ER Exam 2 Practice

What are the non structural causes of vaginal bleeding in non pregnant women?

"COIN E" coagulopathy ovulatory dysfunction iatrogenic not otherwise classified endometrial

What are the structural causes of vaginal bleeding in non pregnant women?

"PALM" polyp adenomyosis leioma malignancy

44.1 Several patients have been brought into the ED with a chief complaint of headache. Which of the following patients should be seen fi rst (ie, which is most likely to have a potentially life-threatening condition)? A. A 52-year-old man with headache of 8-hour duration, and blood pressure of 210/120 mm Hg. B. A 32-year-old woman with severe throbbing headache involving the right side of her head. C. A 32-year-old woman who underwent an outpatient bilateral tubal ligation under spinal anesthesia and now complains of severe bilateral headache, especially with sitting up. D. A 35-year-old woman with severe headache and a diagnosis given to her of pseudotumor cerebri.

A. A 52-year-old man with headache of 8-hour duration, and blood pressure of 210/120 mm Hg.

. 26.3 A 42-year-old woman complains of an acute onset of significant abdominal pain of 6 hours duration. She states that she underwent in vitro fertilization and is currently 8 weeks pregnant. Her blood pressure is 90/60 mm Hg and her heart rate is 110 beats per minute. Her quantitative hCG level is 22,800 mIU/mL. Transvaginal sonography reveals a singleton intrauterine gestation with cardiac activity, and a moderate amount of free fluid in the cul de sac. Which of the following is the most likely diagnosis? A. Heterotopic pregnancy B. Ruptured corpus luteum C. Cirrhosis with ascites D. Urinary tract infection

A. Heterotopic pregnancy

22.4 A 33-year-old woman is pregnant at 12 weeks' gestation and presents with right flank pain and gross hematuria. She is afebrile. Which of the following imaging tests is most appropriate for this patient? A. Ultrasonography B. KUB C. IVP D. Retrograde pyelography E. Helical CT without contrast

A. Ultrasonography

Which of the following will we NOT give in anaphylaxis

ABX

What is the clinical criteria for anaphylaxis?

Acute onset with involvement of the skin sfter exposure to an allergen associated with: respiratory compromise or hypotension or organ dysfunction (GI symptoms)

90% of heavy bleeding occurs during what phase?

Anovulatory due to decreased progesterone

What is the dx test of choice for appendicitis?

Appendicitis: CT abdomen pelvis with IV and oral contrast

53.2 A 34-year-old woman complains of mild crampy suprapubic abdominal pain, dysuria, and urinary frequency for the last 3 days. She has no fever. Her blood pressure is 125/70 mm Hg, heart rate is 88 beats per minute, respiratory rate is 16 breaths per minute, and temperature is 36.8°C (98.3°F). She has no significant past medical history and is able to drink oral fluids with difficulty. She has a clean-catch urinalysis that reveals 2+ leukocyte esterase, 1+ nitrite, 1+ blood, and 2+ bacteria. Her β-hCG is negative. Which of the following organisms is most likely responsible for her presentation? A. Klebsiella spp B. Escherichia coli C. Pseudomonas aeruginosa D. Proteus mirabilis E. Enterobacter spp

B. Escherichia coli

6.1 A 32-year-old woman is noted to have persistent hypotension from suspected toxic shock syndrome despite 6 L of normal saline given intravenously. Which of the following is the best next step? A. Use colloid (albumin) for the next bolus. B. Initiate norepinephrine infusion. C. Administer corticosteroid therapy. D. Transfuse with fresh-frozen plasma. E. Activated protein C.

B. Initiate norepinephrine infusion.

6.3 A 32-year-old woman is admitted to the hospital for acute pyelonephritis. The patient is treated with oral ciprofloxacin. After 4 days of therapy, she returns to the ED with persistent fever to 38.9°C (102°F) and flank tenderness. The urine culture reveals E coli greater than 100,000 colony-forming units per mL susceptible to ciprofloxacin. When you arrive to examine her, you note that she is tachypneic, tachycardiac, and appears lethargic. Which of the following is the next step? A. Order an intravenous pyelogram. B. Obtain IV access and administer a fluid bolus. C. Initiate a workup for fictitious fever. D. Consult a surgeon for possible appendicitis. E. Add antifungal therapy.

B. Obtain IV access and administer a fluid bolus.

30.1 A 30-year-old man presents with altered mental status, fever, and nuchal rigidity. You suspect bacterial meningitis. Which of the following is the appropriate order of your actions? A. Head CT, lumbar puncture, blood cultures, steroids, antibiotics B. Blood cultures, head CT, lumbar puncture, steroids, antibiotics C. Blood cultures, steroids, antibiotics, head CT, lumbar puncture D. Lumbar puncture, blood cultures, steroids, antibiotics, head CT E. Head CT, blood cultures, steroids, antibiotics, lumbar puncture

C. Blood cultures, steroids, antibiotics, head CT, lumbar puncture

10.1 An 18-year-old woman is brought to the ED with suspected anaphylaxis. Which of the following most suggests anaphylaxis rather than a simple allergic reaction? A. Itching B. Watery eyes C. Blood pressure of 80/40 mm Hg D. Hives E. Anxiety

C. Blood pressure of 80/40 mm Hg

24.1 A 22-year-old woman is noted to have lower abdominal pain associated with some dysuria and abnormal menses. Her appetite has decreased recently. The pregnancy test is negative. Which of the following findings would most likely suggest pelvic inflammatory disease? A. Endometrial biopsy showing atypical cells B. Vaginal wet mount demonstrating clue cells C. Cervical motion tenderness on physical examination D. Pain on rectal examination

C. Cervical motion tenderness on physical examination

36.4 An 89-year-old was brought by ambulance from a nursing home for fever and cough. His vital signs include temperature 39.9°C (103.9°F), heart rate 120 beats per minute, blood pressure 89/69 mm Hg, respiratory rate 36 breaths per minute, and pulse oximetry 88% on a nonrebreather face mask. He is clammy and lethargic. He has coarse breath sounds bilaterally although decreased on the left. Which of the following is the most appropriate initial intervention? A. Administer intravenous antibiotics B. Draw blood cultures C. Intubation D. Obtain a chest x-ray

C. Intubation

6.4 A 66-year-old woman is noted to have acute pneumococcal pneumonia and is being treated with antibiotics, and with norepinephrine and dobutamine to maintain her BP and urine output. Which of the following is a bad prognostic sign? A. Urine output of 1 mL/kg/h B. Mean arterial blood pressure of 80 mm Hg C. Lactic acid level of 6 mmol/dL D. Serum bicarbonate level of 22 mEq/L E. Hematocrit 35%

C. Lactic acid level of 6 mmol/dL

44.2 A 22-year-old woman complains of headache of 2 hours duration that is described as unilateral and throbbing with nausea, photophobia, and phonophobia. Which of the following is the most likely diagnosis? A. Cluster headache B. Brain tumor C. Migraine headache D. Tension-type headache

C. Migraine headache

36.2 A 25 y/o woman with no past medical hx presents with fever and productive cough. Her vital signs include temperature 38.8 C (101.9 F) heart rate 115 bpm, respiration 20 per minute BP 115/89 and pulse oximetry 97% on RA. Ronchi are present in the right lung. CXR shows a R middle lobe infiltrate. What should the treatment include?

C. Outpatient tx with azithromycin

26.1 A 22-year-old woman complains of lower abdominal pain and vaginal spotting. Which of the following tests is the first priority? A. Pelvic ultrasound B. KUB (kidneys, ureters, bladder) radiograph C. hCG level D. Chlamydia antigen test of the cervix

C. hCG level

What is the study of choice in pregnant lady with suspected nephrolithiasis?

CT non contrast

What is the MC type of stone?

Calcium phosphate and calcium oxalate radiopaque

53.5 Which of the following patients with pyelonephritis can be safely discharged home with close follow-up? A. A 23-year-old woman in her second trimester of pregnancy. B. A 13-year-old woman who cannot tolerate her diet despite anti-emetics. C. An 88-year-old man with urinary retention and dehydration. D. A 67-year-old woman with 3+ bacteria, a sulfa allergy, and a history of lupus. E. A 44-year-old woman with a kidney stone and hydroureter on CT scan.

D. A 67-year-old woman with 3+ bacteria, a sulfa allergy, and a history of lupus.

10.3 Which of the following management options is the greatest determinant of patient outcome in anaphylaxis? A. Timely administration of steroids B. Administration of diphenhydramine C. Early identification of the allergen D. Early administration of epinephrine E. Aggressive resuscitation with intravenous fluids

D. Early administration of epinephrine

36.3 A 65-year-old smoker with past medical history of chronic obstructive pulmonary disease and diabetes presents with productive cough, chills, and pleuritic chest pain. His vital signs include temperature 38.9°C (102.1°F), heart rate 110 beats per minute, blood pressure 140/89 mm Hg, respiratory rate 24 breaths per minute, and pulse oximetry 92% on room air. On examination, he has a barrel chest with diffuse wheezes bilaterally. His chest x-ray reveals a left-lower-lobe infiltrate and pleural effusion. Which of the following is the best treatment? A. Outpatient treatment with azithromycin B. Outpatient treatment with levofloxacin C. Inpatient treatment with ceftriaxone, azithromycin, and vancomycin D. Inpatient treatment with ceftriaxone and azithromycin

D. Inpatient treatment with ceftriaxone and azithromycin

26.5 A 28-year-old woman complains of lower abdominal cramping pain for about 3 hours, and passed what was described as "liver-like" tissue, after which her pain resolved. In the ED, her blood pressure is 120/70 mm Hg and heart rate is 80 beats per minute. Her uterus is firm and the cervix is closed. The hCG level is 2000 mIU/mL. Transvaginal sonography reveals no intrauterine pregnancy. Which of the following is the next step? A. Laparoscopy B. Methotrexate therapy C. Progesterone level D. Repeat hCG level in 48 hours

D. Repeat hCG level in 48 hours

6.2 A 45-year-old man with acute cholecystitis is noted to have a fever of 38.3°C (101°F), hypotension, and altered sensorium. His HCT is noted to be 24%. Broad-spectrum antibiotics and intravenous saline are administered, and, although his CVP is 10 and his MAP is 80, his ScvO2 remains <70%. Which of the following is most likely to be beneficial? A. Initiate corticosteroids B. Tight glucose control C. Acetaminophen 500 mg PR D. Transfusion E. Lithotripsy

D. Transfusion

44.3 A 34-year-old woman is brought into the ED for "the worst headache of her life." She has some lethargy, photophobia, and nuchal rigidity. A lumbar puncture is performed after examining her eye grounds. Which of the following fi ndings in cerebrospinal fl uid is most concerning for subarachnoid hemorrhage? A. Red blood cells B. White blood cells C. Elevated opening pressure D. Xanthochromia

D. Xanthochromia

10.4 A 32-year-old man collapses in the emergency room after being brought in by paramedics. He was stung by a bee and known to be highly allergic. He appears cyanotic and had extreme stridor in the ambulance. Severe laryngeal edema is notable. Which of the following is the best treatment? A. Nebulized albuterol, H1 and H2 antagonists, corticosteroids, and crystalloids B. Subcutaneous epinephrine, H1 and H2 antagonists, and corticosteroids C. Rapid sequence intubation, subcutaneous epinephrine, and corticosteroids D. Intramuscular epinephrine, rapid sequence intubation, and corticosteroids E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists

E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists

What is the most important thing to do at discharge if you are dx a patient with anaphylaxis

Educate on the use of epi pen

What will you see on an exam of someone with psuedotumor cerebri? Q: what will you NOT see

Hx HA with visual complaints obese female of child bearing age papilledema visual field deficits

What does cullen sign tell you about the patient?

Intra-abdominal bleeding

What is the procedure to break up and remove stones?

Lithotripsy

Ventilator acquired pneumo

New infection >48 hours after intubation

Hospital acquired pneumo

New infection >48hrs after admission

What tool can be used to assess if a patient needs to be admitted or can be discharged with pneumo?

PSI

Community acquired pneumo

Patient has not been hospitalized or in a nursing home in at least 14 days before presentation

Health care associated pneumo

Patient hospitalized 2 or more days in the last 90 days. Nursing home, IV abx, dialysis, wound care, chemo, immunocompromised

What are the MC pathogens for Meningitis?

S. Pneumo S. Aureus N. Meningitidis H. Influ Listeria E.Coli - noeonates Cocsakie - Viral

What common pathogens cause pneumo?

S. pneumo S. Aureus Klebsiella H. Influ atypical = mycoplasma HCA pneunmo = pseudomonas Elderly = leigonella Viral = Influenza

What does TPAL stand for?

T= term births P= preterm births A= abortions L= living children twins count as 1 term birth but 2 live children

What causes the majority of deaths in anaphylaxis

airway compromise 50% occur in the 1st hour

What are the increased risk factors for pyelonephritis

diabetes pregnancy symptoms >7 days resistant pathogens HA infxn Urinary tract obstruction Indwelling cath immunosupressed pt

What is the tx for outpatient stone?

hydration NSAID Antiemetic *tamsulosin* *doxazosin*

What are the 8 predictors of pneumonia in nursing home patients?

increased pulse increased RR Fever decreased alertness acute confusion lung crackles absence of wheezes increased leukocyte >1 = 33% chance of pneumo >3 = 50% chance of pneumo

If someone has allergies with angioedema and using and ACEI what do you do?

tell the patient to stop using the ACEI and f.u with PCP

Risk factors for ectopic pregnancy

tubal surg PID smoking advanced age prior abortion infertility IUD

What is the MC site of obstruction for stones?

ureteropelvic junction

When to see a medical provider for vaginal bleeding?

using 1 pad or tampon q 2-3 hrs bleeding >1 week vaginal bleeding during pregnancy severe pain heavy periods >3 cycles bleeding after menopause bleeding between periods or caused by sex