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1. A 23-year-old man with a known allergy presents to your emergency department complaining of 15 minutes of shortness of breath and pruritus that began when he was eating at a Thai restaurant. While en route to the hospital he noticed swelling of his lips and eyes. Physical examination reveals a patient in mild distress, with diffuse urticaria and mild facial angioedema, without obvious intraoral involvement. Mild wheezing is also present. He is afebrile, with stable vital signs; oxygen saturation is 97% on room air. Which of the following drugs is the first-line treatment for this clinical scenario? A. Antihistamines (H1 and H2 blockers) B. Corticosteroids C. Epinephrine (Adrenalin), 0.01 mg/kg (maximum, 0.5 mg) by intramuscular injection D. Nebulized albuterol (AccuNeb, Proventil) 2. You are evaluating an 8-year-old child with abdominal pain for possible appendicitis. Laboratory testing shows a white blood cell (WBC) count of 7.9 x 109/L. You are wondering whether to pursue the diagnosis further, when your attending physician remarks that the absence of leukocytosis has a negative predictive value (NPV) of 62% for appendicitis. Based on this information, what would you conclude? A. The probability of not having appendicitis is 62% in the absence of leukocytosis B. Approximately 62% of patients without appendicitis will not have leukocytosis C. The positive predictive value for leukocytosis is 38% D. You need to review your evidence-based medicine 3. An 18-year-old woman presents to your clinic with 3 days’ duration of lower abdominal pain and vaginal discharge. She is in mild distress and has a temperature of 99.8°F. Physical examination reveals bilateral lower quadrant tenderness, with guarding but no rebound. Pelvic examination reveals bilateral adnexal tenderness, a friable cervix with thick yellow discharge, and significant cervical motion tenderness. Which of the following treatment regimens would NOT be appropriate? A. Ceftriaxone (Rocephin), 125 mg intramuscularly plus oral doxycycline (eg, Adoxa, Doryx, Vibra-Tabs), 100 mg twice daily for 14 days B. Ceftriaxone, 125 mg intramuscularly plus oral azithromycin (Zithromax), 1 g C. Oral levofloxacin (Levaquin), 500 mg once daily with/without oral metronidazole (Flagyl), 500 mg twice daily for 14 days D. Oral ofloxacin (Floxin), 400 mg once daily with/ without oral metronidazole, 500 mg twice daily for 14 days 4. A 24-year-old man with known severe hemophilia, type A, walks into the emergency department after having been in a motorcycle crash. He was not wearing a helmet. He experienced a 10-minute loss of consciousness and vomited twice at the scene. Currently he complains only of a mild headache. The patient is hemodynamically stable and has a small cephalohematoma. Physical examination reveals no focal neurologic deficit. What would be the next appropriate step in management? A. Head computed tomography (CT) without contrast B. After 6 hours of observation in the emergency department, discharge home if asymptomatic C. Intravenous (IV) infusion of factor VIII, 50 U/kg D. IV infusion of factor VIII, 25 U/kg 5. You are called to manage a 70-year-old woman in cardiac arrest. She has coronary artery disease and collapsed 3 minutes ago. Upon arrival, cardiopulmonary resuscitation is in progress, and bag-mask ventilation is being used. The presenting rhythm is asystole, and 1 mg IV epinephrine has been administered. Which of the following interventions would NOT be appropriate? A. Transcutaneous pacing B. IV vasopressin (Pitressin), 40 U C. IV epinephrine (Adrenalin), 1 mg D. Orotracheal intubation 6. A 56-year-old man with hypertension and renal insufficiency presents with 1 week’s duration of pain and swelling of his right ankle and left knee. He had a similar episode 2 years ago. The review of systems is negative for antecedent trauma, fever, or dysuria. Physical examination reveals a swollen, warm right ankle, with decreased range of motion but no overlying erythema. Which of the following statements is NOT true? A. The condition is polyarticular in 40% of cases B. Point of insertion for arthrocentesis of the ankle should be at the sulcus between the medial malleolus and anterior tibial tendon C. A joint aspirate will show negatively birefringent crystals D. Acute treatment includes nonsteroidal antiinflammatory drugs (NSAIDs), steroids, colchicine, and allopurinol 7. A 41-year-old man is brought to the emergency department after sustaining a high-speed front-end motor vehicle collision. He is complaining of upper back pain and an inability to move his legs. Physical examination shows the patient has no motor strength in his legs but normal strength in his arms. He cannot feel pain up to the level of his nipples. His position sense in the legs remains intact. What is the diagnosis? A. Central cord syndrome B. Brown-Séquard’s syndrome C. Anterior cord syndrome D. Transverse myelitis 8. A 7-year-old girl returns to the emergency department for a wound recheck. Two days earlier she underwent incision and drainage of a superficial leg abscess and was given empiric therapy with cephalexin (Biocef, Keflex). The mother says that the pain, swelling, and erythema are nearly resolved. Wound culture obtained at incision and drainage grew methicillin-resistant Staphylococcus aureus (MRSA). The patient is an otherwise healthy child with no previous hospital visits. Which of the following statements about this clinical scenario is true? A. The antibiotic regimen should be switched to a drug with intrinsic MRSA coverage B. MRSA is a relatively infrequent etiologic pathogen in community-acquired skin infections C. This patient’s MRSA isolate is genetically different from hospital-associated MRSA D. The patient is at risk for the development of severe pneumonia 9. A healthy 45-year-old woman presents to your clinic at the Mount Everest base camp (altitude, 5500 m). She arrived at the camp 8 hours ago and is complaining of headache associated with nausea, vomiting, and general malaise. She appears fatigued, but her physical examination findings, including neurologic and pulmonary evaluations, are normal. Which of the following therapies is NOT indicated? A. Oral analgesics B. Immediate descent C. Acetazolamide D. Dexamethasone (Decadron) 10. A 19-year-old man presents with a Colles’ fracture after falling while playing basketball. Except for being treated for an upper respiratory tract infection, he has no significant medical history. While being sedated with ketamine for fracture reduction, the patient becomes stridulous. Which of the following statements is true? A. The patient should be emergently intubated B. The reversal agent should be administered C. Age older than 16 years is a contraindication to using ketamine for procedural sedation D. Common adverse effects of ketamine therapy include hypersalivation, nystagmus, random limb movements 11. A 3-year-old boy is brought to the emergency department by emergency medical services (EMS) after he was found to be unresponsive at his grandmother’s home. The grandmother reports finding near the child an empty plastic bag, in which she used to keep her blood pressure (BP) medications. The child is hypotensive, bradycardic, apneic, and has pinpoint pupils. After securing an airway, which of the following therapies may be beneficial? A. Cardioversion B. High-dose insulin C. Glucagon (GlucaGen) D. Naloxone HCl (Narcan) 12. What characteristics differentiate a simple febrile seizure from a generalized tonic-clonic seizure? A. Only tonic-clonic seizures show generalized slowing on electroencephalography B. Only generalized tonic-clonic seizures are associated with a postictal period C. Typically there is a family history of tonic-clonic seizures D. Only tonic-clonic seizures involve both hemispheres of the brain 13. A 9-year-old boy with a history of spina bifida, hydrocephalus, and a ventriculoperitoneal shunt that was placed 2 years ago is brought to the emergency department because of 1 week of intermittent nausea and vomiting and worsening headaches. The mother reports no history of fever but says she has been unable to depress the shunt’s chamber. A brain CT shows significantly narrowed ventricles compared with the child’s baseline scan. The boy is crying and holding his head in pain. What immediate therapy may provide some relief? A. Tapping the shunt to release pressure B. Placing the child in the Trendelenburg position C. IV hydration D. IV antibiotics 14. A 58-year-old construction worker was working outside when he was bitten by a pygmy rattlesnake just below the thumb. In the emergency department, you note fang marks, erythema, and swelling up to the elbow. The patient feels nauseous. What is the most appropriate management? A. Emergent fasciotomy B. Broad-spectrum antibiotics for cellulitis C. 10 vials of crotalidae polyvalent immune fab (CroFab) D. Observation in the emergency department for 8 to 12 hours; if the symptoms worsen, administer antivenom 15. A 92-year-old man with congestive heart failure (CHF) is brought to the emergency department by EMS after a syncopal episode. He has had 2 days of nausea, vomiting, and abdominal pain without diarrhea. His medications include digoxin (Digitek, Lanoxin), insulin, and furosemide (Lasix). His blood glucose level in the field was 118 mg/dL. Vital signs include: BP, 112/56 mm Hg; pulse, 53 beats/min (irregular on monitor); respirations, 24 breaths/min; oxygen saturation, 92% on room air. Laboratory test results show: sodium, 135 mmol/L; potassium, 7.5 mmol/L; chloride, 109 mmol/L; bicarbonate, 25 mmol/L; blood urea nitrogen (BUN), 10 mg/dL; creatinine, 1.4 mg/dL. Electrocardiography (ECG) demonstrates a narrow-complex tachycardia. What is the appropriate management? A. Synchronized cardioversion B. Calcium gluconate to treat the elevated potassium level C. Digoxin immune fab (Digibind, DigiFab) for presumed digoxin toxicity D. Magnesium sulfate therapy for the supraventricular tachycardia 16. A 65-year-old man comes to the emergency department because he has been passing bright red blood from his rectum for the last few days. He also complains of 2 days of chest pain and shortness of breath. His medical history includes aortic valve replacement 10 years ago. He reports that he used to be able to hear a click at times but has not heard it in the past few days. Physical examination shows he is hypotensive, and there are no metallic sounds, crackles, or chest wall tenderness. Rectal examination is positive for a small amount of gross blood. The patient tells you he stopped taking his warfarin sodium (Coumadin, Jantoven) when he began bleeding. What is the next step in management? A. Transfuse 2 units of packed red blood cells for the rectal bleeding B. Administer 40 mg furosemide to treat his CHF exacerbation C. Call the cardiothoracic surgeon and begin anticoagulation; this patient has thromboembolic disease D. Admit him to the hospital to rule out myocardial infarction (MI) 17. A 4-year-old girl presents with nausea, vomiting, and watery diarrhea of 3 days’ duration. The mother reports she has been acting increasingly fussy, and her urine output has decreased. On physical examination you note an ill-appearing child with a capillary refill time of more than 2 seconds and an absence of tears. How would you categorize the degree of dehydration? A. Minimal B. Mild C. Moderate D. Severe 18. A 67-year-old man is brought into the emergency department after a witnessed episode of cardiac arrest in a casino. EMS personnel report that security staff on the scene were able to shock the patient out of ventricular fibrillation within 10 minutes using an automated external defibrillator. The patient is still unresponsive but has a pulse and is tachycardic, with a heart rate of 110 to 119 beats/min. What therapy has been reported in the past few years to protect against ischemic brain injury? A. Mild hypothermia B. Amiodarone HCl (Cordarone, Pacerone) C. Lidocaine (Xylocaine) infusion D. Warmed IV fluids 19. A 72-year-old man with a medical history of hypertension, atrial fibrillation, and CHF is brought to the emergency department with slurred speech, right-sided facial drooping, and an inability to use his right arm. The patient is afebrile, with BP, 215/110 mm Hg; pulse, 72 beats/min; respirations, 18 breaths/min; and oxygen saturation, 99% on room air. He is able to follow your commands and answer some of your questions appropriately. He can grip your fingers with his right hand with moderate strength. Which of the following factors would be a contraindication to the use of thrombolytic agents for the treatment of his ischemic stroke? A. Age B. BP 168/86 mm Hg after administering 20 mg of labetalol HCl (Trandate) C. History of atrial fibrillation D. Onset of symptoms 2 hours earlier E. None of the above 20. A 48-year-old man is brought to the emergency department after passing out at home. He had been arguing with his wife when he suddenly collapsed. ECG shows sinus rhythm, with a corrected QT (QTc) interval of 500 ms. What other ECG sign would indicate that this patient is at high risk for cardiac events? A. T-wave alternans B. U wave C. Peaked T waves D. Osborne waves |