The Long

1
The Long

• Sirous Partovi, MD

2
And the Short of It

• Randy Goldstein, MD

3
A patient with acute adrenal insufficiency is
best treated with hydrocortisone and

• A. NS
• B. D5 NS
• C. NS Ca
• D. NS K
• E. Makes no difference

4
A 45 year old WF with history of breast CA
presents with constipation and abdominal pain.
ED evaluation and treatment include

• A. Positive Chvosteks sign
• B. Increase fluid and dietary fiber
• C. IVF and lasix
• D. Referral to oncologist
• E. Obtain Barium enema

5
Treatment of acute asthma attack in patients in
2nd trimester pregnancy includes all except

• A. Prednisone
• B. Beta agonists
• C. SQ epinephrine
• D. IV fluids

6
A mom that delivered her baby yesterday develops
chicken pox. Who must receive VZIG?

• A. Mom
• B. Mom and infant
• C. Mom, infant and 2 year old sibling
• D. Infant and 2 year old sibling
• E. Infant alone

7
Post Exposure Treatment- VZIG

• Pts on high dose steroids
• Immunocompromised without a history of CP
• Pregnant women
• Newborns exposed 5 days prior to birth and 2
  days after delivery
• Neonates born to nonimmune mothers
• Hospitalized premature infants lt 28 weeks
  gestation

8
A pt on chronic dialysis has been taking
magnesium containing antacids. He presents with
hypotension and areflexia. ED treatment includes

• A. Bicarb
• B. Pacing
• C. IV Calcium
• D. Terbutaline
• E. IV fluids

9
An elderly patient c/o bilateral buttock and
posterior upper thigh pain on ambulation.
Diagnostic modality

• A. LS spine x-rays
• B. CT of L- spine
• C. MRI of back
• D. MRA of back
• E. Angiography of BLE

Leriches Syndrome
10
A 55 yo male presents with facial swelling over
one week in conjunction with SOB, ?JVD and
dilated thoracic veins. Most likely diagnosis is

• A. Ascites with anasarca
• B. Mediastinitis
• C. Pulmonary embolism
• D. Bronchogenic CA
• E. Pneumonia

11
Most common cause of sudden death in athletes

• Hypertrophic Cardiomyopathy

12
Earliest complaint of a patient with tetanus

• Locked jaw

13
A patient 2 wks post anterior MI presents with
stroke. ED workup should include

• A. Carotid doppler
• B. Brain MRA
• C. Echocardiogram
• D. Cardiac enzymes
• E. Four vessel angiogram

14
Kids with cyanotic heart disease presenting with
syncope should be placed in

• A. Trendelenberg position
• B. Reverse Trendelenberg position
• C. Knee-chest position
• D. Upside down position
• E. Left decubitus position

15

• 22-year-old man presents with a one day history
  of increasing bilateral leg weakness and
  paresthesias. He has not been ill otherwise and
  his vital signs are normal. Physical exam is
  normal except for symmetric lower extremity
  weakness and decreased deep tendon reflexes.
  Sensation is normal. What is the most likely
  diagnosis?
• Guillain-Barré syndrome
• poliomyelitis
• tick paralysis
• transverse myelitis
• viral hepatitis

16
Guillain-Barré syndrome

• Autoimmune etiology
• Distal weakness is more common
• The ascending paralysis is characteristically
  symmetric or nearly symmetric
• The facial and other cranial nerves are involved
  in 25-50 of the patients.
• Motor deficits predominate
• DTRs are almost always absent in the affected
  extremities
• Recent bacterial infection, preceding
  Campylobacter jejuni infection, and influenza
  vaccination have all been associated

17
Guillain-Barré syndrome

• Diagnosis is based on the patients clinical
  presentation
• Analysis of CSF Albuminocytologic dissociation,
  in which the CSF has a protein content of greater
  than 400 mg/L and a cell count of less than 10/ml
• Heavy metal poisoning, volatile hydrocarbon
  abuse, acute intermittent porphyria are all on
  the diff dx

18
35 year old female with hx of multifocal neuro
deficit. The best way to make the diagnosis is

• A comprehensive psychiatric evaluation
• CT of the head
• Lumbar puncture
• MRI of the head
• EMG and NCS

19
A 2 year old male presents after being struck by
a car
20
Assuming the patient is stable, the next step
would be to

• A) obtain a CT of the abdomen and pelvis
• B) insert a foley catheter
• C) perform a retrograde urethrogram
• D) perform a diagnostic peritoneal lavage
• E) obtain an intravenous pyelogram

21
59 yom with acute chest pain and weakness to left
arm. ECG shows ST elevation in anterior leads.
Treatment should include all of the above, except

• Nitrates
• Beta blockers
• Thrombolytics
• ASA
• Ca channel blockers

22

• Where is the most common site of bursitis in
  the body?

• Olecranon

23

• The most frequent cause of fetal death
  following blunt abdominal trauma during pregnancy
  is

• Placental abruption

24
The antihypertensive most likely responsible for
this finding is a(n)

• ACE inhibitor
• Beta blocker
• Calcium channel blocker
• Diuretic
• Nitrate

25

• Abrupt shaking chills, rusty sputum, lobar
  consolidation

• Strep pneumo

ETOH abuse, current jelly sputum, lobar
infiltrate with bulging fissure

• Klebsiella

HA, malaise, nonproductive cough,interstitial
infiltrates

• Mycoplasma

Old smoker, high fever, dry cough, toxic
appearance, patchy infiltrate, pleural effusion

• Legionella

26

• 53 year old man involved in an MVA and suffered
  a neck injury. The most likely injury is
• Dissection of carotid artery
• jugular vein
• Injury to C7-T2
• Epidural hematoma
• C1-C2 fracture

27
Horners Syndrome

• Unilateral facial ptosis, miosis, and anhydrosis
• Damage to the cervical sympathetic plexus
• Cluster headaches may show Horners
• Horners syndrome may also result from
• Aortic dissection
• Advanced malignancy
• Occlusion of the PICA (Wallenberg syndrome)
• Posterior pharynx abscesses

28

• What is the most common cause of painful hip in
  children?

• Transient synovitis

29
This 16 year old female who presented with heart
palpitations
30
Most likely suffers from

• A) hyperkalemia
• B) hyperthyroidism
• C) supraventricular tachycardia
• D) cocaine abuse
• E) idiopathic palpitations

31
Delta waves WPW syndrome
32
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33

• True statements about this condition includes
• Often atraumatic or associated with a relatively
  minor injury
• Most commonly occurs in boys 10 to 17 years of
  age with obesity and underdeveloped genitalia
• Salter and Harris type I variety
• Internal fixation is the treatment
• All of the above

34
Slipped Femoral Capital Epiphysis

• Often atraumatic, boys 10-17 years (obese)
• Left more common than right
• Insidious onset
• Stiffness in the hip
• An abduction and external rotational deformity is
  characteristic
• CT scan, an MRI scan, or a bone scan should be
  considered if a fracture is clinically suggested
  but remains radiographically occult after plain
  radiographs.
• Treatment is Internal fixation

35

• What is Becks triad?

• Muffled heart tones
• Hypotension
• Increased JVD

36
6 year old presents with fever, sore throat and a
rash
37
The following are true of this disease

• A) Penicillin is the treatment of choice
• B) Its natural history is to resolve
  spontaneously without sequelae
• C) The most common etiology is Strep pneumoniae
• D) It is contagious only before the rash erupts
• E) It is most common in children less than 3
  years of age

38

• This 2 year old child presents with drooling. He
  is otherwise in no distress. The next step should
  be
• Rapid intubation
• Ipecac administration
• Barium swallow study
• Call the friendly GI doc
• Meat tenderizer

39
Esophageal Foreign Bodies

• Esophagus has three normal anatomic sites of
  narrowing where impactions are most common
• The cricopharyngeus muscle
• The crossing point of the aorta
• Lower esophageal sphincter

40

• What are the most common causes of acute mitral
  regurgitation?

• Acute MI
• Bacterial endocarditis
• Trauma

41
This childs lesion is a

• Left CN VI palsy
• Right CN VI palsy
• Left CN III palsy
• Right CN III palsy
• A great party trick

42

• What are the most common signs of pulmonary
  embolism?

• Dyspnea
• Tachypnea

What are the most common ECG findings in a
patient with pulmonary embolism?

• Sinus tachycardia
• Non specific ST-T changes

43

• 38 year old patient with HIV presents with fever,
  shortness of breath and dry cough for 1 week.
  ABG shows PO2 of 59. The treatment should include
  all except
• Oxygen therapy
• Intubation if in distress
• Bactrim IV
• Triple med regimen for TB
• Steroids

44
PCP

• PCP is the most common opportunistic infection in
  AIDS
• Uncommon in patients with CD4 gt200/mm3
• Nonproductive cough, fever, shortness of breath,
  diffuse interstitial infiltrates on chest
  radiograph, and arterial hypoxemia
• Bilateral interstitial infiltrates that begin in
  the perihilar region- can vary considerably,
  ranging from a normal appearance to dense
  consolidation
• Prednisone is indicated for moderate-to-severe
  PCP who have a PaO2 less than 70 mm Hg or an A-a
  gradient greater than 35 mm Hg.

45

• 8-week-old boy presents with cough and
  low-grade fever and conjunctivitis

• Chlamydia

46

• The following etiologies are associated with the
  condition shown on this radiograph, except

1. Collagen vascular diseases
2. Previous hip dislocation
3. Prolonged corticosteroid use
4. Sickle cell anemia
5. Thallasemia minor

47
This 6 year old presents after being treated at
his PCP clinic for 3 days of vomiting
48
A reasonable next step would be to

• A) Obtain a CT of the head
• B) Perform a lumbar puncture
• C) Obtain a cervical spine series
• D) Administer diphenhydramine
• E) Sneak up on the childs left side and yell
  BOO to see if hes faking this and will turn
  his head

49

• Testicular torsion has two peaks

• Infancy
• Adolescence

50
This patient cannot recall how he was injured.
True statement concerning this injury include all
except

• Associated with high incidence of infectious
  complications
• The most common aerobic organisms include
  Strep/Staph
• Eikenella corrodens is found in about one third
  of anaerobic cultures
• ED management includes copious wash out and
  closure
• Complications could include amputation of the
  fingers-hand

51
Clinched Fist Injury

• High incidence of infectious complications
• septic arthritis
• Tenosynovitis
• Osteomyelitis
• Surgical amputation
• Most infected wounds are polymicrobial

52

• The drugs most commonly associated with Torsades

• Class IA (Quinidine and Procainamide)
• Class IC agents

53
A 30 year old male presents complaining of severe
foot pain
54
This patient requires prompt consultation by

• A) a dermatologist
• B) an orthopedic surgeon
• C) an infectious disease specialist
• D) an oncologist
• E) a rheumatologist

55
Fracture Blister
56
6 year old boy presents with URI symptoms for a
week, as well as abdominal pain and swollen
tender joints and the rash shown here. True
statements regarding evaluation and treatment for
this patient include all of the above except
57

1. This is a vasculitis affecting
   arterioles and capillaries
2. Insect stings and drugs could be inciting agents
3. Frank arthritis is usually absent
4. Hematuria is hallmark of renal failure
5. Patient with GI bleeding should be admitted and
   receive IV corticosteroids

58
Henoch-Schönlein purpura

• Purpuric, petechial rash appears from buttocks to
  feet can be seen on extensor surface of arms,
  periauricular area
• Beware of gastrointestinal bleed or nephritis.
  Leg arthralgias common, edema of genitalia seen
• Admission not mandatory, steroids used only with
  GI bleeding

59

• Chronic Lithium (as well as salicylates and
  theophylline) is worse than acute toxicity- True
  or false

• True.True

60
The findings on this x-ray in a 2 year old struck
by a car suggest

• A) Positional artifact
• B) Subluxation of C-2 on C-3
• C) Fracture of a cervical vertebra
• D) A fatal lesion

61
A 1 year old presents with fever and decreased
oral intake
62
Your disposition should be

• A) Observe in the ED for p.o. challenge
• B) Discharge home on oral antibiotics
• C) Admit for overnight observation
• D) Prompt surgical consultation for definitive
  treatment
• E) Emergent ID in the ED

63

• These tender lesions are associated with all
  underlying infections below, except
• Sarcoidosis
• TB
• Yersinia
• Salmonella
• All of the above

64
Erythema Nodosum

• Result of a hypersensitivity vasculitis from
  infections, drugs, or a systemic disease- viral
  URI, streptococcal infections, sarcoidosis, TB,
  and drug exposure.
• Much rarer causes include IBD, histoplasmosis,
  Yersinia, Salmonella, Chlamydia,
  coccidioidomycosis, psittacosis, and autoimmune
  diseases such as SLE.
• Drugs implicated include penicillins, sulfa
  drugs, dilantin, and oral contraceptives

65

• Visual symptoms, acidosis, an elevated osmolar gap

• Methanol poisoning

66
A 4 month old is triaged for fever
67
This x-ray suggests you should

• A) Intubate the patient emergently
• B) Treat with oral antibiotics
• C) Admit for IV antibiotics
• D) Place the patient in respiratory isolation
• E) Look for another source of the fever

68
A diabetic patient presents with fever and this
skin lesion of 1 day duration.All statements
concerning ED treatment are true,except

• Aggressive fluid resuscitation
• Gram /-, anaerobic antibiotic coverage should be
  initiated immediately
• Emergent wide surgical debridement
• Tetanus prophylaxis
• All of the above

69
Fourniers Gangrene

• Polymicrobial, synergistic infection ofthe
  subcutaneous tissues that originates from one of
  three sites skin, urethra, or rectum
• Begins as a benign infection or simple abscess
  that quickly becomes virulent,and leads to
  end-artery thrombosis in the subcutaneous tissue
  that promotes widespread necrosis of previously
  healthy tissue

70
This patient is brought to the ED under police
custody
71
The major complication to be expected with this
patient is

• A) hypoxia
• B) hypercarbia
• C) renal failure
• D) arrhythmia
• E) blindness

72
Hydrocarbon Poisoning
Pulmonary Cough, wheeze, tachypnea, pneumonitis
Ingestion N/V, hemorrhagic gastroenteritis
Systemic Confusion, H/A, ataxia, lethargy, coma, death
Local Irritation, burn, corneal injury
73

• Rotary nystagmus

• PCP

74
35 year old with positional chest pain.
Diagnosis
Acute pericarditis
75

• This 35 year old mentally retarded man with 3
  days of swelling to his face and neck. His temp
  is 101, P 76 RR 20, Pulse OX 98. The
  treatment regimen for this patient includes all
  of the above except
• Admission to floor
• Set up for possible intubation
• IVF replacement, keep NPO
• High dose PCN and Flagyl
• Immediate OMFS/ENT consultation

76
Ludwigs Angina

• Cellulitis of bilateral submandibular spaces and
  the lingual space
• Brawny induration of the suprahyoid region and
  elevation of the tongue
• The primary focus of initial management is
  maintenance of a patent airway

77

• What is Kienbocks disease?

• Post traumatic avascular necrosis seen in lunate
  fractures

78
A 1 week old infant presents with irritability,
tachypnea and poor feeding. O2 sats 82 on room
air.
79
The following interventions would be appropriate
EXCEPT

• Supplemental oxygen
• Evaluation for sepsis
• IV antibiotics
• IV indomethacin
• IV prostaglandin E1

80
35 year old man was involved in MVC, now C/O LUQ
pain. Vital signs are normal. CT of abdomen shows
the injury. False statements include
81

1. This is the most commonly injured organ in
   pediatric blunt trauma
2. Treatment may includes exploratory lap if patient
   deteriorates
3. At least 200 cc of fluid in the peritoneum is
   required for FAST exam to be positive
4. FAST exam would be more sensitive for this type
   of injury
5. High level of suspicion should be given to hollow
   viscous injuries

82
A 1 year old, not moving his right arm after a
fall. He should be

• Placed in a hanging arm splint
• Taken to the OR for internal fixation
• Evaluated for nonaccidental trauma
• Discharged after placement of a long arm cast

83

• 76 year old man presents with sudden onset of
  painless partial visual loss in left eye. Initial
  treatment for this condition includes
• Heparin
• Eye massage
• Heliox
• Mannitol
• None of the above

84
Central Retinal Artery Occlusion

• Between 50 and 70 years of age- 45 CAD
• Risk factors HTN, CAD, DM, CVD, vasculitis,
  cardiac valvular abnormality, and sickle cell
  disease.
• Reduced visual acuity with an afferent pupillary
  defect
• Digital global massage immediately in the ED
• Increase P CO2
• Timolol maleate 0.5 topically
• Acetazolamide

85

• Patient with tinnitus and shortness of breath,
  think.

• Salicylate poisoning

86
A 4 year old presents with high fever for 5 days
and a rash on his trunk
87
Treatment should include

• Amoxicillin 80mg/kg divided BID
• 50 mg/kg IM Ceftriaxone x 1
• Supportive care for viral illness
• IV gammaglobulin
• Stopping all over the counter medications

88
Kawasakis Disease

• Usually lt 5 years old
• 5 days of fever
• Nonpurulent conjuntivitis, strawberry tongue, red
  fissured lips, palmar/solar erythema, rash,
  lymphadenopathy

• Treat with IV gamma-globulin, high dose aspirin
• Complications include coronary artery aneurysms
  in 25

89
65 year old man without prior history presents
with decreased vision in L eye for 2 days. R eye
is normal. L eye is shown here, diagnosis

1. Retinal artery occlusion
2. Retinal vein occlusion
3. Cotton wool spots
4. Retinal detachment
5. None of the above

90
Central Retinal Vein Occlusion

• Painless loss of vision
• Loss of vision can range from minimal to
  recognition of hand motion only.
• Management is aimed at identifying systemic
  disease and monitoring for neovascular glaucoma.

91

• Most common ECG abnormality with Digoxin
  toxicity is

• PVCs

92
8 month old with fever for the previous 4 days.
Now afebrile with the rash shown below.
Treatment includes

• Supportive care only
• IV Penicillin
• Diphenhydramine
• Systemic corticosteroids
• Doxycycline

93
Viral Exanthums

• Roseola (Erythema Subitum)
• Human herpes 6 virus Rapid temperature
  elevation, irritability and often febrile
  seizures lasting 3-4 days followed by
  defervescence and the a rose colored macular
  eruption on the trunk and then spreading to the
  extremities.
• Tx supportive
• Varicella (Chickenpox)
• Varicella zoster virus Viral prodrome of URI and
  fever followed by rapidly appearing crops of
  vesicles of differing ages. Lesions start in the
  scalp and trunk and spread peripherally.
• Tx supportive

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95

• Erythema Infectiosum (Fifth Disease)
• Human parvovirus B-19 Fever with characteristic
  slapped cheek rash later fading and replaced by
  a lacy macular eruption on the extremities.
  Complications include aplastic anemia in those
  with hemoglobinopathies.
• Tx supportive
• Hand-Foot-Mouth Disease
• Cocksackie virus Fever, malaise and anorexia
  with one/all of the characteristic macular and
  vesicular eruption on the palms and/or soles and
  shallow oral ulcers of the soft palate and
  tonsillar pillars (Herpangina)
• Tx supportive

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97

• Herpes Gingivostomatitis
• Herpes simplex virus Painful white-yellow
  friable ulcerations with erythematous halos on
  the lips, gums, tongue and anterior oral mucosa.
  Fever, halitosis and anorexia are common. May
  spread to eyes (conjunctivitis) and extremities
  (Whitlow).
• Tx supportive
• Rubeola
• Measles virus Fever, malaise, cough, coryza,
  conjunctivitis, Kopliks spots (buccal mucosa)
  followed by a blotchy macular eruption beginning
  at the hairline and spreading caudally.
  Complications include pneumonia, otitis,
  encephalitis and bacterial secondary infections
• Tx supportive

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99
32 year old obese woman presents with headache
and decreased visual acuity. CT of head is
negative. Further evaluation and or treatment
should include

1. MRI of brain
2. Carotid doppler
3. Lumbar puncture
4. Mannitol
5. High dose steroids

100
Pseudotumor Cerebri

• 20- to 30-year-old obese women
• Complain of N,V,HA, and visual changes
• The headache is typically chronic and the
  symptoms can mimic those of a brain tumor.
• Pregnancy, oral contraceptives, vitamin A
  overuse, tetracycline, nalidixic acid, and
  corticosteroid withdrawal or prolonged use have
  been associated

101

• Child with GI symptoms and anemia

• Think lead poisoning

102
A 6 year old presents as a restrained passenger
in a car accident
103
An appropriate evaluation of this finding would
include

• A) Diagnostic peritoneal lavage
• B) Exploratory laparotomy
• C) Abdominal sonogram
• D) CT scan of the abdomen and x-ray of the lumbar
  spine
• E) Intravenous pyelogram and barium enema

104

• 55 year old woman with acute onset of decreased
  visual acuity, described as flashing lights.
  Diagnosis

1. Retinal hemorrhage
2. Acute angle closure glaucoma
3. Retinal detachment
4. Inter-ocular foreign body
5. Retinal artery occlusion

105
Retinal Detachment

• Risk factorsHypertension, toxemia of pregnancy,
  central retinal venous occlusion,
  glomerulonephritis, papilledema, or vasculitis.
• Pain is absent
• Retinal detachments diagnosed or suspected in the
  ED need emergent consultation.

106

• Conjunctivitis in a 4 day old infant

• GC

107
This patient was found with altered mental status
by her family
108
In sorting out the etiology of this finding, it
may be harmful to

• A) Administer 5 mg haloperidol
• B) Administer 2 mg lorazepam
• C) Administer 25 mg diphenhydramine
• D) Administer 1 mg benztropine
• E) Administer 25 gm dextrose

109
In sorting out the etiology of this finding.
110
One should

• A) Provide emergent dental hygiene
• B) Search diligently for occult rectal foreign
  bodies
• C) Administer 10 mg IV Ritalin
• D) Withdraw support

111
35 year old post partum female presents with
sudden onset of perianal pain. No fever.
Diagnosis is

1. Rectal prolapse
2. Rectal foreign body
3. Thrombosed hemorrhoid
4. Perirectal abscess
5. Uterine prolapse

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113
This patient presents with 1 week of worsening
dyspnea
114
The exam is unlikely to reveal

• A) Basilar rales
• B) Jugular venous distention
• C) Bounding pulses
• D) Cardiac friction rub
• E) Hypotension

115

• 19 year old man felt a pop and had sudden pain to
  his penis while trying a new sexual position with
  his partner. The injured structures could be all
  of the above except
• Tunica albuginea
• Bulbous cavernosum
• Urethral tear
• All of the above

116

• Patient was stabbed with a kitchen knife. He has
  normal vital signs. FAST exam is shown. The next
  best step in diagnosis is
• Exploratory lap
• Removal of the knife and Repeat FAST in 4 hours
• DPL
• Cut down visualization to see if peritoneum has
  been violated
• CT of abdomen

117

• Most common cause of myocarditis in US

• Coxsackie

Most common cause of myocarditis in Central
America

• Chagas disease

What is the most characteristic of Lyme disease
associated myocarditis

• Conduction abnormality

118
You are called to this patients bedside by a
nurse
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120
His acute respiratory decompensation can likely
be corrected with

• A) Intubation
• B) Left chest tube
• C) Right chest tube
• D) Pericardio-centesis
• E) high flow oxygen

121

• 25 year old HIV patient with above rash for 2
  days. He has R eye pain and photophobia. He
  requires all of the above except
• Slit lamp evaluation
• Cycloplegic agents
• IV acylovir
• Steroids if fluorescein is neg and cells and
  flare are noted
• DC and follow up with an ophthalmologist in 24
  hours

122
Herpes Zoster Keratoconjunctivitis

• As a result of activation of the virus along
  ophthalmic division of the trigeminal nerve
• Unilateral, involves the lids, produces
  significant pain
• Hutchinson sign
• An iritis can occur with photophobia and pain.
  Iritis can be treated with topical steroids
  prednisolone acetate 1 (Pred Forte)
• If HZO is diagnosed, admission and intravenous
  acyclovir should be considered.
• Ophthalmic zoster mandates emergent
  ophthalmologic consultation.

123
This assault victim
124
Should be examined for this finding

• A) Right lower facial paralysis
• B) Dilated left pupil
• C) Inability to abduct the right eye
• D) Inability to depress the right eye
• E) Inability to elevate the right eye

125
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126
35 year old painter accidentally injured himself
while using his high pressure paint gun. All are
true regarding evaluation and treatment of this
injury, except

1. Check for tetanus status
2. Obtain x-rays of the hand
3. DC with follow up in 2 days
4. Call a hand surgeon for immediate surgery
5. None of the above

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128

• The signs of tenosynovitis

• Tenderness along the tendon sheath
• Finger held in flexion
• Pain on passive extension of the finger
• Decreased distal sensation

129
This patient presents after a fishing accident
130
Recommended interventions include all of the
following except

• A) Update tetanus immune status
• B) Document intraocular pressures
• C) Prophylactic antibiotics
• D) Eye shield
• E) Antiemetics

131

• 28 year old female with history of IVDU presents
  with sudden onset of dyspnea. Her temp is 101, P
  130, BP 80/P, and respiratory rate of 36. On
  physical exam you see increased JVD and hear
  crackles in the lung fields. There is S3 and S4
  gallop as well as a harsh apical systolic murmur.
  The most likely cause is
• Acute MI
• Acute PE
• Acute rupture of papillary muscle
• Severe pneumonia
• Drug seeking behavior

132

• The patient shown presents with the above rash
  that has been causing him anxiety and pruritus
  for the past week. Before discharging him home he
  should have
• His tetanus updated
• CBC and Hepatitis profile
• GC and chlamydia swab of penis
• VDRL
• None of the above

133
Pityriasis Rosea

• Mild inflammatory exanthem of unknown cause,
  maybe viral
• Occasionally there are prodromal symptoms
  including malaise, headache, sore throat,
  fatigue, and arthralgia.
• Diagnosis is clinical
• It can be confused with viral exanthem,
  drugeruptions, syphilis, and seborrheic
  dermatitis
• A serologic test for syphilis must be done to
  exclude that diagnosis.

134

• What is the most common presenting complaint for
  an aortic dissection?

• Pain

135
20 year old is bitten by a rattlesnake. 1 hour
later, he complains of severe pain to the hand
136
Interventions that may be indicated include all
except

• A) Diptheria-Tetanus toxoid
• B) 1 vial crotalid antivenin
• C) Narcotic analgesics
• D) Fresh frozen plasma
• E) Fasciotomy

137
What is the name of this fracture?
Bennetts Fracture
138

• The most common associated injury with the above
  fracture is
• Calcaneus fracture
• Tib-fib fracture
• Hip fracture
• Vertebral fracture
• Ankle fracture

139

• The most common cause of pneumonia in a
  3-week-old infant

• Group B strep

The most common cause of meningitis in a
3-week-old infant

• Group B strep

The most common cause of sepsis in a 3-week-old
infant

• Group B strep

140
This patient bit by a spider 3 days ago
141
Treatment for this wound includes

• A) Local debridement and physical therapy
• B) Systemic antibiotics
• C) Systemic steroids
• D) Tetanus toxoid
• E) All of the above

142

• This patient sustained this injury by falling on
  outstretched arm. All statements are true
  regarding the possible complications of this
  injury except
• Early degenerative arthritis
• Delayed union
• Malunion, nonunion, avascular necrosis
• median nerve compression
• All of the above

143

• Most common cause of focal encephalitis in AIDS

• Toxoplasma gondii

144
The patient with this EKG was found unconscious
in an alley
145
Treatment includes

• A) 25 gm Dextrose and 10 units insulin
• B) Rewarming
• C) 200 Joules defibrillation
• D) 1 gm calcium chloride
• E) All of the above

146
Osbourne J waves
shivering
147

• Common complications of this injury includes all
  of the following, except
• Complete avulsion of anterior and posterior
  cruciate ligaments
• Patellar tendon rupture
• Peroneal nerve injury
• Popliteal artery injury
• Posterior joint capsule rupture

148
Associated Injuries

• Clavicle

• Brachial plexus (BP)
• Subclavian vessels

• Anterior shoulder dislocation

• Axillary nerve

149
Associated Injuries

• Radial nerve

150
Associated Injuries

• Brachial artery
• Median nerve

151
Associated Injuries

• Radial nerve

152
A 54 y.o. female with Lupus presents with 2 weeks
of worsening dyspnea presentssevere hypotension
153
This unstable patient should be treated with

• A) High dose steroids
• B) t-PA
• C) Furosemide
• D) Pericardiocentesis
• E) all of the above

154
Electrical Alternans
155

• All statements regarding this condition are
  true, except
• This is the most common type of shoulder
  dislocation
• Axillary nerve injury is a possible injury
• 80 of these injuries are undiagnosed initially
• Presentation of this patient is with arm in
  adducted position and internally rotated with
  abduction causing severe pain
• All of the above

156
A 17 year old male presents with 1 hour of
crushing chest pain after using cocaine
157
Which of the following should be avoided in this
patient

• A) Nitrites
• B) Calcium channel antagonists
• C) Beta blockers
• D) Aspirin
• E) Thrombolytics

158

• Complication of this injury include
• Radial nerve injury
• Ulnar and median nerve injury
• Compartment syndrome
• Gunstock deformity
• All

159

• Biceps reflex

• C6

• L4

Patellar reflex
160
This 80 year old renal dialysis patient presents
with altered mental status
161
Your first intervention should be

• A) Calcium
• B) Bicarbonate
• C) Albuterol
• D) Insulin and glucose
• E) TNK

162
45 year old El Paso resident presents with
bilateral eye findings shown here for the past
year. Diagnosis
Ptyrigium
163
This patient suffered the above injury in a
barroom fight. He lost. True statements regarding
this condition include all except

• Early globe reduction is an important initial
  treatment
• There are no contraindication to performing globe
  reduction
• Patients with spontaneous (atraumatic) luxation
  and no visual impairment in whom the globe is
  easily reduced warrant follow-up within 24 to 48
  hours
• Patients with traumatic luxation are at greater
  risk for underlying ophthalmic injury and warrant
  emergent consultation

164
This 5 year old who fell on her elbow has a

• Nursemaids elbow
• Radial head fracture
• Ulna fracture
• Supracondylar fracture
• Sprain

165

• This patient presents with a red, painful eye for
  one day after he fell sleep with his contact lens
  on. The organism most likely involved with this
  condition is
• Staph
• Pseudomonas
• Strep
• Herpes simplex
• Non of the above

166
This patient who initially presented with a GCS
of 3 but with a maintained airway and spontaneous
resolution of symptoms likely overdosed on

• A) Ethanol
• B) Amytriptyline
• C) Gamma hydroxybutyrate
• D) Phencyclidine
• E) Jimsonweed

167

• False statements regarding this injury include
• More common in children than elderly
• Carries a better prognosis than other cranial
  injuries if diagnosed early
• 80 occur in temproparietal region
• The lucid interval is pathognomonic for this
  injury
• All are true

168
These patients are poisoned with carbon monoxide.
Which is false?

• A) May have COHgb gt10
• B) Have a normal SaO2
• C) May have a normal PaO2
• D) Should receive oxygen via nasal cannula

169
78 year old man presents with sudden onset of
severe abdominal pain that is out of proportion
to his exam. He is in a-fib with ventricular rate
of 140. His guaiac test is positive. Treatment
should include all of the above except

1. Securing airway and breathing
2. Mesenteric angiography
3. Call the surgeons
4. Cardioversion to a normal sinus
5. IVF therapy

170

• 18 year old involved in MVC with head injury was
  intubated in route to ED. After viewing this CXR
  the next treatment should be
• Tube thoracostomy on R
• Tube thoracostomy on L
• CT of the chest
• Reposition the ET tube
• Perform a FAST exam

171
(No Transcript)
172

• What is the most common cause of endocarditis in
  IVDU population?

• Staph aureus

What is the most common cause of infective
endocarditis?

• Strep viridans

173
A 9 month old is brought to the ED for this
finding. History will reveal

• A) Recent trauma
• B) Febrile seizures
• C) A family history of an inherited disease
• D) Antibiotic use
• E) Congenital anomaly

174
Dactylitis

• Earliest manifestation of Sickle Cell Disease.
• Vasoocclusive effects within the bones.
• Hydration and pain control.

175
Sickle Cell Disease clinical presentations

• Vasoocclusive Crisis Small vessel occlusion
  secondary to noncompliant RBCs leads to distal
  hypoxia and pain.
• Examples include dactylitis, bony pain crisis,
  acute chest crisis, stroke, and avascular
  necrosis of the femoral head.
• Treatment Aggressive hydration and pain control.

176
Sickle Cell Disease clinical presentations

• Hemolytic Crisis Massive destruction of sickled
  cells leading to severe anemia and shock. Look
  for jaundice.
• Aplastic Crisis Shutdown of RBC production
  (Parvovirus B-19).
• Sequestration Crisis Splenic enlargement can
  lead to a functional severe anemia. Priapism.

177
Sickle Cell Disease clinical presentations

• Asplenia High risk for infections by
  encapsulated organisms (Strep pneumoniae, H. flu,
  Salmonella, Klebsiella). Bacteremia, pneumonia,
  meningitis and osteomyletitis are more common in
  patients with Sickle Cell Disease.

178

• 68 year old man with acute anterior MI develops
  the following rhythm after receiving tPA.
  Treatment includes
• Cardioversion
• Lidocaine
• Verapamil
• Permanent pacemaker
• None of the above

179
This condition is the third most common cause of
large bowel obstruction. What are the first two
causes

• Cancer
• Diverticulitis
• Volvulus

180
One should perform So he does not develop
ID of septal hematoma
A flat nose
181

• A 15-year-old boy fractures his right tibia while
  playing football. Several hours after the
  incident he develops tachycardia, tachypnea and
  dyspnea. Soon afterwards he becomes comatose.
  Which of the following is most likely?

1. A petechial rash may develop on the chest,
   axilla, and neck
2. Chest x-ray will reveal an area of density or
   consolidation of the lung
3. Heparin therapy instituted immediately will
   alleviate the symptoms
4. The presence of fat globules in the urine
   sediment is diagnostic

182

• What is the bleeding site for most anterior
  epistaxis?

• Kiesselbach's plexus

183

• Lightning strikes a soccer field during a game.
  Ten people are injured. An ambulance crew is
  present. Which of the following victims should be
  treated first?
• A fan who is pregnant and complaining of
  abdominal pain
• A player who is awake, but has an obviously
  deformed right thigh
• A player who is unconscious, and has no
  detectable pulse or visible respiratory effort
• An unconscious man with a palpable pulse and
  visible respiratory effort

184

• A 16-year-old child with sickle cell disease,
  presents with left leg pain and a temperature of
  38.8C (102F). X-ray is shown here.The most likely
  etiologic agent is which of the following?
• Bacteroides
• Escherichia coli
• Klebsiella
• Pseudomonas
• Salmonella

185

• What is the most common cause of esophageal
  perforation?

• Iatrogenic

186

• A 25-year-old woman presents with fever and
  diffuse, desquamating macular erythematous rash.
  She complains of vomiting, diarrhea, myalgias and
  a sore throat. Pharyngeal exam shows diffuse
  hyperemia. Her vital signs are BP, 90/70 P,
  120 R, 24, and T 40C. Which of the following is
  the most likely cause?
• Erythema multiforme
• Kawasaki's disease
• Scalded skin syndrome
• Toxic shock syndrome

187
Toxic Shock Syndrome

• Etiology associated with S aureus (either
  infection or colonization), associated with
  exotoxin production, TSST-1
• Affected patients
• Menstruating females
• Post-partum females
• Other foreign bodies
• Post-influenza
• Post-surgical

188
Toxic Shock Syndrome

• CDC criteria for the diagnosis of TSS
• Temperature gt38.9 C.
• Erythematous macular rash with later
  desquamation, particularly of palms and soles
• Hypotension
• Negative blood, urine, etc. cultures
• Negative tests for RMSF, leptospirosis, measles,
  Hepatitis B, mononucleosis, VDRL

189
Toxic Shock Syndrome

• Involves at least 3 of the following organ
  systems
• GI (vomiting, diarrhea)
• Muscular (myalgias, elevated CPK)
• Renal (pyuria, elevated BUN, creatinine)
• Hepatic (elevation bilirubin, SGOT, SGPT)
• Hematologic (thrombocytopenia)
• CNS (altered mental status)
• Mucosal inflammation (vaginal, conjunctival,
  pharyngeal)

190

• Most common cause of septic arthritis in
  teenagers and young adults

• GC

191

• Ptosis of the upper eyelid, slight elevation
  of the lower lid, constriction of the pupil and
  facial anhidrosis all on the ipsilateral side
  following penetration injury to the neck suggests
  trauma to what anatomical structure?
• A. Brachial plexus
• B. Lateral spinal cord
• C. Phrenic nerve
• D. Stellate ganglion
• E. Vertebral artery

192

• A 26-year-old man presents with a history of
  fever, headache and rash. The rash began on the
  right wrist and progressed to involve all
  extremities. Patient is ill appearing and
  physical exam reveals a palpable spleen.

193

• Which of the following is the most likely
  diagnosis?
• Lyme disease
• Meningoccemia
• Mononucleosis
• Rocky Mountain spotted fever
• Rubella

194
RMSF

• Etiology Rickettsia rickettsi
• Most common Rickettsial infection in the US
• lt5 occur in Rocky Mountains gt50 occur in south
  Atlantic States
• Abrupt onset of fever, chills, headache, extreme
  muscle tenderness (gastrocnemius), photophobia,
  conjunctival infection, 25 of patients have
  pulmonary symptoms (Coryza, Dyspnea), rash
  (absent in 5-15 of cases)

195
RMSF

• Diagnostic Tests
• Fluorescent antibody methods of rickettsial
  identification on biopsy
• Serologic tests
• Clinical diagnosis and treatment, pending test
  results
• Treatment doxycycline or tetracycline for 5-7
  days
• Alternate Chloramphenicol

196

• The classic symptoms of aortic stenosis are

• Dyspnea on exertion
• Angina
• Exertional syncope

The most common cause of aortic stenosis in
patientsgt65 years old is

• Calcific degeneration of the valve cusp

197

• What are the most frequent causes of
  hypercalcemia?

• Malignancies
• Hyperparathyroidism

What is the second leading cause of death in US?

• Malignancies

198

• A 6-year-old girl is brought to the emergency
  department at midnight complaining of rectal
  itching. What is the definitive management for
  this patient?
• Draw CBC looking for eosinophilia
• Obtain stool for culture, gram stain, ova and
  parasites
• Oral mebendazole or pyrantel pamoate
• Oral metronidazole 15 mg/kg/day TID for ten days

The End