Board Review Questions in Emergency Medicine

Resident & Staff Physician®, May 2005, Volume 0, Issue 0

Eric T. Carter, MD

1. All the following criteria support the diagnosis of Kawasaki's disease, except:

A. Platelet count >1000 x 103/?L

C. Cervical lymphadenopathy

E. Bilateral conjunctival injection

2. Charcoal therapy is indicated for the acute overdose ingestion of all the following medications, except:

A. TheophyllineB. A tricyclic antidepressant

D. Aspirin

3. An 18-year-old male surfer presents with a jellyfish sting. All the following are acceptable for rinsing and will not cause nematocyst firing, except:

A. Acetic acid solutionB. Isopropyl alcohol

D. Baking soda solution

4. A 58-year-old woman is brought to the emergency department by emergency medical services with a chief complaint of weakness and fluid retention. She has a history of renal failure but is on vacation and has not had dialysis in 5 days. Her electrocardiogram (ECG) reveals prominent T waves and interventricular conduction delay. Which therapy does NOT directly affect the potassium level?

A. Hemodialysis

C. Glucose and insulin

E. Nebulized albuterol (AccuNeb, Proventil)

5. A 60-year-old man with a history of alcohol abuse is brought to the emergency department by emergency medical services with a decreased level of consciousness. He was found in the city park and appeared to be intoxicated but has since become more obtunded. Appropriate resuscitation has been initiated. His laboratory test results are remarkable only for 3+ urine ketones and the presence of serum acetone. What is the likely cause of his mental status?

A. MethanolB. Ethanol

D. Isopropanol

6. A 23-year-old intravenous (IV) drug user presents to the emergency department with a chief complaint of fever. The patient has a presumably new heart murmur and could be expected to have any of the following findings on physical examination, except:

A. Roth's spotsB. Cotton-wool spots

D. Osler nodes

7. In the Salter-Harris classification of fractures, which class is characterized by a fracture that extends along the physis and into the metaphysis?

A. Salter IB. Salter II

D. Salter IV

8. A posteriorly displaced supracondylar fracture of the humerus may result in injury to which nerve?

A. Radial

C. Ulnar

9. A 36-year-old tall, thin man presents to the emergency department after developing intense chest pain that initially radiated to his back and has now extended into his midback. His heart rate is 110 beats/min, and his blood pressure (BP) is 175/95 mm Hg. Which of the following interventions is/are indicated?

A. Nitroprusside sodium (Nitropress) for BP controlB. Labetalol HCl (Trandate) for BP and heart rate control

D. All the above

10. Which of the following treatment regimens is acceptable for the management of chlamydial infection during pregnancy?

A. Ceftriaxone (Rocephin), 250 mg intramuscular injectionB. Azithromycin (Zithromax), 1 g po

D. Levofloxacin (Levaquin), 500 mg po

11. A 20-year-old man presents to the emergency department complaining of a painful ulcer at the base of his penis and tender nodules in his right inguinal region. Physical examination reveals a single irregular, tender ulcer and fluctuant right-inguinal lymphadenopathy. No vesicles are seen. Which pathogen is causing this condition?

Trichomonas vaginalis

A. Treponema pallidumB. Haemophilus ducreyiC. Chlamydia trachomatisD.

12. A 3-year-old boy with a history of tetralogy of Fallot presents with worsening tachypnea and cyanosis. Which of the following interventions is contraindicated?

A. Oxygen

C. A fluid bolus

E. Knee-chest position

13. A 55-year-old woman presents with a chief complaint of chest pain. Her ECG reveals ST-segment elevation in leads II, III, and aVF. You are in a facility that does not have an interventional catheterization laboratory, and her cardiologist would like her transferred to the nearest catheterization laboratory emergently. Which of the following interventions is NOT indicated?

A. Heparin therapyB. Glycoprotein IIb-IIIa inhibitor

D. Lidocaine (LidoPen Auto-Injector, Xylocaine) prophylaxis

14. A 65-year-old woman presents within 30 minutes after sudden-onset right-sided weakness. The following conditions are contraindications to thrombolytic therapy, except:

A. Improvement of symptomsB. Normal computed tomography (CT) scan (no evidence of hemorrhage or early infarct signs)

D. Seizure at onset

15. A 14-year-old girl presents with a swollen, ecchymotic right eye. She was hit in the eye by a softball 1 hour earlier. Physical examination shows she has a layering of red cells in the anterior chamber, but her visual acuity is intact. What is the most common sequela of this process?

A. Vision lossB. Corneal ulceration

D. Recurrence of bleeding

16. Doxycycline (eg, Adoxa, Doryx, Vibramycin) is an acceptable treatment for all the following tickborne diseases, except:

A. Rocky Mountain spotted feverB. Lyme disease

D. Ehrlichiosis

17. A 32-year-old woman presents to the emergency department with the chief complaints of palpitations and "heart racing." She has a history of hyperthyroidism and had been taking propylthiouracil, but 2 weeks ago she ran out of medication. Which of the following is an acceptable treatment for her tachycardia?

A. Propranolol HCl (Inderal)B. Diltiazem HCl (Cardizem)

D. Verapamil HCl (Calan)

18. Optic neuritis is a common presentation in which of the following diseases?

A. Myasthenia gravisB. Guillain-Barr? syndrome

D. Amyotrophic lateral sclerosis (ALS)

19. Meralgia paresthetica is the entrapment of which nerve?

A. MedianB. Ulnar

D. Lateral femoral cutaneous ANSWERS 1 - A. Kawasaki's disease is an acute vasculitis of unknown origin. Diagnostic criteria are fever for 5 days without another source and 4 of the following features: (1) rash, (2) nonexudative conjunctivitis, (3) mucous membrane involvement, (4) edema and/or erythema of the hands or feet, (5) cervical adenopathy of 1.5 cm or more. A platelet count of more than 1000 x 103/?L is frequently seen and may aid in diagnosis but is not a diagnostic criteria.

2 - C. Charcoal therapy is indicated in the acute ingestion of all the drugs listed, except lithium. Heavy metals are poorly bound by charcoal, and the risks outweigh the benefits of charcoal therapy in the acute setting.

3 - C. All the solutions mentioned may be used to rinse the nematocyst without causing firing, except for sterile water. The hypotonic solution will trigger the nematocyst to fire. The nematocyst can then be removed safely with forceps.

4 - D. Hemodialysis lowers the potassium level by direct filtration. Sodium bicarbonate, glucose and insulin, and albuterol work to drive potassium intracellularly, thereby lowering serum levels. Calcium is a membrane stabilizer but does not directly alter potassium levels.

5 - D. Methanol, ethanol, and ethylene glycol all cause anion gap acidosis. This diagnosis is made by the lack of an anion gap and the presence of acetone. The metabolism of isopropanol results in acetone or ketones, which may be detected in the serum (as acetone) or in the urine (as ketones).

6 - B. Roth's spots (hemorrhage of the retina), Janeway lesions (macular rash of the palms and soles that may be hemorrhagic), and Osler nodes (tender cutaneous lesions, typically of the fingers and toes) are all clinical signs of endocarditis caused by embolization. Cotton-wool spots are areas of retinal damage caused by ischemia of the retinal fiber layer and are not related to endocarditis.

7 - B. A Salter II fracture involves the physis and extends into the metaphysis. Salter I is a separation of the epiphysis and physis from the metaphysis. Salter III fractures involve the physis and extend through the epiphysis to the articular surface. Salter IV fractures are at the articular surface and extend through the epiphysis and metaphysis.

8 - A. Posteriorly displaced fractures may injure the radial nerve. Medial displacement may result in injury to the brachial artery and/or the median nerve. 9 - D. Elevated BP levels in aortic dissection (the cause of this patient's pain) may be treated with labetalol HCl and/or nitroprusside sodium. Early surgical consultation is also indicated. Hypertension and connective tissue disease are the primary risk factors for acute aortic dissection.

chlamydia

10 - B. Chlamydial infection may be treated with azithromycin, doxycycline, tetracycline, or erythromycin (Ery-Tab, PCE Dispertab). However, doxycyline is not used during pregnancy. Ceftriaxone is acceptable and safe for the treatment of gonorrhea during pregnancy, but it does not treat . The only drug listed that is considered safe during pregnancy is azithromycin.

11 - B. Chancroid, a painful ulcer with unilateral adenopathy, is caused by H ducreyi. T vaginalis does not cause an ulcer. Lymphogranuloma venereum ([LGV] caused by C trachomatis) and syphilis (caused by T pallidum) both produce nonpainful ulcers. LGV frequently results in multiloculated clusters of matted nodes that may be unilateral or bilateral.

12 - D. "Tet spells" associated with tetralogy of Fallot are treated by initiation of oxygen therapy to reverse hypercyanosis. Morphine helps reduce outflow obstruction/spasm and has an anxiolytic effect. A fluid bolus helps increase systemic vascular resistance. The knee-chest position helps decrease venous return.

13 - D. Heparin and nitroglycerin are clearly indicated in this instance. Glycoprotein inhibitors are also indicated, especially in the presence of a prolonged transport or ongoing chest pain. Lidocaine (LidoPen Auto-Injector, Xylocaine) prophylaxis is not indicated unless the patient develops ventricular tachycardia or symptomatic ventricular ectopy.

14 - B. This patient clearly falls within the time window for thrombolytic therapy. Anormal CT scan and a lack of contraindications would be an indication for therapy. Rapidly improving symptoms, stroke complicated by seizure, or persistently elevated BP are all contraindications to thrombolysis. A CT scan showing major early stroke signs - edema, sulcal effacement, mass effect, or possible hemorrhage - is also a contraindication to thrombolysis.

15 - D. This patient has sustained a hyphema. Visual loss is rare and warrants investigation for more serious injury. The blow to the eye may result in corneal abrasion, but this would not be a sequela of the hyphema. Cellulitis would be extremely unlikely from a traumatic injury of this type. The most likely sequela is recurrence of bleeding that may occur anytime, but typically within the first 7 to 10 days after injury. 16 - C. Rocky Mountain spotted fever, Lyme disease, and ehrlichiosis are all treated with doxycycline. Tularemia results from the bite of vectors, such as ticks or deerflies, or an infected host (rabbits or rodents). Symptoms are similar to the plague and consist of prolonged, intermittent or remittent fever; suppuration of lymph nodes; and ulcerative skin lesions. Tularemia is treated with an IV aminoglycoside. 17 - A. Adenosine is an atrioventricular (AV) node blocker and would not be indicated for the treatment of thyroid-induced sinus tachycardia. Verapamil HCl and diltiazem HCl are both calcium channel blockers that slow AV node conduction. Propanolol HCl is the only agent that decreases the peripheral effects of hyperthyroidism by reducing sympathetic hyperactivity and the conversion of thyroxine to triiodothyronine.

18 - C. ALS, Guillain-Barr? syndrome, and myasthenia gravis are all neuromuscular diseases. ALS is a disease of the motor nerve fibers of the lateral columns and anterior horns of the spinal cord that results in progressive muscular atrophy. Guillain-Barr? syndrome is the postinfectious autoimmuneinduced destruction of peripheral nerves, resulting in an ascending paralysis. Myasthenia gravis is an autoimmune destruction of the acetylcholine receptors at the neuromuscular junction. MS results from demyelinating plaques in the central nervous system. One of the common presentations of MS is optic neuritis.

(for all answers)

19 - D. Median nerve entrapment is also known as carpal tunnel syndrome, while ulnar nerve entrapment is known as cubital tunnel syndrome. Meralgia paresthetica is entrapment of the lateral femoral cutaneous nerve, resulting in paresthesia or hypesthesia. References

Textbook of Pediatric Emergency Medicine

1. Fleisher GR, Ludwig S, Henretig FM, et al, eds. . 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999.

Cecil Textbook of Medicine.

2. Bennett JC, Plum F, eds. 20th ed. Philadelphia, Pa: WB Saunders; 1996.

Rosen's Emergency Medicine: Concepts and Clinical Practice.

3. Marx Ja, Hockberger RS, Walls RM, eds. 5th ed. St. Louis, Mo: Mosby; 2002.

Emergency Medicine: A Comprehensive Study Guide

4. Tintinalli JE, Kelen GD, Stapczynski J, eds. . 6th ed. New York, NY: McGraw-Hill; 2004.