Emergency Med NBME Form 1 Exam with Complete Solutions

52 yo man - 6 hrs after onset of severe, epigastric abd pain > began at cocktail party > was there for 4 hrs - 3 martinis, lot of food PMHx: HLD (statin) 100.4F 104/min 150/92 mmHg PE: diffuse tenderness over upper quadrants BL - esp epigastrium; no guarding/rebound labs: WBC WNL, BR 3 (direct 2.4), alk phos 210, AST 325, ALT 360, amylase 1200, lipase 600 most likely cause of symptoms? - ANSWER-common bile duct obstruction choledocholithiasis = stone in CBD lipase high so think pancreatitis 2 MC causes: alcohol and gallstones if alcoholic cause - the AST should be higher than ALT (A Scotch and Tonic) abd pain that started right after eating a lot of food > think gallstones he also has PMHx of HLD - another RF for pancreatitis 42 yo man - 30 min after onset of gen weakness, SOB, severe abd cramps, sweating > began while gardening 99.2F 52/min RR: 24/min 98/60 mmHg POx: 98% RA PE: diaphoresis, excessive lacrimation, 2 mm pupils reactive to light; diffuse wheezes; abd - no tenderness; muscle strength 4/5 in ext - muscle fasciculations; DTRs 2+; no Babinski; intact sens after decontamination - most app tx to immediately relieve current symptoms? - ANSWER-administration of atropine homeboy was gardening - exposure to spray insecticides (aka organophosphates - AChE inhibitors) > these can cause acute cholinergic toxicity = DUMBBELLS (diarrhea, urination, miosis/muscle weakness, bradycardia/bronchorrhea, emesis, lacrimation, sweating/salivation) pralidoxime regenerates AChE at musc/nic receptors - only peripheral > useless once aging of bonded complex has occurred atropine reverse peripheral and central musc toxicity 54 yo - 2 hrs of chest pain, SOB, nausea > began while sitting/working at desk > 1 episode of vomiting > pain 7/10, radiates to shoulders, "pressure" 3 similar episodes during past 3 months > occurred on exertion, resolved after 15 min of rest PMHx: HTN, T2DM meds: ASA, metformin, enalapril SHx: smokes 1 pack qd 30 yrs 98.6F 90/min 20/min 154/85 mmHg POx: 99% PE: gucci labs: WNL (including trop) ECG, CXR: gucci ED course: ASA, NTG, morphine administered > 15 min later, pain is now 2/10; pt being observed; repeat trop 4 hrs later WNL; symptoms have resolved most app next step in mgnt? - ANSWER-myocardial perfusion testing within 3 days trops aren't elevated and pt is stable - okay to d/c him and f/u really soon he has RFs for CAD and has had similar episodes of chest pain in the past this episode is diff bc occurred w/o exertion - suggesting the etiology has gotten worse 2014 AHA guidelines: 1. for patients with possible ACS who have *normal serial ECGs and cardiac troponin levels*: it is reasonable to obtain a treadmill ECG (level of evidence: A), stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge (level of evidence: B). > our guy falls under this category due to his prior episodes 2. in patients with possible ACS and a normal ECG, normal cardiac troponin levels, and no history of coronary artery disease (CAD): it is reasonable to initially perform (without serial ECGs and troponin levels) coronary computed tomography angiography to assess coronary artery anatomy (level of evidence: A) or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia (level of evidence: B) 47 yo - 1 hr after can of gas exploded 5 ft from him > pain/loss of hearing in R.ear ED: mild distress 98.8F 90/min 14/min 120/80 mmHg PE: abrasions over R.face/neck/upper chest; blood in ext auditory canal; swelling/ecchymosis of R.pinna; can't hear whispered voices; L.ear - gucci most likely explanation of symptoms? - ANSWER-rupture of the tympanic membrane blast injuries - potential cause of barotrauma barotrauma = results from the air pressure wave generated by an explosion > rapid pressure change allows no time to equalize the pressure > potential injuries: bruising of the eardrum, bleeding into the drum and middle ear, eardrum rupture, ossicular disruption, and inner ear injury resulting in dizziness and tinnitus 13 yo - 30 min after fell off sailboat into freshwater lake > underwater for about 2 min > rescued - cyanotic and unresponsive > began coughing/breathing again after mouth2mouth ED: awake/alert; mild SOB and cough 98.6F 108/min 20/min 93/45 mmhg POx: 94% RA PE: mild wheezes; no signs of ext trauma CXR: mild diffuse int markings most app next step in mgnt? - ANSWER-admission to the hospital for observation I guess you don't give assisted ventilation until O2 really drops - UTD suggests maintaining SpO2 > 94% > if needs oxygen - give noninvasive positive-pressure ventilation via BLPAP or CPAP def needs hospital admission bc CXR looks junky and currently has SOB/cough > make sure she doesn't develop ARDS ~ can develop insidiously over next 72 hrs ~ monitor closely for dyspnea, cough, crackles, and cyanosis 26 yo female - 2 hrs of SOB and mod R.chest pain > SOB when walking up flight of stairs this morning and walking w/ friends at mall earlier > 2 days of nonproductive cough PMHx: sickle cell dz meds: hydroxyurea, acetaminophen w/ codeine prn 1 yr ago: hospitalized for vaso-occlusive crisis ED: mild resp distress BMI: 21 101.1F, 38.4 C 104/min 20/min 128/82 mmHg POx: 91% RA > 95% on 2L O2 NC PE: fine crackles at R.lung base labs: Hgb 8.9, Hct 25.2, WBC 12,600, plt 457,000 CXR: consolidation and infiltrates in R.lung base most likely underlying cause of pt's current condition? - ANSWER-infection homegirl has acute chest syndrome 2/2 sickle cell dz > due to infection and occlusion of pulm microvasculature ACS defined as radiographic evidence of consolidation + at least one of the following: temp > 38.5C, >2% dec in SpO2, PaO2 < 60 mmHg, tachypnea, intercostal retractions/nasal flaring/use of accessory muscles, chest pain, cough, wheezing, rales > HOWEVER: presence of PNA meets the criteria since they can't be distinguished from one another due to the hits that the spleen has been taking over the yrs > autosplenectomy (it shrinks up) > pt more prone to encapsulated organisms make sure to r/o PE w/ VQ scan or CT angio tx: monitor oxygenation; Abx; hydration; exchange transfusion if severe 62 yo man - 2 days of feeling light-headed > no chest pain/palp > usually constipated - BMs qd for past 5 days ~ stools dark reddish brown PMHx: chronic low back pain 98.6F 140/min, reg 24/min 80/50 mmHg PE: too LH to check orthostatics; lungs clear; abd - soft, nontender, not distended; rectal exam - soft, dark red stool; pos for occult blood fingerstick bG: 92 labs: H/H 8.0/22%; WBC 8000; plt 240; LDH 6; coags WNL ECG: sinus tachy ED course: blood sample sent for typing/crossmatch; subclavian cath inserted/confirmed by CXR after 0.9% NS 2L administered: > 120/min, reg > 100/70 mmHg > LDH 4.5 > CVP: 11 (inc) (N3-8) most app next step in mgnt? - ANSWER-packed red blood cell transfusion give whole blood for volume replenishment in blood loss when CVP is high > doesn't inc volume RBC transfusion thresholds: > <7: gen indicated > 7-8: cardiac surgery, HF, oncology pts in tx *> 8-10: ongoing bleeding, symptomatic anemia, ACS, noncardiac surgery* > >10: not gen indicated *don't give hypovolemic shock pt any vasopressors - already max vasoconstricted !!* The "effective blood volume," or that volume which restored arterial blood pressure, urine output, and tissue perfusion, exceeds the "normal blood volume" or the apparent improvement in BP. > which is why most pts in hypovolemic shock get transfused until CVP 10-15 Dr. Pestana: volume replacement starting w/ 2L > follow w/ packed red cells, FFP, plt packs in 1-1-1 ratio 60 yo Hispanic female - 1 wk of cough and low-grade fever > understands some English; doesn't speak fluently > son speaks fluent English/Spanish > physician not fluent in Spanish - can communicate limitedly w/ pt 100F 80/min 16/min 140/70 mmHg POx: 98% RA PE: breath sounds dec at lung bases w/ occ rhonchi that clear w/ cough CXR: no PNA; 1 cm mass that requires f/u in LLL ECG: NSR pt anxious to leave but hospital interpreter w/ another pt most app way to communication the need for further eval of a potential malignancy? - ANSWER-wait for the interpreter before issuing the discharge instructions so many things can get lost in translation - make sure you have a professional to help you relay the info > save your ass, don't get sued 77 yo female - fell at home PMHx: T2DM meds: metformin, insulin ED: somnolent 99.9F 130/min 16/min 78/40 mmHg POx: 98% PE: basilar crackles at L.lung base labs: Hgb 13.2; CMP WNL; HCO3 15; glucose 90 blood cx and CXR ordered most app next step in mgnt? - ANSWER-administration of 0.9% saline remember your ABCs mofo - esp since homegirl is unstable (tachy and HoTN) Dr. Pestana: even though fast CT scanners are available in Level I trauma centers - pt needs to be hemodynamically stable so pics can be taken w/o all the commotion of continuing resuscitation efforts 60 yo female - 12 hrs of mod, diffuse abd pain/vomiting > 2 wks ago: sigmoidectomy for perforated diverticulitis > no fever/diarrhea/dysuria > last BM yest - normal > no flatus today meds: cipro, metro, oxy-acet ED: mod distress; awake/alert 100.2F 100/min 20/min 140/65 mmHg POx: 98% RA PE: heart/lungs gucci; abd - mod distended and diffusely tender in all quadrants; surg incision clean/dry/intact; bowel sounds dec abd x-ray: mult loops of distended small bowel w/ air-fluid levels; no air in rectum most app next step in mgnt? - ANSWER-insertion of a nasogastric tube homegirl clearly has SBO 2/2 adhesions from her prior surgery > classic BOARDs question > MC cause of SBO UTD: pts w/ SBO associated with significant distension, nausea, and/or vomiting > recommend NG tube decompression Dr. Pestana: colicky abd pain, protracted vomiting, prog abd distention, no passage of gas/feces *x-rays: distended loops of small bowel w/ air fluid levels* > "step-ladder" appearance tx: NPO, NG suction, IVF > if unsuccessful - surgery ~ 24 hrs for complete obstruction ~ few days for partial 52 yo - 2 hrs of fever, severe malaise, joint stiffness > wrists, hands, knees PMHx: RA, HTN, hyperchol meds: pred, etanercept, enalapril, HCTZ, ibuprofen ED: sleepy, easily aroused 101.2F 120/min 26/min 90/50 mmHg POx: 92% RA PE: ext cool to touch; mottling over lower ext; no JVD; crackles over L.lung base; cardiac - hyperdynamic precordium; 2/6 sys ejection murmur at base; no S3/S4 labs: Hgb 9.5; WBC 20,500; plt 90,000; PT 16 sec; CMP WNL; BUN 35; albumin 2.1 ECG: sinus tachy but unchanged from prior ECG most likely dx? - ANSWER-sepsis wtf is mottling = veins swell > lacy bluish discoloration on the extremities the other choices just didn't make sense for this case (cardiac tamponade, GIB, NSTEMI, PE) I believe this pt is heading to DIC > inc PT, dec plt 30 yo male - 12 hrs of sharp, stabbing retrosternal chest pain > radiates to L.shoulder, worse w/ insp, relieved by leaning forward > cold several wks ago SHx: no cigs, no recent travel 99.4 F 92/min 12/min 110/70 mmHg PE: lungs clear, soft friction rub, no JVD, no lower ext edema CXR: honestly no clue if there's anything wrong here ECG: diffuse ST elevations (I think) administration of what is most app next step in mgnt? - ANSWER-ibuprofen maybe he has pericarditis 2/2 viral infxn I think there's diffuse ST elevations on the ECG young pt presenting w/ pleuritic chest pain that improves w/ leaning forward > pericardial friction rub w/ auscultations 1st line for viral cause would be NSAIDs > since MC cause of cold is viral - duhh possible to see cardiomegaly on CXR case makes it a point to say there's peripheral edema or JVD - suggesting that this hasn't progressed to tamponade yet if we're thinking this vs myocarditis: > seems like myocarditis will have tachycardia out of proportion to fever > mitral/tricuspid regurg murmur > in new dx of refractory asthma - consider myocarditis 73 yo - 1 hr of severe SOB > "feels like I'm suffocating" PMHx: HTN, CAD, hyperchol meds: ASA, clopidogrel, statin, metoprolol ED: severe resp distress; accessory muscles; speaks in short sentences 98.6F 123/min 28/min 245/113 mmHg POx: 85% on 15L O2 PE: crackles to apex BL; heart sounds gucci; trace peripheral edema ECG: I just see tachy most app next step is administration of what? - ANSWER-nitroglycerin need to focus on BP first since it is crazy high - 245/113 mmHg > furthermore there is pulm edema - 1st line here is IV NTG or nitroprusside rapid BP reduction indicated in CV emergencies (aortic dissection, ACS, acute HF) emphasis in tx pulm edema has shifted from diuretics to vasodilators - esp high dose nitrates combined w/ PPV furosemide is going to take too much time 17 yo girl - 2 days of gen weakness/fatigue > light-headed upon standing; almost fainted earlier today > very thirsty recently no meds, NKDA ED: sleepy, easily aroused BMI: 17 99.1F 118/min 28/min 102/54 mmHg POx: 99% RA PE: dry mucous membranes; lungs clear; abd - soft, nontender serum studies will most likely show what abnormality? - ANSWER-decreased bicarbonate she's in DKA - aka metabolic acidosis, dec bicarb homegirl has T1DM - skinny (low BMI), thirsty, dry, fatigued can also have inc potassium - bc K shifting out in exchange for H (to dec the acidosis that is occurring) > pseudo hyperK 20 yo female - 1 hr after sudden onset of chest pain and SOB > chest pain is worse when takes deep breath > past wk - pain/swelling of L.leg no OCPs SHx: smokes cig qd 3 yrs 99F 130/min 26/min 140/85 mmHg POx: 94% RA PE: lungs clear preg test: neg ECG: most app next step in dx? - ANSWER-CT angiography of the chest homegirl w/ sudden chest pain/SOB - suggestive of PE smoking, OCPs, pregnancy are RFs for embolism > L.leg symptoms suggest DVT > clot broke off and traveled up to lungs signs: tachypnea, tachycardia, hypoxia, rales, diaphoresis, bulging neck veins, heart murmur symptoms: dyspnea, chest pain, apprehension, cough, hemoptysis ECG: S1Q3T3 - seen in <1/4 of pts > MC rhythm: sinus tachy gold standard: pulm angio can also use VQ scans and spiral CTs for dx CT angio of chest: BL PE