Transcript preinserviceexam

The Long
Sirous Partovi, MD
And the Short of It
Randy Goldstein, MD
A patient with acute adrenal insufficiency
is best treated with hydrocortisone and
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A. NS
B. D5 NS
C. NS + Ca
D. NS + K
E. Makes no difference
A 45 year old WF with history of breast CA
presents with constipation and abdominal
pain. ED evaluation and treatment
include:
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A. Positive Chvostek’s sign
B. Increase fluid and dietary fiber
C. IVF and lasix
D. Referral to oncologist
E. Obtain Barium enema
Treatment of acute asthma attack in
patients in 2nd trimester pregnancy
includes all except:
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A. Prednisone
B. Beta agonists
C. SQ epinephrine
D. IV fluids
A mom that delivered her baby
yesterday develops chicken pox.
Who must receive VZIG?
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A. Mom
B. Mom and infant
C. Mom, infant and 2 year old sibling
D. Infant and 2 year old sibling
E. Infant alone
Post Exposure Treatment- VZIG
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Pts on high dose steroids
Immunocompromised without a history of CP
Pregnant women
Newborns exposed 5 days prior to birth and
2 days after delivery
Neonates born to nonimmune mothers
Hospitalized premature infants < 28 weeks’
gestation
A pt on chronic dialysis has been taking
magnesium containing antacids. He presents
with hypotension and areflexia. ED treatment
includes:
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A. Bicarb
B. Pacing
C. IV Calcium
D. Terbutaline
E. IV fluids
An elderly patient c/o bilateral buttock
and posterior upper thigh pain on
ambulation. Diagnostic modality:
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A. LS spine x-rays
B. CT of L- spine
C. MRI of back
D. MRA of back
E. Angiography of BLE
Leriche’s Syndrome
A 55 yo male presents with facial swelling
over one week in conjunction with SOB,
JVD and dilated thoracic veins. Most
likely diagnosis is:
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A. Ascites with anasarca
B. Mediastinitis
C. Pulmonary embolism
D. Bronchogenic CA
E. Pneumonia
Most common cause of sudden
death in athletes
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Hypertrophic Cardiomyopathy
Earliest complaint of a patient with
tetanus
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Locked jaw
A patient 2 wks post anterior MI presents
with stroke. ED workup should include:
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A. Carotid doppler
B. Brain MRA
C. Echocardiogram
D. Cardiac enzymes
E. Four vessel angiogram
Kids with cyanotic heart disease
presenting with syncope should be
placed in:
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A. Trendelenberg position
B. Reverse Trendelenberg position
C. Knee-chest position
D. Upside down position
E. Left decubitus position
22-year-old man presents with a one day history of
increasing bilateral leg weakness and
paresthesias. He has not been ill otherwise and
his vital signs are normal. Physical exam is
normal except for symmetric lower extremity
weakness and decreased deep tendon reflexes.
Sensation is normal. What is the most likely
diagnosis?
A. Guillain-Barré syndrome
B. poliomyelitis
C. tick paralysis
D. transverse myelitis
E. viral hepatitis
Guillain-Barré syndrome
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Autoimmune etiology
Distal weakness is more common
The ascending paralysis is characteristically
symmetric or nearly symmetric
The facial and other cranial nerves are involved
in 25%-50% of the patients.
Motor deficits predominate
DTRs are almost always absent in the affected
extremities
Recent bacterial infection, preceding
Campylobacter jejuni infection, and influenza
vaccination have all been associated
Guillain-Barré syndrome
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Diagnosis is based on the patient’s clinical
presentation
Analysis of CSF: Albuminocytologic dissociation,
in which the CSF has a protein content of
greater than 400 mg/L and a cell count of less
than 10/ml
Heavy metal poisoning, volatile hydrocarbon
abuse, acute intermittent porphyria are all on the
diff dx
35 year old female with hx of
multifocal neuro deficit. The best way
to make the diagnosis is:
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A comprehensive psychiatric evaluation
CT of the head
Lumbar puncture
MRI of the head
EMG and NCS
A 2 year old male presents after
being struck by a car
Assuming the patient is stable, the
next step would be to
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A) obtain a CT of the abdomen and
pelvis
B) insert a foley catheter
C) perform a retrograde urethrogram
D) perform a diagnostic peritoneal
lavage
E) obtain an intravenous pyelogram
59 yom with acute chest pain and weakness to
left arm. ECG shows ST elevation in anterior
leads. Treatment should include all of the
above, except:
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Nitrates
Beta blockers
Thrombolytics
ASA
Ca channel blockers
Where is the most common site of bursitis
in the body?
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Olecranon
The most frequent cause of fetal death
following blunt abdominal trauma during
pregnancy is
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Placental abruption
The antihypertensive most likely
responsible for this finding is a(n)
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ACE inhibitor
Beta blocker
Calcium channel
blocker
Diuretic
Nitrate
Abrupt shaking chills, rusty sputum, lobar
consolidation
 Strep pneumo
ETOH abuse, current jelly sputum, lobar infiltrate
with bulging fissure
 Klebsiella
HA, malaise, nonproductive cough,interstitial
infiltrates
 Mycoplasma
Old smoker, high fever, dry cough, toxic
appearance, patchy infiltrate, pleural effusion
 Legionella
53 year old man involved in an MVA and suffered a
neck injury. The most likely injury is:
A. Dissection of carotid artery
B. jugular vein
C. Injury to C7-T2
D. Epidural hematoma
E. C1-C2 fracture
Horner’s Syndrome
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Unilateral facial ptosis, miosis, and anhydrosis
Damage to the cervical sympathetic plexus
Cluster headaches may show Horner’s
Horner’s syndrome may also result from
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Aortic dissection
Advanced malignancy
Occlusion of the PICA (Wallenberg syndrome)
Posterior pharynx abscesses
What is the most common cause of painful
hip in children?
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Transient synovitis
This 16 year old female who
presented with heart palpitations
Most likely suffers from
 A)
 B)
 C)
 D)
 E)
hyperkalemia
hyperthyroidism
supraventricular tachycardia
cocaine abuse
idiopathic palpitations
Delta waves – WPW syndrome
True statements about this condition
includes:
A. Often atraumatic or associated with a
relatively minor injury
B. Most commonly occurs in boys 10 to 17
years of age with obesity and
underdeveloped genitalia
C. Salter and Harris type I variety
D. Internal fixation is the treatment
E. All of the above
Slipped Femoral Capital Epiphysis
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Often atraumatic, boys 10-17 years (obese)
Left more common than right
Insidious onset
Stiffness in the hip
An abduction and external rotational deformity
is characteristic
CT scan, an MRI scan, or a bone scan should
be considered if a fracture is clinically
suggested but remains radiographically occult
after plain radiographs.
Treatment is Internal fixation
What is Beck’s triad?
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Muffled heart tones
Hypotension
Increased JVD
6 year old presents with fever, sore
throat and a rash
The following are true of this disease
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A) Penicillin is the treatment of choice
B) It’s natural history is to resolve spontaneously
without sequelae
C) The most common etiology is Strep
pneumoniae
D) It is contagious only before the rash erupts
E) It is most common in children less than 3
years of age
This 2 year old child
presents with drooling.
He is otherwise in no
distress. The next step
should be:
A. Rapid intubation
B. Ipecac administration
C. Barium swallow study
D. Call the friendly GI doc
E. Meat tenderizer
Esophageal Foreign Bodies
Esophagus has three normal anatomic sites of
narrowing where impactions are most
common:
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The cricopharyngeus muscle
The crossing point of the aorta
Lower esophageal sphincter
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What are the most common causes of
acute mitral regurgitation?
Acute MI
 Bacterial endocarditis
 Trauma
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This child’s lesion is a
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Left CN VI palsy
Right CN VI palsy
Left CN III palsy
Right CN III palsy
A great party trick
What are the most common signs of
pulmonary embolism?
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Dyspnea
Tachypnea
What are the most common ECG findings
in a patient with pulmonary embolism?
 Sinus tachycardia
 Non specific ST-T changes
38 year old patient with HIV
presents with fever,
shortness of breath and
dry cough for 1 week. ABG
shows PO2 of 59. The
treatment should include
all except:
A. Oxygen therapy
B. Intubation if in distress
C. Bactrim IV
D. Triple med regimen for TB
E. Steroids
PCP
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PCP is the most common opportunistic infection in
AIDS
Uncommon in patients with CD4 >200/mm3
Nonproductive cough, fever, shortness of breath,
diffuse interstitial infiltrates on chest radiograph,
and arterial hypoxemia
Bilateral interstitial infiltrates that begin in the
perihilar region- can vary considerably, ranging
from a normal appearance to dense consolidation
Prednisone is indicated for moderate-to-severe
PCP who have a PaO2 less than 70 mm Hg or an
A-a gradient greater than 35 mm Hg.
8-week-old boy presents with cough and
low-grade fever and conjunctivitis
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Chlamydia
The following
etiologies are
associated with
the condition
shown on this
radiograph,
except:
A. Collagen vascular diseases
B. Previous hip dislocation
C. Prolonged corticosteroid use
D. Sickle cell anemia
E. Thallasemia minor
This 6 year old presents after being treated at
his PCP clinic for 3 days of vomiting
A reasonable next step would be to
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A) Obtain a CT of the head
B) Perform a lumbar puncture
C) Obtain a cervical spine series
D) Administer diphenhydramine
E) Sneak up on the child’s left side and
yell “BOO” to see if he’s faking this and
will turn his head
Testicular torsion has two peaks:
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Infancy
Adolescence
This patient cannot
recall how he was
injured. True
statement
concerning this
injury include all
except:
A. Associated with high incidence of infectious complications
B. The most common aerobic organisms include Strep/Staph
C. Eikenella corrodens is found in about one third of
anaerobic cultures
D. ED management includes copious wash out and closure
E. Complications could include amputation of the fingershand
Clinched Fist Injury
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High incidence of infectious complications:
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septic arthritis
Tenosynovitis
Osteomyelitis
Surgical amputation
Most infected wounds are polymicrobial
The drugs most commonly associated with
Torsades
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Class IA (Quinidine and
Procainamide)
Class IC agents
A 30 year old male presents
complaining of severe foot pain…
…This patient requires prompt
consultation by
A)
 B)
 C)
 D)
 E)
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a dermatologist
an orthopedic surgeon
an infectious disease specialist
an oncologist
a rheumatologist
Fracture Blister
6 year old boy presents with URI symptoms for a
week, as well as abdominal pain and swollen
tender joints and the rash shown here. True
statements regarding evaluation and treatment for
this patient include all of the above except:
A. This is a vasculitis affecting
arterioles and capillaries
B. Insect stings and drugs could be inciting agents
C. Frank arthritis is usually absent
D. Hematuria is hallmark of renal failure
E. Patient with GI bleeding should be admitted and
receive IV corticosteroids
Henoch-Schönlein purpura
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Purpuric, petechial rash appears from buttocks
to feet; can be seen on extensor surface of
arms, periauricular area
Beware of gastrointestinal bleed or nephritis.
Leg arthralgias common, edema of genitalia
seen
Admission not mandatory, steroids used only
with GI bleeding
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Chronic Lithium (as well as salicylates
and theophylline) is worse than acute
toxicity- True or false
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True…….True
The findings on this x-ray in a 2 year
old struck by a car suggest
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A) Positional artifact
B) Subluxation of C2 on C-3
C) Fracture of a
cervical vertebra
D) A fatal lesion
A 1 year old presents with fever and
decreased oral intake
Your disposition should be
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A) Observe in the ED for p.o. challenge
B) Discharge home on oral antibiotics
C) Admit for overnight observation
D) Prompt surgical consultation for
definitive treatment
E) Emergent I&D in the ED
These tender lesions are
associated with all
underlying infections
below, except:
A. Sarcoidosis
B. TB
C. Yersinia
D. Salmonella
E. All of the above
Erythema Nodosum
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Result of a hypersensitivity vasculitis from
infections, drugs, or a systemic disease- viral
URI, streptococcal infections, sarcoidosis,
TB, and drug exposure.
Much rarer causes include IBD,
histoplasmosis, Yersinia, Salmonella,
Chlamydia, coccidioidomycosis, psittacosis,
and autoimmune diseases such as SLE.
Drugs implicated include penicillins, sulfa
drugs, dilantin, and oral contraceptives
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Visual symptoms, acidosis, an elevated
osmolar gap
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Methanol poisoning
A 4 month old is triaged for fever
This x-ray suggests you should
A)
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Intubate the patient emergently
Treat with oral antibiotics
Admit for IV antibiotics
Place the patient in respiratory
isolation
 E) Look for another source of the
fever
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A diabetic patient
presents with fever and
this skin lesion of 1 day
duration.All statements
concerning ED treatment
are true,except
A. Aggressive fluid resuscitation
B. Gram +/-, anaerobic antibiotic coverage should be
initiated immediately
C. Emergent wide surgical debridement
D. Tetanus prophylaxis
E. All of the above
Fournier’s Gangrene
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Polymicrobial, synergistic infection of
the subcutaneous tissues that originates from one
of three sites: skin, urethra, or rectum
Begins as a benign infection or simple abscess
that quickly becomes virulent,and leads to endartery thrombosis in the subcutaneous tissue that
promotes widespread necrosis of previously
healthy tissue
This patient is brought to the ED
under police custody
The major complication to be
expected with this patient is
 A)
hypoxia
 B) hypercarbia
 C) renal failure
 D) arrhythmia
 E) blindness
Hydrocarbon Poisoning
Pulmonary
Cough, wheeze, tachypnea,
pneumonitis
Ingestion
N/V, hemorrhagic
gastroenteritis
Systemic
Confusion, H/A, ataxia,
lethargy, coma, death
Local
Irritation, burn, corneal injury
Rotary nystagmus
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PCP
35 year old with positional chest pain. Diagnosis
Acute pericarditis
This 35 year old mentally
retarded man with 3 days of
swelling to his face and neck.
His temp is 101, P 76
RR
20, Pulse OX 98%. The
treatment regimen for this
patient includes all of the
above except:
A. Admission to floor
B. Set up for possible intubation
C. IVF replacement, keep NPO
D. High dose PCN and Flagyl
E. Immediate OMFS/ENT
consultation
Ludwig’s Angina
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Cellulitis of bilateral submandibular spaces
and the lingual space
Brawny induration of the suprahyoid
region and elevation of the tongue
The primary focus of initial management is
maintenance of a patent airway
What is Kienbock’s disease?
Post traumatic avascular necrosis seen in
lunate fractures
A 1 week old infant presents with
irritability, tachypnea and poor
feeding. O2 sats 82% on room
air.
The following interventions would be
appropriate EXCEPT
 Supplemental
oxygen
 Evaluation for sepsis
 IV antibiotics
 IV indomethacin
 IV prostaglandin E1
35 year old man was involved in MVC,
now C/O LUQ pain. Vital signs are
normal. CT of abdomen shows the injury.
False statements include:
A. This is the most commonly injured organ in
pediatric blunt trauma
B. Treatment may includes exploratory lap if patient
deteriorates
C. At least 200 cc of fluid in the peritoneum is
required for FAST exam to be positive
D. FAST exam would be more sensitive for this type
of injury
E. High level of suspicion should be given to hollow
viscous injuries
A 1 year old, not moving his right arm
after a fall. He should be
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Placed in a hanging
arm splint
Taken to the OR for
internal fixation
Evaluated for
nonaccidental trauma
Discharged after
placement of a long
arm cast
76 year old man presents
with sudden onset of
painless partial visual
loss in left eye. Initial
treatment for this
condition includes
A. Heparin
B. Eye massage
C. Heliox
D. Mannitol
E. None of the above
Central Retinal Artery Occlusion
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Between 50 and 70 years of age- 45% CAD
Risk factors :HTN, CAD, DM, CVD,
vasculitis, cardiac valvular abnormality, and
sickle cell disease.
Reduced visual acuity with an afferent
pupillary defect
Digital global massage immediately in the ED
Increase P CO2
Timolol maleate 0.5% topically
Acetazolamide
Patient with tinnitus and shortness of
breath, think….
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Salicylate poisoning
A 4 year old presents with high fever
for 5 days and a rash on his trunk
Treatment should include
Amoxicillin 80mg/kg divided BID
 50 mg/kg IM Ceftriaxone x 1
 Supportive care for viral illness
 IV gammaglobulin
 Stopping all over the counter
medications
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Kawasaki’s Disease
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Usually < 5 years old
5 days of fever
Nonpurulent
conjuntivitis,
strawberry tongue, red
fissured lips,
palmar/solar erythema,
rash,
lymphadenopathy
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Treat with IV gammaglobulin, high dose
aspirin
Complications include
coronary artery
aneurysms in 25%
65 year old man
without prior history
presents with
decreased vision in L
eye for 2 days. R eye
is normal. L eye is
shown here, diagnosis:
A. Retinal artery occlusion
B. Retinal vein occlusion
C. Cotton wool spots
D. Retinal detachment
E. None of the above
Central Retinal Vein Occlusion
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Painless loss of vision
Loss of vision can range from minimal to
recognition of hand motion only.
Management is aimed at identifying
systemic disease and monitoring for
neovascular glaucoma.
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Most common ECG abnormality with
Digoxin toxicity is
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PVCs
8 month old with fever for the
previous 4 days. Now afebrile with
the rash shown below. Treatment
includes
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Supportive care only
IV Penicillin
Diphenhydramine
Systemic
corticosteroids
Doxycycline
Viral Exanthums
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Roseola (Erythema Subitum)
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Human herpes 6 virus: Rapid temperature
elevation, irritability and often febrile seizures
lasting 3-4 days followed by defervescence and
the a “rose” colored macular eruption on the trunk
and then spreading to the extremities.
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Tx: supportive
Varicella (Chickenpox)
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Varicella zoster virus: Viral prodrome of URI and
fever followed by rapidly appearing crops of
vesicles of differing ages. Lesions start in the
scalp and trunk and spread peripherally.
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Tx: supportive
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Erythema Infectiosum (Fifth Disease)
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Human parvovirus B-19: Fever with characteristic
“slapped cheek” rash later fading and replaced by
a lacy macular eruption on the extremities.
Complications include aplastic anemia in those
with hemoglobinopathies.
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Tx: supportive
Hand-Foot-Mouth Disease
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Cocksackie virus: Fever, malaise and anorexia
with one/all of the characteristic macular and
vesicular eruption on the palms and/or soles and
shallow oral ulcers of the soft palate and tonsillar
pillars (Herpangina)
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Tx: supportive
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Herpes Gingivostomatitis
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Herpes simplex virus: Painful white-yellow friable
ulcerations with erythematous halos on the lips, gums,
tongue and anterior oral mucosa. Fever, halitosis and
anorexia are common. May spread to eyes
(conjunctivitis) and extremities (Whitlow).
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
Tx: supportive
Rubeola
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Measles virus: Fever, malaise, cough, coryza,
conjunctivitis, Koplik’s spots (buccal mucosa) followed by
a blotchy macular eruption beginning at the hairline and
spreading caudally. Complications include pneumonia,
otitis, encephalitis and bacterial secondary infections

Tx: supportive
32 year old obese
woman presents with
headache and
decreased visual
acuity. CT of head is
negative. Further
evaluation and or
treatment should
include:
A. MRI of brain
B. Carotid doppler
C. Lumbar puncture
D. Mannitol
E. High dose steroids
Pseudotumor Cerebri
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20- to 30-year-old obese women
Complain of N,V,HA, and visual changes
The headache is typically chronic and the
symptoms can mimic those of a brain tumor.
Pregnancy, oral contraceptives, vitamin A
overuse, tetracycline, nalidixic acid, and
corticosteroid withdrawal or prolonged use
have been associated
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Child with GI symptoms and anemia
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Think lead poisoning
A 6 year old presents as a restrained
passenger in a car accident
An appropriate evaluation of this
finding would include
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A) Diagnostic peritoneal lavage
B) Exploratory laparotomy
C) Abdominal sonogram
D) CT scan of the abdomen and x-ray of
the lumbar spine
E) Intravenous pyelogram and barium
enema
55 year old woman
with acute onset of
decreased visual
acuity, described as
flashing lights.
Diagnosis
A. Retinal hemorrhage
B. Acute angle closure glaucoma
C. Retinal detachment
D. Inter-ocular foreign body
E. Retinal artery occlusion
Retinal Detachment
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Risk factors:Hypertension, toxemia of
pregnancy, central retinal venous
occlusion, glomerulonephritis,
papilledema, or vasculitis.
Pain is absent
Retinal detachments diagnosed or
suspected in the ED need emergent
consultation.
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Conjunctivitis in a 4 day old infant
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GC
This patient was found with altered
mental status by her family
In sorting out the etiology of this
finding, it may be harmful to

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
A) Administer 5 mg haloperidol
B) Administer 2 mg lorazepam
C) Administer 25 mg diphenhydramine
D) Administer 1 mg benztropine
E) Administer 25 gm dextrose
In sorting out the etiology of this
finding….
One should
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


A) Provide emergent
dental hygiene
B) Search diligently
for occult rectal
foreign bodies
C) Administer 10 mg
IV Ritalin
D) Withdraw support
35 year old post
partum female
presents with
sudden onset of
perianal pain. No
fever. Diagnosis
is:
A. Rectal prolapse
B. Rectal foreign body
C. Thrombosed hemorrhoid
D. Perirectal abscess
E. Uterine prolapse
This patient presents with 1 week
of worsening dyspnea
The exam is unlikely to reveal
 A)
Basilar rales
 B) Jugular venous distention
 C) Bounding pulses
 D) Cardiac friction rub
 E) Hypotension
19 year old man felt a pop
and had sudden pain to
his penis while trying a
new sexual position with
his partner. The injured
structures could be all of
the above except:
A. Tunica albuginea
B. Bulbous cavernosum
C. Urethral tear
D. All of the above
Patient was stabbed with a
kitchen knife. He has
normal vital signs. FAST
exam is shown. The next
best step in diagnosis is:
A. Exploratory lap
B. Removal of the knife and
Repeat FAST in 4 hours
C. DPL
D. Cut down visualization to
see if peritoneum has
been violated
E. CT of abdomen
Most common cause of myocarditis in US:

Coxsackie
Most common cause of myocarditis in Central
America

Chagas disease
What is the most characteristic of Lyme disease
associated myocarditis
 Conduction abnormality
You are called to this patient’s
bedside by a nurse
His acute respiratory decompensation
can likely be corrected with





A) Intubation
B) Left chest tube
C) Right chest tube
D) Pericardiocentesis
E) high flow
oxygen
25 year old HIV patient with
above rash for 2 days. He
has R eye pain and
photophobia. He requires all
of the above except:
A. Slit lamp evaluation
B. Cycloplegic agents
C. IV acylovir
D. Steroids if fluorescein is neg
and cells and flare are noted
E. DC and follow up with an
ophthalmologist in 24 hours
Herpes Zoster Keratoconjunctivitis






As a result of activation of the virus along
ophthalmic division of the trigeminal nerve
Unilateral, involves the lids, produces significant
pain
Hutchinson sign
An iritis can occur with photophobia and pain. Iritis
can be treated with topical steroids prednisolone
acetate 1% (Pred Forte)
If HZO is diagnosed, admission and intravenous
acyclovir should be considered.
Ophthalmic zoster mandates emergent
ophthalmologic consultation.
This assault victim
Should be examined for this finding





A) Right lower facial paralysis
B) Dilated left pupil
C) Inability to abduct the right eye
D) Inability to depress the right eye
E) Inability to elevate the right eye
35 year old painter
accidentally injured himself
while using his high pressure
paint gun. All are true
regarding evaluation and
treatment of this injury, except:
A. Check for tetanus status
B. Obtain x-rays of the hand
C. DC with follow up in 2 days
D. Call a hand surgeon for immediate surgery
E. None of the above
The signs of tenosynovitis




Tenderness along the tendon sheath
Finger held in flexion
Pain on passive extension of the finger
Decreased distal sensation
This patient presents after a fishing
accident
Recommended interventions include
all of the following except
A) Update tetanus immune status
 B) Document intraocular pressures
 C) Prophylactic antibiotics
 D) Eye shield
 E) Antiemetics

28 year old female with history of
IVDU presents with sudden onset
of dyspnea. Her temp is 101, P
130, BP 80/P, and respiratory rate
of 36. On physical exam you see
increased JVD and hear crackles
in the lung fields. There is S3 and
S4 gallop as well as a harsh apical
systolic murmur. The most likely
cause is:
A. Acute MI
B. Acute PE
C. Acute rupture of papillary muscle
D. Severe pneumonia
E. Drug seeking behavior
The patient shown presents
with the above rash that has
been causing him anxiety
and pruritus for the past
week. Before discharging
him home he should have:
A. His tetanus updated
B. CBC and Hepatitis profile
C. GC and chlamydia swab of
penis
D. VDRL
E. None of the above
Pityriasis Rosea





Mild inflammatory exanthem of unknown
cause, maybe viral
Occasionally there are prodromal symptoms
including malaise, headache, sore throat,
fatigue, and arthralgia.
Diagnosis is clinical
It can be confused with viral exanthem, drug
eruptions, syphilis, and seborrheic dermatitis
A serologic test for syphilis must be done to
exclude that diagnosis.

What is the most common presenting
complaint for an aortic dissection?

Pain
20 year old is bitten by a rattlesnake. 1 hour
later, he complains of severe pain to the hand
Interventions that may be indicated
include all except





A) Diptheria-Tetanus toxoid
B) 1 vial crotalid antivenin
C) Narcotic analgesics
D) Fresh frozen plasma
E) Fasciotomy
What is the name of
this fracture?
Bennett’s Fracture
The most common
associated injury with
the above fracture is:
A. Calcaneus fracture
B. Tib-fib fracture
C. Hip fracture
D. Vertebral fracture
E. Ankle fracture
The most common cause of pneumonia in a 3-weekold infant
 Group B strep
The most common cause of meningitis in a 3-weekold infant
 Group B strep
The most common cause of sepsis in a 3-weekold infant
 Group B strep
This patient bit by a spider 3 days
ago
Treatment for this wound includes
A) Local debridement and physical
therapy
 B) Systemic antibiotics
 C) Systemic steroids
 D) Tetanus toxoid
 E) All of the above

This patient sustained this
injury by falling on
outstretched arm. All
statements are true
regarding the possible
complications of this injury
except:
A. Early degenerative arthritis
B. Delayed union
C. Malunion, nonunion,
avascular necrosis
D. median nerve compression
E. All of the above
Most common cause of focal encephalitis in
AIDS

Toxoplasma gondii
The patient with this EKG was found
unconscious in an alley
Treatment includes





A) 25 gm Dextrose and 10 units insulin
B) Rewarming
C) 200 Joules defibrillation
D) 1 gm calcium chloride
E) All of the above
Osbourne J waves
shivering
Common complications of this
injury includes all of the
following, except:
A. Complete avulsion of anterior
and posterior cruciate ligaments
B. Patellar tendon rupture
C. Peroneal nerve injury
D. Popliteal artery injury
E. Posterior joint capsule rupture
Associated Injuries
•Clavicle
Brachial
plexus (BP)
Subclavian
•Anterior shoulder
dislocation

vessels
Axillary nerve
Associated Injuries

Radial nerve
Associated Injuries


Brachial artery
Median nerve
Associated Injuries

Radial nerve
A 54 y.o. female with Lupus presents with
2 weeks of worsening dyspnea presents
severe hypotension
This unstable patient should be
treated with





A) High dose steroids
B) t-PA
C) Furosemide
D) Pericardiocentesis
E) all of the above
Electrical Alternans
All statements regarding this condition are true, except:
A. This is the most common type of shoulder dislocation
B. Axillary nerve injury is a possible injury
C. 80% of these injuries are undiagnosed initially
D. Presentation of this patient is with arm in adducted position
and internally rotated with abduction causing severe pain
E. All of the above
A 17 year old male presents with 1 hour
of crushing chest pain after using cocaine
Which of the following should be
avoided in this patient
A) Nitrites
 B) Calcium channel antagonists
 C) Beta blockers
 D) Aspirin
 E) Thrombolytics

Complication of this
injury include:
A. Radial nerve injury
B. Ulnar and median
nerve injury
C. Compartment
syndrome
D. Gunstock deformity
E. All
Biceps reflex

C6
Patellar reflex

L4
This 80 year old renal dialysis patient
presents with altered mental status
Your first intervention should be
A) Calcium
 B) Bicarbonate
 C) Albuterol
 D) Insulin and glucose
 E) TNK

45 year old El Paso resident presents with bilateral eye
findings shown here for the past year.
Diagnosis
Ptyrigium
This patient suffered the
above injury in a barroom
fight. He lost. True
statements regarding this
condition include all
except:
A. Early globe reduction is an important initial treatment
B. There are no contraindication to performing globe reduction
C. Patients with spontaneous (atraumatic) luxation and no visual
impairment in whom the globe is easily reduced warrant followup within 24 to 48 hours
D. Patients with traumatic luxation are at greater risk for
underlying ophthalmic injury and warrant emergent
consultation
This 5 year old who fell on her elbow
has a





Nursemaids elbow
Radial head
fracture
Ulna fracture
Supracondylar
fracture
Sprain
This patient presents with
a red, painful eye for
one day after he fell
sleep with his contact
lens on. The organism
most likely involved
with this condition is:
A. Staph
B. Pseudomonas
C. Strep
D. Herpes simplex
E. Non of the above
This patient who initially presented with a
GCS of 3 but with a maintained airway
and spontaneous resolution of symptoms
likely overdosed on





A) Ethanol
B) Amytriptyline
C) Gamma
hydroxybutyrate
D) Phencyclidine
E) Jimsonweed
False statements regarding this
injury include:
A. More common in children
than elderly
B. Carries a better prognosis
than other cranial injuries if
diagnosed early
C. 80% occur in temproparietal
region
D. The lucid interval is
pathognomonic for this
injury
E. All are true
These patients are poisoned with
carbon monoxide. Which is false?




A) May have COHgb
>10%
B) Have a normal SaO2
C) May have a normal
PaO2
D) Should receive
oxygen via nasal
cannula
78 year old man presents
with sudden onset of
severe abdominal pain that
is out of proportion to his
exam. He is in a-fib with
ventricular rate of 140. His
guaiac test is positive.
Treatment should include
all of the above except:
A. Securing airway and breathing
B. Mesenteric angiography
C. Call the surgeons
D. Cardioversion to a normal sinus
E. IVF therapy
18 year old involved in MVC
with head injury was
intubated in route to ED.
After viewing this CXR
the next treatment
should be:
A. Tube thoracostomy on R
B. Tube thoracostomy on L
C. CT of the chest
D. Reposition the ET tube
E. Perform a FAST exam
What is the most common cause of
endocarditis in IVDU population?

Staph aureus
What is the most common cause of
infective endocarditis?

Strep viridans
A 9 month old is brought to the ED
for this finding. History will reveal





A) Recent trauma
B) Febrile seizures
C) A family history of
an inherited disease
D) Antibiotic use
E) Congenital
anomaly
Dactylitis



Earliest manifestation
of Sickle Cell
Disease.
Vasoocclusive effects
within the bones.
Hydration and pain
control.
Sickle Cell Disease – clinical
presentations
Vasoocclusive Crisis: Small vessel
occlusion secondary to noncompliant
RBC’s leads to distal hypoxia and pain.
 Examples include: dactylitis, bony pain
crisis, acute chest crisis, stroke, and
avascular necrosis of the femoral head.
 Treatment: Aggressive hydration and pain
control.

Sickle Cell Disease – clinical
presentations
Hemolytic Crisis: Massive destruction of
sickled cells leading to severe anemia and
shock. Look for jaundice.
 Aplastic Crisis: Shutdown of RBC
production (Parvovirus B-19).
 Sequestration Crisis: Splenic enlargement
can lead to a functional severe anemia.
Priapism.

Sickle Cell Disease – clinical
presentations

Asplenia: High risk for infections by
encapsulated organisms (Strep
pneumoniae, H. flu, Salmonella,
Klebsiella). Bacteremia, pneumonia,
meningitis and osteomyletitis are more
common in patients with Sickle Cell
Disease.
68 year old man with acute anterior MI develops the
following rhythm after receiving tPA. Treatment
includes:
A. Cardioversion
B. Lidocaine
C. Verapamil
D. Permanent pacemaker
E. None of the above
This condition is the
third most common
cause of large bowel
obstruction. What are
the first two causes:

Cancer

Diverticulitis

Volvulus
One should perform
I&D of septal hematoma
So he does not develop
A flat nose
A 15-year-old boy fractures his right
tibia while playing football.
Several hours after the incident
he develops tachycardia,
tachypnea and dyspnea. Soon
afterwards he becomes
comatose. Which of the following
is most likely?
A.
A petechial rash may develop on the chest, axilla, and
neck
B.
Chest x-ray will reveal an area of density or
consolidation of the lung
C.
Heparin therapy instituted immediately will alleviate the
symptoms
D.
The presence of fat globules in the urine sediment is
diagnostic
What is the bleeding site for most
anterior epistaxis?

Kiesselbach's plexus
Lightning strikes a soccer field
during a game. Ten people are
injured. An ambulance crew is
present. Which of the following
victims should be treated first?
A. A fan who is pregnant and
complaining of abdominal pain
B. A player who is awake, but has
an obviously deformed right
thigh
C. A player who is unconscious,
and has no detectable pulse or
visible respiratory effort
D. An unconscious man with a
palpable pulse and visible
respiratory effort
A 16-year-old child with sickle cell
disease, presents with left leg
pain and a temperature of
38.8C (102F). X-ray is shown
here.The most likely etiologic
agent is which of the
following?
A. Bacteroides
B. Escherichia coli
C. Klebsiella
D. Pseudomonas
E. Salmonella

What is the most common cause of
esophageal perforation?

Iatrogenic
A 25-year-old woman presents
with fever and diffuse,
desquamating macular
erythematous rash. She
complains of vomiting,
diarrhea, myalgias and a sore
throat. Pharyngeal exam
shows diffuse hyperemia. Her
vital signs are: BP, 90/70; P,
120; R, 24, and T 40C. Which
of the following is the most
likely cause?
A. Erythema multiforme
B. Kawasaki's disease
C. Scalded skin syndrome
D. Toxic shock syndrome
Toxic Shock Syndrome


Etiology: associated with S aureus
(either infection or colonization),
associated with exotoxin production,
TSST-1
Affected patients
a.
b.
c.
d.
e.
Menstruating females
Post-partum females
Other foreign bodies
Post-influenza
Post-surgical
Toxic Shock Syndrome
CDC criteria for the diagnosis of TSS:
 Temperature >38.9 C.
 Erythematous macular rash with later
desquamation, particularly of palms and
soles
 Hypotension
 Negative blood, urine, etc. cultures
 Negative tests for RMSF, leptospirosis,
measles, Hepatitis B, mononucleosis,
VDRL
Toxic Shock Syndrome

Involves at least 3 of the following organ
systems:







GI (vomiting, diarrhea)
Muscular (myalgias, elevated CPK)
Renal (pyuria, elevated BUN, creatinine)
Hepatic (elevation bilirubin, SGOT, SGPT)
Hematologic (thrombocytopenia)
CNS (altered mental status)
Mucosal inflammation (vaginal, conjunctival,
pharyngeal)
Most common cause of septic arthritis
in teenagers and young adults

GC
Ptosis of the upper eyelid, slight elevation of
the lower lid, constriction of the pupil and facial
anhidrosis all on the ipsilateral side following
penetration injury to the neck suggests trauma
to what anatomical structure?





A.
B.
C.
D.
E.
Brachial plexus
Lateral spinal cord
Phrenic nerve
Stellate ganglion
Vertebral artery

A 26-year-old man
presents with a
history of fever,
headache and rash.
The rash began on
the right wrist and
progressed to involve
all extremities. Patient
is ill appearing and
physical exam
reveals a palpable
spleen.
Which of the
following is the
most likely
diagnosis?
A. Lyme disease
B. Meningoccemia
C. Mononucleosis
D. Rocky Mountain
spotted fever
E. Rubella
RMSF




Etiology: Rickettsia rickettsi
Most common Rickettsial infection in the US
<5% occur in Rocky Mountains; >50% occur in
south Atlantic States
Abrupt onset of fever, chills, headache,
extreme muscle tenderness (gastrocnemius),
photophobia, conjunctival infection, 25% of
patients have pulmonary symptoms (Coryza,
Dyspnea), rash (absent in 5-15% of cases)
RMSF

Diagnostic Tests:




Fluorescent antibody methods of rickettsial
identification on biopsy
Serologic tests
Clinical diagnosis and treatment, pending test
results
Treatment: doxycycline or tetracycline for 5-7
days

Alternate: Chloramphenicol
The classic symptoms of aortic stenosis are:



Dyspnea on exertion
Angina
Exertional syncope
The most common cause of aortic stenosis in
patients>65 years old is:

Calcific degeneration of
the valve cusp
What are the most frequent causes of
hypercalcemia?
 Malignancies
 Hyperparathyroidism
What is the second leading cause of death in US?

Malignancies
A 6-year-old girl is brought to the
emergency department at
midnight complaining of rectal
itching. What is the definitive
management for this patient?
A. Draw CBC looking for
eosinophilia
B. Obtain stool for culture, gram
stain, ova and parasites
C. Oral mebendazole or pyrantel
pamoate
D. Oral metronidazole 15
mg/kg/day TID for ten days
The
End