1. health and fitness
2. therapy

MO Orientation & Induction
Test
Dr Toh Hong Chuen
Consultant
Acute and Emergency Care Center, Khoo Teck Puat Hospital, Singapore
Adjunct Assistant Professor, Clinical Senior Lecturer
Yong Loo Lin School of Medicine, National University of Singapore
Program Director
Alexandra Academy for Clinical and Emergency Sonography
42 SAQ
Passing Mark
380/420
NOTE:
1. Write your answers on a blank A4 Paper
2. Write legibly as it will be marked
1
A 87 yr old Chinese lady
presented with fever and bed
sore from nursing home.
1. State two other common
source of infection in this
group of patient (2)
2. If she is hypotensive, is she in
septic shock? (1)
3. What is the amount of initial
fluid challenge? (1)
4. What do you give if she is
still hypotensive after fluids
and vasopresors?(1)
5. State 5 things you must
document in your clinical
notes if this patient is for
DNR (5)
2
47 Ch Female presented with
abdominal pain and fever.
1. State the 3 reason for
ordering a supine AXR. (3)
2. How many air-fluid level
level can a normal person
have on erect AXR? (1)
3. State the most obvious
pathology that you see here
(2)
4. What is the most likely
diagnosis (2)
5. What bedside investigation
should be done for her? (2)
3
You see this set of vital signs for
an A&E patient breathing room
air.
1. What is the perfusion
pressure of this patient? (2)
2. Which blood does the SpO2
measure – Arterial, capillary,
venous or mixture? (2)
3. Can you significantly increase
the oxygen content in this
patient’s blood by giving high
flow oxygen via nonrebreather mask? Why? (2)
4. Calculate the MAP for this
patient based on the systolic
& diastolic BP that you see
here (2)
5. Why does your MAP reading
differ from the one shown
here? (2)
4
This 58 Malay lady presented
with right foot pain.
1. What is the most important
past medical condition to
ascertain in her? (2)
2. What pathology did you find
on this Xray? (1)
3. What physical finding do you
expect to find on clinical
examination? (1)
4. What is your diagnosis (2)
5. Why do you think she is
breathless but has clear
lungs and Spo2 of 97% on
room air? (2)
6. If she needs to be intubated,
what is the initial respiratory
rate that you set? (2)
5
You saw this Xray that your friend
ordered for a patient that was
handed over to you.
1. What is the name of the
splint that we have in the
A&E for this fracture? (2)
2. State 4 physical findings
would require an operative
repair for this injury (4)
3. Do you need to NBM this
patient if he is planned for
surgery? (1)
4. What else is wrong with this
Xray, other than the
fracture? (2) What should
you do to rectify this? (1)
6
A 68 Chinese male vomited out
this material in front of you.
1. What PAC should he be
assigned? (1)
2. If you can only sent one
blood test, what would you
send? (1)
3. Other than esophageal
varices, state 3 other
common causes of this
condition. (3)
4. State two other drugs that
you will give IF you suspect
esophageal varices , on top
of what you would give for
the 3 causes you listed above
(2).
5. What are the doses of these
two drugs? (3)
7
This patient came in for SOB and
you have just intubated him.
1. What does the size of ETT
refers to? (2)
2. What is the appropriate
minimal size of ETT for a
male? (1)
3. What is the formula for
depth of ETT placement? (1)
4. Can a CXR confirm airway
placement? How? (2)
5. What is the choice of
secondary confirmation of
airway placement? (1)
6. What is coming out from this
ETT? (1)
7. What is the most likely cause
of the patient’s respiratory
distress? (1)
8. How would you improve this
patient’s oxygenation other
than setting a high FiO2? (1)
8
You see this on the ECG monitor
of a sick patient.
1. What is your diagnosis? (3)
2. What immediate bedside
test must you do? (1)
3. What is the most important
drug to give if the bedside
test confirms your diagnosis?
(2). How do you give it? (1)
4. State 3 other drugs/route
that you can give (3)
9
This 64 Chinese male came in
drunk. While still under the
influence of alcohol, he
complained of lethargy and
muscle ache.
1. What abnormality do you
find on this ECG? (3)
2. What is you ECG diagnosis?
(2)
3. What bedside test would you
do to confirm your ECG
diagnosis (1) What is your
treatment? (2)
4. What is the most likely cause
of the patient’s muscle ache?
(1) What bedside test would
you do to suggest your
diagnosis? (1)
10
This lady was brought over from
nursing home for “talking
abnormally” and “pain on
eating”.
1. What is the most significant
physical abnormality on her?
(2)
2. What is the most likely
diagnosis? (2)
3. What investigation would
you order? (2) What is the
purpose of this
investigation? (2)
4. After you have solved her
problem, what and what
advice would you give
her/nursing home staff
before you discharge her? (2)
11
54 Ch Male presented with vague
chest pain at rest for only one
day last week. There was no
other symptoms and no CVRF.
Came to ED after his wife bugged
him to. He was completely well
on presentation. The vitals, CXR
and first Trop T are completely
normal.
1. What is the door to ECG
reading time? (1)
2. State 3 ECG abnormalities (3)
3. What is your main ECG
diagnosis? (1)
4. Is this patient suitable for
chest pain protocol? (2)
5. The patient (a VIP) has self
ordered a treadmill at a
private hospital. Should he
go for it and why? (2)
6. Would you start aspirin for
him? (1)
12
A patient was brought into the
ED after her maid found her
“blue”. Paramedics gave the
report that she was asystolic at
scene.
1. What are the 10 causes of
cardiac arrest? (5)
2. What is the most likely cause
of cardiac arrest in this
patient? (1)
3. You have a known diagnosis
for cause of death. Can she
be signed up as a noncoroner’s case? (2).
4. Why? (2)
13
Good quality CPR is a class I
recommendation in patients with
cardiac arrest.
1. How would you perform the
Chest Compression for it to be
“Good Quality” (5)
2. How would you perform the
Bagging (using BVM) for it to be
“Good Quality” (1)
3. Other than calling off
resuscitation, state the TWO
occasions (there are only 2)
when you can STOP chest
compression. (4)
14
A patient comes with the clinical
diagnosis of stroke <2hours. You
are managing bases on
department protocol:
Thrombolysis is contraindicated
in (state true / false)
1. SBP 200mmHg
2. Seizure at scene
3. Hematuria 1 week ago
4. Mass effect on CT
5. Dabigatran
6. Pure sensory stroke
7. Isolated facial weakness
8. Age 82
9. NIHSS score 23
15
A 56 yr old male presents with
left sided weakness <1hours. You
think that pt will benefit from rTPA and intend to start therapy.
1. Who can give the
authorisation to start r-TPA?
(1)
2. What is the risk of ICH post rTPA? (1)
3. What SBP and DBP do you
aim? (2)
4. How often should BP be
monitored in the ED? (1)
5. What is the blood sugar
above which you’ll treat? (1)
6. Do you start aspirin for this
patient? (1)
7. Should you routinely
catheterize/NGT the patient?
8. What should you do if
patient complain of severe
headache (2)
16
45 man with chest pain.
1. Which level is the ICS located
in KTPH? (1)
2. What is the main ECG
findings? (2)
3. State the drugs and doses
that this patient needs at the
A&E (2)
4. Which arm do you set the IV
line and why? (2)
5. What is the number to call to
activate ICS? (1)
6. What is the ideal door-toballoon time? (1)
7. Do you have to wait for the
ICS team to arrive at ICS
before transferring the
patient? (1)
17
A 34yr old lady presented with
vomiting and diarrhoea. She is
still lethargic looking after IV
rehydration.
The following are exclusion
criteria for the GE protocol (state
true/false) (8)
1. Recent abdominal surgey
2. Renal transplant
3. Bloody/mucoid stools
4. Cr >200 (baseline 82)
5. Na 112mmol/L
6. Multiple co-morbidities
7. B-cell lymphoma on
treatment
8. Hypocount 32
9. Who can admit a patient to
EDTU? (1)
10. Who can discharge a patient
to EDTU? (1)
18
This 27 Chinese man presented
with syncope while watching
football. He is otherwise well at
the ED with normal vital signs
and physical findings.
1. What piece of information in
the family history must you
obtain? (2)
2. Describe the main ECG
abnormality (2)
3. What is your ECG diagnosis?
(2)
4. How can you increase the
sensitivity of this finding on
ECG? (2)
5. What is the treatment of
choice? (2)
19
This Bangladeshi man slipped
and hit his head. He has no LOC,
amnesia or disorientation.
Complain of right sided headache
and bleeding from right ear with
material as shown.
1. Can you use the Canadian CT
head rule for this patient? (1)
Why? (1)
2. Describe what you see on
this picture (1)
3. State your diagnosis (2)
4. What clinical sign will
support your diagnosis?(1)
5. Does he need prophylactic
antibiotics? (1)
6. Does he need prophylactic
anticonvulsant? (1)
7. His GCS is 15. Can he be
discharged? (1)
8. Why is the lower limbs not
used in assessment for the
MOTOR component of GCS?
(1)
20
A 42 yr old patient presents with
abdominal pain and vomiting for
3 days. An AXR is done for the
patient.
1. Is the patient male or
female? (1)
2. What abnormalities do you
see on this AXR? (3)
3. Based on this AXR, what is
the most likely cause of the
patient’s problem? (1)
4. What 3 results from point of
care test would help gauge
the severity of her
condition? (3)
5. How often does AXR pick up
this pathology definitely?
Give in terms of % (1)
6. How often does AXR miss
this pathology completely?
Give in terms of % (1)
21
36 Ch Male fell off his bike and
twisted his ankle with deformity
as shown
1. What is the Ottawa ankle
rule? (4)
2. Which part of the knee must
you palpate to exclude a
concomitant fracture? (1) If
the concomitant fracture is
present, what is it called? (1)
3. What makes this ankle injury
a true emergency? (2)
4. The patient has NO malleolar
tenderness. What is the most
likely clinical diagnosis? (2)
22
You are shown this ECG.
1. Explain why is there
“Asystole” on lead II (2)
2. Is the amplitude calibration
correct? (1)
3. Is the speed calibration
correct? (1)
4. State the position of the
following leads: V1, V3, V7,
V8, V9, RV4 (6)
23
This patient came in for severe
SOB at 4am. BP 190/100mmHg,
PR 123, RR 30, SpO2 92% on
NRM. Has some heart problem
but no other medical/surgical
history.
1. What is your diagnosis? (1)
2. What drug would you first
give for this patient? (1) How
do you give this drug? (2)
3. How would you position the
patient? (2)
4. Would you catheterise the
patient immediately? (1)
5. Is morphine indicated? (1)
6. State 2 contraindications to
NIV in this case (2)
24
26 Malay man fell while playing
soccer. Hit his head with LOC 2
mins, but woke up and vomited
twice. Complain of headache and
neckache. GCS 14, BP
150/98mmhg, PR 72, RR 16.
1. What is you CT diagnosis? (1)
2. Is CT neck indicated? (1)
3. How would you describe this
CT to the neurosurgeon? (2)
4. His GCS drops to 11 after you
put down the phone. You
have decided to intubate.
What pre-treatment drugs
would you give? (2) State
dose (2)
5. How should you position the
bed post intubation? (1)
6. Is he a candidate for lung
protective ventilation? (1)
25
1. State the THREE reasons for
securing a patient’s airway
(clue: mnemonic: ABC) (6)
2. State the 3 predictors of a
difficult laryngoscopy in this
patient (3)
3. Would you attempt apneic
oxygenation in this patient?
(1)
26
26 Indian foreign worker started
work in Singapore 3 weeks ago.
Complain of progressive SOB and
cough since arrival. BP
120/78mmHg, RR 16, PR 96,
Temp 36.7.
1. State 2 scoring system for
community acquired
pneumonia. (2)
2. State the main CXR findings
(2)
3. Does this patient need a
chest tube inserted
emergently at the A&E? (1)
Why? (1)
4. What abnormality do you
expect to find on ECG? (1)
5. What is the most likely
organism? (1)
6. His lactate is 1.9mmol/L and
vitals remained stable. What
is your disposition? (2)
27
RSI is commonly performed in
the A&E.
1. What sequence is rapid in
RSI? (1)
2. State the dose of
succinylcholine (in mg/kg) for
routine RSI (1); myasthenia
gravis (1); 7yr old child (1); 7
month old child (1)
3. State the induction drug of
choice and dose in a
hypotensive patient (2)
4. State 3 situations that
exclude the use of pretreatment drugs (3)
28
NO: 28
89 Chinese lady with dementia
presented with poor appetite
and constipation. Occasional
crackles on the lung, abdomen is
soft, bowel sounds present.
1. State the main abnormality
on this Xray (2)
2. Explain the abdominal
findings (2).
3. State the drugs that you
would give to this patient (3)
4. Which discipline should the
patient be admitted to? (1)
29
69 Indian Male present with
diaphoresis and chest pain.
1. State 3 ECG abnormality (3)
2. What is your ECG diagnosis
(1)
3. Would you give the patient
GTN for his chest pain? (1)
Why? (1)
4. What do you expect to find
on lung auscultation? (1)
Explain (3)
30
A 18 yr old student was bitten by
this creature on her right
forearm while watching TV in her
hostel. Complain of slight
redness and swelling. State
true/false (Q1-4):
1. Most land snakes in
Singapore are venomous
2. At scene: she should have
suck out the blood from the
bite
3. At scene: she should have
applied ice to the wound
4. A Right UL IV line is
contraindicated.
5. State 2 POCT that you would
do (2). Why? (2)
6. Should antivenom be given?
(2)
31
pH
pO2
pCO2
HCO3
7.04
76 mmHg
35 mmHg
5 mEq/L
Na
K
Cl
CO2
136 mmol/L
3.0 mmol/L
90 mmol/L
6 mmol/L
1. State 2 acid base disorders ta
cannot occur concurrently
(1)
2. Looking ONLY at the readings
in red, state the acid base
disorders (2)
3. What is the anion gap? (1)
4. Looking at ALL the reading
given, what are the acid base
abnormality? Show your
working (6)
32
A 50kg Caucasian male sustain burn
injury at 5:40am at his worksite.
When you see him at 7am, the
burnt injury are as follow: 15% first
degree burn to the back, 5% partial
thickness burns to each lower limb
and 10% full thickness burn to his
front torso. The parkland formula is
4ml/kg/%BSA.
1. What is the most important
injury to exclude? (1)
2. Calculate his additional fluid
requirement due to the burns
injury (i.e. on top of
maintenance) for the first 24
hours (3)
3. How do you give this fluid over
24 hours? (2) What time does
this fluid regimen ends? (1)
4. Do you start prophylactic abx?
(1)
5. Do you give tetanus toxoid? (1)
6. Does he need to be transferred
to the burns unit in SGH? (1)
33
You need to call the surgical
registrar to see a patient
suspected of acute appendicitis.
1. State 4 main clinical
interventions for this
patients (4)
2. Must you always consult
with the senior on shift
before calling the GS reg? (1)
3. SBAR is the recommended
way of communicating with
the GS registrar. What does
each of the alphabet stands
for? (4)
4. Both the GS and Medical
consultants insist it is not a
surgical or medical issue
respectively. Who decides on
the speciality to admit to in
this case?
34
In the late 1800s, Ignaz
Semmelweis discovered that by
washing hands with an antiseptic
solution before delivery reduced
childbed fever fatalities by 90%.
(for Qn2-6, state true/false)
1. State the 5 moments of hand
hygiene (5)
2. The hand hygiene audit in
the A&E is performed by our
A&E staff (1)
3. The blood culture kit must be
used when taking blood
culture (1).
4. Washing a wound with
sterile normal saline reduces
risk of wound infection
compared to tap water (1)
5. Prophylatic antibiotics would
prevent more wound
infection that good
debridement and irrigation.
(1)
6. Sterile gloves should be worn
during T&S (1)
35
The bag valve mask is commonly
used in the A&E. (Qn1-2 answer
true/false)
1. Bag-valve mask ventilation is
the most important airway
skill (1)
2. You can deliver FiO2 >95%
with BVM. (1)
3. State the 5 predictors of
difficult bag-valve mask
ventilation (5)
4. How much air should you
practically bag for male in
cardiac arrest with an
estimated IBW of 70kg and
actual body weight of 100kg?
(2)
5. What is the compression :
ventilation ratio in an
unintubated patient? (1)
36
A 8 year old child took 8 tablets
of regular Panadol by mistake at
3pm. The mum realised this and
rush the boy to A&E at 8pm.
1. What is the child’s estimated
body weight? (1)
2. State the toxic dose of
paracetamol (1)
3. Other than FBC, RP, PT/PTT
and paracetamol level, what
other blood test would you
do? (1)
4. Can you use the Rumack
Matthew nomogram in this
child? (2)
5. Would you start NAC before
the paracetamol levels
returns? (1) Why? (1)
6. Is activated charcoal
indicated? (1)
7. What do you do if patient
develops an anaphylactoid
reaction to NAC, other than
treating the reaction itself?
(2)
37
You are seeing a crying infant.
There is an established
mnemonic to remember the
causes: (I.T. C.R.I.E.S.S)
1. State what are each of this
alphabet represents? (8)
2. What drug do we have in the
ED to treat infantile colic? (1)
3. The patient is noted to have
retinal haemorrhage in the
absence of trauma. What is
the diagnosis? (1)
38
You are familiar with the IV catheters
and fluids bags in the department.
(For Qn 1-4, write the flow rate in
ml/min, to the nearest 10thml for each
of the catheter)
1.
2.
3.
4.
5.
22 Gauge (1)
20 Gauge (1)
18 Gauge (1)
16 Gauge (1)
What needle/syringe would you
choose to give an anaphylactic
patient 0.3mg of adrenaline? (1)
6. Why do you discard the first 1020mls of the insulin infusion after
priming, before connecting it to
the DKA patient? (1)
7. What is the osmolality &
approximate pH of normal saline?
(2)
8. What is the Na and K concentration
of hartmann’s solution? (2)
39
A 45 male has a history of right sided
migraine. Wakes up with a throbbing
right sided headache for 1 day.
Notices the headache got worse
when he tried to pass motion. There
is no neurological deficit, vitals all
normal.
1. What are the 2 red flags in this
history? (2)
2. Other than ICH, state 4 other
serious causes of headaches to
consider in the ED. (4)
3. Can a BP of 175/98mmHg be the
cause of headache? (1)
4. The headache completely
resolves with paracetamol 1g.
Does he need a CT head now?
(1)
5. What is the cost of CT head in
ED? (1) Who can authorise a CT
head in ED? (1)
40
FAST is a commonly performed
ultrasound exam. This trauma
patient comes in in brief cardiac
arrest with successful ROSC post
intubation.
1. Where on the torso do you
first put the probe for the
RUQ view? (2)
2. Where on the torso do you
first put the probe for the
LUQ view? (2)
3. What pathology do you look
for in the subcostal 4
chamber view? (2)
4. What pathology does the 2
red arrow point to? (2)
5. Other than setting 2 large
bore IV for fluids/call
surgeon, what other
important intervention must
you perform? (2)
41
A 42 Indian lady presented with syncope
while trying to passing urine.
1. Define syncope (2.5)
2. Other than arrhythmia and ischemia,
what are the 5 subtle ECG
abnormalities you want to exclude in
this case? (5)
3. You have heard of that the San
Francisco Syncope rule is used more
to rule in rather than rule out high
risk syncope. What is the rule? (2.5)
42
45 Chinese Male presented with
this ECG.
1. What is your ECG diagnosis?
(1)
2. What are the 5
signs/symptoms of
hemodynamic instability? (5)
3. How will you treat the
rhythm if he is
hemodynamically unstable?
(2)?
4. How will you treat the
rhythm if he is
hemodynamically stable? (2)
The End