How to use these ACD IMG practice questions
The ACD IMG assessment is typically a structured, interview-style assessment built around clinical scenarios. It tests more than recognition of a rash. Your answer needs to show prioritisation, safe management, sensible investigation, communication and awareness of when to escalate in an Australian or New Zealand setting.
These questions are written as single-best-answer drills, but the method transfers to spoken scenarios. For every case, ask yourself:
- What is the most urgent problem?
- Which finding changes the level of triage?
- What information do I need before committing to a diagnosis?
- Which investigation will change management, and which tests would be unnecessary?
- What will I do now, who needs to know, and what safety-netting will I give?
Choose an answer in each practice screen, then read the explanation. The strongest distractor is often a reasonable action performed at the wrong time or without enough attention to severity. MySummaries uses this kind of board-based question drill to turn clinical notes into targeted practice.
Question 1 — triage a blistering eruption
This tests whether you recognise a dermatological emergency before discussing the likely drug or diagnosis.
A 34-year-old woman started lamotrigine 18 days ago. She has fever, malaise, painful dusky macules on the trunk, flaccid blisters, oral erosions and conjunctival soreness. Nikolsky sign is positive. What is the most appropriate immediate action?
Stop the suspected drug and treat this as possible Stevens–Johnson syndrome/toxic epidermal necrolysis. Mucosal involvement, skin pain, epidermal detachment and systemic illness require urgent hospital assessment, supportive care and specialist input. The strongest distractor is taking a biopsy before referral: a biopsy may help confirm the diagnosis, but it must not delay resuscitation, withdrawal of the culprit drug or escalation.
The transferable answer structure is: identify the likely emergency, state the immediate safety actions, stop a possible trigger, escalate, and then explain the investigations that specialists may arrange. Do not lead with a long differential when the patient is unstable.
Question 2 — select a useful biopsy plan
This tests whether the investigation matches the clinical question and the suspected process.
A 61-year-old man has a new crop of palpable purpura over both lower legs. Some lesions are palpable and non-blanching. He has mild ankle arthralgia but is haemodynamically stable. Which investigation plan is most appropriate?
Palpable purpura suggests small-vessel vasculitis. The plan should confirm the cutaneous process with a suitable biopsy and assess renal and other systemic involvement, beginning with urinalysis and renal function and tailoring further tests to the history and examination. The strongest distractor is empiric high-dose corticosteroid treatment: treatment may become necessary, but it should not replace assessment for organ involvement, infection, drugs or an underlying disease.
In an interview, state what the result would change. For example, haematuria or rising creatinine would increase urgency and require escalation, while a purely cutaneous, stable presentation may allow a more measured outpatient pathway.
Question 3 — identify eczema herpeticum
This tests recognition of a serious complication in a patient whose background diagnosis could make the eruption look familiar.
A 9-year-old boy with moderate atopic eczema develops a two-day history of fever and clusters of monomorphic, painful, punched-out erosions across the face and neck. He is lethargic and drinking poorly. What is the best next step?
Fever, pain and monomorphic punched-out erosions in atopic skin are concerning for eczema herpeticum, which requires same-day assessment and systemic antiviral treatment. Poor oral intake adds to the urgency. The strongest distractor is waiting for a swab: microbiological sampling may be useful, but it must not delay treatment and escalation in an unwell child.
A strong spoken response would explicitly mention the child’s general condition, eye involvement, hydration and the need to assess close contacts and infection-control issues according to local policy. It would also include clear return precautions if the child is managed after specialist review.
Question 4 — distinguish anaphylaxis from uncomplicated urticaria
This tests whether you assess airway, breathing and circulation rather than treating the skin appearance alone.
Ten minutes after eating cashew, a 24-year-old develops widespread urticaria, hoarse voice, wheeze and dizziness. What is the most appropriate immediate treatment?
Hoarseness, wheeze and dizziness with acute urticaria indicate anaphylaxis until proven otherwise. Give intramuscular adrenaline promptly, activate emergency support and assess airway, breathing and circulation. The strongest distractor is intravenous hydrocortisone: it is not a substitute for adrenaline and does not provide the required immediate reversal of life-threatening airway or circulatory compromise.
For ACD IMG-style reasoning, do not stop at the medication. Explain how you would reassess response, repeat adrenaline if clinically indicated under local protocol, observe and document the event, provide an allergy referral and discuss an emergency action plan before discharge when appropriate.
Question 5 — investigate a changing pigmented lesion
This tests whether you choose an appropriate diagnostic pathway for possible melanoma without causing avoidable harm.
A 47-year-old woman has a 9 mm asymmetric pigmented lesion on her upper back that has enlarged and developed colour variation over four months. Dermoscopy is suspicious. What is the best next step?
Recent enlargement, asymmetry and colour variation make melanoma a concern. The lesion needs timely specialist assessment and tissue diagnosis using a procedure appropriate to its site and size, with documentation and a plan for definitive management. The strongest distractor is liquid nitrogen: destructive treatment removes the opportunity for histological diagnosis and is unsafe for a suspicious pigmented lesion.
When answering aloud, say what you would examine: the lesion, regional nodes, the rest of the skin and relevant history such as previous skin cancer, family history, sun exposure and immunosuppression. Explain that the biopsy approach depends on the lesion and anatomical site, rather than quoting an inflexible procedure for every case.
Question 6 — manage suspected DRESS
This tests your response to a drug eruption with systemic features and the need to look for organ involvement.
A 58-year-old started allopurinol five weeks ago. He now has a widespread morbilliform eruption, facial oedema, fever and tender cervical nodes. Which next step is most appropriate?
The timing, fever, facial oedema and lymphadenopathy raise concern for DRESS. The suspected drug should be stopped and the patient assessed urgently, including blood count with differential and liver and renal function, with further management and escalation guided by severity. The strongest distractor is a topical emollient while continuing allopurinol: continuing a likely culprit can worsen a potentially serious systemic reaction.
A complete response also covers medication reconciliation, eosinophilia and organ symptoms, specialist involvement, documentation of the suspected allergy, and planned repeat blood tests because organ injury can evolve.
Question 7 — choose the right pathway for severe psoriasis
This tests severity assessment, comorbidity screening and escalation rather than simply naming another topical medicine.
A 39-year-old has extensive plaque psoriasis involving the palms, soles and scalp. Fissures impair work, topical treatment has been used correctly without adequate control, and he reports morning stiffness in several fingers. What is the best next step?
Palmoplantar disease, functional impairment and inadequate response require reassessment and escalation. Morning stiffness raises concern for psoriatic arthritis, so joint symptoms need active assessment and appropriate referral. Comorbidities, mood and treatment safety also matter. The strongest distractor is indefinite continuation of the same topical regimen: topical treatment may remain part of care, but it does not address the failure of control or possible joint disease.
In a structured answer, separate immediate skin management from longer-term treatment selection. Do not promise a particular systemic drug without reviewing contraindications, baseline tests, infection risk, pregnancy considerations where relevant, and local prescribing pathways.
Question 8 — recognise cellulitis mimics
This tests diagnostic discipline and avoids unnecessary antibiotics when the history and examination suggest another condition.
A 72-year-old has a six-month history of itchy, scaly erythema around both ankles. It is symmetrical, there is mild oedema, and he has no fever, pain or rapidly spreading border. What is the most appropriate approach?
Chronic, itchy, symmetrical ankle erythema without systemic illness or rapid progression is more consistent with venous eczema or another dermatitis than cellulitis. Assess venous disease, inspect for ulcers and infection, and provide appropriate skin care and follow-up. The strongest distractor is intravenous antibiotics: unnecessary antibiotics expose the patient to harm and do not treat the likely underlying process.
The safety-net matters: fever, increasing pain, rapid spread, purulence, ulcer deterioration or systemic illness would change the assessment. This is the kind of distinction that demonstrates both clinical reasoning and antimicrobial stewardship.
Question 9 — handle suspected scabies in a household
This tests contact management, examination and practical prevention of recurrence.
A university student has intense nocturnal itch, excoriated papules at the finger webs and wrists, and two housemates with similar symptoms. What is the best management principle?
Nocturnal itch, finger-web involvement and affected housemates support scabies. Management needs a diagnosis-led treatment plan that includes close contacts and practical environmental measures according to local guidance, otherwise reinfestation is likely. The strongest distractor is treating only the student: untreated contacts can maintain transmission even if the initial patient improves.
A safe interview response should ask about infants, older adults, pregnancy, immunosuppression and institutional exposure, because these factors can alter urgency and treatment advice. Explain that itch may persist after successful treatment, while new lesions or ongoing household transmission need reassessment.
Question 10 — plan escalation for a possible melanoma
This final question brings together communication, systems awareness and follow-up rather than testing one isolated fact.
A patient was told six weeks ago that a changing pigmented lesion was probably benign. It has continued to enlarge and now bleeds after minor trauma. The patient is anxious and has no regular general practitioner. What is the best response?
A changing, bleeding lesion needs fresh assessment even if an earlier opinion was reassuring. Document the evolution, examine the patient properly, explain uncertainty and arrange an appropriate urgent diagnostic pathway. Explicitly confirming who will follow up the result is part of safe care, particularly when the patient lacks a regular GP. The strongest distractor is relying on the previous benign impression: clinical evolution changes the risk assessment.
In a spoken answer, check the patient’s understanding, obtain consent for examination and procedures, ask what support they need, and record the referral and safety-netting. A defensible answer identifies not only what should happen, but also how you prevent the patient being lost between services.
Reviewing your performance
A correct option is not enough if you cannot explain the priority behind it. After the ten questions, classify each error:
- Triage error: you under-estimated instability, mucosal disease, systemic illness or rapid progression.
- Investigation error: you chose a test that would not change management or delayed an essential biopsy or assessment.
- Management error: you omitted stopping a culprit drug, escalation, treatment of a time-critical condition or review of comorbidity.
- Communication or systems error: you did not explain consent, follow-up, documentation, referral ownership or safety-netting.
A written response should usually follow this order: problem representation and urgency; key history and examination; prioritised differentials and red flags; investigations; immediate and longer-term management; follow-up and safety-netting. Practise saying that structure aloud, because a well-organised answer is easier for an examiner to follow and safer for a patient.
A marked paper can make the missing step visible rather than merely giving a percentage:
A patient taking a new medicine presents with fever, facial oedema and a widespread eruption. Explain your immediate approach.
3/4I would examine the rash, ask about the new medicine and stop it if it is the likely cause. I would arrange blood tests and refer to dermatology.
You recognised a probable drug reaction and selected useful investigations, but the answer did not prioritise systemic assessment or state how urgently the patient should be escalated.
Missed
−Assess airway, vital signs and symptoms of organ involvement before moving to routine referral
−State the need for urgent review and safety-netting, with documentation of the suspected drug allergy
Model answerI would first assess physiological stability, mucosal involvement and symptoms suggesting liver, renal or pulmonary disease. I would stop the suspected culprit medicine, reconcile all medicines and arrange urgent assessment. I would request a full blood count with differential, liver and renal function and other targeted tests guided by the history. I would document the suspected reaction, involve dermatology or acute services according to severity, and give clear follow-up and return precautions.
That is a MySummaries paper, filled with ACD IMG material. Yours is written from your own notes. Start free
Use the pattern in that review for every missed question. The goal is not to memorise a polished paragraph. It is to make your priorities automatic: danger first, focused information second, justified action third, and reliable follow-up throughout.
A weak-area summary can then tell you whether your errors are concentrated in triage, investigation, treatment or systems thinking:
How MySummaries helps
MySummaries can turn your own ACD IMG notes, referral pathways and dermatology summaries into a revision board, then generate targeted question practice, marked written answers, audio explanations and recorded oral scenarios. Use the weak areas from this set to decide which section needs another pass, rather than revising every topic equally.