EMERGENCY MEDICINE EOR EXAM LATEST ACTUAL EXAM
A 59-year-old woman presents to the accident and emergency department by
ambulance with second- and third-degree burns to her head and neck, and the
anterior surfaces of her upper extremities, right leg, and trunk including her genital
area.
Question
Which of the following represents a reasonable estimation of the extent of her
burns?
Answer Choices
1 36%
2 37%
3 46%
4 45%
5 55% - ANSWER: The correct answer is 55%. This estimation is based on the "rule
of 9s". Body surface area is estimated at 9% for each arm, the head and neck,
anterior surface of upper torso, anterior surface of lower torso, posterior surface
of upper torso, posterior surface of lower torso, anterior surfaces of each leg,
posterior surfaces of each leg and an additional 1% for the groin area for a total of
100%. In this case, 9% for her head and neck, 9% for the anterior surface of each
arm, 9% for the anterior surface of her right leg, 9% for her anterior upper torso,
9% for her anterior lower torso, and 1% for the genital area for a total of 55%.
The other answers are incorrect using the estimation by the "rule of 9s".
A 16-year-old male was hit on the left side of his face by a line drive baseball.
Marked swelling is noted externally to the left eye. There was no loss of
consciousness. Upon physical exam, he complains of diplopia during extraocular
motion testing. Enophthalmos is noted, as well as decreased sensation of the left
cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary
sinus, and a fracture of the orbit. Based on this information, what is the most likely
diagnosis?
A Zygomatic arch fracture
B Orbital blowout fracture
C Le Fort I fracture
D Le Fort II fracture
E Le Fort III fracture - ANSWER: orbital blow out fracture
B Diplopia is common in an orbital blow out fracture, due to entrapment of the
inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs
from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a
transverse fracture separating the body of the maxilla from the pterygoid plate
and nasal septum. A Le Fort II fracture describes a pyramidal through the central
,maxilla and hard palate. Movement of the hard palate and nose occurs, but not
the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the
entire face is separated from the skull due to fractures of the frontozygomatic
suture line, across the orbit and through the base of the nose, and ethmoids. The
entire face shifts, with the globes held in place only by the optic nerve.
What is the most common ECG abnormality in patients with a pulmonary embolism
(PE)?
A Atrial fibrillation
B Sinus tachycardia
C Ventricular ectopy
D Sinus bradycardia - ANSWER: sinus tachycardia
B In most cases, sinus tachycardia is the only abnormality in patients with a PE. You
may also find some ECGs that will have non-specific ST-T wave changes. Sinus
bradycardia and AV blocks are not common findings that are associated with PE.
In the emergency department, you are asked to evaluate a 77-year-old man with a
history of HTN who had a syncopal episode while chasing after his dog. He admits to
recent episodes of chest discomfort, also associated with activity, as well as dyspnea
at lower levels of activity including walking up one flight of stairs. On physical exam,
a grade III/IV crescendo-decrescendo systolic ejection murmur can be heard best
over the right upper sternal border. His EKG demonstrates NSR @ 80 bpm, with
evidence of left ventricular hypertrophy. His troponin levels are negative for
ischemia. What is the next most appropriate test or procedure?
A Echocardiography
B VQ scan
C CT scan of the head
D Serum D-dimer levels - ANSWER: echo
A This patient exhibits all the signs of progression of aortic stenosis, thus
echocardiography is the next most appropriate test. A determination of severity
can then be made, with possible cardiac catheterization if severe aortic stenosis is
suspected, in preparation for surgical intervention if necessary. A VQ scan is
appropriate if pulmonary embolism were suspected. A CT scan of the head could
be considered if a head injury was suspected, but would not be the next step in the
management of this patient. Serum D-dimer levels might be used to rule out
pulmonary embolism, although it is a fairly nonspecific test. An MRI of the heart is
not considered standard of care for aortic stenosis
A 56-year-old male, with history of hyperlipidemia and non-insulin-dependent
diabetes mellitus (NIDDM) presents to the emergency department with a history of
increasing peripheral edema over the past week. On examination he is noted to have
periorbital, scrotal, and +2 pretibial edema. His lungs are CTAB. He denies any chest
pain or shortness of breath. Urine dipstick reveals 4+ protein. Urine microscopic
reveals Maltese crosses consistent with lipiduria. Labs include a decreased serum
,albumin of 2 g/dl, decreased total protein of 5.5 g/dl, and normal glomerular
filtration rate (GFR). What is the most likely diagnosis?
A pyelonephritis
B congestive heart failure (CHF)
C nephrotic syndrome
D prostatitis - ANSWER: Nephrotic syndrome
C The correct answer is (C). This patient has typical symptoms of nephrotic
syndrome, which includes significant proteinuria, hypoalbuminemia, and typical
presentation of edema. He also has a history of hyperlipidemia and laboratory
findings of lipiduria, which is also common in nephrotic syndrome. Furthermore, his
history of diabetes mellitus is also a potential cause of nephrotic syndrome.
Pyelonephritis and prostatitis would present with urine WBCs and is not consistent
with the laboratory findings or edema. CHF would more likely present with dyspnea,
rales on exam, and peripheral edema but would unlikely involve the periorbital area.
DVT would likely present with unilateral swelling of the LE, and discomfort and is not
consistent with the laboratory findings above.
Out of all cervical vertebrae, which two are responsible for the greatest amount of
rotation?
A C1 & C2
B C2 & C3
C C3 & C4
D C4 & C5
E C5 & C6 - ANSWER: C1 & C2
A Approximately 50% of cervical rotation takes place between the C1 (atlas) and C2
(axis) vertebrae. These first two cervical vertebrae have a different shape from the
other cervical vertebrae that allow for this greater range of motion. The remaining
50 % of cervical rotation is split fairly evenly between the remaining vertebrae.
Approximately 50 % of flexion and extension occurs between the occiput at the base
of the skull and C1 with the remaining 50% distributed fairly evenly between the
remaining vertebrae with a slightly higher percentage occurring at the C5 & C6 level.
A 15-year-old boy suddenly collapses on the basketball court; his sports physical
conducted at the beginning of the year did not elicit any abnormal findings. Basic life
support initiated at the scene, however, is unsuccessful in resuscitation. Which of
the following is the most likely etiology of his sudden death?
A mitral valve prolapse
B surgically corrected aortic stenosis
C hypertrophic cardiomyopathy
D rheumatic heart disease - ANSWER: hypertrophic cardiomyopathy
C Hypertrophic cardiomyopathy in adolescence is typically due to familial
hypertrophic cardiomyopathy with an incidence of 1:500. Many patients are
asymptomatic until a sporting event, which may cause symptoms, specifically sudden
cardiac death. Examination may demonstrate a palpable or audible S 4 , an LV (left
, ventricular) heave, systolic ejection murmur (may need to stimulate cardiac activity),
and/or a left precordial bulge. Echocardiography is the gold standard for diagnosis
but family history should be assessed. Stress testing is indicated to assess for
ischemia and arrhythmias. Strenuous activities are prohibited for these patients. The
other cardiomyopathies (dilated and restrictive) are next but are not as common.
Congenital structural abnormalities of the coronary arteries are the next most
common cause. Valvular disorders, including surgically repaired aortic stenosis, are
typically not causes of sudden death, but these patients should be screened for
symptoms and stress tested as necessary.
A 46-year-old female presents with pain to her left wrist. She complains that it is
painful and swollen as she points to the volar aspect of the wrist on the radial side.
On examination, there is a small, soft bump on the dorsum of her wrist with a jelly-
like consistency. What is the most likely diagnosis?
A Cancerous tumor
B Fracture
C Ganglion cyst
D Hematoma
E Lipoma - ANSWER: Ganglion Cyst
C Ganglion cysts commonly occur on the dorsal or volar aspect of the wrist. They
result when a joint capsule or tendon sheath is damaged, allowing synovial fluid to
escape producing a one-way valve, which allows fluid into the cyst, but not back out.
The accumulating fluid forms the ganglion cyst. These cysts may or may not be
tender and can fluctuate in size depending on activity level of the affected extremity.
Cancerous tumors would tend to be much more firm, but also may be relatively pain
free. Fractures would generally be exquisitely tender and if the bump is due to a
displaced bone, it would be much more firm than a ganglion cyst. Hematomas are
generally associated with acute trauma and would be tender and ecchymotic in
many situations. Lipomas are benign fatty tumors that are more commonly seen on
the thenar eminence than the dorsum of the wrist and their size does not change
based on activity level.
A 65-year-old male presents with pain and swelling to his right knee without any
history of injury. He has had this type of pain and swelling before, and does recall
that he had fluid drained out of the knee several years ago. On examination the
patient has a swollen, tender knee with a palpable effusion. There is decreased range
of motion to the joint secondary to the effusion. An arthocentesis is performed, and
the analysis of the fluid reveals calcium pyrophosphonate crystals. Based on these
findings, what is the most likely diagnosis?
A Septic arthritis
B Acute synovitis
C Hemarthoma
D Pseudogout - ANSWER: Psuedogout
D Pseudogout is also known as Calcium Pyrophosphate Deposition Disease (CPDD)
and most commonly affects patients over the age of 65. The knee joint is most
A 59-year-old woman presents to the accident and emergency department by
ambulance with second- and third-degree burns to her head and neck, and the
anterior surfaces of her upper extremities, right leg, and trunk including her genital
area.
Question
Which of the following represents a reasonable estimation of the extent of her
burns?
Answer Choices
1 36%
2 37%
3 46%
4 45%
5 55% - ANSWER: The correct answer is 55%. This estimation is based on the "rule
of 9s". Body surface area is estimated at 9% for each arm, the head and neck,
anterior surface of upper torso, anterior surface of lower torso, posterior surface
of upper torso, posterior surface of lower torso, anterior surfaces of each leg,
posterior surfaces of each leg and an additional 1% for the groin area for a total of
100%. In this case, 9% for her head and neck, 9% for the anterior surface of each
arm, 9% for the anterior surface of her right leg, 9% for her anterior upper torso,
9% for her anterior lower torso, and 1% for the genital area for a total of 55%.
The other answers are incorrect using the estimation by the "rule of 9s".
A 16-year-old male was hit on the left side of his face by a line drive baseball.
Marked swelling is noted externally to the left eye. There was no loss of
consciousness. Upon physical exam, he complains of diplopia during extraocular
motion testing. Enophthalmos is noted, as well as decreased sensation of the left
cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary
sinus, and a fracture of the orbit. Based on this information, what is the most likely
diagnosis?
A Zygomatic arch fracture
B Orbital blowout fracture
C Le Fort I fracture
D Le Fort II fracture
E Le Fort III fracture - ANSWER: orbital blow out fracture
B Diplopia is common in an orbital blow out fracture, due to entrapment of the
inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs
from disruption or swelling of the infraorbital nerve. A Le Fort I fracture describes a
transverse fracture separating the body of the maxilla from the pterygoid plate
and nasal septum. A Le Fort II fracture describes a pyramidal through the central
,maxilla and hard palate. Movement of the hard palate and nose occurs, but not
the eyes. A Le Fort III fracture describes a craniofacial disjunction, wherein the
entire face is separated from the skull due to fractures of the frontozygomatic
suture line, across the orbit and through the base of the nose, and ethmoids. The
entire face shifts, with the globes held in place only by the optic nerve.
What is the most common ECG abnormality in patients with a pulmonary embolism
(PE)?
A Atrial fibrillation
B Sinus tachycardia
C Ventricular ectopy
D Sinus bradycardia - ANSWER: sinus tachycardia
B In most cases, sinus tachycardia is the only abnormality in patients with a PE. You
may also find some ECGs that will have non-specific ST-T wave changes. Sinus
bradycardia and AV blocks are not common findings that are associated with PE.
In the emergency department, you are asked to evaluate a 77-year-old man with a
history of HTN who had a syncopal episode while chasing after his dog. He admits to
recent episodes of chest discomfort, also associated with activity, as well as dyspnea
at lower levels of activity including walking up one flight of stairs. On physical exam,
a grade III/IV crescendo-decrescendo systolic ejection murmur can be heard best
over the right upper sternal border. His EKG demonstrates NSR @ 80 bpm, with
evidence of left ventricular hypertrophy. His troponin levels are negative for
ischemia. What is the next most appropriate test or procedure?
A Echocardiography
B VQ scan
C CT scan of the head
D Serum D-dimer levels - ANSWER: echo
A This patient exhibits all the signs of progression of aortic stenosis, thus
echocardiography is the next most appropriate test. A determination of severity
can then be made, with possible cardiac catheterization if severe aortic stenosis is
suspected, in preparation for surgical intervention if necessary. A VQ scan is
appropriate if pulmonary embolism were suspected. A CT scan of the head could
be considered if a head injury was suspected, but would not be the next step in the
management of this patient. Serum D-dimer levels might be used to rule out
pulmonary embolism, although it is a fairly nonspecific test. An MRI of the heart is
not considered standard of care for aortic stenosis
A 56-year-old male, with history of hyperlipidemia and non-insulin-dependent
diabetes mellitus (NIDDM) presents to the emergency department with a history of
increasing peripheral edema over the past week. On examination he is noted to have
periorbital, scrotal, and +2 pretibial edema. His lungs are CTAB. He denies any chest
pain or shortness of breath. Urine dipstick reveals 4+ protein. Urine microscopic
reveals Maltese crosses consistent with lipiduria. Labs include a decreased serum
,albumin of 2 g/dl, decreased total protein of 5.5 g/dl, and normal glomerular
filtration rate (GFR). What is the most likely diagnosis?
A pyelonephritis
B congestive heart failure (CHF)
C nephrotic syndrome
D prostatitis - ANSWER: Nephrotic syndrome
C The correct answer is (C). This patient has typical symptoms of nephrotic
syndrome, which includes significant proteinuria, hypoalbuminemia, and typical
presentation of edema. He also has a history of hyperlipidemia and laboratory
findings of lipiduria, which is also common in nephrotic syndrome. Furthermore, his
history of diabetes mellitus is also a potential cause of nephrotic syndrome.
Pyelonephritis and prostatitis would present with urine WBCs and is not consistent
with the laboratory findings or edema. CHF would more likely present with dyspnea,
rales on exam, and peripheral edema but would unlikely involve the periorbital area.
DVT would likely present with unilateral swelling of the LE, and discomfort and is not
consistent with the laboratory findings above.
Out of all cervical vertebrae, which two are responsible for the greatest amount of
rotation?
A C1 & C2
B C2 & C3
C C3 & C4
D C4 & C5
E C5 & C6 - ANSWER: C1 & C2
A Approximately 50% of cervical rotation takes place between the C1 (atlas) and C2
(axis) vertebrae. These first two cervical vertebrae have a different shape from the
other cervical vertebrae that allow for this greater range of motion. The remaining
50 % of cervical rotation is split fairly evenly between the remaining vertebrae.
Approximately 50 % of flexion and extension occurs between the occiput at the base
of the skull and C1 with the remaining 50% distributed fairly evenly between the
remaining vertebrae with a slightly higher percentage occurring at the C5 & C6 level.
A 15-year-old boy suddenly collapses on the basketball court; his sports physical
conducted at the beginning of the year did not elicit any abnormal findings. Basic life
support initiated at the scene, however, is unsuccessful in resuscitation. Which of
the following is the most likely etiology of his sudden death?
A mitral valve prolapse
B surgically corrected aortic stenosis
C hypertrophic cardiomyopathy
D rheumatic heart disease - ANSWER: hypertrophic cardiomyopathy
C Hypertrophic cardiomyopathy in adolescence is typically due to familial
hypertrophic cardiomyopathy with an incidence of 1:500. Many patients are
asymptomatic until a sporting event, which may cause symptoms, specifically sudden
cardiac death. Examination may demonstrate a palpable or audible S 4 , an LV (left
, ventricular) heave, systolic ejection murmur (may need to stimulate cardiac activity),
and/or a left precordial bulge. Echocardiography is the gold standard for diagnosis
but family history should be assessed. Stress testing is indicated to assess for
ischemia and arrhythmias. Strenuous activities are prohibited for these patients. The
other cardiomyopathies (dilated and restrictive) are next but are not as common.
Congenital structural abnormalities of the coronary arteries are the next most
common cause. Valvular disorders, including surgically repaired aortic stenosis, are
typically not causes of sudden death, but these patients should be screened for
symptoms and stress tested as necessary.
A 46-year-old female presents with pain to her left wrist. She complains that it is
painful and swollen as she points to the volar aspect of the wrist on the radial side.
On examination, there is a small, soft bump on the dorsum of her wrist with a jelly-
like consistency. What is the most likely diagnosis?
A Cancerous tumor
B Fracture
C Ganglion cyst
D Hematoma
E Lipoma - ANSWER: Ganglion Cyst
C Ganglion cysts commonly occur on the dorsal or volar aspect of the wrist. They
result when a joint capsule or tendon sheath is damaged, allowing synovial fluid to
escape producing a one-way valve, which allows fluid into the cyst, but not back out.
The accumulating fluid forms the ganglion cyst. These cysts may or may not be
tender and can fluctuate in size depending on activity level of the affected extremity.
Cancerous tumors would tend to be much more firm, but also may be relatively pain
free. Fractures would generally be exquisitely tender and if the bump is due to a
displaced bone, it would be much more firm than a ganglion cyst. Hematomas are
generally associated with acute trauma and would be tender and ecchymotic in
many situations. Lipomas are benign fatty tumors that are more commonly seen on
the thenar eminence than the dorsum of the wrist and their size does not change
based on activity level.
A 65-year-old male presents with pain and swelling to his right knee without any
history of injury. He has had this type of pain and swelling before, and does recall
that he had fluid drained out of the knee several years ago. On examination the
patient has a swollen, tender knee with a palpable effusion. There is decreased range
of motion to the joint secondary to the effusion. An arthocentesis is performed, and
the analysis of the fluid reveals calcium pyrophosphonate crystals. Based on these
findings, what is the most likely diagnosis?
A Septic arthritis
B Acute synovitis
C Hemarthoma
D Pseudogout - ANSWER: Psuedogout
D Pseudogout is also known as Calcium Pyrophosphate Deposition Disease (CPDD)
and most commonly affects patients over the age of 65. The knee joint is most
