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North East Thames Regional

Academic Group
FCEM Mock Paper 1
10 Questions
Time 1 hour
January 2007

Glossary of terms used in College examinations


DRAFT 2007
The CEM uses several terms in examinations that may cause confusion. The
following definitions are intended as a guide to the understanding of these
terms. It is important to read the questions carefully and to understand the
term in the context of that question. Examiners and candidates are advised to
be rigorous in the use of these terms.
Abnormality
This is any feature in an examination or investigation, which is outside the
standard deviation of the population being studied. A Clinical abnormality
however would be a pathologically relevant abnormality and would not include
the presence of tubes, prostheses etc.
Assessment
History taking, physical examination and use of investigations.
Class of drug
This is the generic name for the type of drug with a particular
pharmacological affect e.g. anticoagulant, antihypertensive etc.
Clinical findings
This may include symptoms, signs and vital signs. It is information
gleaned from the clinical evaluation, but not the results of investigations even
bedside ones (e.g. BM or Urine Dipstick)
Commonest/Common
>75% incidence, or prevalence
Condition
This would suggest a well know pathological entity or diagnosis that
should be mentioned as contributing to the presenting complaint.
Criteria
This refers to the fact that there is a formal international/national
guideline or scoring system that allows you to define the seriousness of a
condition e.g. CURB-65 score for pneumonia etc.
Definitive management
This may include things you would do in the department but usually
requires you to list the operation or procedure that will cure or contain the
condition.

Disposition
Where the patient is sent following care in the Emergency Department
including follow-up if discharged.
ED management
This requires you to list actions that are life or limb saving or that might
improve the course of the condition if done within the ED. It is not definitive
management. This may however include analgesia, referral to specialty team
etc
Essential
This indicates life saving treatments/management steps that are the
priority, and would not normally include things like analgesia, communication
etc.
Factor
A contributing element or cause to the condition.
Features
When asked for in the context of a medical history this may be either
a symptom or a sign. If asked for key features, you should give the symptoms
or signs that are definitive for that condition rather than general abnormalities
that might be present.
When asked for in the context of an ECG or CXR it might be a
pathological abnormality, or might simply be the presence of an ETT or
central line i.e. abnormality (see above).
Immediate
This indicates what you will do now, rather than include within the
general list of investigations or treatments that a patient needs.
Implication
Something that is suggested or hinted at.
Indicators
This is used in the context of a clinical evaluation. It should include
history, examination and investigations that might indicate that a particular
diagnosis is likely.

Investigations
Specific tests undertaken to make a diagnosis or monitor the patients
condition. They may include bedside tests such as urine dipstick or BM unless
otherwise specified.
Management
Aspects of care including treatment, supportive care and disposition.
This does not include investigations.
Most likely
This requires the commonest or best know items. For example if asked
for two most likely organisms causing a UTI you should list E Coli and
Klebsiella etc
Pathophysiological sequence of events
This requires you to list in time order, the events that happen on a
cellular, or hormonal level, leading to the current condition. For example, if a
lactate is high in the presence of sepsis, you could suggest
Hypotension
Poor organ perfusion
Tissue hypoxia
Anaerobic metabolism
Glycolysis and lactate build up
Rarely <10% of the time
Symptoms
This is what the patient complains of
Signs
This is what you identify by examination, and may include abnormal
observations/measurements of vital parameters.
Strategy
This is your plan of action, and would normally include a list of
investigations, prescriptions, and physical treatments, in a particular order.
Treatment
Measures undertaken to cure or stabilise the patients condition. This
includes oxygen, fluids, drugs, and may also mean surgery. It does not
include investigations.
Usual/normal >90% of the time

Prepared and edited using the ACEM glossary


February 2007

Question 1
Jo a 22 year-old medical student is brought in by his flatmate. He has been
complaining of a fever and headache. He is febrile 38OC. The triage nurse
gives him some paracetamol and sits him the waiting area. You are called
there urgently as he has collapsed. On your arrival he is on the floor with a
GCS of E 2 V 3 M 4.
1. What is the most likely diagnosis, and list the common causative
organisms in this population? (1 Point)
Menigitis
i. N meningitidis
ii. H. influenzae B
iii. S Pneumoniae
iv. Listeria
v. Cryptococcus
vi. Herpes
2. Outline your immediate management, include treatment specific to this
diagnosis? (3 points)
Transfer to resus
Secure Airway
Resuscitate with fluids
Ceftriaxone 2g IV
Aciclovir
CT brain
PCR
? LP as low GCS may indicate Raised ICP
3. What would you expect to find on microscopy of Jos CSF? (2 Points)
Pressure > 30cmH2O
Protein 1-5g/L
Glucose <2.2mol/L
WCC >500, 90%PMN
Gram Stain +ve in 60-90%
4. List 4 common complications of Jos illness (2 Points)
Diabeties Insipidus
Deafness
Blindness
Obstructive Hydrocephalus
5. Jimmy and Matt are Jos flatmates they are worried that they may catch
what Jo had. What prophylaxis can you offer? (2 Points)
Rifapicin covers HIB and N Meninigitidis
All household or child care contacts
Passangers adjacent to index case for >8Hr
Any person who has potentially swallowed saliva
Health care workers who have given mouth to mouth
Alternative Abx Cipro/Ceftriaxone
HIB vaccine if not vaccinated
Meingococcal C vaccine

Question 2
A 19 year old boy presents with a 2-day hx of L sided sharp chest pain. There
was no hx of trauma. He has not been unwell the past couple of days. The
pain is worse on coughing/deep inspiration
His CXR:

1. What is the diagnosis?


2 marks
Spontaneous Pneumothorax
2. Suggest a management plan for this problem
5 marks
Aspirate
Consider second Aspirate if unsuccessful
Intercostal Drain
Remove 24hrs after airleak stops
Follow up with CXR and Resp Clinic
3. Name 3 potential causes for this problem
3 marks
idiopathic/spontaneous/primary
secondary due to underlying lung disease Ca asthma COPD
cystic fibrosis
also trauma iatrogenic

Question 3
Paul attends complaining of a painful big toe. He denies trauma. The
metatarsal joint of his hallux is swollen red and painful to touch.

1. What is you diagnosis and what tests could you do to confirm this? (2
Points)
Gout
Pseudogout
Septic Arthritis
Asiprate joint
WCC
Urate
CRP/ESR
2. What other systems may be affected and how? (2 Points)
Kidney
Gouty Nephropathy
Ureteric Calculi
3. What are the common precipitants? (2 Points)
Mild Trauma
Dietry excess of purines
Alcohol binge
Stress
Illness
Surgery
4. Describe the classical microscopic findings on joint aspirate. (2 Points)
Turbid Fluid
2000- 50,000 WCC (<75% PMN)
Needle Like crystals, Negative birefringence
5. Outline your management of Paul, both immediate and long-term. (2
Points)
NSAIDS
Rest
Colchine
Long term Allopurinol

Question 4
Destin is a 19-year-old mother of 3 from Hackney. She presents with lower
abdominal pain and an offensive discharge.
1. List 6 key features of a sexual history
(3 points)
Type of sexual relationship (stable/casual)
Number of partners
Sex of partner
Barrier/other types of contraception used
Last intercourse
Practices engaged in (oral, vaginal, anal, penetrative/nonpenetrative etc)
Symptoms
Any symptoms noted in partner/s
Previous STDs
Ever had HIV/HepB-C status checked
Previous pregnancies/terminations &
LMP
On speculum examination this is what you see.
2. What does this demonstrate?
(1 point)
Cervicitis
3. List 3 risk factors for this condition.
(2 points)

4. List 4 organisms that might cause this


condition.
(2 points)
gonorrhea
staphylococci
chlamydia
streptococci
trichomonas
bacterial vaginosis
herpes virus
(overgrowth of
human papilloma
normal flora)
virus
candida
5. List 4 steps in your management of this woman.
(2 points)
High vaginal swab
Endocervical chlamydial swab
Viral swab (HVS)
GUM clinic follow-up (inc. cervical smear test)
Antibiotics: Doxycycline, penicillin +/- metronidazole +/- antithrush treatment.
Lifestyle advice

Question 5

A 76-year-old female presents with chest pain, shortness of breath, cough


and wheeze. She is on aspirin, ramipril, simvastatin and inhalers.
On examination she is pyrexial with bibasal crepitations. She has saturations
of 86% on air, BP is 100/67.

1. What does the ECG show? (1 Point)


Atrial Fibrillation with fast ventricular response rate and LBBB
2. What are the common precipitants of this dysrhymthmia? (4 Points)
AMI (chest pain plus LBBB)
LVF (cough, wheeze, SOB, hypoxia)
Pneumonia (cough, wheeze, SOB, hypoxia)
3. Outline your management of this case? (2 Points)
Patient is unstable Hypotensive, Hypoxic
Needs emergency DC Cardioversion
Could consider Amiodarone
May need overdrive pacing
Inotropes
4. How would it change ff the patient had a blood pressure of 160/90 and
Sats of 96%. (2 Points)
Rate control with B Blocker or Ca Channel Blocker
5. List 4 investigations would be helpful in your management? (1 Point)
CXR
ABG
Transthoracic echo
U and E (on ramipril)

Question 6
A 5 year old is brought in after eating the plant pictured below. He is alert and
happy.

1. What is this plant? (1 point)


Foxglove - Digitalis purpurea
2. Which commonly used drug has similar effects in overdose? (1
point)
Digoxin
3. Outline the common ECG changes seen with this drug & plant. (3
points)
ECG Changes
Toxicity
U Wave
Atrial Tachycardia with Block
QT Shortening
Nonparoxysmal junctional Tachycardia
T Wave changes
PVCs
PR Lengthening
V Tach, F
Sinoatrial Arrest
AV Block
Ectopic Rhythms
4. What investigations should you request? (3 Points)
12 Lead
FBC, UE
Sugar
Srum Digoxin
Paracetamol
5. Outline your treatment with reference to the investigations you
have requested (2 points)
Supportive
Digibind/ Digoxin Immune FAB
i. Cardiac Arrest
ii. Life threatening dysrythmias
iii. > 10mg Adult/4mg child
iv. Serum Digoxin levels >15nmol/l
v. Serum potassum >5mmol

Question 7
A 78 year old lady fell whilst ballroom dancing. This is the AP x-ray of her
hip.

1. What does her x-ray show? (2 Points)


Subcapuslar neck of femur fracture
2. What is the significance of the anatomical location of the abnormality?
(2 Points)
Likely that circulation to femoral head ahs been compromised
Need Hemiarthroplasty
3. Outline the classification of these types of injuries? (3 Points)
Intracapsular Garden Classification
Incomplete Impacted Stress fractures. Trabeculae intact buut
I
angulated
II
Undisplaced fracture across entire neck
III
Complete femoral neck fracture with partial displacement
Complete subcapital fracture with total diplacement of fracture
IV
fragments.
4. What is the management for this patient (3 Points)
Analgesia IV Morphine, +/- Femoral nerveblock
Full Bloods
ECG
Refer ortho

Question 8
A 12-year-old boy is brought in with
an acutely painful left hip. His X
Ray is below

1. Describe this X-Ray (2


points)
Slipped upper
Femoral Epiphysis
2. Outline the management
of this case (2 Points)
Refer to Ortho
Analgesia
At risk of AVN
Bed rest
3. What are the risk factors associated with this condition (1 point)
Age 10 -16
Male Sex
Obesity
4. List 4 common other causes of a painful hip in a child, with the
appropriate age ranges. (3 Points)
Perthes 4-8
Osetomylitis
Irritable Hip 3 -6
Inflammatory
Septic Arthritis
Arthritis
Any
Post infectious
5. Outline the Salter Harris classification of paediatric fractures.
Where does this condition fit in to the Salter Harris classification (2
points)

Question 9
You are working at an aid station at a marathon. Caroline a 33-year-old
runner is brought in after collapsing during the race. She is tachycardic and
has a postural drop. Her core temperature is 39C. Shortly there after, Simon
is brought in after a collapse. Simon is vomiting, confused, has very dry skin,
hyperventilating and hypotensive. He has a core temperature of 41C.
1. What is wrong with
a. Caroline? (1 Point)
Heat Exhaustion
b. Simon? (1 Point)
Heatstroke
Classic Features
Heat Exhaustion
Heatstroke
Headache
Neruological
Hyperventillation
Dysfunction
Nausea /Vomitting
Tachycardia
Malaise
Core Temp > 41
Seizures
Dizziness
Dry Skin
Vomitting
Core Temp <40C
Profuse Sweating
Hypotension
Tachycadia
LOC
Orthststic Hypotension
2. How would you treat
a. Caroline? (2 Points)
Rest and fluids
If in doubt treat as heatstoke
b. Simon? (2Points)

Medical Emergency

Clothing reoved and

Aggressive cooling,
patient sprayed with fine
0.1C/min
mist of tepid water

Evaporative, Ice Water

Ice Pack groin and


immersion, Peritoneal
axxilae
lavage, Ice cold saline,

Control shivering and


endovsacular,
seizures
Extracoporeal circulation

Monitor Urine output

IV fluids titrated to CVP


3. What is the mortality for Simons condition? (2 Points)

10%

Maximum core

Determinants of mortality
temperature

Duration of elevation of

Prolonged coma
Temperature

Oliguric renal failue


4. List 3 other temperature reugulation emergencies. (2 Points)
Neuroleptic Malignant Syndrome
Serotonin Syndrome
Malignant Hyperthermia

Question 10
An eighty two year old lady with type two diabetes attends with loss of power
in her right arm, and slurred speech for about 45 minutes today. Her BP is
160/90. Her pulse is 110, irregularly irregular. Her neurological symptoms
have now completely resolved.
1. What is the risk of this lady going on to have a full stroke in the next 2
days? (2 Points)
A
Age
>65
1
Systolic > 140
B
BP
OR
1
Diastolic 90
Unilateral Weakness
2
Clinical
C
Spech Impairment without weakness
1
Features
Other
0
D Diabetes
1
60 min
2
D Duration 10 60 min
1
<10 min
0
2 Day Risk of Stroke
Score
6
High Risk
8%
Moderate Risk
4%
4-5
3
Low Lisk
1%
2. Outline the management of a suspected TIA? (2 Points)
Antiplatelet therapy Aspirin 300mg followed by 75mg OD
Dependant on ABCD2 score admit or DC with TIA clinic follow
up within 48 Hrs NATIONAL Stroke Stragtegy
Urgent Carotid imagining
+/- Echo, Holter
3. Which part of the cerebral circulation is likely to be involved in this
presentation? (2 Points)
Middle Cerebral Artey
4. List 4 common stroke mimics? (2 Points)
Seizures
17%
Systemic infections
17%
Brain tumour
15%
Toxic-metabolic
13%
Remember glucose
5. What is the ROSIER score? (2 Points)
LOC
-1
History
Fit
-1
Arm weakness
1
Leg Weakness
1
Signs
Facial Weaknes
1
Speech Deficit
1
Visual Field Deficit
1

Score
-1 Stroke Unlikely
1 Stroke Likely

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