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Question 1

Sickle cell disease is associated with an increased risk of priapism due to altered blood viscosity and resulting venous obstruction. Initial management of priapism includes ???

Answer 1

aspiration of blood from the corpora cavernosa, often followed by intracavernous injection of phenylephrine.

Question 2

Hemorrhagic shock is the most common type of shock in trauma patients. Areas where large amounts of blood can be lost (or hidden) are “the floor” (external bleeding) “and 4 more”: ???

Answer 2

chest, abdomen, pelvis/retroperitoneum, and thigh.

Question 3

??? lines can be placed rapidly when emergency access is necessary and peripheral access cannot be obtained.

Answer 3

Intraosseous

Intraosseous access can be performed with less required skill and practice than central venous access.

Question 4

In cases of traumatic amputation, the amputated part should be transported how??

Answer 4

by wrapping it in saline-moistened gauze, sealing it in a plastic bag, and placing the bag in a bath of ice water. Cooling of the amputated part prolongs the window for replantation.

Question 5

All trauma patients should be triaged using the Glasgow coma scale (GCS), which can predict the severity and prognosis of coma, during the primary survey. The GCS assesses which 3 components ?

Answer 5

the patient’s ability to open his/her eyes, motor response, and verbal response.

Question 6

patient with chronic lower abdominal pain and several normal evaluations requires screening for ?? particularly in women of childbearing age, with increased incidence during times of stress or social changes (eg, marriage, postpartum, moving in with partner).

Answer 6

intimate partner violence (IPV).

Question 7

patient’s presentation—muscle weakness, dark urine, decreased urine output, elevated creatinine, and blood on urinalysis without a significant number of red blood cells (RBCs) on urine microscopy—is consistent with ???

Answer 7

rhabdomyolysis

Question 8

which drugs can cause rhabdo?

Answer 8

primarily statins, colchicine, ethanol, cocaine

Question 9

Patients with rhabdomyolysis are at risk of developing ??? due to both intravascular volume depletion and pigment-induced nephropathy

Answer 9

acute kidney injury

Question 10

Treatment of rhabdomyolysis involves ???

Answer 10

aggressive volume resuscitation to replace intramuscular and intravascular fluid. Affected muscle groups must be monitored closely because the initial tissue damage and subsequent volume replacement create a risk for acute compartment syndrome.

Question 11

Manifestations of ?? include flank pain, nausea, and vomiting; urinalysis demonstrates hematuria and proteinuria without casts. A wedge-shaped cortical infarction on CT scan is diagnostic.

Answer 11

renal infarction

Question 12

Patients with hyperkalemia who develop arrhythmias or other significant ECG changes should be treated rapidly with

Answer 12

intravenous calcium to stabilize the cardiac myocyte

Temporary measures (eg, intravenous insulin plus glucose) and definitive treatment (eg, dialysis) to reduce serum potassium should follow calcium administration.

Question 13

Patients with the syndrome of inappropriate antidiuretic hormone secretion who are asymptomatic or have mild symptoms usually respond to fluid restriction. Patients with severe symptoms require treatment with ???

Answer 13

hypertonic (3%) saline.

Question 14

Ingestion of ??? is unique among the most common toxic alcohol ingestions because it presents with a normal anion gap (eg, 10 mEq/L in this patient) and the absence of acidosis (suggested by the normal serum bicarbonate in this patient).

*also no signs of ethanol in blood

Answer 14

isopropyl alcohol

*no treatment required

Question 15

what are the three reasons for urology consult for kidney stone?

Answer 15

1. urosepsis
2. stone >10mm
3. no stone passage in 4-6 weeks

Question 16

what is the management of kidney stone <10mm, no sepsis?

Answer 16

can be discharged home,

hydration, pain control, alpha blockers (tamsulosin), and strain urine

Question 17

Postictal lactic acidosis commonly occurs following a tonic-clonic seizure. If metabolic acidosis is found on labs what to do?

Answer 17

repeat labs in 2 hours

It is a transient anion gap metabolic acidosis that resolves without treatment within 90 minutes following resolution of seizure activity.

Question 18

??? presents with flank pain, low-volume voids with or without occasional high-volume voids, and, if bilateral, renal dysfunction.

Answer 18

obstructive uropathy

​​​​​​​Intermittent episodes of high-volume urination can occur when the obstruction is overcome by a large volume of retained urine (post-obstructive diuresis)

Question 19

Magnesium toxicity can occur from increased intake of magnesium-containing compounds, especially in patients with impaired renal function. Toxicity classically causes ???

Answer 19

neuromuscular effects (eg, decreased deep tendon reflexes, weakness, respiratory depression) and cardiovascular effects (eg, bradycardia, hypotension).

Question 20

Protracted vomiting can cause ??? Patients typically have severe chest/back pain and may have pneumomediastinum with crepitus or a precordial crunching sound on auscultation (Hamman sign).

Answer 20

esophageal rupture (Boerhaave syndrome).

Esophageal perforation is a surgical emergency.

Question 21

what is this finding ?

Answer 21

perforated peptic ulcer

Peptic ulcer disease can be complicated by perforation, revealed as intraperitoneal free air. Emergent surgical exploration is indicated for patients with severe symptoms and a systemic inflammatory response.

Question 22

Complete small-bowel obstruction usually presents with nausea, vomiting, abdominal bloating, and dilated loops of bowel on abdominal x-ray. what are the most common etiology ???

Answer 22

Adhesions, typically postoperative

Question 23

Thrombosed external hemorrhoids usually appear as purple or blue anal bulges below the dentate line and may cause severe pain. Although conservative management (eg, fiber, stool softeners, topical anti-inflammatories and antispasmodics) is usually indicated, patients with severe pain should undergo ???

Answer 23

hemorrhoidectomy under local anesthesia.

Question 24

Sigmoid volvulus occurs when a segment of sigmoid colon twists on its mesentery, forming a closed-loop obstruction that often appears on abdominal x-ray as a dilated, inverted, U-shaped loop (“coffee bean” sign). ??? are risk factors.

Answer 24

Chronic constipation and colonic dysmotility

Question 25

Sudden-onset, severe abdominal pain and anion-gap metabolic acidosis should raise suspicion for acute mesenteric ischemia. Most cases arise in the setting of thromboembolism (eg, atrial fibrillation). Diagnosis is generally made with ???

Answer 25

CT mesenteric angiography.

Question 26

patient with fever, right upper quadrant (RUQ) pain, and gas in the gallbladder wall has clinical manifestations of acute ???, a life-threatening form of acute cholecystitis due to infection with gas-forming bacteria (eg, Clostridium, some Escherichia coli strains). Predisposing factors include relative immunosuppression (eg, age >50, diabetes mellitus) and vascular disease (eg, compromised cystic artery blood supply, atherosclerosis). Crepitus in the abdominal wall adjacent to the gallbladder is occasionally detectable. Complications include gangrene and perforation, the latter of which may transiently relieve pain but subsequently result in peritoneal signs.

Answer 26

emphysematous cholecystitis

Question 27

Young women on prolonged oral contraception are at greatest risk for which liver mass??. Although most lesions are benign and asymptomatic, life-threatening complications such as malignant transformation or rupture can occur. Rupture should be suspected in the setting of sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock.

Answer 27

hepatic adenoma

Question 28

Patients with upper gastrointestinal bleeding who have a depressed level of consciousness and ongoing hematemesis should be ???

Answer 28

intubated to protect the airway as a part of initial stabilization and resuscitation

prompt endoscopic treatment with ligation or sclerotherapy should then be performed to stop the bleeding

Question 29

Although constipation and advanced age are risk factors for both types of volvulus, patients with ??? volvulus tend to be younger and often report prior self-resolving episodes because many have a congenital mobile cecum (ie, mesentery failed to fuse with the parietal peritoneum).

Answer 29

cecal

tx with emergency laparotomy and resection of volvulized colon

Question 30

which procedure is indicated for gallstone pancreatitis ?

Answer 30

Endoscopic retrograde cholangiopancreatography is required to relieve the biliary obstruction and prevent serious infectious complications.

Question 31

2-week-old with previously normal feeding and stooling patterns has new-onset bilious emesis and abdominal distension concerning for ??? Additional signs and symptoms include poor feeding, dehydration (eg, dry mucous membranes, sunken fontanelle), and/or hypovolemic shock

Answer 31

malrotation with midgut volvulus (ie, intestinal torsion).

Question 32

all hemodynamically stable infants with bilious emesis and a nondiagnostic x-ray, as seen in this patient, warrant an ??? to evaluate for midgut volvulus.

Answer 32

upper gastrointestinal (GI) series

Question 33

Sigmoid volvulus often presents as slowly progressive abdominal discomfort/distension in an elderly patient and a “coffee bean”–shaped dilated loop of colon on abdominal x-ray. Patients without perforation or peritonitis can undergo ??? to reduce the twisted segment and avoid emergency surgery

Answer 33

flexible sigmoidoscopy

Question 34

patient with a negative abdominal CT scan following blunt abdominal trauma (BAT) (eg, handlebar impact) now has persistent upper abdominal discomfort and nausea accompanied by a low-grade fever and a large upper abdominal fluid collection. This presentation is most concerning for ???

Answer 34

pancreatic duct injury, with resulting leakage of inflammatory pancreatic juice leading to accumulation of peripancreatic fluid.

Ductal injury may require cholangiopancreatography for diagnosis. Some (eg, low-grade) pancreatic injuries can be managed nonoperatively, but most ductal injuries require surgical intervention.

Question 35

penetrating abdominal trauma (PAT) (ie, stab wound) to the left upper quadrant with possible injury to underlying organs (eg, stomach, small bowel, spleen). In addition to tachycardia (ie, possible early hemorrhagic shock), the patient has peritonitis (rigidity, diffuse tenderness). This presentation is highly concerning for intraabdominal injury with ongoing hemorrhage and warrants ???

Answer 35

immediate exploratory laparotomy.

Question 36

Patients with penetrating abdominal trauma and hemodynamic instability, peritonitis, evisceration, or impalement should undergo ???

Answer 36

exploratory laparotomy

Question 37

Persistent pneumothorax and large air leak despite tube thoracostomy in the setting of blunt chest trauma suggest ??

Answer 37

tracheobronchial rupture

Question 38

Tracheobronchial injury should be considered in trauma patients with extensive extrapulmonary air. Classic findings are rapid, large air leak into the chest-tube drainage system and persistent pneumothorax/pneumomediastinum despite tube thoracostomy. ?? is the definitive test for diagnosis; high-resolution CT scan can diagnose major injuries but may miss small tears

Answer 38

Bronchoscopy

Question 39

Acute bacterial prostatitis is characterized by fever, dysuria, and a swollen, tender prostate. Most cases are caused by coliform organisms (eg, Escherichia coli) that have contaminated the urethra and entered the prostate via intraprostatic urinary reflux. Urine culture is required to define the underlying pathogen, but 6 weeks of therapy with ??? is generally required to ensure eradication.

Answer 39

trimethoprim-sulfamethoxazole or a fluoroquinolone

Question 40

patient’s fever, dysuria, leukocytosis, and tender, swollen prostate indicate acute bacterial prostatitis (ABP). In ABP, prostatic swelling can sometimes impinge the urethra and cause difficulty voiding or acute urinary retention (with renal insufficiency). A ??? is generally required for decompression because passage of urethral catheters can lead to sepsis (dislodging of bacteria from infected prostate) or prostatic rupture

Answer 40

suprapubic catheter

Question 41

Blood transfusion should be initiated early in patients with hemorrhagic shock. Group ??? should be transfused immedietly

Answer 41

O, Rh D-negative blood (universal donor)

while waiting for type-specific blood to be available

Question 42

Blood products should be administered early in patients with signs of hemorrhagic shock. They should be administered in a ratio of ??? (fresh frozen plasma/packed red blood cells/platelets) to reduce coagulopathy, a leading contributor to mortality in trauma patients.

Answer 42

1:1:1

Question 43

Hematuria in the setting of direct penile trauma is concerning for urethral injury and should prompt ???

Answer 43

retrograde urethrography.

Retrograde urethrography involves x-ray of the urethral tract following injection of radiopaque contrast through the urethral meatus. Extravasation of contrast from the urethra is diagnostic of urethral injury. Urethrography should precede any attempts at urethral (eg, Foley) catheterization because catheterization can worsen the injury, potentially converting a partial urethral tear into a complete urethral laceration

Question 44

what is the appropriate method of fluid resuscitation in setting of hemorrhagic shock?

Answer 44

Balanced resuscitation, which restricts crystalloid use and uses blood products to maintain a blood pressure just sufficient for tissue perfusion (ie, permissive hypotension) until hemorrhage is controlled, can decrease these adverse effect

Large-volume crystalloid resuscitation increases coagulopathy, hypothermia, and mortality in trauma patients.

Question 45

All patients with smoke inhalation should be suspected to have acute carbon monoxide (CO) poisoning and treated with ??? . Early symptoms of CO poisoning are typically neurological and include agitation, confusion, and somnolence.

Answer 45

100% oxygen via a nonrebreather facemask

Question 46

Organophosphates are acetylcholinesterase inhibitors that are primarily used as agricultural pesticides. Toxicity is characterized by signs of cholinergic excess (eg, miosis, bronchospasm, muscle fasciculations/weakness, diarrhea, vomiting, lacrimation) and can rapidly lead to respiratory failure. Management includes first ??? and treatment with atropine followed by pralidoxime.

Answer 46

decontamination (removal of clothes, irrigation of skin) to prevent cutaneous absorption

Question 47

severity of esophageal injury cannot be predicted by either clinical symptoms or the extent of oral injury seen on physical examination with consumption of alkaline or acidic solution. Therefore, in the absence of perforation or severe respiratory distress,??? within the first 24 hours is recommended to assess the severity of esophageal damage

Answer 47

upper endoscopic evaluation

Question 48

patient has had a traumatic avulsion of a permanent tooth, and the tooth is present. what is the management???

Answer 48

The tooth and the socket should be rinsed gently with normal saline and then reimplanted.

Question 49

Patients with epiglottitis who develop rapid-onset respiratory failure (eg, tripod position, hypoxia, drooling, tachypnea) require urgent airway management. This includes bag-valve-mask ventilation with 100% oxygen followed by endotracheal intubation with advanced equipment (eg, video laryngoscope). A single failed attempt at video-assisted endotracheal intubation should prompt ???

Answer 49

surgical cricothyrotomy, which bypasses the epiglottal swelling and potential obstruction.

Question 50

Patients with a Loxosceles reclusa (brown recluse) spider bite initially have a small, red papule that can progress to form a larger necrotic wound (loxoscelism). management??/

Answer 50

Most cases will resolve with the application of cold packs and local wound care.

Question 51

patient with recurrence of anaphylactic symptoms (eg, hives, wheezing, emesis) after initial resolution is having a biphasic anaphylactic reaction and should be treated with ???

Answer 51

an additional dose of intramuscular (IM) epinephrine.

Question 52

patient has decreased vision and signs of ocular inflammation/infection (eg, conjunctival chemosis [ie, edema], layering leukocytes in the anterior chamber) after recent cataract surgery. This combination of findings is consistent with ???? a vision-threatening bacterial (or, less commonly, fungal) infection of the intraocular space that most commonly occurs within one week of surgery

Answer 52

postoperative endophthalmitis

Question 53

In the absence of obvious open globe injury (OGI), suspected corneal injury should be assessed with ???

Answer 53

fluorescein staining. Localized fluorescein uptake is diagnostic of corneal abrasion, whereas fluorescein uptake followed by clearing in a waterfall pattern (Seidel sign) is concerning for full-thickness corneal laceration with OGI.

Question 54

patient whose eye was injured by a tree branch has persistent pain, tearing, and foreign body sensation, concerning for a ??

Answer 54

corneal injury (eg, abrasion, laceration)

Question 55

??? presents with acute eye pain and vision loss after a trauma. Examination shows a tight orbit characterized by a rock-hard eyelid, periorbital edema, proptosis, and resistance to retropulsion (ie, pushing on the eye).

Answer 55

Orbital compartment syndrome (OCS)

Question 56

Corneal abrasion is diagnosed with fluorescein stain and, in contact lens users, is treated with ???

Answer 56

topical antibiotics that provide antipseudomonal coverage (eg, fluoroquinolones).

Question 57

??? presents with an acute onset of severe eye pain and blurred vision associated with nausea and vomiting. Examination reveals a red eye with steamy cornea and moderately dilated pupil that is non reactive to light.

Answer 57

Angle closure glaucoma occurs predominantly in people aged 55-70 years

Question 58

initial management of acute angle close glaucoma ?

Answer 58

Combination therapy with multiple topical agents is recommended; a typical regimen includes timolol (which reduces aqueous production), apraclonidine (which decreases aqueous production and increases outflow), and pilocarpine (which causes ciliary muscle contraction to open the trabecular meshwork at the corneal angle) eye drops. In addition, oral or intravenous acetazolamide is recommended to rapidly reduce further production of aqueous humor. Subsequently, laser iridotomy can facilitate aqueous outflow and provide definitive management.

Question 59

Patients with mild snake bite envenomation should be managed how?

Answer 59

observed closely for 12-24 hours following the event. Repeat wound examinations and laboratory evaluation are important. Most medically significant snakebites in North America can be treated appropriately with antivenom if symptoms progress

Question 60

Acute iron poisoning can occur after accidental ingestion of prenatal vitamins and presents with abdominal pain, hematemesis, shock, and anion gap metabolic acidosis. ??? is the primary therapy.

Answer 60

Deferoxamine, a chelating agent that binds free iron, forming a complex that can be renally excreted

Question 61

Cyanide is a rapidly lethal toxin that may be produced in house fires. Patients with clinical features concerning for cyanide poisoning (eg, reddish skin, lactic acidosis) should be treated empirically with ??? .

Cyanide inhibits oxidative phosphorylation, halting aerobic metabolism and forcing a switch to anaerobic metabolism that results in lactic acidosis (eg, pH 7.15, lactic acid 25). Because tissues cannot effectively use oxygen, venous blood remains saturated with oxygen and appears bright red (causing reddish-colored skin).

Answer 61

hydroxocobalamin

Question 62

Tricyclic antidepressant overdose can present with CNS, cardiac, and anticholinergic findings. ??? is used to treat cardiac toxicity, which is characterized by prolonged QRS duration (>100 msec) and ventricular arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).

Answer 62

Sodium bicarbonate

Question 63

Difference in tx for hypothermia?

Mild: 32-35 C (90-95 F) Tachycardia, tachypnea, Ataxia, dysarthria, increased shivering

Moderate: 28-32 C (82-90 F): Bradycardia, lethargy, hypoventilation, decreased shivering, atrial arrhythmias

Severe: <28 C (82 F): Coma, cardiovascular collapse, ventricular arrhythmias

Answer 63

Mild hypothermia: passive external warming (remove wet clothing, cover with blankets)

Moderate hypothermia: active external warming (warm blankets, heating pads, warm baths)

Severe hypothermia: active internal rewarming (warmed pleural or peritoneal irrigation, warmed humidified oxygen)

Question 64

Characteristics of acute and chronic salicylate toxicity include vomiting, tinnitus, pulmonary edema, hyperthermia, tachypnea, and an anion gap metabolic acidosis. ??? is indicated in patients with altered mental status, pulmonary edema, renal failure, and persistent acidosis.

Answer 64

Hemodialysis

**sodium bicarbonate is also a therapy possible

Question 65

patient’s initial symptoms (ie, gradual headache, sleep difficulty, dyspnea with exertion) are likely due to acute mountain sickness (AMS). The development of drowsiness suggests progression to ???, a rare, life-threatening emergency

Answer 65

high-altitude cerebral edema (HACE)

Question 66

Acute mountain sickness vs high-altitude cerebral edema treatment ??

Answer 66

AMS: acetazolamide or O2

HACE: dexamethasone; definitive treatment requires immediate descent.

Question 67

​​​​​​​Initial management of frostbite starts with rapid rewarming of affected tissues in a warm water bath. For patients with persistent signs of tissue ischemia (sensory loss, gray appearance, absent capillary refill), studies such as ??? can help identify those who would benefit from thrombolysis (tPA)

Answer 67

angiography or technetium-99m scintigraphy

Question 68

Decompression sickness in divers is caused by rapid ascent to the surface that leads to formation of nitrogen bubbles in the tissues and bloodstream. It is diagnosed clinically, and the definitive treatment is ???

Answer 68

hyperbaric oxygen therapy.

Question 69

Large local reactions can be treated successfully with ???

Answer 69

antihistamines and topical steroids.

Question 70

Exercise-associated ??? occurs in conditioned athletes and is caused by the sudden decrease in venous return after cessation of exercise, which fails to meet increased cardiac demand. It is characterized by collapse (with no loss of consciousness) immediately after completion of exercise

**No LOC

Answer 70

postural hypotension

Question 71

High-pressure injection injury is a limb-threatening condition. The entrance wound may look deceptively benign, but the injected material can spread into the hand and forearm, leading to tissue ischemia, necrosis, and compartment syndrome. Given the high risk of amputation, what management??

Answer 71

surgical debridement and fasciotomy should be performed immediately.

Question 72

Clavicle fracture can injure the underlying brachial plexus and subclavian artery. Hard signs of arterial injury (eg, absent pulses, distal ischemia) require immediate surgical intervention. Soft signs of vascular injury (eg, unexplained hypotension, stable hematoma, reduced pulse) warrant ???

Answer 72

CT angiography for further evaluation.

Question 73

?? hip dislocation commonly occurs in head-on motor vehicle collisions in which the knee strikes the dashboard. The leg appears shortened and internally rotated. Complications include sciatic nerve injury (eg, impaired dorsiflexion) and arterial injury with avascular necrosis of the femoral head.

Answer 73

Posterior

Question 74

iolent muscle contractions (eg, seizure, electrocution injury) can cause ??? shoulder dislocation. On examination, the arm is held in adduction and internal rotation, with flattening of the anterior aspect of the shoulder. X-ray shows loss of the normal relation between the humeral head and glenoid and internal rotation of the humeral head.

Answer 74

posterior

Question 75

best evaluated on physical examination with the calf squeeze test, which simulates gastrocnemius contraction. Absent foot plantar flexion in response to calf squeeze is consistent with ???

Answer 75

Achilles tendon rupture.

Question 76

Humeral neck fractures may become further displaced with closed reduction attempts, increasing the risk for avascular necrosis of the humeral head. Therefore, dislocation associated with humeral neck fracture typically requires ???

Answer 76

open surgical repair.

Question 77

Cat bites are at high risk of infection due to inoculation of bacteria into deep puncture wounds. ??? has activity against Pasteurella multocida and oral anaerobes and is the first-line agent for antibiotic prophylaxis.

Answer 77

Amoxicillin with clavulanate

Question 78

patients with known or suspected measles should be isolated and placed on ?? precaution

Answer 78

airborne precautions (negative pressure room, N95 face mask for health care personnel)

Question 79

Patients develop symptoms rapidly with systemic (fever, chills, malaise) and local compressive (eg, mouth pain, drooling, dysphagia, muffled voice, airway compromise) manifestations. Physical examination findings are often striking due to mass effect from edema. The submandibular area is usually tender and indurated, and the floor of the mouth is often elevated, displacing the tongue.

Answer 79

Ludwig angina is a rapidly progressive cellulitis of the submandibular space. Most cases arise from dental infections in the mandibular molars that spread contiguously down the root into the submylohyoid (and then sublingual) space. The infection is usually polymicrobial with a mixture of oral aerobic (eg, viridans streptococci) and anaerobic bacteria

Question 80

Puncture of the thin soft tissue overlying the hand metacarpophalangeal joints (eg, clenched-fist punch to the human mouth) can result in septic arthritis, presenting with joint pain, erythema, swelling, fluctuance, and painful range of motion. Treatment requires ??

Answer 80

urgent surgical irrigation and debridement and antibiotic therapy

Intravenous (IV) antibiotics (eg, ampicillin/sulbactam) are started intraoperatively after obtaining joint cultures, and the wound is left open to drain and heal by secondary intention.

Question 81

order of LP vs. antibiotics for bacterial meningitis

Answer 81

if hemodynamically stable: LP first

if hemodynamically unstable/critically ill/status epilepticus/hypotension, administered antibiotics first

Question 82

Compartment syndrome is caused by increased pressure within an enclosed fascial space that limits perfusion. Severe pain that increases with passive stretch is a classic early feature. ??? can confirm the diagnosis.

Answer 82

Measurement of compartment pressures

Definitive management is emergency fasciotomy

Question 83

???? fractures are the most common hip fractures in older adults and most typically occur due to mechanical falls. Examination findings include shortening and external rotation of the leg compared with the contralateral side.

Answer 83

Femoral neck and intertrochanteric

Question 84

Hip dislocation should be reduced within 6 hours of injury to minimize the risk of osteonecrosis of the femoral head. Dislocation without associated fracture is usually managed with ???? reduction, whereas dislocation with fracture warrants open (ie, operative) reduction.

Answer 84

closed (ie, nonoperative)

Question 85

Positive-pressure ventilation can rapidly exacerbate tension pneumothorax (TP) and cause cardiovascular collapse. Therefore, decompression with ??should be performed prior to intubation for patients with TP who also need airway protection—an important exception to the typical order.

Answer 85

needle thoracostomy

Question 86

patient with chronic production of voluminous thick sputum, wet crackles that clear with coughing (suggestive of stagnant, viscous secretions or mucostasis), and recurrent sinopulmonary infections now presents with worsening hemoptysis. The presentation is highly suggestive of ???, a disorder characterized by vicious cycles of infection and inflammation resulting in airway dilation.

Answer 86

bronchiectasis

Question 87

chronic bronchitis vs. bronchiectasis

Answer 87

Chronic bronchitis also causes daily mucus production. However, it mainly affects individuals with a significant smoking history and generates less sputum volume relative to bronchiectasis

history of recurrent infection (typically bacterial exacerbation), copious sputum production, and hemoptysis is more consistent with bronchiectasis.

Question 88

??? typically presents with shortness of breath, cough, hypoxemia, and bilateral lung crackles. Characteristics that favor this over multifocal pneumonia include recent ascent to high altitude, the absence of leukocytes >15,000/mm3, and rapid improvement with supplemental oxyge

Answer 88

High-altitude pulmonary edema (HAPE)

multifocal pneumonia usually occurs after long stays at altitude

both are verions of high altitiude illness

Question 89

Even without chest wall fracture, blunt thoracic trauma can cause ????. Tachypnea and hypoxemia are classic symptoms, and imaging often demonstrates patchy, irregular alveolar infiltrates

Answer 89

pulmonary contusion

Question 90

Bacterial aspiration pneumonia is a common cause of hospital-acquired pneumonia, particularly in the setting of ??? medications, gastric suppressive medications, intubation, anesthesia, or nasogastric feeding. Patients typically develop fever, productive cough, and infiltrate in a dependent portion of the lung.

Answer 90

sedative or antipsychotic

Question 91

??? is a relatively common complication of endotracheal intubation. It causes asymmetric chest expansion during inspiration and markedly decreased or absent breath sounds on the left side on auscultation.

Answer 91

Right mainstem bronchus intubation

Repositioning the endotracheal tube by pulling back slightly will move the tip between the carina and vocal cords and solve the problem

Because the right mainstem bronchus diverges from the trachea at a relatively non-acute angle, an ETT advanced too far will preferentially enter into the right main bronchus.

Question 92

When foreign body aspiration is suspected, immediate ??? is performed to confirm the diagnosis and remove the aspirated object.

Answer 92

rigid bronchoscopy

Question 93

Sudden-onset respiratory distress with unilateral hyperinflation and mediastinal shift on x-ray are concerning for ???

Answer 93

foreign body aspiration

Over half of aspirated foreign bodies lodge in the right mainstem bronchus. Although x-ray may be normal, classic findings include hyperinflation distal to the obstruction (due to air trapping during expiration) and mediastinal shift away from the affected side

Question 94

Initial management of patients with burns includes administration of 100% oxygen and early assessment of the airway. In patients with strong indicators of inhalation injury (eg, oropharyngeal blistering), ??? should be performed.

Answer 94

endotracheal intubation

Question 95

Complicated parapneumonic effusions and empyemas often present with continued symptoms (fever, pleuritic pain) despite adequate antibiotic coverage for pneumonia. Chest x-ray usually shows loculation, and thoracentesis reveals fluid that is exudative with ? glucose, ? protein, ? pH Most complicated parapneumonic effusions and all empyemas require drainage (eg, chest tube) in addition to antibiotics

Answer 95

Low glucose (<60 mg/dL) due to consumption (high metabolic activity) by activated neutrophils and bacteria

Low pH (<7.2) due to anaerobic utilization of glucose by neutrophils and bacteria

High protein due to increased microvascular permeability and cellular destruction

also high WBC and LDH count

Question 96

Wheezing, a common chief complaint in children, is primarily due to asthma or a viral illness. However, sudden-onset, unilateral wheezing that is unresponsive to albuterol raises suspicion for ??

Answer 96

foreign body (FB) aspiration.

Question 97

Diagnosing anaphylaxis may be challenging in patients with confounding conditions (eg, asthma), nonclassic presentations (eg, protracted symptoms), or ongoing physiologic shifts (eg, childbirth, dialysis). ??? is the most important step in management of anaphylaxis.

Answer 97

Intramuscular epinephrine

Question 98

In patients with severe, acute asthma, elevated or inappropriately normal PaCO2 suggests respiratory muscle weakness and impending respiratory failure, which require ???

Answer 98

mechanical ventilatory support

Question 99

Altered mental status in the setting of an acute exacerbation of chronic obstructive pulmonary disease (COPD) raises suspicion for ??? and should be promptly investigated with arterial blood gas analysis.

Answer 99

symptomatic hypercapnia

The clinical manifestations of symptomatic hypercapnia are predominantly neurologic

Question 100

Patients with an acute asthma exacerbation usually have respiratory alkalosis with a low PaCO2 due to hyperventilation. A normal or elevated PaCO2 is an alarming and extremely important finding that suggests ??

Answer 100

impending respiratory failure.

Question 101

??? in patients with acute exacerbation of chronic obstructive pulmonary disease helps to unload the work of breathing and decreases mortality and need for intubation.

Answer 101

Noninvasive positive pressure ventilation

Question 102

Pulseless electrical activity (PEA) is the presence of an organized rhythm (eg, atrial fibrillation in this patient) on cardiac monitoring without a palpable pulse (or measurable blood pressure) in a cardiac arrest patient. The advanced cardiac life support (ACLS) guidelines recommend managing PEA with ??? tocardiopulmonary resuscitation (CPR) and vasopressor therapy (eg, epinephrine) achieve adequate cerebral and coronary perfusion.

Answer 102

cardiopulmonary resuscitation (CPR) and vasopressor therapy (eg, epinephrine)

Question 103

patient involved in a high-risk (eg, significant damage) motor vehicle collision (MVC) has anterior chest wall pain and tenderness, concerning for blunt chest trauma. He is hemodynamically stable and his chest x-ray and extended Focused Assessment with Sonography for Trauma (eFAST) are normal. The next step is to obtain an ??? to screen for blunt cardiac injury (BCI).

Answer 103

ECG

BCI, which most commonly occurs due to rapid deceleration with MVCs and can cause tamponade or wall rupture or be clinically silent. Sinus tachycardia, arrhythmia, or ST changes may be seen. Abnormal ECG is followed by observation for approximately 24 hours (eg, risk of fatal arrhythmias), in addition to cardiac enzyme testing and echocardiography (eg, rule out tamponade)

Question 104

which finding?

Answer 104

aortic dissection

Question 105

Intravenous ??? are the treatment of choice for the initial medical management of patients with acute aortic dissection, as they lower heart rate and blood pressure and reduce left ventricular contractility.

Answer 105

beta blockers (eg, labetalol, esmolol)

+ pain control, nitroprusside if needed, and surgical repair

Question 106

??? is the most common cause of intracoronary stent thrombosis.

Answer 106

not taking dual antiplatelet therapy (DAPT) increased thrombotic risk (eg, 6-12 months) is mitigated by the administration of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor blocker (eg, clopidogrel, prasugrel, ticagrelor).

Question 107

??? emergency causes characteristic, progressive changes on ECG (eg, peaked T waves → loss of P waves → widened QRS → sine wave pattern → asystole).

Answer 107

Hyperkalemic

Question 108

immediate defibrillation (as opposed to cardioversion) provides a high-energy shock at a random point in the cardiac cycle (unsynchronized shock) and is indicated in patients with ????

Answer 108

ventricular fibrillation or pulseless ventricular tachycardia

Question 109

Based on the Advanced Cardiac Life Support guidelines, all patients with a pulse who have a persistent tachyarrhythmia (narrow or wide complex) causing evidence of hemodynamic instability—including severe hypotension, signs of organ hypoperfusion (eg, confusion, ischemic chest pain), or acute heart failure—should undergo immediate ???

Answer 109

direct current syncrhonized cardioversion

Question 110

the cornerstone of NSTEMI medical management is ???, which should be given to all patients with no contraindications (eg, allergy, bleeding).

Answer 110

dual antiplatelet therapy (DAPT) with aspirin (which the patient already took) and a P2Y12 receptor blocker (eg, clopidogrel, prasugrel)

Question 111

Patients with NSTEMI should also receive ??? to inhibit clot formation (typically for 48 hr). In addition to DAPT, other medications that reduce morbidity and mortality rates in coronary artery disease include:

Beta blockers (reduce myocardial oxygen demand)

Statins (anti-inflammatory effects)

ACE inhibitors or angiotensin II receptor blockers (facilitate cardiac remodeling)

Aldosterone antagonists (in select patients)

Answer 111

anticoagulants (eg, heparin)

Question 112

In general, anaphylaxis is likely when symptom onset is rapid and ≥???` organ systems are affected. The most commonly used diagnostic criterion involves skin/mucosa (eg, flushing, pruritus) involvement, which occurs in >90% of patients, with cardiovascular (eg, hypotension) or respiratory (eg, stridor, bronchospasm) manifestations. However, patients with exposure to a known allergen require only hypotension for diagnosis.

Answer 112

2

Question 113

Hard signs of vascular injury include pulsatile bleeding, bruits or thrills over the injury, an expanding hematoma, and signs of distal ischemia (eg, absent pulses, cool extremities). In the presence of a penetrating injury, such signs indicate need for ???

Answer 113

urgent surgical repair.

Question 114

The ???? is involved in up to half of inferior wall MIs, which are recognized by ischemic changes in ECG leads II, III, and aVF and commonly present with atypical epigastric pain rather than classic substernal chest pain.

Answer 114

right ventricle

Question 115

Whenever inferior wall MI is suspected based on ischemic changes in the inferior ECG leads, ??? involvement should be evaluated using a right-sided precordial ECG, which is obtained via precordial lead placement in a mirror image on the right side of the chest. ST-segment elevation in lead V4R is highly accurate in confirming RVMI.

Answer 115

right ventricle

Question 116

Right ventricular myocardial infarction commonly presents with epigastric pain and nausea and is commonly associated with hypotension and bradycardia. A ??? should be obtained to confirm the diagnosis.

Answer 116

right-sided precordial ECG

Question 117

patient has a classic presentation of arterial occlusion leading to ???: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia (cool extremity), and Paralysis (6 Ps)

Answer 117

acute limb ischemia (ALI)

Question 118

As soon as acute limb ischemia is clinically diagnosed (eg, pallor, pulselessness), ??? should be initiated. This prevents thrombus propagation and distal thrombosis while the patient undergoes further diagnostic procedures or awaits surgical intervention.

Answer 118

anticoagulation (eg, intravenous heparin infusion)

Question 119

Certain medications can disrupt the normal baroreceptor response and cause or contribute to orthostatic syncope. Medications with alpha-1 receptor blocking properties like ??(4)? are particularly common precipitants of orthostatic symptoms, and patients taking concomitant exacerbating medications (eg, other vasodilators) are at greater risk of experiencing symptoms.

Answer 119

Terazosin, prazosin, doxazosin

Antipsychotics (eg, risperidone)

Antihistamines, TCAs

Question 120

which rythm?

Answer 120

wolff-parkinson white

Question 121

??? is due to rapid accumulation of a small amount of fluid within a stiff pericardium, causing a sudden rise in intrapericardial pressure. Unlike subacute tamponade, the cardiac silhouette can be normal on chest x-ray.

Answer 121

Acute cardiac tamponade

Question 122

This patient’s deficits include the following:

Weakness of bilateral, symmetric lower limbs

Sparing of the upper limbs

Upper motor neuron signs (eg, hyperreflexia, upgoing Babinski, spastic gait)

Urinary incontinence (suggesting dysfunction of the adjacent frontal lobe)

These deficits could be due to a lesion in the lower spinal cord. However, the patient’s constant headache and lack of sensory findings suggest that the lesion is located in the brain. A mass in the anterior midline of the brain attached to the falx cerebri is one possible explanation. Therefore, this woman’s symptoms are likely caused by a ???, a benign brain tumor that usually grows very slowly.

Answer 122

parasagittal (ie, parafalcine) meningioma

Question 123

.Patients with persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability with a pulse should undergo ???

Answer 123

immediate synchronized cardioversion

Question 124

patient’s ECG reveals a narrow QRS complex tachycardia with a regular rhythm and P waves obscured by the QRS complexes. These findings are consistent with ????, an episodic cardiac arrhythmia that originates above the ventricles (ie, at or above the atrioventricular [AV] node).

Answer 124

paroxysmal supraventricular tachycardia (PSVT)

Question 125

???? is the most common type of paroxysmal supraventricular tachycardia, resulting from abnormal conduction through 2 distinct atrioventricular nodal pathways. ECG typically demonstrates a narrow QRS complex tachycardia with a regular rhythm and buried (not visible) P waves. usually affects young patients (eg, age <40) with an otherwise normal heart.

Answer 125

Atrioventricular nodal reentrant tachycardia

Question 126

patient with sudden-onset, severe abdominal pain, hemodynamic instability (eg, symptomatic hypotension with weakness and diaphoresis), and flank ecchymoses likely has ??

Answer 126

ruptured abdominal aortic aneurysm (AAA). Patients age >60, smokers, men, and those with a history of atherosclerosis or connective tissue diseases are at increased risk for AAA.

Question 127

what is common here?

Sudden onset with lack of warning symptoms suggests an abrupt, extreme drop in cardiac output, which is characteristic of tachyarrhythmia (usually ventricular tachycardia), that disrupts normal ventricular filling and/or coordinated contraction.

Syncope occurs while the patient is at rest and supine; benign causes (eg, vasovagal, orthostatic) typically do not occur when the patient is in the recumbent position.

Recent palpitations suggest previous transient arrhythmic episodes.

Sudden death in a young family member (eg, age <40) raises suspicion for an inherited cardiac conduction syndrome that predisposes to ventricular tachycardia (eg, congenital long QT syndrome, Brugada syndrome).

Answer 127

red flags for cardiac syncope due to arrhythmia

Question 128

Red-flag features suggesting an arrhythmic cause of cardiac syncope include sudden onset with lack of warning symptoms, ????, history of palpitations, and family history of a young relative with a sudden, unexplained death. Ventricular tachycardia is the most common arrhythmic cause of syncope and sudden cardiac death.

Answer 128

occurrence while at rest and supine

Question 129

patient’s history may be most suggestive of ???, an autosomal dominant condition during which episodes of ventricular tachycardia can develop. The episodes commonly occur at night and may be triggered by fever (eg, influenza infection), due to hyperthermia-induced changes in sodium current that impact cardiac action potential.

Answer 129

Brugada syndrome

Question 130

This patient’s presentation - bradycardia, atrioventricular block, hypotension, and diffuse wheezing - is suggestive of ??? overdose

Answer 130

beta blocker

Question 131

Beta blocker overdose presents with bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock. Intravenous fluids and atropine are the first-line treatment options. ???? should be administered in patients with profound or refractory hypotension

Answer 131

Intravenous glucagon

Glucagon increases the intracellular levels of cyclic AMP and has been effective in treating both beta blocker and calcium channel blocker toxicity

Question 132

pericardial effusion causes what change on ECG??

Answer 132

electrical alternans

Question 133

​​​​​​​In patients with hemodynamic instability and signs and symptoms consistent with an abdominal aortic aneurysm (AAA) but without a known history, a ??? should be performed. A CT scan is helpful in symptomatic patients who are stable, while those who are unstable with a known history of AAA should undergo emergent repair.

Answer 133

focused bedside ultrasound

Question 134

In patients with underlying chronic adrenal insufficiency, acute stressors (eg, procedure, illness, trauma) can trigger adrenal crisis, which presents with hypoglycemia and severe hypotension often refractory to initial volume resuscitation. Treatment requires rapid volume repletion and administration of ????

Answer 134

hydrocortisone or dexamethasone.

Question 135

Ischemia-reperfusion syndrome is a form of ??? that occurs following reperfusion of an acutely ischemic limb. Symptoms include severe pain that is worsened on passive range of motion, paresthesias, and sensory and motor deficits. The diagnosis is confirmed by measuring compartment pressures. Definitive management includes urgent fasciotomy.

Answer 135

compartment syndrome

Question 136

As type A aortic dissections are surgical emergencies with mortality rates of 1%-2% per hour following symptom onset, confirming or excluding the diagnosis is critical. ??? is the initial study of choice in hemodynamically stable patients with no evidence of renal dysfunction. It can reveal an intimal flap separating the true and false lumens in the aorta.

Answer 136

CT angiography

Transesophageal (not transthoracic) echocardiography has excellent sensitivity and specificity and is the preferred diagnostic study in patients with hemodynamic instability or renal insufficiency;

Question 137

??? is a noninvasive test that is highly sensitive and specific for peripheral arterial disease in symptomatic patients. It is the preferred first step to confirm the diagnosis in most cases.

Answer 137

Ankle-brachial index

Question 138

​​​​​​​An ankle-brachial index of ? is considered diagnostic of occlusive PAD with a 90% sensitivity and 95% specificity in symptomatic patients.

Answer 138

0.90