Download EMQ Questions 90

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

GCS
15

Pulse
90

BP
110/80 mmHg

RR
16
deg C
bpm SR
/ 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

GCS
15

Pulse
100

BP
120/80 mmHg

RR
24
deg C
bpm SR
/ 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

GCS
15

Pulse
40
bpm, SR with first degree block

BP
80/40
mmHg

RR
16
/ min
deg C
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.
2.
3.
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)
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)
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.
5.
6.
7.
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)
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)
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)
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.
9.
10.
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)
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)
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 interdigital 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

BP
100/60 mmHg
bpm
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

Heart rate 120
bpm

BP
mmHg; pulsus paradoxus present
13
80/60
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

BP
130/90 mmHg
bpm
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

BP
120/80 mmHg
bpm
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 hyperresonance.
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.