EMQ 1

Select ONE agent (in toxic overdose or exposure) that best fits each scenario. For each scenario, assume that

the patient is an otherwise healthy 30 year-old man who takes no usual medications, and is not concurrently

poisoned by another agent. Clinical information pertains to untreated acute, severe toxicity. An agent may be

selected more than once.

A. Isoniazid F. Verapamil

B. Digoxin G. Iron

C. Amphetamine H. Salicylate

D. Amitriptyline I. Strychnine

E. Colchicine J. Cyanide

1. Symptoms: Nausea, agitation, painful muscle spasms.

Signs:

Temp 385 deg C

GCS 15 (distressed)

Pulse 100 bpm SR

BP 130/90 mmHg

RR 28 / min

Muscle spasm and opisthotonus are marked.

2. Symptoms: Anxiety, agitation, dysphoria.

Signs:

Temp 38 deg C

GCS 14 (confused)

Pulse 120 bpm SR

BP 150/95 mmHg

RR 20 / min

Mydriasis, sweating, myoclonus, features of paranoid delusions.

3. Symptoms: Nausea, vomiting, diarrhoea.

Signs:

Temp 365 deg C

GCS 15

Pulse 90 bpm SR

BP 110/80 mmHg

RR 16 / min

Features of mild dehydration. Bone marrow suppression and rhabdomyolysis 2 days post ingestion.

4. Symptoms: Headache, dyspnoea. Deteriorating mental state after inhalation of toxic gas.

Signs:

Temp 37 deg C

GCS 9 (obtunded)

Pulse 110 bpm SR

BP 140/90 mmHg

RR 28 / min

Profound lactic acidosis on arterial blood gases.

5. Symptoms: Initial abdominal pain and diarrhoea, resolving spontaneously within hours.

Signs:

Temp 37 deg C

GCS 15

Pulse 100 bpm SR

BP 120/80 mmHg

RR 24 / min

Vasodilatation, hepatorenal failure and metabolic acidosis 14 hours after exposure.

6. Symptoms: Drowsiness, before generalized seizure.

Signs:

Temp 375 deg C

GCS 13 before generalized seizure

Pulse 120 bpm SR

BP 90/50 mmHg

RR 24 / min

Before seizure: Mydriasis, dry mouth, flushed skin that’s hot to touch and dry.

7. Symptoms: Nausea, abdominal pain, xanthopsia.

Signs:

Temp 365 deg C

GCS 13 (confused)

Pulse 200 bpm, supraventricular tachycardia with AV block

BP 80/40 mmHg

RR 20 / min

8. Symptoms: Nausea, vomiting, tinnitus, vertigo.

Signs:

Temp 39 deg C

GCS 13 (delirious)

Pulse 100 bpm SR

BP 110/70 mmHg

RR 30 / min

Dehydrated. Arterial blood gases show hyperglycaemia, primary metabolic acidosis and primary

respiratory alkalosis.

9. Symptoms: Dizziness and weakness.

Signs:

Temp 365 deg C

GCS 15

Pulse 40 bpm, SR with first degree block

BP 80/40 mmHg

RR 16 / min

10. Symptoms: Blurred vision, photophobia, nausea, before generalized seizure.

Signs:

Temp 37 deg C

GCS 15 before generalized seizure

Pulse 110 bpm SR

BP 130/85 mmHg

RR 18 / min

Before seizure: Lactic acidosis on arterial blood gases. Mydriasis, ataxia, hyper-reflexia, skin cool and dry.

EMQ 2

Select ONE antidote that is best indicated for each setting. Assume that in each setting, there is no other

clinical problem (including concurrent toxicity from other agents), and that the antidote is not contra-indicated

for other reasons. An antidote may be selected more than once.

A. Atropine F. Dicobalt Edetate

B. Cyproheptadine G. Methylene Blue

C. Ethanol H. Pralidoxime

D. Calcium I. Pyridoxine

E. Folinic Acid J. Succimer (2,3 dimercaptosuccinic acid)

11. A 40 year-old man presents with exposure to a toxin from his workplace. Assessment reveals heavy metal

poisoning.

12. A 65 year-old lady develops bone marrow suppression and acute renal failure from supratherapeutic doses of an

agent used to treat her psoriasis. This agent is administered once per week.

13. A 70 year-old woman develops dyspnoea and headache soon after undergoing intravenous regional anaesthesia,

which utilized intravenous prilocaine. The patient is unwell and cyanosed. Arterial blood taken for analysis is

chocolate-brown coloured; it shows marked metabolic acidosis.

14. A 45 year-old man is rescued from a factory fire. The patient was trapped in the burning building, and suffers a

toxic inhalation. Despite normal and stable haemodynamic parameters, he has mental obtundation, and severe

lactic acidosis from tissue hypoxia.

15. A 35 year-old man is poisoned by deliberate ingestion of insecticides. The patient’s haemodynamic parameters

have already been appropriately treated with another antidote. The intention now is to reverse the

pathophysiological processes at the neuromuscular endplates.

16. A 50 year-old woman presents after overdose of her slow-release antihypertensive agent. She is drowsy, with

profound bradycardia and hypotension. The chosen antidote should help normalise cardiac output AND

peripheral vascular resistance.

17. A 65 year-old man overdoses on an antibiotic used to treat pulmonary tuberculosis. He develops a generalized

seizure.

18. A 20 year-old man develops acute confusion, tachycardia and hypertension. He had been taking excessive

amounts of his prescribed fluoxetine.

19. A healthy 30 year-old woman underwent an uneventful general anaesthetic for an elective surgical procedure.

Neostigmine is administered to reverse the muscle relaxant, but a concurrent agent is needed to counter

neostigmine’s unwanted effects on her heart rate.

20. After deliberately ingesting motor vehicle engine coolant, a 25 year-old man develops acute renal failure.

EMQ 3

Select ONE condition that best matches each scenario. Assume that in each scenario, there is no other clinical

problem. A condition may be selected more than once.

A. Croup F. Anaphylaxis

B. Acute Asthma G. Whooping Cough

C. Bronchiolitis H. Apparent Life-Threatening Event

D. Acute Epiglottitis I. Peritonsillar abscess

E. Inhaled Foreign Body J. Retropharyngeal abscess

21. An 11 month-old boy is referred to the ED with 3 days of persistent cough, preceded by 1 week of

rhinorrhoea, conjunctivitis and low-grade fever. He is usually healthy, but is unvaccinated.

On examination:

Not unwell

No stridor

Temp 375 deg C

O2 sats 98 % on RA

Frequent bouts of severe coughing, followed by gagging. Chest clear on auscultation.

22. An 18 month-old girl presents at noon with acute respiratory distress and stridor. She was perfectly well

just before this episode, playing with her 4 year-old brother in the toy room.

On examination:

Distressed

Marked stridor

Temp 37 deg C

O2 sats 95 % on RA

Chest exam: no abnormalities other than transmitted upper airway sounds. No rash.

23. A 6 month-old boy is brought to ED by his parents one evening. They report poor feeding and apparent

breathing difficulties. He had coryza and fever in the preceding 2 days.

On examination:

Moderately unwell

Temp 38 deg C

O2 sats 94 % on RA

Bilateral chest hyperinflation, subcostal recession and scattered expiratory wheezes.

24. A 14 month-old boy is brought in by his parents at 0100hrs, with fever and cough. The child had coryza,

irritability and malaise in the preceding 3 days.

On examination:

Well looking, happy child

Stridor evident when crying

Temp 375 deg C

O2 sats 98 % on RA

Barking cough. Clear chest with good bilateral breath sounds.

25. A 20 month-old boy is brought in by ambulance one afternoon. He suffered acute respiratory distress

while having lunch at a nearby restaurant. His parents state he was perfectly well before that.

On examination:

In distress, vomiting

Stridor evident at rest

Temp 375 deg C

O2 sats 95 % on RA

Diffuse erythematous, blanching rash. Lip swelling. Reduced bilateral breath sounds, some wheezes also

heard.

26. A 24 month-old boy is brought in by ambulance one evening, with respiratory distress. The child is

unvaccinated. He was completely well only 4 hours before. On examination:

Unwell, toxic looking. Sitting forward, drooling.

Stridor evident at rest

Temp 395 deg C

O2 sats 92 % on RA

Marked work of breathing, with subcostal recession. Reduced breath sounds bilaterally, with transmitted

stridor.

27. A 4 week-old boy is brought in by his concerned parents. The child appeared to suffer a sudden choking or

gagging episode, followed by a brief period of apnoea and cyanosis. The whole event lasted less than 1

minute. He was completely well before the episode, and seems to be well now. The child was prematurely

born at 34 weeks gestation, but had been developing normally since.

Well looking infant

No stridor, wheeze or other signs of respiratory compromise

Temp 37 deg C

O2 sats 99 % on RA

Child is small for age, but within expected range, based on past history.

28. An 18 month-old girl is brought in by her parents at 0400hrs, with cough and breathing difficulty. The child

is usually healthy, except for eczema. She has no usual medications or known allergies. Her mother

reports episodic coughing at night and early morning over the last few months, especially when she

suffers a viral respiratory tract infection. There is a strong family history of atopy.

Not unwell

Mild subcostal recession

Temp 375 deg C

O2 sats 94 % on RA

Good breath sounds bilaterally, with scattered expiratory wheezes.

29. A 3 year-old boy presents with sore throat and fever. The child is usually healthy, but had an upper

respiratory tract infection 3 days prior. Since then, his sore throat has progressed insidiously. He cannot

swallow liquids or food, owing to throat pain. There is no cough.

Unwell, with muffled voice. Drooling.

Inspiratory stridor when crying

Temp 39 deg C

O2 sats 96 % on RA

Neck stiffness present.

30. A 13 year-old girl presents with sore throat (worse on the right) and fever. She had milder symptoms over

the preceding 3 days, but currently complains of the “worst sore throat ever”, in a muffled voice. She

complains of pain when swallowing even cool water.

Miserable.

No stridor or respiratory distress.

Temp 39 deg C

O2 sats 98 % on RA

Tender cervical lymphadenopathy, worse on the right. Trismus present.

EMQ 4

Select ONE condition that best matches each set of arterial blood gases. Assume that in each scenario, there is

no other clinical problem. A condition may be selected more than once.

A. Hyperventilation of an intubated patient with severe, end-stage COPD F. Excess mineralocorticoid activity

B. Pyloric stenosis in a neonate G. Type I renal tubular acidosis

C. Excessive consumption of antacids H. Hyperventilation in a normal patient

D. Diabetic ketoacidosis with severe hyperglycaemia I. Pneumonia

E. Hypoventilation from narcotic overdose; no respiratory pathology J. Salicylate poisoning

1. FiO2 21 %

pH 7.05 mmHg (7.36-7.44)

pCO2 20 mmHg (35-45)

pO2 105 mmHg (85 -110)

HCO3 10 mmol/L (21-28)

Na+ 125 mmol/L (135-145)

K+ 5.5 mmol/L (3.2-4.3)

Cl- 95 mmol/L (99-109)

2. FiO2 21 %

pH 7.10 mmHg (7.36-7.44)

pCO2 30 mmHg (35-45)

pO2 60 mmHg (85 -110)

HCO3 18 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 4.5 mmol/L (3.2-4.3)

Cl- 100 mmol/L (99-109)

3. FiO2 21 %

pH 7.50 mmHg (7.36-7.44)

pCO2 45 mmHg (35-45)

pO2 90 mmHg (85 -110)

HCO3 38 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 3.5 mmol/L (3.2-4.3)

Cl- 100 mmol/L (99-109)

4. FiO2 21 %

pH 7.20 mmHg (7.36-7.44)

pCO2 35 mmHg (35-45)

pO2 100 mmHg (85 -110)

HCO3 18 mmol/L (21-28)

Na+ 135 mmol/L (135-145)

K+ 4.0 mmol/L (3.2-4.3)

Cl- 105 mmol/L (99-109)

5. FiO2 21 %

pH 7.05 mmHg (7.36-7.44)

pCO2 24 mmHg (35-45)

pO2 100 mmHg (85 -110)

HCO3 16 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 5.0 mmol/L (3.2-4.3)

Cl- 90 mmol/L (99-109)

6. FiO2 100 %

pH 7.50 mmHg (7.36-7.44)

pCO2 30 mmHg (35-45)

pO2 190 mmHg (85 -110)

HCO3 35 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 3.0 mmol/L (3.2-4.3)

Cl- 100 mmol/L (99-109)

7. FiO2 21 %

pH 7.50 mmHg (7.36-7.44)

pCO2 28 mmHg (35-45)

pO2 100 mmHg (85 -110)

HCO3 22 mmol/L (21-28)

Na+ 135 mmol/L (135-145)

K+ 4.0 mmol/L (3.2-4.3)

Cl- 105 mmol/L (99-109)

8. FiO2 30 %

pH 7.50 mmHg (7.36-7.44)

pCO2 40 mmHg (35-45)

pO2 150 mmHg (85 -110)

HCO3 35 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 3.0 mmol/L (3.2-4.3)

Cl- 85 mmol/L (99-109)

9. FiO2 21 %

pH 7.30 mmHg (7.36-7.44)

pCO2 60 mmHg (35-45)

pO2 70 mmHg (85 -110)

HCO3 28 mmol/L (21-28)

Na+ 140 mmol/L (135-145)

K+ 4.5 mmol/L (3.2-4.3)

Cl- 100 mmol/L (99-109)

10. FiO2 21 %

pH 7.55 mmHg (7.36-7.44)

pCO2 45 mmHg (35-45)

pO2 90 mmHg (85 -110)

HCO3 35 mmol/L (21-28)

Na+ 155 mmol/L (135-145)

K+ 2.5 mmol/L (3.2-4.3)

Cl- 100 mmol/L (99-109)

EMQ 5

Select ONE stroke syndrome that best matches each scenario. Assume that in each scenario, there is no other

clinical problem. That is, all clinical features result from an acute, isolated episode of that syndrome. A

syndrome may be selected more than once.

A. Anterior Cerebral Artery Infarction F. Cerebellar Infarction

B. Middle Cerebral Artery Infarction G. Lacunar Infarction

C. Posterior Cerebral Artery Infarction H. Cervical Artery Dissection

D. Vertebrobasilar Infarction I. Intracerebral Haemorrhage

E. Basilar Artery Occlusion J. Subarachnoid Haemorrhage

31. 55 year-old man with history of hypertension. Sudden onset of headache, nausea and vomiting, followed

within minutes by left hemiparesis and altered conscious state. Patient on warfarin for aortic valve

replacement.

On examination:

GCS 13

Pulse 55 bpm, SR

BP 200/100 mmHg

Left hemiparesis (limbs affected equally), left homonymous hemianopia and apraxia.

32. 58 year-old woman with history of hypertension. Received manipulative neck treatment by an osteopath

a few hours ago. Sudden onset of left sided head, face and neck pain.

On examination:

GCS 15

Pulse 70 bpm, SR

BP 140/90 mmHg

Partial left Horner’s Syndrome.

33. 70 year-old woman with history of hypertension. Recent palpitations of unknown cause. Progressive

vertigo, nausea, blurred vision and clumsiness. All symptoms commenced simultaneously.

On examination:

GCS 15

Pulse 100 bpm, AF

BP 150/90 mmHg

Left oculomotor (CN III) palsy, and right hemiparesis.

34. 75 year-old man with gradual onset of weakness, isolated to his right upper limb. No other symptoms.

Gradual improvement over 3 hours. Longstanding history of hypertension.

On examination:

GCS 15

Pulse 70 bpm, SR

BP 160/95 mmHg

Mild motor deficit in right upper limb. These signs resolve on repeat examination one hour later. No

other neurological abnormality. Sensory function and coordination are normal. Normal CT brain.

35. 65 year-old man with history of hypertension and atrial fibrillation, which is untreated. Sudden onset of

headache, vomiting, dysarthria. Declining conscious state.

On examination:

GCS 10

Pulse 140 bpm, AF

BP 200/100 mmHg

Gross ataxia, dysarthria and nystagmus.

36. 68 year-old man with history of hypertension. Gradual onset of right leg and foot weakness, with some

word-finding difficulty. No other symptoms.

On examination:

GCS 15

Pulse 70 bpm, SR

BP 150/90 mmHg

Moderate motor and sensory deficit in right lower limb. Mild expressive dysphasia. No other neurological

abnormality.

37. 48 year-old woman with history of adult polycystic kidney disease, who smokes. Very sudden onset of

bifrontal headache, while lifting weights at gym. Associated nausea and vomiting.

On examination:

GCS 15

Pulse 90 bpm, SR

BP 190/100 mmHg

Photophobia and meningism noted. No focal neurological deficits.

38. 65 year-old woman with history of ischaemic heart disease and diabetes. Awoke the same morning with

right-sided weakness and inability to speak.

On examination:

GCS 14

Pulse 80 bpm, SR

BP 160/95 mmHg

Right hemiparesis (limbs affected equally) and hemineglect. Right homonymous hemianopia. Aphasia.

39. 70 year-old woman with history of hypertension. Sudden onset of altered vision when reading, associated

with moderate right sided posterior headache.

On examination:

GCS 15

Pulse 110 bpm, AF

BP 160/95 mmHg

Marked left homonymous hemianopia, with preservation of ocular light reflexes bilaterally. Inability to

read, but writing is preserved. No other neurological deficits.

40. 50 year-old man with history of hypertension. Very sudden onset of headache and vomiting before

collapsing. Comatose on arrival to ED. Relatives report he complained of vertigo four days prior to event.

On examination:

GCS 6 (eyes spontaneously open, but no motor response and nonsensical speech)

Pulse 100 bpm, SR

BP 190/100 mmHg

Quadriplegia. Upward gaze seems to be preserved.

EMQ 6

You respond to a “Code Blue” activation in a ward of a rural hospital. The patient was found to have an acute

critical condition. For each scenario, select ONE option that is the most appropriate initial / immediate

intervention for the condition. Assume that in each scenario, all Basic Life Support measures, including

effective cardiac compressions and artificial ventilation if indicated, are being provided. However, no agents

other than oxygen have been administered. The patient also has a functioning peripheral intravenous cannula

in situ. All electrical therapy uses a biphasic waveform. An intervention may be selected more than once.

A. Defibrillation – 200J as single shock F. Intravenous adrenaline – 100mcg

B. Defibrillation – 100J as single shock G. Intramuscular adrenaline – 300mcg

C. Synchronized cardioversion – 100J or more H. Intramuscular adrenaline – 100mcg

D. Synchronized cardioversion – 10 to 20J I. Application of ice to the face

E. Intravenous adrenaline – 1.0mg J. Defibrillation – 200J as 3 stacked shocks

41. 65 year-old man admitted for investigation of chest pain. Witnessed collapse 3 minutes ago, with

ventricular fibrillation (VF) captured on cardiac monitor. Remains in VF.

42. 2 month-old girl. Weight 6 kg. Recent poor feeding and failure to thrive. Pulse rate noted to be 210 bpm.

Regular narrow complex tachycardia on monitor, with rate as above. Normal BP, normal oxygen

saturations.

43. 12 month-old girl. Weight 10 kg. Known peanut allergy. Developed a rash soon after inadvertent exposure

to peanuts. Stridor, angio-oedema evident. GCS 15. Tachycardic for age, but normal BP. Widespread itchy

rash.

44. 70 year-old woman post elective bowel surgery. Found collapsed 4 minutes ago, with ventricular

tachycardia (VT) captured on cardiac monitor. Normal serum potassium. GCS 3. Remains in VT.

45. 65 year-old man with history of hypertension, admitted for pneumonia. Developed palpitations, with

chest pain and dizziness.

GCS 11

Pulse 180 bpm, atrial fibrillation

BP 80/40 mmHg

46. 12 month-old boy. Weight 10 kg. Admitted for septic workup. Found unresponsive and pulseless. Blood

glucose is normal; intravenous fluid bolus given. Sinus tachycardia on cardiac monitor. Remains pulseless,

with GCS of 3.

47. 8 year-old boy. Weight 25 kg. Admitted for respiratory infection. Known congenital heart disease. Sudden,

witnessed collapse, with VF on monitor. Serum potassium and glucose normal.

48. 30 year-old woman who developed a severe allergic reaction to intravenous penicillin. She has a known

allergy to this antibiotic. Ward staff administered nebulized adrenaline. She has acute airway obstruction,

and anaphylactic shock. She became pulseless and unresponsive. Sinus tachycardia on cardiac monitor.

49. 60 year-old woman admitted with acute pericarditis. Since admission, she developed dyspnoea and

dizziness before collapsing in the ward. She is now unresponsive and pulseless.

GCS 3

Heart rate on monitor 180 bpm, sinus rhythm

BP 80/40 mmHg

Distended neck veins. Inaudible heart sounds. A bedside echocardiogram is being performed.

50. 12 month-old boy. Weight 10 kg. Admitted with possible sepsis for investigation. Ward staff noted he was

pale and lethargic.

GCS 8

BP not recordable, but faint femoral pulse present

Afebrile

Child is pale and sweaty. Cardiac rhythm strip is shown:

EMQ 7

Select ONE condition that best matches each scenario. Assume that in each scenario, there is no other clinical

problem. That is, all clinical features result from an acute, isolated episode of that condition. A condition may

be selected more than once.

A. Bacterial conjunctivitis F. Acute angle closure glaucoma

B. Viral conjunctivitis G. Central retinal artery occlusion

C. Retinal detachment H. Central retinal vein occlusion

D. Chalazion I. Anterior ischaemic optic neuropathy

E. Subconjunctival haemorrhage J. Optic neuritis

51. 75 year-old man with history of rheumatoid arthritis. Headache and left sided jaw pain in preceding days.

Progressive painless loss of vision in left eye over hours.

On examination: Markedly reduced visual acuity in left eye, with relative afferent pupillary defect (RAPD).

No abnormality in right eye. Tender in left temporal area.

52. 35 year-old woman with a few hours of painful right eye, worse with eye movement. Rapid loss of vision

in same eye. She has no history of myopia.

On examination: Moderate reduction in visual acuity in right eye, with very poor colour vision; normal on

left. Swollen, oedematous right optic disc on fundoscopy.

53. 75 year-old woman with history of hypertension, diabetes and peripheral vascular disease. Gradual,

painless loss of vision in left eye over days.

On examination: Marked reduction in visual acuity in left eye; normal on right. Fundoscopy: Swollen,

oedematous left optic disc; diffuse retinal haemorhages in all quandrants.

54. 30 year-old woman with 2 days of progressive pain in left eyelid, associated with redness and swelling. No

vision disturbance.

On examination: Not unwell. Focal, slightly tender, inflammed nodule on left upper eyelid. Normal visual

acuity; no ocular abnormality.

55. 35 year-old man with 4 days of bilateral red eyes. It commenced in the right eye, and spread to involve the

left eye after 2 days. No pain, but persistent eye irritation. Suffered a respiratory tract infection one week

prior.

On examination: Bilateral conjunctival injection and periauricular lymphadenopathy. Small follicles on

inferior palpebral conjunctiva with slit lamp examination.

56. 60 year-old man with very sudden, profound, painless loss of vision in right eye. Past history of

hypertension. He reports several episodes of transient visual loss in the same eye, but each was very short

lived.

On examination: Right sided monocular blindness with RAPD. Fundoscopy: pale retina with cherry red

macula.

57. 50 year-old man with longstanding myopia. Complains of flashing lights in right eye, associated with

multiple “floaters” across his field of vision. Upon arrival to ED, he reports “a shade coming over my right

eye”. No pain. No symptoms when right eye covered.

On examination: Bilateral myopia. Visual field deficit affecting right eye only, in supero-temporal

quadrant. No abnormality seen with standard fundoscopy.

58. 60 year-old woman with history of hypermetropia. Presents with sudden left eye / periorbital pain,

blurred vision, nausea and vomiting.

On examination of left eye: Unilateral mid-dilated, ovoid pupil. Marked conjunctival injection. Cloudy

cornea. Reduced visual acuity. No abnormality in right eye.

59. 25 year-old man with 2-day history of right eye redness, discomfort and purulent discharge. He reports

waking on last 2 mornings with sticky right eyelids that are adherent. He has no history of myopia.

On examination: Unilateral right sided red eye, with marked conjunctival injection and mucopurulent

discharge. Reduced visual acuity in same eye, but improved with pinhole correction. No abnormality in left

eye.

60. 50 year-old woman discovered a terrifying appearance of her left eye, when she gazed into her mirror that

morning. She sneezed a few times earlier that day, owing to hay fever. She reports no pain, no visual loss,

or any other symptoms. Examination reveals the image below (darker shades around the left eye are

actually red). There is no deficit of visual acuity or visual fields.

EMQ 8

Select ONE option of antimicrobial agent(s) that is most appropriate as empiric treatment for each scenario.

Assume that in each scenario, there is no other clinical problem. That is, all clinical features result from an

acute, isolated episode of that condition. Assume also that the patient has known allergy / adverse reaction to

the selected agent(s). An option may be selected more than once.

A. Azithromycin and ceftriaxone F. Vancomycin

B. Flucloxacillin G. Fluconazole

C. Valacyclovir or famciclovir H. Cefotaxime and amoxicillin

D. Penicillin I. Metronidazole

E. Permethrin J. No empiric antibiotic is currently indicated

61. A usually healthy 5 year-old boy presents with 24 hours of sore throat and fever, with no prodromal

symptoms. Examination reveals a febrile, unwell looking boy with tender cervical lymphadenopathy,

exudative tonsillophrayngitis and strawberry tongue. The child is fully vaccinated.

62. A 3 week-old girl is brought in by her parents with 24 hours of fever and poor feeding. Examination reveals

a febrile, lethargic looking infant without an obvious focus of infection. Cardiovascular examination is

unremarkable; serum glucose is normal.

63. A 24 year-old woman presents with vaginal discharge, dyspareunia and dysuria. Examination reveals

cervical excitation and cervicitis on speculum inspection, with mucopurulent discharge. A swab is taken of

the discharge.

64. A 30 year-old woman complains of vulval irritation, dysuria, dyspareunia and offensive vaginal discharge.

Examination reveals mucosal inflammation of the vulva and vagina. Punctate cervical haemorrhages are

noted, without discharge. Initial microscopy of vaginal swabs reveals motile parasites.

65. A GP refers a 40 year-old man with 3 days of progressive right leg pain, swelling and redness. The patient

is usually healthy. Examination reveals a febrile, though not unwell man. He has circumferential swelling

and marked erythema of his right leg above the ankle. The area is tender. There is regional

lymphadenopathy.

66. A 7 year-old girl is brought in by her parents with 24 hours widespread rash, in the background of 2 days

of low-grade fever and malaise. The child is usually healthy, and is up to date with vaccinations.

Examination reveals a well-looking, afebrile child. Several erythematous macules are present on her face,

torso and all limbs. Some lesions are small blisters. There is no tenderness, and no cellulitis. The child is

able to eat and drink without problems.

67. A 60 year-old woman presents with right-sided hemifacial pain for 3 days. She reports paroxysms of sharp

pain in her right forehead and ear. Examination reveals an afebrile, well-looking patient. A crop of

erythematous, maculo-papular skin lesions is noted lateral to her right eye. That region is sensitive to

touch. The patient states she only noticed the rash this same day.

68. A 40 year-old man presents 2 days of intense itching of his hands, feet and groins, which are worse at

night. He resides in shared, supported accommodation. Examination reveals a well-looking man with no

fever. Small, longitudinal erythematous papules are noted in the affected areas, especially in the inter-

digital spaces of his hands and feet. There are no lesions on his head and neck.

69. A 19 year-old woman is referred by her GP with 4 days of sore throat. She is usually healthy, and resides at

a university residential college. Soon after commencing amoxicillin, she developed a slightly itchy

widespread rash. Examination reveals a not unwell, afebrile patient, with widespread exanthem without

cellulitis. She has exudative tonsillopharyngitis with tender cervical lymphadenopathy.

Hepatosplenomegaly is present. Laboratory investigations reveal derangement of liver enzymes and

lymphocytosis.

70. A 65 year-old homeless man develops generalized muscle spasms 2 days after sustaining an open wound

on his right leg. The man’s history is unknown. Examination reveals a critically unwell patient with risus

sardonicus, lockjaw, trismus and generalized muscle rigidity. The wound on his right leg is heavily

contaminated with soil.

EMQ 9

Select ONE option that is the most appropriate specific, initial treatment for the condition described in each

scenario. Assume that in each scenario, there is no other clinical injury. That is, all clinical features result from

that acute, isolated injury. All necessary advanced life support, fluid resuscitation and analgesia (if required)

are already provided, in a tertiary trauma hospital. An option may be selected more than once.

A. Large bore tube thoracostomy F. Heart rate and BP optimisation; urgent cardiothoracic referral

B. Needle thoracostomy G. Emergent laparotomy

C. Ultrasound-guided needle pericardiocentesis H. Emergent thoracotomy

D. 3-sided dressing over injury I. Urgent embolization of bleeding vessel(s)

E. Positive pressure ventilation J. No specific treatment intervention currently indicated

71. A 55 year-old woman was involved in a high speed, rollover motor vehicle accident. She complains of

abdominal pain.

Examination:

GCS 13

Heart rate 120 bpm

BP 80/50 mmHg

Rigid, silent abdomen. Haemodynamics unresponsive to 3L of rapid intravenous fluid infusion.

72. A 25 year-old man was involved in a high speed, motorcycle accident.

Examination:

GCS 15

Heart rate 110 bpm

BP 100/60 mmHg

Chest x-ray reveals a fractured left 1st rib, widened mediastinum, left upper lobe pulmonary contusion and

a small left haemothorax.

73. A 74 year-old woman who is on rivaroxaban sustained high-force blunt trauma to her sternum. She

complains of chest pain, dyspnoea and dizziness.

GCS 13

Heart rate 120 bpm

BP 80/60 mmHg; pulsus paradoxus present

Extensive bruising over sternum. Distended neck veins, muffled heart sounds. Widened mediastinum on

chest x-ray, without other abnormality. Small voltage ECG complexes, with electrical alternans.

74. A 19 year-old man was allegedly stabbed in the chest at a bar brawl.

Examination:

GCS 14

Heart rate 120 bpm

BP 90/50 mmHg

A deep penetrating wound in left chest wall is present, with blood oozing from wound. Soon after arrival,

the patient suffers a cardiopulmonary arrest, with pulse electrical activity.

75. A 35 year-old builder fell 3m from a scaffold, sustaining blunt trauma to his right chest wall.

Examination:

GCS 14

Heart rate 140 bpm

BP 90/50 mmHg

No chest movement on right, with stony dull percussion of entire hemithorax. Absent right sided breath

sounds.

76. A 27 year-man suffers a gunshot wound to the right chest.

Examination:

GCS 15

Heart rate 100 bpm

BP 130/90 mmHg

Sucking chest wound on right, approximately 5cm in diameter. Small ipsilateral haemo-pneumothorax.

Stable haemodynamic parameters.

77. A 20 year-old man was tackled heavily in a football match, sustaining blunt trauma to his left side. He

complains of left upper quadrant pain, worse with movement.

Examination:

GCS 15

Heart rate 90 bpm

BP 120/80 mmHg

CT of the abdomen reveals a splenic laceration, with subcapsular, non-expanding parenchymal

haematoma.

78. A 30 year-old woman has just been transferred from rural hospital. She sustained a closed head injury

from a motor vehicle accident, and was intubated / ventilated for the transfer via fixed wing transport.

She had no other injury, so received no intervention other than neuro-protection. She was clinically stable

during the flight. Soon after her arrival in your ED, the ventilator alarms are triggered.

Examination:

GCS 3 (sedated and paralysed)

Heart rate 100 bpm

BP 80/50 mmHg

Distended neck veins. Trachea deviated to left. Reduced breath sounds on right, with ipsilateral hyper-

resonance.

79. A frail 85 year-old man fell off a chair at his home, hitting his left chest wall against a table edge. He

complains of left sided chest pain, markedly worse with any movement, including inspiration.

Examination:

GCS 14 (agitated from pain and hypoxia)

Heart rate 100 bpm

BP 160/90 mmHg

Oximetry 90 % on high flow oxygen

Bony crepitus, tenderness and bruising on left chest wall, consistent with multiple fractured ribs.

Paradoxical segmental chest wall movement in same area. No haemo- or pneumothorax on chest X-ray.

80. A 40 year-old man sustained a right-sided haemo-pneumothorax from blunt trauma. A large bore

intercostal catheter was inserted 1 hour ago, which initially drained 600ml of blood. He has received 3

litres of intravenous crystalloids. Initially stable, the patient deteriorated.

Examination:

Pale and sweaty

GCS 13 (agitated from hypoxia)

Heart rate 130 bpm

BP 90/60 mmHg

Oximetry 91 % on high flow oxygen

Another 500ml of blood drained via the intercostal tube in the last 15 minutes.