You are working in the paediatric emergency department. A four-year-old girl is waiting to see the triage nurse following a wrist injury. The mother gives the child a packet of nuts to eat. Shortly afterwards, she develops a widespread rash, swelling of the lips and tongue, and becomes short of breath. The child is brought straight to the resuscitation area. What dose of intramuscular (IM) adrenaline should be administered?

1. A. 500 mcg

2. B. 300 mcg

3. C. 200 mcg

4. D. 150 mcg

5. E. 75 mcg

A 60-year-old male, with known left bundle branch block (LBBB) on his electrocardiogram (ECG), presents with chest pain. You are asked to review his ECG taken at triage. What ECG changes make the likelihood of an acute myocardial infarction more likely in the context of pre-existing LBBB?

1. A. Concordant ST-segment elevation of at least 1 mm in at least one lead

2. B. Concordant ST-segment elevation of at least 3 mm in at least two leads

3. C. Concordant ST-segment depression of at least 3 mm in leads V1, V2, or V3

4. D. Concordant ST-segment depression of at least 4 mm in leads V1, V2, or V3

5. E. Excessively discordant ST-segment elevation of 2 mm when the QRS result is negative

A 23-year-old male has been brought to the emergency department following a jump off a high wall. He is complaining of pain in his right calcaneum. When assessing the plain radiograph of the calcaneum, what is the normal Böhler’s angle?

1. A. 0–5°

2. B. 20–40°

3. C. 60–100°

4. D. 120–140°

5. E. 140–160°

A patient presents with right arm weakness and a Glasgow Coma Scale (GCS) of 13/15. Computerised tomography (CT) of the patient’s head shows an acute subarachnoid haemorrhage; you proceed to perform a CT angiogram, which demonstrates an aneurysm. You are referring to the neurosurgical team. According to the World Federation of Neurosurgical Societies (WFNS) grading scale, what is the grade of this aneurysmal subarachnoid haemorrhage?

1. A. Grade 1

2. B. Grade 2

3. C. Grade 3

4. D. Grade 4

5. E. Grade 5

You are seeing a 28-year-old male who has quadriplegia from a spinal cord injury at the level of C4. He attends unwell with headache, sweating above the level of the injury and facial flushing. He is hypertensive on examination at 190/105. What is the likely underlying cause?

1. A. Urinary retention

2. B. Spinal shock

3. C. Pheochromocytoma

4. D. Neurogenic shock

5. E. Renal failure

You have been asked by management to improve the provision of care to patients with femoral neck fractures. You wish to commence a quality improvement project. In order to assess the current situation, you undertake an initial analysis of the problem. Which analysis tool maps impact against difficulty?

1. A. Priority matrix

2. B. Pareto diagram

3. C. Ishikawa diagram

4. D. Root cause analysis

5. E. Process map

You are critically appraising a paper looking at the effect of tranexamic acid on patient outcome following traumatic brain injury. The results are presented with p-values. At what p-value is the result statistically significant?

1. A. <1

2. B. <0.9

3. C. <0.5

4. D. <0.1

5. E. <0.05

You are preparing for the arrival of a one-year-old male infant who is in atraumatic cardiac arrest. His estimated weight is 10 kg. The emergency medicine registrar has written up the resuscitation doses. Which resuscitation dose needs to be corrected?

1. A. Energy for defibrillation – 80 J

2. B. Tracheal tube internal diameter (uncuffed) – 4 mm

3. C. Fluid bolus – 100 ml IV/IO

4. D. Adrenaline – 1 ml of 1:10,000 adrenaline IV/IO

5. E. Glucose – 20 ml of 10% dextrose IV/IO

You are reviewing a paper that is assessing a novel test for the diagnosis of acute coronary syndrome. The paper presents the sensitivity and specificity of the test. Which statement is true regarding these statistical measures?

1. A. Sensitivity increases with increasing prevalence of a condition

2. B. The sensitivity is calculated as the number of true negatives divided by all of those without the disease

3. C. Specificity decreases with decreasing prevalence of a condition

4. D. Sensitivity measures the proportion of patients who have the disease who are identified correctly by the test

5. E. The specificity is calculated as the number of true positives divided by all of those with the disease

You are investigating a complaint made by a 62-year-old female patient who attended the department with wrist pain following a fall. The treating clinician diagnosed a sprain and did not perform any imaging. She subsequently went to another hospital, where a fracture of the distal radius was diagnosed. In England, under the NHS constitution, within how many working days should the complainant receive an acknowledgement?

1. A. 1 day

2. B. 2 days

3. C. 3 days

4. D. 5 days

5. E. 7 days

A 37-week pregnant woman is brought to the emergency department in labour. She has umbilical cord prolapse. Which would be an appropriate initial management step while awaiting obstetric help?

1. A. Asking the expectant mother to adopt the knee-chest position

2. B. Lowering of the presenting part manually

3. C. Emptying of the urinary bladder

4. D. Re-inserting the loops of the cord lying outside the vagina

5. E. Avoiding the left lateral position

You have been called to the paediatric resuscitation area to review a six-year-old boy with suspected meningococcal septicaemia. He is drowsy and has paralysis of upward gaze. Which management step should be avoided?

1. A. Give 0.25 g/kg bolus of 20% Mannitol over 5 minutes

2. B. Give 3 ml/kg hypertonic saline over 5 minutes

3. C. Intubation and ventilation to control PaCO₂ (4–4.5 kPa)

4. D. Insertion of an internal jugular line

5. E. Cautious fluid resuscitation

You are reviewing a 42-year-old male with a painful and red right eye. Which clinical feature would favour a diagnosis of anterior uveitis rather than acute conjunctivitis?

1. A. Keratic precipitates

2. B. Absence of an irregular pupil

3. C. Pain not worsened on accommodation

4. D. Purulent discharge

5. E. Enlarged periauricular lymph nodes

You are giving a lecture on forensic medicine to the departmental junior doctors. Regarding victims of alleged sexual assault, which statement is correct?

1. A. Accelerated hepatitis B vaccination should not be considered if the perpetrator is not known to be hepatitis B negative

2. B. The definition of rape is the non-consensual penetration of the vagina only by a penis under the Sexual Offences Act 2003

3. C. Non-consensual, intentional insertion of an object or part of the body other than the penis into the vagina or anus is sexual assault by penetration

4. D. A pelvic examination should always be conducted

5. E. The Sexual Offences Act 2003 treats any sexual intercourse with a child under the age of 16 as rape

You are preparing to close a leg wound in a 10-year-old boy. You have decided to close it using sutures with lidocaine local anaesthesia. How many millilitres of 1% lidocaine should be used?

1. A. 3 ml

2. B. 4 ml

3. C. 9 ml

4. D. 12 ml

5. E. 15 ml

You are deciding on whether a patient with a confirmed pulmonary embolism (PE) can be managed as an outpatient. According to the Pulmonary Embolism Severity Index (PESI) score, which physiological parameter puts the patient at risk of increased mortality?

1. A. Pulse ≥105 bpm

2. B. Systolic BP <110 mmHg

3. C. Respiratory rate ≥25 breaths per minute

4. D. Temperature <36°C

5. E. Oxygen saturation <94%

According to the Royal College of Psychiatrists, which feature is not regarded as a red-flag risk factor for suicide when a patient presents with self-harm?

1. A. Lesbian, gay, bisexual and transgender (LGBT)

2. B. Recently bereaved

3. C. Ethnic minority group

4. D. Female

5. E. Living alone

You are asked to review a three-year-old girl who has presented unwell following a recent diarrhoeal illness. Blood tests results reveal acute kidney injury, anaemia and thrombocytopenia. What is the likely causative organism of the recent diarrhoeal illness?

1. A. Campylobacter jejuni

2. B. Escherichia coli

3. C. Rotavirus

4. D. Salmonella

5. E. Clostridium difficile

You are creating a protocol for the investigation of suspected PE in pregnant patients. Which statement applies to management of this patient group?

1. A. Women presenting with symptoms of an acute PE should have an electrocardiogram performed

2. B. D-dimer testing should be performed

3. C. Low-molecular-weight heparin should be given in doses titrated against the patient’s current weight

4. D. Treatment with low-molecular-weight heparin should be commenced only once a PE is confirmed with imaging

5. E. In massive PE with cardiovascular compromise, low-molecular-weight heparin is the preferred treatment

A 23-year-old male is brought to the emergency department after being found unresponsive in a river whilst under the influence of alcohol. His temperature is unrecordable. On transfer to the trolley in the resuscitation area he goes into cardiac arrest. As the emergency physician in charge (EPIC), you are called to the resuscitation area. He is in ventricular fibrillation (VF). He is defibrillated three times but remains in VF. Until what core temperature is reached should defibrillation be withheld?

1. A. 32°C

2. B. 33°C

3. C. 34°C

4. D. 30°C

5. E. 31°C

As the EPIC, you are asked by a junior doctor to review a patient with a suspected inguinal hernia. Regarding hernias of the groin, which statement is correct?

1. A. Femoral hernias occur more often in women than in men

2. B. Inguinal hernias are at a much higher risk of strangulation than femoral hernias

3. C. Groin hernias are more common in women than in men

4. D. Inguinal hernias are more common on the left than on the right

5. E. Direct inguinal hernias are twice as common as indirect hernias

A 15-year-old child presents following an intentional ingestion of ferrous fumarate tablets. Regarding the management of iron overdose, which statement is correct?

1. A. Poisoning is unlikely if there is resolution of gastrointestinal symptoms up to 24 hours from ingestion

2. B. In severe poisoning, chelation therapy should be administered only once a serum iron concentration is available

3. C. Desferrioxamine does not affect interpretation of iron levels

4. D. A raised anion gap metabolic acidosis indicates severe toxicity

5. E. Bowel obstruction is often an early complication

You are preparing a lecture on paediatric fractures. Regarding physeal fractures in paediatric patients, which statement is correct?

1. A. Salter–Harris grade 3 fractures are the most common

2. B. Salter–Harris grade 1 fractures carry the poorest prognosis

3. C. In Salter–Harris grade 1 fractures, the physis is compressed

4. D. Salter–Harris grade 4 fractures go through the physis

5. E. An osseous bridge may form in Salter–Harris grade 1 fractures

You are assessing the airway of a 42-year-old male who is about to undergo sedation for reduction of an elbow dislocation. When assessing his airway, you ask the patient to open his mouth and protrude his tongue. On inspection of the pharynx, you are only able to observe the base of the uvula and the soft palate. What Mallampati score is this?

1. A. Class 1

2. B. Class 2

3. C. Class 3

4. D. Class 4

5. E. Class 5

A patient presents with an acutely swollen right arm. Regarding upper-extremity deep vein thrombosis (UEDVT), which statement is correct?

1. A. Subclavian and axillary veins are least affected

2. B. Secondary forms are less common than primary forms

3. C. Catheter-associated UEDVT accounts for a minor proportion of secondary forms

4. D. Compression ultrasonography has a sensitivity of 70% and a specificity of 60%

5. E. A superior vena cava filter should only be placed in exceptional situations

A 42-year-old woman is diagnosed with cellulitis. She is administered intravenous flucloxacillin. Immediately after administration, she becomes unwell and develops anaphylaxis. She is moved to the resuscitation area and given 1 litre of intravenous 0.9% saline and two doses of 500 mcg IM adrenaline, 5 minutes apart. Despite this treatment, she remains hypotensive and in respiratory distress. As the EPIC, you are called to the resuscitation area. What is the next most appropriate step?

1. A. A third dose of IM adrenaline (500 mcg)

2. B. Intravenous metaraminol (0.5 mg)

3. C. Commence intravenous adrenaline infusion (1 mg adrenaline in 100 ml of 0.9% saline at a rate of 0.5–1.0 ml/kg/hour)

4. D. Intravenous glucagon (5 mg)

5. E. Intravenous salbutamol (250 mcg)

A GP trainee working in your department is anxious about prescribing an antibiotic in a male patient with known prolonged QTc interval on his electrocardiogram. Which of the following antibiotics should be avoided?

1. A. Nitrofurantoin

2. B. Clarithromycin

3. C. Co-amoxiclav

4. D. Vancomycin

5. E. Flucloxacillin

As the EPIC, you have been asked to review a 62-year-old diabetic man with suspected necrotising fasciitis. Which statement is correct?

1. A. Necrotising fasciitis type 2 is polymicrobial, that is, aerobic and anaerobic organisms

2. B. Necrotising fasciitis type 1 is monomicrobial

3. C. Necrotising fasciitis type 2 infection is often associated with gas in the tissue

4. D. Necrotising fasciitis type 2 is usually seen in those with underlying illness and the elderly

5. E. Necrotising fasciitis type 2 is most commonly caused by group A streptococcus

A 76-year-old male is brought to the emergency department after being in a river while under the influence of alcohol. The paramedics state that they are unable to record a temperature. Which statement is correct regarding hypothermia?

1. A. In hypothermic cardiac arrest, adrenaline should be withheld until a temperature of 28°C is reached

2. B. Severe hypothermia is defined as 20–25°C

3. C. Moderate hypothermia is defined as 28–32°C

4. D. In hypothermic cardiac arrest, adrenaline should be given every 3–5 minutes between 30 °C and 35°C

5. E. In hypothermic cardiac arrest, signs of life should be checked for 30 seconds

You request a computerised tomography scan of the thorax, abdomen and pelvis (CT-TAP) for a trauma patient. The report mentions an incidental adrenal tumour (incidentaloma) of the left adrenal gland. Which statement is true regarding these?

1. A. Approximately 85% are malignant lesions

2. B. If the lesion is ≤4 cm, it is probably low risk

3. C. If the lesion is lipid-rich, it is likely malignant

4. D. Prevalence is lower in patients with hypertension

5. E. The least common abnormality for adrenal incidentalomas is hyper-secretion of cortisol

A 48-year-old male presents with sudden onset hearing loss. Regarding this presentation, which statement is correct?

1. A. Viral, vascular or autoimmune are unlikely causes

2. B. Tuning fork tests have little utility

3. C. Sudden hearing loss is defined as the onset of hearing loss over a period of 72 hours or less

4. D. Steroid treatment should be avoided

5. E. At audiometry, the criterion for diagnosis is a decrease in hearing of at least 15 decibels that affects at least three sound frequencies

You are referring to the local hyperbaric unit a patient who is unwell with fatigue, arthralgia and shortness of breath following a dive. What factor may protect against the risk of decompression sickness?

1. A. Inter-current illness

2. B. Obesity

3. C. Cold

4. D. Dehydration

5. E. Regular diving

A 27-year-old male presents unwell 72 hours after taking 50 paracetamol tablets. He is in acute liver failure. He is administered fluid resuscitation and commenced on intravenous acetylcysteine. In the context of acute liver failure secondary to paracetamol overdose, according to the King’s College criteria, what derangement would be an indication for referral for consideration of liver transplant?

1. A. Prothrombin time >50 seconds

2. B. Creatinine 200 μmol/L

3. C. Arterial pH <7.30

4. D. Grade 2 hepatic encephalopathy

5. E. Urea >11 mmol/L

A community nurse presents to the emergency department following a needlestick injury from a known HIV-positive patient. Regarding HIV post-exposure prophylaxis following sexual exposure (PEPSE), which statement is correct?

1. A. Truvada and raltegravir should be used as first-line agents

2. B. The course should be discontinued if the patient has missed more than 24 hours of medication

3. C. PEPSE can be offered up to 24 hours from potential exposure

4. D. PEPSE should be given for 14 days

5. E. If the patient is potentially exposed to HIV within the last 48 hours of the course, the PEPSE should be continued for another 28 days

You are reviewing a 72-year-old patient who has presented with lethargy and easy bruising. A full blood count taken at triage reveals pancytopenia. You suspect aplastic anaemia. Which drug may cause this?

1. A. Indomethacin

2. B. Aspirin

3. C. Naproxen

4. D. Mefenamic acid

5. E. Meloxicam

You are reviewing a four-year-old child in whom the paediatric triage nurse is concerned about Kawasaki disease. What feature is a mandatory part of the diagnostic criteria for this condition?

1. A. Polymorphous exanthema

2. B. Bilateral non-exudative conjunctival injection

3. C. Changes in lips and oral cavity

4. D. Fever for at least 5 days’ duration

5. E. Cervical lymphadenopathy

You are reviewing a 42-year-old male who has avulsed an upper incisor. What is the best initial treatment to enable survival of the tooth?

1. A. Tooth should be wrapped in gauze

2. B. Tooth should be stored in the patient’s saliva

3. C. Tooth should be stored in milk

4. D. Tooth should be stored in saline

5. E. Immediate re-implantation of the tooth

You are preparing a lecture on paediatric fluid management. Which statement is correct regarding maintenance fluids in children?

1. A. Maintenance fluids should not be prescribed using the Holliday–Segar formula

2. B. 20 ml/kg/day for the first 10 kg of weight should be used

3. C. Isotonic crystalloids that contain sodium in the range 131–154 mmol/L should be avoided

4. D. Consider restricting fluids to 50–80% of routine maintenance needs if there is a risk of water retention associated with non-osmotic antidiuretic hormone (ADH) secretion

5. E. Plasma electrolyte concentrations do not need to be monitored

A 32-year-old female is sent urgently from her optician to the emergency department; there is no letter but the patient says that the optician said she has signs of high pressure at the back of the eye. The patient wonders whether it could be idiopathic intracranial hypertension. Which feature would cast doubt on the diagnosis of this condition?

1. A. Abducens nerve palsy

2. B. Normal neuroimaging

3. C. Normal cerebrospinal fluid (CSF) composition

4. D. CSF opening pressure of 15 cmH₂O

5. E. Papilloedema

You are assessing a 32-year-old patient who has back pain and shooting pains down both legs. You suspect cauda equina syndrome. You perform a neurological examination. What is the motor innervation of L4?

1. A. Knee extensors and foot dorsiflexors

2. B. Hip flexors and thigh adductors

3. C. Foot and toe dorsiflexors

4. D. Knee extensors

5. E. Foot and toe plantar flexors