ITEMREP

A 34-year-old man presents after a high-speed motor vehicle crash. Chest x-ray is performed and shown in Figure 1-7. Which of the following is the most likely diagnosis?

Diaphragmatic rupture

A 22-year-old woman presents with a chief complaint of a painful vaginal lump and vulvar pain while walking (Fig. 3-2). She denies any vaginal discharge, fevers, or abdominal pain. Her urine human chronic gonadotropin (B-hCG) is negative. Which of the following is true?

A Word catheter should be placed after incision and drainage and left in place for 6 to 8 weeks.

Among patients who have contraindications to beta-blocker therapy, which of the following calcium channel blockers (CCBs) can be given as a substitute for beta-blockers to patients with a non-ST-elevation MI (NSTEMI)?

Diltiazem

Which of the following is the most effective therapy for acute arsenic poisoning?

Dimercaprol

Which of the following toxins is most commonly associated with seizures?

Alcohol

Among adults with asthma, which of the following demographics has the highest risk of morbidity and mortality?

Black women

Which of the following is true regarding traumatic aortic injury (TAI)?

CT aortography has better sensitivity than transthoracic echocardiogram.

Which of the following is the best modality to diagnose posterior sternoclavicular dislocation?

CT chest

Which of the following is the preferred imaging modality to diagnose a parapharyngeal abscess in the ED?

CT scan of the neck

The manifestations of hyperphosphatemia are related to its effects on:

Calcium

A 56-year-old man with long-standing hypertension and mild renal insufficiency presents to the ED with vague complaints of fatigue and generalized malaise. His EKG is shown in Figure 2-14. Which of the following is the next best step in management of this patient?

Calcium chloride

Which of the following is true regarding genital herpes simplex infection?

The primary attack is usually more severe than recurrent episodes.

A 28-year-old man presents with an acute, progressively worsening headache and fever for 1 day. Physical examination reveals a toxic-appearing, slightly confused patient with fever and meningismus. Which of the following is the most appropriate next step in management?

Ceftriaxone, vancomycin, and dexamethasone

Among trauma patients, which of the following is the most common incomplete spinal cord syndrome?

Central cord syndrome

Which of the following represents the correct medial to lateral configuration of permanent teeth?

Central incisor, lateral incisor, canine, premolar, molarIn which of the following hematologic malignancies is a hyperviscosity syndrome (leukostasis) due to elevated numbers of WBCs most likely to occur?@Acute myelogenous leukemia (AML)

Retrobulbar hemorrhage can result in what devastating complication?

Central retinal artery occlusion (CRAO)

A 50-year-old man develops acute onset severe right flank pain. A CT scan demonstrates a calculus in the bladder. The patient has never had a kidney stone before. He asks you what his risk of getting another stone is. You tell him that the lifetime risk of recurrence is approximately:

50%

In setting of a normal peripheral white blood cell (WBC) count and a suspected 'traumatic' lumbar puncture, the cerebrospinal fluid (CSF) should contain approximately 1 WBC per every ?? red blood cells (RBCs)?

500

Which of the following is the lowest acute toxic ingestion of acetaminophen requiring treatment with N-acetylcysteine (NAC) in the adult patient?

7.5 g

A 5-year-old boy presents with confirmed rotavirus diarrhea. He is tachycardic and lethargic with sunken eyes, poor skin turgor, and dry mucous membranes. Which of the following is the most appropriate next step in management?

0.9 NS 20 mL per kg bolus

What is the duration of action of naloxone?

1 hour

Among close contacts of a patient diagnosed with meningitis caused by Neisseria meningitidis, what is the approximate likelihood of transmission without prophylactic antibiotic therapy?

1%

A 24-year-old man with no past medical history presents with sudden onset of shortness of breath and chest pain. He appears uncomfortable. Vital signs are 98.6°F, 100, 24, 150/92, 96% RA. He has significantly decreased breath sounds on his left side. Chest x-ray is shown in Figure 2-12. Which of the following is the most appropriate next step in management?

100% oxygen by non-rebreather mask

An 87-year-old woman is brought to the ED by her caretaker with dehydration and excessive somnolence. Her initial blood work reveals a sodium level of 119 mEq/L and a glucose level of 1,100. Which of the following represents her actual sodium level?

135 mEq/L

What is the half-life of carboxyhemoglobin with a 100% oxygen nonrebreather mask?

90 minutes

Which of the following represents the approximate proportion of acute myocardial infarctions (MIs) that occur without a history of chest pain?

25%

Which of the following is the most appropriate suture to be used for gaping intraoral lacerations involving the mucosal surface?

4-0 polyglactin 910 (Vicryl)

Excision of thrombosed hemorrhoids is not recommended or effective after:

48 hoursA 4-year-old girl is brought in by her mother, who is worried that 'she swallowed something and it's stuck.' The patient was in her usual health until this morning's breakfast, which she could not swallow and rapidly vomited. An anteroposterior (AP) chest X-ray demonstrates a coin positioned en face in the upper chest. The patient looks well and is otherwise asymptomatic. What is the next appropriate step?@Endoscopy

Which of the following patients with a febrile seizure most likely requires further evaluation with a LP to look for an infectious source?

A 9-month-old currently receiving antibiotics for otitis media

A 26-year-old is brought to the ED by EMS three hours after ingesting an overdose of his mother's digoxin. Which of the following is true?

A digoxin level may overestimate the amount of digoxin ingested.

A 4-week-old male infant is brought in by his parents with progressive, projectile, nonbilious emesis. Labs are drawn and an IV is placed and the patient is sent for an ultrasound. Ultrasonography reveals a hypertrophic pylorus and the surgeon is consulted for pyloric stenosis. What are the labs likely to reveal?

A hypochloremic, hypokalemic, metabolic alkalosis

Which of the following findings should cast doubt on a diagnosis of Guillain-Barre syndrome (GBS)?

A patient who presents with symmetrical sensory loss but who has no motor weakness.

Which of the following is true regarding treatment for acute aspirin toxicity?

A urinary pH goal of 7.5 to 8 is desirable.

A 62-year-old woman with a history of hypertension, diabetes mellitus, and emphysema presents with a 3-week history of dyspnea on exertion, three-pillow orthopnea, and bilateral lower extremity edema. She denies fevers, cough, or chest pain. A chest x-ray is shown in Figure 1-16A and B. The patient's electrocardiogram (EKG) does not show any ischemic changes. Her vitals are: Respiratory rate 22 per minute, pulse 108, BP 154/88, pulse oximetry 88% on room air. What is the next best step in management?

Administer oxygen, nitrates, and furosemide

A 38-year-old pregnant woman presents to the ED with vaginal bleeding and abdominal pain radiating to the back. She is 25 weeks by dates and has had an uncomplicated pregnancy with routine prenatal care. She admits to smoking one pack of cigarettes per day and otherwise has no significant history. Her uterus is firm and tender on examination and there is bright red blood oozing from the cervical os. The most likely diagnosis is:

Abruptio placentae

A 62-year-old man presents after a motor vehicle collision with severe ankle pain after his left foot got caught under the accelerator. His foot is shown in Figure 1-1. Which of the following is likely to be true regarding this patient?

Accompanying bony fracture is extremely likely.

Which of the following treatments has been shown to be effective in the prevention of acute mountain sickness (AMS)?

Acetazolamide

A 65-year-old man presents with sudden, painful loss of vision in his right eye. His visual acuity is markedly decreased in the affected eye. Which of the following is the most likely cause of his symptoms?

Acute angle closure glaucoma

Which of the following is a criterion for acute respiratory distress syndrome (ARDS)?

Acute onset

Which of the following is true regarding heart transplant recipients?

Acute rejection is usually diagnosed by endomyocardial biopsy.A 65-year-old asymptomatic man presents with the EKG as shown in Figure 2-3. Which of the following is the most likely associated condition?@Chronic obstructive pulmonary disease (COPD)

An 85-year-old woman presents with right shoulder stiffness. She was diagnosed with a shoulder sprain 3 weeks ago after a fall, and has been wearing a sling since then. Physical examination demonstrates an afebrile patient with painful, restricted range of motion of the shoulder in all directions. Which of the following is the most likely diagnosis?

Adhesive capsulitis

A 34-year-old man with a history of schizophrenia is brought to the ED by police with acute agitation. He was reported to be threatening passersby on the street. He now begins to threaten staff, stating that he will kill anyone who comes near him, and starts to swing punches at people standing near him. The patient is physically restrained by security staff and secured to a cart in four-point restraints. He is still yelling at the top of his lungs and struggling against the restraints. Which of the following is the most appropriate next step in management?

Administer haloperidol and lorazepam.

A 22-year-old man presents with palpitations. He reports no chest pain, shortness of breath, or lower extremity edema. He states that he 'got really drunk' the night before. He denies any past medical history, family history, or illicit drug use. His examination is unremarkable except for irregular tachycardia. His electrocardiogram (EKG) is shown in Figure 1-5. Which of the following is the most likely etiology?

Alcohol use

]

All of the above.

On the basis of these results, the presumptive diagnosis of bacterial meningitis is made. Which of the following is the most appropriate therapy?"

Ampicillin, ceftriaxone, vancomycin, and dexamethasone

A 63-year-old male with a history of nephrolithiasis presents to the ED with acute onset right flank pain. He receives an uncontrasted CT scan which is unrevealing, and he has no hematuria. A repeat study with contrast is performed, a slice of which is shown in Figure 1-14. The patient feels better and has minimal pain. His vital signs are T 98.4, P 84, RR 16, BP 156/82, SaO2 98% on RA. Which of the following is true?

An upper extremity pulse deficit is the most specific physical examination finding.

What is the most common cause of lower gastrointestinal (GI) bleeding (LGIB) in children?

Anal fissure

What is the most commonly encountered anorectal problem in infants?

Anal fissure

A 50-year-old woman with no past medical history presents with acute onset of fever, chills, shortness of breath, and cough. She has crackles in her right middle lung field and chest x-ray shows right middle lobe consolidation. Vital signs in the emergency department (ED) are normal. Which of the following is the most appropriate next step in management?

Antibiotics

A 45-year-old woman with a history of untreated hyperthyroidism presents with acute onset of left foot pain. Physical examination reveals normal vital signs, an irregular heart rhythm, clear lung sounds, and loss of pulses in the left foot with decreased capillary refill, and cyanotic, paralyzed toes. Which of the following is the most appropriate next step in management?

Anticoagulation and emergent embolectomy

A patient presents with new-onset psychosis. Which of the following suggests a medical, rather than a psychiatric, cause for the symptoms?

Aphasia

When compared with patients with deep venous thrombosis (DVT) of the lower extremities, patients with an upper extremity DVT

Are more likely to have an underlying diagnosis of cancer

Which of the following is true regarding toxic alcohols?

As little as one tablespoon of 40% methanol may be lethal in adults.

A 63-year-old man with a history of multiple myeloma presents with acute onset of generalized weakness, blurry vision, diffuse mucosal bleeding, and headache. A complete blood count and comprehensive chemistry panel is sent, but the laboratory is unable to perform the analysis, citing 'inappropriate blood sample.' Which of the following is the most appropriate definitive management?

Plasmapheresis

A 22-year-old man presents with an episode of left-sided chest pain that lasted 4 hours, but resolved an hour before presenting to the ED. The pain was dull and radiated to his left shoulder. The patient states that he used cocaine at a party 12 hours ago. Physical examination is unremarkable and vital signs are normal. The electrocardiogram (EKG) is shown in Figure 2-11. Which of the following is most appropriate at this time?

Aspirin

A 34-year-old man presents with chest pain for 4 hours, resolved at presentation. He has been smoking marijuana, which he obtained from an unknown source. His vital signs are 98.6°F, 115, 20, 167/95, 98% RA. His physical examination reveals pupillary dilation, tachycardia, and diaphoresis. His electrocardiogram (EKG) demonstrates ST depressions in V3-V5. Initial troponin level is 0.20 ng per mL. Which of the following is the most appropriate therapy at this time?

Aspirin

A 4-year-old boy is brought by his parents because he swallowed some of his grandmother's antihypertensive medicine. He is sleepy, bradycardic, and hypotensive. Which of the following is the most appropriate treatment?

Atropine, glucagon, calcium, and high-dose insulin with glucose

A 23-year-old man presents with shoulder pain after falling. A shoulder radiograph is shown in Figure 1-9. Which of the following is the most likely additional injury?

Axillary nerve injury

Which of the following is the recommended treatment of a patient with group A B-hemolytic streptococcal (GAS) pharyngitis and a penicillin allergy?

Azithromycin

A 65-year-old smoker presents with sudden onset of shortness of breath for 2 hours. He denies chest pain, fever, productive cough, or lower extremity edema. Vitals signs are 99°F, 95, 24, 200/95, 92% on RA. He has bilateral wheezes. Which of the following best differentiates between obstructive lung disease and congestive heart failure (CHF)?

B-type natriuretic peptide (BNP)

Which of the following rhythm disturbances is considered pathognomonic for digoxin toxicity?

Bidirectional ventricular tachycardia

A 66-year-old man is brought to the ED after a high-speed motor vehicle collision. He complains of chest pain. Given the extreme deceleration mechanism, you suspect traumatic aortic injury. Which of the following is present in most ED patients with traumatic aortic injury?

BP >140/90

Which of the following is the most common cause of dysuria?

Bacterial infection

A 55-year-old man presents with right arm and leg weakness and left-sided facial droop. Which of the following arteries is most likely involved?

Basilar artery

A 34-year-old man with schizophrenia is brought to the ED by his family because he 'keeps ignoring' them. They report that for the last few hours, when they argue with him about taking his risperidone, he stares off into the space and does not acknowledge them in any way. This lasts for a few minutes and gradually improves until the next conversation. They want to speak with the psychiatrist about putting him on a new antipsychotic medication. His vital signs are normal and physical examination is unremarkable except that when you question him about his medication, he becomes visibly angry and his eyes look up to the ceiling. After he calms down in a few minutes, he resumes normal eye contact and conversation. Which of the following is the most appropriate action at this time?

Benztropine 1 mg IM

Which of the following is the most common serious complication of the edrophonium (Tensilon) test?

Bradycardia

Patients suffering from a hyperviscosity syndrome (leukostasis) due to severely elevated numbers of WBCs (hyperleukocytosis) most commonly present with symptoms reflecting involvement of which of the following organ systems?

Brain and pulmonary

After physiologic jaundice of the newborn (icterus neonatorum), which of the following is the most common cause of neonatal jaundice?

Breast milk jaundice

Which of the following is true regarding the physical examination of a patient with asthma?

Respiratory rate correlates poorly with the severity of an asthma exacerbation.

A 22-year-old woman at 36 weeks of gestation is being treated with magnesium sulfate for preeclampsia while awaiting transfer to a nearby hospital for definitive management. Upon reevaluating the patient, you find her to be quite somnolent with markedly decreased deep tendon reflexes and a decreased respiratory rate. After managing the airway, the next best step in management is intravenous:

Calcium gluconate

Which of the following is the most common cause of viral otitis media?

Respiratory syncytial virus (RSV)

A 5-year-old boy is brought to the ED by his parents for diarrhea. He has had multiple, loose bowel movements mixed with blood for 2 days, associated with shaking chills. The patient has not traveled or been exposed to antibiotics. He appears dehydrated and ill. Which of the following is the most likely cause?

Campylobacter

Traumatic hyphema

Can be complicated by rebleeding

Which of the following is true regarding candidiasis?

Candida is part of the normal oral flora in most humans.

In a perilunate dislocation, which bone is dorsally dislocated?

Capitate

An otherwise healthy 12-year-old male is brought to the ED with a chief complaint of chest pain. The patient has been complaining of the pain over the past week. Which of the following is true?

Cardiac causes of chest pain more commonly occur in the setting of exertion.

A 1-week-old infant is brought to the emergency department (ED) with fast breathing, irritability, and poor feeding. Room air pulse oximetry is 88% and the patient appears to have decreased activity. His temperature is 99.8ºF. Chest x-ray reveals a slightly enlarged heart with increased pulmonary consolidation. Lung examination reveals mild wheezes with good air exchange. Albuterol and oxygen are initiated. Which of the following medications is indicated?

CefotaximeWhich of the following is true regarding aspirin-induced asthma (AIA)?@It is a common precipitant of severe, life-threatening asthma.

A 27-year-old man presents to the ED with pruritus ani, tenesmus, and yellowish mucoid discharge from his rectum. Upon further questioning, he acknowledges recent unprotected anal intercourse. The recommended regimen for treating this patient is:

Ceftriaxone 125 mg IM plus doxycycline 100 mg PO b.i.d. x 7 days

A 72-year-old man develops acute onset shaking chills and shortness of breath a few days after an URI. His past medical history is significant for diabetes and stable coronary artery disease. Vital signs are 101°F, 115, 24, 144/95, 90% RA. Physical examination reveals a patient with rigors and right lower lobe crackles. Which of the following is the most appropriate next step in management?

Ceftriaxone and azithromycin IV and admit

A 65-year-old man presents with dyspnea on exertion for several weeks. He does not regularly see physicians and reports no past medical history. Chest x-ray is shown in Figure 3-1. Which of the following is the most likely etiology of his symptoms?

CHF

Patients stricken with viral-induced myocarditis will most likely present with symptoms and findings consistent with:

CHF

A 65-year-old man presents with spontaneous pneumothorax. Which of the following is the most likely associated condition?

COPD

A 15-year-old man is brought to the ED after being submerged in a lake for 'a minute or two.' He had been water skiing when he lost control and 'wiped out' and then was lying face down in the water without moving. He was not breathing when his friends pulled him out of the water, but he regained spontaneous respirations after they performed cardiopulmonary resuscitation. In the ED, he is awake, but somnolent, breathing spontaneously with a pulse oximetry of 95% on room air and making purposeful movements and following commands. The next most important step in management is:

Cervical spine films

A 34-year-old woman who takes phenelzine for depression presents with agitation, severe hypertension, mydriasis, and hyperthermia. Which of the following foods did she most likely eat before presentation?

Cheese

A 65-year-old woman pedestrian presents after being struck by a car moving at about 20 mph. She has an obvious, open, deformed leg fracture and was unable to walk at the scene. Her prehospital vital signs are P 105, 85/55, and 100% RA. She is awake and alert and in significant pain. You confirm that her airway, breathing, and pulses are intact. On visual inspection, she has an open tibial shaft fracture and has decreased sensation distal to the fracture. Which of the following is the most important next step in management?

Chest and pelvis x-rays

A 26-year-old woman at 31 weeks' gestation is brought to the ED after a high-speed motor vehicle accident. She was an unrestrained passenger but was not ejected from the vehicle. She is brought in lying on a backboard with a c-collar and is complaining of difficulty breathing. Her room air oxygen saturation reads 82%, although it increases to 93% on a nonrebreather. A chest x-ray was taken and is shown in Figure 4-5. Which of the following is true?

Chest tubes should be placed higher in pregnant than in nonpregnant women.

A 9-month-old infant is brought to the emergency department (ED) with a bruise on his thigh suffered from falling out of his high chair. Radiographs reveal a midshaft femur fracture. Which of the following is the most likely contributing factor?

Child abuse

Which of the following is the most common cause of multiple rib fractures in children?

Child abuse

The most common cause of sexually transmitted disease (STD) in the United States is:

Chlamydia trachomatis

A patient presents for evaluation 2 weeks after recovering from a sore throat. Which of the following findings is most suggestive of rheumatic fever?

Choreiform movements

An 18-year-old primigravida at 35 weeks of gestation presents with abdominal pain, vaginal discharge, and a low-grade fever. She states that she was well until two days ago when, after coughing, she experienced a small stream of fluid running down her leg which she thought was urine. Her temperature is 102°F and her pulse is 108. Her examination reveals a yellowish discharge in the vaginal vault with a tender uterus. What is the most likely cause of her symptoms?

Chorioamnionitis

Which of the following is true regarding the MB fraction of creatine kinase (CK-MB) in acute myocardial infarction (MI)?

Returns to baseline within 72 hours

The pictured deformity in Figure 1-10 occurs in:

Rheumatoid arthritis

A 45-year-old man presents with abrupt onset of fever, cough, chills, and shortness of breath. One week earlier, he was present in a government office where an explosion thought to be a terrorist attack occurred. He appears toxic and in moderate respiratory distress. Chest x-ray is shown in Figure 1-12. Which of the following is the most appropriate therapy at this time?

Ciprofloxacin

A 66-year-old woman who recently completed chemotherapy for colon cancer through a right chest Port-a-Cath presents with a chief complaint of right arm pain, swelling, and weakness. The right hand is warm, and well perfused. The radial pulse is equal to the contralateral side. There is no evidence of cellulitis. An upper extremity DVT is suspected. Which of the following is the next best test?

Compression Doppler ultrasound

A 42-year-old man presents with left ear and posterior periauricular pain for 3 days. The ear is shown in Figure 3-3. Which of the following is the most important next step in diagnosis?

Computed tomography (CT)

A 55-year-old woman presents with left knee pain after being struck at 5 miles per hour by a car turning into her pedestrian lane. Her knee is significantly tender inferior and lateral to the patella. She is able to fully extend her leg though with considerable pain and her neurovascular and ligamentous exams are intact. Knee radiographs are normal. Which of the following is the most appropriate next step in management?

Computed tomography (CT) scan of the knee

A 56-year-old woman presents with acute organophosphate overdose, with severe bronchorrhea, bradycardia, and coma. She is intubated for airway protection, and atropine therapy is initiated. After 10 mg of atropine, her heart rate (HR) is 130, blood pressure (BP) is 160/90, and her secretions are still copious. Which of the following is the most appropriate next step in management?

Continue atropine therapy and add pralidoxime

The family of a 49-year-old woman with a history of hypertension brings her to the emergency department (ED) with a chief complaint of mumbled, incomprehensible speech that started approximately 5 hours ago along with weakness of her right arm, leg, and face. Computed tomography (CT) of her head reveals an area of infarction in her left hemisphere but no evidence of bleeding. Upon returning from CT, the nurse tells you her blood pressure is 200/105. Which of the following summarizes the best approach to managing this patient's blood pressure?

Continue to monitor the patient's blood pressure without treatment.

A 4-year-old girl presents with vomiting and diarrhea. She is diagnosed with acute gastroenteritis. Presence of which of the following findings still allows the patient to be a suitable candidate for oral rehydration therapy (ORT)?

Continued diarrhea

A 62-year-old woman with a history of known peptic ulcer disease presents with a chief complaint of hematemesis and black tarry stools. Her vital signs include a pulse of 105 and a SBP of 115 mm Hg. Her initial hemoglobin is 9.6 g per dL. Which of the following is most likely to be useful in this patient?

Continuous pantoprazole infusion

Which of the following is true regarding gonococcal septic arthritis?

Synovial fluid Gram stain is positive more often than culture.

Which of the following is true regarding pediatric EKG analysis?

T-wave inversion in the anterior precordial leads (V1-V3) is a normal finding in school-aged children.

A 19-year-old woman presents with a red, painful eye for 2 days. She is a contact lens wearer. The eye is shown in white light, as seen in Figure 2-6. Which of the following is the most likely diagnosis?

Corneal ulcer

A 76-year-old woman presents after a fall from standing height onto a countertop. She landed on the right side of her ribcage and complains of pain in that area and difficulty taking a deep breath. Vital signs are normal and physical examination is remarkable only for point tenderness in the right lateral fourth and fifth ribs. A chest x-ray done in the ED is normal. Which of the following is the most appropriate next step in management?

Discharge home with pain medication and incentive spirometer

A 44-year-old woman presents with right wrist pain. She fell on her hand the previous day and has pain in her radial wrist. The wrist is tender in the anatomic snuffbox. Plain radiographs of the wrist are completely normal. Which of the following is the most appropriate next step in management?

Discharge home with thumb spica splint

Which of the following is the most common cause of encephalitis?

Enteroviruses

A 42-year-old previously healthy woman presents with a 'bad' sore throat and painful swallowing. She is febrile, but nontoxic and in no respiratory distress. A lateral soft-tissue neck film is ordered and is shown in Figure 2-5. Which of the following is the cause of this patient's illness?

Epiglottitis

A 65-year-old woman presents with 2 hours of severe, diffuse, progressively worsening acute abdominal pain. Blood pressure is 150/90, and abdominal examination demonstrates a palpable pulsatile mass. Abdominal CT scan is shown in Figure 2-7. Which of the following is true regarding management of this patient?

The patient should be crossmatched for 10 units of packed red blood cells.

A 45-year-old woman presents with intermittent epigastric pain and nausea for several weeks. She denies fever, diarrhea, cough, and chest pain. She does not take medications, drink alcohol, or smoke. She has had an extensive workup including CT scan of the abdomen and pelvis, gall bladder ultrasound, and cardiac stress testing, all of which were normal. You suspect gastritis. Which of the following is the most likely cause?

Helicobacter pylori infection

Which of the following is the most effective treatment for lithium poisoning?

Hemodialysis

A 1-week-old term male infant who was delivered at home is brought to the ED by his parents with abdominal distension, difficulty passing stools, failure to thrive, and bilious vomiting. Digital rectal examination reveals an empty rectal vault but stimulates significant stool and gas production once the finger is removed. Which of the following is the most likely cause of these symptoms?

Hirschsprung's disease

A 9-year-old boy presents with fever, sore throat, and refusal to eat or drink because of severe odynophagia. His oropharyngeal examination is shown in Figure 3-5. Which of the following is the most likely etiology?

Coxsackievirus

A 44-year-old man with AIDS presents with chronic diarrhea, flatulence, and generalized malaise for 1 month. Which of the following is the most likely cause of his symptoms?

Cryptosporidium spp.

A 35-year-old patient is brought to the ED by his parents for evaluation of psychiatric illness. Which of the following is an indication for hospital admission on psychiatric grounds?

Homicidal ideation

A 59-year-old man with a history of alcoholic cirrhosis presents with worsening abdominal pain and swelling. He normally receives therapeutic paracenteses every few weeks but has not had one in a month. He has no fever, vomiting, or diarrhea. Vital signs are 98.9°F, 85, 18, 105/65, 99% RA. He has mild cognitive deficits per his baseline with hepatic encephalopathy (HE). He is in no respiratory distress. Abdominal examination demonstrates moderate distention with fluid wave but only mild tenderness and no rebound or guarding. Which of the following is the most appropriate next step in management?

Diagnostic paracentesis

A 7-year-old girl presents with syncope without a prodrome. EKG shows QT prolongation. Family history is most likely to reveal which of the following?

Deafness

Which of the following is an expected laboratory abnormality in patients with HELLP syndrome?

Decreased hemoglobin

Which of the following is the major pathophysiologic mechanism in gastroesophageal reflux disease?

Decreased lower esophageal sphincter tone

A 42-year-old man presents with left foot pain. He states his foot folded underneath him after he jumped from a short ledge during a game with his son. His body weight first landed on his plantar-flexed foot and then the foot folded beneath him. He now has difficulty ambulating. An x-ray is shown in Figure 1-11. Which of the following is true?

Degenerative arthritis is the most common complication.

Which of the following is true regarding neck trauma?

Delayed neurologic deficits after blunt neck trauma suggest carotid artery dissection.

Patients with botulism most classically present with which of the following?

Descending symmetric paralysis.

A 2-year-old boy is brought to the ED by his parents for loud breathing for several hours. He had upper respiratory symptoms for several days, followed by a persistent, high-pitched cough. The parents have noticed loud inspiratory noises for the last two evenings. Vital signs are 99.5°F, 112, 24, 93% RA. The patient appears to be in mild respiratory distress, with mild inspiratory stridor and frequent bouts of coughing. Lungs are clear to auscultation. Which of the following is the most appropriate management?

Dexamethasone

Which of the following is associated with carpal tunnel syndrome?

Diabetes

Which of the following helps to differentiate a sympathomimetic crisis from an anticholinergic crisis?

Diaphoresis

A 64-year-old man presents to the ED with several weeks of heel pain. He used to have pain only with heavy exercise, but gradually it has started limiting walking as well. It even occurs in the morning when he wakes up and walks for the first time. He decided not to inform his primary care doctor about this pain and came to the ED for evaluation. He has mild tenderness to palpation on the proximal plantar heel but an otherwise unremarkable physical examination. Radiographs are normal. Which of the following is the most appropriate next step in management?

Discharge with Achilles tendon stretching exercises

Thirty minutes after a 35-year-old woman presents to the ED with a severe asthma exacerbation, you intubate her because she is showing signs of fatigue and ventilatory failure. You use ketamine and succinylcholine, and pass the endotracheal through the vocal cords without difficulty. A colleague who is assisting you aggressively 'bags' the patient until the respiratory therapist connects the mechanical ventilator. Thirty seconds after intubation, the nurse reports that the patient's blood pressure (BP) has dropped to 93/46. Her BP before intubation was 138/80. The patient has an 18-gauge peripheral intravenous (IV) line in her left antecubital fossa and her trachea appears midline. What is the best course of action?

Disconnect the ventilator but keep the endotracheal tube (ETT) in place and allow the patient to exhale.

Shortly after intubating a 70-kg patient for severe, refractory asthma, the ventilator alarm is set off due to elevated peak airway pressures. The plateau pressure is within normal limits (30 mm Hg). The ventilator settings are assist-control, rate 12 per minute, tidal volume 500 mL, peep 0 cm H2O, and inspiratory flow rate 60 L per minute. The POx is 98% to 99% with an FiO2 of 100%. The BP is 135/80, and the pulse is 115 with sinus tachycardia on the monitor. What is the next best step?

Do nothing, the elevated peak airway pressure is unlikely to harm the patient

A 24-year-old man with no past medical history presents with intermittent fevers, shortness of breath, cough, and malaise for 1 week. Vital signs are 100.3°F, 85, 20, 145/92, 98% RA. Chest x-ray demonstrates patchy interstitial infiltrates. Which of the following is the most appropriate treatment regimen?

Doxycycline

Which of the following is true regarding adult epiglottitis?

Drooling and stridor are infrequent presenting signs.

In an acute NSTEMI, which of the following advantages does bivalirudin possess over unfractionated and low-molecular weight heparins?

Lower incidence of major bleeding

A 6-year-old boy presents with diffuse arthralgias, fatigue, and fever for several days. He had a 'virus' with fever and sore throat several weeks before, which resolved spontaneously. Physical examination demonstrates a febrile child with significant tenderness and limited range of motion in his left knee with milder findings in his right wrist. Which of the following is the most appropriate next step in management?

EKG

Which of the following is useful as a sensitive screening test for clinically significant complications of blunt cardiac injury?

EKG

Among patients presenting with a NSTEMI, which of the following describes the appropriate use of antiplatelet therapy?

Either clopidogrel or a GPIIbIIIa inhibitor should be used in addition to aspirin.

Which of the following is true regarding elder abuse?

Elder abuse is associated with increased morbidity and mortality.

Which of the following laboratory abnormalities is most commonly associated with hyperemesis gravidarum?

Elevated liver enzymesWhich of the following has the greatest immediate effect on preload in the management of acute congestive heart failure (CHF)?@Nitroglycerin

A 55-year-old man presents with severe chest pain radiating to the back. A CT scan of the chest reveals both ascending and descending aortic dissections. Which of the following is true regarding this patient?

Emergent surgery is warranted.

A 3-year-old girl swallows a button battery. Plain radiographs demonstrate that the battery is lodged in the esophagus. Which of the following is the most appropriate next step in management?

Endoscopic removal

Which of the following is an indication for antibiotic prophylaxis in patients with prosthetic heart valves?

Endoscopic retrograde cholangiopancreatography (ERCP)

A 23-year-old man presents to the ED with loss of consciousness after being kicked in the head. He is now awake and alert and complains of a headache. Brain computed tomography (CT) is performed and a slice is shown (Fig. 1-6). Right after the CT scan, he becomes unresponsive. Which of the following is the most appropriate next step in management?

Endotracheal intubation

A 3-year-old male is brought to the ED by his parents with a chief complaint of excessive drowsiness, fever, and decreased oral intake. Examination reveals an ill-appearing child, with tachypnea and increased work of breathing. He is pale, and his extremities are cool and mottled with decreased peripheral pulses. He is not interactive during the examination, and his vitals reveal T 102.7, P 185, BP not measurable, RR 56, SaO2 93%. An IV is established and the patient is given broad-spectrum antibiotics and three boluses of normal saline at 20 mL per kg per bolus, for a total of 60 mL per kg, with little improvement in his perfusion or clinical status. Which of the following vasopressors is the initial preferred agent?

Epinephrine

A 6-year-old girl is brought to the emergency room 4 hours after developing a brief choking episode while playing with her toys. Her chest x-ray is shown in Figure 1-8. Where is the foreign body located?

Esophagus

Which of the following best describes the use of chest x-rays in the diagnosis of acute aortic dissection?

Even a completely normal chest x-ray does not exclude aortic dissection.

A 44-year-old male presents to the ED with a 3-day history of a painful rash on his right buttock and leg (Fig. 4-4). He has a history of inflammatory bowel disease and is on immunosuppressive therapy with 6-mercaptpurine and low-dose methotrexate. He first presented to his primary care physician who referred him to the emergency room due to concern for disseminated varicella zoster virus (VZV) infection. Which of the following is true?

Even in immunocompromised patients, disseminated VZV is rarely fatal.

Which of the following is true regarding anaphylaxis?

Exercise may trigger anaphylaxis.

A 35-year-old man presents with a severe head injury after being struck in the head with a baseball bat. His vital signs are HR 135, BP 82/45, RR 20. Which of the following is the most likely cause of his hypotension?

Extracranial cause

Which of the following effects is directly responsible for the QRS prolongation seen in tricyclic antidepressant poisoning?

Fast sodium channel blockade

A 26-year-old primigravida is diagnosed with a spontaneous abortion at 6 weeks' gestation. She asks you, 'why did this happen?' Which of the following is the most common cause of first-trimester miscarriage?

Fetal chromosomal trisomy

Which of the following is true regarding rheumatoid arthritis (RA)?

Fifteen percent of patients will have a negative rheumatoid factor (RF).

A 26-year-old woman presents with a rash on her legs (Fig. 4-6). She states that she has been feeling somewhat tired lately and notes generalized body and joint aches, as well as a sore throat. Over the last day or so, she has noted a rash developing over her anterior shins. The rash is very tender to the touch and is nonpruritic. Which of the following is true?

First-line treatment is with aspirin or nonsteroidal antiinflammatory drugs (NSAIDs).

Which of the following is a negative symptom of schizophrenia?

Flat affect

Which of the following studies has the highest sensitivity for traumatic pericardial tamponade?

Focused Assessment with Sonography in Trauma (FAST) scan

A 60-year-old man presents with acute urinary retention. He has been unable to urinate for the last 10 hours and has extreme discomfort in his lower abdomen. His physical examination is normal except for a distended suprapubic region and nontender prostatic hypertrophy. He appears very uncomfortable. Which of the following is the most appropriate next step in management?

Foley catheter placement

Which of the following is true regarding West Nile virus (WNV) infections?

Following recovery, immunity is likely lifelong.

A 45-year-old woman with a history of hypertension presents with tongue swelling, as shown in Figure 4-11. She was recently started on a new blood pressure medication. Despite therapy with steroids, antihistamines, and epinephrine, her condition continues to worsen. In addition to measures for airway control, which of the following is most likely to be helpful in this patient?

Fresh frozen plasma

Cancer of which of the following organs is the most common cause of superior vena cava (SVC) syndrome?

Lung

Which of the following is the most likely cause?"

Gastroenteritis

A 54-year-old man with a history of chronic alcohol abuse is brought in by his wife because of a 'big stomach' and confusion. She tells you his stomach has been big for 1 year but over the last month she adds that he seems to be forgetting things, has had difficulty sleeping, and has not been tending to his own appearance. Which of the following is true?

Gastrointestinal (GI) bleeding may exacerbate or trigger this condition.

The most common complication of peptic ulcer disease (PUD) is:

Gastrointestinal bleeding

A 56-year-old man with a history of alcoholic cirrhosis presents with altered mental status. According to his wife, he reportedly stopped taking his lactulose several days prior to his ED evaluation. He is disoriented and confused and demonstrates asterixis. He has normal vital signs. Laboratory studies are unremarkable except for a chronically elevated prothrombin time (PT). Noncontrast CT of the brain is normal. The ammonia level is only mildly elevated. Which of the following is the next best step in management?

Give lactulose

Which of the following is the major complication of ischemic central retinal vein occlusion (CRVO)?

Glaucoma

A 64-year-old woman is brought in by emergency services (EMS) with a chief complaint of 'anaphylaxis.' The patient has a known peanut allergy and inadvertently ingested some ground nuts in a dish prepared by a friend. She has a known history of coronary artery disease and is taking metoprolol. Her symptoms do not respond to epinephrine, corticosteroids, or antihistamines. She is intubated but remains hypotensive and unstable. Which of the following may be of benefit?

Glucagon

Which of the following vasculitis syndromes is most likely to present as pulmonary hemorrhage requiring emergent airway management?

Goodpasture's syndrome

A 34-year-old man is brought into the emergency department (ED) after a motor vehicle collision. Which of the following findings is an indication to perform a computed tomography (CT) of the abdomen/pelvis with IV contrast to look for renal injury in this patient?

Gross hematuria

The absence of which of the following has almost 100% sensitivity in the setting of trauma?

Gross hematuria

A 55-year-old woman presents with sore throat, runny nose, intermittent low-grade fevers, and generalized malaise. She feels like something is stuck in her throat, causing odynophagia. She is nontoxic appearing, has no respiratory distress, and has normal vital signs. A lateral soft tissue of the neck is shown in Figure 2-16. Which of the following is the most likely etiology?

H. influenzae

A 29-year-old male emergency medicine resident physician presents immediately after a needle stick from performing a procedure on a known chronic hepatitis B (HB) virus carrier. He has not ever received vaccination for HB. Which of the following is the next best step in management?

HB vaccine plus HBIG

A 62-year-old man with a history of chronic alcoholism presents with acute-onset epigastric abdominal pain. Initial labs reveal a white blood cell (WBC) count of 19,000 per mm3, a normal chemistry with a glucose of 168 mg per dL, a lactate dehydrogenase (LDH) of 400 IU per L, liver enzymes demonstrating an aspartate aminotransferase (AST) of 137 SF units and an alanine aminotransferase (ALT) of 94 SF units, and a lipase level that is five times the lab's upper limit of normal. You admit him with a diagnosis of acute pancreatitis. Which of the following is true?

He has 3 Ranson's criteria upon admission.

Upon starting your shift, you receive sign-out on a 46-year-old male diabetic patient who is being treated with an intravenous insulin drip for diabetic ketoacidosis (DKA). Two hours later, a repeat chemistry panel reveals the following: Na+ 141 mEq/L, Cl- 112 mEq/L, HCO3- 17 mEq/L, blood urea nitrogen (BUN) 16 mg/dL, creatinine 0.9 mg/dL, glucose 278 mg/dL. Which of the following is true?

He should be given subcutaneous insulin and his insulin infusion can be discontinued after 30 to 60 minutes.

Which of the following is the most common complication of otitis media?

Hearing loss

A 47-year-old man with a history of alcoholism presents with a chief complaint of jaundice, right upper quadrant pain, and a low-grade fever. He had his last drink earlier in the day. Which of the following is true?

Hepatomegaly is the most common physical examination finding.

One week after returning from India, the parents of a previously healthy 9-year-old girl bring her to the emergency room for evaluation of a 3-day history of progressive fever, headache, malaise, nausea without vomiting, and generalized abdominal pain with minimal loose stools but no frank diarrhea. In addition to completing the CDC's routine vaccination series, she received additional vaccinations for Hepatitis A and Yellow fever prior to her trip and she took Mefloquine for malaria prophylaxis throughout her visit. In the emergency room, she is noted to appear dehydrated but has a pulse in the low 50s. There is also a faint, blanching, erythematous rash over her chest and upper abdomen. Blood testing reveals anemia with a minimally elevated white blood cell (WBC) count, and moderately elevated liver function tests. Which of the following is true?

Her relative bradycardia in the setting of a high fever may indicate Typhoid fever.

Which of the following is the most effective method of eliminating symptoms in acquired immune deficiency syndrome (AIDS) patients with Cryptosporidium diarrhea?

Highly active antiretroviral therapy (HAART)

Appropriate initial therapy in an adult patient with epiglottitis includes which of the following?

Humidified oxygen, IV ceftriaxone

Which of the following is the earliest electrocardiogram (EKG) finding in acute myocardial infarction (MI)?

Hyperacute T waves

A 26-year-old woman presents with intermittent nausea and vomiting, orthostatic lightheadedness, and mild diffuse abdominal pain. She also notes that her skin has darkened over the last month although she has been indoors. Which of the following laboratory abnormalities are you most likely to find?

Hyponatremia

A 77-year-old man with type 2 diabetes presents with a 4-day history of progressively worsening left ear pain, hearing loss, and discharge. On examination, he has a temperature of 101°F, he appears fatigued, and his tympanic canal is markedly edematous with foul drainage. His glucose level is 400. Which of the following is true regarding this condition?

IV ciprofloxacin and ENT consultation are indicated.

Most cases of pseudogout are:

Idiopathic

Primary chronic adrenal insufficiency is usually due to:

Idiopathic

Which of the following is the most common cause of dilated cardiomyopathy?

Idiopathic

A 25-year-old woman presents to the ED with worsening left-sided pelvic pain and vaginal discharge. She states that she was seen in the office by her primary care doctor 3 days ago for similar problems, received an injection of an antibiotic and was given a prescription that she has not had a chance to fill. In the ED, she has a fever, purulent vaginal discharge, cervical motion tenderness, and a palpable, tender left-sided adnexal mass. Which of the following is true?

If untreated, rupture of the mass and secondary peritonitis may occur.

Which of the following is true regarding electrical injury?

In contrast to other mass casualty traumatic events, patients without signs of life should be resuscitated first.

Which of the following is true about gastric volvulus?

In most cases, a nasogastric tube cannot be passed into the stomach.

Which of the following, when associated with the presence of an infection, comprises the most accurate definition of septic shock?

Inadequate tissue perfusion

A 62-year-old woman with a history of O2-dependent chronic obstructive pulmonary disease (COPD) presents to the ED with a chief complaint of dyspnea and increased cough productive of yellow phlegm. The patient uses 2 L of O2 at home. The patient is an ill-appearing, dyspneic woman speaking in sentence fragments. Her SaO2 reads 85% on 4 L of O2 by nasal cannula. As you start to increase her O2, you wonder if you are going to eliminate her respiratory drive. The next best step is to:

Increase the O2 to 6 L, because minute ventilation changes little in COPD patients exposed to higher levels of oxygen

You are working in the ED when a 74-year-old woman with chronic obstructive pulmonary disease (COPD) presents with an acute COPD exacerbation. You start her on bilevel positive airway pressure (BiPAP) at a rate of 10, an inspiratory positive airway pressure (IPAP) of 10 mm Hg and an expiratory positive airway pressure (EPAP) of 4 mm Hg. Twenty minutes later, the patient's oxygenation has not improved. Which of the following changes would most likely increase this patient's oxygenation?

Increase the patient's EPAP from 4 to 7, and the IPAP from 10 to 15

The most common cause of death in recipients of a solid-organ transplant is:

Infection

A 20-year-old man presents with fever, sore throat, and fatigue for 1 week. He took a friend's antibiotic after 2 days of illness and developed a red rash all over his body, so he stopped the antibiotic. His oropharynx is mildly red without exudates, and he has cervical lymphadenopathy and splenomegaly. Rapid strep testing and monospot are both negative. Which of the following is the most likely diagnosis?

Infectious mononucleosis

A 12-year-old boy presents with progressive testicular swelling. Testicular examination is shown in Figure 1-15. Which of the following is the most common complication of this condition?

Infertility

Which of the following routes of administration causes the fastest onset of action of cocaine?

Inhalation

Which of the following is true regarding acute salicylate toxicity?

Initial symptoms of toxicity are tinnitus and altered hearing.

A 46-year-old morbidly obese (BMI >40) male patient is referred to the ED to exclude a DVT after he presented to his primary care physician's office with calf swelling and pain for 1 week. His subsequent Doppler study demonstrates a thrombosis limited to the peroneal vein. Which of the following describes the next best steps in management?

Initiate anticoagulation with warfarin or dabigatran (Pradaxa) and low-molecular weight heparin, and refer for primary care follow-up

What is the most common cause of death in patients with hemophilia A?

Intracranial hemorrhage

A 26-year-old man with a history of bipolar disorder is brought in by his mother with a chief complaint of agitation. She states that her son has been very anxious and restless, has not been sleeping, and abruptly stopped taking his lithium medication 2 days ago. His mother has a history of Graves' disease but is otherwise healthy. In the ED, the patient's vital signs include a temperature of 104.1°F, pulse of 120, with sinus tachycardia visible on the monitor, and a blood pressure (BP) of 140/70. On examination he is mildly agitated, warm and diaphoretic, tremulous, and has a slight lid lag. Which of the following is the next best step?

Intravenous propranolol administration

Which of the following has been shown to increase the risk of brain tumors?

Ionizing radiation

Which of the following results from a lesion within the pons?

Ipsilateral facial droop with contralateral hemiparesis.

Erysipelas

Is an infection of the dermis that involves the lymphatic system

Radiation enteritis. . .

Is primarily treated with supportive care.

A 65-year-old man presents with a chief complaint of double vision. On examination, covering either eye causes the diplopia to resolve. Which of the following is the most likely cause?

Isolated cranial nerve palsy

Which of the following is true regarding hip fractures?

Isolated fractures of the lesser trochanter are most commonly seen in young adults.

Which is the most appropriate management for a patient with suspected smallpox lesions?

Isolation

Which of the following is the most commonly ingested alcohol after ethanol?

Isopropanol

A 6-year-old boy presents with left hip pain and a limp. There is no history of trauma. The pain is relieved by rest. Plain radiographs are shown in Figure 4-10. Which of the following is true regarding this condition?

It is much more common in boys than in girls.

Which of the following is true regarding botulism?

It is not contagious.

A 20-year-old previously healthy female college student presents to the ED with diarrhea. She went on a camping trip 2 weeks ago but denies any other travel. She notes seven to eight watery, foul-smelling stools per day and generalized abdominal cramping. A test for fecal leukocytes, ordered in triage after the patient had a large diarrheal stool, is negative. Which of the following is the best management?

Metronidazole 250 mg t.i.d. for 7 days

Which of the following is true regarding isopropanol poisoning?

Ketosis without acidosis is the characteristic lab abnormality.

What is the most common source of bleeding in an anterior nosebleed?

Kiesselbach plexus

Which of the following is the most appropriate initial antihypertensive medication for use in patients with severely elevated blood pressure and acute cardiac ischemia?

Labetalol

Which of the following parenteral agents is the initial preferred agent for blood pressure management in patients with acute aortic dissection?

Labetalol

Which of the following is the most sensitive physical examination test for an anterior cruciate ligament (ACL) tear?

LachmanA 34-year-old woman presents with shoulder pain following a fall. Physical examination is normal except for tenderness in the middle of the clavicle. Radiographs demonstrate a nondisplaced clavicle fracture. Which of the following is the most appropriate course of action?@Shoulder sling

A 44-year-old man presents after a motor vehicle crash (MVC) with scrotal pain. Blood was noticed initially at the urethral meatus, but a 16-Fr Foley catheter was mistakenly placed with return of yellow urine. Which of the following is the most appropriate next step in management?

Leave the catheter in place and obtain urologic consultation

A 55-year-old man presents from his doctor's office with nausea, vomiting, right upper quadrant pain, and abnormal outpatient labs. Which of the following is consistent with alcoholic hepatitis?

Leukocytosis

Which of the following is true about appendicitis in pregnancy?

Leukocytosis may be physiologic during pregnancy.

Phenytoin most closely resemble which of the following antidysrhythmics?

Lidocaine

Which of the following is true regarding lipase and amylase in the setting of acute pancreatitis?

Lipase is more specific than amylase.

Among patients presenting to the ED with chest pain, which of the following physical examination findings is the biggest risk factor for aortic dissection?

Long, slender fingers

Which of the following is true regarding the use of corticosteroids in asthma management?

Long-term systemic corticosteroid use may be complicated by weight gain, aseptic necrosis of the femur, and PUD.

Which of the following is true about pilonidal abscesses?

Longitudinal incisions should be made lateral to the sacral midline.

A 15-year-old previously healthy female is brought to the ED by her parents with a chief complaint of SOB, palpitations, lightheadedness, and severe fatigue. The patient had been diagnosed with 'a viral infection' by her pediatrician five days before presenting to the ED. While she initially seemed to improve, she complains of feeling SOB with a sense that her heart is 'beating out of her chest' for the past day. Her parents noted she was breathing fast, and she appeared to be 'winded' even when sitting down. Upon arrival, she is pale and ill-appearing, with vitals of T 98.6, P 143, RR 28, BP 105/70, and SaO2 of 92% on RA. A chest x-ray demonstrates fluffy bilateral infiltrates. Her lung examination reveals tachypnea with increased work of breathing, and rales without wheezes. Which of the following is true of the patient's likely underlying problem?

Loop diuretics and inotropes may be helpful in her management.

A 22-year-old woman presents to the ED with symptoms of extreme panic. She tells you that she just used lysergic acid diethylamine (LSD) for the first time. Which of the following is true regarding this patient?

Lorazepam may be used to reduce agitation.

Which of the following deficits below the level of injury is consistent with an anterior cord syndrome?

Loss of pain and temperature sensation and motor function and bladder incontinence.

Which of the following characteristics are true regarding Kernig's and Brudzinski's signs in the diagnosis of meningitis?

Low sensitivity but high specificity

A 36-year-old primigravida presents to the ED at 32 weeks' gestation with epigastric pain. Her BP is 150/100, but other vital signs are normal. While the nurse is performing his assessment in the room, the patient begins to seize. The next best step in management is:

Magnesium 6 g slow IV pushWhich of the following is true regarding urine analysis?@White blood cell casts indicate renal parenchymal inflammation.

A 44-year-old woman presents with right leg pain. She has noticed increasing pain in the middle of her tibia over the last few weeks since she started training for a marathon. Physical examination of the entire lower extremity is normal except for mild tenderness to palpation in the area of pain. Radiographs of the tibia are normal. Which of the following is true regarding this patient's condition?

Magnetic resonance imaging (MRI) is the test of choice to differentiate shin splints from stress fractures.

Which of the following is the most common cause of large bowel obstruction?

MalignancyWhich of the following is a risk factor for cholelithiasis?@All of the above

A 32-year-old G3P2 at 39 weeks' gestation presented to your community ED after spontaneous rupture of membranes and with regular uterine contractions roughly 3 minutes apart. Although the fetal head delivers without difficulty, the shoulders appear to be trapped and you suspect shoulder dystocia. The next best step in management should be:

McRobert maneuver

A 75-year-old man presents with a fall on an outstretched hand. Radiographs demonstrate a distal radius fracture with dorsal displacement of the distal segment. Which of the following is the most likely nerve injury?

Median

A rash that starts on the wrists and ankles is typical in cases of:

Meningococcemia

Which of the following opioids may predispose to serotonin syndrome?

Meperidine

The most common etiology of an intracranial tumor is:

Metastases

Which of the following can be used to treat hypertrophic cardiomyopathy?

Metoprolol

Which of the following represents the characteristic acid-base disturbance seen in aspirin toxicity?

Mixed respiratory alkalosis with metabolic acidosis

A 3-year-old boy had a ventriculoperitoneal shunt (VPS) placed at 22 months due to hydrocephalus. It has not been revised since then and he has had no problems with it. He is now brought to the ED with a history of fever of 38.2°C, headache, and 'fussiness.' Which of the following is true about this patient?

Most patients with a VPS infection have peripheral leukocytosis.

Which of the following is true regarding imaging of patients with suspected sinusitis?

Most patients with viral upper respiratory infections (URIs) have abnormal CT scan findings.

A 29-year-old woman presents after going running on the treadmill with cough, shortness of breath, and chest tightness. She has no throat swelling or rash. Her examination is normal except for bilateral wheezes. She has been taking an over-the-counter medication for her intermittent migraine headaches. What medication is the most likely cause?

Naproxen

Which of the following is true about Salmonella infections?

Nearly half of the patients hospitalized with salmonellosis are immunocompromised.

Which of the following therapies has the fastest onset of action in reducing serum potassium levels in cases of hyperkalemia?

Nebulized albuterol

A 7-year-old girl is brought in by her father after choking on a plastic toy. She was coughing violently and gasping in the car, so the father tried the Heimlich maneuver and a blind finger sweep but she seemed to get worse. His daughter is now unconscious and cyanotic. After performing a jaw-thrust maneuver, you fail to locate the foreign body. Attempts to place an endotracheal tube fail, as the tube seems to be striking an object. What is the best next step?

Needle cricothyroidotomy

Which of the following is the most common toxicity associated with cyclosporine?

Nephrotoxicity

A 32-year-old pregnant woman in her third trimester presents with dysuria. She has a penicillin allergy. Urinalysis demonstrates bacteria, but no white blood cells, leukocyte esterase, or nitrites. Physical examination is normal. Which of the following is the most appropriate next step in management?

Nitrofurantoin

A 35-year-old marathon runner who is asymptomatic presents from an outside hospital with an 'abnormal EKG.' The EKG is shown in Figure 3-4. Your advice to the patient is:

No acute therapy, routine follow-up

A 29-year-old man is sent by his primary care doctor's office for evaluation of an abnormal EKG. He is asymptomatic and his physical examination is normal. The EKG is shown in Figure 2-1. Which of the following is the most appropriate next step in management?

No acute therapyWhich of the following is most characteristic of ethylene glycol overdoses?@Hypocalcemia

A previously healthy 35-year-old male is brought to the ED with a chief complaint of fever and altered mental status. The patient had been well until 1 day prior to admission, when he developed a fever and general malaise. He was too ill to work on the day of evaluation, and when his wife returned from work, she found him hot, sweaty, and 'out of it.' The patient presents with a temperature of 102.1 F, P 103, RR 18, BP 125/75, SaO2 97% RA. He is awake, but somnolent and confused. A lumbar puncture is performed which reveals gram-positive cocci in pairs. His wife asks about receiving prophylactic therapy. Which of the following is most appropriate?

No prophylaxis is indicated.

Which of the following is an absolute contraindication to the use of epinephrine in anaphylaxis?

None of the above

Which of the following is an ingredient in sitz baths?

None of the above

Which of the following is true regarding liver abscesses?

None of the above.

A 55-year-old woman with chronic obstructive pulmonary disease (COPD) presents with acute dyspnea, purulent cough, and fever. Vital signs are 100.4°F, 110, 22, 175/90, 98% on 4L NC. She has mild neck muscle retractions and bilateral rhonchi. Chest x-ray shows no focal infiltrate. Albuterol nebulizer, methylprednisolone 125 mg IV, and levofloxacin 500 mg IV have only minimally improved respiratory distress. Which of the following is the next best step in management?

Noninvasive positive pressure ventilation

A 5-day-old neonate presents for routine follow-up. The child is acting normally. Funduscopic examination demonstrates bilateral retinal hemorrhages. Which of the following is the most likely cause?

Normal birth trauma

A 35-year-old man presents with acute onset of pleuritic, right-sided chest pain for 2 days associated with mild dyspnea. He has no fever, cough, or chills. He reports no past medical history except smoking. Vital signs are 98.9°F, 105, 20, 120/70, 97% RA. Examination is unremarkable except for tachycardia. Electrocardiogram (EKG) shows sinus tachycardia without any other abnormalities, and chest x-ray reveals a small right-sided pleural effusion with clear lung fields. Which of the following is the next best step in management?

Order d-dimer

Which of the following toxins is suggested by the smell of garlic?

Organophosphate

A 62-year-old male is being transported to the hospital by EMS with a chief complaint of chest pain and shortness of breath. After placing the patient on oxygen and giving aspirin and sublingual nitroglycerin, the EMS providers transmit the initial 12-lead EKG, which is shown in Figure 2-9. Which of the following is the most appropriate next step upon EMS arrival?

Prepare the catheterization laboratory's STEMI team for immediate cardiac catheterization.

A 65-year-old man with multiple myeloma presents with generalized weakness and fatigue. His physical examination is unremarkable except for severe lethargy. Serum calcium level is 14 mg per dL. Which of the following is the most appropriate next step in management?

Normal saline

A 23-year-old man presents with flaccid bilateral lower extremity paralysis 1 day after being assaulted. An anterior lumbar spinal cord injury is identified. Which of the following is the most appropriate therapy at this time?

Normal saline hydration

In a normal singleton pregnancy, which of the following is true?

Only fetuses with a longitudinal lie can be safely delivered vaginally.

A 6-year-old girl is brought to the ED by her parents with multiple loose, nonbloody stools for 1 day. She has no vomiting or fever. Many of her classmates in school have similar symptoms. She appears mildly dehydrated, with slightly sunken eyes and dry mucous membranes. Vital signs are 99°F, 115, 22, 95/55, 100% RA. Basic chemistry and complete blood count panels are normal. Which of the following is the most appropriate therapy?

Oral fluid therapy with sugar and salt solution

A mother brings in her 12-year-old son with a chief complaint of alopecia. The patient denies any complaints and has been well recently. The lesion is shown in Figure 4-2. Which of the following is the treatment of choice?

Oral griseofulvin

Which of the following is true regarding hypokalemia?

Patients with a recent myocardial infarction (MI) are at increased risk for ventricular arrhythmias if the potassium concentration is less than 4.0 mEq/L.

Which of the following is the main therapeutic action of mannitol in patients with head injury?

Osmotic diuresis

Which of the following is true regarding treatment of otitis media?

Otitis media represents the number one reason for outpatient antimicrobial prescriptions in the United States.

A 22-year-old man presents with a swollen area on his scrotum shown in Figure 4-1. The area is firm and nontender to palpation and does not transilluminate. Which of the following is the most appropriate next step in management?

Outpatient urology referral

A 59-year-old female with a history of sick sinus syndrome status post pacemaker placement presents to the ED with a chief complaint of dizziness and shortness of breath. Her vital signs are T 98.6, P 42, BP 96/48, and SaO2 97% on RA. Her initial EKG demonstrates sinus bradycardia, with occasional ventricular escape beats. No pacer spikes are observed. After a magnet is applied to the patient's pacemaker, a repeat EKG demonstrates a paced rhythm at a rate of 70 beats per minute. Which of the following is the most likely cause of the patient's pacemaker dysfunction?

Oversensing

A 67-year-old female with a history of AML presents to the ED with a chief complaint of headache, dizziness, shortness of breath, and fever that began on the day of presentation. She had been evaluated by her hematologist 2 days prior, at which time her WBC count was 22,000 per μL, and she was told she had a relapse of her AML and needed to resume chemotherapy. In the ED, her WBC count is 132,000 per μL, hemoglobin is 8.7 g per dL, and platelet count is 42,000 per μL. A chest x-ray reveals interstitial infiltrates, and a lumbar puncture is normal. SaO2 is 94% on RA. Which of the following is the next best course of action?

Oxygen, aggressive IV hydration, allopurinol, antibiotics

Which of the following is the most specific EKG finding in acute pericarditis?

PR depressions

Which of the following is true about peptic ulcer disease?

Pain that wakes patients in the middle of night is typical of duodenal ulcers.

Which of the following is true regarding orbital cellulitis?

Pain with extraocular movements is a characteristic finding.

'Hard' findings of vascular injury mandating immediate angiography after trauma to an extremity include:

Palpable thrill

Erosion into the carotid artery is most commonly a complication of which of the following?

Parapharyngeal abscesses

A 70-year-old woman presents with blurry vision in her right eye and a right-sided headache. The patient also complains of malaise, and is tender in her right temporal region. Which of the following is true regarding this patient's illness?

Patients have a higher risk of arterial aneurysms.

Which of the following is true with respect to carditis caused by Lyme disease?

Patients most commonly present with variable degrees of atrioventricular (AV) block.

Which of the following is true regarding retropharyngeal abscesses (RPAs)?

Patients with RPAs generally prefer to lie supine.

An 18-year-old woman presents to the emergency department (ED) with acute onset severe right lower quadrant pain. Initially, she was doubled over with pain and had immediate nausea and vomiting just prior to her ED evaluation. The pain resolved almost completely after 15 minutes, and then she had a second episode while in the ED waiting room. The patient is currently pain-free. Her last menstrual period was 2 weeks ago. She has a family history of kidney stones. Her vital signs are normal. Physical examination is unremarkable except for mild fullness and tenderness in the right adnexa. Her CBC, chemistry, and urinalysis are normal and her urine pregnancy is negative. Which of the following is the most appropriate next step in management?

Pelvic ultrasound

A 24-year-old woman previously unvaccinated presents with progressively worsening sore throat and fever for 3 days. Her oropharyngeal examination reveals an extensive grayish membrane extending between both tonsils. Which of the following is the most appropriate management?

Penicillin plus antitoxin

Which of the following is a manifestation of hypocalcemia?

Perioral paresthesias

An ED thoracotomy is performed on a trauma patient. Which of the following is the structure labeled in Figure 1-17?

Phrenic nerve

A 22-year-old man presents for substernal chest burning for several weeks which is worse after eating. He denies fever, cough, or shortness of breath. He does not smoke, drink alcohol, drink caffeine, or take over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). His only medication is a pill for acne. His physical examination, chest x-ray, and EKG are normal. Which of the following is the most likely cause?

Pill esophagitis

A 22-year-old gang member is brought to an urban ED with a gunshot wound to his arm. Primary survey of the patient is intact, but a handgun is found in the patient's clothes. Which of the following is the most appropriate action by the physician at this time?

Place the gun away from care providers and notify local law enforcement.

A nasogastric tube (NGT) should be:

Placed in patients who have rectal bleeding of uncertain origin

Which of the following is a reasonable indication to perform tube thoracostomy in a patient with a parapneumonic pleural effusion?

Pleural fluid pH 7.0

Which of the following is true regarding patients with a primary spontaneous pneumothorax?

Pleuritic chest pain and dyspnea are the most common symptoms.

Which of the following correctly matches the vasculitic syndrome to its primary clinical manifestations?

Polyarteritis nodosa (PAN) and peripheral neuropathy and bowel ischemia

A 52-year-old woman presents with right upper quadrant pain and fever for 2 days. The pain is unaffected by eating, but she states that it hurts to breathe and cough. Vital signs are 102.5°F, 110, 20, 165/92, 100% RA. She appears fatigued and in some pain. She does not have jaundice. Her lungs are clear. She has definite right upper quadrant tenderness without a positive Murphy sign. Chest radiography is normal. You order a right upper quadrant ultrasound, which shows a normal gall bladder, but a large, cavitary, fluid-filled lesion in her right hepatic lobe. Which of the following is the most likely etiology?

Polymicrobial

A 23-year-old man with a history of human immunodeficiency virus (HIV) presents with shortness of breath, fever, and malaise. A chest x-ray is shown (Fig. 2-8). Arterial blood gas shows a PaO2 of 60 mm Hg. Which of the following, in addition to antibiotics, is the most appropriate therapy?

Prednisone

A 27-year-old woman at 33 weeks of gestation presenting with liver tenderness and evidence of coagulopathy is most suggestive of:

Preeclampsia

Which of the following most places women at risk for abruptio placentae?

Preeclampsia

A patient presents with the electrocardiogram (EKG) shown in Figure 1-3. Which of the following is the most likely pathophysiologic mechanism?

Preexcitation

In a human immunodeficiency virus (HIV)-positive patient with PCP pneumonia who has a sulfa allergy precluding the use of trimethoprim-sulfamethoxazole (TMP-SMX), which of the following is the best outpatient regimen?

Primaquine plus clindamycin

Which of the following is the number one cause of death in patients with congestive heart failure (CHF)?

Progressive hemodynamic deterioration

Which of the following best supports a diagnosis of pertussis in a child with cough?

Prolonged course

Which of the following is true regarding Bordetella pertussis infections?

Prophylaxis with erythromycin is recommended for adults who come into contact with pertussis-infected individuals.

What is the most common electrocardiographic (EKG) abnormality in patients with heatstroke?

QT interval prolongation

A 6-month-old infant born at term is brought by her parents for evaluation of cough. The patient has been coughing for 3 days, with rhinorrhea and congestion and fevers up to 101°F. Her past medical history and birth history are unremarkable. Vital signs in the ED are 100.1°F, 133, 42, 90/palp, and 98% RA. The patient is smiling, active, and tachypneic with mild nasal flaring and lungs exhibit moderate expiratory wheezes. Which of the following is true regarding this patient's condition?

RSV is the most common cause.

Which of the following is true regarding the systemic inflammatory response syndrome (SIRS) and sepsis in pediatric patients?

Regardless of the other criteria, patients must have either a leukocyte or a temperature abnormality to meet the definition of pediatric SIRS.

A 67-year-old woman with a history of hyperlipidemia, coronary artery disease, and hypertension is brought in by emergency medical services (EMS) after developing acute vertigo, ataxia with a tendency to veer to the left, nausea, and vomiting. She has had no tinnitus or decreased hearing. On examination, you find her to be mildly dysarthric and unable to stand or walk due to imbalance. Her right arm is very clumsy but her left arm appears to be normal. Her family tells you that she does not normally have problems with balance but that she had an acute fall without loss of consciousness approximately 2 weeks ago. What do you expect to see on her head CT?

Right cerebellar infarction

A 2-year-old boy is brought in by his parents with a rash on his trunk. On examination, you discover a rose-colored maculopapular rash on his chest, neck, and arms. The patient is currently afebrile, but the parents tell you that the patient was seen by one of your colleagues yesterday for a febrile seizure. Which of the following is the most likely diagnosis?

Roseola infantum

A 22-year-old woman presents with intermittent fever and chills for 2 weeks. She has no past medical history, but reports using intravenous heroin several times a week. Physical examination reveals a febrile, ill-appearing woman with a heart murmur. Blood cultures are most likely to reveal which of the following organisms?

S. aureus

The most common cause of acute mesenteric ischemia is:

SMA embolism.

A 45-year-old woman with alcoholic cirrhosis presents with abdominal distention and pain with low-grade fever. You suspect spontaneous bacterial peritonitis (SBP) and perform a paracentesis. The total cell count is 300 cells per mm3 with 60% neutrophils. Which of the following is the most appropriate next step in management?

Search for alternate cause for symptoms

Which of the following is true regarding posterior shoulder dislocations?

Seizures are a common mechanism of injury.

What is the most common cause of death in patients with toxic epidermal necrolysis (TEN)?

Sepsis

Which of the following is the most common cause of acute respiratory distress syndrome (ARDS)?

Sepsis

Which of the following is the most common cause of death in patients with sickle cell disease?

Sepsis

Which of the following is more characteristic of endocarditis in IV drug users than in nondrug users?

Septic pulmonary emboli

A 47-year-old man without significant past medical history presents with a chief complaint of burning epigastric abdominal pain. It does not radiate and occasionally wakes him up in the middle of the night. He takes no medicines and denies drinking alcohol. You suspect he may have peptic ulcer disease and want to test for Helicobacter pylori. Which of the following is the best initial screening method?

Serologic testing (IgG antibody testing)

A 68-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department (ED) with worsening dyspnea, cough, and subjective intermittent fevers. He tells you that he spent 1 week in the intensive care unit (ICU) 6 months ago after being intubated for a similar episode and states 'I don't ever want to be intubated again.' You discuss the use of noninvasive positive pressure ventilation (NIPPV) with him (bilevel positive airway pressure [BiPAP]) and he is agreeable. With which of the following comorbidities is BiPAP safe to use?

Severe hypertension

A 42-year-old woman presented to the emergency department (ED) with acute-onset epigastric abdominal pain and nausea without vomiting. Her workup revealed acute pancreatitis and she was admitted. After receiving appropriate analgesics and antiemetics, she is now hungry and wants something to eat. Which of the following is true?

She may eat a low calorie, carbohydrate-rich diet.

A 24-year-old woman presents with a diffuse rash (see Fig. 2-15). She had 'sores' of her mouth and eyes as well as numerous 'spots' on her trunk, but now the rash has spread throughout her body. She is uncomfortable and her skin is warm and tender. Pressure applied to skin adjacent to the lesions seems to extend the lesion into the normal appearing skin. In exploring her recent history, which of the following is most likely?

She was being treated for a urinary tract infection.

A 6-year-old child presents after a seizure. She has had acute gastroenteritis for the past 2 days. Electrolytes are normal. Which of the following is the most likely cause?

Shigella

The joints most commonly affected by decompression sickness (DCS) are:

Shoulders and elbows

What is the most common dysrhythmia in hypothyroid cardiovascular disease?

Sinus bradycardia

An 82-year-old female taking digoxin for congestive heart failure (CHF) is brought to the ED with confusion and an arrhythmia. Her blood tests subsequently reveal a supratherapeutic digoxin level. At baseline, the patient is not known to have any rhythm disturbance or block. Which of the following rhythm disturbances is most likely present?

Sinus bradycardia with multiple premature ventricular contractions (PVCs)

Which of the following is the most common arrhythmia in patients with pulmonary embolism (PE)?

Sinus tachycardia

Which of the following is the most important factor in determining the risk of rupture of an abdominal aortic aneurysm (AAA)?

Size of the aneurysm

Which of the following is the most important factor in determining the chance of spontaneous passage of a kidney stone?

Size of the stone

Which of the following is a risk factor for pelvic inflammatory disease (PID)?

Smoking

Which of the following is true about primary spontaneous pneumothorax?

Smoking is the most significant risk factor.

A 41-year-old female is referred from her dentist because her blood pressure was 212/105 when she presented for her root canal. She complains of dental pain in the area of the affected tooth, but she denies headache, blurry vision, nausea, or extremity weakness or numbness. The remainder of her review of systems is negative. Her physical examination is unrevealing except for carious teeth. She has never been diagnosed with hypertension, but admits that she had not seen a physician 'in years.' She has no drug allergies or known contraindications to any specific drug therapy. Which of the following is the next best step?

Start the patient on Hydrochlorothiazide 25Â mg PO daily, and discharge her to follow-up with her primary care physician.

A 4-year-old previously healthy girl presents to the ED with a 2-day history of cough productive of yellow sputum, fevers up to 102.4°F, pleuritic chest pain, and dyspnea. On examination, she is tachypneic and mildly toxic appearing. Her chest x-ray reveals a right middle lobe infiltrate. Which of the following organisms is the most likely cause of this problem?

Streptococcus pneumoniae

A 50-year-old man without past medical history presents with acute onset of cough, shortness of breath, and fever for 2 days. He has crackles in his left middle lung field and chest x-ray is shown in Figure 2-4. Which of the following is the most likely etiologic cause?

Streptococcus pneumoniae

A 74-year-old man with a history of hyperlipidemia is brought in by emergency medical services (EMS) with an acute ischemic right hemispheric stroke. Soon after returning from CT, he has a generalized seizure which terminates without treatment after 1 minute. Which of the following is true about this patient?

The patient should be given a loading dose of phenytoin after his seizure.

A 44-year-old man is struck on the head with a baseball bat. A CT scan of the brain is shown in Figure 4-3. Which of the following is the most likely diagnosis?

Subarachnoid hemorrhage

A 22-year-old diabetic man presents 1 day after being punctured in his left arm during a hiking accident. Since the accident, he has noted increasingly intense pain in his arm along with mild swelling and redness. On examination, his arm is noted to be mildly swollen and erythematous with an innocuous appearing puncture wound on the volar aspect of his right forearm. His arm is extremely tender, although there is no crepitus. A plain film is obtained which reveals subcutaneous emphysema. Which of the following is the next best step in management?

Surgical consult

A 34-year-old man presents with acute onset of penile pain and swelling, which occurred during sexual intercourse. His penis is shown in Figure 4-8. Which of the following is the most appropriate definitive management?

Surgical repair

A 65-year-old man with a past history of severe hypertension presents with sudden onset of shortness of breath and chest pain that started 8 hours ago. He also reports orthopnea and lower extremity edema but denies chest pain. He saw his primary care physician who noted a new diastolic murmur. Vital signs are as follows: T, 98.4; HR, 110; BP, 115/76; RR, 25; and SpO2, 90% RA. On exam, the patient is in moderate respiratory distress, with a diastolic murmur at the right upper sternal border, bilateral crackles, and lower extremity pitting edema. The electrocardiogram (EKG) shows signs of left ventricular hypertrophy (LVH), troponin I is negative, and chest x-ray demonstrates cardiomegaly and pulmonary edema. Which of the following is the most appropriate definitive therapy?

Surgical valve replacement

A 22-year-old woman presents with a severe sore throat and difficulty swallowing. Her physical examination is consistent with pharyngitis. Which of the following criteria make group A streptococcus (GAS) more likely as a cause of her illness?

Tender anterior cervical lymphadenopathy

Which of the following is true regarding pulsus paradoxus (PP)?

The 'paradox' refers to the fact that heart sounds are heard when at the same time no peripheral pulse is felt.

Security is called to help restrain an agitated patient in the ED. In helping to restrain the patient, one of the officers is inadvertently stuck by a contaminated needle that the nurse was using to obtain an IV. The patient is known to have chronic active hepatitis B (HepB) and the officer says he was immunized once against HepB but is a 'nonresponder.' Which of the following is true?

The HepB vaccine should still be given since many initial nonresponders will respond to a second HepB vaccine series.

Which of the following is true regarding malaria?

The causative organism is a parasite.

Which of the following best summarizes the role of chest x-rays in the diagnosis of community-acquired pneumonia (CAP)?

The chest x-ray is the most important test in the diagnosis of pneumonia.

A 46-year-old male suffered a snakebite on his hand by a 'brightly colored snake' at a ranch in Texas. His friend snapped a picture of the snake and a colleague notes it looks like a coral snake. The patient has minimal pain and swelling at the bite site. Which of the following is the next best step in management (Fig. 1-4)?

The patient should immediately receive North American coral snake antivenin.

Which of the following is true regarding temporomandibular joint (TMJ) dislocations?

The patient will present with a protruding mouth.

Which of the following is true regarding perimortem cesarean section?

The fetus should be delivered within 5 minutes of maternal cardiac arrest.

Which of the following is true regarding the most common EKG findings in benign early repolarization (BER)?

The junction of the QRS and the ST segment (J point) is notched.

Which of the following is true regarding acute mesenteric ischemia (AMI)?

The mortality rate of AMI is roughly 70%.

A 13-year-old boy is brought to the emergency department (ED) by his mother with a 3-week history of a nonproductive cough that 'won't go away.' She asks you if he might have 'walking pneumonia.' Which of the following is true?

The most common causes are Mycoplasma pneumoniae and C. pneumoniae, and macrolides are the antibiotics of choice.A 35-year-old woman presents in a coma (Glasgow Coma Scale 3) after a motor vehicle crash and is intubated for airway protection. Further evaluation reveals no life-threatening chest, abdomen, or pelvic injuries. Vital signs are normal. A computed tomography (CT) scan of the head is normal. Which of the following is the most likely diagnosis?@Diffuse axonal injury (DAI)

Which of the following is true regarding patients with temporal (or giant cell) arteritis?

The most specific finding is jaw claudication.

Which of the following is more characteristic of migraine headaches than cluster headaches?

The pain is throbbing in quality.

A 42-year-old anxious woman presents to the ED with low back pain radiating down her left leg. She states that she has a history of a herniated disk but has never had advanced imaging or surgery. While the patient is lying supine, you lift her right leg to approximately 45 degrees, causing the patient to complain of pain radiating down her left leg below the knee. How do you interpret this result?

The patient has a lumbar radiculopathy probably caused by a left-sided herniated disk.

A 43-year-old otherwise healthy male presents with a 1 week history of a productive cough, subjective fevers and chills, and mild shortness of breath, without chest pain. The patient was transferred from an urgent care facility, where he was found to be hypoxic, with a SaO2 of 87% on room air (RA). A chest x-ray confirms pneumonia. Antibiotics are ordered and the patient is admitted. An admission electrocardiogram (EKG) is ordered and is shown in Figure 1-2. Which of the following is most likely?

The patient has an increased risk for sudden cardiac death.

A 50-year-old man presents with inability to swallow his secretions and feeling like something is stuck in his throat after swallowing a piece of steak. You suspect an esophageal food impaction. Which of the following is true regarding this patient?

The patient likely has a predisposing anatomic abnormality of his esophagus.

Which of the following is true regarding Rocky Mountain spotted fever (RMSF)?

The peripheral white blood cell (WBC) count is usually normal.

A 42-year-old woman who is a self-described 'seafood fanatic' presents with a chief complaint of an 'allergic reaction.' Thirty minutes after eating tuna at a local restaurant she developed a severe headache, palpitations, nausea, abdominal cramping, and remarkable facial flushing. She has eaten fish for her entire life without incident. Which of the following is true?

The symptoms are due to excessive histamine levels in the fish.

A 38-year-old woman with a history of asthma presents to the ED with a chief complaint of wheezing and chest tightness typical of her asthma. She had recently run out of her medicines and complains of upper respiratory symptoms for the last week. Accompanying her is her 6-year-old son and 72-year-old mother, both of whom have asthma. Which of the following summarizes the treatment differences of acute asthma exacerbations between these groups?

The treatment of children with acute asthma exacerbations is similar to the treatment of adults and includes B-agonists, anticholinergics, and corticosteroids.

A 4-year-old boy is brought to the ED with a severe sore throat and a history of 'refusing to eat.' He has severe pharyngitis on examination, but a lateral neck x-ray is taken that you feel is consistent with a retropharyngeal abscess (RPA). You are surprised to find, however, that the patient's subsequent CT was normal. The radiologist tells you this was probably due to poor technique. What technique should be used to most accurately assess the prevertebral space on x-ray?

The x-ray should be taken in extension and inspiration.

A 23-year-old woman presents with a fever and sore throat for 3 days. She thinks she has strep throat. Which of the following findings is more characteristic of streptococcal pharyngitis than viral pharyngitis?

There are no reliably distinct features

Which of the following is true regarding cluster headaches?

They occur more commonly in men.

A 65-year-old woman with a history of chronic alcoholism presents with confusion, ataxia, and nystagmus. Which of the following is the most appropriate therapy?

Thiamine

A 42-year-old man with a history of alcohol abuse presents with acute epigastric abdominal pain. His workup reveals acute pancreatitis and he denies any prior history of pancreatitis. A CT scan that was ordered as part of his workup is shown in Figure 2-10. Which of the following is true?

This finding is common and normally resolves without intervention.

Which of the following is true regarding the image shown in Figure 4-7?

This patient should be allowed to bear weight as tolerated.

Which of the following is true regarding pediatric community-acquired pneumonia (CAP)?

Toddlers and young children more frequently develop CAP than middle-aged adults.

A 47-year-old woman without any past medical history presents with several days of progressively worsening left eye pain, blurry vision, and redness. Visual acuity in the left eye is slightly reduced. The patient notes that exposure of the right eye to light causes increased pain in her left eye. Her left pupil is constricted and minimally reactive to light with perilimbic conjunctival injection. There is no discharge. Which of the following is the most appropriate treatment?

Topical cycloplegic mydriatics

Which of the following spinal injuries is most likely to be stable?

Transverse process fracture

A 45-year-old woman with a history of asthma presents with her typical acute asthma exacerbation. She has had a runny nose and a sore throat but denies fever or productive sputum. Examination reveals bilateral wheezes. Her vital signs are 98.6°F, 110, 24, 156/95, 99% RA. She feels slightly better after an albuterol nebulizer treatment. You send off labs, and the white blood cell (WBC) count returns elevated at 13.5K. Which of the following is the next best course of action?

Treat airway inflammation with prednisone

A 23-year-old woman on oral contraceptives pills alternatively: 1) on an oral contracceptive, or 2) oral contraceptives complains of vague bilateral lower abdominal and pelvic pain. She has recently had a new sexual partner. Her menstrual period ended 4 days ago. Vital signs are normal. Physical examination shows mild-moderate tenderness in bilateral adnexa and cervix. Urinalysis is normal and urine pregnancy is negative. Which of the following is the most appropriate next step in management?

Treat with ceftriaxone and doxycycline

Which of the following is true regarding post-MI pericarditis?

Treatment generally involves nonsteroidal anti-inflammatory drug (NSAID) therapy.

Which of the following is true regarding traumatic iridocyclitis?

Treatment involves long-acting cycloplegics.

A 28-year-old female presents with a painful left index finger after it was inadvertently caught in a car door. X-rays are negative for a fracture, but there is a 50% subungual hematoma. The volar finger pad and paronychial tissues appear intact. Which of the following is true?

Trephination alone results in similar cosmetic and functional outcomes as nail removal.

A 24-year-old woman at 35 weeks of gestation presents to your community ED after experiencing a small gush of fluid running down her leg approximately 2 hours before presentation. She has no abdominal pain, vaginal bleeding, or other complaints. Which of the following is true?

Trichomonas vaginitis can result in a false-positive Nitrazine paper test.

A 34-year-old man with AIDS presents with cough, malaise, and exertional dyspnea for 8 days. He stopped his highly-active anti-retroviral therapy several weeks prior due to side effects. His vital signs are 100.4°F, 95, 22, 165/85, 95% RA. Chest radiography shows an interstitial pneumonia pattern. Which of the following is the most appropriate treatment?

Trimethoprim-sulfamethoxazole

Applying a magnet to the chest of a patient with a pacemaker:

Turns the sensing function off

Which of the following Salter-Harris fractures carries the poorest prognosis?

Type V

Which of the following is the most frequently affected structure in thoracic outlet syndrome?

Ulnar nerve

A 6-year-old girl presents with abdominal pain. She has had moderate, constant periumbilical pain for several hours with associated nausea. Her parents noted a rash on her legs and buttocks for several days, which they attributed to poison ivy. Physical examination demonstrates an afebrile, uncomfortable patient, diffuse abdominal tenderness without true rebound or guarding, a maculopapular rash on the legs and buttocks, and diffuse joint tenderness. Which of the following is the most important next step in evaluation?

Urinalysis

What is the most common cause of immediate postpartum hemorrhage?

Uterine atony

An 11-month-old male infant is brought in by his parents to the ED with a rash (Fig. 4-9). They state that he appeared to have some discharge from his eyes and then developed a diffuse, tender 'redness' to his skin, which had a 'rough' feel to it. Their pediatrician diagnosed him with a viral syndrome and prescribed oral antipyretics as needed. Since then, his skin appears to have wrinkled, formed blisters, and is now peeling in large sheets. Which of the following is the treatment of choice?

Vancomycin

An 85-year-old woman presents from a nursing home with fever and hypotension. According to the paramedic, she began to have lethargy and refused to get out of bed one day ago. There is no reported history of cough, shortness of breath, diarrhea, headache, or rash. Her vital signs are: 102.4°F, 122, 22, 72/44, 95% RA. The patient's physical examination is nonfocal, and routine laboratory work is sent. Which of the following is the most appropriate empiric antibiotic therapy at this time?

Vancomycin and piperacillin-tazobactam

A 52-year-old previously healthy female collapses while coaching her daughter's soccer team and bystanders initiate chest compressions. When EMS arrives, they find the patient in ventricular fibrillation. EMS immediately defibrillates the patient and initiates ACLS. They also placed a temporary supraglottic airway. After following ACLS algorithms for 14 minutes including three defibrillation attempts, the patient experiences a return of spontaneous circulation (ROSC). Shortly after arrival in the emergency department (ED), a definitive airway is obtained and placement is confirmed by x-ray. The patient is noted to be comatose, with a GCS of 3, and has the following vital signs: T 95.8°F, P 115, BP 79/40 (MAP = 53), SaO2 97% on the ventilator. Which of the following is true?

Vasopressors are needed to raise her blood pressure prior to the initiation of cooling.

Which of the following occurs earliest during hepatitis A infection?

Viremia

Among adults, which of the following is the most common cause of acute diarrheal illness in the United States?

Viruses

A 26-year-old pregnant woman at 8 weeks presents to the ED with a chief complaint of nausea and vomiting. Her abdomen and pelvic examinations are normal and her ultrasonogram reveals a normal live intrauterine pregnancy at 8 weeks. Her urine reveals no ketones. Which of the following is the best recommendation for reducing her symptoms?

Vitamin B6

A 42-year-old man presents with pain, warmth, and swelling over his posterior elbow (Fig. 2-13). The patient reports frequently having to lean on his elbow while performing electrical work as part of his job. The patient has full range of motion but flexion and extension of the elbow results in increased pain. Fluid is subsequently aspirated from the affected area. Which of the following is the minimum white blood cell (WBC) count suggestive of infection?

WBC >10,000 per mm3

Which of the following findings on urinalysis is found in pyelonephritis but not cystitis?

WBC casts

Pulmonary infections with which of the following may be transmitted from person to person?

Y. pestis

Which of the following is true regarding temporomandibular joint (TMJ) syndrome?

Young women are at highest risk.

]

]

A 46-year-old woman presents to the ED with cough, fever, and dyspnea. Her chest x-ray is shown in Figure 1-13. You initiate empiric treatment for community-acquired pneumonia and perform a diagnostic thoracentesis because of the size of the effusion and her declining respiratory status. Which of the following results on pleural fluid compels you to perform urgent tube thoracostomy?

pH 7.0