Cardio
Trauma
Endo/Metabolic Disorders
Nervous System
Infectious
100
A 47-year-old woman presents to the ED with fever, chest pain, and a new murmur. A history of which of the following indicates a higher risk of bacterial endocarditis in this patient?
- A Chronic hemodialysis
- B Insulin-dependent diabetes mellitus
- C Repaired ventricular septal defect
- D Situs inversus
A. Chronic Hemodialysis
100
A 32-year-old man presents following a rollover motor vehicle collision. On arrival, he is confused and has a heart rate of 132 beats per minute and blood pressure of 88/56 mm Hg. Two units of packed red blood cells are ordered by the trauma team. While receiving his second unit of blood, the patient begins to complain of generalized pruritus. The patient's blood pressure is now 118/76 mm Hg and he appears uncomfortable with diffuse urticaria. He is without petechiae, wheezing, or oral swelling. Which of the following is the best next step in management?
- A Acetaminophen
- B Diphenhydramine
- C Discontinue the transfusion and return blood to blood bank
- D Methylprednisolone
B for benadryl
100
A patient is found to be hyponatremic. Laboratory evaluation reveals low serum osmolality, urine sodium concentration > 20 mmol/L and a fractional excretion of sodium (FENa) > 1%. He appears to be "fluid overloaded." Which of the following is the most likely cause of this hyponatremia?
- A Cirrhosis
- B Congestive heart failure
- C Hypertensive nephropathy
- D Syndrome of inappropriate ADH release (SIADH)
C. Hypertensive Nephropathy
Hyponatremia is defined as sodium less than 135 mEq/L. Hyponatremia can occur in a hypovolemic, euvolemic, or hypervolemic state. Hypervolemic hypo-osmolar hyponatremia is associated with fluid overload. The etiology is usually from a perceived low intravascular volume by the kidneys and active water reabsorbtion in excess to sodium retention. If urine sodium is low (<20) causes include liver failure, cirrhosis, hepatorenal syndrome, nephrotic syndrome, and CHF. If urine sodium is high (>20) causes include acute or chronic renal failure, such as that caused by hypertensive nephropathy. Treatment of hypervolemic hypo-osmolar hyponatremia is dialysis.
100
A 76-year-old man with a mechanical aortic valve on warfarin presents with altered mental status and left-sided weakness. A CT scan of the head shows an intraparenchymal hemorrhage with no midline shift. The patient’s international normalized ratio is 3.6, and the platelet count is 255,000/µL. Which of the following is the most appropriate therapeutic intervention?
- A Do not reverse the international normalized ratio and admit to the ICU
- B Give 4-factor prothrombin complex concentrate, platelets, and vitamin K orally, and admit to the ICU
- C Give 4-factor prothrombin complex concentrate, vitamin K 10 mg IV, and admit to the ICU
- D Give vitamin K 10 mg IV and admit to the ICU
C. PCC, Vitk, ICU
100
A previously healthy 4-year-old girl presents to the ED after a six-minute generalized tonic-clonic seizure. Her parents state that, over the past two days, the patient appeared drowsy and seemed to be off-balance when she walked. Vital signs are HR 130 bpm, RR 24/min, and T 39.5°C. On exam, you note the findings seen in the image above, which are limited to the mouth. Which of the following is the most appropriate next step in management?
- A Administer IV steroids, ceftriaxone, and vancomycin
- B Consult pediatric neurology for urgent EEG monitoring
- C Head CT scan, lumbar puncture, and administer IV acyclovir
- D Supportive care and transfer to a burn center
C Head CT scan, lumbar puncture, and administer IV acyclovir
Early steroid administration (A) is beneficial in bacterial meningitis. Its role in viral encephalitis has not been validated. EEG monitoring (B) is useful in the ongoing management of encephalitis but not in the acute management. The differential diagnosis should also include Stevens-Johnson syndrome, which is a milder form of toxic epidermal necrolysis. These patients sometimes require transfer to a burn center (D). However, the patient in the clinical scenario has isolated oral lesions that are characteristic of HSV infection.
200
A 39-year-old man presents to the ED complaining of general weakness. He has signs of an upper respiratory infection on exam. His rhythm strip is seen above. Which of the following is the most appropriate next step in management?
- A Administer 325 mg aspirin and send for a troponin
- B Apply transcutaneous pacemakers and admit
- C Consult cardiology
- D Symptomatic care and discharge
D. Symptomatic care and discharge
200
A 5-year-old healthy girl presents to the emergency department after a fall from her bed. Her mother witnessed the fall and is concerned about head trauma. Which of the following factors, if present, would be an indication for computed tomography of her head?
- A Laceration of her forehead
- B Loss of consciousness
- C Occipital scalp hematoma
- D Slowed verbal responses
D. Slowed verbal responses
LOC <5 secs is fine, if you ask PECARN
200
Which of the following most commonly causes an anion gap metabolic acidosis?
- A Benzodiazepines
- B Diarrhea
- C Ethylene glycol
- D Vomiting
C. Ethylene glycol
Benzodiazpines (A) are sedative agents and can cause respiratory depression resulting in a respiratory acidosis, but in rare cases over overdose can cause metabolic acidosis due to the use of propylene glycol as a diluent in the parenteral formulations. Diarrhea (B) causes a non-anion gap metabolic acidosis. Vomiting (D) causes metabolic alkalosis.
200
In a patient who presents to the emergency department with acute onset of neurologic symptoms, which of the following features is more suggestive of a transient ischemic attack?
- A Associated vomiting
- B Headache concurrently with neurologic symptoms
- C Loss of consciousness
- D Negative symptoms, or loss of function
D.
Migraine headache is by far the most common entity presenting with transient neurologic symptoms that can be confused with TIA. Symptoms that are suggestive of a migraine headache include neurologic symptoms, such as tingling or paresthesias, particularly in the face and arm that move or march, flashing or shape-like visual changes, jerking limb movements, and pain. Associated vomiting (A) is common with migraine and can occur after syncope. Vomiting is extremely rare with TIA and seizure. A headache concurrently with neurologic symptoms (B) is suggestive of migraine, but the headache can be delayed for even one hour after the onset of neurologic symptoms.
Headache may also occur after a seizure. A headache can occur with TIA, but rarely at the same time as the neurologic symptoms. Loss of consciousness (C) or alteration in mental status, almost never occurs in either TIA or migraine headache. This is more characteristic of a patient presenting with seizure or syncope.
200
A 37-year-old man presents with persistent fever and night sweats. He complains of weight loss, frequent diarrhea, malaise, and poor appetite. He has a history of HIV but has resisted taking antiretroviral therapy. In addition to antiretroviral therapy, which of the following medications is indicated?
- A Amphotericin and flucytosine
- B Clarithromycin, ethambutol, and rifabutin
- C Fluconazole
- D Ganciclovir
B Clarithromycin, ethambutol, and rifabutin
Amphotericin and flucytosine (A) are antifungal medications used to treat infections with cryptococcal meningitis, which can also occur in AIDS patients with CD4+ T cell counts of ≤ 50 cells/mm³. Symptoms typically include fever, headache, altered mental status, and neurological abnormalities. Fluconazole (C) is an antifungal medication that may be initiated after initial treatment of a cryptococcal infection or for treatment of candidal esophagitis in patients with AIDS. It has no effect on atypical Mycobacterium. Ganciclovir (D) is an antiviral medication that may be used to treat cytomegalovirus (CMV). CMV can also cause fever and gastrointestinal (e.g., esophagitis, diarrhea, hepatitis) symptoms in AIDS, though its most common and serious complication is retinitis, which presents with visual complaints. CMV is the leading cause of blindness in AIDS. Disseminated CMV may also cause pulmonary (e.g., diffuse interstitial infiltrates) and central nervous system manifestations (e.g., encephalitis, radiculomyelitis, mononeuritis).
300
A 55-year-old man presents to the emergency department with chest pain after a syncopal episode. He has a history of diabetes, hyperlipidemia, hypertension, recent STEMI, and coronary artery disease. ECG is performed and is demonstrated above. What is the most likely diagnosis?
- A Arrhythmogenic right ventricular cardiomyopathy
- B Brugada syndrome
- C ST elevation myocardial infarction
- D Ventricular aneurysm
D. Ventricular Aneurysm
300
A 32-year-old 24-week pregnant woman presents after being involved in a head-on motor vehicle collision. She arrives hypotensive and shortly thereafter loses pulses. After three minutes of resuscitation, she continues to be in PEA arrest. There is no fetal or maternal cardiac activity seen on bedside ultrasound. What is the next step in management?
- A Continue resuscitation as there is no fetal heartbeat
- B Continue resuscitation for two more minutes then perform cesarean section if there is no maternal return of spontaneous circulation
- C Perform a perimortem cesarean section
- D Terminate resuscitation
C. Perform a perimortem C-section, Within 4 minutes of arrest
300
A 54-year-old man with a history of alcohol use disorder is brought to the emergency department after his family caught him lighting paper on fire in his bedroom. When you confront him about this, he states, “Somebody snuck into my bedroom and lit a fire.” His family informs you that, for the past 6 weeks, he has been acting erratically and telling elaborate lies. He has normal vital signs. The physical exam reveals decreased sensation to light touch up to his ankles bilaterally. He is unable to perform a tandem walk and has a positive Romberg test. Which of the following additional findings is associated with this condition?
- A Bilateral lateral rectus palsy
- B Bradykinesia
- C Small pupils that accommodate but do not constrict with light
- D Tremulousness and responding to internal stimuli
A. Bilateral rectus palsy
Korsakoff syndrome is the result of accumulated neurologic insults and tends to occur as a consequence of Wernicke encephalopathy, which is the result of acute thiamine deficiency. Wernicke syndrome is classically characterized by encephalopathy, gait ataxia, and ophthalmoplegia. Ocular findings commonly include nystagmus, lateral rectus palsy (mostly bilateral), and even pupillary abnormalities. Prompt treatment of Wernicke encephalopathy with intravenous thiamine is warranted to avoid significant morbidity and mortality.
300
A healthy 35-year-old woman presents with bilateral lower extremity weakness. Her symptoms initially started as numbness and tingling 2 days ago and have progressed to weakness over the past day. She notes a recent bout of diarrhea after a camping trip 2 weeks ago. On exam, she has decreased sensation to light touch, 2/5 strength in her lower extremities, and decreased ankle and patellar reflexes. Her weight is 60 kg and her forced vital capacity is 600 mL. Which of the following is the most appropriate next step?
- A High-dose intravenous corticosteroids
- B Intravenous immunoglobulin
- C Intubation and mechanical ventilation
- D Lumbar puncture
- E Plasmapheresis
C. Tube them
High-dose intravenous corticosteroids (A) are not indicated in the treatment of Guillain-Barré syndrome, and may in fact be harmful. Intravenous immunoglobulin (B) and plasmapheresis (E) are both treatments that reduce the time to recovery, but these are rarely initiated in the emergency department and would not take priority over securing the patient’s airway, given her decreased FVC. A lumbar puncture (D) can aid in the diagnosis of Guillain-Barré syndrome, but management of the patient’s airway takes priority. 
300
A 36-year-old man with a history of HIV/AIDS presents to the emergency department with mental status changes, headache, and fever for two days. According to his friend, he has had a steady decline over the last several days and thought that he had a viral illness. The patient has also had two episodes of vomiting and has not been eating. The friend does not think the patient has been compliant with his medications, but he is unaware of the patient having had any past complications from HIV/AIDS. Vital signs include a HR of 92 bpm, BP 127/60 mm Hg, RR 20 breaths/minute, and T 38.8°C. On examination, his lungs are clear and his abdomen is nontender. He is awake and attempting to answer questions but is disoriented. Noncontrast computed tomography of the head reveals an area of hypoattenuation with surrounding edema in the left frontal lobe. What is the most likely diagnosis?
- A HIV encephalopathy
- B Primary central nervous system lymphoma
- C Progressive multifocal leukoencephalopathy
- D Toxoplasma gondii
B Primary central nervous system lymphoma
Patients with HIV encephalopathy (A) typically present with memory loss, depression, and movement disorders. Fever is not usually associated with the illness. Additionally, a mass lesion will not be seen on CT of the head. Magnetic resonance imaging may show multiple hyperintense signals in the subcortical white matter. Progressive multifocal leukoencephalopathy (C) is a demyelinating disease that also does not present with a mass lesion on head CT. Patients with this disorder typically present with neurologic deficits and cognitive impairment. The most common cause of mental status changes and fever in patients with HIV/AIDS is Toxoplasma gondii (D). Patients with this infection typically have a CD4 cell count less than 100 cells/microliter. However, Toxoplasma gondii lesions are generally multiple rather than solitary. Magnetic resonance imaging of the brain is required to differentiate primary central nervous system lymphoma from Toxoplasma gondii. 
400
Which of the following AV nodal blocks is most commonly associated with an acute inferior wall myocardial infarction?
- A First degree
- B Third degree
- C Type I second degree (Wenckebach)
- D Type II second degree
C. Wenckebach (Type 1 second degree)
10% of inferior wall MI have this
400
Which of the following best classifies the fracture shown in the image above?
- A Salter-Harris type I
- B Salter-Harris type II
- C Salter-Harris type III
- D Salter-Harris type IV
II - above the growth plate
400
A 63-year-old man with a history of chronic alcohol use presents to the emergency department for generalized weakness. Vital signs are within normal limits for his age. He denies recent trauma. Which of the following physical exam findings suggests vitamin C deficiency in this patient?
- A Decreased proprioception
- B Mee lines
- C Perifollicular hemorrhages
- D Xanthelasma
C. Perifollicular hemorrhages
Decreased proprioception (A) may be a sign of vitamin E deficiency, which can cause axonal degeneration of the posterior columns and spinocerebellar tracts of the central nervous system. Mee lines (B) are horizontal white or hypopigmented lines on the finger nails seen in arsenic or heavy metal poisoning. Xanthelasma (D) are yellow-colored papules or plaques, typically found on the eyelids, as a result of hypertriglyceridemia.
400
A 62-year-old woman presents to the ED with acute onset of double vision and headache. On exam, you note the left eye is looking laterally and slightly downward, while the right eye is looking directly at you. Her left pupil is dilated and poorly reactive to light. A CT scan of her brain is normal. Which of the following is the most appropriate next step in management?
- A Epley maneuver
- B Lumbar puncture
- C Slit-lamp examination
- D Tonometry
The patient presents with a headache and isolated third cranial nerve palsy. The muscles innervated by the third cranial nerve move the eye primarily upward and inward. Third cranial nerve lesions present with the eye looking laterally and slightly downward (down and out). A complete third cranial nerve lesion involves motor fibers and the fibers of pupillary constriction. Therefore, complete lesions also present with a dilated pupil nonreactive to light. A sudden onset of a complete third cranial nerve lesion in nontraumatic patients should be considered the result of compression of the third cranial nerve by an aneurysm of the posterior communicating artery. Given that the patient has a normal head CT scan, a lumbar puncture should be performed to evaluate for subarachnoid blood. CT angiography of the brain is a reasonable alternative to lumbar puncture in experienced centers.
400
A 30-year-old woman presents to the emergency department with a new onset of a rash. She has no significant past medical history but is known to the emergency department for the treatment of frequent sexually transmitted infections. She denies any preceding genital ulcers. Vital signs are all unremarkable. Physical examination is remarkable for the rash noted above, which appears pustular in nature. Which of the answer options below is the most appropriate treatment for her condition?
- A Acyclovir 5% topical
- B Ceftriaxone 1 g IM daily for 2 days followed by cefixime bid for 1 week
- C Ceftriaxone 250 mg IM with azithromycin 1 g PO
- D Penicillin G 2.4 million units IM once
B. Rocephin 1g IM daily for 2 days (ouch) followed by cefixime bid for 1 week
Complications related to gonorrheal infections include ectopic pregnancy, chronic pelvic pain, and pelvic inflammatory disease. If left untreated, disseminated gonococcal infections can occur and present with petechiae or pustular acral skin lesions with an erythematous base, asymmetric arthralgias, tenosynovitis or septic arthritis, and fevers or malaise. This patient has a rash consistent with disseminated gonococcal infection and requires treatment with ceftriaxone 1 g IM/IV daily for 2 days followed by cefixime bid for a minimum of 1 week.
500
A 67-year-old woman presents with gradually worsening exertional dyspnea and lower extremity edema. She is diagnosed with constrictive pericarditis. Which of the following is the definitive treatment for this condition?
- A Diuretic medications
- B Nonsteroidal antiinflammatory medications
- C Pericardiectomy
- D Pericardiocentesis
C. Pericardiectomy
500
A 65-year-old man presents, complaining of severe right-sided frontotemporal headache, which began acutely two hours prior to arrival as he was reaching up to change a light bulb. The pain radiates through his anterior right neck and shoulder and is described as dull, throbbing, and pulsatile. The patient notes numbness and weakness of his left arm and hand. Past medical history is unremarkable. Physical exam demonstrates normal vital signs, a right-sided ptosis, a right pupil 2 mm in diameter and unreactive, and a 4 mm reactive left pupil. The patient's left upper extremity demonstrates pronator drift and diminished grip strength. Noncontrast head CT is negative for acute hemorrhage or mass. What is the most appropriate treatment for this patient's condition?
- A Consult cardiothoracic surgery for operative intervention
- B Consult neurosurgery to perform a coiling procedure
- C Consult neurosurgery to perform an extraventricular drain to lower intracerebral pressure
- D Systemic anticoagulation
- E Systemic thrombolytic therapy
E Systemic thrombolytic therapy
500
A 31-year-old woman with a history of depression and a previous suicide attempt by an overdose of her medications presents to the emergency department with polyuria and polydipsia for 1 week. She indicates she was diagnosed with diabetes in the past, but she did not like the medication that was prescribed to her. Metformin caused her to have abdominal cramping and diarrhea, so she stopped taking it. Her examination is unremarkable. Laboratory tests confirm uncomplicated diabetes with a glucose of 498 mg/dL without ketosis or an elevated anion gap. Her other electrolytes are within normal limits. After adequate hydration therapy and confirmation of an improved glucose level, you find the patient appropriate for discharge to follow up with her primary doctor. Which of the following medications is safest for use in this patient?
- A Glipizide
- B Insulin glargine
- C Repaglinide
- D Rosiglitazone
D. Rosiglitazone
Need to know drugs that can cause hypoglycemia
500
A 45-year-old woman presents, complaining of one day of vision loss in her left eye associated with a left retro-orbital headache. She denies trauma or preceding illness. On exam, her vital signs are T 36.8°C, BP 112/80 mm Hg, HR 74 bpm. Visual acuity is 20/20 in the right eye, 20/400 in the left eye, and 20/40 using both eyes. She has a left-sided afferent pupillary defect. Visual field testing reveals left-sided central vision loss. Which of the following is most accurate regarding her condition?
- A Strict blood glucose control reduces the likelihood for future recurrences
- B The diagnosis is confirmed by measurement of an intraocular pressure > 20
- C The diagnosis is made by magnetic resonance venography
- D The syndrome is associated with multiple sclerosis
- E Therapy should be aimed at removing the acute obstruction of the ophthalmic artery
D. Associated with MS
The patient’s exam is consistent with optic neuritis, an acute monocular loss of vision caused by focal demyelination of the optic nerve. Most cases are retrobulbar and do not involve any visible changes on funduscopy (especially during an acute episode). But on occasion and with more protracted cases, optic disk pallor may be seen. An afferent pupillary defect, however, is always present. Approximately 30% of patients presenting with acute optic neuritis develop multiple sclerosis (MS) within 5 years. The classic clinical syndrome of MS consists of recurring episodes of neurologic symptoms that rapidly evolve over days and slowly resolve. 
500
Several individuals have presented to your Emergency Department with lesions similar to those shown above over the last 2 days. Each patient also reports a prodrome of fever, malaise, and back pain. Upon further investigation, they all returned from London on the same flight recently. Which of the following is the most likely diagnosis?
- A Rubella
- B Rubeola
- C Varicella
- D Variola
D. Variola (Smallpox)
These patients are presenting with signs and symptoms consistent with variola, also known as smallpox. This disease was eradicated in 1979 as declared by the WHO and routine vaccination is no longer performed. It is an airborne pathogen and is a potentially devastating biological weapon. In this scenario, it was likely deployed as part of a terrorist attack given multiple patients with a common potential exposure. Signs and symptoms of smallpox include a prodrome of fever, myalgias, back pain, and malaise. The classic rash consists of macules and papules that progress to pustules, which coalesce in a centrifugal distribution, on the face and limbs more than the trunk and often developing first on the face and oral mucosa. These pustules are deep-seated, firm, and well-circumscribed. They progress slowly with each stage lasting 1-2 days. Unlike varicella, the smallpox lesions appear generally at the same stage of development. Diagnosis is usually clinical, but must be confirmed by viral swab of oral mucosa or an open pustule. Management begins with containment. The patients should be placed in immediate contact and droplet isolation as should family members and close contacts. The CDC and local law enforcement should be contacted immediately. Vaccination and immunoglobulin during the first few days of exposure may attenuate disease severity. Supportive care is the primary therapy once the rash appears. Untreated mortality of smallpox is approximately 30%
Rubella (A) or the German measles classically presents with a mild fever, marked postauricular and suboccipital lymphadenopathy and a nonspecific, diffuse, erythematous, maculopapular rash. Rubeola (B) or the measles classically presents with a prodrome of cough, conjunctivitis, and coryza followed by the development of Koplik spots, which are tiny red spots with a white and bluish hued center that appear on the buccal mucosa opposite the lower molars. Finally, patients develop an erythematous, maculopapular rash beginning at the hairline and then spreading from the head to the feet over ~3 days. Varicella (C) presents with a rash that is initially maculopapular, but then becomes vesicular with lesions occurring in crops and at multiple stages of development. These lesions will spare the palms and soles.