KFP – Emergency medicine

Andrew Callaghan, a 28-year-old man, presents to your rural general practice after being involved in a single-vehicle motorbike accident on a dirt road 30 minutes ago. He was not wearing a helmet. He was found at the scene by a passerby and brought directly to your clinic as there is no ambulance service in the region. He was reportedly unconscious for a brief period but is now alert, although drowsy. He complains of severe neck pain and a headache, and is nauseated. He denies loss of movement in his limbs, but you note some abrasions and bruises to his left shoulder and leg.

Medications: Nil regular

Allergies: Nil known

Past history: Unremarkable

Social history: Works as a shearer; drinks 6–8 standard drinks on weekends; non-smoker

Examination findings: GCS 14 (E4, V4, M6), BP 135/85 mmHg, HR 82 bpm, RR 18, SpO2 98% RA, Temp 36.9°C. Tenderness over cervical spine with limited range of motion due to pain. No focal neurological deficits noted on limb examination. No signs of external head trauma other than scalp abrasions.

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What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Murray, a 52-year-old woman, presents to your suburban general practice with sudden onset severe central chest pain radiating to her back. The pain started one hour ago while she was gardening and is described as ‘tearing’. She appears pale and diaphoretic. She denies nausea, vomiting, or shortness of breath. She has a history of hypertension, which is poorly controlled, and takes amlodipine irregularly.

Medications: Amlodipine 10 mg PRN (infrequent adherence)

Allergies: Nil known

Past history: Hypertension, no prior cardiac events

Family history: Father died of a ‘ruptured artery’ at age 60

Social history: Smoker – 10 cigarettes/day; no alcohol

Examination findings: BP 178/95 mmHg (right arm), 152/88 mmHg (left arm); HR 102 bpm, regular; RR 22; SpO2 98% on room air; afebrile. JVP not elevated. Heart sounds dual with no murmur. Peripheral pulses present and symmetrical. ECG shows sinus tachycardia, no ST elevation or depression.

What are the most appropriate immediate management actions? Select three (3) from the following list:

Daniela Rossi, a 62-year-old woman, presents to your regional general practice after collapsing at home. Her husband states she briefly lost consciousness while getting out of bed this morning. She appeared pale and clammy, and was unresponsive for approximately 30 seconds. She recovered spontaneously but has remained lightheaded. There was no preceding chest pain, palpitations, or seizure activity. She reports some mild shortness of breath and a sensation of ‘skipped beats’ over the past few days.

Medications: Atenolol 50 mg daily, Rosuvastatin 10 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia, TIA (2 years ago)

Family history: Brother died suddenly at 58 from a cardiac arrest

Social history: Retired teacher, non-smoker, occasional wine

Examination findings: BP 105/65 mmHg, HR 38 bpm irregular, RR 18, Temp 36.8°C, SpO2 96% on RA. Heart sounds are variable in intensity. Lungs clear. Capillary refill time normal. No focal neurological deficit on examination.

Investigations: ECG shows bradycardia with intermittent dropped beats (see image)

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What are the most appropriate next steps in management? Select three (3) from the following list:

Sophie Liang, a 7-year-old girl, is brought to your rural emergency clinic by her mother after being stung by a bee while playing in the backyard 15 minutes ago. Her mother states that Sophie initially cried and complained of pain, but over the last 10 minutes she has developed widespread urticaria, facial swelling, and is now complaining of throat tightness and difficulty breathing. She has no previous history of allergy or anaphylaxis.

Medications: Nil

Allergies: Nil known

Past history: Mild intermittent asthma

Family history: Atopy in mother

Examination findings: Sophie is distressed, hoarse-voiced and tachypnoeic. BP 84/50 mmHg, HR 138 bpm, RR 30, SpO2 94% on room air. Periorbital oedema and generalised urticaria are visible. Audible wheeze on auscultation. Capillary refill time is 3 seconds. No stridor. No rash aside from urticaria.

What are the most appropriate immediate management actions? Select four (4) from the following list:

Michael Dunne, a 64-year-old man, presents to your rural urgent care centre after developing sudden onset severe left-sided abdominal pain that radiates to the groin. The pain started one hour ago while he was chopping firewood. He rates it 9/10 in intensity and describes it as ‘tearing’. He is diaphoretic and visibly distressed.

Medications: Ramipril 10 mg daily, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, type 2 diabetes, hyperlipidaemia, 45 pack-year smoking history

Family history: Father had coronary artery disease

Social history: Retired mechanic, drinks 2–3 beers per night, lives alone

Examination findings: BP 100/60 mmHg, HR 115 bpm, RR 24, SpO2 97% on RA, Temp 36.7°C. Abdomen soft but tender in the left lower quadrant with a pulsatile mass palpable periumbilically. Peripheral pulses are diminished on the left leg. Bowel sounds present. No guarding or rigidity.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jake Morrison, a 19-year-old apprentice electrician, is brought into your rural general practice clinic by a friend after being found confused and agitated at a local music festival. He has vomited twice and appears disoriented. His friend reports Jake took a ‘couple of pills’ earlier in the day but is unsure what they contained. The event has been running all day in hot weather (~38°C), and Jake has been dancing for hours. He has no known past medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with parents, recreational drug use on weekends reported by friend

Examination findings: BP 140/95 mmHg, HR 128 bpm, RR 26, Temp 40.2°C, SpO2 98% on room air. He is flushed, confused, and restless. Pupils are dilated and reactive. Muscle tone is increased, particularly in lower limbs. No focal neurological signs. Skin is dry and hot. Capillary refill time <2 seconds. No signs of trauma or rash.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Emily Zacharias, a 32-year-old woman, presents to your regional ED at 2:00 AM with sudden onset severe left-sided flank pain radiating to the groin. She describes the pain as ‘excruciating’ and is writhing in bed. She has had some nausea and one episode of vomiting. She denies any dysuria, fever, or vaginal bleeding. Her last menstrual period was two weeks ago. This has never happened before.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil surgical history, otherwise well

Social history: Works as a vet nurse, non-smoker, social drinker

Examination findings: BP 128/78 mmHg, HR 102 bpm, RR 18, SpO2 99% RA, Temp 37.2°C. Abdomen is soft with marked tenderness over the left flank. No guarding or peritonism. Bowel sounds present. No palpable mass. No costovertebral angle tenderness. Urinalysis shows microscopic haematuria.

What are the most appropriate next steps in management? Select three (3) from the following list:

Patrick Latu, a 55-year-old man, presents to your metropolitan GP clinic after developing sudden onset slurred speech and right arm weakness while at work approximately 45 minutes ago. His colleague noticed he was ‘not making sense’ and had drooping on the right side of his face. Symptoms have partially improved but he is still dysarthric. He denies headache or loss of consciousness.

Medications: Perindopril 4 mg daily, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia, ex-smoker (20 pack-year history)

Family history: Father had a stroke at 63

Social history: Works as an accountant, no alcohol, active lifestyle

Examination findings: BP 150/88 mmHg, HR 76 bpm, RR 16, SpO2 98% RA, Temp 36.9°C. Facial droop is present on the right, with mild right arm weakness (power 4/5). NIHSS score: 4. No signs of trauma or seizure activity.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah Taukolo, a 24-year-old G2P1 woman at 36 weeks gestation, presents to your rural general practice clinic complaining of a sudden onset of severe upper abdominal pain and feeling faint. She describes the pain as constant, radiating to her back. There is no vaginal bleeding. Fetal movements have decreased over the past few hours. She reports normal antenatal care to date with no known complications. Her first delivery was via spontaneous vaginal delivery at term.

Medications: Ferrous sulfate

Allergies: Nil known

Past history: Nil significant

Social history: Lives on a remote property, no alcohol or drugs, non-smoker

Examination findings: BP 90/55 mmHg, HR 118 bpm, RR 22, Temp 36.5°C, SpO2 97% RA. Abdomen is firm with marked tenderness in the upper uterus. Uterus feels tense and ‘woody’. Fetal heart sounds are not audible with Doppler. No per vaginal bleeding. No uterine contractions noted.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Thomas Bain, a 46-year-old construction worker, is brought to your rural ED by his co-workers after falling from a scaffold approximately 3 metres high. He landed on his feet and immediately complained of severe back pain. He was wearing a harness but struck the ground before it engaged fully. He has remained alert and oriented but is unable to stand or walk due to pain.

Medications: Nil

Allergies: Nil known

Past history: Smoker, otherwise well

Social history: Lives with partner, no alcohol or recreational drug use

Examination findings: GCS 15. BP 130/85 mmHg, HR 96 bpm, RR 20, SpO2 98% RA. Midline lumbar spine tenderness. No obvious bruising. No neurological deficits on lower limb exam. Normal anal tone. Able to move all limbs. Pain worsens with minimal movement.

Investigations: Not yet performed.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Maria Novak, a 38-year-old woman, presents to your metropolitan GP clinic with sudden onset severe shortness of breath and pleuritic chest pain. The symptoms began one hour ago while she was at her desk at work. She denies cough or fever. She returned from a long-haul flight from Europe two days ago. She has no past history of cardiorespiratory disease.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Migraine with aura

Social history: Office worker, non-smoker, drinks socially, lives with partner

Examination findings: BP 125/78 mmHg, HR 112 bpm, RR 24, Temp 36.8°C, SpO2 93% on room air. She appears mildly distressed and tachypnoeic. Heart sounds dual. Clear chest on auscultation. ECG shows sinus tachycardia.

What are the most appropriate next steps in management? Select four (4) from the following list:

Gurpreet Singh, a 68-year-old man, is brought into your GP clinic in a regional town by his wife. She reports he suddenly became confused and had difficulty speaking about 30 minutes ago. On arrival to your clinic, Gurpreet appears drowsy and is slurring his words. His wife denies trauma, fever, recent travel, or alcohol intake. He has a known history of type 2 diabetes and atrial fibrillation but is not taking anticoagulation due to a prior gastrointestinal bleed.

Medications: Metformin 1000 mg BD, Atenolol 50 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, atrial fibrillation, previous GI bleed 3 years ago

Family history: Nil significant

Social history: Retired farmer, lives with wife, non-smoker

Examination findings: BP 170/95 mmHg, HR 88 irregularly irregular, RR 20, SpO2 97% RA, Temp 36.6°C. GCS 13 (E4V4M5), expressive dysphasia, mild right facial droop. Power 4/5 in right arm and leg. Pupils equal and reactive. No neck stiffness or rash.

What are the most appropriate next steps in management? Select four (4) from the following list:

Isaac Thompson, a 5-year-old boy, is brought to your rural general practice by his mother. He has had 24 hours of vomiting and lethargy. This morning, she noted he was drowsy and had rapid breathing. He has not passed urine since last night. He has no recent travel history. There are no sick contacts at home. His vaccinations are up to date. His mother says he has been drinking water but has not kept any food down.

Medications: Nil

Allergies: Nil known

Past history: Previously well

Family history: Father has type 1 diabetes

Social history: Lives with parents and attends kindergarten

Examination findings: GCS 13 (E4V4M5). BP 90/55 mmHg, HR 128 bpm, RR 32, Temp 36.9°C, SpO2 98% RA. Capillary refill time 3 seconds. Breath smells fruity. Abdomen soft, no organomegaly. Mild dry mucous membranes and reduced skin turgor.

Point of care BSL: 22.4 mmol/L

What are the most appropriate immediate management steps? Select four (4) from the following list:

David Reynolds, a 72-year-old man, presents to your coastal GP clinic with sudden-onset vertigo, nausea, and unsteadiness that began one hour ago while gardening. He describes a sensation that the world is spinning and has vomited twice. He is unable to walk without support. There is no headache or hearing loss. He denies recent infections or trauma. He has a history of hypertension and atrial fibrillation, for which he is not anticoagulated.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, atrial fibrillation (not anticoagulated)

Social history: Retired teacher, lives alone, ex-smoker

Examination findings: BP 145/84 mmHg, HR 76 irregularly irregular, RR 18, SpO2 97% RA, Temp 36.8°C. Horizontal nystagmus present. No hearing loss. Mild dysmetria on finger-nose testing. Unable to perform Romberg. No facial asymmetry. No limb weakness.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amir Rahman, a 30-year-old man, presents to your suburban general practice clinic after being found unresponsive by his flatmate approximately 20 minutes ago. He is now rousable but drowsy and confused. There is an empty packet of alprazolam found nearby. His flatmate reports Amir has a history of anxiety and depression and may have recently lost his job. There is concern he may have taken a deliberate overdose.

Medications: Alprazolam (recently prescribed), Sertraline 50 mg daily

Allergies: Nil known

Past history: Generalised anxiety disorder, depression

Social history: Lives in shared accommodation, smoker, no alcohol or drugs reported

Examination findings: BP 110/65 mmHg, HR 68 bpm, RR 10, Temp 36.5°C, SpO2 94% on room air. GCS 13 (E3V4M6). Pupils are equal and reactive. Slurred speech and mild ataxia. No signs of trauma. No localising neurological deficits. Blood glucose: 6.2 mmol/L.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Lisa Tran, a 29-year-old woman, presents to your regional GP clinic after being bitten by a brown snake while bushwalking an hour ago. She reports feeling lightheaded and nauseous, with some abdominal discomfort. The bite occurred on her right lower leg and she applied a compression bandage shortly after the incident. She is accompanied by a friend who drove her to the clinic. There is no bleeding or swelling at the bite site.

Medications: Combined oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Active, non-smoker, no drug use

Examination findings: BP 105/60 mmHg, HR 110 bpm, RR 22, Temp 36.8°C, SpO2 98% RA. She appears anxious, pale, and mildly diaphoretic. Bite site is not swollen or bruised. No ptosis or limb weakness at this stage. Capillary refill 3 seconds. No signs of active bleeding or coagulopathy.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Samuel O’Leary, a 63-year-old man, presents to your inner-city GP clinic with sudden onset of severe epigastric pain that radiates to the back. The pain started 2 hours ago after a heavy meal and is associated with nausea and two episodes of vomiting. He reports drinking a bottle of wine last night and has a history of binge drinking on weekends. He denies chest pain or diarrhoea.

Medications: Nil regular

Allergies: Nil known

Past history: Hypertension, alcohol use disorder (not in treatment)

Social history: Lives alone, drinks heavily on weekends, smoker (15/day)

Examination findings: BP 138/90 mmHg, HR 108 bpm, RR 22, Temp 37.9°C, SpO2 97% RA. Epigastric tenderness with mild guarding. Bowel sounds present. No jaundice. No abdominal distension or peritonism. No signs of chronic liver disease.

Point-of-care blood glucose: 9.1 mmol/L

What are the most appropriate next steps in management? Select three (3) from the following list:

Elena Dimitriou, a 44-year-old woman, presents to your coastal general practice with a sudden-onset severe thunderclap headache that started 20 minutes ago while she was showering. She describes it as the ‘worst headache of her life’ and is visibly distressed. She has photophobia and nausea but has not vomited. She denies trauma or previous similar episodes. Her partner called the clinic concerned about her rapid deterioration.

Medications: Candesartan 8 mg daily

Allergies: Nil known

Past history: Hypertension (diagnosed 6 months ago)

Social history: Works as a primary school teacher, no smoking or alcohol use

Examination findings: BP 168/92 mmHg, HR 82 bpm, RR 20, Temp 37.1°C, SpO2 99% RA. GCS 15. Mild photophobia. No focal neurological deficit. Neck stiffness present. Fundoscopy unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

John-Paul Morris, a 58-year-old man, presents to your rural general practice with sudden-onset severe lower abdominal pain and a visibly distended abdomen. The pain began two hours ago and has worsened steadily. He has not passed wind or opened his bowels in the last 24 hours. He feels nauseated and vomited once this morning. He has a history of open appendectomy 30 years ago.

Medications: Esomeprazole 20 mg daily

Allergies: Nil known

Past history: Appendectomy, gastro-oesophageal reflux disease

Social history: Farmer, non-smoker, occasional alcohol

Examination findings: BP 110/70 mmHg, HR 102 bpm, RR 20, SpO2 98% RA, Temp 37.4°C. Abdomen distended, tympanic, with high-pitched bowel sounds and diffuse tenderness. No rebound or guarding. Hernial orifices intact. No visible masses.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Daniela Cruz, a 21-year-old university student, presents to your urban GP clinic after being sexually assaulted the night before. She is accompanied by a friend and is visibly distressed. She has not changed her clothes or showered since the incident. She reports vaginal penetration without a condom and is concerned about pregnancy and sexually transmitted infections. She has no significant past medical history and takes no regular medications.

Medications: Nil

Allergies: Nil known

Past history: Unremarkable

Social history: Lives in shared accommodation, no regular partner, occasional alcohol use

Examination findings: BP 118/74 mmHg, HR 84 bpm, RR 18, Temp 36.7°C, SpO2 99% RA. Daniela is tearful and reluctant to speak. No visible injuries are apparent. No active bleeding.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Malcolm Fraser, a 70-year-old man, is brought into your rural GP clinic by his neighbour after being found confused and disoriented in his yard on a hot summer afternoon. The ambient temperature is 42°C. He was last seen well earlier that morning. He appears flushed, sweaty, and is intermittently confused. His neighbour reports that Malcolm lives alone and does not have air conditioning.

Medications: Hydrochlorothiazide 25 mg daily, Metoprolol 50 mg BD

Allergies: Nil known

Past history: Hypertension, atrial fibrillation (rate controlled)

Social history: Lives alone, widowed, independent with ADLs

Examination findings: BP 96/60 mmHg, HR 112 bpm (irregular), RR 24, Temp 40.4°C, SpO2 98% RA. GCS 14 (confused speech). Skin is hot and dry. No focal neurological deficits. No signs of trauma.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Naomi Barlow, a 26-year-old woman, presents to your inner-city GP clinic complaining of progressive shortness of breath and sharp pleuritic chest pain for the past 12 hours. She recently gave birth to her first child via emergency caesarean section 10 days ago. She reports feeling more breathless on exertion and has a mild dry cough. No fevers or leg pain. She has no prior medical conditions and is not currently taking any regular medications other than a progestogen-only pill started postpartum.

Medications: Progestogen-only pill

Allergies: Nil known

Past history: Nil significant

Obstetric history: G1P1, emergency C-section at 39 weeks, no complications during pregnancy

Examination findings: BP 114/78 mmHg, HR 106 bpm, RR 24, Temp 36.7°C, SpO2 94% RA. Alert and oriented. Mild tachypnoea. No calf tenderness or swelling. Clear chest on auscultation. No signs of infection. ECG shows sinus tachycardia.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Benjamin Lloyd, a 36-year-old man, presents to your regional GP clinic after being bitten on the hand by a dog two hours ago. The dog was unvaccinated and is owned by a neighbour. The bite broke the skin and is now red, swollen, and painful. Benjamin has no tetanus booster in the last 10 years and is unsure of the dog’s vaccination status. He reports no known allergies and is otherwise healthy.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works as a gardener, non-smoker

Examination findings: BP 122/76 mmHg, HR 84 bpm, Temp 37.5°C. The dorsal aspect of the left hand shows two puncture wounds with surrounding erythema and mild swelling. No crepitus or fluctuance. Active range of motion of fingers is preserved but painful. No systemic symptoms.

What are the most appropriate next steps in management? Select four (4) from the following list:

Carla Nguyen, a 48-year-old woman, presents to your metropolitan GP clinic with acute onset severe central chest pain radiating to the left arm and jaw. The pain began 30 minutes ago while she was walking her dog and is associated with diaphoresis and nausea. She has a history of type 2 diabetes and hypertension. She denies previous similar episodes. She is visibly distressed and anxious about the possibility of a heart attack.

Medications: Metformin 1000 mg BD, Perindopril 5 mg daily

Allergies: Nil known

Past history: Type 2 diabetes mellitus, hypertension

Social history: Non-smoker, no alcohol use, works as a teacher

Examination findings: BP 140/85 mmHg, HR 98 bpm, RR 22, Temp 36.9°C, SpO2 97% RA. ECG shows ST elevation in leads II, III, and aVF.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Olivia Chen, a 2-year-old girl, is brought to your suburban GP clinic by her father with a one-day history of fever, drooling, and difficulty swallowing. She refuses to eat or drink and is irritable. Her voice sounds muffled, and she appears to be leaning forward with her neck extended. Her father reports a high fever overnight but denies any recent choking episodes or foreign body ingestion.

Medications: Nil

Allergies: Nil known

Past history: Up-to-date immunisations

Social history: Lives with parents and attends daycare

Examination findings: Temp 39.6°C, HR 140 bpm, RR 32, SpO2 96% RA. Olivia appears toxic, is drooling, and refuses to lie down. No stridor is audible at rest, but she becomes more distressed when supine. Throat examination is not attempted due to distress. No rash or neck stiffness noted.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Steven Park, a 60-year-old man, presents to your rural GP clinic with sudden onset of severe right lower leg pain, numbness, and coldness. He reports that the leg ‘went dead’ about an hour ago while he was sitting on his verandah. He denies trauma, fever, or back pain. He has a history of hypertension, hyperlipidaemia, and smokes one pack per day.

Medications: Atorvastatin 20 mg daily, Irbesartan 150 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Lives alone on a remote property, long-term smoker, drinks occasionally

Examination findings: BP 142/88 mmHg, HR 96 bpm, RR 18, Temp 36.5°C, SpO2 98% RA. Right leg is pale, cold, with absent dorsalis pedis and posterior tibial pulses. Capillary refill >3 seconds. Sensory loss over foot and lower leg. Power reduced (2/5). No calf tenderness or swelling.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Anna Watson, a 32-year-old woman, presents to your metropolitan general practice clinic with acute right lower quadrant abdominal pain that started 6 hours ago. She describes the pain as sharp and constant. She has associated nausea but no vomiting or diarrhoea. Her last menstrual period was two weeks ago. She has no known medical conditions and has not had previous surgery.

Medications: Oral contraceptive pill

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works in retail

Examination findings: Temp 37.8°C, HR 96 bpm, BP 116/70 mmHg, RR 18, SpO2 99% RA. Abdomen soft with marked tenderness in the right iliac fossa and mild guarding. No rebound tenderness. No adnexal mass or cervical motion tenderness on gentle bimanual examination. Bowel sounds present.

What are the most appropriate immediate next steps in management? Select three (3) from the following list:

Trevor Smith, a 54-year-old man, presents to your rural general practice with increasing shortness of breath and productive cough over the past 3 days. He is known to have chronic obstructive pulmonary disease (COPD) and was discharged from hospital 2 months ago after a similar exacerbation. He has been using his salbutamol inhaler frequently without relief. He denies chest pain or haemoptysis but reports increased fatigue and difficulty sleeping due to breathlessness.

Medications: Tiotropium daily, Salbutamol PRN, Seretide 250/50 BD

Allergies: Nil known

Past history: COPD (moderate-severe), 40 pack-year smoking history

Social history: Lives alone, retired truck driver, smokes 10 cigarettes/day

Examination findings: BP 130/85 mmHg, HR 104 bpm, RR 28, Temp 37.8°C, SpO2 89% RA. Diffuse expiratory wheeze. No peripheral oedema. Mild use of accessory muscles. Alert but fatigued.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Gabrielle Dunne, a 35-year-old woman, presents to your urban GP clinic with severe right-sided abdominal pain that began suddenly while she was at the gym. She describes it as sharp and ‘stabbing’, localised to the lower abdomen. She has felt faint and nauseated but has not vomited. She is sexually active and not using contraception. Her last menstrual period was six weeks ago. She has no prior pregnancies or surgeries.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, non-smoker, drinks socially

Examination findings: BP 92/60 mmHg, HR 112 bpm, Temp 36.9°C, RR 22, SpO2 97% RA. Tenderness and guarding in the right lower quadrant. Cervical motion tenderness present on bimanual examination. No masses palpable. Vaginal bleeding not noted.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Tommy Weston, a 6-year-old boy, is brought to your rural GP clinic by his mother after he suddenly developed difficulty breathing while playing with his older brother. She reports he had been well all day and then began wheezing and coughing suddenly. He is now visibly distressed and clutching his chest. He has no known allergies or past respiratory illness. His immunisations are up to date.

Medications: Nil

Allergies: Nil known

Past history: No previous asthma or hospitalisations

Social history: Lives with parents and two siblings, attends school

Examination findings: Temp 36.8°C, HR 128 bpm, RR 32, SpO2 91% RA. Stridor heard on inspiration. Mild intercostal recession. Speaking in short phrases. No rash or fever. Chest auscultation reveals reduced air entry on the right.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Damien Foster, a 67-year-old man, presents to your coastal general practice with sudden-onset severe central abdominal pain radiating to the back. He appears pale and diaphoretic. He has a known history of hypertension and smokes 20 cigarettes per day. He denies trauma, vomiting, or change in bowel habits. The pain began 45 minutes ago while he was working in his garden and has progressively worsened.

Medications: Amlodipine 10 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Retired, lives with wife, long-term smoker

Examination findings: BP 85/60 mmHg, HR 112 bpm, RR 24, Temp 36.6°C, SpO2 97% RA. Abdomen soft but tender centrally with pulsatile mass palpable. No peritonism. Distal pulses present but weak.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Layla Haddad, a 22-year-old woman, presents to your urban GP clinic after a syncopal episode while standing in line at a shopping centre. She reports feeling lightheaded, nauseated, and then briefly losing consciousness. She regained consciousness within seconds and was alert but shaken. This is the first time this has happened. She is otherwise well and reports no chest pain, palpitations, or incontinence. No family history of sudden cardiac death.

Medications: Levonorgestrel IUD

Allergies: Nil known

Past history: Nil significant

Social history: University student, non-smoker, occasional alcohol use

Examination findings: BP 110/70 mmHg lying, 95/65 mmHg standing; HR 72 bpm; RR 16; SpO2 99% RA. ECG shows normal sinus rhythm. No murmurs or focal neurological signs. Alert and oriented.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Raymond Cook, a 74-year-old man, presents to your regional GP clinic with a 3-hour history of sudden-onset visual loss in his left eye. He describes it as a “curtain coming down” over his vision. He has no pain or redness. Vision in the right eye is normal. He has a history of hypertension and hyperlipidaemia and is compliant with his medications. He denies headache, jaw claudication, or scalp tenderness.

Medications: Perindopril 5 mg daily, Atorvastatin 20 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Retired accountant, non-smoker, lives with spouse

Examination findings: BP 134/76 mmHg, HR 78 bpm, Temp 36.7°C. Visual acuity: 6/6 right eye, no light perception in left eye. Left pupil non-reactive with a relative afferent pupillary defect. Fundoscopy shows pale retina with a cherry red spot at the macula. No temporal artery tenderness.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Amanda Zhou, a 28-year-old woman, presents to your suburban GP clinic with sudden onset severe lower back pain following a lifting injury while moving furniture the previous evening. She describes the pain as sharp and localised to the lumbar spine, with no radiation down the legs. She denies bowel or bladder symptoms and has no history of trauma beyond the lifting incident. She has never experienced similar pain before.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works as a graphic designer, non-smoker, recreational runner

Examination findings: BP 118/76 mmHg, HR 78 bpm, Temp 36.8°C, RR 16. She is tender over the lumbar paraspinal muscles with no midline spinal tenderness. Straight leg raise is negative bilaterally. No focal neurological deficits. Power and reflexes normal in both lower limbs. Gait normal.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Joshua King, a 40-year-old man, presents to your GP clinic after being stung on the hand by a bee 15 minutes ago while gardening. He reports rapidly developing swelling of his lips and face, difficulty breathing, and lightheadedness. He has no known allergies and has never had a reaction to insect stings before. He is visibly distressed, clutching his chest, and speaking in short sentences.

Medications: Nil

Allergies: Nil known

Past history: Asthma as a child

Social history: Works as a landscaper, lives locally

Examination findings: BP 85/60 mmHg, HR 124 bpm, RR 30, Temp 36.7°C, SpO2 91% RA. Generalised urticaria. Audible wheeze. Stridor not present. Peripherally cool. GCS 15.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Patricia Holmes, a 65-year-old woman, presents to your rural GP clinic with a 2-hour history of acute, severe headache and right-sided weakness. Her husband reports that she became confused and slurred her speech shortly after the headache began. She is usually independent and has no previous history of stroke. She takes antihypertensives for well-controlled hypertension.

Medications: Amlodipine 10 mg daily

Allergies: Nil known

Past history: Hypertension

Social history: Lives with husband, retired, non-smoker

Examination findings: BP 182/96 mmHg, HR 78 bpm, RR 18, Temp 36.9°C, SpO2 98% RA. GCS 14 (confused speech). Right facial droop and weakness of right arm and leg (power 3/5). No neck stiffness. Pupils equal and reactive. No signs of trauma.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Reuben Clark, a 46-year-old man, presents to your metropolitan GP clinic complaining of progressive shortness of breath and chest tightness over the last 3 hours. He has a known history of moderate asthma but has been stable for the past year. He ran out of his preventer inhaler two weeks ago. He has been using salbutamol more frequently over the past few days. Today he woke with worsening wheeze and was unable to complete sentences by the time he reached your clinic.

Medications: Salbutamol inhaler PRN (frequent use over last 48 hours)

Allergies: Nil known

Past history: Asthma since adolescence

Social history: Works in retail, lives with partner, former smoker

Examination findings: RR 32, HR 122 bpm, BP 138/88 mmHg, Temp 36.9°C, SpO2 92% on room air. Speaking in short phrases. Use of accessory muscles. Expiratory wheeze. No cyanosis. Peak expiratory flow (PEF) is 45% of predicted.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Gavin Murphy, a 72-year-old man, is brought to your rural general practice by his wife after he was found disoriented and unsteady on his feet early this morning. He has a history of type 2 diabetes and takes insulin. He was last seen well before going to bed at 10 pm. This morning, he was confused, sweating, and appeared pale. He is now alert but drowsy and reports feeling shaky and hungry.

Medications: Insulin glargine (nightly), metformin 1000 mg BD

Allergies: Nil known

Past history: Type 2 diabetes mellitus

Social history: Lives with wife, recently unwell with poor appetite

Examination findings: BP 118/70 mmHg, HR 88 bpm, RR 16, Temp 36.6°C, SpO2 98% RA. GCS 15. Capillary blood glucose: 2.4 mmol/L. No focal neurological signs.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Andrew Bolton, a 19-year-old male, is brought to your regional general practice by friends after an episode of aggressive behaviour, agitation, and hallucinations at a music festival. They report he consumed an unknown quantity of ‘party drugs’ around 3 hours ago. On arrival, he is extremely agitated, sweating profusely, and intermittently shouting incoherently. He is unable to provide a coherent history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: University student, occasional recreational drug use

Examination findings: Temp 39.4°C, HR 136 bpm, BP 168/95 mmHg, RR 28, SpO2 98% RA. Pupils dilated, skin flushed and dry. Marked agitation and combativeness. No signs of trauma. GCS fluctuates between 13–14 due to confusion and aggression.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Karen Ellis, a 58-year-old woman, presents to your suburban GP clinic complaining of sudden, severe epigastric pain radiating to the back. The pain started an hour ago after eating a fatty meal. She describes it as constant and deep. She feels nauseated and has vomited twice. She has a history of gallstones but declined previous surgical management. She has type 2 diabetes and hypertension.

Medications: Metformin 1000 mg BD, Amlodipine 5 mg daily

Allergies: Nil known

Past history: Gallstones, type 2 diabetes, hypertension

Social history: Non-smoker, occasional alcohol, lives with partner

Examination findings: Temp 37.9°C, HR 108 bpm, BP 100/68 mmHg, RR 24, SpO2 97% RA. She appears unwell and in pain. Tenderness and mild guarding in the epigastric region. No jaundice. Bowel sounds present.

Point-of-care blood glucose: 13.8 mmol/L

What are the most appropriate immediate management steps? Select four (4) from the following list:

Emily Waters, a 10-year-old girl, is brought to your suburban GP clinic by her mother with a 1-hour history of right elbow pain and deformity following a fall from monkey bars at school. She landed directly on her outstretched hand. She is in significant pain and refuses to move the arm. There are no other injuries reported. She is right-hand dominant.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Active, attends school, lives with parents and sibling

Examination findings: Temp 36.8°C, HR 110 bpm, RR 20, SpO2 99% RA. Obvious deformity of the right elbow with significant swelling and tenderness. Skin intact. Capillary refill <2 seconds. Radial pulse palpable. Sensation preserved in hand. She is distressed and protective of the limb.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Daniela Rossi, a 51-year-old woman, presents to your metropolitan GP clinic with sudden onset severe tearing chest pain radiating to her back. The pain started while she was walking up stairs and has not improved. She feels lightheaded and nauseated. She has a history of poorly controlled hypertension and smokes one pack per day. She denies trauma or prior similar episodes.

Medications: Amlodipine 10 mg daily (intermittently)

Allergies: Nil known

Past history: Hypertension, no prior cardiac disease

Social history: Smoker, works in retail, lives alone

Examination findings: BP 180/95 mmHg in right arm, 150/88 mmHg in left arm; HR 110 bpm, RR 22, Temp 36.7°C, SpO₂ 98% RA. Chest clear. Peripheral pulses present but unequal. No murmurs. ECG shows sinus tachycardia without ST changes.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Sophie Nguyen, a 30-year-old woman, presents to your inner-city general practice with a 12-hour history of worsening left leg pain, redness, and swelling. She reports a small scratch on her shin while hiking two days ago. The leg is now tender, warm, and increasingly swollen. She has no significant past medical history and is otherwise well. She denies fever or systemic symptoms.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Works in hospitality, lives with flatmates, non-smoker

Examination findings: Temp 37.4°C, HR 90 bpm, BP 120/76 mmHg, RR 16, SpO₂ 99% RA. Left lower leg is erythematous with poorly demarcated margins, warm to touch, and mildly tender. No fluctuance or necrosis. No lymphangitic streaking or regional lymphadenopathy. Systemic examination unremarkable.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Michael Dunbar, a 68-year-old man, presents to your rural GP clinic with acute onset of dizziness, nausea, and unsteady gait that began two hours ago while gardening. He denies chest pain or palpitations but describes the sensation as ‘the world spinning’. He has type 2 diabetes and is on antihypertensives. No history of ear infections or recent illness.

Medications: Metformin 1000 mg BD, Ramipril 10 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension

Social history: Retired farmer, non-smoker, lives with wife

Examination findings: BP 138/84 mmHg, HR 76 bpm, RR 18, SpO₂ 97% RA. Horizontal nystagmus present, worse when looking to the right. Positive Romberg sign. No hearing loss or tinnitus. No facial weakness. Finger-nose testing normal. No other focal neurological deficits.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Sarah Evans, a 34-year-old woman, presents to your GP clinic after an intentional overdose of her prescribed amitriptyline approximately 2 hours ago. She admits to ingesting around 30 tablets (75 mg each) following an argument with her partner. She is drowsy but rousable and says she regrets the action. Her flatmate found her and brought her in immediately. She has a history of major depression but no previous overdose.

Medications: Amitriptyline 75 mg nocte (recent dose increase)

Allergies: Nil known

Past history: Major depressive disorder

Social history: Lives with flatmate, currently unemployed, non-smoker

Examination findings: BP 102/66 mmHg, HR 118 bpm, RR 20, Temp 37.1°C, SpO₂ 97% RA. GCS 14 (drowsy but oriented). Pupils dilated. Dry mouth noted. ECG shows sinus tachycardia with QRS duration of 130 ms.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Jacob Lewis, a 17-year-old male, is brought to your GP clinic by his mother after experiencing sudden-onset chest pain and shortness of breath while playing basketball. He is otherwise fit and healthy, with no history of asthma or cardiac disease. He reports the pain as sharp, worse on inspiration, and localised to the right side. There was no trauma.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with parents, Year 12 student, non-smoker

Examination findings: HR 104 bpm, BP 122/76 mmHg, RR 22, SpO₂ 96% RA. Tall, thin male with mild respiratory distress. Reduced breath sounds on the right, hyperresonant to percussion. No wheeze or crepitations. Trachea midline. No signs of infection or fever.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Dean Wallace, a 62-year-old man, presents to your general practice with sudden onset severe pain, swelling, and redness of his left great toe that started overnight. He describes the pain as intense and throbbing, worsened by even light pressure from his bedsheet. He has a history of hypertension and chronic kidney disease stage 3. He drinks alcohol daily and had a rich meal with red meat and wine last night.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, chronic kidney disease (eGFR 48 mL/min)

Social history: Retired builder, drinks 2–3 glasses of wine daily, non-smoker

Examination findings: Temp 37.4°C, HR 84 bpm, BP 136/78 mmHg. Left first MTP joint is swollen, erythematous, hot and exquisitely tender. No overlying breaks in the skin. No systemic symptoms or rash. Other joints are normal.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Matthew Clarke, a 64-year-old man, presents to your general practice complaining of sudden difficulty speaking and weakness in his right arm and leg that resolved spontaneously after 25 minutes. He did not seek help at the time but was encouraged by his wife to attend the clinic after the episode. He now feels well and has no current deficits. He has hypertension and hyperlipidaemia, and is a current smoker.

Medications: Atorvastatin 20 mg daily, Irbesartan 150 mg daily

Allergies: Nil known

Past history: Hypertension, hyperlipidaemia

Social history: Smokes 15 cigarettes/day, lives with wife, semi-retired

Examination findings: BP 142/80 mmHg, HR 78 bpm, RR 16, Temp 36.5°C, SpO₂ 98% RA. No focal neurological signs currently. Gait normal. Cardiovascular exam unremarkable. ECG shows normal sinus rhythm.

What are the most appropriate immediate management steps? Select four (4) from the following list:

Claire Jackson, a 42-year-old woman, presents to your GP clinic after stepping on a rusty nail while walking barefoot in her garden 90 minutes ago. The nail punctured the sole of her foot and has been removed. She is experiencing moderate pain and has cleaned the area with water. She has not had a tetanus booster in the past 15 years. She has no significant medical history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: Lives with partner, works as a florist, non-smoker

Examination findings: Small puncture wound on plantar aspect of left foot, no active bleeding, mild erythema, no pus or signs of infection. No foreign body visible. Sensation and pulses intact.

What are the most appropriate immediate management steps? Select three (3) from the following list:

Jason Reid, a 21-year-old male, is brought to your metropolitan GP clinic by his friend after falling while skateboarding. He struck the right side of his head on the pavement but did not lose consciousness. Since the fall, he has complained of headache, dizziness, and nausea. He is alert but slightly irritable. He denies neck pain, vomiting, or amnesia. No alcohol or drug use was reported.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Social history: University student, lives with roommates, plays recreational sports

Examination findings: GCS 15, BP 124/78 mmHg, HR 88 bpm, RR 16, Temp 36.8°C, SpO₂ 99% RA. Pupils equal and reactive. No focal neurological deficits. No scalp laceration. Mild tenderness over right parietal area. No signs of base of skull fracture.

What are the most appropriate immediate management steps? Select three (3) from the following list: