EMERGENCY MEDICINE ACTUAL EXAM SCRIPT
QUESTIONS AND ANSWERS RATED A+
✔✔Which of the following pairings of referred pain and causal disease is least likely to
be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis - ✔✔A. sacral pain—ovarian torsion
Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and
cervical motion tenderness, but it is not known to cause sacral pain.
✔✔A 72 year old man with a history of diverticulosis presents with vague abdominal
pain for the past day. His physical exam is notable for normal vital signs, left lower
quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown
stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis
without perforation. Of the following choices, which is the most appropriate
management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids - ✔✔E. admission for intravenous
antibiotics and fluids
For mild episodes of diverticulitis in which there is no evidence of perforation or
peritonitis, there is no indication for immediate surgical intervention. Conservative
management with intravenous fluids and antibiotics as well as bowel rest is typically first
attempted. Although colon carcinoma may be a precipitating factor in the development
of diverticulitis, barium enema should be avoided in the acute period due to high risk of
bowel perforation. Although some patients with mild cases of diverticulitis may be
discharged home with conservative treatment, the elderly are at higher risk of
perforation and should be admitted. *Guaiac positive stool* in seen in up to *50%* of
patients with diverticulitis. There is no reason to suspect acute blood loss requiring
transfusion in diverticulitis.
✔✔Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube
placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or
heavy lifting.
, C. Over 80% of esophageal perforations are iatrogenic, usually as complications of
upper endoscopy, dilation, or sclerotherapy.
D. Over 90% of spontaneous esophageal perforations occur in the proximal
esophagus.
E. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or
esophagogastric junction. - ✔✔D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
Over 90% of spontaneous esophageal perforations occur in the *distal* esophagus,
whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or
the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt
injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.
✔✔Working in the ED, you have identified a bony object wedged in the mid-esophagus
of a 45 year old patient. Failure to promptly remove a foreign body impacted in the
esophagus could result in:
A. Esophageal perforation and mediastinitis
B. Epiglottal edema and airway obstruction
C. The rapid development of xerostomia
D. Barrett's esophagitis - ✔✔A. Esophageal perforation and mediastinitis
The complications of esophageal foreign bodies are rare but serious. They include
esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-
to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal
compression (from both the esophageal foreign body and resultant edema or infection).
Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act
as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb
rupture and pneumothorax formation.
✔✔A mother brings her 35 year old son to the emergency department because of
tremor and mutism for the past three days. His mother found him in his room this
morning lying stiffly in his bed, soiled with urine and feces. He appears confused and
will not respond to questions. He was diagnosed with schizophrenia last year and has
been on several medications. Last month after his most recent hospital admission for
schizophrenia, he was discharged with a prescription for haloperidol. On physical exam,
he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12.
His neuromuscular exam shows extremely rigid extremities, and his laboratory values
are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine
phosphokinase levels. What is the most likely explanation for these findings?
A. neuroleptic-induced acute dystonia
B. neuroleptic malignant syndrome
C. schizophren - ✔✔B. neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to
antipsychotic medications, with haloperidol being the most common cause. It is
,characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental
status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile
blood pressure, incontinence, dysrhythmias). While this patient's temperature is only
102.7, students should note that any patients with temperatures greater than 105 most
likely have non-infectious etiologies for temperature elevation. NMS is thought to be due
to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists
of stopping the causative agent and providing supportive care. Medications such as
*dantrolene, bromocriptine, amantadine, and lorazepam* are also often used. Tardive
dyskinesia is a chronic movement disorder that results from prolonged use of
antipsychotics and can include involuntary and periodic movements of the tongue or
lips, mouth puckering, or flailing movements either of the extremities or of the spine.
Neuroleptic-induced acute dystonia is an acute spasm of a muscle or muscle group
associated with the use of antipsychotic agents. It presents with patients complaining of
neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from
tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia is an
extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia,
catatonic type, a diagnosis of exclusion, usually does not present with this degree of
impairment.
✔✔A 25 year old man returns to the ED, 24 hours after being released from the hospital
with a new diagnosis of schizophrenia. He has recently started to take haloperidal for
his psychotic symptoms. In the ED he is noted to have involuntary contractions of the
muscles of the face, a protruding tongue, deviation of the head to one side, and
sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no
electrolyte or hematological abnormalities. Of the following choices, the preferred
medication for this condition is:
A. diphenhydramine
B. lorazepam
C. phenobarbital
D. metoprolol - ✔✔A. diphenhydramine
Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs
in up to 5% of patients. Dystonic reactions, which can occur at any point during long-
term therapy and up to 48 hours after administration of neuroleptics in the emergency
department, involve the sudden onset of involuntary contraction of the muscles in the
face, neck, or back. The patient may have protrusion of the tongue (buccolingual crisis),
deviation of the head to one side (acute torticollis), sustained upward deviation of the
eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely
laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and
increasing under emotional stress, which occasionally misleads emergency physicians
to believe they may be hysterical in nature. Dystonic reactions should be treated with
*IM or IV benztropine (Cogentin®), 1 to 2 mg*, or *diphenhydramine (Benadryl®), 25 to
50 mg*. Intravenous administration usually results in near-immediate reversal of
symptoms. Patients should receive oral therapy with the same medication for 48 to 72
hours to prevent recurrent symptoms.
, ✔✔A 70 year old male with acute delirium requires administration of haloperidol for
agitation. Which of the following is a recognized side effect of haloperidol?
A. first degree heart block
B. nephrogenic diabetes insipidus
C. prolonged QT interval
D. transient hepatitis - ✔✔C. prolonged QT interval
Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of
haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia
✔✔A 19 year old woman is brought to the emergency department by her friends
because she has been saying that she is a superhero and trying to run into traffic to
prove that she is indestructible. The friends report that she has been using drugs but
they do not know which ones. Which of the following pairs of ocular finding and
recreational drug is commonly observed?
A. dilated pupils - heroin
B. internuclear ophthalmoplegia - marijuana
C. pinpoint pupils - amphetamines
D. vertical nystagmus - phencyclidine - ✔✔D. vertical nystagmus - phencyclidine
Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin)
cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple
sclerosis. CN VI palsy is not associated with any specific drugs.
✔✔A 42 year old former custodial worker presents stating, "I think that people can hear
what I am thinking." In the emergency department, he becomes extremely agitated and
threatening, and his psychoses become more severe. In choosing an antipsychotic
medication, which of the following would be the most appropriate choice?
A. haloperidol
B. chlorpromazine
C. thioridazine
D. ketamine - ✔✔A. haloperidol
Haloperidol is the most studied high potency antipsychotic agent used in agitated
patients. Typical dosing is *5-10 mg IM every 10-30 minutes*. Unlike thioridazine,
haloperidol *does not cause respiratory depression*, has *negligible anticholinergic side
effects*, and rarely causes hypotension. Although benzodiazepines can be used in the
agitated patient, respiratory depression can occur, and close monitoring is essential.
✔✔A 20 year old college student is brought to the emergency department by campus
police after he was found by his roommate saying people in the TV were trying to kill
him. Which of the following criteria is not an indication for admission?
A. first-time psychiatric episode
QUESTIONS AND ANSWERS RATED A+
✔✔Which of the following pairings of referred pain and causal disease is least likely to
be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis - ✔✔A. sacral pain—ovarian torsion
Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and
cervical motion tenderness, but it is not known to cause sacral pain.
✔✔A 72 year old man with a history of diverticulosis presents with vague abdominal
pain for the past day. His physical exam is notable for normal vital signs, left lower
quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown
stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis
without perforation. Of the following choices, which is the most appropriate
management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids - ✔✔E. admission for intravenous
antibiotics and fluids
For mild episodes of diverticulitis in which there is no evidence of perforation or
peritonitis, there is no indication for immediate surgical intervention. Conservative
management with intravenous fluids and antibiotics as well as bowel rest is typically first
attempted. Although colon carcinoma may be a precipitating factor in the development
of diverticulitis, barium enema should be avoided in the acute period due to high risk of
bowel perforation. Although some patients with mild cases of diverticulitis may be
discharged home with conservative treatment, the elderly are at higher risk of
perforation and should be admitted. *Guaiac positive stool* in seen in up to *50%* of
patients with diverticulitis. There is no reason to suspect acute blood loss requiring
transfusion in diverticulitis.
✔✔Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube
placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or
heavy lifting.
, C. Over 80% of esophageal perforations are iatrogenic, usually as complications of
upper endoscopy, dilation, or sclerotherapy.
D. Over 90% of spontaneous esophageal perforations occur in the proximal
esophagus.
E. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or
esophagogastric junction. - ✔✔D. Over 90% of spontaneous esophageal perforations
occur in the proximal esophagus.
Over 90% of spontaneous esophageal perforations occur in the *distal* esophagus,
whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or
the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt
injury or penetrating trauma, and carcinoma are other causes of esophageal perforation.
✔✔Working in the ED, you have identified a bony object wedged in the mid-esophagus
of a 45 year old patient. Failure to promptly remove a foreign body impacted in the
esophagus could result in:
A. Esophageal perforation and mediastinitis
B. Epiglottal edema and airway obstruction
C. The rapid development of xerostomia
D. Barrett's esophagitis - ✔✔A. Esophageal perforation and mediastinitis
The complications of esophageal foreign bodies are rare but serious. They include
esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-
to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal
compression (from both the esophageal foreign body and resultant edema or infection).
Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act
as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb
rupture and pneumothorax formation.
✔✔A mother brings her 35 year old son to the emergency department because of
tremor and mutism for the past three days. His mother found him in his room this
morning lying stiffly in his bed, soiled with urine and feces. He appears confused and
will not respond to questions. He was diagnosed with schizophrenia last year and has
been on several medications. Last month after his most recent hospital admission for
schizophrenia, he was discharged with a prescription for haloperidol. On physical exam,
he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12.
His neuromuscular exam shows extremely rigid extremities, and his laboratory values
are notable for a white blood cell count of 15000/mm3 and abnormally elevated creatine
phosphokinase levels. What is the most likely explanation for these findings?
A. neuroleptic-induced acute dystonia
B. neuroleptic malignant syndrome
C. schizophren - ✔✔B. neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life-threatening reaction to
antipsychotic medications, with haloperidol being the most common cause. It is
,characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental
status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile
blood pressure, incontinence, dysrhythmias). While this patient's temperature is only
102.7, students should note that any patients with temperatures greater than 105 most
likely have non-infectious etiologies for temperature elevation. NMS is thought to be due
to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists
of stopping the causative agent and providing supportive care. Medications such as
*dantrolene, bromocriptine, amantadine, and lorazepam* are also often used. Tardive
dyskinesia is a chronic movement disorder that results from prolonged use of
antipsychotics and can include involuntary and periodic movements of the tongue or
lips, mouth puckering, or flailing movements either of the extremities or of the spine.
Neuroleptic-induced acute dystonia is an acute spasm of a muscle or muscle group
associated with the use of antipsychotic agents. It presents with patients complaining of
neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from
tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia is an
extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia,
catatonic type, a diagnosis of exclusion, usually does not present with this degree of
impairment.
✔✔A 25 year old man returns to the ED, 24 hours after being released from the hospital
with a new diagnosis of schizophrenia. He has recently started to take haloperidal for
his psychotic symptoms. In the ED he is noted to have involuntary contractions of the
muscles of the face, a protruding tongue, deviation of the head to one side, and
sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no
electrolyte or hematological abnormalities. Of the following choices, the preferred
medication for this condition is:
A. diphenhydramine
B. lorazepam
C. phenobarbital
D. metoprolol - ✔✔A. diphenhydramine
Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs
in up to 5% of patients. Dystonic reactions, which can occur at any point during long-
term therapy and up to 48 hours after administration of neuroleptics in the emergency
department, involve the sudden onset of involuntary contraction of the muscles in the
face, neck, or back. The patient may have protrusion of the tongue (buccolingual crisis),
deviation of the head to one side (acute torticollis), sustained upward deviation of the
eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely
laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and
increasing under emotional stress, which occasionally misleads emergency physicians
to believe they may be hysterical in nature. Dystonic reactions should be treated with
*IM or IV benztropine (Cogentin®), 1 to 2 mg*, or *diphenhydramine (Benadryl®), 25 to
50 mg*. Intravenous administration usually results in near-immediate reversal of
symptoms. Patients should receive oral therapy with the same medication for 48 to 72
hours to prevent recurrent symptoms.
, ✔✔A 70 year old male with acute delirium requires administration of haloperidol for
agitation. Which of the following is a recognized side effect of haloperidol?
A. first degree heart block
B. nephrogenic diabetes insipidus
C. prolonged QT interval
D. transient hepatitis - ✔✔C. prolonged QT interval
Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of
haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia
✔✔A 19 year old woman is brought to the emergency department by her friends
because she has been saying that she is a superhero and trying to run into traffic to
prove that she is indestructible. The friends report that she has been using drugs but
they do not know which ones. Which of the following pairs of ocular finding and
recreational drug is commonly observed?
A. dilated pupils - heroin
B. internuclear ophthalmoplegia - marijuana
C. pinpoint pupils - amphetamines
D. vertical nystagmus - phencyclidine - ✔✔D. vertical nystagmus - phencyclidine
Sympathomimetics (cocaine, amphetamines) cause dilated pupils. Opiates (heroin)
cause pinpoint pupils. Internuclear ophthalmoplegia is associated with multiple
sclerosis. CN VI palsy is not associated with any specific drugs.
✔✔A 42 year old former custodial worker presents stating, "I think that people can hear
what I am thinking." In the emergency department, he becomes extremely agitated and
threatening, and his psychoses become more severe. In choosing an antipsychotic
medication, which of the following would be the most appropriate choice?
A. haloperidol
B. chlorpromazine
C. thioridazine
D. ketamine - ✔✔A. haloperidol
Haloperidol is the most studied high potency antipsychotic agent used in agitated
patients. Typical dosing is *5-10 mg IM every 10-30 minutes*. Unlike thioridazine,
haloperidol *does not cause respiratory depression*, has *negligible anticholinergic side
effects*, and rarely causes hypotension. Although benzodiazepines can be used in the
agitated patient, respiratory depression can occur, and close monitoring is essential.
✔✔A 20 year old college student is brought to the emergency department by campus
police after he was found by his roommate saying people in the TV were trying to kill
him. Which of the following criteria is not an indication for admission?
A. first-time psychiatric episode
