1. The EMS brings in a 44-yr old man c/o chest pain.

He admitted snorting
cocaine before the pain started 2 hours prior. His past history is only significant for
hypertension but also takes alprazolam to “calm his nerves”. On examination, his
VS read HR 103, BP 172/90, RR 20, SaO2 99% on room air. All of the following can
be considered as part of his management EXCEPT:

A. Aspirin
B. Nitroglycerine
C. Diltiazem
D. Metoprolol
E. Lorazepam

2. A 60-yr old male presented with a severe central chest pain. It was sudden in
onset, tearing in nature and radiated to his jaw. He had stopped his anti-
hypertensives on his own accord after a BP check was normal a few years prior. On
examination, his VS read BP 200/114, HR 104, RR 18, SaO2 99%. There is a
diastolic murmur at the right sternal border and CXR reveals a widened
mediastinum. In your further diagnostic efforts, you would next order for

A. ECG
B. Transthoracic echocardiography
C. Transesophageal echocardiography
D. CT chest
E. MRI chest

3. A 25-yr old man was brought by his brother to your ED after noticing him to
be ‘unwell’. He admitted having a poor work performance record and has been
abusing injectable drugs. Clinically, he looks ill and his VS are HR 102, BP 112/66,
T 38.6C, RR 18, SaO2 94% (RA). There is a right-sided cardiac murmur, varying
with respiration, and splenomegaly. CXR shows multiple bilateral patchy infiltrates.
CBC reveals WBC 14,000 with 91% neutrophils, Hct 33% and platelets 250,000.
Your next best management steps would be to

A. order latex-agglutination assay, CT chest and initiate corticosteroid therapy

B. obtain at least 3 sets of blood cultures, transthoracic echocardiogram and
initiate penicillin G
C. send for acid-fast bacilli smear and culture, and start Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol
D. do blood cultures, MRI scan, and prescribe Ibuprofen
E. order borrelia serology and start augmentin
4. A 42-yr old accountant presents to the ED c/o acute onset substernal chest
pain. It is sharp and radiates to his back, but admits that he got some relief when
sitting up. He smokes 20 cigarettes/day and takes tablets for his diabetes. He also
blames the increased stress because of his company’s poor financial performance.
On examination, his VS are HR 98, BP 146/88, RR 16, T 37.8. His lungs are clear
but there is a friction rub. The rest of clinical examination is unremarkable. His
ECG is shown below. CXR and echocardiography are reported as normal. Which
would be your best statement of management?

A. Prescribe morphine, oxygen, nitrates, aspirin, and admit as acute coronary

syndrome
B. Start LMW heparin for possibility of pulmonary embolism and organize CT
chest
C. Start oxygen and morphine IV, and repeat right leads ECG
D. If pain doesn’t settle with IV morphine, start thrombolytics
E. Reassure and discharge on NSAIDs

5. A 55-yr old hypertensive patient presented with a 30-min h/o central chest
discomfort and sweating. His VS are HR 92, BP 160/92, RR 20, SaO2 98% on RA.
Apart from distress due to pain, his clinical examination is essentially normal. He is
given morphine, nitroglycerine, aspirin and oxygen. His ECG shows ST elevation in
leads II, III and aVF. A short while later, his BP dropped to 62/34 and his HR is
100. Which of the following best describes your next management steps?

A. Refer him immediately to the cardiologist

B. Give IV N/S and order urgent echocardiography
 C. Initiate IV dobutamine and refer for CCU admission
D. Give IV N/S, do right-sided ECG and consider IV dobutamine
E. Start clopidogrel and arrange for urgent cath lab

6. A 4-yr old boy is brought to your ED after the mother noticed him to be
unusually inactive the whole afternoon. She denies any trauma or recent illness, and
the child has been healthy since birth. On examination, he looks lethargic and his
VS read HR 202, BP 62/44, T 36.9, SaO2 98% (RA), RBS 5.9 and ECG confirms a
narrow complex tachycardia. His clinical findings are otherwise unremarkable. The
statement which best describes his management would be to

A. do a quick F.A.S.T
B. start an IV line and give bolus of 20ml/kg NS
C. have the patient put his head into a basin of icy cold water
D. place the patient on continuous ECG monitoring and deliver synchronized
shock starting at 0.5 J/kg
E. do a septic screen work-up and refer to the on-call pediatrician

7. A 34-yr old unmarried lady presented with shortness of breath. She denies
fever, coughing up any blood or sputum, and long-distance travel. Her LMP was 6
days before and she has not been on any medications. On examination, her VS read
HR 106, BP 116/82, T 37, SaO2 90% on RA. Examination of her lower limbs is
equivocal. The statement which best describes your management is:

A. Lower limb Doppler ultrasound scan will be crucial in her diagnosis

B. Spiral chest CT scan is contraindicated
C. Ventilation-perfusion scan can be an alternative investigation to spiral CT in
view of similar accuracy
D. Low molecular weight heparin ought to be started prior to investigations
E. The Hampton hump and Westermark sign on CXR are suggestive of
pulmonary embolism, but are infrequently observed

8. While assessing a middle-aged male in your ED who had an episode of

syncope, you note these findings on his ECG:
His VS, RBS, past history and clinical examination are otherwise unremarkable.
Your best management would be to:

A. order for echocardiography

B. admit for immediate electrophysiological studies
C. CT head
D. admit for pacemaker insertion
E. reassure and discharge to cardiology out-patient clinic

9. A 63-yr old man presents with central chest pain associated with nausea and
sweating, after returning from a trip abroad. He gave a history of similar chest pain
3 days before, when ECG at a peripheral clinic where he traveled to showed acute
myocardial infarct. In suspecting a re-infarction this time, the most useful
investigation is

A. myoglobin
B. CK-MB
C. Troponin T
D. AST
E. LDH

10. The EMS brings in a middle-aged man c/o severe heavy chest pains. He
experienced 2 episodes while watching television earlier and the pains radiated to
his left shoulder. He experienced similar chest pains over the preceding months, but
only after walking to the shops a kilometer away, and relieved by rest. His past
history is significant for hypertension and smoking a pack a day. Clinically, he looks
comfortable and his VS are HR 74, BP 156/78, RR 16, SaO2 99%. ECG shows
normal sinus rhythm with no acute changes, while troponin I is negative. Which of
the following statements best describes your management of this patient?

A. Administer diltiazem and admit directly to CCU

B. Observe as stable angina and discharge after 8 hours if pain free
C. Arrange for cardiac catheterization lab investigation and management
D. Oxygen, aspirin, clopidogrel, LMW heparin and further risk stratification
E. Reassure, NSAIDs and discharge with out patient follow-up appointment

11. A 31-yr old man presents with intermittent headaches, nausea and vomiting,
associated with palpitations and sweating, over the previous 2 months. VS read HR
116, BP 198/124, SaO2 98%, T 37C. Apart from blood, and 24-hr urine
investigations, the next best management step is:

A. Lowering the BP with esmolol

B. Lowering the BP with phentolamine
C. Renal artery Doppler
D. Surgical referral
E. CT of the abdomen

12. A young adult man presented to the ED c/o fever, sore throat, and neck pain
for 24hours. He had a molar tooth extracted the week before. His VS are HR 104,
BP 146/78, T39C, RR 16. On examination, you notice he is drooling of saliva. His
tongue is elevated from a submandibular swelling which extends down the neck.
Which of the following statements best describes his management?

A. He requires ENT referral as a case of peritonsillar abscess

B. He can be prescribed oral penicillin, analgesics and antipyretics and
discharged with an ENT follow-up
C. He most invariably has diabetes mellitus
D. Airway patency and IV antibiotics are management priorities
E. Treatment involves incision and drainage of the fluctuant swelling

13. A 53-yr old hypertensive man presents with recurrent epistaxis for which he
has been pinching his nostrils for 1 hour. He takes atenolol and appears anxious. His
VS are HR 104, BP 200/108. On local examination, there seems to be a bleeding
point from the anterior nostril where blood is still oozing from. Which would be
your NEXT most appropriate management?
 A. Insert a nasal tampon
B. Administer IV labetolol to control his BP
C. Check CBC and coagulation studies
D. Sedate with diazepam and generous application of silver nitrate to the
anterior nasal mucosa
E. Insert posterior nasal pack and refer to ENT for admission

14. For an otherwise healthy teenager who presents with acute otitis media, your
choice of anti-microbial agent is primarily aimed at

A. Chlamydia trachomatis
B. Staphylococcus aureus
C. Moraxella catarrhalis
D. Haemophilus influenza
E. Streptococcus pneumonia

15. A patient presents to your ED with a h/o sore throat. Which of the following
statements best describes the recommended management?

A. Presence of cough, conjunctivitis, rhinorrhea and mucosal ulcers will

definitely require antibiotic therapy
B. Testing for Grp A Beta Hemolytic Strep (GABHS) should be done for
patients who present with fever, absence of cough, and tender swollen
anterior neck lymph nodes
C. The Rapid Antigen Detection Test (RADT) is insensitive in adults and
requires confirmatory culture testing
D. In RADT positive patients without h/o allergy, penicillin should not be
started until confirmation from culture and sensitivity testing
E. Trismus, tonsillar enlargement and presence of exudates are typical of
Ludwig’s angina

16. A retired elderly teacher presents with a c/o loss of vision of his left eye which
occurred briefly when reading the newspaper. He denies any headaches, eye pain, or
loss of consciousness, and gives no past h/o significance. The best management plan
would be:

A. Refer to on-call ophthalmologist

B. Order for urgent carotid angiogram
C. If his CT is negative, start aspirin and admit
D. If visual acuity and slit lamp examination are normal, reassure and refer to
ophthalmology OPD
E. Initiate prednisolone 60mg OD
17. A young worker c/o left eye pain after feeling ‘something’ entering his eye
while he was drilling a metal plate at work. His visual acuity is 20/20 right eye and
20/70 left eye. Slit-lamp examination fails to detect any foreign body but only shows
a corneal defect after fluorescein staining. Your next best step would be to

A. Order CT scan of orbits

B. Order MRI scan of orbits
C. Reassure, anesthetic and antibiotic eye drops plus eye patch, eye clinic follow
up
D. Do plain AP & lateral globe x-rays
E. Anesthetic and antibiotic ointment, ED follow-up at 24 hours

18. Which of the following statements is TRUE?

A. Therapy for ocular allergic conditions should include topical corticosteroids

B. Significant systemic side effects may be seen with the use of ocular
medications such as beta-blockers
C. Patients with painful eye conditions such as corneal abrasions should be
discharged with topical anesthetics
D. Chloramphenicol is effective against many gram-positive and gram-negative
organisms and is a commonly prescribed ophthalmic antibiotic
E. Instillation of topical proparacaine will relieve pain due to scleritis

19. A middle-aged Asian man presents to your ED with a severe left eye pain
associated with nausea. Testing reveals reduced vision in the affected eye, which is
red and has a hazy cornea. His left pupil is poorly reactive to light and tonometry
reads an IOP of 58 mmHg. Which of the following is NOT a recommended
treatment?

A. Timolol drops
B. Pilocarpine drops
C. Prednisolone dops
D. Acetazolamide tablets
E. Breathing of 95% O2 + 5% CO2 mixture

20. A patient presents to your ED with pneumonia. In deciding admission going

by the Patient Outcome Research Team (PORT) prediction rule, which of the
following is NOT scored?

A. Age of 55 yrs
B. Lives in a nursing home
C. Heart rate of 126/min
 D. Hb of 11g/dL
E. Presence of pleural effusion

21. Your local airport clinic refers a young, otherwise healthy foreigner, who
complained of a sharp pleuritic chest pain whilst awaiting his connecting flight back
to Europe in the transit lounge. His vital signs are all normal. ECG shows sinus
rhythm while CXR reveals a right-sided pneumothorax of ~15% and he is admitted
to your ED observation ward. A repeat CXR the next morning shows some decrease
in the pneumothorax size while all vital signs remain normal and stable. Your next
best management step would be to

A. expedite pneumothorax resolution with a small pigtail catheter (14-16 Fr)

B. perform needle decompression in the 2nd intercostal space, midclavicular line
C. continue observation until complete resolution of the pneumothorax
D. discharge with a return appointment in 24 hrs
E. discharge to catch the next flight and an advice for reassessment on arrival in
his hometown

22. A 60-yr old lady is brought to your ED by the family c/o increasing SOB,
cough productive of yellow phlegm and increasing sleepiness. She weighs 148kg and
has gained 10kg in the previous week. She doesn’t smoke and denies any fever or
early morning headaches. On examination, she is very sleepy but arousable, and her
VS read HR 104, BP 155/97, RR 32, T 36. There are bilateral basal crackles in her
chest. Apart from obese abdomen and warm, erythematous + tender, tense edema in
both her legs, the rest of her examination is normal. Investigations reveal Hct 48%,
leukocyte 16,400, Creat 1.1 mg/dL, (ABG) pH 7.30, pO2 42mmHg, pCO2 72mmHg.
Her CXR shows cardiomegaly and increased basal lung markings while
echocardiography shows right ventricular dilatation and hypocontractility with
estimated right ventricular SBP of 55mmHg. The most appropriate management for
her would be

A. Furosemide, O2 via venturi mask, repeat ABG and reassessment

B. IV digoxin, dobutamine and furosemide
C. IV epoprostenol
D. Non-invasive positive pressure ventilation
E. Endotracheal intubation and positive pressure ventilation

23. A 27-yr old female presents with a dull right-sided chest pain. She admits
some leg pain, similar to what she’s had before, which she attributes to her sickle
cell disease. On examination, her VS are HR 109, BP 108/69, RR 28, T 38.6, and
there is wheezing in her chest. Investigations revealed Hb 8.4, WBC 15,200, Pltt
110,000, and her CXR shows a right lower lobe infiltrate. The most appropriate
management is
 A. Admit for oxygenation, bronchodilators, hydration, empirical broad-
spectrum antibiotics, analgesics and consider blood transfusion
B. Admit for IV hydration and pain control, and decide on appropriate
antibiotic therapy after obtaining blood/sputum culture results
C. Order spiral CT chest to evaluate for the presence of pulmonary embolism
D. Initiate bronchodilator therapy and if response is good, discharge her on
antibiotics
E. Initiate outpatient analgesic, bronchodilator and antibiotic therapy with a
next-day follow-up appointment

24. A 3-yr old boy was brought by his parents with a h/o fever, cough and
difficulty in breathing for 2 weeks. CXR shows a right middle lobe infiltrate and a
large pleural effusion. Thoracentesis reveals purulent fluid and culture later grows
Bacteroides Melaninogenicus. This infection is most likely a complication of

A. Immunologic defect
B. Cystic fibrosis
C. Foreign body aspiration
D. Subacute appendicitis
E. Toxic hydrocarbon inhalation

25. An asthmatic patient is brought by her workmates immediately after she

experiences an acute attack of dyspnoea. On examination, she looks around 50kg, is
alert but very anxious, and her VS are HR 124, BP 138/90, RR 24, T 37.6, SaO2
91%. Her chest sounds “tight” with scattered wheezes. Which of the following best
describes your management of this patient?

A. Administer a small dose of midazolam to allay her anxiety

B. If pneumonia is suspected, CBC is necessary for diagnosis
C. Administration of oral steroids within 1 hr of onset of dyspnoea can lower
her rate of relapse after ED discharge
D. If she is pregnant, subcutaneous epinephrine is safe
E. If she deteriorates and requires endotracheal intubation + IPPV, her tidal
volume should be set at 500-750ml to overcome airway resistance

26. The EMS bring in an elderly male patient who c/o difficulty in breathing. He
is an ex-smoker and is on various inhalers plus domestic oxygen for COPD. He looks
slightly cyanosed and his SaO2 on admission is 84%. Which of the following best
describes your management?

A. Administer high dose oxygen, 10-12LPM via non-rebreather mask

 B. Administration of aminophylline significantly improves FEV1 and reduces
need for hospital admission
C. Consider antibiotic therapy if there is increased dyspnoea, increased sputum
volume and sputum purulence
D. Use of combination of albuterol and ipratropium provides no superior
bronchodilatation than treatment with either component alone
E. Endotracheal intubation should be done if his ABG shows pH 7.26 and pCO2
58 mmHg

27. A store manager brings his 32-yr old female staff who has been noticed
to be dropping items and having minor accidents at work. She herself c/o being
unsteady when carrying boxes and her colleagues have been having difficulties
understanding her speech. Clinically she looks well and has normal vital signs, but
there is tremor and dysarthria. Careful examination of her eyes shows pigmentation
between the sclera and cornea. Which of the following options best describes your
diagnostic work up?

A. Serum copper and ceruloplsmin

B. CT scan of her head
C. Urgent referral for 4-vessel neck angiography
D. Peripheral blood film and Vit B12 level
E. Thyroid function test

28. A 42-year-old man (65kg) is transferred to your ED from the psychiatric day
care following a witnessed seizure. He had been previously observed drinking large
amounts of water. On examination, he is somnolent but arousable to voice, with
normal VS. Investigation results return as: Na 106, K 3.5, Cl 94, HCO 3 22, BUN 4,
Creat 0.5, Glu 5. Shortly afterwards, he has a generalized tonic-clonic seizure that is
not resolved with Lorazepam 2 mg IV. The next therapeutic intervention should be

A. Endotracheal intubation
B. Hypertonic saline 500 ml
C. Sodium bicarbonate 100 mEq
D. Benztropine 2mg IV
E. Phenytoin 1g IV

29. A 69-yr old Caucasian man presents with a 2-days’ history of low back pain
radiating down the legs, and problems with passing urine. There is no h/o trauma
and he admits that when using the toilet paper to wipe himself, it feels different. On
examination, his VS read HR 56 and BP 148/100. His bladder is clinically distended.
There is also symmetrical weakness of his legs with absent bulbocavernosus and
lower limb reflexes. The statement which best describes your management is
 A. Treatment is aimed towards the etiology
B. Urgent urology referral is required for the possibility of prostatic
hypertrophy
C. Suprapubic bladder catheterization should be undertaken immediately
D. Lumbo sacral spine x-rays will most probably be diagnostic
E. Immediate neurosurgical operative intervention is mandatory

30. An elderly male presents after accidentally slipping on the wet floor and
injuring his head. There is no LOC or past history of note. On examination, he is
alert and has normal VS. However, he is unable to raise his right arm to take off his
cap. There is also sensory deficit in his thumb. Assuming the injury has not affected
other levels, which of the following is TRUE?

A. Concomitant ptosis and miosis may be present

B. Lesion at C7 - C8 level would fit the picture
C. Weakness of intrinsic right hand muscles will be characteristic
D. Inability to lift up a drinking cup off the table is expected of his right hand
E. Surgical treatment would be a strong consideration for this patient

31. The CT scan of a 67-yr old man reveals a cerebral infarct involving the left
middle cerebral artery. Which of the following fits the clinical picture?

A. Right nasal and left temporal hemianopia

B. Right hemiparesis, leg weaker than arm
C. Left nasal and right temporal hemianopia
D. Left hemiparesis, leg weaker than arm
E. Right limbs sensory deficit

32. You have just started your morning shift at 0700 hrs in Ramadhan when an
elderly female PT presents to your ED with pain “down below” especially on
defecation. She gives a past history of diabetes, hypertension and COPD, and is on
medications for these. Her VS are normal and examination reveals a 4X4 cm
perianal abscess. Which statement best fits her further management?

A. As she is already fasting, she can undergo GA straight away

B. Her ASA class is II
C. Etomidate is the best choice of sedative because it has no cardiorespiratory
depressive effects
D. If endotracheal intubation has to be done, being edentulous poses more
difficulty to airway management than with a full set of teeth
E. For spinal anesthesia, she is best positioned lying on her side with the
shoulder raised with pillows so as to minimize upward spread and
hypotensive side-effects of the anesthetic agent
33. You attend to an elderly lady who slipped and fell at home and sustained a
Smith’s fracture of her right wrist. She has a past h/o NIDDM, hypertension and
COPD, moderately controlled with medications and home oxygen. She also has mild
cervical osteoarthritis. Her VS are normal. The most appropriate choice for
conducting a manipulation and reduction of her fracture is

A. General anaesthesia
B. IV Midazolam 5mg + Pethidine 50mg
C. Intra-haematoma block with Bupivacaine
D. Brachial plexus block
E. Intra-venous regional anaesthesia (Bier’s Block)

34. Which of the following concerning lumbar puncture procedure is

CORRECT?

A. Changing of patient’s position from lying to sitting increases the chances of

spinal headache
B. It is contraindicated if head CT scan shows loss of superior cerebellar cistern
C. Best results are obtained by using a spinal needle size 17
D. Orthostatic fronto-occipital headaches occurring 24-hrs after the procedure
will invariably require a therapeutic epidural blood patch
E. Macroscopic bloody CSF in the first 2 tubes is diagnostic of acute
subarachnoid hemorrhage

35. In the use, and conduct of local or regional anesthesia,

A. Lipid solubility (lipid : water Partition Coefficient) primarily determines the

agent’s duration of action
B. Lidocaine with adrenaline generally lasts longer than plain bupivacaine, in
infiltration anesthesia
C. Excessive dermal absorption of lidocaine:prilocaine eutectic mixture has a
complication of methemoglobinemia
D. Due to its high potency and rapid onset, tetracaine is widely used for
neuronal blockade, especially in spinal and ophthalmic anesthesia
E. Compared to the aminoamides, aminoesters are chemically more stable and
are less likely to cause systemic toxicity

36. When prescribing antibiotics in cases of infection, which ONE of the

following is considered the best choice?

A. Clindamycin for Strep Viridans endocarditis

 B. Gentamicin for pneumonia cause by Klebsiella
C. Oral vancomycin for Staphylococcal cellulitis
D. IV Chloramphenicol for severe conjunctivitis in a newborn
E. Oral Levofloxacin + Metronidazole for outpatient treatment of
uncomplicated pelvic inflammatory disease

37. Which of the following statements regarding infections is TRUE?

A. Clostridial myonecrosis is best treated with a combination of hyperbaric

oxygen (HBO), surgery and antibiotics
B. Necrotizing faciitis typically has early involvement of the skin and sparing of
the muscles
C. Bartholin abscesses are usually found in the 3 & 7 o’clock positions
D. Erysipelas is commonly a Staph Aureus cellulitis with indistinct margins
E. Clinical tetanus infection confers immunity to most healthy subjects

38. A 24-yr old lady presents to the ED c/o fever and being unwell. Her PMH is
of note for a motor vehicle crash for which she underwent splenectomy 6 yrs
previously. On examination, she looks toxic and her VS read HR 106, BP 114/72, T
38.9, SaO2 96% (RA), RR 20, RBS 5.1. The most probable pathogens you would
have to especially consider and treat for are:

A. Encapsulated organisms: Strep pneumonia, Haem Influenza

B. Pneumocystis, Cryptococcus, toxoplasma
C. Gram negative organisms: E.coli, Kleb pneumonia
D. Anaerobes: Bacteroides fragilis, Clostridium welchii
E. Staph aureus, strep pyogenes

39. A 78-yr old man presented with acute urinary retention. He is awaiting
surgery for his benign prostatic hypertrophy. Which of the following drugs might
have contributed to this?

A. Iprtropium bromide inhaler

B. Theophylline
C. Serevent inhaler
D. Montelukast
E. Sodium chromoglycate

40. A father brings his son who c/o testicular pain. In considering testicular
torsion, which of the following makes the diagnosis UNLIKELY?

A. History of prior strenuous event

 B. Firm tender testis lying horizontally
C. Positive cremasteric reflex
D. Twelve (12) years of age
E. Nausea, vomiting and low grade fever

41. You assess a young adult male who presents with “problem of his private
part”. On examination, you notice his penis to be erected and is painful. Which of
the following best suits his case?

A. History of back trauma suggests fracture of his lumbar transverse processes

B. Priapism must involve hardening of corpora cavernosa and glans penis
C. History of sexual intercourse invariably points to a diagnosis of penile
fracture
D. Peyronie’s disease is ventral curvature caused by thickened plaque along the
corpus spongiosum
E. Aspiration of dark acidic intra-cavernosal blood can be diagnostic

42. You are advocating the use of Laryngeal Tube in the pre-hospital care by the
EMS paramedics. All of the following are advantages of this device EXCEPT:

A. Provides patent & secure airway

B. Can be safely placed “blindly” without a laryngoscope
C. Allows for insertion of tube exchange catheter and fibreoptic bronchoscope
D. Insertion can be done quickly in 15 seconds
E. Gastric contents can be suctioned through the device

43. Concerning the understanding and management of disasters, which of the

following statements is a FACT rather than a myth?

A. Any kind of assistance, including international help, is needed immediately

after a catastrophic event (e.g. earthquake)
B. Disasters bring out the worst in human behaviour (e.g. rioting, looting)
C. Disasters are not random killers but strike hardest on vulnerable groups
D. Relocation of victims in temporary settlements is the best alternative to
proving shelter
E. Foreign medical volunteers with extensive medical expertise and equipment
are usually needed

44. Which one of the following statements BEST describes the respective
biological agent/condition?
 A. Botulism - quick onset blurred vision, urinary retention and descending
paralysis
B. Anthrax – fatality is worst if infected via ingestion through the
gastrointestinal tract
C. Q fever – young farmer with fever, malaise, irritable + neutropenia and
positive tube agglutination test
D. Ricin – animal protein toxin causing a very slow onset of nausea, vomiting,
abdominal cramps, and mild hepatic, splenic or renal dysfunction
E. Ebola – South American visitor with fever + mediastinal infiltrates and
pleural effusion on CXR

45. One of your ED nurses requests to be checked up for pain on micturation.

On direct questioning, she has increased frequency but denies other symptoms. She
is 4-weeks pregnant and has no significant past history. Which of the following
statements best suits her?

A. Urine culture is mandatory to determine the best antibiotic choice

B. Treating bacteriuria will indirectly reduce risk of prematurity and low birth
weight
C. For a positive nitrite test, it is best to avoid early morning specimen urine
D. Admission for IV antibiotics is warranted
E. Trimethoprim/sulfamethoxazole is contraindicated because of the potential
for causing kernicterus of the newborn

46. An elderly woman presents to your ED with abdominal pain and not passing
urine for 12 hours. She gives a past history of transitional cell bladder carcinoma
treated palliatively. On examination, she is slightly confused but has normal vital
signs. Blood investigations show Na 140, K 4.7, Ur 32.6, Creat 456 while urine
dipstick is positive for blood, protein and leucocytes. KUB ultrasound shows
hydroureter and hydronephrosis bilaterally, and an abnormal bladder appearance
and volume of 15 ml. Which of the following would be your next appropriate step?

A. Admit to Short Stay Ward for IV antibiotics

B. 3L IV fluids over 12 hours
C. Suprapubic catheterization
D. Urgent decompressive bilateral nephrostomy
E. Urgent nephrology referral for dialysis

47. You are presented with the following five patients at your ED. Which one of
them would be the BEST suited antibiotic choice for the corresponding condition
mentioned?
 A. 58-yr old male with acute bronchitis - azithromycin 500mg PO day one,
250mg PO days two through five
B. 29-yr old female with 1-day h/o mild acute sinusitis – Trimethoprim-
Sulphamethoxazole PO bid X 5days
C. Middle-aged HIV +ve male with pneumonia, pO2<70, CD4 <200/mm3 –
trimethoprim/sulfamethoxazole 320mg/1,600mg IV q6h + prednisone 40 mg
PO q12h
D. Teenage girl, rape victim – ampicillin/sulbactam 3g IV once plus
amoxicillin/clavulanate 500mg PO tid X 5days + hepatitis B immune globulin
0.06ml/kg IM once
E. 35-yr old maid bitten by domestic cat – cephalexin 500mg PO qid or
erythromycin 500mg PO qid X5days

48. The family of a diabetic elderly lady brings her in with a h/o of repeated falls
at home. They have also noticed her being more confused and disoriented after
starting on a new medication. On examination, her VS are HR 68, BP 114/66, RR
12, T 37. Apart from confusion and inability to answer questions, the rest of her
examination is unremarkable. Blood investigations reveal Na 107, K 2.9, Cl 76,
HCO3 21, BUN 6.1, Creat 98, Glu 5.3. Which new therapy would have explained
her situation?

A. Acetazolamide
B. Amiloride
C. Spironolactone
D. Furosemide
E. Hydrochlorothiazide

49. In the safe proper practice of Emergency Medicine,

A. Forty microgram should be written as 40.0 mcg

B. Informed consent involves providing reasonable explanation of procedure or
treatment, risks and benefits
C. Presence of a life-threatening illness signifies that a patient lacks “medical
decision capacity”
D. A “Do Not Resuscitate” (DNR) order document can be legally signed by
either of the patient, physician or 1st degree family members
E. A Jehovah’s Witness patient’s refusal of blood transfusion must be honored
unless this will clearly lead to his death

50. Which of the following statements is CORRECT?

A. Haloperidol- lorazepam combination as chemical restraints has an excellent

safety profile despite rare cases of dystonia or orthostatic hypotension
B. Under no circumstances should an unstable patient be transferred from one
medical facility to another
C. Quantitative ethanol level is necessary for clinical determination of
‘intoxication’ status and hence initiation of treatment against his wishes
D. Emergency treatment to a minor (child) should be legally delayed until
parental consent is obtained
E. Prisoners and subjects under police custody have the legal right to refuse
medical treatment and which hospital they are brought to