PaEasy Emergency Medicine,
Emergency Medicine EOR Practice,
Emergency Medicine EOR Exam, ER
Final, ER
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 - ✔️✔️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.
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% - ✔️✔️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 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting
'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation.
Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past
medical history is positive for occasional headaches; they have been coming more
frequenly lately. Social history reveals alcohol use (1 case of beer each weekend) and
tobacco (1 pack per day). Medications include ibuprofen as needed for headaches; he
has been taking 800 mg 3 times a day for the past week. You place a nasogastric tube
and find bright red blood that fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL.
Evaluation of his blood pressure and pulse reveals orthostatic changes that resolve with
an intravenous fluid bolus of 500 cc of Lactated Ringer's solution. What should you do
next?
Answer Choices
1 Transfuse 2 units of packed red blood cells an - ✔️✔️refer for emergency endoscopy
He should be referred for an emergency upper endoscopy.
This patient is most likely bleeding from a gastric ulcer. His recent NSAID use, as well
as his alcohol and tobacco habits, make him at risk for peptic ulcer disease. His
symptoms of melena and hematemesis, along with his anemia, make the diagnosis
quite straightforward.
It appears that this patient is still actively bleeding based on the results of the
nasogastric tube irrigation; therefore, the priority should be getting the ulcer to stop
bleeding. Upper endoscopy should be performed so that the bleeding site can be
identified and treated with electrocautery, coagulation, or injection of epinephrine or a
sclerosing agent. If the bleeding cannot be stopped with endoscopic interventions,
angiographic embolization should also be tried. If these interventions do not succeed,
the patient has rapid deterioration, or if he requires more than 6 units of blood in a 24-
hour period, then emergency surgery may be indicated.
The other choices are not the best options for immediate management. This individual
cannot be followed simply with transfusions and serial CBC's because he appears to
still be actively bleeding.
,Helicobacter pylori infection may very well be playing a part in the etiology of this man's
ulcer, but evaluation for H. pylori can be done with a biopsy at the time of his
endoscopy; it will not help in his immediate management.
A barium esophagram will not identify actively bleeding ulcers and cannot treat active
bleeding.
While NSAID, alcohol, and tobacco use may have precipitated this man's GI bleed,
counseling about his use of these substances will not sufficiently treat his immediate
bleed.
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 - ✔️✔️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 - ✔️✔️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 - ✔️✔️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 - ✔️✔️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?
Emergency Medicine EOR Practice,
Emergency Medicine EOR Exam, ER
Final, ER
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 - ✔️✔️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.
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% - ✔️✔️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 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting
'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation.
Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past
medical history is positive for occasional headaches; they have been coming more
frequenly lately. Social history reveals alcohol use (1 case of beer each weekend) and
tobacco (1 pack per day). Medications include ibuprofen as needed for headaches; he
has been taking 800 mg 3 times a day for the past week. You place a nasogastric tube
and find bright red blood that fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL.
Evaluation of his blood pressure and pulse reveals orthostatic changes that resolve with
an intravenous fluid bolus of 500 cc of Lactated Ringer's solution. What should you do
next?
Answer Choices
1 Transfuse 2 units of packed red blood cells an - ✔️✔️refer for emergency endoscopy
He should be referred for an emergency upper endoscopy.
This patient is most likely bleeding from a gastric ulcer. His recent NSAID use, as well
as his alcohol and tobacco habits, make him at risk for peptic ulcer disease. His
symptoms of melena and hematemesis, along with his anemia, make the diagnosis
quite straightforward.
It appears that this patient is still actively bleeding based on the results of the
nasogastric tube irrigation; therefore, the priority should be getting the ulcer to stop
bleeding. Upper endoscopy should be performed so that the bleeding site can be
identified and treated with electrocautery, coagulation, or injection of epinephrine or a
sclerosing agent. If the bleeding cannot be stopped with endoscopic interventions,
angiographic embolization should also be tried. If these interventions do not succeed,
the patient has rapid deterioration, or if he requires more than 6 units of blood in a 24-
hour period, then emergency surgery may be indicated.
The other choices are not the best options for immediate management. This individual
cannot be followed simply with transfusions and serial CBC's because he appears to
still be actively bleeding.
,Helicobacter pylori infection may very well be playing a part in the etiology of this man's
ulcer, but evaluation for H. pylori can be done with a biopsy at the time of his
endoscopy; it will not help in his immediate management.
A barium esophagram will not identify actively bleeding ulcers and cannot treat active
bleeding.
While NSAID, alcohol, and tobacco use may have precipitated this man's GI bleed,
counseling about his use of these substances will not sufficiently treat his immediate
bleed.
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 - ✔️✔️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 - ✔️✔️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 - ✔️✔️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 - ✔️✔️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?
