SAEM 241 – 390 with 150 complete
solutions.
SAEM 241 – 390 with 150 complete
solutions.
A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain,
progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F).
On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder
is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is
not an acceptable next step?
A. MRI of the spine
B. Analgesia
C. Foley catheter to drain the bladder
D. Hospital admission for neurosurgical consultation in the morning
E. Antibiotics to cover a broad spectrum of organism - ANSWER D. Hospital admission for neurosurgical
consultation in the morning
he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being
dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical
evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus,
chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover
Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder
decompression for symptomatic relief is important, as is analgesia
Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral nervous system.
B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often
necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The "atropine test" is diagnostic when 0.5 mg of atropine is given intravenously and the patient's
symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them. - ANSWER B. A myasthenic crisis
involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation.
,SAEM 241 – 390 with 150 complete
solutions.
The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed
against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads
to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms
are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as
the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon
test, where edrophonium is given and the patient's symptoms are observed to transiently improve. The
administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates
them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring
intubation, frequently for prolonged periods.
A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the
emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable
for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG
showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood
pressure, which of the following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful
in this setting
B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac output
D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade - ANSWER C. Nitroglycerin
decreases BP by decreasing venous return and cardiac output
The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset
of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure
patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term
cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.
A 14 year-old child presents to the emergency department. His blood pressure is 210/140. He complains
of a headache, nausea, and recent blurred vision. Of the following choices, the best goal for lowering his
mean arterial blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
,SAEM 241 – 390 with 150 complete
solutions.
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour - ANSWER C. 25% in the first hour
The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, defines hypertensive
urgency. With end-organs symptoms, as above, the presumptive diagnosis is hypertensive emergency.
In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the
first hour, thereby alleviating symptoms while not compromising cerebral perfusion.
A 2 year old male is brought to the ED in status epilepticus. He has not responded to adequate doses of
benzodiazepines. Which of the following possible causes of a seizure must be evaluated for in the
emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for - ANSWER E. All of the above possible causes
must be evaluated for
The answer is E. Seizures have a number of secondary causes, which must be identified and corrected
before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and
bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as
INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse.
Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus.
Shock is defined as:
A. tachycardia
B. hypotension
C. altered mental status
D. hypovolemia
E. inadequate tissue and organ perfusion - ANSWER E. inadequate tissue and organ perfusion
, SAEM 241 – 390 with 150 complete
solutions.
The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia,
hypotension and altered mental status are all signs and symptoms of shock.
The four classic types of shock include all of the following EXCEPT:
A. Distributive
B. Obstructive
C. Hypovolemic
D. Cardiogenic
E. Traumatic - ANSWER E. Traumatic
The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate
circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of
blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock
states (usually hypovolemic, but also distributive in the case of pericardial tamponade), but there is no
"traumatic" shock subtype.
An early sign and symptom of shock is:
A. Cyanosis
B. Decreased respiratory rate
C. Tachycardia
D. Hypotension
E. Bradycarda - ANSWER C. Tachycardia
The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur
earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased
respiratory rate, which occur as the body attempts to maintain perfusion.
All patients with shock should receive as the first priority:
A. Supplemental oxygen
solutions.
SAEM 241 – 390 with 150 complete
solutions.
A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain,
progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F).
On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder
is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is
not an acceptable next step?
A. MRI of the spine
B. Analgesia
C. Foley catheter to drain the bladder
D. Hospital admission for neurosurgical consultation in the morning
E. Antibiotics to cover a broad spectrum of organism - ANSWER D. Hospital admission for neurosurgical
consultation in the morning
he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being
dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical
evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus,
chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover
Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder
decompression for symptomatic relief is important, as is analgesia
Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral nervous system.
B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often
necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The "atropine test" is diagnostic when 0.5 mg of atropine is given intravenously and the patient's
symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them. - ANSWER B. A myasthenic crisis
involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation.
,SAEM 241 – 390 with 150 complete
solutions.
The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed
against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads
to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms
are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as
the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon
test, where edrophonium is given and the patient's symptoms are observed to transiently improve. The
administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates
them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring
intubation, frequently for prolonged periods.
A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the
emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable
for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG
showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood
pressure, which of the following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful
in this setting
B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac output
D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade - ANSWER C. Nitroglycerin
decreases BP by decreasing venous return and cardiac output
The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset
of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure
patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term
cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.
A 14 year-old child presents to the emergency department. His blood pressure is 210/140. He complains
of a headache, nausea, and recent blurred vision. Of the following choices, the best goal for lowering his
mean arterial blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
,SAEM 241 – 390 with 150 complete
solutions.
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour - ANSWER C. 25% in the first hour
The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, defines hypertensive
urgency. With end-organs symptoms, as above, the presumptive diagnosis is hypertensive emergency.
In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the
first hour, thereby alleviating symptoms while not compromising cerebral perfusion.
A 2 year old male is brought to the ED in status epilepticus. He has not responded to adequate doses of
benzodiazepines. Which of the following possible causes of a seizure must be evaluated for in the
emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for - ANSWER E. All of the above possible causes
must be evaluated for
The answer is E. Seizures have a number of secondary causes, which must be identified and corrected
before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and
bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as
INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse.
Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus.
Shock is defined as:
A. tachycardia
B. hypotension
C. altered mental status
D. hypovolemia
E. inadequate tissue and organ perfusion - ANSWER E. inadequate tissue and organ perfusion
, SAEM 241 – 390 with 150 complete
solutions.
The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia,
hypotension and altered mental status are all signs and symptoms of shock.
The four classic types of shock include all of the following EXCEPT:
A. Distributive
B. Obstructive
C. Hypovolemic
D. Cardiogenic
E. Traumatic - ANSWER E. Traumatic
The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate
circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of
blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock
states (usually hypovolemic, but also distributive in the case of pericardial tamponade), but there is no
"traumatic" shock subtype.
An early sign and symptom of shock is:
A. Cyanosis
B. Decreased respiratory rate
C. Tachycardia
D. Hypotension
E. Bradycarda - ANSWER C. Tachycardia
The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur
earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased
respiratory rate, which occur as the body attempts to maintain perfusion.
All patients with shock should receive as the first priority:
A. Supplemental oxygen
