ER Quizlet

A 66-year-old female with a history of nephrotic syndrome presents to the emergency department complaining of a non-productive cough and dyspnea on exertion following a recent vacation to Orlando. She is currently taking prednisone. What diagnosis is highly suspected in this patient due to her history of nephrotic syndrome? A pneumonia B pulmonary embolism C chronic obstructive pulmonary disease (COPD) exacerbation D Cushing's syndrome E asthma exacerbation

B

A 7-year-old male presents to the emergency department with right leg pain after falling off a swing at the school playground. Imaging of the right lower extremity shows the following fracture pattern: Which type of Salter-Harris Classification is observed? A Type I B Type II C Type III D Type IV E Type V

C

You are evaluating a 72-year-old male who is referred to the emergency department from his primary care office. On examination you note a lethargic obese male with the following vitals: BP of 225/135 a P of 88, and T of 98.4˚F. He reports discontinuing all his medications for blood pressure 6 months ago due to financial reasons. Which of the following physical examination findings would be most consistent with a diagnosis of a hypertensive emergency? A normal exam B xanthelasma C varicose veins D papilledema E enlarged nodular prostate

D The correct answer is (D). This patient has significantly elevated blood pressure, lethargy, and evidence of hypertensive encephalopathy, which is supported by a physical examination finding of papilledema. Additional workup may be indicated to rule out other causes of his papilledema. Target organ damage is apparent in anyone with hypertensive emergencies and may be neurological, renovascular, cardiovascular, or a combination thereof. Prompt treatment is necessary to prevent complications. Although the physical examination may be normal, evidence of end-organ damage is likely on examination and/or laboratory/diagnostic studies. Choices (B), (C), (E) are not representative of end-organ damage seen in hypertensive emergencies.

A 21-year-old male presents to the emergency department due to vomiting blood. He is a college student and was initiated into a fraternity earlier in the week, and admits to drinking enough alcohol to make him vomit that night. There was no blood in the vomit at that time. The hematemesis started today, about 20 minutes after he finished a workout at the gym. He notes that today was a particularly tough workout, as he increased the amount of weight he was lifting significantly compared to previous workouts. His vital signs are as follows: heart rate 86 bpm, respirations 14, BP 126/82, temp 98.8°F. What is his most likely diagnosis? A Mallory-Weiss syndrome B Peptic ulcer disease C Arteriovenous malformation D Esophageal varices E Erosive gastritis

A The correct answer is Mallory-Weiss syndrome. This is characterized by a nonpenetrating mucosal tear at the gastroesophageal junction, which may arise from a sudden increase in transabdominal pressure, such as lifting, retching, or vomiting. Peptic ulcer disease usually presents with a history of dyspepsia. Arteriovenous malformations usually present with melena or hematochezia. Esophageal varices usually develop secondary to portal hypertension, and are most often found in patients with cirrhosis. Erosive gastritis is often due to NSAIDs, alcohol, or severe medical or surgical illness, and is more often associated with chronic blood loss.

Two days following an uneventful 4-vessel CABG, a 57-year-old man develops a sudden onset of lightheadedness and palpitations. His vital signs are stable, and physical examination demonstrates no abnormalities. Given the results of his EKG, as shown (Figure 2), which of the following is the most appropriate next step in management? A Direct-current cardioversion B Nitroglycerin patch C Digoxin 0.125 mg PO daily D Neurology consult E Meclizine 25 mg PO Q6H

The Correct Answer is: A Among the choices offered here, choice A is the most appropriate next step in management of a patient with new onset atrial flutter, as determined by EKG; it most effectively converts most patients to normal sinus rhythm. Choice B is inappropriate, as the patient is not demonstrating angina pectoris, and the EKG does not demonstrate evidence of ischemia or infarction. Choice C is inappropriate, as it is the least effective agent for slowing the ventricular response when compared to beta blockade or calcium channel blockers, all of which act by blocking the AV node (digixon may occasionally convert atrial flutter to atrial fibrillation). Choice D is inappropriate, as the patient's symptoms of lightheadedness do not stem from neurologic changes. Choice E is inappropriate, as the patient's symptoms do not stem from vertigo.

A 22-year-old recent immigrant from Vietnam, who is 28 weeks pregnant with her first child, presents to the emergency department with complaints of worsening dyspnea and lower extremity edema. She is unable to answer definitively whether or not she has a history of rheumatic fever. On physical examination, a possible opening snap, loud S 1 , and a very soft diastolic rumbling murmur is auscultated. When the patient is placed in the left lateral decubitus position, the murmur is accentuated, and heard best at the apex. With inspiration, the murmur does not increase in amplitude. On echocardiogram, mitral stenosis is noted. Which of the following is the most appropriate next step in management of this patient? A Beta blockade and support stockings B ACE inhibitor C Mitral valve replacement D Cardiac catheterization E Increased sodium intake to maintain fluid volume

The Correct Answer is: A Choice A is the most appropriate next step in the management of this pregnant patient with mitral stenosis. In pregnancy, blood volume, cardiac output, and heart rate are increased. In pregnant patients with mitral stenosis, this increases the pressure across the mitral valve and can lead to pulmonary edema. The use of appropriate beta blockade is helpful for decreasing the heart rate, and may be used in conjunction with digoxin if the patient develops atrial fibrillation, a common dysrhythmia in this patient population. Support stockings are helpful in preventing venous pooling in the lower extremities, which can lead to large fluctuations in hemodynamics. Choice B, ACE inhibitors, are contraindicated in pregnancy, secondary to the teratogenic effects. Choice C, mitral valve replacement, is indicated only if medical management is insufficient to prevent congestive heart failure, a serious consideration in this valvulopathy, which is the most likely to cause death in pregnancy. Choice D, cardiac catheterization, is used for evaluation of coronary artery disease, but is not indicated in this young patient with few risk factors for coronary artery stenosis. Choice E, increased sodium intake to maintain fluid volume, would worsen the pressure across the mitral valve, and thus is incorrect, as avoidance of fluid overload is one of the keys to management of a pregnant patient with mitral stenosis, especially in the latter stages of pregnancy. Patients who are well-controlled throughout pregnancy, with medical management, are still at risk during labor and delivery, when large fluctuations in hemodynamics will occur.

A 24-year-old man with a recent history of a viral illness comes to the emergency room complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. Which of the following would be the most likely electrocardiographic findings? A Diffuse ST segment elevation B Peaked T waves C Inferior Q waves D Loss of R-wave amplitude E U waves

The Correct Answer is: A In a patient with these signs, symptoms, and lab findings, acute pericarditis is the most likely diagnosis. In patients with acute pericarditis, EKG changes occur secondary to inflammation of the subepicardium, leading to widespread elevation of the ST segments, often with upward concavity, which returns to normal after several days, followed by T wave inversion. No significant QRS complex changes are noted, so choice C, the development of inferior Q waves (frequently associated with an inferior myocardial infarction), is incorrect. Choice B is frequently noted with severe hyperkalemia. Loss of R-wave amplitude, choice D, is associated with myocardial infarction. Choice E, U waves, are associated with hypokalemia.

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Serial troponin elevations above the 99 th percentile of normal are noted. Which of the following would be the most appropriate next step in the management of this patient? A Clopidogrel, heparin, and aspirin, followed by cardiac catheterization B Nuclear stress test C Treadmill stress test D Thiazide diuretics and loop diuretics E Dobutamine stress echocardiogram

The Correct Answer is: A In patients with non-ST-segment myocardial infarction, such as this patient with ischemic symptoms and serial troponin elevation above the 99 th percentile of normal, clopidogrel, aspirin, and heparin prior to cardiac catheterization are recommended, with the intention of percutaneous coronary intervention. In addition, morphine, oxygen, nitrates, beta blockade, ACE inhibitors, statin therapy, and glycoprotein IIb/IIa inhibitors should be considered, depending on the patient's blood pressure, heart rate, and hemodynamic stability. Choice D would be useful in the treatment of patients with hypertension and lower extremity edema. Choices B, C, and E, are all forms of stress testing, which should be performed in patients with symptoms of angina pectoris, but not for patients with acute myocardial infarction.

A 36-year-old auto mechanic presents to the emergency department after hurting his back on the job. While lifting an object, he experienced sudden pain in his lower back with radiation to the right buttock. He was initially treated for muscle strain with a nonsteroidal anti-inflammatory drug (NSAID) after x-rays of his lumbosacral spine demonstrated no pathology. He continued to complain of this low back pain now radiating posteriorly down his left leg to the mid-thigh. Physical examination is unremarkable. The most likely diagnosis is A lumbosacral strain B left S1 radiculopathy C cauda equina syndrome D L5-S1 disc herniation E lateral femoral cutaneous neuropathy

The Correct Answer is: A Low back pain is one of the more common presenting neurologic complaints to a primary care provider. Most acute pain syndromes are benign, self-limiting conditions, with pain arising from myofascial sources. Patients with back pain and normal neurologic examinations are unlikely to have any serious underlying pathology and further diagnostic testing is usually unrevealing.

What is the most common blood gas abnormality in patients with a pulmonary embolism? A Respiratory alkalosis B Metabolic acidosis C Metabolic alkalosis D Respiratory acidosis E Compensated respiratory acidosis

The Correct Answer is: A Respiratory alkalosis occurs as a result of the hyperventilation.

A 22 year-old male is involved in a motor vehicle crash resulting in fracture of the left femur and left ribs 3 through 6. Approximately 24 to 36 hours after admission he becomes mildly confused and his RR increases to 40. Chest x-ray reveals diffuse pulmonary opacities. ABG shows pH 7.39, PCO 2 34, PO 2 55. What is the most likely diagnosis? A ARDS B Cardiac contusion C Pleural effusion D Pneumothorax E Pulmonary thromboembolism

The Correct Answer is: A The acute onset of respiratory distress after trauma is consistent with ARDS (A). The chest x-ray findings are inconsistent with cardiac contusion (B), pleural effusion (C), pneumothorax (D) and pulmonary thromboembolism (E).

A 47-year-old male presents to the hospital with complaints of palpitations. He has a history of hypertension, for which he takes diltiazem. On exam he is alert, awake, and oriented. His blood pressure is 144/76, his pulse rate is 52, and his respiratory rate is 18. Lung sounds are clear, and cardiac is a regularly irregular rhythm. There is no peripheral edema noted, and a neurological exam is non-focal. The rhythm strip shown is produced. Based on these findings, what is the next step in the treatment of this patient? A Stop diltiazem B Cardiac catheterization C Permanent pacemaker insertion D Immediate cardiac surgery E Intravenous digoxin

The Correct Answer is: A This patient has a second-degree AV block, Mobitz Type I, or Wenckebach. In this case, putting the patient on a calcium channel blocker can increase the vagal tone and slow the rate down. The best intervention for this patient is to stop the diltiazem. If there is a suspicion of ischemia, then cardiac catheterization is warranted. There is no indication for a pacer or surgery.

33-year-old female presents to the emergency department for the complaint of abdominal pain that has been present for the last month. During her workup, she has an ECG completed. She denies any shortness of breath, palpitations, orthopnea, dyspnea on exertion, syncope, weakness, or headaches. On physical exam, she is alert, awake, and in no distress. Her vital signs are as follows: temperature is 98.9, pulse is 100, respiratory rate is 18, and blood pressure is 132/90. Her HEENT is within normal limits, her neck is supple with a slightly enlarged thyroid that is non-tender without nodules, her lungs are clear, and cardiac is a regularly irregular rhythm. Based on these findings, what is the best therapy for this patient? A No therapy B Ablation therapy C Beta blockers D Digoxin E Verapamil

The Correct Answer is: A This patient has asymptomatic bigeminy. In this case, the patient is otherwise healthy and has no other medical problems. Patients with this presentation require no therapy, and this is an incidental finding on her evaluation. Only monitoring of the patient is considered.

What is the most likely reason for a patient to have cardiogenic shock? A Acute myocardial infarction B Sepsis C Trauma D Aortic dissection E Pericardial effusion

The Correct Answer is: A While trauma can account for a patient being subjected to cardiogenic shock, the overwhelming etiology for the shock comes from an MI.

A 61-year-old man arrives at the emergency department (ED) suffering an acute myocardial infarction as a result of coronary artery thrombosis. One of the agents administered to the patient is a thrombolytic agent. From the choices below, which drug is a thrombolytic agent? A abciximab B alteplase C warfarin D heparin E clopidogrel

The Correct Answer is: B Both warfarin and heparin are anticoagulants that are indicated for the prevention of thrombi. They do not actively lyse clots, but are capable of preventing further thrombogenesis. Both abciximab and clopidogrel are considered antiplatelet agents. Abciximab inhibits the activation of glycoprotein IIb/IIIa receptors on platelets, which helps to reduce platelet aggregation. Clopidogrel blocks adenosine diphosphate (ADP) receptors on platelets. The binding of ADP to these receptors is an important cellular mechanism in stimulating platelet aggregation. Alteplase converts plasminogen to plasmin, which then actively dissolves the fibrin threads associated with a thrombus.

A 22-year-old man is brought to the emergency department by paramedics after having sustained a single stab wound along the left sternal border at the fourth intercostal space. Upon arrival to the emergency department, he was hypotensive and tachycardic. The neck veins were distended and heart sounds were muffled. Which of the following interventions is the most appropriate first-line management of this patient? A Left tube thoracostomy B Pericardiocentesis C Fluid resuscitation D Immediate intubation

The Correct Answer is: B Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done. A left tube thoracostomy may be indicated in this patient but would not relieve symptoms. Fluid resuscitation though applied to all trauma patients would help stabilize the patient until more therapeutic interventions could be completed. Immediate intubation, even if indicated, would require a prophylactic tube thoracostomy to prevent the development of tension pneumothorax in the event of an unrecognized lung injury. Emergency thoracotomy will relieve the signs and symptoms associated with cardiac tamponade and allow for repair of any underlying cardiac injuries.

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is the most appropriate treatment for his high-output congestive heart failure? A IV dextrose alone B IV thiamine C IV enalapril D IV dopamine E IV diltiazem

The Correct Answer is: B Choice B is the most appropriate treatment, as the patient is demonstrating high output congestive heart failure secondary to beriberi, or thiamine deficiency. In 50% of patients, IV thiamine administration, along with other vitamins and glucose, will resolve the patient's symptoms. Choice A, IV dextrose alone in patients with very low thiamine stores, can worsen signs and symptoms of heart failure. Choice C, IV enalapril, is appropriate therapy for patients in need of better blood pressure control, and as an ACE inhibitor, in patients with left ventricular systolic dysfunction, which is not the cause of this patient's heart failure. Choice D, IV dopamine, is useful in patients in need of pressor support, but will not help treat high-output heart failure secondary to thiamine deficiency. Choice E, IV diltiazem, is useful for heart rate control in patients with atrial fibrillation with a rapid ventricular rate.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates a "water bottle" cardiac silhouette. Which of the following diagnostic studies would be considered the most appropriate next step in management of this patient? A Cardiac catheterization B Transthoracic echocardiography C CT of the thorax D VQ scan E Lower extremity venous doppler

The Correct Answer is: B Choice B, transthoracic echocardiography, would allow for monitoring of a patient with acute pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops. Choice A, cardiac catheterization, would be appropriate in a patient with acute myocardial infarction. Choice C, CT of the thorax, is not as effective or specific as transthoracic echocardiography for the development of a pericardial effusion and/or tamponade. Choices D and E would be appropriate diagnostic studies if pulmonary embolism is suspected, but not as the next step in management of this patient with pericarditis.

A 62-year-old man presents to the emergency department with aphasia and right lower extremity weakness that started about 4 hours ago. He now has progressing right upper extremity weakness, worsening right lower extremity weakness, and decreased sensation throughout his right side. This cerebral ischemia is best characterized as A transient ischemic attack B stroke in evolution C completed stroke D subarachnoid hemorrhage E global cerebral ischemia

The Correct Answer is: B During a stroke in evolution, symptoms will worsen or new symptoms will appear. A completed stroke is one in which neurologic symptoms have stabilized, whereas a transient ischemic attack produces deficits that resolve over time. This patient's symptoms do not match those of an acute subarachnoid hemorrhage. Global cerebral ischemia as seen in sudden cardiac arrest would involve loss of consciousness.

What is the most common ECG abnormality in patients with a pulmonary embolism (PE)? A Atrial fibrillation B Sinus tachycardia C Ventricular ectopy D Sinus bradycardia E High grade AV block

The Correct Answer is: B In most cases, sinus tachycardia is the only abnormality in patients with a PE. You may also find some ECGs that will have non-specific ST-T wave changes. Sinus bradycardia and AV blocks are not common findings that are associated with PE.

A 70-year-old man, with a history of HTN and aortic valve replacement 3 months ago, presents with complaints of arthralgia, myalgia, anorexia, fatigue, and weight loss over the last month, with recent dyspnea on exertion and lower extremity edema. Vital signs are as follows: Temperature 38°C, BP 102/64, P 98, RR 20. On physical exam, a new high-pitched, blowing, decrescendo diastolic murmur is noted along the left lower sternal border. Two separate blood cultures are positive for S. aureus, and found to be methicillin-resistant. A transesophageal echocardiogram demonstrates a paravalvular abscess. Which of the following is the most appropriate therapy in the management of this patient? A IV vancomycin B IV vancomycin, IV gentamicin, and PO rifampin with surgical treatment C IV amphotericin plus flycytosine, and surgical treatment D Outpatient IV ceftriaxone E IV penicillin G

The Correct Answer is: B In patients with prosthetic valve infection with methicillin-resistant S. aureus, the treatment of choice is IV vancomycin for 6 to 8 weeks, plus IV or IM gentamicin for the initial 2 weeks secondary to nephrotoxicity, and PO rifampin for 6 to 8 weeks, with susceptibility to gentamicin determined before initiation of rifampin. Surgical therapy decreases mortality in patients with S. aureus endocarditis, from over 70% with medical therapy alone to 25%, and should be considered in patients with paravalvular abscesses and symptoms suggestive of moderate to severe refractory congestive heart failure. Therefore, choice B is the most appropriate next step in the management of this patient. Choice A does not offer sufficient coverage for methicillin-resistant S. aureus. Choice C is appropriate therapy for infective endocarditis when the causative organism is Candida. Outpatient antibiotic therapy is only appropriate in patients who are stable, without clinical or echocardiographic findings to suggest complications, and IV Ceftriaxone is not appropriate for the treatment of methicillin-resistant S. aureus prosthetic valve endocarditis. Choice E is appropriate therapy for pencillin-susceptible streptococci, such as S. bovis.

A 53-year-old man presents to the emergency department because of fever, headache, and confusion. On physical examination, you note an obtunded man who appears acutely ill with temperature of 104°F, blood pressure of 128/76 mm Hg, pulse of 98, and respiratory rate of 20. The patient has stomatitis, nuchal rigidity, and a positive Kernig sign. CSF examination shows increased opening pressure, 80 WBC/mL (normal < 10/mL), mildly elevated protein, and normal glucose. Which of the following tests would confirm the most likely causative organism? A CT of the head B polymerase chain reaction test for herpes simplex virus C blood culture for herpes simplex virus D serum IgG for herpes simplex virus E MRI of the head

The Correct Answer is: B The patient's presentation is consistent with viral meningitis with potential encephalitis. The presence of active stomatitis indicates herpes simplex virus as the most likely causative organism. A CT of the head could be considered prior to performing a lumbar puncture and may show temporal lobe abnormalities that support a diagnosis of herpes virus encephalitis, but like an MRI will not identify the causative organism and has limited sensitivity. Of the three herpes tests described, the PCR technique is the most likely to identify the herpes simplex virus as the causative organism in the CSF due to its high sensitivity and specificity. Serum IgG indicates prior infection from herpes simplex virus but does not confirm the causative organism of the patient's encephalitis. Viral blood cultures for herpes simplex would likely show no growth even in the presence of herpes simplex virus encephalitis.

A 27-year-old African American female presents to the emergency department with low blood pressure of 100/40, palpitations, and shortness of breath. She is currently under treatment for Wolff-Parkinson-White syndrome and has been taking procainamide for the last two years. An electrocardiogram is obtained on the monitor and reveals the rhythm strip shown. What is the treatment of choice for this patient? A Intravenous calcium B Intravenous magnesium C Oral potassium D Subcutaneous epinephrine E Metoprolol

The Correct Answer is: B The rhythm strip reveals ventricular tachycardia in the form of torsades de pointes. In this case, the primary medical intervention is to administer magnesium sulfate to counter the irregular activity. Antiarrhythmics, antidepressants, and some antibiotics can be responsible for this arrhythmia. In addition to the magnesium, administration of beta-blockers can also be helpful.

An 89-year-old female was found to have had an episode of syncope while at home. There was no history prior to the event, and the patient denies any chest pain prior to the episode occurring. On exam, the patient is alert, awake, and oriented, and is only complaining of mild shortness of breath. Her ECG is as shown. Which of the following is the best choice for treating this patient? A No treatment B Permanent pacemaker C Digitalis therapy D Ablation therapy E Beta blockers

The Correct Answer is: B This patient has a third-degree AV block that is symptomatic, with syncope and mild shortness of breath. The treatment for this patient is pacemaker insertion. Immediate insertion depends on the vital signs of the patient. If the patient's vital signs are stable, a transdermal pacer can be used until a scheduled pacer insertion within 24 hours. If the vital signs are not stable, immediate intervention with either central venous pacing wires or an immediate pacer insertion is warranted.

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency department complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted, with over 200 mL of pericardial fluid described. Which of the following would be this patient's most likely electrocardiographic finding (Figure 7)? A Torsades de pointes B U waves C Electrical alternans with sinus tachycardia D Peaked T waves E Convex elevation of the J point

The Correct Answer is: C Choice C, electrical alternans with sinus tachycardia, a beat-to-beat alteration in one or more components of the ECG signal, is considered a specific sign of pericardial effusion, often with cardiac tamponade, as it represents the periodic swinging motion of the heart in the effusion at a frequency that is ½ the heart rate. Choice A, torsades de pointes, is a type of ventricular tachycardia frequently seen, and is associated with electrolyte disturbances or the use of certain types of antiarrhythmic drugs. Choice B, U waves, are associated with hypokalemia. Choice D is frequently noted with severe hyperkalemia. Choice E, convex elevation of the J point, is seen in patients suffering from hypothermia.

What is the most common clinical finding on vital signs in a patient with cardiogenic shock? A Fever B Hypertension C Hypotension D Tachypnea E Bradycardia

The Correct Answer is: C Hypoperfusion to the body is what generally causes the end organ failure associated with shock. The patient may also be tachycardic, but may not have fever or an increased respiratory rate as part of the abnormality. In most cases patients will have tachycardia unless they suffer a significant pump failure, which may cause bradycardia.

A 23-year-old female who has a history of supraventricular tachycardia is having an acute episode again. She has attempted a valsalva maneuver without success in breaking the arrhythmia. The ECG confirms SVT. What is the next step in therapy for this patient? A Atropine B Amlodipine C Adenosine D Amiodarone E Metoprolol

The Correct Answer is: C Intravenous adenosine is the treatment of choice in this clinical situation. If successful the adenosine will break the cycle of tachycardia, usually with a pause. The initial dose is 6mg, followed by two, 12 mg doses if unsuccessful. While this is the standard protocol as guided by ACLS, additional doses of adenosine can be given in a hospital setting, as the half-life of the drug is extremely short. Amiodarone and amlodipine would not have an effect on the supraventricular effect of the arrhythmia.

A 33-year-old woman treated with trifluoperazine for the past 3 months is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? A a delayed allergic reaction has occurred with trifluoperazine B tardive dyskinesia has begun to develop in the patient C the patient has developed neuroleptic malignant syndrome D the patient has developed serotonin syndrome E the patient has overdosed on trifluoperazine

The Correct Answer is: C Neuroleptic malignant syndrome is an uncommon but serious complication with therapeutic doses of antipsychotic drug therapy, particularly the first-generation (typical) class. Cardinal signs and symptoms include a body temperature above 100.4°F, altered state of consciousness, autonomic dysfunction, and rigidity.

A 62-year-old man is brought to the emergency department after being found unresponsive in his car. On physical examination, his pupils are noted to be 7 mm on the right and 3 mm on the left. Which of the following diagnostic tests is most likely to identify the cause of the patient's signs and symptoms? A CBC with differential B serum electrolytes C MRI with contrast D liver function tests E skull X-rays

The Correct Answer is: C The patient's unilateral symptoms are best explained by a local anatomical cause (e.g., tumor) that would be detected with an imaging study (MRI). An MRI is preferred over skull X-rays to assess directly for intracranial pathology. CNS abnormalities arising from systemic causes are more likely to be symmetric.

A 56-year-old male was admitted to the regular medical floor with a diagnosis of sepsis due to urinary tract infection. While on the floor he became acutely unstable and had a blood pressure of 70/40. A medical emergency code was called, which revealed the rhythm shown. There was no palpable pulse on exam, and no evidence of heart sounds on auscultation. The patient was not responding to any stimulus during this time, and there did not appear to be any spontaneous respirations noted. Based on this clinical scenario, what would be the most appropriate medical procedure to perform on this patient? A Emergent cardiac catheterization B Synchronized cardioversion C Unsynchronized cardioversion D Temporary pacemaker insertion E No intervention, the patient has not survived

The Correct Answer is: C This patient is exhibiting ventricular fibrillation with hypotension. Because this patient is unstable in this clinical setting, immediate unsynchronized cardioversion (C) is warranted. Once corrected, consideration for cardiac catheterization (A) is reasonable since patients may have native coronary disease that caused the fibrillation. Unsynchronized cardioversion (C) would not initiate a cardiac response, and temporary pacemaker (D) must first have an established electrical rhythm to appropriately pace the patient. The patient still has a low blood pressure, therefore no intervention (E) would prove to be fatal.

A 27-year-old man presents to the emergency department with a five-day complaint of substernal pleuritic chest pain, which worsens while lying supine. He is in no distress. A friction rub is noted over the precordium. The patient's vital signs are as follows: temperature is 100.4˚F, pulse rate is 94, respiratory rate is 20, and blood pressure is 136/84. An ECG reveals widespread diffuse ST elevations with PR interval depressions. He was recently treated for a viral respiratory infection. Which of the following is the most appropriate initial management for this patient? A Administer a broad spectrum antibiotic B Administer intravenous tissue plasminogen activator (T-PA) C Begin a nonsteroidal anti-inflammatory agent D Perform needle thoracentesis E Refer for immediate cardiac catheterization

The Correct Answer is: C This patient's diagnosis is acute inflammatory pericarditis. Viral infections are the most common cause of acute pericarditis, and males are the most commonly affected. A pericardial friction rub and EKG changes are characteristic of this diagnosis. Treatment is focused on the underlying inflammation, with NSAIDS being first-line and short course corticosteroids also being appropriate. Antibiotics are not indicated unless a bacterial etiology is confirmed or there are significant risk factors. Choices B, D, and E are not appropriate for this condition and could be harmful.

A 24-year-old HIV-positive man comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. Prior to examining him, you have reviewed his chart. Laboratory findings demonstrate troponins x 3, which are negative for myocardial ischemia. His EKG demonstrates diffuse ST segment elevations throughout. Which of the following physical exam findings would be most likely in this patient? A Roth spots B Splenic enlargement C Janeway lesions D Pericardial friction rub E Splinter hemorrhages

The Correct Answer is: D Choice D is the most likely finding, as this patient is exhibiting signs, symptoms, and EKG findings pathognomonic for acute pericarditis, which is likely infectious in the setting of a patient with HIV. A pericardial friction rub is heard best with the patient in a seated position, during expiration, and is frequently found in patients with pericarditis. Choice A B, C, and E are physical exam findings seen in acute bacterial endocarditis.

A 42-year-old woman with a history of migraine cephalgia and Raynaud's phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following is the most appropriate treatment regimen? A 24-hour nitroglycerin dermal patch B Thiazide diuretics C Loop diuretics D Calcium channel blockers E Aspirin

The Correct Answer is: D Choice D, calcium channel blockers, and long-acting nitrate therapy have been proven to be effective for preventing recurrences of episodes of Prinzmetal angina, with short-acting sublingual or IV nitroglycerin useful for relieving acute episodes. Choice A, 24-hour nitroglycerin dermal patch, is inappropriate, as patients can develop nitrate tolerance, and thus need a 12-hour nitrate-free period every day. Choices B and C, thiazide and loop diuretics, have no proven benefit in patients with Prinzmetal angina. Aspirin, choice E, may worsen episodes of prinzmetal angina, and thus is not recommended.

During a hospitalization for pneumonia, troponin levels are drawn on a 62-year old-man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99 th percentile of normal. If acute myocardial infarction is ruled out, which of the following disease entities could also cause troponin elevation? A Mitral regurgitation B Gout C Parkinson's disease D Sepsis E Herpes zoster

The Correct Answer is: D Choice D, sepsis, is one of a long list of disease entities that can cause troponin elevation, including arrhythmias (both tachycardic and bradycardic), aortic valve disease, hypertrophic cardiomyopathy, invasive cardiac surgeries and procedures, severe pulmonary hypertension, pulmonary embolism, myocardial infiltrative diseases (such as amyloidosis, sarcoidosis, scleroderma, and hemochromatosis), acute respiratory failure, burns, pericarditis, endocarditis, myocarditis, and even occasionally due to extreme athletic activities such as marathon running. Not included on this long list, however, are choices A, B, C, and E.

A 35-year-old man is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? A phenobarbital B valproate C phenytoin D lorazepam E donepezil

The Correct Answer is: D In most patients suffering from generalized convulsive status epilepticus (GCSE), benzodiazepines such as lorazepam and diazepam are effective initial therapies due to their relatively high lipid solubility. As a result, they are able to cross the blood-brain barrier easily, which gives them the potential to stop seizures quickly. Lorazepam's lipid solubility is less compared to diazepam, and it also redistributes to fat more slowly. Hence, lorazepam tends to have a longer duration of action (12 to 24 hours) than diazepam (20 to 30 minutes). Phenytoin is often administered immediately after benzodiazepine administration for long-term seizure control, as it has a long half-life (20 to 36 hours) compared to diazepam. Phenytoin is not given first because its lipid solubility is less than the benzodiazepines and therefore cannot enter the brain quickly enough to terminate seizure activity.

A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure associated with diaphoresis, nausea, and dyspnea, radiating down his left arm for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. His EKG demonstrates evidence of acute anterolateral myocardial infarction on EKG, with ST segment elevation across the precordial leads, indicative of left anterior descending coronary artery stenosis. Which of the following is the most appropriate next step in management of this patient? A Dobutamine stress echocardiogram B Transthoracic echocardiogram C Nuclear stress test D Cardiac catheterization E Exercise treadmill stress test

The Correct Answer is: D In patients suffering from acute ST elevation myocardial infarction (STEMI), cardiac catheterization with percutaneous coronary intervention within 90 minutes substantially decreases morbidity and mortality outcomes; thus, choice D is the most appropriate next step in management of this patient. A transthoracic echocardiogram, choice B, will likely be performed during this patient's hospitalization, as it is can assist in assessment of complications of MI. However, the primary goal for acute STEMI is reperfusion in a timely manner, and thus TTE would not be the next step in the management of this patient. Choices A, C, and E are all forms of stress testing, which are useful testing modalities for patients with chest pain who are not actively infarcting.

A 24-year-old female HIV-positive patient, who is not currently on medication, presents to the emergency department with acute dyspnea, tachycardia, fever, nonproductive cough, and a room air oxygen saturation of 92%. She admits feeling poorly for the past five days. A physical exam reveals bilateral basilar crackles. An x-ray reveals the image shown. What is the most likely causative organism of this clinical picture? Posteroanterior chest x-ray of PCP, demonstrating extensive bilateral basilar lung involvement. A Chlamydia psittaci B Histoplasmosis C Klebsiella pneumoniae D Pneumocystis jiroveci E Streptoccocus pneumoniae

The Correct Answer is: D Pneumocystis is an opportunistic fungal infection of immunocompromised patients, most frequently seen in patients with untreated HIV/AIDS. Patients often present with fever, dyspnea, a nonproductive cough, decreased arterial oxygen pressure, and tachycardia. Lung auscultation may reveal adventitious sounds, but may also be without abnormality. Chest x-ray results classically include bilateral diffuse infiltrates with perihilar involvement. Although the other etiologies are associated with pneumonia, and may be seen in immunocompromised patients, pneumocystis pneumonia occurs in up to 80% of untreated HIV patients and is a leading cause of death.

A 23-year-old man, unrestrained driver, is brought to the emergency department by ambulance after having been involved in an automobile accident. His vitals are BP: 99/54 mm Hg, P: 112/min, R: 18/min, oxygen saturation: 99%, T: 99.8°F. Examination reveals mild abdominal tenderness with pain radiating to the right shoulder. What is the most appropriate diagnostic test to order initially? A Computed tomography of the abdomen and pelvis B Diagnostic peritoneal lavage C Flat and upright abdominal radiographs D Diagnostic ultrasound

The Correct Answer is: D The initial evaluation of blunt abdominal trauma is by the performance of a FAST (focused assessment with sonography for trauma) ultrasound, which is performed by an emergency department physician or surgeon. CT scan remains an adjunct test in hemodynamically stable patients or in patients in whom further assessment of solid intra-abdominal organs is required.

A 22-year-old woman, with no previous medical problems, suddenly cried out, fell to the ground, extended her legs, flexed her arms, and jerked her extremities for 30 seconds. There was associated tongue biting and urinary incontinence. She awoke slowly over a 10-minute period and recalled nothing about the episode. She remained lethargic for several hours but the rest of her neurologic examination was normal. What is the most likely etiology for this episode? A epilepsy B hyperventilation C cardiac arrhythmia D seizure E stroke

The Correct Answer is: D This event represents a well-demarcated episode affecting some combination of consciousness, motor, and/or sensory function consequent to abnormal electrical discharges in the brain. This is consistent with the definition of a seizure. Epilepsy refers to multiple, recurrent seizures. This history is not consistent with hyperventilation, stroke, or cardiac arrhythmia, which would typically include chest pain, shortness of breath, dyspnea on exertion, or focal neurological deficits.

A 24-year-old male is brought to the emergency department by his girlfriend. She states that he began having a seizure in the car approximately seven minutes ago. She is not sure of his medications, but states he has a known seizure history and has seizures a few times a year. The patient is currently actively seizing. Which of the following is the first-line agent to give this patient? A Carbamazepine B Gabapentin C Levetiracetam D Lorazepam E Phenytoin

The Correct Answer is: D This patient has a known history of seizures, with current ongoing seizure activity and the concern of status epilepticus, a true emergency. Prolonged seizure activity is associated with hyperthermia, metabolic disturbances, cardiopulmonary dysfunction, and irreversible damage. Lorazepam, a benzodiazepine, increases the activity of gamma-aminobutyric acid (GABA) in the brain, thereby calming the excessive electrical nerve activity related to the seizure and slowing the central nervous system. It is the preferred first line agent for temporary control of seizure activity due to the duration of action of approximately 12 to 24 hours. This allows additional therapeutic agents to be administered while gaining control of the seizure activity. The other agents are antiepileptic medications, which are used for long-term seizure control. They are differentiated by efficacy, convenience, side effects, and drug-drug interactions.

A 42-year-old healthy male presents to the emergency department with the complaint of a progressively worsening sore throat, and difficulty swallowing over the past 48 hours. He also complains of a subjective fever, but denies any headaches, nausea, or vomiting. On exam, the patient is afebrile and in mild distress, with a presentation of leaning forward on the exam table. His TM examination is normal, there is no rhinorrhea, and the oropharynx is patent without signs of stridor. His lungs are clear, and he has a regular rhythm on cardiac exam. What diagnostic test is indicated for a definitive diagnosis? A Chest x-ray B Complete blood count (CBC) C Nasal bacterial culture D Soft tissue neck x-ray E CT scan of the neck

The Correct Answer is: D This patient has a presentation that is consistent with acute epiglottitis. While ensuring that the airway is patent and the patient can maintain the airway, the first step in determining the diagnosis is a soft tissue neck x-ray, to determine inflammation to the epiglottis. While rare, epiglottitis can be from a bacterial infection, and can be quite serious and sometimes fatal.

Which of the following indicates EKG changes consistent with a suspected pulmonary embolus? A Increased QRS amplitude with tall R waves in limb leads and deep S waves in V1 and V2 B Notched P wave in leads I and II with an increased duration C Prolonged PR interval with peaked T waves D Prolonged QRS duration with QS complex in V1, monophasic R wave in leads I and V6 E Sinus tachycardia with a right ventricular strain pattern, prominent S in lead I, Q wave and inverted T in lead III

The Correct Answer is: E Approximately 70% of patients with a pulmonary embolus will demonstrate EKG changes. The changes present may range from sinus tachycardia to findings consistent with marked right heart strain and dilatation. The correct answer also includes the classic "S1Q3T3" pattern of changes associated with pulmonary embolism. The findings in choice A are consistent with left ventricular hypertrophy. Choice B is indicative of left atrial enlargement. Choice C is consistent with hyperkalemia. Choice D indicates left bundle branch block. These changes are not commonly associated with pulmonary embolism.

A 24-year-old female HIV-positive patient, who is not currently on medication, presents to the emergency department with acute dyspnea, tachycardia, fever, nonproductive cough, and a room air oxygen saturation of 92%. She admits feeling poorly for the past five days. A physical exam reveals bilateral basilar crackles. An x-ray reveals Pneumocystis jiroveci pneumonia. The patient has no drug allergies. Which of the following is the first-line treatment of choice? A Amphotericin B B Clarithromycin C Clindamycin D Pentamidine E Trimethoprim-sulfamethoxazole

The Correct Answer is: E Based upon current clinical data, the preferred agent for treatment of Pneumocystis jiroveci infections is oral trimethoprim-sulfamethoxazole. Second-line medications may include single agent or combination therapy, utilizing clindamycin, primaquine, dapsone, pentamadine, and/or atovaquone. Clarithromycin is the agent of choice for Mycobacterium avium complex infection, and amphotericin B would be indicated for Cryptococcal meningitis, as well as other fungal infections.

A 65-year-old man presents to the emergency department with an acute ischemic stroke. His CT scan is normal. His blood pressure is 180/100 mm Hg. What is the most appropriate treatment for his hypertension? A labetalol (Normodyne) 20 mg IV B nifedipine (Procardia) 10 mg po C nitroprusside (Nipride) drip at 1 mg/kg/min D clonidine (Catapres) 0.1 mg po E no antihypertensive at this time

The Correct Answer is: E Blood pressure is typically elevated at the time of presentation in acute ischemic stroke. It will decline without medication in the first few hours to days. Aggressively lowering blood pressure in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. This potentially salvageable brain tissue is referred to as the penumbra. Decreasing blood flow to the ischemic penumbra by acutely lowering blood pressure may result in eventual infarction of this brain tissue. Treatment of previously undiagnosed hypertension should be deferred for several days. Blood pressure should be treated if there are other indications, such as angina or heart failure. Control of blood pressure is appropriate in patients who are receiving tissue plasminogen activator (t-Pa) for their stroke. Blood pressure should be lowered cautiously to a systolic of less than 185 mm Hg and a diastolic of less than 110 mm Hg. This is thought to decrease the incidence of intracerebral hemorrhage in these patients.

A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency room complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted with over 200 mL of pericardial fluid described. Which of the following is the most appropriate next step in management? A Enoxaparin 1 mg/kg subcutaneously Q 12 H B EKG C Cardiac catheterization D Penicillin V 500 mg PO BID x 10 days E Emergent pericardiocentesis

The Correct Answer is: E Choice E, emergent pericardiocentesis, should be considered when patients exhibit symptoms suggestive of severe cardiac tamponade, such as described above, with confirmatory echocardiographic findings of a large pericardial effusion, as this can be fatal if not treated promptly. Choice A is inappropriate, as this could lead to worsening of cardiac tamponade if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively. Choice B could provide additional confirmation of the diagnosis if a reduction in amplitude of QRS complexes is demonstrated, and electrical alternans of the P, QRS, and T waves, but would not provide any therapeutic benefit. Choice C could be the next appropriate step in management of myocardial infarction, but not in cardiac tamponade. Choice D represents appropriate therapy for patients with acute rheumatic fever, but not for patients with cardiac tamponade.

What is the most common radiologic finding in a patient with a tension pneumothorax? A Pleural effusion B Infiltrate C Enlarged cardiac silhouette D Elevated diaphragm E Mediastinal shift

The Correct Answer is: E Collapse of the lung, followed by an increase in intrapleural pressure, will lead to a tension pneumothorax. In most cases, the air leaks through the subcutaneous spaces. But in a tension pneumothorax, the air is locked in and creates a life-threatening emergency.

A 46-year-old female with a history of poorly-controlled diabetes and grand mal seizures presents for evaluation of bilateral foot pain. She describes the pain as burning and has noticed it is worse at night. She occasionally has this pain in her feet. She denies other medical conditions, and her medications are metformin and dilantin. Which of the following medications, used for the suspected diagnosis, should be avoided in this patient? A Capsaicin B Desipramine C Gabapentin D Lidocaine patch E Tramadol

The Correct Answer is: E Diabetic peripheral neuropathy is the diagnosis, and describes any neuropathy in the diabetic patient. This patient is exhibiting a distal symmetric polyneuropathy with the classic associated symptoms, commonly called "pins and needles" by patients. When associated with pain and functional impact, pharmacologic therapy is warranted. There are many agents to choose from, with each of the answer choices being options. However, in a patient with a known seizure disorder, tramadol should be avoided, as it decreases the seizure threshold. Gabapentin, also a seizure medication, may be used, but close monitoring is suggested.

A 23-year-old female has been seen in your Emergency Department after being beaten by her husband. As you counsel her before she leaves, which of the following will you recommend? A Avoiding the behavior that brought on the attack B Couples counselling C Leaving the relationship D Prosecuting her husband E Referral to a local women's shelter

The Correct Answer is: E The appropriate course of action when working with a person who has suffered intimate partner violence is to validate his or her experience, document clearly and non-judgmentally, and assess immediate safety. Referrals to appropriate resources (E) should be made, but decisions regarding the relationship (B, C) and any legal action (D) should be left to the patient rather than continuing a pattern of controlling behavior. Suggesting she avoid behaviors that provoke her attacker (A) puts the blame on the victim.

Which medication is the treatment of choice for symptomatic patients with hypertrophic cardiomyopathy? A Calcium channel blockers B Nitrates C Thiazide diuretics D Alpha antagonists E Beta-blockers

The Correct Answer is: E The use of beta-blockers in symptomatic hypertrophic cardiomyopathy is useful for gaining rate control. This will allow for the optimal amount of filling in order to maintain enough of an ejection fraction.

A 52-year-old male with chronic alcoholism is brought to the emergency department by his family, due to his acting differently for several days. A physical exam reveals nystagmus, eye muscle weakness, global confusion, retrograde amnesia, and ataxia. Which of the following is the most likely etiology of the diagnosis? A Cerebrovascular accident B Hypoxemia C Uremia D Vitamin B12 deficiency E Vitamin B1 (thiamine) deficiency

The Correct Answer is: E This patient exhibits classic symptoms associated with Wernicke encephalopathy. Wernicke encephalopathy is due to vitamin B1 (thiamine) deficiency. In the United States, this condition occurs most frequently in chronic alcoholics, but it may be seen in any condition affecting thiamine levels. Each of the other etiologies listed may also cause neurologic findings, and should be considered in the differential diagnosis and evaluation of this patient.

A 68-year-old male presents with the complaint of palpitations in the center of his chest over the last few hours. The symptoms come and go, and last anywhere from 30 seconds to a few minutes. There is some associated lightheadedness with these episodes, and occasionally there is mild shortness of breath. While examining the patient, he has another episode. During this time, the patient's vital signs reveal a pulse of 170 and a blood pressure of 118/69. Based on this history and the findings on the exam and rhythm strip shown, what is the best treatment for this patient? A Diltiazem B Digoxin C Lisinopril D Metoprolol E Amiodarone

The Correct Answer is: E This patient is having non-sustained ventricular tachycardia (NSVT). Based on the clinical presentation, this patient can benefit from an infusion of amiodarone. The dose is normally a 150mg bolus, followed by a drip of 1mg/min for the first 6 hours, then followed by 0.5mg/min for the next 18 to 24 hours. The other agents would not be able to maintain a rhythm for this type of abnormality.

A 28-year-old female, recently treated for sinusitis, presents to the Emergency Department with acute diarrhea and abdominal cramps for 3 days. She states that she passes foul-smelling, mucus-like, watery stools as often as 20 times a day. She denies any recent outings or events. She feels well aside from the annoyance of diarrhea and occasional flush feeling. Her temperature is 99.9°F and her pulse is 94 beats/minute. She appears well overall and has mild diffuse abdominal pain to palpation. Her rectal exam is negative for occult or frank blood. What is the most likely diagnosis? Normal values Pulse: 60 to 100 beats/minute Temperature: 98.6°F A. Viral gastroenteritis B. Antibiotic-associated colitis C. Irritable bowel syndrome D. Ulcerative colitis

. Answer: B Explanation: Antibiotic-associated colitis is caused by recent antibiotic use. It can present as frequent, watery, mucus-like stools up to 30 times a day with associated cramps and fever. Bloody diarrhea is rare. It may require treatment with metronidazole.

What is the correct equation to calculate the anion gap? A. K+ - (HCO3 − + H2O2) B. Na+ - (HCO3 − + Cl− ) C. Cl− + (H2O2 + HCO3) D. Na+ + (Cl− + H2O2)

. Answer: B Explanation: The anion gap is the difference between the serum sodium ion concentration and the serum bicarbonate and chloride ion concentrations.

A 22-year-old male is brought to the Emergency Department for the evaluation of "black stools for 3 days." Physical examination reveals pallor, heart rate of 136 beats/minute, and blood pressure 96/40 mm Hg. The abdomen is soft without hepatosplenomegaly, guarding, or rebound. After obtaining a complete blood count (CBC), clotting studies, and a type and cross, what is the next most appropriate step? Normal values Pulse: 60 to 100 beats/minute Blood pressure: Systolic 90 to 120, diastolic 60 to 80 A. Meckel scan B. Gastric lavage C. Upper gastrointestinal radiograph series D. Abdominal ultrasound E . Endoscopy

. Answer: E Explanation: The patient's presentation is consistent with a gastrointestinal bleed. Endoscopy will help identify the location of the bleed and allow for treatment of it.

A 55-year-old woman presents to the Emergency Department having been bitten by her cat. What pathogen is most likely to cause an infection in this patient? A. Pasteurella multocida B. Staphylococcus epidermidis C. Eikenella corrodens D. Pseudomonas aeruginosa

Answer: A Explanation: Bites from cats can cause deep puncture wounds that can be contaminated with P. multocida

What is the drug of choice for treating anaphylaxis? A. Epinephrine B. Hydrocortisone C. Hydroxyzine D. Diphenhydramine

Answer: A Explanation: Epinephrine, given subcutaneously or intramuscularly, is the treatment of choice. Corticosteroids may reduce the likelihood of a recurrence of anaphylaxis but are not effective acutely. Antihistamines can help reduce the symptoms of anaphylaxis.

What injection techniques can minimize the pain of anesthetizing a forehead laceration? A. Rapid injection B. Subdermal injection C. Use of a large needle D. Use of cool solution

Answer: B Explanation: Injection of anesthesia subdermally can reduce the pain of the process, as does using a small needle.

Cleansing of open wounds is best accomplished using which method? A. Soaking the wound in sterile water B. Irrigating with large volumes of normal saline under pressure C. Irrigating liberally with iodine-based disinfectants D. Soaking the wound in hydrogen peroxide

Answer: B Explanation: Open wounds are best cleansed by irrigating thoroughly using normal saline under pressure. Iodine-based disinfectants and hydrogen peroxide can damage healthy tissue.

Which of the following eye complaints requires an immediate referral to an ophthalmologist? A. Conjunctival injection B. Painless loss of vision C. Photophobia D. Hemorrhage in sclera

Answer: B Explanation: Painless vision loss can result from retinal tears or detachments, vascular obstruction, demyelinating diseases, toxins, or neoplasms and require immediate ophthalmic consultation.

How many days should sutures for lacerations on the face stay in place before removal? A. 1 to 2 B. 3 to 5 C. 7 to 10 D. 10 to 14

Answer: B Explanation: Sutures on the face should be removed 3 to 5 days after placement. Removal sooner than 3 to 5 days may result in dehiscence, and later removal may result in scar track patterns.

What historical feature suggests primary dysrhythmia as a cause of syncope? A. Prodromal events B. Unheralded loss of consciousness C. Recent use of a cephalosporin antibiotic D. Related to rapid position changes

Answer: B Explanation: Syncopal episodes that are brief and have no prodromal symptoms associated with them are often caused by cardiac arrhythmias. Syncope preceded by prodromal symptoms may be related to migraines or seizures. Syncope preceded by cephalosporin use is more likely drug-induced and, if related to rapid position changes, may result from orthostatic hypotension, an atrial myxoma, or a thrombus.

A 41-year-old woman presents with recurrent episodes of severe headache in association with an elevated systolic blood pressure (as high as 195). In evaluation of possible pheochromocytoma, which would be the most appropriate diagnostic test? A. Serum renin levels B. Urine metanephrines and vanillylmandelic acid C. Levels of serum serotonin and its metabolites D. Serum cortisol levels E . Urine levels of aldosterone and its metabolites

Answer: B Explanation: The classic triad of pheochromocytoma symptoms is episodic palpitations, headaches, and diaphoresis. Patients with pheochromocytomas often have severe hypertension that may be resistant to treatment and may be paroxysmal. Initial evaluation is done through urine levels of metanephrines and vanillylmandelic acid.

A 47-year-old male was involved in a motor vehicle accident. The emergency technician reports that the patient was not wearing a seat belt and the steering wheel was bent forward in the car. The blood pressure is 80/60 and the heart rate is 120 beats per minute. There is a large ecchymosis over the left flank area. What is the possible mechanism of injury in this patient? A. Penetrating trauma B. Blunt trauma C. Blast trauma D. Multiple traumas

Answer: B Explanation: The patient most likely went forward during the accident and struck the steering wheel, resulting in internal organ injuries from blunt trauma.

The rescue squad brings an unresponsive patient to the Emergency Department. The patient makes grunting sounds and opens his eyes only in response to painful stimuli. He also withdraws from painful stimuli. What is the Glasgow coma scale score for this patient? A. 4 B. 8 C. 11 D. 13

Answer: B Explanation: The patient receives a 2 out of 4 for opening eyes to pain, a 2 out of 5 for making incomprehensible noises, and a 4 out of 6 for withdrawing from painful stimuli. These add to 8.

A 20-year-old man fell out of a truck 30 minutes ago and landed on his right knee. He reports a severe laceration to his right knee contaminated by several pieces of gravel and dirt but denies head injury, loss of consciousness, or any other injury. A proximally based flap, 5 cm on each side, is raised from the knee. The wound is irregular, has devitalized edges, and has sections of subcutaneous tissue with poor vascularization. What is the most appropriate next step? A. Arranging for delayed closure B. Radiography of the knee C. Referral for arthroscopy D. Primary closure of the wound

Answer: B Explanation: The patient's mechanism of injury is such that he could also have sustained a fracture. Radiography will identify any further injury and any foreign bodies in the wound that must be dealt with before suturing the wound

. A 55-year-old man is brought to the Emergency Department after a 3-day binge on whiskey. He stopped drinking abruptly several hours ago because of severe, diffuse, abdominal pain. He has no history of diabetes mellitus. His vital signs are blood pressure 80/48, pulse 112 beats/minute and regular, temperature 99.8°F, and respirations 28 per minute. He appears slightly dehydrated but not malnourished. He is somewhat confused but is able to answer questions. His blood glucose is 250 mg/dL. Arterial blood gas determination reveals an anion gap acidosis. What is the appropriate intravenous fluid to administer to the patient? Normal values Pulse: 60 to 100 beats/minute Respiration: 12 to 20 per minute Blood pressure: Systolic 90 to 120, diastolic 60 to 80 Temperature: 98.6°F Glucose: 70 to 105 mg/dL A. Normal saline B. Normal saline plus bicarbonate C. Normal saline plus glucose and thiamine D. Normal saline plus insulin

Answer: C Explanation: A patient who is a chronic alcoholic and is suspected of having Wernicke's syndrome requires inpatient treatment with an initial intravenous infusion of thiamine. In addition, controlling any electrolyte imbalances (usually potassium and magnesium) will help prevent progression to Korsakoff syndrome. Giving intravenous glucose first may deplete the liver's supply of thiamine, worsening or even precipitating Wernicke-Korsakoff syndrome

A 3-year-old boy ingested a calculator battery approximately 20 minutes ago. He is in no distress. Chest radiograph demonstrates the battery in the esophagus. What is the most appropriate next step in his care? A. Administer intravenous glucagon. B. Have the parents observe his stools for passage of the battery. C. Perform immediate endoscopic removal. D. Perform the Heimlich maneuver. E . Administer syrup of ipecac.

Answer: C Explanation: Batteries can be corrosive to the mucosa and should be removed immediately.

What diagnostic procedure evaluates cardiac wall motion and ventricular function? A. Chest radiograph B. Stress test C. Echocardiogram D. Cardiac catheterization E . Electrocardiogram

Answer: C Explanation: Echocardiograms provide real-time information on cardiac wall motion, ventricular function, and valve movement.

A racquetball player was swinging back for an overhand shot when he hit the back wall of the court with his right index finger. He crushed the fingertip between the wall and the racquet handle. On physical examination, he has a 50 percent subungual hematoma, fracture of the distal nail, and maceration of the distal pad. What should be the next step in his care? A. Drainage of the hematoma through the nail B. Removal of the nail C. Radiography of the digit D. Primary closure with absorbable sutures

Answer: C Explanation: The patient's mechanism of injury is such that he could also have sustained a fracture. Radiography will identify any further injury that must be dealt with before treating the other conditions.

Which of the following is the most important to obtain first when evaluating abdominal pain? A. Complete blood count (CBC) with differential B. Computed tomography (CT) scan of the abdomen and pelvis C. Pain history D. Urinalysis E . Liver profile

Answer: C Explanation: The patient's pain history will give the most information. The history includes but is not limited to the location of pain, severity, quality, onset, duration, alleviating and exacerbating factors, other symptoms, and whether this has happened before.

What is the stage in wound healing that involves the accumulation of lymphocytes and granulocytes and the removal of debris and macrophages? A. Proliferation stage B. Epithelialization C. Inflammatory stage D. Neovascularization E . Tissue remodeling

Answer: C Explanation: Wound healing consists of inflammation, proliferation and tissue formation, and tissue remodeling. During the inflammation stage, leukocytes accumulate and remove necrotic tissue and foreign debris from the damaged area.

A 26-year-old man is brought to the emergency room by paramedics after he complains of dizziness and headache. Emergency room examination shows mydriasis of the right eye with right pupillary diameter of 5 mm and left pupillary diameter of 2 mm. The patient denies any precipitating events or general medical condition. While awaiting further examination, he is observed surreptitiously placing eye drops in his right eye. When questioned about this action, he becomes angry, denies the behavior, and abruptly leaves the hospital. What is the most likely diagnosis? A. Conversion disorder B. Dependent personality disorder C. Malingering D. Factitious disorder

Answer: D Explanation: Patients with factitious disorder intentionally produce or feign symptoms. Factitious disorder differs from malingering in that with malingering there is an external incentive present that motivates the patient to manufacture symptoms. With factitious disorder, there is no external incentive present other than a motivation to assume a sick role.

. A 58-year-old male presents to the emergency department with a laceration of his hand from a kitchen knife. His current medications include metformin for diabetes mellitus, aspirin for coronary artery disease, prednisone for chronic obstructive pulmonary disease, and simvastatin for hypercholesterolemia. Which of his medications is most likely to affect the length of time it takes for his wound to heal? A. Aspirin B. Simvastatin C. Metformin D. Prednisone

Answer: D Explanation: Prednisone decreases inflammation and will delay the healing process.

A 28-year-old male presents to the emergency room (ER) after being thrown from the back of a pickup truck at high speed. He received 2 L of intravenous fluid in transit to the hospital. His pulse upon arrival at the ER is 120 and blood pressure is 60/40. He is awake and without focal neurological signs. He has a distended tender abdomen and a stable pelvis, with no deformities of the lower extremities. A portable chest x-ray is normal. Which of the following is the most appropriate next step in management? A. Immediate computed tomography (CT) scan of the abdomen and head B. Fluid administration while awaiting cell counts on lavage fluid C. Dopamine infusion to improve blood pressure followed by observation D. Immediate ultrasound/exploratory laparotomy and administration of blood products

Answer: D Explanation: The patient's tachycardia, hypotension, and abdominal exam are consistent with shock secondary to internal organ injuries. He needs blood products to help stabilize his circulation and an ultrasound/exploratory laparotomy to determine the extent of injury.

Why is the history of a wound important in determining treatment requirements? A. The age of the wound determines scar size after suturing. B. The mechanism of injury determines when sutures should be removed. C. The extent of injury determines the need for tetanus immunization. D. The degree of contamination of the wound determines the risk of infection.

Answer: D Explanation: The risk of infection is determined by the degree of contamination in addition to the mechanism of the wound, its location, the patient's age, and any comorbidities.

What type of suture and needle should be used for closure of a laceration on the chin of a 4-year-old girl? A. 2-0 nonabsorbable on a taper needle B. 2-0 absorbable on a cutting needle C. 3-0 nonabsorbable on a cutting needle D. 5-0 absorbable on a cutting needle E . 5-0 nonabsorbable on a cutting needle

Answer: E Explanation: Facial laceration repairs are best done with nonabsorbable sutures using a fine suture such as a 5-0.

A 55-year-old woman with a history of mitral stenosis, secondary to rheumatic heart disease, presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that recently she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. Which of the following tachyarrhythmias is she most likely to demonstrate on EKG? A Ventricular tachycardia B Atrial flutter C Ventricular fibrillation D Ventricular bigeminy E Torsades de pointes

B Choice B is correct. As patients with mitral stenosis age, and their mitral stenosis progresses to moderate or moderately severe mitral stenosis (most commonly after their fourth decade), the incidence of atrial arrhythmias—including premature atrial contractions, paroxysmal tachycardia, atrial flutter, and atrial fibrillation—increases. Choices A, C, D, and E are less likely, given that they are ventricular arrhythmias.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies a history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Based on his electrocardiogram, which of the following is his most likely diagnosis? A Normal sinus rhythm at 65 bpm with premature atrial complexes B Atrial fibrillation with a rapid ventricular rate of approximately 140 bpm C Atrial flutter with 2:1 conduction D Sinus tachycardia at a rate of approximately 120 bpm E Ventricular fibrillation

B Choice B is correct. This patient's EKG demonstrates atrial fibrillation, with disorganized atrial activity, as evidenced by the lack of discrete p waves and irregularly irregular ventricular activity. Choice A, normal sinus rhythm with PACs, would demonstrate a somewhat irregular rhythm, but discrete p waves would be noted. Choice C, atrial flutter, would be characterized by a regular ventricular rate with a sawtooth morphology. Choice D, sinus tachycardia, would demonstrate a regular, though fast, ventricular rate with discrete p waves. Choice E, ventricular fibrillation, would be an irregularly irregular rhythm; however, QRS complexes would not be clearly defined.

A teenage girl presents to the emergency department with her parents. She has had symptoms of a urinary tract infection for the last two days, but did not tell her parents until today. She is not sexually active. Today, the girl also has diffuse abdominal pain with vomiting, general malaise, and difficulty breathing. She has no significant past medical history. Her physical exam reveals sinus tachycardia and deep fast respirations with no localization of abdominal pain or rebound tenderness. Initial lab test results reveal a plasma glucose = 378 mg/dL and serum bicarbonate = 14 mEq/L. What is the most likely diagnosis? A Hyperosmolar nonketotic hyperglycemia B Diabetic ketoacidosis C Chronic corticosteroid use D Gestational diabetes E Schmidt syndrome

B The correct choice is B, diabetic ketoacidosis (DKA). Classic signs and symptoms of this disorder include polyuria, polydipsia, marked fatigue, nausea, vomiting, signs of dehydration, fruity breath odor, postural hypotension, Kussmaul respirations, and possibly mental stupor or coma. Patients with type 1 diabetes mellitus may present for the first time in DKA. DKA is commonly precipitated by a recent infection. Choice A, hyperosmolar nonketotic hyperglycemia, is seen in patients with type 2 diabetes and presents with extremely high plasma glucose levels without acidosis and ketosis. Choice C, chronic corticosteroid use, can cause hyperglycemia and possible glucose intolerance or diabetes mellitus. This patient has no history of oral corticosteroid use. Choice D, gestational diabetes, occurs in women who are pregnant. Choice E, Schmidt syndrome, is an autoimmune polyglandular syndrome which includes diabetes mellitus in greater than 50% of patients.

A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure radiating down his left arm, associated with diaphoresis, nausea, and dyspnea, for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. According to the most recent American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation MI recommendations, an EKG should be performed on patients with a clinical suspicion for acute coronary syndrome within how many minutes of their arrival to the emergency department? A 1 minute B 5 minutes C 10 minutes D 15 minutes E 20 minutes.

C Choice C is correct, as the 2007 American College of Cardiology/American Heart Association Guidelines for Management of Patients with Unstable Angina/Non-ST-Elevation MI recommend that an ECG "be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 minutes of ED arrival for all patients with chest discomfort or other symptoms suggestive of ACS." Although choices A and B would be optimal, the question asks for the goal time for which busy emergency departments should aim for in obtaining an EKG in at-risk patients. Choices D and E are less desirable, as times greater than 10 minutes increase both morbidity and mortality rates.

You are evaluating a 67-year-old male with known cirrhosis of the liver secondary to alcoholic liver disease, although he has been sober for the past year. He is brought in to the emergency department by his daughter, who notes that for the past few days he has seemed to be more confused. On examination you note the patient to be mildly confused but alert to person and place. He has noticeable asterixis. He is not currently taking any medications and his blood alcohol level is undetectable. What is the treatment of choice in this case based on your physical examination findings? A amoxicillin B prednisone C lactulose D folic acid E thiamine

C The correct answer is (C). This patient most likely has hepatic encephalopathy due to end-stage liver disease. Asterixis indicates an increase in serum ammonia. The treatment of choice is lactulose. Both folic acid and thiamine are used in the treatment of alcoholic liver disease, but do not treat elevated ammonia levels. Antibiotics may be used secondarily in patients nonresponsive to lactulose, but amoxicillin is not preferred. Prednisone is not a treatment for hepatic encephalopathy.

A 6-year-old female presents to the emergency department with left wrist pain after falling off the monkey bars at the school playground. Imaging of the left upper extremity shows the following fracture pattern: Which type of Salter-Harris Classification is observed? A Type I B Type II C Type III D Type IV E Type V

The Correct Answer is: A A Salter-Harris Type I (A) involves the entire epiphysis. Type II (B) is the entire epiphysis along with a portion of the metaphysis, Type III (C) involves a portion of the epiphysis only, Type IV (D) involves a portion of the epiphysis along with a portion of the metaphysis, and Type V (E) is a compression injury of the epiphyseal plate (nothing is "broken off").

A patient is brought to the Emergency Department by ambulance. He is a 27-year-old male who is well known to the paramedic team as a heroin addict. He is arousable and does not remain alert when aroused. Which of the following physical signs would help to confirm the diagnosis of opioid intoxication? A Bradycardia B Diaphoresis C Mydriasis D Rhinorrhea E Tachypnea

The Correct Answer is: A Bradycardia (A), lowered respiratory rate, miosis and somnolence are the main effects of opiates. As with most medications, withdrawal effects are the opposite of the effects of overdose. Tachycardia, tachypnea, rhinorrhea and diaphoresis (B, D, & E) can all occur in opiate withdrawal. Mydriasis (C) is common with other substances of abuse, such as cocaine and LSD.

A 48-year-old man is brought to the emergency department by his sister after suffering from loss of consciousness, followed by muscle rigidity and rhythmic contractions, and then a return to a normal state. When asked about medication use, the patient states he is currently being treated with a drug for depression but cannot remember the name. He claims that he has never had a seizure or seizure-like activity prior to this event. Approximately 6 hours after the first episode, the patient suffers a second one while still in the ED. Which of the following medications is the patient most likely taking? A bupropion B duloxetine C fluoxetine D nortriptyline E phenelzine

The Correct Answer is: A Bupropion has been shown in some patients to cause seizures in a dose-dependent fashion, particularly in those with a history of head trauma or electrolyte abnormalities. Tricyclic antidepressants (eg, nortriptyline), selective serotonin reuptake inhibitors (eg, fluoxetine), serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), and monoamine oxidase inhibitors (eg, phenelzine) have not been associated with seizures.

During a hospitalization for acute exacerbation of COPD, troponin levels are drawn on a 62-year-old man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99 th percentile of normal. Which of the following choices would qualify this patient for the most recent ACC/AHA consensus guideline's definition of myocardial infarction? A Ischemic symptoms B New right bundle branch-block on EKG C J wave on EKG D Pulmonary vascular congestion on CXR E Elevated WBC count

The Correct Answer is: A Choice A is the most appropriate choice, as troponin elevation may occur in the setting of patients who do not suffer from acute coronary syndrome. Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99 th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." Choice C, J wave, is characteristic of patients with hypothermia. Choice D, pulmonary vascular congestion, is frequently noted on CXR of patients with congestive heart failure. Choice E, an elevated WBC count, is indicative of an infectious process.

A 66-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations for over 2 weeks, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 3. Which of the following choices is the most appropriate next diagnostic study for this patient? A Transthoracic echocardiogram B Cardiac catheterization C Nuclear stress test D Holter monitor E Event recorder

The Correct Answer is: A Choice A, transthoracic echocardiogram, is correct, as it can demonstrate the presence of valvular heart disease. The presence of valvular heart disease can change the recommendations for embolism prophylaxis. Choice B, cardiac catheterization, is useful in patients suspected to have unstable angina, or who have sustained a myocardial infarction. Choice C, nuclear stress test, is useful in patients suspected to have angina pectoris, and may be a useful diagnostic study in this patient with cardiac risk factors (once the issue of atrial fibrillation has been treated). Choices D and E would be useful tests if the EKG had not established a diagnosis for this patient, with the Holter monitor indicated in patients experiencing symptoms on a daily basis, and the event recorder indicated in patients demonstrating more sporadic symptoms.

A 27-year-old female presents to the emergency department with severe RUQ pain. Ultrasonography reveals gallstones. In preparation for a potential cholecystectomy, a CBC is obtained that reveals a normocytic anemia with an increased mean corpuscular hemoglobin concentration (MCHC). She is slightly jaundiced and you are able to palpate her spleen on examination. What is her underlying diagnosis? A Hereditary spherocytosis B Iron deficiency anemia C Sickle cell anemia D Thalassemia E Von Willebrand's disease

The Correct Answer is: A Hereditary Spherocytosis (HS) is characterized by jaundice, an enlarged spleen, and often gallstones; gallstones are more frequently seen in young people, triggering the investigation into HS. An increased MCHC is a characteristic feature of HS and is almost the only condition in which this finding is seen. Iron deficiency anemia does not have an increased MCHC. Sickle Cell has characteristic findings different than the presenting findings. Thalassemia is noted for a microcytosis and Von Willebrand's is a coagulation disorder.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. A transthoracic echocardiogram reveals significant aortic stenosis secondary to congenital bicuspid aortic valve, left ventricular hypertrophy, and normal left ventricular systolic function. Which of the following is the most appropriate next step in management? A Cardiac catheterization followed by aortic valve replacement B Monitoring via repeat transthoracic echocardiogram in 6 months C Monitoring via transesophageal echocardiogram in 6 months D Treadmill exercise stress test E Automatic internal cardiac defibrillator placement

The Correct Answer is: A In symptomatic patients demonstrating significant aortic stenosis, aortic valve replacement after cardiac catheterization, to evaluate for coronary artery disease and possible concomitant coronary artery bypass surgery with aortic valve replacement, is indicated. As the patient is demonstrating the classic symptoms of severe aortic stenosis, choice A is the most appropriate next step in management. Choices B and C are thus inappropriate, as the patient is already symptomatic. If the patient were not symptomatic, choice B would be a viable choice compared to choice C, because it is less invasive than transesophageal echocardiogram. Choice D would be inappropriate, as strenuous physical activity should be avoided in patients with severe aortic stenosis. Choice E is appropriate therapy for patients at risk for ventricular tachycardia/fibrillation.

Which of the following is the drug of choice for acute hypertensive encephalopathy? A Labetolol B Clonidine C Furosemide D Nifedipine E Nitroglycerin

The Correct Answer is: A Neurologic emergencies associated with elevated blood pressure must be throurougly evaluated to determine the diagnosis and appropriate treatment plan. In the case of hypertensive encephalopathy, immediate attention must be focused on blood pressure reduction. Multiple agents are known to decrease blood pressure, but selection must also focus on how rapidly each agent works, how titratable the agent is, and any potential sequelae from using a particular agent. Sodium nitroprusside was classically the agent of choice for rapid blood pressure management, but it has fallen out of favor due to its monitoring requirements and rate of toxicity. Labetolol, a beta-blocker, is recommended for acute management, except in the case of cocaine intoxication. It has a rapid onset of action, can be titrated, and is given IV. Use of labetolol should be avoided in patients with known asthma, COPD, congestive heart failure, bradycardia, and second or third degree heart block. Additional agents appropriate for hypertensive encephalopathy include enalaprilat, esmolol, fenoldopam, hydralazine, and nicardipine, with each being considered carefully (based on patient condition and other factors). Agents with known CNS adverse effects, such as clonidine, should be avoided. Use of clonidine must also be monitored due to potential rebound hypertension. Nifedipine use is discouraged in hypertensive emergencies. Nitroglycerin should not be used for hypertensive encephalopathy because it increases intracranial pressure

A 76-year-old man, is brought to the emergency department by his niece after she found him wandering around his yard in the cold wearing only a tee shirt and jeans. When she set up his pill container about 36 hours earlier, he seemed his usual self but, in retrospect, possibly a little more confused than usual. The niece says that he has "high blood," treated with a "white fluid pill," "sugar diabetes," treated with an oral medication, and early "old timer's" dementia treated with "a memory pill." Vital signs include an oral temperature of 100.8F, pulse 100 beats per minute, respirations 24 and somewhat shallow, and blood pressure of 88/52. Initial examination reveals a slightly dehydrated, stuporous man appearing older than his stated age, who smells strongly of urine. He has no lateralizing signs. What is the most likely cause of the mental status changes? A hyperglycemic hyperosmolar state B lactic acidosis C stroke D urinary tract infection E worsening dementia

The Correct Answer is: A The combination of confusion and dehydration in a patient with diabetes type 2 who is taking a diuretic strongly suggest hyperosmolar state. Patients with lactic acidosis (B) have marked hyperventilation and, usually, signs and symptoms of a serious illness. The lack of lateralizing signs makes a stroke (C) less likely. Urinary tract infection (D) could certainly cause confusion and incontinence in an elderly man and should be investigated. Alzheimer dementia (E) progresses slowly; sudden decompensation is usually due to delirium.

A 32 year-old male presents to the emergency department in Acute Renal Insufficiency (AKI). Which of the following conditions would be most likely observed in intrinsic AKI? A Septic shock B Congestive heart failure C Benign prostatic hypertrophy D NSAID overdose E Chronic liver failure

The Correct Answer is: A The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous. Prerenal acute kidney injury can be caused from hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), and impaired renal autoregulation (NSAIDs, ACE-I/ARB, cyclosporine)---(E), (D), and (B). Postrenal causes include bladder outlet obstruction including bladder stones and BPH (C).

A 32-year-old female is brought into the emergency department by her partner. His report indicates that she had been in her usual state of good health until a couple of days ago. At that time she started to complain of feeling fatigued. She now appears jaundiced and lethargic, and is complaining of chest pain. On exam, her spleen is palpable. Hemoglobin is 6 g/dl and she is Coombs positive. What is the most likely diagnosis? A Autoimmune hemolytic anemia B Glucose-6-phosphate dehydrogenase deficiency C Hereditary spherocytosis D Pyruvate kinase deficiency E Thalassemia

The Correct Answer is: A The onset of autoimmune hemolytic anemia (AHA) is often abrupt and dramatic. Anemia can develop in days, along with jaundice and splenic enlargement. When this triad is present, the suspicion for AHA must be high. The diagnostic test for AHA is the Coombs test. If positive, it confirms the presence of the antibody on the red cells. All other diseases listed are Coombs negative hemolytic anemias.

A 23-year-old man presents to the outpatient clinic for follow-up from a recent urgent care visit. He complains of sore throat, fever, fatigue, myalgias, and a rash that started 5 days ago, and have worsened since he was seen in the urgent care 3 days ago. The patient appears non-toxic with a temperature of 39.4 degrees Celsius. Physical exam reveals pharyngeal and tonsillar erythema without exudates, generalized lymphadenopathy, a morbilliform rash on his trunk, and no hepatosplenomegaly. A rapid strep screen and Monospot performed at the local urgent care were reportedly negative. Which of the following prevention strategies should be recommended to this patient? A Abstain from sexual activity B Avoid aspirin C Avoid contact sports and rest D Bedrest and increased fluids E Take the full course of antibiotics

The Correct Answer is: A The patient presentation is consistent with acute retroviral syndrome. The patient is highly contagious and should be counseled on strategies to prevent transmission of HIV to others (A). Aspirin use in viral syndromes (B) is associated with Reye's syndrome, but most often occurs in children with influenza or varicella. Avoiding contact sports (C) is appropriate patient education for a patient with infectious mononucleosis, and patients with group A strep pharyngitis should be instructed to take the full course of their antibiotics (E).

A 36-year-old man presents to the emergency department with a tight bandage around his chest to help reduce pain from a chest wall injury on his right side that occurred during mixed martial arts sparing. Physical exam reveals dullness to percussion, dry crackles and diminished breath sounds over the right lower lobe. Chest x-ray shows elevation of the right hemi-diaphragm. What is the most likely diagnosis? A Atelectasis B Bronchiectasis C Pleural Effusion D Pneumothorax E Pulmonary edema

The Correct Answer is: A The patient's injury places him at risk of atelectasis, pneumothorax, or other traumatic injuries. The physical exam and chest x-ray findings are classic for atelectasis (A). Pleural effusion (C) would present with fluid in the costophrenic angle on chest x-ray. Pneumothroax (D) would typically present with findings in the upper lung fields including hyperresonance to percussion. Pulmonary edema (E) would present with increased vascular markings and evidence of fluid within the alveolar space on chest x-ray.

A 78-year-old woman with a medical history of diabetes and hypertension presents to the emergency department complaining of left hand weakness and slurred speech. Which of the following tests is most likely to determine the source of an arterial thrombus? A carotid ultrasound B CT of the brain C erythrocyte sedimentation rate D magnetic resonance angiography (MRA) of the vertebral arteries

The Correct Answer is: A The patient's symptoms are consistent with pathology arising from the anterior cerebral circulation including the carotid arteries. A CT should be ordered to rule out acute hemorrhage and an erythrocyte sedimentation rate may be useful if giant cell arteritis were suspected. An MRA of the vertebral arteries would likely show deficits but is not likely to demonstrate the etiologic location of this stroke.

A 77-year-old female who was admitted to the hospital for acute coronary syndrome was found to have the rhythm strip shown when she arrived to the floor. Her initial vital signs were as follows: temperature is 99.0, pulse rate is 140, blood pressure is 100/65, and respiratory rate is 16. An initial bolus and infusion of amiodarone was started, with little success of slowing the rate or converting the patient's rhythm. About an hour later, the blood pressure dropped to 80/55 and she was becoming diaphoretic, with increased dyspnea and some mild chest discomfort. What is the next step in treating this patient? A Synchronized cardioversion B Increase dose of amiodarone C Infusion of magnesium sulfate D Intravenous metoprolol E Adenosine

The Correct Answer is: A This patient has unstable, sustained ventricular tachycardia. Because of the symptoms, and most importantly the blood pressure, it is critical to intervene immediately to prevent a cardiac arrest. The treatment option of choice in this case is synchronized cardioversion. Adenosine is not a viable option and may put the patient into a lethal arrhythmia.

A 62-year-old female with a known history of hypertension presents due to the abrupt onset of a severe headache, marked vertigo, nausea, vomiting, and ataxia. On physical exam, you note nystagmus, sensory loss, and weakness of the right face. What is the most likely diagnosis? A Cervical artery dissection B Cerebellar hemorrhage C Internal auditory artery occlusion D Lacunar infarction E Spinal cord compression

The Correct Answer is: B A cerebellar hemorrhage can result from multiple causes, similar to other intracerebral hemorrhages, such as hypertension, blood dyscrasias, trauma, and arteriovenous malformations. Patient presentation may range from an abrupt onset of headache to full coma, depending on the severity of the hemorrhage. Presentation is often similar to cerebellar infarction, with CT findings assisting in the differentiation. Symptoms may include all of those listed above as well as nuchal pain, altered consciousness, altered respiratory rate, abnormal eye movements, and impaired papillary responses. Cervical artery dissection may present with similar symptoms, including the abrupt onset of headache, but is not typically associated with ataxia, vertigo, or vomiting. Internal auditory artery occlusion is associated with vertigo and unilateral hearing loss. Lacunar infarction occurs within small resistance vasculature, with motor and sensory symptoms related to the impacted brain region. Spinal cord compression may be acute or progressive, with motor weakness and sensory loss caudad to the lesion.

A 55-year-old woman with a history of mitral valve replacement and mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the past few weeks she has noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her INRs have been therapeutic for the past 4 weeks. Which of the following is the most appropriate next step in treating this patient? A IV quinidine B IV ibutilide C IV vasotec D IV amiodarone E IV dopamine

The Correct Answer is: B Choice B, IV ibutilide, has been found to be most effective in converting atrial flutter to sinus rhythm out of all the choices listed. Choice A is contraindicated, as the atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice C is useful for blood pressure control, but not for heart rate control. Choice D is useful for chronic atrial flutter heart rate management, or for helping to maintain sinus rhythm after cardioversion has occurred. Choice E is useful for pressor support, and not for heart rate control or conversion to normal sinus rhythm.

A 55-year-old woman with a history of hypertension and 2 vessel CABG presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for the last 24 hours she has also noticed palpitations. On physical examination, her vital signs are stable. On EKG, she demonstrates atrial flutter with 2:1 AV block. Her echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following is the most appropriate therapy for this patient? A IV ibutilide after 4 weeks of anticoagulation with warfarin B IV ibutilide alone C IV quinidine after 4 weeks of anticoagulation with warfarin D IV quinidine alone E IV dopamine

The Correct Answer is: B Choice B, IV ibutilide, is the most appropriate choice for this patient. Therapy for patients with atrial flutter and atrial fibrillation is the same in regards to anticoagulation; therefore, in a patient with a CHADS2 score of 1 and with symptoms of less than 48 hours duration, cardioversion to normal sinus rhythm, whether chemically or electrically, is recommended. Out of all the choices listed, IV ibutilide has been found to be most effective in converting atrial flutter to sinus rhythm. Choices C and D are contraindicated, regardless of the type of anticoagulation paired with it, as quinidine is a class I antiarrhythmic. The atrial conduction may decrease to the point that 1:1 atrial to ventricular conduction can occur with the administration of class I antiarrhythmics. The ventricular rate can then increase to rates greater than 200 bpm, and hemodynamic collapse may occur. Choice E is useful for pressor support, which is not indicated in this patient who is quite stable.

A 67-year-old female presents to the emergency department with abdominal pain, bloating, inability to pass gas or stool, and vomiting. Which of the following, if present, would be a contraindication to placing a nasogastric tube? A Esophagitis B Esophageal strictures C Esophageal varices D Peptic ulcer disease E Gastroesophageal refulx disease

The Correct Answer is: B Contraindications to nasogastric tube placement include choanal atresia, significant facial trauma, basilar skull fracture, esophageal stricture or atresia, esophageal burn, zenker's diverticulum, recent surgery on the esophagus or stomach, or a history of gastrectomy or bariatric surgery.

A 33-year-old IV drug user presents to the emergency department with pleuritic chest pain, cough, chills, diaphoresis, anorexia, and malaise. On physical exam, her temperature is 40°C, BP 98/55, P 115 bpm, and RR 22. No murmur could be appreciated. Two separate blood cultures are positive for S.aureus. An EKG, CXR, and transesophageal echocardiogram are ordered. Which of the following lesions is most likely to be seen on TEE in this patient? A Aortic valve vegetation B Tricuspid valve vegetation C Mitral valve vegetation D Left ventricular hypertrophy E Ventricular septal defect

The Correct Answer is: B In almost 50% of cases involving IV drug users, the only site of infection is the tricuspid valve, and most lesions are right-sided, so choice B is the most appropriate answer. Left ventricular hypertrophy, choice D, is seen in patients with a history of hypertension. Choice E, ventricular septal defect, is frequently associated with a holosystolic murmur.

In addition to insulin and fluid replacement with 0.9% saline, which electrolyte is commonly infused in the type 2 diabetic patient who arrives in the emergency department in a hyperglycemic, hyperosmolar, nonketotic state? A bicarbonate B potassium C calcium D magnesium E sulfate

The Correct Answer is: B Insulin not only causes cellular uptake of glucose but also of potassium. Hypokalemia may develop when insulin is infused to correct either a hyperglycemic hyperosmolar state or a diabetic ketoacidosis. Hence, in order to avoid hypokalemia, potassium chloride can be added to a saline solution, as long as the serum potassium is not elevated.

A 22-year-old patient with sickle cell disease presents to the emergency department complaining of chest pain, fever, and non-productive cough. On physical exam his temperature is 100.6˚F, BP is 144/88, pulse is 110, respiratory rate is 24, and pulse oximetry is 84%. CBC shows a WBC of 11,500, hemoglobin of 8.3%, and hematocrit of 28%. What is the most likely diagnosis? A Acute bronchitis B Acute chest syndrome C Asthma D Bronchiectasis E Pneumothorax

The Correct Answer is: B Patients with sickle cell disease are prone to acute chest syndrome, resulting from sickling of cells within the lung that typically presents with chest pain, tachypnea, cough, fever, and oxygen desaturation. Acute bronchitis (A) and bronchiectasis (D) typically present with a productive cough without significant oxygen desaturation and anemia. Patients with asthma (C) and spontaneous pneumothorax (E) will be afebrile and have normal hemoglobin and hematocrit.

A 19-year-old woman presents to the emergency department complaining of headache. The headaches are generalized and increasing in intensity. They have not responded to over-the-counter (OTC) medications. She complains of approximately 1 week of blurred vision, intermittent diplopia, and vague dizziness. Her medical history includes obesity and acne. She takes Accutane and oral contraceptives. She is found to have bilateral papilledema, visual acuity of 20/30 on physical examination, and a normal MRI of the brain. The next most appropriate step would be A CT scan of the head B lumbar puncture C therapy with high-dose prednisone D stat cerebral arteriogram E reassurance and follow-up in the office in 6 months

The Correct Answer is: B The presence of headache associated with papilledema raises the concern for a brain tumor. The MRI excluded a mass lesion, raising a strong suspicion of pseudotumor cerebri. This is also known as benign intracranial hypertension. It is not a benign condition, however, since it causes severe headache and may result in visual loss. It is particularly frequent in obese adolescent girls and young women. The etiology is unknown but may be associated with the use of oral contraceptives, vitamin A, and tetracycline. The presentation consists of headaches caused by an increase in intracranial pressure and blurring of vision. There may be diplopia, but the remainder of the neurologic examination is unremarkable. Papilledema is virtually always part of the presentation. The mental status is normal. The differential diagnosis includes venous sinus thrombosis, sarcoidosis, and tuberculosis or carcinomatous meningitis. The last two are excluded by lumbar puncture. An abnormal cerebrospinal fluid is not consistent with pseudotumor cerebri. The diagnosis is made by excluding mass lesions with CT scan or MRI and demonstrating markedly increased intracranial pressure by lumbar puncture. The treatment involves weight loss, diuretics, and steroids. Repeat lumbar punctures to remove cerebrospinal fluid and decrease intracranial pressure are effective. In cases that are unresponsive to these measures, lumbar-peritoneal shunting is effective, as is unilateral optic nerve sheath fenestration. Effective treatment can improve headaches and prevent vision loss.

A 78-year-old woman with known diabetes mellitus type 2 is brought to the emergency room after a neighbor became concerned when newspapers began piling up on her doorstep and called the police. In the emergency department, she is found to be lethargic and disoriented, with tenting of the skin, sunken eyes, and dry mucous membranes. She is hypotensive and has a rapid pulse. She is wearing a diaper that apparently has been in place for several days, but is barely moist. What is the most appropriate fluid therapy for them to initiate? A 0.45% saline B 0.9% saline C 5% dextrose in water D 5% dextrose in 0.45% saline E Lactated Ringers

The Correct Answer is: B This woman is severely dehydrated so 0.9% saline is indicated. If she were less dehydrated, 0.45% saline (A) would be appropriate because of likely hyperosmolality. Once her glucose has dropped to 250 mg/dL, she should receive dextrose in water (C) or 0.45% saline (D) to prevent her glucose level from dropping too low. Lactated Ringers ı is contraindicated in patients who are likely to have severe acidosis or alkalosis.

A 24-year-old intoxicated male presents to the emergency department after being in a fight. He was punched in the nose, and now has mild deformity of the nose and some epistaxis. An x-ray reveals a fractured nasal bone. During his physical exam, what must you look for in order to prevent permanent destruction of his nasal septum? A Orbital fracture B Posterior epistaxis C Septal hematoma D Facial fracture E Deviated septum

The Correct Answer is: C A septal hematoma can cause ischemic necrosis of the nasal septal cartilage if not identified and drained. A deviated septum can be expected with a nasal bone fracture, and must be addressed by the otolaryngologist. Excessive epistaxis that does not resolve with direct pressure and anterior packing may indicate a posterior bleed.

A 68-year-old female presents to the emergency department with signs and symptoms of an acute ischemic stroke. The initial CT scan is normal. Her blood pressure is 164/105. What is the most appropriate treatment for the blood pressure of this patient? A Atenolol PO B Clonidine PO C Close monitoring D Labetolol IV E Nicardipine IV

The Correct Answer is: C Aggressively lowering blood pressure may decrease blood flow to the ischemic tissue, thus decreasing the chances of recovery or increasing the risk of further infarction. In the setting of an acute ischemic stroke, blood pressure elevation should be monitored closely, with some elevation expected. This elevation is expected to decline without medication in the first few hours to days, but if elevation continues to a systolic blood pressure greater than 220mmHg, or mean arterial pressure greater than 120mmHg, medication is advised. Medications may include intravenous labetolol or nicardipine, with close monitoring of the patient. After the acute phase following a stroke, appropriate oral medications may be considered for outpatient hypertension management.

A 4 year-old male presents to the emergency department with vomiting, severe abdominal pain, and diarrhea that occurred 2 hours after "getting candy from Grandma's purse". Which of the following medications did the child most likely ingest? A Cisplatin B Erythropoietin C Ferrous sulfate D Lisinopril E Vincristine

The Correct Answer is: C Stage 1 of iron toxicity secondary to ferrous sulfate ingestion (C) is characterized by acute GI irritation; this is followed by a latent phase (Stage 2) that can then progress to systemic iron toxicity (Stage 3), that can progress to hepatic failure (Stage 4) or delayed sequelae (Stage 5). Cisplatin (A), erythropoietin (B), and vincristine (E) are parenterally administered and unlikely to be present in a patient's purse. Lisinopril (D) toxicity consists of cardiovascular symptomatology (e.g., hypotension and tachycardia).

A 70-year-old woman who was found barely responsive at home by her daughter is brought to the emergency department. Evaluation reveals that she is in a hyperglycemic hyperosmolar state with a severe fluid deficit. Treatment is initiated with vigorous saline rehydration and a continuous infusion of insulin. At what point should her glucose be added to her treatment? A when her condition becomes stable B when her urine output reaches 50 mL/hour C when her blood glucose reaches 250 mg/dL D if she develops hypokalemia E if she begins to spill ketones in her urine

The Correct Answer is: C In hyperglycemic hyperosmolar states, the serum glucose rapidly corrects with fluid administration alone. However, with vigorous rehydration, glucose may fall precipitously and lead to severe hypoglycemia. To avoid this, glucose should be added to water, half-normal, or normal saline as soon as the patient's blood glucose is less than or equal to 250mg/dL. She should continue to receive insulin IV until she is stabilized (A) when it can be switched to subcutaneous administration. The goal of fluid therapy in this patient is restoring her urine output to 50 mL per hour (B) or more. Because insulin drives potassium into the cells and can cause hypokalemia (D), potassium chloride should be given unless the patient has chronic kidney disease or oliguria. Persons in a hyperglycemic hyperosmolar state typically do not spill ketones (E) the way persons with diabetic ketoacidosis do.

What is the most common cause of pneumothorax in a healthy patient? A Traumatic B Infectious C Ruptured bleb D Surfactant abnormality E Malignancy

The Correct Answer is: C Rupture of a bleb is thought to be more relevant to young, thin men, and also patients who have a family history of them, and smoking.

A 27-year-old African American with sickle cell anemia presents to the emergency department with acute onset intractable pain. She is taking quick, shallow breaths and her oxygen saturation is 84% on room air. She appears desiccated, states she hasn't eaten in the last 24 hours, and says that she "just doesn't feel well." She is also afebrile. What should your next course of action be? A Start morphine, hydrate, and start antibiotics B Start morphine, oxygen, and start antibiotics C Start oxygen, hydrate, and exchange transfusion D Start oxygen, hydrate, and give pneumococcal vaccination E Start oxygen, hydrate, and start antibiotics

The Correct Answer is: C Start oxygen, hydrate, and exchange transfusion Exchange transfusions are primarily indicated for the treatment of intractable pain crises, priapism, and stroke. Patients should be kept well hydrated, and oxygen should be given if the patient is hypoxic. Antibiotics would be used if there was an infection identified, but are not part of initial treatment in a sickle crises.

Radiculopathy due to nerve root compression occurs most commonly at which nerve root within the brachial plexus? A C5 B C6 C C7 D C8 E T1

The Correct Answer is: C The C7 nerve root is affected the most often (approximately 45-60%). This radiculopathy can result from foraminal encroachment of the spinal nerve, cervical disk herniation, tumor, and multiple sclerosis. C7 radiculopathy can present with weakness in the triceps, which cause elbow extension, and finger flexion and extension. C6 is another common site of radiculopathy. C6 radiculopathy can present with weakness in the biceps, brachioradialis, and wrist extensor muscles. Cervical radiculopathy at the C5, C8, and T1 are less common, but still possible. C5 radiculopathy can present with deltoid and biceps muscle weakness. C8 radiculopathy can present with finger flexor weakness and T1 radiculopathy with finger abduction weakness.

A 21-year-old man presents to the emergency department complaining of a swollen left ear (see image) after he experienced blunt trauma in a collegiate wrestling match. Which of the following is the most appropriate management for this condition? A Evacuation B Evacuation followed by antibiotics C Evacuation with subsequent antibiotics and splinting D Ice and compression E Reevaluation in 24 hours

The Correct Answer is: C The patient has an auricular hematoma that must be evacuated to prevent cartilage necrosis or infection. Evacuation, antibiotics, and splinting (C) remove the hematoma, minimize the risk of infection, and help prevent the re-accumulation of blood.

A 43-year-old male presents to the Emergency Department complaining of right eye pain after treating his yard with fertilizer and lime. He attempted to flush his eye at home without relief of pain. Which of the following is the most appropriate initial step in managing this patient's symptoms? A Double evert his eyelids to look for remaining foreign bodies B Fluorescein stain his eye C Instill proparacaine 0.5% ophthalmic solution D Irrigate his eye until the pH is between 6.8 and 7.4 E Refer to ophthalomogist

The Correct Answer is: C The patient requires all of the above steps and should be given pain relief (C) prior to thoroughly flushing the eye (D), removing foreign bodies (A), assessing for corneal injuries (B), and referring to ophthalmology (E).

A 17-year-old male is brought to your Emergency Department by his girlfriend. She states that he has been behaving strangely for the last three days, with rapidly fluctuating moods ranging from euphoric to irritable and paranoid. The patient states that he is fine, just a little nervous about an upcoming test in school. His pulse is 126 beats per minute, BP 182/106, pupils are widely dilated, and he is diaphoretic. What is his most likely diagnosis? A Acute anxiety B Bipolar disorder C Cocaine intoxication D Heroin intoxication E Thyrotoxicosis

The Correct Answer is: C This patient's presentation with tachycardia, hypertension, diaphoresis, and mydriasis along with the behavioral changes is consistent with cocaine intoxication (C). His physical symptoms could be explained by thyrotoxicosis (E), but he has no history of hyperthyroid symptoms such as weight loss and it would not explain the mydriasis. Acute anxiety (A) or bipolar disorder (B) might explain some of the mood changes but would not account for all of his physical signs. Heroin withdrawal (D) would cause some similar symptoms, but intoxication would cause somnolence and pinpoint pupils.

A 68-year-old woman with a history of hypertension and diabetes mellitus type 2 comes to the emergency department with her son, who noticed that while decorating for Christmas she seemed more dyspneic than normal, and had to sit down frequently. In addition, he noticed that she was pale and diaphoretic, and insisted on driving her to the emergency department. On questioning, she denies chest pain, but admits to being more fatigued than usual, with frequent jaw discomfort during activity. Activities such as vacuuming her house cause dyspnea, and she now has to stop several times while carrying laundry up from the basement. On physical examination, the patient's blood pressure is 90/50, pulse 99 bpm, respirations 22, and she is afebrile. Auscultation of the chest demonstrates a new systolic murmur. An EKG demonstrates normal sinus rhythm with nonspecific ST and T wave changes. Which of the following would be the most appropriate next step in the management of this patient? A Transesophageal echocardiogram B Nuclear stress test C Cardiac catheterization D Serial serum troponin levels E CXR

The Correct Answer is: D Choice D, checking serial serum troponin levels, is the most appropriate next step in the management of this patient. Women and diabetics may present with atypical symptoms with acute non-ST-segment myocardial infarction, including dyspnea, jaw discomfort, and epigastric discomfort. Frequently, women present much later than men with these symptoms. Therefore, a high level of suspicion should be maintained when women present with symptoms of dyspnea, even in the setting of nonspecific EKG changes, and drawing serum troponin levels before any other testing is recommended. Once non-ST-segment myocardial infarction has been ruled out, choices E and B, and also transthoracic echocardiogram, would likely be evaluated. Transesophageal echocardiogram may be required if better visualization of the heart valves is required, but not as the next step. Choice C, cardiac catheterization, would likely occur if an abnormal stress test demonstrating symptoms of myocardial ischemia is found.

A 70-year-old man, with a history of pulmonary hypertension and obstructive sleep apnea, presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension is noted. Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur. The murmur is heard over the second and third left intercostal spaces. An S 3 is appreciated. Abdominal exam reveals hepatomegaly and splenomegaly. Which of the following maneuvers would be the most appropriate to choose for better identification of the murmur? A Left lateral decubitus position listening with the bell of the stethoscope B Standing C Seated leaning forward D Inspiration E Expiration

The Correct Answer is: D Choice D, inspiration, will increase the intensity of the murmur of pulmonic regurgitation/insufficiency. The Valsava maneuver will diminish the intensity of the murmur. Choice B, standing, will cause the mid-systolic click associated with mitral valve prolapsed to move toward S1 or become more audible. Choice A, rolling the patient to the left lateral decubitus position, is most useful in identification of the murmur of mitral stenosis. Choices B, C, and E, have no effect on the Graham Steell murmur of pulmonic regurgitation.

A patient who is intoxicated presents to the emergency department. On ocular exam, you notice mydriasis. Which substance could he have been using? A sedatives B PCP C opioids D cocaine

The Correct Answer is: D Patients intoxicated with cocaine present with mydriasis. In opioid intoxication, the pupils are constricted. PCP intoxication is associated with nystagmus.

A 55-year-old woman with a history of mitral stenosis (secondary to rheumatic heart disease) presents to the emergency department with increasing dyspnea while walking up one flight of stairs. She denies chest pain and discomfort, but states that for last 24 hours she has also noticed palpitations. She also admits to lower extremity edema, which is new within the last week. On EKG, she demonstrates atrial flutter with 2:1 AV block. Which of the following is the most appropriate therapy for this patient? Aspirin 325 mg B Plavix 75 mg C Plavix 75 mg and aspirin 81 mg D Warfarin, dosed to INRs between 2.0 and 3.0 E Dipyridamole 200 mg and aspirin 25 mg

The Correct Answer is: D Patients with atrial flutter of less than 48 hour duration may be cardioverted without anticoagulation, unless they have mitral valve disease, in which case they should be treated with warfarin; therefore, choice D is the most appropriate choice. Choices A, B, C and E are inappropriate, as there is no data to support that any of these therapies offer adequate anticoagulation for embolism prophylaxis, for either atrial fibrillation or atrial flutter. Choice A is recommended for cardiac risk factor modification for men, according to the Framingham Risk Trial. Choice C is appropriate therapy following PTCA and stent placement.

A 56-year-old male who works in construction climbing ladders has developed pain to the right foot for several days. You have seen and examined the patient a few days after the patient started complaining of pain to the foot. Your initial x-rays of the foot are negative for fracture. He continues to have pain, and decreased ability to bear weight. Based on this clinical scenario, how many days after the initial examination should another x-ray be ordered to look for a stress fracture? A 1-2 days B 5-7 days C 10-12 days D 14-30 days E 180 days

The Correct Answer is: D Radiographic evidence of stress fractures is not immediately apparent after the initial onset of symptoms. Estimates of anywhere from 14 to 42 days before visible signs of a stress fracture can be detected on X-ray have been put forth with a commonly utilized range of 14 to 30 days. Any answer choice above that included numbers less than 14 days would simply be inaccurate due to the gradual appearance of the classic x-ray findings of a stress fracture. After 180 days from the time of stress fracture onset, the fracture should be nearly healed if managed properly. If a stress fracture is highly suspected in light of negative x-rays, imaging with a bone scan should help make the diagnosis. MRI scans may help confirm the diagnosis, but they are rarely utilized in the work-up of suspected stress fractures.

A 14-year-old boy presents to the emergency department with acute scrotal pain and vomiting for the past 2 hours. His left testicle is in extreme pain and he states the pain started while playing basketball in gym class. On physical exam of the affected testicle, which of the following findings would suggest testicular torsion? A Transillumination B Positive Prehn's sign C Positive cremasteric reflex D Abnormal transverse lie E Mass of enlarged veins palpated

The Correct Answer is: D Testicular torsion is most common between ages 12-18 with the classic presentation of abrupt and severe onset of pain with nausea/vomiting. The testicle on physical examination is painful, swollen, high-riding, tender, and has an abnormal transverse lie (D). Transillumination (A) is when light is placed behind the scrotum and fluid is illuminated in cases of hydroceles. Prehn's sign (B) is pain relief with elevating the scrotum and is positive in cases of epididymitis. The cremasteric reflex (C) is a normal finding that causes elevation of the testis on the ipsilateral side when the inner aspect of the inner thigh is stroked. The absence of cremasteric reflex on the affected side is often found in acute torsion. A mass of enlarged veins (E), or "bag of worms," is a finding associated with a varicocele.

A 23-year-old man presents to the outpatient clinic for follow-up from a recent urgent care visit. He complains of sore throat, fever, fatigue, myalgias, and a rash that started 5 days ago, and have worsened since he was seen in the urgent care 3 days ago. The patient appears non-toxic with a temperature of 39.4 degrees Celsius. Physical exam reveals pharyngeal and tonsillar erythema without exudates, generalized lymphadenopathy, a morbilliform rash on his trunk, and no hepatosplenomegaly. A rapid strep screen and Monospot performed at the local urgent care were reportedly negative. Which of the following laboratory tests is most likely to confirm the expected diagnosis? A Complete blood count B Cytomegalovirus titer C Group A beta-hemolytic strep culture D HIV viral load E Epstein-Barr virus titer

The Correct Answer is: D The patient presentation is consistent with acute retroviral syndrome, which is best confirmed during this initial presentation phase through direct testing for the HIV virus, such as an HIV viral load (D). The lack of tonsillar exudates, a negative monospot, and presence of generalized adenopathy make infectious mononucleosis (B and E) less likely. A CBC (A) may show lymphopenia and support the diagnosis, but it doesn't confirm the diagnosis.

A 67-year-old female with a history of oxygen dependent emphysema presents with a 4-hour history of increasing shortness of breath and pleuritic chest pain on the right side. Her resting oxygen saturation rate is 90%, and she is having pain on inspiration. On examination, the patient has decreased lung sounds with wheeze on the left and absent sounds on the right. There is also tympany to percussion on the right. Based on these findings, what is the best therapy for this patient? A Needle insertion to right chest wall B Supportive care C Increased oxygen delivery D Chest tube insertion E Nebulized albuterol

The Correct Answer is: D The treatment for this patient, who has a pneumothorax, is chest tube insertion and reinflation of the lung. Once the air leak has been eliminated and the lung appears reinflated on serial chest x-rays, the chest tube may be removed.

A 22-year-old African American male presents to the emergency department with shortness of breath, which started 2 hours prior to arrival. He does not have a history of pulmonary disease that he is aware of, and he states that in the past at random events he has had similar episodes. He does nothing to get the episodes to stop, and he also states that he feels his chest pounding at the same time of the shortness of breath. He has no medical history that he is aware of, and he takes no medications or any illicit drugs. On examination he is alert, awake, and oriented. His vital signs show T 99.0, P 142, R 18, and BP 132/82. His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rate of 142 with visible delta waves. Given the clinical situation above, what is the best medication for managing this patient's condition with a long-term approach? A Amiodarone B Atropine C Hydralazine D Flecainide E Digoxin

The Correct Answer is: D This patient has Wolff-Parkinson-White (WPW) syndrome along with atrial fibrillation and a rapid ventricular response. Of the choices given in managing this patient's tachycardia, oral flecainide (D) will serve to slow the process within the accessory pathway and prolong the refractory period. Amiodarone (A) has been shown to not be effective in managing the patient's tachycardia with respect to WPW, and the other medications (B, C, and E) would not have an effect on the condition and may actually worsen the patient's symptoms.

A 70-year-old man with a history of pulmonary hypertension and obstructive sleep apnea presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension is noted. Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur. With inspiration, the murmur increases in intensity and is heard over the second and third left intercostal spaces. An S 3 is appreciated. Palpation of the precordium reveals a hyperdynamic right ventricle, and both a systolic and diastolic thrill. The abdominal exam reveals hepatomegaly and splenomegaly. Based on this patient's history and physical exam findings, which of the following is the most likely finding on echocardiogram? A Tricuspid regurgitation B Aortic stenosis C Atrial septal defect D Pulmonic regurgitation/insufficiency E Mitral stenosis

The Correct Answer is: D This patient is demonstrating signs and symptoms of right heart failure, and with a history of pulmonary hypertension and a high-pitched diastolic blowing murmur (Graham Steell murmur), Choice D is the most likely of the choices offered. A blowing holosystolic murmur at the left lower sternal border is characteristic for tricuspid regurgitation, Choice A. Choice B, aortic stenosis, presents with a systolic ejection murmur. An atrial septal defect, Choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice E, mitral stenosis, presents with a diastolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex.

A 22-year-old African American male presents to the emergency department with shortness of breath, which started 2 hours prior to arrival. He does not have a history of pulmonary disease that he is aware of, and he states that in the past at random events he has had similar episodes. He does nothing to get the episodes to stop, and he also states that he feels his chest pounding at the same time of the shortness of breath. He has no medical history that he is aware of, and he takes no medications or any illicit drugs. On examination he is alert, awake, and oriented. His vital signs show T 99.0, P 142, R 18, and BP 132/82. His chest x-ray is negative for any acute cardiopulmonary disease, and his electrocardiogram has an irregularly irregular rate of 142 with visible delta waves. Based on the information provided, what anatomical pathway is responsible for the above findings of the delta waves? A Intranodal pathway B Bachmann's bundle C Perkinje fibers D Bundle of Kent E Bundle of His

The Correct Answer is: D This patient is exhibiting Wolff-Parkinson-White (WPW) syndrome by evidence of the delta waves on the electrocardiogram. The anatomic pathway that is known to be the causative abnormality in WPW is the Bundle of Kent (D). Intranodal pathway (A), Bachmann's bundle (B), Perkinje (C), and His bundles (E) are not the anatomic pathways found with WPW.

A 49-year-old female with a known history of hypertension presents to the emergency department with a generalized headache that is throbbing. She states she had run out of her normal blood pressure medication about a week ago and since then she has noticed that her headache came about and has been getting worse. She denies any nausea, vomiting, visual changes, chest pain, or other symptoms. On exam the patient has a BP 227/120, P 78, R 18. Her HEENT exam is essentially normal, lungs are clear to auscultation, and heart is a regular rhythm without murmur or gallop. Given this clinical situation, which medication would be the most appropriate to address the patients condition? A IV nitroprusside B Oral furosemide C Spironolactone D IV labetalol E Oral hydralazine

The Correct Answer is: D This patient's clinical situation is one of a hypertensive emergency. In this situation the goal is to bring down the systolic pressure to prevent end organ damage. Given the possible choices, the best choice would be intravenous labetalol (D) due to its effective quick onset, and its ability to be tolerated with most patients. While oral furosemide (B) and hydralazine (E) can both be effective in managing hypertension, the IV dosing of labetalol would be the better choice. Nitroprusside (A) is no longer a treatment option. Spironolactone (C) would not have strong enough effects to appropriately lower the blood pressure in an efficient manner.

A 65-year-old recent alcoholic comes to the emergency department with recent onset of dyspnea, with exertion, 3 pillow orthopnea, lower extremity edema, and palpitations, in which he describes his heart as racing. Which of the following is most likely to be the cause of his high-output congestive heart failure? A Mitral regurgitation B Aortic stenosis C Uncontrolled hypertension D Ruptured chordae tendinae E Beriberi

The Correct Answer is: E Choice E, beriberi, also known as thiamine deficiency, is common among alcoholics, and the only high-output cause of congestive heart failure among the choices offered. Other causes include severe anemia, thyrotoxicosis, and arteriovenouis shunting (for example, in hemodialysis patients). Choice A, mitral regurgitation, is a cause of excessive preload, leading to heart failure. Choice D, ruptured chordate tendinae associated with mitral regurgitation, would also be a cause of excessive preload, leading to heart failure. Choices B and C, aortic stenosis and uncontrolled hypertension, are causes in which too much afterload leads to heart failure.

A 24-year-old man with a recent history of a viral illness comes to the emergency department complaining of severe left-sided chest discomfort, which radiates through to the left trapezius region. On coming into the room, you note that he is sitting up and hunched forward. On physical examination, the patient's temperature is 39°C, blood pressure is 135/78, with a pulse of 85 bpm, and a pericardial friction rub is noted. Laboratory findings demonstrate elevated serum creatine kinase levels and normal serial troponin levels. His EKG demonstrates peaked T waves. His CXR demonstrates no acute process. Which of the following is the most appropriate treatment for this patient? A Morphine B Enoxaparin C Nitroglycerin D Penicillin V E Indomethacin

The Correct Answer is: E Choice E, indomethacin 25-75 mg QID, and bed rest would be the most appropriate treatment in a patient with acute viral pericarditis, as a nonsteroidal anti-inflammatory agent will ameliorate the inflammatory process. Choices A and C are appropriate in a patient suspected of acute coronary syndrome. Choice B, enoxaparin, is contraindicated in patients with pericarditis, as anticoagulants could lead to worsening of pericardial effusion and cardiac tamponade, especially if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively.

A 50-year-old woman with a history of hypertension complains of chest tightness and dyspnea while walking up one flight of stairs. She recently experienced an episode of near-syncope while walking her dog. She denies a history of rheumatic fever. On auscultation, a crescendo-decrescendo systolic ejection murmur is heard at the upper right sternal border, radiating to the carotids bilaterally. Troponin levels are negative at 0, 3, and 6 hours. Her EKG demonstrates evidence of left ventricular hypertrophy. Given the patient's physical exam findings and recent symptoms, which of the following is the most appropriate next diagnostic study? A Chest X-ray B Transesophageal echocardiogram C Holter monitor D Treadmill exercise stress test E Transthoracic echocardiogram

The Correct Answer is: E Choice E, transthoracic echocardiogram, is a simple, sensitive, and non-invasive diagnostic tool which can evaluate for the presence of valvulopathy in a patient in this age group, who is likely demonstrating severe aortic stenosis secondary to a congenital bicuspid valve. Patients with a congenital bicuspid aortic valve typically develop symptoms once the valve leaflets have become calcified and thickened, secondary to the undue stress over many years on a structurally abnormal aortic valve. Choice A might be able to give evidence of cardiomegaly or calcification of heart valves, but would not be sensitive enough to detect the degree of valvulopathy, if present. Choice B, transesophageal echocardiogram, would give information regarding valvulopathy, but is a more invasive test; therefore, choice E is more appropriate. Choice C is a useful diagnostic tool for evaluation of patients complaining of palpitations, but incorrect for this patient, who has no symptoms of palpitations.

Which of the following is the most reliable clinical tool for confirming endotracheal intubation in an emergency situation? A Auscultation over the stomach B Endotracheal tube condensation C Pulse oximetry monitoring D Sellick maneuver E Visualizing the tube passing through the vocal cords

The Correct Answer is: E Clinical assessments and practices used to assess tube placement, and help with placement, such as auscultating for breath sounds and noise within the stomach, have not had a confirmation rate comparable to directly visualizing the tube passing through the vocal cords. Tube condensation may occur with esophageal intubation as well. The Sellick maneuver may help with correct positioning, but is not a confirmatory test. Once placement is suspected, confirmation with an end-tidal CO 2 detector and chest x-ray is recommended. Pulse oximetry measurement should be performed throughout the intubation, with decreased saturations representing a worsening clinical condition and/or esophageal intubation.

A 64-year-old female who has a history of injectable drug use presents with blood work that reveals leukocytosis with a left shift, and there is suspicion of osteomyelitis based on the patient's prior history. Based on this history, what bone would be most affected by hematogenous osteomyelitis in adults? A Feet B Long bones C Pelvis D Sternoclavicular bones E Vertebrae

The Correct Answer is: E Hematogenous osteomyelitis accounts for about 20% of all cases of osteomyelitis in adults. It is more common in males and the prevalence is higher amongst those who are IV drug abusers, patients being treated with dialysis or who have sickle cell disease. Other conditions which may lead to sepsis (i.e. patients with central lines, urinary infections, and urethral catheterization) increase the risk of hematogenous osteomyelitis. Unlike children, the long bones are rarely affected in adults with the vertebrae being the most likely location for the bone infection to occur. Lumbar vertebrae are most often affected, followed by thoracic and cervical vertebrae. Osteomyelitis of the sternoclavicular bones and pelvic bones are not uncommon sites, but these tend to be most frequent amongst IV drug abusers. The feet do not tend to be significantly affected by hematogenous osteomyelitis as frequently as osteomyelitis caused by infected foot ulcers as are often seen in those with diabetes or peripheral vascular disease.

A 36 year-old woman with no significant past medical history presents with gradual onset of dyspnea and fatigue leading to an episode of "fainting" this morning. Physical exam reveals increased jugular venous pressure, weak carotid pulses, clear lungs, and a loud S2. What is the most likely diagnosis? A Aortic stenosis B Cardiac tamponade C Mitral Regurgitation D Pulmonary fibrosis E Pulmonary hypertension

The Correct Answer is: E The patients symptoms are due to decreased cardiac output resulting from decreased preload associated with pulmonary hypertension (E). Aortic stenosis (A) presents more commonly in geriatric patients who present with a murmur. Cardiac tamponade (B) can decrease cardiac output, but would lead to decreased heart sounds. Mitral regurgitation (C) would cause pulmonary edema and rales in conjunction with increased jugular venous pressure. Pulmonary fibrosis (E) is unlikely in this patient with normal lung sounds.

A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 3. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following questions, when answered, will help to determine the next course of therapy? A How long has the patient been a diabetic? B Has the patient ever had an allergic reaction to aspirin? C Does the patient have a family history of dysrhythmia? D Is the patient a smoker? E How long has the patient been experiencing palpitations?

The Correct Answer is: E This patient has atrial fibrillation. Choice E is the most important question to ask to determine the next course of therapy. If the patient has been experiencing definitive symptoms for less than 48 hours, direct current cardioversion can be performed, as the risk of atrial clot formation and thromboembolism is low. Choice A is incorrect because the CHADS2 scoring system does not take into account how long the patient has been diabetic. Choice B is incorrect because aspirin therapy is not utilized. Choice C is incorrect because family history is not a factor in determining the patient's treatment plan. Choice D is incorrect because smoking status is used in calculating Framingham risk score, not a CHADS2 score.

A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the best test to definitively diagnose this medical problem? A Chest x-ray B Transthoracic echocardiography C Transesophageal echocardiography D Cardiac catheterization E Computed tomography

The Correct Answer is: E This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. Given this clinical situation, the best test to evaluate for a potential dissection is by computed tomography (E). This test is sensitive enough to determine if there is a luminal irregularity. While echocardiography (B and C) may be able to show evidence of an aneurysm, it is not specific enough to show all the areas of an aneurysm. In this situation a chest x-ray (A) would not give enough specificity to appropriately diagnose an aneurysm, as well as a cardiac catheterization (D).