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EBEEM practice questions

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Question 1Emergency Medicine (European Curriculum of Emergency Medicine)

A 3-year-old child is brought to the emergency department with a barking cough, hoarse voice and inspiratory stridor that began overnight. He is alert, has mild suprasternal retractions and no drooling. Which initial pharmacological measure is most appropriate?

  1. Intravenous fluid bolus of 20 mL/kg
  2. Nebulised salbutamol repeated every 20 minutes
  3. Intramuscular ceftriaxone after blood cultures
  4. Nebulised adrenaline combined with a single dose of oral dexamethasone Correct answer.

Explanation

The picture is croup (acute laryngotracheitis), where the combination of nebulised adrenaline for rapid mucosal oedema reduction and a single systemic corticosteroid shortens symptoms and reduces admission. Adrenaline acts within minutes but wears off, so steroid is co-administered. Antibiotics, bronchodilators and fluid boluses do not treat the underlying subglottic oedema.

Question 2Emergency Medicine (European Curriculum of Emergency Medicine)

In an adult with confirmed tension pneumothorax and haemodynamic instability, what is the immediate priority?

  1. Immediate needle decompression followed by definitive chest drainage Correct answer.
  2. Urgent chest radiograph before any intervention
  3. Non-invasive ventilation with high-flow oxygen
  4. Pericardiocentesis guided by ultrasound

Explanation

Tension pneumothorax is a clinical diagnosis and a time-critical emergency; decompression must not wait for imaging. Needle decompression relieves the pressure, then a chest drain is placed for definitive management. Imaging delays treatment and risks cardiac arrest.

Question 3Emergency Medicine (European Curriculum of Emergency Medicine)

A 68-year-old man with atrial fibrillation presents 90 minutes after sudden onset of right arm weakness and expressive aphasia. Non-contrast CT excludes haemorrhage and blood pressure is 168/94 mmHg. Which statement about intravenous thrombolysis is correct?

  1. It is contraindicated in any patient with atrial fibrillation
  2. It should be given only after a full 24-hour observation period
  3. It should be withheld because blood pressure exceeds 160/90 mmHg
  4. It is indicated because the patient is within the therapeutic time window and has no exclusion on imaging Correct answer.

Explanation

Intravenous thrombolysis is indicated within 4.5 hours of symptom onset when haemorrhage is excluded and no other contraindication exists. A blood pressure of 168/94 mmHg is below the 185/110 mmHg threshold for treatment, though it must be controlled before and after the infusion. Atrial fibrillation is not a contraindication.

Question 4Emergency Medicine (European Curriculum of Emergency Medicine)

Which finding is most consistent with the diagnosis of anaphylaxis rather than a simple vasovagal reaction?

  1. Rapid onset of urticaria with bronchospasm and hypotension after a bee sting Correct answer.
  2. Bradycardia with pallor and sweating
  3. Transient dizziness relieved by lying flat
  4. Isolated hypotension without any cutaneous or respiratory features

Explanation

Anaphylaxis is a rapidly developing multisystem reaction, typically involving skin or mucosal changes together with respiratory compromise or hypotension after exposure to a trigger. The combination of urticaria, bronchospasm and hypotension after a sting is classic. Vasovagal collapse features bradycardia and prompt recovery on lying flat.

Question 5Emergency Medicine (European Curriculum of Emergency Medicine)

A 24-year-old woman presents with a 3-day history of dysuria, frequency and suprapubic discomfort, with no fever, flank pain or vaginal discharge. What is the most appropriate management?

  1. Empirical antifungal treatment
  2. Urgent ultrasound of the renal tract
  3. Short course of oral nitrofurantoin with symptomatic advice Correct answer.
  4. Immediate intravenous antibiotics and admission

Explanation

Uncomplicated cystitis in a non-pregnant woman is treated with a short oral antibiotic course such as nitrofurantoin, guided by local resistance data. Systemic features, flank pain or pregnancy would prompt broader assessment. Imaging and antifungals are not indicated in straightforward bacterial cystitis.

Question 6Emergency Medicine (European Curriculum of Emergency Medicine)

A 45-year-old man is found with pinpoint pupils, a respiratory rate of 6/min and a Glasgow Coma Scale of 6. Which immediate action is indicated?

  1. Flumazenil administration as first-line therapy
  2. Physostigmine infusion
  3. Immediate CT head before any treatment
  4. Naloxone administration with airway support and ventilation Correct answer.

Explanation

The triad of pinpoint pupils, depressed consciousness and hypoventilation suggests opioid toxicity. Naloxone reverses opioid-induced respiratory depression, but airway protection and assisted ventilation are equally essential because naloxone has a shorter half-life than many opioids. Flumazenil is for benzodiazepines and carries seizure risk.

Question 7Emergency Medicine (European Curriculum of Emergency Medicine)

Which single parameter is used in the quick Sequential Organ Failure Assessment (qSOFA) score?

  1. Urine output
  2. Serum lactate
  3. Bilirubin level
  4. Respiratory rate of 22/min or more Correct answer.

Explanation

The qSOFA score uses three bedside criteria: respiratory rate of 22/min or more, altered mentation and systolic blood pressure of 100 mmHg or less. Each scores one point, and two or more points flag a high risk of poor outcome in suspected infection. Lactate, bilirubin and urine output are not part of qSOFA.

Question 8Emergency Medicine (European Curriculum of Emergency Medicine)

A patient is in cardiac arrest with a shockable rhythm. After the second defibrillation and two minutes of cardiopulmonary resuscitation, what is the recommended next drug intervention?

  1. Intravenous atropine 3 mg
  2. Intravenous amiodarone 300 mg
  3. Intravenous sodium bicarbonate 1 mmol/kg
  4. Intravenous adrenaline 1 mg Correct answer.

Explanation

In shockable cardiac arrest, adrenaline 1 mg is given after the second shock and then every three to five cycles, while amiodarone is added after the third shock. Adrenaline is thus the next drug after the second defibrillation. Atropine and bicarbonate are not routine drugs in adult cardiac arrest.

Question 9Emergency Medicine (European Curriculum of Emergency Medicine)

A 70-year-old woman with a history of hypertension presents with sudden severe interscapular tearing pain and a blood pressure difference of 30 mmHg between arms. What is the most appropriate initial diagnostic strategy in a haemodynamically stable patient?

  1. Transthoracic echocardiography alone
  2. D-dimer testing to exclude the diagnosis
  3. Contrast-enhanced CT angiography of the aorta Correct answer.
  4. Immediate exercise stress testing

Explanation

The presentation suggests acute aortic dissection, and contrast-enhanced CT angiography is the first-line investigation in a stable patient because it rapidly confirms the diagnosis and defines the extent. Immediate blood pressure and pain control should occur in parallel. Stress testing is dangerous and echocardiography alone cannot exclude dissection.

Question 10Emergency Medicine (European Curriculum of Emergency Medicine)

A 30-year-old woman presents with sudden onset of severe left-sided flank pain radiating to the groin, with visible haematuria. Which initial imaging modality is preferred for suspected renal colic in a young adult?

  1. Intravenous pyelography
  2. Magnetic resonance urography
  3. Plain abdominal radiograph alone
  4. Non-contrast CT of the kidneys, ureters and bladder Correct answer.

Explanation

Non-contrast CT of the kidneys, ureters and bladder has high sensitivity and specificity for urinary calculi and is the preferred initial test in adults with suspected renal colic. It also identifies alternative diagnoses. Intravenous pyelography is largely obsolete and plain films miss many stones.

Question 11Emergency Medicine (European Curriculum of Emergency Medicine)

A 55-year-old man presents with a 4-hour history of painful, sustained penile erection without sexual stimulation. Which intervention is the first step in management?

  1. Oral phosphodiesterase-5 inhibitor
  2. Corporal aspiration with or without irrigation of saline Correct answer.
  3. Intracavernosal injection of a vasoactive agent
  4. Immediate surgical shunt placement

Explanation

Priapism lasting more than four hours is a compartment syndrome of the penis and requires immediate corporal aspiration, often with saline irrigation, to relieve ischaemia. Shunt surgery is reserved for cases that fail aspiration and irrigation. Phosphodiesterase inhibitors and vasoactive injections would worsen the condition.

Question 12Emergency Medicine (European Curriculum of Emergency Medicine)

A 28-year-old woman presents with a 2-day history of unilateral throbbing headache with photophobia and vomiting. Which finding would most raise concern for a secondary headache requiring urgent investigation?

  1. Thunderclap onset reaching maximum intensity within one minute Correct answer.
  2. Headache relieved by lying down in a dark room
  3. Recurrent headache pattern identical to previous migraines
  4. Bilateral temporal tightness worsening with stress

Explanation

A thunderclap headache that peaks within one minute is a red flag for subarachnoid haemorrhage and other vascular emergencies and requires urgent CT and further evaluation. Typical migraines, tension headaches and headaches relieved in a dark room are primary headache patterns without such alarm features.

Question 13Emergency Medicine (European Curriculum of Emergency Medicine)

A 60-year-old man with chronic obstructive pulmonary disease presents with drowsiness, a respiratory rate of 24/min and an arterial blood gas showing pH 7.28, PaCO2 8.5 kPa and PaO2 7.0 kPa on room air. What is the most appropriate initial oxygen strategy?

  1. Controlled oxygen titrated to a target saturation of 88-92% Correct answer.
  2. High-flow oxygen targeting 94-98% saturation
  3. No oxygen therapy to avoid worsening hypercapnia
  4. Immediate intubation and ventilation

Explanation

In acute exacerbations of COPD with hypercapnic acidosis, oxygen should be titrated to a target saturation of 88-92% to avoid worsening hypercapnia while correcting hypoxaemia. Non-invasive ventilation should be considered in parallel for acidotic respiratory failure. Withholding oxygen is dangerous.

Question 14Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement best describes the role of point-of-care lung ultrasound in a patient with undifferentiated dyspnoea in the emergency department?

  1. It is contraindicated in patients requiring non-invasive ventilation
  2. It replaces chest radiography for diagnosing pneumothorax in all cases
  3. It reliably distinguishes bacterial from viral pneumonia
  4. It can identify B-lines suggesting pulmonary oedema and pleural effusion at the bedside Correct answer.

Explanation

Bedside lung ultrasound detects B-lines consistent with interstitial fluid, pleural effusion and lung consolidation, and integrates into rapid assessment of dyspnoea. It complements rather than replaces radiography, and it cannot determine the microbiological cause of pneumonia. Non-invasive ventilation is not a contraindication.

Question 15Emergency Medicine (European Curriculum of Emergency Medicine)

A 40-year-old man is rescued from a house fire with soot in the oropharynx, hoarse voice and stridor. What is the most important immediate concern?

  1. Impending upper airway obstruction from inhalation injury Correct answer.
  2. Cyanide toxicity requiring immediate antidote
  3. Carbon monoxide poisoning alone
  4. Thermal injury to the lower airways

Explanation

Soot, hoarseness and stridor after smoke exposure indicate upper airway oedema that can progress rapidly to complete obstruction, so early airway assessment and intubation are critical. Carbon monoxide and cyanide toxicity may coexist but do not explain stridor. The upper airway is the primary site of thermal injury.

Question 16Emergency Medicine (European Curriculum of Emergency Medicine)

A 22-year-old man presents with a deep laceration over the volar aspect of the wrist with loss of sensation over the palmar surface of the thumb, index and middle fingers. Which structure is most likely injured?

  1. Ulnar nerve
  2. Musculocutaneous nerve
  3. Radial nerve
  4. Median nerve Correct answer.

Explanation

Sensation over the palmar aspect of the thumb, index, middle and radial half of the ring finger is supplied by the median nerve, which lies superficially at the volar wrist and is vulnerable to lacerations. Radial nerve injury affects the dorsum of the hand, and ulnar nerve injury affects the little finger and ulnar palm.

Question 17Emergency Medicine (European Curriculum of Emergency Medicine)

A 19-year-old woman is brought in after a suspected sexual assault. Which action should be prioritised in the emergency department?

  1. Perform a pregnancy test only after 48 hours
  2. Obtain a detailed history before any medical care
  3. Refuse examination until police arrive
  4. Provide immediate medical care, including emergency contraception and prophylaxis, with consent and forensic evidence preservation Correct answer.

Explanation

The priority is the patient's immediate medical and psychological needs, including emergency contraception, sexually transmitted infection prophylaxis, injury treatment and, where indicated, forensic sampling with informed consent. Care should never be delayed for police involvement. A detailed forensic history is not a precondition for treatment.

Question 18Emergency Medicine (European Curriculum of Emergency Medicine)

Which of the following is a recognised feature of diabetic ketoacidosis rather than hyperosmolar hyperglycaemic state?

  1. Blood glucose usually above 40 mmol/L with minimal ketosis
  2. Absence of abdominal pain
  3. Serum osmolality above 320 mOsm/kg
  4. Serum bicarbonate below 18 mmol/L with ketonaemia Correct answer.

Explanation

Diabetic ketoacidosis is defined by ketonaemia with metabolic acidosis, typically a bicarbonate below 18 mmol/L and a pH below 7.3. Hyperosmolar hyperglycaemic state shows very high glucose and osmolality with little or no ketosis. Abdominal pain is common in ketoacidosis and does not distinguish the conditions.

Question 19Emergency Medicine (European Curriculum of Emergency Medicine)

A patient presents with a wide-complex tachycardia at 180/min and is haemodynamically unstable with hypotension and altered consciousness. What is the correct immediate management?

  1. Oral beta-blocker and observation
  2. Synchronised electrical cardioversion Correct answer.
  3. Intravenous adenosine 6 mg
  4. Carotid sinus massage

Explanation

Any tachyarrhythmia causing haemodynamic instability should be treated with synchronised electrical cardioversion. Adenosine is used for stable regular narrow-complex tachycardia and is not appropriate in an unstable patient with a wide-complex rhythm. Vagal manoeuvres and oral drugs have no role in unstable patients.

Question 20Emergency Medicine (European Curriculum of Emergency Medicine)

A 35-year-old woman presents with severe colicky abdominal pain, vomiting and a palpable tender mass in the right iliac fossa. She has had similar episodes of right lower quadrant discomfort in the past. What is the most likely diagnosis?

  1. Diverticulitis
  2. Appendicitis
  3. Ovarian torsion Correct answer.
  4. Biliary colic

Explanation

Sudden severe unilateral pelvic pain with vomiting and a tender adnexal mass in a woman of reproductive age suggests ovarian torsion, which is a surgical emergency requiring urgent gynaecological assessment. Recurrent similar episodes may reflect intermittent torsion. Appendicitis usually produces migrating pain with fever, and diverticulitis is uncommon at this age.

Question 21Emergency Medicine (European Curriculum of Emergency Medicine)

A 65-year-old man presents with acute urinary retention, a distended bladder and severe suprapubic pain. What is the most appropriate immediate intervention?

  1. Urethral catheterisation for bladder decompression Correct answer.
  2. Intravenous diuretic administration
  3. Oral alpha-blocker and outpatient review
  4. Suprapubic aspiration as the routine first step

Explanation

Acute urinary retention with a painful distended bladder requires immediate decompression, usually by urethral catheterisation, followed by monitoring for post-obstructive diuresis and investigation of the cause. Oral medication alone is too slow. Suprapubic aspiration is reserved for failed urethral catheterisation.

Question 22Emergency Medicine (European Curriculum of Emergency Medicine)

A patient arrives after a high-voltage electrical injury. Which complication should be specifically anticipated even when the skin appears minimally burned?

  1. Delayed hypersensitivity reaction
  2. Deep tissue injury with rhabdomyolysis and arrhythmia Correct answer.
  3. Immediate compartment syndrome of the contralateral limb
  4. Isolated superficial burns only

Explanation

High-voltage current travels through tissues, causing deep muscle damage and rhabdomyolysis with risk of acute kidney injury, hyperkalaemia and cardiac arrhythmias, while entry and exit skin wounds may look small. Cardiac monitoring and assessment of urine output and creatine kinase are therefore essential.

Question 23Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement about the use of tranexamic acid in major trauma is correct?

  1. It is contraindicated in all patients with head injury
  2. It should be given only after 24 hours from injury
  3. It should be administered as early as possible, ideally within 3 hours of injury, in patients with significant bleeding Correct answer.
  4. It replaces the need for blood product transfusion

Explanation

Tranexamic acid reduces mortality in trauma patients with significant bleeding when given early, ideally within three hours of injury. Beyond that window the benefit is uncertain and it may be harmful. It is an adjunct to, not a replacement for, haemostatic resuscitation.

Question 24Emergency Medicine (European Curriculum of Emergency Medicine)

A 50-year-old woman is brought in with a reduced level of consciousness and a temperature of 40°C after being found in a hot room during a heatwave. Her skin is hot and dry. Which cooling measure is appropriate in the emergency department?

  1. Ice packs applied to the neck, axillae and groin with active fanning Correct answer.
  2. Rapid intravenous infusion of warm fluids
  3. Oral antipyretics alone
  4. Warm blankets to prevent shivering

Explanation

Heat stroke requires rapid active cooling, and ice packs to the neck, axillae and groin combined with fanning increase heat loss. Antipyretics are ineffective because the hypothalamic set point is normal, and warming measures worsen the condition. Fluid resuscitation should be given but not warmed if it impedes cooling.

Question 25Emergency Medicine (European Curriculum of Emergency Medicine)

A 3-month-old infant presents with poor feeding, lethargy and a temperature of 38.2°C. Which statement about the approach to this infant is correct?

  1. Fever in this age group can be managed at home with antipyretics
  2. Urine testing is unnecessary in this age group
  3. Lumbar puncture is contraindicated in all infants under 3 months
  4. Fever in infants under 3 months always requires a full septic screen and admission Correct answer.

Explanation

Infants under three months with fever have a higher risk of serious bacterial infection and are generally investigated with a full septic screen, including blood, urine and cerebrospinal fluid cultures, and admitted for empirical antibiotics. Outpatient management is not appropriate at this age.

Question 26Emergency Medicine (European Curriculum of Emergency Medicine)

A 24-year-old man is brought to the emergency department after collapsing during a marathon on a hot day. His core temperature is 41.2°C, he is confused, and his skin is hot and dry. Which cooling strategy is most appropriate as the immediate priority in exertional heat stroke?

  1. Active warming to promote sweating and heat dissipation
  2. Cold-water immersion with concurrent haemodynamic monitoring Correct answer.
  3. Antipyretic therapy with intravenous paracetamol
  4. Oral rehydration with cool fluids and rest in a shaded area

Explanation

Exertional heat stroke is a life-threatening emergency in which rapid reduction of core temperature is the single most important intervention, and cold-water immersion is the most effective method. Antipyretics do not act on the non-pyrogenic hyperthermia of heat stroke, and cooling should begin before or alongside other resuscitation.

Question 27Emergency Medicine (European Curriculum of Emergency Medicine)

Which finding on a 12-lead ECG most strongly suggests hyperkalaemia in an emergency department patient with renal impairment?

  1. Prolonged QT interval with prominent U waves
  2. Sawtooth flutter waves at 300/min
  3. Tall, peaked T waves with a narrow base Correct answer.
  4. Widespread ST-segment elevation with PR depression

Explanation

Hyperkalaemia classically produces tall, peaked, narrow-based T waves, and progression can lead to widening of the QRS and sine-wave morphology. These changes reflect altered myocardial membrane potential and warrant urgent calcium administration when severe.

Question 28Emergency Medicine (European Curriculum of Emergency Medicine)

A 68-year-old man presents with sudden painless loss of vision in the right eye described as a curtain descending over the field. Which diagnosis should be actively excluded because of its time-critical nature?

  1. Acute angle-closure glaucoma
  2. Central retinal artery occlusion Correct answer.
  3. Vitreous haemorrhage
  4. Optic neuritis

Explanation

A curtain-like visual loss is typical of amaurosis fugax or retinal artery occlusion, and central retinal artery occlusion is a sight-threatening emergency requiring immediate assessment for reperfusion and stroke risk. The retinal appearance of pallor with a cherry-red spot supports the diagnosis.

Question 29Emergency Medicine (European Curriculum of Emergency Medicine)

In a patient with suspected acute aortic dissection, which initial pharmacological target is recommended to reduce the risk of propagation while definitive imaging is arranged?

  1. Heart rate above 100/min to limit clot formation
  2. Systolic blood pressure above 160 mmHg to maintain organ perfusion
  3. Heart rate below 60/min and systolic blood pressure around 100–120 mmHg Correct answer.
  4. Diastolic blood pressure below 40 mmHg to reduce wall stress

Explanation

In acute aortic dissection the aim is to reduce the rate of rise of aortic pressure (dP/dt), so heart rate is controlled first with a beta-blocker and systolic pressure is then titrated to roughly 100–120 mmHg. This limits extension of the dissection while preserving vital organ perfusion.

Question 30Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement best describes the recommended initial airway approach in an adult with a suspected cervical spine injury who requires bag-mask ventilation in the emergency department?

  1. Perform blind nasotracheal intubation as the first-line technique
  2. Hyperextend the neck to improve the view during bag-mask ventilation
  3. Apply routine axial traction during laryngoscopy to align the spine
  4. Use manual in-line stabilisation with jaw thrust and avoid routine traction Correct answer.

Explanation

Airway management in suspected cervical injury should combine manual in-line stabilisation with a jaw thrust to open the airway, avoiding excessive neck movement. Routine traction is not recommended because it can distract the spine and worsen injury, and blind nasal intubation is no longer first-line.

Question 31Emergency Medicine (European Curriculum of Emergency Medicine)

A previously healthy 32-year-old woman presents with fever, hypotension and a diffuse erythematous rash, and tampons are found on examination. Which organism is most likely responsible for this presentation?

  1. Clostridium perfringens
  2. Staphylococcus aureus producing toxic shock syndrome toxin-1 Correct answer.
  3. Neisseria meningitidis
  4. Streptococcus pyogenes producing streptolysin O

Explanation

Toxic shock syndrome associated with tampon use is classically caused by Staphylococcus aureus strains producing toxic shock syndrome toxin-1, a superantigen that drives fever, rash, hypotension and multi-organ dysfunction. Management includes removing the source, aggressive fluid resuscitation and antibiotics with antitoxin cover.

Question 32Emergency Medicine (European Curriculum of Emergency Medicine)

A 45-year-old man with no known cardiac disease presents with a regular narrow-complex tachycardia at 180/min and is haemodynamically stable. Which intervention is the most appropriate first step?

  1. Intravenous amiodarone bolus
  2. Immediate synchronised cardioversion under sedation
  3. Attempt vagal manoeuvres, then intravenous adenosine if unsuccessful Correct answer.
  4. Intravenous atropine 0.5 mg

Explanation

For a stable regular narrow-complex tachycardia, vagal manoeuvres followed by adenosine are recommended to slow atrioventricular conduction and to help diagnose and terminate the rhythm. Synchronised cardioversion is reserved for instability or failure of pharmacological measures.

Question 33Emergency Medicine (European Curriculum of Emergency Medicine)

Which parameter is used in the National Early Warning Score version 2 (NEWS2) but not in the original NEWS?

  1. Respiratory rate
  2. Level of consciousness
  3. Systolic blood pressure
  4. Supplemental oxygen requirement Correct answer.

Explanation

NEWS2 added the use of supplemental oxygen as a scored parameter and changed the scoring of consciousness to use the ACVPU scale. Respiratory rate, blood pressure and consciousness were already included in the original NEWS.

Question 34Emergency Medicine (European Curriculum of Emergency Medicine)

A 58-year-old man is found unresponsive with a blood glucose of 1.8 mmol/L. He has no intravenous access and cannot swallow safely. Which treatment should be given first?

  1. Oral sucrose solution by spoon
  2. Intravenous insulin with dextrose infusion
  3. Intramuscular glucagon followed by intravenous glucose when access is obtained Correct answer.
  4. Oral glucose gel placed in the mouth

Explanation

In severe hypoglycaemia without intravenous access, intramuscular glucagon is the first-line treatment because it mobilises hepatic glycogen and can be given rapidly. Once access is secured, intravenous glucose is given to restore and maintain normoglycaemia.

Question 35Emergency Medicine (European Curriculum of Emergency Medicine)

A 72-year-old woman presents with acute confusion, fever and a temperature of 39°C, and a urine dipstick is positive for nitrites and leucocytes. Which statement reflects the recommended approach to diagnosis in this patient?

  1. A positive urine dipstick alone confirms urinary tract infection as the cause of confusion
  2. Antibiotics should be withheld until a urine culture result is available
  3. Delirium in older adults is almost always due to urinary tract infection
  4. Urinary tract infection should be considered but other causes of delirium must be actively excluded Correct answer.

Explanation

In older adults, asymptomatic bacteriuria is common, so a positive dipstick does not prove that a urinary tract infection explains delirium. A structured search for other causes such as pneumonia, medication effects or metabolic disturbance is essential before attributing confusion to the urinary tract.

Question 36Emergency Medicine (European Curriculum of Emergency Medicine)

A patient with severe community-acquired pneumonia has a CURB-65 score of 3. Which statement best reflects the recommended management implication of this score?

  1. Admission to hospital with consideration of intensive care assessment Correct answer.
  2. Treatment as an outpatient with no follow-up required
  3. Immediate discharge after a single dose of intravenous antibiotics
  4. Safe discharge home with oral antibiotics

Explanation

A CURB-65 score of 3 indicates severe pneumonia with high mortality risk, and current guidance recommends hospital admission with consideration of intensive care. Lower scores may allow outpatient management, but a score of 3 or more requires inpatient care.

Question 37Emergency Medicine (European Curriculum of Emergency Medicine)

A 25-year-old man presents after a blunt abdominal trauma from a bicycle handlebar. He is haemodynamically stable with localised epigastric tenderness. Which imaging strategy is most appropriate for evaluating possible solid organ injury?

  1. Immediate diagnostic peritoneal lavage
  2. Plain abdominal radiograph
  3. Contrast-enhanced computed tomography of the abdomen Correct answer.
  4. Bedside ultrasound of the abdomen as the definitive test

Explanation

In a haemodynamically stable patient with suspected blunt abdominal trauma, contrast-enhanced computed tomography is the reference standard for detecting and grading solid organ injury. Focused ultrasound is useful for rapid triage of free fluid but cannot reliably exclude or grade organ injury.

Question 38Emergency Medicine (European Curriculum of Emergency Medicine)

A 30-year-old woman presents with a swollen, painful calf after a long-haul flight. Which statement about the diagnostic approach to suspected deep vein thrombosis is correct?

  1. D-dimer is most useful in patients with high pretest probability
  2. A positive D-dimer confirms the diagnosis and warrants anticoagulation alone
  3. Compression ultrasound should be avoided until D-dimer results are available
  4. A negative D-dimer can exclude deep vein thrombosis in patients with low pretest probability Correct answer.

Explanation

D-dimer has a high negative predictive value in patients with low clinical probability, so a negative result can safely exclude deep vein thrombosis in that group. In high-probability patients, imaging is required because a positive D-dimer is non-specific.

Question 39Emergency Medicine (European Curriculum of Emergency Medicine)

Which finding is most consistent with a tension pneumothorax requiring immediate needle decompression?

  1. Bilateral crackles with a normal tracheal position
  2. Tracheal deviation towards the affected side with stridor
  3. Unilateral wheeze with a normal blood pressure
  4. Tracheal deviation away from the affected side with severe respiratory distress and hypotension Correct answer.

Explanation

Tension pneumothorax produces progressive accumulation of intrathoracic pressure, shifting mediastinal structures away from the affected side and causing obstructive shock with hypotension and severe distress. Decompression should not be delayed for imaging in this setting.

Question 40Emergency Medicine (European Curriculum of Emergency Medicine)

A 40-year-old woman presents with a generalised tonic-clonic seizure lasting more than five minutes. Which drug and route represent the recommended first-line treatment in the emergency department?

  1. Intravenous lorazepam Correct answer.
  2. Intramuscular haloperidol
  3. Intravenous phenytoin as the first agent
  4. Oral carbamazepine

Explanation

Status epilepticus is first managed with a benzodiazepine such as intravenous lorazepam to terminate seizure activity, followed by a second-line antiepileptic if seizures persist. Early termination reduces neuronal injury and systemic complications.

Question 41Emergency Medicine (European Curriculum of Emergency Medicine)

A 55-year-old man is found with a blood glucose of 32 mmol/L, profound dehydration and a calculated serum osmolality of 340 mOsm/kg with minimal ketones. Which diagnosis is most likely?

  1. Lactic acidosis
  2. Alcoholic ketoacidosis
  3. Diabetic ketoacidosis
  4. Hyperosmolar hyperglycaemic state Correct answer.

Explanation

Marked hyperglycaemia with very high serum osmolality, profound dehydration and absent or minimal ketosis characterises hyperosmolar hyperglycaemic state. It typically occurs in older patients with type 2 diabetes and carries high mortality, requiring careful fluid and electrolyte correction.

Question 42Emergency Medicine (European Curriculum of Emergency Medicine)

A 28-year-old woman presents with colicky right loin pain, visible haematuria and a temperature of 38.6°C. Which management step is most important?

  1. Discharge with oral analgesia and outpatient review
  2. Elective lithotripsy referral
  3. Restriction of fluids to reduce urine output
  4. Urgent urological review for decompression of an obstructed infected system Correct answer.

Explanation

An obstructed, infected urinary tract (obstructive pyelonephritis) is a urological emergency because it can rapidly progress to sepsis and renal loss. Urgent decompression by nephrostomy or ureteric stent, together with antibiotics, is required.

Question 43Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement about the use of non-invasive ventilation in acute exacerbation of chronic obstructive pulmonary disease is correct?

  1. It should replace medical therapy and bronchodilators
  2. It is most effective when the patient is unable to protect the airway
  3. It is contraindicated in all patients with hypercapnia
  4. It reduces intubation rates and mortality when used with pH between 7.25 and 7.35 Correct answer.

Explanation

Non-invasive ventilation in COPD exacerbation with respiratory acidosis improves outcomes, reducing both intubation and mortality, and is recommended when pH is between about 7.25 and 7.35 despite optimal medical therapy. It is used alongside bronchodilators, corticosteroids and controlled oxygen.

Question 44Emergency Medicine (European Curriculum of Emergency Medicine)

A 62-year-old man presents with sudden painless loss of vision in one eye and is found to have a cherry-red spot at the macula with retinal pallor. Which underlying condition should be urgently investigated?

  1. Retinal detachment
  2. Atrial fibrillation as a source of retinal embolus Correct answer.
  3. Giant cell arteritis
  4. Acute angle-closure glaucoma

Explanation

Central retinal artery occlusion typically results from an embolus, often of cardiac origin such as in atrial fibrillation or from carotid atheroma. Urgent assessment for an embolic source and stroke risk is essential because these patients have a high subsequent vascular event rate.

Question 45Emergency Medicine (European Curriculum of Emergency Medicine)

A 35-year-old woman presents with a severe headache, fever and neck stiffness, and a non-blanching petechial rash. Which action should be taken immediately after initial assessment?

  1. Administer empirical intravenous antibiotics without waiting for lumbar puncture Correct answer.
  2. Perform lumbar puncture before any antibiotic administration
  3. Give oral antibiotics and arrange outpatient review
  4. Await computed tomography before starting treatment

Explanation

Suspected bacterial meningitis or meningococcaemia requires immediate empirical intravenous antibiotics because delay increases mortality. Lumbar puncture and imaging should not delay treatment, and steroids may be given according to local protocol.

Question 46Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement about the management of a patient with suspected severe sepsis and hypotension after fluid resuscitation is correct?

  1. Antibiotics should be delayed until blood cultures are confirmed positive
  2. A vasopressor such as norepinephrine should be started to maintain adequate mean arterial pressure Correct answer.
  3. Further fluid boluses should be continued indefinitely regardless of response
  4. Beta-blockade is recommended to reduce tachycardia

Explanation

When hypotension persists despite adequate fluid resuscitation, vasopressors such as norepinephrine are indicated to maintain organ perfusion, with a mean arterial pressure target usually around 65 mmHg. Fluid administration should be reassessed continuously to avoid overload.

Question 47Emergency Medicine (European Curriculum of Emergency Medicine)

A 19-year-old man presents with sudden severe testicular pain of 2 hours' duration, nausea and a high-riding testis with an absent cremasteric reflex. Which action is most appropriate?

  1. Scrotal support and analgesia with outpatient review
  2. Antibiotic treatment for epididymitis
  3. Immediate surgical exploration for suspected testicular torsion Correct answer.
  4. Urgent Doppler ultrasound before any surgical referral

Explanation

Testicular torsion is a time-critical surgical emergency, and salvage rates fall significantly after about 6 hours. Clinical suspicion warrants immediate surgical exploration rather than delaying for imaging when the diagnosis is strongly suspected.

Question 48Emergency Medicine (European Curriculum of Emergency Medicine)

Which statement about the emergency management of a patient with severe hyperkalaemia and ECG changes is correct?

  1. Sodium bicarbonate is the first-line treatment in all patients
  2. Potassium-binding resins act rapidly and are sufficient alone
  3. Intravenous calcium is given first to stabilise the myocardium while measures to shift and remove potassium are started Correct answer.
  4. Insulin-dextrose is contraindicated in the presence of ECG changes

Explanation

With ECG changes, intravenous calcium is given immediately to protect the myocardium, followed by insulin-dextrose to shift potassium intracellularly and definitive removal strategies such as dialysis. Calcium does not lower potassium but prevents life-threatening arrhythmia while other measures take effect.

Question 49Emergency Medicine (European Curriculum of Emergency Medicine)

A 70-year-old man with a history of atrial fibrillation presents with sudden onset of severe abdominal pain out of proportion to examination findings and a lactate of 4 mmol/L. Which diagnosis should be considered first?

  1. Acute appendicitis
  2. Uncomplicated diverticulitis
  3. Renal colic
  4. Acute mesenteric ischaemia Correct answer.

Explanation

Pain out of proportion to examination, atrial fibrillation and raised lactate strongly suggest acute mesenteric ischaemia from an embolus to the superior mesenteric artery. Early computed tomography angiography and surgical or interventional revascularisation are time-critical because bowel infarction develops rapidly.

Question 50Emergency Medicine (European Curriculum of Emergency Medicine)

A 45-year-old woman is brought in after a deliberate overdose of paracetamol 8 hours ago. She is asymptomatic with normal liver enzymes. Which statement about management is correct?

  1. Activated charcoal is the definitive treatment regardless of time since ingestion
  2. Intravenous N-acetylcysteine should be started based on the timed serum paracetamol concentration plotted on the treatment nomogram Correct answer.
  3. Liver transplantation should be arranged immediately for all patients
  4. N-acetylcysteine is only effective if given after liver failure develops

Explanation

The decision to treat paracetamol overdose with N-acetylcysteine is guided by the timed serum concentration plotted on the treatment nomogram, and treatment is most effective when started early. Activated charcoal may be considered within about one hour of ingestion but is not definitive therapy.