ROSH REVIEW Emergency Medicine
UPDATED Actual Exam Questions and
CORRECT Answers
A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between
his fingers after returning home from summer camp 1 week ago. He reports several other
campers had similar symptoms. On exam, you note excoriations in the inguinal region and
axillae surrounding scattered, erythematous papules. Which of the following is the most
appropriate treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - CORRECT ANSWER- ✔✔Correct Answer ( C )
Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite
Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be
considered in patients with generalized pruritus, especially when exposure to others with
similar symptoms is reported. The rash of scabies involves papules, which are often
excoriated. Burrows are pathognomonic but not uniformly present. Unless previously
infected, pruritus generally takes 3-6 weeks to develop because symptoms are due to delayed
(Type IV) sensitivity reaction. The pruritus is classically worse at night and affects the web
spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical
region. Except in cases involving an immunocompromised host, the scalp and face are
generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected
with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice
for primary scabies infection is the application of topical scabicidal agents, with repeat
application in 7 days. The treatment of choice is permethrin 5% lotion. Individuals affected
by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may
return to school or work 24 hours after the first treatment.
Should family members of an infected individual also be treated for scabies? - CORRECT
ANSWER- ✔✔Yes, family members and sexual contacts.
Scabies - CORRECT ANSWER- ✔✔Sarcoptes scabiei
Pruritic rash worse at night
,Linear burrows
Interdigital spaces of hands/feet, penis, breasts
Permethrin (first line)
Ivermectin
**head and back are sparred
(head involved in children)
An 18-month-old boy presents to the emergency department with worsening shortness of
breath. The parents report he has had a cough, runny nose, and fussiness for the past five
days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse
wheezing. The patient is given an albuterol nebulizer treatment without any improvement of
his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms
is the most likely cause of his symptoms?
Bordetella pertussis
Haemophilus influenzae
Parainfluenza virus
Respiratory syncytial virus - CORRECT ANSWER- ✔✔Correct Answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection in
patients less than two years of age. It remains the leading cause for hospitalization in infants
under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus
(RSV), but may be caused by other viral agents. Bronchiolitis is inflammation of the lower
respiratory tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased
mucus production. The resultant lower airway obstruction causes increased work of breathing
and wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old,
rhinorrhea, tachypnea, and wheezing. Unlike asthma or reactive airway disease, there is often
no significant improvement with albuterol. There is often a history of several days of upper
respiratory symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests,
blood work, and radiographs are not usually needed. Radiographs may demonstrate
hyperinflation and atelectasis, but do not show any focal infiltrates like with pneumonia.
Bronchiolitis is usually self-limited, with respiratory status typically improving over 2-5
days. Management involves supportive care.
Bronchiolitis - CORRECT ANSWER- ✔✔
,What months of the year contain the peak incidence of RSV in North America? - CORRECT
ANSWER- ✔✔November to March.
A 76-year-old man presents to the emergency department with shortness of breath and
lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124
beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended
neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his
heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his
abdomen. Which of the following is the most appropriate diagnostic test?
Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - CORRECT ANSWER- ✔✔Correct Answer ( A )
Explanation:
This patient presents with a clinical picture consistent with obstructive shock. His distended
neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent
with pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without
obstructing cardiac function. Tamponade occurs when rapid fluid accumulation results in
elevated pressures that inhibit venous return. This is a dynamic process over the course of the
cardiac cycle, therefore bedside echocardiography is the diagnostic test of choice. Fluid
around the heart with evidence of right atrial compression and right ventricular diastolic
collapse are diagnostic of pericardial tamponade.
Pericardial Effusion - CORRECT ANSWER- ✔✔
What is the emergent treatment of pericardial tamponade? - CORRECT ANSWER-
✔✔Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse
pain consistent with an acute sickle cell pain crisis. While in the emergency department, she
develops acute onset headache, right sided facial droop and right arm weakness. A CT scan
confirms the diagnosis. Which of the following is the next best step in management?
Alteplase
Exchange transfusion
, MRI brain
Tranexamic acid - CORRECT ANSWER- ✔✔Correct Answer ( B )
Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient
developed symptoms concerning for acute ischemic stroke. For pediatric patients with acute
ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of
choice. Transfusion goals include decreasing hemoglobin S levels to less than 30% and
obtaining a total hemoglobin level of 10 g/dL. For adults with acute ischemic stroke in the
setting of sickle cell disease, consider tissue plasminogen activator (tPA). tPA is not indicated
or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage.
Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric
hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell - CORRECT ANSWER- ✔✔
What is the most common bacterial cause of acute chest syndrome in adults with sickle cell
disease? - CORRECT ANSWER- ✔✔Atypical bacteria such as Chlamydia pneumoniae,
Mycoplasma pneumoniae, Mycoplasma hominis.
Correct Answer ( B )
Explanation:
The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results
when multiple areas of the atrial myocardium simultaneously depolarize and contract. As a
result, the atrial walls do not contract in a coordinated fashion, but rather "quiver" or
"fibrillate." The electrocardiographic hallmarks of atrial fibrillation are a narrow, complex,
irregularly irregular rhythm and no discernible P waves. The rate may be slow, normal, or
fast. Atrial fibrillation is usually associated with ischemic or valvular heart disease, and can
also be seen in cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial
fibrillation may be asymptomatic, or may complain of palpitations, dizziness,
lightheadedness, chest pain, or dyspnea. Patients in whom atrial fibrillation results in a rapid
ventricular rate may develop clinical heart failure due to inadequate ven - CORRECT
ANSWER- ✔✔A 52-year-old man with a history of diabetes mellitus and hypertension
presents to the ED with palpitations and dyspnea that have been present intermittently over
the past week. His vital signs include HR 135 beats/minute, blood pressure 136/87 mm Hg,
UPDATED Actual Exam Questions and
CORRECT Answers
A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between
his fingers after returning home from summer camp 1 week ago. He reports several other
campers had similar symptoms. On exam, you note excoriations in the inguinal region and
axillae surrounding scattered, erythematous papules. Which of the following is the most
appropriate treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - CORRECT ANSWER- ✔✔Correct Answer ( C )
Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite
Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be
considered in patients with generalized pruritus, especially when exposure to others with
similar symptoms is reported. The rash of scabies involves papules, which are often
excoriated. Burrows are pathognomonic but not uniformly present. Unless previously
infected, pruritus generally takes 3-6 weeks to develop because symptoms are due to delayed
(Type IV) sensitivity reaction. The pruritus is classically worse at night and affects the web
spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical
region. Except in cases involving an immunocompromised host, the scalp and face are
generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected
with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice
for primary scabies infection is the application of topical scabicidal agents, with repeat
application in 7 days. The treatment of choice is permethrin 5% lotion. Individuals affected
by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may
return to school or work 24 hours after the first treatment.
Should family members of an infected individual also be treated for scabies? - CORRECT
ANSWER- ✔✔Yes, family members and sexual contacts.
Scabies - CORRECT ANSWER- ✔✔Sarcoptes scabiei
Pruritic rash worse at night
,Linear burrows
Interdigital spaces of hands/feet, penis, breasts
Permethrin (first line)
Ivermectin
**head and back are sparred
(head involved in children)
An 18-month-old boy presents to the emergency department with worsening shortness of
breath. The parents report he has had a cough, runny nose, and fussiness for the past five
days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse
wheezing. The patient is given an albuterol nebulizer treatment without any improvement of
his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms
is the most likely cause of his symptoms?
Bordetella pertussis
Haemophilus influenzae
Parainfluenza virus
Respiratory syncytial virus - CORRECT ANSWER- ✔✔Correct Answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection in
patients less than two years of age. It remains the leading cause for hospitalization in infants
under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus
(RSV), but may be caused by other viral agents. Bronchiolitis is inflammation of the lower
respiratory tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased
mucus production. The resultant lower airway obstruction causes increased work of breathing
and wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old,
rhinorrhea, tachypnea, and wheezing. Unlike asthma or reactive airway disease, there is often
no significant improvement with albuterol. There is often a history of several days of upper
respiratory symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests,
blood work, and radiographs are not usually needed. Radiographs may demonstrate
hyperinflation and atelectasis, but do not show any focal infiltrates like with pneumonia.
Bronchiolitis is usually self-limited, with respiratory status typically improving over 2-5
days. Management involves supportive care.
Bronchiolitis - CORRECT ANSWER- ✔✔
,What months of the year contain the peak incidence of RSV in North America? - CORRECT
ANSWER- ✔✔November to March.
A 76-year-old man presents to the emergency department with shortness of breath and
lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124
beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended
neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his
heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his
abdomen. Which of the following is the most appropriate diagnostic test?
Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - CORRECT ANSWER- ✔✔Correct Answer ( A )
Explanation:
This patient presents with a clinical picture consistent with obstructive shock. His distended
neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent
with pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without
obstructing cardiac function. Tamponade occurs when rapid fluid accumulation results in
elevated pressures that inhibit venous return. This is a dynamic process over the course of the
cardiac cycle, therefore bedside echocardiography is the diagnostic test of choice. Fluid
around the heart with evidence of right atrial compression and right ventricular diastolic
collapse are diagnostic of pericardial tamponade.
Pericardial Effusion - CORRECT ANSWER- ✔✔
What is the emergent treatment of pericardial tamponade? - CORRECT ANSWER-
✔✔Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse
pain consistent with an acute sickle cell pain crisis. While in the emergency department, she
develops acute onset headache, right sided facial droop and right arm weakness. A CT scan
confirms the diagnosis. Which of the following is the next best step in management?
Alteplase
Exchange transfusion
, MRI brain
Tranexamic acid - CORRECT ANSWER- ✔✔Correct Answer ( B )
Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient
developed symptoms concerning for acute ischemic stroke. For pediatric patients with acute
ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of
choice. Transfusion goals include decreasing hemoglobin S levels to less than 30% and
obtaining a total hemoglobin level of 10 g/dL. For adults with acute ischemic stroke in the
setting of sickle cell disease, consider tissue plasminogen activator (tPA). tPA is not indicated
or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage.
Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric
hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell - CORRECT ANSWER- ✔✔
What is the most common bacterial cause of acute chest syndrome in adults with sickle cell
disease? - CORRECT ANSWER- ✔✔Atypical bacteria such as Chlamydia pneumoniae,
Mycoplasma pneumoniae, Mycoplasma hominis.
Correct Answer ( B )
Explanation:
The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results
when multiple areas of the atrial myocardium simultaneously depolarize and contract. As a
result, the atrial walls do not contract in a coordinated fashion, but rather "quiver" or
"fibrillate." The electrocardiographic hallmarks of atrial fibrillation are a narrow, complex,
irregularly irregular rhythm and no discernible P waves. The rate may be slow, normal, or
fast. Atrial fibrillation is usually associated with ischemic or valvular heart disease, and can
also be seen in cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial
fibrillation may be asymptomatic, or may complain of palpitations, dizziness,
lightheadedness, chest pain, or dyspnea. Patients in whom atrial fibrillation results in a rapid
ventricular rate may develop clinical heart failure due to inadequate ven - CORRECT
ANSWER- ✔✔A 52-year-old man with a history of diabetes mellitus and hypertension
presents to the ED with palpitations and dyspnea that have been present intermittently over
the past week. His vital signs include HR 135 beats/minute, blood pressure 136/87 mm Hg,
