EMERGENCY MEDICINE UPDATED FINAL EXAM
QUESTIONS AND ANSWERS RATED A+
✔✔What is the most common cause of death in Americans aged 20 to 40 years?
A. Drug overdose
B. Trauma
C. Cancer
D. AIDS-related illness
E. Pneumonia - ✔✔B. Trauma
✔✔Following a motor vehicle collision, in which of the following patients is an
emergency department Caesarian section most likely indicated, assuming a fetus at 29-
weeks gestation?
A. Mother with gunshot wound to abdomen, blood pressure 96/42; fetal heart tones
undetectable
B. Mother with severe head trauma, blood pressure 170/90; fetal heart tones 120 beats
per minute
C. Mother with abdominal pain, blood pressure of 80/40; fetal heart tones 100 beats per
minute
D. Mother with vaginal bleeding, blood pressure 118/78; fetal heart tones 80 beats per
minute
E. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart
tones of 100 beats per minute - ✔✔E. Mother pulseless and apneic for 2 minutes'
duration and still in arrest; fetal heart tones of 100 beats per minute
The answer is E. Though emergency C-section after maternal death is a rarely indicated
procedure, rapid intervention (within minutes) of maternal demise has resulted in viable
births.
✔✔A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He
arrives at the emergency department in a cervical collar and on a backboard. His only
complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the
neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the
patient has difficulty raising his arms against gravity and there is decreased grip
strength bilaterally. The remainder of his neurological exam is normal. What is the most
appropriate management for this patient?
A. Administration of IV steroids and ordering of cervical MRI
B. Immediate neurosurgical decompression
C. Flexion and extention radiographs to rule out ligamentous injury
D. Discharge home with a hard cervical collar with neurosurgical follow-up
E. Reassurance and discharge with NSAIDs given the non-anatomical distribution of
weakness - ✔✔A. Administration of IV steroids and ordering of cervical MRI
,The answer is A. Central cord syndrome results from a hyperextension injury, typically
in elderly patients with significant degenerative joint disease. The ligamentum flavum
buckles into the cord, resulting in a contusion of the cord's central portion.
✔✔A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface
and has sudden and severe low back pain. The pain radiates down his right leg and he
develops numbness over the anterior shin and dorsum of the foot. On physical exam he
has decreased sensation to pinprick over the dorsum of the right foot (medially) and
some weakness in right foot dorsiflexion. At which level is a protruding intervertebral
disc most likely?
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1 - ✔✔D. L4-L5
The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot
are functions of the L5 nerve root. Herniation of the L4-5 disc would result in
compression of L5.
✔✔Which of the following cervical spine fractures is considered stable?
A. Transverse process fracture
B. Flexion teardrop fracture
C. Bilateral facet dislocation
D. Hangman's fracture of C2
E. Jefferson fracture of C1 - ✔✔A. Transverse process fracture
The answer is A.
A transverse process fracture involves only one of the supporting spinal columns (the
posterior column) and is therefore stable.
✔✔A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street
fight. At the scene, there is some bleeding, which is controlled with direct pressure. He
presents to the emergency department breathing comfortably and in no distress. His
pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a
1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea.
There is mild oozing and no obvious underlying hematoma. There is no obvious
subcutaneous air, and he has clear lung sounds. What is the most appropriate
management for this patient?
A. Local wound exploration and discharge home if no significant injury identified
B. Angiography, esophogram, and admission for observation
C. Local wound exploration and discharge home after 6-hour observation period
D. CT scan of the neck and discharge home after 6 hours of observation
E. Immediate operative - ✔✔B. Angiography, esophogram, and admission for
observation
, The answer is B. Zone I penetrating neck injuries are located between the sternal notch
and the cricoid cartilage. A major concern is injury to non-compressible vascular
structures such as common carotid, vertebral, subclavian, aortic arch. Other structures
in this area include trachea, esophagus, and lung apices. Physical exam is often
unreliable and angiography, esophogram, and observation are warranted.
✔✔Which of the following patients should undergo abdominal trauma evaluation?
A. 22 year old with stab wound to fourth intercostal space on right
B. 30 year old with pelvic pain and tenderness after fall
C. 25 year old restrained passenger in high-speed MVA; no abdominal complaints
D. None of the above
E. All of the above - ✔✔E. All of the above
The answer is E. The diaphragm can rise to as high a level as the fourth intercostal
space and can be injured by stab wounds at this level. Unsuspected injuries are
common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-
abdominal injuries and can distract a patient from such an injury. Therefore, all of these
patients need an evaluation of their abdomens.
✔✔Which of the following trauma patients can be managed conservatively without
immediate laparotomy in the OR?
A. 27 year old man with hemoperitoneum by bedside ultrasound; hypotensive
B. 19 year old man with splenic laceration; peritoneal signs on exam
C. 24 year old man with liver laceration; hemodynamically stable
D. 30 year old man with a gunshot wound to the epigastrium
E. All of the above should go to the OR for exploratory laparotomy. - ✔✔C. 24 year old
man with liver laceration; hemodynamically stable
✔✔Which of the following is an accurate statement?
A. Bedside ultrasound is the test of choice for diagnosing solid organ injury.
B. Diagnostic peritoneal lavage usually cannot identify the presence of
hemoperitoneum.
C. Bedside ultrasound can image the retroperitoneum.
D. Bedside ultrasound can reliably determine the etiology of hemoperitoneum.
E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum. -
✔✔E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum.
The answer is E. Diagnostic peritoneal lavage is extremely sensitive for the detection of
hemoperitoneum and can lead to many negative laparotomies. Neither bedside
ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage
though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal
cavity, and CT scan is the test of choice for diagnosing solid organ injury.
✔✔A 36 year old man is a restrained driver involved in a high speed MVA where his car
is struck on the driver's side door with significant intrusion. His physical exam is
, significant for a large contusion on his left flank. His abdominal exam is benign and
rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross
hematuria. Which test is indicated to evaluate for the presence of urologic injury?
A. CT abdomen / pelvis with IV and transurethral contrast
B. Ultrasound of the bladder
C. CT abdomen / pelvis without contrast
D. Ultrasound of the kidneys
E. CT abdomen / pelvis with IV contrast alone - ✔✔A. CT abdomen / pelvis with IV and
transurethral contrast
✔✔In which of these patients is emergency department thoracotomy indicated?
A. All of the above should undergo emergency department thoracotomy.
B. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being
extricated, and arrives at the E.D. after a 45-minute transport
C. Patient with stab wound to the anterior chest who is dyspneic with an oxygen
saturation of 80% and a blood pressure of 168/102
D. Pedestrian struck with massive pelvic fractures who loses pulses and blood
pressure at the scene
E. Patient with a gunshot wound to the chest who upon arrival is unconscious and
pulseless, with a systolic blood pressure of 60 - ✔✔E. Patient with a gunshot wound to
the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure
of 60
The answer is E. Emergency Department thoracotomy is a controversial procedure.
When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt
trauma has a dismal success rate and is generally not considered an indication for ED
thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An
awake patient with a relatively normal blood pressure does not need one performed in
the Emergency Department. An unconscious and pulseless patient with a detectable
blood pressure has the best chance for survival.
✔✔A 32 year old female is shot with a 38-caliber pistol at close range in the right
anterior chest. She presents to the emergency department intoxicated and yelling. Her
vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%.
She has clear breath sounds bilaterally. The entrance wound is just above the right
breast and an exit wound is noted in the right axilla. What is the most appropriate
management of this patient?
A. IV access, endotracheal intubation and simultaneous placement of a right chest
tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable
B. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in
the OR to search for cardiac or pulmonary vascular injury
C. IV access, endotracheal intubation, emergency department thoracotomy to search
for cardiac or pulmonary vascular injury
D. IV access, portable chest X-ray, right ch - ✔✔A. IV access, endotracheal intubation
and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-
ray, and admission to the ICU if stable
QUESTIONS AND ANSWERS RATED A+
✔✔What is the most common cause of death in Americans aged 20 to 40 years?
A. Drug overdose
B. Trauma
C. Cancer
D. AIDS-related illness
E. Pneumonia - ✔✔B. Trauma
✔✔Following a motor vehicle collision, in which of the following patients is an
emergency department Caesarian section most likely indicated, assuming a fetus at 29-
weeks gestation?
A. Mother with gunshot wound to abdomen, blood pressure 96/42; fetal heart tones
undetectable
B. Mother with severe head trauma, blood pressure 170/90; fetal heart tones 120 beats
per minute
C. Mother with abdominal pain, blood pressure of 80/40; fetal heart tones 100 beats per
minute
D. Mother with vaginal bleeding, blood pressure 118/78; fetal heart tones 80 beats per
minute
E. Mother pulseless and apneic for 2 minutes' duration and still in arrest; fetal heart
tones of 100 beats per minute - ✔✔E. Mother pulseless and apneic for 2 minutes'
duration and still in arrest; fetal heart tones of 100 beats per minute
The answer is E. Though emergency C-section after maternal death is a rarely indicated
procedure, rapid intervention (within minutes) of maternal demise has resulted in viable
births.
✔✔A 76 year old restrained driver is involved in a head-on collision at about 35 mph. He
arrives at the emergency department in a cervical collar and on a backboard. His only
complaint is neck pain, and he has mild posterior neck tenderness. A CT scan of the
neck shows no fracture and only degenerative arthritis. Upon re-evaluation you note the
patient has difficulty raising his arms against gravity and there is decreased grip
strength bilaterally. The remainder of his neurological exam is normal. What is the most
appropriate management for this patient?
A. Administration of IV steroids and ordering of cervical MRI
B. Immediate neurosurgical decompression
C. Flexion and extention radiographs to rule out ligamentous injury
D. Discharge home with a hard cervical collar with neurosurgical follow-up
E. Reassurance and discharge with NSAIDs given the non-anatomical distribution of
weakness - ✔✔A. Administration of IV steroids and ordering of cervical MRI
,The answer is A. Central cord syndrome results from a hyperextension injury, typically
in elderly patients with significant degenerative joint disease. The ligamentum flavum
buckles into the cord, resulting in a contusion of the cord's central portion.
✔✔A 46 year old construction worker falls 6 feet off a ladder onto a concrete surface
and has sudden and severe low back pain. The pain radiates down his right leg and he
develops numbness over the anterior shin and dorsum of the foot. On physical exam he
has decreased sensation to pinprick over the dorsum of the right foot (medially) and
some weakness in right foot dorsiflexion. At which level is a protruding intervertebral
disc most likely?
A. L1-L2
B. L2-L3
C. L3-L4
D. L4-L5
E. L5-S1 - ✔✔D. L4-L5
The answer is D. Sensation of the dorsal aspect of the foot and dorsiflexion of the foot
are functions of the L5 nerve root. Herniation of the L4-5 disc would result in
compression of L5.
✔✔Which of the following cervical spine fractures is considered stable?
A. Transverse process fracture
B. Flexion teardrop fracture
C. Bilateral facet dislocation
D. Hangman's fracture of C2
E. Jefferson fracture of C1 - ✔✔A. Transverse process fracture
The answer is A.
A transverse process fracture involves only one of the supporting spinal columns (the
posterior column) and is therefore stable.
✔✔A 23 year old man is stabbed in the anterior neck with a 3-inch knife during a street
fight. At the scene, there is some bleeding, which is controlled with direct pressure. He
presents to the emergency department breathing comfortably and in no distress. His
pulse is 88, blood pressure 126/76, and oxygen saturation 99% on room air. There is a
1cm laceration 2cm above the right sternoclavicular junction, lateral to the trachea.
There is mild oozing and no obvious underlying hematoma. There is no obvious
subcutaneous air, and he has clear lung sounds. What is the most appropriate
management for this patient?
A. Local wound exploration and discharge home if no significant injury identified
B. Angiography, esophogram, and admission for observation
C. Local wound exploration and discharge home after 6-hour observation period
D. CT scan of the neck and discharge home after 6 hours of observation
E. Immediate operative - ✔✔B. Angiography, esophogram, and admission for
observation
, The answer is B. Zone I penetrating neck injuries are located between the sternal notch
and the cricoid cartilage. A major concern is injury to non-compressible vascular
structures such as common carotid, vertebral, subclavian, aortic arch. Other structures
in this area include trachea, esophagus, and lung apices. Physical exam is often
unreliable and angiography, esophogram, and observation are warranted.
✔✔Which of the following patients should undergo abdominal trauma evaluation?
A. 22 year old with stab wound to fourth intercostal space on right
B. 30 year old with pelvic pain and tenderness after fall
C. 25 year old restrained passenger in high-speed MVA; no abdominal complaints
D. None of the above
E. All of the above - ✔✔E. All of the above
The answer is E. The diaphragm can rise to as high a level as the fourth intercostal
space and can be injured by stab wounds at this level. Unsuspected injuries are
common in high speed motor vehicle crashes. Pelvic injuries are associated with intra-
abdominal injuries and can distract a patient from such an injury. Therefore, all of these
patients need an evaluation of their abdomens.
✔✔Which of the following trauma patients can be managed conservatively without
immediate laparotomy in the OR?
A. 27 year old man with hemoperitoneum by bedside ultrasound; hypotensive
B. 19 year old man with splenic laceration; peritoneal signs on exam
C. 24 year old man with liver laceration; hemodynamically stable
D. 30 year old man with a gunshot wound to the epigastrium
E. All of the above should go to the OR for exploratory laparotomy. - ✔✔C. 24 year old
man with liver laceration; hemodynamically stable
✔✔Which of the following is an accurate statement?
A. Bedside ultrasound is the test of choice for diagnosing solid organ injury.
B. Diagnostic peritoneal lavage usually cannot identify the presence of
hemoperitoneum.
C. Bedside ultrasound can image the retroperitoneum.
D. Bedside ultrasound can reliably determine the etiology of hemoperitoneum.
E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum. -
✔✔E. Diagnostic peritoneal lavage cannot determine the etiology of hemoperitoneum.
The answer is E. Diagnostic peritoneal lavage is extremely sensitive for the detection of
hemoperitoneum and can lead to many negative laparotomies. Neither bedside
ultrasound nor diagnostic peritoneal lavage can identify the source of the hemorrhage
though. A trauma ultrasound at the bedside can only identify fluid in the peritoneal
cavity, and CT scan is the test of choice for diagnosing solid organ injury.
✔✔A 36 year old man is a restrained driver involved in a high speed MVA where his car
is struck on the driver's side door with significant intrusion. His physical exam is
, significant for a large contusion on his left flank. His abdominal exam is benign and
rectal exam reveals a normal prostate. A Foley catheter is placed with return of gross
hematuria. Which test is indicated to evaluate for the presence of urologic injury?
A. CT abdomen / pelvis with IV and transurethral contrast
B. Ultrasound of the bladder
C. CT abdomen / pelvis without contrast
D. Ultrasound of the kidneys
E. CT abdomen / pelvis with IV contrast alone - ✔✔A. CT abdomen / pelvis with IV and
transurethral contrast
✔✔In which of these patients is emergency department thoracotomy indicated?
A. All of the above should undergo emergency department thoracotomy.
B. Unbelted driver in a high-speed motor vehicle crash who loses his pulse while being
extricated, and arrives at the E.D. after a 45-minute transport
C. Patient with stab wound to the anterior chest who is dyspneic with an oxygen
saturation of 80% and a blood pressure of 168/102
D. Pedestrian struck with massive pelvic fractures who loses pulses and blood
pressure at the scene
E. Patient with a gunshot wound to the chest who upon arrival is unconscious and
pulseless, with a systolic blood pressure of 60 - ✔✔E. Patient with a gunshot wound to
the chest who upon arrival is unconscious and pulseless, with a systolic blood pressure
of 60
The answer is E. Emergency Department thoracotomy is a controversial procedure.
When chosen carefully, successful resuscitation can occur. Cardiac arrest due to blunt
trauma has a dismal success rate and is generally not considered an indication for ED
thoracotomy. Thoracotomy for penetrating chest wounds has the best success rate. An
awake patient with a relatively normal blood pressure does not need one performed in
the Emergency Department. An unconscious and pulseless patient with a detectable
blood pressure has the best chance for survival.
✔✔A 32 year old female is shot with a 38-caliber pistol at close range in the right
anterior chest. She presents to the emergency department intoxicated and yelling. Her
vitals include a pulse of 92, blood pressure of 134/84, and oxygen saturation of 97%.
She has clear breath sounds bilaterally. The entrance wound is just above the right
breast and an exit wound is noted in the right axilla. What is the most appropriate
management of this patient?
A. IV access, endotracheal intubation and simultaneous placement of a right chest
tube, bedside ultrasound, portable chest X-ray, and admission to the ICU if stable
B. IV access, portable chest X-ray, tube thoracostomy, and exploratory thoracotomy in
the OR to search for cardiac or pulmonary vascular injury
C. IV access, endotracheal intubation, emergency department thoracotomy to search
for cardiac or pulmonary vascular injury
D. IV access, portable chest X-ray, right ch - ✔✔A. IV access, endotracheal intubation
and simultaneous placement of a right chest tube, bedside ultrasound, portable chest X-
ray, and admission to the ICU if stable
