Emergency Medicine 🚨

A 33 year old man was admitted to the emergency department after a head injury. On arrival, he has a Glasgow Coma Scale score of 15. A few hours later, his Glasgow Coma Scale score drops to 12. What is the SINGLE most appropriate immediate action?

A 60 year old man presents to the Emergency Department complaining of feeling exhausted and unwell in general since earlier in the day. He also reports that over the past hour, he feels his heart racing which is extremely distressing. On further discussion, he notes that he was diagnosed with diabetes mellitus ten years ago and is on metformin. Ramipril was added on to his treatment plan five years ago due to high blood pressure. An urgent ABG was performed, and the report is available.

pH 7. 33 (7.35-7.45)

pCO2 5.0 kPa (4.7-6.0)

pO2 12 kPa (12-14)

Sodium 138 mmol/L (135-145)

Potassium 6.8 mmol/L (3.5-5.0)

Which of the following is the most appropriate next step in the management of this patient?

A 33 year old woman has recurring tightness in her chest accompanied by palpitations and sweating. These episodes occur several times a week and are associated with increased respiratory rate and tingling and numbness around the mouth and fingers. What is the SINGLE most likely diagnosis?

A 65 year old man who has been prescribed amitriptyline for depression, has been brought to the emergency department with suspected overdose. He is not giving a coherent history. His skin looks dry and flushed. On examination, his pupils are dilated. His blood pressure is 90/60 mmHg. What is the SINGLE most appropriate immediate action?

A 32 year old man is brought into the Emergency Department following a road traffic accident. He has multiple injuries with tenderness and swelling of his anterior chest wall. He complains of severe sternal pain that is worse with respiration. Cardiac tamponade is suspected which a bedside ultrasound scan confirms. His initial observations include a blood pressure of 90/60 mmHg and a heart rate of 100 beats/minute. A few minutes later his observations show a blood pressure of 80/40 mmHg and a heart rate of 130 beats/minute. He remains conscious throughout. What is the SINGLE most appropriate initial management?

A 12 year old girl when playing in the garden accidentally stepped on a hive and was bitten several times. She has numerous wheals on her body and complains of severe itching which is worsening in the last few hours. Her medical history includes penicillin allergy. Her observations are within normal limits. What is the SINGLE most appropriate management?

A 60 year old man was involved in a high-speed road traffic accident. He was brought into the Emergency Department resuscitation room by the paramedics. He complains of severe right upper quadrant pain. On examination, there are no external bleeding. He has normal breath sounds. His abdomen is slightly distended. His right upper quadrant is tender with bruising. He has a temperature of 36.7°C, heart rate of 120 beats/minute, blood pressure of 89/56 mmHg, respiratory rate of 28 breaths/minute and an oxygen saturation of 96%. His capillary refill time is 4 seconds. Intravenous fluids have been started. What is the SINGLE most appropriate investigation?

A 10 year old boy is brought unconscious to the Emergency Department by his parents. His parents report that he was playing with his brother in the park when he sat down and then fell unconscious. There was no head injury. The incident occurred 25 minutes ago, and he has not regained consciousness since. He is unresponsive but breathing normally. His airways are patent. He has vesicular breath sounds. His heart rate is 120 beats/minute. There are no visible wounds. What is the SINGLE next most appropriate management?

A 25 year old woman has been feeling anxious and nervous for the last few months. She also complains of several episodes of palpitations and tremors in the past few weeks. Her symptoms develop rapidly and last for a few minutes. She mentions that taking alcohol initially helped her relieve her symptoms but now this effect is wearing off and she has palpitations and tremors even after drinking alcohol. What is the SINGLE most likely diagnosis?

A 5 year old boy with a febrile convulsion lasting eight minutes. He has been given intravenous lorazepam to control his seizures. What is the SINGLE most likely side effect of intravenous lorazepam that is potentially life-threatening?

A 15 year old girl is admitted in the medical ward after taking a 28 tablets of paracetamol with a large amount of alcohol. Her plasma paracetamol concentration taken 4 hours post ingestion is just below the concentration that would suggest treatment with N-acetylcysteine. What is the SINGLE most appropriate next course of action?

A 55 year old man had a cardiac arrest in a shopping mall and was successfully resuscitated following defibrillation by the paramedics. He is currently being managed in the Intensive Care Unit (ICU) on a ventilator. His vitals were taken and are as follows:

Pulse 120 beats/minute

Blood pressure 100/50 mmHg

An arterial blood gas was also done for this patient and the results are as follows:

pH 7.03 (7.35-7.45)

PCO2 9.8 (4.7-6.0 kPa)

PaO2 12 (10-14 kPa)

Bicarbonate (HCO3) 18 (22-26 mmol/L)

What is the SINGLE most appropriate next step in the management of this patient?

A 21 year old man attends the urgent care centre with shortness of breath and wheezing. He has been taking his salbutamol and salmeterol inhalers regularly for his asthma. Over the past 2 days, he had to increase his salbutamol inhaler frequency to reduce his wheezing. Auscultation of his chest reveals a widespread wheeze. He has a heart rate of 109 beats/minute, a respiratory rate of 24 breaths/minute, a temperature of 37.3°C and an oxygen saturation of 93%. He is able to finish a sentence in one breath. What is the SINGLE most appropriate test to be performed to determine the severity of his asthma exacerbation?

An 8 year old girl was playing on the swing alone in the garden when she was found seizing on the floor by her father. She was brought into the Urgent Care Centre accompanied by her father. The father says that the seizure lasted 8 minutes. After that, she was drowsy and vomited. She vomited a few minutes after the seizure, 10 minutes after the seizure and again an hour after the seizure. She does not have a history of epilepsy. She has no rash. Her neurological examination is unremarkable. Her observations are within normal limits. What is the SINGLE most appropriate management?

An 8 year old boy is rushed into A&E coughing, cyanosed and with a urticaria rash. His mother tells the staff that he began to cough after eating a cookie at a garden party. What is the SINGLE most likely diagnosis?

A 34 year old man had a car crash and is being observed in the emergency department. He is slowly deteriorating and his GCS has fallen from 13 to 7. What is the SINGLE most appropriate next step in management?

DESCRIPTION

• Intubate and ventilate
• Patients with GCS 8 or less
• Prioritize this step
• Part of the ABC protocol

A 33 year old beekeeper has a whole body rash every time she is stung by a bee. She would have 2 or 3 bee stings a year. They result in an itchy rash that starts a few hours after a bee sting and resolves in days. She suffers from severe eczema which she has had since she was a child. She was also told by her parents that she has multiple food allergies when she was young which includes strawberries and mangos. What is the SINGLE most appropriate advice?

A 32 year old man presents to the Emergency Department. He experienced chest pain 8 hours back while playing football. The chest pain was central, non-radiating and dull. It lasted for 20 minutes. The patient had taken aspirin 300 mg before he arrived at the hospital. His father had a sudden cardiac death at age 31 years old. On examination, he is afebrile. His heart rate is 85 beats/minute, blood pressure is 110/70 mmHg, respiratory rate is 15 breaths/minute and SpO2 is 96%. Investigations were performed which show

ECG – No abnormalities detected

Troponin T on arrival 2 ng/L (<12)

Creatine kinase 300 U/L (25-195)

What is the SINGLE most appropriate next step?

A 21 year old woman is brought into the Emergency Department by her college friend as she has been vomiting and has not been eating for the past 2 days. She has type 1 diabetes mellitus and has administered her basal insulin in the morning. She has not been able to tolerate any fluids or food orally over the past 12 hours. She is sweating and trembling. She feels very lethargic and is confused. She has a heart rate of 100 beats/minute, respiratory rate of 20 breaths/minute and a capillary blood glucose level of 1.1. She does not currently have an intravenous line. What is the SINGLE most appropriate management?

A 2 year female old child was playing with her toys when suddenly she became short of breath and started having stridor. She is brought into the hospital by her anxious parents. She is seen in respiratory distress with loud coughing and stridor. A few minutes later, she becomes unconscious. What is the SINGLE most appropriate management?

A 23 year old male arrives at Accident & Emergency in an ambulance. The paramedics state that the patient was involved in a road traffic accident and that a group of bystanders called the ambulance. The patient was unconscious when the ambulance arrived. Upon physical examination, it is revealed that the patient’s abdomen has numerous bruises all over it and that he has cold, clammy and pale peripheries. His vitals are as follows:

Blood pressure 70/40 mmHg

Heart rate 130 beats per minute

Temperature 36.4°C

What is the SINGLE most likely cause of his cold and clammy peripheries?

A 54 year old man attends the Emergency Department after consumption of several tablets. He is nauseous and complains of ringing in both ears. He has been vomiting several times since coming to the department. He has a diagnosis of bipolar disorder and has been using lithium for several years. He also takes aspirin for secondary prevention following a myocardial infarction a year ago. He takes levothyroxine for his hypothyroidism. A few days ago, he started on diazepam and paracetamol for back muscle spasm. What is the SINGLE most likely overdose of medication causing his symptoms?

A 38 year old man is seen having stridor and wheezing a few minutes after consuming a cake at a restaurant. The paramedics arrive at the scene. His pulse is 120 beats/minute, blood pressure is 80/60 mmHg and he is seen struggling to breathe. Anaphylaxis is suspected by the paramedics. What is the SINGLE most appropriate route of administration of adrenaline in this case?

Parents of an 11 month old baby want to know the steps for CPR for their child as they have recently attended a funeral of their neighbours’ child who died very suddenly after an episode of apnoea. They want to know what they can do if an event like this occurs. What is the SINGLE most appropriate advice in regards to CPR for their child?

A 65 year old man was involved in a high-speed road traffic accident. He was brought into the Emergency Department resuscitation room by the paramedics. He complains of severe right upper quadrant pain. On examination, there are no visible external injuries or external bleeding. He has normal breath sounds. His right upper quadrant is tender with some bruising. He has a temperature of 36.7°C, heart rate of 110 beats/minute, blood pressure of 120/75 mmHg, respiratory rate of 25 breaths/minute and an oxygen saturation of 97%. What is the SINGLE most appropriate investigation?

A 4 year old child playing with toys unattended suddenly develops breathlessness and stridor and is rushed into the hospital by his father. The child is drooling and unable to swallow. What is the SINGLE best investigation likely to lead to a diagnosis?

A 27 year old man presents to the emergency department after a road traffic accident where his right foot was stuck under a truck for several hours. On examination, his right foot is swollen and tender. Sensation is reduced between the space of the 3rd metatarsal and big toe. His dorsalis pedis pulse is not felt. What is the SINGLE most likely diagnosis?

A 12 year old comes into the Emergency Department with severe burns all over his body from a house fire. There is oropharyngeal swelling and soot in the mouth. He is in severe pain. What is the SINGLE most appropriate management?

A 31 year old man attends the Emergency Department intoxicated with alcohol. He drinks a litre of whiskey and 6 cans of beer a day but over the past 24 hours, he had drunk more. He is well known to the hospital as he is frequently brought into the accidents and emergency department drunk with minor injuries. He is tearful and would like support with his alcohol addiction. He refuses to be admitted to the hospital. He is accompanied by his friend who lives with him. What is the SINGLE most appropriate action?

A 35 year old woman is brought to the Emergency Department by her husband following eating a cake with peanuts in the restaurant. She has severe stridor and a bilateral polyphonic wheeze which started a few minutes after consuming the cake. Her blood pressure is 82/49 mmHg and heart rate is 130 beats/minute. She looks pale and her face is oedematous. What is the SINGLE most appropriate initial management?

A 20 year old man presents to A&E after having severe injuries from a road traffic accident. On presentation he is breathless and has severe chest pain. His systolic blood pressure is 70 mmHg and his pulse rate is 130 beats/minute. What is the SINGLE most appropriate initial action?

You are working in the Emergency Department. A patient, who has presented feeling generally unwell, collapses. In resus, he is found to have a heart rate of 36 beats/minute and a blood pressure of 87/62 mmHg. An ECG reveals sinus bradycardia. What is the most appropriate initial management?

A 24 year old woman has been brought to the Emergency Department having taken 36 tablets of paracetamol following an argument with her partner. She weighs 60 kg. She has no previous psychiatric history. What is the SINGLE most appropriate management?

A 25 year old man has been stabbed in the right-hand side of his abdomen with a small knife. He presents with severe pain in his right upper quadrant with guarding. IV fluids are being administered. He is very anxious and agitated. His temperature is 36.5°C, heart rate 120 bpm, BP 85/55 mmHg. SaO2 97% on 10L oxygen. The A&E doctor thinks his liver might have been damaged in the attack and calls the surgeons to assess him. Which is the SINGLE most appropriate initial management?

A 23 year old girl presented with shortness of breath, perioral paresthesia and carpopedal spasm 20 minutes after a huge argument with her boyfriend. She denies chest pain. What is the SINGLE most appropriate next course of action?

A 19 year old man is rushed into A&E by his friends who left him immediately before they could be interviewed by the medical staff. He is semiconscious. His respiratory rate is 7/min, blood pressure is 120/75 mmHg, and pulse rate is 60 bpm. He is noted to have needle track marks on his arms and he has pinpoint pupils. What is the SINGLE most appropriate management?

A 28 year old woman, with a background of chronic alcoholism presents with bright-red haematemesis and abdominal pains. On examination, she has cool extremities and is seen to be confused. Her blood pressure is 85/60 mmHg and her heart rate is 120 beats/minute. What is the SINGLE most appropriate next step in management?

An 8 year old child swallowed 12 tablets of paracetamol 4 hours ago. Serum paracetamol levels, when tested at 4 hours post ingestion, are above the line on the nomogram. What is the SINGLE next most appropriate action?

A 24 year old man is brought into the Emergency Department by his friend who drops him off and leaves before speaking to any staff member. He has a Glasgow Coma Scale of 9. His heart rate is 50 beats/minute, respiratory rate is 9 breaths/minute and blood pressure is 110/70 mmHg. On examination, there are needle marks on his forearm and both his pupil diameters are measured at 2 mm. What is the SINGLE most appropriate management?

A 42 year old man is called on the telephone by his GP following receiving results of his lithium level. His lithium level is 1.6 mmol/L (0.6-1.0). He takes lithium regularly for his bipolar disorder. On further questioning, he admits to having tremors, muscle weakness and dizziness over the last week. What is the SINGLE most appropriate action?

A 55 year old man tripped and fell onto a barbecue pit in the park and burnt his left arm. He is brought in by his son to the Accidents & Emergency department 30 minutes later. Below is the picture of the patient’s arm.

He is fully conscious. He denies alcohol intake during the barbecue party. Pain relief has been administered. What is the SINGLE most appropriate management?

An 11 year old boy fell from his bicycle earlier in the day and hit his head on a lampost. He was brought in by his mother to the Emergency Department. He cannot remember the event and cannot remember riding the bicycle. The accident was witnessed by his mother. She says he was not going at a high speed as he was cycling uphill. He lost consciousness for a few seconds after the injury but recovered well. He was not wearing a helmet. On examination, there is a small swelling on the frontal area with no visible lacerations or bleeding. He has a Glasgow Coma Scale of 15/15. His neurological examination was unremarkable. What is the SINGLE most appropriate management?

A 44 year old man comes into Accidents and Emergency confused and with nausea, vomiting, muscle weakness and a coarse tremor. He has blurred vision, dizziness and tinnitus. He takes lithium regularly for his bipolar disorder and has recently increased doses. His lithium levels are requested and results show a level of 1.75 mmol/L (0.6-1.0). He last took his lithium tablet 14 hours ago. His ECG shows a normal sinus rhythm. His blood pressure is 130/80 mmHg. He has been asked to stop lithium temporarily in the department. What is the SINGLE most appropriate action?

A 55 year old woman presents to A&E with the complaint of aching chest pain. She is very nervous and anxious as she thinks that this could be a heart attack. She has no family history of cardiac disease and has no other medical problems. She was given sublingual GTN which has failed to relieve her symptoms. Upon further questioning, she admits that the pain is worse when she breathes in. Her chest X-ray is reported as ‘normal’ and an ECG is performed, which also shows no significant acute changes. Her vitals are as follows:

Temperature: 37.2 °C

Heart rate: 110 beats/minute

Blood pressure: 125/85 mmHg

A full blood count has been done and shows:

Haemoglobin: 12.8 g/dL

Platelets: 320 x 109/L

White cell count: 7.8 x 109/L

CRP is 10.7 mg/L

What is the SINGLE most likely diagnosis in this patient?

A 6 month old boy has been brought A&E following an apnoeic episode at home. He is now completely well but his parents are very anxious as their family friend’s child died of sudden infant death syndrome at a similar age. The parents would like to know how to perform CPR on a baby of his age. What is the SINGLE most recommended technique for cardiac compressions?

A 76 year old woman has become tired and confused following an influenza like illness. She is vomiting and with abdominal pain. She is also breathless with signs of consolidation of the left lung base. Her temperature is 39.0 °C. She has a blood pressure of 80/60 mmHg A blood count showed:

A 39 year old man with a history of depression and sciatica attends the Emergency Department with a history of deliberate ingestion of a significant amount of amitriptyline tablets a four hours ago. He appears agitated and confused. He has a heart rate of 130 beats/minute, a respiratory rate of 12 breaths/minute and a temperature of 38.9°C. An ECG recording reveals sinus tachycardia, widened QRS complexes with tall T waves. He has a blood pressure of 108/66 mmHg after fluid resuscitation. Shortly after presenting to the Emergency Department, he becomes unconscious. His arterial blood test done on an arterial blood gas analyzer show the following:

PaO2 8.5 kPa (>10 kPa)

PaCO2 = 6.0 kPa (4.7-6 kPa)

pH = 7.21 (7.35-7.45)

HCO3-= 15 mmol/l (22-26 mmol/L)

Sodium 138 mmol/L (135-145)

Potassium 5.8 mmol/L (3.5 – 5)

He was intubated and ventilated. What is the most appropriate management?

A 9 month old child aspirated a foreign object which was removed at the hospital. The child is now fine. His parents would like to know what they should do should this occur again. What is the SINGLE most appropriate advice to give them?

A 47 year old diabetic man was found unconscious on the floor when his partner arrived home. The paramedics arrived and his capillary blood glucose was found to be 1.2. He has type 2 diabetes mellitus and takes insulin, metformin and linagliptin. He has no other medical problems. He is profusely sweating and starts to have a seizure. He does not have intravenous access. What is the SINGLE most appropriate management?

A 22 year old man presents to the Emergency Department with coughing and dyspnoea. He is a known asthmatic and usually uses salbutamol occasionally. His respiratory rate is 30 breaths/minute, heart rate is 110 beats/minute, and oxygen saturation is 93%. He is given oxygen 100% by face mask. What is the SINGLE most appropriate initial management?

A 23 year old single male was brought to emergency department by his father exhausted and frightened. His father tells you that his son, who was previously healthy, had, for no apparent reason, a sudden attack of fear, dizziness, sweating, palpitations and the feeling that his heart is going to stop beating. The symptoms started to decrease gradually after about 10 minutes. Which is the SINGLE most likely diagnosis?

A 21 year old lady after a heavy bout of drinking last night comes to the emergency department with vomiting blood, feeling dizzy, and having intense abdominal pain. On examination, her limbs feel cold. She has a pulse of 130 beats/minute and blood pressure of 85/58 mmHg. After initial resuscitation with oxygen and fluids, she still continues to bleed and continues to vomit blood. What is the SINGLE next best step?

A 31 year old man was involved in a road traffic accident and has severe pain at the right outer upper thigh and groin. There is clear deformity of the hip and shortening of the right leg. A femoral shaft fracture is suspected. His blood pressure is 100/70 mmHg. He has a heart rate of 90 beats/minute and a respiratory rate of 19 breaths/minute. He is saturating at 97% at room air. What is the SINGLE most appropriate next action?

A 32 year old man presents to A&E in hypovolaemic shock immediately following a road traffic accident. He is tachycardic, sweating and anxious. He was also noted to have bruises on his abdomen. What mechanism explains the manifested symptoms?

A 9 year old child was admitted following a road traffic accident. On admission his initial GCS was 15. His GCS dropped to 13 during the night. What is the SINGLE most appropriate management?

A 24 year old man was under the custody of police when he was punched. He is now cyanosed and unresponsive. He has absent breath sounds. What is the SINGLE most appropriate initial action?

A 24 year old female is rushed to the Accident & Emergency Department by ambulance because of sharp, stabbing chest pain. The chest pain started 2 hours ago and lasted for 20 minutes with severe intensity while she was at rest and is accompanied by difficulty in breathing, tremors and palpitations. She has no past medical history of note and is not taking any medications. Her father had hypertension and passed away a few months ago from a myocardial infarction. An electrocardiogram (ECG) was found to be normal. A chest X-ray was found to be normal. Cardiac troponins, full blood count, d-dimer and renal profile were normal. She has a heart rate of 110 beats/minute, a blood pressure of 100/70 mmHg and a respiratory rate of 20 breaths/minute. Her oxygen saturation is 97%. What is the SINGLE most likely cause of this patient’s symptoms?

A 20 year old woman brings herself into the Emergency Department after having a paracetamol overdose 6 hours ago. She intended to commit suicide however she now regrets her decision. She recently received news that she failed a university exam. She lives with her boyfriend who is supportive. Her plasma paracetamol level was plotted just below the treatment line on the paracetamol treatment graph. What is the most appropriate action for the A&E doctor?

A 26 year old man presents to the Emergency Department with the complaint of a 24 hour history of epigastric pain and haematemesis. He had ingested an unknown drug four days ago, but he cannot remember the name of the drug or the amount of the drug that he took at the time because he had been drunk. He has no past medical history of note and takes no chronic medication. He indulges in social drinking occasionally. Blood tests were done, and the results are as follows:

Creatinine 230 μmol/L (70-150 μmol/L)

Bilirubin 20 μmol/L (3-17 μmol/L)

Alanine transferase (ALT) 1880 U/L (5-35 U/L)

Aspartate transaminase (AST) 3150 U/L (5-35 U/L)

Alkaline phosphatase (ALP) 215 U/L (30-150 U/L)

Gamma glutamyl transferase (GT) 80 U/L (8-60 U/L)

Prothrombin time (PT) 20 seconds (10-14 secs)

He has a pulse rate of 128 beats/minute, blood pressure of 100/60 mmHg, respiratory rate of 25 breaths/minute and a temperature of 37.1°C. What SINGLE most likely drug did this patient ingest?

SSA 55 year old lady with a history of hypertension, diabetes, and hypercholesterolemia was sent to the Emergency Department from her GP after she experienced a 20-minute episode of dull, aching, left-sided, non-radiating chest discomfort which started while doing yard work 5 hours ago. She has no significant family history and is a non-smoker. She has had similar chest pain before but for a shorter duration. Prior to arrival, she was given 300mg of aspirin. She is pain-free on arrival, haemodynamically stable and on examination, ECG is normal. High sensitivity Troponin T on arrival and three hours later are both normal. Her renal function is normal. When the Emergency Department doctor goes back into the room to reassess her, she says she feels fine and asks if she can go home. What is the most appropriate action?

A 54 year old man attends the Emergency Department with a history of severe vomiting over the past few days. He has a high fever and abdominal pain. His arterial blood gas shows the following:

pH 7.48 (7.35 -7.45)

PaO2: 8 kPa (10-14 kPa)

PaCO2: 9.1 kPa (4.7-6.0)

Bicarbonate 29 mmol/L (22-26)

What is the SINGLE most likely interpretation of his arterial blood gas?

A 29 year old man is involved in a fight and receives a strong blow to his face. He is taken to the Accident & Emergency department where periorbital ecchymosis, enophthalmos and diplopia on upward gaze is noted. What is the most likely fractured bone?

A 48 year old man has been having diarrhoea, vomiting and mild abdominal pain for the past 4 days. He was brought to the Emergency Department by his wife as he was disoriented in the morning. His blood pressure is 110/75 mmHg and his heart rate is 89 beats/minute. His temperature is 37.9°C. His blood test show the following:

Haemoglobin 144 g/L (130-180)

White cell count 18 x 109/L (4-11)

Platelets 325 x 109/L (150-400)

Serum urea 11.5 mmol/L (2.0-7)

Serum creatinine 185 μmol/L (70-150)

Serum calcium 2.51 mmol/l (2.1-2.6)

eGFR 60 mL/min

Sodium 124 mmol/L (135-145)

Potassium 3.6 mmol/L (3.5-5.0)

Glucose (fasting) 3.6 mmol/L (3.5-5.5)

What is the SINGLE most appropriate solution to be administered intravenously?

A 33 year old man fell from a ladder onto his back earlier in the day. He presents to the Emergency Department with severe back pain with macroscopic haematuria. There are bruises on his right flank. He initially presented with a heart rate of 120 beats/minute and blood pressure of 85/60 mmHg. After giving him intravenous fluids and pain relief, his pulse dropped to 85 beats/minute and his blood pressure was recorded at 120/76 mmHg. What is the SINGLE most appropriate initial diagnostic step?

A 20 year old man presents to A&E after having severe injuries from a road traffic accident. On presentation he is breathless and has severe chest pain. Paradoxical respiration with shortness of breath is seen. His systolic blood pressure is 85 mmHg. respiratory rate is 25 breaths/min, oxygen saturation of 88% and his pulse rate is 110/min. What is the SINGLE most appropriate initial action?

A 35 year old man with a known peanut allergy presents to Accident & Emergency after having unknowingly ingested a cupcake with nuts. He has widespread wheezes bilaterally on auscultation and he is experiencing stridor and dyspnoea. His lips and tongue have also started to swell. Intravenous access has been established. His heart rate is 110 beats/minute and his blood pressure is 88/ 59 mmHg. What is the SINGLE most appropriate immediate treatment for him?

A 24 year old male presents to A&E with 40% partial thickness burns after having been in a house fire. His pulse rate is 115 bpm and respiratory rate is 29 breaths per minute. His systolic blood pressure is 80 mmHg. What is the SINGLE most appropriate management?

A 59 year old man has sudden onset left-sided chest pain and shortness of breath that started 12 hours ago. The chest pain is worse on inspiration. He smokes 15 cigarettes a day since he was 30 years old. His ECG shows sinus tachycardia. On examination, he has good air entry on both lungs. He has a temperature of 38°C, heart rate of 110 beats/minute, blood pressure of 110/70 mmHg, respiratory rate of 25 breaths/minute and an oxygen saturation of 92% on room air. A chest X-ray was performed and is seen below:

What is the SINGLE most likely diagnosis?

A 52 year old man is involved in a road traffic accident where he was hit by a car while riding his bike. He was taken by ambulance to the Emergency Department. In the ambulance, he becomes more dyspnoeic and is in agony due to his chest pain. His blood pressure is 95/61 mmHg and heart rate is 120 beats/minute. His right chest is bruised and appears to pull inwards during inspiration while his left chest pulls outwards. There are no breath sounds identified on the right chest. What is the SINGLE most likely diagnosis?

A 48 year old man was being evaluated for hypertensive retinopathy in the eye clinic before he was referred to the Emergency Department for insidious and progressive onset of nausea, drowsiness and palpitations. Apart from hypertension, he had no other significant past medical history. An ECG taken revealed tall tented T waves, flattened P waves and widened QRS. Investigations showed the following:

Sodium 142 mmol/L (135-145)

Potassium 7.1 mmol/L (3.5-5)

Blood glucose 5.2 mmol/L

IV calcium chloride was administered by the junior doctor on duty and senior assistance has been requested. What is the SINGLE most appropriate next step in the management of this patient?

A 35 year old patient is brought to the Emergency Department after having a road traffic accident. He has bruises on his chest. A chest X-ray shows a widened mediastinum. He has a pulse of 129 beats/minute, a blood pressure of 80/40 mmHg and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?

A 5 year old boy was playing with his friends when one of his older friends carrying a kettle of hot water accidentally tripped and fell with the hot water spilling all over the child’s left arm. His parents quickly ran tepid tap water over his left arm for 10 minutes. He was then brought into the Paediatric A&E immediately by his parents. On assessment, partial thickness burns are seen with multiple blisters over his left arm, forearm and hand. What is the SINGLE most appropriate management?

A 22 year old man was rushed into the emergency department. He describes recurrent episodes of fearfulness, palpitations, with peri-oral tingling and cramping of the hands. His symptoms last 5 – 10 minutes. He is worried he may be having a heart attack. An ECG shows sinus tachycardia. He has a respiratory rate of 34 breaths/minute. What is the SINGLE most appropriate immediate intervention?

A 9 year old girl is brought by her mother to the A&E with stridor, wheezing and a rash. The young girl came from visiting her friend at her farm house. Her lips are beginning to swell. She has a very itchy generalised urticarial rash. What is the SINGLE most appropriate treatment?

A 44 year old man with a history of alcohol dependency presents with confusion. He responds poorly to questions and is seen to be irritable. He is unsteady and has unco- ordinated walking. His blood glucose is 3.5 mmol/L. He has no other relevant medical history. What is the SINGLE most appropriate immediate action?

A 70 year old male presents with a 2 day history of productive cough and shortness of breath. He complains of chills and rigors. He is ill-looking. He has a temperature of 38.5°C, respiratory rate of 26 breaths/minute, and a pulse rate of 125 beats/min. His blood pressure is 88/45 mmHg and oxygen saturation is 90% on room air. On auscultation, bronchial breath sounds are heard in the periphery. He is given a fluid challenge of 1L normal saline. His blood pressure post fluid challenge is 90/40 mmHg. What is the SINGLE best term to use in his condition?

A 59 year old man is brought to the Emergency Department following a motor vehicle accident. He is speaking in full sentences but is unable to hear. The patient is breathing without difficulty and his extremities are well perfused. On examination, you note mastoid ecchymosis and rhinorrhoea. His pulse rate is 86 beats/minute, blood pressure is 128/84 mmHg and respiratory rate is 17 breaths/min. Which bone is most likely fractured?

A 20 year old was found unconscious on the floor at the park in the early morning after a night out with his friends in the pub. The paramedics are unable to arouse him. He smells of alcohol. He has a heart rate of 100 beats/minute, respiratory rate of 18 breaths/minute and a capillary blood glucose level of 1.2. He does not have intravenous access. What is the SINGLE most appropriate management?

A 44 year old man collapsed in the park and was brought in by the police to the hospital. On arrival, he has a Glasgow Coma Scale of 14. He smells of alcohol. His capillary blood glucose is 1.5. He does not have intravenous access and the medical staff are struggling to obtain intravenous access. He is aware of his likely diagnosis. What is the SINGLE most appropriate management?

A 78 year old man has been having diarrhoea for a few days. He was brought to the Emergency Department by his wife as he was disoriented in the morning. His blood pressure is 95/80 mmHg and his heart rate is 70 beats/minute. He is afebrile. He has decreased skin turgor. His blood test show the following:

Haemoglobin 129 g/L (130-180)

White cell count 16 x 10^9/L (4-11)

Platelets 305 x 109/L (150-400)

Serum urea 10.5 mmol/L (2.0-7)

Serum creatinine 180 μmol/L (70-150)

Serum calcium 2.52 mmol/l (2.1-2.6)

eGFR 60 mL/min

Sodium 159 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5.0)

Glucose (fasting) 5.2 mmol/L (3.5-5.5)

What is the SINGLE most appropriate solution to be administered intravenously?

A 12 year old boy fell from a bicycle and hit his head on the pavement. He has difficulty remembering the events that unfolded right before he injured his head. The accident was witnessed by his mother. He did not lose consciousness. He has had three discrete episodes of vomiting since the injury. There is a small swelling on his forehead with no visible lacerations or bleeding. He has a Glasgow Coma Scale of 15/15. His neurological examination was unremarkable. What is the SINGLE most appropriate management?

A 46 year old man presents to the Emergency Department with breathlessness and fever. He has been coughing for the past few days. He feels very short of breath when walking. He has a temperature of 40.3°C, heart rate of 120 beats/minute, blood pressure of 110/80 mmHg, respiratory rate of 26 breaths/minute and an oxygen saturation of 96% on 15 litres of oxygen. Intravenous Hartman solution has been started. Arterial blood gas reveals the following:

pH 7.21 (7.35-7.45)

PaO2: 11 kPa (10-14)

PaCO2: 3.5 kPa (4.7-6.0)

Bicarbonate 17 mmol/L (22-26)

Lactate 9 mmol/L (2-4)

Base excess – 4 mmol/L (= 2)

What is the SINGLE most appropriate management?

A 24 year old man presents to Emergency Department (ED) with 40% partial thickness burns. His pulse rate is 105 bpm and his respiratory rate is 25 breaths per minute. His systolic blood pressure is 80 mmHg. What is the SINGLE most appropriate management?

A 49 year old man presents to the Emergency Department with a productive cough and fever. When asked about urinary symptoms, he says he has not passed much urine today. On examination, he appears drowsy. There are crackles heard on the right base of his lungs. His heart rate is 105 beats/minute, and respiratory rate is 25 breaths/minute. His blood results show the follow:

Haemoglobin 130 g/L

White cell count 15 x 10^9/L

Platelets 300 x 10^9/L

CRP 168 mg/L

Serum urea 13 mmol/L

Serum creatinine 240 μmol/L

What is the SINGLE most appropriate management?

A 25 year old medical student presents with dyspnoea, chest pain and nausea. Her problems began yesterday when she was attending a marching parade in the centre of the city. She states that she could not catch her breath and had lateral chest pain which was not of a pleuritic nature. She returned home and took tramadol and tried to sleep it off. When she woke up this morning her symptoms were still present and in addition, she felt nauseous. Her history is negative for recent surgery, trauma or travel. She is taking no other medications except oral contraceptive pills. Physical examination is unremarkable. Her temperature is 37.2°C, pulse 90 beats/minute, BP 140/93 mmHg. respiratory rate 19 breaths/minute and BMI is 30 kg/m2. The results of her blood test and ECG are shown below.

Investigations:

Haemoglobin 130 g/L (115-160)

White cell count 7 x 109/L (4.0-10.0)

Platelet count 190 x 109/L (150-400)

Serum urea 6.1 mmol/L (2.5-7.8)

Serum creatinine 70 mmol/L (45-95)

D-dimer 4200 ng/mL ( < 500)

Prothrombin time (PT) 12 secs (10-14)

Activated partial thromboplastin time (APTT) 37 secs (35-45)

Bleeding time 5 minutes (3-9)

What is the most likely diagnosis?

A 49 year old woman presents to the Emergency Department with a productive cough of green sputum. She feels unwell, feverish and lethargic. On examination, bronchial breathing is heard at her right base. She has a respiratory rate of 27 breaths/minute. oxygen saturation of 90% on room air, pulse rate of 130 beats/minute and a blood pressure of 85/40 mmHg. What is the SINGLE next most appropriate action?

A 33 year old woman was painting her room when she developed a severe headache, vomited and fell off the stool. She feels well now and has a Glasgow Coma Scale of 15. On examination, there is a small bruise on her forehead. What is the SINGLE next appropriate investigation to identify the cause?

A 55 year old lady comes in with severe haematemesis. She is anxious and aggressive. Her medical history includes liver disease. Her INR is 9; heart rate is 110 bpm; Systolic BP is 110 mmHg: SpO2 is 94%. What is the SINGLE most appropriate management?

A 54 year old man was found unconscious in the medical ward following an acute myocardial infarction earlier in the day. He has no palpable pulse and no detectable blood pressure. His ECG is seen below:

Cardiopulmonary resuscitation is started. What is the most appropriate method to deliver adrenaline?

A 21 year old man, who was heavily drinking a few hours ago at an evening party presents to Accidents & Emergency with a history of vomiting repeatedly during the night. He vomited fresh blood an hour ago. Since then, he has had no further vomiting. He denies any melena. He has a heart rate of 70 beats/minute, a blood pressure of 120/80 mmHg, a respiratory rate of 15 breaths/minute. His blood results show:

Urea 4 mmol/L

Haemoglobin 153 g/L

What is the SINGLE most appropriate management?

A 24 year old woman has taken an overdose of 56 paracetamol tablets 10 hours ago. She had taken it with the intent to end her life but now regrets the act. She is extremely anxious but otherwise asymptomatic. She has no relevant past medical history. Her blood pressure is 120/70 mmHg, heart rate is 90 beats/minute, and oxygen saturation is 99% on air. Which is the SINGLE most appropriate next step?

A 16 year old female teenager was brought to the Emergency Department after being stabbed on the upper right side of her back 2 hours ago. An erect chest X-ray revealed homogenous opacity on the lower right lung. The trachea is centrally placed. She has a blood pressure of 80/60 mmHg, a pulse of 122 beats/minute, and a respiratory rate of 34 breaths/minute. What is the SINGLE most likely diagnosis?

A 22 year old man attends the Emergency Department with a stab wound to the chest. The man complains of left-sided chest pain and difficulty in breathing. On examination, there is a single stab wound to his left chest just below his clavicle. His trachea deviates to the right. On auscultation, the patient has an absence of breath sounds on the left side chest. His pulse rate is 122 beats/minute and BP 95/55 mmHg. The patient has been started on high-flow oxygen. What is the most appropriate next step in his management?

A 32 year old woman presents to the Emergency Department complaining of abdominal pain since morning. She has a non-radiating pain in the epigastric region, vomited thrice at home and feels extremely tired and thirsty. She has a past medical history of type 1 diabetes mellitus and is on insulin. However, she missed her doses both yesterday and this morning as she was preparing for an important meeting. On examination, she appears tired, her mucous membranes are dry, and her capillary refill time is prolonged. Her blood pressure is 96/70 mmHg, and pulse rate is 120 beats/minute. She is breathing heavily and has a fruity smell in her breath. Her respiratory rate is 28 breaths/minute. A bedside capillary blood glucose is 28 mmol/L and a urine dipstick test for ketone bodies is 3+. Which of the following is the most appropriate initial fluid to administer?

A 47 year old man had a road traffic accident and was presented to the Emergency Department with multiple injuries. On physical examination, perineal bruising was noticed. There is blood at the urethral meatus. A pelvic fracture has been confirmed. He has not passed urine since the accident which was 7 hours ago. He has a heart rate of 100 beats/minute, blood pressure of 120/80 mmHg, respiratory rate of 20 breaths/minute and an oxygen saturation of 99%. What is the SINGLE most appropriate next course of action?

A 32 year old woman presents to the Emergency Department with vomiting and abdominal pain. Her symptoms started 12 hours ago. She feels extremely fatigued and is thirsty. She has a past medical history of type 1 diabetes mellitus and is on insulin. On examination, she appears tired, her mucous membranes are dry, and her capillary refill time is prolonged. Her blood pressure is 100/75 mmHg, and pulse rate is 122 beats/minute. Her respiratory rate is 28 breaths/minute. A bedside capillary blood glucose is 18.1 mmol/L and a urine dipstick test for ketone bodies is 3+. What is the SINGLE most appropriate investigation?

An 18 year old female was brought into the ED after ingestion of 28 paracetamol tablets after breaking up with her boyfriend. She came in confused and unwell. She was admitted in the medical ward and N-Acetylcysteine was given. 24 hours later, her laboratory results show a normal FBC, an arterial pH of 7.1, Prothrombin time of 17 seconds and creatinine of 255μmol/L. She is still confused and lethargic. What is the SINGLE most appropriate management?

Normal Lab values:

Creatinine 70-150μmol/L

pH 7.35-7.45

Prothrombin time (PT): 11-14 sec

A 44 year old female comes to the Emergency Department with complaints of the worst headache of her life which started two days ago. The pain is at the back of her head and the maximum pain experienced 8 hours ago after which her pain has slowly been resolving. She vomited twice yesterday. She has no history of migraines and is usually fit and healthy. She was assessed by the triage nurse and had a Glasgow Coma Scale of 15/15, equal and reactive pupils, and no neurological deficit. Whilst waiting for the doctor to assess her, she becomes unresponsive and a quick assessment shows a Glasgow Coma Scale of 3/15, right pupil larger than the left pupil and response sluggish to light. Her blood pressure is 155/80 mmHg, heart rate is 100 beats/minute and respiratory rate is 22 breaths/minute. What is the SINGLE most appropriate next step in management?

A 4 year old boy is brought into the Emergency Department by his mother. He has reportedly been drowsy and pyrexial for the past 2 hours. Whilst waiting to be seen he becomes unresponsive. He makes no respiratory effort. 5 rescue breaths were given. A brachial or carotid pulse cannot be detected. Unfortunately, an Ambu-bag is not available. What is the SINGLE most appropriate ratio of compressions to ventilations as part of cardiopulmonary resuscitation for this patient?

A 38 year old woman who is vomiting repeatedly is brought into Accident & Emergency (A&E). Empty packets of amitriptyline are found in both her pockets. She is confused, appears very unwell and is unable to give an accurate history. Her Glasgow Coma Scale (GCS) score is assessed to be 11/15. The results of her arterial blood gas (ABG) reveals marked metabolic acidosis with a pH of 7.1. An ECG performed shows QRS prolongation with a heart rate of 120 beats/minute. Her blood pressure is 85/60 mmHg. What is the SINGLE most appropriate management for this patient?

A 27 year old man presents to the Emergency Department after being hit on the road while changing his tire. He has an obvious fracture of his femur with external bleeding. His observations show the following:

Heart rate 112 beats/minute

Blood pressure 110/67 mmHg

Respiratory rate 28 breaths/minute

Saturations 98%

What is the estimated blood loss in this patient?

A 35 year old man had a fight in a bar which involved blunt trauma to his head. Since the injury, he has developed bleeding from the auditory meatus associated with ringing and hearing loss in his ear. Clear fluid is seen coming from his nose. What is the SINGLE most appropriate investigations of choice?

A 13 year old boy presents with recurrent episodes of facial and tongue swelling. He also complains of abdominal pain which occurs occasionally. His father has had similar episodes. What is the SINGLE most likely diagnosis?

A 68 year old woman has had a carotid angiogram done and it was subsequently decided to place two stents in her carotid arteries. The access for the carotid endarterectomy procedure was obtained via the femoral arteries. Post-operatively, the patient was found to have bilateral groin swelling. The patient also appeared weak and anxious and her blood pressure was measured at 85/55 mmHg. What is the SINGLE most appropriate immediate step in management of this patient?

A 25 year old male with a history of frequent binge drinking presents 4 hours after having had a takeaway meal following a night’s heavy drinking. He complains of nausea and has vomited on several occasions. After the last vomiting episode, he vomited approximately a cupful of blood. On admission, he smells of alcohol, pulse of 100 beats/minute, blood pressure of 140/80 mmHg. He has some tenderness in the epigastrium. What is the SINGLE most likely diagnosis?

A 3 year old child presented to the Emergency Department with his mother. The mother tells you that the child was playing with his small toys and suddenly became breathless and started to cough. She says that the child remained conscious throughout and has been able to vocalise. The child has been previously well. On examination, the child is afebrile, heart rate is 90 beats/minute, respiratory rate is 24/minute, blood pressure is 120/70 mmHg and SpO2 is 96%. A wheeze is present over the right side of the chest on auscultation. There is no stridor or cyanosis. What is the SINGLE next most appropriate investigation?

A 19 year old boy presents with nervousness, a runny nose, watering eyes, tremors and muscle cramps. He says that he has also been having trouble sleeping and feels like he lacks mental clarity. He is a known drug addict and he claims that he has been trying to stop taking drugs for the past three days. He looks agitated and sweaty. What is the SINGLE most likely drug that he has been taking?

A 58 year old man presents with sudden onset chest pain and shortness of breath. He has a background of COPD on salbutamol and ipratropium inhalers. He is a heavy smoker. A chest x-ray demonstrates a 50% pneumothorax by volume on the left side. His oxygen saturation is 86% and his respiratory rate is 25 breaths/minute. What is the SINGLE most appropriate management?

A 21 year old man has been found unconscious in an alleyway with a respiratory rate of 5 breaths/minute and a pulse of 55 beats/minute. His pupils are constricted. What is SINGLE most appropriate management?

A 53 year old man has been started on enalapril 2 weeks ago as part of his management for essential hypertension. His blood test taken today shows the following:

Sodium 138 mmol/L (135-145)

Potassium 6.1 mmol/L (3.5-5)

Urea 5 mmol/L (2.0-7)

Creatinine 90 μmol/L (70-150)

eGFR 90 mL/min (>90)

He denies any muscle weakness, paresthesia or syncope. An ECG was performed and is reported as normal. His blood pressure is 130/89 mmHg. What is the SINGLE most appropriate immediate action?

An 18 year old girl attends the Emergency Department following taking more than several tablets of paracetamol the day before. She cannot remember the exact time she took the tablets. She is extremely anxious but otherwise asymptomatic. She has no relevant past medical history. She weighs 55kg. Her blood pressure is 120/75 mmHg. heart rate is 105 beats/minute and SaO2 is 99% on air. Which is the SINGLE most appropriate next step?

A 33 year old man was involved in a road traffic accident. He has acute abdominal pain. On abdominal examination, there is bruising along the site of the portion of the seat belt. His abdomen is very tender. A computerised tomography scan of his abdomen shows a subcapsular splenic haematoma. He has a pulse rate of 90 beats/minute, respiratory rate of 24 breaths/minute, and a blood pressure of 120/80 mmHg. What is the SINGLE most appropriate action?

An employer sent his worker to the emergency department after having hit his head on a heavy machine. He did not lose consciousness and is not vomiting, however he does not remember the events leading up to the injury. A clinical examination including a neurological assessment is normal. What is the SINGLE most likely investigations you would do?

An 18 month old boy pulled over a cup of hot tea that was on a high table. The hot liquid splashed over him and he now presents with a 6% partial thickness burn on his chest. What is SINGLE best treatment for him?

A 75 year old man presents to the Emergency Department with severe neck pain. He reports that he has been taking 6 grams of paracetamol every day for the past 5 days, which has kept his pain somewhat under control. On examination, he has tenderness over his cervical spine and his observations are normal. His liver function test are seen below:

Serum alanine transferase (ALT) 119 U/L (5-35)

Serum alkaline phosphatase (ALP) 240 U/L (30-150)

His serum paracetamol level is 15mg/L What is the most appropriate management?

A 42 year old woman is brought to the Emergency Department by her husband who states that she has swallowed the contents of his heart medication propranolol. It has been approximately two hours since the overdose. She feels dizzy but remains alert and orientated. Her temperature is 37.3°C, heart rate is 50 beats/minute, blood pressure is 70/40 mmHg, respiratory rate 12 breaths/minute and oxygen saturations 98% breathing room air. A 12-lead ECG shows a normal QRS duration and QT interval. She has been started on intravenous fluids and her blood pressure was retaken with a reading of 95/66 mmHg. What is the most appropriate next management?

A 21 year old girl looking unkempt, comes to the hospital asking for painkillers for her abdominal pain. She is agitated, and looks malnourished. She is also sweating, shivering and complains of joint pain. What is the SINGLE most likely substance misuse?

A 56 year old patient is brought in by his wife and friends to the Emergency Department unconscious. His wife reports that he suddenly lost consciousness in the car with no movement or response. He is not breathing, and you cannot feel his pulse. CPR starts immediately and the ECG monitor records the picture as shown below:

What is the most appropriate medication to give?

A 2 year boy attends the Emergency Department with his mother. He was playing with a small toy when his mother saw him take a small part of the toy out and put it in his mouth. Moments later, he started coughing with noisy breathing. He is conscious but continues to have noisy breathing and tachypnoea. He is alert and able to vocalise. There are decreased breath sounds on his left chest. What is the SINGLE most appropriate management?

A 25 year old transgender woman presents to the Emergency Department with feeling unwell with nausea, shortness of breath and lethargy. She also reports that over the past hour, she feels her heart racing which is extremely distressing. She takes spironolactone and 7-beta estradiol regularly. Blood test were requested which shows the following:

Haemoglobin 132 g/L (130-180)

White cell count 11 x 10^9/L (4-11)

Neutrophils 3 x 3 x 10^9/L (2-7.5)

Platelets 420 x 10^9/L (150-400)Sodium 139 mmol/L (135-145)

Sodium 136 mmol/L (135-145)

Potassium 6.6 mmol/L (3.5-5)

Creatinine 80 μmol/L (70-150)

eGFR >90 mL/min

Thyroid stimulating hormone 5.0 mU/L (0.5-5.7)

Which of the following is the most appropriate next step in the management of this patient?

A 35 year old woman drinks 2 litres of vodka a day. She is well known to the hospital as she is frequently brought into accidents and emergency department drunk with minor injuries. She now wants to stop drinking alcohol and is willing to seek help for her alcohol dependence. However, her main concern is that she has no support and lacks encouragement. What would you do?

A 54 year old unconscious man was found with no palpable pulse, no detectable blood pressure, and with a flat ECG reading. What is the SINGLE best management?

A butcher comes to the emergency department after accidentally stabbing his groin with a knife. He tried to use a towel to stop the bleeding but has bled so much that the towel is now soaked with blood. His blood pressure is 80/50 mmHg and pulse is 130 beats/minute. What percentage of circulatory blood did he lose?

A 56 year old man with a background of lung cancer with bone metastases is admitted to the hospital because of rapid confusion over the past 3 days. He presents with his family. He denies any palpitations or syncope. His blood test shows the following:

Haemoglobin 132 g/L (130-180)

White cell count 11 x 10/L (4-11)

Neutrophils 6.1 x 10^9/L (2-7.5)

Platelets 350 x 10^9/L (150-400)

Serum urea 6.9 mmol/L (2.0-7)

Serum creatinine 113 μmol/L (70-150)

Adjusted serum calcium concentration 3.41 mmol/l (2.1-2.6)

Serum sodium 144 mmol/L (135-145)

Potassium 5.7 mmol/L (3.5 – 5)

Albumin 33 g/L (35-50)

What is the SINGLE most likely appropriate action?

A butcher comes into A&E after accidentally stabbing his groin with a knife. He tried to use a towel to stop the bleeding but has bled so much that the towel is now soaked with blood. His blood pressure is 75/40 mmHg and pulse is 120 beats/minute. What is the SINGLE most appropriate initial management?

A 78 year old woman presents to the Emergency Department with severe epigastric pain and vomiting for the past 2 days. The pain is referred to her right shoulder. Generalised rigidity of the abdomen is noted when examining. She denies chest pain. She has a temperature of 37.2°C, a respiratory rate of 22 breaths/minute and a pulse of 102 beats/minute. Her medical history is significant for rheumatoid arthritis. What is the SINGLE most appropriate initial investigation?

A 23 year old woman has been found unconscious by her partner. There are several packets of paracetamol and an empty bottle of vodka alongside her. When she comes to the Emergency Department, she is confused and unable to estimate when she took the tablets. Her Glasgow Coma Scale (GCS) score is 14/15. Which is the SINGLE most appropriate next step?

A 19 year old man presents to the Emergency Department with a sudden onset of breathlessness and left pleuritic chest pain. His medical history includes Marfan syndrome. On examination, he has diminished breath sounds on the left with hyper- resonance over the left lung. His blood pressure is 80/30 mmHg and pulse rate is 110 beats/minute. He was given oxygen. A chest X-ray is seen below:

What is the SINGLE appropriate management?

A 60 year old woman with history of a urinary tract infection, hypertension and gallstones presents to the emergency department. She complains of upper right abdominal pain, rigors and feeling unwell. Her urine dipstick is negative for white cell and nitrates. She has a temperature of 38.9°C. Her blood pressure is 88/55 mmHg, oxygen saturation of 92% on room air, pulse rate of 130 beats/minute and respiratory rate of 24 breaths/minute. What is the SINGLE most likely diagnosis?

• Left hemithorax expanded
• Mediastinum shifted to the right
• Possible diagnosis: Pneumothorax
• Suspected underlying cause: Marfan syndrome
• Additional symptom: Low blood pressure
• Management: Needle decompression for tension pneumothorax.

A 10 year old boy is rushed to Accident & Emergency after his parents found him unconscious on the kitchen floor. It is revealed that he ingested medication belonging to his grandmother who is a known epileptic and who has atrial fibrillation and hypertension. The grandmother cannot tell which medications are missing. The child is hypotensive with dilated pupils and an ECG reveals extrasystoles. Which SINGLE most likely drug has he taken?

A 44 year old health care worker attends the Emergency Department with sudden onset of chest pain and shortness of breath following an episode of a coughing fit earlier in the day. She has a background of COPD and has had a dry cough for the past few years. She smokes 20 cigarettes a day for the past 20 years. She flew to the UK from Taiwan 2 days ago. An ECG shows sinus rhythm. Her heart rate is 80 beats/minute and respiratory rate is 25 breaths/minute. Her blood pressure is 120/70 mmHg and oxygen saturation is 91% on air. Her chest X-ray is shown below.

What is the SINGLE most appropriate action?

A fit and active 60 year old man comes with an acute onset swelling and pain of his calf. On examination, the mid-calf measures 3 cm larger in girth than the other calf. There is no redness and the skin appears well perfused. Peripheral pulses are present. He describes worsening pain when the ankle is dorsiflexed. What is the SINGLE most likely diagnosis?

A 14 year old girl has been brought to the emergency department having taken an unknown amount of paracetamol 2 hours ago. She has no previous psychiatric history and is physically well. When would be the SINGLE most appropriate time to attain plasma paracetamol concentration levels following her presentation to A&E?

An 18 year old, previously well student in his first year at university, was brought in to the emergency department in an agitated, deluded and disoriented state. What is the SINGLE most probable reason for his condition?

You are beginning your shift at the accident and emergency (A&E) department when the nurse informs you there is an adult patient experiencing an asthma attack. The nurse states that the patient is having difficulty forming sentences with one breath, is using their accessory muscles of respiration, is normotensive but has tachycardia and tachypnoea. The nurse has measured the PEF of the patient at 34% predicted. Upon entering the room, you auscultate the chest and are unable to hear breath sounds and observe the SpO2 is 94%. Which of the following signs indicate life-threatening asthma?

A 68 year old male presents to the Emergency Department with sudden onset chest pain and shortness of breath for 1 day. The patient is a suspected case of lung cancer and underwent a lung biopsy 1 day back for a right lung mass. His oxygen saturation is 72%, blood pressure is 110/70 mmHg, heart rate is 110 beats/minute and respiratory rate is 29 breaths/minute. On examination, the patient is dyspnoeic and hyper-resonance is noted along with diminished breath sounds over the right lung. He was given oxygen and analgesia. A chest X-ray was done which is seen below:

What is the SINGLE most appropriate step in management?

A 21 year old man was brought to the Emergency Department after having a road traffic accident. He was stationary in the car when he was hit from the front by another car going at 70 miles/hour. He has chest pain and he feels breathless. He has a blood pressure of 100/60 mmHg, a pulse of 110 beats/minute, a respiratory rate of 30 breaths/minute and oxygen saturation of 91%. On examination, he is tender at the 5th to 7th anterior ribs on his left chest. He has decreased breath sounds on the left chest. Percussion of his left chest is dull. What is the SINGLE most likely diagnosis?

A 7 year old girl has become acutely unwell while visiting a friend’s house and has been brought immediately to the Emergency Department. Her friend’s mother gives a history of cooking a dessert with nuts. On assessment, she is fully conscious but has got stridor, wheeze and a sudden onset erythematous rash. Supplementary oxygen has been started. What is the SINGLE immediate management?

A 35 year old woman comes to the Emergency Department with confusion, weakness, vomiting, and abdominal pain. She has a heart rate of 117 beats/minute and a respiratory rate of 30 breaths/minute. Her blood pressure is 89/60 mmHg and oxygen saturation is 97%. Her blood and urine results show:

Blood ketones 4.3 mmol/L (<0.6 mmol/L)

Urine ketones +++

Venous pH 7.21 (7.35-7.45)

Venous blood glucose 35 mmol/L (<11 mmol/L)

Bicarbonate 17 mmol/L (22-26 mmol/L)

Sodium 150 mmol/L (135-145)

Potassium 5.7 mmol/L (3.5-5.0)

What is the most appropriate initial management?

A 32 year old man presents to the Emergency Department after a motorcycle crash. The patient has bruises around the left orbital area. His Glasgow coma scale (GCS) is 14 on initial assessment in the department. On examination, an alcoholic breath is noted. 2 hours after the initial assessment, his GCS drops to 8. What is the SINGLE most important initial investigation?

A 15 year old boy developed a rash and severe itch after his football game on the field. His whole body is itchy and it is covered with an erythematous rash. He has a temperature of 36.7°C, heart rate of 70 beats/minute, blood pressure of 130/80 mmHg. respiratory rate of 15 breaths/minute and an oxygen saturation of 97%. What is the SINGLE most appropriate management?

A 33 year old man has severe burns on his chest and arms after his shirt caught on fire during a barbecue event. Which of the following formulas is used for calculating fluids for burn patients?

A 34 year old man with a 3 year history of depression attends the Emergency Department with a history of deliberate ingestion of a significant amount of amitriptyline tablets a few hours ago. He appears agitated and confused with mydriasis. He feels very thirsty. He has a heart rate of 130 beats/minute, a respiratory rate of 20 breaths/minute and a temperature of 39.1°C. He had a single brief convulsion which he recovered from. An ECG recording reveals sinus tachycardia and widened QRS complexes. He has a blood pressure of 80/40 mmHg despite fluid resuscitation. His arterial blood gas shows the following:

PaO2 8.5 kPa (>10 kPa)

PaCO2 = 4.3 kPa (4.7-6 kPa)

pH 7.22 (7.35-7.45)

HCO3- = 16 mmol/l (22-26 mmol/L)

What is the most appropriate management?

An 88 year old man is brought to the hospital by his daughter as he has been increasingly confused over the past week. He has not been eating or drinking well over the past few days. He is lethargic and irritable. His medical history includes dementia and diabetes mellitus type 2. His pulse rate is 99 beats/minute. His blood pressure was recorded as 101/65 mmHg on lying down and 80/50 mmHg on standing. On examination, his mucous membranes are dry and his skin turgor is reduced. His blood results show the following:

Haemoglobin 119 g/L (130-180)

White cell count 9 x 10^9/L (4-11)

Platelets 305 x 10^9/L (150-400)

Serum urea 9.5 mmol/L (2.0-7)

Serum creatinine 170 μmol/L (70-150)

Serum calcium 2.52 mmol/l (2.1-2.6)

eGFR 65 mL/min

Sodium 152 mmol/L (135-145)

Potassium 3.9 mmol/L (3.5-5.0)

Glucose (fasting) 6.9 mmol/L (3.5-5.5)

What is the SINGLE most appropriate solution to be administered intravenously?

A 66 year old man is brought to the Emergency Department complaining of severe substernal pain which started suddenly a few hours ago. The pain is described as sharp. There was no associated trauma to his chest. His medical history includes hypertension. His ECG shows ST elevation in two contiguous leads. His blood test show:

Troponin T 350 ng/L (<12)

D-dimer 1620 ng/ml (<500)

On examination, his pulse is 120 beats/minute. His blood pressure on his left arm is 110/65 mmHg and his right arm is 169/80 mmHg. Breath sounds are normal on both sides. What is the SINGLE most likely diagnosis?

A 32 year old man is brought to A&E by his wife with symptoms of chest pain, abdominal pain, palpitations, tinnitus, nausea and altered mental status. His wife says that she found a bottle of empty medication on the toilet floor and it is likely that he consumed the whole bottle. He has a respiratory rate of 34 breaths/minute. His arterial blood gas shows the following:

pH 7.31 (7.35 -7.45)

PaO2: 13 kPa (10-14 kPa)

PaCO2: 3.0 kPa (4.7-6.0)

Bicarbonate 18 mmol/L (22-26)

His blood results show the following:

Haemoglobin 133 g/L (130-180)

White cell count 8 x 109/L (4-11)

Platelets 350 x 109/L (150-400)

Sodium 137 mmol/L (135-145)

Potassium 4.1 mmol/L (3.5-5)

Creatinine 80 μmol/L (70-150)

eGFR >90 mL/min

His ECG shows sinus rhythm with a rate of 95 beats/minute. What is the SINGLE most likely medication that he could have taken?

A 3 year old boy presents to the Emergency Department with his parents with a severe wheezing and shortness of breath. He has been started on inhaled corticosteroids a few months ago by his GP for suspected asthma. He is drowsy with evidence of cyanosis. There is intercostal and subcostal recessions. On auscultation of his chest, there is a widespread wheeze. His heart rate is 170 beats/minute and respiratory rate is 45 breaths/minute. What is the SINGLE most likely feature that shows life threatening asthma?

A mother brings her two year old daughter into the Emergency Department. The child was eating some peanuts whilst the mother was preparing food. When the mother returned to check on her she could hear a high pitched noise when the daughter was breathing. The daughter is well and talks to you saying “a peanut went down my throat”. On auscultation you hear an expiratory wheeze on the right side of the child’s chest. There is no hoarseness of voice and no drooling. Her observations are within normal limits. She is afebrile. A chest X-ray was performed which was normal. What is the SINGLE most appropriate next step?

A 33 year old male was involved in a road traffic accident. He was sitting in the front passenger seat and wearing a seatbelt when the car was hit on the left side. On examination there are bruises on the left side of his chest and abdomen and there is marked abdominal distention. His pulse is 130 beats per minute and his blood pressure is 60/40 mmHg. What is the SINGLE most likely injury?

A 35 year old woman was admitted to the medical ward for pneumonia and was started on intravenous co-amoxiclav. 10 minutes after starting co-amoxiclav, she develops a generalised itchy rash and becomes breathless. On auscultation, a widespread wheeze is heard throughout her lung fields. Her heart rate is 138 beats/minute and her blood pressure is 70/55 mmHg. What is the SINGLE most appropriate management?

A 17 year old girl has taken an overdose of 30 paracetamol tablets 3 hours ago. She is extremely anxious but otherwise asymptomatic. She has no past medical history. She weighs 50kg. Her blood pressure is 120/70 mmHg, heart rate is 100 beats/minute, and oxygen saturation is 98% on air. Which is the SINGLE most appropriate next step?

A 63 year old woman is brought to the Emergency Department. Her daughter found her confused and on the floor. She presumes that her mother tripped on a cable that was running across the room and fell. She also tells you that her mother had a few glasses of wine before the accident and is probably confused as a result. On examination, her left pupil is dilated and unresponsive to light. On inspection, there is bruising of the right side of her head. She has a Glasgow Coma Scale of 10. An urgent non-contrast CT scan of her brain was requested which shows a crescent-shaped hyperdensity in the left side. What is the most likely diagnosis?

A 3 year old boy presents to the Emergency Department with his parents with a severe wheezing and shortness of breath. He has been started on inhaled corticosteroids a few months ago by his GP for suspected asthma. He is drowsy with cold periphery. There are intercostal and subcostal recessions. On auscultation of his chest, there is a widespread wheeze. His heart rate is 160 beats/minute and respiratory rate is 40 breaths/minute. What SINGLE feature shows life-threatening asthma?

A 34 year old man was involved in a road traffic accident. Whilst in the ambulance his Glasgow Coma Scale deteriorates from a score of 13 to 9. His respiratory rate increases from 30 to 48 breaths/minute. What is the SINGLE most appropriate management?

A 66 year old man who was alcohol intoxicated fell and hit his head on the pavement 3 hours ago. He presents to the Emergency Department with head pain and a bruise on his right temple. His friends who were present with him give a history of loss of consciousness right after the fall, which lasted 5 minutes. He does not take any regular medications. He is confused on verbal response. He opens his eyes to speech. On motor response, he is able to obey commands. He has a heart rate of 70 beats/minute, blood pressure of 130/80 mmHg, and a respiratory rate of 20 breaths/minute. What is the SINGLE most appropriate management?