Quiz 3: Test

1. A 5-month-old child presents to the Paediatric Emergency Department with inconsolable crying. The crying episodes have become more frequent, which is why her parents decided to attended hospital, as this was very unusual for her. She has not had a fever. She has been passing urine without concern and is breastfeeding well.
On examination, her abdomen is unremarkable and is soft non tender. Mum denies any diarrhoea or vomiting. However, 30 minutes after arrival, you are called to re-examine her. She has pallor, is inconsolable and you can palpate a mass in her right upper quadrant.
What diagnosis are you most concerned with here?

2. A 70-year-old woman attends the Emergency Department with ongoing epistaxis for the last 2 hours. She has a history of pulmonary embolism and taking warfarin. She has been applying direct pressure to her nose for the last 30 minutes, with no improvement.
The examination shows profuse bleeding from both nostrils.
Her observations are:RR 18, saturations 94% on airHR – 115 beats per minuteBP – 105/65
You transfer her to the Resuscitation area and obtain iv access.
Which intervention is most likely to rapidly control her epistaxis?

3. A 33-year-old female presented to the Emergency Department with a painful left index finger after been bitten by a pet rat while visiting a friend 4 days ago. The patient has no past medical history and no known drug allergies.
She was seen by her GP on the day of presentation who prescribed a 7-day course of co-amoxiclav. The patient’s pain progressed over the next few hours and now her pain is unbearable.
Vitals: BP 135/80 mmHg, PR 93 bpm, Temp 37.3, RR 16 bpm, O2 Saturation of 96% on air.
Which of the following is a typical clinical finding of the most likely diagnosis?

4. A 32-year-old man attends the Emergency Department with a fever and malaise since 3 days. Today he has developed discomfort and redness over the left side of his chest. He has no past medical history and is on no regular medications.
On examination his temperature is 38.2C, heart rate 115 beats per minute, BP 140/80, RR 14, oxygen saturations 98% on air and pain score 4/10. He has diffuse mild erythema and tenderness over the left anterior chest wall, with no swelling, palpable crepitus or abscess palpable.
Which of the following statements is true regarding his risk of having necrotising fasciitis?

5. A 6-year-old child presents to the ED with acute onset breathing difficulties, severe wheeze and an urticarial rash after eating peanuts. He is hypotensive and tachycardic at front door triage and you are called to assist.
After requesting to move the child to resus, your first priority at triage is:

6. A 13-year-old child attends the Paediatric Emergency Department with his mother. Six weeks ago, he tripped whilst playing football at school and injured his left leg but was able to continue playing. Over the last few weeks, mum has noticed he has been limping and complaining of pain in his left knee.
He is tall for his age, having had a recent growth spurt, on the 90th centile for height but the 25th centile for weight. He is well in himself.
What is the most likely diagnosis?

7. You perform HINTS examination. What results will indicate the patient may be having a posterior circulation stroke?

8. The patient mentions to you that whilst she was at work during her break, she felt something go into her other eye. She rubbed her eye vigorously to remove this sensation. She still feels some discomfort. You examine using the slit lamp and fluorescein dye which reveals that the patient has a 40% corneal abrasion. How should the patient’s left eye be managed?

9. A 49-year-old, presented to the Emergency Department (ED) three weeks following a horse-riding injury. She had fallen off her horse and subsequently the horse stepped onto her right thigh and hamstring. Image of the same is shown below. There was complete and pain-free range of motion of the affected side hip and knee. There were no neurovascular deficits. Routine blood investigations including FBC, CRP were normal and relevant X-rays showed no signs of fracture or osteomyelitis.
Which is the most likely diagnosis?

10. A 49-year-old, presented to the Emergency Department (ED) three weeks following a horse-riding injury. She had fallen off her horse and subsequently the horse stepped onto her right thigh and hamstring. Image of the same is shown below. There was complete and pain-free range of motion of the affected side hip and knee. There were no neurovascular deficits. Routine blood investigations including FBC, CRP were normal and relevant X-rays showed no signs of fracture or osteomyelitis.
What is the most appropriate initial ED management for this patient?

11. A 7-year-old girl with known asthma is wheezy and short of breath. Her Mum has tried giving her salbutamol inhaler throughout the day.
On assessment her oxygen saturation is 94% on air, RR 23, HR 113. She is colouring a picture in the waiting room and is able to speak in full sentences.
Which is the best initial management?

12. A 7-year-old girl with known asthma is wheezy and short of breath. Her Mum has tried giving her salbutamol inhaler throughout the day.
On reassessment, she has deteriorated with RR 35, sats 91% and unable to speak in full sentences. She has HR 127. She is uncooperative with peak flow testing. She appears confused and is not responding to her Mum.
Which is the most concerning sign?

13. A 69-year-old with known COPD attends your emergency department (ED) very short of breath. SPo2: 88% on 40% of oxygen. They have received three salbutamol nebulisers, and one ipatropium via the ambulance service with no improvement.
ABG on 40% O2: pO2 10 (75mmHg), pCO2 8 (60mmHg), pH 7.01, BE -2, Lactate 2.5. HCO3 28mmol/L.
CXR is shown below.
What is the best next action?

14. A 69-year-old with known COPD attends your emergency department (ED) very short of breath. SPo2: 88% on 40% of oxygen. They have received three salbutamol nebulisers, and one ipratropium via the ambulance service with no improvement.
Which one of the following is an indication to start NIV?

15. A 28-year-old male was involved in an altercation outside a pub and received a single stab wound to the chest.
He appears pale and anxious and is complaining of shortness of breath. He has symmetrical chest rise and clear, equal breath sounds without crepitations or wheeze. It is difficult to hear his heart sounds in the noisy emergency department. His neck veins appear distended.
His vital signs are as follows:
Oxygen saturations 96% in room air
Respiratory rate 26 breaths per minute
Heart rate 127 beats per minute
Blood pressure 88/52 mmHg
Which of the following options is the most appropriate next step in this patient’s management?

16. A 28-year-old male was involved in an altercation outside a pub and received a single stab wound to the chest.
The patient becomes unresponsive and does not have a palpable carotid pulse. In terms of traumatic cardiac arrest, which of the following is not one of the initial management priorities?

17. A 28-year-old male was involved in an altercation outside a pub and received a single stab wound to the chest. E-fast is suggestive of cardiac tamponade.
You decide to perform a resuscitative thoracotomy. Which anatomical structure is commonly injured during this procedure?

18. Which of the following patients has the strongest predictor of a difficult airway, when considering the decision to perform a drug-assisted intubation?

19. patient was drilling on a construction site and now is having catastrophic bleeding from a puncture wound accidentally sustained to his right mid-thigh. Despite haemostatic dressings and a tourniquet applied near the injured site, bleeding is profuse. This patient is known to take Apixaban for atrial fibrillation.
What is the next best course of action?

20. A 65-year-old man has been brought in by his son. He recently had an elective tracheostomy inserted prior to radiotherapy for oropharyngeal squamous cell carcinoma.
He developed acute respiratory distress approximately fifteen minutes prior to arrival. He has increased work of breathing with accessory muscle use, is clearly distressed and pointing at his tracheostomy. His oxygen saturations are 83% in room air. You immediately move the patient into a resuscitation cubicle.
Which of the following options is the immediate first step in the management of this patient?

21. A 65-year-old man, he recently had an elective tracheostomy inserted prior to radiotherapy for oropharyngeal squamous cell carcinoma.
High-flow O2 has been applied to both the patient’s mouth and nose. An attempt at passing a suction catheter was unsuccessful.
The cuff of the tracheostomy tube has been deflated, however the patient has now stopped breathing and has no pulse.
Alongside commencing cardiopulmonary resuscitation (CPR), what is the next step in managing this patient’s airway?

22. A patient presents with bleeding from their tracheostomy. The tracheostomy was inserted 3 weeks ago. A small amount (<10mls) of bright red blood was noted by the patient to be coming from the tracheostomy. It now appears to have resolved spontaneously. The patient is taking apixaban for atrial fibrillation.
What is the most appropriate next step in management?

23. A 27-year-old female has a 5 day history of myalgia & pyrexia, and has been self-medicating with paracetamol. Over the last 48 hours she has developed nausea, vomiting and right upper quadrant pain. Today she is drowsy and disoriented.
On examination she has scleral icterus and is tender in her right upper quadrant.
Observations: Temperature 37.8ºC, HR 122, BP 101/58, RR 26, SpO2 100% on room air
Arterial Blood Gas (ABG):
pH 7.303, pCO2 3.3, pO2 14.3, HCO3- 14, Na+ 135, K+ 5.1, Cl- 96, lactate 4.3
Bloods:
Total bilirubin 60µmol/L (<21)
ALP 432U/L (30-130)
GGT 1171U/L (<60)
ALT 2657U/L (<41)
AST 2893U/L (1-45)
Urea 11.4mmol/L (2.5-7.8)
Creatinine 177µmol/L (45-84)
INR 1.9 PT 72 seconds (10-14)
What is the most appropriate next step in management?

24. An 8-year-old boy presents to the emergency department after falling onto his elbow. He is holding his elbow and tells you that “it feels sore”. When you examine him, he has a tender swollen elbow. Also, of note, you realise he is unable to pinch/grab things between his index finger and his thumb. He is able to perform all other movements using his hand.
What nerve is most likely to be injured with this injury?

25. An 8-year-old boy presents to the emergency department after falling onto his elbow. He is holding his elbow and tells you that “it feels sore”. When you examine him, he has a tender swollen elbow. Also, of note, you realise he is unable to pinch/grab things between his index finger and his thumb. He is able to perform all other movements using his hand.
What is the most important next step in the definitive management of this patient?

26. 73-year-old woman was treated by her GP in the community for a lower limb cellulitis with flucloxacillin She has a background of hypertension, osteoarthritis, dyslipidaemia and chronic excess alcohol intake. Her medications include amlodipine, atorvastatin and regular paracetamol. HR: 120/min, RR:23/min, BP: 110/60 mm of hg, afebrile. minor resolving cellulitic changes over a small area of her left calf with an otherwise unremarkable examination.
Her white cell count and CRP are minimally elevated. Her electrolytes, renal function, lactate, serum glucose and ketones are all unremarkable. Her albumin is 17g/L (normal 35-50 g/L). Her pH is 7.14, bicarbonate 18mmol/L (normal 22-30mmol/L) and PaCO2 4.5kPa (normal 4.5-6kPa)
What is the likely cause of her blood gas findings?

27. A 7-year-old male presents with a 1 day history of vomiting and right sided ear pain. There is a history of preceding coryzal symptoms for 1 week.
His observations are as follows:
Oxygen saturations 100% in room air, Respiratory rate 24, Heart rate 103 bpm, BP 128/78 mmHg, Temp 38.1oC.
On examination, his left ear is normal. On examination of his right ear, you see the following appearances on otoscopy:
What would be your next step in the management of this patient?

28. A 7-year-old boy with known congenital heart disease was brought to the Emergency Department (ED) by his parents with complaints of fatigue, light-headedness and 2 episodes of vomiting since this morning.
He is alert, and his observations are HR- 180/min, BP-85/50mmHg, Spo2-100% in RA, RR-20/min. CRT is 2 seconds. Weight 22 Kg
What is the next step in managing this child?

29. A 7-year-old boy with known congenital heart disease was brought to the Emergency Department (ED) by his parents with complaints of fatigue, lightheadedness and 2 episodes of vomiting since this morning. The patient becomes drowsy. Central pulses are palpable.
HR- 300 beats per minute, BP-70/40mmHg, RR -28/per minute.
The monitor shows the rhythm below.
What is the most appropriate next step?

30. A 6-day-old baby is pre-alerted to your paediatric resuscitation room. They have low oxygen levels on pulse oximetry and are breathing fast.
The paediatric team are present and suspect that this baby has severe bronchiolitis
On your assessment, the baby has floppy tone.
Which of the following options is the most appropriate initial bedside investigation?

31. A 38-year-old female presents to your Emergency Department (ED) after having a sudden onset headache. She suffers with migraines and is under a lot of stress at work, but she states her current headache is much worse and is a different type of pain. The headache started five hours ago and was at its worst at onset. She has a GCS of 15 and no neurological deficit.
Which of the following is a known risk factor for the development of a subarachnoid haemorrhage?

32. A 38-year-old female presents to your Emergency Department (ED) after having a sudden onset headache. She suffers with migraines and is under a lot of stress at work, but she states her current headache is much worse and is a different type of pain. The headache started five hours ago and was at its worst at onset. She has a GCS of 15 and no neurological deficit.
CT scan is reported as normal.
What is the most appropriate next step?

33. A 38-year-old female presents to your Emergency Department (ED) after having a sudden onset headache. She suffers with migraines and is under a lot of stress at work, but she states her current headache is much worse and is a different type of pain. The headache started five hours ago and was at its worst at onset. She has a GCS of 15 and no neurological deficit.
The CT head report confirm a left-sided subarachnoid haemorrhage.
Which of the following is the most suitable first-line treatment in the ED?

34. A 28-year-old male presents to the emergency department (ED) with a sudden onset of redness, eye watering and photophobia in his right eye. He denies any trauma to the eye and reports no significant medical history.
On examination, the right eye appears injected with ciliary flush, and there is a small, round corneal ulcer with an overlying epithelial defect. Examination of his left eye is unremarkable.

What is the most likely diagnosis for the patient’s right eye symptoms?

35. A 34-year-old male is brought into the emergency department (ED) by ambulance after having completed a series of deep dives earlier in the day. Approximately 2 hours after his last dive, he began to complain of weakness, shortness of breath, and a persistent headache.
Patient has increased work of breathing. Breath sounds are reduced on the right, with hyper-resonance on percussion. Oxygen saturations are 90% on air.
Which of the following is the possible underlying pathology?

36. A 34-year-old male is brought into the emergency department (ED) by ambulance after having completed a series of deep dives earlier in the day. Approximately 2 hours after his last dive.
The patient complains of severe right knee pain. What is the next best step in management?

37. Peak incidence of peritonsillar abscess (quinsy) is observed in which of the following age groups?

38. A 24-year-old navy diver, develops acute onset chest pain and shortness of breath. She attends the Emergency Department (ED) and her x-ray shows a pneumothorax which is maximally 3 cm at the hilum. She is haemodynamically stable.
Which management option would be the best for her?

39. A 24-year-old, develops acute onset chest pain and shortness of breath. She attends the Emergency Department (ED) and her x-ray shows a pneumothorax which is maximally 3 cm at the hilum. She is haemodynamically stable.
You start to consent her, what would you tell her?

40. A three-day-old male infant is brought to the Emergency Department (ED) by his mother, who reports his eyes has been red, swollen and sticky since this morning. his vital signs are within the normal range.
Image of the eye shown below.
What is the most likely causative agent in this case?

41. A three-day-old male infant is brought to the Emergency Department (ED) by his mother, who reports his eyes has been red, swollen and sticky since this morning. Diagnosed as ophthalmia neonatorum
Which of the following complications is most likely to occur if treatment is delayed?

42. A 43-year-old gentleman presents to the Emergency Department (ED) with alleged history of consumption of total of 120 50mg Nytol (diphenhydramine) tablets.
A VBG has been performed and shows no electrolyte abnormalities or acidosis. The patient’s ECG shows a QRS duration of 148ms (normal is 120ms). What treatment should be given to the patient?

43. A 43-year-old gentleman presents to the Emergency Department (ED) with alleged history of consumption of total of 120 50mg Nytol (diphenhydramine) tablets. he develops generalised tonic-clonic seizure activity.
Which of the following drugs should not be used to treat seizures in this patient?

44. Which of the following should be used to grade the severity of this patient’s nausea and vomiting in pregnancy?

45. 28-year-old runner is brought by ambulance to your Emergency Department (ED), following a collapse soon after completing a marathon.
Which one of the following clinical features would indicate that your patient has heat exhaustion?

46. 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. Recently have symptoms of an upper respiratory tract infection.
Urinalysis has been done, which is negative for blood, leukocytes, nitrites and protein.
what is the likely diagnosis?

47. You see a 1-week-old in the Emergency Paediatric Department. You examine her and find a defect in her abdominal fascia that is approximately 1cm in diameter. It is fully reducible and does not seem to cause her any discomfort. She is otherwise well.
Which of the following is the most significant risk factor for an umbilical hernia?