SINGLE BEST ANSWER

ANSWERS ALL QUESTIONS.

EMERGENCY MEDICINE
Case 1 A 48-year-old man is noted to have a 2-day history of sore throat, subjective fever at
home, and no medical illnesses. He denies cough or nausea. On examination, his
temperature is 38.3C (101F), and he has some tonsillar swelling but no exudate. He
has bilateral enlarged and tender lymph nodes of the neck. The rapid streptococcal
antigen test is negative. Which of the following is the best next step?
A. Oral clindamycin
B. Treatment based on results from throat culture
C. Observation
D. Begin amantadine
Which of the following patients is most likely to have group A streptococcal infection?
A. An 11-month-old male infant with fever and red throat
B. An 8-year-old girl with fever and sore throat
C. A 27-year-old man with a temperature of 38.9C (102F), pharyngitis, and cough
D. A 52-year-old woman who complains of fever of 39.2C (102.5F) and sore throat
A 19-year-old college student has had a sore throat, mild abdominal pain, and fever for 5
days. He was playing football with some friends, and was tackled just short of the goal
line, hitting the grass somewhat forcibly. He experiences some abdominal pain, and
passes out. The EMS (emergency medical services) is called and his vital signs reveal
the heart rate as 140 beats per minute and blood pressure as 80/40 mm Hg with a
distended abdomen. Which of the following is the most likely etiology?
A. Vasovagal reaction
B. Ruptured aortic aneurysm
C. Complications of Epstein-Barr infection
D. Ruptured jejunum
An 18-year-old woman presents with fever and a sore throat. She is sitting up drooling,
with some stridor. Her temperature is 39.4C (103F) and she appearsill. Which of the
following is your next step?
A. Examine the pharynx and obtain a rapid antigen test.
B. Empiric treatment with penicillin.
C. Throat culture and treatment based on results.
D. Send the patient to radiology for an anteroposterior (AP) neck radiograph.
E. Prepare for emergent airway management.
Case 2 A 48-year-old man is being seen for chest pain. In the initial evaluation of this patient,
which of the following is the most important diagnostic test?
A. Chest x-ray
B. ECG
C. Serum cardiac markers
D. Computed tomography
E. Cholesterol levels
A 58-year-old man presents to his physicians offi ce complaining of 2 hours of
substernal chest pain and dyspnea. Which of the following is the most important next

step in management?
A. Administration of propranolol
B. Aspirin to chew
C. Sublingual nitroglycerin
D. Administration of a diuretic agent
E. Chest radiograph
A 45-year-old man is seen in the emergency department with 3 hours of substernal
chest pain radiating to his left arm. The ECG shows only nonspecific changes. Hearing
that the ECG is normal, he requests to go home. Which of the following statements is
most accurate?
A. The patient may be safely discharged home.
B. If a repeat ECG in 30 minutes is normal, myocardial infarction is essentially ruled out
and the patient may be safely discharged.
C. The patient should be advised that half of heart attack patients have a nondiagnostic
ECG and serial cardiac biomarkers levels should be assessed.
D. The patient should undergo an immediate thallium stress test to further assess for
coronary artery disease to help clarify the management.
Case 3 A 75-year-old man is found to have asymptomatic atrial fi brillation. Which of the
following is the most common complication of his atrial fibrillation?
A. Sudden death
B. Stroke
C. Shock
D. Dyspnea
An 83-year-old woman with a history of hypertension presents to the emergency
department with dyspnea, fatigue, and palpitations. Her blood pressure is 85/50 mm Hg
and her heartbeat is 150 beats per minute and irregular. Which of the following is the
best treatment for this patient?
A. Diltiazem
B. Metoprolol
C. Coumadin
D. DC cardioversion
A 62-year-old woman is seen in the emergency department for wrist pain after tripping
and falling. She is found to have a distal radius fracture on x-ray, which is reduced and
splinted. However, her heart rate is 80 beats per minute and irregular to palpation. On
ECG, she is diagnosed with atrial fibrillation with a ventricular response of 114 beats per
minute. She does not recall ever being told about this condition. Which of the following
is the best initial treatment for this patient?
A. Diltiazem
B. DC cardioversion
C. Synthroid
D. Ibutilide
Case 4 A 22-year-old baseball player comes into the ED complaining of 12 hours of intermittent
chest pain and a pounding heartbeat. He denies a history of trauma. On examination, he
is tachycardic. Which of the following is the best next step?
A. Synchronized cardioversion
B. Valsalva maneuver

C. Discharge home and follow up within the next 48 hours

D. Obtain an ECG
A 52-year-old healthy jogger is brought to the ED following a syncopal episode. A
diagnosis of ventricular tachycardia is made, and the patient is cardioverted. She states
that she has had prior episodes of VT lasting less than 30 seconds each. What is the
most appropriate treatment?
A. Likely no further therapy is needed.
B. Amiodarone
C. -blocker
D. Procainamide
All of these are AV nodal blocking maneuvers except:
A. Diving reflex
B. Carotid massage
C. Valsalva maneuver
D. Holding ones breath at the end of expiration
An 87-year-old woman presents with chest pain and shortness of breath. The 12-lead
ECG shows a sawtooth pattern with a heart rate of 150 beats per minute. What is the
most likely diagnosis?
A. AVNRT
B. VT
C. Atrial flutter
D. Atrial fibrillation with rapid ventricular rate
A 37-year-old woman presents with chest pain after smoking crack 2 hours ago. What
are you most likely to see on the ECG?
A. Sinus tachycardia
B. SVT
C. VT
D. Atrial fibrillation
Case 5 A 17-year-old adolescent boy who is a type I diabetic is brought in by his parents with
concern about diabetic ketoacidosis. He has had several prior episodes of DKA. Which of
the following is most diagnostic of DKA?
A. Polyuria, polydipsia, fatigue
B. Hypotension, dehydration, fruity breath odor
C. Hyperglycemia, ketosis, metabolic acidosis
D. Serum blood sugar of 600 mg/dL in the face of high concentrations of insulin
E. Elevated HCO3 and elevated glucose
A 28-year-old insulin-requiring woman is found in her apartment by her husband. She is
stuporous and cannot provide any history. EMS is called and takes the patient to the
emergency center, and a diagnosis of severe DKA is made. Her blood pressure is 80/40
mm Hg and heart rate 140 beats per minute. The glucose level is 950 mg/dL, potassium
level 6 mEq/L, HCO3 4 mEq/L. Which of the following is the most appropriate initial
treatment?
A. Administer 20 units regular insulin intramuscularly, and normal saline at 250 mL/h.
B. Begin an intravenous dopamine drip to raise BP above 90, then insulin at 10 U/h.
C. Initiate normal saline 2 L with KCl 20 mEq/L, insulin 10 U/h.

D. Provide an intravenous normal saline 2 L bolus, and start an insulin drip at 10 U/h.
The patient in Question 5.2 is undergoing therapy. Which of the following principles is
most accurate in the treatment of DKA?
A. Isotonic saline with no dextrose should be used during the hospitalization because the
patient is diabetic.
B. Typically, intravenous insulin and dextrose solution will need to be continued until the
acidosis has resolved.
C. Potassium replacement is rarely necessary.
D. Sodium bicarbonate is helpful to resolve the anion gap more quickly.
The physician explains to a 25-year-old man who has recently been hospitalized with
DKA that patients in DKA often have other illnesses or precipitating factors that initiated
the ketoacidosis. Which of the following is the most common underlying etiology in DKA?
A. Asthmatic exacerbation
B. Cocaine use
C. Cholecystititis
D. Missed insulin doses
E. Urinary tract infection
Case 6 A 32-year-old woman is noted to have persistent hypotension from suspected toxic
shock syndrome despite 6 L of normal saline given intravenously. Which of the following
is the best next step?
A. Use colloid (albumin) for the next bolus.
B. Initiate norepinephrine infusion.
C. Administer corticosteroid therapy.
D. Transfuse with fresh-frozen plasma.
E. Activated protein C.
A 45-year-old man with acute cholecystitis is noted to have a fever of 38.3C (101F),
hypotension, and altered sensorium. His HCT is noted to be 24%. Broad-spectrum
antibiotics and intravenous saline are administered, and, although his CVP is 10 and his
MAP is 80, his ScvO2 remains <70%. Which of
the following is most likely to be beneficial?
A. Initiate corticosteroids
B. Tight glucose control
C. Acetaminophen 500 mg PR
D. Transfusion
E. Lithotripsy
A 32-year-old woman is admitted to the hospital for acute pyelonephritis. The patient is
treated with oral ciprofl oxacin. After 4 days of therapy, she returns to the ED with
persistent fever to 38.9C (102F) and fl ank tenderness. The urine culture reveals E coli
greater than 100,000 colony-forming units per mL susceptible to ciprofl oxacin. When
you arrive to examine her, you note that she is tachypneic, tachycardiac, and appears
lethargic. Which of the following is the next step?
A. Order an intravenous pyelogram.
B. Obtain IV access and administer a fluid bolus.
C. Initiate a workup for fictitious fever.
D. Consult a surgeon for possible appendicitis.
E. Add antifungal therapy.

A 66-year-old woman is noted to have acute pneumococcal pneumonia and is being

treated with antibiotics, and with norepinephrine and dobutamine to maintain her BP
and urine output. Which of the following is a bad prognostic sign?
A. Urine output of 1 mL/kg/h
B. Mean arterial blood pressure of 80 mm Hg
C. Lactic acid level of 6 mmol/dL
D. Serum bicarbonate level of 22 mEq/L
E. Hematocrit 35%
Case 7 A 32-year-old man was involved in a knife fi ght and had stab injuries to his abdomen,
although it is unclear how deep these injuries are. He is brought into the emergency
room with a heart rate of 110 beats per minute and blood pressureof 84/50 mm Hg.
Based on the clinical assessment, which of the following is the amount of acute blood
loss he has experienced?
A. 250 mL
B. 500 mL
C. 1000 mL
D. 1500 mL
Which of the following is an advantage of the FAST examination in a patient with
hemorrhagic shock?
A. Can identify retroperitoneal hematomas
B. Can be performed quickly at bedside
C. Can identify the specific site of injury
D. Can quantify the exact amount of blood loss
A 20-year-old man involved in a motor vehicle accident is brought into the emergency
room having lost much blood at the accident scene. His initial blood pressure is 80/40
mm Hg and heart rate 130 beats per minute. He is given 3 L of normal saline
intravenously and is still hypotensive. Which of these statements most accurately
describes the pathophysiology of his condition?
A. Insufficient cardiac preload
B. Insufficient myocardial contractility
C. Excessive systemic vascular resistance
D. Excessive IL-6 and leukotrienes
A 35-year-old man has been involved in a motor vehicle accident, and is found to be
hypotensive. Which of the following locations of bleeding can cause significant
complications but does not explain the hypotension?
A. Chest and abdomen
B. Pelvic girdle and soft-tissue compartments
C. External bleeding
D. Intracranial bleeding
Case 8 A 23-year-old man is involved in an altercation in the parking lot after a baseball game.
He suffers a single stab wound 2-cm medial and superior to the left nipple. His blood
pressure is 110/80 mm Hg and heart rate is 80 beats per minute. Which of the following
management options is most appropriate for this patient?
A. CXR, wound exploration, and ECG
B. CXR and CT scan of the abdomen

C. CXR and echocardiography

D. CXR, echocardiography, and laparoscopy
For which of the following patients is CT imaging an appropriate diagnostic option?
A. A 38-year-old man with diffuse abdominal pain, involuntary guarding, and a 6-in knife
impaled just below the umbilicus
B. A 22-year-old man with a single stab wound to the back, pulse rate of 118 beats per
minute, blood pressure of 94/80 mm Hg, and gross hematuria
C. A 16-year-old adolescent boy with a single stab wound 2 cm above the left inguinal
crease, with heart rate of 120 beats per minute and blood pressure of 90/78 mm Hg
D. A hemodynamically stable, 34-year-old woman, who is 26 weeks pregnant and has a
single stab wound to the back and no other abnormalities on physical examination
A 34-year-old man is brought into the emergency department after a motor vehicle
accident. He complains of dyspnea and initially had an oxygen saturation of 88%. On
examination, he has decreased breath sounds of the right chest and now has an oxygen
saturation of 70% on room air. Which of the following is the most appropriate next step?
A. Chest radiograph
B. CT of the chest
C. Tube thoracostomy
D. Heparin anticoagulation
Case 9 A 78-year-old man is brought to the emergency center from an extended care facility.
The patient reportedly was found to have fallen down in the bath room. He has
contusions over his face and is confused. According to reports by his caretakers, this is
his baseline mental status. How would you clear his C-spine?
A. Palpation of his C-spine for tenderness, if not tender than ask him to turn his head and
if no pain is reported, the C-spine is cleared.
B. Keep him in C-spine precaution and reexamine him later when his mental status is
improved.
C. Obtain CT, MRI, if these are negative, obtain flexion/extension films.
D. CT of the C-spine.
E. Remove the collar if he denies neck pain.
Which of the following approaches is most appropriate for the clearance of the C-spine in
a 25-year-old man who the driver of a car struck from behind? He is hemodynamically
stable, nonintoxicated, and has a GCS of 15.
A. NEXUS criteria
B. Canadian C-spine rule
C. CT of the C-spine
D. 3-view x-ray of the C-spine
E. Remove the collar because he does not have any pain
Which of the following is the most appropriate next step in the management of a 22year-old man with C5 fracture and C5-C6 subluxation, absence of motor or sensory
functions below the C4 level, heart rate of 45, and BP 100/60?
A. Maintain mean arterial pressure >85 to 90 mm Hg
B. Surgical airway
C. Orotracheal intubation with rapid sequence induction
D. Blind nasotracheal intubation
E. Administer atropine 1mg intravenously

Which of the following patients presentation is most compatible with the Brown-Sequard
syndrome?
A. A 20-year-old man with absence of all motor/sensory functions in all extremities
B. A 20-year-old man with greater weakness in the upper extremities than the lower
extremities
C. A 20-year-old man with complete motor paralysis, loss of vibratory sensation and
proprioception on the ipsilateral side, and contralateral loss of pain and temperature
sensation.
D. A 20-year-old man with fracture/dislocation of C5-C6 and intact motor/sensory
functions throughout
E. A 20-year-old man with normal CT of the C-spine and motor and sensory deficits
below the C6 level
Case 10
An 18-year-old woman is brought to the ED with suspected anaphylaxis. Which of the
following most suggests anaphylaxis rather than a simple allergic reaction?
A. Itching
B. Watery eyes
C. Blood pressure of 80/40 mm Hg
D. Hives
E. Anxiety
A 6-year-old girl with a known peanut allergy is brought to the ED by ambulance after
accidentally eating a cookie made with peanut butter at a school party. She is wheezing
with hives. Which of the following should be the first intervention?
A. Endotracheal intubation
B. Normal saline 20 cc/kg IV
C. Examination of the skin
D. Epinephrine 0.15 mg intramuscular
E. Nebulized albuterol
Which of the following management options is the greatest determinant of patient
outcome in anaphylaxis?
A. Timely administration of steroids
B. Administration of diphenhydramine
C. Early identification of the allergen
D. Early administration of epinephrine
E. Aggressive resuscitation with intravenous fluids
A 32-year-old man collapses in the emergency room after being brought in by
paramedics. He was stung by a bee and known to be highly allergic. He appears
cyanotic and had extreme stridor in the ambulance. Severe laryngeal edema is notable.
Which of the following is the best treatment?
A. Nebulized albuterol, H1 and H2 antagonists, corticosteroids, and crystalloids
B. Subcutaneous epinephrine, H1 and H2 antagonists, and corticosteroids
C. Rapid sequence intubation, subcutaneous epinephrine, and corticosteroids
D. Intramuscular epinephrine, rapid sequence intubation, and corticosteroids
E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical
airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists
Case 11
A 24-year-old man is brought into the ED complaining of an exacerbation of his asthma.

Which of the following is the most appropriate method of assessing the severity of his
disease?
A. Spirometry
B. Measurement of the diffusion capacity of the lungs
C. Measurement of the peak expiratory flow
D. Measurement of the alveoli oxygen tension
A 19-year-old woman is admitted to the hospital for an exacerbation of asthma likely
precipitated by pollen and colder weather. Her inpatient regimen includes both
intravenous and inhalant medications. Which of the following medications is most likely
to be used as part of discharge plan?
A. Theophylline
B. Antibiotics
C. Magnesium
D. Histamines
E. Corticosteroids
Which of the following initial ventilator settings is appropriate for intubated asthmatics?
A. IMV mode, rate 16, tidal volume 6 to 8 mL/kg
B. IMV mode, rate 16, tidal volume 10 to 12 mL/kg
C. AC mode, rate 8 to 10, tidal volume 6 to 8 mL/kg
D. AC mode, rate 8 to 10, tidal volume 10 to 12 mL/kg
E. AC mode, rate 16, tidal volume 6 to 8 mL/kg
Case 12
An 18-year-old man was involved in an altercation at a local bar. He suffered a laceration
of the scalp, neck, forehead, and upper lip. Which of the following is likely to be most
challenging to repair from a cosmetic perspective?
A. Scalp
B. Neck
C. Forehead
D. Cheek
E. Upper lip
A 24-year-old woman was the victim of domestic violence and received treatment at the
local emergency department for multiple contusions and lacerations of the face. Six
months after treatment, she notices a defect of the nasal septum with communication
between the right and left nasal passage way.
Which of the following is the most likely diagnosis?
A. Physician use of epinephrine on the nasal septum
B. Patient use of cocaine
C. Hematoma of the nasal septum
D. Post-traumatic stress syndrome
48-year-old man was rock climbing when he slipped and suffered a laceration to his right
lower leg. He put pressure on it, wrapped the area, and made his way to the ED. He
recalls getting all his shots when he was a child, but doesnt recall the last tetanus
booster. Which of the following is the best choice regarding tetanus prevention?
A. Diphtheria toxoid/tetanus toxoids (DT) vaccine 0.5 mL IM
B. DT 0.5 mL IM and tetanus immune globulin (TIG) 250 units IM
C. DT 0.5 mL IM, TIG 250 units IM, and intravenous penicillin 600,000 units every 6 hours
D. Admit to the ICU to observe for muscle spasm and administer 2500 units TIG IM and
0.5 mL tetanus toxoid IM in the opposite deltoid muscles

An 18-year-old man presents to the emergency department complaining of right ear

pain after sustaining a cut on his ear during a wrestling match. On examination, you
note some swelling and exposed cartilage of the right upper ear. Which of the following
is a correct statement?
A. Exposed cartilage should be left undressed and the patient should be discharged with
follow-up.
B. Hemostasis and evacuation of an auricular hematoma should not be performed
because it promotes infection.
C. When repairing an ear laceration, make sure to avoid placing sutures in the cartilage
and only include the perichondrium when approximating the skin edges.
D. Tetanus toxoid is not recommended for these types of injuries.
A 5-year-old boy is brought to the ED by his mom for a forehead laceration after hitting
his head on the jungle gym. There was no loss of consciousness. The child is alert and
active. He has a 3-cm forehead laceration which crosses the hairline. Which of the
following is the most appropriate method of wound closure in this patient?
A. Shave the hair surrounding the laceration and close with interrupted sutures.
B. Close with staples.
C. Close with steri-strips.
D. Close with interrupted sutures.
Case 13
Match the single best therapy (A to E) to the clinical scenarios in Questions 13.1 to 13.4.
A. Identify the species, clean and immobilize the site, and administer antivenin.
B. Clean bite site and treat with prophylactic antibiotics.
C. Clean site, observe animal, and watch for signs of secondary infection.
D. Clean the site and begin rabies prophylaxis with active and passive immunization.
E. Admit for radical surgical debridement in the operating room.
13.1 Your dog, who was immunized against rabies within the last year, bites your
neighbor.
13.2 A woman arrives in your ED with a human bite to her breast that occurred earlier in
the day. There is a small puncture wound and no signs of cellulitis.
13.3 A scoutmaster brings a boy scout to the ED with a snakebite to his left foot. He says
he heard the snakes rattle just before it bit him. His entire foot is purple, swollen to his
mid-calf, and very painful to the touch.
13.4 While raking leaves under his fruit tree at dusk, a man says a bird flew into his face.
When he checked his face in the mirror he saw a bite mark under blood streaks.
Case 14
A 58-year-old man experienced a neurologic deficit and is diagnosed as having a stroke.
Which of the following is the most likely etiology?
A. Ischemic
B. Hemorrhagic
C. Drug-induced
D. Trauma-induced
E. Metabolic-related
An 80-year-old man is being evaluated for possible thrombolytic therapy after presenting

with 2 hours of right arm weakness and aphasia. Which of the following is a
contraindication for thrombolytic therapy?
A. Bilateral cerebral infarct
B. Hemorrhagic stroke
C. Hypertension-related stroke
D. Age of 80 years
14.3 An otherwise healthy 65-year-old woman is taken to the ED with probable stroke.
Which of the following are the most urgent diagnostic studies?
A. Coagulation studies
B. ECG and cardiac enzymes
C. Bedside blood glucose and CT scan of the head
D. MRI of the head with and without contrast
14.4 A 67-year-old woman is seen in the emergency room with left arm weakness and
right facial droop. Her blood pressure is 180/105 mm Hg. Which of the following is the
best management for the hypertension?
A. Lower the blood pressure to less than 160/80 mm Hg by giving a small dose of
labetalol.
B. Lower the blood pressure to less than 120/80 mm Hg.
C. No intervention for her blood pressure, but continue to monitor.
D. Lower the blood pressure to below 160/80 mm Hg if she is eligible for tPA.
Case 15
A 37-year-old man is brought into the ED because he passed out at work. He denies any
prodromal symptoms. Family history is negative for sudden cardiac death. In the ED, his
BP lying down is 125/75 mm Hg, heart rate is 75 beats per minute, and respiratory rate
is 14 breaths per minute. The patients blood pressure and heart rate standing are
120/75 mm Hg and 77 beats per minute, respectively. His ECG shows a sinus rhythm
with a rate of 72. Physical examination does not reveal any abnormal findings. Currently,
he is lucid and has no neurologic abnormalities. After a complete evaluation of this
patient, which of the following is the most common etiology of syncope?
A. Dysrhythmia
B. Orthostasis
C. Idiopathic
D. Situational

A 35-year-old woman presents to the ED complaining of feeling lightheadedness. She

noticed some vaginal bleeding earlier in the day. Her blood pressure is 85/53 mm Hg,
heart rate is 130 beats per minute, and respiratory rate is 18 breaths per minute. Which
of the following is the most appropriate next step in management?
A. Obtain a urine pregnancy test.
B. Obtain a serum quantitative beta human chorionic gonadotropin (-hCG).
C. Obtain immediate IV access and begin fluid resuscitation.
D. Obtain stat OB/GYN consult.
A 21-year-old man is brought to the ED after collapsing to the ground while playing
basketball. He is alert and oriented, denies chest pain, difficulty breathing, or any other
physical complaints. There was no trauma. He denies any past medical problems.
Physical examination is unremarkable. Which of the following elements on his ECG is
concerning for a life-threatening cause of syncope?

A. Heart rate of 55
B. P-wave inversion in lead aVR
C. Sinus arrhythmia
D. QTc of 495 msec
A 72-year-old man is brought to the ED by paramedics after passing out at the
supermarket. His syncopal episode was witnessed by shoppers who stated the patient
collapsed, hitting his head. The patient is currently alert and oriented, and denies any
persistent symptoms. His past medical history is significant for carotid stenosis, for
which he takes aspirin and clopidogrel. What is most appropriate next step in the
management of this patient?
A. Head CT scan
B. Order a carotid duplex ultrasound
C. Obtain an ECG
D. Chest radiograph