emergency medicine rosh mock exam
questions and answers
A 32-year-old woman presents with persistent nausea over the last two weeks. She is
approximately 10 weeks pregnant. She has been able to tolerate fluids, but has had decreased
food intake. She denies any abdominal or pelvic pain or vaginal bleeding. What medication is
considered first-line treatment for this patient? - ANSWER>>*Pyridoxine*:1st line tx for
NAUSEA in pregnancy!
-doesn't help w/vomiting
-Pyridoxine is a water-soluble B complex vitamin that is necessary in the metabolism of lipids,
amino acids, and carbohydrates
#2:add antihistamine(benadryl) or 5HT3 antagonist(zofran:category B); also meclizine(category
B), dimendydrinate
#3: methylprednisolone or chlorpromazine
-Prochlorperazine: category C
What electrolyte abnormalities can be seen in patients with hyperemesis gravidarum? -
ANSWER>>hypokalemia w/hypochloremic metabolic alkalosis
A 39-year-old man presents to the Emergency Department with left hand pain. He denies
recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes
mellitus and tobacco abuse. His examination is shown above. Which of the following is the most
appropriate initial therapy for this patient? - ANSWER>>*I&D*
DX: felon=pyogenic infection or ABSCESS of the digital subcutaneous tissue and pulp
-caused by *Staph aureus*
-.If left untreated, the infection may spread to the flexor tendon sheath leading to flexor
tenosynovitis, or to the bone leading to osteomyelitis
True or false: Incision and drainage should be avoided in cases of herpetic whitlow. -
ANSWER>>True, as this can lead to secondary bacterial infection
An 18-year-old man is brought in by EMS following a motor vehicle collision with prolonged
extrication. His vitals on arrival are HR 110, BP 100/60, RR 20. He is noted to have *periorbital
ecchymosis with tarsal plate sparing("raccoon eyes")* on physical examination. Which of the
following is the most likely diagnosis? - ANSWER>>*Basilar skull fracture*
,-PE: mastoid ecchymosis (Battle sign), hemotympanum, CSF leaks (presenting as otorrhea or
rhinorrhea), & periorbital ecchymosis with tarsal plate sparing ("raccoon eyes")
-Any patient with a suspected basilar skull fracture should undergo *a head CT* to look for
extra-axial hematoma formation as well as cerebral damage, which is common
-Extra-axial hematomas associated with a basilar skull fracture are a *neurosurgical
emergency*
-CSF leaks in the setting of basilar skull fractures are typically self limited
Orbital floor fractures - ANSWER>>"blowout fractures," most often occur due to direct trauma
to the eye
-Periorbital ecchymosis in this setting will also not show tarsal plate sparing as seen with basilar
skull fractures
-teardrop sign: herniated tissue and muscle
globe rupture - ANSWER>>=full thickness injury to sclera
-traumatic vision-threatening emergency that can present with corneal or scleral lacerations,
bullous subconjunctival hemorrhage, iris abnormalities ("teardrop pupil"), or uveal prolapse
-positive seidel test: aqueous flow on fluorescein testing
-tx: eye shield, avoid tonometry, elevate head of bed, NPO, antiemetics, analgesia, antibiotics,
emergent ophthalmology consult
What bone is most commonly involved in basilar skull fractures? - ANSWER>>temporal bone
What basic metabolic panel abnormality is associated with upper GI bleeding? -
ANSWER>>Elevated BUN/Creatinine ratio
A 77-year-old woman presents with an acute change in mental status. She has a history of
diabetes mellitus, hypertension, and prior ischemic stroke. Home medications include aspirin,
clopidogrel, lisinopril, and glyburide. She was found by family to be confused and diaphoretic.
Her blood sugar was 32 mg/dL. She was given 50 grams of intravenous dextrose by emergency
personnel with a return to her baseline mental status. On arrival to the emergency department,
her blood sugar is 185 mg/dL. When asked, she thinks she may have accidentally taken an extra
dose of her glyburide this morning. She is currently asymptomatic and asking when she can go
home. Which of the following is the most appropriate management of this patient? -
ANSWER>>*Admission for 24-hour observation*
-b/c the hypoglycemic effect of *sulfonylureas* lasts up to 24 hours allowing for once-daily
dosing
-work by promoting endogenous insulin secretion by the pancreas
, What is trench foot? - ANSWER>>Prolonged wet and cold (but nonfreezing) exposure causing
reversible neurovascular injury
What medication is indicated in cases of recurrent hypoglycemia associated with sulfonylurea
overdose? - ANSWER>>Octreotide, a somatostatin analogue that inhibits release of insulin from
the pancreatic beta-islet cells
A 27-month-old girl presents to the ED with parents after one episode of generalized
convulsions. Parents note she has was initially lethargic but then cleared to baseline.
Temperature in the ED is 102.9°F. As you move to examine her, she has another generalized
tonic clonic seizure. It rapidly terminates without intervention and she returns to baseline.
Which of the following is the next most important step in this child's workup? -
ANSWER>>*Observation & Reassurance* if patient remains at mental baseline and don't
continually have seizures requiring intervention
DX: COMPLEX Febrile seizure
-any event not meeting the criteria for a simple febrile seizure
-should raise suspicion for serious disease such as meningitis, intracranial hemorrhage, or
intracranial mass
- should prompt providers to consider further workup with laboratory testing, lumbar puncture,
EEG, and neuroimaging; *however, if the patient returns to baseline despite repeat seizures (2-
3), then this testing is not required*
What would you expect to find on the cerebrospinal fluid analysis of a patient with bacterial
meningitis? - ANSWER>>Elevated white blood cell count, elevated protein, low glucose,
organisms on gram stain
simple febrile seizure - ANSWER>>(1) generalized tonic-clonic seizure
(2) occurring in the appropriate age group of age 6 months to 5 years
(3) seizure is less than 15 minutes in duration
(4) the child has a nonfocal neurologic exam
(5) there is no recurrence of seizures within 24 hours
A 39-year-old woman presents to the ED with fever and altered mental status after an
intentional overdose. On physical exam, you note lower extremity hyperreflexia and
myoclonus. Vital signs are BP 170/110 mm Hg, HR 126 beats per minute, RR 24 breaths per
minute, and T 101.2°F. Which of the following is the classic antidote to this toxicologic process?
- ANSWER>>*cyproheptadine*or benzodiazepines, hydration/cooling
questions and answers
A 32-year-old woman presents with persistent nausea over the last two weeks. She is
approximately 10 weeks pregnant. She has been able to tolerate fluids, but has had decreased
food intake. She denies any abdominal or pelvic pain or vaginal bleeding. What medication is
considered first-line treatment for this patient? - ANSWER>>*Pyridoxine*:1st line tx for
NAUSEA in pregnancy!
-doesn't help w/vomiting
-Pyridoxine is a water-soluble B complex vitamin that is necessary in the metabolism of lipids,
amino acids, and carbohydrates
#2:add antihistamine(benadryl) or 5HT3 antagonist(zofran:category B); also meclizine(category
B), dimendydrinate
#3: methylprednisolone or chlorpromazine
-Prochlorperazine: category C
What electrolyte abnormalities can be seen in patients with hyperemesis gravidarum? -
ANSWER>>hypokalemia w/hypochloremic metabolic alkalosis
A 39-year-old man presents to the Emergency Department with left hand pain. He denies
recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes
mellitus and tobacco abuse. His examination is shown above. Which of the following is the most
appropriate initial therapy for this patient? - ANSWER>>*I&D*
DX: felon=pyogenic infection or ABSCESS of the digital subcutaneous tissue and pulp
-caused by *Staph aureus*
-.If left untreated, the infection may spread to the flexor tendon sheath leading to flexor
tenosynovitis, or to the bone leading to osteomyelitis
True or false: Incision and drainage should be avoided in cases of herpetic whitlow. -
ANSWER>>True, as this can lead to secondary bacterial infection
An 18-year-old man is brought in by EMS following a motor vehicle collision with prolonged
extrication. His vitals on arrival are HR 110, BP 100/60, RR 20. He is noted to have *periorbital
ecchymosis with tarsal plate sparing("raccoon eyes")* on physical examination. Which of the
following is the most likely diagnosis? - ANSWER>>*Basilar skull fracture*
,-PE: mastoid ecchymosis (Battle sign), hemotympanum, CSF leaks (presenting as otorrhea or
rhinorrhea), & periorbital ecchymosis with tarsal plate sparing ("raccoon eyes")
-Any patient with a suspected basilar skull fracture should undergo *a head CT* to look for
extra-axial hematoma formation as well as cerebral damage, which is common
-Extra-axial hematomas associated with a basilar skull fracture are a *neurosurgical
emergency*
-CSF leaks in the setting of basilar skull fractures are typically self limited
Orbital floor fractures - ANSWER>>"blowout fractures," most often occur due to direct trauma
to the eye
-Periorbital ecchymosis in this setting will also not show tarsal plate sparing as seen with basilar
skull fractures
-teardrop sign: herniated tissue and muscle
globe rupture - ANSWER>>=full thickness injury to sclera
-traumatic vision-threatening emergency that can present with corneal or scleral lacerations,
bullous subconjunctival hemorrhage, iris abnormalities ("teardrop pupil"), or uveal prolapse
-positive seidel test: aqueous flow on fluorescein testing
-tx: eye shield, avoid tonometry, elevate head of bed, NPO, antiemetics, analgesia, antibiotics,
emergent ophthalmology consult
What bone is most commonly involved in basilar skull fractures? - ANSWER>>temporal bone
What basic metabolic panel abnormality is associated with upper GI bleeding? -
ANSWER>>Elevated BUN/Creatinine ratio
A 77-year-old woman presents with an acute change in mental status. She has a history of
diabetes mellitus, hypertension, and prior ischemic stroke. Home medications include aspirin,
clopidogrel, lisinopril, and glyburide. She was found by family to be confused and diaphoretic.
Her blood sugar was 32 mg/dL. She was given 50 grams of intravenous dextrose by emergency
personnel with a return to her baseline mental status. On arrival to the emergency department,
her blood sugar is 185 mg/dL. When asked, she thinks she may have accidentally taken an extra
dose of her glyburide this morning. She is currently asymptomatic and asking when she can go
home. Which of the following is the most appropriate management of this patient? -
ANSWER>>*Admission for 24-hour observation*
-b/c the hypoglycemic effect of *sulfonylureas* lasts up to 24 hours allowing for once-daily
dosing
-work by promoting endogenous insulin secretion by the pancreas
, What is trench foot? - ANSWER>>Prolonged wet and cold (but nonfreezing) exposure causing
reversible neurovascular injury
What medication is indicated in cases of recurrent hypoglycemia associated with sulfonylurea
overdose? - ANSWER>>Octreotide, a somatostatin analogue that inhibits release of insulin from
the pancreatic beta-islet cells
A 27-month-old girl presents to the ED with parents after one episode of generalized
convulsions. Parents note she has was initially lethargic but then cleared to baseline.
Temperature in the ED is 102.9°F. As you move to examine her, she has another generalized
tonic clonic seizure. It rapidly terminates without intervention and she returns to baseline.
Which of the following is the next most important step in this child's workup? -
ANSWER>>*Observation & Reassurance* if patient remains at mental baseline and don't
continually have seizures requiring intervention
DX: COMPLEX Febrile seizure
-any event not meeting the criteria for a simple febrile seizure
-should raise suspicion for serious disease such as meningitis, intracranial hemorrhage, or
intracranial mass
- should prompt providers to consider further workup with laboratory testing, lumbar puncture,
EEG, and neuroimaging; *however, if the patient returns to baseline despite repeat seizures (2-
3), then this testing is not required*
What would you expect to find on the cerebrospinal fluid analysis of a patient with bacterial
meningitis? - ANSWER>>Elevated white blood cell count, elevated protein, low glucose,
organisms on gram stain
simple febrile seizure - ANSWER>>(1) generalized tonic-clonic seizure
(2) occurring in the appropriate age group of age 6 months to 5 years
(3) seizure is less than 15 minutes in duration
(4) the child has a nonfocal neurologic exam
(5) there is no recurrence of seizures within 24 hours
A 39-year-old woman presents to the ED with fever and altered mental status after an
intentional overdose. On physical exam, you note lower extremity hyperreflexia and
myoclonus. Vital signs are BP 170/110 mm Hg, HR 126 beats per minute, RR 24 breaths per
minute, and T 101.2°F. Which of the following is the classic antidote to this toxicologic process?
- ANSWER>>*cyproheptadine*or benzodiazepines, hydration/cooling
