Rosh Review Questions and Answers 2023 with complete solution A patient presents with dizziness. Romberg testing with the eyes open is normal, but with the eyes closed, the patient sways and almost falls over. Given this Romberg test result, pathology i

Rosh Review Questions and Answers 2023 with complete solution A patient presents with dizziness. Romberg testing with the eyes open is normal, but with the eyes closed, the patient sways and almost falls over. Given this Romberg test result, pathology in which of the following systems is most likely? A Cardiovascular B Cerebellar C Vestibular D Visual Ans- Vestibular In the US, what is a common cause of imbalance due to peripheral disease? Ans- Diabetic distal peripheral polyneuropathy An elderly man complains of dizziness upon standing. He denies being dizzy once he has stood for 5 minutes, and also denies being dizzy when supine or seated. He denies associated chest pain, palpitations, or dyspnea. Which of the following tests should first be performed during the evaluation of this positional dizziness? A Chest radiograph B Head-up tilt-table testing C Orthostatic vital signs D Transesophageal echocardiography Ans- C orthostatic vital signs List some medications whose side effects can cause symptoms of orthostasis? Ans- Antiparkinsonian drugs, antiadrenergics, anticholinergics, antidepressants, antiarrhythmics, antipsychotics, diuretics, narcotics and sedatives. Orthostatic hypotension diagnostic criteria Ans- Decrease in systolic blood pressure ≥ 20 Decrease in diastolic blood pressure ≥ 10 Inadequate physiologic response to postural changes *rhythm strip showing SVT* A 1-year-old boy presents with the rhythm seen above. Physical exam is unremarkable except for tachycardia. Which of the following vagal maneuvers is the most effective to treat this rhythm? A Apply external ocular pressure B Apply ice to the face C Blow on the patient's face with a straw D Perform carotid massage Ans- B apply ice to the face It is important that when performing this maneuver that you do not occlude the nose or mouth, and apply the ice only over the patient's forehead, eyes, and bridge of the nose for 10-15 seconds. Adenosine, an AV-nodal blocking agent, can also be administered in stable patients. What is the treatment for a hemodynamically unstable child with supraventricular tachycardia? Ans- Cardioversion at 0.5 to 1 J/kg. If unsuccessful, increase energy dose to 2 J/kg on subsequent attempts. *US of empty gestational sac* A 26-year-old woman presents with abdominal cramping after a positive home pregnancy test. Her vitals are T 98.7°F, HR 94, BP 110/66, RR 18, oxygen saturation 97%. Her exam is unremarkable. Labs reveal a serum beta HCG of 1000 mIU and she is Rh positive. She states that the pregnancy is wanted. An ultrasound is performed as seen above. Which of the following is appropriate management for this patient? A Administer methotrexate B Administer Rhogam and discharge home with repeat beta hCG in 48 hours C Administer Rhogam and methotrexate D Discharge home with repeat beta hCG in 48 hours Ans- D Discharge home with repeat beta hCG in 48 hours What is the success rate of methotrexate in the management of early ectopic pregnancy? Ans- 85-93%. *image of subconjunctival hemorrhage* A 55-year-old woman with a history of chronic bronchitis presents and is concerned about the appearance of her left eye. She denied a change in vision or any discomfort but is concerned because she noticed "blood in my eye" this morning. Evaluation of the patient demonstrates intact extraoccular muscles; pupils that are equal, round, and reactive to light; and visual acuity of 20/30 in each eye. Which of the following is the most appropriate next step in the evaluation and management of her complaint? A CT scan of the orbit and facial bones to evaluate for globe injury B Measure intraocular pressure to rule out a retrobulbar hematoma C Obtain an ophthalmology consultation D Reassure the patient and discharge her home E Stain with fluorescein dye and assess for a corneal abrasion Ans- D Reassure the patient and discharge her home What injury can occur if Hemoccult drops are instilled in the eye? Ans- Severe alkali burns can occur. Subconjunctival Hemorrhage Ans- Patient will be complaining of blood in the eye PE will show blood under conjunctiva and stops at limbus Most commonly caused by coughing, sneezing, minor trauma Treatment is reassurance *abdominal xray of large bowel* Which of the following is prominently visualized in the image above? A Haustra B Plicae circulares C Teniae coli D Valvulae conniventes Ans- A haustra Large bowel Ans- haustra teniae coli (runs length of large intestine--contractions cause appearance of haustra) small bowel Ans- Valvulae conniventes -muscular folds of small intestine -begin in second part of duodenum -disappears in distal ileum What is the upper limit of normal diameter for the different segments of bowel? Ans- Small bowel (3 cm), colon (6 cm), cecum (9 cm)—the 3/6/9 rule. Large Bowel Obstruction Ans- CRC > diverticulitis, volvulus, strictures High-pitched bowel sounds Abdominal distension NGT, surgery subdural hematoma presentation Ans- The presentation varies with the severity of the underlying injury, but patients commonly present with a diminished level of consciousness, headache, and focal neurologic deficits corresponding to the area of injury. If sufficient bleeding occurs, intracranial pressure increases and herniation may occur characteristic presentation of subdural hematoma on head CT Ans- collection of hyperdense blood in a crescent-shaped pattern conforming to the convexity of the hemisphere and often extending past cranial sutures subdural hematoma Ans- crescent shaped blood collection between dura and arachnoid matter tear in BRIDGING VEINS alcoholics and elderly prone epidural hematoma Ans- biconvex (lens) shaped blood between dura and skull tearing of MIDDLE MENINGEAL ARTERY adolescents and young adults (trauma) subarachnoid hemorrhage Ans- blood in circle of willis, cisterns, and fissures rupture of berry aneurysm polcystic kidney disease RF intracerebral hemorrhage Ans- blood in parenchyma and ventricles hypertensive vasculopathy territory of penetrator arteries What is a subdural hygroma? Ans- A collection of clear, xanthochromic blood-tinged fluid in the dural space. A 14-year-old girl presents with right thigh pain that has been going on for the last month. She recalls being kicked in the leg during soccer practice before her symptoms started. She was last seen in the ED two weeks ago and was diagnosed with a muscle contusion. On exam there is a mass palpable over the anterior distal thigh. X-ray of the femur shows a distal femoral diaphyseal lesion with cortical destruction and periosteal reaction with high suspicion for osteosarcoma. Which of the following is true regarding this disease? A Blunt trauma is associated with the pathogenesis of osteosarcoma B Ionizing radiation for childhood cancer is a risk factor for osteosarcoma C Osteosarcoma most often involves the axial skeleton followed by the long bones D Pathologic fracture is a common presenting sign Ans- B Ionizing radiation for childhood cancer is a risk factor for osteosarcoma most common sites of involvement for osteosarcoma Ans- 1. distal femur 2. proximal tibia 3. proximal humerus 4. middle and proximal femur osteosarcoma clinical presentation Ans- 1. localized pain (several mos) 2. pain frequently begins after injury 3. systemic Sx generally absent 4. soft tissue mass (large and tender to palpation) What lab abnormalities are associated with osteosarcoma? Ans- Laboratory studies are generally not useful in diagnosis of osteosarcoma, but the most common lab abnormalities include elevated alkaline phosphatase, lactate dehydrogenase (LDH), and erythrocyte sedimentation rate (ESR). xray findings for osteosarcoma Ans- codman's triangle sunburst pattern *EKG showing hyperkalemia* A 67-year-old man with hypertension and end-stage renal disease presents after an incomplete dialysis session secondary to shortness of breath. His vital signs are BP 110/95, HR 65, RR 22, T 37.3°C, and oxygen saturation 99% on 2L NC. You obtain the ECG above. Which of the following is the most appropriate next step in this patient's management? A Calcium gluconate B Cardiology consultation C Defibrillation D Transcutaneous pacing Ans- A calcium gluconate What is the approximate duration of action of calcium on cardiac membrane stabilization? Ans- 30 to 60 minutes Hyperkalemia Ans- Patient with a history of renal failure, DKA, rhabdomyolysis, tumor lysis Complaining of lethargy, weakness, paralysis PE will show bradycardia, hypotension, cardiac dysrhythmia ECG will show peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, kayexalate, bicarbonate *picture of black widow spider* A 25-year-old man is brought into the ED after he was bit by a spider. He brings the dead spider with him to show you. Which of the following statements is correct regarding this type of spider bite? A A bite causes local necrotic wound toxicity B An antivenom is not available in the United States C Envenomation causes the release of acetylcholine and norepinephrine at nerve terminals leading to severe muscle cramping and systemic effects D The spider's venom contains a variety of cytotoxic enzymes Ans- C Envenomation causes the release of acetylcholine and norepinephrine at nerve terminals leading to severe muscle cramping and systemic effects Symptoms of black widow bite Ans- dizziness, restlessness, profuse sweating, difficulty speaking, ptosis, hypertension, and tachycardia *radiograph demonstrates a markedly dilated single loop of colon consistent with a sigmoid volvulus* A 85-year-old nursing home patient presents with diffuse abdominal pain and distension, nausea, but no vomiting. The above abdominal radiograph is obtained. What is the management of this patient? A Enema B Nasogastric tube and bowel rest C Sigmoidoscopy D Surgical intervention Ans- C Sigmoidoscopy What is the most common cause of bowel obstruction in pregnancy? Ans- Cecal volvulus. Sigmoid volvulus Ans- -elderly bedridden Pt with psych/neuro hx -h/o constipation -sigmoidoscopy A 17-year-old boy presents after injuring his left ankle while playing soccer. Which of the following indicates the need for imaging of the ankle? A Inability to walk prior to arrival, but ambulatory during evaluation B Tenderness over the anterior edge of the distal medial malleolus C Tenderness over the base of the fifth metatarsal D Tenderness over the posterior edge of the distal lateral malleolus Ans- D Tenderness over the posterior edge of the distal lateral malleolus Ottawa Ankle Rules: determining a need for a radiograph in setting of ankle injuries evaluated within 48 h of injury An ankle radiograph Ans- 1. tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus 2. tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus 3. inability to bear weight for at least four steps both immediately after the injury and at the time of evaluation Ottawa Ankle Rules A foot radiograph Ans- pain in the midfoot region with any of the following: 1. bone tenderness at navicular bone 2. bone tenderness at the base of the fifth metatarsal 3. inability to bear weight for at least 4 steps both immediately after injury and at the time of evaluation What fracture of the proximal fibula is associated with a medial ankle disruption? Ans- Maisonneuve fracture Ottawa Foot and Ankle Rules X-rays required if: Ans- Patient cannot bear weight for 4 steps Distal 6 cm tibia/fibula tenderness Medial/lateral malleolus tenderness 5th metatarsal tenderness Navicular tenderness *image of one dilated pupil* Which type of cerebral herniation is associated with the finding above? A Central transtentorial B Cerebellotonsillar C Uncal D Upward transtentorial Ans- C Uncal What is Babinski's sign? Ans- Dorsiflexion of the great toe and fanning of the other toes when the sole is stimulated. Traumatic Brain Injury Ans- Cushing reflex: hypertension + bradycardia + respiratory depression Decorticate posturing: upper extremity flexion, lower extremity extension Decerebrate posturing: upper/lower extremity extension Oculocephalic response: eyes moving in opposite direction of head turning = intact brainstem function Oculovestibular response: irrigation of saline into the ear; no eye movement = brainstem injury GCS ≤ 8: intubate Prevent hypotension and hypoxia A 49-year-old woman presents to the ED with right shoulder pain after falling from her bicycle while riding at a high speed. Her exam is unremarkable except that her right arm is locked in abduction over her head as seen in the image above. Which of the following is the likely diagnosis? A Anterior shoulder dislocation B Inferior shoulder dislocation C Posterior shoulder dislocation D Sternoclavicular joint dislocation E Superior shoulder dislocation Ans- B Inferior shoulder dislocation What are the motor deficits seen with injury to the axillary nerve? Ans- Paralysis of the teres minor and deltoid muscles, resulting in loss of abduction of the arm, weak flexion, extension, and rotation of shoulder and is associated with flat shoulder deformity. Inferior Shoulder Dislocation Ans- Arm raised, inability to adduct arm Rotator cuff detachment Brachial plexus, axillary artery often injured *xray of scaphoid fracture* Which of the following is the most concerning complication of this injury? A Avascular necrosis B Infection C Malunion D Osteoarthritis Ans- A Avascular necrosis What is the recommend splint for a scaphoid fracture? Ans- Thumb spica splint Scaphoid Fracture Ans- FOOSH Snuff box tenderness Possibly negative radiographs Complication: avascular necrosis Thumb spica splint