Exit MCQ Pegawai Perubatan Siswazah 2020

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Quizzes Created: 1 | Total Attempts: 101

| Attempts: 101

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A 76-year-old man presents to the ED in acute respiratory distress, gasping for breath while on face mask. Paramedics state that he was found on a bench outside of his apartment in respiratory distress. Initial vitals include a HR of 90 beats per minute, a BP of 170/90 mm Hg, and an RR of 33 breaths per minute with an oxygen saturation of 90%. Upon physical examination, the patient is coughing up pink, frothy sputum, has rales two-thirds of the way up both lung fields, and has pitting oedema of his lower extremities. A chest radiograph reveals bilateral perihilar infiltrates, an enlarged cardiac silhouette, and a small right-sided pleural effusion. After obtaining IV access and placing the patient on a monitor, which of the following medical interventions is most appropriate?
- A. Morphine sulfate only
- B. Nitroglycerin only
- C. Nitroglycerin and a loop diuretic
- D. Aspirin
- E. Antibiotics

Exit MCQ Pegawai Perubatan Siswazah 2020 - Quiz

About This Quiz

There are 30 questions. You have to answer all questions. The passing marks 25. There is no negative marking. You have 40minutes to answer all questions.

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2.

A 29-year-old man presents to the ED complaining of RLQ pain for 24 hours. He states that the pain first began as a dull feeling around his umbilicus and slowly migrated to his right side. He has no appetite, is nauseated, and vomited twice. His BP is 130/75 mm Hg, HR is 95 beats per minute, temperature is 38.3°C, and his RR is 16 breaths per minute. His WBC is 14,000/μL. As you palpate the LLQ of the patient’s abdomen, he states that his RLQ is painful. What is the name of this sign?
- A. Blumberg sign
- B. Psoas sign
- C. Obturator sign
- D. Raynaud sign
- E. Rovsing sign
Correct Answer

A. E. Rovsing sign

Explanation

The Rovsing sign is a clinical sign used to diagnose appendicitis. It is characterized by pain in the right lower quadrant (RLQ) of the abdomen when pressure is applied to the left lower quadrant (LLQ). In this case, the patient experiences RLQ pain when the LLQ is palpated, indicating a positive Rovsing sign. This sign is suggestive of appendicitis, as the pain is likely due to inflammation of the appendix. The other options (Blumberg sign, Psoas sign, Obturator sign, and Raynaud sign) are not associated with RLQ pain or appendicitis.

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3.

Which statement is true regarding preoxygenation during Rapid Sequence Intubation?
- A. It should not delay the act of intubation when adequate oxygenation cannot be achieved due lack of patient cooperation
- B. The aim is to replace all the nitrogen in the lungs with oxygen and to increase the arterial pressure of Oxygen before the apnoeic period.
- C. Tools to improve preoxygenation in every patient include increasing tidal volume and respiratory rate.
- D. If performed properly preoxygenation can prevent the development of respiratory acidosis during the apnoeic period.
Correct Answer

A. B. The aim is to replace all the nitrogen in the lungs with oxygen and to increase the arterial pressure of Oxygen before the apnoeic period.

Explanation

Preoxygenation is an important step in Rapid Sequence Intubation (RSI) to increase the oxygen reserve in the lungs before inducing apnea. The aim of preoxygenation is to replace the nitrogen in the lungs with oxygen, increasing the arterial pressure of oxygen. This helps to delay the onset of desaturation during the apneic period, providing a longer safe apnea time. Increasing tidal volume and respiratory rate are not tools to improve preoxygenation, and preoxygenation cannot prevent the development of respiratory acidosis during the apneic period.

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4.

You are caring for a 54-year-old woman with a history of schizophrenia and coronary artery disease who presents to the ED for chest pain. Her vital signs are within normal limits and her ECG is normal sinus rhythm with nonspecific ST/T wave changes. Her first troponin is sent to the laboratory and you are planning to admit her to the hospital for a complete acute coronary syndrome (ACS) evaluation. She receives aspirin and nitroglycerin and her chest pain resolves. A few minutes later, the nurse alerts you that the patient has become unconscious. You go to the bedside and find the patient awake and alert. You review the rhythm strip below. What is your next step in management?
- A. Start CPR
- B. IV Magnesium sulphate stat
- C. Defibrillate patient with monophasic defibrillator 200J with sedation
- D. Defibrillate patient with biphasic defibrillator 200J without sedation
- E. Synchronize cardiovert patient 120J
Correct Answer

A. B. IV Magnesium sulphate stat

Explanation

The patient's ECG shows a wide QRS complex with a regular rhythm, indicating ventricular tachycardia (VT). VT can be a life-threatening arrhythmia and immediate treatment is needed. Intravenous magnesium sulfate is the treatment of choice for stable VT. Therefore, the next step in management would be to administer IV magnesium sulfate stat to the patient.

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5.

An 87-year-old man is brought to the ED on a long board and in a cervical collar after falling down a flight of steps. He denies losing consciousness. On arrival, his vital signs include a HR of 99 beats per minute, BP of 160/90 mm Hg, and RR of 16 breaths per minute. He is alert and speaking in full sentences. Breath sounds are equal bilaterally. Despite an obvious right arm fracture, his radial pulses are 2+ and symmetric. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Which of the following is a true statement?
- A. Epidural hematomas are very common in the elderly age population.
- B. Cerebral atrophy in the elderly population provides protection against subdural hematomas.
- C. Increased elasticity of their lungs, allows elderly patients to recover from thoracic trauma more quickly than younger patients.
- D. The most common cervical spine fracture in this age group is a wedge fracture of the sixth cervical vertebra.
- E. Despite lack of cervical spine tenderness, imaging of his cervical spine is warranted.
Correct Answer

A. E. Despite lack of cervical spine tenderness, imaging of his cervical spine is warranted.

Explanation

Despite the lack of tenderness and bony deformities in the cervical spine, imaging is still necessary in this case. The patient is an elderly man who fell down a flight of steps, which puts him at risk for cervical spine injury. The presence of a long board and cervical collar further indicates the possibility of cervical spine injury. Imaging is needed to rule out any fractures or other injuries that may not be evident on physical examination.

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6.

A 75-year-old man presents to the ED with a depressed level of consciousness. His wife is at the bedside and states he was stacking heavy boxes when he complained of a sudden intense headache. He subsequently sat down on the couch and progressively lost consciousness. She states that he had a headache the previous week that was also sudden but not as intense. He had gone to visit his primary-care physician who sent him to have a CT scan of the brain, which was normal. Over the course of the past week, he complained of intermittent pulsating headaches for which he took sumatriptan. In the ED, you intubate the patient and obtain the non-contrast head CT seen below. The scan is most consistent with which diagnosis?
- A. Meningoencephalitis
- B. SAH
- C. Normal pressure hydrocephalus
- D. Epidural hematoma
- E. Subdural hematoma
Correct Answer

A. B. SAH

Explanation

The patient's presentation with a sudden intense headache, loss of consciousness, and a history of previous sudden headaches suggests a subarachnoid hemorrhage (SAH). The normal CT scan from the previous week does not rule out SAH, as early bleeding may not be visible on imaging. The non-contrast head CT obtained in the ED may show signs of SAH, such as blood in the subarachnoid space or ventricles. Meningoencephalitis, normal pressure hydrocephalus, epidural hematoma, and subdural hematoma are less likely based on the clinical presentation and imaging findings.

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7.

A 78-year-old man presents to the emergency department (ED) com- plaining of left arm weakness that started 10 minutes ago in the clinic. The patient states that he has a history of hypertension and diabetes, but has never had similar symptoms in the past. He is feeling well otherwise. His blood pressure (BP) is 157/85 mm Hg, heart rate (HR) is 87 beats per minute, temperature is 37.1°C, and respiratory rate (RR) is 14 breaths per minute. His neurologic examination is unremarkable and the patient embarrassingly states that his left arm is no longer weak. Which of the following is the most likely diagnosis?
- A. Thrombotic stroke
- B. Conversion disorder
- C. Migraine with focal neurologic deficit
- D. Transient ischemic attack (TIA)
- E. Todd paralysis
Correct Answer

A. D. Transient ischemic attack (TIA)

Explanation

The patient's symptoms of sudden onset left arm weakness that resolved within a short period of time, along with his risk factors of hypertension and diabetes, are consistent with a transient ischemic attack (TIA). A TIA is a temporary disruption of blood flow to a certain part of the brain, causing temporary neurological symptoms. The fact that the patient's neurologic examination is unremarkable further supports this diagnosis. Thrombotic stroke and migraine with focal neurologic deficit would typically have longer-lasting symptoms, while conversion disorder and Todd paralysis would not have resolved on their own.

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8.

You are notified that emergency medical service (EMS) is bringing in a patient who collapsed 5 minutes ago in his house and was intubated at the scene by paramedics. On arrival to the ED, you confirm ET placement and continue cardiopulmonary resuscitation (CPR). You connect the patient to the cardiac monitor and see the rhythm below. Which of the following is the most appropriate next step in management?
- A. Perform synchronized cardioversion at 100 J.
- B. Immediately defibrillate at 200 J.
- C. Confirm the rhythm in two leads, begin CPR, then defibrillate at 200 J.
- D. Confirm the rhythm in two leads, begin CPR, then administer amiodarone.
- E. Confirm the rhythm in two leads, begin CPR, then administer epinephrine and atropine.
Correct Answer

A. E. Confirm the rhythm in two leads, begin CPR, then administer epinephrine and atropine.

Explanation

The most appropriate next step in management is to confirm the rhythm in two leads, begin CPR, and then administer epinephrine and atropine. This is because the rhythm shown on the cardiac monitor is pulseless electrical activity (PEA), which is a non-shockable rhythm. In PEA, there is electrical activity in the heart, but it does not result in a palpable pulse. The initial management of PEA involves confirming the rhythm in two leads to rule out any reversible causes, such as hypovolemia or hypoxia, and then starting CPR. Epinephrine and atropine are medications commonly used in the ACLS algorithm for the management of PEA.

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9.

A 55-year-old man presents to the ED with fever, drooling, trismus, and a swollen neck. He reports a foul taste in his mouth since a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and protrusion of the tongue. He appears “bull-necked” with tense and markedly tender oedema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphadenopathy. His vital signs are: HR 105 beats per minute, BP 140/85 mm Hg, RR 26 breaths per minute, and temperature 38.9°C. Which of the following is the most appropriate next step in management?
- A. Administer a dose of IV antibiotics and obtain a soft-tissue radiograph of the neck.
- B. Administer a dose of IV antibiotics then perform an incision and drainage at the bedside.
- C. Begin steroids to decrease inflammation and obtain an ear, nose, and throat (ENT) consult.
- D. Discharge the patient with oral antibiotics and ENT follow-up.
- E. Secure his airway, start IV antibiotics, and obtain an ENT consult.
Correct Answer

A. E. Secure his airway, start IV antibiotics, and obtain an ENT consult.

Explanation

The patient's presentation is consistent with Ludwig angina, a rapidly progressive cellulitis of the submandibular space. The presence of fever, drooling, trismus, and a swollen neck, along with the foul taste in the mouth and tenderness over the lower second and third molars, suggest an odontogenic source of infection. The "bull-necked" appearance with tense and markedly tender oedema and brawny induration of the upper neck indicates significant involvement of the deep neck spaces. These findings indicate a potential for airway compromise. Therefore, the most appropriate next step in management would be to secure the patient's airway, start IV antibiotics to cover the likely polymicrobial flora, and obtain an ENT consult for further evaluation and management.

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10.

A 54-year-old woman presents to the ED because of a change in behaviour at home. For the past 3 years she has end-stage renal disease requiring dialysis. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. On examination, the patient is alert and oriented to person only. The remainder of her examination is normal. An initial 12-lead ECG is per- formed as seen below. Which of the following electrolyte abnormalities best explains these findings?
- A. Hypokalaemia
- B. Hyperkalaemia
- C. Hypocalcaemia
- D. Hypercalcemia
- E. Hyponatremia
Correct Answer

A. B. Hyperkalaemia

Explanation

The ECG shows peaked T waves, widened QRS complex, and loss of P waves, which are consistent with hyperkalemia. Hyperkalemia can cause cardiac conduction abnormalities, leading to changes in the ECG. The patient's symptoms of fatigue, confusion, and decreased appetite are also consistent with hyperkalemia.

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11.

A 49-year-old woman presents to the ED with difficulty breathing after a morning jog. Her initial vitals include a HR of 60 beats per minute, a BP of 120/55 mm Hg, and an RR of 20 breaths per minute with an oxygen saturation of 94% on room air. Upon physical examination, the patient appears to be in mild distress with audible wheezing. She is able to speak in partial sentences and states that she occasionally uses an inhaler. Given this patient’s history and physical examination, which of the following measures should be taken next?
- A. Peak expiratory flow
- B. Chest radiograph
- C. β-Natriuretic peptide level
- D. Rectal temperature
- E. ABG
Correct Answer

A. A. Peak expiratory flow

Explanation

The patient's symptoms of difficulty breathing, wheezing, and use of an inhaler suggest that she may be experiencing an asthma exacerbation. Peak expiratory flow (PEF) is a measurement of how well air flows out of the lungs and can help assess the severity of asthma. It is a useful tool in monitoring and managing asthma. Therefore, measuring the patient's PEF would be the next appropriate step in evaluating her condition. Chest radiograph, β-Natriuretic peptide level, rectal temperature, and ABG are not indicated based on the given history and physical examination findings.

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12.

A 47-year-old man is brought to the ED by EMS after being found wandering in the street mumbling. His BP is 150/75 mm Hg, HR is 110 beats perminute, temperatureis 38°C,RRis16breathsperminute,oxygensaturation is 99% on room air, and fingerstick glucose is 98 mg/dL. On examination, the patient is confused with mumbling speech. His pupils are dilated and face is flushed. His mucous membranes and skin are dry. Which of the following toxic syndromes is this patient exhibiting?
- A. Sympathomimetic syndrome
- B. Anticholinergic syndrome
- C. Cholinergic syndrome
- D. Opioid syndrome
- E. Ethanol syndrome
Correct Answer

A. B. Anticholinergic syndrome

Explanation

The patient in this scenario is exhibiting symptoms of anticholinergic syndrome. This is indicated by his dilated pupils, flushed face, dry mucous membranes and skin, and confusion with mumbling speech. Anticholinergic syndrome is caused by the inhibition of the neurotransmitter acetylcholine in the central and peripheral nervous systems. This can result from the use of medications with anticholinergic properties, such as certain antidepressants or antihistamines.

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13.

An 82-year-old man presents to the ED feeling weak and dizzy. He has a past medical history of hypertension and diabetes and both are well controlled on hydrochlorothiazide, benazepril, atenolol, and metformin. On review of systems, he denies chest pain, gastrointestinal (GI) bleeding, and syncope, but states that he feels short of breath. His temperature is 37°C orally, BP is 86/60 mm Hg, HR is 44 beats per minute, RR is 18 breaths per minute, oxygen saturation is 98% on room air, and glucose is 116 mg/dL. He is immediately connected to the cardiac monitor. Which of the following choices best describes the ECG seen below?
- A. Normal sinus rhythm
- B. First-degree AV block
- C. Second-degree Mobitz I (Wenckebach) AV block
- D. Second-degree Mobitz II AV block
- E. Third-degree AV block
Correct Answer

A. C. Second-degree Mobitz I (Wenckebach) AV block

Explanation

The ECG shows a progressive lengthening of the PR interval until a QRS complex is dropped, indicating a second-degree AV block. Specifically, it is a second-degree Mobitz I (Wenckebach) AV block, as evidenced by the progressive prolongation of the PR interval until a QRS complex is dropped. This is a common finding in older individuals and is often benign, but it can also be associated with underlying cardiac pathology.

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14.

You are called to the bedside of a hypotensive patient with altered mental status. The nurse hands you an ECG which shows atrial flutter at 150 beats per minute with 2:1 arteriovenous (AV) block. You feel that the patient is unstable and elect to perform emergency cardioversion. You attach the monitor leads to the patient. What is the critical next step in electrical cardioversion?
- A. Set the appropriate energy level
- B. Position conductor pads or paddles on patient
- C. Charge the defibrillator
- D. Turn on the synchronization mode
- E. Administer 25μg of fentanyl IV
Correct Answer

A. D. Turn on the synchronization mode

Explanation

The critical next step in electrical cardioversion is to turn on the synchronization mode. This is important because atrial flutter with 2:1 AV block can cause the ventricles to beat at a rapid rate, and if electrical cardioversion is performed without synchronization, it can result in ventricular fibrillation. By turning on the synchronization mode, the defibrillator will deliver the electrical shock during the appropriate phase of the cardiac cycle, minimizing the risk of inducing a lethal arrhythmia.

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15.

Paramedics bring a 44-year-old man to the ED. He was found in the middle of the street after being struck by a car. His systolic BP is 70 mm Hg; a diastolic BP cannot be obtained. The heart rate is 125 beats per minute, and oxygen saturation is 89% on room air. The patient’s eyes are closed. You ask the patient his name and he doesn’t respond. There is no response when you ask him to move his limbs. You notice that his left foot is severely deformed and there is a large laceration to his right arm. Which of the following is the most appropriate next step in management?
- A. Prepare for emergent orotracheal intubation.
- B. Begin aggressive fluid resuscitation and administer morphine for pain.
- C. Apply a tourniquet just above his left foot and begin fluid resuscitation.
- D. Apply pressure to the laceration, splint the left foot, and order a radiograph.
- E. Administer packed RBCs and bring him to the CT scanner for a pan-scan.
Correct Answer

A. A. Prepare for emergent orotracheal intubation.

Explanation

The patient in this scenario is presenting with signs of severe trauma, including low blood pressure, tachycardia, low oxygen saturation, and unresponsiveness. These findings indicate that the patient is in a critical condition and requires immediate intervention. Orotracheal intubation is the most appropriate next step in management as it ensures the patient's airway is secured and allows for effective ventilation and oxygenation. This is crucial in preventing further deterioration and providing necessary support for the patient's vital functions.

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16.

A 55-year-old man with hypertension and a one-pack-per-day smoking history presents to the ED complaining of three episodes of severe heavy chest pain this morning that radiated to his left shoulder. In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His BP is 155/80 mm Hg, HR 76 beats per minute, RR 15 breaths per minute. He does not have chest pain in the ED. An ECG reveals sinus rhythm with a rate of 72. A troponin I is negative. Which of the following best describes this patient’s diagnosis?
- A. Variant angina
- B. Stable angina
- C. Unstable angina
- D. Non–ST-elevation MI
- E. ST-elevation MI
Correct Answer

A. C. Unstable angina

Explanation

Based on the given information, the patient is a 55-year-old man with a history of hypertension and smoking. He presents with three episodes of severe chest pain that radiated to his left shoulder, which occurred while he was reading the newspaper. These symptoms are consistent with unstable angina, as they occurred at rest and are not relieved by rest. The patient's blood pressure and heart rate are within normal limits, and the ECG and troponin I are negative, ruling out ST-elevation MI. Therefore, the best diagnosis for this patient is unstable angina.

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17.

A 41-year-old woman presents to the ED complaining of pain in her RUQ that is steady but gets worse with eating over the past 2 days. The pain also radiates to the right side of her midback. She denies vomiting. Her only medication is an oral contraceptive. Her BP is 140/75 mm Hg, HR is 80 beats per minute, temperature is 37°C, and RR is 16 breaths per minute. Laboratory tests are within normal limits. An abdominal ultrasound reveals stones in her gallbladder, but no thickened wall or pericholecystic fluid. What is the most likely diagnosis?
- A. Cholangitis
- B. Urolithiasis
- C. Cholecystitis
- D. Biliary colic
- E. Peptic ulcer disease
Correct Answer

A. D. Biliary colic

Explanation

The patient's presentation of pain in the right upper quadrant (RUQ) that worsens with eating and radiates to the right side of the midback, along with the presence of gallstones on abdominal ultrasound, is consistent with biliary colic. Biliary colic is caused by temporary obstruction of the cystic duct by a gallstone, leading to intermittent pain. The absence of a thickened wall or pericholecystic fluid on ultrasound suggests that there is no inflammation or infection, ruling out cholecystitis and cholangitis as the diagnosis. Urolithiasis and peptic ulcer disease do not typically present with RUQ pain.

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18.

A 20-year-old man was found on the ground next to his car after it hit a tree on the side of the road. Bystanders state that the man got out of his car after the collision but collapsed within a few minutes. Paramedics subsequently found the man unconscious on the side of the road. In the ED, his BP is 175/90 mm Hg, HR is 65 beats per minute, temperature is 37.3°C, RR is 12 breaths per minute, and oxygen saturation is 97% on room air. Physi- cal examination reveals a right-sided fixed and dilated pupil. A head CT is shown below. Which of the following is the most likely diagnosis?
- A. Epidural hematoma
- B. Subdural hematoma
- C. Subarachnoid hemorrhage (SAH)
- D. Intracerebral hematoma
- E. Cerebral contusion
Correct Answer

A. A. Epidural hematoma

Explanation

The most likely diagnosis in this case is epidural hematoma. The presence of a right-sided fixed and dilated pupil, along with the history of a car accident and subsequent collapse, suggests that there is a space-occupying lesion in the brain causing increased intracranial pressure. The head CT scan would likely show a biconvex or lens-shaped hematoma, which is characteristic of an epidural hematoma. This type of hematoma typically occurs due to a tear in the middle meningeal artery after a traumatic head injury.

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19.

Which of the patients below has received adequate preoxygenation and is ready for induction and paralysis of RSI?
- A. A neck stab wound patient with an expanding hematoma and a saturation of 100% on a nasal cannula, asked to breathe for 3 minutes after adding an NRM
- B. A 30-year-old presenting with SAH and decreasing levels of consciousness with a saturation of 98% on room air asked to take 8 deep breaths in room air
- C. An agitated asthmatic patient with an oxygen saturation of 85% despite attempts at nasal cannula and NRM complicated by the patient’s lack of compliance
- D. A COPD patient with worsening clinical presentation and unresponsive to bronchodilators with a saturation of 75% in whom good face seal cannot be achieved with PP masks.
Correct Answer

A. A. A neck stab wound patient with an expanding hematoma and a saturation of 100% on a nasal cannula, asked to breathe for 3 minutes after adding an NRM

Explanation

The patient in option A has received adequate preoxygenation and is ready for induction and paralysis of RSI because they have a saturation of 100% on a nasal cannula, which indicates that their oxygen levels are fully saturated. Additionally, they were asked to breathe for 3 minutes after adding an NRM, which further ensures that their oxygen levels are optimized before the procedure.

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20.

A 22-year old is brought to the emergency department following a motor vehicle collision with a GCS of 6. Full spinal precautions are in place. You initiate the RSI protocol. Which is the best position to achieve maximum preoxygenation in this patient?
- A. Patient flat on the gurney at chest level of intubating clinician with head in sniffing position
- B. Patient in Trendelenberg position with inline neck airway manoeuvres
- C. Head elevated using a 10cm cushion placed under the occiput with neck slightly flexed.
- D. Patient in reverse Trendelenberg with neck in neutral position.
Correct Answer

A. A. Patient flat on the gurney at chest level of intubating clinician with head in sniffing position

Explanation

The best position to achieve maximum preoxygenation in this patient is option A. Placing the patient flat on the gurney at chest level of the intubating clinician with the head in the sniffing position helps to align the airway and facilitate optimal oxygenation. This position allows for proper visualization of the vocal cords during intubation and helps prevent airway obstruction. Additionally, it minimizes the risk of aspiration and provides better control of the airway during the procedure.

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21.

Based on this ECG, what is the best description for the management of this patient
- Thrombolytic is the next choice of management if patient has persistent chest pain more than 12hours from the onset
- PCI and thrombolytic are equally effective within first 3 hours of chest pain onset
- Any patient whom failed thrombolytic therapy should be consider for Primary PCI
- PCI has no contraindication or limitation
Correct Answer

A. PCI and thrombolytic are equally effective within first 3 hours of chest pain onset

Explanation

The given answer states that PCI (percutaneous coronary intervention) and thrombolytic therapy are equally effective within the first 3 hours of chest pain onset. This means that both treatment options have similar efficacy in relieving the symptoms and managing the condition in the early stages of chest pain. However, it does not provide any information about the management if the patient has persistent chest pain for more than 12 hours or if thrombolytic therapy fails.

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22.

A 67-year-old man is brought to the ED by emergency medical service (EMS). His wife states that the patient was doing his usual chores around the house when all of a sudden he started complaining of severe abdominal pain. He has a past medical history of coronary artery disease and hypertension. His BP is 85/70 mm Hg, HR is 105 beats per minute, temperature is 37.2°C, and his RR is 18 breaths per minute. On physical examination, he is diaphoretic and in obvious pain. Upon palpating his abdomen, you feel a large pulsatile mass. An electrocardiogram (ECG) reveals sinus tachycardia. You place the patient on a monitor, administer oxygen, insert two large-bore IVs, and send his blood to the laboratory. His BP does not improve after a 1-L fluid bolus. Which of the following is the most appropriate next step in management?
- A. Order a CT scan to evaluate his aorta.
- B. Call the angiography suite and have them prepare the room for the patient.
- C. Order a portable abdominal radiograph.
- D. Call surgery and have them prepare the operating room (OR) for an exploratory laparotomy.
- E. Call the cardiac catheterization laboratory to prepare for stent insertion.
Correct Answer

A. D. Call surgery and have them prepare the operating room (OR) for an exploratory laparotomy.

Explanation

The patient's presentation with sudden severe abdominal pain, a large pulsatile mass on palpation, diaphoresis, and hypotension is highly concerning for a ruptured abdominal aortic aneurysm (AAA). This is a surgical emergency that requires immediate intervention. The most appropriate next step in management is to call surgery and have them prepare the operating room for an exploratory laparotomy. This procedure allows for direct visualization of the aorta and repair of the ruptured AAA, which is necessary to prevent further hemorrhage and improve the patient's chances of survival.

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23.

You are evaluating a child in your emergency department who presents with posterior rib fractures. You are suspicious of non-accidental trauma. Which of the following is NOT a feature that should raise suspicion of non-accidental trauma?
- A. Vague or inconsistent stories regarding the mechanism of traumatic injury.
- B. Delays in presentation.
- C. Injuries inconsistent with the developmental age of the child.
- D. Bruising in toddlers and young school-aged children around the shins.
- E. All of the above are concerning for non-accidental trauma
Correct Answer

A. D. Bruising in toddlers and young school-aged children around the shins.

Explanation

Bruising in toddlers and young school-aged children around the shins is not a feature that should raise suspicion of non-accidental trauma. This is because bruising in this area is commonly seen in active children who are learning to walk and run, and it is often due to accidental bumps and falls. The other features mentioned in options A, B, and C, such as vague or inconsistent stories regarding the mechanism of injury, delays in presentation, and injuries inconsistent with the developmental age of the child, are all red flags that should raise suspicion of non-accidental trauma. Therefore, option D is the correct answer.

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24.

Which is the correct statement in the management of disaster at ground zero?
- Medical Team, Police and other rescue team will be in the Yellow zone area
- Search and Rescue Team will be in the Red zone area and under the control of the Medical Commander
- Medical Incident Commander will take lead at the Red zone area
- Ambulatory victims will be tagged yellow and send to the hospital via
Correct Answer

A. Medical Team, Police and other rescue team will be in the Yellow zone area

Explanation

In the management of a disaster at ground zero, the correct statement is that the Medical Team, Police, and other rescue teams will be in the Yellow zone area. This means that these teams will be stationed in an area designated as the Yellow zone, which is likely a safer area compared to the Red zone where the Search and Rescue Team operates. The Yellow zone is where initial medical assessments and treatments can be provided to victims before they are transported to the hospital.

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25.

45 years old with underlying Hypertension presented with sudden onset of palpitation. Her Bp was 150/90mmhg, Pulse was 167/min. Saturation 98% under RA and patient orientated. ECG showed as below. The Emergency Physician decided for a trial of Intravenous drug. Which statement is FALSE in the management of this patient?
- Synchronize cardioversion must be avoided as this is stable tachycardia
- Calcium Channel blocker is the preferred drug if the patient has bronchial asthma
- Patient must be explained the adverse or side effect of the drug given prior to the drug administration
- Carotid bruit must be excluded prior to valsalva maneuver especially in elderly patient
Correct Answer

A. Synchronize cardioversion must be avoided as this is stable tachycardia

Explanation

The statement "synchronize cardioversion must be avoided as this is stable tachycardia" is false in the management of this patient. Stable tachycardia can be treated with synchronized cardioversion if the patient is hemodynamically unstable or if there are signs of end-organ damage. This patient's presentation of sudden onset palpitations, elevated blood pressure, and rapid pulse rate indicates the need for immediate intervention to restore normal heart rhythm and prevent complications.

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26.

A29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sided (less than 10% of the hemithorax) spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management?
- A. Discharge the patient with follow-up in 24 hours
- B. Perform needle decompression in the second intercostal space, midclavicular line
- C. Insert a 20F chest tube into right hemithorax
- D. Observe for another 6 hours
- E. Admit for pleurodesis
Correct Answer

A. A. Discharge the patient with follow-up in 24 hours
27.

A 68-year-old woman with recently diagnosed uterine cancer is brought to the ED by her daughter. The patient complains of acute onset right-sided chest pain that is sharp in character and worse with inspiration. Her BP is 135/85 mm Hg, HR 107 beats per minute, RR 20 breaths per minute, and oxygen saturation 97% on room air. Physical examination reveals a swollen and tender right calf. ECG is sinus tachycardia. Which of the following is the most appropriate next step in management?
- A. Start heparin therapy prior to diagnostic study
- B. Administer thrombolytics
- C. Order a ventilation-perfusion scan
- D. Order a CT angiogram
- E. Order a D-dimer
Correct Answer

A. A. Start heparin therapy prior to diagnostic study

Explanation

The patient's presentation is consistent with a possible pulmonary embolism (PE), as evidenced by the acute onset chest pain, tachycardia, and swollen and tender right calf (suggesting a deep vein thrombosis). The most appropriate next step in management is to start heparin therapy prior to diagnostic study. This is because the patient is hemodynamically stable and anticoagulation with heparin is the first-line treatment for PE. Diagnostic studies such as a ventilation-perfusion scan or CT angiogram can be ordered after initiating heparin therapy to confirm the diagnosis. Administering thrombolytics would not be appropriate as the patient is stable and there is no evidence of hemodynamic instability. Ordering a D-dimer alone would not be sufficient to confirm the diagnosis of PE.

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28.

65 years old man. Presented with sudden onset of epigastric pain associated with presyncopal attack. His BP 70/40mmhg, pulse 87/min, saturation 99% under nasal prong 3l/min, cool periphery and thready pulse volume. ECG was done and showed as below. What is the next best management for this patient?
- Get large IV cannula and start Noradrenaline infusion
- Get consent for thrombolytic drugs to look for any contraindication
- Refer cardiology department which is 250km away from your hospital for coronary angiogram
- Insert large IV Cannula and run 250ml of normal saline 0.9%
- Serve ticagrelor 180mg stat and give IVI metalase
Correct Answer

A. Insert large IV Cannula and run 250ml of normal saline 0.9%

Explanation

The patient presents with sudden onset of epigastric pain associated with a presyncopal attack. His low blood pressure, cool periphery, and thready pulse volume suggest hypovolemia and possible shock. The next best management would be to insert a large IV cannula and run 250ml of normal saline 0.9% to restore intravascular volume and improve blood pressure. This initial resuscitation is crucial before considering other interventions such as thrombolytic drugs or referral for coronary angiogram.

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29.

17 years old boy alledged fall from bicycle 2 days ago. He complained of pain over the right elbow. He went to GP for treatment. Imaging was done and he was discharged home with analgesic. However, he turned up to hospital again as the pain get worse and he was unable to move his right elbow. Xray of the right elbow was reviewed again. Which one is true based on this xray.
- Anterior fat pad sign is always pathological
- Posterior fat sign is absent in normal patient
- Posterior fat pad sign is always pathological
- Sailor sign will present if the posterior fat pad sign abnormal
Correct Answer

A. Posterior fat sign is absent in normal patient

Explanation

The correct answer is "Posterior fat sign is absent in normal patient." This means that in a normal patient, the x-ray will not show any indication of a posterior fat pad sign. This is important because the absence of this sign can help differentiate between a normal patient and a patient with a pathological condition.

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30.

In the management of Diabetic Ketoacidosis, below are the main objective in its management except
- Fluid resuscitation is needed to keep patient well hydrated after having significant losses.
- Potassium should be corrected and monitored once patient started on insulin
- ECG and other investigation must be done to look for any other causes for DKA
- Insulin must be started as soon as possible once the diagnosis is made
- Dextrose 5% must be added in the fluid management if the glucose level less than 15g/dl to avoid hypoglycaemia
Correct Answer

A. Insulin must be started as soon as possible once the diagnosis is made

Explanation

The correct answer is that insulin must be started as soon as possible once the diagnosis is made. This is because insulin is the mainstay of treatment for diabetic ketoacidosis (DKA). It helps to lower blood glucose levels and reverse the metabolic acidosis associated with DKA. It also promotes the movement of potassium back into cells, helping to correct the potassium imbalance often seen in DKA. Therefore, prompt initiation of insulin therapy is crucial in the management of DKA.

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65 years old man. Presented with sudden onset of epigastric pain associated with presyncopal attack. His BP 70/40mmhg, pulse 87/min, saturation 99% under nasal prong 3l/min, cool periphery and thready pulse volume. ECG was done and showed as below. What is the next best management for this patient?

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