Emergency Medicine EOR

A 50yo woman presents to the ED following a syncopal episode. On physical exam she is diaphoretic. She is alert and oriented. Her blood pressure is 90/50 mm Hg and respirations are 12 per minute. Her rhythm strip is shown on back of card. What is the most appropriate pharmacologic treatment for this patient's condition? A. Adenosine B. Amiodarone C. Atropine D. Amlodipine E. Aenolol

C. Atropine (initial tx for symptomatic sinus bradycardia)

A 61yo man presents with intermittent shock-like spasms of pain in his right cheek. The pain only lasts a few seconds at a time but recurs frequently. He notes that shaving each morning causes intense spasms of pain, as does chewing. What is the first-line treatment for his likely diagnosis? A. Baclofen B. Botulinum injections C. Carbamazepine D. Diazepam E. Indomethacin

C. Carbamazepine (1st line for trigeminal neuralgia)

Which of the following is associated with multifocal atrial tachycardia? A. Pericardial effusion B. Crohns disease C. Chronic obstructive pulmonary disease D. Ventricular aneurysm E. Congestive heart failure

C. Chronic obstructive pulmonary disease (MAT occurs when at least three different atrial ectopic foci depolarize to pace the heart. These are seen on an ECG as an irregular rhythm with P waves with at least three distinct morphologies)

A 45yo man with a history of Marfan Syndrome is noted to have a high-pitched blowing diastolic murmur at the left sternal border. What valvular disorder is most likely present? A. Mitral regurgitation B. Aortic stenosis C. Aortic regurgitation D. Mitral stenosis

C. Aortic regurgitation

A 34yo woman presents to the ED with severe right eye pain. The pain began after she entered a dark movie theatre. On physical exam, you note a mid-dilated pupil (4 mm) and corneal edema. Which of the following is the correct combination of medications in the treatment for this process? A. Acetazolamide IV, topical apraclonidine, topical timolol B. Mannitol IV, topical timolol, prednisolone IV C. Topical prednisolone, mannitol IV, topical timolol D. Topical timolol, topical apraclonidine, topical prednisolone

A. Acetazolamide IV, topical apraclonidine, topical timolol

A patient presents with pruritic, perioral honey-colored crusts. This rash seen above is associated with which one of the following conditions? A. Acute glomerulonephritis B. Arthritis C. Clostridioides difficile colitis D. Secondary syphilis E. Intussusception

A. Acute glomerulonephritis (poststreptococcal glomerulonephritis results from an antecedent infection of the skin/throat caused by GABHS weeks after the infection)

A 57yo man presents to the ED with a fever and altered mental status. The patient stays at a homeless shelter and was noticed to be acting strange and confused by the supervisor. His temperature is 104°F, blood pressure is 127/68 mm Hg, pulse is 120/min, respiratory rate is 24/min, and oxygen saturation is 98% on room air. PE is notable for a confused man who answers questions inappropriately. Neurologic exam is notable for intact cranial nerves and no pain with flexion of the neck or exacerbation of headache with rapid alternating movements of the head. CSF studies show 62 RBC/mcL, lymphocytic pleocytosis with 100 WBC/mcL, and protein 100 mg/dL, but culture is pending. Which of the following is the appropriate treatment for this patient, given the most likely etiology of his presentation? A. Acyclovir B. Ibuprofen, metoclopramide, and magnesium C. Observation D. Vancomycin, ceftriaxone, and dexamethasone E. IVIG

A. Acyclovir (pt has HSV encephalitis)

A 45yo woman presents to the ED with palpitations. She is placed on the monitor which shows a rapid narrow-complex tachycardia. Her heart rate is 160 bpm and blood pressure is 120/70 mm Hg. Vagal maneuvers are attempted and fail. Next, adenosine 6 mg IV is given intravenously without a change in her rhythm. Repeat vitals show a heart rate 165 bpm and blood pressure 120/70 mm Hg. What is the most appropriate next step in management? A. Adenosine 12 mg intravenous B. Adenosine 6 mg intravenous C. Synchronized cardioversion D. Vagal maneuvers E. Amiodarone 3mg intravenous

A. Adenosine 12 mg intravenous (in a stable patient with PSVT, after vagal maneuvers and a single dose of adenosine 6 mg have been attempted and fail, it is most appropriate to give adenosine 12 mg intravenously)

A 22yo woman presents with lower abdominal pain that started two days ago. Today, she had three episodes of vomiting but denies any diarrhea or dysuria. On examination, her temperature is 38.8°C, heart rate 105 beats per minute, and blood pressure 128/72. She is ill-appearing with bilateral lower quadrant tenderness. Pelvic examination reveals moderate yellow discharge and uterine tenderness. There are no adnexal masses appreciated. Pregnancy test is negative. What is the next step in the management of this patient? A. Admission for intravenous cefotetan and doxycycline B. Admission for intravenous ciprofloxacin and metronidazole C. Discharge home following intramuscular ceftriaxone with a 14 day course of oral doxycycline and metronidazole D. Order a computed tomography scan of the abdomen and pelvis with intravenous and oral contrast E. Urgent referral with OBGYN for surgery

A. Admission for intravenous cefotetan and doxycycline (pt with PID is ill-appearing with vomiting and a high fever making her a candidate for inpatient management with IV abx)

What is the most common site of compartment syndrome? A. Anterior compartment of the lower leg B. Anterior compartment of the thigh C. Lateral compartment of the lower leg D. Volar compartment of the forearm E. Laterala. compartment of the upper arm

A. Anterior compartment of the lower leg (MC from tibia fracture)

A 10yo boy presents to the ED with a rash and bruising to his legs for 2 days. He reports no pain or other associated symptoms. He had a mild URI 3 weeks ago, but that resolved without any complication. His vital signs are within normal limits. On exam, he is well appearing with small petechiae to his torso and lower legs. His CBC results show a WBC of 8,200 cells/microL, a hemoglobin of 12.3 g/dL, and platelets of 31,000 cells/microL. What is the primary pathophysiology behind this patient's thrombocytopenia? A. Antibody-mediated destruction of platelets B. Diffuse microvascular coagulation and thrombosis with platelet consumption in thrombi C. Impaired platelet production in the bone marrow D. Splenic sequestration of platelets E. Genetic disorder

A. Antibody-mediated destruction of platelets (pt presents with immune thrombocytopenia which can occur after a viral illness in children)

A 69yo man with a PMH of DM, HTN, and medication non-compliance presents to the ED with a fever and a cough that has been progressively worsening. He has not has any recent travel or hospitalizations. His temperature is 102°F, blood pressure is 117/68 mm Hg, pulse is 120/min, respiratory rate is 30/min, and oxygen saturation is 94% on room air. A CXR shows right lower lobe infiltrate. Which of the following is the most appropriate treatment for this patient's symptoms? A. Azithromycin and ceftriaxone B. Cefepime C. Piperacillin-tazobactam and vancomycin D. Vancomycin, cefepime, and amikacin

A. Azithromycin and ceftriaxone (community-acquired pneumonia)

Which of the following conditions has a negative Nikolsky sign? A. Bullous pemphigoid B. Pemphigus vulgaris C. Staphylococcal scalded skin syndrome D. Toxic epidermal necrolysis E. Steven-Johnson syndrome

A. Bullous pemphigoid

A 75yo man with a history of renal colic presents with right flank pain radiating to the right groin. During triage, the patient has a syncopal event. Urinalysis shows no red cells. His blood pressure is 110/60 mm Hg. What is the best management indicated for this patient? A. CT abdomen and pelvis with contrast B. CT abdomen and pelvis without contrast C. Discharge home with urology follow up D. Intravenous antibiotics E. KUB

A. CT abdomen and pelvis with contrast (s/sx concerning for an AAA)

A 77-year-old woman presents to the ED with acute painless vision loss. On funduscopic exam, you note a pale retina with a cherry red spot on the fovea. Which of the following is the most likely diagnosis? A. Central retinal artery occlusion B. Central retinal vein occlusion C. Idiopathic intracranial hypertension D. Optic neuritis E. Macular degeneration

A. Central retinal artery occlusion

A 61yo previously healthy man presents with three days of gross hematuria and clots in his urine. He denies any dysuria, flank pain, fever, or trauma. On exam, his heart rate is 78 beats per minute, blood pressure 142/72 mm Hg, and temperature 37.4°C. He has no abdominal tenderness or fullness on palpation. GU exam is unremarkable. UA is negative for leukocyte esterase and nitrites. There are > 100 red blood cells/hpf and 6 white blood cells/hpf. Creatinine is 1.1. What is the next step in the management of this patient? A. Computed tomography of the abdomen and pelvis with intravenous contrast B. Continuous bladder irrigation C. Discharge home with ciprofloxacin for five days D. Discharge home with urology referral E. Insertion of foley catheter

A. Computed tomography of the abdomen and pelvis with intravenous contrast (rule out underlying structural disease or mass)

A 32yo G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last 6 months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but does not have any vaginal discharge. On exam, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are felt. Her pregnancy test is negative. What is the most likely diagnosis? A. Endometriosis B. Mittelschmerz C. Pelvic inflammatory disease D. Ruptured ovarian cyst E. Ovarian torsion

A. Endometriosis (Dysmenorrhea, pelvic pain, and dyspareunia are the most frequent presenting complaints with normal physical exam)

A 59yo woman presents with pain and swelling of the face that began yesterday. She states that the symptoms began abruptly with a fever and chills. PE reveals well-demarcated bright red, indurated skin in a malar distribution. The skin has a peau d'orange appearance. What is the most likely diagnosis? A. Erysipelas B. Rosacea C. Scarlet fever D. Systemic lupus erythematosus E. Contact dermatitis

A. Erysipelas

What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis? A. Glucose-6-phosphate-dehydrogenase deficiency B. Hereditary spherocytosis C. Paroxysmal nocturnal hemoglobinuria D. Pyruvate kinase deficiency E. Sickle cell disease

A. Glucose-6-phosphate-dehydrogenase deficiency (pneumocystis pneumonia prophylaxis is most commonly initiated with trimethoprim-sulfamethoxazole, an agent associated with hemolysis in patients with G6PD deficiency)

An 18yo presents to the ED with severe pain in his penis. He indicates he has had some mild irritation to the glans and foreskin areas recently. After intercourse tonight he was unable to reduce the foreskin and now has severe pain in the tip of his penis. On examination, the penis is flaccid and the foreskin is retracted proximally. There is swelling to the tip of the penis with mild erythema. What is the most likely diagnosis? A. Paraphimosis B. Penile fracture C. Phimosis D. Priapism E. Peyronie's disease

A. Paraphimosis (inability to reduce the proximal edematous foreskin distally over the glans penis into its natural position)

A 53yo woman is being evaluated for hypercalcemia. She has anorexia, constipation, fatigue, and polydipsia. She has a PMH of nephrolithiasis. Laboratory studies reveal hypophosphatemia and elevated 1,25-dihydroxyvitamin D. Which of the following is the most likely diagnosis? A. Primary hyperparathyroidism B. Hyperthyroidism C. Hypoparathyroidism D. Vitamin D deficiency E. Secondary hyperparathyroidism

A. Primary hyperparathyroidism

A 68yo man with a history of severe COPD presents with altered mental status. His oxygen saturation is 90% on 4 liters of oxygen via nasal cannula. A venous blood gas is obtained with the following results: pH: 7.15 pO2: 45 mm Hg pCO2: 100 mm Hg HCO3: 38 mEq/L The patient has which of the following acid-base disturbances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis (with chronic metabolic compensation)

Which of the following is one of the most helpful signs to rule out testicular torsion? A. Presence of a bell-clapper deformity B. Presence of Prehn sign C. Presence of the cremasteric reflex D. Vertical lie of testicle E. Exquisite tenderness on DRE

C. Presence of the cremasteric reflex

Which of the following types of traumatic events has the highest probability of resulting in post-traumatic stress disorder? A. Combat exposure B. Death of a loved one C. Rape D. Kidnapping E. Robbing

C. Rape (while many types of events can cause PTSD, sexual relationship violence, such as rape or childhood sexual assault, has the highest probability of causing PTSD)

A 56yo woman with a history of HTN, DM, and hypercholesterolemia presents with acute substernal chest pain that is worse with exertion and associated with nausea and shortness of breath. Her sibling and parent both had "heart attacks" before the age of 55 years. Which of the following offers a proven mortality benefit in acute coronary syndrome? A. Amlodipine B. Aspirin C. Morphine D. Nitroglycerin E. Oxygen

B. Aspirin (ASA has been proven to reduce mortality in patients with acute myocardial infarction by 25-50%, both independently and with the use of fibrinolytic therapy)

A 52yo man with a history of DM and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 150 beats/minute, blood pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His ECG is shown on back of card. Which of the following is the most appropriate initial management? A. Administer intravenous adenosine B. Administer intravenous diltiazem C. Sedate the patient and perform synchronized cardioversion with 100 joules D. Transport the patient to the cardiac catheterization suite

B. Administer intravenous diltiazem (atrial fibrillation seen on ECG so pt needs rate control since stable)

A 27yo previously healthy man comes to the ED with chest pain. He had a viral syndrome with a low-grade fever a few days earlier. He describes the chest pain as sharp, retrosternal in location, with radiation to the left trapezius ridge. It improves with sitting forward and worsens when he lays down. Vital signs are normal. His electrocardiogram is shown on back of card. His initial cardiac biomarkers are negative. Which of the following treatments is most appropriate? A. Administration of aspirin and emergent cardiac catheterization B. Administration of ibuprofen and NSAID and discharge home C. Hospital admission for cardiac monitoring and serial cardiac enzymes D. Prescription for azithromycin and discharge home E. Administration of fibrinolytic

B. Administration of ibuprofen and NSAID and discharge home (acute pericarditis)

What is the most common symptom of hemorrhoids? A. Mucoid discharge B. Bleeding with defecation C. Pruritus D. Painful defecation E. Dyspareunia

B. Bleeding with defecation

A 17yo girl with a history of sickle cell disease and asthma presents with four days of fever, cough, and left chest pain. Temperature is 102.2°F, pulse rate is 98/min, respirations are 24/min, blood pressure is 135/90 mm Hg, and SaO₂ is 92% on room air. PE reveals an uncomfortable-appearing girl with intercostal retractions. Which of the following is most likely to confirm the diagnosis? A. Acute drop in hemoglobin and reticulocytosis B. Chest X-ray with left-sided lobar infiltrate C. Chest X-ray with left-sided pneumothorax D. ECG with precordial ST segment elevations E. Clinical diagnosis

B. Chest X-ray with left-sided lobar infiltrate (fever in a sickle cell pt is a medical emergency and part of criteria for acute chest syndrome which is diagnosed with CXR that shows lobar infiltrate)

A 45yo woman presents to the ED with dysuria and right flank pain. Her symptoms started 6 days ago with urinary urgency and dysuria. She developed the flank pain 2 days ago and has associated chills and nausea. Vital signs are remarkable for a temperature of 100.0°F, HR 80 bpm, RR 13/min, BP 130/60 mm Hg, and SpO₂ 99%. What is the most appropriate management of this patient? A. Ceftriaxone 1g daily B. Ciprofloxacin 500 mg twice daily C. Fosfomycin 3 g once D. Nitrofurantoin 100 mg twice daily E. Doxycycline 100mg twice daily

B. Ciprofloxacin 500 mg twice daily (pyelonephritis can be treated with FLQ, TMP-SMX, augmentin, or cefpodoxime)

What is the best step in management if a patient presents with a patellar dislocation? A. Angiogram B. Closed reduction C. Computed tomography scan D. Orthopedic consultation E. Discharge with supportive care instructions

B. Closed reduction

A 55yo man with a history of DM and HTN presents with foot pain. He is a local carpenter and does a lot of work in his garage. He first noticed the pain while working in his garage a week ago but kept working despite the pain. On exam, the patient has a puncture wound on the bottom of his foot that is erythematous with purulent discharge. An X-ray of the foot shows soft tissue edema and a periosteal reaction of the distal aspect of the second metatarsal. What is the most likely causative organism? A. Group A Streptococcus B. Pseudomonas aeruginosa C. Salmonella D. Staphylococcus aureus E. Staphylococcus epidermidis

B. Pseudomonas aeruginosa (MC organism isolated from plantar puncture wound-related osteomyelitis)

A 49yo woman presents with chest pain and shortness of breath. Her pain is constant, non-exertional and does not radiate into the back. She denies hemoptysis, history of previous venous thromboembolism, trauma or surgery within the last four weeks or unilateral leg swelling. She takes no medications. She smokes a half pack of cigarettes per day. Her vital signs at triage are temperature 98.6°F, blood pressure 120/80 mm Hg, and heart rate 108 bpm. Her heart rate improves to 97 bpm upon reevaluation. Her physician decides to evaluate her for a pulmonary embolism. In addition to an ECG and a chest X-ray, which of the following is the most appropriate next step in the diagnosis of pulmonary embolism? A. CT pulmonary angiogram B. D-dimer followed by a CT pulmonary angiogram if positive C. Use the pulmonary embolism rule-out criteria to exclude pulmonary embolism D. V/Q scan

B. D-dimer followed by a CT pulmonary angiogram if positive (pt is PERC positive with initial HR >100bpm so should be evaluated for pulmonary embolism)

A 46yo woman without significant PMH presents with drooping of the left side of her face which she noticed this morning when she looked into the mirror. She is unable to completely close her left eye and cannot raise her eyebrows on the left side. Her vision is intact. When asked to puff out her cheeks, air leaks out the left side. The rest of her neurologic exam is normal. Which of the following is the most appropriate initial management? A. CT head followed by administration of tPA B. Discharge home with oral prednisone and eye lubricant and patch at night C. Magnetic resonance imaging of the brain D. Stat neurology consult for neuro-interventional procedure E. Admit for IV prednisone administration

B. Discharge home with oral prednisone and eye lubricant and patch at night (Bell palsy does not need admission)

A 32yo man presents by EMS after being the unhelmeted operator of a motorcycle involved in a collision with a truck. He was found 15 feet from where his motorcycle was found and is intubated at the scene for depressed mental status. His vital signs on arrival are HR 38/min, BP 62/40 mm Hg, T 36.2°C, and RR 14/min on mechanical ventilation. His extremities are warm, well-perfused, and without obvious deformity. His exam is otherwise significant only for widespread road rash. Which of the following is the most likely cause of the patient's hypotension? A. Cardiogenic shock B. Distributive shock C. Hypovolemic shock D. Obstructive shock E. Dissociative shock

B. Distributive shock (neurogenic shock in the setting of spinal cord injury is a type of distributive shock)

A 22yo woman presents with symmetric lower extremity weakness. She recently had a diarrheal illness. Which of the following might you expect on further workup? A. Creatine kinase elevation B. Elevated protein of the cerebrospinal fluid C. Hyperreflexia D. Meningeal enhancement on MRI of the brain E. Anti-Jo-1 serum antibodies

B. Elevated protein of the cerebrospinal fluid (pts with Guillaain-Barre syndrome often have preceding respiratory or gastrointestinal infection with the MC being Campylobacter jejuni, CMV, EBV, and Mycoplasma pnemoniae)

A 58yo man presents with two days of fever and lower back pain. DRE reveals a swollen and tender prostate. His urinalysis reveals 100 WBC/hpf, leukocyte esterase, and nitrites. What is the most likely pathogen causing this condition? A. Chlamydia trachomatis B. Escherichia coli C. Klebsiella D. Pseudomonas E. Staphylococcus aureus

B. Escherichia coli (acute prostatitis

A 65yo man with a PMH of HTN presents to the ED with tearing chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first? A. Aspirin B. Esmolol C. Heparin D. Nitroprusside E. Nicardipine

B. Esmolol (first step in managing aortic dissection is BP control SBP 100-120 within 20min with non-selective beta-blockers)

A 25yo woman with a history of hypertension presents to the ED after a syncopal event. She is complaining of lower abdominal pain. Her heart rate is 132 beats/minute and her blood pressure is 85/41 mm Hg. Her urine pregnancy test is positive. Which of the following is the most appropriate next step in management? A. Administer rho(D) immune globulin B. Establish intravenous access C. Obtain a 12-lead electrocardiogram D. Order an abdominal ultrasound E. Order a pelvic ultrasound

B. Establish intravenous access (most appropriate for this hemodynamically unstable pt who has likely significant hemorrhage from a ruptured ectopic pregnancy and requires fluid resuscitation and possible blood transfusion)

A 40yo man with ulcerative colitis presents to the ED with severe abdominal pain. His temperature is 99.9°F, pulse 120 bpm, respirations 20/minute, blood pressure 80/50 mm Hg, and oxygen saturation 98% on room air. His abdomen is markedly distended, diffusely tender with guarding, and tympanitic to percussion. Abdominal XR shows a markedly distended colon with loss of haustra and pneumoperitoneum, but no air-fluid levels. His serum lactate level is 8 mmol/L. In addition to intravenous fluids and antibiotics, which of the following is the best management at this time? A. Bowel rest and observation B. Exploratory surgery C. Nasogastric tube insertion D. Therapeutic paracentesis E. PO challenge

B. Exploratory surgery (concern for toxic megacolon for which definitive tx is surgery)

A 28yo woman presents to the ED following a finger injury while playing flag football. She states that she sustained a direct blow to the pointer finger when the ball struck her fingertip. On PE, the patient has swelling and tenderness at the distal interphalangeal joint. The fingertip rests in 45 degrees of flexion. She is unable to demonstrate active extension of the distal interphalangeal joint but has full passive extension. The skin is intact. X-ray of the finger is obtained, which shows soft tissue swelling but no fracture or dislocation. Which of the following is the most appropriate management for this patient? A. Buddy taping B. Extension splinting of the distal interphalangeal joint C. Extensor tendon reconstruction D. Physical therapy for range of motion and strengthening

B. Extension splinting of the distal interphalangeal joint (mallet finger deformity occurs when the extensor tendon of the DIP is ruptured)

A 34yo man presents to the ED with left arm pain after a fall on an outstretched hand while walking his dog. He has tenderness and swelling of the forearm as well as wrist pain with attempted pronation and supination. An X-ray is obtained as seen on back of card. What eponym is associated with this fracture? A. Colles fracture B. Galeazzi fracture C. Hutchinson fracture D. Monteggia fracture E. Smith fracture

B. Galeazzi fracture

A 23yo man presents to the ED for vomiting and diarrhea, but on examination, a loud murmur is heard. He says he has had a murmur his whole life and denies any cardiac symptoms. A chest X-ray shows an enlarged cardiac silhouette, and an ECG shows deep, dagger-like Q-waves in the inferior and lateral leads. Which of the following physical exam findings is most consistent with this condition? A. Decreased pulses in the lower extremities compared to the right upper extremity B. Holosystolic murmur at left lower sternal border that decreases with squatting C. Holosystolic murmur at left lower sternal border that increases with squatting D. Large tongue, flat nasal bridge, single palmar crease E. Pulsus alternans

B. Holosystolic murmur at left lower sternal border that decreases with squatting (HOCM murmurs increase with Valsalva and decrease with squatting)

A 55yo man with diabetes presents to the emergency department for acute-onset atraumatic right knee pain associated with redness and an effusion. He has no history of similar episodes and reports no fever. Arthrocentesis yields cloudy yellow fluid with 10,000 white blood cells/µL, blue needle-shaped crystals on microscopy, and a negative Gram stain. Which of the following is the most appropriate treatment of this patient's condition? A. Allopurinol orally and discharge B. Indomethacin orally and discharge C. Intravenous ceftriaxone and admission D. Rest, ice, compression, and physical therapy referral E. Urgent referral for inpatient surgery

B. Indomethacin orally and discharge (pts with gout and normal kidney function my be treated with indomethacin orally or other NSAID meds and discharged for further management)

An 80yo woman, with a history of type 2 DM, presents with slowly worsening vision. Her vision is worse in low-intensity light and she has blurring in the center of her vision. PE shows intact peripheral visual fields with a positive Amsler grid distortion. Fundoscopic exam reveals drusen located in the macula of the retina. What is the most likely diagnosis? A. Diabetic retinopathy B. Macular degeneration C. Open-angle glaucoma D. Presbyopia E. Cataracts

B. Macular degeneration

A 46yo man with a history of DM and chronic alcohol use presents to the ED with lower back pain that has progressively worsened over the last five days. He denies a history of trauma. On examination, he has a temperature 100.2 F, heart rate 87 beats/minute, and BP 146/75. He has tenderness with percussion over the midline lower lumbar spine. Achilles and patellar reflexes are intact. He has mild decreased sensation of both feet, but his strength is intact. What is the next best step in management? A. Complete blood count B. Magnetic resonance imaging of the lumbosacral spine C. Pain control with ibuprofen and discharge home D. Plain radiographs of the lumbosacral spine E. CT scan without contrast of lumbar spine

B. Magnetic resonance imaging of the lumbosacral spine (spinal epidural abscess)

Which of the following is the most common cause of status epilepticus in a patient with known epilepsy? A. Hypoglycemia B. Medication noncompliance C. Meningitis D. Trauma E. Alcohol or illicit substance intake

B. Medication noncompliance (recall how to manage status epilepticus in the ED?)

A 25-year-old man presents to the emergency department with complaints of palpitations, shortness of breath, vomiting, and diarrhea. His past medical history is significant for Graves disease and asthma. He is in acute distress and diaphoretic. His blood pressure is 170/110 mm Hg, heart rate is 165 beats/minute, respirations are 53 breaths per minute, and his oral temperature is 39.3°C. Which of the following is the correct sequence of agents used to treat this condition? A. Esmolol, Lugol solution, methimazole, hydrocortisone, cholestyramine B. Metoprolol, methimazole, hydrocortisone, ipodate, cholestyramine C. Potassium iodide, dexamethasone, atenolol, propylthiouracil, cholestyramine D. Propranolol, iopanoic acid, propylthiouracil, cholestyramine, dexamethasone

B. Metoprolol, methimazole, hydrocortisone, ipodate, cholestyramine (iodine-containing agents must be given AFTER thionamide administration or else iodine is used as substrate for more thyroid hormone synthesis)

A 52yo man presents with two episodes of bright red blood per rectum. He denies any abdominal pain. Vital signs are stable. PE reveals no abdominal tenderness and no source of bleeding on anoscopy, but bright red blood is visualized inside the anus. A review of old records shows a colonoscopy report from three years ago with diverticulosis. Which of the following is the most appropriate management plan? A. Emergent sigmoidoscopy B. Observation with serial blood counts and GI consultation C. Pantoprazole D. Vasopressin E. Conrtrast barium enema study

B. Observation with serial blood counts and GI consultation (diverticular disease and angiodysplasia are MC causes of lower GI bleed)

A 6-week-old infant presents with decreased appetite. The child is underweight for her age, and her mother says that she is not eating well. Physical exam reveals a continuous heart murmur in the left infraclavicular space and a thrill in the suprasternal notch. Which of the following findings would be expected on echocardiogram? A. Overriding aorta B. Patent ductus arteriosus C. Right ventricular outflow obstruction D. Ventricular septal defect E. Atrial septal defect

B. Patent ductus arteriosus

Which of the following is the most common pulmonary complication of influenza? A. Empyema B. Pneumonia secondary to superimposed bacterial infection C. Primary viral pneumonia D. Spontaneous pneumothorax E. Pleural effusion

B. Pneumonia secondary to superimposed bacterial infection

A 25yo man is brought to the ED by police for bizarre behavior. His family arrives and states that his behavior changed about eight months ago. He does not abuse drugs or alcohol. On examination, he has a flat affect and appears to be responding to internal stimuli. His speech is disorganized and he says, "I've been running from the Russians who are trying to steal my thoughts." His laboratory and urine studies are unremarkable. What is the most likely diagnosis? A. Schizoaffective disorder B. Schizophrenia C. Schizophreniform disorder D. Schizotypal personality disorder

B. Schizophrenia (delusions or disorganized speech and one of the following: hallucinations, negative symptoms, or grossly negative or catatonic behavior)

A 26yo man presents to the ED after briefly losing consciousness when hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head? A. A collection of blood layering in the basilar cisterns B. A crescent-shaped frontal hematoma crossing suture lines C. A lenticular-shaped hematoma in the temporal region D. An intraparenchymal hemorrhage within the frontal lobe

C. A lenticular-shaped hematoma in the temporal region (epidural hematoma)

A 55yo man presents with right knee pain. He denies having any trauma to the affected joint. The symptoms started three days ago and have progressively worsened. His history is significant for DM and HTN. Vital signs are remarkable for a temperature of 38.5°C, HR 110 bpm, BP 120/80 mm Hg, and RR 20 breaths/min. Exam demonstrates an edematous and erythematous right knee that is warm to the touch. The knee pain is exacerbated with passive range of motion. An arthrocentesis is performed. Which of the following lab results is diagnostic of septic arthritis? A. Cloudy, yellow in appearance, 20,000 WBCs with positively birefringent crystals present on analysis B. Cloudy, yellow in appearance, 45,000 WBCs with negatively birefringent crystals present on analysis C. Cloudy, yellow in appearance, 75,000 WBCs with no crystals present on analysis D. Transparent, yellow in appearance, 5,000 WBCs with no crystals present on analysis

C. Cloudy, yellow in appearance, 75,000 WBCs with no crystals present on analysis (diagnostic for septic arthritis if synovial fluid contains > 50,000 WBCs and more than 75% neutrophils)

Injury to which of the following structures characterizes a strain? A. Bone diaphysis B. Bone metaphysis C. Connective tissue between muscle and bone D. Connective tissue between separate bones of a joint E. Cartilage

C. Connective tissue between muscle and bone

A 42yo man with a history of heavy alcohol use presents with severe abdominal pain and vomiting following an alcohol binge. Lab values are as follows: WBC 14,000, Hgb 10, platelets 98,000, lipase 9,000, AST 200, ALT 107, T. bill 1.6, Na 134, K 5.1, Cr. 3.1, and glucose 313. Which of the following lab values is associated with increased mortality according to the Ranson Criteria? A. AST of 200 B. Creatinine of 3.1 C. Glucose of 313 D. Lipase of 9,000 E. WBCs of 2,000/mm^3

C. Glucose of 313

Which of the following correctly describes electrocardiographic features of second-degree type I atrioventricular block? A. Absence of discernible P waves B. Constant PR interval followed by a dropped beat C. Grouped beats D. Sawtooth P waves E. Peaked T waves

C. Grouped beats

A 55yo man presents with fever and right upper quadrant pain. On examination, you note that the patient is jaundiced and slightly altered. Clinically you make the diagnosis of cholangitis. Which of the following is the final component of Reynold's pentad? A. Acute kidney injury B. Dilated common bile duct C. Elevated lipase D. Hypotension E. Jugular vein distention

D. Hypotension (Reynold's pentad-- fever, RUQ pain, jaundice, confusion, hypotension)

A 27yo woman with a history of lupus presents to the ED for finger pain and swelling for the past three days. She has never had these symptoms before. Her lupus has been well-controlled on daily prednisone. On exam, she is well-appearing with normal vital signs. Her finger shows purulence of the lateral and proximal nail fold with surrounding erythema, warmth and a palpable fluctuant mass. Given this patient's diagnosis, what is the most appropriate initial treatment? A. Cover with a dry dressing and discharge with oral acyclovir B. Discharge home with warm compresses and limb elevation C. Incision and drainage and discharge with oral cephalexin D. Incision and drainage and discharge with wound care information E. Urgent referral to hand specialist

C. Incision and drainage and discharge with oral cephalexin (I&D for paronychia and give abx since pt is immunocompromised)

A 62yo woman was walking her dog when she began to experience intense substernal chest pressure. She became very diaphoretic and felt nauseated. She called 911 and was brought to the ED. Her electrocardiogram is shown on back of card. Which of the following best describes the location of the patient's myocardial infarction? A. Anterolateral B. Anteroseptal C. Inferior D. Posterior

C. Inferior

A 35yo African American woman presents to the ED with facial swelling. On physical exam, you note perioral angioedema. Which of the following medications is most likely the cause of this process? A. Amiodarone B. Heparin C. Lisinopril D. Metoprolol E. Amlodipine

C. Lisinopril

A 44yo man with SLE presents to the ED with chest pain and dyspnea. Vital signs are notable for tachycardia and hypotension with a narrow pulse pressure. Bedside ultrasound confirms a large pericardial effusion with collapse of the right ventricle during diastole. Which classic ECG findings are associated with this disease process? A. Delta wave and shortened PR interval B. Diffuse ST elevation C. Low voltage and electrical alternans D. S wave in lead I and a Q wave and inverted T wave in lead III E. Progressive prolongation of PR interval

C. Low voltage and electrical alternans (cardiac tamponade)

A 30yo man presents to the ED with three weeks of diarrhea. He reports colicky abdominal pain associated with frequent episodes of pale, loose, foul-smelling stools. He returned from a camping trip in New Hampshire 1 month prior. His vital signs are temperature 37.1°C, heart rate 85 bpm, and blood pressure 125/80 mm Hg. Which of the following is the most appropriate treatment for this condition? A. Ciprofloxacin 500 mg daily for 7 days B. Clindamycin 300 mg qid for 7 days C. Metronidazole 250 mg tid for 7 days D. Rifaximin 200 mg tid for 7 days

C. Metronidazole 250 mg tid for 7 days (tx of choice for Giardia lamblia infection)

A 34yo pregnant woman at 10 weeks gestation presents to the ED for vaginal bleeding and abdominal pain. On examination, the patient's cervical os is closed. A transvaginal ultrasound confirms an intrauterine pregnancy but is unable to detect cardiac activity. What classification of spontaneous abortion does the patient have? A. Incomplete abortion B. Inevitable abortion C. Missed abortion D. Threatened abortion E. Complete abortion

C. Missed abortion

A 32yo woman presents with progressive fatigue, shortness of breath, and chest discomfort that has worsened over the last 2 days. She had a mild URI last week but otherwise reports no significant PMH. She does not take any medications and reports no illicit drug use. On exam, she has a T 37.9°C, HR 132 bpm, RR 16/min, and oxygen saturation 98% on room air. Lungs are clear to auscultation. CXR demonstrates mild cardiomegaly without infiltrates. ECG shows sinus tachycardia with nonspecific ST segment and T wave changes. Troponin I is 0.25 ng/mL (normal range ≤0.05 ng/mL). What is the likely cause of her symptoms? A. Acute coronary artery thrombosis B. Community-acquired pneumonia C. Myocarditis D. Pulmonary embolism E. Pneumothorax

C. Myocarditis

Which of the following causes acute painful loss of vision? A. Central retinal artery occlusion B. Central retinal vein occlusion C. Optic neuritis D. Retinal detachment E. Amaurosis fugax

C. Optic neuritis (an inflammatory, demyelinating disease of the optic nerve, presents as an acute monocular loss of vision)

A 67yo man with a history of HTN and DM presents to the ED with sudden onset of left leg weakness. His examination is notable for 3/5 strength in his left lower extremity as well as diminished sensation over his left toes, foot, and leg. He has a flat affect and appears slow in his speech. Which of the following vascular territories is most likely affected in this patient? A. Left lenticulostriate arteries B. Left posterior cerebral artery C. Right anterior cerebral artery D. Right middle cerebral artery E. Left middle cerebral artery

C. Right anterior cerebral artery (Symptoms of an ACA infarction include contralateral lower extremity weakness and sensory loss with sparing of the upper extremity and face)

A 39yo woman presents to the ED with right leg pain and mild swelling. She denies any previous medical history or trauma. She does not take any medication. Examination is remarkable for tenderness along the right calf venous distribution and minimal swelling of the right lower leg. What is the most appropriate diagnostic workup of this patient? A. Duplex ultrasonography to evaluate for deep venous thrombosis. If negative, send a D-dimer. If D-dimer is positive, treat for deep venous thrombosis. B. Duplex ultrasonography to evaluate for deep venous thrombosis. If negative, the patient may be discharged. C. Send a D-dimer. If negative, the patient may be discharged. D. Send a D-dimer. If positive, treat for deep venous thrombosis.

C. Send a D-dimer. If negative, the patient may be discharged (In a patient with low-to-moderate risk for DVT, the appropriate workup includes at least a negative high-sensitivity D-dimer test in order to complete the workup without imaging)

An 18-month-old boy presents with his father for a cough and difficulty breathing. The father states that the child has had nasal congestion and coryza for the last two days. On exam, he has a barking cough, inspiratory stridor, and a prolonged inspiratory phase. Which of the following would you expect to see on radiographic evaluation? A. Edema of the epiglottis B. Intraluminal membranes of the tracheal wall C. Subglottic narrowing D. Thickening of the retropharyngeal space E. Tonsilar exudates

C. Subglottic narrowing (child with croup)

Which muscle is most commonly involved with rotator cuff injuries? A. Infraspinatus B. Subscapularis C. Supraspinatus D. Teres minor E. Teres major

C. Supraspinatus

A 30yo man presents to the ED with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging? A. Bony tenderness in the malleolar zone B. Bony tenderness in the midfoot zone C. Swelling over the lateral malleoli D. Inability to bear weight on the ankle

C. Swelling over the lateral malleoli (Use Ottawa ankle Rules... swelling is common in ankle sprains and without any bony tenderness in a pt who is able to bear weight is more indicative of an ankle sprain)

A 21yowoman presents with pain, tearing, photophobia, and left eye redness. She has been wearing her contact lenses continuously for the last two weeks. A slit lamp exam reveals a white, hazy opacity on the cornea at the 3 o'clock position of the cornea with associated limbal flush. Which of the following is the most appropriate pharmacotherapy? A. Topical acyclovir B. Topical amphotericin B C. Topical ciprofloxacin D. Topical cyclopentolate E. Topical timolol

C. Topical ciprofloxacin (1st line for corneall ulceration to protect against Pseudomonas aeruginosa)

A 60yo man with a history of tobacco use, hypertension, and stable angina presents to the ED with chest pain. He states he previously could walk 15 minutes before the chest pain would start, but today it began immediately upon exertion and lasted longer than before. He denies pain at rest, and his symptoms today resolved with sublingual NTG. Vital signs and examination are unremarkable. An ECG is obtained, which is shown on back of card, and his initial troponin is negative at four hours from pain onset. Which of the following is the most likely diagnosis? A. Non-ST elevation myocardial infarction B. ST elevation myocardial infarction C. Unstable angina D. Wellens syndrome E. Stable angina

C. Unstable angina

A 60-year-old man with a history of chronic obstructive pulmonary disease presents by EMS in respiratory distress. He is diaphoretic and is sitting up in bed leaning forward. His vital signs are T 100.1°F, HR 95 beats/minutes, RR 30 breaths/minute, BP 150/90 mm Hg, and oxygen saturation 79% on room air. There is poor air movement with prolonged expiratory wheezes. A nonrebreather face mask is placed, but his work of breathing and oxygen saturation are not improving. In addition to intravenous glucocorticoid and nebulized beta-agonist medications, which of the following is most appropriate next step in management? A. Ceftriaxone and azithromycin B. Endotracheal intubation C. Intravenous magnesium sulfate D. Noninvasive positive pressure ventilation

D. Noninvasive positive pressure ventilation (beneficial for COPD patients with severe acute exacerbations who are acidemic (pH < 7.36), hypercapnic (PaCO2 > 50 mm Hg), hypoxemic (PaO2 < 60 mm Hg or SaO2 < 90 mm Hg), or who have severe dyspnea, respiratory fatigue or increased work of breathing)

A 31yo man with a history of type 1 DM and obesity presents to the ED with chest pain. He reports sudden-onset substernal chest pain 10 minutes prior to arrival with associated shortness of breath, nausea, and lightheadedness. EMS staff gave him NTG and ondansetron on the scene, and his symptoms have since resolved. On chart review, this patient has undergone an extensive work-up of episodes similar to this, including a stress test, cardiac catheterization, and chest imaging, all of which were normal. He has also been admitted for multiple overnight observations with normal cardiac rule-out testing. He reports continued persistent concern over the past two months regarding his "attacks" but not about a specific disease process or cause of his symptoms. Which of the following is the most likely diagnosis? A. Factitious disorder B. Generalized anxiety disorder C. Illness anxiety disorder D. Panic disorder

D. Panic disorder

A 5yo boy with a history of sickle cell anemia presents with dyspnea and fatigue. His mother notes that 1 week prior, he had a fever, headache, and bright red rash on his cheeks, which has since resolved. Laboratory studies show a decrease in his baseline hemoglobin by 30%. Infection with which virus likely precipitated his current symptoms? A. Coxsackievirus B. Human herpesvirus 6 C. Measles virus D. Parvovirus B19 E. Rubella

D. Parvovirus B19 (erythema infectiosum)

A 45yo woman, who works as a day laborer, presents with epigastric abdominal pain that began one hour prior to arrival. She has been having abdominal discomfort after meals for the past several weeks. Today, she developed sudden onset, severe abdominal pain far worse than what she has been experiencing. She denies back pain, nausea, and vomiting. On exam, she is tachycardic but has otherwise normal vital signs. Her abdomen is significantly tender in the epigastric region with rebound and guarding. Chest X-ray is on back of card. What is the most likely diagnosis? A. Cholecystitis B. Gallstone pancreatitis C. Gastritis D. Perforated gastric ulcer E. Duodenal atresia

D. Perforated gastric ulcer (when ulcer erodes through entire bowel, results in perforated gastric ulcer and there is free air under diaphragm on XR)

A 22yo healthy man presents with acute onset pleuritic, left-sided chest pain and mild dyspnea. Social history includes smoking a pack of cigarettes a week. Vital signs include blood pressure 142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation 97% on room air. He is in no acute distress. His CXR is shown on next card. Which of the following is the best next step in management? A. Discharge home with ibuprofen for pain relief B. Order a computed tomography scan of the chest C. Perform a chest tube thoracostomy D. Place patient on 100% oxygen and repeat chest radiograph in six hours E. Order a d-dimer lab test

D. Place patient on 100% oxygen and repeat chest radiograph in six hours (pt is healthy and minimally symptomatic from simple spontaneous PTX... pleural edge can be seen in apical left lung)

A 61yo woman with no PMH or family history of heart disease presents with a trimalleolar ankle fracture after a fall. As part of her preoperative workup, an ECG is obtained. A portion of the rhythm strip is shown on back of this card. Which of the following is the most appropriate next step? A. Administer intravenous calcium chloride, insulin, glucose, and sodium bicarbonate B. Order serial cardiac biomarkers and admit to cardiology C. Place transcutaneous pacer pads and make arrangements for a transvenous pacemaker D. Reassure the patient and the orthopedic surgeon that no treatment is necessary

D. Reassure the patient and the orthopedic surgeon that no treatment is necessary (asymptomatic 1° AV block evidenced by prolonged PR interval)

A 65yo woman presents to the ED with acute onset vertigo. She denies associated decreased hearing or tinnitus. Vital signs are normal. Horizontal head impulse test shows a corrective saccade when the head is turned to the left. Dix-Hallpike maneuver elicits a leftward rotary nystagmus that is fatigable. Which of the following mechanisms will provide the most definitive treatment of this condition? A. Dopamine receptor antagonism B. Inhibition of the reabsorption of sodium from the distal convoluted tubules C. Positive allosteric modulators of GABA type A receptors D. Relocation of free floating otoconia

D. Relocation of free floating otoconia (most definitive treatment for BPPV is the Epley maneuver which uses gravity to relocate free floating otoconia along the semicircular canals and into the utricle, where they are unlikely to cause vertigo)

An 18-month-old boy presents to the ED with worsening shortness of breath. The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. CXR does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms? A. Bordetella pertussis B. Haemophilus influenzae C. Parainfluenza virus D. Respiratory syncytial virus E. Pneumococcus pneumoniae

D. Respiratory syncytial virus (bronchiolitis is the MC lower respiratory tract infxn in pts <2yo and leading cause of hospitalization in infants)

An 18yo man presents complaining of fever, right-sided abdominal pain, anorexia, and vomiting. When you palpate his left lower quadrant, he complains of pain in his right lower quadrant. Based on this information, which of the following signs is considered positive? A. McBurney sign B. Obturator sign C. Psoas sign D. Rovsing sign E. Murphe's sign

D. Rovsing sign (positive when palpation of the left lower quadrant causes pain in the right lower quadrant, by pushing bowel contents towards the ileocecal valve and thus increasing pressure around the appendix)

A 56yo woman with a history of lung cancer presents to the ED with confusion, nausea, and vomiting. She is unable to provide much history due to her confusion. She is dehydrated and is oriented only to self. She is afebrile. Her renal function is normal. Her serum calcium level is 14 mg/dL (normal 9-10.5 mg/dL). What is the most likely mechanism for her hypercalcemia? A. Abnormal calcium clearance in the kidneys B. Bony erosion due to metastases C. Production of vitamin D analogues by the tumor D. Secretion of parathyroid hormone related protein from the tumor E. Increased dietary calcium m

D. Secretion of parathyroid hormone related protein from the tumor (complication of malignancy is hypercalcemia... solid tumors are most likely to result in hypercalcemia due to secretion of parathyroid hormone related proteins [PTHrp] from the tumor)

A 75yo man with a long-standing history of constipation presents complaining of abdominal pain for the last two days. He is now experiencing abdominal distention, constipation, and inability to pass gas for the last 12 hours. On examination, his abdomen is distended and tympanitic to percussion. An abdominal XR shows a grossly distended loop of colon lacking haustral markings and a "bent inner tube" appearance. What is the most likely diagnosis? A. Cecal volvulus B. Intussusception C. Irritable bowel syndrome D. Sigmoid volvulus E. IBS

D. Sigmoid volvulus (common in elderly, debilitated pts with a hx of chronic constipation, chronic laxative intake, or intake of anti-motility meds)

A 93yo man on aspirin presents to the ED with epistaxis. On PE, you note bleeding from bilateral nares and down the posterior pharynx. You are unable to visualize the source of bleeding. Which of the following vessels is most likely the source of bleeding in this patient? A. Facial artery B. Kiesselbach plexus C. Labial artery D. Sphenopalatine artery E. Anterior ethmoidal artery

D. Sphenopalatine artery (posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate)

An 81yo man with a history of atrial fibrillation presents with abdominal pain. He fell two weeks ago and was advised to stop his anticoagulation medication after the fall. He reports diffuse, severe abdominal pain but is minimally tender on examination. He has symmetric pulses in his extremities. What is the most likely anatomic location of his pathology? A. Aortic bifurcation B. Celiac trunk C. Inferior mesenteric artery D. Superior mesenteric artery E. Right colic artery

D. Superior mesenteric artery (acute mesenteric ischemia MC vessel involved is superior mesenteric artery)

A 51yo man with a history of alcohol use presents with three days of anorexia, nausea, vomiting, and RUQ abdominal pain. Vital signs are HR 115, BP 114/83, RR 20, and oxygen saturation 96% on room air. On PE, he appears jaundiced and tender hepatomegaly is noted. Liver function tests are notable for AST 433 IU/L, ALT 206 IU/L, and total bilirubin 8.0 mg/dL. INR is prolonged at 1.6. Which of the following is the appropriate treatment for this condition? A. Cholecystectomy B. Liver transplantation C. N-acetyl-cysteine D. Supportive care E. Transjugular intrahepatic portosystemic shunt

D. Supportive care (tx of alcoholic hepatitis is supportive including IV hydration, thiamine, glucose supplementation, correction electrolyte imbalances, nutritional supports, and control of etoh withdrawal sx with benzos)

A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate? A. Pes anserinus bursa B. Infrapatellar bursa C. Prepatellar bursa D. Suprapatellar bursa E. Pretibial bursa

D. Suprapatellar bursa (is not a true bursa but rather an extension of the knee joint capsule where fluid can flow if there is a knee effusion or hemarthrosis)

Which of the following is correct when estimating an adult burn patient's percent of total body surface area affected? A. Each arm is approximately 18% B. The area covered by the patient's palm is approximately 5% C. The entire head is approximately 18% D. The perineum is approximately 1% E. Each leg is approximately 9%

D. The perineum is approximately 1%

A 24yo woman presents with right thumb pain. She recently fell while skiing. On examination, she has swelling and tenderness over the base of the thumb on the ulnar side. She has weakness when pinching an object between her thumb and index finger. Which of the following structures is most likely to be injured? A. Extensor pollicis brevis B. Extensor pollicis longus C. Radial collateral ligament D. Ulnar collateral ligament

D. Ulnar collateral ligament ("gamekeeper's thumb" and "skier's thumb" from forceful radial abduction of the thumb)

Which of the following is the most sensitive finding in cauda equina syndrome? A. Back pain B. Saddle anesthesia C. Urinary incontinence D. Urinary retention E. Radiation of pain down legs

D. Urinary retention (a postvoid residual of greater than 100-200 ml should alert the emergency physician to the likelihood of this syndrome)

A 75yo woman with a history of atrial fibrillation presents to the ED with 40 minutes of sudden onset left leg pain. On PE, her leg is dusky and cool to the touch. Which of the following is the most likely diagnosis? A. Venous insufficiency B. Deep venous thrombosis C. Compartment syndrome D. Phlegmasia cerulea dolens E. Arterial thromboembolism

E. Arterial thromboembolism

A 67yo man presents to the ED with shortness of breath. His symptoms have gradually been worsening over the past month, however, after a recent URI, he noticed his symptoms markedly worsened. The patient has a PMH of diabetes, HTN, CKD, and heart failure. The patient's oxygen saturation is 90% on room air. PE is notable for bilateral lower extremity pitting edema and pulmonary crackles. Initial laboratory values are notable for a potassium of 5.6 mEq/L, a blood urea nitrogen of 45 mg/dL, and a creatinine of 2.2 mg/dL. An initial ECG is within normal limits, and a chest radiograph shows trace bilateral pleural effusions with increased interstitial markings. Which of the following is the best next treatment for this patient? A. Digoxin B. Dobutamine C. Oxygen D. Hemodialysis E. Furosemide

E. Furosemide (pts who are acutely volume overloaded should be promptly treated with diuretics as part of initial therapy, as early intervention may produce better outcomes and reduce mortality)

A 21yo woman presents with painful urination. She has no vaginal discharge and is not sexually active. Which of the following is most sensitive for a urinary tract infection on urine dipstick testing? A. Bacteria B. Blood C. Protein D. Nitrites E. Leukocyte esterase

E. Leukocyte esterase (an enzyme found in neutrophils which are not normally present in urine unless an infection is present) Different Q banks say different things... some say nitrities others say leukocyte esterase

Which acute valvular disorder is most consistent with a harsh systolic murmur, best heard at the apex of the heart and loudest in early or mid-systole? A. Aortic regurgitation B. Aortic stenosis C. Tricuspid regurgitation D. Mitral stenosis E. Mitral regurgitation

E. Mitral regurgitation (primarily caused by papillary muscle or chordae tendineae rupture from myocardial infarction or valve leaflet perforation from infective endocarditis)

A 67yo man with a history of bronchogenic carcinoma presents with fever and shortness of breath. His vital signs are T 101.5°F, HR 112 bpm, RR 22/min, BP 100/60 mm Hg, and SpO2 92% on room air. He has right basilar crackles on auscultation and dullness to percussion. A CXR demonstrates a right lower lobar consolidation with costophrenic angle blunting. Which of the following values suggests the presence of an exudative pleural effusion? A. Partial pressure of arterial oxygen < 70% B. Pleural fluid:serum LDH <0.6 C.Pleural fluid pH 7.6 D. Pleural fluid:serum protein ratio < 0.5 E. Pleural fluid lactate dehydrogenase twice that of serum lactate dehydrogenase

E. Pleural fluid lactate dehydrogenase twice that of serum lactate dehydrogenase (use Light criteria... exudative effusions are due to pleural diseases that produce pleural fluid secretion or leakage with high protein content, whereas transudative effusions have a low protein content)

A 35yo woman with a history of migraines and polycystic kidney disease presents to the ED with a severe, diffuse headache. The onset was abrupt, approximately 1 hour prior to arrival. Her vital signs are within normal limits. She has photophobia and phonophobia, as well as pain with extraocular movements. Which of the following is the most likely diagnosis? A. Classic migraine B. Idiopathic intracranial hypertension C. Meningitis D. Tension-type headache E. Subarachnoid hemorrhage

E. Subarachnoid hemorrhage (atraumatic SAH is due to ruptured aneurysms and PCKD is a risk factor for developing berry aneurysms)

A 32yo man presents to the ED with a report of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A CXR is obtained and shown on back of this card. Which of the following abnormalities is likely to be noted on an echocardiogram? A. Diffuse myocardial hypokinesis B. Mitral valve vegetations C. Pericardial effusion D. Cardiac tamponade E. Tricuspid valve vegetations

E. Tricuspid valve vegetations (endocarditis affecting tricuspid valve)

A 30yo woman presents complaining of vaginal itching and irritation. She also complains of vaginal discharge. Which of the following supports a diagnosis of uncomplicated candidal vaginitis? A. Cervical motion tenderness on bimanual examination B. Positive amine odor with KOH preparation C. Trichomonads on microscopic examination D. Vaginal pH > 4.5 E. Vaginal pH < 4.5

E. Vaginal pH < 4.5

T/F: Permethrin cannot be used in pregnancy for the treatment of pediculosis capitits (head lice).

False, permethrin is 1st line therapy tx in all populations (pregnant, lactating, infants, etc.)!