ROSH REVIEW Emergency Medicine UPDATED ACTUAL Questions and
CORRECT Answers
1. A 14-year-old boy pre- Correct Answer ( C )
sents complaining of in- Explanation:
tense pruritus in his
groin, axillae, and be- This patient has scabies; a pruritic dermatitis caused by cutaneous
tween his fingers after re- infection with the mite Sarcoptes scabei, var hominis. Scabies is
turning home from sum- spread by skin-to-skin contact and should be considered in patients
mer camp 1 week ago. with generalized pruritus, especially when exposure to others with
He reports several other similar symptoms is reported. The rash of scabies involves papules,
campers had similar symp- which are often excoriated. Burrows are pathognomonic but not
toms. On exam, you note uniformly present. Unless previously infected, pruritus generally
excoriations in the inguinal takes 3-6 weeks to develop because symptoms are due to delayed
region and axillae sur- (Type IV) sensitivity reaction. The pruritus is classically worse at
rounding scattered, ery- night and affects the web spaces of the fingers, flexor aspect of the
thematous papules. Which wrists, axillae, groin, nipples, and the periumbilical region. Except
of the following is the most in cases involving an immunocompromised host, the scalp and face
appropriate treatment? are generally spared. Diagnosis is clinical but can be confirmed by
Ketoconazole placing scrapings collected with a #15 blade scalpel in mineral oil
Lindane for microscopic examination. The treatment of choice for primary
Permethrin scabies infection is the application of topical scabicidal agents, with
Prednisone 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.
2. Should family members of Yes, family members and sexual contacts.
an infected individual also
be treated for scabies?
3. Scabies 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)
4. An 18-month-old boy pre- Correct Answer ( D )
sents to the emergency Explanation:
department with worsen-
ing shortness of breath. The patient has bronchiolitis, which is the most common lower
The parents report he has respiratory tract infection in patients less than two years of age. It
had a cough, runny nose, remains the leading cause for hospitalization in infants under one
and fussiness for the past year of age. Bronchiolitis is most commonly caused by respiratory
five days. On exam, the syncytial virus (RSV), but may be caused by other viral agents.
patient demonstrates sub- Bronchiolitis is inflammation of the lower respiratory tract, which
costal retractions, tachyp- involves edema, epithelial cell necrosis, bronchospasm, and in-
nea, and diffuse wheez- creased mucus production. The resultant lower airway obstruction
ing. The patient is given an causes increased work of breathing and wheezing. Bronchiolitis is
albuterol nebulizer treat- a clinical diagnosis based on age under two years old, rhinorrhea,
ment without any improve- tachypnea, and wheezing. Unlike asthma or reactive airway disease,
ment of his wheezing. there is often no significant improvement with albuterol. There is
Chest X-ray does not show often a history of several days of upper respiratory symptoms, such
any abnormality. Which of as rhinorrhea, mild cough, and mild fever. Rapid antigen tests,
the following organisms is blood work, and radiographs are not usually needed. Radiographs
the most likely cause of his may demonstrate hyperinflation and atelectasis, but do not show
symptoms? any focal infiltrates like with pneumonia. Bronchiolitis is usually
Bordetella pertussis
, Haemophilus influenzae self-limited, with respiratory status typically improving over 2-5
Parainfluenza virus days. Management involves supportive care.
Respiratory syncytial virus
5. Bronchiolitis
6. What months of the year November to March.
contain the peak incidence
of RSV in North America?
7. A 76-year-old man pre- Correct Answer ( A )
sents to the emergency de- Explanation:
partment with shortness
of breath and lighthead- This patient presents with a clinical picture consistent with ob-
edness. Vital signs include structive shock. His distended neck veins, full right upper quad-
blood pressure 70/56 rant, muffled heart sounds, and hypotension are all consistent with
mm Hg, heart rate 124 pericardial tamponade. A pericardial sac slowly accumulating fluid
beats/minute, respiratory can stretch without obstructing cardiac function. Tamponade occurs
rate 22 breaths/minute, when rapid fluid accumulation results in elevated pressures that
and temperature 37.6°C. inhibit venous return. This is a dynamic process over the course
He has distended neck of the cardiac cycle, therefore bedside echocardiography is the
veins and occasional diagnostic test of choice. Fluid around the heart with evidence of
dropped radial beats. His right atrial compression and right ventricular diastolic collapse are
lungs are clear to ausculta- diagnostic of pericardial tamponade.
tion, but his heart sounds
are distant. He has some
fullness to palpation of the
right upper quadrant of his
, abdomen. Which of the fol-
lowing is the most appro-
priate diagnostic test?
Bedside echocardiogra-
phy
Chest radiograph
Computed tomography
angiogram of the chest
Electrocardiogram
8. Pericardial Effusion
9. What is the emergent Pericardiocentesis.
treatment of pericardial
tamponade?
10. An 8-year-old Correct Answer ( B )
African-American girl with Explanation:
a history of sickle cell ane-
mia presents with diffuse Cerebrovascular events are a potential complication of sickle cell
pain consistent with an disease. This patient developed symptoms concerning for acute
acute sickle cell pain cri- ischemic stroke. For pediatric patients with acute ischemic stroke in
sis. While in the emergency the setting of sickle cell disease, exchange transfusion is the treat-
department, she devel- ment of choice. Transfusion goals include decreasing hemoglobin
ops acute onset headache, S levels to less than 30% and obtaining a total hemoglobin level
right sided facial droop of 10 g/dL. For adults with acute ischemic stroke in the setting of
and right arm weakness. A sickle cell disease, consider tissue plasminogen activator (tPA). tPA
CT scan confirms the diag- is not indicated or approved for use in pediatric patients
nosis. Which of the follow-
CORRECT Answers
1. A 14-year-old boy pre- Correct Answer ( C )
sents complaining of in- Explanation:
tense pruritus in his
groin, axillae, and be- This patient has scabies; a pruritic dermatitis caused by cutaneous
tween his fingers after re- infection with the mite Sarcoptes scabei, var hominis. Scabies is
turning home from sum- spread by skin-to-skin contact and should be considered in patients
mer camp 1 week ago. with generalized pruritus, especially when exposure to others with
He reports several other similar symptoms is reported. The rash of scabies involves papules,
campers had similar symp- which are often excoriated. Burrows are pathognomonic but not
toms. On exam, you note uniformly present. Unless previously infected, pruritus generally
excoriations in the inguinal takes 3-6 weeks to develop because symptoms are due to delayed
region and axillae sur- (Type IV) sensitivity reaction. The pruritus is classically worse at
rounding scattered, ery- night and affects the web spaces of the fingers, flexor aspect of the
thematous papules. Which wrists, axillae, groin, nipples, and the periumbilical region. Except
of the following is the most in cases involving an immunocompromised host, the scalp and face
appropriate treatment? are generally spared. Diagnosis is clinical but can be confirmed by
Ketoconazole placing scrapings collected with a #15 blade scalpel in mineral oil
Lindane for microscopic examination. The treatment of choice for primary
Permethrin scabies infection is the application of topical scabicidal agents, with
Prednisone 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.
2. Should family members of Yes, family members and sexual contacts.
an infected individual also
be treated for scabies?
3. Scabies 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)
4. An 18-month-old boy pre- Correct Answer ( D )
sents to the emergency Explanation:
department with worsen-
ing shortness of breath. The patient has bronchiolitis, which is the most common lower
The parents report he has respiratory tract infection in patients less than two years of age. It
had a cough, runny nose, remains the leading cause for hospitalization in infants under one
and fussiness for the past year of age. Bronchiolitis is most commonly caused by respiratory
five days. On exam, the syncytial virus (RSV), but may be caused by other viral agents.
patient demonstrates sub- Bronchiolitis is inflammation of the lower respiratory tract, which
costal retractions, tachyp- involves edema, epithelial cell necrosis, bronchospasm, and in-
nea, and diffuse wheez- creased mucus production. The resultant lower airway obstruction
ing. The patient is given an causes increased work of breathing and wheezing. Bronchiolitis is
albuterol nebulizer treat- a clinical diagnosis based on age under two years old, rhinorrhea,
ment without any improve- tachypnea, and wheezing. Unlike asthma or reactive airway disease,
ment of his wheezing. there is often no significant improvement with albuterol. There is
Chest X-ray does not show often a history of several days of upper respiratory symptoms, such
any abnormality. Which of as rhinorrhea, mild cough, and mild fever. Rapid antigen tests,
the following organisms is blood work, and radiographs are not usually needed. Radiographs
the most likely cause of his may demonstrate hyperinflation and atelectasis, but do not show
symptoms? any focal infiltrates like with pneumonia. Bronchiolitis is usually
Bordetella pertussis
, Haemophilus influenzae self-limited, with respiratory status typically improving over 2-5
Parainfluenza virus days. Management involves supportive care.
Respiratory syncytial virus
5. Bronchiolitis
6. What months of the year November to March.
contain the peak incidence
of RSV in North America?
7. A 76-year-old man pre- Correct Answer ( A )
sents to the emergency de- Explanation:
partment with shortness
of breath and lighthead- This patient presents with a clinical picture consistent with ob-
edness. Vital signs include structive shock. His distended neck veins, full right upper quad-
blood pressure 70/56 rant, muffled heart sounds, and hypotension are all consistent with
mm Hg, heart rate 124 pericardial tamponade. A pericardial sac slowly accumulating fluid
beats/minute, respiratory can stretch without obstructing cardiac function. Tamponade occurs
rate 22 breaths/minute, when rapid fluid accumulation results in elevated pressures that
and temperature 37.6°C. inhibit venous return. This is a dynamic process over the course
He has distended neck of the cardiac cycle, therefore bedside echocardiography is the
veins and occasional diagnostic test of choice. Fluid around the heart with evidence of
dropped radial beats. His right atrial compression and right ventricular diastolic collapse are
lungs are clear to ausculta- diagnostic of pericardial tamponade.
tion, but his heart sounds
are distant. He has some
fullness to palpation of the
right upper quadrant of his
, abdomen. Which of the fol-
lowing is the most appro-
priate diagnostic test?
Bedside echocardiogra-
phy
Chest radiograph
Computed tomography
angiogram of the chest
Electrocardiogram
8. Pericardial Effusion
9. What is the emergent Pericardiocentesis.
treatment of pericardial
tamponade?
10. An 8-year-old Correct Answer ( B )
African-American girl with Explanation:
a history of sickle cell ane-
mia presents with diffuse Cerebrovascular events are a potential complication of sickle cell
pain consistent with an disease. This patient developed symptoms concerning for acute
acute sickle cell pain cri- ischemic stroke. For pediatric patients with acute ischemic stroke in
sis. While in the emergency the setting of sickle cell disease, exchange transfusion is the treat-
department, she devel- ment of choice. Transfusion goals include decreasing hemoglobin
ops acute onset headache, S levels to less than 30% and obtaining a total hemoglobin level
right sided facial droop of 10 g/dL. For adults with acute ischemic stroke in the setting of
and right arm weakness. A sickle cell disease, consider tissue plasminogen activator (tPA). tPA
CT scan confirms the diag- is not indicated or approved for use in pediatric patients
nosis. Which of the follow-
