1. A 27 year-old woman woke up this morning with her eyelids stuck together.

She has a gritty feeling on

the surface of her eyes, has ongoing discharge and her eyes look red. She finds the bright lights of the
emergency department a little uncomfortable.

Q1. What is the likely diagnosis? (1.0)

Q2. What features on history/ examination should be obtained in a patient with this condition? (2 points)
(1.0)

Q3. What advice will you give to this patient? (2 point) (1.0)

2. It’s your first day on the job in the ED and first up is a 23 year-old male with a 2 day history of a sore
throat. He’s had difficulty swallowing and finds it painful to eat and drink. His airway is patent with no
added sounds, he vocalises normally, and appears well hydrated with a heart rate of 105/min and a
temperature of 38.2C.

Inspection of his throat reveals this:

Q1. What does inspection of the patient’s throat show? (1.0)

Q2. What clinical decision rule might help determine the need for antibiotics? Explain (2.0)
3. A 32 year-old woman is referred to the ICU post caesarean section. She had an uneventful elective
caesarian section 10 hours previously.She has been referred because in the last 2 hours she has
developed vaginal bleeding and oozing from her epidural site. Her vital signs are unremarkable except for
a small oxygen requirement.

The following coagulation results are obtained: INR—4.8, APTT—97sec, fibrinogen--<0.1

Q1. Describe the results? (1.0)

Q2. What abnormality would you expect to see on a blood film? (1.0)

Q3. What is the differential diagnosis? (1.0)

4. A 22 year old woman with a past history of a seizure disorder presents to the ED with a 3 day history of
progressive rash and fever. The rash began as macules and papules on the chest and neck and has now
become blistered and eroded and involves the mouth and eyes. Her temperature is 39 0C and she feels
miserable

Q1. What is the likely diagnosis ?

Q2. Suggest possible underlying aetiologies
Q3. How should this patient be managed?

5. A 27 year old man had a dizzy spell and then collapsed while playing indoor soccer. Bystanders
thought that he had a brief loss of consciousness but he woke up quickly and now feels well. He denies
any current symptoms.
 Q1. Describe the abnormal features on his ECG? (1.0)

Q2. What is the likely diagnosis and underlying abnormality? (1.0)

Q3. What ongoing treatment may he need? (1.0)

6. Jo a 22 year-old medical student is brought in by his flatmate. He has been complaining of a fever and
headache. He is febrile 38OC. The triage nurse gives him some paracetamol and sits him the waiting
area. You are called there urgently as he has collapsed. On your arrival he is on the floor with a GCS of
E 2 V 3 M 4.

Q1. What is the most likely diagnosis, and list the common causative organisms in this population? (1.0)

Q2. Outline your immediate management, include treatment specific to this diagnosis? 3 points (1.5)

Q3. Jimmy and Matt are Joʼs flatmates they are worried that they may catch what Jo had. What
prophylaxis can you offer? (0.5)

7. Paul attends complaining of a painful big toe. He denies trauma. The metatarsal joint of his hallux is
swollen red ,painful to touch and suspecting to be gout.

Q1. What are the common precipitants? (2 Points) (1.0)

Q2. Describe the classical microscopic findings on joint aspirate. (1.0)

Q3. Outline your management of Paul, both immediate and long-term.(1.0)

8. You are working at an aid station at a marathon. Caroline a 33-year-old runner is brought in after
collapsing during the race. She is tachycardic and has a postural drop. Her core temperature is 39C.
Shortly there after, Simon is brought in after a collapse. Simon is vomiting, confused, has very dry skin,
hyperventilating and hypotensive. He has a core temperature of 41C.

Q1. What is wrong with a. Caroline? b. Simon? (1.0)

Q2. How would you treat a. Caroline? b. Simon? (1.0)

Q3. List 2 other temperature reugulation emergency condition? (1.0)

9. A patient attends the ED with sudden onset of vertigo and vomiting

Q1. What findings suggest a central cause? (1.0)

Q2. Once a central cause is eliminated what test can help, and how is it carried out ? (2.0)

10. A 38 year old woman comes in feeling rather unwell, complaining of a headache and nausea. She
noticed that her ankles started swelling last couple of weeks and she is concerned as she is 32 weeks
pregnant.

Q1. What features would constitute a diagnosis of preeclampsia? (1.0)

Q2. As you are attending to her patient suddenly becomes drowsy and decreased responsive. She then
starts twitching on her mouth. What happened to her ? Outline your management.? (2.0)

11. A 5 month old boy is brought in by his parents because of intermittent screaming. They got a bit
concerned in the morning when he appeared to be less active than usual. Was not eating and for the last
2 hours started screaming intermittently and kicking with his legs up in the air. On the way to the hospital
he vomited once.
On examination he is lethargic but calm initially. HR is 140, BP 80/65. Abdomen is firm with a fullness felt
in the RUQ. When you are examining him child starts to cry as above and vomits some bile stained fluid.

Q1.Describe your initial management. ( 4points) (2.0)

Q2. What is the likely diagnosis? bedside investigation could aid with the diagnosis? (1.0)

12. Johny is two and is brought in by his mum. He has been irritable and has had a fever for the last five
days, which does not seem to get better despite paracetamol. Today mum noticed a rash and some
lumps in his neck. He is refusing to walk.

Q1.What is the likely diagnosis?

Q2. What are other criteria not given in history needed to establish this diagnosis? ( 2 points) (1.0)

Q3. What complications may occur? (1.0)

13. Mohan is brought in by the Police. He had jumped on the tracks at Liverpool Street station. He was
aggressive and required restraint hand cuffs, and pepper spray. The police detained him

Q1. Which section is used here by the police and explains? (1.5)

Q2. Explain the section commonly used in ED? (1.5)

14. Ethan is a fire fighter who is brought in after being trapped in a burning house. He has extensive
partial and full thickness burns to his anterior chest, abdomen, and circumferential burns both legs.

Q1.Calculated percentage burn in this patient is 54% Assuming Ethan weighs 90kg, calculate his fluid
requirements? (1.0)

Q2. List two toxins that Ethan may have been exposed to, and their antidotes. (2.0)

15. Kylie, a 16 year old brings in Justin her 4 month old who “fell of the changing mat yesterday”. Justin is
very quite and small. He weighs 4Kg. They are accompanied by Mary, Kylies grandmother, who looks
after Justin 3days a week, while Kylie is a school.. There is a large bruise to Justin right thigh and she
cries everytime it is touched? Xray shows Spiral fracture of mid-shaft Right Femur

Q1. What is the likely mechanism of injury? (0.5)

Q2. List 2 other injuries that would make you suspicious of non accidental injury? (1.0)
Q3. Outline your management of this case? 4 points (1.5)

16. A 12-year-old boy is brought in with an acutely painful left hip. His X Ray is below

Q1. What are the risk factors associated with this condition? (1.0)

Q2. Describe this X-Ray? (1.0)

Q3. Outline management of this case? 2 points (1.0)

17. 25 yr old male brought to ED by his friends , he looks drunk but doesn’t smell of alcohol, vomiting and
slurred speech friend says he is working in garage have been using antifreeze today.

Q1. What drug will you give as an antidote?

Q2. What finding will you see on urine microscopy?

Q3. What type of picture is seen in ABG?

18. This man presents with a wound to his hand.

Q1. Name landmarks for a median nerve block?

Q2. Which drug is use for local anaesthesia? dose?

Q3. How do you know if you hit the nerve? What do you do?

19.

An 11-month old child is brought in to ED after having fallen out of a carrying chair while being taken
upstairs by his mother. His mother states that he did not cry but fell asleep immediately afterwards. Then
he made some jerking movements of his limbs. When the ambulance crew attended to him, his GCS was
10/15 but is now 14/15.

Q1. What are the differences in GCS measurement between adults and children? (1.5)

Q2. What are the possible indications for immediate CT scan in this patient according to NICE? (1.5)
20. A 6 year old boy is brought in to ED by his mother. His GP has diagnosed him with asthma 3 weeks
ago after a history of cough and wheeze.

Q1. According to recent BTS guidelines, list 4 immediate assessments necessary for this child? (1.0)

Q2. List 2 features of an acute severe attack in this age group? (1.0)

Q3. List 2 immediate treatments including routes and doses? (1.0)

21. Your hospital is conducting an audit of data protection procedures.

Q1. List 3 situations where clinical information can be given by ED without patient’s consent? (1.5)

Q2. List 3 situations in ED where confidentially can be breached? (1.5)

22. A 72 yr old man fell forwards and injured his mouth and chin. He was brought to the ED immobilised
on a spinal board. He is fully alert and orientated

Q1. Give 4 signs suggestive of neurogenic shock? (2.0)

Q2. Your FY2 doctor thinks this is a case of central cord syndrome. Give 2 features of central cord
syndrome. (1.0)

23. With regards to the NICE guidelines on Urinary Tract Infection in Children

Q1. How will you collect the urine if the baby is seriously ill? (1.0)

Q2. In a child greater than 3 what results on urine dipstick would merit immediate antibiotics? (1.0)

Q3. List 4 factors that constitute an atypical UTI? (1.0)

24. A six-week-old baby who was born at 32 weeks is brought in with poor feeding, difficulty in breathing
and lethargy.

Q1. Who are at particular risk of developing bronchiolitis? (1.0)

Q2. Indication for PICU referral? (2.0)

25. A 4-week-old baby is brought in with vomiting.

Q1. What are the classic symptoms and signs of hypertrophic pyloric stenosis?

Q2. What are the classic findings on blood gas analysis & biochemistry?

Q3. Outline the definitive management of this condition? (2points)

26. Outline the sequence of medication in APLS pathway for the treatment of status epilepticus in
children. (3.0)

27. Regarding safe sedation in emergency department

Q1. What is conscious sedation?

Q2. Name drug , route and dose commonly used in dissociative sedation?

Q3. What instructions will you give while discharging? (2 points)

28. 60/m presented with left distal radius fracture you wanted to perform biers block
.
Q1. What agent is used and what dose level cause methaemoglobinemia.

Q2. Name 4 group of patients who are at high risk of LA toxicity

Q3. What are the benefits in using ultrasound guidance for nerve blocks?

29. 54/f presents to ED with severe colicky pain suspecting to be ureteric colic

Q1. What is your immediate management?

Q2. What is the most sensitive and specific investigation ? Reason?

Q3. Apart from peristing pain what is the criteria for admiting patients? (2points)

30.
26/m athlete recently had a small injury to his hand, at present there is an increase in hand swelling ,
severe pain and spikes of fever suspecting to be cellulitis.

Q1. Difference between erysipelas and cellulitis?

Q2. Which are the factors increase risk of infection?

Q3. How will you manage this case?

31. You have been called for help in labour room to resuscitate newborn baby.

Q1. If gasping or not breathing what is your next step? (1.0)

Q2. What are the components of apgar score and when it is calculated? (2.0)

32.

Q1.Under which zone of neck it belongs ?

Q2. Give 2 indications for emergency surgical exploration in theatre?

Q3. What radiological investigation will you do and give reason?

33.

36/m came with c/o unilateral pleuritic chest pain , cough and dyspnoea with no corbids and underwent
ultrasound chest .

Q1. Describe the image and what it signifies?

Q2. What is light’s criteria?
Q3. Give 2 example each of transudate and exudates?

34. There has been a massive pile up on the freeway. One of the potentially seriously injured patients is
32 weeks pregnant.While the trauma team assembles you have time to consider the implications of
pregnancy for the management of the trauma patient.

Q1. What airway and breathing issues need to be considered in the management of severe trauma in the
pregnant patient?

Q2.  What issues specifically concerning the fetus need to be considered?

35. 24-year-old man was brought to the ED following an assault. He was set upon by a gang of youths
reportedly wielding baseball bats and knives

Q1.  Describe how you would recognize flail chest? 2 points (1.0)

Q2. How will you manage a flail chest? 4 points (2.0)

36. An ambulance was called and the paramedics splinted her right lower limb and gave her IV
morphine for pain. On arrival, she is GCS 15 and her vital signs are within normal limits. you examine the
right ankle and see this with no vascular involvement.

Q1. What is Mangled Extremity Severity Score?

Q2. How would you manage an open fracture in the emergency department?

37. A 26 year old male presents with nausea, vomiting and confusion. The following blood gas is
obtained on admission

pH --7.24     (7.35-7.45)
pCO2 --27     (35-45)
paO2--91        (80-100)
HCO3-- 11       (22-26)
Cl --110               (95-105)
sodium --142       (138-146)
potassium--4.1     (3.5-4.0)
lactate-- 7              (0-2)
glucose-- 2.1          (4-8)

Q1. Describe the blood gas?

Q2. Name two causes of raised lactate associated with low glucose?

Q3. Name two causes of metabolic acidosis with raised anion gap?

38. A 57 year old man presents to the ED with 18 hours of severe upper abdominal pain, fever, nausea
and vomiting. He looks jaundiced, his HR is 120bpm, BP 110/60, RR 22 and his temperature is 37.8 oC.
He is tender and guarded in his right upper quadrant on abdominal palpation.

Q1. What is the most likely diagnosis? Reason?

Q2. What treatment is needed in ED?

39. 40 year old male attends with acutely painful toe following a weekend DIY incident:

Q1. What is the diagnosis?

Q2. What is the treatment option?

Q3. How would you assess this injury?

40. 45 yr old female does gardening and decorating works daily presented with pain at the radial side of
the wrist, fusiform swelling over the thumb side of the wrist, and difficulty gripping with the affected side of
the hand.

Q1. What is the probable diagnosis?

Q2. What is Finkelstein test?

Q3. What is your initial management other than analgesics?

41. Regarding central line insertion.

Q1. What difficulty will you face while placing subclavian line comparing with ijv?

Q2. What is the surface anatomy for line insertion of rt subclavian?

42. 4yr boy sustained injury to b/l upper part of leg wih severe pain, nurse is unable to obtain iv
access, preparing for mechanical I-O access.

Q1. What is the first choice of insertion site in this patient?

Q2. What needle size is used for patient >39kg?

Q3. what blood samples can you send from this blood?

43. You have been asked to cannulate and draw blood sample for a patient in ward.

Q1. What bottle lid color will you use for a)Fbc b)coagulation test c)biochemistry

Q2. What is the flow rate /min for a)orange color b)green?

44. Regarding lumbar puncture

Q1. What are the two absolute contraindication other than patient refusal?
Q2. Patient has continous leak from puncture site not resolving what will you do?

Q3. How will you position the patient?

45. 56/m presented with abdominal pain and distention, chronic alcoholic, on examination you
see ascites and shifting dullness present, performed ascitic tap.

Q1.What is the ideal site for diagnostic tap?

Q2. Calculate SAAG value and classify whether it is Transudate/Exudate?

Q3. Give one absolute contraindication for paracentesis?

46. Describe the structures A to F

47. A 24-year-old man was brought to the ED following an assault found to have Rt side
pneumothorax on CXR. You planned to place an intercostal chest drain.

Q1. What are the borders of triangle of safety?

Q2. What is the rare and potential fatal complication that can occur after treatment of
pneumothorax.

Q3. Give 2 relative contraindication for ICD other than skin infection?

48. One of your staff in ED sustained needle stick injury from an HIV +ve patient
immediately she washed the wound and had tetanus.

Q1. Give two steps to help reduce the incidence of injury?

Q2. How will you manage? (4points)

49. 34-year-old man was brought to the ED following an minor inury to Rt knee c/o
pain and swelling around the knee. FY1 doctor wants to know about knee examination.

Q1. What is Mcmurray test?

Q2. Give any two points in Ottawa knee rule as to whether or not to xray knee?

50. 64 year old female presented with c/o lower abdominal pain and distention,
spontaneously relieved by passage of large amount of faeces.

Q1. What is your probable diagnosis?

Q2. Suddenly pt develops marked distention, fever and severe pain what do you
suspect now?

Q3.How will you manage ? (2points)

51. 54/m suffered from traumatic brain injury intubated and connected to portable
ventilator. While shifting the patient to radiology room suddenly desaturates spo2 76%,
nursing staff called for help.

Q1. What will you do immediately?

Q2. After your initial action still patient desaturates what will you do now?

Q3. What is minimum monitoring needed during transfer of patient?

52. 76/f diagnosed to have pneumonia in respiratory failure, junior clinical fellow wanted
to intubate since anesthetist was busy in some other case , he performed RSI and while
connecting to ventilator suddenly patient desaturated . You connected to end tidal co2
monitor which shows:
Q1. Explain the graph?

Q2. What will you do immediately?

Q3. What will be your next step?

54. 62 yr old man is brought to resus area. He c/o central chest pain ,sob, sweating since 1hr.
Rhythm strip shows

Q1. Give 3 history points and 3 ecg features that would increase likelihood of this patient
having VT than SVT with aberrant conduction? (1.5+ 1.5)

55. 72-year-old woman presents with a fever, shortness of breath and a productive cough. She
has right basal crackles on examination. You make a diagnosis of pneumonia. Her observations
are as follows: heart rate 116 bpm, respiratory rate 32/min, BP 100/50 mmHg. She feels drowsy
and a set of bloods are taken, which reveal her urea to be 6.5 mmol/l.

Q1. What is her CURB-65 score? Show calculation

Q2. What will be your antibiotic choice (dose, route, duration)?

56. 25 yr old nurse that works in ED recently returned from India and developed loose stools 10
episodes for the past 3 days. Since today stool become bloody, fever and abdominal cramps.

Q1. Give 4 history points you will ask for travelers diarrhea?

Q2. List 2 organism that may cause this presentation?

57. Regarding Mental capacity act 2005.

Q1. Describe 2 stage test for assessing capacity?

Q2. Give any three out of six qualifying safeguards gor admission and treatment?

58. 52yr old African lady with sickle cell anaemia came with c/o chest pain,cough,tachypnoea
and wheezing.

Q1. What is diagnosis?

Q2. Give 2 indication for blood transfusion?

Q3. How will you manage?