Intern Year: Peer Viii Part 2 & Critical

Front 1

Which of the following statements regarding complications of anterior shoulder dislocations and reductions is correct?

A
Avulsion fracture of the greater tuberosity of the humerus occurs in 10% to 15% of dislocations B
Axillary nerve injury is assessed by testing sensation in the axilla C
Bankart fracture is a compression fracture of the posterolateral humeral head D
Hill-Sachs deformity refers to a fracture of the anterior glenoid rim

Back 1

Avulsion fracture of the greater tuberosity of the humerus occurs in 10% to 15% of dislocations

Associated fractures are also common, occurring in 25% to 40% of cases. Avulsion fractures of the greater tuberosity of the humerus can be seen on plain radiographs obtained in patients with shoulder dislocations 10% to 15% of the time. The most common fracture seen with anterior shoulder dislocations is a Hill-Sachs deformity, which is a compression fracture of the posterolateral humeral head, and this can occur in 40% of cases. A Bankart fracture is a fracture of the anterior glenoid rim, which occurs in approximately 5% of cases

Front 2

Which of the following statements regarding closure of scalp lacerations is correct?

A
Blindly clamping a vessel is the best way to gain control of active bleeding B
Complications of scalp wound infection include osteomyelitis and brain abscess C
Hair should be shaved prior to suturing or stapling a scalp wound D
Hair should not be washed for 24 to 48 hours after wound closure

Back 2

Complications of scalp wound infection include osteomyelitis and brain abscess

When scalp lacerations involve the galea aponeurotica, bacteria can penetrate the layer of loose connective tissue beneath it, gaining access to the venous sinuses of the brain

Front 3

Laboratory and clinical findings of joint fluid infection include significant leukocytosis (___
?___cL); glucose ________

Back 3

>15,000/m

lower than 40 mg/dL of serum glucose

Front 4

When performing an emergency department thoracotomy, after the incision has been made and the pleural cavity has been entered, in the presence of cardiac arrest and with no obvious injury on entry, what should be accomplished first?

A
Begin direct cardiac compressions B
Clamp the aorta C
Open the pericardium D
Pass a nasogastric tube to help distinguish the aorta from the esophagus

Back 4

Open the pericardium

Front 5

Which of the following statements regarding the use of procedural sedation agents is correct?

A
Hypertension is a common side effect of the rapid administration of sedative agents B
Propofol is generally considered unsafe for use in the emergency department C
Using two drugs increases the risk of side effects that are seen with each drug individually D
When both a benzodiazepine and a narcotic agent are used, the benzodiazepine should be given first and the opioid dose titrated

Back 5

Using two drugs increases the risk of side effects that are seen with each drug individually

This effect is greater when the opioid is given with a benzodiazepine. Because the opioid has the greater potential to cause respiratory depression, the suggested method is to administer narcotics first and titrate benzodiazepines.

Front 6

In which of the following presentations would succinylcholine administration for rapid sequence intubation be the safest?

A
Hemiplegia from a stroke 1 month earlier
B
Major injuries from a burn 1 week earlier
C
Peaked T waves on ECG
D
Renal failure with serum potassium 4.2 mEq/L

Back 6

Renal failure with serum potassium 4.2 mEq/L

Renal failure alone does not predispose to an exaggerated hyperkalemic response; if serum potassium is normal, succinylcholine can be used safely.

With certain myopathies and denervation problems, there can be an exaggerated, potentially life-threatening hyperkalemic response. With crush injury, major burn injury, stroke, and spine injury, the predisposition to hyperkalemia from succinylcholine does not occur for approximately 5 days; it resolves when the injury heals or, with stroke or spine injury, in about 6 months

Front 7

Placement of a magnet over an automated implantable cardioverter-defibrillator, or AICD:

A
Causes the internal defibrillator of the AICD to fire automatically B
Causes the same response regardless of manufacturer, model, and mode of operation C
Should be the first response in a patient with an AICD who presents in ventricular fibrillation D
Temporarily stops the AICD response to a tachydysrhythmia

Back 7

Temporarily stops the AICD response to a tachydysrhythmia

When a magnet is applied over an AICD, it temporarily turns off the defibrillation action; thus, the AICD will not respond to a tachydysrhythmia and will not fire the defibrillator. When a magnet is placed over a pacemaker or AICD, the pacing function is not disabled; rather, the pacer reverts to an established rate and mode of operation.

Front 8

Which of the following statements regarding the removal of a rust ring from the cornea is correct?

A
Iron oxidation over 1 to 2 days kills surrounding epithelial cells and allows the ring to be removed in one piece B
Ring does not form for 12 to 24 hours following the deposition of a metallic corneal foreign body C
Rotating burrs cause significant corneal injury and should not be used in the emergency department D
Size of the ring has minimal impact on corneal healing

Back 8

Iron oxidation over 1 to 2 days kills surrounding epithelial cells and allows the ring to be removed in one piece

The preferred method of removal in the emergency department is with a rotating drill device. This can be done safely by the emergency physician. If the preferred burr or commercial eye spud is unavailable, a 25-gauge needle on a 1- to 3-mL syringe as a handle is recommended in several emergency medicine texts. When using a needle for foreign body or rust ring removal, the needle should be held parallel to the surface of the cornea to avoid puncturing the cornea.

Front 9

Which of the following wounds can be appropriately managed with primary closure at the time of emergency department presentation?

A
Deep laceration to the bottom of the foot B
Dog bite to the face C
Heavily contaminated wound D
Human bite wound to the palm

Back 9

Dog bite to the face

Certain wounds are almost never managed with primary closure, including wounds with heavy contamination from soil, organic matter, feces, or freshwater streams or lakes and wounds involving heavy tissue damage. Additional exclusions are large stellate lacerations to the foot and human and dog bite wounds on the hand. Human bite wounds should never be closed and are typically extended for exploration and debridement

Front 10

Which of the following components of a professional liability lawsuit must be proved in order for the plaintiff to prevail?

A
Any causation B
Breach of duty C
Ethical misconduct D
Negligence that could have led to injury or harm

Back 10

Breach of duty

In a professional liability action against an emergency physician, the plaintiff, in order to prevail, must prove that: • The physician had a duty to provide reasonable care and breached that duty, • Actual injury or harm occurred, and • The physician's actions were the proximate cause.

Front 11

A 16-year-old boy presents with testicular pain of several hours' duration. Examination reveals scrotal edema and exquisite tenderness to the right testis.

Which of the following statements regarding emergency department treatment is correct?

A
Detorsion confirmed by relief of pain and restoration of blood flow on Doppler eliminates the need for surgical exploration B
Even after successful detorsion, the testis is unlikely to return to its normal anatomic position C
If one rotation of 180 degrees does not relieve the pain completely, further efforts at detorsion should be continued by rotating an additional turn D
Testicular torsion occurs in a medial direction in the majority of cases, so detorsion is accomplished by rotating the right testis internally or clockwise

Back 11

If one rotation of 180 degrees does not relieve the pain completely, further efforts at detorsion should be continued by rotating an additional turn

Front 12

Which of the following statements regarding epistaxis and control of bleeding is correct?

Blood seen exiting the nasolacrimal duct outside the eye following packing is an indication for immediate removal of packing

Most patients who are successfully treated with a posterior nasal pack may be discharged with followup in 2 to 3 days

Since a direct causal relationship exists between elevated blood pressure and epistaxis, blood pressure control should be accomplished first

The risk of sinusitis with short-term anterior nasal packing is minimal

Back 12

The risk of sinusitis with short-term anterior nasal packing is minimal

Front 13

Which of the following courses of illness is consistent with plague?

Conjunctivitis with skin blisters progressing to full-thickness burns, hemorrhagic pulmonary necrosis, bone marrow suppression, and death from secondary infection

Flulike illness with malaise, fever, and cough progressing to shock, dyspnea, stridor, and hemorrhagic meningitis

Rhinorrhea and miosis followed by increased secretions, dyspnea, and muscle fasciculations progressing to apnea, seizures, flaccid paralysis, and death

Sudden onset of fever, malaise, and cough followed by fulminant pneumonia, hemoptysis, respiratory failure, disseminated intravascular coagulation, circulatory collapse, and death within 24 hours

Back 13

Sudden onset of fever, malaise, and cough followed by fulminant pneumonia, hemoptysis, respiratory failure, disseminated intravascular coagulation, circulatory collapse, and death within 24 hours

Typical presenting signs and symptoms of anthrax exposure are flulike illness beginning with malaise, fever, and nonproductive cough with progression to sepsis, shock, hemorrhagic mediastinitis, dyspnea, stridor, and hemorrhagic meningitis. Chest radiographs classically show enlarged hilar nodes

Front 14

Regarding a diagnostic test with a reported specificity of 50% and a sensitivity of 93%, which of the following statements is correct?

A
It could be helpful in identifying a rare condition B
It will have few false-negative results C
The overall accuracy is dependent on the disease prevalence D
The results make no change in the post-test probability of disease

Back 14

It will have few false-negative results

The mnemonic "SnNout" is useful to describe this: a high sensitivity (Sn), negative (N) result rules out (out) the diagnosis

The mnemonic "SpPin" is a helpful way to describe this: high specificity (Sp), positive result (P), rules in (in) the diagnosis.

. Negative predictive value, or NPV, places sensitivity into the context of disease prevalence; positive predictive value, or PPV, does the same for specificity. The rarer the disease is, the more specific a test must be to be helpful clinically.

Front 15

A child who accidentally ingested her grandmother's glyburide developed hypoglycemia and a depressed level of consciousness that were reversed with the administration of dextrose by prehospital providers.
Which of the following agents should be administered next?

Diazoxide

Glucagon

Octreotide

Somatostatin

****

Back 15

Octreotide

Sulfonylureas such as glyburide cause the release of preformed insulin that can result in life-threatening, recurrent hypoglycemia. In a child, even a single pill can be life threatening. Octreotide is a synthetic somatostatin analogue that can antagonize the release of insulin. It has been demonstrated to decrease the incidence of hypoglycemic episodes in sulfonylurea poisonings and is the favored treatment after dextrose. Somatostatin is very short acting; octreotide, in contrast, was purposely synthesized as a longer-acting analogue

Front 16

What is the goal for urine output in the treatment of rhabdomyolysis with acute renal injury?

A
1 mL/kg/hr B
3 mL/kg/hr C
100 mL/hr D
400 mL/hr

****

Back 16

3 mL/kg/hr

The goal for urine output in rhabdomyolysis with acute renal injury is 3 mL/kg/hr, or about 200 mL/hr

note: If the urine pH is acidic (<6.5), deposition of myoglobin is likely to occur

Front 17

When assessing brainstem function in an unconscious patient using the oculovestibular response using cold water, which of the following indicates an intact cortical response?

A
Eyes deviate away from stimulus B
Eyes deviate away from stimulus, followed by nystagmus and return to midline C
Eyes deviate toward stimulus D
Eyes deviate toward stimulus, followed by nystagmus and return to midline
***

Back 17

Eyes deviate toward stimulus, followed by nystagmus and return to midline

Front 18

A 35-year-old woman with known myasthenia gravis presents with a fever and right lower quadrant pain. Abdominal CT scanning reveals acute appendicitis. While in the emergency department, she begins to complain of increasing shortness of breath. Vital signs remain stable.
What is the appropriate next step?

Administer pyridostigmine

Measure forced vital capacity

Perform emergent intubation

Perform the ice bag test

***

Back 18

Measure forced vital capacity


The patient in this question is exhibiting symptoms consistent with myasthenic crisis, which occurs in approximately 15% to 20% of patients with myasthenia gravis. She has no acute objective signs of respiratory failure, but her ventilatory status must be evaluated with either a forced vital capacity (FVC) or negative inspiratory force (NIF) measurement

Front 19

A 25-year-old woman presents with increasing motor weakness in her lower extremities for 1 day. Neurologic examination is remarkable for absent deep tendon reflexes at her ankle and knee, as well as grade 3/5 motor strength in her quadriceps and grade 2/5 motor strength in the muscle groups distal to her thigh. She says that she recently had a cold.

Which of the following test results could predict impending respiratory failure and the need for intubation?

A
Forced vital capacity greater than 40 mL/kg B
Negative inspiratory force less than 30 cm H2O C
Pco2 less than 25 mm Hg D
PEFR less than 300 L/min

Back 19

Negative inspiratory force less than 30 cm H2O

Front 20

67-year-old woman presents after three episodes of hematemesis. She denies significant past medical history and is taking only an over-the-counter medication for osteoarthritis. She appears anxious and diaphoretic. During the interview, she vomits 250 mL of bright red blood. Physical examination is notable for blood pressure 79/58, pulse 122, moderate epigastric abdominal tenderness, and bloody stool.
Which of the following is most likely to control the bleeding?

Bedside esophagogastroduodeno- scopy

Nasogastric tube placement with lavage

Omeprazole infusion followed by vasopressin drip

Sengstaken-Blakemore tube

Back 20

Bedside esophagogastroduodeno- scopy

Front 21

A 55-year-old man with a history of hypertension presents with acute shortness of breath and pleuritic chest pain. An ECG shows sinus tachycardia. Computed tomography of the chest is ordered (Figure 48). Following administration of 2 L normal saline, vital signs are blood pressure 90/50, pulse 110, respirations 20, and oxygen saturation 97% on 4 L of oxygen. The image shows a large filling defect in the right main pulmonary artery and a filling defect in a distal branch of the left pulmonary artery.

What are the most appropriate next steps in the management of this patient's condition?

A
Obtain a transthoracic echocardiogram; if there is evidence of right ventricular dysfunction, start unfractionated heparin and thrombolytic therapy B
Start low-molecular-weight heparin; admit the patient for monitoring of clinical status and right ventricular function C
Start thrombolytic therapy and unfractionated heparin; obtain thoracic surgery consultation D
Start unfractionated heparin; obtain a transthoracic echocardiogram and a troponin level; if either is abnormal, start thrombolytic therapy

Back 21

Start thrombolytic therapy and unfractionated heparin; obtain thoracic surgery consultation

Anticoagulation and thrombolytic therapy are indicated in a patient with confirmed PE, a sustained systolic blood pressure of less than 100 mm Hg, and no contraindications to thrombolytic therapy

Front 22

in addition to seizures, what are pre-eclamptic patients at risk for developing

Back 22

ICH

Front 23

A 32-year-old man with diabetes presents with headache and left eye pain. He describes the headache as sharp, isolated to his left midface, and progressively worse over the past 2 days. Four days earlier, he underwent a root canal for a complicated dental abscess.

Which of the following physical examination findings would be most consistent with a serious intracranial complication of a dental abscess?

A
Decreased vision in the left eye with an afferent pupil defect B
Lateral gaze palsy of the left eye C
Left-sided facial paresis D
Left-sided ptosis, miosis, and loss of sweating

Back 23

Lateral gaze palsy of the left eye

This question describes a patient with a cavernous sinus thrombosis (CST) secondary to a dental abscess and a lateral gaze palsy on the ipsilateral side, as the facial pain is an expected finding. Cranial nerves II, III, IV, and VI all run through the cavernous sinus

Front 24

A 42-year-old woman with a history of a hiatal hernia and chronic gastric reflux symptoms presents with sudden-onset left upper quadrant abdominal pain and retching. Vital signs include blood pressure 86/40, pulse 121, temperature 37°C (98.6°F), and oxygen saturation 98% on room air. The upper abdomen is mildly distended, and breath sounds are decreased in the left lower lobe of the lungs. The nurse is unable to pass a nasogastric tube. Laboratory test results include the following: lactate, 8 mg/dL; pH, 7.13; and Hgb, 12 g/dL. Chest radiographs reveal a distended stomach above the diaphragm.
After appropriate fluid resuscitation, which of the following should be initiated in the emergency department?

Broad-spectrum antibiotics

Endoscopy

Packed red blood cells

Sodium bicarbonate

Back 24

Broad-spectrum antibiotics

In a patient who presents with sudden pain after vomiting, a history of hiatal hernia, and signs of shock, along with radiographic findings of a distended stomach above the diaphragm, the diagnosis of a strangulated paraesophageal hernia with subsequent gastric volvulus is likely.

Front 25

For which of the following patients is intravenous thrombolytic therapy for ischemic stroke the appropriate next step?

A
45-year-old man with a history of cirrhosis, symptom onset 120 minutes earlier; platelet count 75,000/mcL, blood pressure 175/90, NIH stroke scale score 24, head CT negative B
45-year-old woman with sudden-onset headache with seizure, symptom onset 90 minutes earlier; blood pressure 160/90, NIH stroke scale score 18, head CT negative C
60-year-old man with a history of hypertension on atenolol, symptom onset 60 minutes earlier; blood pressure 210/170, NIH stroke scale score 15, head CT negative D
60-year-old woman with a history of brain tumor and resection 6 months earlier, symptom onset 90 minutes earlier; blood pressure 175/90, NIH stroke scale score 18, head CT negative

Back 25

60-year-old woman with a history of brain tumor and resection 6 months earlier, symptom onset 90 minutes earlier; blood pressure 175/90, NIH stroke scale score 18, head CT negative

criteria for tPA in acute ischemic stroke are as follows: • Age 18 years and older • Clinical diagnosis of ischemic stroke causing a measureable neurologic deficit • Time of symptom onset well established to be less than 180 minutes before treatment would begin Exclusion criteria are as follows: • Evidence of intracranial hemorrhage on noncontrast head CT • Only minor or rapidly resolving stroke symptoms • High clinical suspicion of subarachnoid hemorrhage even with normal CT findings • Active internal bleeding within the past 21 days • Known bleeding diathesis, including but not limited to: platelet count less than 100,000/mcL; heparin within 48 hours and elevated activated PTT; recent use of anticoagulant and elevated PT greater than 15 seconds or INR greater than 1.7 • Within 3 months of intracranial surgery, serious head trauma, or previous stroke • Within 14 days of major surgery or serious trauma • Recent arterial puncture at noncompressible site • Lumbar puncture within 7 days • History of intracranial hemorrhage, arteriovenous malformation, or aneurysm • Witnessed seizure at stroke onset • Recent acute MI • On repeated measurements, systolic pressure greater than 185 mm Hg or diastolic pressure greater than 110 mm Hg at time of treatment requiring aggressive treatment to reduce blood pressure to within these limits

Front 26

A mother brings in her 6-week-old daughter for evaluation of a cough. Birth history is normal. On physical examination, the baby appears normal, has normal oxygenation, and is breathing comfortably, but within minutes she has a paroxysm of violent coughing with cyanosis that spontaneously resolves within 1 minute.
Which of the following is a recommended treatment for this condition?

Intravenous macrolide

Nebulized albuterol

Parenteral corticosteroids

Subcutaneous epinephrine

Back 26

Intravenous macrolide

) The presentation described in this question is classic for pertussis. Although pertussis is also known as whooping cough because of the loud inspiratory sound made during paroxysms of coughing, young infants do not demonstrate this characteristic feature, probably because they lack the inspiratory strength to generate the sound. Antibiotics have no effect on the course of the illness once paroxysmal coughing begins. Nonetheless, intravenous administration of a macrolide antibiotic such as erythromycin or azithromycin is recommended to minimize spread of the causative agent

Front 27

you have a respiratory alkalosis with metabolic acidosis; how can you distinguish ethylene glycol OD from salycilate from the blood gas alone?

Back 27

It is rare to see compensation in salycilate poisoning

so if your pH is 7.23, and your CO2 is 23 and your HCO3 is 10 this would demonstrate adequate compensation (the last two numbers of pH=CO2)