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Step 2 > Emergency Medicine: Pretest > Flashcards

Emergency Medicine: Pretest Flashcards

1
Q

Which medication is typically used to treat supraventricular tachycardias?

A

Adenosine

This is an ultrashort-acting AV nodal blocking agent. Because it is so fast-acting it must be delivered through a large vein with a rapid intravenous fluid bolus. In addition to adenosine, maneuvers that increase vagal tone have been shown to slow conduction through the AV node. Some of these maneuvers include carotid sinus massage, Valsalva maneuver, and facial immersion in cold water.

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1
Q

Large R waves and inverted T waves in leads V1-V3 are indicative of what?

A

Right heart strain

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1
Q

Dysuria in young men is almost always because of what?

A

Urethritis

This is commonly sexually transmitted.

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1
Q

What are the Ranson criteria and what are they used for?

A

The Ranson criteria are used for predicting mortality rates in patients with pancreatitis. The presence of more than 3 criteria equals 1% mortality, while the presence of 6 or more criteria approaches 100%.

Ranson criteria at admission:

  1. Age > 55
  2. WBC > 16,000
  3. Glucose > 200
  4. LDH > 350
  5. AST greater than 250

Ranson criteria within 48 hours of admission:

  1. Hematocrit fall > 10%
  2. BUN rise > 5
  3. Serum calcium less than 8
  4. Arterial PO2 < 60
  5. Base deficit > 4
  6. Fluid sequestration > 6L
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1
Q

A 50% chance of passage of a renal stone occurs when the stone is what size?

A

4-6mm

6mm stones pas 10% of the time.

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1
Q

What are the 3 zones of the neck?

A
  1. Zone I: Extends superiorly from the sternal notch and clavicles to the cricoid cartilage
  2. Zone II: Area between the cricoid cartilage and the angle of the mandible
  3. Zone III: Extends from the angle of the mandible to the base of the skull

Zone II injuries are taken directly to the operating room for surgical exploration.

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1
Q

What condition is described as a polymicrobial necrotizing fasciitis of the perineal subcutaneous tissue that originates from the skin, urethra, or rectum?

A

Fournier syndrome

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1
Q

What is the single most common drug that leads to death in overdose?

A

Acetaminophen

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1
Q

What is the treatment for isoniazid-induced seizures?

A

Pyridoxine (Vitamin B6)

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1
Q

What are the potential causes of anion gap metabolic acidosis?

A
  1. Methanol, metformin
  2. Uremia
  3. Diabetic ketoacidosis
  4. Paraldehyde
  5. Iron, isoniazid
  6. Lactate
  7. Ethylene glycol, ethanol
  8. Salicylate

This can be remembered by the pneumonic MUDPILES.

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1
Q

Profound hyperglycemia without ketonuria is suggestive of what diagnosis?

A

Nonketotic hyperosmolar crisis (NKHC)

This syndrome is more common in type 2 diabetes mellitus. Patients are profoundly dehydrated because of osmotic diuresis. The mainstay of NKHC therapy consists of replacing fluid losses.

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1
Q

Postpartum eclampsia needs to be managed with what?

A

Magnesium sulfate

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1
Q

Hypertension, bradycardia, and respiratory depression make up what triad?

A

Cushing reflex

This is observed in 1/3 of patients with a potentially lethal increase in intracranial pressure.

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1
Q

What is the gold standard diagnostic approach to mesenteric ischemia?

A

Angiography

Unlike any other diagnostic tool, it is capable of both diagnosing and treating the problem.

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1
Q

Any patient presenting to the emergency department in the second or third trimester of pregnancy with bleeding should have ultrasound performed before pelvic examination to rule out what?

A

Placenta previa

Placenta previa is a contraindication to digital examination of the cervix, as placental trauma from the examination itself can lead to prfuse vaginal bleeding.

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1
Q

What is the best method of diagnosing corneal abrasions?

A

Slit-lamp examination by observing fluorescein uptake in the area of the defect

Patients wearing contact lenses should be treated with topical antibiotics with antipseudomonal coverage.

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3
Q

What is the mainstay of treatment for pericarditis?

A

Anti-inflammatory medications (I.E. NSAIDs)

An echocardiogram should be performed to rule out a pericardial effusion and tamponade.

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3
Q

What 3 medications should be given to a patient with an anaphylactice reaction to an allergen?

A
  1. Epinephrine
  2. Antihistamine (I.E. diphenhydramine, ranitidine)
  3. Corticosteroid (I.E. methylprednisolone)

Antihistamines block the action of the circulating histamines at target tissue receptors. Corticosteroids have an onset of action of 4-6 hours after administration, and therefore are of limited value in the acute setting, but should be given since giving them early may blunt to biphasic reaction of anaphylaxis.

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3
Q

What drug can be given to decrease runs of torsades des pointes?

A

Magnesium sulfate

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3
Q

Altered mental status, hyperthermia, and muscle rigidity make up the classic triad for what condition?

A

Neuroleptic malignant syndrome (NMS)

This is a rare, but fatal reaction commonly associated with the use of antipsychotics. The cornerstone of treatment is supportive care with rapid cooling, fluid and electrolyte repletion, and monitoring. Dantrolene, a nonspecific skeletal muscle relaxant, generally used in the treatment of malignant hyperthermia, is also effective for NMS.

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3
Q

What is the best method of diagnosing benign positional vertigo?

A

Dix-Hallpike maneuver

The maneuver involves having the patient go from sitting to a supine position with eyes open and head rotated to the affected side. The test is positive if the maneuver reproduces vertigo and the patient exhibits latent rotary nystagmus.

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4
Q

What intracompartmental pressure measured with a Stryker device is considered diagnostic of compartment syndrome?

A

> 30mmHg

The presence of a pulse does not rule out compartment syndrome. The only way to diagnose compartment syndrome is to measure intracompartmental pressure with a Stryker device.

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6
Q

Cardiac contusion most commonly occurs in what part of the heart?

A

Right ventricle

It is the most anterior aspect of the heart and closest to the sternum.

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6
Q

What is the fastest method of lowering intracranial pressure?

A

Hyperventilation

The onset of action is within 30 seconds.

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6
Q

Which street drug can cause significant hyponatremia?

A

3,4-Methylenedioxymethamphetamine (MDMA)

It is a potent stimulus for serotonin release which results in the excessive release of vasopressin (ADH). This combined with large free-water intake (increased thirst), and increased sodium loss from physical exertion (dancing) result in hyponatremia.

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7
Q

All patients with chest pain and shortness of breath should recieve what test?

A

Electrocardiogram (ECG)

It is a quick, noninvasive test that often provides substantive information.

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8
Q

What symptoms are characteristic of the anticholinergic toxidrome?

A

Delirium, mumbling speech, tachycardia, elevated temperature, flushed face, dry mucous membranes and skin, dilated pupils, and hypoactive bowel sounds.

This can be remembered by the phrase “Blind as a bat (mydriasis), red as a beet (flushed skin), hot as a hare (hyperthermia due to lack of sweating), dry as a bone (dry mucous membranes), and mad as a hatter (mental status change)”.

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8
Q

What is the appropriate management of a patient who presents after exposing an eye to superglue?

A

Application of large amounts of erythromycin gel in the eye

This lubricates the eye and prevents the abrasive effect.

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9
Q

What is the first-line therapy for patients with stable supraventricular tachycardia?

A

Adenosine

It is safe and effective and has a short half-life. It blocks conduction at the atrioventricular node leading to a brief period of asystole, which can be very disconcerting to those recieving or administering the medication.

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10
Q

Which medication is notorious for causeing seizures that are refractory to standard therapy?

A

Isoniazid

Pyridoxine (vitamin B6) is the treatment of choice.

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11
Q

Different degrees of paralysis and loss of pain and temperature sensation in the setting of intack position, touch, and vibratory sensation are characteristic of what?

A

Anterior cord syndrome

The hallmark is the preservation of the posterior columns, maintaining position, touch, and vibratory sensation.

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11
Q

What has proven effective for both prophylaxis and treatment of acute mountain sickness?

A

Acetazolamide

Supplemental oxygen and a descent of 1500 to 3000 feet will reverse high-altitude sickness in most cases. Nausea and vomiting can also be treated symptomatically. Hyperbaric oxygen is indicated in severe cases.

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12
Q

What must happen for “flail chest” to occur?

A

Fracture of 3 or more adjacent ribs at two points

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13
Q

What is the most common cause of arrest in children?

A

Respiratory

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14
Q

What is the most useful diagnostic test in a patient suspected to have a spinal epidural abscess?

A

Magnetic resonance imaging (MRI)

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15
Q

Respiratory depression with apnea, interrupted by periods of agitation and combativeness (especially following attempts at intubation) are a distinctive feature of intoxication with which substance?

A

Gamma-hdroxybutyrate (GHB)

GHB is a natural neurotransmitter that induces sleep. It has been sold as a muscle builder (sleep increases release of growth hormone), a diet aid, and a sleep aid. Patients with GHB overdose generally have a decreased level of consciousness. In contrast to other sedative/hynotic overdoses, the level of consciousness tends to fluctuate quickly between agitation and depression.

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16
Q

Which organ is most commonly injured as a result of blunt abdominal trauma?

A

Spleen

In approximately 66% of cases, it is the only damaged intraperitoneal organ. The liver is the second most commonly injured organ.

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17
Q

Brown-Sequard syndrome (hemisection of the spinal cord) results in what symptoms?

A
  1. Ipsilateral motor paralysis
  2. Contralateral loss of pain and temperature
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18
Q

What is the treatment for post-lumbar puncture headache?

A

A blood patch

This is done by injecting an aliquot of the patient’s blood in a sterile fashion just external to the dura mater at the same interspace where the LP occurred.

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19
Q

Which toxic alcohol does not cause metabolic acidosis?

A

Isopropyl alcohol

This is because it is metabolized to acetone, a ketone, not an acid. Isopropyl alcohol intoxication is often remembered by “ketosis without acidosis.” Another unique finding is the presence of “pseudo renal failure” or isolated false elevation of creatinine with a normal BUN. This results from interference of acetone and acetoacetate by the colorimetric method used to measure the creatinine level.

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20
Q

How does the Prehn sign help differentiate between testicular torsion and epididymitis?

A

The pain from epididymitis is relieved by physically lifting the testicle, but the pain from testicular torsion is not

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20
Q

What is the initial treatment for acute pancreatitis?

A

Supportive: bowel rest, fluid resuscitation, and analgesia

90% of patients recover without complications. Surgery is reserved for complications of alcoholic pancreatitis, such as pseudocysts, phlegmons, and abscesses.

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20
Q

How does Central cord syndrome present?

A

Greater neurological deficits in the upper extremities compared to the lower extremities

In addition, patients with central cord syndrome usually have decreased rectal sphincter tone and patchy, unpredictable sensory deficits.

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20
Q

1-2 weeks of fever, localized pain in the back, and progressive weakness is suggestive of what diagnosis?

A

Spinal epidural abscess

An elevated white blood cell count is also commonly seen. Magnetic resonance imaging is the most useful diagnostic test.

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20
Q

What are the two main therapeutic agents in treating hepatic encephalopathy?

A

Lactulose and neomycin

Serum ammonia level is usually elevated in hepatic encephalopaty. Lactulose is a poorly absorbed sugar metabolized by colonic bacteria that traps ammonia and helps excrete it in the stool. Neomycin is a poorly absorbed aminoglycoside that is believed to act by reducing colonic bacteria responsible for producing ammonia.

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21
Q

Which medication is the most effective and most rapid means of reducing preload in a patient with congestive heart failure?

A

Nitroglycerin

Nitrates decrease myocardial preload and, to a lesser extent, afterload. Nitrates increase venous capacitance, including venous pooling, which decreases preload and myocardial oxygen demand. It is most beneficial when the patient who presents with congestive heart failure is also hypertensive. It is administered sublingually, intravenously, or transdermally. By contrast, Sodium Nitroprusside is is a mixed venous and arteriolar dilator; it reduces both pre- and afterload. It can be used in patients with acute pulmonary edema, but is typically reserved for individuals with a systolic blood pressure greater than 100 mmHg who fail to respond to adequate doses of standard preload reducers.

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22
Q

What causes miliaria rubra (heat rash)?

A

Sweat gland blockage and staphylococcal infection

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23
Q

What cause of chest pain occurs at rest and follows a circadian pattern, with most episodes occurring in the early hours of the morning?

A

Prinzmetal (Variant) angina

This is caused by focal coronary artery vasospasm.

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25
Q

What is the first test that should be used to diagnose ovarian torsion?

A

Doppler ultrasound

CT scan may be necessary if the doppler study is equivocal.

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25
Q

What is the most common cause of painful rectal bleeding in the first year of life and in adults?

A

Anal fissures

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26
Q

The following signs/symptoms are characteristic of which diagnosis?

  1. Eye pain
  2. Fever
  3. impaired eye motility
  4. Decreased visual acuity
  5. Proptosis
A

Orbital cellulitis

Staphylococcus aureus and Haemophilus influenzae are common etiologies. Mucormycosis must be considered in diabetics and immunocompromised patients.

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28
Q

What is the preferred treatment for an ST-elevation myocardial infarction?

A

Primary percutaneous intervention (I.E. angioplasty or stent)

It has been shown to improve long-term mortality over thrombolytic therapy.

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30
Q

What kind of crystals are found in pseudogout?

A

Calcium pyrophosphate crystals

The synovial fluid will reveal rhomboid-shaped crystals that are weakly positively birefringent under polarized light.

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31
Q

What is the best method of managing intussusception?

A

Air enema

This is both diagnostic and therapeutic.

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32
Q

In addition to peaked T-waves, hyperkalemia can cause what two electrocardiogram (ECG) changes?

A
  1. Loss of P waves
  2. Widening of the QRS complex

Eventually the tracing assumes a sine-wave pattern, followed by ventricular fibrillation or asystole.

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32
Q

Supraventricular tachycardia that is refractory to vagal maneuvers should be treated with what?

A

Adenosine

This is a very short-acting AV nodal blocking medication.

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32
Q

The following signs/symptoms are characteristic of which diagnosis?

  1. Eye pain
  2. Blepharospasm (any abnormal contraction or twitch of the eyelid)
  3. Tearing
  4. Photophobia
  5. Foreign body sensation in eye
  6. Injected eye
  7. Punctuate lesions on corneal examination
  8. Decreased visual acuity
A

Ultraviolet keratitis (snow blindness)

This is essentially a radiation burn when an individual comes in close contact with an ultraviolet-ray-containing light source (Sun lamp, tanning bed, high altitude). Patients usually present 6-10 hours after exposure.

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33
Q

Myxedema coma is a life-threatening complication of which condition?

A

Hypothyroidism

Mortality in myxedema coma approaches 20-50% even with appropriate management.

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33
Q

What is the best method of diagnosing multiple sclerosis (MS)?

A

Magnetic resonance imaging (MRI)

Demyelinating MS lesions are often well demonstrated on MRI but cannot be visualized on computed tomography (CT).

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33
Q

What is the mainstay of diabetic ketoacidosis management?

A

Aggressive fluid resuscitation and insulin therapy

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34
Q

Which kind of fracture occurs when the head is thrown into extreme hyperextension because of abrupt deceleration?

A

Hangman’s fracture (traumatic spondylolysis of C2)

This is characterized by bilateral fractures of the pedicles. Today the most common cause of a hangman’s fracture is the result of head-on automobile collisions.

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35
Q

What disease presents as a prodrome of 1-2 days of mild headache and myalgias, followed by high fever, chills, multiple rigors, and the following associated symptoms?

  1. Pulmonary: Cough, dyspnea, chest pain, hemoptysis
  2. Gastrointestinal: Nausea, vomiting, diarrhea, anorexia
  3. Neurological: Headache, altered mental status
A

Legionnaires disease

This is caused by Legoinella pneumophila, an intracellular organsim that lives in aquatic environments.

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37
Q

What is the most common pathogen responsible for causing necrotizing otitis externa?

A

Pseudomonas aeruginosa

This is an uncommon complication of otitis externa that occurs primarily in adult diabetics and other immunocompromised individuals. It is associated with a high mortality rate.

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39
Q

Which 5 drugs can be effectively administered via endotracheal tube?

A
  1. Naloxone
  2. Atropine
  3. Versed
  4. Epinephrine
  5. Lidocaine

This is remembered by the mnemonic NAVEL.

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41
Q

A 90% chance of passage of a renal stone occurs when the stone is what size?

A

<4cm

4-6mm stones pass 50% of the time. >6mm stones pas 10% of the time.

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42
Q

A transvaginal ultrasound can typically identify a gestational sac when the beta-hCG level is greater than what level?

A

1000mIU/mL

It can identify the yolk sac when the beta-hCG level is greater than 2500 mIU/mL.

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43
Q

Fracture of the neck of the 5th metacarpal is known as what?

A

Boxer’s fracture

It is one of the most common fractures of the hand and usually occurs from a direct impact to the hand (I.E. a punch with a closed fist).

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44
Q

What is the treatment of choice for miliaria rubra (heat rash)?

A

The antibiotic Chlorhexidine

This should be used in the acute phase. Salicylic acid may also be used to assist in desquamation but should not be used on large areas because of possible salicylate intoxication.

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45
Q

What should be given to contact lens-wearing patients with corneal abrasions?

A

Antipseudomonal medication (I.E. Tobramycin or fluoroquinolone drops)

It is important to distinguish corneal abrasions from corneal ulcers. Ulcers are deeper infections of the cornea that develop from corneal epithelial defects (I.E. abrasions). Contact lens wearers are also at high risk for corneal ulcers. The hallmark of a corneal ulcer is a shaggy, white infiltrate within the corneal epithelial defect.

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47
Q

What is the hallmark of beta-blocker toxicity?

A
  1. Bradycardia
  2. Hypotension
  3. Cold extremities
  4. Low blood sugar

Onset of toxicity is usually within 4 hours of ingestion. Management consists of fluid resuscitation and atropine. Patients with significant toxicity should recieve glucagon.

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49
Q

A fundoscopic examination that reveals a macular cherry-red spot with a pale retina and less pronounced arteries is diagnostic of what condition?

A

Central retinal artery occlusion

This is commonly caused by emboli, thrombi, vasculitis, or trauma. Treatment aims to dislodge the clot from the main artery to one of its branches and includes digital massage, vasodilation, and lowering intraocular pressure.

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50
Q

What causes Horner syndrome?

A

Interrupted sympathetic nerve supply to the eye

Unilateral findings of ptosis, miosis, and anhidrosis are seen.

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51
Q

When should blood products be administered in a trauma patient?

A

When vital signs only transiently improve or remain unstable despite resuscitation with 2-3 L of crystalloid fluid

If there is obvious major blood loss and the patient is unstable, blood transfusion should be started concomitantly with crystalloid administration.

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52
Q

The following findings are consistent with which diagnosis?

  1. Muscle weakness
  2. Hyporeflexia
  3. Intestinal ileus
  4. Respiratory paralysis
  5. Electrocardiogram (ECG) changes: Flattened T waves, presence of U waves, and prolonged QT and PR intervals
A

Hypokalemia

Potassium deficiency results in hyperpolarization of the cell membrane.

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54
Q

Transverse fracture of the distal radial metaphysis, which is dorsally displaced and angulated is called what?

A

Colles fracture

This is the most common wrist fracture seen in adults.

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55
Q

What is the most common site of intracranial cerebral artery thrombosis?

A

Middle cerebral artery

Clinical findings can include contralateral hemiplegia, hemianesthesia, and homonymous hemianopsia. The upper extremity deficit is usually more severe than the lower-extremity deficit. Aphasia occurs if the dominant hemisphere is involved.

56
Q

What agent is most commonly used for rate control in the emergency department for a patient with stable atrial fibrillation?

A

Diltiazem

This is a calcium channel blocker with excellent AV nodal blocking effects. Amiodarone is also used for rate control in atrial fibrillation; however, it is not a first-line agent and is recommended to be used selectively in patients with low left ventricular ejection fraction.

58
Q

What has priority over all other aspects of resuscitation in the critically ill or injured patient?

A

Airway assessment and management

58
Q

What is the treatment for benign positional vertigo?

A

Antiemetics, antihistamines, and Epley maneuver (a series of head and body turns that reposition the canalith)

60
Q

Exposure to rust removing agents containing hydroflouric acid (HF) should be managed how?

A

Calcium gluconate gel and electrocardiogram monitoring

Fluorid avidly binds to available cations such as calcium and magnesium, thereby causing cell death. Profound hypocalcemia has been demonstrated in HF exposure.

62
Q

What condition is described as a potentially life-threatening cellulitis of the connective tissue of the floor of the mouth and neck that begins in the submandibular space and is commonly caused by an infected or recently extracted tooth?

A

Ludwig angina

The most common physical findings are bilateral submandibular swelling and tongue protrusion or elevation.

64
Q

What medication is considered first-line in treating hemodynamically stable ventricular dysrhythmias?

A

Amiodarone

Other commonly used medications include procainamide and lidocaine. Unstable arrhythmias require cardioversion.

65
Q

Which medication was shown with the strongest evidence in the ISIS-2 trial to independently reduce mortality in patients with and acute myocardial infarction?

A

Aspirin

This should be administered early to all patients suspected of have an acute coronary syndrome, unless there is a contraindication.

66
Q

What are some of the early and late symptoms of acute mountain sickness?

A
  1. Early: Nausea, vomiting, headache, and anorexia (symptoms of an acute viral syndrome)
  2. Late: Peripheral edema, oliguria, retinal hemorrhages, and finally high-altitude pulmonary or cerebral edema.
67
Q

What is the first-line treatment for a stable patient with supraventricular tacchycardia?

A

Vagal maneuvers to slow conduction and prolong the refractory period in the AV node

This can be accomplished by asking the patient to bear down as if they are having a bowel movement and hold the strain for at least 10 seconds. If vagal maneuvers fail, the next step is giving adenosine.

69
Q

What medication class other than antipsychotics can cause dystonic reactions?

A

Antiemetics

Dystonic reactions may occur with the use of dopamine-blocking agents. They respond almost immediately to administration of diphenhydramine (Benadryl).

70
Q

What 3 criteria qualify an effusion as exudative?

A
  1. LDH greater than 200 units
  2. Fluid-to-blood LDH ratio greater than 0.6
  3. Fluid-to-blood protein ratio greater than 0.5
72
Q

An isolated fracture of the shaft of the ulna is called what?

A

Nightstick fracture

This can occur after a direct blow to the ulna and usually occurs when an individual raises his or her forearm up to protect their face from a blow.

73
Q

What differentiates bacterial from fungal meningitis on examination of cerebrospinal fluid?

A
  1. Bacterial meningitis > 1000 white blood cells (WBCs), majority polymorphonucleur leukocytes, gram stain positive
  2. Fungal meningitis < 500 WBCs, majority monocytes, gram stain negative
74
Q

The diaphram is innervated by the phrenic nerve, which originates from the spinal cord at what level?

A

C3-C4

The intercostal muscles of the rib cage are supplied by nerves that originate in the thoracic spine. Therefore, abdominal breathing in the absence of thoracic breathing indicates an injury below C4.

76
Q

Which organism causes Q fever?

A

Coxiella burnetii

Patients look ill, are diaphoretic, and febrile.

77
Q

What should be used as the first-line agent for nearly all cocaine toxicities?

A

Benzodiazepines

Benzodiazepines restore the central nervous system inhibitory tone on the peripheral nervous system.

78
Q

What medication class is contraindicated in a patient with cocaine-induced acute coronary syndrome?

A

B-adrenergic antagonists

If beta-adrenergic receptors are antagonized, alpha-adrenergic receptors are left unopposed and available for increased stimulation by cocaine. This may worsen into cornary and peripheral vasoconstriction, hypertension, and possible ischemia. Therefore, benzodiazepines, which decrease central sympathetic outflow, are the cornerstone in treatment to relieve cocaine-related chest pain.

79
Q

What is the drug of choice for patients with long-QT syndrome?

A

Beta-blockers

The protective effect of beta-blockers is related to their adrenergic blockade diminishing the risk of cardiac arrhythmia. Implantation of cardioverter-defibrillators appears to be the most effective therapy for high-risk patients.

80
Q

The following findings are consistent with what diagnosis?

  1. Lethargy or coma
  2. Hypothermia
  3. Bradycardia
  4. Periorbital and nonpitting edema
  5. Delayed relaxation phase of deep tendon reflexes (areflexia in more severe cases)
A

Myxedema coma

This is a complication of hypothyroidism and can be triggered by sepsis, trauma, surgery, congestive heart failure, prolonged cold exposure, or use of sedatives or narcotics.

81
Q

Pleural effusions are most easily detected on xray when the patient is in what position?

A

Lateral decubitus with affected side down

Accumulations of 5 to 50mL of fluid can be detected with this view. Small effusions can be missed entirely on supine views and are not generally apparent on PA and lateral views until 200mL or more of fluid are present.

82
Q

What is the mainstay of treatment for thrombotic thrombocytopenic purpura (TTP)?

A

Plasmapheresis

Plasmapheresis decreases TTP mortality from 90% to 10%.

83
Q

Which vessel supplies the AV node and inferior wall of the left ventricle in 90% of patients?

A

Right coronary artery

84
Q

What position should a seizing patient be placed in?

A

Lateral decubitus

This is to prevent aspiration of gastric contents. Other initial measures are oxygen administration, pulse oxymetry, glucose level determination, and an placement of an intravenous line.

85
Q

In an emergency what blood type should be administered to a man and a woman of childbearing age?

A
  1. Men: Type O, Rh-Positive
  2. Childbearing age women: Type O, Rh-Negative
86
Q

What are the “motor response” criteria of the Glasgow coma scale?

A
  • Obeys: 6
  • Localizes: 5
  • Withdraws (pain): 4
  • Flexion (pain): 3
  • Extension (pain): 2
  • None: 1
88
Q

What is the study of choice if urethral injury is suspected?

A

Retrograde urethrogram

89
Q

What is the preferred site for insertion of a chest tube?

A

4th or 5th intercostal space at the anterior or midaxillary line

The tube should be positioned posteriorly and toward the apex so that it can effectively remove both air and fluid.

90
Q

What is the treatment of stable ventricular tachycardia?

A

Amiodarone

92
Q

Angioedema is a rare, but serious side effect of what commonly used drug class?

A

Angiotensin-converting enzyme (ACE) inhibitors

This type of angioedema is usually limited to the lips, tongue, and face.

93
Q

What true emergency in an uncircumsized male is described as fixed retraction of the foreskin beyond the glans?

A

Paraphimosis

Manual reduction is the first-line treatment.

94
Q

Compression of cranial nerve III leading to aniscoria (unequal pupils), ptosis, impaired extraocular movements, and a sluggish pupillary light reflex is indicative of what?

A

Ipsilateral uncal herniation

As herniation progresses, compression of the ipsilateral oculomotor nerve eventually causes ipsilateral pupillary dilation and nonreactivity.

94
Q

What are patients with hypertensive encephalopathy managed with?

A

Short-acting titratable intravenous antihypertensive medications such as nitroprusside or labetalol

Typically, the mean arterial pressure (MAP) should be lowered by 20-25% in the first hour of treatment.

95
Q

What is the antidote for beta-blocker toxicity?

A

Glucagon

Intravenous fluids and symptomatic treatment with norepinephrine or atropine may be required.

96
Q

What is the treatment of salicylate toxicity?

A
  1. Activated charcoal
  2. Intravenous hydration
  3. Sodium bicarbonate

Sodium bicarbonate alkalizes both the serum and the urine. Because salicylic acid is a weak acid, it is ionized in an alkaline environment and gets “trapped,” limiting tha amount that crosses the blood-brain barrier and increasing urinary excretion.

97
Q

Which part of the scaphoid bone is the most prone to avascular necrosis?

A

The proximal portion

There is no direct blood supply to the proximal portion of the bone. The more proximal the fracture is in scaphoid injuries, the greater the likelihood of developing avascular necrosis.

98
Q

The following findings on electrocardiogram (ECG) are suggestive of what diagnosis?

  1. Short PR interval (
  2. Widened QRS interval (>100 milliseconds)
  3. Delta wave
A

Wolff-Parkinson-White (WPW) syndrome

99
Q

What is the treatment for Henoch-Schonlein purpura?

A

Supportive management with NSAIDs for pain control

Steroids are used for patients with severe abdominal pain.

101
Q

What is the diagnostic test of choice for an aortic dissection?

A

Transesophageal echocardiogram (TEE)

This is highly sensitive, quick, and does not require radiation or contrast. Computed tomography (CT) is the test of choice if TEE is not readily available.

103
Q

What is the initial treatment of choice for thrombotic thrombocytopenic purpura (TTP)?

A

Daily plasmapheresis until platelet count normalizes

Red blood cells may be transfused in patients with symptomatic anemia.

104
Q

What is the treatment for diverticulitis?

A

Intravenous hydration, bowel rest, and broad-spectrum antibiotics to cover both aerobic and anaerobic bacteria (Metronidazole + fluoroquinolone)

105
Q

What is the emergent treatment of cardiac tamponade?

A

Operative thoracotomy

Pericardiocentesis is not optimal for traumatic tamponade, as the pericardium can fill with clots.

107
Q

Inferior wall myocardial infarction (MI) is characterized by ST elevation in which leads?

A

At least two of the inferior leads (II, III, aVF)

Reciprocal ST changes (I.E. ST depression) in the anterior precordial leads (V1-V4) in the setting of an inferior wall MI predict larger infarct distribution.

108
Q

Superficial punctate keratitis visualized on slit-lamp exam with fluorescein confirms what diagnosis?

A

Ultraviolet keratitis

Treatment consists of analgesia, cycloplegics to reduce ciliary spasm and pain, erythromycin ointment, and ophthalmology follow-up in 1-2 days. Fortunately, most patients with ultraviolet keratitis make a full recovery with supportive care alone.

109
Q

An electrocardiogram showing a narrow complex tachycardia at 300 beats per minute with no variability and absent P waves is diagnostic of what?

A

Supraventricular tachycardia

This is the most common pathologic arrhythmia of childhood.

110
Q

What is the treatment for decompression sickness?

A

Hyperbaric oxygen

Intravenous flluids and supplemental oxygen may also be warranted. This condition is characterized by the dissolution of nitrogen from the blood. Arterial gas embolism can occur in patients with an underlying patent foramen ovale. Symptoms are usually sudden and dramatic - divers who have been thought to drown, actually passed out during ascent because of an underlying gas embolism.

112
Q

What is the cause of the majority of all acute episodes of diarrhea?

A

Viruses (Rotavirus and Norwalk virus)

In addition, enteric adenovirus is a common cause of gastroenteritis.

113
Q

What are the 4 Kanavel criteria for flexor tenosynovitis?

A
  1. Symmetric swelling of the finger
  2. Tenderness over the flexor tendon sheath
  3. Pain with passive extension
  4. Posture of the digit is flexed
114
Q

What is the initial treatment of choice for patients in second-degree, Mobitz I AV heart block?

A

Atropine

The majority of patients respond to atropine without further treatment. Observation alone is appropriate for stable patients.

116
Q

A spearing injury, resulting from hitting another player with the crown of the head/helmet, results in what kind of fracture?

A

Jefferson fracture

Spearing generates an axial loading force that is transmitted through the occipital condyles to the superior articular surfaces of the lateral masses of the first cervical vertebra (C1). This is considered an unstable fracture and is associated with C2 fractures 40% of the time.

117
Q

Orbital floor fractures usually present with what symptom?

A

Pain that is greatest with upward eye movement

It may also present with impaired ocular motility or diplopia if the inferior rectus muscle becomes entrapped, and it may present with infraorbital hypoesthesia because of compression of the infraorbital nerve.

118
Q

What is the antidote to hypoglycemia secondary to sulfonylureas?

A

Octreotide

120
Q

Loss of consciousness results from injury to which functional area of the brain?

A

Reticular activating system

121
Q

Symmetric proximal muscle weakness and a heliotrope rash are characteristic of which diagnosis?

A

Dermatomyositis

This is an idiopathic inflammatory myopathy with associated dermatitis. The characteristic of the disease is progressive symmetric proximal muscle weakness with possible dysphagia, symmetric heliotrope rash in the periorbital region or neck, elevated creatinine kinase, and abnormal electromyogram and muscle biopsy. There is also an associated risk of malignancy.

122
Q

What is the treatment for organophosphate toxicity?

A

Pralidoxime and Atropine

Organophosphates inhibit acetylcholine esterase and cause cholinergic crisis. Cholinergic crisis is commonly remembered by the pneumonic SLUDGE (salivation, lacrimation, urination, defecation, gastrointestinal upset, emesis) or DUMBBELS (defecation, urination, miosis, bronchospasm, bronchorrhea, emesis, lacrimation, salivation). Pralidoxime works by causing acetylcholinesterase to start working again.

123
Q

Transverse fracture of the distal radial metaphysis with associated volar displacement and angulation is called what?

A

Smith fracture

Displacement and angulation is opposite to that of Colles fracture.

124
Q

Abdominal breathing in the absence of thoracic breathing indicates an injury below what level?

A

C4

The intercostal muscles of the rib cage are supplied by nerves that originate in the thoracic spine, while the diaphragm is innervated by the phrenic nerve which originates from C3-C4.

125
Q

Which drug is most commonly associated with the acute treatment of Wolff-Parkinson-White syndrome?

A

Procainamide

126
Q

What condition presents initially wtih flu-like symptoms, but within 24-48 hours may abruptly deteriorate into septic shock, respiratory failure, and mediastinitis, with a chest xray often revealing a widened mediastinum, and death usually within 3 days?

A

Inhalation anthrax

Anthrax is normally a disease of sheep, cattle, and horses. Disease in humans occurs when spores are inhaled. Working with untreated animal hides increases the risk for anthrax exposure.

127
Q

It is important to recognize transient ischemic attacks (TIA) and to evaluate patients for what?

A

Cardiac or carotid arterial sources of emboli

TIAs often precede ischemic stroke, with up to 50% of patients with a TIA having a stroke in the next 5 years. The highest incidence is in the first month.

128
Q

Which 2 medications should be given to patients with cardiogenic pulmonary edema as in congestive heart failure?

A

Nitroglycerin and loop diuretic

Together, these medications act to improve the overall functional capacity of the heart.

129
Q

What are the “verbal responsiveness” criteria of the Glasgow coma scale?

A
  • Oriented: 5
  • Confused: 4
  • Inappropriate words: 3
  • Incomprehensible sounds: 2
  • None: 1
131
Q

What is considered the hallmark finding of ethylene glycol ingestion?

A

Crystalluria

Its absence, however, does not rule out the diagnosis.

132
Q

What is the most common fracture associated with anterior shoulder dislocation?

A

Compression fracture of the humeral head (Hill-Sachs deformity)

This may occur in 50% of anterior dislocations. Fracture of the anterior glenoid rim (Bankart fracture) is present in approximately 5% of cases.

133
Q

Light-induced pupillary dilation is characteristic of what diagnosis?

A

Afferent pupillary defect (Marcus Gunn pupil)

This is a result of a lesion in the anterior visual pathway of the retina, optic nerve, or optic chiasm preventing reception of the light in the affected eye.

134
Q

What finding on ultrasound is diagnostic of deep vein thrombosis?

A

Failure of the deep vein under interrogation to collapse fully when pressure is applied to the skin with the ultrasound probe

Normal deep veins collapse under moderate pressure applied by the sonographer.

135
Q

Headaches described as worse in the morning, associated with nausea and vomiting, and worse with position are usually caused by what?

A

A mass lesion

Patients do not usually present with focal neurological symptoms.

136
Q

What condition is characterized by prolonged conduction of atrial impulses without the loss of any impulse?

A

First-degree heart block

On an ECG, this translates to a PR interval greater than 200 milliseconds with a narrow QRS complex (< 120 milliseconds). This does not require treatment.

137
Q

Which extraintestinal manifestation of crohn’s disease is not associated with Ulcerative colitis?

A

Nephrolithiasis

This is seen as a result of hyperoxaluria because of increased oxalate absorption in patients with ileal disease. Because ulcerative colitis affects only the large bowel, this extraintestinal manifestation is seen only in patients with Crohn disease.

138
Q

A 10% chance of passage of a renal stone occurs when the stone is what size?

A

>6mm

140
Q

What is the treatment for thyroid storn?

A
  1. Propranolol
  2. Propylthiouracil (PTU)
  3. Iodine

Propranolol is the most important factor in reducing mortality, by blocking peripheral adrenergic hyperactivity. PTU is used to inhibit new hormone synthesis in the thyroid and has a small effect on inhibiting peripheral conversion of T4 to T3. Iodine is administered to block hormone release from the thyroid but should be given 1 hour after PTU to prevent organification of the iodine.

141
Q

What is the treatment for orbital cellulitis?

A

Admission to the hospital and intravenous antibiotic treatment (Cefuroxime, a combination of penicillin and nafcillin, or vancomycin)

143
Q

What is the earliest change seen on electrocardiogram in an acute myocardial infarction?

A

Hyperacute T waves

They may appear minutes after the interruption of blood flow. The hyperacute T wave, which is short-lived, evolves to progressive elevation of ST segments.

144
Q

What will the cerebrospinal fluid analysis of a patient with bacterial meningitis reveal?

A
  1. Elevated white blood cell count
  2. Predominant polymorphonuclear leukocytes
  3. Elevated protein
  4. Low glucose
146
Q

What is the treatment of adrenal crisis in the setting of septic shock?

A

Hydrocortisone

146
Q

Where do more than 50% of angiodysplasias of the gastrointestinal tract occur?

A

Right side of the colon

Angiodysplasias are responsible for 3-20% of acute lower Gastrointestinal bleeds.

147
Q

Fever, anemia, thrombocytopenia, renal insufficiency, and neurologic changes make up the classical pentad of what condition?

A

Thrombotic thrombocytopenic purpura (TTP)

In TTP, platelet-fibrin thrombi deposit in vessel and cause injury to red blood cells and platelets, resulting in microangiopathy hemolytic anemia, and thrombocytopenia. Risk factors include pregnancy, autoimmune disorders (I.E. systemic lupus erythematosus), infection, allogenic bone marrow transplantation, malignancy, and medications (I.E. quinine, clopidogrel, and ticlopidine).

148
Q

Anticoagulation is required prior to cardioversion of a patient who has been in atrial fibrillation for how long?

A

_>_48 hours

Warfarin, along with heparin, are agents used for anticoagulation. In stable atrial fibrillation, the patient would undergo an echocardiogram prior to defibrillation and if no clot is visualized, heparin is administered and cardioversion can take place immediately.

149
Q

What medication class is the cornerstone of cocaine-induced acute coronary syndrome treatment?

A

Benzodiazepines

These are excellent medications to use in cocaine-related chest pain as it reduces the sympathetic drive leading to a reduction in blood pressure and heart rate.

151
Q

What is the definitive diagnostic study of choice for a patient with suspected malrotation with midgut volvulus?

A

Upper gastrointestinal series

This is a radiologic examination of the upper gastrointestinal tract. It consists of a series of X-ray images of the esophagus, stomach and duodenum. Contrast in the gut will fail to demonstrate the classic “C-Loop” of the four parts of the duodenum and instead will show a “corkscrew” appearance clssic of this condition.

152
Q

What is the most appropriate antibiotic for treatment of spontaneous bacterial peritonitis?

A

An antibiotic with both gram(-) and gram(+) coverage (I.E. a third generation cephalosporin)

153
Q

What is the diagnostic test of choice in a patient with a suspected pituitary adenoma?

A

High-resolution magnetic resonance imaging

Non-contrast and contrast-enhanced computed tomography (CT) are not particularly sensitive for these lesions that sit in the sella turcica.

154
Q

What is the appropriate approach to managing a patient with a bite from an animal with an unknown rabies status?

A

Administration of immunoglobulin in addition to the cell vaccine

It is also important to note the powerful effects of water and soap irrigation in these cases, as it has been proven as the most effective means of lowering the virulence of the organism and should be administered quickly. If the patient has had a severe allergic reaction to the vaccine in the past, immunoglobulin should be administered alone.

155
Q

The central nervous system effects of cocaine are best managed with what?

A

Benzodiazepines

Benzodiazepines decrease sympathetic tone and prevent hyperthermia and seizures.

156
Q

What is the usual cause of dysfunctional uterine bleeding (DUB)?

A

Anovulation

This condition is defined as any abnormality in the regular bleeding pattern of the menstrual cycle. When the ovaries fail to secrete an ovum, Luteinization does not occur, and without the progesterone of leutinization, the endometrium proliferates. This can lead to endometrial hyperplasia, which increases the risk for carcinoma.

158
Q

What are the typical findings on examination of the cerebrospinal fluid of a patient with viral meningitis?

A
  1. Mildly elevated protein
  2. Mildly elevated white blood cells
  3. Normal glucose
  4. Normal polymorphonuclear neutrophil and eosinophil counts
159
Q

Rupture of the extensor tendon that inserts into the base of the distal phalanx is know as what?

A

Mallet finger

The most important aspect of management is to keep the distal interphalangeal (DIP) joint in continuous extension until healing occurs.

161
Q

Which organism is most frequently associated with Henoch-Schonlein purpura?

A

Campylobacter jejuni

162
Q

What predominates as the causitive agent in myocarditis in the United States?

A

The enteroviruses (especially coxsackievirus B)

164
Q

What is the smallest amount of blood loss that will result in a decrease in systolic blood pressure?

A

30-40% of blood volume

Class III hemorrhage is characterized by 30-40% blood loss and is characterized by tachypnea, tachycardia (HR>120), decrease in systolic BP, delayed capillary refill, decreased urine output, and a change in mental status.

166
Q

Fracture at the junction of the middle and distal thirds of the radius, with an associated dislocation of the distal radialulnar joint is called what?

A

Galeazzi fracture

167
Q

What is the most common type of elbow fracture in kids?

A

Supracondylar fracture

The most serious complication of supracondylar fractures is Volkmann ischemic contracture. This occurs when high-pressure builds up in the forearm compartments leading to a compartment syndrome. Patients who develop pain upon passive extension of the fingers, forearm tenderness, or refuse to open the hand have a very high risk of developing this condition.

168
Q

What is the treatment of alcoholic ketoacidosis?

A

Hydration with 5% dextrose in normal saline (D5NS)

Thiamine supplementation should be given as prophylaxis against Wernicke encephalopathy.

169
Q

Abdominal pain that radiates to the back and is associated with nausea, vomiting, epigastric tenderness, and a history of ethanol abuse is suggestive of what diagnosis?

A

Alcoholic pancreatitis

The initial treatment for acute pancreatitis is supportive: bowel rest, fluid resuscitation, and analgesia. 90% of patients recover without complications. Surgery is reserved for complications of alcoholic pancreatitis, such as pseudocysts, phlegmons, and abscesses.

170
Q

What is the most common organism that causes epididymitis in men over age 35 years

A

E. Coli

In men under age 35 years old it is Chlamydia trachomatis and Neisseria gonorrhoea.

171
Q

What is the treatment for stable atrial fibrillation?

A

Rate control with diltiazem or verapamil

Metoprolol or digoxin may also be used, but may depress the blood pressure.

172
Q

During which week of gestation can an embryo be first detected via the following methods?

  1. Transvaginal ultrasound
  2. Transabdominal ultrasound
A
  1. Transvaginal ultrasoun: 6 weeks
  2. Transabdominal ultrasound: 7 weeks
173
Q

Within how many hours of symptoms onset can thrombolytic therapy be administered to patients having an acute ST-elevation myocardial infarction?

A

_<_12 hours

Previous hemorrhagic stroke, known intracranial neoplasm, active internal bleeding, and suspected aortic dissection or pericarditis are all absolute contraindications to thrombolytic therapy.

174
Q

What two agents are favored in the management of a patient with a hypertensive crisis?

A

Labetalol and Nitroprusside

175
Q

A branching or dendritic ulcer of the eye is characteristic of what condition?

A

Corneal epithelial disease

This is caused by herpes simplex virus. Patients will have typical herpetic skin lesions in the eyelids and conjunctiva. Patients should be treated with topical antivirals such as trifluridine, with topical antibiotics added to prevent secondary bacterial infection.

176
Q

What is the most common pathologic arrhythmia of childhood?

A

Supraventricular tachycardia

177
Q

What is the most common ultrasound finding in patients who have ovarian torsion?

A

Unilateral enlarged ovary

This occurs secondary to edema. Patients with no ovarian or adnexal masses measuring 3-4 cm in diameter and normal-sized ovaries are extremely unlikely to have ovarian torsion.

178
Q

What is the classic triad of symptoms associated with a vertebrobasilar stroke?

A

The 3 D’s: Dizziness, dysphagia, and diplopia

The brainstem (dysphagia, facial droop, vertigo, and vertical nystagmus), cerebellum (ataxia, vertigo, and vertical nystagmus), and visual cortex (diplopia) are all anatomical areas supplied by the posterior circulation, specifically the vertebrobasilar artery.

179
Q

What is the most common cause of respiratory distress in infants (especially those under the age of 6 months)?

A

Respiratory syncytial virus

This is also the most common cause of bronchiolitis in infants.

180
Q

What are the “eye opening” criteria of the Glasgow coma scale?

A
  • Spontaneous: 4
  • To verbal command: 3
  • To pain: 2
  • None: 1
181
Q

The following signs/symptoms are characteristic of which diagnosis?

  1. Mid-dilated, nonreactive pupil
  2. Corneal clouding
  3. Decreased vision
A

Increased intraocular pressure

This is typical of acute angle-closure glaucoma.

182
Q

What is the most useful diagnostic test obtainable in a suspected carbon monoxide poisoning?

A

Carboxyhemoglobin level

183
Q

What is the most effective method for relieving acute pericardial tamponade in the trauma setting?

A

Thoracotomy

This involves incision of the pericardium with removal of blood from the pericardial sac.

184
Q

What is a potentially life-saving intervention in tricyclic antidepressant overdose?

A

Sodium bicarbonate

This is because an alkaline pH combined with a sodium load increases conductance through cardiac fast sodium channels and prevents ventricular dysrhythmias as evidenced by narrowing of the QRS complex on an electrocardiogram.

185
Q

What is the best test for diagnosing appendicitis?

A

Abdominal computed tomography (CT) with IV and oral or rectal contrast

186
Q

Fracture of the proximal one-third of the ulnar shaft combined with a radial head dislocation is called what?

A

Monteggia fracture

This injury commonly occurs from either a direct blow to the posterior aspect of the ulna. It is associated with an injury to the radial nerve.

187
Q

What is generally the first-line agent in an actively seizing patient?

A

Parenteral benzodiazepines (Diazepam, Lorazepam, Midazolam)

188
Q

Which medication is a common precipitant of visual hallucinations?

A

Digoxin

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