SAEM - Emergency Medicine || A+ Guaranteed.
A thin 18 year old female complains of acute onset of sharp right-sided chest pain this morning.
She has developed some mild shortness of breath during the morning and thought she should get
it checked out. Her chest X-ray is shown in the Figure. The next course of action should be:
[image]
A. Chest tube placement
B. Antibiotics
C. Electrocardiogram
D. Needle decompression correct answers The answer is A. This patient has a large right-sided
spontaneous pneumothorax that is not under tension. She needs oxygen and chest tube
placement. This can be done with proper procedural analgesia and sedation since there is no
immediate threat. Primary spontaneous pneumothorax tends to occur in healthy young men (and,
less commonly, women) of taller than average height. Other risk factors include cigarette
smoking, asthma, COPD, interstitial lung disease, connective tissue diseases, and lung cancers.
A 28 year old patient arrives after helicopter transfer from an outlying center, where he had been
intubated for altered mental status after significant alcohol intoxication. There were no reported
signs of chest trauma, but the patient now has decreased breath sounds on the left. His vital signs
are stable. Based upon the chest X-ray in the figure, what is the next step in management of this
patient?
[image]
A. Nasogastric tube placement
B. Chest tube placement
C. Endotracheal tube adjustment
D. Needle decompression correct answers The answer is C. The patient has a right-mainstem
intubation and resultant opacification of the left lung secondary to unilateral lack of ventilation.
In an adult male, the ETT should generally be inserted to a depth (to the lip line) of 22-24cm; the
corresponding depth range for an adult female is 21-23cm
A 25-year old female presents to the ED with dyspnea and chest pain. Chest CT, with contrast, is
performed and some pertinent "slices" are shown in the Figure. What is the diagnosis?
,[image]
A. Aortic dissection, Type I
B. Bilateral pulmonary embolism
C. Gas embolism
D. Acute Respiratory Distress Syndrome correct answers The answer is B. Helical CT studies of
the pulmonary vasculature are increasingly used for detection of pulmonary embolism. Though
there are questions about CT's ability to detect small (e.g. subsegmental) emboli, CT scans have
high sensitivity for proximal embolism such as that depicted in the accompanying figure. The
patient whose images are shown was found to have moderate-severe right ventricular
dysfunction and received thrombolytic therapy in the ED - she had an excellent outcome.
The X-ray in the figure indicates:
[image]
A. Need to withdraw the endotracheal tube from the mainstem
B. A chest radiograph that was taken with the patient rotated
C. Right upper lobe pneumonia
D. Mediastinal shift due to fluid in the right hemithorax correct answers The answer is D. The
patient is not intubated. The pathology in the right hemithorax appears as hyperdensity, rather
than air density (not a pneumothorax), and involves more than the right upper lobe.
Regarding the epidemiology of asthma in the United States, which of the following is true?
A. Etiology is thought to be genetic, not environmental
B. Prevalence increased in the 1980's, and then decreased in the 1990's
C. More common in males than females in adult and pediatric populations
D. Incidence is comparable for Caucasians and African-Americans correct answers The answer
is B. Despite an increase in asthma prevalence in the United States, Canada, Great Britain and
Australia in the 1980s, the 1990s saw a decrease in prevalence in these areas. Regarding gender,
,male children are more likely than female children to have asthma, however the reverse is true
with adults. African-Americans have a higher prevalence of asthma than Caucasians. Migrants
who relocate from an area of low asthma prevalence to an area of high asthma prevalence tend to
have an increased prevalence of asthma suggesting a role for environmental factors in the
development of asthma.
Regarding pulsus paradoxus and asthma, which of the following statement s is correct
A. The presence of pulsus paradoxis in asthma indicates severe disease
B. Pulsus paradoxus is pathognomonic for asthma
C. The absence of pulsus paradoxis in asthma rules out severe disease
D. Pulsus paradoxus is a fall in systolic blood pressure during inspiration correct answers The
answer is A. Pulsus paradoxus is defined as a fall in systolic blood pressure of greater than 10mm
Hg upon inspiration. It is typically present during acute asthma exacerbations in severe asthma;
however, its absence does not rule out severe disease. Although initially present, a pulsus
paradoxus may disappear after only minimal improvement in air flow through the larger airways.
Pulsus parodoxus may occur in other diseases besides asthma (for example, pericardial
tamponade).
Which of the following is correct regarding the use of corticosteroids in acute asthma
exacerbation?
A. Beneficial effects occur within the first hour of administration.
B. Inhaled steroids should be avoided
C. Intravenous steroids are superior to the oral route
D. Tapering is needed with all corticosteroid regimens correct answers The answer is B. Oral
and intravenous steroids are equally efficacious in treating an asthma exacerbation. Yet, in the
setting of a severe asthma exacerbation, a patient may have difficulty taking oral medications and
the intravenous route is preferred
Which of the following is true regarding the treatment of acute asthma exacerbation in the
Emergency Department?
A. Intramuscular terbutaline is preferred over intravenous
, B. Heliox should only be used in the intubated patient.
C. Anticholinergics by inhalation may be beneficial
D. Intravenous albuterol may be indicated correct answers The answer is C. Salmeterol is a long-
acting beta2-selective adrenergic agonist that has no role in the treatment of an acute asthma
exacerbation, but it is frequently preferred for outpatient asthma management due to its BID
dosing schedule.
Which of the following drugs is MOST beneficial in an acute COPD exacerbation?
A. Methylxanthines such as theophylline
B. Steroids such as solumedrol
C. Beta adrenergic agonists such as albuterol
D. Mucokinetic agents such as acetylcysteine correct answers The answer is C. Mucokinetic
agents should not be used acutely in treatment of COPD exacerbation. These agents act to
mobilize secretions, and this increases the work of the patient's breathing.
Regarding the pathogens involved in community-acquired pneumonia, which of the
following is true?
A. Co-infection with multiple bacteria, such as Chlamydia and Strep pneumoniae commonly
occur
B. Etiologic agents for patients admitted to the ICU with pneumonia most commonly include
Neisseria meningitidis and Strep pneumoniae
C. Milder cases of community acquired pneumonia are frequently caused by Chlamydia
D. Q fever, caused by Coxiella burnetii, may present as pneumonia, particularly in patients
exposed to rabbits correct answers The answer is A. Co-infection with multiple bacteria, such as
Chlamydia and S. pneumoniae, is a well-recognized occurrence and should be sought out to
ensure appropriate antibiotic coverage.
Which of the following patients is the most likely to develop S. pneumoniae pneumonia?
A thin 18 year old female complains of acute onset of sharp right-sided chest pain this morning.
She has developed some mild shortness of breath during the morning and thought she should get
it checked out. Her chest X-ray is shown in the Figure. The next course of action should be:
[image]
A. Chest tube placement
B. Antibiotics
C. Electrocardiogram
D. Needle decompression correct answers The answer is A. This patient has a large right-sided
spontaneous pneumothorax that is not under tension. She needs oxygen and chest tube
placement. This can be done with proper procedural analgesia and sedation since there is no
immediate threat. Primary spontaneous pneumothorax tends to occur in healthy young men (and,
less commonly, women) of taller than average height. Other risk factors include cigarette
smoking, asthma, COPD, interstitial lung disease, connective tissue diseases, and lung cancers.
A 28 year old patient arrives after helicopter transfer from an outlying center, where he had been
intubated for altered mental status after significant alcohol intoxication. There were no reported
signs of chest trauma, but the patient now has decreased breath sounds on the left. His vital signs
are stable. Based upon the chest X-ray in the figure, what is the next step in management of this
patient?
[image]
A. Nasogastric tube placement
B. Chest tube placement
C. Endotracheal tube adjustment
D. Needle decompression correct answers The answer is C. The patient has a right-mainstem
intubation and resultant opacification of the left lung secondary to unilateral lack of ventilation.
In an adult male, the ETT should generally be inserted to a depth (to the lip line) of 22-24cm; the
corresponding depth range for an adult female is 21-23cm
A 25-year old female presents to the ED with dyspnea and chest pain. Chest CT, with contrast, is
performed and some pertinent "slices" are shown in the Figure. What is the diagnosis?
,[image]
A. Aortic dissection, Type I
B. Bilateral pulmonary embolism
C. Gas embolism
D. Acute Respiratory Distress Syndrome correct answers The answer is B. Helical CT studies of
the pulmonary vasculature are increasingly used for detection of pulmonary embolism. Though
there are questions about CT's ability to detect small (e.g. subsegmental) emboli, CT scans have
high sensitivity for proximal embolism such as that depicted in the accompanying figure. The
patient whose images are shown was found to have moderate-severe right ventricular
dysfunction and received thrombolytic therapy in the ED - she had an excellent outcome.
The X-ray in the figure indicates:
[image]
A. Need to withdraw the endotracheal tube from the mainstem
B. A chest radiograph that was taken with the patient rotated
C. Right upper lobe pneumonia
D. Mediastinal shift due to fluid in the right hemithorax correct answers The answer is D. The
patient is not intubated. The pathology in the right hemithorax appears as hyperdensity, rather
than air density (not a pneumothorax), and involves more than the right upper lobe.
Regarding the epidemiology of asthma in the United States, which of the following is true?
A. Etiology is thought to be genetic, not environmental
B. Prevalence increased in the 1980's, and then decreased in the 1990's
C. More common in males than females in adult and pediatric populations
D. Incidence is comparable for Caucasians and African-Americans correct answers The answer
is B. Despite an increase in asthma prevalence in the United States, Canada, Great Britain and
Australia in the 1980s, the 1990s saw a decrease in prevalence in these areas. Regarding gender,
,male children are more likely than female children to have asthma, however the reverse is true
with adults. African-Americans have a higher prevalence of asthma than Caucasians. Migrants
who relocate from an area of low asthma prevalence to an area of high asthma prevalence tend to
have an increased prevalence of asthma suggesting a role for environmental factors in the
development of asthma.
Regarding pulsus paradoxus and asthma, which of the following statement s is correct
A. The presence of pulsus paradoxis in asthma indicates severe disease
B. Pulsus paradoxus is pathognomonic for asthma
C. The absence of pulsus paradoxis in asthma rules out severe disease
D. Pulsus paradoxus is a fall in systolic blood pressure during inspiration correct answers The
answer is A. Pulsus paradoxus is defined as a fall in systolic blood pressure of greater than 10mm
Hg upon inspiration. It is typically present during acute asthma exacerbations in severe asthma;
however, its absence does not rule out severe disease. Although initially present, a pulsus
paradoxus may disappear after only minimal improvement in air flow through the larger airways.
Pulsus parodoxus may occur in other diseases besides asthma (for example, pericardial
tamponade).
Which of the following is correct regarding the use of corticosteroids in acute asthma
exacerbation?
A. Beneficial effects occur within the first hour of administration.
B. Inhaled steroids should be avoided
C. Intravenous steroids are superior to the oral route
D. Tapering is needed with all corticosteroid regimens correct answers The answer is B. Oral
and intravenous steroids are equally efficacious in treating an asthma exacerbation. Yet, in the
setting of a severe asthma exacerbation, a patient may have difficulty taking oral medications and
the intravenous route is preferred
Which of the following is true regarding the treatment of acute asthma exacerbation in the
Emergency Department?
A. Intramuscular terbutaline is preferred over intravenous
, B. Heliox should only be used in the intubated patient.
C. Anticholinergics by inhalation may be beneficial
D. Intravenous albuterol may be indicated correct answers The answer is C. Salmeterol is a long-
acting beta2-selective adrenergic agonist that has no role in the treatment of an acute asthma
exacerbation, but it is frequently preferred for outpatient asthma management due to its BID
dosing schedule.
Which of the following drugs is MOST beneficial in an acute COPD exacerbation?
A. Methylxanthines such as theophylline
B. Steroids such as solumedrol
C. Beta adrenergic agonists such as albuterol
D. Mucokinetic agents such as acetylcysteine correct answers The answer is C. Mucokinetic
agents should not be used acutely in treatment of COPD exacerbation. These agents act to
mobilize secretions, and this increases the work of the patient's breathing.
Regarding the pathogens involved in community-acquired pneumonia, which of the
following is true?
A. Co-infection with multiple bacteria, such as Chlamydia and Strep pneumoniae commonly
occur
B. Etiologic agents for patients admitted to the ICU with pneumonia most commonly include
Neisseria meningitidis and Strep pneumoniae
C. Milder cases of community acquired pneumonia are frequently caused by Chlamydia
D. Q fever, caused by Coxiella burnetii, may present as pneumonia, particularly in patients
exposed to rabbits correct answers The answer is A. Co-infection with multiple bacteria, such as
Chlamydia and S. pneumoniae, is a well-recognized occurrence and should be sought out to
ensure appropriate antibiotic coverage.
Which of the following patients is the most likely to develop S. pneumoniae pneumonia?
