+Review Questions RUSH M4 Clerkship
Review Questions RUSH M4 Clerkship
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1. A healthy, thin 32-year-old male presents to the ER with complaint of 2 days of SOB. His vital signs are normal, and his O2 sat is 99% on RA. A CXR is obtained which demonstrates a small PTX, occupying less than 10% on the hemithorax. He is kept for observation, and a repeat CXR in 6 hrs shows improvement in his PTX. What is the next most appropriate step in his management?
a) Discharge patient home with follow-up in 1 day
b) Perform needle decompression followed by chest tube placement
c) Place a R-sided chest tube
d) Continue observation and repeat CXR in another 6 hrs
e) Consult thoracic surgery for further recommendations
2. A 57-year-old male who is well-known to your ED presents with complaint of chest pain. He is a known alcoholic, and was brought by EMS with complaints of acute onset chest and neck pain, with associated dysphagia. His vitals are: 170/80, HR 110, sat 97% RA, RR 22, afebrile. On exam, you hear a crunching sound when you listen to his heart. An ECG shows sinus tachycardia with non-specific ST/T changes, and a CXR shows subtle lateral displacement of the left mediastinal pleura. What is his most likely diagnosis?
a) Esophageal perforation
b) Aspiration pneumonia
c) Aortic dissection
d) Acute pericarditis
e) Pulmonary embolus
3. A 72-year-old male with poorly controlled HTN presents to the ER with sudden onset of severe, tearing chest pain, radiating to his back. You are concerned about an acute aortic dissection. Which of the following is the preferred study of choice to diagnose an aortic dissection?
b) TTE (transthoracic echo)
c) TEE (transesophageal echo)
d) CT angiogram
4. A 52-year-old male presents to the ER with complaint of having a piece of steak stuck in his stomach. He states that he is now unable to swallow his secretions, and is spitting his saliva into an emesis basin during your examination. His vital signs are normal and he otherwise appears well. CXR is negative for any free air. Which of the following is the most appropriate next step in his management?
a) Perform the Heimlich maneuver to dislodge the steak
b) Consult general surgery for laparotomy
c) Administer IV glucagon while calling GI for endoscopy
d) Administer papain (a meat tenderizer) while calling GI for endoscopy
e) Administer syrup of ipecac to induce vomiting
5. A 48-year-old healthy female presents to the ER for evaluation of 5 days of severe, substernal chest pain that wakes her from sleep in the morning. The pain is non-exertional, and tends to resolve spontaneously in about 20-30 minutes. She has an episode of pain while she is in the ER, and an EKG performed during this episode of pain shows ST-elevation. Her troponin is normal. Her pain resolves with SL NTG x 1. She is admitted for further evaluation of her chest pain, and her workup shows insignificant CAD. Which of the following medications is most appropriate to treat this patient’s condition?
a) Calcium channel blocker
6. The nurse calls you to evaluate a patient whose AICD is firing. He is in the ER for a knee injury and has just come back from radiology when his AICD begins firing. His nurse puts him on the monitor, which shows normal sinus rhythm, and an EKG shows the same. While you are talking to him, his AICD fires again, while he is in sinus rhythm. What is the most appropriate next step in his management?
a) Call cardiology to arrange for the removal of his AICD
b) Give the patient pain medication and admit to the CCU
c) Place a magnet over the AICD
d) Obtain a CXR
e) Call the device representative to come evaluate the patient’s AICD
7. An 83-year-old woman with afib and HTN and DM comes to the ER for evaluation of abdominal pain and vomiting. She has a fever of 100.1F, her BP is 102/72, her HR is 92 and irregular, and her RR is 18. Her abdominal exam is soft, and her pain seems out of proportion to her exam. You are concerned about mesenteric ischemia as the cause for her pain. You order an obstructive series for further evaluation. Which of the following would be the most suggestive of mesenteric ischemia?
b) Pneumatosis intestinalis
c) Air-fluid levels
d) Sentinel loop of bowel
e) Absence of gas in the rectum
8. A 33-year-old male presents with severe, colicky pain that begins in his L flank and radiates to his L groin. He had similar pain last week but it was less severe and resolved spontaneously. He repots hematuria, some nausea and vomiting, but no fever or chills. His vitals are normal and his exam is significant for a soft and nontender abdomen, with some mild L CVAT. Which is the most appropriate next step in the management of this patient?
a) Perform an ultrasound to evaluate for testicular torsion
b) Perform an ultrasound to evaluate for a AAA
c) Perform a CT of the abdomen/pelvis
d) Call surgery to evaluate this patient’s abdominal pain
e) Start IVF, give IV toradol for pain and Zofran for nausea
9. A 72-year-old man with a history of CAD and HTN comes to the ER for evaluation of sudden onset of severe abdominal pain. He looks quite uncomfortable, is pale and diaphoretic, with BP 85/60 and HR 106. You feel a large pulsatile mass on palpation of his abdomen. You start 2 large bore IVs and send labs, place the patient on the monitor, and give him morphine for pain. He remains hypotensive after his first 1 L IVF bolus. Which of the following is the most appropriate next step?
a) Call the cath lab to present for angiogram
b) Call surgery and have them prepare for an exploratory laparotomy
c) Obtain a CT scan to evaluate his aorta
d) Call the angiography suite to prepare for an evaluation of his aorta
e) Order a stat portable abdominal xray
10. A sexually-active 21-year-old male presents to the ER with one hour of severe R testicular pain. He denies trauma. On exam, he is quite uncomfortable, and his R scrotum is swollen, tender and firm, and he has no cremasteric reflex on the R. His vitals are normal aside from a HR of 108. Which of the following is the most appropriate next step in the management of this patient?
a) Obtain a STAT Doppler ultrasound of his testicles and scrotum and consult urology
b) Swab his urethra for STD and treat if positive
c) Obtain at CT to evaluate for a kidney stone
d) Treat with ceftriaxone and doxycycline, recommend an HIV test, and refer for outpatient follow-up
e) Send a UA and treat with antibiotics if suggestive of UTI
11. A 23-year-old female presents to the ER with LLQ pain, which began suddenly and has been persistent. She admits to associated nausea and vomiting. She had this pain a couple of weeks ago, but it resolved spontaneously. Her vitals are normal aside from a HR of 104. Her abdominal exam is notable for moderate LLQ pain, and she has L adnexal tenderness on her pelvic exam without evidence of vaginal bleeding or discharge. Which of the following is the most appropriate diagnostic test for this patient?
a) Obstructive series
b) CT abdomen and pelvis
c) MRI of abdomen and pelvis
d) Doppler pelvic ultrasound
12. A 63-year-old male presents to the ER for evaluation of diffuse abdominal pain that he noticed upon waking up today. He had a routine screening colonoscopy the day before, which was uncomplicated. The patient has no nausea, vomiting, fever, chills or diarrhea. His vital signs are normal. His chest xray is shown below. Which of the following is the most likely diagnosis?
e) Ascending cholangitis
Question 12 image
13. A 22-year-old sexually-active female presents to the ER for evaluation of lower abdominal pain and vaginal spotting for 2 days. She has a history of ovarian cysts. She denies new sexual partners. Her vitals are normal. What is the next best test to obtain for this patient?
a) GC/chlamydia culture
c) Urine pregnancy test
d) Pelvic ultrasound
e) Obstructive series
14. For which of the following patients is an abdominal CT scan contraindicated?
a) A 54-year-old man with abdominal pain s/p MVC, negative FAST exam, BP 125/80, HR 110
b) A 22-year-old woman, negative urine pregnancy test, RLQ pain with low grade temp
c) A 45-year-old man with abdominal pain, fever, WBC 12,000, lipase 250, BP 120/70, HR 110
d) A 70-year-old man with abdominal pain, a 10-cm pulsatile mass in his epigastrium, BP 70/50, HR 110
e) A 65-year-old woman with R flank pain that radiates to her groin, hematuria, and BP 140/70 and HR 110
15. A 24-year-old female presents to the ER for evaluation after sexual assault. On physical exam, you note vaginal trauma as well as scattered abrasions and contusions on her extremities. Which of the following medications should be offered to this patient?
a) Ceftriaxone, azithromycin, metronidazole, antiretrovirals, emergency contraception
b) Ceftriaxone, tetanus, metronidazole, antiretrovirals, emergency contraception
c) Ceftriaxone, azithromycin, tetanus, metronidazole, emergency contraception
d) Ceftriaxone, azithromycin, tetanus, antiretrovirals, emergency contraception
e) Ceftriaxone, azithromycin, tetanus, metronidazole, antiretrovirals, emergency contraception
16. A 46-year-old male comes to the ER for 2 weeks of fever, back pain and leg weakness. His leg weakness is bilateral, seems to be getting worse. He denies trauma or prior surgery. He has no other PMH, admits to social ETOH, smokes cigarettes, and admits to IV heroin use. His vitals are significant for a fever of 102F, with normal BP and HR. On exam, he has midline and paraspinal lumbar tenderness with normal overlying skin, and his neuro exam shows increased BLE DTRs and decreased BLE strength. His LS spine xrays are normal, his WBC is 14,000, and his ESR and CRP are elevated. Which of the following is the most likely diagnosis?
a) Ankylosing spondylitis
b) Spinal metastatic lesion
c) Vertebral compression fracture
d) Multiple sclerosis
e) Spinal epidural abscess
17. A 79-year-old woman presents to the ER with her family for evaluation of several days of increasing fatigue, now very tired. She has had low-grade fevers for 2 days, and seems more confused than usual. She also is not eating well. Her vitals are: BP 86/50, HR 125, RR 18, T101.3F, 97% on RA. Her exam is only notable for dry mucous membranes. Her neurological exam is nonfocal aside from only being A&OX1 (usually is A&OX3). Her WBC is 13,200, her Hb is 11, her chemistry is normal aside from BUN 22 and Cr 1.6. A CXR is clear, and her UA shows a UTI with 100. You give her a 1000 cc bolus of IVF and start broad-spectrum IV antibiotics. Her repeat BP is 82/46, and you are concerned about urosepsis. Which of the following is the next most appropriate course of action to manage this patient with early goal-directed therapy?
a) Transfuse one unit of PRBCs to increase her oxygen-carrying capacity
b) Start a norepinephrine drip to increase her BP
c) Place a central venous line into her RIJ to measure her CVP (central venous pressure)
d) Place a central venous line into her RIJ to measure her mixed venous O2 saturation (SvO2)
e) Obtain a stat CT head to evaluate her altered mental status
18. A 63-year-old male with HTN and IDDM, comes to the ED for evaluation of 2 days of perineal pain, with subjective fevers and chills. His vitals: BP 95/60, HR 116, T 103.2F, RR 22. His accucheck reads “high”. On exam, you note erythema, tenderness and crepitus on his medial thigh, and widespread erythema and purplish discoloration over his scrotum. His scrotum is very tender, warm, and erythematous as well. What is his most likely diagnosis?
b) Cutaneous candidiasis
c) Testicular torsion
e) Fournier gangrene
19. A 49-year-old diabetic male presents with several days of L knee pain, which began after he tripped on a curb and fell. He states he can no longer stand or walk due to his pain. On exam, he has no abrasions or bruises. He does have a large knee effusion, and his knee is warm, diffusely tender, and swollen. His vitals are normal aside from a temperature of 101.3F, his glucose is 164. Which of the following is the most appropriate diagnostic test?
a) Knee xrays
c) ESR and CRP
d) MRI of the knee
20. A 24-year-old woman without any significant PMH, comes with fever, headache, a “sunburn-like” rash, and some confusion. Her roommate says she has also been complaining of nausea, vomiting, diarrhea and abdominal pain for a few days. Her BP is 80/45, HR 110, T 102.4F, and RR 16. She is currently on her period and states she cannot be pregnant. Her exam is significant for: diffuse blanching rash, supple neck, and a fine desquamation of her skin (especially on her hands and feet). On pelvic exam, you remove a tampon, and note no discharge. Her WBC is 15,000, she has acute renal insufficiency, and has elevated liver enzymes. You are most concerned about:
a)Toxic shock syndrome
c) Rocky Mountain Spotted Fever
d) Kawasaki’s disease
e) Scarlet fever
21. A 57-year-old diabetic man presents with fever, drooling, trismus and a swollen neck. He reports that his symptoms began with tooth pain after a dental extraction 2 days ago. On exam, the patient is anxious and ill-appearing, and has bilateral submandibular swelling, elevation and protrusion of his tongue, and tender and brawny edema and induration of his upper neck. He is febrile and tachycardic, but has a normal BP. Which of the following is the most appropriate next step in his management?
a) Send cultures, start IV antibiotics, and obtain a soft tissue xray of his neck
b) Secure his airway, start IV antibiotics, and consult ENT
c) Start IV antibiotics, obtain a CT scan of the soft tissues of his neck
d) Start IV antibiotics, obtain a CT scan of the soft tissues of his neck, and consult ENT
e) Perform a bedside I&D, send cultures of the obtained fluid, start IV antibiotics and consult ENT
22. A 73-year-old woman with h/o COPD on daily steroids, NIDDM and HTN presents to the ED with RLE pain and redness. Reports she got a bug bite on her leg one week ago, but developed worsening pain today. On exam, she has a 10 x 8 cm area of redness, warmth and tenderness to her right medial thigh, with redness ascending up to her groin. Her vitals: BP 90/55, HR 115, RR 24, T 102.3F, 98% RA. Her WBC is 19,000, Hb 13, plt 175,000. Based on this available information, which of the following best describes her clinical state?
b) SIRS (systemic inflammatory response syndrome)
c) Severe sepsis
d) MODS (multisystem organ dysfunction syndrome)
e) Septic shock
23. A 28-year-old male presents to the ER for reevaluation of a sore throat. He was treated with IM bicillin for strep throat (positive culture), and now has worsening pain and difficulty swallowing. His voice is a bit muffled, but he is not in any respiratory distress and is handling his secretions without difficulty. On exam, he has a low-grade temp, but otherwise his vitals are normal. You visualize a normal soft palate, as well as swelling of his right tonsillar arch and uvular deviation to the left. Which of the following is the most appropriate next step in management?
a) CT scan of his neck
b) Admit for IV antibiotics and OR drainage
c) Admit for IV antibiotics and pain control
d) Perform needle aspiration at bedside, change him to clindamycin, and d/c him home with close outpt f/u
e) Switch to a po clindamycin and d/c home with close outpt f/u
24. A 43-year-old woman without any significant PMH presents to the ER with 3 days of fever, sore throat and odynophagia. She has no cough or nasal congestion. You notice she sits leaning forward slightly, and is spitting her saliva into a basin. Her voice sounds hoarse. Her vitals are: BP 110/70, HR 130, RR 22, 99% RA, T 101.8F. On exam, she has a slight wheeze over her neck, and what you can see of her oropharynx shows a hyperemeic posterior oropharynx without tonsils and a midline uvula. A soft tissue lateral neck xray shows edema of the prevertebral soft tissues and absence of the vallecular space. Which of the following is the most likely diagnosis?
d) Peritonsillar abscess
e) Retropharyngeal abscess
25. A 19-year-old female with no significant PMH presents with 5 days of lower abdominal pain, R>L. On ROS, she admits to nausea, vomiting, fever and chills, and decreased po intake. She just finished her period. Her vitals are normal aside from T 101.4 and HR 110. On pelvic exam, she has CMT and R-sided adnexal tenderness. Her WBC is 16,500, and her urine pregnancy test is negative. Pelvic ultrasound shows a R complex mass. Which is of the following is the most appropriate next step in her management?
a) Start antibiotics and consult GYNE for possible laparoscopic drainage
b) Treat her with levofloxacin for 14 days, outpt gyne follow-up
c) Treat with IM ceftriaxone and d/c home with 14 days of doxycycline and outpt gyne follow-up
d) Treat with flagyl and cephalexin for 14 days with outpt gyne follow-up
e) Treat her with one-time doses of ceftriaxone and azithromycin with outpt gyne follow-up
26. A 33-year-old male presents to the ER after attempting suicide by drinking insecticide – he was just fired from his job as a landscaper, which prompted his suicide attempt. He is brought by EMS and is diaphoretic, and is drooling and vomiting, and covered in diarrhea. He has pinpoint pupils, and has wheezing on his lung exam. What is the treatment for this patient’s poisoning?
b) Atropine and pralidoxime (2-PAM)
27. A 20-year-old male is brought to the ER by EMS from a dance club, where he was found minimally responsive lying on the floor. He became combative on route to the ER. His vitals are: 120/65, 75, 12, 96% RA. When he is not stimulated, his RR and oxygenation drop. He improves temporarily with sternal rub. You administer narcan without any change in status, and his blood sugar is normal. Which of the following substances did he likely ingest?
28. A 48-year-old female presents to the ER for evaluation of 2-3 weeks of intermittent headaches, nausea and feeling tired. Symptoms are worse at home, seem to get better when she’s at work or outside of the house. She endorses sick contacts at home – her husband and teenage son are having similar sx, and her son was diagnosed as having a viral illness. She comes to the ER because she feels like this is going on longer than a typical viral illness. She has normal vital signs and a normal physical exam. Which of the following tests is most likely to give you your diagnosis in this patient?
b) Monospot test
c) Influenza swab
d) Carboxyhemoglobin level
e) Pregnancy test
29. A 22-year-old female comes to the ER with complaints of nausea and vomiting and abdominal pain. After some questioning, she admits to taking Tylenol in an attempt to kill herself, but she will not tell you how much she took. You give her activated charcoal, give her Zofran and IVF, and obtain a 4-hr Tylenol level. She is now feeling much better, and wants to go home. When you plot her Tylenol level on the nomogram, however, treatment is indicated. She and her mother really want to take her home since she is remorseful and is feeling much better, and her mother accepts responsibility for her safety. What is the best management option for this patient?
a) Administer NAC and admit the patient to the hospital under a psychiatric hold
b) Consult psychiatry for their recommendations
c) Administer first dose of NAC and d/c home with her mother if she remains asymptomatic
d) Consult your hospital’s legal department for their recommendations
e) Have the patient sign-out AMA and contract with the patient and her mother for the patient’s safety
30. A 48-year-old male is brought to the ER by EMS after found wandering the streets, apparently confused. His BP is 160/80, HR 112, 99%RA and T 100.4F. His blood sugar is normal. His face is flushed and his pupils are dilated but symmetrical. What toxidrome does this patient exhibit?
a) Anticholinergic syndrome
b) Cholinergic syndrome
c) Ethanol syndrome
d) Opiod syndrome
e) Sympathomimetic syndrome
31. A 25-year-old female presents to the ER after an intentional overdose. Her vitals are: BP 120/70, HR 101, RR 29, T 100.1F. Her CBC and chemistry (including LFTs) are normal. Her room-air ABG is: 7.51, PCO2 11, PO2 132. Which of the following substances did she likely ingest?
32. A 26-year-old male is brought to the ER by EMS due to strange behavior on the street. He is very agitated, and is fighting the police officers. He is aggressive on arrival to the ER as well, requiring multiple security guards to restrain him. His vitals are significant for hypertension and tachycardia, with normal temp and normal oxygenation. On exam, he is agitated, his skin is cool and diaphoretic, and he has persistent vertical and horizontal nystagmus. Which of the following is his most likely diagnosis?
a) Anticholinergic toxidrome
b) Cocaine intoxication
c) Cocaine withdrawal
d) Opiate withdrawal
e) PCP intoxication
33. A 26-year-old man with a history of depression, is brought to the ER after being found lying on his apartment floor next to an empty pill bottle. His HR is 116, his BP is 96/46, RR 14, and sat 97% on 2 L NC. He is obtunded without a gag reflex, but withdraws his extremities to deep palpation. His blood sugar is normal. His EKG shows a QRS of 140 msec. Which of the following is the best next step in managing this patient?
a) Intubate, give charcoal thru NG tube, and given IV narcan
b) Intubate, give charcoal thru NG tube, and give IV sodium bicarbonate
c) Intubate, give syrup of ipecac thru NG tube, and give IV sodium bicarbonate
d) Intubate, give charcoal thru NG tube, and give IV NAC
e) Give syrup of ipecac, then intubate and give IV sodium bicarbonate
34. A 70-year-old woman with HTN, DM, and ETOH abuse is brought to the ER by her daughter, who states that she is acting very confused today. She does not seem to recognize her daughter, and is anxious appearing. Her HE is 90, BP 170/80, RR 16, T 99.2F. She is diaphoretic and agitated, and appears tremulous. Which is the most appropriate immediate management of this patient?
a) Check a blood sugar and give D50 if low
b) Give IV benzos for ETOH withdrawal
c) Activate the stroke team and get an emergent CT head
d) Request a psych consult
e) Give her Haldol for her agitation
35. An otherwise healthy 19-year-old college student presents to the ER with fever, headache, sore throat, myalgias, and a rash. You are concerned about bacterial meningitis due to his complaints, rash, and meningismus. His vitals are significant for hypotension, tachycardia and fever. Which of the following best describes your priorities in managing this patient?
a) Administer Tylenol for his fever and pain control for his headache
b) Begin IVF, IV abx, and perform an LP
c) Collect 2 sets of blood cultures before starting IV antibiotics
d) Contact his parents to obtain permission for the LP
e) Obtain a CT head
36. A 65-year-old man presents to the ER with a headache and confusion, and his family reports that he seems drowsy today. His BP is 220/120, his HR is 100, and his RR is 18. He is afebrile and has a nonfocal neurological exam. He does have papilledema on exam, and a CT head shows no hemorrhage or ischemia. Which of the following is the most appropriate way to manage his BP?
a) High-dose IV lasix to decrease his preload
b) IV labetalol to BP 140/80
c) IV labetalol to BP 170/90
d) Mannitol to decrease his BP and his ICP
e) IV propofol for rapid reduction in his BP
37. An 82-year-old female is sent to the ER from her nursing home for altered mental status and a fever of 102.1F. She is disoriented and confused, and her muscles seem “stiff” per the NH. They report that she has been more agitated lately, and has been getting Haldol for her nighttime agitation. Her BP is 220/120, her HR is 130, and her RR is 20. On exam, she is tremulous, diaphoretic, and has muscular rigidity of her arms and legs. What is her most likely diagnosis?
a) Malignant hyperthermia
38. A 62-year-old man presents with 2 days of knee pain. No history of trauma. On exam, his knee is red, tender and swollen. Xrays are negative for fractures. Arthrocentesis shows 20,000 WBCs, mainly neutrophils, a negative gram stain, and positively birefringent rhomboid shaped crystals. What is his most likely diagnosis?
e) Septic arthritis
39. A 45-year-old male presents with acute onset of pain to his posterior ankle, than began when he missed a step walking up the steps at the train. He states he felt a “snap” and now is having significant difficulty walking. On exam, he has swelling of his distal calf. Which of the following physical exam signs is most likely to be positive in this patient?
a) Ballotable patella
b) Homan sign
c) Lachman test
d) McMurray test
e) Thompson test
40. A 26-yer-old male presents with R hand pain, swelling, and redness for 3 days. He denies any trauma, insect bites, IV drug use, or recent travel. On exam, he has a fever of 102F, and an area of redness surrounding several punctate lacerations over his R 3rd and 4th metacarpals, with associated tenderness. He is neurovascularly intact, but has some limited flexion of his fingers due to swelling and pain. What is the most appropriate management for this patient?
a) Admit for IV antibiotics
b) Suture, d/c home with close outpt f/u
c) Suture, d/c home with oral abx and outpt f/u
d) Wound irrigation, home with po abx
e) Wound irrigation, update tetanus
41. A 25-year-old male presents with finger pain s/p “jamming” his finger while playing football. His xray does not show a fracture. On exam, his finger looks like the photo below. What is the best way to manage this injury?
a) Buddy tape his finger
b) Place a dorsal splint to immobilize the PIP and DIP joints; remove splint in 1-2 weeks
c) Place a dorsal splint to immobilize the PIP and DIP joints; remove splint in 1 week
d) Place a dorsal splint to immobilize the DIP joint; remove splint in 1-2 weeks
e) Place a dorsal splint to immobilize the DIP joint; remove splint in 6-8 weeks
Question 41 image
42. A 24-year-old male presents with a swollen finger, 3 days after he was bitten by his dog. He has a fever of 101.4F. His R index finger is held in flexion and is symmetrically swollen from the MCP joint to the distal fingertip. He has pain with passive extension of the finger and with palpation of the flexor tendon sheath. Based on your diagnosis, you call the hand surgeon. What name is used for the criteria to make this diagnosis?
43. A 56-year-old male presents after falling from his roof, about 7 feet. He landed on his feet, and then fell to the ground. His exam is nonfocal aside from swelling and pain to his R heel, and an xray shows a calcaneal fracture. Several hours later, he complains of burning in his foot, and you find pain with passive movement of his foot. His pulses are symmetrical. Which of the following is the most appropriate next step in his management?
a) Ice, elevate, pain control
b) Elevate, ace wrap on foot
c) CT his foot to r/o occult fracture missed on plain xray
d) US his leg to r/o DVT
e) Measure his compartment pressures
44. A 25-year-old woman presents for eval of 3 months of wrist pain, which began after she fell onto her outstretched hand. She did not go to the ER at the time, but now is concerned b/c of persistent pain. She is neurovascularly intact, but has pain to palpation of her snuffbox. What is the most likely reason for her pain?
a) AVN of the scaphoid
b) Acute fracture of the scaphoid
c) Fracture of the lunate
d) Fracture of the distal ulna
e) Hematoma of the wrist
45. What is the best method to preserve an amputated digit that you are hoping can be reimplanted?
a) Attempt partial reimplantation while waiting for OR
b) Irrigate with NS, wrap in moist sterile gauze, place in sterile watertight container placed in ice water
c) Irrigate with NS, wrap it in sterile gauze moistened with saline, place on ice
d) Irrigate with povidone-iodine solution, wrap it in moist sterile gauze, and place it on ice
e) Irrigate with povidone-iodine solution, wrap it in sterile gauze moistened with saline, and place it in ice water
46. A 44-year-old carpenter presents after accidentally injecting his index finger with a high-pressure paint gun. He has severe hand pain, and his exam shows a 2 mm wound over his second proximal phalange. He has normal ROM and cap refill. Xray is negative for fracture, but does show small amount of subcutaneous air. Which of the following is the most appropriate disposition for this patient?
a) Apply a radial gutter splint, give broad-spectrum abx, and admit to ortho for operative debridement
b) Apply a radial gutter splint, d/c home with close outpt ortho f/u
c) Apply a radial gutter splint, d/c home with po abx and outpatient ortho f/u
d) Obtain a CT to r/o occult fracture and d/c home with outpt f/u
e) D/C home with pain medication, repeat xrays in one week to r/o occult fracture, outpt ortho f/u
47. Which of the following associations are paired incorrectly?
a) Anterior elbow dislocation and brachial artery injury
b) Humeral shaft fracture and axillary nerve injury
c) Olecranon fracture and ulnar nerve injury
d) Posterior elbow dislocation and ulnar and medial nerve injuries
e) Supracondylar fracture and brachial artery and medical nerve injury
48. In addition to pain near the malleoli, which of the following is an indication for an xray according to the Ottawa ankle and foot rules?
a) Achilles reflex is diminished on the side of the injury
b) Bony tenderness present at the navicular or at the base of the 5th metatarsal
c) Bony tenderness at the anterior edge of the distal 12 cm or at the tip of either malleolus
d) Effusion present on physical exam
e) Patient able to bear weight for at least 4 steps immediately after the injury but not at the time of evaluation in the ER
49. A 22-year-old woman is brought to the ER by her roommate for HA and confusion. The roommate states that the woman had a headache, neck stiffness and photophobia earlier in the day. She has later become confused, prompting the ER visit. Her BP is 120/80, HR 110, T 102F, RR 16. What is the next step in managing this patient?
a) Start abx, obtain CT brain before performing LP
b) Perform LP, await results to determine if abx are indicated
c) Give Tylenol, start IVF, and perform an LP
d) Give Tylenol, start IVF, start IV abx, and perform an LP
e) Order a head CT, perform an LP, and then start abx
50. A25-year-old male presents for evaluation of a headache. He was in the ER one day earlier and had an LP done to r/o SAH – he was d/c’ed home after the LP was normal. Now his headache is worsened, and is worse with sitting or standing and is better when lying down. He is neurologically intact. What is the definitive treatment for his headache?
a) Blood patch
b) 1 L IVF bolus
c) IV caffeine and IV fluids
d) Treatment with migraine “cocktail”
51. A 22-year-old female with known IIH comes to the ER for evaluation of a severe headache. She has tried her usual medications without relief, but her pain is otherwise typical of her headaches. Her CT head is unchanged from baseline, and she does not have papilledema. Which of the following treatment is likely to provide quick relief?
a) IV mannitol
b) IV corticosteroids
c) IV metoclopramide
d) LP with removal of 15 cc of CSF
52. A 72-year-old man presents with daily headaches for 3-4 weeks. They are worse in the morning and get better by the afternoon. He also has gradually worsening weakness of his RUE and RLE. Which of the following headache syndromes are his symptoms most consistent with?
a) Cluster headache
b) Headache from intracranial hypertension
c) Headache from a mass lesion
d) Tension-type headache
e) Waking migraine
53. What diagnosis is most consistent with this CT head of a patient with a headache?
a) Epidural hematoma
e) Subdural hematoma
Image for question 53
54. A 64-year-old presents with a severe r-sided headache that he noticed after leaving the movie theater this afternoon. He has associated nausea and vomiting, and blurred vision. He is also seeing “halos”. On exam, he has r-sided conjunctival injection, and a minimally reactive pupil on the right. Which examination will likely give you his diagnosis?
a) Fluorescein examination
b) Fundoscopic examination
c) LP with cell count
d) Measurement of intraocular pressure
e) Visual acuity
55. An 81-year-old male with h/o HTN and DM presented from the clinic with 20 minutes of LUE weakness. By the time he gets to the ER, his neuro exam is normal and his weakness has resolved. Which of the following is his most likely diagnosis?
a) Conversion disorder
b) Migraine with focal neurologic deficit
c) Thrombotic stroke
e) Todd paralysis
56. A 62-year-old male presents to the ER for evaluation of facial droop, nausea, vomiting, and unsteady gait for one day. He also admits to some blurred vision and difficulty swallowing. On exam, he is hypertensive, has a R facial droop, diplopia, vertical nystagmus and severe ataxia. What is his most likely diagnosis?
b) Lacunar infarct
d) Posterior cerebral artery occlusion
e) Vertebrobasilar artery occlusion
57. A 6-month-old girl is brought to the ER for excessive crying. On exam, she has swelling and tenderness to her left femur. Her father explains this as saying her leg got stuck in her crib rails. Her xray is below. What is the next best step in her management?
a) Genetic workup for osteogenesis imperfecta
b) Ortho consult for reduction and splinting
c) Place postmold and d/c home with outpt ortho f/u
d) Check her calcium and phosphate levels
e) Obtain skeletal survey and contact Child Protective Services
Image for Question 57
58. A 9-month-old boy comes to the ER for evaluation of 2 days of fever, vomiting, and fussiness. He seems to fuss, then vomit, then appear more comfortable. He has decreased urine output, but no fever. Which of the following statements is true regarding this condition?
a) Air enema is the therapeutic intervention of choice
b) Most present with vomiting, colicky abdominal pain, and currant jelly stools
c) Most have a “lead point” as the underlying pathologic cause
d) Plain abdominal xrays usually confirm the diagnosis
e) Surgical intervention is often indicated
59. An 8-year-old girl with sickle cell disease presents with a fever and cough. On exam, her temperature is 101.8 F, and she is tachypneic. She has unilateral rales on her lung exam, consistent with the pneumonia on her CXR. She is given IVF and IV abx and admitted. What complication is she most at risk for developing?
a) Acute chest syndrome
b) CHF due to her anemia and infection
60. A 2-year-old male is brought to the ER for evaluation of limping for one day. He has no trauma, but he was limping when he woke up. He has a fever of 100.6 F, and mild rhinorrhea. He has pain with ROM of his LLE and won’t bear weight on his leg. He has no skin changes, no leg swelling, and a normal WBC, ESR and CRP, and his xrays of his hip and knee are normal. He improves with motrin in the ER. What is the most appropriate management for this patient?
a) Admit for IV abx
b) Bone scan
c) Ultrasound-guided aspiration of his hip joint
d) Splint leg and d/c home with outpt ortho f/u
e) Home with NSAIDs and close outpt f/u
61. A 16-month-old healthy girl, with up-to-date immunizations, comes to the ER with an apparent first time simple febrile seizure. She is noted to return to baseline shortly after her arrival in the ER, and has a nonfocal exam aside from fever and mild URI symptoms. What is the most appropriate course of action for this patient?
a) Obtain full set of labs, including blood and urine cultures, CXR, and tailor treatment based on these results
b) Obtain blood and urine cultures, treat with IM ceftriaxone x 1, and d/c home with PCP f/u in am
c) Obtain blood work, CT head, and consult neurology
d) Reassure parents and d/c home with close outpt f/u
e) Obtain CT head, perform LP, and treat based on results of same
62. A 14-year-old boy presents with knee pain for 1-2 weeks. Did have injury playing basketball and “landing funny” on his leg. He has no fever, no chills, no rash. On exam, he has no focal knee tenderness, with good ROM of the knee. He does seem to have some pain with ROM of his hip. What is his most likely diagnosis?
a) Legg-Calve-Perthes disease
b) Osgood-Schlatter disease
c) Transient synovitis of his hip
e) Septic arthritis of the hip
63. A healthy 4-month-old boy is brought to the ER by EMS for apparent apneic episode at home. His mom performed CPR before EMS arrived, and he seems to have responded to that quickly. While being observed in the ER, he again became apneic and cyanotic and bradycardic. What is the most important initial intervention?
a) Chest compressions
d) Jaw thrust, chin lift, and BVM ventilation
e) Oxygen by NRBM
64. A 5-year-old girl is brought to the ER with fever, cough and congestion. She appears quite dehydrated and lethargic on your exam, and is hypotensive and tachycardic with a low grade temp. Your RN attempts IV x 2 without response. How should you proceed in obtaining IV access?
a) IO needle
b) IJ central line
c) Femoral vein central line
d) IV antecubital fossa
e) Saphenous vein cut-down
65. A 22-year-old female, G2P2, with h/o chlamydia, presents with acute onset of lower abd pain and vaginal bleeding for 2 hours. Her HR is 120 and her BP is 90/60, and she appears quite uncomfortable. On exam, she has a closed os, but R adnexal tenderness is present, and she has some blood in her vault. What diagnosis do you most strongly suspect?
a) Ectopic pregnancy
d) Ovarian torsion
e) Ruptured ovarian cyst
66. A 28-year-old G3P1112 presents to the ER with vaginal spotting for one day. She is 26 weeks pregnant. She has no pain, and her vitals are normal. Which diagnosis do you think is most likely in this patient?
a) Ectopic pregnancy
b) Placenta previa
c) Placental abruption
d) Threatened miscarriage
e) Ovarian cyst
67. A 38-year-old woman presents to the ER with suprapubic pain and dysuria and fever for 2-3 days. She is febrile in the ER, and has a HR 115 and BP 90/50. She is 2 weeks post-c/s and has been doing well. On exam, she has marked suprapubic tenderness without rebound/guarding/rigidity, and has scant vag d/c (yellow and scant dark red blood). What is her most likely diagnosis?
b) Retained POC
e) Uterine atony
68. A 29-year-old female, G2P1001, presents to the ER at 9 weeks of pregnancy with vaginal bleeding. On exam, she has some blood in the vault, but no brisk bleeding. Her os is closed and an US shows an IUP with positive FHTs. What is her diagnosis?
a) Complete AB
b) Incomplete AB
c) Inevitable AB
d) Missed AB
e) Threatened AB
69. A 49-year-old female presents to the ER with heavy vaginal bleeding for about one week, which is not usual for her. She has had some irregular periods lately, which is also atypical for her. Her abdomen is nontender, and her pelvic exam shows vaginal bleeding, an enlarged uterus, without palpable adnexal masses. An US is normal. What is the next best exam or treatment for this patient?
b) Endometrial biopsy
c) Hormonal therapy
d) Hormonal levels
70. A 44-year-old male without PMH is brought to the ER by EMS from the scene of a marathon. He is A&Ox2, appears confused, and feels quite warm is his skin is moist. He is feeling better with IVF. His labs show a mild elevation in AST and ALT but are otherwise normal. What is his diagnosis?
a) Heat edema
b) Heat exhaustion
c) Heat syncope
d) Heat stroke
e) Shock liver
71. A 39-year-old male presents after sustaining an electric shock when changing a light fixture at his house. He has no complaints aside from pain in the fingertip that was shocked, and he has localized redness there but o/w has normal exam of his hand and finger. His heart and lung exams are normal. What test, if any, should be performed on this patient?
e) Xray of hand
72. A 46-year-old male presents from his work with a chemical burn to his arm. He was working with hydrofluoric acid. He irrigated the area with water, but still has pain and burning to his arm, and thinks the burning is getting worse. What treatment should he be given?
a) Calcium gluconate
b) Silver sulfadiazene (silvadene) ointment
c) Surgical debridement
d) Tourniquet to the arm
e) Immerse arm in ice water
73. A man presents from his work at a restaurant with a burn to his right arm, sustained by scalding water. Some areas are just red, but he does have 3 fluid-filled bullae as well. He is neurovascularly intact. The burn involves the dorsum of his hand, up to his mid-forearm. What degree is his burn, and what % of his skin is involved?
74. A 32-year-old female who is vacationing at a nearby resort is brought by EMS after she had a syncopal event while ascending from a dive. She is now awake, but has a headache and feels lightheaded. The dive went well until her ascent. Her HR and BP are normal, her sat is 92% on RA, and she seems a bit confused when you try to get a history of the event. Otherwise her neuro exam and PE is normal. What caused her symptoms?
c) Dysbaric air embolus
d) Nitrogen narcosis
e) Cardiac arrhythmia
75. A 22-year-old male presents after being bit by a stray dog. He describes an unprovoked bite. He was bit to his calf, bit is able to walk normally, and is neurovascularly intact. He has no active bleeding at the site of the bite. Aside from wound care with cleanser and saline, oral and topical antibiotics, and updating his tetanus, what else should be done for this patient?
a) Suturing the laceration
b) Irrigation with betadine
c) Rabies immunization protocol
d) Admission for IV antibiotics
e) Instruct him to try to find the dog and then call animal control
76. A 32-year-old male presents for evaluation of what he thinks is a spider bite to his leg. He was on vacation in the south, was staying in a cabin, and noticed this skin change when he woke up one morning. On exam, he has a small area of necrosis on his leg, with petechiae extending around it. His calf is tender to touch and he is having difficulty walking due to the pain. He does not have a fever or chills. Which is the most likely cause of his symptoms?
a) Black widow spider bite
b) Brown recluse spider bite
77. A 19-year-old male comes to the ER with eye pain. You notice his face looks a bit sunburned, and he admits to going to the tanning bed several times this week. He has pain, redness, tearing, and a foreign body sensation. His exam shows: PERRL, EOMI, conjunctival injection, tearing, and diffuse punctate corneal lesions with a discrete inferior border. What is his most likely diagnosis?
a) Corneal abrasion
b) Corneal foreign body
e) UV keratitis
78. A 16-year-old male presents with these skin changes. He is awake and alert, with stable vital signs. What is his diagnosis?
a) Allergic reaction to ink tattoo
c) Lightning strike victim
d) Allergic reaction to henna tattoo
e) Child abuse
Image for Question 78
79. A mother brings her 6-year-old daughter to the ER for evaluation after she found a bat flying in the child’s bedroom overnight. The daughter has no complaints, and does not think she was bit, but the mom is worried. She was unable to catch the bat. On examination, you do not see any bite marks on the child. What is the most appropriate treatment for this patient?
a) Prescribe po doxycycline
b) Reassure mom that the child was not bit, and d/c home with outpatient follow-up
c) Admit to the hospital for 23 hr observation
d) Give human rabies immune globulin and human diploid cell vaccine
e) Given human diploid cell vaccine alone
80. A 22-year-old female presents to the ER with R eye pain, redness, tearing, and blurred vision. She wears contacts and admits to sleeping in them for several days. Her exam shows a large corneal abrasion over the visual axis. What is the most appropriate treatment for her?
a) Emergent optho consult
b) PO antibiotics and d/c home
c) Cipro eye drops, pain meds, d/c home with optho f/u
d) PO Cipro and Cipro eye drops, pain meds, d/c home with optho f/u
e) Cipro eye drops, tetracaine eye drops, d/c home with optho f/u
81. A 63-year-old female presents with a painful rash to her face. On exam, she has shingles over her scalp and half of her forehead. She also has a couple vesicles on the tip of her nose. She has some burning to her eye, but has normal visual acuity and a normal neuro exam. What complication are you most concerned about?
a) CNS involvement leading to meningitis
b) Sinus involvement leading to sinusitis
c) Optho involvement leading to anterior uveitis or corneal scarring
d) Ear involvement leading to mastoiditis
e) Permanent scarring to her face
82. A 72-year-old male presents to the ER concerned for a painless red eye. He has had a URI recently, and has been coughing and sneezing a fair amount. He is worried because he is on xaralto for afib. His vision in normal. What is the most appropriate ER w/u for this patient?
a) Check IOP
b) Reassure patient and d/c home
c) Check coags and d/c home if normal
d) D/C home with topical Cipro eye drops
e) Consult optho emergently
Image for Question 82
83. A 22-year-old male presents after accidentally splashing bleach in his eye. He has pain and eye tearing. What is the most appropriate next step in his management?
a) Irrigate with normal saline
b) Check the pH of his eye
c) Consult optho emergently
d) Apply erythromycin eye ointment
e) Apply tetracaine eye drops
84. A 42-year-old male is sent from his primary care clinic for evaluation of possible periorbital cellulitis. He is otherwise healthy, but has had a progressively painful R eye. He denies trauma or foreign body, does not wear contacts, and has no fever or chills. On exam he has diffuse periorbital redness and swelling, he has some pain with EOM testing, and seems to have a restricted lateral gaze. His pupils are equal and reactive, and he has a normal fluorescein exam. What is the most appropriate next step in his management?
a) Benadryl and cool packs
b) Topical erythromycin ointment to the eye
c) Emergent optho evaluation
d) IV vancomycin
e) CT scan of the orbits and sinuses
85. A 17-year-old male comes to the ER for evaluation of R eye pain s/p being punched in the face during a fight. He has some double vision, as well as sensitivity to light. On exam, he has periorbital ecchymosis, and some eyelid swelling. His pupils are equal and reactive. He has some limitation on upward gaze. He does have some periorbital tenderness as well. What is his most likely diagnosis?
a) Periorbital contusion
b) Orbital blow-out fracture
c) Retinal detachment
d) Retrobulbar hematoma
e) Ruptured globe
86. A 28-year-old female with type I DM presents with DKA due to medication noncompliance. She is hypotensive and tachycardic, her blood sugar is 722, K is 5.7, bicarb is 6, and pH is 7.15.What is the best initial therapy for this patient?
a) 0.9 NS 2 liter bolus, then 10 U regular insulin subQ
b) 0.9 NS 2 liter bolus, 1 amp sodium bicarb, and 10 U of regular insulin IV
c) 0.9 NS 2 liter bolus, then 10 U regular insulin IV
d) 0.9 NS 2 liter bolus, begin IV insulin bolus and IV insulin drip
e) 0.9 NS 2 liter bolus, kayexelate, and IV insulin bolus and IV insulin drip
87. A 38-year-old female with a history of “thyroid problems” is brought to the ER by her family for evaluation of vomiting, diarrhea, and confusion. She is febrile to 101.4 F, BP is 130/80, HR is 146 and irregular, and her RR is 22. Her EKG shows AFIB with RVR. Which is of the following is the most appropriate next step in her management?
a) Give her Ativan for her anxiety
b) Start aggressive IVF
c) Start IVF and broad-spectrum antibiotics
d) Give ceftriaxone and perform an LP
e) Given propranolol and PTU, following by Lugol Iodine solution an hour later
88. A 22-year-old with type I DM presents with presumed DKA, and admits that she has been noncompliant with her insulin b/c she ran out of it 4 days ago. She is hypotensive, tachycardic, and tachypneic. Her blood glucose is 450, her pH is 7.16, her bicarb is 6, and she has ketones and glucose in her urine. Her breath smells fruity. Which of the following criteria are most applicable to make the diagnosis of DKA?
a) Ketones and glucose in her urine
b) pH 7.16, blood glucose 450, bicarb of 6, and ketones in her urine
c) Blood glucose of 450 with ketones and glucose in her urine
d) Bicarb of 6, fruity breath
e) Bicarb of 6, fruity breath, and tachypnea
89. A 37-year-old male presents by EMS with confusion and fever. She has unknown PMH, and cannot provide history. Her vitals are: 180/90, 140, 22, T 101.8. Her exam is significant for confusion, tremors, and a goiter. What is the most appropriate management for this patient?
a) Tylenol, broad-spectrum antibiotics, IVF
b) Ativan, tylenol, IVF
d) Tylenol, propranolol and PTU
e) Tylenol, iodine
90. A 22-year-old woman presents to the ER with sudden, painless vision loss in her R eye. She noticed then upon awakening this morning. She states her mother is a patient in the ICU, and she says the nurses upstairs told her to come to the ER to be evaluated. She has a normal neuro exam and eye exam, and a normal CT head and orbits. What is her most likely diagnosis?
a) Anxiety attack
b) Multiple sclerosis
c) Conversion disorder
d) Somatization disorder
91. A 43-year-old male with known schizophrenia comes to the ER by EMS for bizarre behavior. He is often noncompliant with his medications. His vitals are stable. He is agitated, and appears to be responding to internal stimuli and seems paranoid. What is the best choice for sedating this patient?
a) Ativan and haldol
b) 4-point locked restraints
d) Ketamine and ativan
e) Ativan and soft restraints
92. A 54-year-old female with a history of depression presents after overdosing on her psychiatric meds. She won’t tell you the name of her medication, but her EKG looks like this. What is the next best intervention for her?
a) Cardioversion with sedation
b) Activated charcoal and cardiac monitoring
c) Sodium bicarbonate
d) Whole bowel irrigation
Image for Question 92
93. A 72-year-old female is brought to the ER by her family for strange behavior. He reportedly does not have any psychiatric history, but he has been talking to himself and states that he is seeing haloes around the lights, and his family states he is “seeing things”. His family is very worried. On exam, he is in NAD. He is afebrile. His HR is irregular in the 70s, his BP is 150/70, his RR is 16, and his sat is 97% on RA. He is cooperative, but does seem distracted. What is his most likely diagnosis?
a) Digoxin toxicitiy
b) Alcohol withdrawal
c) Alcohol intoxication
94. A 56-year-old man with a history of HTN, hypercholesterolemia, comes to the ER with complaints of intermittent palpitations for one week. He does not have any associated chest pain, but sometimes has associated SOB. His current vitals are: BP 130/75, HR 130, RR 16, O2 sat 99% on RA. His EKG is below. What is the most appropriate next step in the management of this patient?
a) Prepare sedation for synchronized cardioversion at 100 J.
b) Consult cardiology to take patient to the cath lab.
c) Administer diltiazem.
d) Administer warfarin.
e) Administer adenosine.
Image for Question 94
95. Another 56-year-old male with a history of HTN comes to the ER for evaluation of progressive weakness, paresthesias and muscle cramping. He is a smoker, and has a history of borderline diabetes as well. On examination, the patient is awake and alert, but does look generally weak. His EKG is shown below (courtesy of ECGGuru.com). Which of the following is the most critical next step in the management of this patient?
a) Administer aspirin and call the cath lab.
b) Perform a bedside accucheck.
c) Alert the stroke team and obtain a stat head CT.
d) Administer IV calcium gluconate.
e) Administer IV insulin and dextrose.
Image for Question 95
96. A healthy 28-year-old female with no significant PMH comes to the ER for evaluation of mild URI symptoms. Right before you discharge her, she asks you if you can do an EKG for her – she states she needs one for a new employee physical. Your EKG tech performs her EKG, which is shown below. She has no chest pain, shortness of breath or palpitations. Now that you have seen her EKG, which is your next step in her management?
a) Give her aspirin and draw cardiac enzymes.
b) Consult cardiology for pacemaker placement.
c) Discharge her home with reassurance.
d) Admit her for serial enzymes and a stress test.
e) Arrange for outpatient Holter monitoring.
Image for Question 96
97. A 66-year-old female with h/o HTN, DM, hyperlipidemia, comes to the ER for evaluation of L-sided cheat pain and shortness of breath that began about 45 minutes prior to presentation. She arrives via EMS, and has been given ASA and one SL NTG on route. She has persistent pain and her vitals are: BP 85/45, HR 108, RR 22, and sat 94% on room air. This is her EKG upon arrival. What is the most appropriate definitive treatment for this patient?
a) Electrical cardioversion.
b) Administer IV calcium gluconate.
c) Continue SL NTG until pain-free.
d) Percutaneous angioplasty.
e) Thrombolytic therapy.
Image for Question 97
98. A healthy 20-year-old female presents to the ER with complaints of acute substernal chest pain. She describes the pain as sharp, with radiation to her back. The pain is worse when lying down, better with sitting up. She denies recent travel, fever or illness. She is a smoker, but denies illicit drug use. She does take birth control pills. Her current vitals are: T 100.1, HR 99, BP 132/85, RR 18 and sat 97% on RA. Her lungs are clear to auscultation, and you are not sure if you hear a friction rub or not. Her calves are symmetrical and nontender. Her CXR is normal, and her bedside ECHO (performed by your attending) looks ok. Her EKG is as follows. Which of the following is the most appropriate next step in the management of this patient?
a) Prescribe an NSAID and discharge the patient home.
b) Check a D-dimer followed by a CT chest if the D-dimer is abnormal.
c) Prescribe antibiotics and discharge her home with close outpatient follow-up.
d) Call cardiology to take the patient to the cath lab.
e) Administer thrombolytics.
Image for Question 98
99. A 79-year-old woman is brought to the ER by her family. She complains of fatigue, dizziness, and lightheadedness. She does not complain of chest pain or shortness of breath. Her vitals are: BP 140/70, HR 37, RR 16, afebrile, O2 sat 94% on RA. Her nurse starts and IV, places her on the monitor, and obtains an EKG. Which of the following is the most appropriate next step in the management of this patient?
a) Give ASA, order cardiac enzymes, and admit to the CCU for monitoring.
b) Obtain labs, including a set of cardiac enzymes, and observe in the ED. If her labs are normal, discharge her home with her family to follow-up with her PCP in 1-2 days.
c) Place a magnet on her chest to turn off her pacemaker.
d) Place external pacing pads on her and admit her to the CCU.
e) Admit for Holter monitoring and an echocardiogram.
Image for Question 99
100. A 56-year-old male is brought to the ER by EMS after a syncopal event. He was at dinner with his wife, and suddenly she noticed he had lost consciousness for about one minute. He had had 2 glasses of wine and a regular meal. He thinks he may have had slight chest pressure and shortness of breath before he passed out. His nurse puts him on the monitor and hands you this rhythm strip. What does this show?
a) First degree AV block
b) Mobitz type I
c) Mobitz type II
d) Third degree AV block
e) Sinus arrhythmia
Image for Question 100
101. A 43-year-old female with h/o borderline HTN, comes to the ER for evaluation of 2 hours of constant epigastric pain. She has a history of mild epigastric pain with eating for about 6 months, but this pain is much more severe. She does not drink alcohol, and is not taking any medications. Her vitals are: HR 115, BP 165/95, RR 18, sat 99% RA. The nurse notes that she is orthostatic as well, and appears pale. Her abdomen is diffusely tender, with rebound and guarding, and her bowel sounds are absent. Her stool in guaiac positive. What is her most likely diagnosis?
a. Perforated gastric ulcer
d. Boerhaave syndrome
e. Abdominal aortic aneurysm
102. A 48-year-old woman presents to the ER with a compliant of hematemesis. An NGT is placed, with coffee ground emesis output. You consult GI to evaluate this patient with an upper GI bleed. What is the most common etiology of an UGI bleed?
a. Peptic ulcer
b. Gastric erosions
d. Esophageal varices
e. Mallory-Weiss tear
103. A 43-year-old woman with a history of alcohol abuse comes to the ER for evaluation of one day of hematemesis. He has mild epigastric pain. She admits to drinking alcohol the night before her presentation, and admits to several episodes of vomiting that was nonbloody before the hematemesis began. Her vital signs are: BP 130/75, RR 18, HR 115, sat 98% RA. Which of the following is her most likely diagnosis?
a. Boerhaave syndrome
b. Esophageal varices
c. Perforated gastric ulcer
d. Mallory-Weiss tear
104. A 56-year-old male presents to the ER with large amounts of hematemesis. The paramedics have already placed 2 large-bore IVs and have started IVF. His current vitals are: BP 80/45, HR 120, RR 22, sat 96% on RA. On exam, his abdomen is soft and nontender, but he has stigmata of liver disease. His WBC is 9000, Hb is 8.4, Plt 40, and his chemistry shows elevated LFTs. Which of the following is his most likely diagnosis?
a. Perforated gastric ulcer
b. Esophageal varices
c. Boerhaave syndrome
d. Acute pancreatitis
e. Mallory-Weiss tear
105. A 72-year-old woman presents to the ER with generalized weakness and dark stools for the last 3 weeks. She denies any hematemesis but admits to decreased appetite, some constipation, and unintentional weight loss over the last few months. On exam, she is pale and tired-appearing. Her BP is 120/70, HR 90, RR 16, sat 98% RA. Which of the following is her most likely diagnosis?
d. Ruptured AAA
106. A 38-year-old man presents to the ER after stepping on a rusty nail. His last tetanus vaccine was when he was a child, and he reports having a “severe” allergic reaction from it. Which of the following is the best course of action regarding tetanus immunizations in the patient?
a) Give tetanus toxoid.
b) Give tetanus immunoglobulin.
c) Give both tetanus toxoid and tetanus immunoglobulin.
d) Give neither the tetanus toxoid nor the tetanus immunoglobulin due to his prior severe allergic reaction.
e) Give both the tetanus toxoid and immunoglobulin after pretreatment with Benadryl and prednisone.
107. A healthy 26-year-old female presents with a left forearm laceration sustained by a piece of glass. She has pain at the laceration site itself, but nowhere else. She denies a foreign body sensation. On exam, the laceration is 4 cm long, bleeding has been controlled with pressure, and she has normal strength and sensation of the arm. Which of the following statements regarding imaging this patient is CORRECT?
a) As the patient does not have a foreign body sensation, no imaging is indicated.
b) Imaging is not indicated because her bleeding is controlled and she is neurovascularly intact.
c) Plain films are the next appropriate step for this patient’s care.
d) CT is used more commonly than xray to look for foreign bodies in lacerations.
e) Plain films cannot detect glass in soft tissue.
108. A 4-year-old boy comes to the ER with a forehead laceration. The laceration is 4 cm and begins on the forehead and then crosses the hairline. He has a normal neurological exam and had no LOC. Which of the following is the best option for laceration repair?
a) Shave the hair around the laceration and close with simple interrupted sutures.
b) Close with staples.
c) Shave the hair around the laceration and close with Dermabond.
d) Close with Steri-Strips.
e) Close with simple interrupted sutures.
109. A 55-year-old woman presents to the ER with a dog bite that has caused a puncture wound to her forearm. The wound is fairly deep, but bleeding is controlled with pressure. The dog’s vaccines are up-to-date and confirmed. Which of the following statements about dog bites is correct?
a) Dog bites present a low risk for infection if properly cleaned.
b) Dog-bite infections are most commonly due to Pasteuerlla multocida.
c) Delayed primary closure is a good option for dog bite wounds.
d) Clindamycin is the most commonly used antibiotic for dog bites.
e) Well-cleaned wounds do not require antibiotics, even in the case of dog bites.
110. A 45-year-old female comes to the ER after cutting her hand while chopping vegetables at home. She has a superficial laceration to her thenar eminence, without active bleeding, and no concern for foreign body retention. She is neurovascularly intact. Which of the following choices is the most appropriate way to clean her wound?
a) Take a normal saline bottle, punch holes in it, and use this to irrigate the wound.
b) Use a high-pressure syringe and irrigate with water.