SINGLE BEST ANSWER ANSWERS ALL QUESTIONS. EMERGENCY MEDICINE Case 1 A
48-year-old man is noted to have a 2-day history of sore throat, subjective fever at home, and no medical illnesses. He denies cough or nausea. On examination, examination, his temerature temerature is !8.!"# $%&%"'(, and he has some tonsillar s)elling but no exudate. He has bilateral enlarged and tender lymh nodes of the nec*. +he raid stretococcal antigen test is negative. hich of the follo)ing is the best next ste A. Oral clindamycin . +reatment based on results from throat culture #. Observation /. egin amantadine hich of the follo)ing atients is most li*ely to have grou A stretococcal infection A. An %%-month-old male infant )ith fever and red throat . An 8-year-old girl )ith fever and sore throat #. A 20-year-old 20-year-old man )ith a temerature of !8.1"# $%&2"'(, haryngitis, and cough /. A 2-year-old )oman )ho comlains of fever of !1.2"# $%&2."'( and sore throat A %1-year-old college student has had a sore throat, mild abdominal ain, and fever for days. He )as laying football )ith some friends, and )as tac*led just short of the goal line, hitting the grass some)hat forcibly. He exeriences some abdominal ain, and asses out. +he 35 $emergency $emergency medical services( is called and his vital signs reveal the heart rate as %4& beats er minute and bl ood ressure ressure as 8&64& mm Hg )ith a distended abdomen. hich of the follo)ing is the most li*ely etiology A. 7asovagal reaction . utured aortic aneurysm #. #omlications of 3stein-arr 3stein-arr infection /. utured jejunum An %8-year-old )oman resents )ith fever and a sore throat. 5he is sitting u drooling, )ith some stridor. Her temerature is !1.4"# $%&!"'( and she aearsill. hich of the follo)ing is your next ste A. 3xamine the harynx and obtain a raid antigen test. . 3miric treatment )ith enicillin. #. +hroat culture and treatment based on results. /. 5end the atient to radiology for an anteroosterior $A9( nec* radiograh. 3. 9reare for emergent air)ay management.
Case 2 A
48-year-old 48-year-old man is being seen for chest ain. :n the initial evaluation of this atient, )hich of the follo)ing is the most imortant diagnostic test A. #hest x-ray . 3#; #. 5erum cardiac mar*ers /. #omuted tomograhy 3. #holesterol levels A 8-year-old 8-year-old man resents to his hysician
ste in management A. Administration of roranolol . Asirin to che) #. 5ublingual nitroglycerin /. Administration of a diuretic agent 3. #hest radiograh A 4-year-old man is seen in the emergency deartment )ith ! hours of substernal chest ain radiating to his left arm. +he 3#; sho)s only nonseci>c changes. Hearing that the 3#; is normal, he re?uests to go home. hich of the follo)ing statements is most accurate A. +he atient may be safely discharged home. . :f a reeat 3#; in !& minutes is normal, myocardial infarction is essentially ruled out and the atient may be safely discharged. #. +he atient should be advised that half of heart attac* atients have a nondiagnostic 3#; and serial cardiac biomar*ers levels should be assessed. /. +he atient should undergo an immediate thallium stress test to further assess for coronary artery disease to hel clarify the management. Case 3 A
0-year-old man is found to have asymtomatic atrial > brillation. hich of the follo)ing is the most common comlication of his atrial >brillation A. 5udden death . 5tro*e #. 5hoc* /. /ysnea An 8!-year-old )oman )ith a history of hyertension resents to the emergency deartment )ith dysnea, fatigue, and alitations. Her blood ressure is 86& mm Hg and her heartbeat is %& beats er minute and irregular. hich of the follo)ing is the best treatment for this atient A. /iltia@em . etorolol #. #oumadin /. /# cardioversion A 2-year-old )oman is seen in the emergency deartment for )rist ain after triing and falling. 5he is found to have a distal radius fracture on x-ray, )hich is reduced and slinted. Ho)ever, her heart rate is 8& beats er minute and irregular to alation. On 3#;, she is diagnosed )ith atrial >brillation )ith a ventricular resonse of %%4 beats er minute. 5he does not recall ever being told about this condition. hich of the follo)ing is the best initial treatment for this atient A. /iltia@em . /# cardioversion #. 5ynthroid /. :butilide
Case 4 A
22-year-old baseball layer comes into the 3/ comlaining of %2 hours of intermittent chest ain and a ounding heartbeat. He denies a history of trauma. On examination, he is tachycardic. hich of the follo)ing is the best next ste A. 5ynchroni@ed cardioversion . 7alsalva maneuver
#. /ischarge home and follo) u )ithin the next 48 hours /. Obtain an 3#; A 2-year-old healthy jogger is brought to the 3/ follo)ing a syncoal eisode. A diagnosis of ventricular tachycardia is made, and the atient is cardioverted. 5he states that she has had rior eisodes of 7+ lasting less than !& seconds each. hat is the most aroriate treatment A. Bi*ely no further theray is needed. . Amiodarone #. C-bloc*er /. 9rocainamide All of these are A7 nodal bloc*ing maneuvers excetD A. /iving reEex . #arotid massage #. 7alsalva maneuver /. Holding onebrillation )ith raid ventricular rate A !0-year-old )oman resents )ith chest ain after smo*ing crac* 2 hours ago. hat are you most li*ely to see on the 3#; A. 5inus tachycardia . 57+ #. 7+ /. Atrial >brillation Case 5 A
%0-year-old adolescent boy )ho is a tye : diabetic is brought in by his arents )ith concern about diabetic *etoacidosis. He has had several rior eisodes of /IA. hich of the follo)ing is most diagnostic of /IA A. 9olyuria, olydisia, fatigue . Hyotension, dehydration, fruity breath odor #. Hyerglycemia, *etosis, metabolic acidosis /. 5erum blood sugar of && mg6dB in the face of high concentrations of insulin 3. 3levated H#O! and elevated glucose A 28-year-old insulin-re?uiring )oman is found in her aartment by her husband. 5he is stuorous and cannot rovide any history. 35 is called and ta*es the atient to the emergency center, and a diagnosis of severe /IA is made. Her blood ressure is 8&64& mm Hg and heart rate %4& beats er minute. +he glucose level is 1& mg6dB, otassium level m3?6B, H#O! 4 m3?6B. hich of the follo)ing is the most aroriate initial treatment A. Administer 2& units regular insulin intramuscularly, and normal saline at 2& mB6h. . egin an intravenous doamine dri to raise 9 above 1&, then insulin at %& J6h. #. :nitiate normal saline 2 B )ith I#l 2& m3?6B, insulin %& J6h.
/. 9rovide an intravenous normal saline 2 B bolus, and start an insulin dri at %& J6h. +he atient in Kuestion .2 is undergoing theray. hich of the follo)ing rinciles is most accurate in the treatment of /IA A. :sotonic saline )ith no dextrose should be used during the hositali@ation because the atient is diabetic. . +yically, intravenous insulin and dextrose solution )ill need to be continued until the acidosis has resolved. #. 9otassium relacement is rarely necessary. /. 5odium bicarbonate is helful to resolve the anion ga more ?uic*ly. +he hysician exlains to a 2-year-old man )ho has recently been hositali@ed )ith /IA that atients in /IA often have other illnesses or reciitating factors that initiated the *etoacidosis. hich of the follo)ing is the most common underlying etiology in /IA A. Asthmatic exacerbation . #ocaine use #. #holecystititis /. issed insulin doses 3. Jrinary tract infection Case 6 A
!2-year-old )oman is noted to have ersistent hyotension from susected toxic shoc* syndrome desite B of normal saline given intravenously. hich of the follo)ing is the best next ste A. Jse colloid $albumin( for the next bolus. . :nitiate noreinehrine infusion. #. Administer corticosteroid theray. /. +ransfuse )ith fresh-fro@en lasma. 3. Activated rotein #. A 4-year-old man )ith acute cholecystitis is noted to have a fever of !8.!"# $%&%"'(, hyotension, and altered sensorium. His H#+ is noted to be 24L. road-sectrum antibiotics and intravenous saline are administered, and, although his #79 is %& and his A9 is 8&, his 5cvO2 remains M0&L. hich of the follo)ing is most li*ely to be bene>cial A. :nitiate corticosteroids . +ight glucose control #. Acetaminohen && mg 9 /. +ransfusion 3. Bithotrisy A !2-year-old )oman is admitted to the hosital for acute yelonehritis. +he atient is treated )ith oral ciroE oxacin. After 4 days of theray, she returns to the 3/ )ith ersistent fever to !8.1"# $%&2"'( and E an* tenderness. +he urine culture reveals 3 coli greater than %&&,&&& colony-forming units er mB suscetible to ciroE oxacin. hen you arrive to examine her, you note that she is tachyneic, tachycardiac, and aears lethargic. hich of the follo)ing is the next ste A. Order an intravenous yelogram. . Obtain :7 access and administer a Euid bolus. #. :nitiate a )or*u for >ctitious fever. /. #onsult a surgeon for ossible aendicitis. 3. Add antifungal theray.
A -year-old )oman is noted to have acute neumococcal neumonia and is being treated )ith antibiotics, and )ith noreinehrine and dobutamine to maintain her 9 and urine outut. hich of the follo)ing is a bad rognostic sign A. Jrine outut of % mB6*g6h . ean arterial blood ressure of 8& mm Hg #. Bactic acid level of mmol6dB /. 5erum bicarbonate level of 22 m3?6B 3. Hematocrit !L Case 7 A
!2-year-old man )as involved in a *nife > ght and had stab injuries to his abdomen, although it is unclear ho) dee these injuries are. He is brought into the emergency room )ith a heart rate of %%& beats er minute and blood ressureof 846& mm Hg. ased on the clinical assessment, )hich of the follo)ing is the amount of acute blood loss he has exerienced A. 2& mB . && mB #. %&&& mB /. %&& mB hich of the follo)ing is an advantage of the 'A5+ examination in a atient )ith hemorrhagic shoc* A. #an identify retroeritoneal hematomas . #an be erformed ?uic*ly at bedside #. #an identify the seci>c site of injury /. #an ?uantify the exact amount of blood loss A 2&-year-old man involved in a motor vehicle accident is brought into the emergency room having lost much blood at the accident scene. His initial blood ressure is 8&64& mm Hg and heart rate %!& beats er minute. He is given ! B of normal saline intravenously and is still hyotensive. hich of these statements most accurately describes the athohysiology of his condition A. :nsu=cient cardiac reload . :nsu=cient myocardial contractility #. 3xcessive systemic vascular resistance /. 3xcessive :B- and leu*otrienes A !-year-old man has been involved in a motor vehicle accident, and is found to be hyotensive. hich of the follo)ing locations of bleeding can cause signi>cant comlications but does not exlain the hyotension A. #hest and abdomen . 9elvic girdle and soft-tissue comartments #. 3xternal bleeding /. :ntracranial bleeding
Case 8 A
2!-year-old man is involved in an altercation in the ar*ing lot after a baseball game. He suNers a single stab )ound 2-cm medial and suerior to the left nile. His blood ressure is %%&68& mm Hg and heart rate is 8& beats er minute. hich of the follo)ing management otions is most aroriate for this atient A. #, )ound exloration, and 3#; . # and #+ scan of the abdomen
#. # and echocardiograhy /. #, echocardiograhy, and laaroscoy 'or )hich of the follo)ing atients is #+ imaging an aroriate diagnostic otion A. A !8-year-old man )ith diNuse abdominal ain, involuntary guarding, and a -in *nife imaled just belo) the umbilicus . A 22-year-old man )ith a single stab )ound to the bac*, ulse rate of %%8 beats er minute, blood ressure of 1468& mm Hg, and gross hematuria #. A %-year-old adolescent boy )ith a single stab )ound 2 cm above the left inguinal crease, )ith heart rate of %2& beats er minute and blood ressure of 1&608 mm Hg /. A hemodynamically stable, !4-year-old )oman, )ho is 2 )ee*s regnant and has a single stab )ound to the bac* and no other abnormalities on hysical examination A !4-year-old man is brought into the emergency deartment after a motor vehicle accident. He comlains of dysnea and initially had an oxygen saturation of 88L. On examination, he has decreased breath sounds of the right chest and no) has an oxygen saturation of 0&L on room air. hich of the follo)ing is the most aroriate next ste A. #hest radiograh . #+ of the chest #. +ube thoracostomy /. Hearin anticoagulation Case 9 A
08-year-old man is brought to the emergency center from an extended care facility. +he atient reortedly )as found to have fallen do)n in the bath room. He has contusions over his face and is confused. According to reorts by his careta*ers, this is his baseline mental status. Ho) )ould you clear his #-sine A. 9alation of his #-sine for tenderness, if not tender than as* him to turn his head and if no ain is reorted, the #-sine is cleared. . Iee him in #-sine recaution and reexamine him later )hen his mental status is imroved. #. Obtain #+, :, if these are negative, obtain Eexion6extension >lms. /. #+ of the #-sine. 3. emove the collar if he denies nec* ain. hich of the follo)ing aroaches is most aroriate for the clearance of the #-sine in a 2-year-old man )ho the driver of a car struc* from behind He is hemodynamically stable, nonintoxicated, and has a ;#5 of %. A. 3J5 criteria . #anadian #-sine rule #. #+ of the #-sine /. !-vie) x-ray of the #-sine 3. emove the collar because he does not have any ain hich of the follo)ing is the most aroriate next ste in the management of a 22year-old man )ith # fracture and #-# subluxation, absence of motor or sensory functions belo) the #4 level, heart rate of 4, and 9 %&&6& A. aintain mean arterial ressure P8 to 1& mm Hg . 5urgical air)ay #. Orotracheal intubation )ith raid se?uence induction /. lind nasotracheal intubation 3. Administer atroine %mg intravenously
hich of the follo)ing atientcits belo) the # level An Case 10
%8-year-old )oman is brought to the 3/ )ith susected anahylaxis. hich of the follo)ing most suggests anahylaxis rather than a simle allergic reaction A. :tching . atery eyes #. lood ressure of 8&64& mm Hg /. Hives 3. Anxiety A -year-old girl )ith a *no)n eanut allergy is brought to the 3/ by ambulance after accidentally eating a coo*ie made )ith eanut butter at a school arty. 5he is )hee@ing )ith hives. hich of the follo)ing should be the >rst intervention A. 3ndotracheal intubation . ormal saline 2& cc6*g :7 #. 3xamination of the s*in /. 3inehrine &.% mg intramuscular 3. ebuli@ed albuterol hich of the follo)ing management otions is the greatest determinant of atient outcome in anahylaxis A. +imely administration of steroids . Administration of dihenhydramine #. 3arly identi>cation of the allergen /. 3arly administration of einehrine 3. Aggressive resuscitation )ith intravenous Euids A !2-year-old man collases in the emergency room after being brought in by aramedics. He )as stung by a bee and *no)n to be highly allergic. He aears cyanotic and had extreme stridor in the ambulance. 5evere laryngeal edema is notable. hich of the follo)ing is the best treatment A. ebuli@ed albuterol, H% and H2 antagonists, corticosteroids, and crystalloids . 5ubcutaneous einehrine, H% and H2 antagonists, and corticosteroids #. aid se?uence intubation, subcutaneous einehrine, and corticosteroids /. :ntramuscular einehrine, raid se?uence intubation, and corticosteroids 3. :ntravenous einehrine, raid se?uence intubation )ith rearation for a surgical air)ay, corticosteroids, nebuli@ed albuterol, and H% and H2 antagonists
A Case 11
24-year-old man is brought into the 3/ comlaining of an exacerbation of his asthma.
hich of the follo)ing is the most aroriate method of assessing the severity of his disease A. 5irometry . easurement of the diNusion caacity of the lungs #. easurement of the ea* exiratory Eo) /. easurement of the alveoli oxygen tension A %1-year-old )oman is admitted to the hosital for an exacerbation of asthma li*ely reciitated by ollen and colder )eather. Her inatient regimen includes both intravenous and inhalant medications. hich of the follo)ing medications is most li*ely to be used as art of discharge lan A. +heohylline . Antibiotics #. agnesium /. Histamines 3. #orticosteroids hich of the follo)ing initial ventilator settings is aroriate for intubated asthmatics A. :7 mode, rate %, tidal volume to 8 mB6*g . :7 mode, rate %, tidal volume %& to %2 mB6*g #. A# mode, rate 8 to %&, tidal volume to 8 mB6*g /. A# mode, rate 8 to %&, tidal volume %& to %2 mB6*g 3. A# mode, rate %, tidal volume to 8 mB6*g An Case 12
%8-year-old man )as involved in an altercation at a local bar. He suNered a laceration of the scal, nec*, forehead, and uer li. hich of the follo)ing is li*ely to be most challenging to reair from a cosmetic ersective A. 5cal . ec* #. 'orehead /. #hee* 3. Jer li A 24-year-old )oman )as the victim of domestic violence and received treatment at the local emergency deartment for multile contusions and lacerations of the face. 5ix months after treatment, she notices a defect of the nasal setum )ith communication bet)een the right and left nasal assage )ay. hich of the follo)ing is the most li*ely diagnosis A. 9hysician use of einehrine on the nasal setum . 9atient use of cocaine #. Hematoma of the nasal setum /. 9ost-traumatic stress syndrome 48-year-old man )as roc* climbing )hen he slied and suNered a laceration to his right lo)er leg. He ut ressure on it, )raed the area, and made his )ay to the 3/. He recalls getting Fall his shotsG )hen he )as a child, but doesn
An %8-year-old man resents to the emergency deartment comlaining of right ear ain after sustaining a cut on his ear during a )restling match. On examination, you note some s)elling and exosed cartilage of the right uer ear. hich of the follo)ing is a correct statement A. 3xosed cartilage should be left undressed and the atient should be discharged )ith follo)-u. . Hemostasis and evacuation of an auricular hematoma should not be erformed because it romotes infection. #. hen reairing an ear laceration, ma*e sure to avoid lacing sutures in the cartilage and only include the erichondrium )hen aroximating the s*in edges. /. +etanus toxoid is not recommended for these tyes of injuries. A -year-old boy is brought to the 3/ by his mom for a forehead laceration after hitting his head on the jungle gym. +here )as no loss of consciousness. +he child is alert and active. He has a !-cm forehead laceration )hich crosses the hairline. hich of the follo)ing is the most aroriate method of )ound closure in this atient A. 5have the hair surrounding the laceration and close )ith interruted sutures. . #lose )ith stales. #. #lose )ith steri-stris. /. #lose )ith interruted sutures. atch Case 13
the single best theray $A to 3( to the clinical scenarios in Kuestions %!.% to %!.4. A. :dentify the secies, clean and immobili@e the site, and administer antivenin. . #lean bite site and treat )ith rohylactic antibiotics. #. #lean site, observe animal, and )atch for signs of secondary infection. /. #lean the site and begin rabies rohylaxis )ith active and assive immuni@ation. 3. Admit for radical surgical debridement in the oerating room. %!.% Qour dog, )ho )as immuni@ed against rabies )ithin the last year, bites your neighbor. %!.2 A )oman arrives in your 3/ )ith a human bite to her breast that occurred earlier in the day. +here is a small uncture )ound and no signs of cellulitis. %!.! A scoutmaster brings a boy scout to the 3/ )ith a sna*ebite to his left foot. He says he heard the sna*e
A Case 14
8-year-old man exerienced a neurologic de>cit and is diagnosed as having a stro*e. hich of the follo)ing is the most li*ely etiology A. :schemic . Hemorrhagic #. /rug-induced /. +rauma-induced 3. etabolic-related An 8&-year-old man is being evaluated for ossible thrombolytic theray after resenting
)ith 2 hours of right arm )ea*ness and ahasia. hich of the follo)ing is a contraindication for thrombolytic theray A. ilateral cerebral infarct . Hemorrhagic stro*e #. Hyertension-related stro*e /. Age of 8& years %4.! An other)ise healthy -year-old )oman is ta*en to the 3/ )ith robable stro*e. hich of the follo)ing are the most urgent diagnostic studies A. #oagulation studies . 3#; and cardiac en@ymes #. edside blood glucose and #+ scan of the head /. : of the head )ith and )ithout contrast %4.4 A 0-year-old )oman is seen in the emergency room )ith left arm )ea*ness and right facial droo. Her blood ressure is %8&6%& mm Hg. hich of the follo)ing is the best management for the hyertension A. Bo)er the blood ressure to less than %&68& mm Hg by giving a small dose of labetalol. . Bo)er the blood ressure to less than %2&68& mm Hg. #. o intervention for her blood ressure, but continue to monitor. /. Bo)er the blood ressure to belo) %&68& mm Hg if she is eligible for t9A. A Case 15
!0-year-old man is brought into the 3/ because he assed out at )or*. He denies any rodromal symtoms. 'amily history is negative for sudden cardiac death. :n the 3/, his 9 lying do)n is %260 mm Hg, heart rate is 0 beats er minute, and resiratory rate is %4 breaths er minute. +he atientndings. #urrently, he is lucid and has no neurologic abnormalities. After a comlete evaluation of this atient, )hich of the follo)ing is the most common etiology of syncoe A. /ysrhythmia . Orthostasis #. :dioathic /. 5ituational
A !-year-old )oman resents to the 3/ comlaining of feeling lightheadedness. 5he noticed some vaginal bleeding earlier in the day. Her blood ressure is 86! mm Hg, heart rate is %!& beats er minute, and resiratory rate is %8 breaths er minute. hich of the follo)ing is the most aroriate next ste in management A. Obtain a urine regnancy test. . Obtain a serum ?uantitative beta human chorionic gonadotroin $C-h#;(. #. Obtain immediate :7 access and begin Euid resuscitation. /. Obtain stat O6;Q consult. A 2%-year-old man is brought to the 3/ after collasing to the ground )hile laying bas*etball. He is alert and oriented, denies chest ain, di=culty breathing, or any other hysical comlaints. +here )as no trauma. He denies any ast medical roblems. 9hysical examination is unremar*able. hich of the follo)ing elements on his 3#; is concerning for a life-threatening cause of syncoe
A. Heart rate of . 9-)ave inversion in lead a7 #. 5inus arrhythmia /. K+c of 41 msec A 02-year-old man is brought to the 3/ by aramedics after assing out at the suermar*et. His syncoal eisode )as )itnessed by shoers )ho stated the atient collased, hitting his head. +he atient is currently alert and oriented, and denies any ersistent symtoms. His ast medical history is signi>cant for carotid stenosis, for )hich he ta*es asirin and cloidogrel. hat i s most aroriate next ste in the management of this atient A. Head #+ scan . Order a carotid dulex ultrasound #. Obtain an 3#; /. #hest radiograh
