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Question

A 56-year-old man presents to the emergency department with severe substernal chest pressure radiating to his jaw for 50 minutes. Electrocardiogram (ECG) reveals 3 mm ST-segment elevation in leads V1 through V4 with reciprocal ST depression in leads III and aVF. His blood pressure is 135/85 mmHg and heart rate is 78 bpm. A cardiac catheterization laboratory is available on-site. Which reperfusion strategy is most appropriate?

Medicine

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Question

A 68-year-old man presents with palpitations, dizziness, and cold extremities. Examination reveals a pale, diaphoretic patient with a blood pressure of 75/45 mmHg and an irregular pulse of 165 bpm. The ECG demonstrates atrial fibrillation with a rapid ventricular response and no identifiable P waves. What is the immediate treatment of choice?

Medicine

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Question

A 48-year-old woman with a history of mitral valve prolapse presents with a 3-week history of low-grade fever, night sweats, fatigue, and weight loss. On examination, she has splinter haemorrhages under the nails and a new harsh holosystolic murmur at the apex. Infective endocarditis is suspected. What is the single most critical microbiological investigation to establish the diagnosis prior to antimicrobial therapy?

Pathology

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A 42-year-old white man attending his family doctor has persistent clinic blood pressure readings averaging 154/96 mmHg, confirmed on 24-hour ambulatory blood pressure monitoring (daytime average 146/92 mmHg). Routine blood tests, urinalysis, and ECG are normal. A decision is made to start drug treatment alongside lifestyle advice. Which of the following is an appropriate first-line drug class?

Family Medicine

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Question

A 22-year-old woman with a known history of asthma is brought to the emergency department unable to complete sentences in one breath. Her respiratory rate is 28 breaths/min, heart rate is 115 bpm, and peak expiratory flow (PEF) is 45% of her predicted value. On auscultation, widespread expiratory polyphonic wheezes are present bilaterally. Which initial medical regimen is most appropriate?

Medicine

Question · Easy

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A 67-year-old male with severe chronic obstructive pulmonary disease (COPD) presents with worsening dyspnoea, increased sputum volume, and green purulence. Despite 60 minutes of controlled oxygen therapy, nebulized bronchodilators, and systemic steroids, an arterial blood gas shows: pH 7.27, PaCO2 8.2 kPa (61.5 mmHg), PaO2 8.4 kPa (63 mmHg), and HCO3- 29 mmol/L on FiO2 0.28. What is the most appropriate next step in respiratory management?

Medicine

Question · Hard

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A 34-year-old woman who returned from an 11-hour flight 4 days ago presents with sudden-onset right pleuritic chest pain and shortness of breath. She has no prior medical history but takes a combined oral contraceptive pill. Her pulse is 108 bpm, respiratory rate is 22 breaths/min, blood pressure is 122/78 mmHg, and oxygen saturation is 94% on room air. Her Wells score indicates that pulmonary embolism is likely. Which imaging modality is the definitive investigation of choice?

Medicine

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A 75-year-old man presents with a 4-day history of cough, right-sided pleuritic chest pain, and high fevers. On examination, he is confused to time and place (Abbreviated Mental Test score 6/10), his respiratory rate is 32 breaths/min, blood pressure is 86/55 mmHg, and pulse is 104 bpm. Blood urea is 8.4 mmol/L. Chest X-ray demonstrates right lower lobe consolidation. What is this patient's CURB-65 score, and what is the recommended management setting?

Medicine

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Question

A 52-year-old man presents with melaena and two episodes of haematemesis. He has been taking regular naproxen for chronic back pain. His heart rate is 112 bpm, blood pressure is 98/60 mmHg, and capillary refill time is 3 seconds. What is the immediate priority in his management?

Medicine

Question · Easy

Question

A 58-year-old man with decompensated alcoholic cirrhosis presents with increasing abdominal distension, mild diffuse abdominal discomfort, and a low-grade fever of 38.1°C. Diagnostic paracentesis of ascitic fluid is performed. What laboratory finding in the ascitic fluid establishes the diagnosis of spontaneous bacterial peritonitis (SBP)?

Pathology

Question · Hard

Question

A 64-year-old woman is admitted with sepsis secondary to a urinary tract infection. Her baseline serum creatinine was 70 micromol/L (0.8 mg/dL) two weeks ago. On repeat testing 24 hours into admission, her serum creatinine has risen to 185 micromol/L (2.1 mg/dL) and her urine output has been 0.4 mL/kg/h for the past 8 hours. Based on KDIGO criteria, what condition is present?

Medicine

Question · Easy

Question

A 62-year-old male with end-stage renal disease misses two consecutive haemodialysis sessions and presents with generalized profound muscle weakness. His ECG reveals tall, peaked, tented T waves, flattening of P waves, and slight widening of the QRS complex. Urgent venous biochemistry demonstrates a serum potassium of 7.2 mmol/L. What is the single most urgent first step in medical management?

Medicine

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A 19-year-old woman with type 1 diabetes is admitted with nausea, vomiting, abdominal pain, and Kussmaul respiration. Capillary glucose is 24 mmol/L, blood beta-hydroxybutyrate is 5.4 mmol/L, and arterial blood gas reveals pH 7.15 and bicarbonate 11 mmol/L. Intravenous 0.9% sodium chloride fluid resuscitation is commenced. When starting a fixed-rate intravenous insulin infusion (0.1 units/kg/h), what is the key rule regarding serum potassium management?

Medicine

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A 36-year-old woman with known autoimmune Addison disease presents to the resuscitation bay with severe weakness, abdominal cramps, vomiting, and confusion following a gastrointestinal viral infection. Her blood pressure is 70/40 mmHg and pulse is 120 bpm. Serum sodium is 124 mmol/L, potassium is 6.2 mmol/L, and capillary blood glucose is 3.1 mmol/L. What is the immediate treatment of choice?

Medicine

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Question

A 69-year-old man is brought to the emergency department with sudden onset of right-sided hemiparesis and expressive aphasia that started exactly 90 minutes ago. Non-contrast brain CT demonstrates no acute intracranial haemorrhage or early ischemic changes. His blood pressure is 160/95 mmHg, blood glucose is 6.8 mmol/L, and platelets are 220 x 10^9/L. He has no history of recent surgery or bleeding diathesis. What is the most appropriate next step in management?

Medicine

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Question

A 24-year-old male university student is admitted with high fever, severe headache, photophobia, and neck stiffness. On physical examination, Kernig and Brudzinski signs are positive, and he has a purpuric, non-blanching rash on his trunk and lower extremities. What is the most critical immediate clinical action?

Medicine

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Question

A 45-year-old woman presents to the emergency department with a sudden-onset 'thunderclap' headache that reached peak intensity within 30 seconds, describing it as the worst headache of her life. She has mild photophobia and neck stiffness. A non-contrast CT brain scan performed 14 hours after symptom onset is reported as normal. What is the necessary next diagnostic investigation?

Medicine

Question · Hard

Question

A 67-year-old woman with urosepsis remains hypotensive after 30 mL/kg of intravenous crystalloid and now needs a noradrenaline infusion to keep her mean arterial pressure (MAP) at 65 mmHg. Her serum lactate is 3.4 mmol/L and blood cultures are pending. How is her condition classified under the Sepsis-3 definitions?

Medicine

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A 43-year-old farmer in rural Malta who keeps dogs presents in mid-summer with high fever, severe headache, myalgia, and a maculopapular rash involving the palms and soles. Physical examination reveals an indolent, painless black necrotic eschar with an erythematous halo ('tache noire') in the right groin and regional lymphadenopathy. What is the causative pathogen, and what is the treatment of choice?

Pathology

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Question

A 19-year-old man presents with a 24-hour history of periumbilical colicky abdominal pain that has localized to the right iliac fossa and is now constant and sharp. On physical examination, there is localized tenderness and guarding at McBurney point, and pressure applied in the left lower quadrant elicits pain in the right iliac fossa (positive Rovsing sign). His temperature is 38.0°C and white blood cell count is 14.5 x 10^9/L with neutrophil predominance. What is the most likely diagnosis?

Surgery

Question · Easy

Question

A 66-year-old woman presents to the surgical triage with right upper quadrant abdominal pain, rigors with a temperature of 39.4°C, and visible scleral icterus (Charcot triad). Her blood pressure is 88/54 mmHg, heart rate is 120 bpm, total bilirubin is 82 micromol/L, alkaline phosphatase is 420 U/L, and abdominal ultrasound reveals a dilated common bile duct (12 mm) containing a calculus. Following aggressive intravenous fluid resuscitation and broad-spectrum antibiotics, what is the definitive urgent intervention?

Surgery

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Question

A 54-year-old male with a history of chronic dyspepsia and non-steroidal anti-inflammatory drug (NSAID) use presents with sudden, catastrophic upper abdominal pain that started 2 hours ago. On examination, he lies completely motionless with shallow respirations; the abdomen is rigid, board-like, and exquisitely tender to light palpation throughout. An erect chest radiograph reveals a crescent of free gas under the right hemidiaphragm (pneumoperitoneum). What is the definitive management?

Surgery

Question · Easy

Question

A 46-year-old man presents with severe epigastric pain radiating directly through to the back, relieved slightly by leaning forward, accompanied by persistent vomiting. Serum lipase is 1,850 U/L (normal < 60 U/L). On day 2 of admission, laboratory testing reveals: PaO2 7.8 kPa on air, serum calcium 1.85 mmol/L, serum urea 18 mmol/L, white blood cell count 17.5 x 10^9/L, and blood glucose 11.2 mmol/L. What is the severity assessment and initial supportive management priority?

Surgery

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Question

A 61-year-old woman with a history of open appendicectomy 15 years ago presents with a 2-day history of cramping central abdominal pain, bilious vomiting, marked abdominal distension, and absolute obstipation (no passage of flatus or feces for 36 hours). Abdominal radiograph demonstrates centrally located dilated loops of bowel (> 3 cm caliber) with multiple air-fluid levels and plicae circulares traversing the full lumen diameter. What is the most likely diagnosis?

Surgery

Question · Easy

Question

A 30-year-old motorcyclist is brought to the emergency department following a high-speed collision. He is pale, diaphoretic, and confused. Blood pressure is 75/40 mmHg and heart rate is 135 bpm. Examination of the chest reveals reduced breath sounds and dullness to percussion over the entire left hemithorax. Neck veins are flat and the trachea is midline. A large-bore chest tube is inserted, immediately draining 1,600 mL of frank blood with ongoing active output of 250 mL/h over the next 2 hours. What is the definitive life-saving management?

Surgery

Question · Hard

Question

A 74-year-old male with a history of heavy smoking and hypertension presents to the emergency department with sudden severe lower back pain radiating to both flanks, accompanied by lightheadedness and diaphoresis. On examination, his blood pressure is 84/50 mmHg, heart rate is 115 bpm, and a large, tender, expansile pulsatile mass is palpable in the epigastrium. What is the diagnosis, and what is the immediate management?

Surgery

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A 70-year-old woman with a history of atrial fibrillation not taking anticoagulants presents with acute, excruciating pain in her right lower leg that started 3 hours ago. On physical examination, the right leg below the knee is pale, cold to touch, and marbled. Sensation is diminished over the dorsum of the foot, dorsiflexion is weak, and no pulses (femoral, popliteal, dorsalis pedis) can be palpated or detected by handheld Doppler on the right side. What condition is present, and what is the immediate medical management?

Surgery

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Question

A 72-year-old man with known benign prostatic hyperplasia presents with severe suprapubic pain and an inability to pass urine for the past 14 hours. On examination, there is a smooth, tender, dull mass palpable extending from the symphysis pubis up to the umbilicus. What is the immediate first-line management?

Surgery

Question · Easy

Question

A 38-year-old man presents with severe, intermittent, colicky right flank pain that radiates down into the right groin and ipsilateral scrotum. He cannot find a comfortable position and paces around the examination room. Dipstick urinalysis shows 3+ blood and trace leukocytes, with no nitrites. What is the primary imaging modality of choice to confirm the diagnosis?

Surgery

Question · Easy

Question

On postoperative day 6 following an elective open right hemicolectomy, a 64-year-old patient develops a low-grade fever of 38.3°C. Examination of the midline laparotomy incision demonstrates localized erythema, warmth, induration, and purulent discharge emerging from the inferior edge of the wound. The fascia is intact on palpation. How is this surgical site infection (SSI) classified, and what is the primary management?

Surgery

Question · Easy

Question

On day 2 after an emergency laparotomy, a 66-year-old man's ward observations are: respiratory rate 23/min, SpO2 94% on room air, blood pressure 104/68 mmHg, pulse 112/min, alert, and temperature 38.3°C. Using the Royal College of Physicians National Early Warning Score 2 (NEWS2, SpO2 scale 1), what is his score and the expected clinical response?

Surgery

Question · Medium

Question

During general anaesthesia with sevoflurane and suxamethonium for an emergency appendicectomy, a 22-year-old male develops sudden masseter muscle rigidity, unexplained hypercapnia (end-tidal CO2 rises from 38 to 78 mmHg despite hyperventilation), tachycardia of 145 bpm, and body temperature rapidly escalating to 39.8°C. Blood gas confirms severe combined metabolic and respiratory acidosis with hyperkalaemia. What is the definitive pharmacological antidote?

Surgery

Question · Hard

Question

A 48-year-old woman discovers a painless, discrete, firm 2 cm lump in the upper outer quadrant of her left breast. There is no overlying skin tethering or nipple discharge, and no axillary lymphadenopathy is palpable. What standard diagnostic pathway must be performed to evaluate any discrete breast lump?

Surgery

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A 71-year-old man presents with complete large bowel obstruction due to an obstructing adenocarcinoma of the sigmoid colon. Abdominal CT confirms a tight sigmoid tumor without signs of cecal perforation, but the cecum is dilated to 11 cm. What emergency surgical procedure is traditionally indicated to resect the tumor and avoid a primary anastomosis in an unprepared, acutely obstructed left colon?

Surgery

Question · Hard

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Immediately following an uncomplicated vaginal delivery at 39 weeks of gestation, a newborn infant is limp, apneic, and cyanotic. After initial drying, warming, and stimulation on the resuscitation table, the infant remains apneic and the umbilical cord pulse indicates a heart rate of 70 bpm at 60 seconds of life. What is the immediate priority intervention according to neonatal resuscitation guidelines?

Paediatrics

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Question

A full-term male infant is noted to be visibly jaundiced on physical examination at 10 hours of life. The mother is blood group O Rh-negative and the infant is group A Rh-positive. An urgent serum bilirubin is 155 micromol/L (9.1 mg/dL). Which statement regarding jaundice occurring within the first 24 hours of life is correct?

Paediatrics

Question · Easy

Question

A 4-year-old boy (weight 16 kg) is brought to the emergency department 15 minutes after eating a peanut-containing snack. He presents with generalized urticaria, facial and lip angioedema, inspiratory stridor, and severe respiratory distress. His blood pressure is 78/48 mmHg and oxygen saturation is 90% on room air. What is the single most important first-line medication, and how should it be given?

Paediatrics

Question · Easy

Question

A 20-month-old toddler is brought to the clinic following a generalized tonic-clonic seizure that lasted 2 minutes during an acute febrile illness (tympanic temperature 39.1°C secondary to viral otitis media). The child is now fully conscious, interacting normally with parents, and physical examination reveals no focal neurological signs and no signs of meningism. The parents are terrified. Which of the following features defines this as a simple febrile seizure?

Paediatrics

Question · Easy

Question

A 5-year-old child (weight 20 kg) with known epilepsy is brought to the emergency department in active, continuous generalized tonic-clonic status epilepticus lasting 12 minutes. High-flow oxygen has been applied. A dose of buccal midazolam (10 mg) was given by paramedics 8 minutes ago with no cessation of seizure activity. What is the immediate pharmacological step according to advanced paediatric life support guidelines?

Paediatrics

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Question

A 10-month-old infant is brought to the paediatric emergency department with a 3-day history of profuse watery diarrhoea and vomiting. On examination, the infant is lethargic with sunken eyes, dry mucous membranes, prolonged capillary refill time of 4 seconds, cold extremities, and a weak, thready pulse of 165 bpm. Blood pressure is 68/40 mmHg. What is the immediate fluid resuscitation requirement for this infant in hypovolaemic shock?

Paediatrics

Question · Easy

Question

An 18-month-old boy presents in the middle of the night with a 2-day history of low-grade fever, runny nose, and the sudden onset of a harsh, barking, seal-like cough accompanied by inspiratory stridor that worsens when he is agitated. He is sitting up comfortably, has no drooling, and his chest auscultation reveals transmitted upper airway noises without wheeze. What is the most likely diagnosis, and what is the single most effective initial pharmacological treatment?

Paediatrics

Question · Easy

Question

A 4-month-old infant presents in winter with a 3-day history of clear rhinorrhoea, fever of 38.1°C, tachypnoea (64 breaths/min), intercostal and subcostal recessions, and poor feeding (taking less than 40% of usual volume). On auscultation, widespread fine end-inspiratory crackles and scattered expiratory wheezes are heard bilaterally. Oxygen saturation is 90% on room air. Respiratory syncytial virus (RSV) is suspected. What constitutes the cornerstone of evidence-based management?

Paediatrics

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Question

A 3-year-old girl is brought to the clinic with a 6-day history of high spiking fevers up to 39.8°C that have not responded to paracetamol or amoxicillin. Examination demonstrates bilateral non-exudative bulbar conjunctival injection, dry cracked erythematous lips, a prominent 'strawberry tongue', a polymorphous erythematous macular rash over the trunk, and marked induration and erythema of the palms and soles with swollen fingers. Her ESR is 88 mm/hr and platelet count is elevated. What life-threatening cardiovascular complication is this child at risk for if treatment is delayed, and what is the primary medical regimen?

Paediatrics

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Question

A 7-year-old boy presents with colicky abdominal pain, swollen and tender ankles, and a symmetrical, non-blanching, raised purpuric rash distributed over his buttocks, perineum, and posterior lower extremities. He recovered from an upper respiratory tract infection 10 days ago. Platelet count is normal at 285 x 10^9/L and coagulation studies (PT/APTT) are completely normal. Urinalysis reveals 2+ blood and 1+ protein. What is the most likely diagnosis, and what parameter requires mandatory serial outpatient monitoring?

Paediatrics

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Question

During a routine developmental surveillance review of an infant at 12 months of age, which developmental milestone combination is considered normal for this chronological age?

Paediatrics

Question · Easy

Question

A 2-year-old toddler is referred for evaluation of persistent abdominal distension, chronic pale offensive loose stools, muscle wasting over the gluteal region, and deceleration in linear growth (falling from the 50th to below the 3rd percentile on the growth chart). Introduction of wheat-based solid foods occurred at 6 months. Coeliac disease is suspected. What is the initial serological screening investigation of choice?

Paediatrics

Question · Medium

Question

A 4-week-old first-born male infant presents with a 5-day history of non-bilious vomiting immediately following every feed, which has become forceful and projectile. The infant appears hungry and eager to feed again after vomiting. On examination, he is mildly dehydrated, and a firm, smooth, mobile olive-sized mass is palpable in the right upper quadrant. Capillary blood gas analysis reveals a classic metabolic disturbance. What is the diagnosis and characteristic biochemical abnormality?

Paediatrics

Question · Hard

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