Acute care & Trauma

Question 1

A 65-year-old male smoker with hypertension, dyslipidaemia, and diabetes mellitus presents with chest pain. ECG changes suggest an acute MI. He is taken for an urgent coronary angiogram. Three days later, he is noticed to have developed an elevated serum creatinine, oliguria, and hyperkalaemia.

Answer 1

AKI

Question 2

A 35-year-old man with a history of congenital valvular heart disease undergoes a dental procedure without appropriate antibiotic prophylaxis. Several weeks later, he presents with fever and respiratory distress. He is intubated, and Streptococcus viridans is isolated in all blood cultures drawn at the time of admission. Echo demonstrates a mitral valve vegetation. Laboratory tests reveal a rising serum creatinine and urine output decline. Urine analysis reveals more than 20 WBCs, more than 20 RBCs, and red cell casts. Urine culture is negative. Renal ultrasound is unremarkable. Serum ESR is elevated.

Answer 2

AKI

Question 3

A 60-year-old man presents with acute onset of shortness of breath, fever, and cough. A chest x-ray (CXR) shows a right lower lobe infiltrate, and sputum has gram-positive diplococci. He is given intravenous antibiotics but his respiratory status declines over 24 hours. He becomes hypotensive and is transferred to the ICU. He is intubated for hypoxaemia and requires vasopressors for septic shock despite adequate volume resuscitation. He requires high levels of inspired oxygen (FiO₂) and positive end-expiratory pressure (PEEP) on the ventilator to keep his oxygen saturation >90%. Repeat CXR shows bilateral alveolar infiltrates, and his PaO₂/FiO₂ ratio is 109.

Answer 3

Acute Respiratory Distress Syndrome (ARDS)

Question 4

A 48-year-old man has a 4-month history of increasing fatigue and anorexia. He has lost 5.5 kg and noticed increased skin pigmentation. He has been otherwise healthy. His mother has Hashimoto’s thyroiditis and one of his sisters has type 1 diabetes. His BP is 110/85 mmHg (supine) and 92/60 mmHg (sitting). His face shows signs of wasting and his skin has diffuse hyperpigmentation, which is more pronounced in the oral mucosa, palmar creases, and knuckles.

Answer 4

Addison’s (=adrenal insufficiency)

Question 5

A 54-year-old woman with hypothyroidism complains of persistent fatigue, despite adequate thyroxine replacement. She has noticed increasing lack of energy for the past 3 months and additional symptoms of anorexia and dizziness. She also has significant loss of axillary and pubic hair. Her BP is 105/80 mmHg (supine) and 85/70 mmHg (sitting). The only abnormal finding on physical examination is a mild increase in thyroid size, with the thyroid having rubbery consistency.

Answer 5

Addison’s (=adrenal insufficiency)

Question 6

A 45-year-old man presents to the emergency department with restlessness and tremors. He is anxious, pacing in the hallway. Initial vital signs show a heart rate of 121 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse he states that he is nauseous and wants something to help with the shakes. During physician interview, the patient admits to heavy alcohol use and that he is trying to cut down on drinking. He also says that his current symptoms started to develop about 5 hours after his last drink.

Answer 6

Alcohol withdrawal

Question 7

A 14-year-old girl presents in severe respiratory distress to the emergency department. Her past medical history includes asthma and a peanut and tree nut allergy. Shortly after ingestion of a biscuit in the school cafeteria, she began complaining about flushing, pruritus, and diaphoresis followed by throat tightness, wheezing, and dyspnoea. The school nurse called an ambulance. No medications were administered and the patient did not have an epinephrine (adrenaline) auto-injector prescribed by her allergist. Her physical examination reveals audible wheezing and laryngeal oedema and an oxygen saturation of 92%.

Answer 7

Anaphylaxis

Question 8

A 65-year-old man reports being stung while working in his garden. He removed the sting and found the dying bee. In the past he tolerated insect stings on several occasions without reaction. On this occasion, within minutes, he experienced flushing, sweating, and a brief loss of consciousness. Too confused to call for help, he was found 10 minutes later by his wife. On arrival of an ambulance he was rousable, without respiratory distress or rash. Systolic BP was 75 mmHg and pulse rate was 55 bpm.

Answer 8

Anaphylaxis

Question 9

A patient may follow a biphasic time course, or the presentation may be atypical and limited to a single organ system (e.g., only laryngeal oedema or GI symptoms after shellfish ingestion). Biphasic reactions describe the recurrence of symptoms after resolution of the initial episode and can occur up to 78 hours after the event, with the majority occurring at 8 to 10 hours. The severity of symptoms is highly variable, with about one third more severe, one third severe, and one third less severe.

Answer 9

Anaphylaxis

Question 10

A 17-year-old boy is brought to the hospital by the police owing to an overdose of unknown drugs after a fight with his girlfriend. Initial physical examination is unremarkable except for a BP of 149/99 mmHg and sinus tachycardia at a rate of 130 bpm. However, shortly after arrival in the emergency department, the patient seizes and requires intubation. Serum electrolyte panel and ABG analysis reveal a wide anion-gap metabolic acidosis. Screen for drugs of abuse and alcohol is negative. The patient is found to have a serum salicylate level of 94.8 mg/dL.

Answer 10

Aspirin (salicylate) overdose

Question 11

A 48-year-old woman presents to the emergency department with vague complaints of feeling unwell over the past several days. She reports generalised body pains and consequently has taken Goody’s powder, paracetamol, diphenhydramine, and several other cold preparations over the past 72 hours. Since the night before presentation, she appeared confused and provided vague responses to questions. In addition, she cannot understand that she has been ingesting multiple medications that included the same chemical. On physical examination, she is noted to have hyperpnoea. Laboratory investigations reveal a serum bicarbonate level of 9 mmol/L and a salicylate level of 50.6 mg/dL.

Answer 11

Aspirin (salicylate) overdose

Question 12

A 25-year-old woman presents with shortness of breath. She reported that in high school, she occasionally had shortness of breath and would wheeze after running. She experiences the same symptoms when she visits her friend who has a cat. Her symptoms have progressively worsened over the past year and are now a constant occurrence. She also finds herself wheezing when waking from sleep approximately twice a week.

Answer 12

Asthma

Question 13

Symptoms may start as a non-productive cough, chest tightness, shortness of breath, or wheezing, either spontaneously or on exposure to trigger factors. When the cough is productive, it is associated with clear and sometimes stringy sputum. Frequently, the patient is a non-smoker and will often have an atopic history, such as childhood eczema. In people with nasal polyps, examination of the lung is usually normal.

Answer 13

Asthma

Question 14

A 27-year-old woman with a history of moderate persistent asthma presents to the emergency department with progressive worsening of shortness of breath, wheezing, and cough over 3 days. She reports prior exposure to a person who had a runny nose and a hacking cough. She did not receive significant relief from her rescue inhaler and experienced worsening symptoms, despite increased use. She has been compliant with her maintenance asthma regimen, which consists of an inhaled corticosteroid and a leukotriene receptor antagonist for maintenance therapy and salbutamol as rescue therapy. Her cough is disrupting her sleep pattern and as a consequence she is experiencing daytime somnolence, which is affecting her job performance.

Answer 14

exacerbated asthma

Question 15

As a result of an accident in the kitchen, a 20-month-old toddler had boiling pasta and water spilled onto her head, face, and upper body. Physical examination reveals blistering sloughing skin with underlying wet, tender erythema.

Answer 15

Burns injury

Question 16

A 50-year-old electrician was servicing a high-voltage transformer when a distant switch inadvertently sent current to the transformer, with a resulting arc and electrocution. The worker was thrown back by the force and his clothing was ignited. Physical examination reveals charring of the dominant hand, with deep arching injury across the antecubital fossa and axilla, consistent with passage of high-voltage current. The upper torso demonstrates leathery deep burns consistent with flame injury.

Answer 16

Burns injury

Question 17

A 70-year-old woman with a history of hypertension, hyperlipidaemia, 40 pack-years of cigarette smoking, and remote percutaneous transluminal coronary angioplasty is witnessed falling to the ground while brushing her pavement. She has not complained of any preceding symptoms. The emergency medical personnel who respond to the scene find her unconscious, pale, and without a pulse. After the pads from an automated external defibrillator are attached, the patient is noted to be in ventricular fibrillation.

Answer 17

Cardiac arrest

Question 18

A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of hypertension and hyperlipidaemia, and is being treated with a beta-blocker and statin therapy. She does not smoke and drinks alcohol in moderation. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 beats per minute. There is an audible S4 and the jugular venous pressure is elevated 3 cm above normal.

Answer 18

Chronic congestive heart failure

Question 19

A 60-year-old man presents to the accident and emergency department. He reports being progressively short of breath. He has a history of uncontrolled hypertension, non-insulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years. He underwent a successful primary angioplasty for a large acute anterior myocardial infarction 2 months ago. His blood pressure is 75/40 mmHg, his heart rate 110 beats per minute, and his respiratory rate 30. He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram performed in the A&E department reveals impaired systolic function, with an ejection fraction of 20%.

Answer 19

Chronic congestive heart failure

Question 20

A 70-year-old woman complains of increasing exertional dyspnoea for the last 2 days and now has dyspnoea at rest. She has a history of hypertension for the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are hydrochlorothiazide daily for the last 3 years. She has been prescribed lisinopril but failed to fill the prescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm. There is an audible S4 and the jugular venous pressure (JVP) is elevated 2 cm above normal. Lung examination reveals fine bibasal crepitations. There is no ankle oedema. Echocardiogram shows an ejection fraction of 60%.

Answer 20

Chronic congestive heart failure (acute exacerbation)

Question 21

A 73-year-old woman with previous history of myocardial infarction presents to the emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure (JVP) is elevated 3 cm above normal and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination. Echocardiogram shows an ejection fraction of 35%

Answer 21

Chronic congestive heart failure (acute exacerbation)

Question 22

A 76-year-old woman presents to the outpatient clinic with a complaint of shortness of breath with moderate exertion that has been gradually worsening over the past 6 months. She is a fairly active and healthy person except for a history of hypertension that her primary care physician has been treating for about 20 years with lisinopril and hydrochlorothiazide. She denies any chest pain with exertion. On physical examination, she has normal jugular venous pressure, no hepatojugular reflux, and no lower extremity oedema. Her cardiac examination reveals a non-displaced apical impulse, normal S1 and S2, and a fairly loud S4 with no murmurs.

Answer 22

HF with preserved ejection fraction

Question 23

A 56-year-old woman presents to the emergency department with shortness of breath at rest, orthopnoea, and paroxysmal nocturnal dyspnoea that developed in the last 5 days. Her past medical history includes obesity, hypertension, diabetes mellitus, and chronic kidney disease stage II. She had a cardiac catheterisation done 2 years ago due to exertional chest pain that revealed non-obstructive coronary artery disease. On examination she is tachycardic with a heart rate of 110 bpm and her blood pressure is 192/98 mmHg. She has jugular venous distension up to her jaws, trace lower extremity oedema, and bi-basal crackles. She has a normal S1 and S2, but has a summation gallop with no murmurs.

Answer 23

HF with preserved ejection fraction

Question 24

A 52-year-old woman presents with gradually increasing dyspnoea on exertion over the past 2 years. Recently she has required 2 pillows at night to alleviate recumbent dyspnoea. On examination, she has an apical diastolic murmur.

Answer 24

Mitral stenosis

Question 25

A 36-year-old prima gravida presents with dyspnoea on exertion and 2 pillow orthopnoea during her second trimester. Previous physical examinations had disclosed no cardiac abnormalities. On current physical examination, she has a loud S1 and a 2/6 diastolic rumble.

Answer 25

Mitral stenosis

Question 26

A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.

Answer 26

Aortic stenosis

Question 27

It may occur in the setting of acute MI and leads to high left atrial pressure and pulmonary oedema secondary to reduced left atrial compliance. It usually presents as a sudden and marked increase in CHF symptoms, with weakness, fatigue, dyspnoea, and sometimes respiratory failure and shock. It is usually associated with peripheral vasoconstriction, pallor, and diaphoresis. Occasionally no murmur is heard, because the lack of left atrial compliance leads to equalisation of pressures between the left atrium and ventricle midway through systole.

Answer 27

Acute mitral regurgitation

Question 28

laterally displaced apical impulse (with left ventricular dilation), diminished S1, with or without S3, with or without right ventricular heave, and palpable P2 (if pulmonary hypertension has developed).

Answer 28

Chronic mitral regurgitation

Question 29

A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.

Answer 29

Aortic regurgitation

Question 30

A 31-year-old black man presents to clinic for the first time for a routine physical examination. He denies any complaints. On physical examination the only abnormality is a systolic murmur best heard over the second right intercostal space and an early diastolic murmur best heard over the third left sternal border. LVEF is 55% to 60% with mild LVH. Left ventricular end-systolic diameter is 45 mm and aortic root diameter is 3.5 cm.

Answer 30

Aortic regurgitation

Question 31

patients can present with sudden onset of pulmonary oedema and hypotension or in cardiogenic shock. Patients may also present with signs and symptoms of myocardial ischaemia or aortic root dissection. An apical diastolic rumble may be present. Pulse pressure may not be increased due to reduced systolic pressure

Answer 31

Aortic regurgitation

Question 32

A 66-year-old man with a smoking history of one pack per day for the past 47 years presents with progressive shortness of breath and chronic cough, productive of yellowish sputum, for the past 2 years. On examination he appears cachectic and in moderate respiratory distress, especially after walking to the examination room, and has pursed-lip breathing. His neck veins are mildly distended. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Heart and abdominal examination are within normal limits. Lower extremities exhibit scant pitting oedema.

Answer 32

COPD

Question 33

A 56-year-old woman with a history of smoking presents to her primary care physician with shortness of breath and cough for several days. Her symptoms began 3 days ago with rhinorrhoea. She reports a chronic morning cough productive of white sputum, which has increased over the past 2 days. She has had similar episodes each winter for the past 4 years. She has smoked 1 to 2 packs of cigarettes per day for 40 years and continues to smoke. She denies haemoptysis, chills, or weight loss and has not received any relief from over-the-counter cough preparations.

Answer 33

COPD

Question 34

weight loss, haemoptysis, cyanosis, and morning headaches secondary to hypercapnia. Physical examination may demonstrate hypoxia, use of accessory muscles, paradoxical rib movements, distant heart sounds, lower-extremity oedema and hepatomegaly secondary to cor pulmonale, and asterixis secondary to hypercapnia. Patients may also present with signs and symptoms of complications. These include severe shortness of breath, severely decreased air entry, and chest pain. Patients with this disease often have other comorbidities, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, and lung cancer

Answer 34

COPD

Question 35

A 20-year-old man is brought to the accident and emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67 mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per minute, temperature 37.1°C (98.8°F). On mental status examination, he is drowsy. Physical examination reveals Kussmaul breathing (deep and rapid respiration due to ketoacidosis) with acetone odour and mild generalised abdominal tenderness without guarding and rebound tenderness. Initial laboratory data are: blood glucose 25.0 mmol/L (450 mg/dL), arterial pH 7.24, pCO2 25 mmHg, bicarbonate 12 mmol/L (12 mEq/L), WBC count 18.5 × 10^9/L (18,500/microlitre), sodium 128 mmol/L (128 mEq/L), potassium 5.2 mmol/L (5.2 mEq/L), chloride 97 mmol/L (97 mEq/L), serum urea 11.4 mmol/L (32 mg/dL), creatinine 150.3 micromol/L (1.7 mg/dL), serum ketones strongly positive.

Answer 35

DKA

Question 36

A 1-year-old boy presents with sudden-onset fever and vomiting. Findings include irritability, tachycardia, pallor, cold extremities, diffuse skin rash with abdominal petechiae, and signs of meningeal irritation. Blood tests show leukocytosis, markedly decreased platelet count, increased PT/PTT, decreased fibrinogen, elevated fibrin degradation products, elevated urea, and metabolic acidosis. Gram-negative cocci were found in CSF and meningococci confirmed. Protein C activity is reduced.

Answer 36

Disseminated intravascular coagulation (DIC)

Question 37

A 45-year-old man with acute onset of pancreatitis presents with episodes of epistaxis, increased PT/PTT, and decreased platelet count. Further coagulation work-up reveals increased thrombin time, decreased fibrinogen level, positive D-dimers, and increased fibrin degradation products. The blood culture is negative.

Answer 37

Disseminated intravascular coagulation (DIC)

Question 38

A 56-year-old man presents to the emergency department with headache, fever, blurred vision, and somnolence followed shortly by unresponsiveness to verbal commands. For the last 2 weeks he had been feeling ill and had decreased appetite and myalgias. Three days prior to presentation he experienced intermittent confusion, severe headache, and fever. Examination was limited by a generalised tonic-clonic seizure, for which he received lorazepam.

Answer 38

Encephalitis

Question 39

A 19-year-old man presents to the emergency department with a witnessed generalised tonic-clonic seizure episode. One month previously he had an upper respiratory tract infection. Over the last 2 weeks he developed headaches, blurred vision, generalised weakness, and progressive difficulty in walking. Examination revealed pain on eye movement as well as limb and gait ataxia.

Answer 39

Encephalitis

Question 40

A 45-year-old homeless man is found unconscious in the street. He appears stiff, with continuously shaking extremities, foaming at the mouth, and urinary incontinence. On arrival to the emergency department, he has stopped shaking but is still unconscious. Stiffening and shaking resume a few minutes later. Two empty medicine bottles are found in his pocket, labelled phenytoin and valproic acid.

Answer 40

Status epilepticus

Question 41

A 15-year-old girl wakes up disoriented and confused. She remains still in bed, looking continuously around the room as if daydreaming. When asked about her strange behaviour, she does not appear to understand and replies with unintelligible words. For the last 3 years, she has been having subtle early morning body jerks and has been told by her teachers that she frequently stares and seems inattentive in class.

Answer 41

Status epilepticus

Question 42

Patients may present with prolonged periods of confusion, disorientation, memory loss, or personality changes, with no other associated motor manifestations. Patients may also present with repetitive contraction of a muscle, group of muscles, or an entire limb, with no change of consciousness or awareness, or rarely with only subjective changes or an isolated aphasia

Answer 42

Status epilepticus

Question 43

A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterwards. Further review of the history reveals that the patient has been experiencing ‘jerks’ in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These ‘jerks’ do not seem to present a problem during the rest of the day.

Answer 43

Generalised seizure

Question 44

A 55-year-old woman recently diagnosed with a brain tumour in the left hemisphere has a witnessed seizure event. The seizure is initially recognised when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.

Answer 44

Generalised seizure

Question 45

A previously healthy and developmentally normal 18-month-old boy presents to the emergency department by ambulance after his parents witnessed a seizure. The parents report the boy had a febrile illness with mild upper respiratory symptoms and they treated him with paracetamol and ibuprofen at home. The child then began to have frequent jerking movements of all limbs. The rectal temperature was 39.5°C (103.1°F). The parents called the emergency services, and a paracetamol suppository was administered during transport to the emergency department. The jerking stopped after approximately 5 minutes. Afterwards, the child was sleepy but responsive to verbal stimulation. Examination revealed a diffuse erythematous maculopapular rash and a normal mental and neurological status.

Answer 45

Febrile seizure

Question 46

A 10-month-old girl is brought to the emergency department with a history of recurrent right arm and leg jerking followed by prolonged sleepiness. The parents report a 2-day history of fever with chest congestion and irritability. The child is admitted to hospital for neurological evaluation.

Answer 46

Febrile seizure

Question 47

A 6-year-old female without a significant past medical history presents for evaluation of frequent unusual episodes for the past 3 months. The unusual episodes consist of sudden activity arrest with staring and minimal eyelid flutter for 10 to 20 seconds occurring 5 to 10 times per day. The patient is unresponsive to voice or tactile stimulation during the episodes. She is able to immediately resume activities without any recollection of the event once the episode finishes. Her teachers have noted that she stares off in class repeatedly and does not seem to be remembering instructions and classroom material. The diagnosis of attention-deficit/hyperactivity disorder had been suggested. One such unusual episode is induced in front of medical staff with hyperventilation.

Answer 47

Absence seizure

Question 48

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.

Answer 48

Focal seizure

Question 49

A 70-year-old man presents with a generalised tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond, mumbles words that do not make sense, and stares. After several minutes he is usually responsive. His past medical history includes hypertension and hypercholesterolaemia. He had a stroke during the preceding year. Although he recovered significantly, he still walks with a limp on the left side.

Answer 49

Focal seizure

Question 50

Patients may present complaining of features consistent with auras, such as déjà vu, or abnormal odours or tastes. Sometimes this is preceded by a generalised seizure, but then behavioural changes, interpreted as confusion, continue. The individual may sometimes still be able to carry out reasonably complicated everyday tasks. Patients may also describe the seizure as a decline in memory or behaviour rather than as a discrete episode.

Answer 50

Focal seizure

Question 51

Triphasic presentation: patients experience a brief loss of consciousness followed by a lucid interval lasting from minutes to hours. This is then followed by headache, progressive obtundation, and hemiparesis. Bleeding may eventually cause a “blown pupil” secondary to uncal herniation. The “blown pupil” will be ipsilateral and the hemiparesis will be contralateral.

Answer 51

Epidural haematoma

Question 52

An 18-year-old man hit the previous day while playing football presents with overall good orientation, but reports feeling “slow” with a severe headache and limited memory for the events occurring immediately before and after the impact. He also describes feeling worse now than he did immediately after the impact. He has no visible head injury and did not lose consciousness, but does report sensitivity to light and sound.

Answer 52

Concussion

Question 53

A 15-year-old girl was playing lacrosse and was struck in the head with the ball. She remembers everything up to and including the event, but her memory for events after being concussed is suspect for the details of the rest of the day. She further reports feeling dizzy and nauseated, as well as feeling both emotional (both laughing and crying for no reason) and extremely irritable. She continued to play after being struck and had worsening symptoms. After the game she went to the emergency department, where she had a CT scan, the results of which were normal.

Answer 53

Concussion

Question 54

A 50-year-old man presents to clinic with a complaint of central chest discomfort of 2 weeks’ duration, occurring after walking for more than 5 minutes or climbing more than 1 flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his examination is normal.

Answer 54

Stable ischaemic heart disease

Question 55

A 60-year-old man with a history of a myocardial infarction presents to clinic for follow-up. He was started on aspirin, beta-blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressure resolves with sublingual glyceryl trinitrate or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight. He is normotensive on examination with a heart rate of 72 bpm. The remainder of his examination is normal.

Answer 55

Stable ischaemic heart disease

Question 56

A 65-year-old man, who smokes and has a history of hypertension and peripheral vascular disease, now presents with increasing frequency and severity of chest discomfort over the past week. He reports that he previously had chest pain after walking 100 metres, but now is unable to walk more than 50 m without developing symptoms. The pain radiates to the left side of the neck and is only eased after increasing periods of rest.

Answer 56

Unstable angina

Question 57

A 45-year-old woman, with a history of type 1 diabetes diagnosed when she was a teenager, presents to the accident and emergency department complaining of abdominal pain, nausea, and shortness of breath that woke her up from sleep.

Answer 57

Unstable angina

Question 58

A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads. Three doses of sublingual glyceryl trinitrate provide little relief.

Answer 58

Non ST-elevation MI

Question 59

A 54-year-old man with a medical history of hypertension, diabetes, dyslipidaemia, smoking, and family history of premature coronary artery disease presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and light-headed and is short of breath. Examination reveals a hypotensive, diaphoretic man in considerable discomfort with diffuse bilateral rales on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.

Answer 59

ST-elevation MI

Question 60

A 70-year-old woman is 2 days post-operative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40 pack-year history of smoking. She reports feeling suddenly unwell with dizziness, nausea, and vomiting. She denies any chest pain. On examination she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.

Answer 60

ST-elevation MI

Question 61

A 19-year-old man presents with a 2-day history of headache and associated nausea. He says that bright light hurts his eyes. He has no significant past medical history, is not currently taking any medicine, and reports no drug allergies. He works as a librarian and has not travelled overseas for the past year. He lives with his girlfriend whom he has been seeing for 2 years. They have a pet hamster.

Answer 61

Viral meningitis

Question 62

Parents bring their 2-year-old child who has been ill for 1 day with irritability, vomiting, and fever. The child has a widespread maculopapular rash.

Answer 62

Viral meningitis

Question 63

A 1-month-old girl presents to her general practitioner with a high fever, feeding difficulties, and irritability for the past 24 hours. Examination reveals altered mental status and a bulging fontanelle.

Answer 63

Bacterial meningitis

Question 64

An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.

Answer 64

Bacterial meningitis

Question 65

A 20-year-old college student presents to the emergency department with fever and confusion. The previous night he felt unwell and complained of a headache. This morning he was difficult to arouse, seemed confused, and felt warm to touch. On physical examination he is acutely unwell with fever, tachycardia, and mild hypotension. He opens his eyes and withdraws in response to painful stimuli. Nuchal rigidity and a few truncal petechiae are present.

Answer 65

Meningococcal disease

Question 66

A 9-month-old girl is brought to the emergency department with a history of fever and a rash. She was in good health until this morning, when she developed a fever, irritability, and poor feeding. In the afternoon her parents noticed purple bruises on her legs and trunk. On examination she is alert but appears acutely unwell with fever, tachycardia, cool extremities, delayed capillary refill time of 5 seconds, and multiple ecchymoses on her legs and trunk.

Answer 66

Meningococcal disease

Question 67

A 78-year-old woman presents to hospital for an elective right hemicolectomy. She has a past medical history of hypertension, angina on exertion, and diabetes mellitus. She is independently mobile, does her own shopping, and has a 30-pack-a-year history of smoking. The operation was uncomplicated. On day 5 post-surgery, she becomes confused. On examination, she has a Glasgow Coma Scale score of 14/15. She has a temperature of 38.5°C (101.3°F), a respiratory rate of 28 breaths/minute, and oxygen saturations of 92% on 2 L of oxygen per minute. She is tachycardic at 118 bpm, and her BP is 110/65 mmHg. On chest auscultation, she has coarse crackles in the right lower zone. Her surgical wound appears to be healing well and her abdomen is soft and not tender.

Answer 67

Sepsis

Question 68

A 21-year-old man presents to the emergency department with central nervous system depression, respiratory depression, and miosis (1 mm pupils). Friends state that the patient was seen injecting himself at a party, at which time he became unresponsive. He is deeply unresponsive to pain and gives no history. The patient is a known drug user. He has track marks on both upper extremities and syringes are found among his belongings.

Answer 68

Opiate overdose

Question 69

A 20-year-old woman presents 3 hours after ingesting two packets of paracetamol tablets following an argument with her boyfriend. She is asymptomatic.

Answer 69

paracetamol overdose

Question 70

A 38-year-old woman presents with nausea and pain from a tooth abscess. On further questioning she states that she has been ingesting small handfuls of paracetamol-containing pills every few hours over the previous 2 to 3 days.

Answer 70

paracetamol overdose

Question 71

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.

Answer 71

(ischaemic) stroke

Question 72

A 70-year-old man with a history of chronic hypertension and atrial fibrillation is witnessed by a family member to have nausea, vomiting, and right-sided weakness as well as difficulty speaking and comprehending language. The symptoms started with only mild slurred speech before progressing over several minutes to severe aphasia and right arm paralysis. The patient is taking warfarin.

Answer 72

(haemorrhagic) stroke

Question 73

A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness.

Answer 73

Subarachnoid haemorrhage

Question 74

A young man is brought to the emergency department after being involved in a high-speed motor vehicle accident. He was an unrestrained driver, and no airbags were deployed. He has multiple areas of abrasions, lacerations, and ecchymosis on his scalp and face. On neurological examination, he does not open his eyes to painful stimuli; he is intubated, and he withdraws his left side to pain. His right side is plegic. His right pupil is 3 mm and reactive to light and his left pupil is 8 mm and non-reactive.

Answer 74

Subdural haematoma

Question 75

An older man with a longstanding history of atrial fibrillation on anticoagulation with warfarin is brought into the emergency department by his carer, who states his concern about the patient’s confusion at home. The carer describes frequent falls over the last several months and says that the patient is dropping utensils from his right hand. On neurological examination, his pupils are equal, round, and reactive to light. He has a right-sided pronator drift and is weaker on his right side than on his left. His mental status testing reveals poor concentration and attention, and impaired short- and long-term recall and registration.

Answer 75

Subdural haematoma