BOARD REVIEW QUESTIONS
April 2017 | Volume 17 Issue 4
Challenging ABEM style questions for enhanced learning and deeper understanding of the EMRAP program
www.emrap.org
Editor-in-Chief: Mel Herbert, MD Executive Editor: Stuart Swadron, MD Associate Editor: Dan Joseph, MD
Question #1 A 55-year old male with a history of diabetes presents to the Emergency Department with sudden onset abdominal pain, nausea, and vomiting. The patient’s surgical history is significant for a roux-en-y gastric bypass one year ago after which he lost 90 lbs. Vital signs are: HR 120, RR 20, BP 100/60, T 98.6ºF (37ºC). Physical exam reveals diffuse tenderness and guarding throughout all four quadrants of the abdomen. Which of the following is the most likely diagnosis? 1. 2. 3. 4.
Cecal volvulus Closed loop bowel obstruction Mesenteric ischemia Sigmoid Volvulus
Question #2 A 27-year old male presents with a thigh laceration after tripping while climbing a fence. Physical exam shows a 6 cm laceration to the anterior thigh. According to the recent study by Kappel et al, which of the following is true of wound edge eversion during repair? 1. 2. 3. 4.
Wound edge eversion improves cosmetic outcome Wound edge eversion increases likelihood of dehiscence Wound edge eversion increases likelihood of infection Wound edge eversion decreases wound tension
Question #3 A 33-year old male with a history of panic disorder presents to the ER with shortness of breath. Physical exam reveals a male in significant distress with audible stridor. Bedside rhinoscopy reveals vocal cords held in adduction throughout the patient’s respiratory cycle but no obvious edema or foreign body. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Nasotracheal intubation Oropharyngeal intubation Ketamine induction Racemic epinephrine
Question #4 A 17-year old male presents to the Emergency Department with chest pain and shortness of breath that occurred spontaneously 20 minutes prior. Physical exam is remarkable for diminished breath sounds on the right side and chest radiograph confirms a moderate pneumothorax. Which of the following is true regarding Heimlich valve placement in this patient? 1. 2. 3. 4.
Heimlich valve placement is associated with more frequent complications than open thoracostomy Heimlich valve placement is associated with more severe complications than open thoracostomy Heimlich valve placement is contraindicated due to the patient’s age Heimlich valve placement is contraindicated in simple pneumothoraces
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BOARD REVIEW QUESTIONS
Question #5 Which of the following is considered massive transfusion? 1. 2. 3. 4.
Transfusion of 5 units or more of PRBCs Transfusion of 10 units or more of PRBCs Replacement of greater than one blood volume in 24 hours Replacement of greater than 50% of blood volume in 12 hours
Question #6 A 27-year old male is brought into the Emergency Department by EMS after being pinned by a forklift against a wall. Vital signs are: HR 130, BP 80/palp, O2 sat 98%. The patient endorses pain at his hips only and physical exam reveals an unstable pelvis. While waiting for the trauma surgeon to drive in, the patient is given 2 units of packed red blood cells, 2 units of fresh frozen plasma, and 1 pack of platelets. Repeat blood pressure is 76/ palp. Labs are remarkable for a fibrinogen of 100. In addition to continued resuscitation, which of the following should be administered next? 1. 2. 3. 4.
Cryoprecipitate Desmopressin Platelets Prothrombin Complex Concentrate
Question #7 Which of the following is the appropriate ratio of packed red blood cells to platelets to fresh frozen plasma during massive transfusion? 1. 1:1:1 2. 1:1:2 3. 1:1:4 4. 1:2:2 Question #8 Which of the following patients should receive tranexamic acid (TXA)? 1. A 25-year old male with a stab wound who requires transfusion 30 minutes after his initial injury 2. A 33-year old female with a large splenic laceration who requires transfusion 4 hours after her initial injury 3. An 85 year old male with multiple long bone fractures as well as a liver laceration who is 5 hours into his hospital stay and has required 10 units of packed red blood cells 4. None of the above patients should receive TXA Question #9 A 65-year old male with a history of congestive heart failure on digoxin is brought in by his family for nausea and vomiting. Vital signs are: HR 45, RR 20, BP 102/74, O2 sat 94%, Temp 98.6ºF (37ºC). ECG shows a sinus bradycardia with downward-sloping ST segments but no ST elevations. Frequent premature ventricular contractions are also noted. Laboratory analysis is remarkable for a serum potassium of 5.8 meq/L. Digoxin level is 12 ng/mL. In addition to considering Digibind (anti-digoxin antibodies), which of the following is most likely to improve this patient’s condition? 1. 2. 3. 4.
Activated charcoal Broad spectrum antibiotics Dialysis IV fluids
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BOARD REVIEW QUESTIONS
Question #10 Which of the following interventions has been shown to reduce the incidence of post-lumbar puncture headaches? 1. 2. 3. 4.
Blunt tipped spinal needles Caffeine intake before the procedure IV fluids Topical lidocaine
Question #11 Which of the following is associated with increased lactic acid levels? 1. Acetaminophen 2. Albuterol 3. Carbon Monoxide 4. Glipizide Question #12 According to this month’s Paper Chase segment discussing the article by Ferguson et al, which of the following is true of combining propofol and ketamine (ketofol) in comparison to propofol alone? 1. 2. 3. 4.
Ketofol was associated with decreased respiratory depression Ketofol was associated with improved patient satisfaction Ketofol was associated with increased success rates None of the above are true
Question #13 A 75-year old female presents to the Emergency Department with cough and shortness of breath. Vital signs are: HR 115, RR 40, BP 96/66, T 102.2ºF (39ºC), and O2 sat 88%. Physical exam reveals rhonchi throughout the right lung and chest radiograph confirms a lobar pneumonia. According to this month’s EMRAP segment, which of the following should be the goal oxygen saturation when titrating this patient’s supplemental O2? 1. 2. 3. 4.
94-98% 98-99% 100% There is no difference between the above therapies
Question #14 According to the recent Academic Emergency Medicine article by Helland et al, which of the following is the most accurate way to diagnose pneumothorax by ultrasound? 1. Four views of each hemithorax 2. Two views of each hemithorax 3. Single view at the highest point on the chest wall Question #15 According to Pottecher et al’s recent article in the Journal of Trauma, which of the following prehospital vital signs is sufficiently sensitive to predict the need for massive transfusion? 1. 2. 3. 4.
Prehospital shock index Pulse pressure/heart rate ratio Systolic blood pressure None of the above
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BOARD REVIEW QUESTIONS
Question #16 A 3-year old female is brought into the Emergency Department after swallowing a coin. The father witnessed the incident, but the child has remained asymptomatic. Chest radiograph shows the coin in the distal esophagus. The child has no coughing, no stridor, and is tolerating liquids by mouth. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Emergent endoscopy Ipecac administration Observation for 12-24 hours followed by repeat imaging Surgical consult
Question #17 A 20-year old male with a history of cocaine abuse is brought in by the police for agitation. Vital signs are: HR 140, RR 30, BP 170/106, O2 98%. Physical exam reveals an agitated and diaphoretic male requiring multiple officers to restrain him. Which of the following agents is the most appropriate initial agent to administer intramuscularly? 1. 2. 3. 4.
Diazepam Haloperidol Lorazepam Midazolam
Question #18 According to this month’s mailbag segment with Rob Orman and Anand Swaminathan, which of the following patients is most appropriate for an “easy IJ” (cannulating the IJ with a long peripheral IV)? 1. A 23-year old male with sickle cell disease in a pain crisis who requires basic labs, pain medicine, and IV hydration 2. A 33-year old male with a positive FAST exam after a motor vehicle accident 3. A 45-year old male with a GI bleed 4. A 70-year old female who is hypotensive and febrile
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