A 68-year-old man presents with crushing central chest pain radiating to the left arm for 45 minutes. ECG shows ST elevation in leads II, III and aVF. Blood pressure is 90/60 mmHg.
What is the most appropriate immediate management?
A. IV metoprolol
B. Sublingual glyceryl trinitrate
C. Immediate fibrinolysis
D. IV morphine only
E. Urgent primary PCI
Answer: E. Urgent primary PCI
Key Point:
Inferior STEMI with hypotension → likely right ventricular involvement → avoid nitrates and beta-blockers.
First line in Australia: Primary PCI within 90 minutes (if available).
A patient with atrial fibrillation is started on warfarin. Which drug significantly increases INR?
A. Rifampicin
B. Carbamazepine
C. Metronidazole
D. Phenytoin
E. St John’s wort
Answer: C. Metronidazole
High-yield:
Warfarin metabolism = CYP2C9
Inhibitors ↑ INR → bleeding risk
Metronidazole, amiodarone, macrolides, azoles.
A 24-year-old woman presents with acute pelvic pain and fever. Cervical motion tenderness is present. Most appropriate initial antibiotic regimen?
A. Amoxicillin alone
B. Doxycycline + metronidazole + ceftriaxone
C. Azithromycin single dose
D. Ciprofloxacin
E. Metronidazole alone
Answer: B
PID (Australian guidelines):
Ceftriaxone IM single dose
Doxycycline 14 days
Metronidazole 14 days
Covers gonorrhoea, chlamydia, anaerobes.
A 5-year-old child has barking cough, inspiratory stridor, and hoarseness. Most likely diagnosis?
A. Epiglottitis
B. Croup
C. Bronchiolitis
D. Asthma
E. Foreign body
Answer: B. Croup
Classic triad:
Barking cough + stridor + hoarseness
Treatment: oral dexamethasone ± nebulised adrenaline if severe.
Which electrolyte abnormality is seen in primary hyperaldosteronism?
A. Hyponatraemia
B. Hyperkalaemia
C. Hypokalaemia
D. Hypercalcaemia
E. Metabolic acidosis
Answer: C. Hypokalaemia
Classic:
Hypertension + hypokalaemia + metabolic alkalosis.
A 60-year-old smoker presents with painless haematuria. Most likely diagnosis?
A. Renal stone
B. UTI
C. Bladder cancer
D. Prostatitis
E. Glomerulonephritis
Answer: C. Bladder cancer
Exam pearl:
Painless haematuria in older smoker = malignancy until proven otherwise.
Which drug is first line for acute anaphylaxis?
A. IV hydrocortisone
B. IM adrenaline
C. Salbutamol neb
D. IV chlorpheniramine
E. Oxygen alone
Answer: B. IM adrenaline
Dose: 0.5 mg IM (1:1000) into lateral thigh.
Repeat every 5 min if needed.
Which antipsychotic is most associated with agranulocytosis?
A. Haloperidol
B. Risperidone
C. Olanzapine
D. Clozapine
E. Quetiapine
Answer: D. Clozapine
Mandatory blood monitoring.
ANC monitoring weekly initially.
A pregnant woman at 32 weeks has severe hypertension and proteinuria. Most serious complication?
A. Polyhydramnios
B. Placenta previa
C. Eclampsia
D. Gestational diabetes
E. Hyperemesis
Answer: C. Eclampsia
Pre-eclampsia → seizures.
Treatment of seizures: IV magnesium sulfate.
A patient presents with sudden severe “worst headache of life”. CT brain normal. Next step?
A. MRI
B. Lumbar puncture
C. Discharge home
D. Repeat CT in 1 week
E. Start aspirin
Answer: B. Lumbar puncture
Rule out subarachnoid haemorrhage (xanthochromia).
Which vaccine is contraindicated in pregnancy?
A. Influenza (inactivated)
B. Tdap
C. MMR
D. Hepatitis B
E. COVID mRNA
Answer: C. MMR
Live vaccines contraindicated.
A patient with asthma overuses salbutamol. What is a sign of poor control?
A. Using SABA once weekly
B. Night waking once per month
C. SABA use >2 times per week
D. No wheeze
E. FEV1 95%
Answer: C
Australian asthma control marker.
A diabetic patient presents with abdominal pain, Kussmaul breathing, glucose 28 mmol/L. Most important initial therapy?
A. IV insulin immediately
B. IV fluids
C. Bicarbonate
D. Potassium bolus
E. Morphine
Answer: B. IV fluids
DKA management order:
IV fluids
IV insulin
Potassium replacement
Which feature suggests Crohn disease rather than ulcerative colitis?
A. Continuous colonic involvement
B. Rectal involvement
C. Skip lesions
D. Bloody diarrhoea
E. Toxic megacolon
Answer: C. Skip lesions
Crohn: transmural, fistula, strictures, cobblestone.
A patient on ACE inhibitors develops persistent dry cough. Mechanism?
A. Histamine release
B. Serotonin excess
C. Bradykinin accumulation
D. Aldosterone suppression
E. Beta receptor blockade
Answer: C
Classic ACEI side effect.
A 72-year-old man presents with sudden painless loss of vision in the right eye. Fundoscopy shows a pale retina with a cherry-red spot. Most appropriate immediate management?
A. IV methylprednisolone
B. Ocular massage + urgent ophthalmology referral
C. Acetazolamide only
D. Laser photocoagulation
E. Aspirin only
Answer: B
Central retinal artery occlusion = ocular stroke.
Emergency → ocular massage + lower IOP (acetazolamide) + urgent specialist referral.
A 35-year-old woman presents with tremor, weight loss, palpitations, and lid lag. TSH suppressed, free T4 elevated. First-line treatment in Australia?
A. Radioactive iodine immediately
B. Propranolol + carbimazole
C. Thyroidectomy
D. Iodine monotherapy
E. Levothyroxine
Answer: B
Graves disease initial management:
• Carbimazole (blocks thyroid peroxidase)
• Beta-blocker for symptom control
Serious adverse effect: agranulocytosis → check FBC if sore throat.
A 3-year-old presents with high fever, drooling, tripod position, and muffled voice. Most likely diagnosis?
A. Croup
B. Epiglottitis
C. Peritonsillar abscess
D. Retropharyngeal abscess
E. Bronchiolitis
Answer: B
Red flags: drooling + tripod + toxic child.
Do NOT examine throat.
Secure airway urgently.
A 50-year-old alcoholic presents with confusion, ophthalmoplegia, and ataxia. Immediate management?
A. IV glucose
B. IV thiamine before glucose
C. Diazepam
D. Haloperidol
E. Naloxone
Answer: B
Wernicke encephalopathy.
Always give thiamine before glucose to prevent worsening.
Which medication is most associated with hyperkalaemia?
A. Hydrochlorothiazide
B. Furosemide
C. Spironolactone
D. Salbutamol
E. Insulin
Answer: C
Spironolactone = potassium-sparing aldosterone antagonist.
Dangerous in renal impairment or ACEI combination.
A 45-year-old woman presents with sudden unilateral pleuritic chest pain and dyspnoea. She recently had long-haul travel. Most appropriate initial investigation?
A. D-dimer
B. CTPA
C. V/Q scan
D. Chest X-ray
E. ECG
Answer: B
High clinical suspicion → go straight to CTPA.
D-dimer only if low probability.
A patient on long-term prednisolone stops abruptly and presents with hypotension, abdominal pain, and weakness. Diagnosis?
A. Septic shock
B. Addison disease
C. Adrenal crisis
D. Hypoglycaemia
E. Anaphylaxis
Answer: C
Steroid withdrawal → acute adrenal insufficiency.
Treat: IV hydrocortisone + IV fluids.
Which feature is most suggestive of meningococcal septicaemia?
A. Blanching rash
B. Non-blanching purpuric rash
C. Vesicular rash
D. Maculopapular rash
E. Urticaria
Answer: B
Non-blanching purpura = red flag.
Immediate IV ceftriaxone.
A 60-year-old man presents with painless progressive dysphagia to solids then liquids. Most likely diagnosis?
A. Achalasia
B. Oesophageal carcinoma
C. Peptic stricture
D. Diffuse spasm
E. Globus
Answer: B
Solids → liquids progression = mechanical obstruction → cancer until proven otherwise.
