BOARD REVIEW QUESTIONS

Transcription

1 September 2017 Volume 17 Issue 9 Challenging ABEM style questions for enhanced learning and deeper understanding of the EMRAP program Editor-in-Chief: Mel Herbert, MD Executive Editor: Stuart Swadron, MD Associate Editor: Dan Joseph, MD Question #1 A 70-year old female with a history of diabetes and hypertension presents to the Emergency Department with 6 hours of severe dizziness and nausea. The dizziness is worse with movement but is also present at rest. On neurologic exam, the patient has a normal motor and sensory exam bilaterally. While evaluating extra ocular movements the patient demonstrates vertical nystagmus. Which of the following is the most likely cause of this patient s symptoms? 1. Benign paroxysmal positional vertigo 2. Cerebellar stroke 3. Orthostatic hypotension 4. Vestibular neuritis Question #2 A 55-year old male presents to the Emergency Department with severe dizziness. He has a history of diabetes, hypertension, as well as peripheral vertigo in the past. During your HINTS exam, the patient is able to keep his eyes on your nose during head impulse testing, has no nystagmus, and a negative test of skew. Which of the following is the most appropriate next step in management? 1. Dix-Hall pike maneuver 2. Epley maneuver 3. Meclizine administration 4. MRI brain Question #3 At the beginning of your shift, one of your ED partners signs you out a 65 year old female with a history of diabetes who is presenting with vertigo. He reports that the patient s neurologic exam is remarkable for trouble with finger to nose and rapid alternating movement testing. He reports that the patient is pending CT scan. 20 minutes later radiology calls to inform you that the CT scan is negative. Which of the following is the most appropriate next step in management? 1. CT angiogram head and neck 2. Epley maneuver 3. MRI brain 4. Symptomatic treatment with meclizine 1

2 Question #4 A 25-year old male presents with a painful tooth. He reports initially it was sensitive to cold drinks only but the pain has progressed and he is now uncomfortable and unable to sleep. Which of the following structures is LEAST like to be the cause of this patient s pain? 1. Enamel 2. Dentin 3. Pulp 4. Root Question #5 Which of the following is true regarding the use of antibiotics for irreversible pulpitis? 1. Antibiotics can reduce pain associated with these infections 2. Antibiotics can reduce the duration of symptoms 3. Antibiotics can prevent the progression to dental abscess 4. Antibiotics have not been shown to have an appreciable benefit Question #6 A 27 year old female presents with significant pain to her right first lower molar. Physical exam reveals an obvious cavity without surrounding erythema or evidence of abscess. Which of the following is the most appropriate way to provide local anesthesia? 1. Inferior alveolar nerve block 2. Infraorbital nerve block 3. Lingual block 4. Maxillary nerve block Question #7 Which of the following is NOT an independent risk factor for coronary artery disease? 1. Chemotherapy 2. Chronic alcohol use 3. HIV infection 4. All of the above are risk factors Question #8 A 55-year old male with a history of congestive heart failure presents to the Emergency Department with shortness of breath. Vital signs are: HR 110, BP 210/120, RR 40, O 2 sat 86% on room air. Physical exam is remarkable for rales bilaterally as well as 1+ edema bilaterally. Bedside RUSH ultrasound exam shows a markedly diminished ejection fraction and an inferior vena cava that collapses with inspiration. Which of the following is LEAST likely to be effective acutely? 1. Enalapril 2. Furosemide 3. Nitroglycerin 4. Non-invasive positive pressure ventilation 2

3 Question #9 Which of the following may cause false positive screening for THC on urine drug testing? 1. Diphenhydramine 2. Dextromethorphan 3. Naprosyn 4. Oxycodone Question #10 A 25-year old male presents to the Emergency Department with shortness of breath. He was seen and discharged earlier in the shift after successful drainage of a peritonsillar abscess. On arrival vital signs are: HR 110, RR 30, BP 130/90, O 2 sat 85%. The patient is placed on 100% O 2 with no change in his oxygen saturation. Physical exam is remarkable for a previously drained peritonsillar abscess. The uvula is now midline and the patient has no stridor and his neck is supple. Which of the following is the most appropriate next step in management? 1. CT neck 2. Intubation 3. Methylene blue 4. Racemic epinephrine Question #11 A 24-year old female with a history of insulin dependent diabetes mellitus presents to the ER with nausea and vomiting. She reports she noticed painful urination 2 days prior and since then the symptoms have progressed. Vital signs are: HR 115, RR 20, BP 130/80, T 102.2ºF (39ºC). Physical exam is remarkable only for tachycardia. Laboratory analysis is as follows: Sodium 130 meq/l, Potassium 4.8 meq/l, Chloride 100 meq/l, Bicarbonate 8 meq/l and glucose 400 mg/dl (22.22 mmol/l). Which of the following is the most appropriate initial therapy? 1. Sodium chloride bolus 2. Insulin IV bolus 3. Insulin IV drip 4. Subcutaneous insulin Question #12 A 45-year old female with insulin dependent diabetes presents to the Emergency Department with nausea and elevated blood sugar after running out of her insulin yesterday evening. Vital signs are: HR 90, RR 20, BP 142/86, T 98.6ºF (37ºC). Physical exam is unremarkable. Laboratory analysis is as follows: Sodium 132 meq/l, Potassium 4.8 meq/l, Chloride 100 meq/l, Bicarbonate 16 meq/l and glucose 400 mg/dl (22.22 mmol/l). ph is 7.3. According to this segment, in addition to IV fluids which of the following is the most appropriate initial therapy? 1. Insulin IV bolus 2. Insulin IV drip 3. Metformin 4. Subcutaneous insulin Question #13 Which of the following is the appropriate management of a patient s insulin pump when treating them for diabetic ketoacidosis? 1. Decrease the threshold for insulin administration 2. Increase the insulin administration rate 3. Increase the threshold for insulin administration 4. Turn off the pump 3

4 Question #14 In which of the following patients is pre-oxygenation with bag valve mask ventilation most appropriate prior to intubation? 1. Agitated delirium patient who requires aggressive sedation 2. Altered patient with a salicylate overdose 3. Head trauma patient spontaneously breathing but with diminished GCS 4. None of the above Question #15 A 55-year old male is brought in by EMS in cardiac arrest. They report initial rhythm was ventricular fibrillation. On arrival the patient is intubated and initial rhythm is asystole. A pre-cordial thump is performed. Which of the following is the proposed mechanism of this intervention? 1. Decreased afterload 2. Increased coronary blood flow 3. Increased preload 4. Provoking a stretch activated ion channel Question #16 According to this month s Trauma Myths section with Anand Swaminathan, which of the following is true regarding intubating patients with manual in-line stabilization? 1. Manual in-line stabilization is not effective at immobilizing the cervical spine 2. Manual in-line stabilization reduces the first pass success intubation rate 3. Manual in-line stabilization is associated with increased time required for successful intubation 4. All of the above are true Question #17 A 55-year old male is brought to the Emergency Department after a motorcycle crash. He received 100mcg of fentanyl by EMS during transport. Vital signs are: HR 130, RR 20, BP 90/60, O 2 94%. He has an obvious femur fracture, however his GCS is 15, and his abdomen is soft and nontender. Which of the following is true regarding this patient s abdominal exam? 1. The abdominal exam is unreliable because of the patient s distracting injury 2. The abdominal exam is unreliable because of the patient s hypotension 3. The abdominal exam is unreliable because of the fentanyl administered by pre-hospital providers 4. The abdominal exam is reliable in this patient and he is unlikely to have a clinically significant intra-abdominal injury Question #18 A 45-year old male with a history of depression and schizophrenia is brought in by EMS for altered mental status. He was found down next to several bottles of an over-the-counter cough syrup. Vital signs are: HR 140, RR 20, BP 190/110, T 102.2ºF (39ºC). Physical exam reveals an altered male with hyperreflexia, clonus, and muscle rigidity greater in the lower extremity compared to upper extremities. Which prescription medication is the patient most likely to be taking? 1. Alprazolam 2. Paroxetine 3. Haloperidol 4. Valproic acid 4

5 Question #19 According to this month s Paper Chase segment, which of the following was found when comparing intravenous administration of midazolam 5mg plus droperidol 5 mg versus droperidol 10mg versus olanzapine 10mg? 1. The combination of an antipsychotic and a benzodiazepine was associated with a higher rate of intubation 2. The combination of an antipsychotic and a benzodiazepine was associated with a higher incidence of QTc prolongation 3. The combination of an antipsychotic and a benzodiazepine was associated with a higher rate of cardiac events 4. The combination of an antipsychotic and a benzodiazepine was associated with a higher success rate of sedation Question #20 According to the recent JAMA article discussed in this month s Paper Chase, which of the following is true regarding early intubation for in-hospital cardiac arrest? 1. Intubation was associated with increased survival 2. Intubation was associated with improved neurologic outcome 3. Intubation was associated with improved rate of return of spontaneous circulation 4. None of the above are true Question #21 A 33-year old female presents to the Emergency Department with a sudden onset severe headache 7 hours prior to presentation. CT head is negative and lumbar puncture is remarkable for red blood cells and xanthochromia. CT angiogram is negative. Which of the following is the most appropriate next step in management? 1. Discharge 2. Formal angiogram 3. MR angiogram 4. Repeat lumbar puncture at another level 5