Enter Title

YOU TAKE MY BREATH AWAY

100

A 16-year-old high school football player presents to the pediatric emergency department with pain in his chest and left shoulder after an injury that he sustained during a football game, approximately 1 hour ago. While running and holding the football in his left arm, he was tackled from behind. The patient fell forward and landed forcefully on his chest, with the weight of the opposing player on top of him. At that time, he heard a “cracking” sound and immediately felt pain in his chest and left shoulder. In the emergency department, the boy is alert and fully oriented. He is very uncomfortable and is holding his hand over the left side of his chest. He tells you that it is difficult to breathe. His vital signs include a heart rate of 100 beats/min, respiratory rate of 24 breaths/min, blood pressure of 130/80 mm Hg, temperature of 37°C, and pulse oximetry of 96% on room air. On physical examination, his breath sounds are clear and equal bilaterally. The patient is taking shallow breaths because of pain, but is not in respiratory distress. He is tender to palpation over the left sternoclavicular junction, as well as over his left first rib, and you note bruising over these areas. He has no focal tenderness on examination of his left shoulder, but he refuses to move his left shoulder due to pain. You find no evidence of trauma to his head and his cervical spine is nontender to palpation. The remainder of his physical examination findings, including a full neurologic examination, is unremarkable. An electrocardiogram reveals sinus tachycardia with no other abnormality. You administer an intravenous analgesic and order plain radiographs of the patient’s chest and left shoulder, which reveal a non-displaced fracture of his left first rib. His left shoulder radiograph reveals no fracture or dislocation. He continues to complain of severe pain over his left sternoclavicular joint and subjective dyspnea, and refuses to move his left shoulder due to pain. His vital signs are unchanged........ Of the following, the BEST next step in his evaluation is....... A. bone scan B. computed tomography of the chest C. echocardiography D. no further imaging E. plain radiographs of the ribs

B. computed tomography of the chest

200

A 12-year-old boy is brought to the emergency department after being involved in a house fire. He is currently awake, alert, and oriented. He is complaining of throat and chest pain. His temperature is 37°C, pulse is 110 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 115/70 mm Hg. His oxygen saturation by pulse oximetry is 100% on room air. Physical examination shows an emotionally upset child in no apparent physical distress. There is no apparent trauma to the head, trunk, or extremities. There is soot around his mouth, nose, and the exposed skin on his neck, hands, and feet. When the soot is washed away, there is no redness or burn to any area of skin. The boy’s oropharynx is erythematous. He is breathing comfortably. On auscultation, his lungs are clear with transmitted upper airway sounds, and his heart has a regular rhythm. The boy’s extremities are warm and well-perfused. His abdomen is soft, nontender, and non-distended. His pupils are equal, round, and reactive. The remainder of his neurologic examination is unremarkable.......... Of the following, the MOST appropriate next step in management is...... A. dexamethasone, 10 mg intravenously B. endotracheal intubation C. hyperbaric oxygen therapy D. methylene blue, 1 mg/kg intravenously E. noninvasive positive pressure ventilation

B. endotracheal intubation

300

A 14-year-old adolescent is brought to the emergency department via emergency medical services with complaints of shortness of breath, and moderately severe sharp chest and shoulder pain after he was hit by a teammate during football practice. The patient’s medical history is significant for mild persistent asthma and seasonal allergic rhinitis, which are well controlled on leukotriene receptor antagonist monotherapy. The patient did have symptoms of an upper respiratory infection and bronchitis during the preceding 3 days and was completing treatment with azithromycin. There is no antecedent history of vomiting or respiratory distress. On physical examination, you find a well-developed, well-nourished adolescent in mild respiratory distress. His respiratory effort appears splinted because of chest pain and he is anxious in appearance. His respiratory rate is 30 breaths/min. Oxygen saturation is 94% in room air. Cardiac examination is remarkable for mild tachycardia, but no murmur, rub, or gallop. Auscultation of the lungs reveals moderate aeration. The lungs are clear to auscultation without wheezing, crackles, or asymmetry. Subcutaneous crepitus is demonstrated at the shoulders, neck, and jaw line. The abdomen is soft, nontender, and nondistended. His extremities are well-perfused with symmetric pulses. ............... Of the following, the MOST likely explanation for this patient’s clinical presentation is....... A. commotio cordis B. pneumomediastinum C. pneumothorax D. splenic rupture E. status asthmaticus

B. pneumomediastinum

400

A 16-year-old adolescent presents to the emergency department after sustaining chest trauma when his all-terrain vehicle flipped over. He is currently awake and alert, but is complaining of difficulty breathing and has severe pain on the lower anterior aspect of his right chest. Vital signs show a temperature of 37°C, respiratory rate of 24 breaths/min, heart rate of 120 beats/min, blood pressure of 110/70 mm Hg, and oxygen saturation of 92% on room air. His breathing is rapid and shallow. On auscultation, there is good air entry in all segments of the left lung. The inferior aspect of the right chest moves inward upon inspiration and outward upon expiration. The right lung has decreased breath sounds at the base...... Of the following, the BEST next step is to... A. administer morphine sulfate, 5 mg intravenously B. obtain computed tomography of the chest C. perform endotracheal intubation D. perform internal fixation of anterior ribs E. place a chest tube

A. administer morphine sulfate, 5 mg intravenously

500

A 2-year-old girl was found face down on the surface of the family's above ground pool. She was out of her caregiver's sight for 10 min before she was found. When she was pulled from the water, she was motionless, blue, and not breathing. Emergency medical services (EMS) were immediately called and when they arrived 5 min later, she was still not breathing. The EMS personnel performed cardiopulmonary resuscitation consisting of chest compressions and rescue breathing, with the return of spontaneous circulation within 5 min. As she was not spontaneously breathing in the emergency department, the girl was endotracheally intubated. Upon arrival in the intensive care unit, the girl’s vital signs were a temperature of 36°C, heart rate of 150 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 100/60 mm Hg. Pulse oximetry was 95% on 50% oxygen via mechanical ventilation. On physical examination, there was no spontaneous movement. On painful stimulus, the girl exhibited extensor posturing, but did not open her eyes. Her pupils were 4 mm, equal, and sluggishly reactive. There were no external signs of trauma. Her abdomen was soft, nontender, non-distended, with no organomegaly. Her extremities were cool with capillary refill time of approximately 3 seconds........ Of the following, the MOST appropriate next step in the management of this patient is....... A. hyperventilation to achieve arterial CO2 tension of 30 to 32 mm Hg B. maintenance of arterial hemoglobin oxygen saturation greater than 93% C. mannitol 0.25 g/kg intravenously every 6 hours D. placement of an external ventricular drain E. placement of a strain gauge intracranial pressure monitor

B. maintenance of arterial hemoglobin oxygen saturation greater than 93%

FEVER BITES

100

A 14-year-old adolescent boy presents to your office for evaluation 4 hours after he sustained a puncture wound to his left heel. He stepped on a rusty nail while walking without shoes across a parking lot. The nail initially lodged in his left heel, but he pulled it out at that time. His heel bled slightly, but the bleeding resolved after only a few minutes. The patient’s mother brought him to your office for evaluation because he has been complaining of constant pain in his left heel since his injury. The teenager has a history of obesity, type 2 diabetes mellitus, and asthma. His medications include an inhaled corticosteroid and metformin. The patient’s immunizations are up to date; a review of his chart confirms that he received a tetanus booster 2 years ago. The adolescent appears very well and is in no distress. He is afebrile, and his vital signs are normal for his age. His weight is at the 97th percentile for his age. Examination of the boy’s left foot reveals a 4-mm puncture wound on his left heel that is surrounded by some jagged skin tissue. The wound is not bleeding, and there is no surrounding erythema or warmth. There is no drainage from the wound. On palpation of the wound, you do not detect any retained foreign body. While you are irrigating and debriding the puncture wound, the teenager’s mother asks you about the likelihood that the wound will become infected....... Of the following, the factor MOST likely to increase the patient’s risk of developing a wound infection is....... A. daily inhaled corticosteroid use B. history of type 2 diabetes mellitus C. lack of shoes at the time of the injury D. relative location of the wound on the heel rather than forefoot E. setting of the injury (paved surface)

B. history of type 2 diabetes mellitus

200

A previously well, 56-day-old female infant arrives at your office with a 1-day history of fever (up to 38.9°C). The parents deny cough, congestion, nausea, rash, skin lesions, vomiting, and diarrhea. The baby lives with her parents and 2 siblings who are 2 years of age and 5 years of age. No one else at home is ill. The baby is being fed formula 1.5 oz to 2 oz every 2 to 3 hours (down from her usual 2.5 oz to 3 oz per feed). You review the baby’s birth history and see that her birth weight was 3.3 kg; her birth was a full-term, uncomplicated pregnancy and delivery; her nursery stay was without complications; and she went home in 2 days. She has no prior illnesses. She received hepatitis B vaccine in nursery. The family has been in your practice since the birth of the oldest child and has kept appointments reliably. The baby’s vital signs show a temperature of 38.8°C, a heart rate of 130 beats/min, and a respiratory rate of 24 breaths/min. Physical examination shows a strong cry, but she is consolable by her mother. She is comfortable in her mother’s arms and well appearing. The remainder of the physical examination findings are unremarkable. Laboratory results show the following: · White blood cell count, 12,800/µL (12.8 × 109/L), with 45% neutrophils, 3% bands; 49% lymphocytes; 3% monocytes · Hemoglobin, 13.4 g/dL (134 g/L) · Platelet count, 227 × 103/µL (227× 109/L) A urinalysis shows the following: · Specific gravity, 1.017 · pH, 7.0 · Dipstick, negative The blood and urine cultures are pending......... Of the following, the BEST next step in the management of this infant’s condition would be to....... A. admit and observe pending cultures B. admit and treat with ampicillin and cefotaxime pending culture results C. discharge home with follow-up in 24 hours D. perform a lumbar puncture and begin ampicillin and ceftriaxone pending culture results E. prescribe amoxicillin and follow-up in 24 hours

C. discharge home with follow-up in 24 hours

300

The parents of a 17-year-old college student in your practice call to ask your advice. The student awoke this morning to find a bat flying around his dormitory room. He and his roommate opened the window and the bat flew out. He feels well and on self-examination noticed no skin lesions or bite marks. His immunizations are up to date, including receipt of diphtheria–tetanus–pertussis vaccine at 11 years of age...... Of the following, the BEST course of action is to...... A. begin a 5-day course of amoxicillin–clavulanic acid B. begin a rabies vaccine series C. get a tetanus vaccine booster D. monitor his skin for signs of new skin lesions over the next 2 weeks E. provide reassurance

B. begin a rabies vaccine series

400

A 14-year-old adolescent girl presents to an Arizona urgent care, where you practice, after being stung by a scorpion. Approximately 3 hours before arrival, the teenager—who is on a camping trip with her Girl Scout troop—felt a sharp pain in her left calf just after she crawled into her sleeping bag to rest for the night. Upon feeling the pain, she got out of the sleeping bag, shook the bag, and saw a scorpion (Centruroides exilicauda) crawl out. Her temperature is 36.8°C, heart rate is 84 beats/min, blood pressure is 90/60 mm Hg, respiratory rate is 18 breaths/min, and pulse oximetry is 99% on room air. A medical history form provided to you by one of the trip chaperones indicates that the adolescent has up-to-date immunizations and no significant past medical history or allergies. The patient appears anxious, but is in no distress. She complains of a sharp pain and occasional tingling in her left calf, but she has no other symptoms. A complete physical examination is significant only for a 2-mm puncture wound on the girl’s left calf with no surrounding swelling or erythema. A full neurologic examination, including close assessment of the cranial nerves, reveals no abnormalities. You tap gently on the puncture wound on her left calf, which causes her to cry out sharply with pain. You apply a cool compress to the site of the wound........ Of the following, the BEST next step in management for this patient’s symptoms is administration of........ A. Centruroides exilicauda antivenin therapy B. intramuscular midazolam C. intravenous calcium gluconate D. oral acetaminophen E. oral diphenhydramine

D. oral acetaminophen

500

An 18-month-old girl with chronic malnutrition caused by intestinal malabsorption presents to the emergency department with fever, irritability, and left arm weakness. Vital signs show a temperature of 38.2°C, respiratory rate of 36 breaths/min, heart rate of 138 beats/min, blood pressure of 110/50 mm Hg, and a weight of 9 kg. On physical examination, she is irritable, has a facial droop, and left-sided weakness and tremor. Laboratory data shows: White blood cells, 8,500/µL (8.5 x 109/L) /Hemoglobin, 11 g/dL (110 g/L) /Platelets, 307 x 103/µL (307 x 109/L) /Differential, 54% segmented neutrophils, 37% lymphocytes, 8% monocytes, 1% eosinophils /Cerebrospinal fluid (CSF) results: White blood cells, 147/µL (4% segmented, 83% lymphocytes) /Red blood cells, 10/µL /Glucose, 25 mg/dL (1.4 mmol/L) /Protein, 179 mg/dL The purified protein derivative skin test result is 14 mm of swelling. You suspect tuberculous meningitis.......... Of the following, the immune defect that BEST explains this child’s increased susceptibility to this infection is....... A. decreased phagocytic cell function B. impaired antibody specific responses C. increased lymphocyte anergy D. increased natural killer cell levels E. upregulation of regulatory T cells

C. increased lymphocyte anergy

STICK AND STONES MAY BREAK MY BONES

100

A 10-year-old boy presents to the emergency department after he was hit in the head with a baseball. His vital signs show a temperature of 37°C, blood pressure of 120/80 mm Hg, pulse of 60 beats/min, and respiratory rate of 15 breaths/min. He is awake and alert, complaining of a headache and blurry vision. He denies any other pain, nausea, vomiting, difficulty breathing, or dizziness. There is a boggy, tender area over his right temporal area with no other signs of trauma. Pupils are 3 mm, equal, and reactive. When he looks straight ahead, his right eye deviates medially. Extraocular movements and cranial nerves are otherwise intact. Mental status examination and the remainder of the neurologic examination are unremarkable. A computed tomography of the head confirms your suspected diagnosis......... Of the following, the MOST appropriate initial step in management is....... A. hospital admission for observation B. intubation and mechanical ventilation C. magnetic resonance imaging of the brain D. neurosurgery consultation E. ophthalmology consultation

D. neurosurgery consultation

200

A 4-year-old girl is brought by emergency medical services to your small community emergency department 30 min after she was struck by a car traveling at approximately 40 mph. The girl ran out into the street after a rolling soccer ball and was struck by the oncoming car. She was thrown several feet on impact and had a 1- to 2-min loss of consciousness. Her mother witnessed the incident and immediately called 911. On arrival to the emergency department, the paramedics report that the girl’s left ankle is markedly swollen with an obvious deformity, there is a large bleeding laceration over the left side of her forehead, and there are several bruises across her abdomen. The girl is moaning with some intermittent gurgling and a small amount of blood coming from her mouth. She does not answer questions or follow your instructions to move her legs and squeeze your hands. Paramedics immobilized her entire spine by using a pediatric backboard and cervical immobilization collar. Her vital signs on arrival to the emergency department show a heart rate of 160 beats/min, respiratory rate of 40 breaths/min, and a blood pressure of 50/30 mm Hg...... Of the following, the BEST next step in management is to... A. administer 20 mL/kg of isotonic crystalloid fluid solution intravenously B. apply a pressure bandage to her left forehead laceration C. open her airway with a jaw-thrust maneuver D. perform a chest radiograph E. transport to a tertiary hospital that has pediatric surgical capabilities

C. open her airway with a jaw-thrust maneuver

300

A 15-year-old adolescent presents to your office for evaluation of left shoulder pain after a fall directly onto the lateral aspect of the left shoulder. On physical examination, you note mild swelling and tenderness at the distal end of the clavicle. He reports pain when he adducts his shoulder. He does not have any weakness with upper extremity muscle testing. Anteroposterior, axillary, and scapular Y radiographs of the shoulder are normal...... Of the following, the MOST likely diagnosis is...... A. acromioclavicular joint sprain B. occult clavicle fracture C. rotator cuff tear D. shoulder dislocation with spontaneous reduction E. sternoclavicular dislocation

A. acromioclavicular joint sprain

400

A 17-year-old female soccer player is brought to the emergency department (ED) following a head injury that occurred while she was playing in a soccer game. Approximately 20 minutes ago, she collided head-to-head with another player while she was running and fell to the ground. Her mother, who accompanied her daughter to the ED, tells you that she had a very brief loss of consciousness (less than 15 seconds) immediately following the injury and that she has seemed “dazed” since it occurred. She vomited once about 10 minutes ago. A review of the patient’s medical history indicates that she has no significant past medical or surgical history, takes no medications, has no allergies, and has had no prior head injuries. In the ED, the patient is sleepy, but answers all questions appropriately and follows instructions. When you ask her about her current symptoms, she states: “My head still hurts, but it is starting to feel a little better now.” Her vital signs are within normal limits. On physical examination, her pupils are equal in size and reactivity. She has a 3 x 4 cm area of ecchymosis near the center of her forehead, but no hematomas or step-offs on palpation of her entire forehead and scalp. There are no focal deficits on a complete neurologic examination, although she tells you that she feels tired and wants to lie down again after you ask her to walk back and forth across the room. The remainder of the physical examination is unremarkable...... Of the following, the MOST appropriate next step in the management of this patient is to... A. admit her to the hospital for 24-hour observation B. continue to observe her in the emergency department C. discharge her home with her mother now D. obtain neurosurgical consultation E. order computed tomography of the brain

B. continue to observe her in the emergency department

500

A tearful mother brings her 2-year-old son to your office 30 minutes after he pulled on the handle of a mug full of hot coffee left on the edge of the kitchen counter. The coffee spilled onto the boy and burned his right upper arm and chest. He is crying loudly, without stridor or respiratory difficulty. Physical examination reveals a 3 × 3–cm “ruptured” blister on the child’s upper chest with an erythematous, tender base. There is also a 3 × 4–cm area of superficial erythema without blister formation on the child’s right upper arm. The child’s mother states that he has been very healthy and takes no medications. His immunizations are up to date. After administration of an oral analgesic, you clean the boy’s burns with soap and water........ Of the following, the MOST appropriate next step in management is....... A. application of topical lidocaine gel to the burned areas B. debridement of the ruptured blister on the upper chest C. prescription of a course of oral cephalexin D. referral to a burn center due to the upper chest burn E. reporting of the injury to child protective services

B. debridement of the ruptured blister on the upper chest

MORE EMERGENCIES!!

100

A 10-year-old boy presents to the emergency department after being thrown off his bike and hitting the right side of his head on the sidewalk. This occurred after he hit a “speed bump” while biking at full speed. He seemed “dazed” for a few seconds initially, but he has been alert and talking to his mother during the car ride to the emergency department. On physical examination, the boy has tenderness and a hematoma over the right temporoparietal region of his head. The remainder of his initial physical examination findings, which include a complete neurologic examination, are unremarkable. On subsequent examination 30 min later, the boy seems much more lethargic, his speech is slurred, and his responses to very simple questions seem delayed. His mother tells you that before your reassessment, he said he “had a really bad headache.”........... Of the following, the MOST likely explanation for the boy’s current symptoms is........ A. basilar skull fracture B. concussion C. epidural hematoma D. subarachnoid hemorrhage E. subdural hematoma

C. epidural hematoma

200

A 2-year-old girl is brought to your office because she refuses to move her right arm. Her father reports that, several hours earlier, he was walking with her and holding her hand. The girl pulled away from him and then cried out in pain. On physical examination, the girl holds her right elbow in a slightly flexed position with the forearm pronated. She does not appear to have tenderness with palpation of the upper arm, elbow, forearm, or wrist. There is no redness or bruising.................. Of the following, the MOST accurate statement regarding this girl’s injury is that it................ A. can result from a fall on an outstretched hand B. generally results in swelling around the elbow C. involves dislocation of the proximal radius D. more commonly occurs in boys E. occurs only in children younger than 5 years of age

A. can result from a fall on an outstretched hand

300

A community hospital calls the pediatric emergency department where you are working seeking to transfer an 11-year-old boy with a grade IV laceration to his left kidney. This injury was sustained when the boy fell 10 feet from a tree, landing on his left side. The transferring physician asks for your recommendation regarding insertion of an indwelling bladder catheter to monitor the boy’s urine output prior to transporting him to your hospital........ Of the following, the MOST accurate statement regarding this patient is that....... A. a bladder catheter should be inserted before performing a rectal examination B. bladder catheterization is contraindicated if prostate enlargement is detected C. bladder catheterization should not be performed if bruising to the perineal area is noted D. the presence of red blood cells on urinalysis is a contraindication to bladder catheterization E. urologic consultation is recommended before bladder catheterization

C. bladder catheterization should not be performed if bruising to the perineal area is noted

400

A 15-year-old adolescent boy arrives at your office immediately after an injury to the right shoulder. He landed awkwardly on the shoulder during wrestling practice, and now reports pain over the right sternoclavicular joint. The boy reports no other symptoms. On physical examination, there is a noticeable depression of the medial clavicle at the sternoclavicular joint......... Of the following, the MOST appropriate statement regarding this injury is that........... A. no treatment is necessary but the boy will have a persistent mild bony deformity B. the boy should be treated with a figure-eight harness for 4 weeks to 6 weeks C. the boy should be treated with his arm in a sling for 4 weeks to 6 weeks D. the boy should undergo elective surgery once the pain and swelling resolve E. the boy will require additional evaluation and will likely need prompt surgery

E. the boy will require additional evaluation and will likely need prompt surgery

500

You are seeing a 19-month-old boy in your office for follow-up 2 days after a 5-day hospitalization for treatment of orofacial burns. The boy chewed on a frayed extension cord last week and he sustained a 1 x 1.5 cm full-thickness burn to his right oral commissure and lower lip, as well as a small partial-thickness burn to the right side of his chin. His parents tell you that the boy has been doing well since discharge from the hospital. He has had no fevers and he has been able to tolerate fluids and soft foods. His pain has been well controlled. In your office, the boy’s vital signs are normal for his age and he appears well. Physical examination reveals only the healing burns at the right oral commissure and lower lip with eschar formation, and a small healing, partial thickness burn to the right side of his chin. There are no signs of infection. The boy’s mucous membranes are moist, and his extremities are warm and well-perfused. The boy’s parents ask you about potential for delayed complications from his recent injury.......... Of the following, the boy is MOST at risk for.......... A. acute hemolytic anemia within the next 1 to 2 weeks B. acute renal failure within the next 1 to 3 weeks C. progressive sensorineural hearing loss over the next 6 to 12 weeks D. severe bleeding within the next 1 to 2 weeks E. ventricular arrhythmias within the next 1 to 2 weeks

D. severe bleeding within the next 1 to 2 weeks