BOARD REVIEW QUESTIONS
February 2016 | Volume 16 Issue 2
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 65-year old obese male with a history of diabetes, stable angina, and COPD presents to the ER with right arm pain after a mechanical fall. X-ray shows an anterior shoulder dislocation. The patient is unable to tolerate reduction without anesthesia and given his risk factors, the decision is made to perform an interscalene brachial plexus block. Which of the following is the most common feared complication from this procedure? 1. 2. 3. 4.
Hematoma formation Permanent loss of motor or sensory function Unilateral phrenic nerve paralysis Vascular injury
Question #2 A 55-year old male with a history of congestive heart failure presents to the ER with shortness of breath. Vital signs are: HR 115, BP 205/115, RR 30, O2 sat 91% on room air. Physical exam reveals a diaphoretic male in moderate distress with crackles on ausculatation of the bilateral lung fields. According to this month’s EMRAP segment, which of the following interventions is NOT indicated for the acute management of this patient’s condition? 1. 2. 3. 4.
ACE inhibitor Furosemide (Lasix) Nitroglycerin Positive pressure ventilation
Question #3 A 65-year old female with a history of congestive heart failure presents to the ER with shortness of breath. Vital signs are: HR 105, BP 205/105, RR 32, O2 sat 88% on room air. Physical exam reveals bilateral crackles. The patient is started on nitroglycerin at 200 mcg/min. Repeat vitals are: HR 100, BP 170/100, RR 26, O2 sat 92%. Which of the following additional agents is most likely to help this patient? 1. 2. 3. 4.
Captopril Diltiazem Esmolol Metoprolol
Question #4 According to this month’s EMRAP segment, which of the following is an advantage of using a bougie for intubation? 1. 2. 3. 4.
Bougies allow for intubation without visualization of the cords Bougies can be used with intubating LMA’s as well as with video laryngoscopy Using a bougie allows confirmation of position by feeling the tracheal rings All of the above are correct
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BOARD REVIEW QUESTIONS
Question #5 A 65-year old male with a history of hypertension presents to the ER with palpitations for four hours. He denies chest pain, shortness of breath, or any other associated symptoms. Vital signs are: HR 115, RR 18, BP 145/90, O2 sat 98%. EKG shows atrial fibrillation. Electrolytes and TSH levels are normal. The patient has no prior history of atrial fibrillation. According to this segment, which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Electrical cardioversion Procainamide Rate control with a calcium channel blocker Rate control with a beta blocker
Question #6 A 72-year old female with a history of hypertension presents to the ER with palpitations for 12 hours. She is found to be in new onset atrial fibrillation and successfully cardioverted with resolution of her symptoms. According to this month’s EMRAP segment with Cameron Berg MD, which of the following is the most appropriate disposition for this patient? 1. 2. 3. 4.
Admission for monitoring Discharge Discharge with anticoagulation Observation in the emergency department for 24 hours
Question #7 A 65-year old female with a history of CHF with an ejection fraction of 20% presents to the ER with palpitations for 3 days. Vital signs are: HR 125, RR 20, BP 145/90, O2 sat 98%. EKG shows atrial fibrillation with a rapid ventricular response. Which of the following medications is contraindicated for this patient? 1. 2. 3. 4.
Diltiazem Digoxin Metoprolol Labetolol
Question #8 A 65- year old female with a history of paroxysmal atrial fibrillation presents to the ER with 3 days of palpations. ECG shows atrial fibrillation with a rate of 125. She takes Coumadin and her INR today is 3. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Electrical cardioversion Procainamide Rate control with a calcium channel blocker Rate control with a beta blocker
Question #9 According to this month’s EMRAP segment with Michelle Lin and Robert Rodriguez, which of the following is the risk of developing cancer in a female patient following a chest CT scan? 1. 1/50 2. 1/300 3. 1/1,000 4. 1/10,000
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Question #10 A 33-year old female with a history of schizophrenia and polysubstance abuse is brought in to the Emergency Department for agitation. On arrival she is yelling obscenities and attempting to attack staff. Which of the following is the feared complication of using droperidol in this patient? 1. 2. 3. 4.
Hypokalemia Hyperkalemia QT prolongation Widened QRS
Question #11 According to this month’s Paper Chase discussing the Annals of Emergency Medicine paper “Intravenous subdissociative-dose ketamine versus morphine for analgesia in the emergency department: a randomized controlled trial,” which of the following is true regarding ketamine for analgesia? 1. 2. 3. 4.
Ketamine was equally effective to morphine and had less minor adverse effects Ketamine was equally effective to morphine but had more minor adverse effects Ketamine was inferior to morphine and had more minor adverse effects Ketamine was inferior to morphine but had less minor adverse effects
Question #12 According to this month’s Paper Chase discussing cutaneous abscesses, which of the following is true of irrigation after incision and drainage? 1. Irrigation after incision and drainage was associated with lower rates of treatment failure 2. Irrigation after incision and drainage was associated with higher rates of treatment failure 3. Irrigation after incision and drainage had no effect on the rates of treatment failure Question #13 A 75-year old female with diabetes and hypertension presents to the Emergency Department with wrist pain after a fall. Xray reveals a distal radius fracture. According to this month’s EMRAP segment with Bryan Hayes, when discharging with analgesia, which of the following medications is least likely to increase this patient’s chance of stroke or MI? 1. 2. 3. 4.
Celecoxib Ibuprofen Ketorolac (Toradol) Naprosyn (Naproxen)
Question #14 A 17-year old female with a history of depression presents to the Emergency Department after an intentional suicide attempt. Parents witnessed the child ingest a bottle of Tylenol 60 minutes prior to arrival. However, they are unsure how many pills were in the bottle. A serum acetaminophen level drawn on arrival is undetectable. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Activated charcoal N-acetylcysteine Repeat acetaminophen level at 4 hours No further testing or intervention
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BOARD REVIEW QUESTIONS
Question #15 A 25-year old male is brought in by police for suicidal ideation. He reports attempting to overdose on Tylenol 2 hours prior to presentation. Serum acetaminophen levels drawn on presentation reveal a level of 50 ug/ml. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Activated charcoal N-acetylcysteine Repeat acetaminophen level at 4 hours No further testing or intervention
Question #16 A 5-year old female presents to the Emergency Department with inability to ambulate. Vital signs are: HR 145, RR 20, BP 100/90, T 102.2ºF (39ºC). Physical exam reveals a child who has significant pain with range of motion of her left hip and refuses to bear weight. Labs are remarkable for a WBC count of 15,000 cells/mm3 and an ESR of 60mm/h. According to the Kocher criteria, which of the following represents the likelihood that this patient has septic arthritis? 1. 35% 2. 55.90% 3. 87.30% 4. 99.60% Question #17 A 4-year old male presents to the ER with hip pain and fever. A bedside ultrasound is performed showing a hip effusion. According to this month’s EMRAP segment, which of the following effusion measurements is the cutoff above which the diagnosis of septic arthritis is likely? 1. 2. 3. 4.
0.5 mm 1 mm 2 mm 3 mm
Question #18 A 55-year old male is brought in by EMS for a gunshot wound to the face. On arrival, the patient has a single gunshot wound to the right cheek. He has a GCS of 15 and is moving all extremities without deficit. According to this month’s EMRAP segment with Chris Colwell, which of the following is true regarding spinal immobilization of this patient? 1. 2. 3. 4.
Immobilization is harmful, and doubles the mortality rate Immobilization is required for this patient Immobilization improves morbidity but not mortality Immobilization improves both morbidity and mortality
Question #19 A 25-year old male is brought in to the ER after an injury at his machine shop. The patient’s glove was caught in a machine causing his hand to be in. The patient arrives with a deep wrist laceration with pulsatile bleeding. According to this month’s EMRAP segment, which of the following is the recommended time in which the tourniquet can remain in place? 1. 2. 3. 4.
30-60 min 1-2 hours 3-4 hours 5-6 hours
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Question #20 A 45-year old male is brought in to the ER in cardiac arrest. CPR and ACLS are immediately started. Initial rhythm is asystole. The patient is given several rounds of epinephrine, bicarbonate, and calcium chloride. After 20 minutes, a rhythm check confirms persistent asystole. End-tidal CO2 however is 33. Which of the following reflects this patient’s chance of neurologically intact survival? 1. Less than 1% 2. 2% 3. 5% 4. 12%
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