SAEM Practice 2020

The major abnormality on the image below is at which level? (a) C3/C4 (b) C4/C5 (c) C5/C6 (d) C6/C7

(c) C5/C6 The answer is C. The patient has anterior displacement of C5 on C6. --For further reading, see Hamilton et al, Emergency Medicine: An approach to clinical problem-solving (Chapter 48: Head and neck trauma).

The pathophysiology of cardiogenic shock is: A. Cardiac pump failure B. Endotoxins C. Hypoxia D. Hypovolemia E. Vasodilation

A. Cardiac pump failure

A patient presents after accidentally splashing liquid detergent in her eyes. She complains of bilateral eye pain. What is the most appropriate initial step in her management? A. Irrigate copiously with normal saline. B. Assess visual acuity with a Snellen chart. C. Perform a full eye examination. D. Stain the cornea with fluorescein to better assess for corneal burn. E. Assess pH of the tears.

A. Irrigate copiously with normal saline.

The X-ray in the figure indicates: [image: right sided whiteout mediastinum shift left] A. Mediastinal shift due to fluid in the right hemithorax B. Need to withdraw the endotracheal tube from the mainstem C. A chest radiograph that was taken with the patient rotated D. Right upper lobe pneumonia

A. Mediastinal shift due to fluid in the right hemithorax The answer is A. The patient is not intubated. The pathology in the right hemithorax appears as hyperdensity, rather than air density (not a pneumothorax), and involves more than the right upper lobe.

Which diagnosis is suggested by the EKG shown in the Figure? [image shows right sided leads with V1 elevation] A. right-ventricular ischemia B. digoxin overdose C. pericarditis D. dextrocardia

A. right-ventricular ischemia

Using the rule of 9s, what is the approximate burn surface area of a victim who has sustained second-degree burns to the anterior chest and anterior area of both arms? A. 20% B. 25% C. 30% D. 35%

B. 25%

The five diagnostic criteria for Ludwig's angina include all the following EXCEPT: A. sparing of the glandular tissues B. large amounts of visible pus in the submandibular space C. spread of cellulitis by continuity, not by lymphatics D. bilateral cellulitis E. presence of gangrene

B. large amounts of visible pus in the submandibular space

A 54 year old female presents with palpitations. She is otherwise asymptomatic. EKG shows atrial fibrillation. Vital signs are HR 130-150, BP 148/78, RR 16, T 36.7. What management intervention is most important to accomplish next? A. Anticoagulation B. Cardioversion C. Pharmacologic ventricular rate control D. Radiofrequency ablation

C. Pharmacologic ventricular rate control "If the patient is stable, the first priority is to achieve ventricular rate control."

What is the normal range for intraocular pressure in humans (in mmHg)? A. 0-10 B. 10-20 C. 20-30 D. 30-40 E. 40-50

B. 10-20

A 29-year-old male presents to the emergency department complaining of substernal chest pressure. The patient used cocaine and alcohol 3 hours prior to admission. On exam, the patient has a blood pressure of 160/100 mm Hg and heart rate of 150 beats per minute with ST-segment changes in the inferior leads on EKG. Which of the following is the best medication to treat the patient's cardiovascular status? A. Lidocaine B. Lorazepam C. Metoprolol D. Phenoxybenzamine

B. Lorazepam The answer is B. In a patient with suspected myocardial ischemia secondary to cocaine abuse, beta blockade (choices C) is contraindicated as it may lead to unopposed alpha-adrenergic effects and could cause worsening hypertension.

A 26 year old female is brought into the Emergency Department for suicidal ideations. She has been depressed with the thoughts of wanting to hurt herself for the past 2 days. Her past medical history is significant for hypertension, seasonal allergies, and panic disorder. Currently she is married and living with her husband. She is employed and has been working at a bank for 7 years. The patient denies any alcohol or drug use. Which factor in this patient's history increases the patient's suicide risk? A. Female gender B. Panic disorder C. Married status D. Job employment

B. Panic disorder

A young woman presents with an amitriptyline overdose. She is agitated and confused. In overdoses of this class of medications, an indicator of severe toxicity would include A. Serum amitriptyline level > 200 mcg/dl B. Prolonged QRS interval C. Metabolic acidosis with a pH < 7.25 D. Elevated osmolar gap > 20

B. Prolonged QRS interval

During opiate withdrawal which of the following symptoms would you expect to find? A. Urinary retention B. Tachypnea C. Pruritis D. Constipation

B. Tachypnea The answer is B. Withdrawal syndromes tend to have symptoms that are the reverse of intoxication syndromes. In opiate withdrawal, individuals present with CNS excitation, diarrhea, mydriasis, tachypnea and often abdominal cramping and vomiting. While uncomfortable, opiate withdrawal is not life threatening and is managed symptomatically

What is the most common cause of fatal anaphylaxis? A. radiographic contrast dye B. penicillin C. insect stings D. foods, including shellfish, nuts, and eggs

B. penicillin

An 8 year old female presents with a regular, narrow-complex SVT. You diagnose AV nodal reentrant tachycardia. Which pharmacologic agent would be most appropriate for initial management? A. Diltiazem B. Digoxin C. Adenosine D. Lidocaine

C. Adenosine "Adenosine, a purinergic blocking agent that causes acute and transient AV nodal blockade, is the drug of choice for acute termination of AVNRT. Multiple studies have shown that adenosine is nearly 100 percent effective in terminating AVNRT."

A 51-year-old male with long-standing hypertension presents with abrupt onset of severe chest pain radiating to the back. He describes a tearing sensation. Vital signs are HR 110, BP 175/105, RR 20, T 37.4. EKG shows LVH. CBC, electrolytes, BUN/Creatinine are all normal. CXR is as shown below. What diagnostic test would be most appropriate for making a definitive diagnosis at this time? [image shows CXR w/ wide mediastinum] A. MRI of the thoracic spine B. Aortogram C. CT of the chest with IV contrast D. Esophagram using Gastrograffin

C. CT of the chest with IV contrast "CT of the chest is the test most often used to confirm the diagnosis of aortic dissection. CT is readily available in most Emergency Departments, and has a sensitivity of 83-98% and specificity of 87-100% for aortic dissection (highest accuracy with helical scans). Other benefits associated with the use of CT include the ability to identify intramural thrombus, pericardial effusion, and potentially reveal another etiology for the patient's pain. The major disadvantage of CT is the need for iodinated contrast, which requires normal renal function."

A 73 year old woman is brought in by BLS after witnessed collapse. They found the patient unresponsive and provided CPR until arrival in the Emergency Department. In the Emergency Department the EKG demonstrates a wide-complex, regular rhythm and there is no palpable carotid pulse, consistent with PEA arrest. The patient is intubated and CPR is continued. According to ACLS guidelines, what is the next step in this patient's management? A. Defibrillation B. Heparin C. Epinephrine D. Nitroglycerine

C. Epinephrine

A 59-year-old woman was recently diagnosed with a large annular sigmoid colon cancer. Her severe pain for the last 4 days in her left lower quadrant and back prompted her primary care physician to order a CT of the abdomen which revealed air surrounding the colon and in the retroperitoneum. One antibiotic that should be considered as part of her management should be: A. Ampicillin/Sulbactam B. Cephalexin C. Metronidazole D. Gentamicin

C. Metronidazole

Where are the normally dominant pacemaker cells of the heart found? A. bundle of His B. atrioventricular node C. sinoatrial node D. accessory pathway of Kent

C. sinoatrial node

A 50 year-old male presents with a chief complaint of chronic nasal itching and "a sore that won't go away" over the past few months. Of the following choices, which is the most appropriate management? [image nasty basal/scc looking thing] A. prescription of topical steroid cream and follow-up in 5-7 days B. provision of an antibiotic-soaked dressing and reassessment in the E.D. within 48 hours C. urgent or next-day outpatient follow-up in Dermatology Clinic D. CT scan of the face for signs of nasal or facial trauma E. screening of the eyes for zoster opthalmicus

C. urgent or next-day outpatient follow-up in Dermatology Clinic The patient's history and presentation are highly suggestive of malignancy.

Of the following choices, which diagnosis is most likely in a 35-year old female with intermittent palpitations and the EKG shown in the Figure? [image shows delta waves] A. digoxin overdose B. asthma C. pericarditis D. Wolff-Parkinson-White syndrome

D. Wolff-Parkinson-White syndrome

While lifting weights after a few months off of his training regimen, the patient felt a pop in the right arm. He has weakness of, and pain with, elbow flexion and supination. Of the choices below, which is the most likely diagnosis? A. humerus fracture B. acromioclavicular separation C. rotator cuff tear D. biceps rupture E. elbow dislocation

D. biceps rupture

You are caring for a 24-year-old man with appendicitis in the Emergency Department. You dosed him with Morphine upon arrival. The morphine provided relief for a few hours, but he is now experiencing severe pain again. He denies allergies to medications. You call the surgical intern to evaluate and admit the patient. She directs you not to administer any additional narcotic pain medications until after her evaluation because it will interfere with her physical examination. What is the most appropriate course of action to address your patient's pain at this time? A. Administer narcotic pain medications B. Administer acetaminophen C. Administer non-steroidal anti-inflammatory agents D. Administer no pain medications until after the intern's examination

A. Administer narcotic pain medications

A patient presents after an unknown ingestion. Her initial electrocardiogram (EKG) is shown below [image shows sinus tachy] Based on the EKG, an overdose with which of the following medications would be most likely? A. Amitriptyline B. Ibuprofen C. Nifedipine D. Clonidine

A. Amitriptyline The answer is A. Amitriptyline is a tricyclic antidepressant (TCA). As such, it has anticholinergic activity that will cause a sinus tachycardia. Additional EKG findings with TCA toxicity include interval prolongation and terminal 40 ms right axis deviation. Clonidine, nifedipine, and metoprolol typically cause bradycardia. NSAIDs, like ibuprofen, rarely affect the heart rate.

A 48 year old female cirrhotic patient presents to the ED with 4 episodes of painless hematemesis and now melanotic stools, last 1 hour ago. She is known to have esophageal varices. Her initial vital signs were BP 90/40, HR 120, RR 18, 97%, Oral temp 98.0 °F. In addition to her initial fluid resuscitation and correction of any coagulopathy, which of the following ED therapies is the most appropriate to aid in the patient's stabilization and recovery? A. IV octreotide B. Nasogastric lavage C. IV Cimetidine D. Sengstaken-Blakemore tube placement

A. IV octreotide

If the parents are present and refuse treatment for their child in a life-threatening emergency, prehospital care providers should: A. Provide treatment for the child B. Call the police to have the parents arrested C. Confirm the identities of the parents and follow parental wishes D. Contact their ambulance service's legal counsel to discuss whether to treat E. Contact on-line medical control for physician permission to treat

A. Provide treatment for the child

The most common cause of diarrhea in children is: A. Rotavirus and Norwalk virus B. Clostridia and Yersinia C. E. coli D. Salmonella and Shigella E. Campylobacter and Staph. aureus

A. Rotavirus and Norwalk virus

A patient presents with right shoulder pain after a wrestling match. He has difficulty elevating his arm. What is the most likely diagnosis? A. acromio-clavicular separation B. clavicle fracture C. deltoid rupture D. humerus dislocation E. proximal humerus fracture

A. acromio-clavicular separation

A 78-year-old female presents to the Emergency Department with acute respiratory distress speaking in single word sentences. Her vital signs reveal a blood pressure of 210/120, heart rate of 110, respiratory rate of 35, and oxygen saturation of 82% on oxygen by face mask. Her lung exam reveals course crackles bilaterally. Which of the following is the most appropriate pharmacotherapy? A. Midazolam B. Nitroglycerin C. Morphine D. Metoprolol E. Albuterol

B. Nitroglycerin

Recurrent cellulitis in the distal phalanx of the right thumb in a 32 year old carpenter who is otherwise healthy should prompt the ED physicians to perform: A. Screening for Human Immunodeficiency Virus B. Radiographic imaging for suspected retained foreign body C. A deep, longitudinal 2-cm incision to explore the thumb for an abscess D. Testing for diabetes mellitus

B. Radiographic imaging for suspected retained foreign body

The treatment of cardiogenic shock may include all of the following EXCEPT: A. Treatment of ischemia B. Dopamine C. Phenylephrine D. Dobutamine E. Intra-aortic balloon pump

C. Phenylephrine The answer is C. The goal of therapy is to improve oxygenation, minimize ischemia, improve pump function, and decrease afterload. An intra-aortic balloon pump may be a temporizing measure. Phenylephrine would increase afterload and worsen cardiac output.

Which factor is least reliable in differentiating between organic and inorganic causes of confusion? A. acute versus chronic onset B. Vital sign abnormalities C. Presence of attention deficit D. Signs of trauma

C. Presence of attention deficit Presence of an attention deficit is common to all confusional states. All the other options may be used to differentiate organic versus non-organic causes of confusion. Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs. Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions.

A patient presents to the ED after a fall with chest pain. A chest xray shows a rib fracture but no pneumothorax, and a chest CT is ordered. What is the most appropriate treatment for a small pneumothorax, detected only on chest CT, in a hemodynamically stable trauma patient? A. 100% oxygen B. Heliox by face mask C. Immediate needle decompression D. Chest tube placement

A. 100% oxygen The answer is A. An occult pneumothorax may resorb with only oxygen administration, not requiring invasive management. Needle decompression is used for tension pneumothorax, and heliox may be used for reactive airway disease to reduce resistance to flow.

Incomplete angulated fractures of long bones are denoted by the term: A. greenstick fracture B. march fracture C. open fracture D. Salter-Harris fracture E. torus fracture

A. greenstick fracture

A patient with which of the following conditions classically presents with conjunctival injection (a "red" eye)? A. ultraviolet keratitis B. central retinal artery occlusion C. central retinal vein occlusion D. retinal detachment E. vitreous hemorrhage

A. ultraviolet keratitis Ultraviolet (UV) keratitis constitutes a sunburn of the cornea. Common exposures include welding torches, sun-tanning booths, prolonged sun exposure (i.e.; high altitude skiing without ski goggles). The classic presentation of UV keratitis is that of a "red" eye - incredibly injected conjunctiva, eye pain, and photophobia. Central retinal artery and vein occlusion, retinal detachment, and vitreous hemorrhage affect structures deep to the conjunctiva and generally do not cause conjunctival injection.

What corneal pathology is predicted in a patient with a foreign body lodged in the conjunctiva of the upper eyelid? A. vertical corneal abrasions B. dendrites C. rust ring D. corneal ulcer directly opposite the location of the foreign body E. branching abrasions with terminal bulbs

A. vertical corneal abrasions

Which of the following statements regarding use of Helicopter Emergency Medical Services (HEMS) for trauma scene transports is true? A. Nonphysician crews staff most HEMS vehicles in the United States B. The potential benefit of HEMS in improving trauma outcome remains unstudied. C. Transport of a patient from a motor vehicle collision to a trauma center is termed "secondary" transport if a helicopter is used. D. If the patient is in cardiopulmonary arrest, HEMS transport should be expedited to maximize chances of patient survival. E. The flight physician should take command of the trauma scene upon HEMS arrival.

A. Nonphysician crews staff most HEMS vehicles in the United States

A 20 year old man used his left hand to punch another person in a bar fight. The man complains of pain and swelling over the ulnar aspect of his hand. His X-ray is shown in the Figure. What type of fracture does he have? A. Bennett's fracture B. Boxer's fracture C. Colles' fracture D. Smith's fracture E. Rolando's fracture

B. Boxer's fracture

A 17 year old boy injured his right shoulder playing football. He tried to arm-tackle a player when his right arm was pulled away from his body and back (abducted and extended). He felt a sudden pain in his shoulder. He presents to the emergency department holding his arm in slight abduction and external rotation by his good arm. He has severe pain with adduction or internal rotation. What is the most common fracture associated with this injury? A. Avulsion fracture of the greater tuberosity of the humerus B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity) C. Clavicle fracture D. Acromioclavicular joint separation E. Fracture of the anterior glenoid lip (Bankart's fracture)

B. Compression fracture of the posteriolateral aspect of the humeral head (Hill-Sachs deformity)

A 28 year old female is 4 months pregnant and presents with dysuria. Her UA reveals leukocyte esterase and nitrates. Of the following, the best treatment is: A. Amoxicillin B. Macrodantin (nitrofurantoin) C. Ciprofloxacin D. Doxycycline E. Bactrim

B. Macrodantin (nitrofurantoin)

In pediatric resuscitation the following drugs may be given by the endotracheal route, EXCEPT: A. epinephrine B. digoxin C. naloxone D. atropine E. lidocaine

B. digoxin The drugs which may be given by endotracheal route can be remembered by the mnemonic "LEAN" — lidocaine, epinephrine, atropine, naloxone. Up to 10 times the IV dose diluted to 5mls and followed by 3-5 positive pressure breaths is necessary to achieve equivalent plasma concentrations. Digoxin must be given by the IV route.

Of the following, which diagnosis is most likely given the EKG shown in the Figure? [image shows ST elevation in II,III,aVF] A. anteroseptal myocardial infarction B. inferior myocardial infarction C. anterior myocardial infarction D. posterior myocardial infarction

B. inferior myocardial infarction The answer is B. The EKG demonstrates classic findings (ST-segment elevations in II, III, AVF) associated with inferior myocardial infarction.

Which physical examination finding is typical of a Bell's palsy? A. ophthalmoplegia B. ipsilateral forehead weakness C. contralateral facial droop D. ipsilateral diminished auditory acuity E. ataxia

B. ipsilateral forehead weakness

A 14 year-old child presents to the emergency department. His blood pressure is 210/140. He complains of a headache, nausea, and recent blurred vision. Of the following choices, the best goal for lowering his mean arterial blood pressure is to have it drop by: A. Until symptoms resolve B. 5% in the first 5-6 hours C. 25% in the first hour D. 50% in the first hour E. To normal for his age in the first hour

C. 25% in the first hour The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, with end-organs symptoms, the presumptive diagnosis is hypertensive emergency. In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the first hour, thereby alleviating symptoms while not compromising cerebral perfusion.

As compared to adults, children with shock usually: A. Have more reliable signs and symptoms B. Have similar epidemiology (i.e. causes for shock states) C. Are able to maintain their blood pressure better D. Have different treatment priorities E. Do not need specialized care

C. Are able to maintain their blood pressure better The answer is C. While the treatment priorities for pediatric and adult shock are similar, there are some differences; thus, a specialized approach to care is often required. The epidemiology is different, since in children shock tends to be caused by trauma and infections. Children's signs and symptoms may be more subtle than those of adults in shock, rendering the physical examination less reliable in pediatrics. One of the key differences is a child's ability to maintain blood pressure despite presence of shock.

Which of the following methods is NOT used to establish the correct endotracheal tube size in a pediatric patient over 1 year of age: A. (age in years + 16) divided by 4 B. approximation with child's little finger C. age in months divided by 3 D. approximation with child's nares E. body length using a Broselow emergency tape

C. age in months divided by 3 All of the other methods can be used in the evaluation of correct tube size. Pediatric chest tube size can be estimated by multiplying the endotracheal tube size by 4. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 91 and 277.

All of the following are generally accepted indications for endotracheal intubation of the pediatric trauma patient, EXCEPT: A. respiratory failure from hypoxia or hypoventilation B. GCS score less than or equal 9, to secure airway and provide controlled hyperventilation C. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function D. any trauma patient in decompensated shock and resistant to initial fluid resuscitation E. any inability to ventilate by bag-valve-mask methods or the need for prolonged control of the airway

C. gastric distension due to excessive volume or rate of ventilation impairing ventilatory function

Which of the following vital signs is a cause for concern in the term newborn? A. heart rate of 165 B. respiratory rate of 50 C. heart rate of 95 D. respiratory rate of 70 E. systolic blood pressure of 65

C. heart rate of 95 Bradycardia (defined in Rosen's text as a heart rate of <100) can be a critically important manifestation of neonatal distress; therefore, caregivers must be familiar with expected vital signs in newborns.

A 55 year old female with a history of end-stage renal disease presents to the emergency department with weakness. Her EKG is shown in the Figure, and reveals: [image: peaked T waves] A. hypocalcemia B. pericarditis C. hyperkalemia D. acute MI

C. hyperkalemia The answer is C. The EKG shows signs of hyperkalemia as characterized by diffuse peaked T waves. Other EKG changes include widening of the QRS complex and biphasic QRS-T segments. The heart rate may be slow, with ventricular fibrillation and cardiac arrest as the terminal events. Acute myocardial ischemia can be represented by hyperacute T waves as well, but in these cases the T wave changes are more likely to be focal (i.e. in an anatomical distribution corresponding to the area of threatened myocardium).

An 80 year old nursing home patient is brought to the emergency department with an acute onset of confusion. Which of the following metabolic abnormalities is the most likely explanation? A. hypocalcemia B. hypokalemia C. hypernatremia D. hyperphosphatemia

C. hypernatremia The differential diagnosis of acute confusional states is lengthy. It includes many metabolic/nutritional abnormalities including hypoglycemia, hypo-/hypernatremia, and hypercalcemia. Hypokalemia alone, however, is not a common cause of altered mental status.

All of the following are commonly used in the supportive treatment of thyroid storm EXCEPT: A. corticosteriods B. oxygen C. acetaminophen to manage hyperpyrexia D. amiodarone to control dysrhythmias E. diuretics to treat congestive heart failure

D. amiodarone to control dysrhythmias The answer is D. Amiodarone is an iodine-rich antidysrhythmic with poorly-defined effects on thyroid function that has been associated with both hyperthyroidism and hypothyroidism. It should therefore be avoided in the management of thyroid disease. Propranolol is standard therapy in thyroid storm and, in addition to its effects of adrenergic blockade, also may reduce dysrhythmias. Of note, aspirin should be avoided in the treatment of hyperpyrexia as it may increase the level of active thyroid hormone by displacing thyroid hormone from thyroglobulin.

What is the most common heart rhythm seen in pediatric arrest? A. Wolff-Parkinson-White syndrome B. ventricular fibrillation C. paroxysmal atrial tachycardia D. bradycardia E. atrial fibrillation

D. bradycardia Bradycardia, the most common rhythm seen in pediatric arrest (which in turn is usually hypoxemic in etiology), can be a harbinger of progression to asystole if untreated. Outside of the arrest situation, the most common rhythm disturbance encountered is paroxysmal atrial tachycardia; however, patients with supraventricular tachycardias are usually stable. Wolff-Parkinson-White syndrome can also present in infants but is not as common and is not often seen in the arrest situation. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 4th edition, page 86.

A collection of purulent material in the location as depicted in the figure represents a: [image shows infection in finger pad] A. furuncle B. cellulitis C. paronychia D. felon E. herpetic whitlow

D. felon The patient has an infection of the deep space of the fingertip, known as a felon; this is treated with an incision procedure. Paronychia involves the dorsal aspect of the nail area, whitlow is a painful lesion on the skin, and furuncle and cellulitis also involve the skin rather than the deep space. -- For further reading, see Hamilton et al, Emergency Medicine: An approach to clinical problem-solving (Chapter 45: Open injuries to the hand).

A patient sustains a forearm laceration as shown in the Figure. Regarding the wound, which of the following is true? [image] A. Due to presence of the flap, the wound should be closed with 6-0 suture. B. "Undermining" subcutaneous tissues may be a useful technique to reduce post-closure skin tension. C. Because of the high tension on the wound, a Penrose drain should be placed to reduce chances of infection. D. After shaving of the nearby hair, the wound is a good candidate for closure with tissue adhesives.

B. "Undermining" subcutaneous tissues may be a useful technique to reduce post-closure skin tension. The answer is B. Undermining of skin "recruits" tissue by separating the skin from the deeper subcutaneous structures. Though in some cases, slight excision of protruding fatty tissue may be necessary, trimming of all visible fatty tissue is unnecessary. The wound is subject to high tension, and thus 6-0 suture or tissue adhesives are not optimal choices for closure. Drains are rarely indicated for initial wound care in the ED, and would not be necessary in the wound in the Figure.

A 45 year old male presents to the emergency department with sharp pains on the right side of the head. Upon exam, there are vesicular eruptions with crusting lesions on the patient's right forehead terminating in the patient's right eyebrow. The patient is extremely sensitive to light in his right eye. Which of the following is false regarding this patient? A. The patient probably had chicken pox as a child B. A Tzanck preparation can distinguish Herpes simplex virus from herpes zoster virus infection. C. These lesions can occur anywhere on the body. D. Acyclovir is an accepted treatment of this condition. E. Treatment is most effective if given within 72 hours of when the eruption begins.

B. A Tzanck preparation can distinguish Herpes simplex virus from herpes zoster virus infection.

You are treating an 80 you male in whom you suspect a lower GI bleed. Which of these following statements is TRUE regarding the guaiac test? A. A false positive may be caused by ingestion of magnesium-containing antacids B. A false positive may be caused by the presence of methylene blue C. A false negative may be caused by the presence of bromide preparations D. A false negative may be caused by the presence of chlorophyll

B. A false positive may be caused by the presence of methylene blue The answer is B. Red fruits or meats, methylene blue, chlorophyll, iodide, cupric sulfate and bromide preparations can cause a false positive guaiac test. A false negative guaiac test can be caused by bile or ingestion of magnesium-containing antacids or ascorbic acid. Red Jell-O, tomato sauce, wine, iron therapy and Pepto-Bismol may cause the stool to look bloody when it is not.

Which of the following is true about myasthenia gravis? A. It typically presents as an ascending weakness of the peripheral nervous system. B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation. C. Weakness improves as the involved muscles are used repeatedly. D. The "atropine test" is diagnostic when 0.5 mg of atropine is given intravenously and the patient's symptoms improve within two minutes. E. Cooling exacerbates the symptoms, and heat alleviates them.

B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation. The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon test, where edrophonium is given and the patient's symptoms are observed to transiently improve. The administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring intubation, frequently for prolonged periods.

A 27 year old man is shot in the right leg. He is unconscious. The wound appears to be pulsatile. The medics report he has lost a lot of blood. His heart rate is 160, and his BP is 70/30. He has received 2 liters of IVF normal saline. The next step in management would be: A. Check a hemoglobin level and hematocrit B. Administer Type O Rh+ blood C. Wait for cross-matched blood D. Give more saline E. Wait for type-specific blood

B. Administer Type O Rh+ blood The answer is B. Patients in extremis with acute hemorrhage need aggressive fluid resuscitation. After an initial crystalloid bolus, blood products should be initiated. Type O is the universal donor type, with Rh-negative blood reserved for women of childbearing age. Type-specific blood is another option, but usually takes at least 15-20 minutes to obtain; cross-matching of blood takes even longer.

A 32 year old G1P0 at 33 weeks EGA comes into the emergency department complaining of a severe headache. She has contractions every 3 minutes. She is experiencing flashes of light in front of her eyes. Her pregnancy has been uncomplicated until this time, and her only medical problem is mild asthma. Her vital signs are: T 36.5 C (97.7 F), BP 172/114, P 78, R 14, and a room air SpO2 99%. Her lungs have bilateral crackles at the bases, and her cervix is dilated at 3 cm and effaced at 50%. Her urinalysis has 2+ protein, and her complete blood count shows: WBC 8,000/mm3, hematocrit 38%, platelets 215,000/mm3. Her BUN and creatinine are normal, her AST is 250 U/L, and her ALT is 316 U/L. The electronic fetal monitor shows a reactive and variable heart tracing at a rate in the 150s. What is the appropriate next step in management for her? A. Give furosemide B. Administer magnesium sulfate C. Start terbutaline, as a tocolytic that could prophylax against an asthma flare as well D. Start PGE2 gel E. Discharge the patient and tell her to return for a cervical check the next day

B. Administer magnesium sulfate This patient falls in the category of severe pre-eclampsia, which is a form of pregnancy-induced hypertension. It is characterized by hypertension with proteinuria or pathologic edema. Pre-eclampsia can be categorized as mild or severe. It is diagnosed as severe if one of the following is present: headache unresponsive to analgesics, visual disturbances, diastolic blood pressure over 110 mm Hg, pulmonary edema, elevated liver enzymes, 2+ or greater proteinuria, oliguria, elevated creatinine, hemolysis, or intrauterine growth restriction. Patients with mild pre-eclampsia do not always require hospitalization (choice B), but those with severe pre-eclampsia must be admitted for IV access and fetal monitoring. This patient already shows signs of being in labor with frequent contractions and a dilated and effaced cervix, and thus does not need to be given prostaglandins, which are used to "ripen" the cervix for labor induction. The most urgent management issue for her is prevention of seizures, which can cause permanent CNS damage, intracranial bleeding, and death. Administering magnesium sulfate is the most effective method. Since delivery is the definitive treatment for severe pre-eclampsia, tocolytics such as terbutaline should not be administered. Diuretics such as furosemide are not suggested in this patient, as hypovolemia can cause fetal hypoperfusion.

A 25 year old female is carried into the ED by two friends who state that she has not been acting right and is now not breathing well. The patient has a history of depression and substance abuse. Her vital signs are notable for BP 115/70, HR 99, RR 6, and Temperature 98.9F. Oxygen saturation on room air is 87%. She is somnolent and is noted to have bruising to both arms and miotic pupils. You begin bag-valve-mask ventilation and her oxygen saturation increases to 98%. Which of the following is the most appropriate next step in management? A. Administer activated charcoal B. Administer naloxone C. Administer flumazenil D. Administer syrup of ipecac

B. Administer naloxone

For which of the following cases (all of which are characterized by an ingestion history known with certainty) is gastric lavage most likely indicated? A. Adult patient, kerosene ingestion (8 oz, 20 minutes PTA) B. Adult patient, nortriptyline ingestion (50 mg/tab x 100 tablets, 45 minutes PTA) C. Adult patient, metoprolol ingestion (100 mg/tab x 100 tablets, 6 hours PTA) D. Adult patient, ibuprofen ingestion (800 mg/tab x 5 tabs, 20 minutes prior to arrival (PTA) in the ED

B. Adult patient, nortriptyline ingestion (50 mg/tab x 100 tablets, 45 minutes PTA) The answer is B. Gastric lavage (GL) is generally not effective if performed more than a few hours (exact time ranges depend on clinical circumstances) after ingestion. Due to risks of lavage (aspiration, gastric/esophageal perforation), trivial ingestions are not an indication for GL. Due to the risk of aspiration with hydrocarbons and further injury with caustic ingestions, GL is contraindicated for hydrocarbon and caustic ingestions

Suicide rates are consistent with the average population in this population: A. Presence of underlying panic disorder B. African-American males C. Men with AIDS D. Females with breast implants

B. African-American males The answer is B. The epidemiology of suicide varies according to age, gender and race. Overall, men have higher rates of completed suicide and women have greater numbers of suicide attempts. Suicide risk among men shows a bimodal distribution with increased risk between the ages of 15 and 24 and after age 65. Suicide risk among women peaks after age 60. People who suffer from a chronic disease such as AIDS are at increased risk for committing suicide. The dramatic increase in suicide rates among adolescents is thought to be due to changing demographics and greater access to firearms. Underlying psychiatric illness increases a person's risk of suicide. Major depression, bipolar, borderline personality disorder, schizophrenia, and panic disorder are all associated with increased suicide rates. Of note, One study demonstrated that 40% of people who suffer from panic attacks would attempt suicide at some point in their lives. Studies have demonstrated that the presence of breast implants portends a higher risk of suicide.

A teenager presents one hour after ingesting a "handful" of acetaminophen tablets. Which of the following statements is TRUE? A. The intravenous formulation of N-acetylcysteine is safer than oral N-acetylcysteine. B. An acetaminophen level drawn at hour four dictates need for antidotal therapy. C. Serial liver function tests are indicated in all acetaminophen ingestions. D. Renal sequelae are expected.

B. An acetaminophen level drawn at hour four dictates need for antidotal therapy. The answer is B. An acetaminophen level drawn at hours 4-20 can be plotted on the Rumack-Matthew nomogram to guide therapy based on the potential for hepatic (not renal) toxicity. Liver function tests are not indicated for trivial acetaminophen ingestions, but may be useful in severe ingestions. Charcoal binds acetaminophen and should be given early. N-acetylcysteine (NAC), the antidote, is only FDA-approved in the United States for oral use, although IV NAC has been used safely for years in other countries. One side-effect of the IV preparation is anaphylactoid reaction.

A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street fight. At the scene, there is some bleeding, which is controlled with direct pressure. He presents to the emergency department breathing comfortably and in no distress. His pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a 1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea. There is mild oozing and no obvious underlying hematoma. There is no obvious subcutaneous air, and he has clear lung sounds. What is the most appropriate management for this patient? A. Local wound exploration and discharge home if no significant injury identified B. Angiography, esophogram, and admission for observation C. Local wound exploration and discharge home after 6-hour observation period D. CT scan of the neck and discharge home after 6 hours of observation E. Immediate operative exploration

B. Angiography, esophogram, and admission for observation The answer is B. Zone I penetrating neck injuries are located between the sternal notch and the cricoid cartilage. A major concern is injury to non-compressible vascular structures such as common carotid, vertebral, subclavian, aortic arch. Other structures in this area include trachea, esophagus, and lung apices. Physical exam is often unreliable and angiography, esophogram, and observation are warranted.

A 60 year old female presents with palpitations. Her EKG, shown below, reveals: [image shows sawtooth p waves] A. ventricular tachycardia B. atrial flutter C. sinus arrhythmia D. atrial fibrillation

B. Atrial flutter Atrial flutter has a characteristic saw-tooth pattern. It is generally a regular, narrow complex rhythm. The atrial rate is approximately 300. The rate of conduction can be in a fixed or variable ratio, but 2:1 (atrial:ventricular) is common, resulting in a frequently encountered ventricular rate of about 150. This example has a variable block (2:1 to 4:1). -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 174-175.

A 74 year old cancer patient presents to the ED for labored breathing. You arrive in the room and see a patient with significantly labored breathing in a tripod position, speaking in short sentences, who says "I...just...can't...catch my breath!" Vital signs are obtained and show a HR of 113 bpm, BP of 90/43, SpO2 95% on 2L by nasal cannula, RR 34, temp 98.4F. On exam, lung sounds are clear bilaterally with good inspiratory effort, heart sounds are present but quiet, distended neck veins, and there is no peripheral edema. What test is most likely to confirm your suspected diagnosis? A. Chest radiography B. Bedside cardiac ultrasound C. D-dimer D. EKG

B. Bedside cardiac ultrasound

A 25-year old female presents to the ED with dyspnea and chest pain. Chest CT, with contrast, is performed and some pertinent "slices" are shown in the Figure. What is the diagnosis? [image] A. Gas embolism B. Bilateral pulmonary embolism C. Acute Respiratory Distress Syndrome D. Aortic dissection, Type I

B. Bilateral pulmonary embolism The answer is B. Helical CT studies of the pulmonary vasculature are increasingly used for detection of pulmonary embolism. Though there are questions about CT's ability to detect small (e.g. subsegmental) emboli, CT scans have high sensitivity for proximal embolism such as that depicted in the accompanying figure. The patient whose images are shown was found to have moderate-severe right ventricular dysfunction and received thrombolytic therapy in the ED - she had an excellent outcome.

You are taking care of a 65 year old male with sudden onset of sharp central chest pain and shortness of breath about 1 hour ago. He also says his left arm feels "funny." His vital signs are HR 113 bpm, BP 175/101, RR 28 breaths per minute, SpO2 94% on room air, and temp 98.7F. On exam, the patient is diaphoretic, uncomfortable, but his exam is otherwise unremarkable. Which bedside diagnostic maneuver will help you confirm your suspicions about his diagnosis? A. Ankle/brachial indices bilaterally B. Bilateral upper extremity blood pressures C. Valsava maneuver to reproduce murmurs D. Auscultation of carotid arteries for bruits

B. Bilateral upper extremity blood pressures

A 62 year-old female with a history of congestive heart failure presents after a family picnic with worsening shortness of breath. This is exacerbated by walking or lying in the recumbant position. Her blood pressure is 150/80, heart rate 90, respiratory rate is 24, temperature is 98oF and pulse oximetry reads 88%. She speaks in broken sentences. She has JVD to the angle of the mandible and her trachea is midline. Her lungs have symmetrically decreased air movement with crackles halfway up. What is the best way to support her breathing while waiting for medications to take effect? A. Oxygen delivered by nasal cannula B. Bilevel positive pressure ventilation C. Needle thoracostomy D. Intubation and mechanical ventilation

B. Bilevel positive pressure ventilation

For a patient in neurogenic shock, the correct treatment would likely be all of the following EXCEPT: A. Spinal immobilization B. Blood transfusion C. High dose steroids D. IV fluid bolus E. Phenylephrine

B. Blood transfusion The answer is B. Treatment of a spinal cord injury with neurogenic shock includes high dose steroids, IV fluids, immobilization, and potentially pressors. Blood transfusions are generally not indicated, and care must be taken to avoid fluid overload. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 247-248.

A 24 year old female without prior medical history presents with a one day history of left sided facial weakness. It was preceded by a headache behind her left ear. On exam she is unable to wrinkle her left forehead or close her left eye. The corner of her mouth droops on the left. The rest of the exam is normal. Which of the following would be inappropriate in the care of this patient? A. Evaluation of Lyme disease if the patient lives in or has visited a Lyme endemic area. B. CT of the brain with and without intravenous contrast. C. Protecting her left eye with moisturizing drops and a patch at bedtime. D. A short course of prednisone. E. Acyclovir.

B. CT of the brain with and without intravenous contrast. The answer is B. Bell's palsy is an idiopathic palsy of the facial nerve. Although it is the most common cause of a facial nerve palsy, other etiologies must be ruled out. Inability to move the forehead muscle indicates a peripheral lesion, making stroke much less likely. If the remainder of the neurological exam is normal, then imaging is not needed. Lyme disease is a well known cause of facial nerve palsy and patients should be evaluated for this if they live in an endemic region. Half of cases present with retroauricular pain around the time of onset. Most neurologists recommend a short course of prednisone as part of treatment. There is evidence that herpes simplex virus is involved as a causative agent, and acyclovir is recommended. Also extremely important is to protect the involved eye, as it is at risk of drying out because lacrimal gland functioning can be impaired, and the eye is unable to close fully.

Which pharmacologic treatment for hyperkalemia works through stabilization of cardiac membranes? A. Magnesium B. Calcium C. Bicarbonate D. Insulin and glucose

B. Calcium The answer is B. "Immediate antagonism of K+ at the cardiac membrane is achieved with IV administration of calcium chloride or gluconate. This is indicated in patients with unstable dysrhythmia or hypotension."

A nurse notifies you that a new patient has just arrived in the Emergency Department. She is an elderly female who is unresponsive and diaphoretic. Her family members are very concerned that she is having another stroke. Her blood pressure is 90/40, heart rate is 105, and her oxygen saturation is 95% on room air. Which of the following is the most appropriate next step in patient care? A. Place the patient on oxygen by nasal cannula B. Check a bedside glucose measurement C. Administer intravenous thrombolytic therapy D. Administer aspirin per rectum E. Obtain a stat head CT

B. Check a bedside glucose measurement

A 23 year old woman is dropped off by her boyfriend after an unknown overdose. You notice that she is has very large pupils and is sweating profusely. Her respiratory rate, blood pressure and heart rate are elevated. Which of the following is the most likely agent to have caused her symptoms? A. Jimson weed B. Cocaine C. Heroin D. Insulin

B. Cocaine Cocaine is a sympathomimetic. Sympathomimetics and anticholinergics such as Jimson Weed can be differentiated by the presence of sweating although both can cause delirium and mydriasis. Aspirin or salicyclate toxicity can cause increased respiratory drive through direct stimulation of the medullary respiratory center but should not cause papillary changes. Heroin will result in a classic toxidrome of miosis, CNS and respiratory depression as will other opiates.

With respect to larygneal assessment, the Figure depicts what grading scale? [image] A. Macintosh B. Cormack-Lehane C. Mallampati D. Miller E. LMA

B. Cormack-Lehane The answer is B. The Cormack-Lehane scale allows communication of relative ease of visualization of laryngeal structures during laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway.

Which of the following statements regarding psychotic behavior is true? A. Brief psychotic episodes, often precipitated by events such as death of a loved one, can be characterized by extremely bizarre behavior and speech B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary C. Delusional disorder usually results in impairment in daily functioning D. Schizophreniform disorder is present when a patient meets the diagnostic criteria for schizophrenia but the process has been present for less than one year

B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary Psychosis can be limited to nonbizarre delusions; patients with this disorder (delusional disorder) rarely have impairment in daily functioning. Fixed, false beliefs that are not held by others with a patient's cultural background are characteristic of delusional thinking.

A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower quadrant pain associated with loose stools. He has had no fevers or bloody bowel movements. Similar symptoms in the past were self-limited. All vital signs lie within normal limits. Physical examination shows mild tenderness in the left lower quadrant, normal active bowel sounds and neither masses nor peritoneal signs. His primary-care physician can see him tomorrow in his clinic. What should be done next in the E.D.? A. Discharge home after a single dose of IV antibiotics B. Discharge home on high-fiber diet, laxatives and stool softeners C. Gastroenterology consult for endoscopy D. Admit for observation and serial examinations

B. Discharge home on high-fiber diet, laxatives and stool softeners This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.

A 32 year old woman walks into the emergency department two weeks after a fall from a bus. She tripped stepping off the bus and landed with her right hip on the last stair. The fall was only a few feet in distance. She noted very little immediate pain, and there was no pain at all by the next day. However, the next week her right hip began to "burn." After a day's burning sensation she developed a rash involving the hip region. She denies any chest pain, shortness of breath, nausea or vomiting. Physical examination shows a unilateral, erythematous, maculopapular rash extending from below her umbilicus to her back in a band-like pattern. There are no open lesions or cuts. What is the appropriate management of this patient? A. Discharge home for rest and ice for the next few days for a late-appearing post-traumatic process. B. Discharge home with analgesics and an antiviral. C. Obtain an X-ray for fat emboli. D. Discharge home with a first-generation cephalosporin for a bacterial process. E. Refer to orthopedics for evaluation of possible right hip fracture.

B. Discharge home with analgesics and an antiviral. This patient has herpes zoster, commonly known as shingles, which begins as an erythematous rash and after as many as several days becomes vesicular. Shingles can often present after minor trauma, which is thought to reactivate latent varicella-zoster virus. While this patient may relate pain and symptoms to the fall, her ability to ambulate without problems and lack of pain directly after the fall make obtaining an X-ray and referral to orthopedics unnecessary. (Although it may be possible for a patient to ambulate on an impacted hip fracture, the clinical picture points away from orthopedic trauma.) The rash appearance renders a simple ecchymosis or contusion (choice A) unlikely. The characteristic dermatomal distribution of this rash makes a bacterial infection (choice D) much less likely than herpes zoster. Shingles was classically treated with analgesics only, but addition of acyclovir (choice B), if begun within the first several days of the rash, can reduce the incidence of post-herpetic neuralgia.

A 63 year old female presents to the ED at noon, stating that she noticed marked facial swelling (see Figure - top half) upon awakening that morning. She has breast cancer, without brain metastases on a recent MRI. She has no urticaria or respiratory symptoms. A CT scan of the chest was performed from the ED (see Figure - bottom half). Regarding this patient's condition, which of the following is true? [image] A. Trendelenburg positioning is recommended. B. Elevation of the head of the patient's bed is recommended. C. All patients with this condition require immediate radiation therapy. D. Seizures are a common presenting sign. E. The vascular component of this problem commonly poses a threat to the patient's airway integrity.

B. Elevation of the head of the patient's bed is recommended. This patient has superior vena cava syndrome, which is usually caused by tumor-related compression on the SVC. Historically, emergent radiation therapy was the major treatment regimen, but chemotherapy is also a therapeutic option. Elevation of the head of the bed has been shown to have immediate salutary effects. Figure A shows the classic facial plethora which may be seen. Figure B reveals a large mediastinal tumor, with caval compression. Patients with SVC syndrome do not seize, unless there are associated mass lesions in the brain. Airway impingement is uncommon in the absence of a tumor or other mass directly compressing the trachea.

A 19-year-old G1P0 female, at 38 weeks EGA, presents to the emergency department complaining of headache, blurry vision and leg swelling. The physical examination reveals BP of 150/100, facial and hand edema, and hyperreflexia. Fetal heart monitoring demonstrates a reassuring pattern with no uterine contractions. Urine dipstick reveals 2+ proteinuria. Of the following, which factor is the most critical in formulating an ultimate management plan for this patient? A. Extent of maternal edema B. Fetal age C. Presence of variable decelerations on nonstress testing D. Symptom duration

B. Fetal Age The cure for pre-eclampsia is delivery of the baby, and the fetal age and maturity are the most important factors to consider in determining the planning for delivery. For pregnant women at or near term, induction of labor is usually indicated.

In treating hepatitis secondary to alcoholic liver disease, all of the following are true EXCEPT: A. Treatment is primarily supportive including fluids and electrolyte correction. B. Glucose should be administered prior to thiamine to avoid precipitating acute Wernicke's encephalopathy C. Magnesium replacement should be initiated empirically except in the setting of contraindications such as renal failure or hypermagnesemia. D. Coexisting gastritis should be sought out and treated appropriately. E. Nutritional status should be assessed with attention to possible protein restriction.

B. Glucose should be administered prior to thiamine to avoid precipitating acute Wernicke's encephalopathy Alcoholics often have low thiamine levels due to poor nutrition, and low glucose levels due to the suppression of gluconeogenesis by alcohol. However, thiamine should always be replaced prior to glucose to avoid the potential complication of precipitating Wernicke's encephalopathy. Magnesium levels may appear normal on laboratory testing, but alcoholics typically have low magnesium stores and should be given magnesium empirically unless contraindications for magnesium exist. Alcoholics should also be evaluated for gastritis and overall nutritional status and should be referred appropriately.

You are working the swing shift in the fast track area of an inner-city Chicago Emergency Department during the summer, on the 4th day of greater than 90 degree heat. Your fast track quickly fills up with patients presenting with varying heat related complaints.You are concerned that overcrowding is becoming dangerous, and quickly move to diagnose and treat your patients. Select the heat related complaint with the correct treatment from the list below: A. Heat cramps: increase free water intake B. Heat syncope: removal from heat, PO or IV hydration, and rest C. Heat edema: administration of diuretics D. Prickly heat: application of talc or corn starch to effected areas

B. Heat syncope: removal from heat, PO or IV hydration, and rest

The primary etiology of peptic ulcer disease is: A. NSAID use B. Helicobactor pylori C. Zollinger-Ellison Syndrome D. stress E. cigarette smoking

B. Helicobactor pylori

A 76-year-old man presents to the ED with upper GI bleeding with passage of occasional maroon colored stools. Which of the following would be an indication for immediate transfusion of packed red blood cells? A. His hemoglobin decreased from 14 g/dL on week ago to 11g/dL today B. His ECG shows ST segment depression in the inferior, septal and anterior leads C. His heart rate is 113 beats per minute and his blood pressure is 110/76 mmHg (with a history of hypertension) D. His medications include NSAIDs

B. His ECG shows ST segment depression in the inferior, septal and anterior leads

A 65-year-old female presents with a chief complaint of palpitations and dyspnea on exertion. Vital signs are BP 130/84, HR 160 (and irregularly irregular), RR 14, T 37.8. EKG shows a narrow complex, irregularly irregular rhythm with absence of p-waves and an undulating baseline. What endocrine abnormality is most likely to be a direct cause of this abnormal rhythm? A. Cushing's syndrome B. Hyperthyroidism C. Hyperparathryoidism D. Addison's disease

B. Hyperthyroidism The answer is B. Atrial fibrillation is a common arrhythmia. Its hallmark is the absence of P waves and irregular rhythm. It is associated with many medical conditions including ischemic heart disease and thyrotoxicosis. Atrial fibrillation increases the risk of thrombus formation and arterial embolism. AF's many treatment options include calcium channel blockers, beta blockers, amiodarone, quinidine, and cardioversion. Pacing is not a treatment option.

A 27 year old male presents to the emergency department with 12 hours of worsening abdominal pain, associated with 1 episode of nausea and non-bloody non-bilious vomiting as well as a slight fever. Initially the pain was centered around the umbilicus and the patient attributed it to the take-out food he ate last night. Now the pain has migrated to his lower right abdomen and become more severe. Which of the following is the most effective management? A. Administration of an enema to ensure the patient has a bowel movement while in the emergency department, followed by a reassessment to ensure resolution of pain B. IV access, analgesia, NPO, pre-op labs, surgical consult, and possibly a CT scan of the abdomen, and administration of antibiotics C. Dietary counseling and arrangement of GI followup for this patient's acute irritable bowel syndrome D. Administration of famotidine, maalox and viscous lidocaine, followed by a reassessment to ensure resolution of pain

B. IV access, analgesia, NPO, pre-op labs, surgical consult, and possibly a CT scan of the abdomen, and administration of antibiotics

A 56 year old male patient presents to the emergency department with confusion and a cough. He says that a few days ago, he fell against a railing and has had a soreness in his right chest. He's been using over the counter pain medicines, and the pain has somewhat improved. However, today, his wife noticed that he didn't know the date and thought she was their daughter. He is normally completely oriented. He's also been coughing all day. On exam, the patient is pleasant but disoriented to time. Neurologic exam is otherwise normal. Cardiovascular exam reveals tachycardia with good pulses peripherally, no murmurs. His lungs have diffuse crackles. Exam is otherwise normal. Vital signs are: HR 123, BP 103/52, RR 26, Temp 99.9F, SpO2 93% on RA. Laboratory analysis reveals an anion gap acidosis. CXR shows bilateral pneumonitis. Which of the following is most likely to improve this patient's condition? A. IV antibiotics B. IV bicarbonate C. IV fluid resuscitation D. IV insulin infusion

B. IV bicarbonate

You are taking care of diabetic 32 year old male in the emergency department. He presents with several days of illness including vomiting, diffuse abdominal pain, and weakness. On exam, the patient appears uncomfortable and dehydrated. He is taking frequent deep breaths and his breath has a fruity odor. His abdominal exam shows a soft abdomen with mild diffuse tenderness but no rebound or guarding. Lung sounds are clear and cardiovascular exam is normal. Vital signs are: HR 123 BP 105/65 RR 19 SpO2 98% RA Temp 100.3. Initial laboratory studies show: Sodium 128 meq/L Potassium 2.3 meq/L Glucose 434 mg/dL Chloride 94 meq/L What is the most appropriate initial therapy? A. IV lactated ringer's solution B. IV normal saline with potassium C. IV 3% sodium chloride D. IV insulin

B. IV normal saline with potassium

A 22 year old running back is struck from behind by a 300-pound lineman. The blow occurs below the knee as his foot is firmly planted and two other linemen are holding his upper body. He presents to the emergency department with gross anterior dislocation of the tibia on the femur. His foot is cool and pale, and dorsalis pedis and posterior tibial pulses are not detected by Doppler ultrasound. What is the most appropriate management for this patient? A. Open reduction in OR with exploration of popliteal artery B. Immediate reduction in emergency department under conscious sedation without X-rays C. Immediate orthopedic consultation without attempts to manipulate the knee D. Immediate arteriography to assess for popliteal artery disruption

B. Immediate reduction in emergency department under conscious sedation without X-rays The answer is B. A knee dislocation frequently injures the popliteal artery, threatening the survival of the limb. Immediate reduction for the dislocation is warranted to attempt to restore flow through the artery, and should be attempted by the ED physician without waiting for orthopedics. Transport to the OR is an unnecessary delay, and while arteriography will be indicated, the most urgent priority is restoring blood flow.

Paramedics arrive with a nursing home patient in respiratory distress. The patient is breathing at 30 breaths per minute, has a blood pressure of 180/100, a heart rate of 95, and an oxygen saturation of 88%. On physical exam, she is diaphoretic. speaking in few word sentences, has jugular venous distention, diffuse rales in both lungs, and bilateral lower extremity edema. She states that she does not want to end up on a ventilator in the ICU like her late husband. Paramedics provide you with a phone number for her son. She is given nitroglycerin, aspirin, and furosemide. The most appropriate next step in management is: A. Administer morphine based on the ethical principal of double effect B. Initiate treatment with bilevel positive airway pressure (BiPAP) C. Proceed with rapid sequence endotracheal intubation D. Contact her son to clarify her code status

B. Initiate treatment with bilevel positive airway pressure (BiPAP)

Regarding temporal arteritis, which of the following is TRUE? A. It commonly causes elevations in rheumatoid factor B. Its diagnosis hinges on temporal artery biopsy C. Men are affected more often than women D. It responds nicely to non-steroidal anti-inflammatory agents E. Temporal arteritis commonly affects patients with multiple sclerosis

B. Its diagnosis hinges on temporal artery biopsy

Since hiking in Connecticut 2 weeks ago, a 27-year-old woman has developed a rash and low-grade temperature. The anular-macular rash appears to be spreading from one location. She remembers multiple insect bites. The correct diagnosis is: A. scarlet fever B. Lyme disease C. tinea D. Rocky Mountain spotted fever E. varicella

B. Lyme disease

With respect to airway assessment, the Figure depicts what classification scale? [image shows tongues covering uvula to different degrees] A. LMA B. Mallampati C. Macintosh D. Cormack-Lehane E. Miller

B. Mallampati The answer is B. The Mallampati scale allows communication of ability to visualize structures of the posterior oropharynx, as a means of predicting ease of laryngoscopy and intubation. The Miller and Macintosh are types of laryngoscope blades, and the LMA (laryngeal mask airway) is a type of airway.

A 35 year-old male is placed on his back on the gurney in physical restraints for violent behavior. Which life-threatening complication can arise? A. circulatory obstruction B. Metabolic acidosis C. Asphyxia D. Rhabdomyolysis

B. Metabolic acidosis Bruises and abrasions are the most common complication of physical restraints. After restraint application, patients need to be monitored frequently and positions changed to prevent neurovascular complications such as circulatory obstruction, pressure sores, and rhabdomyolysis. Positional asphyxia can arise when patients are placed into the prone or hobbled position. Protracted struggle against restraints can promote a significant metabolic acidosis that has been associated with cardiovascular collapse. Patients who continue to struggle with physical restraints should be chemically restrained as well

A 55 year-old man is brought down from the outpatient procedures clinic after becoming severely short of breath during an endoscopy under light sedation. His pulse oximeter is reading 100% on a non-rebreather mask. You notice an interesting discoloration of his blood when it is drawn. What antidote should be administered? A. Deferoxamine B. Methylene blue C. Hydroxycobalamin D. Amyl nitrite

B. Methylene blue The answer is B. Nitrates/nitrites, local anesthetics, dapsone, and phenazopyridine are the common causes of methemoglobinemia. Methemoglobinemia causes the oxygen dissociation curve to shift to the left, making the remaining hemoglobin less likely to give up oxygen to the tissues. Blood from patients with methemoglobinemia is a chocolate brown color. Methylene blue is the antidote. Pulse oximetry is unreliable in patients with methemoglobinemia, since the pulse oximeter cannot differentiate oxyhemoglobin from methemoglobinemia.

A 27 year old is found unresponsive in his car in the hospital parking lot and brought in by security. During your initial evaluation you find him to be cyanotic with pulse oximetry reading 82% on room air with a respiratory rate of 4 breaths per minute. Radial pulses are present at 120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an intravenous line due to extensive scarring of his arms. You are suspicious of an overdose, which medication would you want to rapidly administer as a potential antidote in this situation? A. Glucose B. Naloxone C. Thiamine D. Flumazenil

B. Naloxone The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic pupils. In addition, intravenous drug users often use up their veins. While hypoglycemia can definitely cause a depressed mental status and needs to be assessed, it should not result in respiratory depression or miotic pupils. Thiamine is utilized to prevent Wernicke's encephalopathy particularly in malnourished patients who present with hypoglycemia but is not an antidote per se. Flumazenil can be used to temporarily reverse the respiratory depression caused by benzodiazepines but also carries with it the risk of precipitating withdrawal and uncontrollable seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with altered mental status.

A 16 year old male presents with a large swollen right knee. He denies any trauma. His physical exam reveals T101 and a swollen right knee. The knee is hot, and there is pain with motion. Also noted is a diffuse rash. The correct diagnosis is: A. Osgood-Schlatter B. Neisseria gonorrhea C. gout D. pseudogout E. juvenile rheumatoid arthritis

B. Neisseria gonorrhea

Which clinical scenario is use of chemical restraint indicated? A. Patient's remarks are felt to warrant negative reinforcement B. Patient's behaviors and actions pose an imminent harm to self C. Patient is responding to verbal tactics, but requires multiple attempts D. Patient is uncooperative with the history

B. Patient's behaviors and actions pose an imminent harm to self he answer is B. Physical and chemical restraints should only be used when verbal tactics have failed and when the patient is an immediate threat to himself, others or the integrity of the emergency department. From a medico-legal standpoint, clear documentation is very important when a decision is made to apply restraints. Answers A, C, D, and E are all valid reasons for physical or chemical restraints.

A 35 year old woman presents complaining of left wrist pain for several months. She works as a waitress and has noticed increasing wrist pain associated with intermittent numbness and tingling of her thumb, index finger and long finger on the left hand. She states the pain is worse at night and after work. On exam she has tingling in her left thumb and first digit when her wrists are held in flexion for 60 seconds. This is a positive ____________ test and suggests the diagnosis of ______________. A. Finkelstein test/De Quervain's tendonitis B. Phalen's test/carpal tunnel syndrome C. Phalen's test/ulnar nerve compression D. Tinel's sign/carpal tunnel syndrome E. Tinel's sign/radial nerve compression

B. Phalen's test/carpal tunnel syndrome

A 17 year-old has presented after taking a large amount of nortriptyline prescribed for migraine prophylaxis. Clinically, you take care of stabilizing her and initiate appropriate treatment. After reviewing reference materials you calculate that she has taken a potentially lethal dose of this tricyclic antidepressant. Which of the following would you expect to see on her electrocardiogram? A. Prolonged PR intervals B. Prolonged QRS intervals C. Right bundle branch block D. Compacted QT intervals

B. Prolonged QRS intervals The answer is B. Tricyclic antidepressant (TCA) toxicity can result in the following EKG abnormalities: sinus tachycardia (through antimuscarinic activity), prolongation of any of the EKG intervals (through sodium and potassium channel blockade), ventricular dysrhythmias (sodium channel blockade), and right axis deviation of the terminal 40 ms of the QRS complex (sodium channel blockade).

You have a 3 year old female present with her mother with complaints of 2 days of left ear pain. On exam, you are unable to visualize the tympanic membrane due to an obstructing mass. You suspect a foreign body. Which of the following is TRUE regarding the removing a foreign object from the patient's ear canal? A. Avoid suction as it may lead to a perforation of the tympanic membrane B. Referral to an otolaryngologist for foreign body removal under general anesthesia may be required in an uncooperative infant C. To remove a live insect from the external ear canal, grasp a leg with hemostats and pull firmly D. You should avoid the use of lidocaine and other topical anesthetics due to the risk of localized tissue ischemia

B. Referral to an otolaryngologist for foreign body removal under general anesthesia may be required in an uncooperative infant The answer is B. Irrigating the ear canal with warm water is acceptable in many instances, and may remove a foreign object with minimal discomfort. Direct the water jet gently past the object, against the tympanic membrane, and then back out the ear canal, hopefully dislodging the foreign object in the process. However, this technique should not be used in cases of bean or seed insertion because such objects swell when moistened, which makes subsequent removal more difficult and increases the risk of pressure necrosis. Irrigation should also be avoided in cases of tympanic membrane perforation. -- For further reading see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, Chapter 53.

A 10 year old boy presents with high fever and a rash. The rash started on his wrists and ankles and has spread to his trunk, palms, and soles. The correct diagnosis is most likely: A. varicella B. Rocky Mountain spotted fever C. tinea D. Lyme disease E. scarlet fever

B. Rocky Mountain spotted fever

A 17 year old male presents to the emergency department complaining of excruciating groin pain that woke him from sleep. This pain is associated with nausea and radiation into the abdomen. On examination his right testicle is firm, exquisitely tender, and there is unilateral absence of the cremasteric reflex. A bedside diagnostic and therapeutic maneuver would be to: A. Elevate the left testicle B. Rotate his right testicle in a medial to lateral rotation (540 degrees) C. Perform a bedside scrotal ultrasound D. Transilluminate the right testicle

B. Rotate his right testicle in a medial to lateral rotation (540 degrees)

A 7 year old boy falls off his bike onto his outstretched arm and sustains a supracondylar fracture. The fracture originates in the metaphysis and a portion of it extends into the physis (growth plate) without extending through to the epiphysis. How is this fracture classified? A. Salter I B. Salter II C. Salter III D. Salter IV E. Salter V

B. Salter II

Drug-induced urticaria is a common side effect of many drugs. Which statement about urticaria is FALSE? A. Penicillins and opiates are the most common offenders. B. Steroids should always be used in treatment to avoid possible anaphylaxis. C. Nonimmunological urticaria may be caused by degranulation of mast cells. D. Drug-induced urticaria may be immunological or nonimmunological. E. Association with malignancy is not strong enough to investigate for possible cancer when urticaria of unknown origin exists.

B. Steroids should always be used in treatment to avoid possible anaphylaxis. Precipitants of urticaria include food allergies, cold induced, malignancy, SLE, familial, exercise, excessive heat, etc. Drug-induced urticaria does not represent anaphylaxis or indicate its impending development so steroids are usually not indicated. Treatment may only include stopping the offending drug and administering antihistamines or other antipruritics as needed. Although penicillins and opiates are the most common precipitants, drug-induced urticaria has been demonstrated after use of an enormous number of medications.

With regard to U.S. Emergency Medical Services (EMS), all the following are true EXCEPT: A. The Department of Transportation is the federal government agency tasked with promulgation of EMT training requirements. B. The levels of EMT training and EMT-level nomenclature are the same throughout the United States. C. "First responders" are not always Emergency Medical Technicians (EMTs). D. A community is said to have "E-911" when the telephone number of a 911 caller is displayed at the operator's console. E. Most EMTs in the field operate under off-line medical control.

B. The levels of EMT training and EMT-level nomenclature are the same throughout the United States.

6What does the dotted line in the figure depict? [image] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. Placement site for skin clamps. B. The needle entry angle that optimizes eversion of sutured skin edges. C. The approach for subcuticular suture. D. The injection plane for local anesthesia infiltration. E. Use of a "finder needle" to mark suture entry points.

B. The needle entry angle that optimizes eversion of sutured skin edges. The answer is B. Eversion of the skin edges is maximized by directing the needle entry as shown in the figure. Injection for local anesthesia should usually be performed through the wound, rather than through intact skin. Use of skin clamps can damage tissue; in cases where skin stabilization is needed gentle forceps application is preferred. Subcuticular sutures are placed deep to the skin.

With regard to targets for therapy of elevated blood pressure identified during an emergency department visit, which of the following is generally true? A. Patients with hypertensive emergencies should have blood pressure normalized (for age) within an hour or less B. The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction C. Patients with hypertensive emergencies should have mean arterial blood pressure lowered by 50% within 50 minutes D. Patients with hypertensive urgencies are preferably treated with sublingual nifedipine, as compared with intravenous agents E. Patients with hypertensive urgencies should have blood pressure normalized (for age) within an hour

B. The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction Patients with acute aortic dissection who require antihypertensive therapy are usually treated with a combination of a beta-blocker (e.g. propanolol) and a vasodilator (e.g. nitroprusside). Though the specific blood pressure goal varies, most patients should have systolic pressure lowered to at least 120 (some prefer even more dramatic absolute systolic blood pressure goals, as low as 100 or less). Patients with hypertensive emergencies are usually treated with a goal of 20-25% reduction in blood pressure over 30-60 minutes, and patients with hypertensive urgencies should have blood pressure lowered over a longer period (hours to days). Sublingual nifedipine, formerly frequently utilized for mild hypertension, has been more recently identified with potentially dangerous blood pressure reduction "overshoot" (and resultant cerebral hypoperfusion), thus this agent is falling out of favor.

Regarding the EMS role in prehospital care, all the following are true EXCEPT: A. Automatic external defibrillators (AEDs) can be used by firefighters, policemen and other trained first responders. B. Thrombolytic therapy in the field is the standard of care for patients suspected of having an acute coronary syndrome. C. Survival after cardiac arrest is less than 10% when resuscitation efforts are initiated after 10 minutes from the arrest. D. EMS personnel evaluate and release many patients they deem well enough not to need hospital treatment. E. Pharmacotherapy that can be initiated in the field by paramedics in most jurisdictions includes naloxone for opiate overdose, diazepam for seizure control, and beta agonists for acute asthma exacerbations.

B. Thrombolytic therapy in the field is the standard of care for patients suspected of having an acute coronary syndrome.

What is the most common cause of death in Americans aged 20 to 40 years? A. Drug overdose B. Trauma C. Cancer D. AIDS-related illness E. Pneumonia

B. Trauma

A 35-year-old man is taken to the OR emergently after he presented to the ED with sudden severe upper abdominal pain. His portable upright chest x-ray revealed a small amount of air under his right hemi diaphragm. He received intravenous fluids, antibiotics and a surgical consultation in the ED. The most important laboratory necessary for surgery is a: A. White blood cell count with differential B. Type and Screen/Cross C. Serum lipase D. Lactate

B. Type and Screen/Cross

A 3-week old presents to the emergency department with a fever of 100.8. The child is otherwise well appearing. After blood culture, the best management of the options below is: A. Check WBC before further management. B. UA plus urine culture, LP, antibiotics, and admit C. Discharge home D. ampicillin and discharge E. Admit for observation.

B. UA plus urine culture, LP, antibiotics, and admit Fever in a child less than 30 days can be a marker for bacteremia, sepsis, and meningitis. Clinical findings are notoriously unreliable in this age group. The work up is fairly straightforward. Blood culture, urine culture and LP are required. After the work up, the child should be started on antibiotics. Ampicillin and gentamycin is the preferred regimen in this age group. In a child 30-90 days old, there is controversy regarding the management algorithm. Some authorities treat all children under 90 days of age the same; others risk-stratify and perform selective work ups.

A 65 year old male presents to the emergency department with chest pain. Cardiac monitoring shows a wide complex tachycardia. Past medical history is significant only for hypertension. His BP is 100/66, HR 144, RR 24, and T. 37.5. In addition to ongoing chest pain, he reports dyspnea. His level of consciousness is mildly decreased. Management should proceed on the assumption that he has what abnormal rhythm? A. Sinus tachycardia with LVH B. Ventricular tachycardia C. Supraventricular tachycardia with aberrancy D. Wolff-Parkinson-White syndrome with retrograde conduction

B. Ventricular tachycardia "Unstable patients with a wide-complex tachycardia should be treated as if ventricular tachycardia is present. "

A 22 year old G2P1 female with history of pelvic inflammatory disease presents to the Emergency Department with worsening LLQ pain over the past six hours. Pelvic exam reveals scant blood on speculum exam, closed os, and left adnexal tenderness. The beta hCG is 571. Following ACEP's clinical policy, you obtain a pelvic ultrasound to assess the probability of ectopic pregnancy. Which of the following is the earliest diagnostic evidence (100% predictive) for the presence of intrauterine pregnancy? A. Double decidual sac sign B. Yolk Sac C. Fetal heart motion D. Gestational sac

B. Yolk Sac

The pharmacologic interventions most likely to improve outcome when given in the field, as compared to those given upon arrival in the emergency department, include all of the following EXCEPT: A. albuterol B. adenosine C. diazepam D. dextrose E. epinephrine

B. adenosine This question addresses whether the agents listed are "time-critical" rather than whether or not they "work." While useful in effecting rate control for tachycardia, adenosine is the least likely of those listed (assuming an indication for their administration) to impact patient outcome when given in the field as compared to being given in the emergency department. Glucose can be life-saving in patients with hypoglycemia. In addition to its use in cardiac arrest, epinephrine can be life-saving when administered, for example, to patients with anaphylaxis. Bronchodilators can help reverse bronchospasm in severe asthmatics. Diazepam (or other benzodiazepines) can be a critical intervention when there is seizure activity.

Which of the following factors in the fetus is NOT associated with an increased risk for neonatal resuscitation? A. prematurity B. alkalosis (as assessed via fetal scalp capillary monitoring) C. multiple gestation D. thick meconium in amniotic fluid E. intrauterine growth failure

B. alkalosis (as assessed via fetal scalp capillary monitoring) Acidosis (by fetal scalp capillary monitoring), not alkalosis, is associated with an increased risk for neonatal resuscitation. Along with the factors listed above, postmaturity, abnormal fetal heart rate per monitor, congenital infection, and fetal malformation or edema diagnosed by ultrasound are other fetal factors associated with an increased risk of neonatal resuscitation. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 4th edition, page 73.

A 22 year-old man, recently released from hospital with a newly diagnosed psychiatric disorder, was found dead at his home from an overdose of medications prescribed by his doctor. Of the following drugs, which one (taken in isolation), would be most likely to be associated with fatal outcomes in an overdose scenario? A. lithium B. amitriptyline C. lorazepam D. fluoxetine

B. amitriptyline The answer is B. Antidepressant overdose is the most common cause of suicide by ingestion. Cyclic antidepressants are associated with a higher potential for lethality than other antidepressant medications. Often during the early stages of recovery from major depression, patients may have a "mobilization of energy" which allows them to act on their suicidal thoughts, for which they previously lacked the energy.

A 42 year old male presents to the emergency department with a 5-day history of a pruritic vesiculobullous rash on his right forearm. The rash has spread to involve his left palm and elbow. He reports that he developed the rash 48 hours after working in the woods last week with his brother, who developed a similar rash. Antihistamines have decreased the pruritis, but the rash has continued to spread. Appropriate management of this patient's exposure can include all of the following EXCEPT: A. careful washing of all clothing that was worn in the woods B. avoidance of contact with the rash to reduce spreading of the oleoresin antigen C. continued antihistamine therapy D. drainage of large bullae for cosmetic purposes E. oral steroid treatment

B. avoidance of contact with the rash to reduce spreading of the oleoresin antigen This patient has developed allergic contact dermatitis, a type-IV hypersensitivity reaction, likely due to poison ivy or poison oak exposure. Although the rash can be expected to resolve on its own (i.e. without medical intervention) in 1-2 weeks, relief of this patient's symptoms can be facilitated with continued antihistamine therapy and/or oral steroid treatment. The bullae can be drained for cosmetic purposes, but the tops should not be removed to avoid risk for bacterial superinfection. This condition is due to exposure to allergenic plant oleresins, which may remain on the clothing that the patient was wearing at the time of contact; thorough washing should therefore be recommended. The allergen is not present in the bullae of vesicles and so, after the initial washing of the involved site, contact with the rash does not cause it to spread.,

Which of the following pairs of maneuvers are consistent with current recommendations for emergency care for a choking 5-month-old infant? A. back blow then blind finger sweep B. back blow then chest thrust C. chest thrust then Heimlich maneuver D. Heimlich maneuver then blind finger sweep E. Heimlich maneuver then chest thrust

B. back blow then chest thrust Controversy exists about the management of a choking child, but current guidelines rely on the back blow and chest thrust to clear an infant's airway. The Heimlich maneuver is discouraged due to potential injury to abdominal organs, and blind finger sweeps may push a foreign body further into the airway. Currently, for the choking infant less than a year, the following recommended sequence of treatment is: With the infant's torso positioned prone and head down along the rescuer's arm, four blows are delivered in the interscapular area. If the airway is still obstructed, the infant is repositioned supinely along the rescuer's arm and four chest thrusts (cardiac compressions) are delivered. The jaw thrust is used, mouth inspected, and foreign body removed if seen. If obstruction persists, mouth-to-mouth or mouth-to-nose ventilation is attempted. If obstruction persists, the sequence is repeated. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 4th edition, page 83.

A fracture in which there are more than two fragments is: A. compound B. comminuted C. oblique D. spiral E. transverse

B. comminuted

A 50 year old male presents to the emergency department 1 week after having an acute myocardial infarction. He now complains of dizziness. His EKG, shown below, is characterized by: [image all over the place] A. normal sinus rhythm B. complete heart block C. second degree AV block Mobitz Type 2 D. second degree AV block Mobitz Type 1

B. complete heart block The answer is B. In complete AV block, there is no relationship between the P waves (atrial beats) and the ventricular beats. The latter arises from different foci, thus the QRS complex is wide (impulse is not conducted through the normal pathways) and the rate is often slow at < 50/minutes. Complete heart block is common in the setting of ischemia and also in the peri-infarct period. The treatment for complete AV block in this setting is usually permanent pacing.

Women who develop pre-eclempsia in their first pregnancy have a long-term risk for which of the following? A. habitual miscarriage B. diabetes mellitus C. renal failure D. hypertension E. liver disease

B. diabetes mellitus With the exception of diabetes mellitus, follow-up studies of pre-eclamptic women have failed to reveal long term hypertensive disease or other problems listed above. Approximately 50% to 66% of women who have a history of gestational diabetes will develop gestational diabetes with subsequent pregnancies. About half of the women who develop gestational diabetes will develop overt diabetes later in their lives, with the risk particularly high for women manifesting glucose intolerance in the post-partum period. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 2421-2424.

A patient presents after slamming her index finger in a window one day ago (see Figure). Her X-ray is negative. Of the steps listed below, which is the best option for her management? [image] A. antibiotics and discharge B. drainage and discharge C. removal of the nail and suture of the underlying laceration D. splint and discharge E. none of the above

B. drainage and discharge The correct answer is B. This patient has a subungual hematoma. Large subungual hematomas require drainage using an 18-gauge needle or a hot microcautery unit. There is debate concerning management of a subungual hematoma greater than 50% of the nail bed. One study showed there was a 60% incidence of nail bed laceration in these patients; therefore, the authors recommended that the nail be removed and the laceration sutured. However, another study found no difference in outcome between nail trephination alone versus formal nail bed repair.

A 48 year old farmer is plowing his field when a thunderstorm rapidly overcomes him. Drivers on a nearby highway see him struck by lightening. You respond to the scene with EMS. What is the least likely finding on physical exam? A. Glascow Coma Score of 3 B. extensive skin burns C. cardiac asystole D. respiratory arrest

B. extensive skin burns The answer is B. A lightning strike is the discharge of a massive amount of current over a very short period of time. This often causes "short-circuiting" of electrical systems such as heart, respiratory centers, and central and autonomic nervous systems, in addition to arterial and muscular spasm. However, significant skin burns and deep tissue destruction seldom occur.

With growing regionalization of care for many patient types and conditions, the traditional province of "prehospital" care is growing to include "out-of-hospital" care. The increasing need for critical care transport to regional centers has translated into regularly-occurring out-of-hospital, intratransport utilization of all the following EXCEPT: A. mechanical ventilation B. extracorporeal membrane oxygenation (ECMO) C. continuous propofol infusion D. ventilation with nitric oxide-containing gas E. intra-aortic balloon counterpulsation

B. extracorporeal membrane oxygenation (ECMO) EMS or critical care transport services do not generally offer in-flight ECMO. Nitric oxide administration is the intratransport alternative that is available (e.g. in critically ill neonates requiring transport to ECMO centers). Ventilators used in transport are not as versatile as those in the intensive care unit, but mechanical ventilation during transport is common. Similarly, the number of air and ground transport programs providing intra-aortic balloon pump therapy during transit is growing. Continuous drug infusions of many types can be administered during critical care transport. -- For further reading, please see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 1-4.

A 32-year-old G1P0 woman at 32 weeks gestation presents to the emergency department complaining of a worsening headache. Her vital signs are T 98.4, BP 160/115, P 95, R 16. Her urinalysis reveals 3+ protein. Which of the following is the first choice agent to decrease her blood pressure? A. fenoldopam B. labetolol C. nitroglycerin D. nitroprusside E. phentolamine

B. labetolol

A 65 year old male with a past medical history of poorly controlled hypertension presents with new onset unilateral arm and leg weakness. There is no disturbance of consciousness and there is no evidence of cortical findings (such as aphasia, agnosia, or hemianopsia). What is the most likely location of the vascular obstruction? A. basilar artery B. lacunar C. middle cerebral artery D. posterior cerebral artery E. anterior cerebral artery

B. lacunar The answer is B. Lacunar infarcts occur at the small, terminal branches of the vasculature and more commonly occur in African-Americans and patients with diabetes and hypertension. This patient's presentation, evidenced by pure loss of motor function without disturbances in other neurological modalities, is consistent with an infarct in the internal capsule. Because terminal branches of the vasculature supply the internal capsule, it is frequently affected in patients with diabetes and hypertension. A vascular obstruction in the MCA would affect not only motor functions, but also produce cortical findings such as aphasia or agnosia.

A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces. He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12. His neuromuscular exam shows extremely rigid extremities, and his laboratory values are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine phosphokinase levels. What is the most likely explanation for these findings? A. neuroleptic-induced acute dystonia B. neuroleptic malignant syndrome C. schizophrenia, catatonic type D. tardive dyskinesia

B. neuroleptic malignant syndrome Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient's temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as *dantrolene, bromocriptine, amantadine, and lorazepam* are also often used. Tardive dyskinesia is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the tongue or lips, mouth puckering, or flailing movements either of the extremities or of the spine. Neuroleptic-induced acute dystonia is an acute spasm of a muscle or muscle group associated with the use of antipsychotic agents. It presents with patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia is an extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia, catatonic type, a diagnosis of exclusion, usually does not present with this degree of impairment.

Which of the following drugs is NOT associated with potential toxic side effects related to the inner ear? A. furosemide B. penicillin C. phenytoin D. gentamicin E. aspirin

B. penicillin

Of the following, which is most likely distributed in a Christmas-tree pattern on the posterior thorax? A. atopic dermatitis B. pityriasis rosea C. candidiasis D. eczema E. acanthosis nigrans

B. pityriasis rosea

Treatment with hyperbaric oxygen (HBO) is associated with contraindications. Which of the following is not a relative or absolute contraindication to HBO? A. COPD with air trapping B. pregnancy C. otitis media D. untreated pneumothorax

B. pregnancy The answer is B. Untreated pneumothorax is an absolute contraindication to HBO therapy. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy. The COPD patient with a large bleb represents a relative contraindication for similar reasons. Treatment with doxorubicin, and many other drugs -- such as cisplatin (Cisplatinum®), bleomycin (Blenoxane®), disulfiram (Antabuse®), and mafenide acetate (Sulfamylon®) -- contraindicates HBO therapy because of potentially toxic effects when combined with HBO. URI illnesses such as otitis media are relative contraindications, due to the potential for tympanic membrane rupture secondary to inability of the ears to equalize pressure during therapy. This can be addressed through myringotomy with placement of tubes (in cases where multiple HBO treatments are anticipated). In pregnant patients, HBO therapy has been shown to be safe for the fetus when given at appropriate levels and "doses" (durations). In fact, pregnancy lowers the threshold for HBO treatment of carbon monoxide-exposed pregnant patients. This is due to the high affinity of fetal hemoglobin for CO.

A 70 year old male presents with lightheadedness. He is noted to be bradycardic. His EKG below reveals: [image shows progressive PR lengthening then drop] A. first degree AV block B. second degree AV block Mobitz Type I C. second degree AV block Mobitz TypeII D. complete heart block

B. second degree AV block Mobitz Type I Note progressive increase in the PR interval until a blocked P wave occurs. Also note the progressive shortening of the R-R interval before the nonconducted beat. This type rhythm is usually due to abnormal conduction within the AV node. Mobitz I block may occur in normal individuals with heightened vagal tone. It may also occur as a drug effect, especially from digoxin, calcium channel blockers, beta-blockers, or other sympatholytics.

A 58 year old construction worker who has no primary care doctor comes to the emergency department because of a non-pruritic rash above his ankles. Physical examination reveals bilateral erythematous and swollen ankles that are mildly warm but non-tender to touch. His overlying skin of both legs show mild scaling and thickened skin. There is no puncture site or visible opening in the skin, although he has prominent varicose veins bilaterally (see Figure). His temperature is 37C (98.6F). He appears to be in no acute distress. What is the most likely diagnosis? A. necrotizing fasciitis B. stasis dermatitis C. eczema D. cellulitis E. psoriasis

B. stasis dermatitis This patient's presentation may be confused with cellulitis but is in fact stasis dermatitis. The facts that his rash is bilateral and associated with varicose veins and lack of fever increase the likelihood of a long-term process such as stasis dermatitis (chronic inflammation of the skin due to venous insufficiency). Microvascular changes hinder the delivery of oxygen to the skin and subcutaneous tissues. A secondary bacterial infection can be superimposed upon stasis dermatitis. Necrotizing fasciitis is more likely characterized by a rapid progression of extreme pain and blister/bullae formation that represents widespread tissue destruction; patients often are visibly toxic. The hallmark of eczema is pruritis, and psoriasis would appear as white or silvery, flaky patches, neither of which are present.

A newborn presents to the emergency department a few days after hospital discharge. The infant has been noted to be drooling, choking, and coughing, and the mother reports seeing bubbles at the baby's mouth. Which is the most likely explanation? A. osteogenesis imperfecta B. tracheoesophageal fistula C. congenital diaphragmatic hernia D. foreign body E. inborn error of metabolism

B. tracheoesophageal fistula

A 60 year old male presented to the emergency department with chest pain. He subsequently became unresponsive. The monitor shows the rhythm below. The rhythm is: [image monomorphic wide QRS tachycardia with no p waves] A. sinus tachycardia B. ventricular tachycardia C. atrial fibrillation with rapid ventricular response D. atrial flutter

B. ventricular tachycardia The answer is B. Ventricular tachycardia is wide and complex. It is distinguished from supraventricular tachycardia by width and morphology of the QRS complexes. (Though there are numerous exceptions, supraventricular tachycardias usually exhibit narrow QRS complexes with morphology similar to that when the patient is in sinus rhythm.)

While temperatures vary with time of day and method assessed, the generally accepted upper limit of normal temperature is: A. 98.6 F (37 C) B. 99.5 F (37.5 C) C. 100.4 F (38 C) D. 101.3 F (38.5 C) E. 102.2 F (39 C)

C. 100.4 F (38 C) The hypothalamus regulates body temperature. Fever occurs when the body temperature is raised beyond its normal set point. The upper limit of normal is considered to be 100.4 F or 38 C.

The standard initial ACLS dose of IV epinephrine is: A. 0.1 mg 1:10,000 B. 10mg of 1:10,000 C. 1mg of 1:10,000 D. 1mg of 1:1,000

C. 1mg of 1:10,000 The answer is C. "Epinephrine remains the adrenergic drug of choice in the ACLS guidelines. The 2005 ACLS guidelines recommended the administration of 1 milligram IV or IO of a 1:10,000 solution every 3 to 5 minutes. Doses >1 milligram are not recommended and may be harmful."

Which of the following trauma patients can be managed conservatively without immediate laparotomy in the OR? A. 27 year old man with hemoperitoneum by bedside ultrasound; hypotensive B. 19 year old man with splenic laceration; peritoneal signs on exam C. 24 year old man with liver laceration; hemodynamically stable D. 30 year old man with a gunshot wound to the epigastrium E. All of the above should go to the OR for exploratory laparotomy.

C. 24 year old man with liver laceration; hemodynamically stable

During hypovolemic shock, hypotension tends to develop after the loss of what percent of blood volume? A. 10% B. 20% C. 30% D. 40% E. 50%

C. 30% The answer is C. Some texts divide hypovolemic shock into 4 classes based on the percent of volume loss; Class I is loss of up to 15% of circulating blood volume; Class II is 15-30% loss; Class III, 30-40%; and Class 4, over 40%. In general, blood pressure does not drop until approximately 30% of blood volume is lost.

A CT of the abdomen reveals air surrounding the duodenum and under the diaphragm in a 45 year old man in the ED. Your surgeon has taken him to the OR after rapid IV fluid resuscitation and antibiotics were started in the ED. His family arrives after he already went to the theater and wants to know his risk of dying. You can tell them even with advances in surgery, antibiotics and ICU care his risk of mortality is: A. 1-5% B. 5-20% C. 30-50% D. 50-70%

C. 30-50%

Which of the following is NOT suggestive of perinatal asphyxia? A. umbilical artery academia (pH < 7.00) B. neonatal neurological sequelae C. 5-minute Apgar score of 5-7 D. multiorgan dysfunction E. 5-minute Apgar score of 3 or less

C. 5-minute Apgar score of 5-7

A 38 year old man with sudden severe central abdominal pain for the last hour presents to the ED. He is ill appearing, febrile and has a rigid board-like abdomen. A bedside ultrasound reveals no fluid collections or aneurysm and a plain upright portable chest xray reveals no pneumoperitoneum. Your surgical consultant wants to take the patient for a laparotomy. What percentage of patients have no pneumoperitoneum who go to the operating room with this entity: A. 10% B. 25% C. 50% D. 75%

C. 50%

Approximately what inside diameter size endotracheal tube is appropriate for an 8 year old child? A. 4 mm B. 8 mm C. 6 mm D. 10 mm E. 12 mm

C. 6 mm The correct endotracheal tube size can be approximated by using a simple formula: Inside diameter (ID) in mm = (16 + age in years) / 4. As this is an estimate, it is prudent to have the next smaller and larger size endotracheal tubes available as well. Estimation of tube size based on the size of the patient's fifth finger is less accurate. The tube size may also need to be modified based upon the etiology of the arrest (e.g. airway narrowing from infectious disease). -- For further reading, see Fleisher's Textbook of Pediatric Emergency Medicine, 3rd edition, pages 8-12.

A 55 year old male, who has been missing for several days in wintertime, is found in a forested area several miles away from his house. He is brought to the ED where he is found to have a core temperature of 27 degrees Celcius. He clearly has diminished mental capacity. His initial ECG demonstrates atrial fibrillation with a ventricular rate of 110. Which of the following is the best treatment option? A. Start calcium channel blockage B. Apply a Bair Hugger C. Administer warm IV fluids D. Immerse in a warm water bath at 40 Celcius

C. Administer warm IV fluids The answer is C. The patient is suffering from severe hypothermia. Atrial dysrhythmias are common below 32o C and are associated with a slow ventricular response. It usually converts spontaneously with rewarming. While answers B through E are all active rewarming techniques (active external - Bair Hugger, AVA rewarming, immersion, active core - peritoneal lavage), the best answer for someone with severe hypothermia with mental status change and cardiac dysrhythmias is probably active core rewarming . This technique minimizes rewarming collapse in patients with temperatures below 32o C. The patient will likely need intubated as ileus, bronchorrhea, and depressed protective airway reflexes are common with hypothermia.

Which of the following is an absolute contraindication to surgical cricothyrotomy? A. Acute laryngeal disease B. Bleeding diathesis C. Age < 5 D. Massive neck edema

C. Age < 5 The answer is C. Given that surgical cricothyrotomy is often resorted to only after other techniques have been unsuccessful and/or the patient is not oxygenating or ventilating, most authors state that the only absolute contraindication is age. Because of the anatomic differences between children versus adults including the smaller cricothyroid membrane and the rostral funnel shaped more compliant pediatric larynx, surgical cricothyrotomy has been contraindicated in infants and young children. However, the exact age at which a surgical cricothyrotomy can be done is controversial and not well defined. Various textbooks list the lower age limit from 5 years to 12 years. Choices A, C, and D are all relative contraindications to cricothyrotomy but may be overlooked in an emergent situation when the first priority is to obtain an airway.

A 62 year old female presents via paramedics from home with a complaint of new onset right sided weakness and aphasia. She has a past medical history notable for hypertension, hypothyroidism, and diabetes. On arrival she is awake and alert and continues to have aphasia and right-sided weakness. Her husband states that the change in her speech and strength started acutely 45 minutes ago. Her vital signs on presentation include: T 98.2 HR 90 BP 168/88 RR 16 P OX 97% RA and her finger stick glucose is 172 mg/dL. She is rapidly taken to radiology for a head CT and neurology consult is obtained. The patient has no signs of intracranial hemorrhage on her CT, and in-consultation with the patient, husband and neurologist you consider giving the following drug as treatment for an acute ischemic stroke: A. Abciximab (reopro) B. Aminocarproic acid (Amicar) C. Alteplase (t-PA) D. Warfarin (Coumadin)

C. Alteplase (t-PA)

A 20 year old man was ice skating on a frozen pond and fell through the ice. The water was only about six feet deep and he was able to keep his head above water while bystanders were able to extract him after 10 minutes. The patient was transported to the emergency department and had an initial core temperature of 30 C. The patient's wet clothes were immediately removed and rewarming was initiated. Which of the following physical examination findings is expected? A. Tachycardia B. Hyperventilation C. Altered mental status D. shivering

C. Altered mental status The answer is C. Moderate hypothermia is associated with temperatures of 28-32 C. Shivering ceases at about 32 degrees Celsius. Moderate hypothermia is associated with altered mental status, absence of shivering, bradycardia, and bradypnea

A 65 year old male with a history of COPD presents to the emergency department with increasing dyspnea, rhinorrhea, cough, and sputum production over the last three days. He denies fever or chest pain. His last acute health visit was 6 months ago. His vital signs are as follows: BP 135/75, HR 85, RR 19, SpO2 95%, Oral temp 98.0 °F. His exam is significant for a diffuse expiratory wheeze and prolonged expiratory time. His chest X-ray and EKG are unchanged from baseline and your patient responds to your ED medical therapy. In addition to an inhaled beta agonist your patient's recommended outpatient pharmacotherapy includes: A. A methylxanthine such as theophyline B. A high-dose oral corticosteroid such as prednisone C. An antibiotic such as doxycycline D. A mucokinetic such as guaifenesin

C. An antibiotic such as doxycycline

A mother brings her 3 year old daughter into the emergency department for an arm injury. The mother was holding her hand to cross a busy street. She pulled hard on her daughter's arm to hurry across the street and the child began to cry. Since the incident the child has kept her arm against her body in a slightly flexed and pronated position. She is tender over the radial head and refuses to move her elbow, but there is no swelling or ecchymosis. What is the most appropriate management for this girl? A. Obtain immediate X-rays of the elbow to rule out fracture B. Obtain immediate orthopaedic consult for presumed elbow dislocation C. Apply pressure to the radial head while flexing and supinating elbow D. Apply posterior elbow splint and follow-up with orthopedics within one day E. Apply traction to elbow and splint under conscious sedation

C. Apply pressure to the radial head while flexing and supinating elbow

A 23 year old college novice mountain climber decides to climb a mountain with friends as a graduation present. His first night is spent at an altitude of 8,500 feet at a mountain resort. The next morning he starts to experience a mild headache and nausea. His symptoms get worse throughout the day. His friends want to get to 10,000 feet by nightfall. As a physician at the hotel, the worst advice you can give him is: A. Take acetazolamide. B. Take ibuprofen. C. Ascend with the rest of the team. D. Take supplemental oxygen.

C. Ascend with the rest of the team. The answer is C. The syndrome of high altitude illness ranges from mild AMS (Acute Mountain Sickness) to life threatening conditions of HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). This student is experiencing mild AMS. After the symptoms of altitude illness occur, further ascent to a higher sleeping altitude is contraindicated. Halting ascent or activity to allow further acclimatization may reverse symptoms. Acetazolamide is a carbonic anhhydrase inhibitor that induces a renal bicarbonate diuresis, causing a metabolic acidosis and thereby increasing ventilation and arterial oxygenation. Supplemental oxygen addresses the hypoxic insult of high altitude exposure. Ibuprofen is useful for the treatment of his headache. Dexamethasone can help with the symptoms of AMS, but does not play a role in acclimatization.

A 58 year old man presents to the ER complaining of shortness of breath over the past few days. He states that it is worse when he lies flat and better sitting upright. He also complains of lower extremity swelling. On exam, you find a well-developed, well-nourished man in no acute distress. His vital signs are: HR 103bpm, BP 110/70, Oxygen saturation: 92% on room air, Temp 98.6 orally, RR 18, FS 110. His lung exam reveals rales bilaterally, and his lower extremities have 2+ pitting edema to the ankles. As you are examining him, you note a left arm AV fistula with a palpable thrill. The patient tells you that he also has End-stage renal disease and is on Hemodialysis, but missed his last session. As you are placing initial orders and calling the Nephrologist to discuss his missed dialysis session, the nurse hands you this EKG. Which of the following is the most appropriate pharmacotherapy? [ekg shows peaked T waves] A. Diltiazem B. Amlodipine C. Calcium gluconate D. Verapamil

C. Calcium gluconate

A 20 year old college female recently returned from spring break after hiking in the Virginia woods approximately two weeks prior to her presentation to the E.D. One day prior to presentation, she developed fever, chills, and anorexia. In the emergency department, she complains of headache, photophobia, and myalgias. On exam, one notices a disseminated, non-blanching, papular rash. Which of the following statements regarding this condition is FALSE? A. It is caused by the tick borne parasite Rickettsia rickettsii. B. 95% of patients develop symptoms between the period of April 1 and September 30. C. Characteristically the rash begins on the trunk and spreads to the extremities. D. A skin biopsy shows a necrotizing vasculitis. E. If untreated, fatality rates range between 25-50%; however, treatment reduces the rate to 10%.

C. Characteristically the rash begins on the trunk and spreads to the extremities. The answer is C. Rocky Mountain Spotted Fever characteristically begins on wrist, forearms, and ankles. Within 6-18 hours, the rash spreads centripetally to the arms, thighs, trunk, and face.

A 56 year old female presents to the emergency department complaining that she can't catch her breath. She has associated intermittent sharp chest pain on the right side of her chest that began 3 days ago after she returned from a trip to Europe. She has a history of hypertension (HTN) and is on a beta blocker and hormone replacement therapy. Her physical exam is unremarkable except for a heart rate of 110 and respiratory rate of 28. Her EKG shows sinus tachycardia. Her SpO2 is 90% on 4L nasal cannula and her chest X-ray is normal. The next test should be: A. Lower extremity doppler B. Bedside echocardiogram C. Chest CT scan D. Exercise treadmill

C. Chest CT scan The answer is C. This patient most likely has a PE and has a sufficient presentation to warrant immediate anticoagulation therapy with heparin unless contraindications are present. Risk factors for PE include history of deep venous thrombosis (DVT), recent surgery or pregnancy, limb immobilization, confinement to bed, or underlying malignancy. Other risk factors include HTN, obesity, estrogen replacement therapy or oral contraceptives, autoimmune diseases, and cancer. Symptoms of PE include: dyspnea, pleuritic chest pain, apprehension, cough, hemoptysis, sweating, and syncope. The diagnosis is made: (1) if DVT is demonstrated by duplex US, venography, CT, MRI or some other technique; (2) if V/Q scan is convincingly positive; or (3) if pulmonary angiography, spiral CT, or another convincing test is positive.

A thin 18 year old female complains of acute onset of sharp right-sided chest pain this morning. She has developed some mild shortness of breath during the morning and thought she should get it checked out. Her chest X-ray is shown in the Figure. The next course of action should be: [image ??] photo courtesy of eMedicine.com A. Needle decompression B. Electrocardiogram C. Chest tube placement D. Antibiotics

C. Chest tube placement The answer is C. This patient has a large right-sided spontaneous pneumothorax that is not under tension. She needs oxygen and chest tube placement. This can be done with proper procedural analgesia and sedation since there is no immediate threat. Primary spontaneous pneumothorax tends to occur in healthy young men (and, less commonly, women) of taller than average height. Other risk factors include cigarette smoking, asthma, COPD, interstitial lung disease, connective tissue diseases, and lung cancers.

Which of the following bacteria does NOT produce bloody diarrhea? A. Yersinia enterocolitica B. Campylobacter enteritis C. Clostridium perfringens D. Escherichia coli 0157

C. Clostridium perfringens The answer is C. Clostridium perfringens is the most common cause of food poisoning in the United States. Patients ingest heat-resistant spores of C. pergringens which produce an enterotoxin in the GI tract. Campylobacter, E. coli 0157, Salmonella and Yersinia are all invasive bacteria that can cause bloody enteritis.

A 19 year old with eczema (atopic dermatitis) presents to the urgent care clinic demonstrating pustules within an area affected by his chronic eczema. A Tzanck preparation yields positive results, confirming the diagnosis of eczema herpeticum. Which of the following is FALSE regarding this condition? A. It is often mistaken as an exacerbation or a superimposed impetigo infection. B. Constitutional symptoms and adenopathy are often present. C. Death from this condition is very rare. D. It can be caused by either HSV or VZV. E. Oral or, if necessary, IV acyclovir is used to treat this condition.

C. Death from this condition is very rare. The answer is C. Mortality from this condition has been reported as high as 10%. If this diagnosis is suspected, immediate dermatology consultation should be obtained.

A 2 year old child presents with an overdose of her mother's iron containing multivitamins. What antidote should you consider for iron toxicity? A. Pyridoxine B. Glucagon C. Deferoxamine D. Methylene blue

C. Deferoxamine The answer is C. Deferoxamine binds directly to free iron and thus is the antidote for iron toxicity. It is given intramuscularly or intravenously and often causes the patient's urine to turn color (vin rosé urine). Methylene blue is an antidote for methemoglobinemia. N-acetylcysteine is the antidote for acetaminophen. Pyridoxine is the antidote for isoniazid toxicity and glucagon can serve as an antidote for beta blocker, calcium channel blocker, or insulin overdoses.

All of these steps are involved in pediatric rapid sequence intubation (RSI) EXCEPT: A. If administering succinylcholine, pretreatment with atropine is always indicated in children under age 10. B. Lidocaine pretreatment is usually provided to children with head trauma. C. Due to the fragility of the pediatric C-spine, a cervical collar should always be placed prior to intubation for children under age ten. D. When deciding which size endotracheal tube to use, one may approximate by using the size of the small finger or nares as a reference. E. Uncuffed endotracheal tubes are the preferred devices used in children under 6-8 years of age.

C. Due to the fragility of the pediatric C-spine, a cervical collar should always be placed prior to intubation for children under age ten.

A 41 year old man is seen in the emergency department after a street fight where he punched another man in the mouth. He has a small, jagged laceration over the dorsum of the metacarpophalangeal joint of his right hand. The wound is irrigated copiously, tetanus is given, and the wound is left open to heal by secondary intention because of the infection risk. In addition to treating Streptococcus and Staphylococcus species, antibiotics must also treat which other bacterial species? A. Escherichia. coli B. Actinomyces israelii C. Eikenella corrodens D. Pasteurella multocida

C. Eikenella corrodens The answer is C. There are many species of bacteria in the human mouth, and Eikenella corrodens is an aggressive one, frequently causing infection in the first 24 hours after injury.

A 45 year old female presents to the ED brought in by her husband. He is concerned that the patient is not acting appropriately and has been confused and repeating herself. She even tried to drive in the wrong direction just prior to presentation He does note that yesterday she complained of a headache. She is otherwise healthy, except for occasional NSAIDS, thyroid medication, and prn valcyclovir for oral herpes. He denies alcohol or other substances. On exam, the patient's temperature is 99.8 F, Pulse 108, RR 22, BP 118/77, O2sat 99% RA. Her airway is patent, GCS is 14, and her neck is supple. The rest of the physical exam is non focal. For which of the following conditions is the patient at greatest risk? A. Narcotic abuse B. Influenza C. Encephalitis D. Epilepsy

C. Encephalitis

A 3 year old girl presents after accidentally ingesting an alkali drain cleaner. Which of the following statements regarding her management is true? A. Neutralization therapy using a strong acid is warranted B. Gastric lavage should be performed immediately to reduce gastric injury C. Endoscopy is useful in the assessment of injury D. Activated charcoal should be administered

C. Endoscopy is useful in the assessment of injury The answer is C. Gastric lavage and ipecac therapy are contraindicated due to concern regarding recurrent injury to the esophagus from a second contact with the caustic ingestant. Activated charcoal is contraindicated because it obscures endoscopic assessment (and doesn't work at binding caustics). Neutralization with milk or water may be indicated in caustic ingestions without perforation, but strong acids/alkali should not be used. Endoscopic assessment should be performed early as the risk of procedurally-induced perforation increases with delayed endoscopy.

A 32 year old firefighter presents to the ED complaining of a headache. His friends brought him to the hospital for evaluation, even though he did not want to come. His friends inform you that he had fallen off of a ladder during a rescue attempt just prior to arrival. He fell approximately 15 feet and was initially unconscious at the scene. Your patient denies any other complaints or injuries and has been acting appropriately since regaining consciousness. You get called away from the room by an overhead page announcing an incoming CODE BLUE. You instruct your nurse to order a CT head on your patient. While in the ED, the firefighter begins to become combative and then more somnolent. What is the most likely diagnosis? A. Diffuse axonal injury B. Post-concussive syndrome C. Epidural hematoma D. Subarachnoid hemorrhage

C. Epidural hematoma

With which of the following substances is acute withdrawal most likely life-threatening? A. Lithium B. Cocaine C. Ethanol D. Heroin

C. Ethanol

An 82 year old woman with osteoporosis slips and falls onto her right hip. She cannot get up and is brought to the emergency department by ambulance. As you enter the room you notice her right leg is abducted and externally rotated. What type of injury does she most likely have? A. Subtrochanteric femur fracture B. Intertrochanteric femur fracture C. Femoral neck fracture D. Acetabular fracture E. Posterior hip dislocation

C. Femoral neck fracture The answer is C. Patients with dislocation tend to have internal (not external) rotation.

19 year old man is brought in to the emergency department by EMS after being found obtunded in his apartment. No additional history is available. On arrival, the patient is minimally responsive with sonorous respirations and a palpable rapid pulse. The most appropriate initial diagnostic test would be A. Arterial blood gas B. Electrocardiogram C. Fingerstick glucose D. Urine drug screen

C. Fingerstick glucose Hypoglycemia is a common and readily treatable cause for altered mental status. An ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities caused by respiratory depression. While a urine drug screen may show positives, it cannot quantitate the amount of a substance or the time period in which the exposure occurred so a positive screen may not reflect cause and effect. An EKG, while a part of a toxicology evaluation, is not an appropriate initiate screening test for an unstable patient until airway and readily reversible causes have been addressed.

A mother brings in her 4 year old child who was happily eating "blackberries" from weeds in the garden and is now acting strangely. She has identified them as Belladonna from a quick internet search. Which physical examination finding might you also expect to find in this child? A. Urinary incontinence B. Miosis C. Flushed skin D. Diaphoresis

C. Flushed skin The answer is C. The classic presentation of anticholinergic toxicity is best remembered by the following: hot as Hades; blind as a bat; dry as a bone; red as a beet; mad as a hatter. Patients with anticholinergic toxicity are flushed, warm, psychotic, mydriatic, and dry. Bowel sounds are classically hypoactive.

All of the following are true regarding acute hepatitis EXCEPT: A. The incubation period of HCV is 30-90 days. B. Fecal excretion of hepatitis A virus usually occurs prior to symptoms of acute HAV infection. C. HBV core antibody indicates immunity to HBV. D. An IgM antibody to HAV indicates acute infection with HAV. E. HBe antigen indicates active acute or chronic infection with HBV of high infectivity.

C. HBV core antibody indicates immunity to HBV.

A 46 year old woman presents to the emergency department complaining of abrupt onset of intermittent severe pain in the left flank and abdomen that woke her from sleep. She is pacing around the stretcher and appears extremely uncomfortable. She has never experienced this type of pain previously and denies fevers or other symptoms. Renal calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi in this patient? A. Urinalysis demonstrating hematuria confirms the diagnosis. B. KUB detects less than 10% of calculi. C. Helical CT scan greater than 95% sensitive and specific for renal calculi. D. Ultrasound is the study of choice for detecting small ureteral calculi. E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.

C. Helical CT scan greater than 95% sensitive and specific for renal calculi. Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study.

A 45 year-old is brought in 8 hours after a large overdose of his lithium. What is the best treatment method for this overdose? A. Whole bowel irrigation B. Activated charcoal C. Hemodialysis D. Gastric lavage

C. Hemodialysis The answer is C. Dehydration, over-diuresis, and drug-drug interaction (particularly NSAIDs) are common precipitants of lithium toxicity in the patient chronically taking lithium. In general, the clinical condition, not drug level, should guide therapy. In acute ingestions in particular, lithium levels do not correlate well with symptoms or prognosis. Charcoal does not bind heavy metals like lithium. Hemodialysis is helpful in lithium toxicity.

A 55 year-old male presents with new onset agitation and confusion. Which of the following medical histories would suggest a psychiatric (non-organic) cause? A. History of diabetes mellitus only B. History of alcohol abuse only C. History of hypothyroidism only D. History of chronic obstructive pulmonary disease only

C. History of hypothyroidism only Although hyperthyroidism may result in an agitated state, hypothyroidism is not generally associated with violent behavior. All other answers are potentially treatable medical problems that could account for the presentation of an agitated or violent patient. After assuring the safety of all parties involved, the emergency department physician should rule out organic causes of agitation.

An unconscious 8 year old boy was pulled out of a freshwater lake. It was unknown how long he had been submerged in the water or how much water he had aspirated. The water temperature was 20C at the time he was pulled out of the water. He was found to be hypoxic upon removal and quickly given 100% oxygen. Which of the following is correct with regards to this drowning scenario? A. Adults develop hypothermia more quickly than children in cold water B. Initial treatment of fresh water and salt water drowning are different C. Hypoxia is based on volume of water aspirated and not water content D. Significant ingestion of freshwater will cause hypernatremia

C. Hypoxia is based on volume of water aspirated and not water content

A 60-year-old male is brought in by paramedics after a witnessed cardiac arrest. He remains pulseless and apneic. Rhythm strip is shown below. In addition to providing effective cardiopulmonary resuscitation, what management step is most likely to result in survival? [image: EKG w/ PEA and asystole] A. Atropine B. Transcutaneous pacing C. Identification and treatment of a reversible underlying etiology D. Vasopressin

C. Identification and treatment of a reversible underlying etiology The answer is C. "Patients with PEA and asystole have poor outcomes, but the identification of the underlying etiology is extremely important and the common causes should be reviewed, treated, or excluded during the resuscitation."

Regarding the laceration, in a 30-year old female, as depicted in the Figure, which of the following is true? [image] A. An infraorbital nerve block would provide adequate anesthesia to the area of the laceration B. If lidocaine anesthesia is to be used, the solution should not contain epinephrine C. If there is not much tension on the wound, a topical adhesive (such as Dermabond) may be used to approximate the wound edges D. The eyebrow hair should be shaved to optimize the ability to closely approximate the wound edges E. This laceration is not suitable for topical anesthesia as an adjunct to repair

C. If there is not much tension on the wound, a topical adhesive (such as Dermabond) may be used to approximate the wound edges The answer is C. Eyebrow hair tends to not regrow after being shaved; a petroleum jelly can be used to "retract" the hair if necessary. If anesthesia is to be used to close this wound (wound glue would be a reasonable alternative), topical anesthesia is a good approach as long as care is taken to prevent drip into the eye. An infraorbital nerve block would not provide anesthesia to the area of the laceration. Epinephrine can be used safely in the supraorbital region.

A 36 year old male backpacking in the wilderness loses his way in a snowstorm. Temperatures are well below zero degrees and his clothing is inadequate. He is rescued 5 days later and presents to the ED. Rescue crew has already initiated passive rewarming and have removed patient's damp clothing. On arrival, vital signs show pulse of 100 and temperature of 35.5C. On physical exam, you note patient has several toes that are purple with hemorrhagic blisters on his feet. Which of the following is the most appropriate initial management? A. Tetanus prophylaxis B. Administration of morphine C. Immersion in warm water bath D. Debridement of necrotic tissue

C. Immersion in warm water bath The answer is C. Immersion of the affected extremity is the mainstay of treatment for patients with frostbite. Numbness of the affected area is the most common initial symptom and severe pain is frequently encountered after rewarming. Tetanus prophylaxis and debridement is indicated , but is not the most appropriate initial step in the management of patients with frostbite.

A 39-year-old diabetic man with hypertension and cirrhosis, presents to the ED with an infected tattoo resulting in cellulitis encompassing his entire left arm and forearm. His vital signs are 40.0 C, pulse 140, respirations 28, blood pressure 120/50. His last admission reveals his usual blood pressures to be systolic values of 180-190. To which level of care should he be admitted? A. General medical/surgical ward with IV antibiotics B. Observation unit until vital signs normalize and can tolerate oral antibiotics C. Intensive care unit with IV antibiotics D. Discharge home with daily ED wound checks and oral antibiotics

C. Intensive care unit with IV antibiotics

A 42 year-old woman presents with an overdose of her Xanax (alprazolam) that her family indicates she has been taking for years to help with her anxiety. The bottle indicates that the prescription was filled yesterday with 90 pills and is now empty. The patient is minimally responsive to painful stimuli and does not react when you suction secretions out of her posterior pharynx. What is your next management step? A. Administration of narcan B. Close observation C. Intubation for airway support D. Administration of flumazenil

C. Intubation for airway support The answer is C. Isolated benzodiazepine (BZD) OD is generally quite benign. When taken in combination with other agents, however, BZDs can cause significant morbidity and mortality. Patients with BZD OD commonly present with oversedation. A paradoxical excitation syndrome can occur but is uncommon. While an antidote (flumazenil) exists, supportive care is the key to treatment. Flumazenil, a BZD antagonist, can cause seizures in patients taking BZDs chronically by inducing an acute BZD withdrawal syndrome. It is best used in reversal of BZD-induced iatrogenic oversedation. Here, however, physicians must take heed as the half-life is short and resedation can occur.

An 85 year old woman presents with acute lower abdominal pain and bloody diarrhea for 1 day. On exam her abdomen is slightly distended with diffuse tenderness. Her vital signs are stable. A plain film X-ray shows "thumbprinting" suggesting the diagnosis of: A. Volvulus B. Intussusception C. Ischemic colitis D. Invasive gastroenteritis

C. Ischemic colitis The answer is C. Thumbprinting represents local areas of swelling in the bowel mucosa caused by submucosal edema and hemorrhage and suggests ischemic colitis.

A 53 year-old known alcoholic presents with agitation, vomiting and altered mental status. His fingerstick glucose is 148. His serum ethanol level is undetectable and his head CT is normal. An ABG shows a pH of 7.21, pCO2 of 34, pO2 of 98 on room air. His basic chemistry panel includes a sodium of 136, potassium 4.1, chloride 108, bicarbonate 14, BUN 12, creatinine 1.1. What substance are you concerned that he may have ingested: A. Ethylene glycol B. Salicylates C. Isopropyl alcohol D. Methanoleeette

C. Isopropyl alcohol The patient is presenting with a non anion gap metabolic acidosis. Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis. Salicylates result in an anion gap metabolic acidosis with a superimposed respiratory alkalosis. The following mnemonic can be used to recall the common causes of an increased anion gap metabolic acidosis: CAT MUDPILES; C - cyanide A - alcoholic ketoacidosis T - toluene M - methanol U - uremia D - diabetic ketoacidosis P - paraldehyde I - isoniazid/iron L - lactate E - ethylene glycol S - salicylates Isopropyl alcohol causes a ketosis without an acidosis.

A 27-year-old male presents to the ER after lifting weights at the gym. He reports that while bench-pressing weights, he felt a sudden sharp pain over his chest on the left side. He states that he immediately dropped the weight and walked around. "I think I may have pulled a muscle," he tells you. The patient also reports that he took ibuprofen prior to arrival without relief. The pain is sharp and is worse when he takes a deep breath. He has no other past medical history. He has past surgical history of pyloric stenosis as an infant. He has no other constitutional symptoms of cough, fever, or chills. On exam the patient is a tall, thin young man in no acute distress, but appears uncomfortable. Vital signs: HR 120, BP 120/70, RR 20, O2 sat 90% on room air, Temp 98 orally, FS 100. There is no particular area of reproducible tenderness over entire anterior chest wall and back. There are no external signs of trauma to the chest or back. Breath sounds are clear bilaterally, but diminished on the left. You place him on the monitor and give him oxygen by nasal cannula and his O2 sat is now 94%. His chest X-ray is below. [cxr shows absent left lung markings and sharp demarcation of left lung field] The definitive treatment for this patient is: A. Right sided needle thoracostomy B. Left sided needle thoracostomy C. Left sided chest tube D. Right sided chest tube

C. Left sided chest tube

A 4-year old child sustained a large leg laceration while riding his bike. A medical student who was on his first clinical rotation was told to "numb up" the wound. The patient became symptomatic soon after the student gave the anesthetic. Which of the following is usually the earliest sign of lidocaine toxicity? A. Nausea/vomiting B. Nystagmus C. Lightheadedness and dizziness D. Tonic-clinic seizures

C. Lightheadedness and dizziness The answer is C. Toxic reactions to local anesthetics are usually due to intramuscular or intrathecal injection, or to an excessive dose. The maximal acceptable dose of lidocaine with and without epinephrine is 7mg/kg and 5mg/kg respectively. The initial symptoms of local anesthetic toxicity are lightheadedness and dizziness. Other symptoms noted are peri-oral numbness, tinnitus, progressive CNS excitatory effects including visual and auditory disturbances, shivering, twitching, and, alternatively, generalized clonic-tonic seizures. CNS depression can follow leading to respiratory depression or arrest.

A 26 year old male presents with 24 hours of epigastric pain and chills. The patient states it was his birthday 36 hours ago and he drank more alcohol than he should have. He had multiple episodes of violent, severe retching and non-bilious vomiting that have resolved. The patient feels that he is progressively getting sicker and has lately had chills and rigors. On physical examination, the patient looks unwell with a heart rate of 125 beats per minute and blood pressure of 89/53 mm Hg. He has pain in his epigastrium, a crunching sound on auscultation of his lungs, and subcutanesous emphysema. Which of the following is correct with regards to this patient's condition? A. Majority of cases are managed non-operatively B. Nasogastric tube insertion is contraindicated C. Most injuries occur in the distal esophagus D. Pleural effusions commonly develop on the right side

C. Most injuries occur in the distal esophagus

A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood pressure, which of the following is TRUE? A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful in this setting B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action C. Nitroglycerin decreases BP by decreasing venous return and cardiac output D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia E. Esmolol works through both alpha-1 and selective beta-2 blockade

C. Nitroglycerin decreases BP by decreasing venous return and cardiac output The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.

A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient's condition? [picture of a liver abscess] (a) Emergent percutaneous drainage in the emergency department is indicated. (b) CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. (c) Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately. (d) Elevations of WBC, bilirubin, alkapine phosphatase and serum aminotransferases will be seen on laboratory studies. (e) Etiologic agents of this condition include bacteroides, E. coli, Klebsiella, Pseudomonas, Enterococcus, anaerobic Streptococci, and E. histolytica.

(a) Emergent percutaneous drainage in the emergency department is indicated. The patient has a hepatic abscess, typically caused by gram negatives, anaerobic Streptococci or Entameoba histolytica. Laboratory findings include elevations of WBC, bilirubin, alkaline phosphatase and serum aminotransferases. CXR may demonstrate a right-sided effusion and elevation of the right hemidiaphragm. Treatment with triple coverage antibiotics such as gentamicin, metronidazole and ampicillin should be instituted immediately, however consultation with a general surgeon, interventional radiologist, or gastroenterologist is necessary for definitive treatment, which is drainage of the abscess. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th edition, pages 1414-1417.

A patient with a ventriculo-peritoneal shunt presents to the E.D. with lethargy and vomiting. A CT scan obtained emergently (see the Right image in the Figure) is compared with a CT scan (see the Left image in the Figure) from a month ago. What is the diagnosis? (a) Hydrocephalus and shunt malfunction (b) Encephalitis (c) Meningitis (d) Pseudotumor cerebri (e) Subarachnoid hemorrhage

(a) The two CT scans demonstrate interval failure of the shunt to drain CSF.

The chest X-ray in the Figure was taken in an intoxicated patient who is conversant, but an unreliable historian. The X-ray findings are best described as indicating: (a) Mediastinitis from esophageal perforation (b) Esophageal foreign body (c) Normal chest (d) Intratracheal foreign body

(b) Esophageal foreign body The film reveals a classic appearance of a round foreign body (in this case, a pull-top from a beer can) in the esophagus. The foreign body appears to lie outside the tracheal shadow. There is no sign of mediastinal air (which would be expected with penetrating trauma). The X-ray reveals no signs of mediastinitis, but the risk of esophageal perforation and ultimate mediastinitis prompts endoscopic intervention in this patient. -- For further reading see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, Chapter 53.

A blunt trauma patient presents, transported by EMS from a motor vehicle collision, with inability to provide a history, due to alcohol intoxication. He has no signs of trauma on external evaluation, but he is hypotensive. An ED ultrasound is performed at the bedside, and is depicted in the figure. Given the patients' clinical condition and image seen, what is the most likely diagnosis? (a) Ruptured gallbladder (b) Rupturing abdominal aortic aneurysm (c) Fat embolus from femur fracture (d) Free intraabdominal fluid

(d) Free intraabdominal fluid The answer is D. -- For further reading, see Reference: Ma, OJ and Mateer, J. "Trauma." In: Emergency Ultrasound, 1st Ed. Ma, OJ and Mateer, J (eds.) 2003. 68-88.

A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate is obtained. Which of the following is the most likely operative finding in this patient? (a) Inflamed appendix (b) Rectus sheath hematoma (c) Ruptured spleen (d) Small bowel obstruction

(d) Small bowel obstruction Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman's history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice 6th edition, page 1442.

A 47 year-old male presents, confused, to the ED. He has limited ability to give a history. On physical examination of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall. (a) necrotizing fasciitis (b) Rocky Mountain spotted fever (c) lymphangitis (d) hyperthermia (e) liver disease

(e) liver disease The patient's palmar erythema, spider angiomata, and caput medusa (due to recanalization of the umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall venous engorgement, as well as ascites (another clue to the patient's liver disease).

A 40 year old female presents to the emergency department complaining of a few days of headaches, excessive sweating, anorexia, heat intolerance and palpitations. She has also been having upper respiratory symptoms over the past week. She is found to have a blood pressure of 170/106 and an EKG, urinalysis, fundoscopic examination, serum creatinine, and neurological evaluation are negative. What is the next step in the evaluation/management? A. Perform CT scan of the abdomen B. Avoid sublingual or intravenous therapy in the ED and prescribe an oral beta-blocker C. Obtain a medication history D. Schedule a clonidine suppression test to evaluate for pheochromocytoma E. Administer sublingual nifedipine while the work-up continues

C. Obtain a medication history Sublingual nifedipine risks overzealous blood pressure reduction, and this patient does not have indication for emergent therapy. Similarly, it would be premature to institute therapy with an oral beta-blocker agent based on a single presentation. Elevated plasma levels of free metanephrine and catecholamines, along with the clinical presentation, could point to pheochromocytoma as a possible etiology. The pheochromocytoma workup may include abdominal CT and/or clonidine suppression testing. However, certain medications (such as viral upper respiratory "cold" medications which this patient may have taken, given her symptoms) can also cause the symptoms of this patient. Therefore, further workup or treatment should occur only after a thorough medication history.

An 8 year old boy falls off his bike onto his outstretched hand with his elbow in extension. He presents to the emergency department with obvious anterior bowing of his distal humerus. His distal neurovascular exam is intact. The X-ray shows a transverse supracondylar humerus fracture with dorsal displacement and angulation of the distal fragment. Of the following, which is the most appropriate treatment? A. Splinting the extremity in its current position, and arranging for orthopedic follow-up B. Fracture reduction and casting by the E.D. physician C. Orthopedic consultation for possible open reduction and internal fixation (ORIF) D. CT scan of the elbow E. Splinting and hospital admission for neurovascular checks

C. Orthopedic consultation for possible open reduction and internal fixation (ORIF)

A 46 year old male presents with acute onset frontal and bitemporal headache, associated with neck pain and sensitivity to bright lights. In the emergency department, the patient is febrile, reports several episodes of vomiting, and complains of worsening neck pain with head movement. A lumbar puncture is performed, the results of which are consistent with viral meningitis. A day later the patient complains of worsening headache. Which of the following is correct regarding this complication of lumbar puncture (LP)? A. A larger diameter needle decreases the incidence of post LP headache B. Lying supine for up to six hours will help prevent post LP headache C. Post LP headache is the most common complication of lumbar puncture D. Post LP headaches are typically unilateral and worse with supine position

C. Post LP headache is the most common complication of lumbar puncture The answer is C. A smaller-diameter needle (not larger) is associated with a lower incidence of post-puncture headache because it causes a smaller dural hole (A). Simple analgesics are commonly prescribed, but they have no apparent advantage over bedrest and fluid intake. Lying supine for up to six hours carries no advantage over getting up after the procedure in the prevention of post spinal headache (B). Post LP headaches are typically bilateral and worse when sitting up (D). They improve with the supine position. Treatment of post-LP headache commonly involves keeping the patient supine to maximize intracranial CSF volume, use of oral caffeine, and for severe long-lasting headaches, autologous blood patch. The blood patch involves injecting one's own blood at the LP site in order to form a clot around the meningeal puncture site to avoid further leakage.

Regarding the epidemiology of asthma in the United States, which of the following is true? A. Incidence is comparable for Caucasians and African-Americans B. Etiology is thought to be genetic, not environmental C. Prevalence increased in the 1980's, and then decreased in the 1990's D. More common in males than females in adult and pediatric populations

C. Prevalence increased in the 1980's, and then decreased in the 1990's The answer is C. Despite an increase in asthma prevalence in the United States, Canada, Great Britain and Australia in the 1980s, the 1990s saw a decrease in prevalence in these areas. Regarding gender, male children are more likely than female children to have asthma, however the reverse is true with adults. African-Americans have a higher prevalence of asthma than Caucasians. Migrants who relocate from an area of low asthma prevalence to an area of high asthma prevalence tend to have an increased prevalence of asthma suggesting a role for environmental factors in the development of asthma.

Regarding the diagnosis of pulmonary embolism (PE), which is correct. A. By 80 years of age, one out of four people will develop deep venous thrombosis B. Autospsy studies indicate that approximately 30% of patients who die in the hospital have undiagnosed PE C. Pulseless electrical activity in Emergency Department cardiac arrest victims is associated with PE in 33% D. One-year mortality of PE is 25% even with early diagnosis and treatment

C. Pulseless electrical activity in Emergency Department cardiac arrest victims is associated with PE in 33% Up to two-thirds of patients with PE have no symptoms of DVT. PE is also found in about half of patients who have DVT but who do not have symptoms of PE. Thus, the presence or absence of DVT or symptoms of DVT does not correlate well with the finding of PE. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 1210-1211.

Regarding the role of malignancy in the diagnosis of pulmonary embolism (PE): A. 25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years. B. Hematologic malignancies such as leukemia and have the highest incidence of venous thromboembolism C. Autopsy studies indicate that greater than 60% of patients who die of ovarian cancer have PE. D. The risk of PE is decreased in patients on chemotherapy

A. 25% of PE patients without identifiable risk factors are diagnosed with cancer within 2 years. Patients with esophageal and laryngeal cancer, as well as leukemia and lymphoma have a low incidence of PE, whereas those with ovarian or colon cancers are at higher risk for developing PE. Autopsy studies indicate that up to 30% of patients who die of ovarian cancer have PE. Chemotherapy increases the risk of developing PE. Development of PE without any identifiable risk factors warrants a search for an underlying malignancy. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 1215-1216.

Which of the following patients is the most likely to develop S. pneumoniae pneumonia? A. 64 year old man with type 2 diabetes B. 61 year old man with hypertension C. 65 year old woman with no past medical history D. 59 year old woman who is a cigarette smoker.

A. 64 year old man with type 2 diabetes Otitis media has not been associated with the development of S. pneumoniae pneumonia. The most common pathogen in community-acquired pneumonia, S. pneumoniae, is found in the nasopharynx of 40% of adults. Persons at risk for developing S. pneumoniae pneumonia include the elderly (>65), and those with a history of alcoholism, diabetes, cardiovascular disease, splenectomy, sickle cell disease, malignancy, and immunosuppressive disorders. Vaccination is recommended for all people at increased risk. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 987-989.

Parents bring in their 13 year old girl two hours after she ingested a large amount of Acetaminophen in suicide attempt. She tearfully refuses to drink the activated charcoal. Which of the following is TRUE regarding your ability to administer the charcoal? A. A nasogastric tube may be placed to facilitate treatment B. You cannot force her to take the charcoal C. You must get parental permission prior to treating her D. A court injunction is needed to force her to drink the charcoal

A. A nasogastric tube may be placed to facilitate treatment The answer is A. Charcoal aspiration does carry with it the risk of developing a severe pneumonitis. If necessary, an uncooperative or combative patient may need to be intubated in order to safely deliver the charcoal with the airway secured. Suicidal patients do not have the right to refuse care, and physicians may do what they need to do in an effort to save the patient. In emergencies, parental permission for treatment is unnecessary.

In a 70kg male DKA patient with serum glucose of 573 mg/dL, all of the following statements with regard to fluid and electrolyte imbalances are true EXCEPT: A. A normal magnesium level is reassuring and obviates the need for magnesium replacement. B. The patient is likely to be total body phosphorus depleted. C. Total body water deficit is approximately 5L. D. Serum sodium of 129 mEq represents dilutional hyponatremia and the corrected value is approximately 137 mEq. E. Despite a serum potassium level of 4.8 mEq, the patient is probably total body potassium depleted.

A. A normal magnesium level is reassuring and obviates the need for magnesium replacement. The answer is A. Patients with DKA are typically severely dehydrated with a total body water deficit of approximately 70-80 mL/kg, in addition to being total body depleted of potassium, magnesium, and phosphorous despite initially normal serum levels of these electrolytes.

A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at the emergency department in a cervical collar and on a backboard. His only complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his arms against gravity and there is decreased grip strength bilaterally. The remainder of his neurological exam is normal. What is the most appropriate management for this patient? A. Administration of IV steroids and ordering of cervical MRI B. Immediate neurosurgical decompression C. Flexion and extention radiographs to rule out ligamentous injury D. Discharge home with a hard cervical collar with neurosurgical follow-up E. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness

A. Administration of IV steroids and ordering of cervical MRI The answer is A. Central cord syndrome results from a hyperextension injury, typically in elderly patients with significant degenerative joint disease. The ligamentum flavum buckles into the cord, resulting in a contusion of the cord's central portion.

A patient presents within an hour after sustaining a laceration caused by a knife as depicted in the Figure. Which of the following regarding this patient/presentation is TRUE? [image shows small linear cut on hypothenar eminence] A. An ulnar nerve block would be a preferred method for wound anesthesia. B. The wound should be closed with a topical skin adhesive such as 2-octyl cyanoacrylate. C. Randomized clinical trials have established the importance of prophylactic antibiotics in patients such as this one. D. Since it is difficult to sufficiently irrigate the palm, the laceration should be left open. E. Vertical mattress sutures should be used for wound closure.

A. An ulnar nerve block would be a preferred method for wound anesthesia. The answer is A. An ulnar nerve block provides anesthesia and is likely less painful than direct injection into the wound (which is another reasonable approach to wound anesthesia). Vertical mattress sutures are not recommended for the palm, as this technique places deep structures at risk. Topical skin adhesives are best avoided in the palm, which is prone to sweating and thus increasing the possibility of resultant wound dehiscence. Though many would recommend use of prophylactic antibiotics in a patient with a sufficiently deep palmar laceration, no controlled trials address use of antibiotics in patients with this - or just about any other - type of laceration.

A 24 year old woman presents with difficulty breathing after eating Chinese food. Her vital signs are: T 97.9, HR 120, BP 80/40, RR 28, SPO2 86%. Her voice is hoarse and her lung auscultation reveals wheezes. She has no JVD. The patient's most likely diagnosis is: A. Anaphylactic shock B. Cardiogenic shock C. Spinal shock D. Pulmonary embolism E. Acute myocardial infarction

A. Anaphylactic shock The answer is A. The patient's respiratory symptoms, absence of JVD, and vital signs suggest anaphylaxis (distributive shock). The proximity of symptoms to ingestion of food also suggests an allergic reaction.

Which of the following is true regarding the treatment of acute asthma exacerbation in the Emergency Department? A. Anticholinergics by inhalation may be beneficial B. Intravenous albuterol may be indicated C. Heliox should only be used in the intubated patient. D. Intramuscular terbutaline is preferred over intravenous

A. Anticholinergics by inhalation may be beneficial The answer is A. Salmeterol is a long-acting beta2-selective adrenergic agonist that has no role in the treatment of an acute asthma exacerbation, but it is frequently preferred for outpatient asthma management due to its BID dosing schedule.

In dealing with the potential violent patient, the emergency physician should: A. Approach the patient in a calm, controlled and professional manner B. Assume that the strength of the doctor-patient relationship will ensure safety C. Deal with the patient in a isolated room to protect the patient's privacy D. Use a loud voice and threaten to call security if the patient becomes agitated

A. Approach the patient in a calm, controlled and professional manner Excessive eye contact may be interpreted as a sign of aggression (answer A). Emergency physicians are encouraged to maintain intermittent eye contact with the patient and to keep a professional and calm demeanor. Also a physician should never deal with an agitated or violent patient alone in an isolated room (answer D). Doors should always remain open and exits should never be blocked. Ample security should be close at hand before interviewing the patient (answer E). Finally, involved parties are encouraged to remove any personal effects (e.g. neckties, necklaces, earrings, etc.) that could be used as a weapon by the violent patient.

A 36 year old man is a restrained driver involved in a high speed MVA where his car is struck on the driver's side door with significant intrusion. His physical exam is significant for a large contusion on his left flank. His abdominal exam is benign and rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross hematuria. Which test is indicated to evaluate for the presence of urologic injury? A. CT abdomen / pelvis with IV and transurethral contrast B. Ultrasound of the bladder C. CT abdomen / pelvis without contrast D. Ultrasound of the kidneys E. CT abdomen / pelvis with IV contrast alone

A. CT abdomen / pelvis with IV and transurethral contrast

Esophageal foreign bodies: A. Can be treated with endoscopy B. Cannot be treated with medications C. Occur at the upper Esophageal Sphincter D. Require surgical treatment E. Commonly perforate

A. Can be treated with endoscopy

All of the following are true regarding chest compressions in the infant EXCEPT: A. Chest compressions should be initiated whenever an infant's heart rate is less than 60 bpm. B. An appropriate position for performing chest compressions is to encircle the chest with both hands and place the thumbs side by side on the sternum. C. Compressions should be performed at a rate of 90 per minute. D. Chest compressions should be accompanied by a ventilatory rate of 30 per minute. E. Correct depth of compressions is one-third the anteroposterior diameter of the chest.

A. Chest compressions should be initiated whenever an infant's heart rate is less than 60 bpm.

Regarding the pathogens involved in community-acquired pneumonia, which of the following is true? A. Co-infection with multiple bacteria, such as Chlamydia and Strep pneumoniae commonly occur B. Milder cases of community acquired pneumonia are frequently caused by Chlamydia C. Q fever, caused by Coxiella burnetii, may present as pneumonia, particularly in patients exposed to rabbits D. Etiologic agents for patients admitted to the ICU with pneumonia most commonly include Neisseria meningitidis and Strep pneumoniae

A. Co-infection with multiple bacteria, such as Chlamydia and Strep pneumoniae commonly occur The answer is A. Co-infection with multiple bacteria, such as Chlamydia and S. pneumoniae, is a well-recognized occurrence and should be sought out to ensure appropriate antibiotic coverage.

A 22 year old presents with chest pain and the following EKG: [image: Septal ST elevations] He reports no past medical history and no family history of medical problems. Which substance should you specifically question him about using? A. Cocaine B. Heroin C. Methamphetamine D. Ecstasy

A. Cocaine The answer is A. Cocaine toxicity can cause a variety of cardiovascular sequelae including: cardiac dysrhythmias, coronary artery vasospasm, myocardial ischemia/infarction, and aortic dissection. The central nervous system is also commonly involved with seizures, intracranial hemorrhages/infarctions and hypertensive encephalopathy being common. Mesenteric ischemia can occur as well as rhabdomyolysis.

A 4 year old girl is brought to the ED two hours after being stung by a scorpion while on a camping trip in Arizona. She has periods of agitation and restlessness alternating with calmness. Her vital signs are: blood pressure 106/61, pulse 120, respiratory rate 24, temperature 37.0C, and oxygen saturations of 99% on room air. On physical examination you note drooling, a disconjugate gaze, and occasional jerking movements of the extremities. Which of the following is the most correct regarding the treatment of a scorpion sting in this child? A. Complications of treatment with antivenom include delayed serum sickness B. Treatment with antivemon is not indicated because these symptoms will be self-limiting C. The patient should be intubated because respiratory failure is expected D. Analgesics have a minimal role in controlling symptoms

A. Complications of treatment with antivenom include delayed serum sickness The answer is A. Most scorpion envenomations are mild, limited to pain and paresthesias at the site of envenomation. Children are affected more severely than adults: restlessness, jerking movements of the limbs, roving eye movements, and drooling are seen in severe cases. Anaphylaxis can also occur. Intubation is required rarely. Most envenomations require analgesics only; antivenom is indicated for severe reactions and anaphylaxis. Antivenom treatment is not without complications - serum sickness, and immediate and delayed hypersensitivity reactions occur. Without antivenom treatment, symptoms usually last for 1-2 days

A 29 year old woman is found seizing by her husband and is rushed to the emergency department. On presentation, she is noted to have a BP of 162/112, is still seizing, and looks puffy all over. Her husband tells you that they are expecting their first child in a few months. Which of the following is the next best step in this patient's care? A. Control the seizures with magnesium sulfate. B. Draw blood to check CBC, LFT's, BUN, and creatinine. C. Notify the labor floor that the patient is in the emergency department. D. Perform a CT scan of head if seizures persist. E. Start hydralazine to decrease the patient's blood pressure.

A. Control the seizures with magnesium sulfate. Antihypertensive therapy is only indicated in eclampsia if the diastolic blood pressure remains > 110 mm Hg after seizures are controlled because rapid lowering of blood pressure can result in uterine hypoperfusion. All the other choices (A-D) are appropriate in the management of the patient with eclampsia.

The rate at which a topical medication absorbs into the skin is determined in large part by the "vehicle," or medication base. Which of the following is true regarding medication bases? A. Creams are a mixture of oils, water and preservatives and are best used for acute rather than chronic conditions. B. Ointments are greaseless mixtures of propylene glycol and are contraindicated for dry lesions. C. Bases containing alcohol are best for dry scaly conditions or denuded areas. D. Alcohol-free bases are best for exudative lesions such as poison ivy dermatitis. E. Gels are composed of petroleum jelly and do not contain water.

A. Creams are a mixture of oils, water and preservatives and are best used for acute rather than chronic conditions.

All of the following are reasonable fluids for resuscitation of hypovolemia EXCEPT: A. D5W B. Blood C. Albumin D. Normal saline E. Lactated Ringer's

A. D5W The answer is A. The goal of IV resuscitation is to restore intravascular volume. Fluids that are isotonic are preferred. D5W is hyptonic, and therefore a poor choice for volume resuscitation.

Which of the following is a common physiologic finding in septic shock? A. Decreased urine output B. Increased pulmonary wedge pressure C. Increased cardiac index D. Increased systemic vascular resistance (SVR) E. Normothermia

A. Decreased urine output The answer is A. Patients in septic shock have decreased systemic vascular resistance and cardiac index, secondary to endotoxins. They can be hyper- or hypothermic but usually are not normothermic. The pulmonary wedge pressure is often normal or low. Like all shock states, septic shock is generally associated with decreased urine output.

In differentiating high voltage electrical injury from lightning injury, which of the following is your best discriminator? A. Deep burns B. Fractures or dislocations C. Loss of consciousness D. Cardiac arrest

A. Deep burns The answer is A. Patients with high voltage injury commonly present with devastating burns. The burns are most severe at the source and ground contact points. The most common sites of contact with the source include the hands and the skull. The most common areas of ground contact are the heels. Deep burns occur in less than 5% of lightning injuries. Electrical injuries may cause four types of superficial burns or skin changes: linear burns, punctate burns, feathering, or thermal burns. Loss of consciousness, cardiac arrest and orthopedic injuries can be seen in both high voltage electrical injury and lightning injury. Electrolyte abnormalities are not common in either injury.

A 58 year old male presents to the ED with syncope and back pain. He states that the pain has been excruciating for one day, and associated with dizziness. His other medical problems include CAD, HTN, hypercholesterolemia, and gout. On exam, you note that he is orthostatic, with a standing BP of 80/58, pulse 121. His abdominal and back exam is limited by obesity, but he has no apparent tenderness to palpation over either location. Which of the following is the most likely location of the patient's lesion? A. Descending aorta B. L3 vertebral body C. Kidney D. Appendix

A. Descending aorta

A 65-year-old female presents 2 weeks after an MI complaining of chest pain, fever, and shortness of breath. She has a new friction rub on exam and a leukocytosis. She most likely has: A. Dressler's syndrome B. congestive heart failure C. new myocardial infarction D. pneumonia E. pulmonary embolism

A. Dressler's syndrome The answer is A. Dressler's syndrome is fever, pleuritis, leukocytosis, pericardial friction rub, and evidence of pericarditis or pleural effusion occurring several weeks after MI. It is thought to be autoimmune in nature and is treated with NSAIDs.

A 58-year-old male previously in good health presents with chest pain for two hours. Vital signs are BP 126/78, HR 80 (sinus rhythm), RR 14, oxygen saturation 99%, T 36.8. His EKG shows ST segment elevation in leads II, III, aVF and V1. ST-segment elevation is greater in lead III than in lead II. What additional diagnostic test is indicated prior to giving nitroglycerin? A. EKG with right-sided leads B. CXR C. d-dimer D. Echocardiogram

A. EKG with right-sided leads The answer is A. "Nitrate-induced hypotension is also suggestive of right ventricular infarction, and of tamponade. Initial therapy for both would include volume loading and avoidance of vasodilators or other agents that may lower the blood pressure." "ST segment elevation in lead V1 in the setting of inferior MI (i.e., ST segment elevation in leads II, III, and aVF rather than in the setting of concomitant ST segment elevation in all anterior precordial leads) is suggestive of right ventricular infarction." "ST segment elevation is usually greater in lead III than in lead II when right ventricular infarction coexists with inferior AMI." "Application of "right-sided" precordial leads is the best means to diagnose right ventricular infarction with the ECG. These leads, as a mirror image of the left precordial leads, demonstrate ST segment elevation with right ventricular infarction in leads V3R to V6R, with V4R having the highest sensitivity."

A 27 year old male presents to the emergency department with 12 hours of worsening abdominal pain, associated with 1 episode of nausea and non-bloody non-bilious vomiting as well as a slight fever. Initially the pain was centered around the umbilicus and the patient attributed it to the take-out food he ate last night. Now the pain has migrated to his lower right abdomen and become more severe. What is the best description of the pathophysiology of this disease process? A. Elevated appendiceal intraluminal pressure results initially from luminal obstruction and continued secretion from luminal mucosa B. About fifty percent of patients with appendicitis present atypically C. Innervation of the parietal peritoneum is responsible for the periumbilical pain that is present early in the disease process D. Pregnant patients with appendicitis are more likely to present with right upper quadrant pain than right lower quadrant pain once they are in the third trimester

A. Elevated appendiceal intraluminal pressure results initially from luminal obstruction and continued secretion from luminal mucosa

A 28 year old patient arrives after helicopter transfer from an outlying center, where he had been intubated for altered mental status after significant alcohol intoxication. There were no reported signs of chest trauma, but the patient now has decreased breath sounds on the left. His vital signs are stable. Based upon the chest X-ray in the figure, what is the next step in management of this patient? [image tube can be followed into r lung] A. Endotracheal tube adjustment B. Nasogastric tube placement C. Needle decompression D. Chest tube placement

A. Endotracheal tube adjustment The answer is A. The patient has a right-mainstem intubation and resultant opacification of the left lung secondary to unilateral lack of ventilation. In an adult male, the ETT should generally be inserted to a depth (to the lip line) of 22-24cm; the corresponding depth range for an adult female is 21-23cm.

Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. Esophageal perforation and mediastinitis B. Epiglottal edema and airway obstruction C. The rapid development of xerostomia D. Barrett's esophagitis

A. Esophageal perforation and mediastinitis The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation.

You are performing procedural sedation on a 42 year old male who is quite muscular and requires high doses of analgesia to reduce a dislocated hip sustained during an MVA. He begins to show signs of respiratory depression and needs manual ventilation with a bag valve mask. You are having great difficulty providing manual ventilations due to presumed spasm of the glottis and rigidity of the chest wall musculature. Which of the following analgesics was likely used? A. Fentanyl B. Dilaudid C. Demerol D. Morphine

A. Fentanyl The answer is A. This patient is exhibiting clinical signs of chest wall rigidity and glottic spasm, which is a rare but classic side effect of using high doses of intravenous fentanyl. Chest wall rigidity and glottic spasm, which may make ventilation difficult, are unique complications seen with very high doses of fentanyl given rapidly (generally > 15 mcg/kg). It has been observed at lower doses. This may not reliably be antagonized by naloxone and may require neuromuscular blockade and intubation to enable adequate ventilation. This complication is very rarely reported with the dosages of fentanyl used for PSA but can still happen.

A patient falls onto his face, and has a CT scan of the face as shown in the Figure. Which indirect finding suggestive of possible facial fracture is present on the CT? [image] A. Fluid (blood) in the sinuses B. Nasal fracture C. Exopthalmos D. Extra-sinus air

A. Fluid (blood) in the sinuses The answer is A. Blood in the sinuses can be a useful indirect indicator of facial fracture.

A 21-year-old woman presents to the emergency department with fevers, headache, neck stiffness, and mild confusion over the past several days. Her temperature is 38.0 C (100.4 F), pulse 106, and blood pressure 116/74. On physical exam she looks ill, and her neck is stiff. Her neurologic exam is normal. A lumbar puncture reveals 105 WBC and 1240 RBC in tube #1 and 126 WBC and 1360 RBC in tube #4; all white cells are lymphocytes. The CSF protein is 68 and the glucose is 78. This patient most likely has which of the following? A. HSV encephalitis B. Pneumococcal meningitis C. Subarachnoid hemorrhage D. Subdural hematoma

A. HSV encephalitis

An 80 year old female presents to the ED with mental status changes after her neighbors found her this morning wandering in the stairwell. Patient was last seen normal 4 days ago and has no medical problems. On arrival to the ED, she is agitated and confused. Vital signs include RR of 20, HR of 100, BP of 90/50, and temperature of 40.6 Celsius. Pt is oriented to person only and is inattentive to exam, but appears to move all extremities symmetrically. She does not follow commands. Mucous membranes are dry and skin is dry and hot. What is the most likely diagnosis? A. Heat stroke B. Thyroid storm C. Serotonin syndrome D. Encephalitis

A. Heat stroke The answer is A. Heat stroke is a life-threatening illness defined clinically as a core body temperature that rises above 40.5 degrees Celsius and is usually accompanied by hot, dry skin (though in some cases sweating may be present) and central nervous system abnormalities such as delirium, convulsions, and coma. Treatment goals include lowering the core temperature to < 39.4 degrees Celsius by promoting cooling through conduction and evaporation and treating the complications that might arise with heat stroke, including seizures, respiratory failure, hypotension, rhabdomyolysis, and multi-organ dysfunction syndrome. Acute anticholinergic toxicity may sometimes present with a picture like that of heat stroke, and although the answer options C, D, and E may lead to confused behavior and/or fever in an elderly individual, the constellation of symptoms seen in this woman is most suggestive of heat stroke.

With regard to specific causes of hypertension, which of the following is true? A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible to reduce the risks of worsening neurological deficit D. Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients

A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose mental status changes are reversible Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over hours; however, encephalopathy due to hypertension is more likely reversible than encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is particularly critical for patients with strokes. Laboratory analysis can be important in cases of hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses such as the HELLP syndrome).

All of the following are true regarding the epidemiology of hypothyroidism EXCEPT: A. Hypothyroidism does not occur in infants under six months of age. B. Most cases of hypothyroidism manifest in the winter months. C. Approximately half of myxedema cases are diagnosed after admission to the hospital. D. Hypothyroidism occurs three to ten times more frequently in women than men. E. Peak incidence of hypothyroidism is in the seventh decade.

A. Hypothyroidism does not occur in infants under six months of age. The answer is A. Hypothyroidism may occur at any age including the very young, but is infrequently seen in infants due to regular newborn screening for hypothyroidism. The increased frequency of the disease in women is attributed to the increased prevalence of autoimmune thyroid conditions in women. The majority of cases present in winter months due to the body's decreased ability to accommodate to cold weather in a hypothyroid state.

A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally. The entrance wound is just above the right breast and an exit wound is noted in the right axilla. What is the most appropriate management of this patient? A. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable B. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to search for cardiac or pulmonary vascular injury C. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac or pulmonary vascular injury D. IV access, portable chest X-ray, right chest tube placement if X-ray shows a pneumo- or hemothorax, admission to the ICU for observation E. IV access, endotracheal intubation, CT scan of chest to look for pneumo- or hemothorax, or injuries to the heart or great vessels

A. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable

A 27 year old female presents to the ED with a chief complaint of headache. You determine that the patient is febrile, somnolent, and will only moan the words "my head'. Vital signs are as follows: BP 110/70, HR 110, RR 25, SpO2 97%, Oral temp 103.0 °F. Exam is remarkable for stigmata of IV drug abuse, cachexia, and prominent nuchal rigidity. No papilledema, focal neurological deficits, or trauma sequelae are observed. Which of the following is the most appropriate next step in management? A. IV ceftriaxone and vancomycin B. cervical spine immobilization C. lumbar puncture D. non-contrast head CT

A. IV ceftriaxone and vancomycin

An elderly female presents to the emergency department with vomiting and abdominal pain. She has a history of a cholecystectomy about 5 years ago. On exam, she is significantly uncomfortable and nauseated. Lung and cardiovascular exam is normal. Abdominal exam shows diffuse tenderness, some distention with tympany, and an empty rectal vault. Vital signs are: HR 102 BP 145/86 RR 24 SpO2 96% RA Temp 99.9F. You order an acute abdominal series, which is read by the radiologist as "nonspecific bowel gas pattern, no perforation." What is your management plan? A. IV fluids, pain medication, CT abdomen B. IV fluids, pain medication, consult vascular surgery C. IV fluids, pain medication, discharge if improved D. IV fluids, pain medication, consult vascular surgery for serial exams

A. IV fluids, pain medication, CT abdomen

A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries? A. Inferior orbital wall fracture B. Superior orbital rim fracture C. Ethmoid fracture D. Zygomatic arch fracture E. Inferior orbital rim fracture

A. Inferior orbital wall fracture The patient most likely has an orbital floor fracture with entrapment.

A 20 year-old man presents to the Emergency Department with right-sided chest pain and dyspnea. His symptoms started while walking his dog five hours ago. He describes the pain as sharp, pleuritic, and diffuse throughout his right chest. He has a history of asthma for which he takes albuterol as needed. He took four puffs of his inhaler today without relief. He has no surgical history, and reports occasional cigarette and alcohol use. He denies trauma. On exam, he appears uncomfortable. He has a heart rate of 105 beats/minute, a blood pressure of 145/85, a respiratory rate of 22 breaths/minute, a temperature of 98.9 degrees Fahrenheit and a pulse oximeter reading of 93% on room air. He has decreased breath sounds heard over his right chest. A triage chest x-ray is shown. What is the most appropriate next step in managing this patient? A. Insert a tube thoracostomy B. Administer empiric antibiotics C. Administer prednisone D. Perform a chest computed tomography (CT) angiogram

A. Insert a tube thoracostomy

A 45 year old male alcoholic presents to the ED with syncope and recent alcohol use. He denies any pain except for some "dark diarrhea", and feels anxious. He was told that he may have "liver problems" but has never followed up. His triage vital signs show a pulse of 128, RR 28, BP 88/52, Temp 98.8F. While you are presenting his history to the attending physician, a nurse calls you in because the patient is vomiting copious amounts of coffee-colored emesis mixed with bright blood. He is losing consciousness and acting confused. After the placement of 2 large bore IV's, Isotonic fluids are hung wide open, and blood is ordered. Which of the following is the most appropriate intervention? A. Intubation B. CT scan of abdomen/pelvis C. Sedation for endoscopy D. IR consult for TIPS procedure

A. Intubation

A 32 year old man is brought in by EMS after an acetylene torch exploded in his hands. He was not wearing a mask and his entire face, chest, arms and hands are blackened and blistering. All of the patient's hair in these areas has been burnt off. There are areas of skin missing from his hands and chest. He is awake and alert, crying out from pain. He is able to answer all questions appropriately. He demonstrates no stridor, lungs are clear to auscultation. Heart exam is significant for tachycardia. What is your immediate management? A. Intubation for airway management B. Antibiotic ointment to prevent infection C. Silvadine dressings to soothe and promote rapid healing D. Tepid, sterile water to cool and prevent ongoing burns

A. Intubation for airway management

Which of the following is true regarding the use of iodine in the treatment of thyroid storm? A. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given. B. Dexamethasone must be given 30 minutes prior to iodine administration. C. Iodine should be administered even in patients with known iodine allergy. D. Iodine should be the first drug administered in the treatment of thyroid storm. E. Iodine should be administered only after treatment with propranolol.

A. Iodine should be administered at least one hour after propylthiouracil (PTU) has been given. The answer is A. Iodine inhibits preformed thyroid hormone release and should be administered at least one hour after treatment with PTU to prevent organification of iodine. A typical dose is potassium iodide (SSKI) 5 drops every 6 hours PO or NG, or sodium iodide 1 gm slow IV drip every 8 to 12 hours. Iodine should not be administered to patients with known iodine allergy.

Which of the following statements regarding the topical ophthalmic anesthetic proparacaine is TRUE? A. It is an ester. B. It is cardiotoxic. C. It is often prescribed for home-going analgesia in patients with corneal pathology. D. It stains the tears orange. E. It is an amide.

A. It is an ester. It is an ester. It is important to ask all patients to whom you are considering administering a topical anesthetic about anesthetic allergy. Since proparacaine is an ester, it would be safe to use in patients with amide allergy history. It is not prescribed for home-going use, as it has been shown to slow the corneal healing process. Proparacaine drops are clear, not orange (fluorescein strips will stain tears orange). There are no systemic effects when used in appropriate dosages. -- For further reading, see Micromedex.

A 7 year old girl with severe asthma presents to the emergency department in severe respiratory distress. She clearly has difficulty breathing on her own and is obviously "tiring out." Her oxygen saturation is 85% and falling. The decision is made to intubate her. Of the following agents, which is often recommended (due to its bronchodilatory effects) as the induction agent of choice? A. Ketamine B. Etomidate C. Pentobarbital D. Midazolam

A. Ketamine The answer is A. Ketamine is a dissociative anesthetic and relaxes bronchial smooth muscle, either by blocking parasympathetic effects or by increasing sympathomimetic stimulation. This relaxation can decrease airway resistance within minutes of administration. While the clinical relevance of ketamine's bronchodilation is subject to debate, most major texts mention it as an agent of choice for intubation of patients with reactive airways disease. All of the other induction agents mentioned do not cause bronchodilation.

Regarding the development of cerebral edema in patients being treated for DKA, all of the following are true EXCEPT: A. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema. B. Patients with serum glucose below 250 mg/dL still being treated with insulin are most likely to develop clinically evident cerebral edema. C. Cerebral edema typically occurs six to ten hours following onset of treatment. D. Children have a higher incidence of cerebral edema. E. Mortality of patients developing cerebral edema is 90%.

A. Mannitol and steroids should be administered immediately to any patient suspected of developing cerebral edema. The answer is A. Steroids are not indicated for treatment of cerebral edema and may actually worsen DKA. Mannitol 0.25-2.0 mg/kg should be administered upon any change in mental status of children being treated for DKA as they are at high risk for developing cerebral edema especially when being treated with insulin and serum glucose is below 250 mg/dL.

56 year old male presents with sub-sternal chest pain for 4 hours with worsening shortness of breath for the last 2 hours. The patient's heart rate is 108 beats per minute, respiratory rate of 24 breaths per minute, and oxygenation saturation of 94% on room air. On physical examination, the patient appears dyspneic. On auscultation, he has a harsh II/VI systolic murmur with rales midway up bilateral lung fields. A bedside echocardiogram is done which shows papillary muscle rupture. Which valve's regurgitation is responsible for this patient's shortness of breath? A. Mitral valve B. Aortic valve C. Pulmonic valve D. Tricuspid valve

A. Mitral valve

A 75 year old female is brought the to emergency department by a family member with a history of progressive forgetfulness and confusion. She has a history of dementia. The most common cause of dementia in the elderly patient is: A. Alzheimer's disease B. Parkinson's disease C. Pick's disease D. Vascular dementia

A. Most dementia is Alzheimer's type. The second most common cause of dementia is vascular dementia, which accounts for 10 to 20% of all dementias. Primary degenerative dementias include Alzheimer's disease, vascular dementia, subcortical dementias involving the basal ganglia and thalamus (e.g., progressive supranuclear palsy, Huntington's chorea, Parkinson's disease), and Pick's disease, also known as dementia of the frontal lobe type. Smaller percentages are attributable to causes such as anoxic encephalopathy, hepatolenticular degeneration, tumors, and slow virus infections.

Which of the following descriptors of epidural hematoma is FALSE? A. Most often a result of a skull fracture that traverses a venous sinus B. Classically associated with a "lucid" interval prior to coma C. Present in only about 1% of severe head injury patients D. Immediate surgical evacuation is indicated E. Biconcave blood collection between the skull and dura

A. Most often a result of a skull fracture that traverses a venous sinus The answer is A. Epidural hemorrhage is most often associated with skull fracture across the course of the middle meningeal artery.

A 19 year old presents with bizarre behavior and a friend admits to use of PCP. What ocular findings would you expect? A. Nystagmus B. Monocular diplopia C. Mydriasis D. Afferent pupillary defect

A. Nystagmus The answer is A. A patient with classic PCP intoxication presents with dramatic multidirectional nystagmus, hypertension, and bizarre behavior.

The clinical presentation of clonidine toxicity most closely mimics toxicity from which of the following classes of medication? A. Opioids B. Beta blockers C. Cholinergics D. Stimulants

A. Opioids The answer is A. The hallmark signs and symptoms of clonidine toxicity include: hypotension, bradycardia, mental status change, respiratory depression, and miosis. The presentation very closely mimics opioid toxicity.

A 24 year old female gardener presents to the emergency department with foot pain 30 minutes after working barefoot in her garden. She saw a scorpion in the area. Which of the following signs or symptoms are most expected? A. Pain and paresthesias B. Local erythema and swelling C. Cranial nerve abnormalities D. Puncture mark

A. Pain and paresthesias The answer is A. Although there are many toxic species of scorpions in the world, and all can sting humans, only a few cause serious toxicity. In the United States, only Centruroides exilicauda is capable of causing systemic toxicity. The sting is followed immediately by localized pain and paresthesias, and these can progress to involve the entire extremity or body. Systemic symptoms are unusual in adults, but more common and severe in children. Evidence of a sting, such as a puncture wound is almost never seen on exam. The mainstay of treatment is analgesia. Although antivenom is very effective in alleviating symptoms, both immediate and delayed allergic reactions occur with its use. Routine use of antivenom is not indicated, as most symptoms usually resolve in 1-2 days.

Regarding the diagnosis and treatment of thyroid storm in the emergency department, which of the following is true? A. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease. B. Thyroid storm cannot be diagnosed in the absence of altered mental status. C. The diagnosis of thyroid storm is generally a straightforward clinical diagnosis and rarely confused clinically with other disorders such as psychiatric or other endocrine disorders. D. A stat thyroid-stimulating hormone (TSH) level is required to make the diagnosis. E. Treatment of thyroid storm should only be undertaken after consultation with an endocrinologist.

A. Patients suspected of having thyroid storm should undergo treatment prior to a definitive diagnosis due to the potentially life-threatening nature of this disease. The answer is A. The diagnosis of thyroid storm in the emergency department may be challenging due to the relatively infrequent occurrence of the disease and its typically nonspecific signs and symptoms. Treatment should be initiated in a timely fashion in any patient suspected of having thyroid storm due to the potential lethality of this disease. Immediate laboratory testing is typically not available to confirm clinically suspected cases, although thyroxine (T4) radioimmunoassay and free T4 index are good screening tests for hyperthyroidism. Clinical presentation of thyroid storm may be mistaken for psychiatric illness, heat stroke, sympathomimetic toxidromes, hypoglycemia and withdrawal syndromes, among others. Altered mental status, though frequently present, is not a prerequisite for diagnosis.

Suicide risk is increased in this patient population: A. Patients who are elderly and Caucasian B. Patients who have not been involuntarily committed C. Patients who directly questioned about suicide D. Patient who takes lithium for bipolar affective disorder

A. Patients who are elderly and Caucasian The answer is A.

A 36 year old woman presents to the emergency department two hours after the sudden onset of a severe occipital headache and nausea. She has a history of migraine headaches that typically occur in the right frontal area and are associated with an aura. Her temperature is 98.8 degrees Fahrenheit, her neck is supple, and her neurological exam is normal. A non-contrast CT scan of her head is normal. Of the options below, what is the next step in her management? A. Perform a lumbar puncture to rule out the possibility of subarachnoid hemorrhage. B. Observe for 6 hours, administer acetaminophen and normal saline, and discharge home if she feels better. C. Consult a neurologist for evaluation of atypical migraines. D. Observe for 6 hours and then obtain a repeat CT scan; if normal, discharge home. E. Discharge her home with prochlorperazine and close instructions to return if her symptoms worsen.

A. Perform a lumbar puncture to rule out the possibility of subarachnoid hemorrhage. The answer is A. Sudden onset headache with nausea, vomiting, photophobia, or neck stiffness should raise the concern for spontaneous subarachnoid hemorrhage. Sensitivity of a non-contrast CT scan varies with respect to many factors (e.g. time since bleed) but is generally in the range of 90%; therefore, if the clinical suspicion is high, a lumbar puncture should be performed and a cell count for red blood cells done.

A 67 year old man with a history of peptic ulcer disease presents to the emergency department complaining of feeling light-headed. On ROS he acknowledges having had black tarry stools for the past 2-3 days. On exam he is noted to be pale with the following vital signs: T 97.3 F, HR 126, BP 92/64, RR 22, and melena is noted on rectal exam. Which of the following is an INCORRECT recommendation regarding the initial management of this patient? A. Place two intravenous lines that are 22-gauge. B. Place the patient on cardiac and oxygen saturation monitors. C. Apply supplemental oxygen. D. Administer normal saline intravenously in 10mg/kg boluses. E. Type and cross two units of packed red blood cells.

A. Place two intravenous lines that are 22-gauge. The answer is A. The patient is having gastrointestinal bleeding most likely from a peptic ulcer given his history. Urgent first steps in management include placement of two intravenous lines that are larger-bore than 22-gauge (18 gauge or larger size preferred) to enable rapid volume resuscitation, in addition to the oxygen, monitoring, intravenous fluids and preparation of blood products. Patients with an upper GI bleed who remain hemodynamically unstable require urgent consultation with gastroenterology.

Which of the following is true regarding topical corticosteroid use? A. Potency is measured by the ability to induce vasoconstriction. B. To achieve large differences in potency, it is more effective to vary the dose of a particular steroid than to change the type of steroid. C. Once initiating topical steroids, it is best to maintain the same application schedule without interruption until the symptoms no longer remain. D. Hydrocortisone is the preferred agent for areas of the body characterized by thickened skin (e.g. palms and soles). E. Fluorinated steroids should be used in pregnant woman.

A. Potency is measured by the ability to induce vasoconstriction. The answer is A. Corticosteroids are classified into seven groups. (I is the strongest; VII, the weakest). Each steroid's ability to cause vasoconstriction determines classification. To achieve large differences in potency, it is better to switch agents, as varying the dose of a particular agent does not affect potency as much. In general, vascoconstriction in response to corticosteroid use has been shown to decrease over time, a process known as tachyphylaxis. Therefore, interrupted application schedules are preferred (application for 2 weeks, then 1 week without application). Hydrocortisone is a relatively low potency steroid and does not adequately penetrate thickened parts of the skin such as the sole or palm. Fluorinated steroids are to be avoided in pregnant women.

All of the following are common complications of septic shock EXCEPT: A. Pulmonary embolus (PE) B. Acute tubular necrosis (ATN) C. High-output congestive heart failure (CHF) D. Disseminated intravascular coagulation (DIC) E. Adult respiratory distress syndrome (ARDS)

A. Pulmonary embolus (PE) DIC, ARDS, ATN, and high-output CHF are all complications of shock. While PE is always a concern in critically ill patients, it is not particularly associated with sepsis.

With respect to laboratory findings in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC), all of the following guidelines are generally true EXCEPT: A. Serum bicarbonate is typically severely low (<10mEq) in patients with either DKA or HHNC. B. Serum osmolality in patients with HHNC is typically > 350 mOsm/L. C. BUN is elevated more in patients with HHNC (>50 mg/dL) than in patients with DKA (25-50 mg/dL). D. Patients with HHNC typically have blood glucose > 700 mg/dL, whereas patients with DKA have blood glucose > 350 mg/dL. E. Serum ketones are present in patients with DKA but not usually in patients with HHNC.

A. Serum bicarbonate is typically severely low (<10mEq) in patients with either DKA or HHNC. The answer is A. Although patients with DKA typically have profound metabolic acidosis with serum bicarbonate < 10mEq, acidosis is typically absent in patients with HHNC and serum bicarbonate is usually > 15 mEq.

Once aortic dissection is suspected the physician should plan for early cardiothoracic surgery consultation; additionally, which of the following is the best next step? A. Start IV beta blocker to decrease shearing forces on the aorta and IV sodium nitroprusside to lower blood pressure. B. Order an MRI to characterize the dissection's anatomy. C. Start IV nitroglycerin to lower blood pressure and give aspirin to inhibit platelets. D. Start IV nitroglycerin to lower blood pressure and IV beta blocker to decrease shearing forces on the aorta. E. Start IV sodium nitroprusside to decrease shearing forces on the aorta.

A. Start IV beta blocker to decrease shearing forces on the aorta and IV sodium nitroprusside to lower blood pressure. The answer is A. When a patient has an aortic dissection, it is important to decrease further dissection (i.e. extension of the vascular tear) by reducing shearing forces on the aorta using negative inotropes (beta blockers) and to control hypertension. Sodium nitroprusside is often used for blood pressure control in dissections as it is an easily titratable antihypertensive. Because sodium nitroprusside increases heart rate and may increase shearing forces, a beta blocker should be started before (or concurrently with) it. The effects of nitroglycerin are not easily titratable, making it a less desirable drug for blood pressure control. Aspirin should be avoided, as it may increase bleeding complications. Morphine may be used for pain control and to decrease sympathetic tone. Imaging decisions surrounding aortic dissection are complex, incorporating such factors as patient safety (e.g. transport to imaging areas, administration of dye loads) and need for assessment of nonaortic structures (e.g. pericardial space) and functional anatomy (e.g. valvular regurgitation). As a general rule, MRI is not emergently available and lacks sufficient monitoring capabilities for a patient with suspected acute aortic dissection (MRI is useful for long-term, outpatient monitoring of dissection in most centers).

All patients with shock should receive as the first priority: A. Supplemental oxygen B. Packed red blood cells C. Trendelenburg positioning D. Antibiotics E. Intravenous fluids

A. Supplemental oxygen The answer is A. The fundamental issue in shock is tissue hypoperfusion and hypoxia. All patients in shock should receive supplemental oxygen initially. Steps to improve oxygenation range from nasal cannula to endotracheal intubation.

A 28-year-old man with severe peptic ulcer disease presents with rapid onset of severe central abdominal pain that radiates to the back. He was too ill to sit up thus a left lateral decubitus abdominal xray was performed which showed intra abdominal air above the liver. He received 2 large bore lines, IV fluid resuscitation, appropriate laboratory studies and antibiotics. The next best management step should be: A. Surgical consultation B. Interventional radiology for percutaneous drainage C. Medical Intensive Care Unit admission D. CT scan abdomen with IV contrast only

A. Surgical consultation

A patient presents with itching and swelling in the leg, which is depicted in the Figure, which shows both the posterior thigh and an insect removed from the thigh. Which of the following is true regarding this patient's management? [image tic] A. There is a vaccine available for U.S. use, which is active against a disease transmitted by this insect B. To be exposed to this insect, the patient probably has traveled out of the U.S. within the last month C. Use of forceps in an attempt to remove this insect is contraindicated D. This insect rarely transmits multiple diseases simultaneously

A. There is a vaccine available for U.S. use, which is active against a disease transmitted by this insect This patient had an engorged tick (identified as an Ixodes, or deer tick, by the hospital's pathology department) on the leg. The Lyme disease vaccine, though not yet widely utilized, is available for administration. Removal of ticks is a topic that's often discussed, with varying approaches put forth, but there is in fact little evidence-based support for most removal techniques. One widely referenced procedures book (Roberts and Hedges' Clinical Procedures in Emergency Medicine, 3rd edition, pages 631-632) contends that no technique is better than simple mechanical removal of the tick with forceps. Likelihoods of various tick-borne disease possibilities vary with geographic locale, and thus indications for prophylactic antibiotics also tend to vary. However, it is not uncommon for ticks to simultaneously transmit more than one disease (e.g. Lyme disease and babesiosis).

Which of the following cervical spine fractures is considered stable? A. Transverse process fracture B. Flexion teardrop fracture C. Bilateral facet dislocation D. Hangman's fracture of C2 E. Jefferson fracture of C1

A. Transverse process fracture The answer is A. A transverse process fracture involves only one of the supporting spinal columns (the posterior column) and is therefore stable.

All of the following are common non-infectious causes of fever EXCEPT: A. Trauma B. Thyroid storm C. Pulmonary embolism D. Neuroleptic malignant syndrome E. CVA

A. Trauma There are many non-infectious causes of fever. PE, CVA, thyroid storm and NMS are all classic non-infectious causes. Trauma generally does not cause fever. Hypothermia (environmental) tends to be of more concern.

A 71-year-old male presents after a syncopal episode. He reports 12 hours of recurrent substernal chest pressure. A report from the patient's primary care physician's office states that an EKG performed four days ago was completely normal. Repeat EKG in the ED reveals no ST-segment elevation, but you do note a right bundle-branch block, and a left anterior fascicle block. Troponin I is elevated above normal at 1.6. What intervention would be indicated to provide definitive management for the findings seen on EKG in this patient? A. Urgent placement of a cardiac pacemaker B. Continuous cardiac monitoring for 24-48 hours C. Emergent revascularization with thrombolytics or percutaneous coronary intervention (PCI) D. Radiofrequency ablation

A. Urgent placement of a cardiac pacemaker The answer is A. "In the face of an AMI, the risks of complete heart block are much greater when new or preexisting bi- or trifascicular conduction blocks are present. In this setting, prophylactic placement of a ventricular demand pacemaker is indicated."

Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT: A. Vital signs are usually abnormal, even early in the course of acute appendicitis. B. Rebound is usually elicited only after the appendix has ruptured or infarcted. C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left lower quadrant. D. The obturator sign is pain upon flexion and internal rotation of the hip. E. The psoas sign is pain upon extension of the hip.

A. Vital signs are usually abnormal, even early in the course of acute appendicitis. The answer is A. The presentation of acute appendicitis varies tremendously. Early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. Other variations in presentation include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.

A 23-year-old male presents after a syncopal episode. EKG findings include normal sinus rhythm, a short PR interval (less than 0.12 seconds), QRS duration of 0.11 seconds, and the presence of a "delta wave" (a slurred upstroke to the QRS complex). What condition most likely caused the syncopal episode? A. Wolff-Parkinson-White syndrome B. Dextrocardia C. Vasovagal reaction D. Brugada syndrome

A. Wolff-Parkinson-White syndrome T"The classic WPW syndrome consists of tachycardia with the following three features: a short P-R interval (<0.12 second), QRS duration greater than 0.10 second, a slurred upstroke to the QRS complex, referred to as a delta wave."

Regarding mycobacterium tuberculosis (TB), which of the following is TRUE? A. Worldwide, TB causes more deaths than any other infectious agent B. In the United States, approximately 12-15% of the population is infected with TB. C. In the United States, the incidence of TB has been steadily increasing since the 1950s. D. Worldwide, approximately 45-50% of the population is infected with TB

A. Worldwide, TB causes more deaths than any other infectious agent TB causes more deaths worldwide than any other infectious agent. Approximately one-third of the world's population is infected with TB. In the United States, only about 4-6% of the population is infected with TB. The incidence of TB infection in the United States began decreasing in the 1950s as a result of advancements in public health and pharmacologic treatments. Yet, the incidence has been rising since the 1980s, especially in poor, homeless, minority, and prison populations. The incidence of multi-drug resistant TB has been gradually increasing, especially among AIDS patients. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, page 988.

A 65 year old male presents to the emergency department with palpitations. His heart rate is 250, blood pressure is 140/88, respiratory rate is 24 and oxygen saturation is 95%. The EKG shown in the Figure demonstrates: A. a rhythm which requires immediate defibrillation B. a rhythm requiring verapamil as first line therapy C. a rhythm that is difficult to identify with certainty

A. a rhythm which requires immediate defibrillation

A 44 year old woman presents complaining of the acute onset of left eye pain while walking into a movie theater one hour ago. On physical examination, she has stable vital signs. Her visual acuity is 20/25 on the right eye and 20/200 on the left eye. Her pupillary exam is notable for a minimally reactive dilated left pupil and a steamy cornea. The left eye is red and obviously painful. Which of the following conditions is most likely? A. acute angle closure glaucoma B. vitreous hemorrhage C. central retinal artery occlusion D. hypopyon E. optic neuritis

A. acute angle closure glaucoma

"Silent Suicide" is defined as: A. an act of slowly killing oneself by nonviolent means, such as starvation or non-compliance with essential medical treatment B. an attempted suicide C. suicide involving a number of willing and sometimes not so willing participants D. a self-destructive act disguised as an accident E. recurrent self-destructive acts, such as heavy drinking in the presence of alcoholic liver disease

A. an act of slowly killing oneself by nonviolent means, such as starvation or non-compliance with essential medical treatment The answer is A. "Silent Suicide" is most common in elderly patients and frequently goes unrecognized. Such patients may present to the emergency department repeatedly because of non-compliance with treatment of their medical disorders. "Occult Suicide" is applied to self-destructive acts disguised as accidents and should be suspected in those who have "accidental" self-inflicted gun shot wounds, and in those who "unintentionally" overdose, or who fall from a height. "Chronic Suicidal Behavior" consists of recurrent self-destructive acts. "Mass or Group Suicide" is suicide involving a number of people. "Parasuicide" is an attempted suicide, which is seen more as a gesture than a serious act.

The blood pressure at which malignant hypertension is defined as present is: A. an elevated arterial pressure associated with end organ damage B. an elevated arterial pressure that exceeds the patient's baseline by 33% C. diastolic blood pressure of 110 or greater D. systolic blood pressure of 170 or greater E. systolic blood pressure of 180 or greater

A. an elevated arterial pressure associated with end organ damage Acute end-organ damage associated with a hypertensive emergency (also known as malignant hypertension or hypertensive crisis) can include: hypertensive encephalopathy, intracerebral hemorrhage, hypertensive retinopathy, heart failure and associated pulmonary edema, acute coronary syndrome, acute renal failure, aortic dissection, and eclampsia.

The joint fluid from a patient's knee arthrocentesis shows 75,000 WBC with 75% PMNs, no organisms, no crystals and a glucose of 35. What does the patient need next? A. antibiotics for septic joint and admission for operation B. antibiotics and discharge home C. narcotic pain medicine and discharge home D. non-steroidal anti-inflammatory medicine for gout and discharge home E. treatment for gonorrhea and discharge home

A. antibiotics for septic joint and admission for operation The correct answer is A. The key to successful treatment of a septic joint is rapid diagnosis and treatment. Hospital admission for wash out of the joint and IV antibiotics are indicated for a septic joint. Antibiotics should be started based on gram stain or consideration of likely organisms and then adjusted based on final culture results.

Which of the following pairs of hypertension-associated disease and specific therapy represent reasonable therapeutic approaches? A. aortic dissection - nitroprusside/propranolol B. angina - phentolamine C. bilateral renal artery stenosis - captopril D. pheochromocytoma - hydrochlorothiazide E. pregnancy induced hypertension - furosemide

A. aortic dissection - nitroprusside/propranolol The answer is A. The specific utilization of various medications for the above-mentioned disease processes is subject to debate. For example, aortic dissection therapy generally includes nitroprusside and a beta-blocker, and labetalol is considered a reasonable drug of first choice for many hypertensive conditions. However, captopril is not safe in patients with renal artery stenosis. The problem with using captopril in these patients is that its mechanism of action incurs risk of renal failure in patients with some types of chronic renal disease including renal artery stenosis. Patients with pregnancy induced hypertension have a decreased intravascular volume, despite the edema, and pheochromocytoma is treated with phentolamine.

Which of the ocular findings below is associated with hypertension? A. arterio-venous nicking B. increased cup-to-disk ratio C. retinal nevus D. Roth spots E. cherry red spot

A. arterio-venous nicking Increased cup-to-disk ratio is seen commonly in patients with glaucoma, but this finding is not associated with acute or chronic hypertension. Systemic hypertension can affect the retinal, choroidal, and optic nerve circulations, with the degree of vascular change depending on the severity and duration of the hypertension. Linear or flame-shaped hemorrhages and cotton-wool patches (caused by infarction of the nerve fiber layer resulting from arteriolar occlusion) are relatively common. Long-standing hypertension can produce sclerotic changes in the vessel walls; this is manifest as a copper or silver discoloration of the arterioles. Lipid (hard) exudates result from abnormal vascular permeability associated with hypertension. Optic disk edema, indicating infarction and hypoxia of the optic disk, is a hallmark of malignant hypertension.

A 35 year old male presents with right knee swelling redness and pain for 1 day. He has no medical problems. He has had no injury to his knee. His oral temperature is 101.9 and he appears ill. What is the next course of action? A. arthrocentesis B. radiograph of joint C. medication for presumed gout and discharge D. knee immobilizer E. none of the above

A. arthrocentesis

In a patient with a suspected ruptured globe from penetrating trauma to the eye, all of the following should be performed EXCEPT: A. ascertainment of intraocular pressure via tonometry B. administration of broad spectrum antibiotic therapy C. visual acuity assessment D. ascertainment of tetanus status E. ophthalmology consultation

A. ascertainment of intraocular pressure via tonometry The answer is A. Tonometry should not be performed in patients with suspected ruptured globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to exude from the eye, thereby complicating the injury. Tetanus status is important to check, as ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations in intraocular pressure associated with vomiting. Visual acuity assessment is important and ophthalmology consultation is critical.

A previously healthy 25 year old female arrives at the emergency department with 3 days of headache, nausea, palpitations, and diaphoresis. She initially presented 2 days ago to the hospital's walk-in clinic, where her blood pressure was found to be moderately elevated. At her clinic visit, the initial evaluation for end-organ damage was negative. In the emergency department, assessment of tests sent from the clinic visit is noteworthy for a normal TSH, normal head CT scan, and markedly elevated urine metanephrine levels. If this woman were to require emergency department therapy for hypertension, which of the following agents should be AVOIDED: A. beta-adrenergic receptor blocker B. alpha-adrenergic receptor blocker C. nitroprusside D. calcium channel blocker E. ACE-inhibitor

A. beta-adrenergic receptor blocker Elevated urinary metanephrines in this patient strongly suggest the diagnosis of pheochromocytoma. Initial control of her hypertension should be undertaken with an alpha-adrenergic receptor blockade, or alternatively nitroprusside, calcium channel blocking agents or ACE-inhibitors. Beta-adrenergic blockage should only be given AFTER alpha blockade, to avoid paradoxical increases in blood pressure due to antagonism of skeletal muscle vasodilation. While other agents listed may or may not be optimal for initial blood pressure control, the drug type with the strongest contraindication is the beta-blocker.

A 78 year old man presents with acute onset of painless, complete visual loss in the right eye. Which of the following best explains his symptoms? A. central retinal artery occlusion B. herpes keratitis C. iritis D. optic neuritis E. acute angle closure glaucoma

A. central retinal artery occlusion

A 25 year old man returns to the ED, 24 hours after being released from the hospital with a new diagnosis of schizophrenia. He has recently started to take haloperidal for his psychotic symptoms. In the ED he is noted to have involuntary contractions of the muscles of the face, a protruding tongue, deviation of the head to one side, and sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no electrolyte or hematological abnormalities. Of the following choices, the preferred medication for this condition is: A. diphenhydramine B. lorazepam C. phenobarbital D. metoprolol

A. diphenhydramine Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs in up to 5% of patients. Dystonic reactions, which can occur at any point during long-term therapy and up to 48 hours after administration of neuroleptics in the emergency department, involve the sudden onset of involuntary contraction of the muscles in the face, neck, or back. The patient may have protrusion of the tongue (buccolingual crisis), deviation of the head to one side (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and increasing under emotional stress, which occasionally misleads emergency physicians to believe they may be hysterical in nature. Dystonic reactions should be treated with *IM or IV benztropine (Cogentin®), 1 to 2 mg*, or *diphenhydramine (Benadryl®), 25 to 50 mg*. Intravenous administration usually results in near-immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms.

A 58 year old woman presents to the emergency department one day after her cat bit her index finger. Physical examination shows signs of flexor tenosynovitis. She is admitted to the hospital for IV antibiotics, hand elevation, and emergent hand surgery consultation to consider debridement of the finger. Which of the following would be least likely expected in a patient with flexor tenosynovitis? A. erythema of the flexor surface of the involved digit B. pain with passive extension C. tenderness over the flexor tendon sheath D. swelling of the finger

A. erythema of the flexor surface of the involved digit Other than swelling of the involved digit, there may be little external evidence of a deep space flexor tenosynovitis.

You need to treat an adult with no past medical history, who presents with a hypertensive emergency. You have access to all of the following agents. Which of the following is the preferred agent and initial dose? A. esmolol IV 100-500 mic/kg load B. hydralazine IM 0.1-0.2 mg/kg C. labetolol IV 0.2-1.0 mg/kg bolus D. metoprolol PO 10 mg E. clonidine PO 0.1 mg

A. esmolol IV 100-500 mic/kg load Hyptertensive emergencies require treatment with IV agents, primarily for their fast onset of action and ability to be titrated. One would generally not choose an oral agent, such as metoprolol or clonidine, if the other options were available.

A 20 year old college student is brought to the emergency department by campus police after he was found by his roommate saying people in the TV were trying to kill him. Which of the following criteria is not an indication for admission? A. first-time psychiatric episode B. demonstrates risk for suicide C. inadequate psychosocial support D. lacks capacity to cooperate with treatment

A. first-time psychiatric episode For an acute psychiatric episode, the first goal is medically stabilizing the patient. Subsequently, a patient who presents without previous history of a psychiatric episode does not necessarily need to be admitted. This, of course, depends on the identity and severity of the condition, and whether it can be treated in the emergency department.

A 42 year old former custodial worker presents stating, "I think that people can hear what I am thinking." In the emergency department, he becomes extremely agitated and threatening, and his psychoses become more severe. In choosing an antipsychotic medication, which of the following would be the most appropriate choice? A. haloperidol B. chlorpromazine C. thioridazine D. ketamine

A. haloperidol Haloperidol is the most studied high potency antipsychotic agent used in agitated patients. Typical dosing is *5-10 mg IM every 10-30 minutes*. Unlike thioridazine, haloperidol *does not cause respiratory depression*, has *negligible anticholinergic side effects*, and rarely causes hypotension. Although benzodiazepines can be used in the agitated patient, respiratory depression can occur, and close monitoring is essential.

Metabolic abnormalities often seen with hypothyroidism include all of thefollowing EXCEPT: A. hyperglycemia B. respiratory acidosis from hypoventilation C. anemia D. hyponatremia E. hypercholesterolemia

A. hyperglycemia The answer is A. Hyperglycemia is not typically associated with hypothyroidism. Hypoglycemia may be present, but is unusual, and may suggest hypothalamic-pituitary involvement. Hyponatremia is common and corrects with thyroid replacement. Hypercholesterolemia to over 250 mg/dL is typical. A mild normochromic, normocytic anemia may be present, in addition to respiratory acidosis from hypoventilation.

A 64 year old female presents to the emergency department with chief complaints of occipital headache and chest pain. Physical examination reveals a blood pressure of 200/118 as well as edema of the optic disk. Of the diagnoses below, the most likely is: A. hypertensive crisis B. acute hypertensive (non-emergency/non-urgency) episode C. hypertensive urgency D. moderate hypertension E. white-coat hypertension

A. hypertensive crisis The answer is A. Elevated blood pressure in the setting of optic disk edema is a hallmark of malignant hypertension (also known as hypertensive emergency or hypertensive crisis). While hypertensive urgency is not consistently defined in the medical literature, this patient's presentation indicates that there is some end-organ damage and thus the diagnosis is malignant hypertension. The "white-coat" syndrome, in which patients' blood pressures are elevated only in the clinical setting and not at home, has been shown to account for as many as a fifth of all cases of newly diagnosed "hypertension." Understanding of this phenomenom is important for emergency physicians, since its frequency explains why patients should not be given a diagnosis of new-onset hypertension based on E.D. measurements.

The patient depicted in the figure presents to the ED just after sustaining a pellet-gun wound to the right eye. What do the arrows most likely indicate? [image] A. hyphema B. iritis C. keratitis D. pterygium E. hypopion

A. hyphema The answer is A. The patient has a *fluid level/meniscus in the anterior chamber*, that is most likely indicative of hyphema (collection of blood). Hypopion (collection of purulent material) is less likely in this setting, and keratitis (corneal inflammation) and iritis (inflammation of the iris) are not indicated by the arrows. A pterygium is a growth which is visible on the sclera, and which crosses the limbus onto the cornea.

A 30-year old female, without past medical history, presents with "an ingrown hair" in her thigh, as depicted in the Figure. She is afebrile, nontoxic, and has no regional lymphadenopathy or lymphangitis. Examination reveals marked fluctuance and induration under the erythematous region of the thigh. Which of the following is the best course of therapy? [image] A. incision and drainage with a linear incision B. CT scan of the thigh to rule-out necrotizing fasciitis C. antibiotics for one week, followed by reassessment D. incision and drainage, using a cruciate incision E. needle aspiration with a 30-gauge needle followed by antibiotics and reassessment within 5 days

A. incision and drainage with a linear incision The answer is A. A fluctuant, indurated area such as that pictured and described, tends to not respond to antibiotics (which cannot penetrate well into the abscess cavity). Cruciate incisions are unnecessary and risk wound healing problems. A 30-gauge needle is too small, and needle drainage of an abscess in this location is not generally used (it is more likely appropriate in facial abscesses).

A "BLS" ambulance differs from an "ALS" ambulance in that the BLS ambulance: A. is stocked with different supplies and equipment B. operates under off-line, as opposed to on-line, medical control C. arrives at the patient first D. is staffed by one EMT crew member (and one driver) rather than two EMTs E. is a smaller "van"-type ambulance

A. is stocked with different supplies and equipment

Which coronary vessel is usually the cause of the myocardial infarction in a patient with ST elevation in V1, V2, and V3? A. left anterior descending (LAD) B. left circumflex artery C. posterior descending branch of the right coronary artery D. right coronary artery (RCA) E. right ventricular branch of the right coronary artery

A. left anterior descending (LAD) The answer is A. This EKG pattern is consistent with that of anterior wall myocardial infarction (MI). The LAD supplies the anterior wall of the myocardium. The left circumflex artery, the LAD, or a branch of the RCA supplies the lateral wall of the left ventricle. Proximal occlusion of the LAD will give ST elevation in leads V1-6, aVL and I (an anterolateral MI). Occlusion of a branch of the RCA will result in an inferolateral MI (ST elevation in leads II, III, aVF and I, aVL, V5 and V6). The RCA supplies the inferior wall and SA node. Occlusion in leads II, III and aVF causes an inferior MI. The right ventricle is usually supplied by the RCA or, less commonly, a dominant left circumflex. ST elevation in leads V4 and V5 of a right-side leads EKG suggests infarction of the right ventricle. A posterior MI (ST depression in V1-V3) results from occlusion of the RCA, its posterior descending branch, or a dominant left circumflex.

An intoxicated 30-year old male, unable to give any history other than "knee pain," had an X-ray ordered. Based upon the X-ray results (The X-ray demonstrates patella alta, or a high-riding patella), which of the following would be the most likely physical finding? A. limited ability to extend the leg B. palpable defect in the quadriceps tendon, superior to the patella C. loss of sensation in the thigh D. diminished popliteal pulse E. tenderness over the fibular head

A. limited ability to extend the leg This X-ray finding, which is associated with patellar tendon rupture, is defined as being present when the ratio of the patellar height to the (apparent) length of the patellar tendon exceeds 1:1.2. Patella baja, a low-riding patella, is the finding when the quadriceps tendon is ruptured (in these cases there will often be a palpable defect superior to the patella). Patellar tendon rupture is less common than quadriceps tendon rupture, and patellar tendon rupture is more likely in younger patients (<40 years) while quadriceps rupture more frequently occurs in older patients.

As a general rule, when is blood transfusion indicated in the treatment of hypovolemic shock resulting from acute hemorrhage? A. massive hemorrhage > 30% B. first line treatment C. after dopamine D. minor hemorrhage <10% E. after 1L of crystalloid bolus

A. massive hemorrhage > 30% The answer is A. Blood transfusion can play a vital role in the treatment of hypovolemic shock from acute hemorrhage. It is generally not the first line treatment. It is indicated in massive blood loss or shock that is not responsive to significant crystalloid infusion (2L or 30 ml/kg). Pressors are not indicated in hypovolemic shock. Elderly patients and those with co-morbid illnesses may require blood products earlier than healthy adults.

All of the following may be used in the treatment of acute angle closure glaucoma (AACG) EXCEPT? A. mydriatic agents B. mannitol C. laser iridectomy D. topical beta blockers E. carbonic anhydrase inhibitors

A. mydriatic agents In fact, mydriatic agents are contraindicated. Miotic drops, like Pilocarpine by contrast, are used. Other agents employed in the treatment of AACG include: carbonic anhydrase inhibitors (decreased aqueous production), topical beta blockers (decreased aqueous production), mannitol (decreased intraocular pressure), and iridectomy

A patient with a history of difficult-to-control hypertension is now 6 to 8 weeks pregnant and presents with a hypertensive emergency. Which of the following IV antihypertensives should be avoided? A. nitroprusside B. labetolol C. nicardipine D. esmolol E. hydralazine

A. nitroprusside One of the side effects of nitroprusside is cyanide toxicity, and this agent is thus best avoided in pregnancy. Other side effects of these medications include: headache, abdominal and/or chest pain, GI upset, and seizure.

Which of the following women are considered at increased risk for pre-eclampsia? A. obese B. over 20 years old C. woman with a single intrauterine pregnancy D. cigarette smoker E. multiparous

A. obese

Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the orbit and the patient has right eye pain with extraocular movement. What is the most likely cause of his symptoms? A. retrobulbar hematoma B. chemosis C. hyphema D. orbital blow-out fracture E. ruptured globe

A. retrobulbar hematoma The answer is A. Traumatic proptosis with impaired extraocular movements is classic for retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement. Yet, they do not present with proptosis - unless complicated by retrobulbar pathology.

Of the following choices, which is the most likely diagnosis based on the EKG in the Figure? [image: prolonged QRS duration, a terminal R wave in V1 and a slurred S wave in leads I and V6] A. right bundle-branch block B. left bundle-branch block C. anteroseptal myocardial infarction D. Wolff-Parkinson-White syndrome

A. right bundle-branch block The EKG reveals right bundle-branch block. RBBB are characterized by a prolonged QRS duration, a terminal R wave in V1 and a slurred S wave in leads I and V6. Frequently, an RSR', or "rabbit ears" pattern can also be seen in the precordial leads.

Which of the following pairings of referred pain and causal disease is least likely to be encountered? A. sacral pain—ovarian torsion B. inguinal pain—ureteral colic C. epigastric pain—myocardial infarction D. shoulder pain—ruptured spleen E. thoracic back pain—pancreatitis

A. sacral pain—ovarian torsion Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain.

You are performing procedural sedation to repair a complex facial laceration on a child in the ED. Unfortunately your patient is progressing from clinical signs of moderate sedation to deep sedation and is in need of reversal using flumazenil. In which of the following scenarios is the use of flumazenil appropriate? A. Patient exhibits signs of seizure activity during procedural sedation B. Patient has been given IV fentanyl as a single agent for sedation C. Patient is younger than 3 years old and had a glass of milk four hours ago D. Patient has been given IV ketamine as a single agent for sedation

C. Patient is younger than 3 years old and had a glass of milk four hours ago The answer is C. Flumazenil should not be used on a patient exhibiting seizure activity (A). Also co-ingestion of drugs with pro-convulsant properties (cyclic antidepressants) is associated with an increased risk of seizures, presumably due to loss of the benzodiazepine's protective anticonvulsant effect when the antagonist is administered. For similar reasons (related to GABA effects) flumazenil can theoretically precipitate seizure activity in patients who chronically take benzodiazepines or chloral hydrate. The co-administration of flumazenil also risks cardiac side effects for these patients. Flumazenil would not be indicated for reversal of sedation when using only fentanyl or ketamine (B, D). Naloxone (or another opioid antagonist), not flumazenil, is the appropriate reversal agent for fentanyl. There is no reversal agent available for ketamine. Flumazenil can be used for the acute reversal of benzodiazapine overdose in procedural sedation for children younger than 3. The patient's consumption of milk four hours earlier met the ASA fasting guidelines and is irrelevant.

A 48 year old homeless man with known alcohol abuse and a seizure disorder, presents to the ER with a witnessed seizure earlier that evening. He admits to non-compliance with his medications, especially when drinking. He denies head trauma, fevers, and neck pain. Bedside glucose testing is 138. He is afebrile with a pulse of 110, RR 20, O2sat 96% on RA, and a BP of 132/88. While awaiting further lab work the patient has a grandmal seizure in the department. He receives 2 mg Lorazepam IV push X three doses, to no avail. Which of the following is the most appropriate pharmacotherapy to try next? A. Dextrose 50% in water, 1 amp IV push B. Ceftriaxone 1 gram IV piggyback C. Phenytoin 15 mg/kg IV piggyback D. Sodium Bicarbonate 1 AMP IV push

C. Phenytoin 15 mg/kg IV piggyback

You suspect that your patient has swallowed a nail. Which of the following is an indication for endoscopic or surgical removal of this object? A. Abdominal CT scan shows a 1cm nail in the distal sigmoid colon B. Plain films do not reveal a radiopaque foreign body in the chest or abdomen C. Radiography visualizes the nail in the gastric fundus D. The object has progressed from the jejunum through the ileum after 24 hours

C. Radiography visualizes the nail in the gastric fundus The answer is C. Observation can manage most ingested foreign objects - the patient should pass the object after several days. Propulsive agents can be given to speed movement along the gastrointestinal tract. Serial radiography monitors movement. Endoscopic or surgical intervention is indicated for sharp objects (which may cause perforation), objects greater than 2 cm in width (which are likely to lodge at the pylorus or the ileocecal valve), and long rigid objects (which may have trouble passing through the right angles of the duodenum). Surgery is indicated if an object fails to move after 24 hours (indicating impaction), or if the patient develops symptoms of obstruction or perforation. Body packers may have ingested substances such as cocaine or heroin, which can cause great harm should the packaging be disrupted. Proper management is observation, as most will pass the package(s) without complications. Urgent package retrieval should not be performed because of pressures from law enforcement. Endoscopy can in fact be dangerous to the patient, as it can disrupt the packaging and release toxic drugs. Endoscopic or surgical intervention is warranted should the patient develop signs of systemic drug toxicity. The patient can also be monitored with serial serum drug levels.

A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay. What should be the first step in the management of this patient? A. Administration of phenytoin 1000mg IV B. Administration of mannitol 50 g IV C. Rapid sequence intubation using paralytic agent D. Emergency craniotomy E. Administration of 2 liters NS bolus

C. Rapid sequence intubation using paralytic agent The airway should be managed as the first priority in this patient. The other maneuvers may be helpful but are secondary to securing an airway and providing oxygenation/ventilation. Airway comes first!

A 72-year-old male presents with five hours of substernal chest pain and pressure despite taking three sublingual nitroglycerin. You order an EKG. What findings on the EKG would indicate that this patient is potentially a candidate for thrombolytic therapy? A. ST-segment depression of at least 2mm in any precordial lead B. Ventricular tachycardia C. ST-segment elevation of at least 1 mm in two or more contiguous leads D. Atrial fibrillation with a rapid ventricular response

C. ST-segment elevation of at least 1 mm in two or more contiguous leads The answer is C. "Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-segment elevation in two or more contiguous leads."

A patient presents with a self-inflicted wound, with resultant loss of vision in the right eye. With regard to the figure, which of the following statements is most likely true? [image] A. Medial canthotomy should be performed immediately. B. If ambulance providers contact medical control about a patient with this injury, they should be directed to replace the globe back into the orbit. C. Search for other self-inflicted injuries (or ingestions) is paramount. D. Life-threatening hemorrhage is a major risk with this injury. E. The patient will probably recover visual function.

C. Search for other self-inflicted injuries (or ingestions) is paramount. The answer is C. The patient is unlikely to recover any visual function, which renders more important parallel efforts to identify (treatable) injuries or ingestions that are less obvious than the ocular avulsion. Lateral (not medial) canthotomy is an emergency procedure that may be indicated in some patients with ocular injury and retrobulbar hematoma (with resultant traction on the optic nerve), but the procedure is unlikely to help this patient. Since manipulation of an injured globe risks further trauma and extrusion of vitreous humor, prehospital recommendations for eye trauma are limited to protection of the injured eye and expedited transport to definitive care. Life-threatening hemorrhage is not a major risk with this type of injury.

Management of a 4 year old child with a two-week history of malodorous purulent nasal drainage should include, as an initial step: A. Referral to an otolaryngologist B. Oral amoxicillin for 10-14 days C. Speculum examination of the nares D. Social services consultation to investigate potential child abuse

C. Speculum examination of the nares A commonly missed diagnosis is that of a nasal foreign body in a child who does not provide a history of object insertion into the nares. Children with nasal foreign bodies are often treated with antibiotics for presumed recurrent sinusitis. Nasal foreign bodies may be asymptomatic until the development of secondary signs, such as unilateral purulent discharge or recurrent epistaxis. Proper initial management is examination of the nares with a speculum. Should no foreign body be identified, a CT scan may be indicated. -- For further reading see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, Chapter 53.

The patient in the figure presents with findings of petechiae and mucosal lesions after beginning to take a sulfonylurea for diabetes. He is nontoxic, afebrile, and has no allergic symptoms. Based upon the most likely diagnosis, which of the following statements is true? [image nasty black spots in mouth] A. Platelet transfusions are indicated if platelet count is below 100,000/mm3. B. Intracranial hemorrhage is not a major concern unless the platelet count falls below 2,500/mm3. C. Steroids are usually indicated in adults. D. Prothrombin time is usually twice normal. E. Intra-articular bleeding is commonly seen with this patient's condition.

C. Steroids are usually indicated in adults. The patient's presentation is most consistent with ITP (immune thrombocytopenic purpura). Platelet transfusions can induce inflammatory (autoantibody) response and worsen the patient's condition by increasing platelet destruction. Intracranial hemorrhage is the most feared complication of ITP, and intracranial bleeding is a risk even if levels do not fall as low as 2,500/mm3 (20,000/mm3 is a commonly cited threshold for spontaneous intracranial bleeding). The PT is expected to be normal, and intra-articular bleeding is not a major feature of ITP.

An early sign and symptom of shock is: A. Cyanosis B. Decreased respiratory rate C. Tachycardia D. Hypotension E. Bradycarda

C. Tachycardia The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased respiratory rate, which occur as the body attempts to maintain perfusion.

A patient presents with a question of foreign body in the foot. With reference to the figure, which of the following is true regarding anesthesia of the foot? [image] A. The patient is undergoing infusion of anesthesia into the saphenous vein. B. The patient shown is undergoing a sural nerve block. C. The patient shown is undergoing a posterior tibial nerve block. D. Local anesthesia (at the wound site) is preferred for wounds of the plantar foot. E. Adequate injection at the site depicted, will provide anesthesia for the entire sole of the foot.

C. The patient shown is undergoing a posterior tibial nerve block. The answer is C. The nerve block depicted is a posterior tibial block. Regional blocks are preferred for procedures involving the plantar foot, since there is rich innervation and significant discomfort associated with injections into the soles. The posterior tibial nerve, located between the medial malleolus and Achilles tendon, supplies the medial portion of the sole and the medial side of the foot. The nerve runs next to the posterior tibial artery and is posterior to the pulse. In addition to the posterior tibial nerve block, a sural nerve block is frequently provided when anesthesia is desired for the heel and lateral foot.

What does it mean to have 20/200 vision OD? A. The intraocular pressure in the right eye is 20 and the intraocular pressure of the left eye 200. B. The patient's right eye sees at 200 feet what a normal eye sees at 20 feet. C. The patient's right eye sees at 20 feet what a normal eye sees at 200 feet. D. The patient's left eye sees at 200 feet what a normal eye sees at 20 feet. E. The patient's left eye sees at 20 feet what a normal eye sees at 200 feet.

C. The patient's right eye sees at 20 feet what a normal eye sees at 200 feet. The right eye abbreviation is OD. The left eye abbreviation is OS. Conventionally, the right eye acuity appears above the left eye acuity when written on the chart. -- For further reading, see Tintinalli, et al., Emergency Medicine: Comprehensive Study Guide, 5th edition, page 1505.

All of the following are true regarding the airway in children as compared to adults EXCEPT: A. Endotracheal intubation is usually performed using a straight blade in children. B. The infant's head is naturally in the correct "sniff" position, so a towel under the neck is usually unnecessary. C. The pediatric airway is more posterior than the adult airway. D. The pediatric tongue is relatively larger than the adult tongue. E. Teeth are more easily knocked out during a pediatric intubation than during that of an adult.

C. The pediatric airway is more posterior than the adult airway. The answer is C. The pediatric airway is more anterior than the adult airway. The other choices (A, B, D, and E) are all correct regarding the pediatric airway as compared to that of the adult.

Regarding pulsus paradoxus and asthma, which of the following statement s is correct A. Pulsus paradoxus is pathognomonic for asthma B. The absence of pulsus paradoxis in asthma rules out severe disease C. The presence of pulsus paradoxis in asthma indicates severe disease D. Pulsus paradoxus is a fall in systolic blood pressure during inspiration

C. The presence of pulsus paradoxis in asthma indicates severe disease The answer is C. Pulsus paradoxus is defined as a fall in systolic blood pressure of greater than 10mm Hg upon inspiration. It is typically present during acute asthma exacerbations in severe asthma; however, its absence does not rule out severe disease. Although initially present, a pulsus paradoxus may disappear after only minimal improvement in air flow through the larger airways. Pulsus parodoxus may occur in other diseases besides asthma (for example, pericardial tamponade).

All of the following are true regarding adult epiglottitis EXCEPT: A. The incidence of adult epiglottitis has increased in recent years, whereas the incidence of pediatric epiglottitis has decreased. B. Smokers have a higher incidence of adult epiglottitis. C. The rapidity of symptoms' onset does not correlate with the likelihood of need for airway intervention. D. Type b H. influenza is the most common bacterial pathogen to cause acute epiglottitis. E. Adult epiglottitis is a cellulitis of the supraglottic structures of the airway including the epiglottis, vallecula, and the base of the tongue.

C. The rapidity of symptoms' onset does not correlate with the likelihood of need for airway intervention. Typically, a rapid onset of disease is associated with a higher rate of requiring airway intervention. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 973-974.

Choose the INCORRECT statement regarding thoracentesis from the anterior approach (needle decompression): A. An upright chest X-ray should always be performed following a thoracentesis to confirm the successful relief of a tension pneumothorax and the absence of hemothorax or other complications. B. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib. C. The recommended insertion site is the second intercostal space, midaxillary line. D. After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax. E. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube should be placed as soon as possible.

C. The recommended insertion site is the second intercostal space, midaxillary line. The recommended insertion site for needle decompression of tension pneumothoraces is the second intercostal space along the midclavicular line. If a lateral approach is needed, the recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury. The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin. The remaining answers are all correct statements regarding thoracentesis.

A 74 year old previously healthy man presents to the ED 45 minutes after his speech became acutely slurred while he was having dinner with his daughter. He is afebrile, with a pulse of 68, blood pressure of 148/70, respirations of 18, and oxygen saturation of 98%. On exam, he has a left-sided facial droop, 3/5 strength in his left hand and arm, and marked dysarthria. His fingerstick glucose is normal, as is a noncontrast head CT. The most appropriate management for this patient is: A. Aspirin B. Emergent brain MRI C. Thrombolytic infusion D. Heparin

C. Thrombolytic infusion

A 74 year old man presents with a rash on his right chest. It begins in the back and wraps around to the front in a band or dermatomal distribution. The rash is vesicular. The correct diagnosis is: A. Scarlet fever B. Tinea C. Varicella D. Rocky Mountain spotted fever E. Lyme disease

C. Varicella

All of the following are signs and symptoms of hypovolemic shock EXCEPT: A. Narrow pulse pressure B. Cool, clammy skin C. Warm, moist skin D. Decreased capillary refill E. Tachycardia

C. Warm, moist skin The answer is C. Acute hemorrhage or volume loss is characterized by tachycardia, narrow pulse pressure, poor capillary refill and decreased urine output. Skin tends to be cold and clammy. Late findings include hypotension and altered mental status.

A young male patient presented to the emergency department with a history of single gunshot wound from unknown source and caliber. He was hemodynamically stable and had little pain in the right lower quadrant of the abdomen, which was the site of two wounds about 6 inches apart (see Figure). No other wounds were identified during physical examination. Which of the following statements regarding this case is true? [image] A. The superior-medial wound (at the top right of the Figure) is likely the entrance wound, and the inferior-lateral wound is likely the exit wound, of a single missile B. If it is suspected that the two wounds are from the same missile, the emergency department physician's documentation should note which wound is the entrance, and which is the exit C. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination. D. The two wounds are more likely than not the result of two separate missiles

C. Wound description is essential for the emergency medicine specialist. However, description of a wound as to entrance or exit is best left to forensic examination. The answer is C. The overall evidence points to a superior-medial to inferior-lateral wound trajectory, with subcutaneous ecchymosis indicating the missile track and the more ragged wound at the inferior-lateral (groin) region most likely an exit wound. However, though wound description is very important for the emergency physician (both as a guide to injury evaluation and also as an early characterization of wounds, before interventions such as wound exploration obscure physical findings), speculation as to whether wounds are entrance or exit wounds are best left off of the E.D. record. Clinicians tend to oversimplify and/or misinterpret physical wound characteristics. Thus, the best course is a meticulous description (or photograph) of the wound, noting items such as tattooing (i.e. of gunpowder) or stellate tissue destruction (which can be due to expansion of gun barrel gases in a contact wound) but leaving interpretation of the physical evidence to forensics experts. The wound characteristics are not consistent with self-inflicted injury, though the ED physician should have a low index of suspicion for psychiatric consultation when there is doubt on this subject.

A 54 you male presents with complaints of a foreign body sensation in his left eye. Which of the following is an indication for urgent ophthalmologic referral? A. You note an intraocular pressure of 20 in the affected eye B. You discover a moderate-sized linear corneal abrasion C. You note a small puncture wound in the globe D. Your examination reveals a metallic foreign body that is loosely adherent to the white of the eye

C. You note a small puncture wound in the globe

The components of the Figure (which is a photograph taken of the female perineal region) depict __________ (in the top of the Figure) which can be treated by placement of a __________ (in the lower part of the Figure): A. a cystocele -- pessary B. a benign tumor -- brachytherapy applicator C. a Bartholin's cyst -- Word catheter D. an inguinal lymph node -- gel-applicator for antibiotics administration E. a urinoma -- pediatric Foley catheter

C. a Bartholin's cyst -- Word catheter The answer is C. The patient's Bartholin's cyst will be drained, and placement of a Word catheter (inserted through an incision on the mucosal surface of the labia) will allow for continued drainage and healing.

An 18 year old man presents after twisting his right ankle playing basketball. He has tenderness over the anterior talofibular ligament and there is instability of the ankle with movement. An X-ray shows no fracture or dislocation. He has: A. a first degree sprain B. a second degree sprain C. a third degree sprain D. an occult fracture E. tendonitis

C. a third degree sprain A first degree sprain is minor tearing of the ligamentous fibers with mild hemorrhage and swelling. A second degree sprain is a partial tear of a ligament causing moderate hemorrhage and swelling, tenderness, painful motion and loss of function. A third degree sprain is complete tearing of a ligament resulting in grossly abnormal joint movement in addition to hemorrhage, swelling and pain.

A 22 year old female presents to the emergency department with a "funny feeling" in her chest. She has had similar episodes but never lasting as long as the current episode (3-hour duration). Her heart rate is 200, blood pressure is 128/68, respiratory rate is 20 and her pulse oximetry is 96%. Her EKG is shown in the Figure. The best treatment option for this patient is: [image shows narrow complex tachy] A. cardioversion B. lidocaine C. adenosine D. verpamil

C. adenosine The answer is C. The rhythm shown in the EKG is a narrow complex regular tachycardia. It could also be described as a supraventricular tachycardia (SVT). The first-line treatments of stable SVT are vagal maneuvers or adenosine. Unstable SVT (such as that causing hypotension, heart failure, or myocardial ischemia) should be cardioverted.

A 4-month-old infant presents with 1 day of episodic fussiness followed by normal activity. In the last several hours he has vomited 2-3 times. The patient is interactive and has a normal exam. While his parents receive discharge instructions he becomes fussy and passes a large reddish, jelly-like stool. What is the next course of action? A. admit him for observation B. give him antibiotics for infectious diarrhea C. arrange for a barium enema and surgical consultation D. abdominal CT scan to rule out appendicitis

C. arrange for a barium enema and surgical consultation This child has the classic presentation for intussusception, which is the telescoping of one portion of the intestine into another, cutting off blood supply to the intestine. Classically the patient is 3 months to 6 years in age and has episodes of intermittent abdominal pain and cramping. The characteristic currant jelly stool is a late and infrequent finding. Barium enema is both a diagnostic and often therapeutic procedure, but it can result in perforation; thus, pediatric surgery consultation should occur in conjunction with ordering this test.

A 60 year old male presents with new onset confusion. Which of the following suggests a functional, as opposed to an organic etiology? A. abnormal vital signs B. acute onset C. auditory hallucinations D. disorientation

C. auditory hallucinations The other findings are all characteristic of organic confusional states. Hallucinations can occur with both organic and functional causes of confusion. Hallucinations associated with organic confusion may be visual, tactile, or auditory. Hallucinations in patients with functional disease tend to be auditory.

All of the following may be indications for thoracentesis in the emergency department EXCEPT: A. evacuation of a simple stable pneumothorax (anterior approach) B. acute treatment of a large symptomatic pleural effusion (posterior approach) C. biopsy of a lung mass (anterior or posterior approach) D. diagnosis and treatment of suspected tension pneumothorax (anterior approach) E. diagnostic evaluation of a pleural effusion (posterior approach)

C. biopsy of a lung mass (anterior or posterior approach) The answer is C. All the other answers are common indications for performing a thoracentesis. Lung biopsy is not performed in the emergency department.

A 20 year old man presents to the emergency department with 1 week of intermittent bloody bowel movements associated with crampy abdominal pain, tenesmus, and fecal urgency. He is previously healthy. He is not on medications; nor has he recently traveled. What test will most likely confirm his diagnosis? A. a workup for a bleeding diathesis B. barium enema to rule out intussusception C. colonoscopy to rule out inflammatory bowel disease D. stool culture to rule out invasive bacterial diarrhea

C. colonoscopy to rule out inflammatory bowel disease The answer is C. This patient will need a colonoscopy with intestinal biopsy to evaluate for inflammatory bowel disease such as ulcerative colitis and Crohn's disease or other causes of colitis. Appendicitis usually presents with periumbilical pain migrating to the right lower quadrant with associated anorexia, not bloody bowel movements. Intussusception is uncommon after the age of 6. A stool culture should be obtained to rule out bacterial colitis, but his history is less suggestive of this.

A 57 year-old male is brought in by emergency medical services in cardiac arrest. The paramedics have initiated ventilations via a bag-valve-mask and chest compressions. He has no spontaneous respirations, pulse or blood pressure. The following rhythm is seen on the cardiac monitor: [monitor shows wide QRS ventricular tachycardia] Which of the following is the most appropriate intervention? A. intubation B. epinephrine 1 mg given intravenously C. defibrillation at 360 joules D. therapeutic cooling

C. defibrillation at 360 joules

A 57 year-old male is brought in by emergency medical services in cardiac arrest. The paramedics have initiated ventilations via a bag-valve-mask and chest compressions. He has no spontaneous respirations, pulse or blood pressure. He was defibrillated at 360 joules after which an intravenous line was placed. Which of the following is the most appropriate intervention? A. amiodarone 300 mg B. atropine 1 mg C. epinephrine 1 mg D. lidocaine 100 mg

C. epinephrine 1 mg

In the post-arrest setting, which of the following is the drug of choice in treating hypotension in a child: A. dobutamine bolus B. dobutamine infusion C. epinephrine infusion D. dopamine infusion E. nitroprusside infusion

C. epinephrine infusion While dopamine is the drug of choice in adults, epinephrine infusion is the initial treatment of choice in pediatric patients. As coronary artery disease is rare in children, there is less of a concern regarding its dysrhythmogenic effects and the risk of myocardial infarction. Dobutamine and dopamine infusions also play a role in resuscitating the hypotensive child, but are not first choice agents. Dobutamine bolus alone and nitroprusside have no role to play.

Laboratory abnormalities typically seen with adrenal insufficiency include all of the following EXCEPT: A. hypercalcemia B. azotemia C. hypokalemia D. hyponatremia E. hypoglycemia

C. hypokalemia The answer is C. Hyperkalemia is seen in approximately 64% of patients with adrenal failure. Typically this is because of aldosterone production failure that normally enhances potassium excretion. Even more common is hyponatremia, present in 88% of patients. Hypoglycemia is present in two-thirds of patients and is a significant cause of morbidity and mortality associated with adrenal failure. Hypercalcemia is seen in 6 to 33% for unclear reasons; azotemia and increased hematocrit from hypovolemia may also be present.

A patient presents complaining of severe pain and swelling in the distal aspect of his index finger. He has no history of trauma. On exam he has tense swelling and redness on the pad of the digit. Of the following, which is the best next step? A. antibiotics and discharge B. consult orthopaedics for pinning of a probable fracture C. incision and drainage D. radiograph E. treat for herpetic whitlow and discharge

C. incision and drainage This patient has a felon, an infection of the pulp of the distal finger or thumb. It differs from other subcutaneous abscesses because septa divide the pulp into small fascial compartments. These septa must be divided during the incision and drainage. An incision should be made along the ulnar aspect of digits II-IV and the radial aspect of digits I and V to avoid the pincher surfaces. The incision should be posterior to the digital artery and nerve.

Which of the following psychiatric disorders is associated with the greatest increased risk of committing suicide? A. post-traumatic stress disorder (PTSD) B. schizophrenia C. panic disorder D. major depression

C. panic disorder The answer is C. Most people who commit suicide suffer from either alcoholism or a diagnosable psychiatric illness. 15-20% of people with major depression and 10% of people with schizophrenia will commit suicide. Up to 40% of people with panic disorder will attempt suicide at some point in their lives. PTSD also carries an increased risk.

An 89 year old woman presents complaining of a right temporal headache associated with myalgias. Physical examination reveals an indurated temporal artery. The erythrocyte sedimentation rate is elevated. Which dismissal prescription is most appropriate for this patient? A. hydrocortisone (1%) cream applied to the inflamed artery TID B. acetaminophen 650 mg PO TID C. prednisone 100 mg PO QD D. ice applied to the inflamed artery BID E. ibuprofen 400 mg PO TID

C. prednisone 100 mg PO QD

A 70 year old male with acute delirium requires administration of haloperidol for agitation. Which of the following is a recognized side effect of haloperidol? A. first degree heart block B. nephrogenic diabetes insipidus C. prolonged QT interval D. transient hepatitis

C. prolonged QT interval Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia

A patient with nontraumatic chest pain is administered nitroglycerin in the field and has subsequent drop in blood pressure. An EKG reveals ST-segment elevation in lead V4R. What is the diagnosis? A. anteroseptal MI B. pericarditis C. right-ventricular MI D. unstable angina E. pulmonary embolism

C. right-ventricular MI The answer is C. The ST-segment elevation in the right-sided lead V4R is strongly suggestive of right-ventricular MI.

When using the "SAD PERSONS" scale to determine suicide risk, which factor conveys the least amount of points? A. depression or hopelessness B. rational thinking loss C. separated, divorced or widowed D. stated future intent

C. separated, divorced or widowed The answer is C. Being separated, divorced or widowed is an important but less significant factor in determining suicide risk and so is assigned 1 point on the suicide scale. All the others are high-risk factors and are each assigned 2 points on the suicide scale. A score of 6 or more has a sensitivity of 94% and a specificity of 71% compared with formal psychiatric evaluation to identify the need for hospitalization in patients who present immediately after a suicide attempt.

The patient in the figure sustained minor blunt trauma to the eye, and has a normal head/orbital computed tomography (CT) scan. Ophthalmological examination is normal, other than the blood as shown in the figure (the blood does not cross the limbus). Of the choices below, which diagnosis is the most likely based upon the figure? [image] A. foreign body B. ruptured anterior chamber C. subconjunctival hemorrhage D. hyphema E. globe rupture

C. subconjunctival hemorrhage The answer is C. The subconjunctival blood as depicted in this patient, can be expected to resorb without intervention over days to weeks. The figure does not suggest rupture of anterior chamber or hyphema; globe rupture and foreign body are less likely given the normal examination and CT scan.

A 65 year old male is brought to the emergency department after he was found wandering on the street. He is unkempt and confused. A diagnosis of delirium, rather than dementia, is more likely if which of the following is true? A. there has been a slow progressive loss of memory B. the sleep-wake cycle is unaffected C. there is a change in the level of consciousness D. the confusion is worse during the day

C. there is a change in the level of consciousness atients with delirium have disturbances in consciousness, cognition, and perception. These disturbances tend to occur over a short period of time (hours to days). The delirious patient may be somnolent or agitated. Thought process may be mildly disturbed or grossly disorganized. The clinical presentation may be subdued or explosive, and the course can fluctuate over minutes to hours. The patient's sleep-wake cycle may be altered or reversed; agitation is often present during the night. An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity.

The best treatment, of the options below, for a patient with second degree AV block Mobitz Type II is: A. epinephrine B. aspirin C. transvenous pacing D. lidocaine E. amiodarone

C. transvenous pacing Second degree Mobitz Type II heart block easily degrades to complete heart block. Second degree Mobitz Type II is an atrioventricular-block rhythm in which there are intermittently non-conducted atrial beats not preceded by lengthening AV conduction. It is usually due to a block within the His bundle system. The bradycardia often is unresponsive to atropine and patients tend to require pacing.

Of the following pain patterns, which is the least likely associated with diagnosis of peptic ulcer disease? A. non-radiating, burning epigastric pain B. pain that awakens a patient in the middle of the night C. unrelenting pain over a period of weeks D. relief of abdominal pain with antacids E. pain that is worse preceding a meal

C. unrelenting pain over a period of weeks The answer is C. Pain from peptic ulcer disease typically occurs in periods of exacerbation and remission. Unrelenting pain over weeks or months should suggest an alternative diagnosis. Pain is classically described as non-radiating, burning epigastric pain. Some patients may also complain of chest or back pain. Pain is frequently severe enough to awaken patients from sleep in early morning hours but is often not present upon waking in the morning, as gastric acid secretion peaks around 2 a.m. and nadirs upon awakening.

A 75 year old male is brought in by EMS with CPR in progress. He has been shocked three times and received 1 mg of epinephrine. His rhythm strip as shown in the Figure reveals: [image random up and down strokes] A. atrial fibrillation B. atrial flutter C. ventricular fibrillation D. ventricular tachycardia

C. ventricular fibrillation The answer is C. Ventricular fibrillation is the totally disorganized depolarization and contraction of the ventricles. The EKG is characterized by a variable zig-zag pattern of very rapid, chaotic, and grossly irregular deflections of irregular appearance and varying amplitude. There are no discernible P waves, ST segments, T waves, or even QRS complexes.

An 18 year old male is transported to the emergency department after being involved in a motor vehicle collision. On initial evaluation, he is found to be comatose, hypotensive, and is diagnosed clinically as having a tension pneumothorax on the left side. What is the correct statement regarding needle decompression or chest tube placement in this patient? A. Placement of the needle should be in the 3rd ICS, midaxillary line. B. An 18 French chest tube would be appropriate in this situation. C. A chest x-ray is unnecessary before needle decompression D. The chest tube should be inserted under the lower edge of the rib

C.. A chest x-ray is unnecessary before needle decompression The answer is C. In an unstable patient such as this, a chest x-ray would delay the care of this patient and is unnecessary. This patient needs immediate intervention with needle decompression. A chest tube size of #28 French or greater would be indicated since this patient may have a hemothorax (B). Needle decompression involves placement of a #14 gauge needle in the 2nd intercostal space at the midclavicular line (C). The chest tube should be inserted over the upper border of the rib to avoid the neurovascular bundle at the inferior margin of each rib.

A 25 year old male college student with a history of type I diabetes mellitus presents to the emergency department complaining of worsening headache, vomiting, and fever. On exam, he has a temperature of 101.6 F, meningismus, and photophobia. A lumbar puncture is performed and reveals a CSF glucose consistent with bacterial meningitis. What is the normal ratio between CSF and serum glucose? A. 1:1 B. 2:1 C. 0.4:1 D. 0.6:1

D. 0.6:1 The answer is D. The normal range of CSF glucose is 50 to 80 mg/dL, which is 60% to 70% of the glucose concentration in the blood. Ventricular fluid glucose levels are 6 to 8 mg/dL higher than in lumbar fluid. A ratio of CSF glucose-to-blood glucose of less than 0.5 or a CSF glucose level below 40 mg/dL is invariably abnormal. The ratio is higher in infants, for whom a ratio of less than 0.6 is considered abnormal. Hyperglycemia may mask a depressed CSF glucose level; when present, the CSF glucose-to-blood glucose ratio should be measured routinely. With extreme hyperglycemia, a ratio of 0.3 is abnormal. In patients with systemic hyperglycemia, the ratio changes to 0.4:1.

The best IV access for volume resuscitation of the hypovolemic patient is: A. 22g catheter in the dorsum of the hand B. intraosseous line C. triple-lumen internal jugular central venous catheter D. 16g catheter in the antecubital fossa E. PICC line

D. 16g catheter in the antecubital fossa The answer is D. A large short catheter is preferred for volume resuscitation. The ideal line is a large caliber introduced in a large or central vein. A 14g or 16g catheter in the antecubital fossa is considered adequate in most settings. Triple lumen and picc line catheters (the PICC is a peripherally introduced indwelling central catheter) are long, very narrow catheters; the length and narrowness increase resistance to fluid flow.

Regarding the diagnosis of pyelonephritis, which of the following is FALSE? A. Diabetic patients with bacteriuria are at increased risk for developing pyelonephritis. B. Pyelonephritis is more common in indigent populations. C. Patients with pyelonephritis typically have symptoms for greater than 5 days. D. Abnormal vaginal discharge is typically seen on pelvic exam in patients with pyelonephritis. E. White blood cell casts on urinalysis support a diagnosis of pyelonephritis.

D. Abnormal vaginal discharge is typically seen on pelvic exam in patients with pyelonephritis.

For which of the following cases is activated charcoal therapy most appropriate? A. Drain cleaner ingestion B. Iron supplement overdose C. Lithium overdose D. Acetaminophen overdose

D. Acetaminophen overdose Charcoal acts by adhering to most toxins, impairing toxin absorption, and enhancing elimination. Some toxins (i.e., heavy metals such as lithium, lead, and iron) do not bind to charcoal. Consequently, charcoal is not indicated in isolated heavy metal injections. Also, charcoal is contraindicated in patients with unprotected airways (risk of aspiration) and in caustic ingestions as the black color of the charcoal interferes with the endoscopic evaluation that often follows caustic ingestion. In addition, a caustic ingestion such as alkaline drain cleaner causes its damage by direct contact rather than absorption so charcoal will not be effective.

A 25 year old presents with an ingestion of acetaminophen 2 hours prior to arrival. Which of the following statements is TRUE? A. An acetaminophen level of 84 mg/dl from arrival labs necessitates use of n-acetylcysteine B. AST of 32 and ALT of 27 from arrival labs indicate the absence of hepatotoxicity from this ingestion. C. Acetaminophen toxicity is predicted to occur at a dose of 20 mg/kg. D. Activated charcoal is indicated to treat this ingestion

D. Activated charcoal is indicated to treat this ingestion The answer is D. NAPQI -- the prime toxic mediator -- builds up when glutathione stores deplete and thus causes hepatotoxicity. The first stage of acetaminophen toxicity is largely asymptomatic. The toxic acetaminophen dose, when a single ingestion of nonsustained-release preparation is taken, is about 140 mg/kg. Therapy is guided by the Rumack-Matthew nomogram, provided the ingestion is an acute one involving nonsustained-release preparations. The antidote, N-acetylcysteine, prevents toxicity by inhibiting the binding of NAPQI to hepatocytes.

A 66-year-old patient with CHF, anemia and sepsis has been intubated and on vasopressors while being boarded in the ED for 24 hours. With rising lactate levels and decreasing bowel sounds, a CT of the abdomen obtained reveals multiple areas of mesenteric ischemia. What is the appropriate treatment for his mesenteric ischemia? A. Intravenous thrombolytics B. Surgical decompression C. Intravenous heparin therapy D. Aggressive fluid resuscitation

D. Aggressive fluid resuscitation

A 47 year old man with a history of alcohol abuse presents to the ED after having a seizure. His past includes both seizures and blackouts. His last alcoholic drink was the previous evening. This morning he experienced palpitations, diaphoresis, and dizziness before losing consciousness and having a seizure lasting under a minute. Which of the following is *true* statement with to alcohol and its association with seizures? A. In people with an underlying seizure disorder, excessive alcohol intake is a risk-factor for seizure due to increased likelihood of head injury, predisposition to metabolic disorders, and lowered seizure threshold. B. Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol and its metabolites. C. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal syndrome. D. All of the above statements are true. E. All of the above statements are false.

D. All of the above statements are true.

A 49 year old presents complaining of 1 day of painful bright red blood per rectum. He has painful bowel movements and streaks of blood appear on the toilet paper. He has had hard stools for two weeks after starting opiate pain medication for a broken arm. He has never had these symptoms before. Based on the patient's history, the physician examining the patient will likely find: A. An internal hemorrhoid B. A nonthrombosed external hemorrhoid C. A thrombosed external hemorrhoid D. An anal fissure

D. An anal fissure The answer is D. Sudden sharp pain after defecation along with blood on toilet tissue characterizes anal fissures. A thrombosed external hemorrhoid causes painful bleeding on defecation. Usually there is a history of external hemorrhoids and associated itching, swelling, and mucoid drainage. Internal hemorrhoids usually exhibit painless bleeding that may drip into the toilet after defecation. Rectal cancers also have painless bleeding but usually are associated with a change in bowel movement character and other signs and symptoms of malignancy.

A 12-day-old term infant presents for evaluation of vomiting blood-streaked emesis once after feeding. She is well appearing and well hydrated with normal vital signs and an unremarkable exam. She is breast-fed. What should the physician do next? A. Start an H2 blocker for reflux. B. Start a workup for a bleeding diathesis. C. Begin a septic workup. D. Ask the mother if she has any bleeding from her nipples.

D. Ask the mother if she has any bleeding from her nipples.

A 65 year old man with a history of COPD presents to the ED via ambulance with dyspnea, cough, and increased sputum. He exhibits pursed lip breathing, use of accessory muscles, can only speak in single words, but is alert. Vital signs are BP 145/85, mmHg, HR 105 beats/minute, RR 30 breaths/minute, temperature 99.5 degrees Farhenheit, and pulse oximetry 91% on a face mask with nebulized albuterol/ipatropium bromide. On exam breath sounds are equal with wheezing throughout. Despite additional nebulized treatments his work of breathing and clinical status remains the same. The next step in management would be: A. Magnesium sulfate 2 Grams IV over 20 minutes B. Epinephrine 1:1000 0.5ml subcutaneously C. Heliox 60/40 mixture inhaled D. BIPAP/ non-invasive positive pressure ventilation

D. BIPAP/ non-invasive positive pressure ventilation

Which of the following drugs is MOST beneficial in an acute COPD exacerbation? A. Steroids such as solumedrol B. Methylxanthines such as theophylline C. Mucokinetic agents such as acetylcysteine D. Beta adrenergic agonists such as albuterol

D. Beta adrenergic agonists such as albuterol Mucokinetic agents should not be used acutely in treatment of COPD exacerbation. These agents act to mobilize secretions, and this increases the work of the patient's breathing. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, page 966.

You are working in a small rural ED in Wisconsin during early fall. An entire family of 5 healthy people ranging from 8 to 45 years old present complaining of headaches that started this evening after returning from the woods and cooking dinner on the woodstove. The most likely cause of their symptoms is which of the following? A. ehrlichosis from tick bites B. Tension headaches C. Meningococcemia D. Carbon monoxide toxicity

D. Carbon monoxide toxicity

A 30 year old diabetic female with a seizure disorder presents to the emergency department after a seizure. She is still not back to her baseline mental status after 45 minutes. Her vital signs are HR 103 bpm, BP 127/63, RR 22, temp 99.3F, SpO2 97% on NRB. Her medications include insulin, phenytoin, and hydrocodone/acetaminophen. IV access has been difficult to establish. What is your initial course of action? A. Administer naloxone intranasally B. Intubate for lack of airway protection C. Perform a femoral artery stick to get a phenytoin level D. Check a finger stick blood glucose level

D. Check a finger stick blood glucose level

Epidural hematomas are least likely in which age group? A. Children between 8 and 14 B. Elderly C. Adults excluding elderly D. Children less than 2 years E. Prevalence is the same throughout age groups

D. Children less than 2 years The answer is D. Epidural hematoma (EDH) is less likely in children and elderly because of the close attachment of the dura to the periostium of the skull. This is especially true of children less than 2 years because of the added elasticity of the skull.

A 45 year old woman presents with right upper quadrant pain and fever. The pain is worse after eating. On physical exam she has a Murphy's sign. The most likely diagnosis is: A. Appendicitis B. Diverticulitis C. Cholelithiasis D. Cholecystitis E. Mesenteric Ischemia

D. Cholecystitis Right upper quadrant pain, fever and a Murphy's sign suggests cholecystitis. Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign

A 33 year old female presents to the ED with acute onset of pain in the right foot, first metatarsophalangeal joint. She had a renal transplant 10 years ago, and her only medication is cyclosporine. Regarding this patient's condition, which of the following is true? A. Inability to bear weight on the involved foot is a sign that the diagnosis is not gout, but rather a pathological fracture. B. In about 80% of cases, podagra is accompanied by concomitant involvement of another joint. C. Premenopausal females, compared to males of the same age, are more likely to develop gout. D. Colchicine may result in symptomatic improvement in patients with either gout or pseudogout. E. Though uric acid levels may be normal between gouty attacks, uric acid is virtually always elevated during an acute episode of gout.

D. Colchicine may result in symptomatic improvement in patients with either gout or pseudogout.

A 26 year old woman presents to the ED with right lower quadrant pain. She is afebrile, with a pulse of 118 and a blood pressure of 92/50. On exam, she has significant tenderness to palpation of the right lower quadrant, and right adnexal tenderness. Her urine pregnancy test is positive, and quantitative beta-hCG level is 4125. A pelvic ultrasound is negative with the exception of moderate pelvic free fluid. The most appropriate management for this patient is: A. Consult general surgery for surgical management of suspected appendicitis B. Consult Ob-Gyn for medical management of suspected ectopic pregnancy C. Discharge home with 48 hour follow up for repeat quantitative hCG and ultrasound to further evaluate suspected ectopic pregnancy D. Consult Ob-Gyn for surgical management of suspected ectopic pregnancy

D. Consult Ob-Gyn for surgical management of suspected ectopic pregnancy

A 68 year old female presents to the Emergency Department with altered mental status, combativeness, and diaphoresis for 30 minutes per EMS. PMH is significant for hypertension, insulin responsive type II diabetes, and hypothyroidism. Initial dextrose stick reveals a blood sugar of 26. She returns to her baseline mental status after administration of one amp of D50. The patient has a full neurologic recovery and confirms no oral hypoglycemic agents. The patient can be discharged after which of the following? A. Administration of 2-4ml/kg of D10 intravenously B. Insulin to prevent rebound hyperglycemia C. Glucagon 1mg intramuscularly D. Consumption of meal tray

D. Consumption of meal tray

A 54 year-old female is brought to the emergency room by the fire department after retrieving her from underneath a frozen lake. She has an undetectable blood pressure, respiratory rate is 4, her pulse is not palpable and her temperature is not detectable with a standard oral thermometer. The patient is not responsive. An intravenous line is placed, she is given 4 liters per minute of humidified oxygen and active internal warming measures are initiated. She is placed on the cardiac monitor and this rhythm is seen: [monitor shows wide QRS ventricular tachycardia] Chest compressions are begun and she is defibrillated at 360 joules with no change. What is the most appropriate next action in the resuscitation of this patient? A. Terminate efforts B. Administer lidocaine 100 mg IV C. Defibrillate a second time at 360 joules D. Continue CPR only (+/- "until warmed to above 30oC")

D. Continue CPR only (+/- "until warmed to above 30oC")

An 84 year-old with a history of congestive heart failure is brought in by his family for vomiting and diarrhea. He also complains that things "have weird colors". He has been having odd palpitations but cannot describe them further. His family expresses their concern that he has not been taking his medications correctly. Given his presenting symptoms, which medication are you most concerned about? A. Amiodarone B. Diphenhydramine C. Metoprolol D. Digoxin

D. Digoxin The answer is D. Digoxin toxicity classically presents as weakness, fatigue, nausea/vomiting/diarrhea, confusion, and a visual disturbance hallmarked by yellow/green halos around objects.

Which of the following might suggest central rather than peripheral vertigo? A. Prominent vomiting and diaphoresis B. Horizontal nystagmus on extreme lateral gaze C. Transient and episodically related to head movement D. Diplopia E. Sudden onset

D. Diplopia The answer is D. Any cranial nerve deficit should raise the suspicion for a central process as an etiology for vertigo. Some horizontal nystagmus (on extreme lateral gaze) can be a normal finding.

A 5 year old male is bitten by a snake while playing along a ditch. The child is brought to the ED by his parents with complaint of fang marks to the right index finger. On physical exam, you note absence of swelling to the right hand or fingers. He does appear to have 2 small superficial fang marks, but no bleeding or oozing is present. Vital signs are normal. What is the next most appropriate step in the management of this patient? A. Administer weight based antivenom in pediatric patients B. Administer prophylactic antibiotics with gram positive sensitivity C. Admit for observation of potential compartment syndrome D. Discharge home in 8 hours if patient's exam remains unchanged

D. Discharge home in 8 hours if patient's exam remains unchanged The answer is D. The patient is unlikely to suffer envenomation if he does not have any local or systemic symptoms in 8 hours. The dosage of antivenom is dependent on the degree of symptoms and children receive a proportionately higher dose compared to adults. Prophylactic antibiotics are not recommended

The most common cause of intrinsic lower gastrointestinal (GI) bleeding in an adult is: A. Cancer B. Inflammatory bowel disease C. Polyps D. Diverticulosis

D. Diverticulosis The answer is D. Diverticulosis and angiodysplasia account for 80% of lower GI bleeds. In approximately 10% of all patients with GI bleeding, no source of bleeding will be found.

With regard to U.S. Emergency Medical Services (EMS) systems, all of the following are true EXCEPT: A. EMS medical directors do not have to be trained, or board-certified, in emergency medicine. B. EMS fellowships are available for both ground and air transport, however no EMS subspecialty certification exists. C. EMS is an integral component of disaster management. D. EMS systems operated by a government agency (e.g. a city department of public health) have no malpractice liability. E. There is evidence that helicopter EMS transport for injured patients results in improved mortality.

D. EMS systems operated by a government agency (e.g. a city department of public health) have no malpractice liability.

Which of the following groups has an increased risk of ingested foreign body? A. Smokers B. Asthmatics C. Diabetics D. Edentulous

D. Edentulous Multiple studies have noted that ingested foreign bodies are relatively more common in pediatric, edentulous, incarcerated, and psychiatric patients. No studies that show that asthmatics, tobacco smokers, diabetics, or hypertensives are more likely to ingest foreign bodies.

For a young otherwise healthy patient in anaphylactic shock, the initial best treatment of those listed below is: A. Dopamine B. Broad spectrum antibiotics C. Steroids D. Epinephrine E. Diphenhydramine

D. Epinephrine

A 35 year old female is brought to the emergency department after family members called the police to say she was threatening to kill herself by jumping out a window. She has a long history of depression. Regarding suicide, which of the following statements is FALSE? A. The majority of suicide attempts involve minor injuries or drug overdoses. B. All states have laws giving law enforcement the right to place into custody any individual suspected of being a danger to themselves or others. C. The patient's room needs to be cleared of all potentially dangerous objects such as blunt instruments, glass objects, and the patient's belongings. D. Family sitters provide the best option for close observation of suicidal patients since they often have a calming influence on the patient.

D. Family sitters provide the best option for close observation of suicidal patients since they often have a calming influence on the patient. The answer is D. For any patient presenting with suicidal ideation, the emergency department physician must first stabilize medical condition as most attempts involve minor injury or drug overdoses treatable by emergency room staff. Secondly, all objects and substances should be kept strictly out of reach of the suicidal patient. Once stabilized these patients may be kept under direct supervision. It is not recommended that family members provide the direct supervision because of a possibility of collaboration between family and patient to leave the hospital. In this event, or even before coming into the hospital, all law enforcement has the right to bring into custody any patient at risk of harming self or others.

A 70 year old female presents to the Emergency Department with 3 days of intermittent right-sided abdominal pain. The patient has had associated symptoms of nausea and vomiting. On physical examination, the patient is exquisitely tender in the right side of the abdomen with mild distension. Xray films of the abdomen show pneumobilia and multiple air-fluid levels. What of the following is the most likely diagnosis? A. Acalculous cholecystitis B. Ascending cholangitis C. Cecal volvulus D. Gallstone ileus

D. Gallstone ileus

Which of the following symptoms is not associated with epidural hematomas? A. Severe headache B. Sleepiness C. Nausea D. Hemotympanum E. Neurologic deficits

D. Hemotympanum The answer is D. Although hemotympanum may be found in a patient with an epidural hematoma, it is specifically associated with basilar skull fracture.

A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain, progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F). On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is not an acceptable next step? A. MRI of the spine B. Analgesia C. Foley catheter to drain the bladder D. Hospital admission for neurosurgical consultation in the morning E. Antibiotics to cover a broad spectrum of organism

D. Hospital admission for neurosurgical consultation in the morning he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus, chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder decompression for symptomatic relief is important, as is analgesia

Regarding the diagnosis and treatment of hypoglycemia, which of the following is correct? A. Patients who overdose on oral hypoglycemic agents such as sulfonylureas must have their serum glucose monitored for a minimum of 6 hours before emergency department discharge. B. Patients with type 1 diabetes do not typically develop hypoglycemia. C. Glucagon, administered intramuscularly or subcutaneously, is a safe and universally effective means for increasing blood sugar in hypoglycemic patients. D. Hypoglycemia can present with virtually any neurological deficit. E. Hypoglycemia in adults is typically symptomatic at or below serum glucose of 60 mg/dL.

D. Hypoglycemia can present with virtually any neurological deficit. The answer is D. Glucagon is ineffective in patients without adequate glycogen stores, as would be expected in alcoholics. Further, glucagon can precipitate a severe lactic acidosis in patients with glycogen storage diseases and therefore should not be used in children with hypoglycemia of unknown etiology. Typical symptoms of hypoglycemia include sweating, tachycardia, nervousness, hunger, and neurologic symptoms. Symptoms should not be attributed to hypoglycemia unless the level falls below 40-50 mg/dL. Type 1 diabetics practicing strict control of serum glucose are at high risk for hypoglycemic episodes precipitated by skipping a meal, or by increasing energy output or insulin dose. Due to the extended half-lives of the oral hypoglycemic agents, hospitalization and 24-hour observation (at minimum) are the typical management for overdose of these agents.

A 25 year old previously healthy male presents 7 hours after a rattlesnake bite to his right lower leg. You confirm it is a pit viper based on a photo taken by his friend. Exposing the affected leg reveals a grossly edematous, tender, ecchymotic and tense calf with small bullae forming near the bite. There are preserved pulses and paresthesias in his foot. There is intense pain with passive ranging of the ankle. Which of the following is the most appropriate management of this patient's condition? A. Immediate administration of the FabAV antivenin with ICU admission and surgical consult B. Immediate application of a proximal tourniquet to prevent systemic spread of toxin, FabAV antivenin, and surgical consult in the Emergency department C. IV mannitol and elevation of the extremity with ICU admission D. Immediate decompressive fasciotomy in the OR, along with administration of FabAV antivenin

D. Immediate decompressive fasciotomy in the OR, along with administration of FabAV antivenin

An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture site has a yellowish tinge without blood. Of the following choices, which is the most appropriate management for this patient? A. No specific treatment required B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up C. Placement of tooth fragment in saline gauze, outpatient dental follow-up D. Immediate dental consult to avoid abscess formation E. Replace fractured piece and place acrylic splint

D. Immediate dental consult to avoid abscess formation Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood. These fractures require immediate dental consultation to prevent abscess formation.

A 22 year old man is punched in the nose during a fight. He presents to the emergency department with obvious nasal bone deformity. Pressure controls the bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact vision and extraocular movement. The oropharynx and mandible are unremarkable. Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step? A. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum B. Plastic surgery consult for immediate reduction of nasal fracture C. Facial CT scan to rule out more serious facial fractures D. Incision and drainage of the septal hematoma followed by nasal packing E. Needle aspiration of the septal hematoma

D. Incision and drainage of the septal hematoma followed by nasal packing

Which of the following is correct regarding the use of corticosteroids in acute asthma exacerbation? A. Beneficial effects occur within the first hour of administration. B. Intravenous steroids are superior to the oral route C. Tapering is needed with all corticosteroid regimens D. Inhaled steroids should be avoided

D. Inhaled steroids should be avoided The answer is D. Oral and intravenous steroids are equally efficacious in treating an asthma exacerbation. Yet, in the setting of a severe asthma exacerbation, a patient may have difficulty taking oral medications and the intravenous route is preferred.

Dermatological anthrax may occur wherever spores come into contact with the skin. Of the following options, which statement is FALSE concerning dermatological anthrax: A. Mortality rates are over 20-30% lower than for pulmonary anthrax. B. Antibiotics do not affect the course of local disease. C. Characteristic lesion is a black escar preceded by a vesiculopapular lesion 1 week prior. D. Initial diagnosis is usually made by Gram's stain analysis. E. The organism most likely to cause dermatological anthrax is Bacillus anthracis.

D. Initial diagnosis is usually made by Gram's stain analysis. Diagnosis of cutaneous anthrax is usually made on a clinical basis, often after determining patient exposure while taking the history. In the future, PCR methods may become widely available and useful to make definitive diagnoses. Treatment for cutaneous anthrax is aimed at preventing the dissemination of a disease which is complicated by a significantly higher mortality.

A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden and severe low back pain. The pain radiates down his right leg and he develops numbness over the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to pinprick over the dorsum of the right foot (medially) and some weakness in right foot dorsiflexion. At which level is a protruding intervertebral disc most likely? A. L1-L2 B. L2-L3 C. L3-L4 D. L4-L5 E. L5-S1

D. L4-L5 The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5.

A 45 year old female patient presents to the emergency department in the care of her husband with a complaint of agitation and anxiety. Her husband states that she has been acting "strangely" for the past several days. She's been hyperactive, "agitated", and sometimes delusional. She is previously healthy but has allergies to penicillins, iodine, and morphine. On exam, the patient is clearly anxious and frustrated with the visit. She's diaphoretic and on cardiovascular exam a harsh systolic murmur is heard as well as an irregularly irregular rhythm. Vital signs show a temperature of 101.5, HR 123, BP 175/98, RR 27, and SpO2 98% on RA. An EKG shows rapid atrial fibrillation. What is the definitive treatment for her condition? A. Aspirin, benzodiazepines, fluids B. Acetaminophen, haloperidol, atenolol C. Diltiazem, benzodiazepines, IV fluids D. Lithium, propranolol, acetaminophen

D. Lithium, propranolol, acetaminophen

A 26 year-old presents with agitation, chest pain and a heart rate of 142 bpm after intranasal cocaine use. The EKG is normal except for sinus tachycardia. What is the best medication to use in this situation? A. Haloperidol B. Esmolol C. Diphenhydramine D. Lorazepam

D. Lorazepam The answer is D. Benzodiazepines are the treatment mainstay for cocaine toxicity. Lorazepam and diazepam can be titrated to treat the symptoms of agitation and increased adrenergic tone common to patients with cocaine toxicity. Beta blockers should not be administered due to a potential for unopposed alpha-adreneric stimulation and resultant hypertension. Haloperidol and diphenhydramine can contribute to the hyperthermia common to patients with cocaine toxicity.

A 67-year old male presents in acute respiratory failure. You have chosen etomidate as the induction agent to perform rapid sequence intubation (RSI) on your patient. He is allergic to eggs and penicillin. Which of the following is true regarding etomidate? A. Has a large side effect profile and other agents should be considered first for induction in RSI B. Is not safe to use in patients with cardiovascular disease due to its detrimental effects on myocardial contractility C. It should not be used in patients allergic to soy or eggs D. May cause transient adrenal suppression and should be used with caution in septic patients

D. May cause transient adrenal suppression and should be used with caution in septic patients The answer is D. Etomidate has an acceptable side effect profile and is one of the primary induction agents in RSI. It is a sedative, reduces anxiety and is cardio-protective. Therefore it is primarily indicated for induction when decreased myocardial contractility is a concern. Patients allergic to soy or eggs should not receive propofol, but etomidate is safe to administer. Etomidate has been known to cause transient adrenal suppression and its use in septic patients is controversial.

Severe lead toxicity can commonly result in which of the following clinical symptoms A. Stocking glove peripheral neuropathy B. Constipation C. Dermatitis D. Memory loss

D. Memory loss The answer is D. Lead toxicity affects a variety of systems. The central nervous system effects are many and range from encephalopathy and seizure to sleep disturbance and memory deficits. The peripheral nervous system can also be involved, with paresthesias and wrist drop being common. Colicky abdominal pain is often present. While dermatitis is not common in lead poisoning, you can see bluish lead lines on the gingiva.

A 65 year old male with a history of poorly controlled COPD presents to the emergency department with increasing dyspnea, rhinorrhea, cough, and sputum production over the last three days. He denies fever or chest pain. His last visit resulted in a 3 day ICU stay one month ago. His vital signs are as follows: BP 145/95, HR 85, RR 30, SpO2 89%, Oral temp 98.0 °F. His exam is significant for respiratory distress and diffuse inspiratory and expiratory wheezes. His chest X-ray and EKG are unchanged from 1 month ago but the patient's mental status deteriorates during your treatment. Which of the following are the best initial ventilator settings for this patient after RSI: A. Mode: IMV FIO2:100% Rate: 14 TV: 10 mL/kg B. Mode: AC FIO2:100% Rate: 12 TV: 12 mL/kg C. Mode: IMV FIO2:60% Rate: 10 TV: 10 mL/kg D. Mode: AC FIO2:100% Rate: 8 TV: 8 mL/kg

D. Mode: AC FIO2:100% Rate: 8 TV: 8 mL/kg

A 15 year old boy dives into a swimming pool, hits his head on the bottom, and subsequently is found to have no sensation or motor function below the nipple line. His vital signs are: T 97.9, HR 76, BP 80/40, RR 12, SPO2 84%. He has no JVD and his lungs are clear. The patient's diagnosis is: A. Sepsis B. Hypovolemic shock C. Near drowning D. Neurogenic shock E. Spinal shock

D. Neurogenic shock The answer is D. The patient is most likely suffering a spinal cord injury, producing a disruption of the autonomic nervous system leading to vasodilation and hypotension (without the expected tachycardic response). This entity, called neurogenic shock, is a type of distributive shock like anaphylactic shock It is important to rule out other internal injuries in this patient, and then institute therapy with a pressor agent such as phenylephrine. Spinal shock is not truly a shock state, but is paralysis and a sensory deficiency level w/ areflexia.

A 2 year old is brought in to the emergency department by his mother for difficulty breathing. The mother thinks he might have swallowed or aspirated something. In regards to this patient, which of the following is TRUE regarding foreign body aspiration or ingestion? A. Large objects in the upper airway typically present with mild symptoms B. Small objects in the lower airways typically present with the most severe symptoms C. The most difficult objects to remove are stiff, non-conformable objects D. Objects lodged in the proximal airway have the worst prognosis

D. Objects lodged in the proximal airway have the worst prognosis Large objects in upper airway and trachea have the worst prognosis and typically present with the most severe symptoms.

A 19 year old male presents to the emergency department with allergic-mediated pruritis over large portions of his body. Which of the following is true regarding this condition? A. H2 antagonists such as ranitidine or famotidine have never been shown to provide benefit. B. Topical antihistamine agents should be encouraged to manage the pruritis. C. There is no role for therapies such as Domeboro solution (1:10 diluted aluminum sulfate soaks), potassium permanganate baths, and oat-meal baths. D. Oral doses of antihistamines should be encouraged initially. E. Second generation antihistamines such astemizole, fexofenadine, and loratadine are more effective but cause increased levels of sedation and should be avoided if possible.

D. Oral doses of antihistamines should be encouraged initially. The answer is D. Oral administration of diphenhydramine or hydroxyzine (25 to 50 mg po q6H) is an appropriate adult dose and is effective for pruritis. Intravenous administration can also be used. Topical antihistamines are quickly absorbed, making it difficult to predict the actual dosing if a patient aggressively applies the preparation. Thus, use over large areas of the body should be avoided especially if the patient is currently taking oral antihistamine. The bath or soaking therapies are also recommended to control large areas of pruritis. Second generation antihistamines, although more costly, have lower dosing frequency requirements and cause less sedation.

Regarding esophageal perforation, which of the following is INCORRECT: A. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation. B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. C. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy. D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus. E. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction.

D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus. Over 90% of spontaneous esophageal perforations occur in the *distal* esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.

Toxicological screening is indicated in which patient with suicidal ideation? A. Patient who ingested unknown amount ibuprofen 48 hours earlier B. Patient who threatens to cut both wrists with a knife C. Patient who takes lithium for bipolar affective disorder D. Patient who ingested a "bottle" of tylenol

D. Patient who ingested a "bottle" of tylenol The answer is D. Routine toxicological screening is unnecessary in the evaluation of suicidal patients in whom there are no clinical indications for such testing. With the exception of acetaminophen, essentially all patients with dangerous overdoses and poisoning will demonstrate clinical signs within several hours of ingestion. History, physical examination, and risk determination of suicide, however, is part of the routine evaluation of the suicidal patient.

A 68 year old diabetic male, previously living independently, is brought in by his family. He has been acting abnormally for two days. The family reports he is awake all night and sleepy during the day. He is confused about where he is and the time of day, and sometimes doesn't recognize his daughter and son-in-law. At other times he appears and acts almost normally. Which of the following is *true* regarding his condition? A. Infection is an unlikely cause of his condition unless his temperature is > 102°. B. Dementia is the most likely cause of his condition and the family must be counseled. C. Medications are an unlikely cause of this condition in the elderly. D. Patients can be agitated and combative, or calm and quiet in this condition. E. Treatment includes maximizing sensory input.

D. Patients can be agitated and combative, or calm and quiet in this condition. The scenario describes a patient with delirium, a condition in which patients may be agitated and combative, or calm and quiet. The most common cause of delirium in the elderly is medications, accounting for 22-39% of cases. Infection and metabolic abnormalities are other common causes, and delirium may be the first indication that an infection is present. An elderly patient with delirium resulting from an infection may have a normal temperature, a low temperature, or a high temperature. Delirium is characterized by an *acute onset of a disturbance in level of consciousness, cognition and attentiveness*. It has a fluctuating course, and alterations in sleep-wake cycles are common. Dementia, in contrast, has a slower course, that is gradually progressive over months to years, and consciousness is preserved. In addition to correcting the underlying cause, it is important to minimize stimulation, because the patient with delirium has difficulty processing stimuli.

The most common cause of adult upper gastrointestinal (GI) bleeding is: A. Varices B. Esophagitis C. Mallory-Weiss tears D. Peptic ulcer disease (PUD)

D. Peptic ulcer disease (PUD) The answer is D. The most common causes of upper GI bleeding are (in descending order of frequency): PUD, gastric erosions, varices, Mallory-Weiss tears, esophagitis, and duodenitis.

A trauma patient resuscitated in the ED, has a post-tube thoracostomy computed tomography (CT) scan as depicted in the figure. What finding is present? [image] A. Pericardial tamponade B. Aortic rupture leading to a right hemothorax C. Chest tube not within the thoracic cavity D. Persistent pneumothorax

D. Persistent pneumothorax The answer is D. The chest CT shows a chest tube in place on the right, with incomplete reinflation of the lung. The left hemithorax is grossly normal, but there is a large right pulmonary contusion, as well as pneumothorax and small hemothorax on the right. The aorta appears intact (aortic injuries usually leak into the left hemithorax, not the right).

A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F, BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a tension pneumothorax. Of the following, which is the most appropriate next step in this man's care? A. Placement of a chest tube followed by a chest xray to determine proper placement B. Transfusion of 2 units of O-negative packed red blood cells C. Performance of a chest CT scan to further delineate the pathology D. Placement of a needle decompression device, followed by repeat CXR

D. Placement of a needle decompression device, followed by repeat CXR This patient needs emergent chest decompression and this is rapidly done by needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime. Transfusion of blood does nothing to correct the physiology of a tension pneumothorax

A 14 year old presents just after smoking crack cocaine and complains of chest pain. He describes it as sharp and stabbing in the middle of his chest. His EKG is normal. The intern reads the CXR as "negative" but your supervising resident asks you to have another look (see Figure), after which you make the diagnosis of: [image: big round heart, black in mediastinum, widened] photo courtesy of eMedicine.com A. Pneumonia B. Aortic dissection C. Congestive heart failure D. Pneumomediastinum

D. Pneumomediastinum The answer is D. Look closely along the right heart border and mediastinum. There is a thin strip of air. Pneumomediastinum and pneumopericardium result from Valsalva maneuvers, barotrauma, asthma, and cocaine inhalation from positive pressure devices. On physical exam there may be a Hamman's sign or mediastinal crunch heard over the precordium. Westermark's sign is dilation of pulmonary vessels proximal to a pulmonary embolism resulting in a cut-off appearance of the vessel on CXR.

A 24 year old female presents with fever, vomiting, right flank pain, and dysuria. Her UA reveals leukocyte esterase. The correct diagnosis is: A. Choleycystitis B. Cystitis C. Right lower pneumonia D. Pyelonephritis E. Appendicitis

D. Pyelonephritis

A 22 year old college student arrives in the emergency department complaining of painful, tearing, and redness in the right eye. Blinking increases the pain. She wears contact lenses for distance vision but has no other ocular history. During your examination, you evert her upper eyelid (see Figure). ED management of this patient includes: [image something stuck in inflammed eyelid] A. Instructions to wear an eye patch for the next 48 hours B. Avoidance of Fluorescein examination due to concern for globe rupture C. fluorescein examination of the right cornea D. Removal of the foreign body with a moistened cotton swab

D. Removal of the foreign body with a moistened cotton swab The cornea is one of the most sensitive parts of the body. Tiny foreign bodies (such as the one in the Figure) lying on the surface of the cornea or on the underside of the eyelids can cause tremendous discomfort as they stimulate thousands of corneal nerve fibers with each blink. The patient may not see the foreign body but will complain of tearing and conjunctival reddening. It is important to differentiate between intraocular and extraocular foreign bodies. Intraocular foreign bodies (those that penetrate the globe) may diminish visual acuity by distorting the lens or by causing a vitreal hemorrhage. Extraocular foreign bodies are unlikely to diminish visual acuity unless they lie directly in the visual axis (in line with the pupil). In either case, the patient presenting to the emergency department with a suspected ocular foreign body should receive an eye examination that includes testing of visual acuity while the patient wears corrective lenses (not contact lenses). The proper management of a suspected foreign body includes eversion of both lids, which in this case, resulted in identification of the foreign body. A moistened cotton swab easily removes a foreign body on the palpebral conjunctiva. Fluorescein should then be applied to the cornea. Using a magnifying glass or a slit lamp, examine the cornea for epithelial defects. If a corneal abrasion is identified, the patient should refrain from wearing contact lenses until it has healed. Wearing contact lenses over a corneal epithelial defect predisposes the patient to forming an infectious corneal ulcer. There is no need to patch the eye because patching confers no benefit in healing corneal abrasions.

You are evaluating a woman with pelvic pain. You think that pelvic inflammatory disease (PID) is the cause of her symptoms. Which historical, physical exam or diagnostic finding, if present, would raise your suspicion for PID as the diagnosis? A. She is pregnant at an estimated gestational age of 15 weeks B. An ultrasound demonstrates no blood flow to her left ovary C. She has right lower quadrant tenderness without cervical discharge D. She has an intrauterine device (IUD) in place

D. She has an intrauterine device (IUD) in place

A healthy 32-year old female comes to the emergency department complaining of acute severe lower back pain which is worse with coughing. Her lower spine is tender to palpation. Three days prior she had a lower extremity surgical procedure performed under epidural anesthesia. The surgery and post-operative period were uneventful. The etiology of this patient's pain is most likely: A. Adhesive arachnoiditis B. Anterior spinal artery thrombus C. Spinal epidural abscess D. Spinal epidural hematoma

D. Spinal epidural hematoma The answer is D. The back pain in this patient is likely secondary to a space-occupying lesion in the spinal canal. Epidural hematoma is the most likely option since it was sudden in onset, worse with coughing and occurred soon after the procedure. Adhesive arachnoiditis (A) would be manifest as a progressive loss of nerve function. Anterior spinal artery thrombus would be expected to present with painless paraplegia (B). A spinal epidural abscess would be unlikely so soon after the procedure and is more gradual in onset. The patient is not immunosuppressed and she does not have a fever, rigors or sweats which can be seen in up to 75% of patients. --For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practices, 7th edition, pages 1391-2, 1396

All of the following are common pathogens in otitis media EXCEPT: A. viral agents B. Moraxella catarrhalis C. Strep pneumoniae D. Staph. aureus E. H. influenzae

D. Staph. aureus

A 2 and a half year old girl is brought in to the emergency department by her mother for "loud breathing" and a fever. The mother states the child has been previously healthy and is up to date on all her vaccines. Initial evaluation of the child reveals an ill-appearing child with her head propped upright, who is drooling and making stridorous noises. Her vital signs are notable for a temperature of 104.2 F. Which of the following is most likely in this child? A. Chlamydia pneumonia B. choanal atresia C. viral upper respiratory tract infection D. Stapholococcus aureus retropharyngeal abscess E. viral croup

D. Stapholococcus aureus retropharyngeal abscess This patient exhibits several classic symptoms of retropharyngeal abscess including fever, neck stiffness, and drooling, as well as her generally toxic appearance. Retropharyngeal abscess in children is often associated with foreign body ingestion leading to perforation of the hypopharynx or esophagus. Pneumonia, viral croup and upper respiratory tract infection are unlikely to cause airway obstruction, which is suggested by this patient's drooling. Choanal atresia is typically diagnosed in infancy. Another consideration in this patient would be epiglottitis; however, given her vaccination history, she would be less likely to contract epiglottitis from H. influenzae Type b, which is the most common causative organism.

A right-handed patient sustains a circumferential burn (see figure) to the distal right forearm and hand, which is cool despite warm ambient temperature. Regarding the initial assessment and management of the patient, which of the following is correct? [image] A. As shown in the Figure, the burn represents about 10% of total body surface area B. Pain medication should be withheld pending obtaining operative consent for emergency burn debridement C. Prophylactic penicillin should be given to any patient with a significant burn D. The involved areas of this 3rd-degree burn would be expected to be mostly insensate

D. The involved areas of this 3rd-degree burn would be expected to be mostly insensate The answer is D. The answer is D. 3rd-degree burns are often insensate; withholding pain medication is not necessary; one hand is about 2-3% TBSA, and prophylactic antibiotics are not recommended.

Regarding gastrointestinal bleeding, which of the following is TRUE? A. The mortality of lower gastrointestinal bleeding is higher than the mortality of upper gastrointestinal bleeding B. The most common cause of upper gastrointestinal bleeding in both adults and children is peptic ulcer disease C. Patients with a history of gastrointestinal bleeding almost always bleed again from the same site D. The majority of bleeding from diverticula occurs from the right side of the colon

D. The majority of bleeding from diverticula occurs from the right side of the colon The answer is D. There are many specific etiologies that cause gastrointestinal bleeding. In general, however, the mortality of upper gastrointestinal bleeding is higher than lower gastrointestinal bleeding. In adults, the most common cause of upper gastrointestinal bleeding is peptic ulcer disease. In children, it is esophagitis. Unfortunately, it can be difficult to diagnose the source of gastrointestinal bleeding as the bleeding may often stop and start spontaneously or from different sites.

In establishing a differential diagnosis of abdominal pain, which of the following is true? A. Radiation of pain to the scapula is suggestive of acute hepatitis. B. Cervical motion tenderness is a useful physical finding for differentiating women with or without acute appendicitis. C. In patients with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should be a top consideration. D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology. E. Diverticulitis tends to cause pain in the right upper quadrant.

D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology. The answer is D. Pain prior to nausea and vomiting is often suggestive of a surgical etiology of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.

A 25 year old male is brought to the emergency department by his family, with a complaint of feeling depressed for the past week. In obtaining the history, which of the following statements regarding this patient would support a diagnosis of major depression? A. The screening mnemonic in SAD CAGES is negative B. The patient has no history of medical illness C. There is no family history of depression D. The patient has a history of Crohn's disease

D. The patient has a history of Crohn's disease The answer is D. In SAD CAGES is a screening mnemonic for symptoms, not causes, of major depression. Depression is more common in patients with history of other medical illnesses, some of which may actually cause depressive symptoms. As compared with major depression, dysthymic disorder is a more chronic, and less severe, form of depressive illness.

You are practicing in a trauma center a receive a call from an outlying facility that they would like to transfer a male patient to you with a spinal cord injury after significant flexion and compression of the vertebral body. What does this injury pattern tell you about the patient's symptoms? [image] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. The patient likely has symptoms on only one side of the his body B. Patients with anterior cord syndromes have only sensory symptoms C. The patient likely disproportionately greater weakness in the lower extremities (as compared to the upper extremities) D. The patient likely has paralysis and loss of sensation to pain and temperature bilaterally below the lesion

D. The patient likely has paralysis and loss of sensation to pain and temperature bilaterally below the lesion The answer is D. Answer A describes central cord syndrome, typically caused by hyperextension. Answer C describes Brown-Sequard Syndrome, caused by hemisection of the cord. Answer B is anterior cord, often caused by flexion and injury to the anterior spinal artery; patient with this cord syndrome often have more than just sensory symptoms.

You are treating a 25 year old male with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's disease, you know that: A. Lesions are typically contiguous B. Small bowel involvement is rare C. Bleeding is common due to superficial bowel wall inflammation D. There is a small increased risk of colon cancer

D. There is a small increased risk of colon cancer Although Crohn's disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as "skip lesions") and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.

Many resuscitation drugs can be given via endotracheal tube. When this method is used, what (if any) change in dosing is recommended? A. One-tenth the standard dose should be used B. One-half to one-third the standard dose should be used C. Ten times the standard dose should be used D. Two to three times the standard dose should be used

D. Two to three times the standard dose should be used The answer is D. Several medications can be given via the endotracheal (ET) tube as well, if IV or IO access has not been established. The optimal dosing of drugs administered endotracheally has not been established, but 2-2 1/2 times the IV route is generally accepted.

Delirium is defined as: A. a stressed psychological state resulting from extreme emotional stimulus B. abnormal behavior associated with decreased alertness and decreased psychomotor activity C. abnormal behavior accompanied by hallucinations, occurring in an oriented patient D. a global inability to relate to the environment and process sensory input

D. a global inability to relate to the environment and process sensory input Alterations in mental status resulting from extreme emotional stimulus would usually be functional abnormalities. Patients with delirium manifest increases in alertness and psychomotor activity. Delirium is more than simple alteration of mental status. Delirium is an organic confusional state. Patients with delirium may have hallucinations, but patients who are oriented are more likely to have functional causes for altered mental status.

Labetalol differs from propanolol in that labetalol is: A. a mixed alpha-antagonist and beta-agonist B. selective for the alpha2-adrenergic receptor C. characterized by an elimination half-life of minutes rather than hours D. an alpha-and beta antagonist E. a mixed alpha1-agonist and beta-antagonist

D. an alpha-and beta antagonist D. Labetalol is a non-selective beta-blocker that also possesses alpha-blocking effects. Metoprolol, atenolol, and esmolol are examples of beta1-selective beta-blockers. Esmolol has an elimination half-life of minutes.

A 19 year old female college student presents to the emergency department with fever, headache, and confusion. Physical exam reveals T103. She is lethargic. The HEENT exam is normal, she has nuchal rigidity, and her lungs are clear. Of the following choices, the next step in her treatment should be: A. levofloxacin PO or IV B. head CT C. head CT, followed by lumbar puncture D. ceftriaxone IV E. azithromycin IV

D. ceftriaxone IV The answer is D. In patients with meningitis, early antibiotics administration is of the utmost importance. Antibiotic administration should not be delayed to await diagnostic work up. Ceftriaxone, administered in some regions with vancomycin depending on the resistance profile of likely etiologic agents, is generally considered an antibiotic of choice in meningitis. Azithromycin and levofloxacin do not have good CNS penetration and therefore are not indicated for meningitis.

A 23 year old male college student presents to the emergency department with fever and a headache. He has been ill for 3 days, with fever starting yesterday. Today he noted a rash on his legs. Exam is remarkable for photophobia, neck stiffness and pain with movement, and a petechial rash on his legs and hands. As an astute medical student, you suggest to your resident that an LP needs to be performed to rule out meningitis. Your resident challenges you further and asks what studies you're going to order on the CSF. What do you tell him? A. albumin, LDH, cell count, glucose B. cell count, glucose, crystal analysis, gram stain C. gram stain, LDH, cell count, albumin D. cell count, glucose, protein, gram stain

D. cell count, glucose, protein, gram stain

Contact lens use predisposes patients to which condition? A. central retinal vein occlusion B. retinal detachment C. hyphema D. corneal ulcer E. acute angle closure glaucoma

D. corneal ulcer

Regarding the treatment of suspected but not confirmed adrenal insufficiency, which of the following is most appropriate? A. hydrocortisone 100mg IV every 6 hours B. cortisone 100mg IM every 6 hours C. withholding of steroids until confirmation of the diagnosis of adrenal insufficiency D. dexamthasone 4mg IV every 6 hours E. cosyntropin 0.25mg IV x 1

D. dexamthasone 4mg IV every 6 hours The answer is D. Dexamthasone is the treatment of choice in suspected but not confirmed adrenal insufficiency. It will not affect the serum cortisol level; therefore, it will not interfere with the diagnosis of adrenal insufficiency using the ACTH stimulation test. Administering cosyntropin, a synthetic form of ACTH, and measuring the serum cortisol levels typically perform the ACTH stimulation test. In confirmed adrenal insufficiency, hydrocortisone IV or cortisone IM are the treatments of choice.

Which of the following describes the most commonly indicated initial approach in neonatal resuscitation? A. establish effective ventilation B. chest compressions C. medications D. dry, warm, position, suction, stimulate E. oxygen

D. dry, warm, position, suction, stimulate

A patient with the rhythm shown in the Figure should be treated with: [image shows asystole] A. amiodarone B. verapamil C. defibrillation D. epinephrine

D. epinephrine The answer is D. The flat line above is characteristic of asystole. This is mechanical and electrical standstill. It is important to check that the monitor is working and to check a second lead to rule out very fine ventricular fibrillation. The treatment of choice is epinephrine or vasopressin and atropine

A 27 year old G2P1 female presents to the emergency department in labor at 41 weeks estimated gestational age. The amniotic sac breaks on admission and has thick, brown-tinted fluid. Prior to other steps in resuscitation, the newborn infant should: A. be resuscitated with a bag-valve mask for 45 to 60 seconds. B. receive 500,000u penicillin-G intramuscularly. C. receive 8 mg doxycyline intravenously. D. have his/her trachea suctioned. E. be left unswaddled.

D. have his/her trachea suctioned. In order to prevent aspiration of meconium, the infant should have his/her airway suctioned. (This recommendation is the standard of care at this time, but is becoming somewhat controversial. Some believe the introduction of the endotracheal tube may further contaminate the distal respiratory tract with meconium.) Using a bag-valve mask before suctioning could precipitate meconium aspiration. A dose of penicillin should not delay resuscitation. Doxycycline is contraindicated in patients younger than 8 years. Swaddling and placing of the newborn in an incubator helps to prevent hypothermia.

Which of the following is not a known complication of subarachnoid hemorrhage in the immediate several weeks following the initial bleed? A. rebleeding B. seizure C. cerebral artery vasospasm D. hypernatremia E. hydrocephalus

D. hypernatremia

A 58 year old male with a past medical history significant for more than 30 pack years of tobacco use and recently diagnosed COPD presents to the emergency department with an episode of shortness of breath and increased sputum production for the last several days, which became acutely worse overnight. Which of the following findings would make the patient a good candidate for initiation of noninvasive positive pressure ventilation? A. hemodynamic instability B. noncompliant with face mask for oxygen supplementation C. markedly increased airway secretions D. hypoxia refractory to initial management

D. hypoxia refractory to initial management

Which of the following is FALSE regarding the common skin disorder, seborrheic dermatitis? A. characterized by erythema and waxy scaling B. uncommon between infancy and puberty C. differential diagnosis includes Tinea capitis, psoriasis of scalp, cutaneous lupus erythematosus D. initial therapy often consists of high dose topical steroids E. found in skin folds and hair-bearing of face scalp, chest and groin

D. initial therapy often consists of high dose topical steroids The answer is D. Initial therapy for seborrheic dermatitis is application of anti-dandruff shampoo lathered onto the area and left on for 5-10 minutes. Shampoos can contain zinc pyrethrin (Head and Shoulders), selenium sulfide (Selsun Blue), salicylic acid (Neutrogena T-Sal) or tar (Polytar or Neutrogena T-Gel). The other answers are all correct regarding seborrheic dermatitis.

A 42 year old male with end stage liver disease due to chronic hepatitis C infection arrives to the emergency department in stable condition after an unsuccessful suicide attempt by bilateral wrist laceration. He reports no history of depression or psychiatric disorder. Aside from his liver disease, for which he takes interferon alpha and ribavirin, he reports that he is in good health and takes no other medications. Which of the following factors increased this patient's risk of new-onset suicidal ideation? A. end-stage liver disease B. chronic hepatitis C infection C. ribavirin therapy D. interferon alfa therapy

D. interferon alfa therapy The answer is D. Interferon alfa, an important cytokine in the early immune response to viral infection, has both antiproliferative and antiviral properties. It is the only therapy approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa has been associated with high rates of central nervous system side effects, including anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal ideation. Clinicians should always look up the side effects of their patients' medications, especially unfamiliar drugs. This can both expedite diagnosis of drug-induced complications and prevent them with appropriate pretreatment. Pretreatment with a selective serotonin reuptake inhibitor appears to be an effective strategy to minimize depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver disease can both be difficult diseases to live with, however, these conditions are not known to significantly increase a patients' risk for new suicidal ideation. Depression is not a known side effect of ribavirin treatment. Although males have a higher percentage of successful suicide attempt than females, females have a much higher incidence of suicide attempt and ideation than males overall.

A 53 year old man with non-insulin dependent diabetes mellitus presents with pain, redness, and swelling of the right foot and lower leg, accompanied by a temperature of 102. X-rays reveal no subcutaneous gas and show no evidence of osteomyelitis. The patient has been admitted on three previous occasions for cellulitis of the right foot and notes that this episode is identical. Which of the following antibiotics is the most appropriate initial therapy for a presumed diagnosis of cellulitis? A. oral dicloxacillin B. intravenous nafcillin C. intravenous gentamicin D. intravenous ampicillin-sulbactam E. intravenous cefazolin

D. intravenous ampicillin-sulbactam Gram-positive bacteria (Streptococcus species and S. aureus) most commonly cause cellulitis in non-diabetic hosts. Penicillinase-resistant penicillins (e.g. dicloxacillin, nafcillin, oxacillin) or 1st-generation cephalosporins (cephalexin, cefazolin) can effectively treat cellulitis. However, in diabetics with recurrent cellulitis, the infection is more likely to be polymicrobial and involve gram-negative organisms. A broader-spectrum antibiotic (e.g. ampicillin-sulbactam) with coverage of gram-positive and gram-negative bacteria is recommended. Gentamicin alone is not effective against gram-positive bacteria.

The next step in treatment for a patient with ventricular fibrillation, which is refractory to multiple countershocks and epinephrine, is: A. calcium B. transcutaneous pacing C. adenosine D. lidocaine E. bicarbonate

D. lidocaine OUTDATED The answer is D. Ventricular fibrillation is primarily treated with defibrillation. If three successive shocks and epinephrine have been given, the next line agent would be an antiarrhythmic, such as lidocaine or amiodarone.

A 45 year-old construction worker has sustained a 4 cm, superficial laceration over his dorsal, left forearm by a segment of broken glass. Which of the following local anesthetics is characterized by average potency (lipid solubility), low toxicity and rapid onset of action? A. bupivacaine B. procaine C. tetracaine D. lidocaine

D. lidocaine The answer is D. Lidocaine and bupivacaine are amides but the latter is much more potent, intermediate in onset and longer lasting. Procaine and tetracaine are esters and both are slow in onset, but tetracaine is applied topically and has a potency comparable to bupivacaine. Procaine is the least potent of the listed anesthetics.

A 56 year old energy plant worker with a history of coronary heart disease and mild asthma severs a sharp, metal wire that snaps back and cuts his finger. He does not report a great deal of bleeding, but a 3-cm laceration on the distal right index finger requires sutures for repair. Of the approaches below, which is the best choice for pre-suturing anesthesia? A. lidocaine-epinephrine injection (lidocaine 2.0%, epinephrine 1:1000) as a digital nerve block anesthesia B. lidocaine-epinephrine injection (lidocaine 2.0%, epinephrine 1:1000) as a local infiltration anesthetic C. lidocaine-epinephrine topical solution (lidocaine 2.0%, epinephrine 1:1000) D. lidocaine injection (lidocaine 2%) as digital nerve block anesthetic

D. lidocaine injection (lidocaine 2%) as digital nerve block anesthetic The answer is D. In some cases surgical or dermatological consultants may utilize epinephrine-containing anesthetics in tissues with end-arterial blood supply. Although epinephrine-containing solutions are used routinely by podiatrists in digital blocks of the toes, without morbidity, when performing a digital block, it is advised to use anesthetics that do not contain epinephrine. If epinephrine-containing solutions are inadvertently used for a digital block in otherwise healthy individuals without peripheral vascular disease, it is unlikely that serious ischemic injury will occur. In the emergency department you should follow the general rule proscribing use of such agents in the digits, tip of the nose, penis, and pinna. The rationale for this prohibition is that vasoconstriction in these regions can result in ischemic complications, especially if the patient has underlying peripheral vascular disease. This patient was at risk. Standard concentrations of lidocaine are not likely to achieve effective analgesia when used topically.

A 53 year old obese woman presents to the emergency department, accompanied by three of her children, complaining of severe abdominal pain that began this afternoon after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all of the following EXCEPT: A. positive sonographic Murphy's sign B. pain in the right scapula C. leukocytosis with left shift D. marked inguinal lymphadenopathy E. aminotransferases and bilirubin within normal limits

D. marked inguinal lymphadenopathy This woman is likely suffering from acute cholecystitis. Predisposing factors include female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal limits.

A patient presents to the emergency department with alcohol intoxication (precluding a useful history) and eye pain. The external eye exam reveals an elliptically misshapen pupil, and a hyphema is also noted. A slice from a head CT (obtained due to patient's unclear history and intoxication) is shown on the right side of the Figure. Of the following choices, which is the best next step for the emergency physician evaluating this patient? [image] A. performance of emergency lateral canthal tendon release B. palpation of the globe with mild digital pressure, to determine if increased intraocular pressure is present C. topical corneal anesthesia followed by gentle sweep of a cotton swab over the eye to remove corneal foreign body D. ophthalmology consultation for intraocular foreign body

D. ophthalmology consultation for intraocular foreign body

A 72 year-old presents with an intentional overdose of a bottle of aspirin about 3 hours prior to presentation in the ED. Which of the following arterial blood gas results would you expect to come from this patient? A. pH 7.47 pCO2 31 pO2 96 HCO3 25 B. pH 7.14 pCO2 68 pO2 102 HCO3 23 C. pH 7.33 pCO2 48 pO2 58 HCO3 29 D. pH 7.45 pCO2 21 pO2 124 HCO3 14

D. pH 7.45 pCO2 21 pO2 124 HCO3 14 The answer is D. Acute salicylate overdose characteristically causes a metabolic acidosis mixed with a respiratory alkalosis. Reference

An 85 year old man is undergoing treatment for prostate cancer. He stood up this morning and had immediate severe pain in his right hip. His right leg could not bear weight. X-rays show a fracture through the right femoral neck. The physician should suspect, as the most likely entity, the following: A. elder abuse B. occult trauma C. osteochondritis D. pathologic fracture E. scurvy

D. pathologic fracture A fracture that occurs through abnormal bone is called pathologic. This should be suspected whenever a fracture occurs with minimal trauma. Metastatic carcinoma is the most likely cause of this patient's abnormal bone. Osteoporosis, scurvy, enchondromata, giant cell tumor, cysts, osteomalacia, osteogensis imperfecta, rickets and Paget's disease all weaken bones and may lead to pathologic fractures.

All of the following are suitable home-going analgesics for a patient with a corneal abrasion EXCEPT: A. narcotic analgesics B. cyclopentolate C. homatropine D. proparacaine E. over-the-counter analgesics

D. proparacaine Topical anesthetics should not be prescribed for pain relief, as many cause corneal toxicity when recurrently dosed. Cycloplegic agents like homotropine and cyclopentolate reduce ciliary spasm and offer tremendous relief. OTC and prescription analgesics also work.

Following a brawl at a local bar, a gentleman presents with an impressive right-sided periorbital ecchymosis. All of the following physical examination findings would suggest an orbital blowout fracture EXCEPT: A. diplopia with upward gaze B. right-sided infraorbital subcutaneous emphysema C. right-sided epistaxis D. proptosis E. anesthesia of the right infraorbital region

D. proptosis D. Orbital blowout fractures classically involve the *maxillary or ethmoid sinus* and consequently often cause either epistaxis (through the connection of the maxillary sinus with the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral infraorbital region. *If the inferior rectus muscle gets trapped within the fracture of the inferior orbital wall, patients will be unable to look upward causing diplopia with upward gaze*. Orbital blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should prompt physicians to suspect the possibility of a retrobulbar hematoma.

Which of the following is the most serious toxic effect of the use of MgSO4 in treatment of eclampsia? A. neonatal hypotonia B. renal failure C. Loss of deep tendon reflexes D. respiratory depression E. nausea and vomiting

D. respiratory depression Overdose of MgSO4 can lead to both maternal and neonatal complications including muscle weakness, respiratory depression, and cardiac failure. If renal failure occurs (as a result of severe pre-eclampsia/eclampsia, rather than as a result of MgSO4 itself), plasma concentration of Mg should be followed closely since the kidney excretes Mg. Other toxic effects include loss of deep tendon reflexes, SA and AV node block, respiratory paralysis, cardiovascular collapse and cardiac arrest. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 2423-2424.

Of the following choices, which diagnosis is most likely in a 50-year old male with substernal chest pain and the EKG shown in the Figure? [image ST elevated only in V1] A. pericarditis B. pulmonary embolism C. inferior myocardial ischemia D. right-ventricular myocardial ischemia

D. right-ventricular myocardial ischemia The answer is D. The EKG's marked ST-segment elevation in V1, in the absence of ST-segment elevation in the other anteroseptal leads (V2-V3), is suggestive of right-ventricular ischemia. Right-sided leads should be performed to further assess this possibility.

60 year old male presents to the emergency department with chest pain. His monitor strip, shown below, reveals: [image: unexpected, non-conducted atrial impulses. The R-R interval and P-R intervals are constant. ] A. first degree AV block B. complete heart block C. second degree AV block Mobitz Type 1 D. second degree AV block Mobitz Type 2

D. second degree AV block Mobitz Type 2 -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, page 184.

A patient with no medical history presents to the emergency department for a second opinion. Nearly a week ago, there was a rapid onset of malaise, headache, backache, and fever. A rash began to appear on the leg a few days after the initial symptoms and the patient presented to a hospital-affiliated walk-in clinic for assessment. The patient had no respiratory symptoms but was noted to have some lesions on the tongue. At the time of his assessment at the walk-in clinic, the fever had resolved and the patient was diagnosed as having a viral syndrome. At the walk-in clinic, a digital photograph of the rash was taken and inserted into his computer records (see top of Figure). It is now 3 days after the initial walk-in clinic visit. You are working in the emergency department where the patient presents complaining of a recurrence of high fevers and a spread of the rash which now involves the face, extremities, and torso (see bottom of Figure). What diagnosis is most consistent with the history and accompanying images? [image: spots ALL OVER] Image courtesy of eMedicine.com A. insect bites with secondary infection B. erythema multiforme C. varicella-zoster virus D. smallpox E. measles

D. smallpox The answer is D. The clinical presentation is more consistent with smallpox than any of the other etiologies. Insect bites may have been possible with the initial skin presentation but are much less likely given the spread of the process and the other symptoms. Erythema multiforme is rendered unlikely by the absence of drug ingestion. With chickenpox, fever occurs with the onset of the rash, which is characterized by simultaneous existence of individual lesions at differing stages. Also with chickenpox, the eruption is concentrated over the torso, and given the time course of this example, crusting should have been present if the patient had chickenpox. Since smallpox has been eradicated worldwide, any cases that do occur (e.g. secondary to terrorist activity) are likely to be misdiagnosed as clinicians are unfamiliar with the disease. After a mean incubation period of 1.5-2 weeks, there is a 2-3 day prodromal phase characterized by abrupt onset of severe headache, backache, and fever. The temperature subsides over 2-3 days. An enanthema over the tongue, mouth, and oropharynx precedes the skin rash by a day. The skin rash begins as small, reddish macules, which become papules with a diameter of 2 to 3 mm over a period of one or two days; after an additional 1-2 days, the papules become vesicles with a diameter of 2 to 5 mm. The lesions occur first on the face and extremities but gradually spread to cover the body. Pustules that are 4 to 6 mm in diameter develop about four to seven days after the onset of the rash and remain for five to eight days, followed by umbilication and crusting. As occurred in this example case, there may be a second, less pronounced temperature spike five to eight days after the onset of the rash, especially if the patient has a secondary bacterial infection. Smallpox lesions have a peripheral or centrifugal distribution and are generally all at the same stage of development. Death from smallpox is ascribed to toxemia, associated with immune complexes, and to hypotension.

A 60 year old male with known coronary artery disease presents complaining of recent chest pain. The chest pain typically occurs after exertion and lasts about 15 minutes. He takes a sublingual nitroglycerin or rests and the pain subsides. He is currently pain free. He has had similar episodes for the last 6 months with no change in frequency or intensity of the chest pain. He most likely has: A. acute coronary syndrome B. acute myocardial infarction C. unstable angina D. stable angina E. variant (Prinzmetal's) angina

D. stable angina The answer is D. Acute coronary syndrome is a spectrum of myocardial ischemia through myocardial necrosis. The spectrum includes unstable angina, stable angina and acute myocardial infarction. Unstable angina is of new or recent onset, of changing character, or angina at rest. Stable angina or angina pectoris is chronic and episodic, usually lasting 5 to 15 minutes and relieved by rest or nitroglycerin. Variant angina usually occurs at rest, often precipitated by tobacco or cocaine use. It is defined as ST elevation that resolves as pain goes away. It is thought to be due to artery spasm.

Generally speaking, a patient with a TIA history who presents with a new stroke, likely has which kind of stroke? A. there is equal likelihood for any stroke type B. embolic C. hypoperfusion D. thrombotic E. hemorrhagic

D. thrombotic The answer is D. TIAs are associated with increased risk for thrombotic strokes, the result of ulceration of cerebral artery plaque. Patients with TIA have a 5 to 6% percent chance per year of having a stroke. Antiplatelet therapy reduces risk of stroke in these patients.

A 45 year old man is brought to the E.D., with markedly altered mental status as reported by someone who stays with him at a homeless shelter. The patient is very confused and obtunded, and unable to provide a cogent history; the person who brought him to the E.D. notes the patient has a "drinking problem." The patient's vital signs are normal, except for a respiratory rate of 22. As he lays in the stretcher, his appearance is as depicted in the Figure. Of the following choices, which physical finding is most likely to be present on physical examination? A. Homan's sign B. anterior chest pain upon leaning forward, which is relieved by lying flat C. dendritic rash on the posterior thorax, with a sentinel lesion noted on the left shoulder D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion E. increase in systolic blood pressure by more than 10 mmHg with inspiration

D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion This patient has marked ascites (which may incidentally account for his mild tachypnea due to impairment of respiratory excursion). The most likely explanation given the limited information available is liver disease, and asterixis ("liver flap") as described in choice D is a likely marker of advanced hepatic failure.

A 19 year old woman is brought to the emergency department by her friends because she has been saying that she is a superhero and trying to run into traffic to prove that she is indestructible. The friends report that she has been using drugs but they do not know which ones. Which of the following pairs of ocular finding and recreational drug is commonly observed? A. dilated pupils - heroin B. internuclear ophthalmoplegia - marijuana C. pinpoint pupils - amphetamines D. vertical nystagmus - phencyclidine

D. vertical nystagmus - phencyclidine Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin) cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple sclerosis. CN VI palsy is not associated with any specific drugs.

The Figure depicts drainage from a painful dorsal index finger in a homeless man who denied systemic symptoms. The man stated he had cut his hand on a bottle a few weeks ago. Which of the following is true regarding this presentation and condition? [image] A. Outpatient amoxicillin/clavulinate is usually an appropriate treatment option. B. The injury location rules out a chance of "fight bite" injury from the patient's striking someone in the mouth. C. An X-ray is not indicated since glass from the bottle wouldn't show up. D. The patient should have painless range of motion in the involved digit. E. Admission for intravenous antibiotics and probable surgical clean-out are indicated.

E. Admission for intravenous antibiotics and probable surgical clean-out are indicated. This patient has purulent drainage from an infected finger, and will likely not have painless range of motion. The patient may have a foreign body in the wound (most glass is radiopaque) and the history may not be reliable (e.g. a "fight bite" injury remains a possibility). The lack of fever is somewhat reassuring but does not translate into appropriateness of outpatient management given the severity of infection, the anatomical location, and the patient's doubtful follow-up. There is high likelihood of involvement of important structures, including the joint space, and a digital infection of this type requires admission and surgical subspecialty consultation.

Which of the following is FALSE concerning emergency intervention for traumatic emergencies encountered by EMS paramedics? A. Severely injured patients require endotracheal intubation. B. Intubating head injured patients may result in dental or soft tissue damage. C. Increasing MAP to near normal levels may cause hemodilution and decreased oxygen saturation. D. When short transport time is expected, use of pneumatic antishock garment appears to be associated with increased mortality in penetrating torso injuries. E. Aggressive fluid resuscitation prior to surgical hemostasis is an absolute standard of care to minimize post-traumatic morbidity.

E. Aggressive fluid resuscitation prior to surgical hemostasis is an absolute standard of care to minimize post-traumatic morbidity.

A Wood's light is an ultraviolet source that emits light of 365nm wavelength resulting in different fluorescent patterns when directed at different organisms. Which of the following correctly matches the organism to its fluorescent pattern? A. Erythrasma - red or pink B. Tinea versicolor - green or yellow C. Pseudomonas - yellow or green D. Porphyria cutanea - urine color change to orange or yellow E. All of the above

E. All of the above

Which of the following are potential complications of bacterial meningitis? A. Seizure disorder B. Focal paralysis or sensory loss C. Intellectual impairment D. Sensorineural hearing loss E. All of the above

E. All of the above

Which of the following patients should undergo abdominal trauma evaluation? A. 22 year old with stab wound to fourth intercostal space on right B. 30 year old with pelvic pain and tenderness after fall C. 25 year old restrained passenger in high-speed MVA; no abdominal complaints D. None of the above E. All of the above

E. All of the above The answer is E. The diaphragm can rise to as high a level as the fourth intercostal space and can be injured by stab wounds at this level. Unsuspected injuries are common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-abdominal injuries and can distract a patient from such an injury. Therefore, all of these patients need an evaluation of their abdomens.

A 2 year old male is brought to the ED in status epilepticus. He has not responded to adequate doses of benzodiazepines. Which of the following possible causes of a seizure must be evaluated for in the emergency department? A. Hypoxia B. Hypoglycemia C. Toxic ingestion D. Head trauma E. All of the above possible causes must be evaluated for

E. All of the above possible causes must be evaluated for The answer is E. Seizures have a number of secondary causes, which must be identified and corrected before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse. Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus.

A 26 year old woman presents to the emergency department with episodes of spinning associated with nausea, vomiting, and unsteady gait. These occurred three times in the past 12 hours and come on suddenly when she is lying down and turns onto her right side. The spinning is violent and she has vomited several times. Her symptoms resolve spontaneously in 5 to 10 minutes and she feels fine in the interim. She has recently had an upper respiratory infection and has started no new medications. Her neurologic exam is normal. Laying her down quickly over the side of the bed with her head turned to the left reproduces symptoms. Which of the following medications may be effective in preventing further episodes of vertigo? A. Diphenhydramine B. Meclizine C. Diazepam D. Promethazine E. Any of the above

E. Any of the above The answer is E. This patient has symptoms consistent with benign positional vertigo. It is caused by vestibular stimulation, usually from loose debris in the semicircular canals. Benzodiazipines are useful because of their sedative effect on the limbic system, thalamus, and hypothalamus. Vestibular neurons are mediated by acetylcholine; therefore, anticholinergic agents (e.g., meclizine, diphenhydramine, promethazine) are effective to minimize vertigo.

A 70 year old woman presents with chest pain that began 2 hours ago. She describes it as substernal radiating to her jaw and left shoulder; there is no other area of pain or radiation. She took an aspirin at home but the pain is not better. She also took 3 sublingual nitroglycerin tablets en route to the hospital. Her initial EKG shows ST elevation in the anterior leads >2mm and ST depression in the inferior leads. The nurse has already administered oxygen, placed her on an EKG monitor, and attained IV access. You order beta-blockade and nitroglycerin for pain relief, and the supervising resident asks you which of the following should be done next: A. Give her a GI cocktail to check for pain relief from this. B. Send her to radiology for a good-quality chest X-ray. C. Call cardiology to request a stat echocardiogram to check for wall motion abnormalities and aortic dissection. D. Call her primary care physician. E. Call cardiology for a decision between thrombolytic and percutaneous coronary intervention.

E. Call cardiology for a decision between thrombolytic and percutaneous coronary intervention. The answer is E. This patient is having an acute myocardial infarction. AMI is defined when two of the following three findings are present: clinical history of chest pain of at least 20 minutes duration, EKG changes and/or positive myocardial enzyme testing. This patient has ST elevation with concomitant ST depression in contiguous leads with chest pain. She needs immediate thrombolytic therapy or cardiac catheterization; if percutaneous coronary intervention (PCI) can be achieved within 90-120 minutes of emergency department arrival, the literature supports its selection over thrombolytic therapy as primary intervention. In preparation for either thrombolytic therapy or PCI, you need to control her pain, maximize O2 delivery, decrease work of the heart and inhibit platelet function. O2, nitroglycerin and morphine will increase O2 delivery to the heart. A beta blocker, which should also be administered to AMI patients who lack contraindications, will decrease the work of the heart, and aspirin will inhibit platelets. A glycoprotein IIb/IIIa-inhibitor should also be administered - selections will depend on the exact treatment course chosen for the patient. Anticoagulation with low molecular weight heparin or unfractionated heparin (dose being dependent on exact treatment course for patient) should be started if there are no patient historical or chest X-ray findings suggestive of aortic dissection. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 1011-1052; 170.

A 19 year old man is stabbed in the left chest in the 3rd intercostals space just to the left of the sternum. His vital signs are: T 97.9, HR 130, BP 60/48, RR 18, SPO2 84%. He has significant JVD and his lungs are clear. The patient's diagnosis is: A. Tension pneumothorax B. Lung laceration C. Spinal cord injury D. Hypovolemic shock E. Cardiac tamponade

E. Cardiac tamponade The answer is E. The patient has a stab wound to the left chest near the sternum. His hypotension, clear lungs, and JVD suggest an obstructive shock. He likely has cardiac tamponade and needs emergent decompression either with pericardiocentesis or pericardial window.

Which is the most common associated neurological finding with a distal radius fracture? A. Weakness with flexion at the finger MCP joints B. Wrist drop C. Decreased sensation over the hypothenar eminance D. Weakness of finger adduction E. Decreased sensation over the thenar eminance

E. Decreased sensation over the thenar eminance The answer is E. This finding is due to median nerve injury.

Which of the following is an accurate statement? A. Bedside ultrasound is the test of choice for diagnosing solid organ injury. B. Diagnostic peritoneal lavage usually cannot identify the presence of hemoperitoneum. C. Bedside ultrasound can image the retroperitoneum. D. Bedside ultrasound can reliably determine the etiology of hemoperitoneum. E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum.

E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum. The answer is E. Diagnostic peritoneal lavage is extremely sensitive for the detection of hemoperitoneum and can lead to many negative laparotomies. Neither bedside ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal cavity, and CT scan is the test of choice for diagnosing solid organ injury.

The Figure depicts a patient with toe pain. She does not recollect any trauma. Regarding the Figure and her presentation, which of the following is true? [image shows big swollen white pocket next to toe nail of big toe] A. This patient can be managed with a simple surgical procedure, with no need for outpatient medications other than analgesics B. The cellulitis in the toe is the primary problem C. Occult trauma and fracture are the most likely diagnoses, and the patient will probably require splinting after X-ray D. The indicated procedure will likely be able to be performed without anesthesia in this patient E. Digital block, a surgical intervention, and antibiotic therapy are all indicated in this patient

E. Digital block, a surgical intervention, and antibiotic therapy are all indicated in this patient The answer is E. This patient has a paronychia, complicated by relatively significant extension of purulence as well as cellulitis in the involved great toe. In cases where the paronychia is small, simple lifting of the eponychium (cuticle) may suffice; no digital block is necessary. In a case such as this one, more aggressive intervention, including removal of part of the nail, will necessitate digital block. The patient does not require hospitalization, but antibiotics and close follow-up (especially if there are complicating issues such as diabetes) are indicated.

Which of the following statements regarding intraosseous (IO) access is INCORRECT? A. Marrow and fat emboli are recognized complications of IO access B. Anterior compartment syndrome is a recognized complication of IO access C. Tibial fracture is a recognized complication of IO access D. Long bone fracture is a contraindication of IO access E. Drug delivery by endotracheal route is preferred over the intraosseous route

E. Drug delivery by endotracheal route is preferred over the intraosseous route

With regard to laboratory findings in hypothyroidism, which of the following is false? A. Total thyroxine levels may be normal due to elevated thyroxine-binding globulin (TBG) levels. B. Free T4 and TSH levels are typically low in secondary and tertiary hypothyroidism. C. Serum thyroid-stimulating hormone (TSH) is the most sensitive test to diagnose primary hypothyroidism. D. T3 level may be normal in hypothyroid states. E. Free thyroxine (T4) is always depressed in hypothyroid states.

E. Free thyroxine (T4) is always depressed in hypothyroid states. The answer is E. Free T4 may be normal in early stages of hypothyroidism due to physiologic compensation from elevated TSH levels.

All of the following are common causes of septic shock EXCEPT: A. Pseudomonas aeruginosa B. Streptococcus pneumoniae C. Escherichia coli D. Staphylococcus aureus E. Group A beta-hemolytic Streptococcus

E. Group A beta-hemolytic Streptococcus Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae are common causes of sepsis. Group A beta-hemolytic Streptococcus is a common agent in pharyngitis but rarely causes sepsis.

A 5 year old boy presents with fever and sore throat. On physical exam, the child has enlarged tonsils with exudates. Which of the following is true? A. Treatment of choice is azithromycin B. Vaccination prevents recurrence C. The etiology of the infection is most likely bacterial D. Viruses rarely cause exudative pharyngitis E. If the infection is bacterial, the primary role of antibiotic therapy is to prevent complications

E. If the infection is bacterial, the primary role of antibiotic therapy is to prevent complications Pharyngitis is a common infection in children. Viruses cause the majority of cases. The most common bacterial cause is Group A strep. It is very hard to distinguish bacterial versus viral infections based on clinical grounds. Antibiotics do not significantly alter clinical course; however, they reduce complications such as rheumatic fever and glomerulonephritis. Penicillin is the treatment of choice. There is no vaccine for Group A strep.

During a bar fight, a 42 year old man is stabbed in the left side with an unknown weapon. He presents to the emergency department with dyspnea, pulse of 108, blood pressure of 138/92, and oxygen saturation of 94% on room air. He has absent breath sounds on the left side; you note a small puncture wound in the midaxillary line at the level of the 10th rib. His abdominal exam is normal. Two large-bore IVs are established. What is the appropriate management of this patient? A. Left-sided chest tube, portable chest x-ray, and admission B. Left-sided chest tube, portable chest x-ray, diagnostic peritoneal lavage, and admission C. Endotracheal intubation, left-sided chest tube, portable chest x-ray, and admission D. Endotracheal intubation, portable chest x-ray, exploratory laparotomy in the OR, and admission E. Left-sided chest tube, portable chest x-ray, and abdominal CT scan

E. Left-sided chest tube, portable chest x-ray, and abdominal CT scan

Following a motor vehicle collision, in which of the following patients is an emergency department Caesarian section most likely indicated, assuming a fetus at 29-weeks gestation? A. Mother with gunshot wound to abdomen, blood pressure 96/42; fetal heart tones undetectable B. Mother with severe head trauma, blood pressure 170/90; fetal heart tones 120 beats per minute C. Mother with abdominal pain, blood pressure of 80/40; fetal heart tones 100 beats per minute D. Mother with vaginal bleeding, blood pressure 118/78; fetal heart tones 80 beats per minute E. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart tones of 100 beats per minute

E. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart tones of 100 beats per minute The answer is E. Though emergency C-section after maternal death is a rarely indicated procedure, rapid intervention (within minutes) of maternal demise has resulted in viable births.

A 25 year old female presents with fever, productive cough, and shortness of breath. Physical exam reveals T101, RR 24 and SpO2 of 94%. Her left tympanic membrane is inflamed and there are TM bullae. The chest X-ray reveals a large right middle lobe pneumonia. The organism most commonly associated with this type of presentation is: A. Legionella pneumoniae B. Strep pneumoniae C. H. influenzae D. Moraxella catarrhalis E. Mycoplasma pneumoniae

E. Mycoplasma pneumoniae Mycoplasma pneumoniae is a common cause of pneumonia in young adults. It is classically associated with bullous myringitis. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, page 454.

Rosving's sign is described as: A. Tenderness in the right upper quadrant that is worse with inspiration. B. Pelvic pain upon flexion of the thigh while the patient is supine. C. Pelvic pain upon internal and external rotation of the thigh with the knee flexed. D. Pain that increases with the release of pressure of palpation. E. Pain in the right lower quadrant when left lower quadrant is palpated.

E. Pain in the right lower quadrant when left lower quadrant is palpated. The answer is E. Rosving's sign is pain in the right lower quadrant when the left lower quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh rotation. All of these signs are associated with appendicitis. Murphy's sign is cessation of inspiration during palpation of the right upper quadrant and is associated with acute cholecystitis.

In which of these patients is emergency department thoracotomy indicated? A. All of the above should undergo emergency department thoracotomy. B. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being extricated, and arrives at the E.D. after a 45-minute transport C. Patient with stab wound to the anterior chest who is dyspneic with an oxygen saturation of 80% and a blood pressure of 168/102 D. Pedestrian struck with massive pelvic fractures who loses pulses and blood pressure at the scene E. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60

E. Patient with a gunshot wound to the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure of 60 The answer is E. Emergency Department thoracotomy is a controversial procedure. When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt trauma has a dismal success rate and is generally not considered an indication for ED thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An awake patient with a relatively normal blood pressure does not need one performed in the Emergency Department. An unconscious and pulseless patient with a detectable blood pressure has the best chance for survival.

Regarding the treatment of hyperosmolar hypertonic nonketotic coma (HHNC) and its associated symptoms, which of the following is correct: A. Hyperosmolarity should be corrected within the first few hours in the emergency department. B. Since patients are not acidotic, close monitoring of glucose is not necessary. C. In HHNC patients with severe dehydration, bleeding diathesis is a major clinical concern. D. Half of the fluid deficit should be corrected over the first hour and the remainder over the following 8 hours. E. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC.

E. Phenytoin (Dilantin) is often ineffective for seizures associated with HHNC. The answer is E. Phenytoin (Dilantin) is contraindicated in patients with HHNC as it may impair endogenous insulin release and is often ineffective in the management of seizures associated with HHNC. Half of the fluid deficit should be replaced over the first 8 hours, and the remainder over the ensuing 24 hours. Glucose must be tightly monitored as fluid resuscitation alone may normalize serum glucose or precipitate hypoglycemia in aggressive fluid resuscitation. Too-rapid correction of hyperosmolarity may result in development of cerebral edema, especially in children. Subcutaneous heparin should be considered in patients with severe dehydration due to increased risk of thrombosis from hypovolemia and hyperviscosity.

An 82 year old man presents to the Emergency Department from a nursing home with a productive cough and fever. Six weeks ago he was admitted to the hospital for five days for repair of a proximal femur fracture. His vital signs are significant for a temperature of 38.2 degrees Celsius, a respiratory rate of 28, and a room air oxygen saturation of 86%. He is in mild respiratory distress with bibasilar rhonchi on chest auscultation. A chest radiograph shows a dense retrocardiac opacity. Which of the following medications is the recommended treatment choice for this patient? A. Acyclovir, vancomycin and sulfamethoxasole B. Ceftriaxone and azithromycin C. Doxycycline and amoxicillin-clavulanate D. Nitroglycerine and furosemide E. Piperacillin-tazobactam, ciprofloxacin, and vancomycin

E. Piperacillin-tazobactam, ciprofloxacin, and vancomycin

Regarding pediatric head injury, all the following are true EXCEPT: A. Head trauma is the leading cause of death among injured children. B. A child's cranial vault is larger and heavier in proportion to its total body mass than an adult's. C. Pediatric epidural hematomas are venous in origin. D. A brief seizure occurring immediately after the insult, with rapid return to normal level of consciousness is usually unassociated with intracranial parenchymal injury. E. Retinal hemorrhages are a common finding in mild-moderate trauma.

E. Retinal hemorrhages are a common finding in mild-moderate trauma. Retinal hemorrhages are not commonly found in children in cases of mild-moderate trauma. They are, however, found in 75% of cases of "Shaken Baby Syndrome". Such patients may also have non-specific findings such as failure to thrive, vomiting, seizures or altered levels of consciousness. Head trauma is responsible for up to 80% of trauma deaths. A child's larger head predisposes it to high degrees of torque generated by forces along the cervical spine axis. In contrast to adults, pediatric epidural hematomas are venous in origin, thus predisposing them to a subtle and more subacute presentation over days. "Impact Seizures" as described above are usually unassociated with intracranial parenchymal injury and don't indicate the need to anticonvulsant medication. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 271-273.

A 21-year old male presents with a clean-knife wound sustained 24 hours ago. The laceration is 2cm in length, and located between the MCP and PIP levels of the nondominant hand index finger, on the flexor surface; the wound is well-approximated (i.e., not gaping). The patient has not had tetanus immunization within 10 years and has no complaints other than pain at the laceration site. Which of the following regarding this patient/presentation is TRUE? A. Since the wound appears superficial, there is no risk of involvement of the neurovascular bundle. B. It is too late (at 18 hours post-injury) to provide tetanus immunization. C. The wound should be sutured, primarily due to the potential for dehiscence due to tension on the skin edges. D. The wound should be sutured, primarily to minimize the chances of infection. E. Simple wound cleaning, bandaging, and tetanus immunization are appropriate therapy for this patient.

E. Simple wound cleaning, bandaging, and tetanus immunization are appropriate therapy for this patient. The answer is E. Tetanus can be probably be effective if administered within the first few days of a wound; 24 hours is not too late. Suturing of this wound is not indicated, since it is an old wound, well-approximated, and is on the flexor surface of the digit where skin forces will be minimal. Though suturing is not indicated, careful assessment of the finger for neurovascular injury is appropriate given the anatomical location of the wound over the bundle (the superficial appearance of the wound may be misleading).

All of the following pathogens cause invasive diarrheal infection EXCEPT: A. Salmonella B. Campylobacter C. Yersinia D. Shigella E. Staph. aureus

E. Staph. aureus Shigella, Salmonella, Campylobacter, and Yersinia all cause invasive diarrhea. Other organisms that also cause invasive diarrhea include certain species of E. coli. Staph is a very common cause of food poisoning due to a toxin but rarely becomes invasive. Most diarrheal illnesses are treated with supportive therapy and rehydration. Antibiotics may worsen the situation depending on the organism. Antimotility agents can also worsen the problem. -- For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 838-844.

The patient depicted in the figures developed a rash on the face and chest, with subsequent sparse involvement of the extremities. Of the choices below, which is the most likely diagnosis for the patient depicted in the figures? [image shows peeling skin] A. erythema multiforme minor B. meningococcemia C. cellulitis D. Rocky Mountain spotted fever E. Stevens-Johnson syndrome

E. Stevens-Johnson syndrome

A 40 year old male presents to the emergency department complaining of severe ankle pain after inverting the foot during a soccer game. The triage nurse records the following vital signs: temperature 98.8, pulse 94, respiratory rate 18, BP 188/118. Which of the interventions below is the most appropriate step to take in response to the blood pressure assessment? A. Administer a sublingual antihypertensive agent since the patient probably only has an ankle sprain and will not need an intravenous line B. Establish intravenous access in order to optimize the onset of action of parenteral antihypertensive medications C. Ignore the blood pressure since the patient is asymptomatic other than having ankle pain D. Order an antihypertensive agent to be given in the emergency department because the patient will be discharged with a prescription for one E. Take measures to relieve pain and recheck the blood pressure

E. Take measures to relieve pain and recheck the blood pressure Emergency department therapy should not be instituted based upon a single blood pressure measurement. This is especially true in cases where a patient has a reasonable physiologic explanation (i.e. pain) for elevated blood pressure and other vital signs consistent with pain-mediated sympathetic stimulation. Due to the risk of over-reduction in blood pressure, sublingual agents are rarely appropriate for emergency therapy of hypertension; however, it would be premature to treat the patient with any medication. Asymptomatic patients with elevated blood pressure usually require no cerebral imaging. Additionally, asymptomatic patients usually do not require emergency pharmacologic therapy; even if such therapy is considered the initial abnormal blood pressure should first be rechecked.

Which of the statements below is correct regarding the two airway maneuvers depicted in the figure's left (labeled "A") and right (labeled "B") aspects? [image A:air into mouth B: chin lift jaw thrust] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. Airway opening maneuvers such as those in the figure are not intended to affect the position of the tongue. B. The left side of the figure (labeled A) depicts a jaw-thrust. C. The maneuver depicted in the right side of the figure (labeled B) cannot be used in patients with suspected cervical spine injury. D. Airway maneuvers such as those in the figure are only necessary in patients with complete airway obstruction. E. The chin-lift maneuver risks spinal injury due to its employment of neck extension.

E. The chin-lift maneuver risks spinal injury due to its employment of neck extension. The answer is E. In many patients in the Emergency Department, the inability to rule-out cervical spine injury negates the option to use the chin-lift maneuver, since this method of airway opening can exacerbate C-spine injury.

A nontoxic patient without trauma history, presents with 24 hours of a swollen and painful knee (which has never occurred in the past). Review of systems is negative except for the knee findings. A radiograph is taken (see Figure). With reference to the circled section of the Figure, which of the following is most likely true? [image The figure depicts chondrocalcinosis] A. Since the X-ray is pathognomonic, arthrocentesis is not indicated. B. A knee immobilizer and Orthopedic follow-up are indicated, for a diagnosis of probable meniscal tear. C. The patient has undergone total knee replacement. D. Blood cultures will be positive. E. The patient has pseudogout.

E. The patient has pseudogout. The figure depicts chondrocalcinosis, which is most likely indicative of pseudogout. However, due to the possibility of co-existing infection, arthrocentesis is indicated to confirm the diagnosis and rule-out joint space infection. Blood cultures are not expected to be positive in pseudogout without infection, and in fact blood cultures are often negative even in the presence of a septic joint. There is no radiographic evidence of knee replacement, and meniscal tear is not commonly associated with radiographic findings.

The four classic types of shock include all of the following EXCEPT: A. Distributive B. Obstructive C. Hypovolemic D. Cardiogenic E. Traumatic

E. Traumatic The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock states (usually hypovolemic, but also obstructive in the case of pericardial tamponade), but there is no "traumatic" shock subtype.

Which of the following statements regarding fever and WBC is TRUE? A. WBC is specific for serious bacterial infection. B. WBC is of no clinical value. C. Elevated WBC indicates serious bacterial infection. D. WBC is sensitive for serious bacterial infection. E. WBC is a poor discriminatory predictor of serious bacterial infection.

E. WBC is a poor discriminatory predictor of serious bacterial infection. WBC is a commonly ordered test in the setting of infection. However, it lacks the sensitivity and specificity to be a good discriminatory test for serious bacterial infection. It is more reflective of, and an important marker for, the body's response to the infection

A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient? A. type and cross two units of packed red blood cells B. immediate surgical intervention C. discharge on oral pain medications D. barium enema to evaluate for carcinoma of the colon E. admission for intravenous antibiotics and fluids

E. admission for intravenous antibiotics and fluids For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. *Guaiac positive stool* in seen in up to *50%* of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis.

A sprain is treated with: A. analgesia B. elevation C. ice D. immobilization E. all of the above

E. all of the above

First-line interventions started by the emergency physician for suspected peptic ulcer disease (PUD) may include: A. proton pump inhibitors (PPIs) B. stopping NSAIDs C. antacids D. H2 blockers E. all of the above

E. all of the above

A 4 year old boy presents with fever, sore throat and stridor. Physical exam reveals T103 in an ill-appearing, drooling, stridorous child in mild respiratory distress. The next steps include: A. chest X-ray B. dexamethasone C. observation D. albuterol E. antibiotics and airway management

E. antibiotics and airway management A child presenting to the emergency department with stridor most likely has croup, with epiglottitis being a less common - but more serious - etiology. Croup tends to be the etiology in younger, nontoxic-appearing children, who usually have a characteristic barking ("seal") cough. Treatment of croup includes racemic epinephrine (which is probably no better than nebulized l-epinephrine), and steroids. Epiglottitis is a true emergency. It presents in children who are older, with high fever, and who are ill appearing. One of the key clinical features is drooling, which indicates swelling and pain interfering with handling of secretions. Children with epiglottitis are at risk of airway obstruction and need early airway management, preferably while the problem is still urgent (as opposed to during catastrophic deterioration) and preferably in the operating room. A lateral soft tissue X-ray would most likely reveal signs of an inflamed epiglottic region (e.g. thumbprint sign). Epiglottitis is a bacterial infection treated with antibiotics.

Which of the following is *not* a feature of febrile seizures? A. generalized tonic-clonic seizure B. duration less than 15 minutes C. associated with a rapid rise in body temperature D. occurs in children ages 3 months to 5 years E. associated with postictal state of 30 minutes

E. associated with postictal state of 30 minutes Febrile seizure is not associated with a postictal period. The child usually rapidly regains alertness. Intracranial mass or infection should be a concern if the duration of seizure is greater than 15 minutes or if altered mental status persists after the cessation of seizure activity.

A 22 year old male with IVDA presents to the emergency department with a fever and dyspnea. His physical exam reveals T 101.5, clear lungs and a murmur. Of the following, the correct treatment plan is? A. blood cultures and admission B. amoxicillin and discharge C. surgery D. blood cultures and discharge E. blood cultures, vancomycin, and admission

E. blood cultures, vancomycin, and admission Infective endocarditis has a very high morbidity and mortality if untreated. IVDA with a fever represent a special population at risk. Many emergency departments routinely admit IVDA with a fever even without other findings suggestive of endocarditis. Given the patient's fever and murmur, he should receive blood cultures, IV antibiotics and admission.

Of the choices below, the best treatment of the patient with hyperkalemia and EKG changes is: A. defibrillation B. vasopressin C. lidocaine D. amiodarone E. calcium

E. calcium The answer is E. Hyperkalemia with EKG changes is treated with calcium to stabilize cardiac membranes. Calcium works quickly and is relatively safe unless patients are digitalized. Other treatments for acute hyperkalemia include sodium bicarbonate and insulin/glucose.

A patient develops a rash that starts as multiple bilateral target-like macules and papules on the palms and soles. It progresses to widespread sloughing of the skin requiring admission to the burn unit. Which of the following etiologic agents has NOT been implicated in this syndrome? A. recent immunization B. barbiturates C. penicillins D. sulfa antibiotics E. corticosteroids

E. corticosteroids The syndrome described is the spectrum of erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis. Although the etiology is not always clear, many drugs (including sulfa antibiotics, penicillins, and barbiturates), viral or Mycoplasma infections, and recent immunization have been implicated. Corticosteroids are a controversial adjunct in treatment, but have not been implicated as a cause of the disease.

A 7 year old boy presents with erythema and edema of the left eyelid. Which of the following physical examination findings is consistent with a pre-septal (or periorbital) cellulitis? A. visual acuity impairment B. extraocular movement impairment C. proptosis D. pain with extraocular movement E. fever

E. fever

A 24 year old woman, brought by her sister, enters the emergency department. The 24 year old is writhing in pain, clutching her abdomen and shivering. Her sister states that the patient had a therapeutic abortion performed 3 days ago and has been having worsening abdominal pain ever since. The patient's vital signs are: T 103.4 F, HR 128, BP 104/72, RR 28, O2 saturation 100% in room air and she has marked lower abdominal pain and voluntary guarding. The most appropriate steps in treatment for this woman's condition include all of the following EXCEPT: A. broad-spectrum antibiotics B. laboratory studies including basic chemistry, complete blood count with differential, coagulations studies, DIC panel, serum pregnancy test, and blood cultures C. urgent ob/gyn consult to facilitate rapid transport of patient to the operating room D. intravenous fluids E. high-dose steroids

E. high-dose steroids The answer is E. This patient is most likely suffering from a septic abortion in which retained products of conception developed a local infection. This infection has now spread systemically causing the systemic inflammatory response and potentially causing sepsis. Immediate intravenous fluids and broad-spectrum antibiotics are necessary; however, steroids are contraindicated in such a situation and could worsen the infection. The patient needs to be taken to the OR urgently to remove the retained products of conception.

Low body temperatures in newborns can lead to severe physiologic consequences, which include all EXCEPT: A. metabolic acidosis B. increased oxygen consumption C. hypoglycemia D. apnea E. hyperglycemia

E. hyperglycemia Due to low fat stores, inability to generate heat by shivering, and relatively large surface-to-volume area, the newborn infant is not easily able to maintain body temperature. Metabolic acidosis, increased oxygen consumption, hypoglycemia, and apnea are all physiologic consequences of hypothermia.

Symptoms of secondary adrenal insufficiency include all of the following EXCEPT: A. nausea and vomiting B. weight loss C. weakness D. anorexia E. hyperpigmentation

E. hyperpigmentation The answer is E. Hyperpigmentation is seen in greater than 90% of primary adrenal insufficiency. It is a result of compensatory adrenocorticotropic hormone (ACTH) and melanocyte-stimulating hormone (MSH) secretion. The secretion is a feedback mechanism that is not activated in secondary adrenal insufficiency, for example, adrenal insufficiency from pituitary infarction or hypothalamic insufficiency.

The differential diagnosis of papilledema includes all of the following EXCEPT: A. hypertensive encephalopathy B. hydrocephalus C. intracranial mass D. pseudotumor cerebri E. hyphema

E. hyphema

Which of the following is not a common sign or symptom of thyrotoxicosis? A. hyperhidrosis B. nervousness C. tachycardia D. congestive heart failure E. hypothermia

E. hypothermia The answer is E. Fever, not hypothermia, is commonly seen in thyrotoxicosis. Other common signs and symptoms include tachycardia, congestive heart failure, wide pulse pressure, tremor, thyrotoxic stare, thyromegaly, nervousness, weight loss, and palpitations.

What is the most common category of shock in the pediatric population? A. dissociative B. distributive C. cardiogenic D. obstructive E. hypovolemic

E. hypovolemic

A 45 year old male presents to the emergency department with CP. While you are talking to him he becomes unresponsive. The monitor shows ventricular tachycardia. The correct sequence of treatment is: A. amiodarone B. intubation C. central venous access D. epinephrine E. immediate defibrillation up to three times

E. immediate defibrillation up to three times The answer is E. Unstable VT is treated by a series of three stacked shocks, before medications. Early defibrillation is the key to successful resuscitation.

Which of the following analgesics operates by a non-opioid mechanism? A. fentanyl B. meperidine C. codeine D. hydromorphone E. ketorolac

E. ketorolac

A 56 year old woman presents to the emergency department with a complaint that "my head is spinning." For two days she has experienced a spinning sensation periodically, one that she does not associate with any specific position or movement. It subsides after 30 to 45 minutes. It is associated with nausea. She denies visual changes, weakness, or numbness. She feels unsteady on her feet during these episodes. On physical exam, she has horizontal nystagmus; but her neurologic exam is normal, including cranial nerves, motor strength, reflexes, coordination, and gait. Her tympanic membranes are normal; but Rinne and Weber tests reveal decreased hearing on the right with bone conduction that localized to the left ear suggesting right sensorineural hearing loss. Which of the following conditions is associated with these findings? A. benign positional vertigo B. multiple sclerosis C. brainstem stroke D. vestibular neuronitis E. labyrinthitis

E. labyrinthitis The answer is E. Determination of hearing loss is important in the evaluation of vertigo. Central vertigo, such as that which may be associated with multiple sclerosis or stroke, is not accompanied by acute hearing loss because of the distributed nature of the CN VIII nuclei. Acoustic neuroma, a central process, can cause hearing loss because of direct compression of the CN VIII. Even though vestibular neuronitis involves inflammation of CN VIII, it is not associated with hearing loss. Benign positional vertigo is caused by loose particles in the semicircular canals that induce a false sense of motion; however, auditory hearing is unaffected. Labyrinthitis, or inflammation of inner ear structures including semicircular canals and cochlea, can result in sensorineural hearing loss.

A 20 year old otherwise healthy obese woman presents complaining of headache, nausea, vomiting. She is afebrile and her vital signs are normal. Physical examination reveals papilledema, but an otherwise normal neurological exam without meningismus. Non-contrast CT head scan is negative for intracranial pathology. What is the most appropriate next step? A. EEG B. MRI/MRA C. erythrocyte sedimentation rate/C-reactive protein D. IV antibiotics E. lumbar puncture

E. lumbar puncture Young obese women are predisposed to pseudotumor cerebri - a disease characterized by increased ICP, normal CT, papilledema, normal CSF. Causes include: pregnancy, medications (OCPs, steroids, vitamin A). Sequelae include visual field cuts.

Which of the following is the treatment of choice for torsades de pointes? A. defibrillation B. sodium bicarbonate C. external pacing D. lidocaine E. magnesium sulfate

E. magnesium sulfate The answer is E. Torsades de pointes is a form of ventricular tachycardia in which the QRS morphology twists around the baseline. It may occur spontaneously in the setting of hypokalemia, hypomagnesia, or any drug that prolongs the QT interval. Magnesium best controls it. If that fails, try overdrive pacing. The unstable patient should be cardioverted when the rhythm is sustained, but cardioversion is not likely to have sustained success in the absence of adjunctive therapy (e.g. magnesium).

A college student who had a mild upper respiratory tract infection last week, presents during the spring. He appears toxic, with fever, headache, and a rash (see figure) which was also noted on the wrists, ankles, flanks, and axilla. Of those listed below, which is the most likely diagnosis? [image shows purple spotted rash on extremity] A. angioedema B. herpes zoster C. Lyme disease D. pemphigus vulgaris E. meningococcemia

E. meningococcemia The answer is E. This patient's presentation is consistent with meningococcemia. Lyme disease often presents with a rash (erythema chronicum migrans), but that rash has a different appearance (erythema with central clearing). Pemphgus vulgaris is characterized by intraepidermal blistering, and angioedema is seen more in the mucous membranes. Herpes zoster has an appearance of grouped (painful) vesicles on an erythematous base.

A hemodynamically stable patient presents with pain in the forearm after isolated trauma. The neurovascular examination is normal. A single X-ray is taken, and appears as is shown in the Figure. Of the following choices, which is the best next step? [image really bad ulnar fracture] A. CT scan of the radius and ulna B. MRI to assess for nerve damage C. X-ray of the contralateral arm to assess for symmetry D. splinting of the forearm with Orthopedic follow-up E. obtain another view of the forearm, and also X-ray the elbow and wrist

E. obtain another view of the forearm, and also X-ray the elbow and wrist This patient has an ulnar fracture, which like any other fracture should be imaged in at least two planes. Additionally, views of the wrist and elbow are indicated to assess for fractures or dislocations to joints adjacent to the injury.

A patient presents with facial swelling and pain, with low-grade fever. Of the following, which is the most likely diagnosis given the patient's presentation and facial CT scan [image]: A. pharyngitis B. uveitis C. sinusitis D. Ludwig's angina E. parotitis

E. parotitis

For several conditions of internal malignancies there may be associated cutaneous manifestations. The conditions below all describe common dermatological conditions associated with malignancy EXCEPT: A. acanthosis nigricans B. erythema nodosum C. dermatomyositis D. pruritis E. pemphigus

E. pemphigus Pemphigus is likely an autosomal condition involving antibodies directed at intercellular substance. Significant damage to the epidermis may subsequently lead to dehydration, sepsis, or even death. The other options are known to be associated with internal malignancy. For each condition, there may be several types of malignancy it can be associated with.

Of the following choices, which diagnosis is most likely in a 53-year old cancer patient with chest pain, dyspnea, and the EKG shown in the Figure? A. pericarditis from metastatic disease B. third degree heart block C. anterolateral myocardial ischemia D. infectious myocarditis E. pulmonary embolism

E. pulmonary embolism The answer is E. The EKG's S1Q3T3 pattern (S in lead I, Q and inverted T in lead III), while not pathognomonic, is suggestive of PE as a cause of this patient's symptoms.

A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non-bilious, however it is projectile in nature. What is the most likely condition in this patient? A. viral gastroenteritis B. constipation C. appendicitis D. intussusception E. pyloric stenosis

E. pyloric stenosis The answer is E. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults).

All of the following factors predispose to cecal volvulus EXCEPT: A. pregnancy B. age 25-35 C. prior abdominal surgery D. marathon running E. severe chronic constipation

E. severe chronic constipation Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25-35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle.

All the following are signs of hypoxemia in a newborn, EXCEPT: A. cyanosis B. lethargy C. bradycardia D. unresponsiveness E. tachycardia

E. tachycardia Hypoxemia in newborns may present differently than the same process in adults. Like adults, neonates with hypoxemia may exhibit cyanosis, lethargy, and unresponsiveness, but unlike older patients the heart rate tends to be slow rather than fast.

Which is *not* part of the Ottawa ankle rules? A. inability to walk 4 steps at the time of the injury B. inability to walk 4 steps in the emergency department C. tenderness over the lateral malleolus D. tenderness over the medial malleolus E. tenderness over the talus

E. tenderness over the talus The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is *tenderness over the navicular or base of the 5th metatarsal*, an X-ray should be obtained. If the correct answer to all questions is no, then an X-ray is not needed.

Of the options below, the therapy best for symptomatic 3rd degree heart block is: A. lidocaine B. atropine C. oxygen D. cardioversion E. transcutaneous pacer

E. transcutaneous pacer Complete AV dissociation requires pacing fast enough for adequate perfusion.

Which of the following eye drops will dilate the pupil? A. sulfacetamide B. pilocarpine C. Pred Forte D. proparacaine E. tropicamide

E. tropicamide

The most sensitive bedside test for nerve injury in a finger after trauma is: A. light touch B. O'Riain wrinkle test C. pain D. temperature sensation E. two-point discrimination

E. two-point discrimination Light touch is a good screening test, but two-point discrimination is more sensitive and should be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the nerve is intact.

A 67 year old known alcoholic female is brought to the emergency department by EMS after being found somnolent with the odor of alcohol on her breath. After the primary survey is completed and she is stabilized, she is found to have scaly, sharply marginated, bright red eczematous plaques, vesicles and pustules in her perioral and anogenital areas. Consistent with this exam, she is also noted to have a red, glossy tongue and loss of her nails. With what nutritional deficiency are these findings associated? A. potassium B. magnesium C. calcium D. phosphorus E. zinc

E. zinc Low blood levels of potassium, magnesium, calcium, phosphorus, and zinc can occur as a consequence of dietary deficiency and/or acid-base imbalances in alcoholics. Hypokalemia can cause periodic muscle paralysis and areflexia. Hypocalcemia can cause tetany and weakness. Low phosphorus levels can contribute to myocardial dysfunction, CNS symptoms, muscle weakness and bleeding disorders. Hypomagnesemia can cause a clouded sensorium and other neurological deficiencies. Chronic zinc deficiency leads to the dermatologic consequences described in this patient, including patches and plaques of dry, scaly, sharply marginated and brightly red eczematous dermatitis evolving into vesiculobullous, pustular, erosive, and crusted lesions that initially involve the perioral and anogenital areas. Progression can involve the scalp, hands, feet, trunk and flexural regions. There may be diffuse alopecia and graying of remaining hair. Nail manifestations may include loss of nails or paronychia. A red, glossy tongue is common, and the oropharynx may reveal aphthous-like ulcers. Patients with zinc deficiency tend to be photophobic, irritable, and depressed. Treatment of zinc deficiency consists of dietary or intravenous zinc salt supplementation for 2-3 weeks.

A 68 year old male presents to the emergency department with worsening shortness of breath for 3 days. This morning he woke up from sleep with shortness of breath. He has a past medical history of hypertension and coronary artery disease. He takes losarten, clonidine, metoprolol and aspirin daily. He has no medication allergies. Temperature is 37.5°C, blood pressure is 188/92, heart rate is 94 and respiratory rate is 22. Pulse oximetry on room air shows an oxygen saturation of 93%. The patient appears to be in moderate respiratory distress and is using accessory muscles to breath. His cardiac examination reveals an S3, pulmonary examination reveals bibasilar rales. Jugular venous distention is noted at 6cm. He has 1+ lower extremity edema. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management? A. Nitroglycerin B. Intubation C. Chest radiograph D. Non-invasive ventilation E. Furosemide F. Supplemental oxygen

F. Supplemental oxygen

A 27 year old woman is brought into the emergency department by her roommate 30 minutes after ingesting a bottle of aspirin in a suicide attempt. Which of the following acid-base disorders is most likely to be present in this patient? A. Primary metabolic acidosis with compensatory respiratory alkalosis B. Respiratory acidosis due to somnolence causing decreased respiratory drive C. Respiratory alkalosis due to stimulation of the respiratory center and increased CO2 production D. Primary respiratory acidosis with compensatory metabolic alkalosis

Key is 30 minutes... C. Respiratory alkalosis due to stimulation of the respiratory center and increased CO2 production The answer is C. Aspirin, a salicylate, directly stimulates the medullary chemoreceptor trigger zone and respiratory center, leading to increased CO2 production and increased respiratory rate, causing a primary respiratory alkalosis. A primary metabolic acidosis typically develops as well. Salicylates are absorbed from the stomach and bowel wall and typically have onset of action within 30 minutes.

Which medication is ideal for the agitated or combative patient? A. Nitrous oxide B. Hydromorphone C. Haloperidol D. Propofol

The answer is C. Drugs with a relatively short half-life allow for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed. Antipsychotics (such as haloperidol) and benzodiazepines (such as lorazepam) exhibit most of these characteristics and are commonly used in combination in the emergency department. The use of 5 mg of haloperidol IV/IM with 2 mg of lorazepam IV/IM, repeated every 30 minutes as needed, is recommended for the combative patient who does not have contraindications to these medications. Half doses should be used in the elderly.

A 25 year old female presents with epigastric pain radiating straight through to the back. Laboratory tests are notable only for markedly elevated amylase and lipase. An abdominal X-ray is taken (see Figure). Regarding this patient's presentation, which of the following is most likely true? [picture of an xtra showing stones in the GB] (a) She probably has an ulcer, since the laboratory results are nonspecific. (b) Alcohol use is only associated with pancreatitis in patients older than this woman, and who have been abusing alcohol for years. (c) The abdominal X-ray is concerning for early bowel obstruction. (d) The X-ray reveals that intrathoracic pathology is likely the cause of the patient's symptoms. (e) The most likely explanation for her symptoms is gallstone-related pancreatitis.

(e) The most likely explanation for her symptoms is gallstone-related pancreatitis. The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy, pancreatic carcinoma, atherosclerotic emboli, and scorpion bites. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th edition, pages 1426-1434.

Which of the following drugs is MOST beneficial in an acute COPD exacerbation? A. Beta adrenergic agonists such as albuterol B. Mucokinetic agents such as acetylcysteine C. Steroids such as solumedrol D. Methylxanthines such as theophylline

A. Beta adrenergic agonists such as albuterol The answer is A. Mucokinetic agents should not be used acutely in treatment of COPD exacerbation. These agents act to mobilize secretions, and this increases the work of the patient's breathing.

For a patient who has suffered a severe anaphylactic reaction, which of the following medications would serve little purpose if prescribed upon discharge? A. albuterol inhaler 2 puffs every 4 hours B. Epi-Pen C. benadryl 25-50mg every 4-6 hours D. prednisone 60mg daily for 5 days

A. albuterol inhaler 2 puffs every 4 hours

Which of the following is the commonest type of pediatric rhythm in the setting of cardiopulmonary arrest? A. asystole B. ventricular tachycardia C. atrial flutter D. atrial fibrillation E. supraventricular tachycardia

A. asystole

Which of the following is NOT a potential indication for hyperbaric oxygen therapy? A. necrotizing enterocolitis B. necrotizing fasciitis C. carbon monoxide poisoning D. decompression sickness

A. necrotizing enterocolitis The answer is A. According to the Undersea and Hyperbaric Medical Society, items A-D are all reasonable indications for the use of hyperbaric oxygen therapy. Other potential indications include patients with air or gas embolism, crush injury, and compartment syndrome.

What type of rhythm disturbance is seen in the EKG below? [image: long PR no dropped beats] A. second degree AV block type I B. first degree atrioventricular (AV) block C. second degree AV block type II D. third degree heart block

B. first degree atrioventricular (AV) block

Horner's syndrome is characterized by all of the following EXCEPT: A. ptosis B. ophthalmoplegia C. enophthalmos D. miosis E. anhidrosis

B. ophthalmoplegia

Regarding optic neuritis, all of the following are true EXCEPT: A. commonly affects color vision B. oral steroids are indicated for treatment C. may be the initial manifestation of multiple sclerosis D. preferentially affects women E. associated with afferent pupillary defect

B. oral steroids are indicated for treatment

What other injury(s) may be associated with calcaneal fracture after a fall? A. C-1 fracture B. closed head injury C. lumbar compression fracture D. pelvis fracture E. spleen injury

C. lumbar compression fracture

Which of the following is NOT a frequent cause of airway obstruction in the neonate? A. mucus B. blood C. maternal drugs D. tongue E. meconium

C. maternal drugs

In a newborn, bradycardia is most commonly an indicator of: A. hypothermia B. hypoglycemia C. hyperglycemia D. hypoxemia E. hyperthermia

D. hypoxemia

Shock is defined as: A. tachycardia B. hypotension C. altered mental status D. hypovolemia E. inadequate tissue and organ perfusion

E. inadequate tissue and organ perfusion The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia, hypotension and altered mental status are all signs and symptoms of shock.