BOARD REVIEW QUESTIONS
July 2017 | Volume 17 Issue 7
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 66-year old female is brought into the Emergency Department for shortness of breath. Vital signs are: HR 120, RR 44, BP 88/62, T 102.2ºF (39ºC), O2 86% on room air. Physical exam reveals an ill-appearing female in moderate distress and the decision is made to intubate. According to this month’s EMRAP, which of the following is the most effective method of pre-oxygenation? 1. Face mask at 15L per minute 2. Flush-flow rate of oxygenation via non-rebreather 3. Nasal cannula at 15L per minute 4. Non-rebreather mask at 15L per minute Question #2 According to this month’s EMRAP segment with Jonathan Kantor, which of the following wound repair techniques is NOT recommended for definitive wound closure? 1. Running subcuticular 2. Simple interrupted 3. Staples 4. Vertical mattress Question #3 A 45-year old male is brought into the Emergency Department after a motorcycle crash. Vital signs are: HR 46, RR 16 and irregular, BP 176/92, O2 saturation 93% on face mask O2. Physical exam reveals a male with altered mental status (GCS 5) and a large scalp hematoma. Which of the following is true of the use of lidocaine as a pretreatment for rapid sequence intubation in this patient? 1. 2. 3. 4.
Lidocaine will prevent a reflex bradycardia Lidocaine will prevent a rise in intracranial pressure Lidocaine is associated with improved neurologic outcome Lidocaine is unlikely to have any meaningful effect
Question #4 Which of the following medications has been shown to decrease the hemodynamic response to laryngoscopy? 1. 2. 3. 4.
Esmolol Lidocaine Succinylcholine Vecuronium
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Question #5 According to the recent Annals of Emergency Medicine article by Talan et al. cited in this month’s EMRAP segment, which of the following was seen when using an antibiotics only (vs. surgery) strategy for the treatment of uncomplicated appendicitis? 1. 2. 3. 4.
Antibiotic only treatment was associated with more complications Antibiotic only treatment patients experienced more pain Antibiotic only treatment patients had longer overall hospital courses Antibiotic only treatment patients had better quality of life outcomes
Question #6 Which of the following is the ceiling dose of ibuprofen for treating pain? 1. 2. 3. 4.
400 mg 600 mg 800 mg 1g
Question #7 According to the most recent Cochrane review evaluating pain control with over-the-counter (OTC) medications, which of the following was most effective? 1. 2. 3. 4.
200 mg of ibuprofen and 100 mg caffeine 500 mg acetaminophen 500 mg of aspirin Combination treatment with 1000 mg acetaminophen and 400 mg ibuprofen
Question #8 Which of the following is a contraindication to ketorolac? 1. 2. 3. 4.
Chronic kidney disease History of peptic ulcer disease Malignancy Renal calculi
Question #9 A 5-year old female presents to the Emergency Department with elbow pain after falling off the monkey bars. Physical exam reveals pain to palpation over the medial and lateral aspect of the elbow. The skin is intact and neurovascular exam is normal. An x-ray is shown below. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Analgesia, sedation and reduction in the ED Discharge with reassurance and return precautions Emergent orthopedic consultation Splint and outpatient referral to orthopedics
Image source: Korompilias A. Treatment of pink pulseless hand following supracondylar fractures of the humerus in children, International Orthopaedics 33(1):237-41. April 2008
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Question #10 A 55-year old male presents to the ED with chest pain. Vital signs are: HR 110, RR 20, BP 166/96, O2 98%. There is no jugular venous distention and the chest is clear to auscultation. ECG shows ST elevations in leads II, III, and aVF. A right sided ECG does not show ST segment elevations in V3R-V6R. Which of the following medications are contraindicated for this patient? 1. Aspirin 2. Metoprolol 3. Nitroglycerin 4. None of the above Question #11 A 5-year old female is brought to the ER for a rash that developed 5 days after starting amoxicillin for otitis media. She is otherwise asymptomatic with normal vitals and an unremarkable physical exam. What is the likely cause of this rash? 1. 2. 3. 4.
Allergic reaction Delayed cutaneous reaction Toxic shock syndrome Viral exanthem
Question #12 A 55-year old male presents to the Emergency Department because his glucometer read “critically high.” He has no symptoms and has otherwise been well. Exam is normal. He does say that he ran out of his metformin 2 weeks prior to presentation. After receiving 1 liter of normal saline given in triage, laboratory analysis is remarkable for a blood glucose of 400 mg/dl (22.2 mmol/L). Urinalysis is negative for ketones. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Additional fluid bolus Discharge home Insulin bolus and drip Subcutaneous insulin
Question #13 According to the article cited in this month’s EMRAP segment by Umpierrez et al, which of the following is true of managing mild diabetic ketoacidosis (pH 7.3, anion gap 21, K 4.9 mEq/L)? 1. 2. 3. 4.
Fluids alone should be used Insulin drip alone should be initiated Subcutaneous insulin should be initiated IV or subcutaneous insulin are equally effective
Question #14 Which of the following is the primary mechanism for gabapentin’s abuse potential? 1. 2. 3. 4.
Potentiation of opiate effects Stimulation of GABA receptors Potentiation of D2 receptors Stimulation of 5-HT receptors
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Question #15 A 5-year old male is brought to the Emergency Department after being struck by an automobile. Vital signs are: HR 160, RR 26, BP 78/42, O2 98%. Physical exam reveals an alert male with diffuse abdominal pain. The FAST exam is positive for intraperitoneal fluid. In addition to emergent surgical consultation, which of the following is the most appropriate initial intervention? 1. 2. 3. 4.
10 cc/kg lactated ringer solution 10 cc/kg packed red blood cells 15 mg/kg tranexamic acid 20 cc/kg normal saline
Question #16 According to this month’s EMRAP segment, which of the following patients is at highest risk of DVT formation? 1. 2. 3. 4.
A 33-year old female with a bulky Jones splint for a calcaneal fracture A 40-year old female with an Achilles tendon rupture casted in plantar-flexion A 50-year old male with a bimalleolar ankle fracture in a short leg cast A 55-year old female with a Lisfranc fracture and a short leg cast
Question #17 A 25-year old male presents to the Emergency Department after an intentional overdose of malathion in a suicide attempt several minutes prior to presentation. He appears anxious but is otherwise asymptomatic. Vital signs are: HR 105, RR 20, BP 140/82, O2 saturation 100%. EMS reports they found the empty container of a pesticide on scene. Which of the following is the most appropriate initial intervention? 1. 2. 3. 4.
Activated charcoal Atropine Lorazepam Nasogastric tube insertion and gastric decontamination
Question #18 A 17-year old male is brought to the ED in cardiac arrest. He was found by police huffing in the bathroom. He suddenly lost consciousness shortly after their arrival. On EMS arrival, the patient had an initial rhythm of pulseless ventricular tachycardia. He received 2 rounds of epinephrine and defibrillation was attempted twice without return of spontaneous circulation. On arrival to the ED the patient remains in pulseless ventricular tachycardia. Which of the following is the most appropriate next step in management? 1. 2. 3. 4.
Amiodarone Esmolol Lidocaine Procainamide
Question #19 According to the recent New England Journal of Medicine by Hoberman et al (2016) article on otitis media, which of the following is correct regarding antibiotic course for treatment? 1. 2. 3. 4.
5 days of amoxicillin-clavulanate had less side effects and equivalent efficacy 10 days of amoxicillin-clavulanate was associated with a greater incidence of diarrhea 10 days of amoxicillin-clavulanate was associated with improved treatment outcome No significant difference was found
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Question #20 According to the recent Upchurch et al article in Annals of Emergency Medicine comparing etomidate and ketamine for induction of trauma patients, which of the following is correct? 1. 2. 3. 4.
Etomidate was associated with improved first pass success rate Etomidate was associated with increased likelihood of laryngospasm Ketamine was associated with decreased ICU length of stay Ketamine was associated with a 3% increased absolute mortality rate
Question #21 According to this month’s Paper Chase segment evaluating the study by Gaspari et al in Resuscitation, what percentage of patients with an initial rhythm of PEA or asystole that achieved ROSC had cardiac activity on initial ultrasound? 1. 2. 3. 4.
5% 27% 51% 77%
Question #22 A 13-year old male is brought to the ED after a football injury. He was struck by another player in a head-on collision and lost consciousness for 30 seconds. On arrival to the ED the patient is awake and alert with a normal neurologic exam. He is observed for 6 hours without progression of headache, nausea, or vomiting and the diagnosis of concussion is made. According to the recent Grool et al article in JAMA, when should this patient return to light activity? 1. 2. 3. 4.
24-48 hours 72 hours 7 days As soon as asymptomatic
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