E1 EM
A. ECG is the best initial test for cardiac CP since it is easy to obtain, is not invasive, and can be specific for ischemia. A CXR, CT of the thorax, and barium esophagram all evaluate for other causes of CP.
Which test will best help you identify CP of cardiac origin? A. ECG B. CXR C. CT thorax D. Barium esophagram
B. An 8-year-old girl with fever and sore throat GABS is most common in patients younger than 15 years (although not in infants). McIsaac added age as a criterion because patients older than age 45 years have a much lower incidence of streptococcal pharyngitis.
Which of the following patients is most likely to have group A streptococcal infection? A. An 11-month-old male infant with fever and red throat B. An 8-year-old girl with fever and sore throat C. A 27-year-old man with a temperature of 38.9°C (102°F), pharyngitis, and cough D. A 52-year-old woman who complains of fever of 39.2°C (102.5°F) and sore throat
b. Short acting benzodiazepine Pt most likely has exertional heatstroke where core temp elevations may occur rapidly; therefore, measurement directed at reducing his core temp are appropriate and must be continued. Benzos 1st line for shivering or seizure in heat stroke
33 yom found comatose at a construction site in noon - hour on a hot summer day. His core temperature 41.7 C (107F). The ED physician order evaporative cooling measure and ice packs. The patient begins with intense shivering. Which of the following is best next step? a. Continued observation b. Short acting benzodiazepine c. Begin intravenous cooling solution d. Increase number of ice bags e. Stop the cooling
c. 12 lead ECG Clinical hx is most significant single factor in identifying cardiac from other types of CP. Next best modality is 12 lead ECG
45 yom complains of vague chest discomfort associated with dyspnea. This pain increases with exertion. He is also a "nervous" person and is prone to anxiety. An abnormality of which of the following is most specific for chest pain of cardiac etiology? a. Chest radiograph b. Serum lipid panel c. 12 lead ECG d. pulse oximetry
A. Asthmatic exacerbation Many serious illnesses can precipitate an episode of DKA in the susceptible patient, including infection, stroke, myocardial infarction, pancreatitis, trauma, and surgery. Associated or precipitating illness should always be sought diligently. In most studies, infection is the single most common underlying cause. Noncompliance with insulin therapy is also a very common cause. Asthma exacerbation is not strongly associated with DKA.
Patients in DKA often have other illnesses or precipitating factors that initiated the ketoacidosis. Which one of the following is unlikely to precipitate DKA? A. Asthmatic exacerbation B. Cocaine use C. Cholecystitis D. Missed insulin doses E. Urinary tract infection
B. Insulin and dextrose solution will need to be continued until the acidosis has resolved. The serum glucose often drops much more rapidly than the ketoacidosis resolves; insulin is necessary to metabolize the ketone bodies but dextrose prevents hypoglycemia. Potassium replacement is usually necessary but should wait until hyperkalemia is excluded or has resolved. Bicarbonate does not hasten resolution of DKA.
The patient in Question 5.2 is undergoing therapy. Which of the following principles is most accurate in the treatment of DKA? A. Isotonic saline with no dextrose should be used during the hospitalization because the patient is diabetic. B. Insulin and dextrose solution will need to be continued until the acidosis has resolved. C. Since the patient is hyperkalemic, potassium replacement will not be necessary. D. Sodium bicarbonate is helpful to resolve the anion gap more quickly.
a. Musculoskeletal MC cause. all listed causes of NCCP & listed in decreasing order. GERD MC cause of NCCP in ED pts
Which of the following is the msot common cause of NCCP? a. Musculoskeletal b. Gastrointestinal c. Other-nonspecific d. Psyhicatric e. Pulmonary
b. 8 yo girl with fever and sore throat GABS is MC in pts younger than 15 yo. McIsaac added age as criteria b/c pt older than 45 yo much lower incidence of streptococcal pharyngitis
Which of the following patients is most likely to have group A streptococcal infection? a. 11 month old male infant with fever and red throat b. 8 yo girl with fever and sore throat c. 27 yom with a temperature of 38.9 (102 F), pharyngitis and cough d. 52 yow who complains of fever of 39.2 (102.5F) and sore throat
a. Pain control & monitor patients BP man has hx of HTN, he is in excruciating pain, which could be causing elevated BP. Appropriate tx is control pain, have leg set back into place and monitor his BP. BP should decrease once pain controlled
38 yom presents to the ED after a motor vehicle collision. After complete evaluation it is determined that he sustained a fractured right tibia. The patient has a hx of HTN for which he is on pharmacologic tx. The patient is writhing on the gurney in pain. His BP is 210/104 mmHg. The patient has no complaints except for right leg pain. Which of the following is most appropriate for management? a. Pain control & monitor patients BP b. Start BB and monitor BP c. Call social worker because of suspected drug or alcohol abuse d. Admit the patient to the hospital to get his blood pressure under control
D. Dexamethasone has been shown to decrease the amount of symptomatic time of pharyngitis and also to decrease pain. However, penicillin alone is sufficient, and no other medications are needed.
An 18-year-old woman presents with fever and a sore throat. She meets criteria for treatments for GABS pharyngitis. Which medication would you prescribe (in addition to penicillin)? A. Clindamycin B. Erythromycin C. Acyclovir D. Dexamethasone E. Methotrexate
c. Complication of Epstein Barr infection MC suffered from splenic rupture caused by mononucleosis (EBV). Hypotensive b/c massive hemoperitoneum. Aortic aneurysm is RARE in teens
19 yo college student ahs had a sore throat, mild abdominal pain and fever for 5 days. He was playing football with some friends, and was tackled just short of the goal line, hitting the grass somewhat forcibly. He experiences some abdominal pain, and passes out. EMS is called and his vital signs reveal HR 140 bpm and BP 80/40 mm Hg with a distended abdomen. Which of the following is the most likely etiology? a. Vasovagal reaction b. Ruptured aortic aneurysm c. Complication of Epstein Barr infection d. Ruptured jejunum
b. Typically, intravenous insulin and dextrose solution will need to be continued until the acidosis has resolved. Serum glucose often drops much more rapidly than ketoacidosis resolves; insulin is necessary to metabolize ketone bodies but dextrose prevents hypoglycemia. K replacement usually necessary but should be after hyperkalemia excluded. Bicarbonate does not hasten resolution of DKA
Patient under goes TX: (28 yo insulin requiring woman is gound in her apt by her husband. She is stuporous and cannot provide any history. EMS called and takes the patient to the ER and a diagnosis of severe DKA is made. Her BP is 80/40 mmHg and HR is 140 bpm. Glucose levels is 950 mg/dL, potassium level 6 mEq/L, HCO3 4 mEq/L.) Which of the following principles is most accurate in tx of DKA? a. Isotonic saline with no dextrose should be used during the hospitalization bc patient is diabetic b. Typically, intravenous insulin and dextrose solution will need to be continued until the acidosis has resolved. c. Potassium replacement is rarely necessary d. Sodium bicarbonate is helpful to resolbe anion gap more quickly
e. Urinary tract infection Many serious illnesses can precipitate episode of DKA in susceptible pt, including infection, stroke, MI, pancreatitis, trauma, and surgery. Associated or precipitating illness should always be sought diligently. UTI single MC underlying cause. Missed insulin doses are also common but less than infection
Physician explain to 25 yom who has recently been hospitalize with DKA that patients in DKA often have other illnesses or precipitating factors that initiated ketoacidosis. Which of the following is the most common underlying etiology in DKA? a. Asthmatic exacerbation b. Cocaine use c. Cholecystitis d. Missed insulin doses e. Urinary tract infection
c. Left bundle branch block changes in this make determination of acute MI by ECG extremely difficult. In pts, it is particularly important to obtain serum markers of myocardial damage
Which of the following ECG changes makes the determination of acute MI the most difficult? a. Q wave b. ST segment elevation c. Left bundle branch block d. First degree atrioventricular block e. T wave inversion
d. Provide an intravenous normal saline 2 L bolus, and start an insulin drip at 10 U/h Fluid resuscitation via isotonic crystalloid solution reverse shock and IV insulin reverse ketoacidosis mainstay of therapy. Though most pts will require potassium, should NOT be given while serum K is elevated, typically not until urine output is seen. Pressors have limited role until intravascular volume restored.
28 yo insulin requiring woman is found in her apt by her husband. She is stuporous and cannot provide any history. EMS called and takes the patient to the ER and a diagnosis of severe DKA is made. Her BP is 80/40 mmHg and HR is 140 bpm. Glucose levels is 950 mg/dL, potassium level 6 mEq/L, HCO3 4 mEq/L. Which of the following is the most appropriate initial treatment? a. Administer 20 units regular insulin intramuscularly, and normal saline at 250 mL/h b. Begin an intravenous dopamine drip to raise BP above 90, then insulin at 10 U/h c. Initiate normal saline 2 L with KCl 20 mEq/L, insulin 10 U/h d. Provide an intravenous normal saline 2 L bolus, and start an insulin drip at 10 U/h
b. BB agent Bronchospasm is associated with use of topical BB which can by systematically absorbed
36 yow has been diagnosed with glaucoma. She also has asthma which has been well controlled. After using the drops prescribed for her glaucoma, she develops an exacerbation of her asthma. Which of the following meds is most likely responsible for her asthmatic exacerbation? a. Anticholinergic agent b. BB agent c. Alpha agonist agent d. Beta agonist agent
b. Anterior uveitis Presents as photophobia, red eye WITH pain, cell with flare are noted on slit lamp exam
40 yom complains of acute onset of left eye redness with circumcorneal injection (ciliary flush) and pain with bright lights. On exam, his pupil is small and minimally reactive with cell and flare noted on salt lamp exam. He also has pain in affected eye when light is directed in the unaffected eye (consensual photophobia). Which of the following is the most likely diagnosis? a. Acute angle-closure glaucoma b. Anterior uveitis c. Herpes simplex virus infection d. Corneal abrasion
b. ECG Evaluate for evidence of acute ischemia is 1st indicated test. Provider should always keep in mind negative ECG does NOT rule out cardiac pathology
In the initial evaluation of most ED patient with CP, what is the most important diagnostic test? a. CXR b. ECG c. Serum cardiac markers d. Computed tomography e. Cholesterol levels
a. Hemorrhagic blisters poor prognostic indicator due to their association with deep tissue injury. Blisters should not be debrided or drained bc it leads to tissue desiccation & worsening of injury. Clear blisters on the other hand should be drained bc fluid contains thromboxane, which is though to be destructive to healthy tissue. A demarcation line of helathy tissue is a late sign in hypothermia. Edematous soft tissue is not a prognostic indicator in frostbite
35 yo undomiciled woman, with a hx of schizophrenia, presents to ED complaining of tingling in her fingers. The nursing staff removes her wet clothes and places her in warm hospital gown. Her vitals signs include a BP 130/75 mmHg, HR 80 bpm, temp 36.05C (96.9 F). On exam, you note discolored, frost bitten hands. Which of the following features is a poor prognostic indicator in frostbite? a. Hemorrhagic blisters b. Demarcation line of viable tissue c. Clear fluid filled blisters d. Edematous subcutaneous tissue
e. 2-3 months after demarcation Generally 3 wks min time required to assess viability of tissue after frostbit to see whether amputation is required tissue though to be necrotic sometimes turns out to be viable. line demarcation between viable and nonviable tissue becomes clear in 1 to 2 months after initial cold injury but surgery may be delayed until 2 - 3 months
14 yo adolescent boy wandered into the woods chasing after his dog and lost his bearing. When he finally found, he was brought to the ED with severe frostbite of the fingers of both hands. he has not regained sensation 24 hours after the exposure. Which of the following describes the most appropriate time to wait before deciding on amputation of the affected fingers? a. 24 hrs after episode b. 48-72 hrs after episode c. 3-7 days after episode d. 7-10 days after episode e. 2-3 months after demarcation
c. A random glucose greater than 200 mg/dL with symptoms such as polydipsia and polyuria DM can be defined by 2 separate measurements of fasting glucose more than 125 mg/dL; random glucose 200 mg/dL or more with classic symptoms or a 2 hr glucose tolerance test of 200 mg/dL or more after 75 g glucose load. HbA1c NOT used in diagnosing
16 yo adolescent female has had an increased craving for sweets. She often consumes two to three ice cream sundaes and four large sodas a day but has still managed to maintain her weight. Friends often notice her using the bathroom more frequently but she denies any episodes of purging and states that she just has to urinate after drinking so much cola. On physical exam she is 5 ft 8 in and is 110 lb and thyroid is nonpalpable. Which of the following test results in diagnostic of diabetes mellitus? a. Single fasting glucose of 150 mg/dL b. A 2 hrs oral glucose tolerance test greater than 200 mg/dL with a 100 g glucose load c. A random glucose greater than 200 mg/dL with symptoms such as polydipsia and polyuria d. A HbA1c greater than 7.5%
c. Hyperglycemia, ketosis, metabolic acidosis TRIAD: hyperglycemia, ketosis, acidosis = DKA. Many other conditions cause 1 or 2 of triade, but not all three. Although a fruity breath odor MAY suggest acetone, it is not reliably present and not all clinicians can distinguish it
17 yo adolescent boy who is T1 diabetic brought in by parents with concern about DKA. He has had several prior episodes of DKA. Which of the following si most diagnostic of DKA? a. Polyuria, polydipsia, fatigue b. Hypotension, dehydration, fruity breath odor c. Hyperglycemia, ketosis, metabolic acidosis d. Serum blood sugar 600 mg/dL in face of high concentration of insulin e. Elevated HCO3 and elevated glucose
e. Prepare for emergent airway management Regardless of etiology, alarming for impending respiratory collapse, & preparations for emergent airway management is most important. Drooling and stridor are suspicious for epiglottis which can present more insidiously in adults. Exam of posterior oropharynx may induce laryngospasm and airway obstruction particularly in children; lateral neck radiograph assess for "thumbprint" of epiglottitis may be helpful in making dx; but sending pt w/ respiratory failure to radiology is inappropriate
18 yow presents with fever and a sore throat. She is sitting up drooling, with some stridor. Her temperature is 39.4 (103 F) and she appears ill. Which of the following is your next step? a. Examine pharynx & obtain rapid antigen test b. Empiric treatment with pencillin c. THroat culture and treatment based on results d. Send patient to radiology for an anteroposterior (AP) neck radiograph e. Prepare for emergent airway management
b. Rheumatoid arthritis MC systemic disease with scleritis
50 yow with redness, severe pain, a bluish scleral tinge, and decreased vision in her right eye is noted to have scleritis. Which of the following is MC condition associated with scleritis? a. Systemic lupus erythematosis b. Rheumatoid arthritis c. Inflammatory bowel disease d. Syphilis
c. The patient should be advised that half of heart attack patients have a non-diagnostic ECG and serial cardiac bio-marker levels should be assessed. Roughly half pt with MI, defined by typical rise in cardiac biomarkers will have nondiagnostic ECG upon presentation. Risk stratification by stress testing is sometimes ordered from ED, but only after serial ECG and cardiac biomarkers remain normal
45 yom seen in ED with 3 hours of substernal chest pain radiating to his left arm. ECG shows only nonspecific changes. Hearing that the ECG is normal, he requests to go home. Which of the following statement is most accurate? a. The patient may be safely discharge home b. If a repeat ECG in 30 minutes is normal, myocardial infarction is essentially ruled out and patient may be safely discharged c. The patient should be advised that half of heart attack patients have a non-diagnostic ECG and serial cardiac bio-marker levels should be assessed. d. The patient should undergo an immediate thallium stress test to further assess for coronary artery disease to help clarify the management
b. ECG Crucial 1st dx test of CP. Presence vs absence of ST elevation represents a major therapeutic branch point
48 yom is being seen for chest pain. In the initial evaluation of patient, which oft he following is the most important diagnostic test? a. CXR b. ECG c. Serum cardiac markers d. Computed tomography e. Cholesterol levels
c. Decreased outflow of aqueous humor Acute angle closure glaucome sudden rise in IOP consequence of blocked outflow usually due to pupillary block and not increased production of aqueous humor
50 yow diagnosed with acute angle closure glaucoma. She has acutely decreased visual acuity. Which of the following is the most likely mechanism for this condition? a. Increased IOP caused by increased aqueous humor production b. Nonreactive pupil leading to increased intraocular pressure c. Decreased outflow of aqueous humor d. Separation of retina leading to decreased visual acuity
c. Give her a prescription for her medications instruct her to take them immediately and have her follow up in 48 hrs pt has HTN urgency, no symptoms related to elevated BP and no signs of end organ damage. Pt should restart meds and have BP reassessed in 48 hrs
54 yow present to eh ED requesting med refill on her antihypertensive meds. She has been out of her meds for 2 weeks and cannot get an appointment with her private physician until next week. She normally takes atenolol and hydrochlorothiazide. Her BP 190/100 mmHg. The patient has no complaints. She has been waiting for 4 hours and is in a hurry to get back to work. Which of the following is the most appropriate next step? a. Change her meds to calcium channel blocker b. Admit to the intensive care unit & initiate intravenous nitroprusside c. Give her a prescription for her medications instruct her to take them immediately and have her follow up in 48 hrs d. Counsel pt on dangers of her noncompliance, admit to the hospital and begin patient on intravenous lavetalol
b. Obtain a heat CT scan, give an antihypertensive such as nicardipine and admit to the intensive care unit Man has HTN encephalopathy which is emergent. Symptomatic HTN causing end organ damage. Head CT scan should be obtained prior to starting tx to rul eout intracranial pathology. Appropriate tx is IV anti-HTN meds to decrease his MAP by 20% to 25% over 1 hr
55 yom present to the ED with complaints of a severe headache, diplopia and vomiting. his BP is 210/120 mmHg upon arrival. Which of the following is the best next step? a. Observe the BP and recheck in 1 hr, and supportive measure for the headache and vomiting b. Obtain a heat CT scan, give an antihypertensive such as nicardipine and admit to the intensive care unit c. Give intravenous furosemide to decrease the blood pressure d. Give lorazepam to help the patient relax
d. Nifedipine Pt new onset of angina. Rapid release, short acting dihydropyridines (nifedipine) contraindicated b/c increase mortality in multiple trials. Beta blockers are DOC since increase survival; nitro helps abate CP but have not been shown to impact survival
58 yom present to his physician for follow up of his hypertension and hyperlipidemia. he also reports chest pain and feeling short of breath after climbing two flights of stairs or walking three to four block. The symptoms resolve after several minutes of rest. Which of the following drugs is contraindicated as a first-line agent in the treatment of this patient's new condition? a. Labetalol b. Nitroglycerin c. Enalapril d. Nifedipine e. Aspirin
b. Aspirin to chew While all therapies useful, ASA significantly decreases mortality, with almost no downside in nonallergic pts, and should be given immediately
58 yom presents to his physician's office complaining of 2 hours of substernal chest pain and dyspnea. Which of the following is the most important next step in management? a. Administration of propranolol b. Aspirin to chew c. Sublingual nitroglycerin d. Administration of diuretic agent. e. Chest radiograph
e. Pericarditis Pain described as sharp in nautre rather than dull, aching, pressure. Pain exacerbated by inspiration & finally global ST segment elevation noted on ECG
64 year old woman with a history of hypertension and angina pectoris presents with chest pain for the last 3 hours. She describes the pain as "sharp," it is worse when she inhales deeply, and it is not relieved by sublingual nitroglycerin. Her ECG shows ST elevation in most leads. Which of the following is the most likely diagnosis in this patient? a. Unstable angina pectoris b. Myocardial infarction c. Aortic dissection d. Congestive heart failure e. Pericarditis
c. Admission to the hospital for observation of complications all pts w/ severe heat exhaustion or heat stroke, particularly those who are older, should be admitted
70 yom is brought into the ED complaining of headache and fatigue. His BP 100/70 mmHg, HR 100 bpm, core temp 40.3 (104.5 F). Upon using ice bags, his core temp is down to 38 C (100.4 F). Which of the following is the best next step? a. Observation for 4-6 hrs and then, if stable, discharge home b. Continue ice bags until the core temperature is 36.7 (98 F) c. Admission to the hospital for observation of complications d. Administer cold gastric lavage e. Discharge pt only if he can be placed in different environment after discharge
c. Check for airway, breathing, circulation and then maintain core body temperature by removing wet clothes and wrapping in warm, dry blankets 1st step in emergency care is always to address and stabilize the airway, breathing, and circulation (ABCs). Passice rewarming methods are appropriate including removign wet clothing. It is critical rapid rewarming be avoided if pt may be delayed to receiving definitive care. Incomplete thawing & refreezing is detrimental to tissue. Checking blood glucose is important in pt with altered mental status but should be done after ABCs
72 yow with dementia is reported missing by nursing home staff late one Decemeber night. Pt was found 2 hrs after the police were called lying on park bench, soaking wet, in a thin night gown with no shoes on. EMS has arrived on the scene. Which of the following is most appropriate next step in management? a. Check capillary blood glucose and try to feed pt b. Immediately place the pt on stretched, start an IV and give fluids c. Check for airway, breathing, circulation and then maintain core body temperature by removing wet clothes and wrapping in warm, dry blankets d. Cover the patient with any available materials so that passive rewarming can start
b. Epiglottis Usually bacterial infection tx w/ antibiotics
A 5 yo child brought into office due to mother's concern of difficulty breathing. On examination wheezing is noted. In which of the following conditions is antibiotic therapy most appropriate? a. Asthma b. Epiglottis c. Croup d. Bronchiolitis e. Foreign- body aspiration
d. Incision and drainage of the abscess Pt is suffering from peritonsillar abscess. Of choices listed, incision and drainage is most appropriate. Tonsillectomy is only indicated if there are confirmed cases of recurrent pharyngitis & peritonsillar abscess
A 12 yog was brought ot the emergency department because of sever sore throat, muffled voice, drooling and fatigue. She had been sick for the past 3 days and is unable to eat because of the painful swallowing. The parents deny any history of recurrent pharyngitis. The patient still managed to open her mouth and you were able to see an abscess at the upper pole of the right tonsil with deviation of the uvula toward the midline. Examination of neck reveals enlarged and tender lymph nodes. Which of the following is the most appropriate management? a. Analgesics for pain b. Oral antibiotics c. Nebulized racemic epinephrine d. Incision and drainage of the abscess e. Tonsillectomy & adenoidectomy
A. Second-degree frostbite The patient has clear, fluid-filled blisters on his toes and feet consistent with a diagnosis of second-degree frostbite. First-degree frostbite, also known as frostnip, is more superficial and not associated with blister formation. Chilblain, also known as pernio, occurs on skin that is exposed to cold, but non-freezing conditions. It is most common on the face, ears, and hands and is characterized by red, scaly lesions. Trench foot occurs from chronic exposure of the feet to cool, damp conditions.
A 14-year-old boy wandered into the woods while chasing after his dog and lost his bearings. He was not wearing any shoes. He was found approximately 12 hours later and presents to the ED with clear, fluid-filled blisters on his toes and feet. What is the most likely diagnosis? A. Second-degree frostbite B. Trench foot C. First-degree frostbite D. Chilblains
C. Hyperglycemia, ketosis, metabolic acidosis The triad of hyperglycemia, ketosis, and acidosis is diagnostic of DKA. Many other conditions cause one or two of the triad, but not all three. Although a fruity breath odor may suggest acetone, it is not reliably present, and not all clinicians can distinguish it.
A 17-year-old adolescent boy who is a type I diabetic is brought in by his parents with concern for DKA. He has had several prior episodes of DKA. Which of the following is most diagnostic of DKA? A. Polyuria, polydipsia, fatigue B. Hypotension, dehydration, fruity breath odor C. Hyperglycemia, ketosis, metabolic acidosis D. Serum blood sugar of 600 mg/dL in the face of high concentrations of insulin E. Elevated HCO3 and elevated glucose
C. Complications of Epstein-Barr infection This patient most likely suffered from splenic rupture caused by mononucleosis (EBV). He is hypotensive because of the massive hemoperitoneum. Aortic aneurysm is rare in teenagers.
A 19-year-old college student has had a sore throat, mild abdominal pain, and fever for 5 days. He was playing football with some friends and was tackled just short of the goal line, hitting the grass somewhat forcibly. He experienced some abdominal pain and passed out. The EMS (emergency medical services) was called, and his vital signs revealed the heart rate as 140 beats per minute and blood pressure as 80/40 mm Hg with a distended abdomen. Which of the following is the most likely etiology? A. Vasovagal reaction B. Ruptured aortic aneurysm C. Complications of Epstein-Barr infection D. Ruptured jejunum
D. Provide an intravenous normal saline 2 L bolus, then start an insulin drip at 10 U/h. Fluid resuscitation via isotonic crystalloid solution to reverse shock, and IV insulin to reverse ketoacidosis, are the mainstays of therapy. Though most patients will require potassium, it should not be given while the serum K is elevated, and typically not until urine output is seen. Pressors have a limited role until the intravascular volume is restored.
A 28-year-old insulin-requiring woman is found at home by her husband. She is stuporous and cannot provide any history. She is brought to the ED, and a diagnosis of severe DKA is made. Her blood pressure is 78/40 mm Hg and heart rate 140 beats per minute. The glucose level is 950 mg/dL, potassium level 6 mEq/L, and HCO3 4 mEq/L. Which of the following is the most appropriate initial treatment? A. Administer 20 units regular insulin intramuscularly, and normal saline at 250 mL/h. B. Begin intravenous pressors to raise BP above 90, then insulin at 10 U/h. C. Initiate normal saline 2 L with KCl 20 mEq/L and insulin 10 U/h. D. Provide an intravenous normal saline 2 L bolus, then start an insulin drip at 10 U/h.
B. Short-acting benzodiazepine This patient most likely has exertional heat stroke, in which core temperature elevations may occur rapidly; therefore, measures directed at reducing his core temperature are appropriate and must be continued. Benzodiazepines are first-line therapy for shivering or seizures in heat stroke.
A 33-year-old man is found comatose at a construction site in the noon-hour on a hot summer day. His core temperature is 41.7°C (107.1°F). The ED physician orders evaporative cooling measures and ice packs. The patient begins to exhibit intense shivering. Which of the following is the best next step? A. Continued observation B. Short-acting benzodiazepine C. Begin intravenous cooling solution D. Increase the number of ice bags E. Stop the cooling
D. Reproduced with palpation Musculoskeletal causes are the most common etiologies of NCCP. The best way to confirm the diagnosis is to reproduce the pain with palpation in the anatomical region or with movement. Nitroglycerin is a treatment of CAD. Tracheal deviation suggests tension pneumothorax. Radiation down the left arm may be associated with angina.
A 35-year-old woman presents to her physician's office with CP of 1 week's duration. The physician suspects possible musculoskeletal etiology. Which of the following would be the best evidence to confirm this diagnosis? A. Relief with nitroglycerin B. Tracheal deviation C. Radiation down the left arm D. Reproduced with palpation
A. Alkylanization of the urine This patient has rhabdomyolysis, as evidenced by the markedly elevated CPK levels. The best treatment is IV hydration and alkylanization of the urine to prevent renal damage. With such high CPK levels, a large amount of IV fluids is usually required. Urine alkylanization is important to prevent precipitation of myoglobin and uric acid crystals within the renal tubule. Other treatments include mannitol and loop diuretics.
A 38-year-old man was found after a drug overdose unconscious on the side of a field in the middle of summer. He was found to have a core temperature of 42°C and was significantly volume depleted. His blood pressure is 90/60 mm Hg and heart rate 120 beats per minute. IV fluids are administered, and active cooling measures are undertaken. The patient's CPK levels are 3000 IU/L. Which of the following is the best treatment? A. Alkylanization of the urine B. Insulin C. Tissue plasminogen activator D. Steroids
D. Measure intraocular pressure --> Tonometry. Acute angle closure glaucoma is an uncommon but significant side effect of topiramate (Topamax), an anticonvulsant and antimigraine medication. Patients typically present with bilateral blurry vision, headache, nausea, and vomiting. However, eye redness is minimal or absent, unlike most cases of AACG. Topiramate-induced AACG usually occurs within several weeks of beginning the medication or within several hours if the dosage is doubled.
A 39-year-old man with a history of migraines presents to the ED with a headache over both brows, nausea, and blurry vision for the past 6 hours. He recently started taking topiramate for his migraines and admits to taking a second dose 12 hours ahead of schedule today. The current headache began gradually but is slightly worse than usual, and the blurry vision is new. His vision is usually normal. He denies trauma or fever. Visual acuity is 20/200 in both eyes, and the pupils are each 4 mm and minimally reactive. The conjunctivae are normal, and the anterior chambers are clear but shallow. There is no fluorescein uptake. Fundoscopy is normal. The neurological examination is non-focal. Which of the following is the next most appropriate immediate test? A. CT head without contrast B. CT of orbit C. MRI head D. Measure intraocular pressures
B. Acute anterior uveitis usually presents as photophobia, blurred vision, and a painful red eye. A ciliary flush and cells with flare are noted on slit-lamp examination.
A 40-year-old man complains of acute onset of left eye redness with circumcorneal injection (ciliary flush), blurred vision, and pain with bright lights. On examination, his pupil is small and minimally reactive with cell and flare noted on slit lamp examination. He also has pain in the affected eye when light is directed in the unaffected eye (consensual photophobia). Which of the following is the most likely diagnosis? A. Acute angle-closure glaucoma B. Acute anterior uveitis C. HZV infection D. Corneal abrasion
D. Conjunctival culture When the clinical pattern suggests scleritis, as in this example, a conjunctival culture would not be typically ordered in the absence of discharge. Studies which evaluate systemic diseases such as rheumatoid arthritis, sarcoidosis, syphilis, inflammatory bowel disease, and reactive arthritis would be appropriate. Rheumatoid arthritis is the most common systemic disease associated with scleritis.
A 40-year-old woman presents with a 2 week history of redness, severe pain, and decreased vision in her right eye. She denies conjunctival discharge. Visual acuity is 20/40 in the right eye and 20/20 in the left. The pupils are 3 mm and reactive bilaterally. Extraocular movements are intact but increase the right eye pain. The temporal aspect to the right eye is reddish blue. A drop of phenylephrine is applied to the right eye, but the reddish blue area does not blanch. The right eye is soft but tender to palpation. An ophthalmologist might order all of the following tests except: A. HLA B 27 marker B. Rheumatoid factor C. RPR for syphilis D. Conjunctival culture
c. CT thorax most sensitive & specific test in assessing for possible esophageal perforation, especially in pts given time course of symptoms & histroy of prior surgery
A 45 yom with a known history of Boerhaave syndrome and primary surgical repair 5 yrs ago presents to the ED complaining of 24 hrs of increasing CP and shortness of breath, what diagnostic test should be ordered to rule out perforation? a. ECG b. CXR c. CT thorax d. Barium esophagram
D. An assessment of the ABCs always takes priority in a patient with AMS. The patient's airway, breathing, and circulation should be assessed, and any concerns should be addressed before moving forward with diagnostic and therapeutic interventions. This patient may require naloxone if the examination is consistent with an opiate overdose (eg, pinpoint pupils, respiratory depression, and hypotension), although ABC assessment is the first priority. The patient is at risk for hypoglycemia, and a capillary blood glucose should also be obtained once the ABCs have been addressed. If the patient requires dextrose administration, thiamine administration should also be considered; glucose infusion in a thiamine deficient patient can lead to Wernicke encephalopathy.
A 45-year-old man presents to the ED with AMS. He runs his own business and has been struggling financially since undergoing three surgeries on his right shoulder. He has visited multiple doctors to help control his pain. EMS was called to his office after an employee found him on the floor with a bottle of vodka and a prescription medication bottle. Which of the following is the most appropriate next step? A. Administer naloxone B. Administer thiamine C. Obtain a capillary blood glucose D. Assess the patient's ABCs
B.Pain that worsens with lying down and after a large meal is more suggestive of GERD. While GERD is a cause of pain that may eventually lead to esophagitis or even malignancy, it is not an immediate life threatening cause of CP. Aortic dissection, pulmonary embolism, cardiac tamponade, pneumothorax, and acute myocardial infarction can all lead to imminent death and therefore must be diagnosed and intervened upon immediately if found.
A 45-year-old man presents to the ED with the acute onset of CP. Which of the following would point to a non-life threatening etiology of CP? A. Shortness of breath B. Worse when laying down and after large meals C. Diffuse ST segment elevation D. Cervical subcutaneous emphysema E. Unilateral pleuritic CP
b. Treatment based on results from the throat culture Pt has modified Centor score of 2 (hx fever, tender adenopathy, no cough, > 45yo). Rapid antigen is negative, but a definitive culture should be performed for a Centor score of 2 or 3, treatment should be based on culture results
A 48 yom is noted to have a 2 day history of sore throat, subjective fever at home and no medical illnesses. He denies cough or nausea. On examination his temperature is 38.3C (101 F) and he has some tonsillar swelling but no exudates. He has bilateral enlarged and tender lymph nodes of the neck. The rapid streptococcal antigen test is negative. Which of the following is the best next step? a. Oral clindamycin b. Treatment based on results from the throat culture c. Observation d. Begin amantadine
B. Perform throat culture and treat based on result This individual has a modified Centor score of 2 (history of fever, tender adenopathy, no cough, age >45). The rapid antigen test is negative, but a definitive culture should be performed for a Centor score of 2 or 3, and treatment should be based on culture results.
A 48-year-old man is noted to have a 2-day history of sore throat, subjective fever at home, and no medical illnesses. He denies cough or nausea. On examination, his temperature is 38.3°C (101°F), and he has some tonsillar swelling but no exudate. He has bilateral enlarged and tender lymph nodes of the neck. The rapid streptococcal antigen test is negative. Which of the following is the best next step? A. Oral clindamycin B. Perform throat culture and treat based on results C. Observation D. Begin amantadine
C. An emergent ophthalmology consult is appropriate for a diabetic patient with a deep corneal ulcer and a hypopyon in order to assess for endophthalmitis. This patient will require IV and intravitreal antibiotics and hospital admission.
A 52-year-old woman with Type 2 diabetes presents with 2 days of right eye pain, foreign body sensation, redness, and decreased vision. These symptoms began after she sustained a scratch to her eye when she was trying to pick up her 2-year-old grandchild, who was throwing a tantrum. Visual acuity is 20/200 in her right eye and 20/30 in her left eye. The right pupil is 3 mm and sluggishly reactive, and the left pupil is 3 mm and briskly reactive. The right eye has a ciliary flush; the left conjunctiva is normal. A large, dense white defect is visible on the right cornea, and a hypopyon is also present. Cell and flare are noted. Fluorescein uptake is large and extends deep below and beyond the margins of the ulcer. The right fundus cannot be visualized. Which of the following is the most next most appropriate action? A. Prescribe a topical ophthalmic steroid medication as well as a return to ED in 24 hours. B. Prescribe a topical ophthalmic antibiotic medication and a return to ED in 12 hours. C. Arrange an emergent ophthalmology consultation. D. Check the blood glucose, and if it is normal recommend timely visit to her doctor.
C. Administer thrombolytics, then transfer to PCI center. PCI is the treatment of choice when it can be performed rapidly by an experienced cardiologist. However, if a patient presents to a hospital that does not offer PCI and cannot be transferred to one within 120 minutes, administration of thrombolytics, preferably within 30 minutes of arrival, is indicated. The patient should then be transferred to the nearest PCI center.
A 54-year-old man is seen at a rural ED with 1 hour of nausea and substernal chest pain radiating to his jaw. The ECG shows STEMI. PCI is not performed at this hospital and only performed at a hospital 2 1/2 hours away. Which of the following statements is most accurate? A. Obtain a repeat ECG to assess if the patient truly has a STEMI. B. Transfer the patient now for emergent PCI. C. Administer thrombolytics, then transfer to PCI center. D. Give aspirin, start heparin, and obtain a thallium stress test.
D. Aspirin to chew While all of these interventions may be useful, aspirin significantly decreases mortality, with almost no downside in non-allergic patients, and it should be given immediately. Thus, aspirin is the first intervention.
A 65-year-old man with history of diabetes presents to the Emergency Department stating he has had substernal chest pain and diaphoresis for 45 minutes. Which is the most important next step in management? A. Sublingual nitroglycerin B. Oxygen C. Placement of defibrillator pads D. Aspirin to chew E. Morphine sulfate
B. Check capillary glucose Hypoglycemia can mimic stroke symptoms and can lead to seizures. A quick capillary glucose should be obtained in all patients with stroke or seizure symptoms. The history obtained from friends in this case is critical to making a diagnosis. She likely had a seizure and may be in a postictal state. However, the history of slurred speech and confusion raise suspicion for stroke. She should undergo a CT scan once she is stable, but this should come after capillary glucose testing. Her blood pressure does not require immediate treatment. Therefore, labetalol treatment is unnecessary. She is no longer displaying seizure activity. Therefore, treatment with lorazepam is unnecessary
A 68-year-old woman presents to the ED with AMS. While visiting with friends, she began slurring her speech and became confused. She then developed jerking movements of her extremities and became unresponsive. When EMS arrived, she was conscious and her BP was 160/90 mm Hg. She was not talking or following commands. She was transported to the ED without incident. After addressing her ABCs, what is the most appropriate next step in the management of this patient? A. Administer lorazepam B. Check a capillary glucose C. Obtain a head CT scan D. Administer labetalol
b. Hospitalization with institution of insulin and IV fluids Typical presentation of DKA, common initial presentation of T1 diabetes. immediate hospitalization, IV fluids, insulin
A 7 yo is brought to the office with symptoms of polydipsia, polyphagia, polyuria, and weight loss of 8 lb. For the past 24 hr he has had abdominal pain and vomiting. An urinalysis done in the office shows presence of glucose and ketones. A fingerstick blood glucose is more than 500 mg/dL. Which of the following is the most appropriate management? a. Prescription for oral metformin and referral to a nutritionist b. Hospitalization with institution of insulin and IV fluids c. Prescription of insulin to be started at home, with follow-up in 24 hrs. d. Treatment for acute gastroenteritis and referral to an endocrinologist
C. Admission to the hospital for observation of complications All patients with severe heat exhaustion or heat stroke, particularly those who are older, should be admitted to the hospital.
A 70-year-old man is brought into the ED complaining of headache and fatigue. His blood pressure is 100/70 mm Hg, heart rate is 100 beats per minute, and core temperature is 40.3°C (104.5°F). Upon using ice bags, his core temperature is down to 38°C (100.4°F). Which of the following is the best next step? A. Observation for 4-6 hours and then, if stable, discharge home B. Continue ice bags until the core temperature is 36.7°C (98°F) C. Admission to the hospital for observation of complications D. Administer cold gastric lavage E. Discharge the patient only if he can be placed in a different environment after discharge
C. Assess the ABCs The first step in emergency care is always to address and stabilize the ABCs. Checking a capillary glucose is important in a patient with altered mental status but should be done after ABCs are addressed. The patient's wet clothing should be removed and dry, warm blankets should be used to cover the patient. Intravenous access should also be established and warm intravenous fluids should be given. However, none of these measures should occur until the ABCs have been assessed.
A 72-year-old woman with a history dementia is reported missing by nursing home staff late one December night. The patient is found 2 hours later, lying on a park bench, soaking wet, wearing only a thin night gown and no shoes. EMS has arrived on the scene. Which of the following is the most appropriate next step in management? A. Check capillary blood glucose B. Immediately establish intravenous access and administer intravenous fluids C. Assess the ABCs D. Cover the patient with any available materials
E. ECG The history of chest pain is important to obtain. The ECG is the crucial first diagnostic test in the evaluation of chest pain. Presence versus absence of ST elevation represents a major branch point in deciding treatment. Serum cardiac levels take time and sometimes are not elevated at the time of patient encounter.
In the initial evaluation of a patient with chest pain, which is the most important diagnostic test? A. Treadmill stress test B. PT C. Chest x-ray D. Troponin E. ECG
D. Urinary Tract Infection Infection is a common cause of AMS, especially in the elderly population. The history and physical examination suggests a urinary tract infection with concomitant dehydration as the cause of her AMS. Alzheimer's does not develop rapidly, but rather gradually over time. The history and physical examination is not suggestive of alcohol abuse or polypharmacy.
A 77-year-old woman presents to the ED with her daughter. The patient is usually alert and oriented. At baseline she independently performs all of her activities of daily life (ADLs). Over the past week, she has been eating and drinking less and tells her daughter that she is not hungry. Yesterday she had an episode of urinary incontinence. This morning, she woke up confused, was unable to follow commands, and kept asking where her husband was (he has been deceased for over 5 years). Her HR is 132 beats per minute, and her temperature is 39°C. She appears dehydrated. What is the most likely cause of her AMS? A. Alzheimer's dementia B. Alcohol intoxication C. Polypharmacy D. Urinary tract infection
d. Diagnosis is decreasing in incidence Epiglottitis markedly reduced since intro of Hib vaccine. Children with epiglottitis are more likely to be in tripod position than prone. "Steeple" sign in croup; "thumb" in epiglottitis. Visualization epiglottis should preferentially occur in operating room, where immediate intubation or tracheostomy can occur
A 9 yog being seen in your office with fever & difficulty breathing. You are concerned about the diagnosis of epiglottis. Which of the following is the most accurate statement regarding epiglottis? a. Child usually prefers to be in prone position b. Radiographic finding of "steeple sign" c. Every effort should be made to visualize the epiglottis in the office to confirm the diagnosis d. Diagnosis is decreasing in incidence
D. Atrial fibrillation is the most common dysrhythmia in hypothermia and is characteristic at a core temperature of 30°C. Prolongation of any interval, bradycardia, asystole, atrial fibrillation and flutter, and ventricular tachycardia may also be seen. In this patient a 12-lead ECG was obtained showing an Osborne (J) wave, which is indicative of a junctional rhythm and is consistent with hypothermia. J waves may be seen at any temperature below 32.2°C, most frequently in leads II and V6. Below a core temperature of 25°C, they are most commonly found in the precordial leads (especially V3 and V4) and their size increases. J waves are usually upright in aVL, aVF, and the precordial leads.
A homeless man of unknown age presents to the ED unresponsive. Bystanders believe he was outside all night in a snow storm. His core temperature is 30°C. What is the most common cardiac dysrhythmia seen in hypothermia? A. Sinus tachycardia B. Sinus bradycardia C. Ventricular fibrillation D. Atrial fibrillation
b. Begin rapid rewarming with water 40 to 42 C (103-104F) Rarely practical however in ED should be started ASAP. Critical to avoid deleterious effects of incomplete thawing and prevent refreezing. Although comorbid conditions such as diabetes influence management of hypothermic pt, patients lack of sensation is due to cold injury and this should be rapidly treated, not just treating diabetes
An avid outdoorsman was hiking in mountains when his boot broke through the ice on edge of stream submerging one foot. The pt has a long history of diabetes with known peripheral neuropathy. he was able to hike out to the ranger's station but had lost complete sensation of his wet foot afterwards. The patient has frostbit on his cheeks, hands, and this wet foot shows evidence of trench foot. All wet clothing is removed, he is wrapped in blankets and on arrival to the ED, his vitals are stable except for a core body temperature of 34 C. Which of the following is the most appropriate next step in management? a. Initiate extracorporeal blood warming until a core temp 37 C is reached b. Begin rapid rewarming with water 40 to 42 C (103-104F) c. Rub the skin dry where there is evidence of trench foot to decrease the change of blisters developing d. Treat the patients' diabetes and peripheral neuropathy then reassess sensation in each extremity
d. Atrial fibrillation MC dysrrhthmia in hypothermia & is characteristically seen at core temp 30 C. Prolongation any interval, bradycardia, asystole, A-fib/flutter, ventricular tachy may also be seen. Pt 12 lead ECG obtained showing Osborne J wave, which indicative of junctional rhythm and is consistent with hypothermia. J waves maybe seen at any temp below 32.2C, most frequently in leads 2 & V6. Below a core temp 25 C they are most commonly found in precordial leads (V3 & V4) & size increases. J waves usually upright in Vl, aVF, precordial leads
An undomiciled man of unknown age presents to the ED unresponsive. Bystanders believe he was outside all night in snow storm. His core temperature is 30C. What is most common cardiac dyssrhythmia seen in hypothermia? a. Sinus tachycardia b. Sinus bradycardia c. Ventricular fibrillation d. Atrial fibrillation e. Prolonged QT syndrome
