Emergency Medicine 1

Question: 1 of 12
Which of the following statements is/are true regarding a postoperative pulmonary embolus?
A chest x ray may be normal

Correct

Diagnosis can be confirmed by a radioisotope ventilation/perfusion scan

Correct
ECG may show an S wave in Lead I, a Q wave in Lead III and an inverted T wave in Lead III
Correct
It is invariably associated with chest pain
Incorrect answer selected
It is most commonly seen between seven and 10 days after operation

Correct

A postoperative pulmonary embolus occurs most commonly between seven and 10 days postoperatively and
may occur in the absence of clinical features of a deep venous thrombosis.
Risk factors include

Immobility
Malignancy
Prolonged surgery.

Patients undergoing particular operations (for example, hip surgery) are at particular risk.
The classical clinical presentation is with

Breathlessness
Pleuritic chest pain
Tachycardia
Hypotension.

A chest x ray may be normal.

The diagnosis can be confirmed by a V/Q can or spiral CT scanning.

Question: 2 of 12
Are the following statements about suspected acute pulmonary embolism correct?
A normal chest x ray excludes the diagnosis.

Incorrect answer selected

A normal plasma D dimer excludes the diagnosis.

Incorrect answer selected

A normal V/Q scan has a high negative predictive value.

Correct
Pulmonary angiography is the most reliable investigation for both proximal and distal emboli.
Correct
Spiral CT of the lungs is a sensitive tool for the diagnosis of emboli in proximal pulmonary arteries.
Correct

Poor at detecting small emboli in distal segmental arteries.

Emergency Medicine 2

There is about 2% chance of missing a PE with plasma D dimers. It has very high sensitivity (good
for detection) but poor specificity (poor at exclusion as a number of conditions cause raised D
dimers).
A normal VQ scan makes any but the smallest embolism unlikely.
CXR are almost always normal in small acute PE.
Pulmonary angiography is the gold standard of investigation but mortality in 0.5% cases, major
complications in 1% and minor complications in 0.5%.

Question: 3 of 12
Theme:Vaginal bleeding in pregnancy/puerperium
A Accidental haemorrhage
B Cancer of the cervix
C Coagulation failure
D Ectopic pregnancy
E Hydatidiform mole
F Incomplete abortion
G Missed abortion
H Placenta praevia
I Retained placenta
J Septic abortion
K Severe thyrotoxicosis
L Threatened abortion
M Urethral chemotaxis
N Uterine fibroids
In each of the following statements, select the most likely cause of vaginal bleeding:
A 16-year-old school girl who recently had a surgical termination of pregnancy was re-admitted with
abnormal vaginal bleeding and severe lower abdominal pain and fever. Her haemoglobin was 9 gm/dl and
her white cell count was 20,000/cm3.
Accidental haemorrhage

Incorrect - The correct answer is Septic abortion

The patient's fever and raised white cell count indicate infection and the abnormal bleeding/anaemia indicate
a septic abortion following a failed therapeutic abortion (occurs in approximately 3.6%). Most common
organisms are Escherichia coli, Bacteroides, Streptococci (anaerobic and aerobic) and Clostridium
perfringens.

An Asian woman who is G3P1+1 was admitted with a history of excessive vomiting, vaginal bleeding at 10
weeks gestation and minimal abdominal pain. Abdominal examination indicated a soft uterus, 16 weeks'
gestation, and doughy consistency. An ultrasound scan showed no fetal parts, but a snowy pattern. The
hcG was higher than the value for 10 weeks' gestation.
Accidental haemorrhage

Incorrect - The correct answer is Hydatidiform mole

Emergency Medicine 3

A raised hcG, which is a known cause of hyperemesis, should always raise the suspicion of a molar
pregnancy. The ultrasound appearances of echoes resembling a snowstorm is characteristic of hydatidiform
mole.

An African woman who had been investigated for 10 years primary infertility was admitted with a history of
severe onset lower abdominal pain followed by slight bleeding per vaginum. Her menses was two days
overdue. Her blood pressure was 80/50 mmHg, pulse 146/m and thready, haemoglobin 7 g/dl. Pregnancy
test was positive and ultrasound excluded any evidence of a fetus in either the uterine cavity or adnexa.
Accidental haemorrhage

Incorrect - The correct answer is Ectopic pregnancy

A positive pregnancy test in the absence of an intrauterine pregnancy on ultrasound should always arouse
suspicion of an ectopic pregnancy, which classically presents with haemodynamic compromise. The
patient's infertility is a clue to possible tubal pathology. Bleeding per vaginum is often slight in ectopic
pregnancy, and does not account for the severe anaemia. Ultrasound examination in this case is likely to
show copious free fluid.

A hypertensive, haemodynamically stable, 36 weeks pregnant woman was admitted with a history of
painless vaginal bleeding. She had a similar bleed at 20 weeks' gestation. On abdominal examination, the
uterus was consistent with her gestational age, soft and non- tender. Fetal lie was transverse and fetal heart
was audible.
Accidental haemorrhage

Incorrect - The correct answer is Placenta praevia

Placenta praevia classically presents with a painless bleed, occurring modally at 34 weeks. Bleeding in the
second trimester can be a feature. The lie is transverse because of the position of the placenta. A soft nontender uterus excludes major placental abruption.

A 33-year-old woman G5P4 presented with sudden abdominal pain and slight vaginal bleeding following a
car crash. She was pale, sweating, hypertensive and her pulse rate was 120 bpm. The uterus was tender and
hard, and fetal parts were difficult to define. Cardiotocography CTG showed signs of fetal distress.
Accidental haemorrhage

Correct
Any trauma can cause shearing forces on the placenta and lead to abruption or accidental haemorrhage. The
uterus is characteristically tender and hard, and fetal parts difficult to palpate. Separation of the placenta
leads to fetal compromise. Bleeding may be concealed and can lead to shock.

Further reading:
Causes of bleeding in pregnancy and its management GP Notebook

Question: 4 of 12
Theme:Abdominal pain
A Acute cystitis
B Addison's disease
C Appendicitis

Emergency Medicine 4

D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R

Cancer of the colon

Chronic inflammatory bowel disease
Diverticular disease
Ectopic pregnancy
Endometriosis
Inguinal hernia
Lead poisoning
Pelvic inflammatory disease
Primary spasmodic dysmenorrhoea
Pseudo-obstruction
Ruptured follicular cyst
Toxic megacolon
Urinary retention
Vesical calculus
Volvulus

Each of the subjects below is a woman presenting with lower abdominal pain.
Select the most likely diagnosis from the list of options.
A 23-year-old woman presents with a three day history of low abdominal pain, frequency of micturition and
a yellow, offensive vaginal discharge. Her bowel actions are regular and her weight is steady. Her last
period was three weeks previously and she is on no contraception.
Acute cystitis

Incorrect - The correct answer is Pelvic inflammatory disease

PID is associated with a malodorous, green or yellow discharge. It may be associated with sexually
transmitted diseases such as Chlamydia but may occur in a sexually inactive female.

A 24-year-old woman presents with a four month history of right-sided lower abdominal pain, watery
diarrhoea and a loss of weight of 6 kg. Her periods are regular taking the oral contraceptive pill.
Acute cystitis

Incorrect - The correct answer is Chronic inflammatory bowel

disease
The most likely answer in this case is chronic inflammatory bowel disease given the weight loss, abdominal
pain and diarrhoea. Addison's disease would present insidiously, and typically without bowel symptoms.

A 65-year-old with a ten year history constipation, and of left-sided lower abdominal pain which is worse on
defecation. Her weight is steady and she has normal micturition. She has had no periods for 15 years.
Acute cystitis

Incorrect - The correct answer is Diverticular disease

In a patient of this age diverticular disease is common and would present in this fashion. The fact that
weight loss is not present suggests that malignancy is not present.

Emergency Medicine 5

A 30-year-old woman presents with a six hour history of severe pain in the lower abdomen. She has had a
normal bowel motion this morning and her weight is steady. Her last period was six weeks ago and she has
an IUCD for contraception. BP 90/60 mmHg and HR 100 bpm.
Acute cystitis

Incorrect - The correct answer is Ectopic pregnancy

This patient has a short, acute history of abdominal pain and has features of early shock. She has missed her
last period and has normal bowel motions, with no weight loss. The IUCD is associated with a small risk of
ectopic pregnancy, and this is the most likely diagnosis from the above list.

A 15-year-old girl presents with agonising pain in the right lower abdomen for four hours. She has vomited
once but not had a bowel motion since the previous day. Her weight is steady. Her periods started 12
months ago and are still irregular, but the last was three weeks ago. She denies being sexually active.
Acute cystitis

Incorrect - The correct answer is Appendicitis

This patient has an acute history of right lower abdominal pain, vomiting and relative constipation.
Appendicitis is relatively common at this age, and is the most likely diagnosis in this scenario.

Everything about abdominal pain...

Question: 5 of 12
Are the following true regarding deep vein thrombosis (DVT)?
Is always found in patients with pulmonary emboli

Incorrect answer selected

Is detected most reliably using venography

Correct

Is reliably diagnosed through clinical examination

Incorrect answer selected

Prophylaxis requires twice daily low molecular weight heparin

Incorrect answer selected

Requires long term anticoagulation in patients with recurrent events Correct

DVT is clinically inapparent in approximately 70% of cases and may present with pulmonary embolism
(PE)/arrest or with a post-thrombotic syndrome.
It is diagnosed most reliably with venography which is the gold standard although B mode ultrasonography
has high specificity and sensitivity to enable its routine use.
Prophylaxis requires once daily low molecular weight heparin.
It is not found in about 20% of cases of PE.
Recurrent DVT should receive long term anticoagulation as this drastically reduces the incidence of
recurrent venous thromboembolism (20% to 2%).

Emergency Medicine 6

Question: 6 of 12
Is HELLP syndrome characterised by the following features?
Abnormal renal function

Incorrect answer selected

Fatty liver

Incorrect answer selected

Haemolysis

Correct

Pelvic pain

Incorrect answer selected

Thrombocytopenia

Correct

HELLP syndrome is haemolysis, elevated liver enzymes and low platelets and is frequently misdiagnosed at
presentation.
Many investigators consider the syndrome to be a variant of pre-eclampsia, but it may be a separate entity.
The pathogenesis of HELLP syndrome remains unclear.
Early diagnosis is critical because the morbidity and mortality rates associated with the syndrome have been
reported to be as high as 25%.

Question: 7 of 12
Two hours after delivery a healthy multiparous woman has a grand mal seizure that is initially controlled
with intravenous diazepam. May subsequent management include the following?
Anti-hypertensives

Correct

Diuretics

Correct

Intravenous twice normal saline Incorrect answer selected

Lithium

Incorrect answer selected

Magnesium sulphate

Correct

Magnesium, anti-hypertensives and diuretics may all be utilised in management of eclampsia and preeclampsia.

Question: 8 of 12
A 27-year-old woman is receiving magnesium for eclampsia at 37 weeks gestation.
Is it true that each of the following is a potential maternal effect of this treatment?
Decreased uterine blood flow

Incorrect answer selected

Loss of deep tendon reflexes prior to significant cardiac dysrhythmia

Correct

Sedation

Correct

Sensitisation to depolarising muscle relaxants

Correct

Sensitisation to non-depolarising muscle relaxants

Correct

Emergency Medicine 7

Magnesium is recognised to cause sensitisation to muscle relaxants and depolarising agents and is also a
vasodilator.

Question: 9 of 12
Are the following true regarding features of eclampsia/ pre-eclampsia?
A blood pressure of 160/110 mmHg can suggest a diagnosis of severe pre-eclampsia

Correct

General oedema is a useful diagnostic feature

Incorrect answer selected

Pre-eclampsia always precedes eclampsia

Incorrect answer selected

The use of spinal anaesthesia is entirely contraindicated

Incorrect answer selected

Thrombocytopenia is a common finding in pre-eclampsia

Incorrect answer selected

The diagnostic criteria for pre-eclamptic toxaemia (PET) include hypertension and proteinuria.
Oedema occurs in up to 80% of normotensive parturients whereas pre-eclampsia complicates less than 10%
of pregnancies.
An eclamptic fit may occur without preceding symptoms and signs of pre-eclampsia.
Thrombocytopenia is one part of the haemolysis, elevated liver enzymes, low platelets (HELLP) syndrome
together with haemolysis and elevated liver enzymes.

Question: 10 of 12
Do the most recent confidential enquiry into maternal deaths show the following?
An increase in maternal mortality rate

Correct

The absolute number of deaths from haemorrhage has decreased

Correct
The commonest cause of maternal death was due to associated psychiatric illness
Incorrect answer selected
The overall maternal death rate for indirect causes of death is lower than for deaths from direct
causes
Incorrect answer selected
Thromboembolism is the commonest cause of direct deaths
Correct
The last CEMACH report :
http://www.rcog.org.uk/news/cemach-release-saving-mothers-lives-findings-causes-maternal-deaths-andcare-pregnant-women
revealed that the maternal mortality rate saw an overall increase in the time period reviewed.
The absolute number of deaths from haemorrhage had decreased.
The commonest cause of maternal death was actually cardiac not psychiatric related. Inirect maternal deaths
contributed the majority of maternal deaths

Emergency Medicine 8

Question: 11 of 12
Regarding third stage problems and obstetric emergencies, are the following statements true or false?
Endotoxic shock is associated with reduced fibrinogen degradation products (FDPs).
Incorrect answer selected
Maternal age 35 or over is associated with increased risk of postpartum haemorrhage Correct
Polyhydramnios is associated with increased incidence of amniotic fluid embolism
Correct
Primary PPH is defined as the loss of 1000 ml or more of blood within 24 hours of delivery.
Incorrect answer selected
Uterine inversion is caused by injudicious cord traction with an atonic uterus and fundal placental
insertion
Correct
Primary postpartum haemorrhage (PPH) is the loss of 500 ml or more of blood within 24 hours of delivery.
Endotoxaemia is associated with a disseminated intravascular coagulation and the consumption of
fibrinogen with increased FDPs.

Question: 12 of 12
These blood gases were taken from a patient who is being nursed on the ward 24 hours after total abdominal
hysterectomy and oohphrectomy:
7.21 (7.36-7.44)
pH
4.2 kPa (4.7-6.0)
pCO2
9.6 kPa (11.3-12.6)
pO2
Standard bicarbonate 17.6 mmol/L (20-28)
-6.2 mmol/L (-2 to +2)
Base excess
Are the following statements regarding the biochemistry true?
Hypovolaemia may be a cause.
Correct
Immediate management should consist of administration of IV bicarbonate.
Incorrect answer selected
Sepsis may be an underlying cause.
Correct
The pCO2 is low due to respiratory compensation.

Correct

There is a metabolic alkalosis.

Incorrect answer selected
There is a metabolic acidosis (pH low, base excess low, HCO3 low). Respiratory compensation for
metabolic acidosis consists of hyperventilation eliminating CO2.
As with any critically ill patient, immediate management should follow the airway, breathing, circulation
format.
Sepsis may cause this blood gas picture and should be considered in this patient.
Hypovolaemia may cause metabolic acidosis due to inadequate tissue perfusion and subsequent anaerobic
metabolism and is another differential.