AMC-0052
A 62-year-old man presents to the Emergency Department with fever, productive cough and increasing shortness of breath for 3 days. He has type 2 diabetes mellitus and hypertension. On examination, his temperature is 39.1°C, heart rate is 118 beats/min, blood pressure is 86/54 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 91% on room air. He is confused and has coarse crackles over the right lower lung field. Investigations show haemoglobin 136 g/L (130–180), white cell count 18.6 × 10⁹/L (4.0–11.0), C-reactive protein 184 mg/L (<5), lactate 4.2 mmol/L (0.5–2.2), urea 12.4 mmol/L (3.0–8.0) and creatinine 146 µmol/L (60–110). Chest X-ray demonstrates right lower lobe consolidation. What is the most appropriate immediate management?
A. Oral antibiotics and outpatient review the following day.
B. Intravenous broad-spectrum antibiotics alone and reassess in 6 hours.
C. Intravenous crystalloid resuscitation and prompt intravenous antibiotics, with escalation to vasopressor support if hypotension persists.
D. Intravenous furosemide and fluid restriction.
E. Non-invasive ventilation as the only initial treatment.
Answer: C
C: This patient has sepsis with haemodynamic instability secondary to severe pneumonia, demonstrated by hypotension, confusion, elevated lactate and acute kidney dysfunction. Immediate management includes oxygen as required, intravenous crystalloid resuscitation and prompt appropriate intravenous antimicrobial therapy after obtaining cultures when this does not meaningfully delay treatment. If hypotension persists despite adequate fluid resuscitation, vasopressor therapy—typically noradrenaline—is required to maintain organ perfusion.
A: Hypotension, confusion and elevated lactate indicate severe illness requiring emergency hospital management.
B: Antibiotics are essential, but treating the infection without simultaneously addressing circulatory failure is inadequate.
D: Diuresis and fluid restriction would worsen intravascular depletion and tissue hypoperfusion.
E: Respiratory support may become necessary, but it does not replace immediate treatment of the infection and shock.
Memory anchor: Sepsis + hypotension + high lactate → fluids + IV antibiotics → noradrenaline if still hypotensive.
AMC-0051
A 68-year-old woman presents to the Emergency Department with sudden onset of severe left lower abdominal pain and several episodes of bright red blood mixed with stool. She has hypertension, type 2 diabetes mellitus and atrial fibrillation. On examination, her temperature is 37.3°C, heart rate is 102 beats/min and irregularly irregular, blood pressure is 128/76 mmHg and respiratory rate is 18 breaths/min. Her abdomen is soft with mild left-sided tenderness and no guarding or rebound tenderness. Investigations show haemoglobin 121 g/L (115–165), white cell count 14.2 × 10⁹/L (4.0–11.0), C-reactive protein 18 mg/L (<5), lactate 1.8 mmol/L (0.5–2.2) and creatinine 84 µmol/L (45–90). What is the most likely diagnosis?
A. Acute diverticulitis.
B. Colorectal carcinoma.
C. Acute mesenteric ischaemia.
D. Ischaemic colitis.
E. Ulcerative colitis.
Answer: D
D: Sudden crampy left-sided abdominal pain followed by haematochezia in an older patient with cardiovascular risk factors is characteristic of ischaemic colitis. It results from transient reduction in colonic blood flow and commonly affects watershed areas of the colon. The relatively mild abdominal findings and normal lactate also make advanced acute mesenteric ischaemia less likely.
A: Diverticulitis commonly causes left lower quadrant pain and fever, but significant bloody diarrhoea is not its typical presentation.
B: Colorectal carcinoma usually produces a more chronic presentation such as altered bowel habit, occult bleeding, iron deficiency anaemia or weight loss.
C: Acute mesenteric ischaemia classically causes severe abdominal pain out of proportion to examination findings and may be associated with elevated lactate as bowel ischaemia progresses.
E: Ulcerative colitis usually presents with recurrent or persistent bloody diarrhoea rather than a sudden first episode in an older patient with vascular risk factors.
Memory anchor: Older + vascular risk + sudden left abdominal pain → then bloody stool = ischaemic colitis.
AMC-0050
A 41-year-old man is brought to the Emergency Department after being found confused at home. He has type 1 diabetes mellitus and uses insulin. His partner reports that he exercised vigorously this evening and ate very little afterwards. On examination, his temperature is 36.6°C, heart rate is 104 beats/min, blood pressure is 126/74 mmHg and respiratory rate is 16 breaths/min. He is sweaty, tremulous and confused but has intravenous access. Bedside blood glucose is 2.1 mmol/L (3.9–7.8 random). What is the most appropriate immediate treatment?
A. Subcutaneous rapid-acting insulin.
B. Oral metformin.
C. Intravenous glucose.
D. Intravenous sodium bicarbonate.
E. Intravenous potassium.
Answer: C
C: This patient has severe symptomatic hypoglycaemia with neuroglycopenia and cannot safely self-treat. Because intravenous access is available, intravenous glucose should be administered immediately, followed by reassessment of blood glucose and longer-acting carbohydrate once he has recovered sufficiently to eat safely.
A: Insulin would further reduce the blood glucose and could cause profound neurological injury.
B: Metformin lowers glucose and has no role in treating acute hypoglycaemia.
D: Sodium bicarbonate is not a treatment for hypoglycaemia.
E: Potassium administration does not correct the immediate glucose deficiency.
Memory anchor: Hypoglycaemia + confused + IV access → IV glucose NOW.
AMC-0049
A 33-year-old woman presents 4 months after giving birth with fatigue, weight gain, constipation and difficulty concentrating. She has no previous thyroid disease. On examination, her temperature is 36.4°C, heart rate is 58 beats/min, blood pressure is 116/72 mmHg and respiratory rate is 14 breaths/min. There is no thyroid tenderness. Investigations show thyroid-stimulating hormone 12.8 mIU/L (0.4–4.0) and free T4 7 pmol/L (10–20). She recalls experiencing palpitations and heat intolerance approximately 2 months after delivery, which resolved spontaneously. What is the most likely diagnosis?
A. Graves disease.
B. Postpartum thyroiditis.
C. Toxic multinodular goitre.
D. Subacute granulomatous thyroiditis.
E. Central hypothyroidism.
Answer: B
B: Postpartum thyroiditis is an autoimmune destructive thyroiditis occurring within the first year after delivery. It often follows a biphasic course, with an initial transient thyrotoxic phase followed by hypothyroidism as thyroid hormone stores become depleted. Thyroid function subsequently returns to normal in many women, although permanent hypothyroidism can occur.
A: Graves disease causes ongoing thyroid hormone overproduction and does not typically produce this characteristic transient hyperthyroid-to-hypothyroid sequence.
C: Toxic multinodular goitre is uncommon in this age group and generally causes persistent hyperthyroidism.
D: Subacute granulomatous thyroiditis typically causes a painful, tender thyroid, often following a viral illness.
E: Central hypothyroidism generally produces low free T4 with an inappropriately low or normal TSH rather than markedly elevated TSH.
Memory anchor: Postpartum → hyper first → hypo later → postpartum thyroiditis.
AMC-0048
A 28-year-old man presents with a painful swollen right knee that developed over 12 hours. He has fever and cannot bear weight. He has no history of trauma. On examination, his temperature is 38.7°C, heart rate is 108 beats/min, blood pressure is 122/74 mmHg and respiratory rate is 18 breaths/min. The right knee is hot, markedly swollen and extremely painful with passive movement. Investigations show white cell count 16.8 × 10⁹/L (4.0–11.0) and C-reactive protein 126 mg/L (<5). What is the most appropriate next investigation?
A. Serum rheumatoid factor.
B. Plain X-ray alone.
C. MRI of the knee.
D. Urgent arthrocentesis with synovial fluid analysis.
E. Serum urate level.
Answer: D
D: An acutely hot, swollen monoarticular joint with fever and markedly elevated inflammatory markers must be considered septic arthritis until proven otherwise. Urgent arthrocentesis allows synovial fluid cell count, Gram stain, culture and crystal analysis. After appropriate cultures are obtained, empiric intravenous antibiotics should be commenced promptly.
A: Rheumatoid arthritis usually causes a chronic inflammatory polyarthritis and rheumatoid factor cannot exclude septic arthritis.
B: Plain radiography may provide supplementary information but cannot establish or exclude acute septic arthritis.
C: MRI should not delay diagnostic joint aspiration.
E: Serum urate neither confirms gout nor excludes septic arthritis.
Memory anchor: Hot swollen single joint + fever → septic until proven otherwise → aspirate urgently.
AMC-0047
A 23-year-old woman presents with dysuria, urinary frequency and urgency for 2 days. She has no fever, flank pain, vaginal discharge or vomiting and is not pregnant. On examination, her temperature is 36.8°C, heart rate is 76 beats/min, blood pressure is 116/70 mmHg and respiratory rate is 14 breaths/min. There is mild suprapubic tenderness but no costovertebral angle tenderness. Urinalysis is positive for nitrites and leukocyte esterase. What is the most appropriate treatment?
A. Oral nitrofurantoin.
B. Intravenous ceftriaxone.
C. Oral fluconazole.
D. No treatment unless urine culture is positive.
E. Intravenous gentamicin.
Answer: A
A: This patient has uncomplicated acute cystitis, with typical lower urinary tract symptoms and supportive urinalysis without systemic features of pyelonephritis. Nitrofurantoin is an appropriate first-line oral antimicrobial option for uncomplicated cystitis when there are no relevant contraindications.
B: Intravenous ceftriaxone is unnecessarily broad and invasive for uncomplicated lower urinary tract infection.
C: Fluconazole treats fungal infections and does not provide routine treatment for bacterial cystitis.
D: In a non-pregnant woman with a typical uncomplicated presentation, treatment does not necessarily need to await culture confirmation.
E: Intravenous gentamicin is not appropriate routine treatment for uncomplicated cystitis.
Memory anchor: Dysuria + frequency + no fever/flank pain → cystitis → oral nitrofurantoin.
AMC-0046
A 57-year-old woman presents with sudden onset of severe vertigo, nausea and vomiting. She reports that the room spins for approximately 20 seconds whenever she rolls over in bed or looks upwards. Between episodes she feels well. She has no hearing loss, tinnitus, headache, weakness or sensory symptoms. Neurological examination is normal. The Dix–Hallpike manoeuvre reproduces her vertigo and causes positional nystagmus. What is the most appropriate treatment?
A. Long-term prochlorperazine.
B. Epley manoeuvre.
C. Intravenous antibiotics.
D. Urgent thrombolysis.
E. Oral corticosteroids.
Answer: B
B: Brief episodes of positional vertigo with a positive Dix–Hallpike test are characteristic of benign paroxysmal positional vertigo. The Epley canalith-repositioning manoeuvre moves displaced otoconia out of the affected semicircular canal and is an effective first-line treatment.
A: Vestibular suppressants do not correct the underlying problem and prolonged use may interfere with vestibular compensation.
C: There are no features suggesting bacterial infection.
D: The brief positional episodes and normal neurological examination do not suggest an acute ischaemic stroke.
E: Corticosteroids are not standard treatment for BPPV.
Memory anchor: Seconds of vertigo + head movement + positive Dix–Hallpike → BPPV → Epley.
AMC-0045
A 5-week-old boy is brought to the Emergency Department because of progressively forceful vomiting after feeds. The vomiting is non-bilious, and he appears hungry immediately afterwards. On examination, his temperature is 36.8°C, heart rate is 142 beats/min, blood pressure is 78/46 mmHg and respiratory rate is 32 breaths/min. He is mildly dehydrated. Investigations show sodium 134 mmol/L (135–145), potassium 3.0 mmol/L (3.5–5.0), chloride 88 mmol/L (98–106) and bicarbonate 34 mmol/L (22–28). What is the most likely diagnosis?
A. Hirschsprung disease.
B. Intussusception.
C. Gastro-oesophageal reflux.
D. Hypertrophic pyloric stenosis.
E. Duodenal atresia.
Answer: D
D: Progressive projectile non-bilious vomiting in a young infant who remains hungry after vomiting is classic for hypertrophic pyloric stenosis. Repeated loss of gastric hydrochloric acid produces the characteristic hypochloraemic, hypokalaemic metabolic alkalosis. Fluid and electrolyte abnormalities must be corrected before pyloromyotomy.
A: Hirschsprung disease typically presents with delayed meconium passage, abdominal distension and constipation.
B: Intussusception usually causes episodic severe abdominal pain, vomiting and sometimes red currant jelly stool.
C: Physiological reflux usually causes effortless regurgitation rather than progressive projectile vomiting with significant electrolyte abnormalities.
E: Duodenal obstruction typically produces bilious vomiting.
Memory anchor: Hungry baby + projectile NON-bilious vomiting + alkalosis → pyloric stenosis.
AMC-0044
A 71-year-old man presents with urinary hesitancy, poor urinary stream, nocturia and a sensation of incomplete bladder emptying that has gradually worsened over 2 years. On examination, his abdomen is soft and non-tender. Digital rectal examination reveals a symmetrically enlarged, smooth, non-tender prostate. Urinalysis is normal. What is the most appropriate initial pharmacological treatment for his bothersome lower urinary tract symptoms?
A. Tamsulosin.
B. Oxybutynin alone.
C. Ciprofloxacin.
D. Sildenafil as first-line treatment.
E. Prednisolone.
Answer: A
A: This presentation is typical of benign prostatic hyperplasia. An alpha-1 adrenergic antagonist such as tamsulosin relaxes smooth muscle in the prostate and bladder neck and can provide relatively rapid improvement in bothersome voiding symptoms.
B: Antimuscarinic therapy is principally used for storage symptoms and can worsen urinary retention in susceptible patients.
C: There is no evidence of urinary tract infection or bacterial prostatitis requiring antibiotics.
D: PDE-5 inhibitors can improve lower urinary tract symptoms in selected men but are not the usual first choice for predominantly obstructive symptoms.
E: Corticosteroids do not treat benign prostatic hyperplasia.
Memory anchor: BPH + bothersome obstruction → alpha blocker → tamsulosin.
AMC-0043
A 35-year-old man presents with a 6-week history of bloody diarrhoea, urgency and lower abdominal cramping. He passes six stools daily and has lost 3 kg. On examination, his temperature is 37.1°C, heart rate is 88 beats/min, blood pressure is 124/76 mmHg and respiratory rate is 16 breaths/min. Investigations show haemoglobin 112 g/L (130–180), C-reactive protein 24 mg/L (<5) and faecal calprotectin 620 µg/g (<50). Colonoscopy demonstrates continuous inflammation extending proximally from the rectum. What is the most likely diagnosis?
A. Crohn disease.
B. Irritable bowel syndrome.
C. Ulcerative colitis.
D. Diverticulitis.
E. Coeliac disease.
Answer: C
C: Bloody diarrhoea with urgency and continuous mucosal inflammation beginning at the rectum is characteristic of ulcerative colitis. Unlike Crohn disease, ulcerative colitis typically affects the colon continuously rather than producing skip lesions.
A: Crohn disease can involve any part of the gastrointestinal tract and typically causes patchy transmural inflammation with skip lesions.
B: Irritable bowel syndrome does not cause intestinal inflammation, rectal bleeding or markedly elevated faecal calprotectin.
D: Diverticulitis usually presents with acute focal abdominal pain rather than chronic bloody diarrhoea with continuous colitis.
E: Coeliac disease primarily affects the small intestine and does not produce this colonoscopic pattern.
Memory anchor: UC = rectum first + continuous inflammation + bloody diarrhoea.
AMC-0042
A 46-year-old woman presents with progressive fatigue, constipation and muscle weakness. She has also experienced recurrent renal calculi. On examination, her temperature is 36.7°C, heart rate is 76 beats/min, blood pressure is 142/84 mmHg and respiratory rate is 16 breaths/min. Investigations show corrected calcium 3.02 mmol/L (2.15–2.55), phosphate 0.62 mmol/L (0.80–1.50), parathyroid hormone 14.8 pmol/L (1.6–6.9) and creatinine 82 µmol/L (45–90). What is the most likely diagnosis?
A. Hypoparathyroidism.
B. Vitamin D deficiency.
C. Primary hyperparathyroidism.
D. Chronic kidney disease.
E. Hypocalcaemia of malignancy.
Answer: C
C: Hypercalcaemia accompanied by an inappropriately elevated parathyroid hormone concentration and low phosphate is characteristic of primary hyperparathyroidism. Renal calculi are a classic complication of persistent hypercalcaemia.
A: Hypoparathyroidism causes low calcium and low PTH.
B: Vitamin D deficiency generally causes low or normal calcium with secondary elevation of PTH.
D: Advanced chronic kidney disease usually causes secondary hyperparathyroidism with impaired renal function and often elevated phosphate.
E: Malignancy-associated hypercalcaemia usually suppresses endogenous PTH.
Memory anchor: High Ca²⁺ + high PTH + low phosphate → primary hyperparathyroidism.
AMC-0041
A 52-year-old woman presents with sudden severe epigastric pain that rapidly became generalised. She has used naproxen daily for several months for osteoarthritis. On examination, her temperature is 37.8°C, heart rate is 116 beats/min, blood pressure is 104/68 mmHg and respiratory rate is 24 breaths/min. Her abdomen is rigid with generalised guarding and rebound tenderness. An erect chest X-ray demonstrates free gas beneath the diaphragm. What is the most appropriate management?
A. Oral proton pump inhibitor therapy and outpatient review.
B. Colonoscopy.
C. Observation with repeat abdominal examination in 6 hours.
D. Urgent surgical assessment and operative management.
E. Commence oral antibiotics.
Answer: D
D: Free subdiaphragmatic gas with sudden abdominal pain and generalised peritonism indicates a perforated hollow viscus, most likely a perforated peptic ulcer in this patient using NSAIDs. She requires resuscitation, intravenous antibiotics and urgent surgical management because ongoing contamination can rapidly cause sepsis and shock.
A: Medical ulcer therapy alone is inappropriate in gastrointestinal perforation.
B: Colonoscopy is contraindicated in suspected perforation.
C: Observation would dangerously delay definitive treatment.
E: Antibiotics are required but are insufficient without urgent source control.
Memory anchor: Sudden pain + rigid abdomen + free air → perforation → surgery.
AMC-0040
A 19-year-old university student presents to the Emergency Department with fever, severe headache, photophobia and vomiting. On examination, his temperature is 39.3°C, heart rate is 118 beats/min, blood pressure is 108/66 mmHg and respiratory rate is 22 breaths/min. He has neck stiffness and a non-blanching petechial rash over his trunk and legs. What is the most appropriate immediate management?
A. Arrange lumbar puncture and wait for cerebrospinal fluid results before treatment.
B. Commence intravenous ceftriaxone immediately.
C. Commence oral amoxicillin.
D. Arrange outpatient CT brain.
E. Administer aciclovir alone.
Answer: B
B: This presentation strongly suggests meningococcal meningitis with meningococcaemia. Intravenous antibiotic therapy must be commenced immediately because deterioration can be rapid and treatment should not be delayed for lumbar puncture or imaging when the diagnosis is strongly suspected.
A: Lumbar puncture may be appropriate subsequently but must not delay antibiotic treatment.
C: Oral antibiotics are inadequate for suspected bacterial meningitis.
D: Outpatient imaging is unsafe in this acutely unwell patient.
E: Aciclovir treats herpes simplex virus infection and does not provide appropriate treatment for suspected meningococcal disease.
Memory anchor: Fever + meningism + non-blanching rash → meningococcus → ceftriaxone NOW.
AMC-0039
A 29-year-old woman at 10 weeks’ gestation presents with persistent vomiting, inability to tolerate fluids and a 4 kg weight loss. On examination, her temperature is 36.8°C, heart rate is 108 beats/min, blood pressure is 96/62 mmHg and respiratory rate is 16 breaths/min. She has dry mucous membranes. Investigations show sodium 131 mmol/L (135–145), potassium 3.1 mmol/L (3.5–5.0) and creatinine 78 µmol/L (45–90). Urinalysis demonstrates ketones 3+. What is the most appropriate initial management?
A. Intravenous fluids, electrolyte replacement, thiamine and antiemetic therapy.
B. Immediate termination of pregnancy.
C. Oral fluids alone and discharge.
D. Commence an angiotensin-converting enzyme inhibitor.
E. Administer intravenous glucose before thiamine.
Answer: A
A: This patient has hyperemesis gravidarum with dehydration, ketosis and hypokalaemia. Initial treatment includes intravenous rehydration, correction of electrolyte abnormalities, antiemetic therapy and thiamine supplementation. Thiamine should be administered before dextrose-containing fluids in prolonged vomiting to reduce the risk of precipitating Wernicke encephalopathy.
B: Hyperemesis gravidarum is generally managed medically and does not itself require termination.
C: She has significant dehydration and biochemical abnormalities requiring hospital treatment.
D: ACE inhibitors have no role and are contraindicated during pregnancy.
E: Giving glucose before thiamine in a thiamine-depleted patient can precipitate Wernicke encephalopathy.
Memory anchor: Hyperemesis + ketones → fluids + K⁺ + antiemetic + THIAMINE before glucose.
AMC-0038
A 73-year-old woman presents with a 6-month history of progressive exertional dyspnoea, chest tightness and two episodes of syncope while walking uphill. On examination, her heart rate is 78 beats/min, blood pressure is 118/72 mmHg and respiratory rate is 16 breaths/min. She has a harsh ejection systolic murmur at the right upper sternal edge that radiates to both carotid arteries. What is the most appropriate investigation to confirm the suspected diagnosis and assess its severity?
A. Coronary angiography.
B. Exercise ECG.
C. CT pulmonary angiography.
D. Transthoracic echocardiography.
E. Holter monitoring.
Answer: D
D: The combination of exertional dyspnoea, angina, syncope and a systolic murmur radiating to the carotids strongly suggests severe aortic stenosis. Transthoracic echocardiography confirms the diagnosis and assesses valve anatomy, pressure gradients, valve area and left ventricular function.
A: Coronary angiography does not establish the severity of aortic stenosis and is generally used selectively during pre-intervention assessment.
B: Exercise testing is inappropriate in symptomatic severe aortic stenosis.
C: CTPA investigates pulmonary embolism rather than valvular disease.
E: Holter monitoring may investigate arrhythmias but does not assess the aortic valve.
Memory anchor: Syncope + angina + dyspnoea + murmur to carotids → aortic stenosis → echo.
AMC-0037
A 2-year-old boy is brought to the Emergency Department after developing sudden coughing and choking while eating peanuts. He is now coughing intermittently. On examination, his temperature is 36.8°C, heart rate is 112 beats/min, blood pressure is 94/58 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 95% on room air. Air entry is reduced on the right with unilateral wheeze. What is the most appropriate next step in management?
A. Commence oral antibiotics.
B. Arrange rigid bronchoscopy.
C. Administer nebulised salbutamol and discharge if improved.
D. Arrange spirometry.
E. Observe at home for spontaneous passage of the foreign body.
Answer: B
B: Sudden choking followed by unilateral wheeze and reduced air entry strongly suggests an inhaled foreign body. Rigid bronchoscopy allows direct visualisation and removal and is the definitive investigation and treatment when clinical suspicion is high.
A: Antibiotics do not remove an airway foreign body.
C: Bronchodilators may transiently alter wheeze but do not address the obstruction.
D: Spirometry is inappropriate in a 2-year-old with suspected acute foreign-body aspiration.
E: Observation risks migration, complete obstruction and pulmonary complications.
Memory anchor: Child + sudden choke + unilateral wheeze → foreign body → rigid bronchoscopy.
AMC-0036
A 64-year-old man presents to the Emergency Department with crushing central chest pain radiating to his left arm for 45 minutes. He is diaphoretic and nauseated. On examination, his temperature is 36.7°C, heart rate is 96 beats/min, blood pressure is 138/84 mmHg, respiratory rate is 20 breaths/min and oxygen saturation is 97% on room air. ECG shows ST-segment elevation in leads II, III and aVF. The nearest percutaneous coronary intervention centre can perform PCI within 90 minutes. What is the most appropriate reperfusion strategy?
A. Aspirin alone followed by outpatient cardiology review.
B. Immediate fibrinolysis despite timely PCI availability.
C. Urgent primary percutaneous coronary intervention.
D. Exercise stress testing before reperfusion.
E. Observe for serial troponin measurements.
Answer: C
C: This patient has an acute inferior STEMI and requires immediate reperfusion. When primary PCI can be delivered promptly, it is the preferred reperfusion strategy because it provides effective coronary reperfusion while avoiding the intracranial bleeding risk associated with fibrinolysis.
A: Antiplatelet therapy is important but does not replace urgent reperfusion in STEMI.
B: Fibrinolysis is generally used when timely primary PCI cannot be achieved and there are no contraindications.
D: Exercise testing is inappropriate during an acute STEMI.
E: Reperfusion should not be delayed while awaiting cardiac biomarker results.
Memory anchor: STEMI + timely PCI available → primary PCI NOW.
AMC-0035
A 38-year-old man presents to the Emergency Department with severe left-sided loin pain radiating to the groin. The pain began suddenly 3 hours ago and is associated with nausea and vomiting. He has noticed blood in his urine but has no dysuria. On examination, his temperature is 36.8°C, heart rate is 96 beats/min, blood pressure is 134/78 mmHg and respiratory rate is 18 breaths/min. He is restless because of pain and has mild left costovertebral angle tenderness. Investigations show haemoglobin 145 g/L (130–180), white cell count 9.8 × 10⁹/L (4.0–11.0), creatinine 88 µmol/L (60–110) and C-reactive protein 3 mg/L (<5). Urinalysis demonstrates blood 3+ with negative nitrites and leukocyte esterase. What is the most appropriate imaging investigation?
A. Plain abdominal X-ray.
B. Intravenous pyelogram.
C. Renal ultrasound as the definitive first-line investigation.
D. Contrast-enhanced CT abdomen.
E. Non-contrast CT of the kidneys, ureters and bladder.
Answer: E
E: This presentation is typical of renal colic due to ureteric calculi, with sudden severe loin-to-groin pain, haematuria and no evidence of urinary infection. In a non-pregnant adult, low-dose non-contrast CT KUB is the preferred imaging investigation because it is highly sensitive for urinary calculi and can determine their size and location while identifying alternative causes of pain.
A: Plain abdominal radiography has limited sensitivity because some urinary calculi are radiolucent and small stones may be missed.
B: Intravenous pyelography has largely been replaced by CT because CT is faster and provides greater diagnostic accuracy.
C: Ultrasound is particularly useful when radiation should be avoided, including pregnancy, but is less sensitive for ureteric calculi than CT in a typical non-pregnant adult.
D: Intravenous contrast can obscure urinary calculi and is unnecessary for routine initial investigation of uncomplicated renal colic.
Memory anchor: Loin → groin + haematuria → renal stone → non-contrast CT KUB.
AMC-0034
A 32-year-old woman presents to her General Practitioner with a 4-month history of increasing fatigue, exertional dyspnoea and craving for ice. She reports heavy menstrual bleeding lasting 7 days each month. On examination, her temperature is 36.7°C, heart rate is 94 beats/min, blood pressure is 118/72 mmHg and respiratory rate is 16 breaths/min. She appears pale and has spoon-shaped fingernails. Investigations show haemoglobin 89 g/L (115–165), mean corpuscular volume 68 fL (80–100), mean corpuscular haemoglobin 21 pg (27–33), ferritin 6 µg/L (15–150) and transferrin saturation 7% (20–45). What is the most appropriate initial treatment?
A. Intramuscular vitamin B12.
B. Oral folic acid.
C. Packed red blood cell transfusion.
D. Oral iron replacement and investigation and management of the heavy menstrual bleeding.
E. Erythropoietin therapy.
Answer: D
D: This patient has iron deficiency anaemia, supported by microcytosis, low ferritin, low transferrin saturation, pica and koilonychia. In a haemodynamically stable patient who can tolerate oral therapy, oral iron is appropriate initial replacement. The underlying cause must also be addressed; in this case, her heavy menstrual bleeding requires investigation and management to prevent recurrent iron deficiency.
A: Vitamin B12 is used for B12 deficiency, which typically produces macrocytic rather than microcytic anaemia.
B: Folate deficiency usually causes macrocytic anaemia and does not explain the markedly depleted iron stores.
C: Blood transfusion is generally reserved for severe symptomatic anaemia, haemodynamic instability or situations requiring rapid correction and is not routinely required in this stable patient.
E: Erythropoietin is used in selected conditions such as anaemia associated with chronic kidney disease and does not correct iron deficiency.
Memory anchor: Low Hb + low MCV + low ferritin → iron deficiency → replace iron + find and treat the blood loss.
AMC-0033
A 7-year-old boy is brought to his General Practitioner with swelling around his eyes and ankles that has progressively worsened over the past 5 days. His parents report that his urine has appeared unusually frothy. He had a mild upper respiratory tract infection 2 weeks ago but is otherwise well. On examination, his temperature is 36.8°C, heart rate is 88 beats/min, blood pressure is 104/66 mmHg and respiratory rate is 18 breaths/min. He has bilateral periorbital oedema and pitting oedema of both ankles. Investigations show serum albumin 19 g/L (35–50), creatinine 42 µmol/L (30–70), total cholesterol 7.2 mmol/L (<5.5) and urine protein:creatinine ratio 320 mg/mmol (<20). Urinalysis shows protein 4+ with no blood. What is the most appropriate initial treatment?
A. Intravenous ceftriaxone.
B. Oral corticosteroid therapy.
C. Intravenous cyclophosphamide.
D. Immediate renal biopsy.
E. Oral furosemide as the only treatment.
Answer: B
B: This child has nephrotic syndrome, demonstrated by heavy proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia. In a child of this age with a typical presentation and normal renal function and blood pressure, minimal change disease is the most likely cause. Initial treatment is corticosteroid therapy, and most children achieve remission without requiring renal biopsy.
A: Antibiotics are not indicated without evidence of bacterial infection.
C: Cyclophosphamide may be considered in selected frequently relapsing or steroid-dependent disease but is not first-line treatment for an initial typical episode.
D: Renal biopsy is generally reserved for atypical presentations or steroid-resistant nephrotic syndrome.
E: Diuretics may occasionally be used cautiously for significant oedema but do not treat the underlying disease and should not be used as sole therapy.
Memory anchor: Child + oedema + massive proteinuria + low albumin → minimal change → steroids first.
AMC-0032
A 45-year-old man presents to the Emergency Department with severe central chest pain that began suddenly 40 minutes ago while lifting a heavy object. He describes the pain as tearing and radiating through to his back. His medical history includes poorly controlled hypertension. On examination, his temperature is 36.7°C, heart rate is 104 beats/min, blood pressure is 188/106 mmHg in the right arm and 162/92 mmHg in the left arm, respiratory rate is 20 breaths/min and oxygen saturation is 97% on room air. A new early diastolic murmur is heard at the left sternal edge. He is haemodynamically stable. What is the most appropriate next investigation?
A. Exercise stress test.
B. Coronary angiography.
C. D-dimer testing.
D. Transthoracic echocardiography as the definitive investigation.
E. CT angiography of the aorta.
Answer: E
E: This presentation is highly suspicious for acute aortic dissection, with abrupt tearing chest pain radiating to the back, a blood pressure difference between the arms, severe hypertension and a new murmur suggesting aortic regurgitation. In a haemodynamically stable patient, urgent CT angiography is the preferred investigation because it rapidly demonstrates the location and extent of the dissection and helps guide definitive management.
A: Exercise testing is contraindicated in suspected acute aortic dissection and could precipitate catastrophic deterioration.
B: Coronary angiography is used primarily for suspected coronary artery disease and is not the first investigation for this classic presentation.
C: D-dimer should not delay definitive imaging when clinical suspicion for acute aortic syndrome is high.
D: Echocardiography can provide useful information, but transthoracic imaging may not adequately visualise the entire aorta; transoesophageal echocardiography is particularly useful when the patient is unstable or CT is unsuitable.
Memory anchor: Tearing chest pain → back + unequal arm BP → aortic dissection → stable = CT angiography.
AMC-0031
A 27-year-old woman presents to the Emergency Department with worsening shortness of breath and right-sided pleuritic chest pain that began suddenly 4 hours ago. She returned from a 15-hour international flight 2 days ago and takes the combined oral contraceptive pill. On examination, her temperature is 37.1°C, heart rate is 118 beats/min, blood pressure is 118/72 mmHg, respiratory rate is 26 breaths/min and oxygen saturation is 91% on room air. Her right calf is mildly swollen and tender compared with the left. She has no history of bleeding or renal impairment. What is the most appropriate next investigation?
A. Chest X-ray only.
B. D-dimer testing.
C. Ventilation-perfusion scan.
D. CT pulmonary angiography.
E. Echocardiography.
Answer: D
D: This patient has a high clinical probability of pulmonary embolism, with sudden pleuritic chest pain, hypoxaemia, tachycardia, recent prolonged immobility, oestrogen exposure and features of deep vein thrombosis. In a haemodynamically stable patient with a likely pulmonary embolism, CT pulmonary angiography is the appropriate definitive imaging investigation, provided there is no contraindication to iodinated contrast.
A: A chest X-ray may identify alternative diagnoses but cannot exclude or confirm pulmonary embolism.
B: D-dimer is most useful when the clinical probability of pulmonary embolism is low or intermediate; it should not delay definitive imaging when PE is clinically likely.
C: Ventilation-perfusion scanning is an alternative when CTPA is unsuitable, such as significant contrast allergy or selected patients in whom radiation considerations favour V/Q imaging.
E: Echocardiography may demonstrate right ventricular strain in a haemodynamically unstable patient but is not the primary diagnostic investigation in this stable patient.
Memory anchor: Likely PE + stable → CTPA; low probability → D-dimer first.
AMC-0030
A 30-year-old woman presents to her General Practitioner with a 3-month history of episodic headaches, palpitations and profuse sweating. The episodes occur several times each week, last approximately 20 minutes and are associated with anxiety and tremor. On examination between episodes, her temperature is 36.8°C, heart rate is 86 beats/min, blood pressure is 164/96 mmHg and respiratory rate is 16 breaths/min. During a witnessed episode, her blood pressure rises to 218/116 mmHg. What is the most appropriate initial investigation?
A. Plasma free metanephrines.
B. CT scan of the adrenal glands.
C. Serum aldosterone-to-renin ratio.
D. 24-hour urinary free cortisol.
E. Renal artery Doppler ultrasonography.
Answer: A
A: The episodic triad of headache, palpitations and sweating with paroxysmal severe hypertension strongly suggests phaeochromocytoma. Initial investigation requires biochemical evidence of catecholamine excess, with plasma free metanephrines or fractionated urinary metanephrines being appropriate tests. Adrenal imaging is performed after biochemical evidence supports the diagnosis.
B: CT can localise an adrenal tumour but should generally follow biochemical confirmation rather than being the initial diagnostic test.
C: The aldosterone-to-renin ratio is used to screen for primary aldosteronism, particularly in resistant hypertension or hypertension associated with hypokalaemia.
D: Urinary free cortisol is used when investigating Cushing syndrome.
E: Renal artery imaging may be appropriate when renovascular hypertension is suspected but does not fit this classic episodic presentation.
Memory anchor: Headache + sweating + palpitations + episodic hypertension → phaeochromocytoma → metanephrines first.
AMC-0029
A 61-year-old man presents to his General Practitioner with a 4-month history of progressive difficulty swallowing. Initially he had difficulty swallowing solid food, but over the past month he has also developed difficulty swallowing liquids. He has unintentionally lost 8 kg during this period. He has smoked 20 cigarettes daily for 35 years and drinks four standard alcoholic drinks most days. On examination, his temperature is 36.7°C, heart rate is 82 beats/min, blood pressure is 128/76 mmHg and respiratory rate is 16 breaths/min. There is no palpable cervical lymphadenopathy. What is the most appropriate next investigation?
A. Barium swallow.
B. CT scan of the chest and abdomen.
C. Upper gastrointestinal endoscopy with biopsy.
D. Oesophageal manometry.
E. Therapeutic trial of a proton pump inhibitor.
Answer: C
C: Progressive dysphagia that begins with solids and later involves liquids, particularly when accompanied by weight loss and significant smoking and alcohol exposure, strongly suggests a mechanical obstruction such as oesophageal carcinoma. Upper gastrointestinal endoscopy allows direct visualisation of the lesion and biopsy for histological diagnosis. Staging investigations are performed after tissue diagnosis.
A: A barium swallow can demonstrate structural abnormalities but does not permit biopsy and is not the preferred initial test when malignancy is strongly suspected.
B: CT is important for staging oesophageal cancer but does not replace endoscopy and biopsy for establishing the diagnosis.
D: Oesophageal manometry is used primarily to investigate motility disorders such as achalasia after structural obstruction has been excluded.
E: A proton pump inhibitor trial is inappropriate in a patient with progressive dysphagia and weight loss, which are alarm features requiring urgent investigation.
Memory anchor: Solids → then liquids + weight loss → mechanical obstruction → scope + biopsy.
AMC-0028
A 4-year-old girl is brought to the Emergency Department with a barking cough and noisy breathing that became worse overnight. She has had rhinorrhoea and a low-grade fever for 2 days. On examination, her temperature is 37.8°C, heart rate is 118 beats/min, blood pressure is 96/58 mmHg, respiratory rate is 30 breaths/min and oxygen saturation is 96% on room air. She has inspiratory stridor at rest, a barking cough and moderate intercostal recession. She is alert and able to drink. What is the most appropriate initial treatment?
A. Oral amoxicillin.
B. Nebulised salbutamol.
C. Intravenous ceftriaxone.
D. Dexamethasone alone with discharge immediately after administration.
E. Dexamethasone and nebulised adrenaline.
Answer: E
E: This child has croup with stridor at rest and moderate respiratory distress. Corticosteroid therapy with dexamethasone reduces upper-airway inflammation, while nebulised adrenaline provides rapid temporary improvement by reducing airway mucosal oedema. Because the effect of adrenaline can wear off, the child requires observation after treatment and reassessment before discharge.
A: Croup is usually viral, so antibiotics such as amoxicillin are not routinely indicated.
B: Salbutamol acts primarily on lower-airway bronchospasm and does not effectively treat the upper-airway obstruction of croup.
C: Ceftriaxone is not indicated for typical viral croup without evidence of bacterial infection.
D: Dexamethasone is appropriate, but stridor at rest requires additional nebulised adrenaline and observation rather than immediate discharge.
Memory anchor: Croup + stridor at rest → dexamethasone + nebulised adrenaline + observe.
AMC-0027
A 76-year-old man presents to his General Practitioner with progressive fatigue, exertional dyspnoea and reduced exercise tolerance over the past 3 months. He has no overt bleeding. On examination, his temperature is 36.7°C, heart rate is 88 beats/min, blood pressure is 132/76 mmHg and respiratory rate is 16 breaths/min. He appears pale. Abdominal examination is normal and there is no lymphadenopathy. Investigations show haemoglobin 92 g/L (130–180), mean corpuscular volume 71 fL (80–100), ferritin 8 µg/L (30–300), transferrin saturation 9% (20–45) and C-reactive protein 3 mg/L (<5). What is the most appropriate next step in management?
A. Commence oral iron and arrange no further investigation if the haemoglobin improves.
B. Arrange gastrointestinal investigation for occult blood loss and malignancy.
C. Commence vitamin B12 injections.
D. Arrange bone marrow biopsy.
E. Commence erythropoietin therapy.
Answer: B
B: This patient has iron deficiency anaemia, demonstrated by microcytic anaemia with low ferritin and low transferrin saturation. In an older man without an obvious source of blood loss, occult gastrointestinal bleeding must be investigated, particularly to exclude gastrointestinal malignancy. Iron replacement is appropriate, but improvement with iron does not remove the need to determine the underlying cause.
A: Iron replacement alone is insufficient because an underlying gastrointestinal malignancy could remain undiagnosed.
C: Vitamin B12 deficiency typically causes macrocytic rather than microcytic anaemia.
D: Bone marrow biopsy is not the initial investigation when the laboratory findings clearly demonstrate iron deficiency.
E: Erythropoietin is used in selected causes of anaemia, such as chronic kidney disease, and does not address this patient’s iron deficiency or its underlying cause.
Memory anchor: Iron deficiency in an older man → GI blood loss until proven otherwise → exclude cancer.
AMC-0026
A 24-year-old woman presents to the Emergency Department with worsening lower abdominal pain for 2 days. The pain is predominantly on the right side and is associated with light vaginal bleeding. Her last menstrual period was 7 weeks ago. On examination, her temperature is 36.8°C, heart rate is 96 beats/min, blood pressure is 112/70 mmHg and respiratory rate is 16 breaths/min. She has right lower abdominal tenderness without guarding. Urine pregnancy testing is positive. Investigations show haemoglobin 126 g/L (115–165) and serum β-hCG 3,800 IU/L (<5 in non-pregnant women). Transvaginal ultrasound demonstrates no intrauterine gestational sac and a 2.5 cm right adnexal mass with no fetal cardiac activity. There is a small amount of free pelvic fluid. What is the most appropriate management?
A. Reassure her and repeat ultrasound at 12 weeks.
B. Immediate laparotomy.
C. Methotrexate therapy with appropriate follow-up.
D. Commence progesterone supplementation.
E. Dilatation and curettage.
Answer: C
C: This haemodynamically stable patient has an unruptured ectopic pregnancy. She has a relatively small adnexal mass, no fetal cardiac activity and a β-hCG concentration within a range in which medical treatment can be considered. Methotrexate is an appropriate option provided there are no contraindications and she can reliably attend serial β-hCG monitoring until resolution.
A: An adnexal mass with an empty uterus and positive pregnancy test is concerning for ectopic pregnancy and cannot simply be observed until 12 weeks.
B: Emergency surgery is required for haemodynamic instability or suspected rupture; this patient is currently stable and has no evidence of major intra-abdominal haemorrhage.
D: Progesterone does not treat an ectopic pregnancy.
E: Dilatation and curettage does not treat a confirmed tubal ectopic pregnancy and exposes the patient to an unnecessary procedure.
Memory anchor: Stable + small unruptured ectopic + no fetal heartbeat → think methotrexate.
AMC-0025
A 67-year-old man presents to the Emergency Department with sudden onset of weakness affecting his right arm and leg and difficulty speaking that began 90 minutes ago. He has hypertension and type 2 diabetes mellitus and takes metformin and perindopril. On examination, his temperature is 36.8°C, heart rate is 84 beats/min and regular, blood pressure is 178/96 mmHg, respiratory rate is 16 breaths/min and oxygen saturation is 97% on room air. He has right-sided facial weakness, right arm and leg weakness and expressive aphasia. His blood glucose is 6.8 mmol/L (3.9–7.8 random). What is the most appropriate next investigation?
A. Carotid Doppler ultrasonography.
B. MRI of the brain with contrast.
C. Electroencephalography.
D. Immediate non-contrast CT scan of the brain.
E. CT scan of the brain in 24 hours.
Answer: D
D: This patient has an acute focal neurological deficit consistent with stroke and is within the time window in which reperfusion therapy may be possible. An immediate non-contrast CT brain is required to rapidly distinguish intracranial haemorrhage from ischaemic stroke before thrombolysis is considered. Further vascular imaging is commonly performed urgently to identify large-vessel occlusion and assess suitability for thrombectomy.
A: Carotid imaging may be important later but must not delay emergency brain imaging and reperfusion assessment.
B: MRI can identify acute cerebral ischaemia but is not the routine first investigation when it would delay emergency stroke treatment.
C: EEG is used principally to investigate seizure disorders and does not exclude intracranial haemorrhage.
E: Waiting 24 hours would unnecessarily delay potentially time-critical reperfusion treatment.
Memory anchor: Sudden focal deficit → CT brain NOW → bleed or clot → reperfuse if eligible.
AMC-0024
A 72-year-old woman presents to the Emergency Department after developing sudden severe pain in her right eye associated with blurred vision, headache, nausea and vomiting. She reports seeing coloured haloes around lights. On examination, the right eye is red, the cornea appears hazy and the pupil is mid-dilated and poorly reactive to light. Visual acuity is reduced in the right eye. Intraocular pressure is 48 mmHg (10–21). What is the most appropriate immediate management?
A. Commence topical chloramphenicol.
B. Apply an eye patch and arrange review the following day.
C. Commence pressure-lowering treatment and obtain urgent ophthalmological assessment.
D. Commence topical corticosteroids alone.
E. Reassure the patient and arrange routine outpatient ophthalmology review.
Answer: C
C: This patient has acute angle-closure glaucoma, an ophthalmic emergency that can rapidly cause irreversible optic nerve damage and permanent visual loss. Immediate treatment is required to lower intraocular pressure using appropriate pressure-lowering medications, with urgent ophthalmological involvement for definitive management, usually laser peripheral iridotomy once the acute attack is controlled.
A: Chloramphenicol treats bacterial ocular infection and does not reduce the dangerously elevated intraocular pressure.
B: Delaying treatment risks permanent visual loss.
D: Topical corticosteroids may sometimes be used as an adjunct but do not adequately lower intraocular pressure when used alone.
E: Acute angle-closure glaucoma requires emergency treatment, not routine outpatient follow-up.
Memory anchor: Painful red eye + haloes + mid-dilated pupil → angle closure → lower pressure NOW.
AMC-0023
A 58-year-old woman presents to the Emergency Department with sudden onset of severe right upper quadrant abdominal pain associated with fever, nausea and vomiting. She has had several previous episodes of postprandial right upper quadrant discomfort that resolved spontaneously. On examination, her temperature is 38.4°C, heart rate is 106 beats/min, blood pressure is 126/74 mmHg and respiratory rate is 20 breaths/min. She has marked right upper quadrant tenderness and a positive Murphy sign. Investigations show haemoglobin 132 g/L (115–165), white cell count 15.8 × 10⁹/L (4.0–11.0), C-reactive protein 86 mg/L (<5), bilirubin 18 µmol/L (<20), alkaline phosphatase 105 U/L (30–110) and alanine aminotransferase 32 U/L (<35). What is the most appropriate initial imaging investigation?
A. CT scan of the abdomen.
B. Magnetic resonance cholangiopancreatography.
C. Endoscopic retrograde cholangiopancreatography.
D. Hepatobiliary iminodiacetic acid scan.
E. Right upper quadrant abdominal ultrasound.
Answer: E
E: This presentation is typical of acute cholecystitis, with persistent right upper quadrant pain, fever, inflammatory markers and a positive Murphy sign. Ultrasound is the first-line imaging investigation because it can demonstrate gallstones, gallbladder wall thickening, pericholecystic fluid and a sonographic Murphy sign.
A: CT can identify complications or alternative diagnoses but is not the preferred initial investigation for uncomplicated suspected acute cholecystitis.
B: MRCP is primarily used when choledocholithiasis or biliary obstruction is suspected and is not the routine first investigation here.
C: ERCP is a therapeutic invasive procedure used mainly for biliary obstruction or cholangitis rather than uncomplicated acute cholecystitis.
D: A HIDA scan can help when ultrasound findings are equivocal, but it is generally not the initial imaging test.
Memory anchor: Fever + RUQ pain + Murphy sign → cholecystitis → ultrasound first.
AMC-0022
A 29-year-old man presents to the Emergency Department with progressive weakness and tingling in both feet that began 4 days ago and has now ascended to his thighs. Two weeks earlier he had a self-limiting episode of diarrhoea. On examination, his temperature is 36.8°C, heart rate is 88 beats/min, blood pressure is 128/76 mmHg and respiratory rate is 18 breaths/min. He has symmetrical weakness of both lower limbs, absent knee and ankle reflexes, and mild weakness of both hands. Sensation is mildly reduced distally. What is the most appropriate next step in management?
A. Discharge with outpatient neurology follow-up.
B. Commence high-dose intravenous corticosteroids.
C. Admit to hospital for respiratory and autonomic monitoring and commence intravenous immunoglobulin.
D. Commence oral pyridostigmine.
E. Arrange urgent spinal surgery.
Answer: C
C: This patient has Guillain–Barré syndrome, suggested by progressive symmetrical ascending weakness and areflexia following a gastrointestinal infection. He requires hospital admission because respiratory muscle weakness and autonomic instability can develop rapidly. Respiratory function should be monitored serially, and intravenous immunoglobulin or plasma exchange is used for patients with significant or progressive weakness.
A: Guillain–Barré syndrome can deteriorate rapidly and requires inpatient monitoring.
B: Corticosteroids have not been shown to provide meaningful benefit in Guillain–Barré syndrome.
D: Pyridostigmine is used for symptomatic treatment of myasthenia gravis, which typically causes fatigable weakness without sensory symptoms or areflexia.
E: The symmetrical ascending pattern with areflexia is characteristic of a peripheral neuropathy rather than a surgically correctable spinal lesion.
Memory anchor: Guillain–Barré → ascending weakness + absent reflexes → watch breathing → IVIG/plasma exchange.
AMC-0021
A 63-year-old man presents to the Emergency Department with haematemesis and melaena. He has a history of alcohol-related cirrhosis and oesophageal varices. On examination, his temperature is 36.5°C, heart rate is 118 beats/min, blood pressure is 92/58 mmHg and respiratory rate is 22 breaths/min. He is pale and has cool peripheries. Two large-bore intravenous cannulas are inserted and initial resuscitation is commenced. Investigations show haemoglobin 76 g/L (130–180), platelet count 88 × 10⁹/L (150–400), INR 1.6 (0.8–1.2), urea 14.2 mmol/L (3.0–8.0) and creatinine 112 µmol/L (60–110). After initial haemodynamic resuscitation, what is the most appropriate next management?
A. Commence intravenous proton pump inhibitor therapy alone and observe.
B. Arrange elective endoscopy within 1 week.
C. Insert a Sengstaken–Blakemore tube immediately as definitive treatment.
D. Commence a vasoactive agent such as octreotide and intravenous antibiotics, and arrange urgent endoscopy.
E. Commence oral propranolol.
Answer: D
D: This patient has a suspected acute variceal upper gastrointestinal haemorrhage. Following initial resuscitation, treatment should include a vasoactive drug to reduce portal pressure, prophylactic intravenous antibiotics because infection is common and increases rebleeding and mortality, and urgent endoscopy for diagnosis and endoscopic haemostasis, usually variceal band ligation.
A: Proton pump inhibitors may be used when the bleeding source is uncertain, but PPI therapy alone is inadequate for suspected variceal haemorrhage.
B: Acute variceal bleeding requires urgent rather than elective endoscopy.
C: Balloon tamponade is a temporary rescue measure for uncontrolled massive variceal bleeding when standard therapy fails; it is not definitive first-line treatment.
E: Non-selective beta-blockers are used for prevention of variceal bleeding or rebleeding but are inappropriate during haemodynamic instability and do not control an acute haemorrhage.
Memory anchor: Bleeding varices → resuscitate + vasoactive drug + antibiotics + urgent banding.
AMC-0020
A 34-year-old woman at 34 weeks’ gestation presents to the maternity assessment unit with a severe headache, blurred vision and right upper quadrant abdominal pain. Her pregnancy has previously been uncomplicated. On examination, her temperature is 36.8°C, heart rate is 92 beats/min, blood pressure is 172/112 mmHg and respiratory rate is 18 breaths/min. She has brisk lower limb reflexes and bilateral ankle oedema. Investigations show haemoglobin 118 g/L (115–165), platelet count 82 × 10⁹/L (150–400), creatinine 96 µmol/L (45–90), alanine aminotransferase 124 U/L (<35) and urine protein:creatinine ratio 68 mg/mmol (<30). What is the most appropriate next step in management?
A. Discharge home with oral antihypertensive therapy and review in 48 hours.
B. Commence magnesium sulfate and urgent blood pressure control, with obstetric assessment for delivery after maternal stabilisation.
C. Administer corticosteroids and delay delivery until 37 weeks’ gestation.
D. Commence intravenous fluids rapidly to correct presumed intravascular depletion.
E. Arrange outpatient fetal ultrasound and repeat blood tests in 1 week.
Answer: B
B: This patient has pre-eclampsia with severe features, including severe hypertension, neurological symptoms, right upper quadrant pain, thrombocytopenia and elevated liver enzymes. Magnesium sulfate is given for prevention of eclamptic seizures, severe hypertension requires urgent treatment, and delivery should be planned following maternal stabilisation because she is already 34 weeks pregnant with significant maternal disease.
A: Severe pre-eclampsia requires hospital management and cannot safely be managed as an outpatient.
C: Antenatal corticosteroids may be considered when preterm birth is anticipated, but delivery should not be delayed when maternal indications require it.
D: Aggressive intravenous fluid administration can increase the risk of pulmonary oedema in pre-eclampsia.
E: Outpatient monitoring is unsafe in a patient with severe hypertension and evidence of maternal organ dysfunction.
Memory anchor: Severe pre-eclampsia → magnesium + control BP + stabilise → deliver.
AMC-0019
A 66-year-old woman presents to her General Practitioner with increasing fatigue and mild nausea over the past week. She was recently diagnosed with small-cell lung cancer and has not yet commenced treatment. On examination, her temperature is 36.8°C, heart rate is 78 beats/min, blood pressure is 126/74 mmHg and respiratory rate is 16 breaths/min. She is alert and clinically euvolaemic, with no peripheral oedema or postural hypotension. Investigations show sodium 124 mmol/L (135–145), potassium 4.1 mmol/L (3.5–5.0), serum osmolality 262 mOsm/kg (275–295), urine osmolality 480 mOsm/kg (50–1200) and urine sodium 58 mmol/L (<20 in appropriate sodium conservation). Renal, thyroid and adrenal function are normal. What is the most appropriate initial management?
A. Intravenous 0.9% sodium chloride.
B. Intravenous 3% sodium chloride.
C. Fluid restriction.
D. Oral sodium bicarbonate.
E. Intravenous furosemide.
Answer: C
C: This patient has hypotonic euvolaemic hyponatraemia due to SIADH, strongly associated with small-cell lung cancer. Because the hyponatraemia is moderate and she has no severe neurological symptoms, initial management is fluid restriction while addressing the underlying cause. Sodium must be corrected carefully because overly rapid correction can cause osmotic demyelination. (Queensland Health)
A: Isotonic saline is appropriate for hypovolaemic hyponatraemia but may be ineffective or worsen hyponatraemia in SIADH.
B: Hypertonic saline is generally reserved for severe or significantly symptomatic hyponatraemia, such as seizures or reduced consciousness. (Queensland Health)
D: Sodium bicarbonate does not treat SIADH.
E: Furosemide is not the appropriate first-line treatment for this stable, euvolaemic patient.
Memory anchor: SIADH = euvolaemic + low serum osmolality + concentrated urine → restrict fluids.
AMC-0018
A 26-year-old woman presents to her General Practitioner with a 6-week history of palpitations, heat intolerance, increased sweating and unintentional weight loss of 5 kg despite an increased appetite. On examination, her temperature is 37.2°C, heart rate is 108 beats/min, blood pressure is 138/72 mmHg and respiratory rate is 16 breaths/min. She has a fine tremor, a smooth diffuse goitre and bilateral lid retraction. Investigations show thyroid-stimulating hormone <0.01 mIU/L (0.4–4.0) and free T4 32 pmol/L (10–20). What is the most appropriate next investigation?
A. Thyroid ultrasound.
B. Fine-needle aspiration of the thyroid.
C. CT scan of the neck.
D. TSH receptor antibody testing.
E. Repeat thyroid function tests in 6 months.
Answer: D
D: This patient has biochemical thyrotoxicosis with clinical features strongly suggestive of Graves disease, including a diffuse goitre and eye signs. TSH receptor antibody testing can confirm Graves disease and is particularly useful when establishing the cause of thyrotoxicosis. A positive result supports the diagnosis without requiring thyroid imaging in a typical presentation.
A: Ultrasound is primarily useful for assessing structural thyroid abnormalities such as nodules and is not routinely required to diagnose Graves disease.
B: Fine-needle aspiration is used to assess suspicious thyroid nodules, not diffuse thyrotoxicosis.
C: CT neck is not a routine investigation for uncomplicated Graves disease.
E: This patient has overt thyrotoxicosis requiring investigation and treatment rather than observation for 6 months.
Memory anchor: Low TSH + high T4 + diffuse goitre/eye signs → Graves → TRAb.
AMC-0017
A 69-year-old man presents to the Emergency Department with increasing dyspnoea, productive cough and wheeze over the past 3 days. He has severe chronic obstructive pulmonary disease and continues to smoke 15 cigarettes daily. On examination, his temperature is 37.6°C, heart rate is 108 beats/min, blood pressure is 138/82 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 84% on room air. He is alert but using accessory muscles of respiration. Arterial blood gas analysis shows pH 7.36 (7.35–7.45), PaCO₂ 48 mmHg (35–45), PaO₂ 52 mmHg (80–100) and bicarbonate 27 mmol/L (22–28). What is the most appropriate target oxygen saturation during initial controlled oxygen therapy?
A. 75–80%.
B. 80–84%.
C. 88–92%.
D. 94–98%.
E. 100%.
Answer: C
C: This patient has an acute exacerbation of COPD with significant hypoxaemia. Australian COPD guidance recommends controlled supplemental oxygen targeting an SpO₂ of 88–92%. This corrects dangerous hypoxaemia while reducing the risk of excessive oxygen worsening hypercapnia and respiratory acidosis. (Lung Foundation Australia)
A: This target permits significant ongoing hypoxaemia.
B: An oxygen saturation of 80–84% remains inadequately low.
D: Routinely targeting 94–98% risks over-oxygenation in an acute COPD exacerbation.
E: An SpO₂ of 100% is unnecessary and may increase the risk of oxygen-induced hypercapnia.
Memory anchor: COPD + oxygen → 88–92%.
AMC-0016
A 56-year-old man presents to the Emergency Department with severe epigastric pain radiating to his back that began 8 hours ago. He has vomited several times and reports drinking approximately six standard alcoholic drinks daily. On examination, his temperature is 37.8°C, heart rate is 112 beats/min, blood pressure is 104/66 mmHg and respiratory rate is 22 breaths/min. He has marked epigastric tenderness without rigidity. Investigations show haemoglobin 151 g/L (130–180), white cell count 15.4 × 10⁹/L (4.0–11.0), lipase 1,240 U/L (<60), sodium 137 mmol/L (135–145), potassium 4.1 mmol/L (3.5–5.0), urea 9.6 mmol/L (3.0–8.0) and creatinine 118 µmol/L (60–110). What is the most appropriate initial management?
A. Urgent endoscopic retrograde cholangiopancreatography.
B. Commence broad-spectrum intravenous antibiotics.
C. Keep the patient nil by mouth until the lipase normalises.
D. Intravenous crystalloid fluids, adequate analgesia and early oral feeding as tolerated.
E. Urgent laparotomy.
Answer: D
D: This patient has acute pancreatitis, supported by characteristic epigastric pain radiating to the back and a markedly elevated lipase. Initial treatment is supportive, with intravenous crystalloid resuscitation, adequate analgesia and close monitoring. Oral feeding should be commenced early as tolerated rather than routinely withholding food until pancreatic enzymes normalise.
A: ERCP is indicated urgently when acute pancreatitis is associated with cholangitis or persistent biliary obstruction, neither of which is demonstrated here.
B: Prophylactic antibiotics are not routinely indicated in uncomplicated acute pancreatitis.
C: Prolonged fasting is unnecessary; early enteral nutrition is preferred when tolerated.
E: Acute pancreatitis is generally managed non-operatively unless a specific surgical complication develops.
AMC-0015
A 3-year-old boy is brought to the Emergency Department with a 5-day history of fever, irritability and reduced appetite. His parents have also noticed red eyes and a widespread rash. On examination, his temperature is 39.1°C, heart rate is 128 beats/min, blood pressure is 94/58 mmHg and respiratory rate is 24 breaths/min. He has bilateral non-purulent conjunctival injection, erythematous cracked lips, a strawberry tongue, a polymorphous truncal rash, swollen erythematous hands and feet, and a 2 cm non-tender left cervical lymph node. Investigations show haemoglobin 105 g/L (110–145), white cell count 16.2 × 10⁹/L (5.0–15.0), platelet count 472 × 10⁹/L (150–450), C-reactive protein 96 mg/L (<5) and erythrocyte sedimentation rate 68 mm/hour (<20). What is the most appropriate treatment?
A. Intravenous immunoglobulin and aspirin.
B. Intravenous ceftriaxone.
C. Oral prednisolone alone.
D. Oral amoxicillin.
E. Supportive treatment with paracetamol and fluids only.
Answer: A
A: This child has Kawasaki disease, with prolonged fever, bilateral non-purulent conjunctivitis, oral mucosal changes, rash, extremity changes and cervical lymphadenopathy. Intravenous immunoglobulin is the main treatment and substantially reduces the risk of coronary artery aneurysms; aspirin is also used as part of treatment. Echocardiographic assessment is required to evaluate coronary artery involvement.
B: Ceftriaxone is appropriate for selected serious bacterial infections but does not treat the underlying vasculitis in Kawasaki disease.
C: Corticosteroids may be added in selected high-risk or treatment-resistant cases but are not used alone as standard initial therapy.
D: Amoxicillin does not treat Kawasaki disease.
E: Supportive care alone leaves the child at increased risk of coronary artery complications.
AMC-0014
A 31-year-old woman is brought to the Emergency Department by her partner 8 days after giving birth to her first child. Over the past 3 days she has slept very little, become increasingly agitated and started saying that her baby has been possessed and must be “saved”. She reports hearing a voice telling her that the baby is evil. Her partner says she attempted to leave the house with the baby at 3 am and has become increasingly difficult to manage. She has no previous psychiatric history. On examination, she is restless, suspicious and responding to unseen stimuli. What is the most appropriate next step in management?
A. Reassure her partner that transient mood changes are common after childbirth and arrange review in 48 hours.
B. Commence an antidepressant and arrange outpatient psychiatric follow-up.
C. Ask her partner to supervise her at home and arrange a General Practitioner appointment the following day.
D. Provide psychological therapy and review her in 1 week.
E. Arrange immediate psychiatric assessment and hospital admission, ensuring the safety of both mother and baby.
Answer: E
E: This presentation is consistent with postpartum psychosis, a psychiatric emergency with potentially serious risk to both mother and infant. New-onset hallucinations, delusions, severe behavioural disturbance and markedly reduced sleep shortly after childbirth require immediate specialist psychiatric assessment, safety assessment and usually hospital treatment; outpatient management is inappropriate. (BMJ Best Practice)
A: Postpartum blues causes mild, transient emotional symptoms, not psychosis, hallucinations or dangerous behaviour.
B: Antidepressant monotherapy is not appropriate initial management of an acute psychotic presentation.
C: Home supervision is insufficient given the significant risk associated with her psychosis and impaired judgement.
D: Psychological therapy alone is inappropriate for an acute psychiatric emergency requiring immediate specialist treatment.
AMC-0013
A 68-year-old man presents to the Emergency Department with sudden severe pain in his left leg that began 3 hours ago. He has a history of atrial fibrillation and stopped taking his anticoagulant several months ago. On examination, his temperature is 36.7°C, heart rate is 108 beats/min and irregularly irregular, blood pressure is 142/84 mmHg and respiratory rate is 18 breaths/min. His left leg is pale and cool below the knee, with reduced sensation and weakness of ankle movement. The left dorsalis pedis and posterior tibial pulses are absent, while pulses in the right leg are normal. What is the most appropriate immediate management?
A. Arrange outpatient arterial Doppler ultrasonography.
B. Commence intravenous unfractionated heparin and obtain urgent vascular surgical assessment.
C. Commence aspirin and observe for 24 hours.
D. Apply compression stockings and elevate the affected leg.
E. Commence intravenous antibiotics.
Answer: B
B: This patient has acute limb ischaemia, most likely from an arterial embolus related to atrial fibrillation. The combination of sudden pain, pallor, pulselessness, coolness, sensory loss and weakness indicates a threatened limb. Intravenous unfractionated heparin should be commenced promptly to prevent thrombus propagation while urgent vascular assessment and revascularisation are arranged.
A: Outpatient investigation would dangerously delay treatment of a threatened limb.
C: Aspirin alone is inadequate for acute limb ischaemia requiring urgent anticoagulation and vascular intervention.
D: Compression and elevation are used for venous disorders and may further compromise arterial perfusion.
E: There are no features suggesting infection as the cause of the acute limb symptoms.
AMC-0012
A 74-year-old woman presents to her General Practitioner with a 3-month history of increasing fatigue, headaches and pain in both shoulders, particularly in the morning. She reports difficulty brushing her hair because of shoulder stiffness. Over the past week she has developed pain in her jaw while chewing but has no visual symptoms. On examination, her temperature is 37.2°C, heart rate is 82 beats/min, blood pressure is 136/78 mmHg and respiratory rate is 16 breaths/min. There is tenderness over the right temporal artery and reduced range of movement of both shoulders. Investigations show haemoglobin 108 g/L (115–165), platelet count 486 × 10⁹/L (150–400), C-reactive protein 82 mg/L (<5) and erythrocyte sedimentation rate 76 mm/hour (<30). What is the most appropriate next step in management?
A. Arrange temporal artery biopsy and withhold treatment until the result is available.
B. Commence a non-steroidal anti-inflammatory drug and review in 1 week.
C. Arrange an urgent CT scan of the brain.
D. Commence high-dose corticosteroid therapy immediately.
E. Commence low-dose corticosteroid therapy for polymyalgia rheumatica.
Answer: D
D: This patient has features of giant cell arteritis, including new headache, temporal artery tenderness, jaw claudication and markedly elevated inflammatory markers, with associated polymyalgia rheumatica symptoms. High-dose corticosteroids should be commenced immediately because treatment delay can result in irreversible visual loss; diagnostic confirmation should be arranged without delaying treatment.
A: Temporal artery biopsy may help confirm the diagnosis, but corticosteroid treatment must not be delayed while awaiting biopsy.
B: NSAIDs do not adequately treat giant cell arteritis or prevent its ischaemic complications.
C: CT brain does not establish the diagnosis and would delay essential treatment.
E: The shoulder symptoms suggest polymyalgia rheumatica, but the headache, temporal tenderness and jaw claudication indicate concomitant giant cell arteritis requiring higher-dose corticosteroid therapy.
AMC-0011
A 42-year-old woman develops sudden generalised urticaria, facial swelling, wheeze and dizziness approximately 10 minutes after receiving intravenous cefazolin. On examination, she appears distressed, her temperature is 36.8°C, heart rate is 124 beats/min, blood pressure is 78/46 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 91% on room air. There is widespread expiratory wheeze and swelling of the lips and tongue. What is the most appropriate immediate treatment?
A. Intramuscular adrenaline into the outer mid-thigh.
B. Intravenous hydrocortisone.
C. Intravenous chlorphenamine.
D. Nebulised salbutamol.
E. Intravenous adrenaline bolus.
Answer: A
A: This patient has anaphylaxis with airway, respiratory and cardiovascular involvement. Intramuscular adrenaline is the first-line treatment and should be administered immediately into the outer mid-thigh; treatment must not be delayed for antihistamines or corticosteroids. Further intramuscular adrenaline can be given if there is an inadequate response. (Allergy Australia)
B: Corticosteroids are not first-line treatment and must not delay adrenaline.
C: Antihistamines may improve cutaneous symptoms but do not treat the life-threatening airway obstruction or hypotension.
D: Salbutamol can be used as an adjunct for persistent bronchospasm but does not replace adrenaline.
E: Intravenous adrenaline boluses carry substantial risk and are not first-line treatment for anaphylaxis; refractory cases require specialist management, typically with an adrenaline infusion. (Allergy Australia)
AMC-0010
A 35-year-old woman presents to the Emergency Department with worsening tremor, vomiting, diarrhoea and unsteadiness over the past 2 days. She has bipolar disorder treated with lithium and recently commenced ibuprofen for lower back pain. On examination, her temperature is 37.0°C, heart rate is 96 beats/min, blood pressure is 102/64 mmHg and respiratory rate is 18 breaths/min. She has a coarse tremor, dysarthria and an ataxic gait. Investigations show serum lithium 2.3 mmol/L (0.6–1.0), sodium 138 mmol/L (135–145), potassium 4.2 mmol/L (3.5–5.0), urea 11.2 mmol/L (2.5–7.8) and creatinine 148 µmol/L (45–90). What is the most appropriate initial management?
A. Continue lithium at a reduced dose and repeat the lithium level in 24 hours.
B. Administer activated charcoal.
C. Commence intravenous sodium bicarbonate.
D. Cease lithium and commence intravenous 0.9% sodium chloride.
E. Commence oral sodium chloride tablets.
Answer: D
D: This patient has symptomatic lithium toxicity, with gastrointestinal symptoms, coarse tremor, dysarthria and ataxia, together with impaired renal function. Lithium should be ceased immediately and intravenous 0.9% sodium chloride commenced to correct volume depletion and promote renal lithium elimination. Severe or worsening neurological toxicity, renal impairment or persistently high lithium concentrations may require haemodialysis.
A: Continuing lithium would worsen the toxicity.
B: Activated charcoal does not effectively bind lithium and therefore has no useful role in isolated lithium poisoning.
C: Sodium bicarbonate is not routinely used to enhance lithium elimination.
E: Oral sodium chloride is inadequate for a symptomatic patient who requires intravenous fluid resuscitation.
AMC-0009
A 32-year-old man is brought to the Emergency Department by ambulance because of increasing drowsiness over the past 12 hours. He has a history of type 1 diabetes mellitus and has been unwell with vomiting and diarrhoea for 2 days. On examination, his temperature is 37.8°C, heart rate is 122 beats/min, blood pressure is 94/60 mmHg, respiratory rate is 30 breaths/min and oxygen saturation is 98% on room air. He is dehydrated and has deep, rapid respirations. Investigations show glucose 28.6 mmol/L (3.9–5.5 fasting), ketones 5.8 mmol/L (<0.6), sodium 130 mmol/L (135–145), potassium 5.6 mmol/L (3.5–5.0), bicarbonate 9 mmol/L (22–28), venous pH 7.12 (7.35–7.45) and creatinine 156 µmol/L (60–110). What is the most appropriate initial management?
A. Commence an intravenous insulin infusion immediately.
B. Administer intravenous sodium bicarbonate.
C. Commence 0.9% sodium chloride intravenously before insulin.
D. Administer intravenous potassium immediately.
E. Commence 5% dextrose intravenously.
Answer: C
C: This patient has diabetic ketoacidosis (DKA), characterised by hyperglycaemia, ketosis and metabolic acidosis. The immediate priority is restoration of intravascular volume with intravenous 0.9% sodium chloride. Fluid resuscitation improves tissue perfusion, reduces circulating glucose concentrations and begins correcting electrolyte abnormalities. Once initial fluids have been started and potassium has been assessed, intravenous insulin is commenced to stop ketone production and correct the metabolic acidosis.
A: Insulin is essential but should be started after initial fluid resuscitation.
B: Sodium bicarbonate is not routinely recommended and is reserved for severe acidosis in selected circumstances.
D: Although total body potassium is depleted, the initial serum potassium is elevated; replacement is guided by repeat potassium measurements during treatment.
E: Dextrose is introduced later, once the blood glucose falls while ketoacidosis persists, to allow continued insulin therapy until ketone clearance.
AMC-0008
A 10-year-old boy is brought to the Emergency Department with a 24-hour history of abdominal pain that began around the umbilicus and has now localised to the right iliac fossa. He has vomited twice and has no appetite. On examination, his temperature is 38.1°C, heart rate is 112 beats/min, blood pressure is 108/68 mmHg, respiratory rate is 20 breaths/min and oxygen saturation is 98% on room air. He has localised tenderness and guarding in the right iliac fossa. Investigations show a white cell count of 15.8 × 10⁹/L (4.0–11.0) and C-reactive protein of 54 mg/L (<5). What is the most appropriate next investigation?
A. Abdominal CT scan with intravenous contrast.
B. Plain abdominal X-ray.
C. Abdominal ultrasound.
D. MRI abdomen.
E. No further investigation before surgery.
Answer: C
C: Ultrasound is the preferred initial imaging modality in children with suspected appendicitis because it avoids ionising radiation and has good diagnostic accuracy.
A: CT is reserved for equivocal cases or when ultrasound is non-diagnostic because of radiation exposure.
B: Plain abdominal X-ray has little value in diagnosing appendicitis.
D: MRI may be used in selected cases but is not the routine first-line investigation.
E: Most children undergo imaging before surgery unless the diagnosis is unequivocal.
AMC-0007
A 28-year-old school teacher presents to her General Practitioner because she has noticed a painless lump in the front of her neck over the past 2 months. She reports occasional palpitations but denies weight loss, tremor or heat intolerance. She has no history of neck irradiation and no family history of thyroid cancer. On examination, her temperature is 36.7°C, heart rate is 84 beats/min, blood pressure is 122/74 mmHg and respiratory rate is 14 breaths/min. A solitary, firm, 2 cm thyroid nodule is palpable in the right lobe with no cervical lymphadenopathy. Thyroid function tests show TSH 2.1 mIU/L and free T4 15 pmol/L. What is the most appropriate next investigation?
A. Commence levothyroxine.
B. Arrange a radionuclide thyroid scan.
C. Repeat thyroid function tests in 6 months.
D. Arrange a thyroid ultrasound.
E. Request a CT scan of the neck.
Answer: D
D: A palpable thyroid nodule with a normal TSH should be assessed with ultrasound to characterise its features and determine whether fine-needle aspiration is required. (RACGP)
A: Levothyroxine is not indicated in a euthyroid patient with an undiagnosed thyroid nodule.
B: Radionuclide scanning is primarily used when the TSH is suppressed. (RACGP)
C: A persistent palpable nodule requires structural assessment rather than repeat blood tests alone.
E: CT is not the initial investigation for an uncomplicated thyroid nodule.
AMC-0006
A 6-year-old boy is brought to the Emergency Department because of increasing difficulty breathing. He has a history of asthma and has required two previous hospital admissions. His parents have administered six doses of salbutamol via a spacer over the past hour with minimal improvement. On examination, he is sitting upright, unable to complete full sentences, his temperature is 37.1°C, heart rate is 138 beats/min, respiratory rate is 38 breaths/min and oxygen saturation is 90% on room air. He has widespread wheeze with reduced air entry bilaterally. What is the most appropriate next step in management?
A. Discharge home with oral prednisolone.
B. Commence oxygen, inhaled salbutamol and ipratropium bromide, and administer systemic corticosteroids.
C. Prescribe oral amoxicillin and review in 48 hours.
D. Arrange a chest X-ray before commencing treatment.
E. Nebulise adrenaline.
Answer: B
B: This child has acute severe asthma requiring immediate oxygen, inhaled bronchodilators and systemic corticosteroids.
A: Discharge is unsafe because he has hypoxaemia and severe respiratory distress.
C: There is no evidence of a bacterial infection requiring antibiotics.
D: Treatment should not be delayed for imaging unless another diagnosis is suspected.
E: Nebulised adrenaline is indicated for upper airway obstruction, not acute asthma.
AMC-0005
A 72-year-old man presents to the Emergency Department with sudden onset of left-sided weakness and slurred speech that began 90 minutes ago while eating breakfast. His medical history includes atrial fibrillation, hypertension and hyperlipidaemia. He stopped taking apixaban 3 weeks ago because of recurrent epistaxis. On examination, his temperature is 36.9°C, heart rate is 96 beats/min and irregularly irregular, blood pressure is 168/94 mmHg, respiratory rate is 18 breaths/min and oxygen saturation is 97% on room air. Neurological examination demonstrates left facial weakness, left arm and leg weakness, and dysarthria. Capillary blood glucose is 6.1 mmol/L. What is the most appropriate next step in management?
A. Administer aspirin immediately.
B. Arrange an urgent non-contrast CT scan of the brain.
C. Administer intravenous heparin.
D. Lower the blood pressure to below 120/80 mmHg before further assessment.
E. Arrange an outpatient MRI of the brain.
Answer: B
B: An urgent non-contrast CT brain is required to distinguish ischaemic from haemorrhagic stroke before initiating specific treatment.
A: Aspirin should not be given until intracranial haemorrhage has been excluded.
C: Heparin is not recommended in the acute management of suspected ischaemic stroke.
D: Aggressive blood pressure reduction may worsen cerebral perfusion and is not indicated before imaging.
E: This patient has an acute stroke requiring immediate assessment and treatment, not outpatient investigation.
AMC-0004
A 24-year-old woman presents to the Emergency Department with a 2-day history of fever, dysuria, urinary frequency and right-sided flank pain. She has vomited twice today and is unable to tolerate oral fluids. She has no significant past medical history and is not pregnant. On examination, her temperature is 39.2°C, heart rate is 116 beats/min, blood pressure is 98/62 mmHg, respiratory rate is 22 breaths/min and oxygen saturation is 98% on room air. She has marked right costovertebral angle tenderness. Urinalysis is positive for nitrites, leukocyte esterase and blood. What is the most appropriate next step in management?
A. Prescribe oral trimethoprim and discharge home.
B. Prescribe nitrofurantoin and arrange General Practitioner follow-up.
C. Admit for intravenous antibiotics and intravenous fluids.
D. Arrange an outpatient renal ultrasound.
E. Repeat urinalysis in 48 hours before commencing treatment.
Answer: C
C: This patient has acute pyelonephritis with features of sepsis and requires hospital admission for intravenous antibiotics and fluid resuscitation.
A: Oral antibiotics are inappropriate in a patient with systemic illness and inability to tolerate oral intake.
B: Nitrofurantoin does not achieve adequate renal tissue concentrations and is not suitable for pyelonephritis.
D: Imaging may be required if obstruction or complications are suspected but should not delay treatment.
E: Treatment should begin immediately; delaying therapy increases the risk of complications.
AMC-0003
A 67-year-old man presents to his General Practitioner because of increasing fatigue over the past 4 months. He has noticed intermittent constipation and mild diffuse abdominal discomfort but denies rectal bleeding or weight loss. His medical history includes hypertension treated with perindopril. On examination, he appears pale. His temperature is 36.7°C, heart rate is 88 beats/min, blood pressure is 132/78 mmHg and oxygen saturation is 98% on room air. Abdominal examination is unremarkable. Investigations show haemoglobin 92 g/L (135–180), mean corpuscular volume 72 fL (80–100), ferritin 8 µg/L (30–300), white cell count 6.5 × 10⁹/L and platelet count 410 × 10⁹/L. What is the most appropriate next step in management?
A. Commence oral iron therapy and review in 3 months.
B. Arrange faecal occult blood testing.
C. Arrange urgent bidirectional endoscopy (gastroscopy and colonoscopy).
D. Request a CT scan of the abdomen and pelvis.
E. Reassure the patient that iron deficiency is common in older adults.
Answer: C
C: Iron deficiency anaemia in an older man should be considered gastrointestinal malignancy until proven otherwise and requires urgent upper and lower gastrointestinal investigation.
A: Iron replacement is necessary but should not delay investigation for the cause.
B: Faecal occult blood testing is a screening test and is not appropriate once iron deficiency anaemia is established.
D: CT may be useful after endoscopic assessment but is not the initial investigation.
E: Iron deficiency anaemia in an older man always requires investigation for an underlying cause.
AMC-0002
A 29-year-old woman presents to the Emergency Department with a 6-hour history of left iliac fossa pain and light vaginal bleeding. Her last menstrual period was 7 weeks ago. She has a history of pelvic inflammatory disease. On examination, her temperature is 36.8°C, heart rate is 104 beats/min, blood pressure is 106/68 mmHg, respiratory rate is 18 breaths/min and oxygen saturation is 99% on room air. She has tenderness in the left iliac fossa with mild guarding. A urine pregnancy test is positive. What is the most appropriate next investigation?
A. Repeat the urine pregnancy test in 1 week.
B. Arrange an urgent transvaginal ultrasound and quantitative serum β-hCG.
C. Request a CT scan of the abdomen and pelvis.
D. Commence oral doxycycline for presumed pelvic inflammatory disease.
E. Commence methotrexate immediately.
Answer: B
B: Suspected ectopic pregnancy requires urgent transvaginal ultrasound and quantitative serum β-hCG.
A: Delays diagnosis of a potentially life-threatening condition.
C: CT is not the first-line investigation in early pregnancy and exposes the patient to unnecessary ionising radiation.
D: Ectopic pregnancy must be excluded before treating presumed pelvic inflammatory disease.
E: Methotrexate is only appropriate after the diagnosis is confirmed and eligibility criteria are met.
AMC-0001
A 58-year-old man presents to the Emergency Department with intermittent central chest discomfort that began while walking uphill earlier that morning. The pain lasted approximately 15 minutes and resolved with rest. During the past week he has experienced three similar episodes occurring with progressively less exertion. His medical history includes hypertension, hyperlipidaemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 35 years. On examination, his blood pressure is 148/88 mmHg, heart rate is 82 beats/min, respiratory rate is 16 breaths/min, temperature is 36.8°C and oxygen saturation is 98% on room air. He is currently pain-free. ECG demonstrates normal sinus rhythm without ST-segment elevation or depression, and his initial high-sensitivity troponin is within the normal reference range. What is the most appropriate next step in management?
A. Discharge home because the ECG and troponin are normal.
B. Arrange an outpatient exercise stress test within one month.
C. Admit for serial ECGs and repeat high-sensitivity troponin testing while commencing treatment for suspected acute coronary syndrome.
D. Administer thrombolytic therapy immediately.
E. Perform an urgent CT pulmonary angiogram.
Answer: C
C: High-risk features of non-ST-elevation acute coronary syndrome require admission, serial ECGs, serial troponins and treatment.
A: A normal initial ECG and troponin do not exclude acute coronary syndrome.
B: Stress testing is appropriate only after acute coronary syndrome has been excluded.
D: Thrombolysis is indicated for STEMI, not non-ST-elevation acute coronary syndrome.
E: The presentation is much more consistent with acute coronary syndrome than pulmonary embolism.
Simon R. Downes 