 on arrival. Choose the correct conclusions form the statements below: * **_Patient is very sick and I would assess in ABCDE_** * **_I would involve the surgical team very early in the assessment of the patient_** * Before any further assessment a CT scan is required to determine the underlying pathology * **_Conversation with the patient and family about end of life choices is relevant_** * **_This patient would likely require IC/HDU for further active management of any form_**

Answer 35

You have 3 very intoxicated youths in the ambulance bay. One is restrained by 3 police officers and 2 security guards who want you to sedate him immediately. One is on a stretcher and is in the left lateral position and appears to have vomitus in and around his mouth. One is sitting up on an ambulance stretcher talking to a nurse. You have one resuscitation bay available and a full department. Which patient do you take into the resuscitation area? 1. **_The patient in the left lateral position as he is an airway risk_** 2. The aggressive patient as he is a risk to himself and others and can be easily medically restrained

Answer 36

An 18 month old baby is brough in with burns down its back from boiling water. Which strategy is NOT appropriate? * Give IN fentanyl and gain access for further pain management * After cold water treatment dress with a clear plastic wrap * **_Give a strong oral medication and wait for a result prior to getting IV access and giving further medications_** * Give IM ketamine 3-5mg/kg and attend to the dressing and management when the child settles, given there is expertise in managing the sedated children and the appropriate environment available

Answer 37

Although the CTG can detect foetal distress, it's not useful when diagnosing premature labour. True or false? **_False, they also detect contractions._**

Answer 38

An unconscious patient arrives in the ED, you can give emergency care only up until the point of the primary survey and stabilisation of the patient and must have consent from here on in. **_False._**

Answer 39

68 year old woman presents to the ED 3 weeks after a total knee replacement, complaining of palpitations and feeling as if she is going to pass out. Choose the best course of action (more than one). * **_She should be assessed initially by ABCDE, and if stable then further investigations should take place_** * She should be sent immediately for a CTPA to look for PE * **_If she is deemed potentially unstable, she should get an urgent cardiac echo, to assess for right heart strain as she may be appropriate to thrombolyse_** * D-dimer test can be performed to exclude a PE * In the absence of chest pain, a PE is unlikely

Answer 40

The diagnosis of premature labour is more likely in the presence of which factors (more than one): * **_Positive fetal fibronectin_** * **_More than 4 contractions an hour_** * **_Contractions which are strong and palpable_** * **_Contractions which are painful_** * **_When a shortened cervix on USS is found_**

Answer 41

4 year old boy presents with vomiting and diarrhoea for 24 hours, the frequency of the vomits have dropped off over the last few hours but he is still not drinking. He is assessed as mildly dehydrated but his examination is otherwise normal. Select the correct statements from the ones below * Get IV access and if this fails then IO for fluids, both maintenance and resuscitative * **_Trial of oral fluids, give ondansetron. His history suggests he is improving and discharge after a successful trial of fluids_** * Basic work up including EUC and FBE looking for renal function electrolyte abnormalities and inflammatory markers * An abdominal XR will be use to exclude bowel hydration * **_A history of the same problem in siblings would make this more likely to be a viral gastroenteritis and increase chances of a success_**

Answer 42

Patient withdrawing from high use narcotics need to be observed for withdrawal symptoms because of the risk of seizures. **_False - seizure not part of narcotics withdrawal._**

Answer 43

A 6 year old child presents with high fever, photophobia, headache and painful legs and is drowsy. PR, BP, RR within normal range. Choose one best answer. * It is imperative to perform an immediate LP so that antibiotics may be started * CT is the most urgent investigation and must be performed prior to the LP * **_This child's history is strongly suggestive of meningitis, and in the light of no other clear source of infection, antibiotics should be given early._** * Once the patient has been reviewed by the paediatric team, treatment can commence with antibiotics of their choice * A full septic workup is not required, as the diagnoses is clear

Answer 44

Tetanus toxoid available in most EDs is the same for adults and children. * True * **_False_**

Answer 45

Which of the following are RED FLAGs? * **_I was sitting in chair and out of the blue was struck with a terrible headache_** * I have intermittent chest pain which are worse when I turn around * **_I was eating a meal when I developed severe chest pain. It was like an elephant sitting on my chest_** * **_A women with a plaster cast on her left leg presents with a dry cough and pleuritic chest pain_** * A young man presents with diarrhoea and vomiting for 24 hours, and stated he saw flecks of blood in his vomit * **_An elderly woman on warfarin states she has been unsteady on her feet lately. Her INR is found to be 4._**

Answer 46

A patient has a polypharmacy overdose and has no significant past known medical history. He has hypotension refractory to 4L of fluids. Possibilities for ongoing management are all the below except which one. (This is a theoretical question in an ideal hospital.) * ECMO * Vasopressors * Possible antidotes if ingestant known * **_Try up to another 4L of fluid first_** * Cardiac assist devices

Answer 47

You are working in a clinic in a remote indigenous community and many of your patients come from local families. Choose 1 or more. * Strict adherence to appointment times is essential * **_Having men and women in the clinic at the same time might not work and alternative timing strategies may improve visit compliance_** * **_Displaying local artwork and imagery is a way of demonstrating respect for cultural values and can help to make people feel welcome_** * **_Indigenous employees at the clinic is essential for establishing trust and acceptance of the service provided_** * **_Understanding and utilising family kinship networks can improve engagement in treatment plans_**

Answer 48

38F post MVA with closed head injury, she appears confused and has GCS assessed by the paramedics of 14. Because this represents a minor head injury, she can be moved to a subacute area nad no further neurological examination is necessary. **_False._**

Answer 49

The ED is full. There are 2 ambulance trolleys in triage. You are also advised that the hospital is full. Select some solutions from below (multiple): * _**Call the hospital administrator to make them** **aware of your difficulties, and ask if they have any options such as opening more beds**_ * **_You may have patients in the ED who could be discharged. It is always valuable to do a ward round with the NUM and liaise with admitting teams regarding prompt discharge of their patients_** * You need to declare a major incident and close the ED doors * **_Your department is becoming a high risk environment, and you nursing and medical resources are likely to be under pressure. Be aware of this and reassess sick patients when necessary_** * **_Liaise with the NUM and the bed manager to encourage more bed availability. Call the senior on-call if you are not that person_**

Answer 50

You are informed by the triage nurse that there is a cat 2 chest pain patient in the resus and they don't look well. Do you have a duty of care to that patient? **_Yes, you do_**.

Answer 51

A 48 year old male presents after 45 mins of hcest pain, he has ST elevation in V3-5 of \>3mm, he is still in pain and is getting nitrates and a narcotic. You have been told the lab will be available to cath him in 2 hours. You thrombolyse the patient because of his early presentation and no immediate PCI available. * _**This is the correct option. Thrombolyse within 60 mins of pain onset and no PCI available**._ * This is the incorrect option

Answer 52

An elderly lady presents to the ED with a painful hip and she cannot mobilise. Your initial XR show no obvious fractures. What do you do next * Give adequate analgesia to whatever level is required to mobilise the patient and discharge home with an OP bone scan * CT scan of hip before making any decisions * Get ortho review and if they have no concerns you can discharge the patient * **_Admit this patient under a physician (geriatric team in larger centres) as a mobility issue, she will need further assessment for safety cause of her pain and further imaging_**

Answer 53

A 29 year old woman has taken 'all' her antidepressants medications about 1 hour ago. She is GCS 14. She is tachycardic at 138/min and ECG shows narrow complex. She is flushed but has a normal temperature. Given this history you don't have significant concerns and put her in the psychiatric assessment room for review. Is this the right path? * **_No_** - potentially going to get unwell. Only 1 hour since SSRI intake, (serotonin syndrome- agitated, tachycardic)/benzo/tricyclic(tachycardic, antichoinergic from tricyclic hence the redness), etc. * Yes

Answer 54

A man in his 40's presents with a headache. He states it started as a sudden terrible headache but now (6 hours since it started) it is a lot better and he thinks he is wasting your time. His pain settled with paracetamol, as his neurological examination was normal you discharge him home as a tension headache. * Correct decision * **_Dangerous decision!!!_** (It could be a subarachnoid headache.)

Answer 55

17 year old girl presents with lower abdo pain she is 4 weeks since her last period but they have been "all over the place lately". On exam, she is afebrile but looks flushed, she has a tender abdomen in the RLQ with no guarding. She is with her mother and not sexually active by history taken. Which statements below are correct? * **_BHCG must be done, this could initially be done by urine and also blood_** * UTI is possible and a urine dip test should be done. IF the urine dip test is positive for blood and leucocytes then no further investigation are required * **_Basic bloods looking at inflammatory markers such as WCC and CRP maybe useful, but cannot rule in or rule out pathology_** * **_Pelvic USS request to look for an appendix will be very useful._**

Answer 56

An elderly woman was seen to slump from her chair while having lunch. She had two standard drinks in hte preceding hour but was otherwise well without known significant medical problems. She is now stable with no abnormal findings. Select from the list below correct statements: * This lady needs a cardiology admission whatever your findings after arrival * **_She should be assessed in ABCDE and then secondary survey along with 12 lead ECG, BSL and urine screen to start with_** * **_A CT scan may be of use, depending on the history (e.g. Anticoagulants) and evidence of any trauma_** * She should be advised to never drink again as she has had an allergic reaction * **_After a number of investigations she may be able to go home depending on clinical and social circumstances_**

Answer 57

A 66 year woman presents to ED with pleuritic chest pain, shie is tachycardic 105/min, she has a leg in a POP caste (2 weeks) and a past Hx of DVT. D dimer is negative. Normal CXR and ECG. Choose one correct answer. * She can be discharged because she has a normal D dimer * She is low pretest probabiliy for PE and it is correct to do D-dimer * VQ scan will be the next investigation * **_This lady's most serious and most likely diagnosis are the same, PE. She should no have had a D-dimer done so disregard. The CXR being normal has no relevance other than if you were going to do VQ scan or to look for other diagnosis. I would do a CTPA on this lady. High risk on Wells', no alternative diagnosis more likely._**

Answer 58

When assessing a child for the first time, all the strategies of approach are valid except for which one? * Introduce yourself to the child and carer and gain eye contact with all the people with the child * Get down to the level of the child so you don't appear so imposing * Use distractions such as bubbles and teddy bears * Don't ask permission of the child to examine but be gentle and tell them what you are doing * **_Use things like lollipops which will keep them quiet for extended periods of time_**

Answer 59

If a snake bite victim brings the snake into the ED you try to identify it by any means such as the internet or reference material before treatment **_False._**

Answer 60

The department is full and your senior has asked you to see another patient. You have a 6 pt on your list who have not been referred, discharged or admitted .You are waiting for investigations and senior review. Choose one. * You stand firm and are adamant you will see no more patients until some of yours are sorted out, and you tell your senior to leave you alone * You can see that you have no choice and start to work up the next patient * You make a phone call to the most senior person on- call and complain about the way the department is being run today * **_Ask senior on-site to help with you undifferentiated patients in order to facilitate their disposition, and then go on to see new patients_** * You go to have lunch because you haven't eaten in 4 hours and you are getting grumpy

Answer 61

An ambulance arrives with a patient who was found on the ground outside his house by a neighbour, he is not moving his right side and is not making sense verbally. He lives alone and you have no previous medical records for him. The correct thing to do is thrombolyse him speculatively, as to get all the information will take much longer than the 3 hours available? * True * **_False - can't thrombolyse because we don't know the immediate and long term history. Don't know how long he has been lying there for, or bleeding risks._**

Answer 62

Which type of bite is most likely to get infected? * Human * Dog * **_Cat- 80-90% will get infected_**

Answer 63

A 35 year old woman presents with pleuritic chest pain. Select one or more statements from below which you feel are correct and reflect a risk aware approach. * **_If she is assessed "low pretest probability" for PE, a negative D-dimer (simply red) can be used to 'rule out' PE_** * A CTPA should be done immediately if she is not 'low pretest probability' * **_Discussion about investigating each patient is valuable with senior and specialist colleagues_** * The treatment of PE has a small risk and it's better to over diagnose rather than miss a PE * **_CTPA, VQ scans, Cardiac ECHO, D-dimer and venous doppler scans could all be used in various assessment strategies in potential PE patients_**

Answer 64

25 year old male patient presents with a penetrating abdominal wound after a fight at the bar, he appears sweaty and pale, has a PR of 130/min and a BP 105/80, he has a rigid abdomen. Choose one best statement. * This patient is in shock and should get 20mls/kg bolus of fluid resuscitation, which would be about 1500mls * **_This patient has haemorrhagic shock. He should go to the OT for exploration of the abdomen_** * Analgesia should be withheld until the abdomen is examined by the surgical registrar * An AXR would be useful in this patient * Most penetrating wound can be managed conservatively and that is true in this case

Answer 65

See marker.

Answer 66

Patients who present with AF and who are stable will always be anticoagulated. * True * **_False - in high risk of falls, etc. would have to reconsider risk vs. benefit._**

Answer 67

20 year old known diabetic comes into the ED, she has a RR of 40 and she looks unwell. She is combative, aggressive and threatening. Choose the correct statements: * **_Heavily sedating this patient would be unwise as her high respiratory rate is reducing her acidosis by compensation_** * **_Treatment in a resuscitation area, security for assistance, IV access, and start IV fluids immediately and send off a VBG. She may need chemical restraint to facilitate this._** * **_A small dose of ketamine may be of use to calm the patient and would not reduce the respiratory rate_** * **_You need to keep an open mind and be aware of intracranial pathology in this agitated patient_** * **_Keep in mind toxicological concerns for prescribed and social drugs, as her behaviour may be part of a stimulant toxidrome_**

Answer 68

An 80 year old with urosepsis and a low BP after 2 litres of fluid has been in the ED for 3 hours, you have just come on shift, as a priority you want to know all of the following except which piece of information? * **_CRP and ESR_** * Is she normally on any steroids * Allergies * Past medical history including cardiac history * Has she had antibiotics

Answer 69

The majority of radial head fractures are managed with a broad arm sling and early mobilisation. ## Footnote **_True._**

Answer 70

This man presented to ED with friends. He is conscious. Which statements below are correct? 1. **_He should be assessed using the CABCDE system and resuscitated_** 2. **_As long as he is mentating normally he should not get IV fluid resuscitation as large bolus_** 3. He should be given O negative blood even if his BP is stable 4. His heart is not at risk of laceration as it is too difficult to penetrate past the ribs posteriorly

Answer 71

6 month old boy presents with increasing SOB for 2 days, no feeds or wet nappies all day. He is irritable, hypoxic 90% on RA, has a T 38C. Moist inspiratory and expiratory sounds. He shows marked indrawing. What would you do? * High dose steroids should be given early * **_CXR may be of use once the child is stable and if pneumonia is a concern_** * CPAP may be required and PICU should be involved early * **_Assess by ABCDE and provide high flow O2 including humidified nasal if standard measures are insufficient. Titrate to adequate oxygenation \>94%_** * **_Trial of nebulised beta agonist as it may help but use oxygen through the nebuliser_**

Answer 72

A 40 year old presents with GCS 9, he has a fever of 39 , HR 100, BP 90/60 his RR 24/min and saturation on RA 98%. You need to do an LP as a matter of urgency prior to starting Abx. * True * **_False - GCS 9, unwell, empirical Abx is essential. Should not do LP (may have raised ICP, needs CT etc)._**

Answer 73

Tramadol is a good analgesia to use in patients who are on an SSRI medication. * Good plan * **_Potentially risky - can give serotonin syndrome with SSRI_**

Answer 74

25 year old woman in the WR having collpased earlier. You are told she is still 'hyperventilating' and has been given a paper bag. Her vital signs show mild abnormality (110/min, oxygen saturation 98% RA, BP 110/60). She has a lower leg cast in situ. Choose the correct statements. * After calming her down you can discharge this young woman without further testing * You should first do a CXR and ABG and then with these results review the woman. * **_You first priority is to assess ABCDE; although the vital signs on the triage sheet seem OK you must always do this with each patient_** * **_A thorough history, involving presenting complaints, both recent and distant past medical history and family history, is important. And medications such as OCP_** * **_Combination of collapse, tachycardia and tachypnoea is risk presentation_**

Answer 75

Tocolytics will frequently delay birth by over one week. ## Footnote **_False- 24-48 hours delay only._**

Answer 76

A man in his 50s returns from Africa where he has lived for 10 years. He drinks heavily has no immediate family and presents to the ED with RUQ pain and tenderness to examination. He has a low grade fever. Choose the correct statements from the ones below. * **_He may be immune compromised from chronic alcohol use and should be treated with caution as such_** * **_He may have been exposed to and susceptible to tuberculosis_** * **_Alcohol withdrawal is a potential cause of his fever once other sources have been excluded but he should be managed with an alcohol withdrawal protocol_** * **_Malaria always remains on the differentiated until proven otherwise_** * **_In most circumstance it would be wise to admit this man to hospital for investigation_** * **_He may have cholecystitis_**

Answer 77

Who would you discharge to their usual residence? 1. **_A young man with a laceration to tendons in his right hand who is going to be reviewed by the hand surgeon tomorrow. His hand is NV intact and pain is under control_** 2. **_66 year old lady with dysuria for 2 days, found to have leucocytes, nitrites and WCs in her urine. She appears well and can eat and drink_** 3. An elderly man who has a non-displaced fracture of the distal radius. He usually lives in a self care hostel and mobilises with a 4 wheel walker device 4. A 70 year old woman who is mildly confused and has a UTI. She is haemodynamically stable. 5. A young man has a fracture of the tibia and fibula, sustained by a car rolling back and crushing his lower leg, he is for OT tomorrow. The limb is NV intact and pain in under control in the ED.

Answer 78

A mature 15 year old girl who lives at home presents after an alleged assault by her father, she has bruising and lacerations on her face and various other soft tissue injuries which require no treatment. She does not wish to involve the police and as she is a mature 15 year old you feel you need to respect those wishes. 1. True 2. **_False_**

Answer 79

Most significant risk to neonates from premature labour is: * Necrotising enterocolitis * **_Hyaline membrane disease- Immature lungs, aid that by early administration of steroids (and after birth by giving surfactant)_** * Intraventricular haemorrhage * Patent ductus arteriosus

Answer 80

As long as a consent form is signed you can go ahead with the procedure even if the patient decides against it at a later date. ## Footnote **_False._**

Answer 81

27M presents to ED with breathing problems, he has a known history of asthma, he appears agitated, is saturating 90% on room air, he has a respiratory rate of 36/min and is talking in single words. Which of the statements below are correct? * **_The patient is sick and should be managed in a resuscitation area_** * **_He should get immediate nebulised salbutamol while IV access is gained and if no rapid improvement then IV salbutamol could be started_** * **_Should get early hydrocortisone 100mg IV_** * Empirical dose of antibiotics is indicated * He should get sent to an XR ASAP for pneumothorax * **_IV magnesium may be useful in this patient and should be used_**

Answer 82

A 3 year old girl presents with a history of drinking a bottle of paracetamol elixir. She has vomited 6 times and the mother is concerned that the last vomit had some flecks of blood in it. The ingestion occurred 2 hours ago. Select the one best answer: * She should be given a weight based dose of charcoal * The volume ingested will tell you if a 4 hour level of paracetamol is required * She has a significant upper GI bleed and should have urgent endoscopy * **_An IV line should be placed and blood samples taken if she appears to be unstable, but she will need a 4 hour level of paracetamol to access for the requirement of NAC_**

Answer 83

From the methods of ED doc to ED doc handover below which ones do you think work well? Choose more than one: 1. **_A board round can be done at the shift's end and each patient is assigned to a senior or middle grade doctor_** 2. **_Any difficult or undifferentiated 'long-term' patients should be managed strictly by senior ED doctors_** 3. After a nightshift, it is better for the interns to chase up the night admitting teams if they appear not be aware of their patients 4. Doctors from the previous shift should not leave until all their patients have been referred to admitting teams or admitted

Answer 84

Describe this nasty ankle fracture. * **_There is an unstable comminuted trimalleolar fracture of the ankle, the talus is displaecd laterally_** * There is a fracture of the fibula and tibia * There is a compound fracture of the ankle and will need urgent ORIF * The fracture cannot be adequately described as it is in a cast

Answer 85

25 year old man is brought into the ED with police after an ice binge. He is violent, screaming and kicking. Choose one: * Call the drug and alcohol team for early input as they understand these patients well * De-escalate the patient and the best way is to gain a rapport with him in this situation * Small titrated does of midazolam only should be used * **_Manage in resus, with 5 point restraint. Give IM droperidol 10mg and consider repeating. Supportive management essential and ECG as soon as possible_** * He should get beta-blocker for tachycardia

Answer 86

Regarding migraines, select the correct statement from below: * Visual disturbance makes the diagnosis unlikely * **_First migraine in an elderly patient is a red flag_** * **_Chlorpromaxine and IV fluids are the best approach to most migraines_** * **_NSAIDS and antiemetics may work for a number of migraines particularly when started early_** * CT scan is required for most presentations of migraines

Answer 87

A patient is BIBA. GCS 15, feels a bit strange. BP 98/60 and oxygen saturations of 98%. Not complaining of chest pain or SOB and when you listen to his chest it is clear. What do you do? * Because this is clearly VT I would want to immediately cardiovert this man using a 150J biphasic DC shock * Magnesium is the best first line drug and probably the only thing that will work for him (*This is correct if this was torrsades)* * **_This man has 'conscious VT' or stable VT by parameters we use. I will commence a bolus of amiodarone 300mg and give over 20 mins. I will be prepared to DC cardiovert him if his status changes from stable to unstable._** * I will give a bolus of fluids and observe for a period of time * I will call the cardiology for immediate TTE to help manage the patient

Answer 88

18 year old boy brought into ED by paramedics, he has been given an antihistamine. He states: 'normally i get only abdominal pain with anaphylaxis and I have been in ICU twice, I feel very unwell". His BP is 80/60, he has an urticarial rash. You don't give adrenaline immediately as you think the antihistamine is working. * True * **_False_**

Answer 89

The current best treatment of a bluebottle sting is? * Morphine * Ice * Vinegar * Compression bandage * **_Tolerably hot water_**

Answer 90

25 year old presents with a painful shoulder after falling from his cycle at 50km/hr, choose the correct ANSWERS below: * **_XR shown demonstrates a dislocated shoulder with what appears to be greater trubercle fracture_** * **_This patient may have significant multitrauma by mechanism and should be assessed and treated as such_** * **_This patient will most likely have significant pain and adequate analgesia will need to be given concurrent with the initial surveys, but ABCDE takes precedence_** * The shoulder should be relocated as a priority over standard trauma measures as the discomfort and deformity will not allow a proper primary and secondary survey

Answer 91

The patient presents with sudden left sided loin pain. He is on warfarin for AF. What's the diagnosis? * Perforated bowel * Liver haemorrhage * **_Retroperitoneal haemorrhage most likely from kidney_** * Rupture AAA * Perforated duodenal ulcer

Answer 92

You are the only night doctor in the ED during the night. You have admitted under the care of the cardiologist an elderly man with bradycardia. He is maintaining a heart rate of 50 with isoprenaline until about 3am and then drops to 26/min and becomes diaphoretic and confused despite you increasing the rate of isoprenaline to a predetermined maximum. You call the cardiologist for advice but he does not answer his usual number. What do you do? 1. **_Depending on my level of experience I would use external pacing with mild sedation for this man as an urgent measure and call for advice and assistance. This may be in the form of a senior ED, intensivist or other cardiologist. This many most likely needs a temporary pacing wire until definitive PPM can be placed_** 2. I would leave a message with the cardiologist and do the best I could in the mean time depending on my level of experience. I would then call the ambulance service for transfer of the patient.

Answer 93

You work in a rural ED with no acute trauma services. A 35 year old quad bike rider presents after an accident, not wearing a helmet. Her airway was patent on primary survey, her respiratory rate was 35 and she was normotensive. Her level of consciousness has decreased from GCS 14 to 12, and she has a large swelling over her right parietal scalp. The radiographer is on call but has just gone home. Pick the correct answers: 1. You need to get a CT scan before you talk to anyone 2. She smelled of alcohol so her level of consciousness change is probably due to this 3. She could wait until the morning so that you can get a senior opinion from the VMO when he comes on shift 4. **_You need to discuss this patient with a medical retrieval consultant as soon as possible_** 5. **_She needs an escalation of her level of care imminently_**

Answer 94

In terms of satisfactory urine output the younger the patient the greater the amount of urine per kilogram we like to see. **_True_**. * Adults 0.5ml/kg * Children 1ml/kg * Infants 2ml/kg

Answer 95

If patients have been using methoxyflurane with the paramedics, then I must wait 2 hours before giving IV analgesia. * **_F_****_alse_** - volatile and useful, but duration of action is short.

Answer 96

The commonest form of hypovolaemic shock in adults is: * **_Haemorrhagic --\> adults_** * Non haemorrhagic --\> children

Answer 97

Flumazenil is a mainstay of managing benzodiazepine OD. (It is a competitive antagonist for benzodiazepines.) ## Footnote **_False- we dont know whether this will cause a seizure or how bad their addiction is_**

Answer 98

What is the commonest reversible cause of cardiac arrest in children? * Trauma and haemorrhage * Cardiovascular collapse * **_Hypoxia_** * Drug ingestion * Non accidental injury

Answer 99

An elevated troponin will exclude thoracic aortic dissection when investigating severe chest pain. * True * **_False, a 'Type A' dissection can occlude the coronary artery and cause a troponin leak_**

Answer 100

All the selections below may lead to distributive shock excpet which one? * Sepsis * Anaphylaxis * Adrenal insufficiency * **_Pulmonary embolism_** * High spinal injury

Answer 101

Select the one best description of the fracture from the ones below: * Fracture of the radius in a child, the fracture is incomplete and has a 30-35 degrees of dorsal angulation, the ulnar appears intact. I do not have the views of the elbow * There is a fracture of the wrist in a child, there is dorsal angulation so this is a colles fracture * There is a distal third radial fracture with volar angulation * The ulnar has an incomplete fracture which may be a Galleazzi fracture

Answer 102

A young man presents to the ED on Sunday morning with severe headache, having drung heavily the night before. He is no longer intoxicated but has grazes and bruising around his right eye and a normal neurological examination but appears to you a little unsteady on his feet. Despite fluids and paracetamol, his headaches persist. He is low risk for cerebral injury and has a diagnosis of hangover headache. **_False, he may have a skull fracture._**

Answer 103

Risks when treating sprained ankles include which of the following, more than one: * **_Missing a talar dome fracture_** * **_Giving crutches to patients without clear directions_** * **_Not referring to PT_** * **_Placing a POP cast on painful ankles_**

Answer 104

15 kg child with 10% dehydration and significant ongoing vomiting and diarrhoea. What is her: * Fluid deficit? * 10mLs x 15kg x 10% = 1500mL * Maintenance requirements? * 1000mls + 250mls= 1250 mls * Ongoing losses * 10mL/kg = 150 mLs * Total fluid per hour * 1500 + 1250 + 150 = 2900 mLs