SAEM Practice || Get it Correct.
With regard to specific causes of hypertension, which of the following is true?
A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose
mental status changes are reversible
B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours
C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible
to reduce the risks of worsening neurological deficit
D. Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension
E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients
correct answers A. Hypertensive encephalopathy is more likely than hypertensive stroke in
patients whose mental status changes are reversible
Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over
hours; however, encephalopathy due to hypertension is more likely reversible than
encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is
particularly critical for patients with strokes. Laboratory analysis can be important in cases of
hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be
identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses
such as the HELLP syndrome).
An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth.
He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway
between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture
site has a yellowish tinge without blood. Of the following choices, which is the most appropriate
management for this patient?
A. No specific treatment required
B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up
C. Placement of tooth fragment in saline gauze, outpatient dental follow-up
D. Immediate dental consult to avoid abscess formation
E. Replace fractured piece and place acrylic splint correct answers D. Immediate dental consult
to avoid abscess formation
,Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish
tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood.
These fractures require immediate dental consultation to prevent abscess formation.
The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination correct answers E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and should be
used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the digit
in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the
nerve is intact.
Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye.
Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the
orbit and the patient has right eye pain with extraocular movement. What is the most likely cause
of his symptoms?
A. retrobulbar hematoma
B. chemosis
C. hyphema
D. orbital blow-out fracture
E. ruptured globe correct answers A. retrobulbar hematoma
The answer is A. Traumatic proptosis with impaired extraocular movements is classic for
retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment.
A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the
eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause
,inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement.
Yet, they do not present with proptosis - unless complicated by retrobulbar pathology.
A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at
the emergency department in a cervical collar and on a backboard. His only complaint is neck
pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and
only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his
arms against gravity and there is decreased grip strength bilaterally. The remainder of his
neurological exam is normal. What is the most appropriate management for this patient?
A. Administration of IV steroids and ordering of cervical MRI
B. Immediate neurosurgical decompression
C. Flexion and extention radiographs to rule out ligamentous injury
D. Discharge home with a hard cervical collar with neurosurgical follow-up
E. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness
correct answers A. Administration of IV steroids and ordering of cervical MRI
The answer is A. Central cord syndrome results from a hyperextension injury, typically in elderly
patients with significant degenerative joint disease. The ligamentum flavum buckles into the
cord, resulting in a contusion of the cord's central portion.
A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden
and severe low back pain. The pain radiates down his right leg and he develops numbness over
the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to
pinprick over the dorsum of the right foot (medially) and some weakness in right foot
dorsiflexion. At which level is a protruding intervertebral disc most likely?
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1 correct answers D. L4-L5
, The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are
functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5.
Which of the following cervical spine fractures is considered stable?
A. Transverse process fracture
B. Flexion teardrop fracture
C. Bilateral facet dislocation
D. Hangman's fracture of C2
E. Jefferson fracture of C1 correct answers A. Transverse process fracture
The answer is A.
A transverse process fracture involves only one of the supporting spinal columns (the posterior
column) and is therefore stable.
A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She
presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92,
blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally.
The entrance wound is just above the right breast and an exit wound is noted in the right axilla.
What is the most appropriate management of this patient?
A. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside
ultrasound, portable chest X-ray, and admission to the ICU if stable
B. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to
search for cardiac or pulmonary vascular injury
C. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac
or pulmonary vascular injury
D. IV access, portable chest X-ray, right ch correct answers A. IV access, endotracheal
intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest
X-ray, and admission to the ICU if stable
You are practicing in a trauma center a receive a call from an outlying facility that they would
like to transfer a male patient to you with a spinal cord injury after significant flexion and
With regard to specific causes of hypertension, which of the following is true?
A. Hypertensive encephalopathy is more likely than hypertensive stroke in patients whose
mental status changes are reversible
B. Hypertensive encephalopathy causes adverse outcomes over days or weeks, rather than hours
C. Patients with stroke syndromes must have blood pressure normalized as quickly as possible
to reduce the risks of worsening neurological deficit
D. Laboratory analysis is rarely useful in cases of confirmed pediatric hypertension
E. Laboratory analysis is rarely useful in cases of confirmed hypertension in pregnant patients
correct answers A. Hypertensive encephalopathy is more likely than hypertensive stroke in
patients whose mental status changes are reversible
Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over
hours; however, encephalopathy due to hypertension is more likely reversible than
encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is
particularly critical for patients with strokes. Laboratory analysis can be important in cases of
hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be
identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses
such as the HELLP syndrome).
An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary canine tooth.
He brings the severed piece of tooth with him. On physical exam, the tooth is fractured halfway
between the tip and the gumline. The root of the tooth is still firmly intact. The exposed fracture
site has a yellowish tinge without blood. Of the following choices, which is the most appropriate
management for this patient?
A. No specific treatment required
B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up
C. Placement of tooth fragment in saline gauze, outpatient dental follow-up
D. Immediate dental consult to avoid abscess formation
E. Replace fractured piece and place acrylic splint correct answers D. Immediate dental consult
to avoid abscess formation
,Ellis II dental fracture involves enamel and dentin. The fracture site typically has a yellowish
tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp and often blood.
These fractures require immediate dental consultation to prevent abscess formation.
The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination correct answers E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and should be
used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the digit
in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the
nerve is intact.
Following a motor vehicle crash, a 25 year old man presents complaining of a painful right eye.
Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye protrudes from the
orbit and the patient has right eye pain with extraocular movement. What is the most likely cause
of his symptoms?
A. retrobulbar hematoma
B. chemosis
C. hyphema
D. orbital blow-out fracture
E. ruptured globe correct answers A. retrobulbar hematoma
The answer is A. Traumatic proptosis with impaired extraocular movements is classic for
retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual impairment.
A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor leaks out of the
eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures can cause
,inferior rectus muscle entrapment and secondary pain with impairment of extraocular movement.
Yet, they do not present with proptosis - unless complicated by retrobulbar pathology.
A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He arrives at
the emergency department in a cervical collar and on a backboard. His only complaint is neck
pain, and he has mild posterior neck tenderness. A CT scan of the neck shows no fracture and
only degenerative arthritis. Upon re-evaluation you note the patient has difficulty raising his
arms against gravity and there is decreased grip strength bilaterally. The remainder of his
neurological exam is normal. What is the most appropriate management for this patient?
A. Administration of IV steroids and ordering of cervical MRI
B. Immediate neurosurgical decompression
C. Flexion and extention radiographs to rule out ligamentous injury
D. Discharge home with a hard cervical collar with neurosurgical follow-up
E. Reassurance and discharge with NSAIDs given the non-anatomical distribution of weakness
correct answers A. Administration of IV steroids and ordering of cervical MRI
The answer is A. Central cord syndrome results from a hyperextension injury, typically in elderly
patients with significant degenerative joint disease. The ligamentum flavum buckles into the
cord, resulting in a contusion of the cord's central portion.
A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface and has sudden
and severe low back pain. The pain radiates down his right leg and he develops numbness over
the anterior shin and dorsum of the foot. On physical exam he has decreased sensation to
pinprick over the dorsum of the right foot (medially) and some weakness in right foot
dorsiflexion. At which level is a protruding intervertebral disc most likely?
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1 correct answers D. L4-L5
, The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot are
functions of the L5 nerve root. Herniation of the L4-5 disc would result in compression of L5.
Which of the following cervical spine fractures is considered stable?
A. Transverse process fracture
B. Flexion teardrop fracture
C. Bilateral facet dislocation
D. Hangman's fracture of C2
E. Jefferson fracture of C1 correct answers A. Transverse process fracture
The answer is A.
A transverse process fracture involves only one of the supporting spinal columns (the posterior
column) and is therefore stable.
A 32 year old female is shot with a 38-caliber pistol at close range in the right anterior chest. She
presents to the emergency department intoxicated and yelling. Her vitals include a pulse of 92,
blood pressure of 134/84, and oxygen saturation of 97%. She has clear breath sounds bilaterally.
The entrance wound is just above the right breast and an exit wound is noted in the right axilla.
What is the most appropriate management of this patient?
A. IV access, endotracheal intubation and simultaneous placement of a right chest tube, bedside
ultrasound, portable chest X-ray, and admission to the ICU if stable
B. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in the OR to
search for cardiac or pulmonary vascular injury
C. IV access, endotracheal intubation, emergency department thoracotomy to search for cardiac
or pulmonary vascular injury
D. IV access, portable chest X-ray, right ch correct answers A. IV access, endotracheal
intubation and simultaneous placement of a right chest tube, bedside ultrasound, portable chest
X-ray, and admission to the ICU if stable
You are practicing in a trauma center a receive a call from an outlying facility that they would
like to transfer a male patient to you with a spinal cord injury after significant flexion and
