MOCK EXAM

1. A 34-year-old female has been diagnosed with a deep vein thrombosis (DVT) in her left leg extending to his groin, confirmed on doppler ultrasound. The next available DVT clinic appointment is in three days.
Which of the following is most appropriate next step?

2. A 94-year-old female with dementia was referred to the ED from her residential home. She had a 2 day history of anorexia, lethargy and loose stools 3 times a day. On examination she appeared dehydrated. Her regular medications were paracetamol and omeprazole.
En route to hospital ambulance crew noted a transient arrhythmia (shown) on the cardiac monitor.
Which of the following interventions would reduce the risk of recurrence of the arrhythmia?

3. An 84-year-old man is brought by ambulance having collapsed at home. The ambulance crew report ‘coffee ground’ vomit in a bowl by his chair at home. He has a history of hypertension and osteoarthritis. Two large-bore cannulas have been inserted.
His observations are as follows:
Temperature – 37.2 °C
Heart rate – 102 beats per minute
Blood pressure – 98/64 mm of hg
Respiratory rate – 18 breaths per minute
Oxygen saturation – 96% on room air
His venous blood gas results are as follows:
pH 7.29
pO2 12.5 kPa
PCO2 4.3 kPa
Hb 74 g/L
Lactate 2.6 mmol/L
Which of the following is the most appropriate next management step?

4. The CT head and angiogram confirm that the patient has an ischaemic stroke. The stroke team started thrombolysis in CT and brought the patient to ED resus for observation. After 45 min the patient starts seizing and his GCS drops to 9.
What is the best next management step?

5. A five-month-old boy is taken to the emergency department with swollen, bruised right ankle.
His x-ray is shown below.
What is the most likely diagnosis and cause?

6. A 19-year-old woman presents to the Emergency Department at 3:00 AM on a Sunday morning and reports that she was raped earlier in the night at a party. She states that she knows the perpetrator and wants to involve the police.
She has not showered, changed clothes, or passed urine since the incident. While speaking, she appears calm and alert, and her speech is coherent.
She is haemodynamically stable.
She asks, “Can you help me? I want the police involved, but I’m bleeding — I’m scared something’s wrong.”
What is the most appropriate next step from both an ethical and clinical perspective?

7. A 33-year-old male is brought in by the ambulance after being found by the police in a park, anxious, agitated, and dishevelled. The police witnessed the patient self-inflicting lacerations to both forearms.
After sedation, the patient calms down and allows a mental health assessment. Which of the following is NOT part of a structured self-harm risk assessment?

8. A 69-year-old man has presented to an Emergency Department in a small isolated hospital with sudden onset chest pain which began 3 hours ago. He is sweaty and nauseated. If a decision is made to transfer then the closest cardiac catheter facility is two hours journey time away, Hence fibrinolysis with Alteplace was done in ED. Patient vitals are normal. After 60mins repeat ECG is shown below.
Most appropriate next step ?

9. A 58-year-old woman has presented with a shoulder dislocation. She has considerable pain and evidence of sensory nerve dysfunction over the upper, outer arm. A pre-procedure airway assessment is undertaken. She is asked to open her mouth and protrude her tongue. This view is obtained. Which of the following is the most appropriate next step?

10. An 18-year-old female is brought to the emergency department by her mother due to ongoing refusal to eat. Her medical records confirm a diagnosis of anorexia nervosa. The mother reports a weight loss of 2–3 kg over the past week. On assessment, her vital signs and ECG are within normal limits, but she is found to lack decision-making capacity regarding her treatment.
What is the most appropriate next step in management?

11. A 17-year-old male presents to the emergency department (ED) following an injury sustained while playing basketball. He describes an awkward landing followed by a backward fall, resulting in injury to the posterior aspect of his head.
Assessment of his right leg reveals an obviously swollen and tender right knee with an unstable patella.
How best would you describe the X-ray below:

12. A 36-year-old female presents to the Emergency Department (ED) with sudden onset of thoracic back pain and numbness in her right leg that began the day before. She reports no trauma or previous medical history.
On assessment, her right leg power is found to be 3/5 and she describes altered sensation over the right leg. After few hours the power is worse 2/5
What is the most likely cause of the patient’s symptoms based on the history and progression?

13. A 7-year-old girl is brought to the Emergency Department (ED) by her parents concerned about swollen ankles and a rash on her legs. Vital parameters are within normal limit.
Urinalysis has been done, which is negative for blood, leukocytes, nitrites and protein.
Which of the following is the most appropriate management strategy?

14. A 45-year-old woman presents to the ED with a history of headache persisting for the past 4-5 days, accompanied by an inability to open her left eye for the past day. She does not report any vomiting, fever, confusion, seizures or loss of consciousness. On examination of her left eye, she has a dilated left pupil and ptosis, and the left eye is deviated downward and outward. Examination of the right eye and neurological exam are both normal.
What is the best diagnostic test for this patient ?

15. A 74-year-old male presents to the Emergency Department at 10:00 with a recent history of painless flashes and floaters in his right eye. His past medical history is significant for eye surgery as a teenager for short-sightedness and type II diabetes mellitus with proliferative diabetic retinopathy. On examination, visual acuity in his right eye is 6/12, and in his left eye is 6/6. His visual field is reduced in his right eye and he has experienced a curtain-like shadow across his field of vision. Which of the following can be seen on examination ?

16. A 30-year-old male presents to the emergency department (ED) after waking up with shortness of breath and palpitations. He denies chest pain and syncope but appears pale.
His vital signs are as follows:
Heart rate: 212 bpm
Blood pressure: 112/72 mmHg
Oxygen saturation: 100%
Respiratory rate: 23 breaths per minute
Temperature: 35.2°C
What is the most likely underlying mechanism for the patient’s tachycardia?

17. A 62-year-old man has presented with sudden onset, severe abdominal pain. He is conscious and has a blood pressure of 96/74mmHg. On examination, a pulsatile mass is noted over the abdomen. An ultrasound shows an abdominal aortic measuring 5.2 cm in the anteroposterior diameter. Which of the following actions is most appropriate?

18. A 14-year-old male was bitten by an insect, the insect bite was to his left upper eyelid. The following day his left-sided eyelids became red, swollen and painful. He was seen by his GP and given a course of oral Flucloxacillin. 3-days later, he presents to your Emergency Department (ED), due to worsening left eye pain. He reports double vision, which resolves when he closes his right eye. He feels the vision in the left eye is normal. Which of the following findings on presentation may indicate the need for an urgent lateral canthotomy with cantholysis?

19. A 38-year-old woman, currently 34 weeks pregnant, presents to the emergency department with a persistent headache. She reports having raised blood pressure since 26 weeks gestation. On examination, her blood pressure is 165/115 mmHg, and urinalysis confirms proteinuria.
What is the most appropriate next step in management?

20. A 27-year-old man presents to the emergency department with anaphylaxis. He has had two 500mcg doses of adrenaline intramuscularly but remains hypotensive and has developed audible stridor. You have started IV fluids. While you waiting for the adrenaline infusion to be started, what is the next appropriate step?

21. A 56-year-old man has presented with a two-hour history of sudden onset chest pain. He is a smoker but has no significant medical history and takes no regular medication.He is hemodynamically stable. An ECG confirms inferior ST elevation myocardial infarction (STEMI). He is alert and oriented, and the cardiology team is preparing for emergency angiography and potential primary PCI.
However, the patient refuses to consent to the procedure, stating:”I’ve seen too many people go in for this and not come back out. I’ll take my chances.”
You explain the urgency, benefits, and risks, but he continues to decline intervention. There is no known advance directive or surrogate decision-maker immediately available.

22. A 32-year-old man underwent procedural sedation with intravenous propofol for anterior shoulder dislocation reduction in the Emergency Department. The procedure was uneventful, and 45 minutes have passed since sedation was administered.
He is now awake, alert, oriented, and communicating normally. His vital signs are stable and at baseline, and his pain is well-controlled with oral analgesia. He has not yet tried oral fluids. You are in a busy ED, and the resuscitation cubicle is urgently needed for a higher-acuity patient.
Which of the following best reflects the most appropriate disposition decision at this stage?

23. A 23-year-old female presented to the Emergency Department (ED) with a painful left index finger after being bitten by a pet rat 4 days ago. The patient’s pain progressed over the next few hours and now her pain is unbearable.
What is the immediate management of this case?

24. A 14-year-old boy had an argument with his parents this morning; on the way to school he intentionally consumed some foxglove plant leaves to harm himself. He did not take any other substances. His initial ECG shows sinus arrhythmia, and he has a minimally raised troponin level. At 6 hours post ingestion, he has multiple further episodes of vomiting in the ED and becomes bradycardic with a heart rate of 52 beats per minute. His repeat ECG shows junctional bradycardia. The blood results show a metabolic acidosis and potassium levels of 7.8mmol/L. What would be the preferred initial treatment of hyperkalaemia in this patient?

25. A 13-year-old girl has been brought to ED, as she was becoming increasingly lethargic and drowsy. History of multiple episodes of vomiting since morning. Her blood tests are shown below. Vitals are stable
Na 140 mmol/L pH 7.23
K 5.1 mmol/L HCO3- 16.0 mEq/L
Urea 10.0 mmol/L Blood ketones 4.3 mmol/L
Glucose 19 mmol/L
You have just given her slow fluid bolus with normal saline, and insulin infusion started. Patient complaints of severe headache. What is the next step in treatment?

26. A 6-year-old boy has attended the Emergency Department with worsening shortness of breath. He is unable to complete a sentence in single breath. Peak expiratory flow is 40% of the predicted value. Medical management was initiated. After one hour his peak expiratory flow improved to 45% of the predicted value and he feels better now. Which of the following is the most appropriate plan?

27. A 28-year-old man presents to the Emergency Department after jamming his finger while playing basketball. He reports immediate pain and swelling in the middle finger. Over the next few days, he notices difficulty bending the middle joint and hyperextension of the finger near the base. On examination, there is:
PIP joint hyperextension, DIP joint flexion. What is the most likely diagnosis?

28. A 46-year-old male presents with severe right-sided flank pain. A CT KUB confirms an 11 mm obstructing ureteric stone with associated renal pelvic dilatation. While in the emergency department, the patient deteriorates—developing a fever and becoming hypotensive with a blood pressure of 88/52. You initiate sepsis management, including blood cultures, intravenous fluids, and broad-spectrum antibiotics. The on-call urology registrar is currently in theatre and unavailable.
What is the most appropriate next step in management?

29. David, a 68-year-old man with a history of COPD, presents to the emergency department with increasing shortness of breath, drowsiness, and a productive cough for the past three days. On examination, he is using accessory muscles to breathe and appears fatigued. His initial arterial blood gas (on room air) shows:
pH: 7.25
pO₂: 7.1 kPa
pCO₂: 7.4 kPa
He is started on BIPAP with settings: IPAP 8 / EPAP 2.
Repeat ABG shows:
pH: 7.30
pO₂: 8.0 kPa
pCO₂: 8.0 kPa
What adjustment to the BIPAP settings would best improve his gas exchange?

30. A 64-year-old man presents to the Emergency Department with sudden-onset severe tearing chest pain radiating to the back. He is haemodynamically stable. CT aortogram confirms a Stanford Type B aortic dissection extending from the distal aortic arch to the iliac bifurcation. There is no evidence of end-organ malperfusion.
Initial treatment includes intravenous atenolol, which successfully reduces his heart rate from 95 to 62 bpm. However, his blood pressure remains persistently elevated at 144/88 mmHg despite optimal heart rate control.
What is the most appropriate next step in pharmacological management?

31. A 2-year-old child presents to the Emergency Department (ED) with a 2 minute long episode where he became unresponsive, initially being stiff and then with rhythmic jerking of all four limbs. He was sleepy for 5-10 minutes afterwards.
The parents report that has been feverish for the last 24 hours. Clinical examination is unremarkable.which of the following investigations would be indicated?

32. A 47-year-old gardener has accidentally stabbed his right foot with a garden fork soiled with manure while working in sandals. He tells you that he had a full course of vaccinations as a child and a booster dose 8 years back.
What would you advise him regarding tetanus prophylaxis?

33. A 27-year-old female has presented with lower abdominal pain. Two days previously, she was seen in the Early Pregnancy Diagnostic Service with vaginal bleeding and mild pelvic discomfort. Her exact gestation was unknown. A pelvic ultrasound showed intrauterine foetal pole, her serum β-HCG level was 1,234 mIU/ml. She has now returned with ongoing discomfort. Her repeat serum β-HCG level is 2,879 mIU/ml. On examination cervical OS is closed and few blood spots noted.
What is the most likely diagnosis?

34. A 47-year-old man with a history of chronic alcohol use is admitted to the hospital with weakness and confusion. He reports eating very little over the past two weeks. After admission, he is started on a high-calorie diet. Two days later, he develops muscle weakness and confusion.
What is the most likely diagnosis?

35. A 15-year-old boy is arrested and brought to the Emergency Department (ED) by police with a high suspicion of him having concealed drugs internally. He is asymptomatic and denies possessing drugs. The police officers have given you written authorisation for an intimate body search and x-rays to determine if packages have been swallowed. After your initial assessment you decided to proceed with low dose CT scan (LDCT) for further evaluation, however the boy and his parents refuse permission for imaging. What is the most appropriate next management step?

36. An 87-year-old man has arrived in the ED from a Nursing Home following a collapse. The triage nurse is concerned that this may be due to sepsis. Which of the following clinical features are ‘High Risk Criteria’ in a patient with suspected sepsis?

37. A 2-month-old infant is brought in with bluish discoloration of the lips during crying. On examination, the baby is cyanotic with a harsh systolic murmur at the left upper sternal border. Echocardiography confirms Tetralogy of Fallot.
Which of the defects in Tetralogy of Fallot determines the time at which the child will present?

38. A 60-year-old woman with schizophrenia is brought to the ED from the nearby psychiatric unit following a collapse. Her vital signs are normal. Her ECG is shown below:
Which of the following is the most likely explanation for her collapse?

39. A 17-year-old girl unexpectedly delivers a baby in the Emergency Department. Your colleague is taking care of the mother. The umbilical cord is cut and the baby is handed to you. Baby appears to be full-term, however, on rapid assessment, the baby is apnoeic, floppy, and blue. Resuscitation is started according to the newborn life support.
Which one of the following is true?

40. A 56-year-old man presents with significant breathlessness and atypical chest pain; he is tachypnoeic, tachycardic and has reduced pulse oximetry readings. You suspect that he may have a pulmonary embolism and are considering further investigation.
Which one of the following statements is true?

41. A 27-year-old woman has presented to the ED with a sudden onset severe occipital headache which began two hours earlier. She is in pain however she is alert, and orientated, vital parameters are within normal limits and examination is unremarkable. A non-contrast CT brain has been reported as normal.Which of the following is the most appropriate next step?

42. A 45-year-old woman has a CT head showing an extradural haemorrhage after a road traffic collision. While preparing for airway management, you see your ED colleague discussing the CT images with a senior emergency nurse to plan escalation and transfer.
Which statement best reflects this situation?

43. A 24-year-old woman with known severe depression, has been brought to the Emergency Department following an intentional overdose of Bisoprolol. She was found with an empty packet of 5 mg bisoprolol tablets. Her initial vitals are HR: 50/min, BP: 80/40mm of hg, RR: 24/min, Spo2: 99% on room air. Atropine, glucagon and 1L of NS is administered. Her re-check HR: 66/min BP: 82/40 mm of hg.
What is the most appropriate next step to increase the blood pressure?

44. A 29-year-old woman has presented with a one-hour history of palpitations and dizziness. She is generally healthy but says that she has had the same symptoms before, briefly. Her only regular medication is the oral contraceptive pill.
Her observations are as follows:
Temperature – 37.2 °C
Heart rate – 168 beats per minute
Blood pressure – 114/74mmHg
Respiratory rate – 22 breaths per minute
Oxygen saturation – 99% on room air
ECG is shown below.
What is the likely cause?

45. A 55-year-old female smoker has been brought to the ED after she was taken out of a burning building unconscious. Burn over the torso and the oral cavity is noted. Her arterial blood gas is shown below.
pCO2 2.9 kPa
pO2 11.8 kPa (on room air)
HCO3- 16.5 mEq/l
COHb 16%
BE -10.9
Lactate 5.2 mmol/L
High-flow oxygen is started.
What is the most appropriate next step?

46. A 26yr old man was seated in the back of a classic car when it was involved in a head-on collision at speed. At the time of impact, he was appropriately restrained by the lap belt (seat belt across the lap only). His primary survey is unremarkable and on the secondary survey you notice a bruise over the abdomen due to the seat belt, the rest of the examination is unremarkable.
What is the most appropriate next step?

47. A 24-year-old woman presents to the emergency department with a three-day history of nausea and constant pain localised to the right iliac fossa. On examination, she has a temperature of 38.3°C, pulse rate of 105/min, BP: 120/60 mm of hg and has diffuse tenderness, guarding and rigidity. Her urine pregnancy test is negative. What is the best management step?

48. A 44-year-old man presents after falling from a height and landing on his feet. He reports right knee pain and inability to bear weight. X-rays of both knees are shown below. The left image shows the unaffected side.
What is the most likely diagnosis based on the abnormal radiograph?

49. A 55-year-old obese male is found unconscious at home and brought to the emergency department. On arrival, he is unresponsive with snoring respirations and no signs of trauma. You prepare to manage his airway.
Which one of the following statements regarding basic airway management is true?

50. A 59-year-old man arrives by ambulance following a dizzy spell. He has a history of hypertension and ischaemic heart disease. He does not live locally and asks if he could travel home and see his own doctor to arrange any follow-up. ECG is shown below:
Which of the following is the best advice for this patient?

51. A 22-year-old woman is brought to the Emergency Department in cardiac arrest after being submerged in a frozen lake for approximately 20 minutes. She is in fine ventricular fibrillation and has a core temperature of 30°C on arrival. Her pre-hospital treatment included 2 shocks of 150 joules, the most recent of which was 5 minutes ago. Rhythm check in ED shows asystole. What is the most appropriate next action?

52. A 9-year-old boy is brought to the ED by his parents. He has been unwell and vomiting for 24hrs and is now quite lethargic. The following observations are recorded:
Temperature – 37.9°C
Heart rate – 135 beats per minute
Blood pressure – 75/50mmHg
Capillary refill time – 5 seconds
Respiratory rate – 40 breaths per minute
Oxygen saturation – 95% on room air
A venous blood gas result is as follows:
pH 7.09
pO2 6.8 kPa
pCO2 2.1 kPa
Bicarbonate 9.7 mmol/l
Glucose 13.1 mmol/l
Which is the most appropriate fluid management decision?

53. A 23-year-old man has presented with a two day history of a painful right eye and reduced vision. He is usually a contact lens user but has not worn his lenses for more than a week. His eyes are shown below.
What is the most likely seen on examination?

54. A 44-year-old man has presented with an acute exacerbation of Bronchial Asthma. He is alert and has a salbutamol nebuliser at present. An arterial blood gas (ABG) is obtained (on face-mask oxygen) soon after his arrival and gives the following results:
pH 7.31
pCO2 7.4 kPa
pO2 7.3 kPa
HCO3- 29.8 mEq/L
Which would be the best treatment strategy?

55. A 36-year-old man is intubated in the ED following a road traffic collision. Initial placement is confirmed with normal capnography and chest rise.
Five minutes later, he becomes unresponsive with SpO₂ 79% and HR 42 bpm. There is no chest rise, the bag-valve is soft, and the capnography waveform is flat. Breath sounds are absent bilaterally. The endotracheal tube remains connected and at 26 cm at the lips.
What is the most appropriate immediate action?

56. A 58-year-old man has presented with dull aching eye pain associated with painful eye movements since a couple of days. He is a known case of Rheumatoid arthritis and has no history of problems with his eyes. A picture of the eye is shown below.
Which diagnosis is most likely?

57. A 5-year-old boy is brought to the Emergency Department by his parents after falling 1.5 metres from a garden wall. He did not lose consciousness and has remained alert and interactive throughout. He vomited twice in the hour following the injury but has since eaten and retained fluids without further episodes.
There are no signs of base of skull fracture, no scalp haematoma or open wound, and he has a normal neurological examination. The injury occurred three hours ago, and there have been no concerning symptoms since.
According to NICE head injury guidelines, what is the most appropriate next step in management?

58. A 45-year-old woman has presented with several days of weakness, nausea and abdominal pain. Her husband called an ambulance after she collapsed at home. She is confused (GCS 13/15), with a heart rate of 120 beats per minute and blood pressure of 80/50mmHg. Blood reports show :
Sodium 126 mmol/L
Potassium 6.4 mmol/L
Urea 7.8 mmol/L
Glucose 2.6 mmol/L
What is expected on arterial blood gas?

59. A 5-year-old child was found unresponsive at home and brought to the emergency department by ambulance. On arrival, the heart rate is 54 beats per minute, and blood pressure is 84/50 mmHg. The child is connected to a cardiac monitor, a paediatric emergency call has been activated, and high-flow oxygen has been administered. The first dose of atropine has been given, but the heart rate and blood pressure remain unchanged.
What is the most appropriate next step in management?

60. A 21-year-old female presented in the early hours of Sunday morning stating that she was raped a few hours earlier at a party. She is still intoxicated with an unknown substance and has not yet been able to make a decision about onward referral to the Sexual Assault Referral Centre. She does not complain of injury and has normal vital signs.Which of the following is the most appropriate action?

61. A 46-year-old man, suspected of drunk driving, has been brought to the emergency department after a road traffic accident in which another driver was killed. The patient has a serious head injury and is unconscious. CT scan has been done and reported as Epidural haematoma. A police officer says that a Forensic Medical Examiner (FME) cannot come to the hospital for a number of hours and requests you to collect the blood sample from the patient as early as possible for alcohol and drug testing. Which of the following is the most appropriate next step?

62. A 6-day-old baby was brought to the emergency department by a worried mum. The baby came in contact with a child with chickenpox. Baby never had chickenpox before and VZIG tested by GP is negative. GP has advised them to visit the emergency department. She denies any rash and the baby is asymptomatic. There are no known co-morbidities. On examination, vital parameters are within normal limits and no rash is noted. What is the most appropriate management plan for this patient?

63. A 64-year-old male pedestrian has been brought to the emergency department after being hit by a car. He has several significant injuries. He looks unkempt and smells of alcohol. His coagulation profile results have just been received.
Haemoglobin 6 g/L (14-18 g/l)
International Normalised Ratio (INR) 1.9 (0.8 – 1.2)
Activated Partial Thromboplastin Time (APTT) 62 seconds (35-45 seconds)
Fibrinogen 0.85 g/l (2-4 g/l)
What is the most appropriate initial treatment to reduce the extent of any bleeding?

64. A 54-year-old man who is known to have Chronic Obstructive Pulmonary Disease has presented with increased breathlessness, unable to perform regular activities. Patient is haemodynamically stable. Lung ultrasound has been undertaken using a linear array probe in a para-sagittal orientation over the upper part of the right lung. The following image has been recorded in M-mode.
What is the most likely explanation for the imaging and clinical findings?

65. A previously healthy 15-year-old boy has a spontaneous pneumothorax with a 4cm rim of air on a chest x-ray, and it has been decided that a Seldinger chest drain is indicated. He does NOT consent to the procedure, but his mother consents to the procedure. What is the best option?

66. A 33-year-old woman sustained an injury to her thumb when she awkwardly caught a ball. The x-ray of her hand is shown below.
Which of the following is the most appropriate next action?

67. A trauma team is preparing for the arrival of a four-year-old child who fell from a second-floor balcony. You have been asked to assist in the preparation of emergency fluids and drugs. Which of the following estimates of weight, normal saline (N/S) fluid bolus and endotracheal (ET) tube diameter is most appropriate?

68. A 64-year-old man has arrived by ambulance. He was involved in a car accident the previous day when his vehicle was hit from behind. He did not feel the need for medical attention at the time but upon waking today he felt severe neck pain. He is currently immobilised on a spinal board with a collar. On examination he has a normal upper limb neurological exam but midline tenderness at C2-4. Which is the most appropriate next diagnostic step?

69. A 16-year-old girl presents to the Emergency Department after taking an overdose of paracetamol. She denies suicidal intent and says she was “just angry.” Her physical observations and bloods are normal. She is calm and wants to stay for mental health review, but her parent insists on taking her home.
What is the most appropriate next step?

70. A 16-year-old female presents to the emergency department requesting emergency contraception. On further questioning, she discloses that she is in a sexual relationship with her 49-year-old professor, and they engage in regular intercourse. She reports that they forgot to use a condom during their most recent encounter. She requests that the conversation be kept confidential.
What is the most appropriate management plan?

71. A middle male was brought to the emergency department with complaints of chest pain. He is been partying with his friends and has sniffed cocaine. He has no co-morbidities and is not on any regular medications. On examination, GCS 15/15. His vital parameters are as follows:
Heart rate: 113 beats/min
Respiratory rate: 22 breaths/min
Blood pressure: 210/109 mm of hg
SpO2: 98 % on room air
What is the drug of choice to reduce his blood pressure?

72. A 41-year-old male was brought to the emergency department in an ambulance with a history of collapse, recovered completely now. He has no known co-morbidities and is not on any prescribed medications. On arrival at the hospital, the patient is asymptomatic. His observations are as follows HR: 87/min BP: 98/62 mm of hg RR: 18/min Spo2: 99% on room air and a systolic murmur. An echo image of the 4 chamber view of the patient is shown below.
Most likely ECG finding to be seen ?

73. A previously well 64-year-old man has presented with left – sided arm and leg weakness. He first noticed the symptoms when he was having breakfast a couple of hours back. His wife tells you that he was well when he woke up. He is a known case of IHD, HTN and DM. His regular medication includes aspirin. When considering thrombolysis, which of the following is a contraindication?

74. A 22-year-old man was watching a horror movie at home. He felt faint and became pale and sweaty. He did not lose his consciousness and remembers the entire episode. ECG is shown below. The junior doctor asks you if we need to consider an implantable defibrillator in this patient. Which of the following statements about the need for an implantable defibrillator is most appropriate?

75. A 47-year-old driver is brought to the emergency department in an ambulance after a head-on collision. He was driving under the influence of alcohol when he hit a parked car. He complains of mild neck and chest pain. He has been conscious throughout. He denies any head injury. The primary survey is unremarkable. His chest x-ray is shown below.
What is the most appropriate next step?

76. A 74-year-old man has been brought to the ED from a nursing home with a history of fever since 4-5 days and he has been disoriented since this morning. On examination, a diffuse maculopapular rash is found over the trunk. You suspect meningitis and plan to perform LP.
What is the highest anatomical site where you can perform a lumbar puncture?

77. A 17-year-old boy is brought to the emergency department following a fall from a significant height, landing face first. On arrival, he has a GCS of 5/15. Despite multiple attempts, neither you nor the anaesthetist can intubate the patient. Bag valve mask (BVM) ventilation and ventilation with supraglottic airway are also unsuccessful. His SpO2 is now 76%. Which of the following is the most appropriate next step?

78. An elderly male, a known case of diabetes mellitus and hypertension presented to the emergency department with complaints of shortness of breath for 2 days, which is progressively worsening. There is no history of chest pain.
On examination :
HR: 102/min
BP: 160/100
Spo2 96% on room air
RR: 20/min
BM: 6.7mmol/l
GCS: 15/15
The chest x-ray is shown below.
ECG : ST segment elevation in anterior chest leads
What is the next best step?

79. A 4-year-old kid is brought to the emergency department with complaints of decreased hearing in the right ear. His mother gives a history of multiple episodes of ear infection in the past. On examination, his vital parameters are within normal limits. An image of the tympanic membrane is shown below.
What is the most likely diagnosis?

80. An 69-year-old lady presented to the emergency department with complaints of shortness of breath since morning, which is getting worse. She denies having any associated symptoms and had no similar complaints in the past. She is a known case of diabetes mellitus, hyperlipidemia, peripheral vascular disease and hypertension. On examination, HR: 99/min BP: 140/100 mm of hg RR: 26/min SPo2: 89% on room air, afebrile. You connect her to the oxygen and secure IV access. A bedside chest X-ray is taken and shown below.
What is the most likely diagnosis?

81. A 84-old-man, with known end-stage metastatic prostate cancer arrives in the ED. It is clear that he is approaching the last hours of his life. He is agitated. The nursing team asks you which drug to administer to help this patient.
Which of the following is the most appropriate medication in this situation?

82. A 44-year-old male presented to the emergency department with complaints of chest pain, which is worse on lying down. He denies any shortness of breath or profuse sweating. There have been no similar complaints in the past. The patient has a recent history of dry cough and sneezing and didn’t seek any medical help for the same. On examination, HR: 104/min, BP: 129/80 mm of hg, RR: 19/min, Spo2: 96% on room air, afebrile. ECG is shown below. GP has prescribed NSAID without any improvement. Most appropriate next step in management?

83. A middle-aged male presents to the Emergency Department with a history of palpitations since couple of hours. He also reports recent unexplained weight loss. An ECG was performed in triage, shown below. Laboratory investigations reveal elevated T3 levels with suppressed TSH.
What is the most appropriate next step in his management?

84. You successfully straighten a leg after a presentation of assumed patella dislocation. The patient remains unable to straight leg raise despite adequate analgesia. You obtain the radiograph below.
What is the best course of action?

85. A 47-year-old man has presented to ED complaining that he cannot eat properly as food and saliva dribble from his mouth. He also says that he has pain behind the right ear which started the previous day. His face looks asymmetrical (see image). A vesicular rash is noted over the right ear.
What is the best treatment plan for the patient?

86. A 22-year-old woman presents with lower abdominal pain and abnormal vaginal discharge. On examination, she has bilateral adnexal tenderness, cervical motion tenderness and a pyrexia of 38.5 degrees C. A pregnancy test is negative. Which of the following is the most appropriate management?

87. A 78-year-old woman with schizophrenia is brought to the Emergency Department after falling at home. On examination, you notice multiple bruises in various stages of healing on her arms and back.
She appears withdrawn and avoids eye contact. Her husband, who holds a Lasting Power of Attorney (LPA) for health and welfare, is present and insists on taking her home immediately. The patient does not express a clear opinion about her care.
What is the most appropriate next step?

88. A 42-year-old male recently discharged from hospital following a spinal cord injury to a rehabilitation centre, presented to the ED with complaints of dizzy spells. He feels dizzy when he was made to sit up from lying down position. In the emergency department, ECG was unremarkable. His lying blood pressure is 122/84 and his standing blood pressure is 98/74.
What is the likely cause for his dizzy spells?

89. A seven-year-old child presented to the ED with a two-day history of worsening pain in the upper abdomen and weakness. He a known case of sickle-cell disease. On examination:
Pallor++
Heart rate is 130 /min
Blood pressure 70/45 mm Hg
Lab investigations:
Haemoglobin 65 g/l
White cell count 11.6 x 109/l
Platelets 32 x 109/l
His usual haemoglobin is around 80 g/l.
What is the most likely diagnosis?

90. A 19-year-old woman has presented to the emergency department. She is a known case of depression. Over the past 6 hours, she has taken approximately 30 tablets of 500mg paracetamol. She says that she took 10 tablets every couple of hours and that she last took them 2 hours ago. What is the best management plan?

91. A 67-year-old female has presented with abdominal pain. She is a known case of Ischemic heart disease, hypertension and diabetes. She denies vomiting or changes in her bowel habits. Her vitals are within normal limits. The abdomen is tender with guarding and rigidity. CT abdomen shows a small bowel hernia with gangrenous changes. What is the most likely diagnosis?

92. A 29-year-old man has suffered an un-survivable head injury after an assault. His Glasgow Coma Score is 4/15, he has no brainstem reflexes and his brain CT scan shows a large intracerebral bleed with midline shift. He is intubated and ventilated. His wife says that he has previously said that he was unsure about the organ donation. Wife wants to donate his organs.
Which of the following is most appropriate advice for his wife?

93. A 34-year-old male was involved in a fight. He has been stabbed in his back. He is brought to the emergency department in an ambulance. On examination, the airway is patent, and high-flow oxygen is connected. A stab wound is noted over the upper back. You are suspecting brown Sequard syndrome.

Which one of the following do you expect to see in this patient?

94. A 74-year-old male presents to the emergency department with complaints of generalized weakness and lightheadedness since a few days. On examination, the patient has mild tachycardia, with the rest of the vital parameters within normal limits. Lab called to inform you that haemoglobin is 68 g/l. You decide to transfuse PRBC. After 30 minutes of initiation of blood transfusion, the patient complains of shortness of breath. Re-check spo2 is 90% on room air.
What is the most likely cause of shortness of breath?

95. A 72-year-old female has presented to the emergency department feeling lightheaded. She was received in the resuscitation bay and connected to the cardiac monitor. The rhythm seen on the monitor is shown below.
You believe that this rhythm is ventricular tachycardia, rather than supraventricular tachycardia with aberrant conduction. This is supported by which of the following on the given rhythm strip?

96. A football coach gets one of his players who has fallen over the forearm while playing. On examination, a deformed wrist is noted. An X-ray of the same is taken and shown below.
What is the likely diagnosis?

97. An 82-year-old woman has been found collapsed on the floor following 24 hours of diarrhoea. The patient has mild dementia, diabetes and hypertension. Her regular medications are aspirin, bendroflumethiazide, and gliclazide.
Her blood test results are as follows: Sodium 147 mmol/litre Potassium 2.5 mmol/litre
Urea 8.4 mmol/litre
Creatinine 89 μmol/litre
Glucose 8.7 mmol/l
Haemoglobin 12.1 g/L
White cell count 9.3×109/L
Platelets 217×109/L
Which one of the following is a possible complication in this patient?

98. A 3-year-old girl is brought to the emergency department with ongoing generalised tonic-clonic seizures. She has a known complex neurological disorder and is on a regular maintenance dose of levetiracetam. Her mother administered buccal midazolam at home without effect. On arrival, the child was given an appropriate dose of intravenous lorazepam, but the seizure activity continues.
The child is being monitored, with IV access secured and airway support in place. Blood glucose is normal.
What is the most appropriate next step in the management of her seizure?

99. A 72-year-old woman presents to the emergency department with a 3-day history of profuse watery diarrhoea, lower abdominal cramping, and mild fever. She was discharged from hospital one week ago following treatment for hospital-acquired pneumonia, during which she received a 7-day course of intravenous antibiotics.
On examination:
Temp: 38.1°C
HR: 96 bpm
BP: 114/68 mmHg
WCC: 17 × 10⁹/L
CRP: 145 mg/L
Which of the following antibiotics from her inpatient stay would be the least likely to have contributed to her current presentation?

100. A 37-year-old man has had a motorcycle accident on a slippery road. He is complaining of pain in his right shoulder and a dislocation is suspected.
Which of the following positions of the arm is most suggestive of an anterior shoulder dislocation?

101. A 10-year-old boy has presented with pain in his ankle after falling from his bicycle three hours earlier. After the fall his ankle swelled rapidly and he has not been able to weight-bear since.
His x-ray is shown below.
What is the most likely diagnosis?

102. A three-year-old girl has been brought to the emergency department for the third time this week because of a fever which has now continued for six days. Her parents say that she has a rash on the chest and hand, following appearance of the tongue (see image).
On clinical assessment which of the following features would you particularly looking for?

103. A 32-year-old G2P1 woman at 24 weeks gestation presents to the ED with a sudden-onset pounding headache, facial flushing, and nasal congestion. She has a complete T3 spinal cord injury from a motor vehicle accident 6 years ago and uses an indwelling urinary catheter. She also has a ventriculoperitoneal (VP) shunt for hydrocephalus.
On examination:
BP: 165/100 mmHg
HR: 48 bpm
RR: 18
SpO₂: 99% RA
Temp: 37.1°C
Uterus: non-tender, fetal heart rate normal
Bladder scan: catheter draining well
Rectal exam: reveals impacted stool
She is alert but distressed. You suspect autonomic dysreflexia.
What is the most appropriate next step in her management?

104. A 64-year-old male presents to the emergency department with complaints of loss of balance and numbness in the limbs. The patient is hemodynamically stable. You get a CT brain, which shows medial medullary syndrome. Which of the following do you expect to be commonly seen on examination?

105. A 34-year-old motorcyclist has been taken to the emergency department after his motorcycle slipped on oil and hit a parked car. His left shoulder is very painful.
This x-ray was taken to assess for a shoulder dislocation. Which diagnosis is most accurate?

106. A 44-year-old male is brought to the emergency department in cardiac arrest. The initial rhythm was asystole, and CPR was initiated with the first dose of adrenaline already administered. During ongoing chest compressions, the monitor now displays the rhythm shown below.
What is the most appropriate next step?

107. A 57-year-old, a known case of COPD, has presented with worsening breathlessness. She is brought to the emergency department in an ambulance. She has been managed in the emergency department with repeated doses of nebulised salbutamol and ipratropium bromide as well as oral prednisolone and IV antibiotics. You took an arterial blood gas sample while she was breathing 40% oxygen by face mask with spO2 89%.The results are as follows:pH 7.30 (7.35 7.45)pO2 9.7 kPa (10.5 13.5)pCO2 6.9 kPa (4.6 6.0)Bicarbonate 28 mmol/l (22 28)Base excess 1.2 (-2 to +1)Which one of the following can be considered before non-invasive ventilation?

108. A thirty-year-old presents to the emergency department with a five-day exacerbation of his eczema. Flucloxacillin was started three days earlier by the GP but has not helped. There have been no similar complaints in the past. The vital parameters are within normal limits. An image of the lesion is shown below. What is the likely diagnosis?

109. A 72-year-old male has been brought into the emergency department in the evening after a fall. He is complaining bitterly of pain in her ankle which is being supported in a moulded splint.
When the splint is open this is the appearance of the foot (image). You gained IV access and administered IV paracetamol 1gm.
The X-ray department says they can get the X-ray done immediately. Which is the most appropriate management plan for the patient?

110. A 59-year-old patient presents with bleeding from the tracheostomy. The tracheostomy was inserted 3 weeks ago. A bright red blood was noted by the patient to be coming from the tracheostomy. In ED, you notice the bleeding is continuous and profuse. You have called for help (ENT and anaesthetic). You have suctioned the airway and activated the major haemorrhage protocol.
What is the most appropriate next step in management?

111. A 35-year-old male presented to the emergency department with pain in his left foot since a couple of days. He is a security guard by profession and recently he has been doing a lot of long duties. On examination, his vitals are stable. Examination of the left foot reveals tenderness over the 2nd metatarsal bone. An X-ray of the left foot is taken and shown below.
What will you do next?

112. A 76-year-old woman with Parkinson’s disease and dementia is brought to the ED after accidentally taking 20 paracetamol tablets over the last 6 hours. Her son, who holds Lasting Power of Attorney (LPA) for health and welfare, requests treatment. On assessment, the patient is alert but disoriented and unable to retain information about her condition.
What is the most appropriate approach regarding consent for treatment?

113. A 4-year-old child is brought to the emergency department with high fever, drooling, and respiratory distress. The child is sitting upright, appears anxious, and refuses to lie down. Oxygen saturation is 93% on room air. The child is not speaking and is clinging to the caregiver.
What is the most appropriate next step in management?

114. A 19-year-old male met with an RTA. He complains of pain over the chest and abdomen. On assessment, the airway is patent and the right side of the chest has reduced air entry with hyper-resonance. His vital parameters are as follows :
HR: 123/min
BP: 80/50 mm of hg
SPO2: 89% on high-flow oxygen
RR: 39/min
E-Fast scan images are shown below.
What is the most appropriate next step?