Emergency Medicine Practice | | |
Questions EXAM PROVIDED | | |
WITH VERIFIED ANSWERS
| | |
A |68-year-old |female |presents |to |the |emergency |department |with |signs |and |symptoms |of |an |
acute |ischemic |stroke. |The |initial |CT |scan |is |normal. |Her |blood |pressure |is |164/105. |What |is |
the |most |appropriate |treatment |for |the |blood |pressure |of |this |patient?
A |Atenolol |PO |
B |Clonidine |PO |
C |Close |monitoring |
D |Labetolol |IV |
E |Nicardipine |IV |- |correct |answers*The |Correct |Answer |is: |C |
Aggressively |lowering |blood |pressure |may |decrease |blood |flow |to |the |ischemic |tissue, |thus |
decreasing |the |chances |of |recovery |or |increasing |the |risk |of |further |infarction. |In |the |setting |of
|an |acute |ischemic |stroke, |blood |pressure |elevation |should |be |monitored |closely, |with |some |
elevation |expected.* |This |elevation |is |expected |to |decline |without |medication |in |the |first |few |
hours |to |days, |but |if |elevation |continues |to |a |systolic |blood |pressure |greater |than |220mmHg, |
or |mean |arterial |pressure |greater |than |120mmHg, |medication |is |advised. |Medications |may |
include |intravenous |labetolol |or |nicardipine, |with |close |monitoring |of |the |patient. |After |the |
acute |phase |following |a |stroke, |appropriate |oral |medications |may |be |considered |for |
outpatient |hypertension |management.
You |are |evaluating |a |67-year-old |male |with |known |cirrhosis |of |the |liver |secondary |to |alcoholic |
liver |disease, |although |he |has |been |sober |for |the |past |year. |He |is |brought |in |to |the |emergency
|department |by |his |daughter, |who |notes |that |for |the |past |few |days |he |has |seemed |to |be |more
|confused. |On |examination |you |note |the |patient |to |be |mildly |confused |but |alert |to |person |and
|place. |He |has |noticeable |asterixis. |He |is |not |currently |taking |any |medications |and |his |blood |
alcohol |level |is |undetectable. |What |is |the |treatment |of |choice |in |this |case |based |on |your |
physical |examination |findings?
A |amoxicillin |
,B |prednisone |
C |lactulose |
D |folic |acid |
E |thiamine |- |correct |answers*The |correct |answer |is |(C). |*
This |patient |most |likely |has |hepatic |encephalopathy |due |to |end-stage |liver |disease. |*Asterixis |
indicates |an |increase |in |serum |ammonia. |The |treatment |of |choice |is |lactulose. |Both |folic |acid |
and |thiamine |are |used |in |the |treatment |of |alcoholic |liver |disease, |but |do |not |treat |elevated |
ammonia |levels.* |Antibiotics |may |be |used |secondarily |in |patients |nonresponsive |to |lactulose, |
but |amoxicillin |is |not |preferred. |Prednisone |is |not |a |treatment |for |hepatic |encephalopathy.
A |76-year-old |man, |is |brought |to |the |emergency |department |by |his |niece |after |she |found |him |
wandering |around |his |yard |in |the |cold |wearing |only |a |tee |shirt |and |jeans. |When |she |set |up |his
|pill |container |about |36 |hours |earlier, |he |seemed |his |usual |self |but, |in |retrospect, |possibly |a |
little |more |confused |than |usual. |The |niece |says |that |he |has |"high |blood," |treated |with |a
|"white |fluid |pill," |"sugar |diabetes," |treated |with |an |oral |medication, |and |early |"old |timer's" |
dementia |treated |with |"a |memory |pill." |Vital |signs |include |an |oral |temperature |of |100.8F, |
pulse |100 |beats |per |minute, |respirations |24 |and |somewhat |shallow, |and |blood |pressure |of |
88/52. |Initial |examination |reveals |a |slightly |dehydrated, |stuporous |man |appearing |older |than |
his |stated |age, |who |smells |strongly |of |urine. |He |has |no |lateralizing |signs. |What |is |the |most |
likely |cause |of |the |mental |status |changes?
A |hyperglycemic |hyperosmolar |state |
B |lactic |acidosis |
C |st |- |correct |answers*The |Correct |Answer |is: |A |
The |combination |of |confusion |and |dehydration |in |a |patient |with |diabetes |type |2 |who |is |taking
|a |diuretic |strongly |suggest |hyperosmolar |state.* |Patients |with |lactic |acidosis |(B) |have |marked |
hyperventilation |and, |usually, |signs |and |symptoms |of |a |serious |illness. |The |lack |of |lateralizing |
signs |makes |a |stroke |(C) |less |likely. |Urinary |tract |infection |(D) |could |certainly |cause |confusion |
and |incontinence |in |an |elderly |man |and |should |be |investigated. |Alzheimer |dementia |(E) |
progresses |slowly; |sudden |decompensation |is |usually |due |to |delirium.
A |66-year-old |man |with |a |history |of |HTN |and |diabetes |mellitus, |type |2, |presents |to |the |
emergency |department |with |complaints |of |palpitations |for |over |2 |weeks, |tachypnea, |and |
,chest |pain. |He |denies |history |of |CAD, |stroke, |TIA, |or |congestive |heart |failure. |He |is |afebrile, |
with |vital |signs |as |follows: |BP |145/98, |HR |138, |and |RR |22. |His |EKG |is |shown |(Figure |1). |
Troponins |are |negative |X |3. |Which |of |the |following |choices |is |the |most |appropriate |next |
diagnostic |study |for |this |patient? |
A |Transthoracic |echocardiogram |
B |Cardiac |catheterization |
C |Nuclear |stress |test |
D |Holter |monitor |
E |Event |recorder |- |correct |answers*The |Correct |Answer |is: |A
Choice |A, |transthoracic |echocardiogram, |is |correct, |as |it |can |demonstrate |the |presence |of |
valvular |heart |disease. |The |presence |of |valvular |heart |disease |can |change |the |
recommendations |for |embolism |prophylaxis.* |Choice |B, |cardiac |catheterization, |is |useful |in |
patients |suspected |to |have |unstable |angina, |or |who |have |sustained |a |myocardial |infarction. |
Choice |C, |nuclear |stress |test, |is |useful |in |patients |suspected |to |have |angina |pectoris, |and |may |
be |a |useful |diagnostic |study |in |this |patient |with |cardiac |risk |factors |(once |the |issue |of |atrial |
fibrillation |has |been |treated). |Choices |D |and |E |would |be |useful |tests |if |the |EKG |had |not |
established |a |diagnosis |for |this |patient, |with |the |Holter |monitor |indicated |in |patients |
experiencing |symptoms |on |a |daily |basis, |and |the |event |recorder |indicated |in |patients |
demonstrating |more |sporadic |symptoms.
What |absolute |tissue |pressure |generally |is |used |as |a |guideline |for |diagnosing |compartment |
syndrome?
A |10 |mm |Hg |
B |20 |mm |Hg |
C |30 |mm |Hg |
D |40 |mm |Hg |
E |50 |mm |Hg |- |correct |answers*The |Correct |Answer |is: |C |
Many |trauma |surgery |services |use |an |absolute |tissue |pressure |of |approximately |30 |mm |Hg |as |
the |threshold |for |diagnosing |compartment |syndrome.* |Based |on |the |entire |clinical |picture, |
patients |with |numbers |in |that |range |or |higher |will |likely |require |surgical |decompression |with |a
, fasciotomy, |while |lower |numbers |will |probably |be |managed |with |a |more |conservative |
|
approach.
A |6-year-old |female |presents |to |the |emergency |department |with |left |wrist |pain |after |falling |off
|the |monkey |bars |at |the |school |playground. |Imaging |of |the |left |upper |extremity |shows |the |
following |fracture |pattern:
Which |type |of |Salter-Harris |Classification |is |observed?
A |Type |I |
B |Type |II |
C |Type |III |
D |Type |IV |
E |Type |V |- |correct |answers*The |Correct |Answer |is: |A |
A |Salter-Harris |Type |I |(A) |involves |the |entire |epiphysis.* |
Type |II |(B) |is |the |entire |epiphysis |along |with |a |portion |of |the |metaphysis, |
Type |III |(C) |involves |a |portion |of |the |epiphysis |only, |
Type |IV |(D) |involves |a |portion |of |the |epiphysis |along |with |a |portion |of |the |metaphysis, |and |
Type |V |(E) |is |a |compression |injury |of |the |epiphyseal |plate |(nothing |is |"broken |off").
A |70-year-old |woman |who |was |found |barely |responsive |at |home |by |her |daughter |is |brought |
to |the |emergency |department. |Evaluation |reveals |that |she |is |in |a |hyperglycemic |hyperosmolar
|state |with |a |severe |fluid |deficit. |Treatment |is |initiated |with |vigorous |saline |rehydration |and |a |
continuous |infusion |of |insulin. |At |what |point |should |her |glucose |be |added |to |her |treatment?
A |when |her |condition |becomes |stable |
B |when |her |urine |output |reaches |50 |mL/hour |
C |when |her |blood |glucose |reaches |250 |mg/dL |
D |if |she |develops |hypokalemia |
E |if |she |begins |to |spill |ketones |in |her |urine |- |correct |answers*The |Correct |Answer |is: |C |
Questions EXAM PROVIDED | | |
WITH VERIFIED ANSWERS
| | |
A |68-year-old |female |presents |to |the |emergency |department |with |signs |and |symptoms |of |an |
acute |ischemic |stroke. |The |initial |CT |scan |is |normal. |Her |blood |pressure |is |164/105. |What |is |
the |most |appropriate |treatment |for |the |blood |pressure |of |this |patient?
A |Atenolol |PO |
B |Clonidine |PO |
C |Close |monitoring |
D |Labetolol |IV |
E |Nicardipine |IV |- |correct |answers*The |Correct |Answer |is: |C |
Aggressively |lowering |blood |pressure |may |decrease |blood |flow |to |the |ischemic |tissue, |thus |
decreasing |the |chances |of |recovery |or |increasing |the |risk |of |further |infarction. |In |the |setting |of
|an |acute |ischemic |stroke, |blood |pressure |elevation |should |be |monitored |closely, |with |some |
elevation |expected.* |This |elevation |is |expected |to |decline |without |medication |in |the |first |few |
hours |to |days, |but |if |elevation |continues |to |a |systolic |blood |pressure |greater |than |220mmHg, |
or |mean |arterial |pressure |greater |than |120mmHg, |medication |is |advised. |Medications |may |
include |intravenous |labetolol |or |nicardipine, |with |close |monitoring |of |the |patient. |After |the |
acute |phase |following |a |stroke, |appropriate |oral |medications |may |be |considered |for |
outpatient |hypertension |management.
You |are |evaluating |a |67-year-old |male |with |known |cirrhosis |of |the |liver |secondary |to |alcoholic |
liver |disease, |although |he |has |been |sober |for |the |past |year. |He |is |brought |in |to |the |emergency
|department |by |his |daughter, |who |notes |that |for |the |past |few |days |he |has |seemed |to |be |more
|confused. |On |examination |you |note |the |patient |to |be |mildly |confused |but |alert |to |person |and
|place. |He |has |noticeable |asterixis. |He |is |not |currently |taking |any |medications |and |his |blood |
alcohol |level |is |undetectable. |What |is |the |treatment |of |choice |in |this |case |based |on |your |
physical |examination |findings?
A |amoxicillin |
,B |prednisone |
C |lactulose |
D |folic |acid |
E |thiamine |- |correct |answers*The |correct |answer |is |(C). |*
This |patient |most |likely |has |hepatic |encephalopathy |due |to |end-stage |liver |disease. |*Asterixis |
indicates |an |increase |in |serum |ammonia. |The |treatment |of |choice |is |lactulose. |Both |folic |acid |
and |thiamine |are |used |in |the |treatment |of |alcoholic |liver |disease, |but |do |not |treat |elevated |
ammonia |levels.* |Antibiotics |may |be |used |secondarily |in |patients |nonresponsive |to |lactulose, |
but |amoxicillin |is |not |preferred. |Prednisone |is |not |a |treatment |for |hepatic |encephalopathy.
A |76-year-old |man, |is |brought |to |the |emergency |department |by |his |niece |after |she |found |him |
wandering |around |his |yard |in |the |cold |wearing |only |a |tee |shirt |and |jeans. |When |she |set |up |his
|pill |container |about |36 |hours |earlier, |he |seemed |his |usual |self |but, |in |retrospect, |possibly |a |
little |more |confused |than |usual. |The |niece |says |that |he |has |"high |blood," |treated |with |a
|"white |fluid |pill," |"sugar |diabetes," |treated |with |an |oral |medication, |and |early |"old |timer's" |
dementia |treated |with |"a |memory |pill." |Vital |signs |include |an |oral |temperature |of |100.8F, |
pulse |100 |beats |per |minute, |respirations |24 |and |somewhat |shallow, |and |blood |pressure |of |
88/52. |Initial |examination |reveals |a |slightly |dehydrated, |stuporous |man |appearing |older |than |
his |stated |age, |who |smells |strongly |of |urine. |He |has |no |lateralizing |signs. |What |is |the |most |
likely |cause |of |the |mental |status |changes?
A |hyperglycemic |hyperosmolar |state |
B |lactic |acidosis |
C |st |- |correct |answers*The |Correct |Answer |is: |A |
The |combination |of |confusion |and |dehydration |in |a |patient |with |diabetes |type |2 |who |is |taking
|a |diuretic |strongly |suggest |hyperosmolar |state.* |Patients |with |lactic |acidosis |(B) |have |marked |
hyperventilation |and, |usually, |signs |and |symptoms |of |a |serious |illness. |The |lack |of |lateralizing |
signs |makes |a |stroke |(C) |less |likely. |Urinary |tract |infection |(D) |could |certainly |cause |confusion |
and |incontinence |in |an |elderly |man |and |should |be |investigated. |Alzheimer |dementia |(E) |
progresses |slowly; |sudden |decompensation |is |usually |due |to |delirium.
A |66-year-old |man |with |a |history |of |HTN |and |diabetes |mellitus, |type |2, |presents |to |the |
emergency |department |with |complaints |of |palpitations |for |over |2 |weeks, |tachypnea, |and |
,chest |pain. |He |denies |history |of |CAD, |stroke, |TIA, |or |congestive |heart |failure. |He |is |afebrile, |
with |vital |signs |as |follows: |BP |145/98, |HR |138, |and |RR |22. |His |EKG |is |shown |(Figure |1). |
Troponins |are |negative |X |3. |Which |of |the |following |choices |is |the |most |appropriate |next |
diagnostic |study |for |this |patient? |
A |Transthoracic |echocardiogram |
B |Cardiac |catheterization |
C |Nuclear |stress |test |
D |Holter |monitor |
E |Event |recorder |- |correct |answers*The |Correct |Answer |is: |A
Choice |A, |transthoracic |echocardiogram, |is |correct, |as |it |can |demonstrate |the |presence |of |
valvular |heart |disease. |The |presence |of |valvular |heart |disease |can |change |the |
recommendations |for |embolism |prophylaxis.* |Choice |B, |cardiac |catheterization, |is |useful |in |
patients |suspected |to |have |unstable |angina, |or |who |have |sustained |a |myocardial |infarction. |
Choice |C, |nuclear |stress |test, |is |useful |in |patients |suspected |to |have |angina |pectoris, |and |may |
be |a |useful |diagnostic |study |in |this |patient |with |cardiac |risk |factors |(once |the |issue |of |atrial |
fibrillation |has |been |treated). |Choices |D |and |E |would |be |useful |tests |if |the |EKG |had |not |
established |a |diagnosis |for |this |patient, |with |the |Holter |monitor |indicated |in |patients |
experiencing |symptoms |on |a |daily |basis, |and |the |event |recorder |indicated |in |patients |
demonstrating |more |sporadic |symptoms.
What |absolute |tissue |pressure |generally |is |used |as |a |guideline |for |diagnosing |compartment |
syndrome?
A |10 |mm |Hg |
B |20 |mm |Hg |
C |30 |mm |Hg |
D |40 |mm |Hg |
E |50 |mm |Hg |- |correct |answers*The |Correct |Answer |is: |C |
Many |trauma |surgery |services |use |an |absolute |tissue |pressure |of |approximately |30 |mm |Hg |as |
the |threshold |for |diagnosing |compartment |syndrome.* |Based |on |the |entire |clinical |picture, |
patients |with |numbers |in |that |range |or |higher |will |likely |require |surgical |decompression |with |a
, fasciotomy, |while |lower |numbers |will |probably |be |managed |with |a |more |conservative |
|
approach.
A |6-year-old |female |presents |to |the |emergency |department |with |left |wrist |pain |after |falling |off
|the |monkey |bars |at |the |school |playground. |Imaging |of |the |left |upper |extremity |shows |the |
following |fracture |pattern:
Which |type |of |Salter-Harris |Classification |is |observed?
A |Type |I |
B |Type |II |
C |Type |III |
D |Type |IV |
E |Type |V |- |correct |answers*The |Correct |Answer |is: |A |
A |Salter-Harris |Type |I |(A) |involves |the |entire |epiphysis.* |
Type |II |(B) |is |the |entire |epiphysis |along |with |a |portion |of |the |metaphysis, |
Type |III |(C) |involves |a |portion |of |the |epiphysis |only, |
Type |IV |(D) |involves |a |portion |of |the |epiphysis |along |with |a |portion |of |the |metaphysis, |and |
Type |V |(E) |is |a |compression |injury |of |the |epiphyseal |plate |(nothing |is |"broken |off").
A |70-year-old |woman |who |was |found |barely |responsive |at |home |by |her |daughter |is |brought |
to |the |emergency |department. |Evaluation |reveals |that |she |is |in |a |hyperglycemic |hyperosmolar
|state |with |a |severe |fluid |deficit. |Treatment |is |initiated |with |vigorous |saline |rehydration |and |a |
continuous |infusion |of |insulin. |At |what |point |should |her |glucose |be |added |to |her |treatment?
A |when |her |condition |becomes |stable |
B |when |her |urine |output |reaches |50 |mL/hour |
C |when |her |blood |glucose |reaches |250 |mg/dL |
D |if |she |develops |hypokalemia |
E |if |she |begins |to |spill |ketones |in |her |urine |- |correct |answers*The |Correct |Answer |is: |C |
