EMERGENCY MEDICINE COMPREHENSIVE EXAM
UPDATED QUESTIONS AND ANSWERS RATED A+
✔✔A 29 year old woman is found seizing by her husband and is rushed to the
emergency department. On presentation, she is noted to have a BP of 162/112, is still
seizing, and looks puffy all over. Her husband tells you that they are expecting their first
child in a few months. Which of the following is the next best step in this patient's care?
A. Control the seizures with magnesium sulfate.
B. Draw blood to check CBC, LFT's, BUN, and creatinine.
C. Notify the labor floor that the patient is in the emergency department.
D. Perform a CT scan of head if seizures persist.
E. Start hydralazine to decrease the patient's blood pressure. - ✔✔A. Control the
seizures with magnesium sulfate.
Antihypertensive therapy is only indicated in eclampsia if the diastolic blood pressure
remains > 110 mm Hg after seizures are controlled because rapid lowering of blood
pressure can result in uterine hypoperfusion. All the other choices (A-D) are appropriate
in the management of the patient with eclampsia.
✔✔Which of the following is *not* a feature of febrile seizures?
A. generalized tonic-clonic seizure
B. duration less than 15 minutes
C. associated with a rapid rise in body temperature
D. occurs in children ages 3 months to 5 years
E. associated with postictal state of 30 minutes - ✔✔E. associated with postictal state
of 30 minutes
Febrile seizure is not associated with a postictal period. The child usually rapidly regains
alertness. Intracranial mass or infection should be a concern if the duration of seizure is
greater than 15 minutes or if altered mental status persists after the cessation of seizure
activity.
✔✔A 47 year old man with a history of alcohol abuse presents to the ED after having a
seizure. His past includes both seizures and blackouts. His last alcoholic drink was the
previous evening. This morning he experienced palpitations, diaphoresis, and dizziness
before losing consciousness and having a seizure lasting under a minute. Which of the
following is *true* statement with to alcohol and its association with seizures?
A. In people with an underlying seizure disorder, excessive alcohol intake is a risk-
factor for seizure due to increased likelihood of head injury, predisposition to metabolic
disorders, and lowered seizure threshold.
B. Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol
and its metabolites.
C. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal
syndrome.
D. All of the above statements are true.
,E. All of the above statements ar - ✔✔D. All of the above statements are true.
✔✔A 68 year old diabetic male, previously living independently, is brought in by his
family. He has been acting abnormally for two days. The family reports he is awake all
night and sleepy during the day. He is confused about where he is and the time of day,
and sometimes doesn't recognize his daughter and son-in-law. At other times he
appears and acts almost normally. Which of the following is *true* regarding his
condition?
A. Infection is an unlikely cause of his condition unless his temperature is > 102°.
B. Dementia is the most likely cause of his condition and the family must be counseled.
C. Medications are an unlikely cause of this condition in the elderly.
D. Patients can be agitated and combative, or calm and quiet in this condition.
E. Treatment includes maximizing sensory input. - ✔✔D. Patients can be agitated and
combative, or calm and quiet in this condition.
The scenario describes a patient with delirium, a condition in which patients may be
agitated and combative, or calm and quiet. The most common cause of delirium in the
elderly is medications, accounting for 22-39% of cases. Infection and metabolic
abnormalities are other common causes, and delirium may be the first indication that an
infection is present. An elderly patient with delirium resulting from an infection may have
a normal temperature, a low temperature, or a high temperature. Delirium is
characterized by an *acute onset of a disturbance in level of consciousness, cognition
and attentiveness*. It has a fluctuating course, and alterations in sleep-wake cycles are
common. Dementia, in contrast, has a slower course, that is gradually progressive over
months to years, and consciousness is preserved. In addition to correcting the
underlying cause, it is important to minimize stimulation, because the patient with
delirium has difficulty processing stimuli.
✔✔An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary
canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth
is fractured halfway between the tip and the gumline. The root of the tooth is still firmly
intact. The exposed fracture site has a yellowish tinge without blood. Of the following
choices, which is the most appropriate management for this patient?
A. No specific treatment required
B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up
C. Placement of tooth fragment in saline gauze, outpatient dental follow-up
D. Immediate dental consult to avoid abscess formation
E. Replace fractured piece and place acrylic splint - ✔✔D. Immediate dental consult to
avoid abscess formation
Ellis II dental fracture involves enamel and dentin. The fracture site typically has a
yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp
and often blood. These fractures require immediate dental consultation to prevent
abscess formation.
,✔✔A 22 year old man is punched in the nose during a fight. He presents to the
emergency department with obvious nasal bone deformity. Pressure controls the
bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact
vision and extraocular movement. The oropharynx and mandible are unremarkable.
Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the
following is the most appropriate initial step?
A. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum
B. Plastic surgery consult for immediate reduction of nasal fracture
C. Facial CT scan to rule out more serious facial fractures
D. Incision and drainage of the septal hematoma followed by nasal packing
E. Needle aspiration of the septal hematoma - ✔✔D. Incision and drainage of the
septal hematoma followed by nasal packing
✔✔A 24 year old woman is playing racquetball and sustains a direct blow from the ball
to the right eye. She presents to the emergency department complaining of eye pain
and double vision. On exam, her right eye does not track properly with upward gaze.
This finding suggests which of the following injuries?
A. Inferior orbital wall fracture
B. Superior orbital rim fracture
C. Ethmoid fracture
D. Zygomatic arch fracture
E. Inferior orbital rim fracture - ✔✔A. Inferior orbital wall fracture
The patient most likely has an orbital floor fracture with entrapment.
✔✔A 32 year old man is struck several times in the head with a baseball bat. Upon
emergency medical service arrival, he is mildly confused, vomits once, and complains of
a severe headache. The emergency medical technicians establish two large-bore IVs.
Prior to arrival at the emergency department, he loses consciousness and begins to
seize. He is actively seizing when he is brought into the trauma bay. What should be the
first step in the management of this patient?
A. Administration of phenytoin 1000mg IV
B. Administration of mannitol 50 g IV
C. Rapid sequence intubation using paralytic agent
D. Emergency craniotomy
E. Administration of 2 liters NS bolus - ✔✔C. Rapid sequence intubation using paralytic
agent
The airway should be managed as the first priority in this patient. The other maneuvers
may be helpful but are secondary to securing an airway and providing
oxygenation/ventilation. Airway comes first!
✔✔A 46 year old man is brought in by EMS after a motor vehicle collision in which he
was an unrestrained driver. Although he has no obvious injury to his head or neck, he
, complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F,
BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a
tension pneumothorax. Of the following, which is the most appropriate next step in this
man's care?
A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Transfusion of 2 units of O-negative packed red blood cells
C. Performance of a chest CT scan to further delineate the pathology
D. Placement of a needle decompression device, followed by repeat CXR - ✔✔D.
Placement of a needle decompression device, followed by repeat CXR
This patient needs emergent chest decompression and this is rapidly done by needle
thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal
chest tube will be placed, but placement may not be rapid enough and he may
decompensate in the meantime. Transfusion of blood does nothing to correct the
physiology of a tension pneumothorax
✔✔The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination - ✔✔E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and
should be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves
placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of
wrinkling indicates the nerve is intact.
✔✔Which is *not* part of the Ottawa ankle rules?
A. inability to walk 4 steps at the time of the injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus
E. tenderness over the talus - ✔✔E. tenderness over the talus
The Ottawa ankle rules are a validated (for adults) set of physical exam findings to
determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is
present or if there is *tenderness over the navicular or base of the 5th metatarsal*, an X-
ray should be obtained. If the correct answer to all questions is no, then an X-ray is not
needed.
✔✔Choose the INCORRECT statement regarding thoracentesis from the anterior
approach (needle decompression):
A. An upright chest X-ray should always be performed following a thoracentesis to
confirm the successful relief of a tension pneumothorax and the absence of hemothorax
or other complications.
UPDATED QUESTIONS AND ANSWERS RATED A+
✔✔A 29 year old woman is found seizing by her husband and is rushed to the
emergency department. On presentation, she is noted to have a BP of 162/112, is still
seizing, and looks puffy all over. Her husband tells you that they are expecting their first
child in a few months. Which of the following is the next best step in this patient's care?
A. Control the seizures with magnesium sulfate.
B. Draw blood to check CBC, LFT's, BUN, and creatinine.
C. Notify the labor floor that the patient is in the emergency department.
D. Perform a CT scan of head if seizures persist.
E. Start hydralazine to decrease the patient's blood pressure. - ✔✔A. Control the
seizures with magnesium sulfate.
Antihypertensive therapy is only indicated in eclampsia if the diastolic blood pressure
remains > 110 mm Hg after seizures are controlled because rapid lowering of blood
pressure can result in uterine hypoperfusion. All the other choices (A-D) are appropriate
in the management of the patient with eclampsia.
✔✔Which of the following is *not* a feature of febrile seizures?
A. generalized tonic-clonic seizure
B. duration less than 15 minutes
C. associated with a rapid rise in body temperature
D. occurs in children ages 3 months to 5 years
E. associated with postictal state of 30 minutes - ✔✔E. associated with postictal state
of 30 minutes
Febrile seizure is not associated with a postictal period. The child usually rapidly regains
alertness. Intracranial mass or infection should be a concern if the duration of seizure is
greater than 15 minutes or if altered mental status persists after the cessation of seizure
activity.
✔✔A 47 year old man with a history of alcohol abuse presents to the ED after having a
seizure. His past includes both seizures and blackouts. His last alcoholic drink was the
previous evening. This morning he experienced palpitations, diaphoresis, and dizziness
before losing consciousness and having a seizure lasting under a minute. Which of the
following is *true* statement with to alcohol and its association with seizures?
A. In people with an underlying seizure disorder, excessive alcohol intake is a risk-
factor for seizure due to increased likelihood of head injury, predisposition to metabolic
disorders, and lowered seizure threshold.
B. Alcohol intake itself can precipitate seizures due to the neurotoxic effects of alcohol
and its metabolites.
C. Cessation of alcohol can precipitate seizures as part of the alcohol withdrawal
syndrome.
D. All of the above statements are true.
,E. All of the above statements ar - ✔✔D. All of the above statements are true.
✔✔A 68 year old diabetic male, previously living independently, is brought in by his
family. He has been acting abnormally for two days. The family reports he is awake all
night and sleepy during the day. He is confused about where he is and the time of day,
and sometimes doesn't recognize his daughter and son-in-law. At other times he
appears and acts almost normally. Which of the following is *true* regarding his
condition?
A. Infection is an unlikely cause of his condition unless his temperature is > 102°.
B. Dementia is the most likely cause of his condition and the family must be counseled.
C. Medications are an unlikely cause of this condition in the elderly.
D. Patients can be agitated and combative, or calm and quiet in this condition.
E. Treatment includes maximizing sensory input. - ✔✔D. Patients can be agitated and
combative, or calm and quiet in this condition.
The scenario describes a patient with delirium, a condition in which patients may be
agitated and combative, or calm and quiet. The most common cause of delirium in the
elderly is medications, accounting for 22-39% of cases. Infection and metabolic
abnormalities are other common causes, and delirium may be the first indication that an
infection is present. An elderly patient with delirium resulting from an infection may have
a normal temperature, a low temperature, or a high temperature. Delirium is
characterized by an *acute onset of a disturbance in level of consciousness, cognition
and attentiveness*. It has a fluctuating course, and alterations in sleep-wake cycles are
common. Dementia, in contrast, has a slower course, that is gradually progressive over
months to years, and consciousness is preserved. In addition to correcting the
underlying cause, it is important to minimize stimulation, because the patient with
delirium has difficulty processing stimuli.
✔✔An 18 year old hockey player is hit in the mouth with a puck, fracturing a maxillary
canine tooth. He brings the severed piece of tooth with him. On physical exam, the tooth
is fractured halfway between the tip and the gumline. The root of the tooth is still firmly
intact. The exposed fracture site has a yellowish tinge without blood. Of the following
choices, which is the most appropriate management for this patient?
A. No specific treatment required
B. Application of calcium hydroxide, placement of aluminum foil, and dental follow-up
C. Placement of tooth fragment in saline gauze, outpatient dental follow-up
D. Immediate dental consult to avoid abscess formation
E. Replace fractured piece and place acrylic splint - ✔✔D. Immediate dental consult to
avoid abscess formation
Ellis II dental fracture involves enamel and dentin. The fracture site typically has a
yellowish tinge. Ellis III dental fractures are characterized by exposure of pinkish pulp
and often blood. These fractures require immediate dental consultation to prevent
abscess formation.
,✔✔A 22 year old man is punched in the nose during a fight. He presents to the
emergency department with obvious nasal bone deformity. Pressure controls the
bleeding. Physical exam reveals no maxillary bone or orbital rim tenderness, intact
vision and extraocular movement. The oropharynx and mandible are unremarkable.
Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the
following is the most appropriate initial step?
A. Outpatient follow-up with an ENT specialist to surgically correct a deviated septum
B. Plastic surgery consult for immediate reduction of nasal fracture
C. Facial CT scan to rule out more serious facial fractures
D. Incision and drainage of the septal hematoma followed by nasal packing
E. Needle aspiration of the septal hematoma - ✔✔D. Incision and drainage of the
septal hematoma followed by nasal packing
✔✔A 24 year old woman is playing racquetball and sustains a direct blow from the ball
to the right eye. She presents to the emergency department complaining of eye pain
and double vision. On exam, her right eye does not track properly with upward gaze.
This finding suggests which of the following injuries?
A. Inferior orbital wall fracture
B. Superior orbital rim fracture
C. Ethmoid fracture
D. Zygomatic arch fracture
E. Inferior orbital rim fracture - ✔✔A. Inferior orbital wall fracture
The patient most likely has an orbital floor fracture with entrapment.
✔✔A 32 year old man is struck several times in the head with a baseball bat. Upon
emergency medical service arrival, he is mildly confused, vomits once, and complains of
a severe headache. The emergency medical technicians establish two large-bore IVs.
Prior to arrival at the emergency department, he loses consciousness and begins to
seize. He is actively seizing when he is brought into the trauma bay. What should be the
first step in the management of this patient?
A. Administration of phenytoin 1000mg IV
B. Administration of mannitol 50 g IV
C. Rapid sequence intubation using paralytic agent
D. Emergency craniotomy
E. Administration of 2 liters NS bolus - ✔✔C. Rapid sequence intubation using paralytic
agent
The airway should be managed as the first priority in this patient. The other maneuvers
may be helpful but are secondary to securing an airway and providing
oxygenation/ventilation. Airway comes first!
✔✔A 46 year old man is brought in by EMS after a motor vehicle collision in which he
was an unrestrained driver. Although he has no obvious injury to his head or neck, he
, complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F,
BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a
tension pneumothorax. Of the following, which is the most appropriate next step in this
man's care?
A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Transfusion of 2 units of O-negative packed red blood cells
C. Performance of a chest CT scan to further delineate the pathology
D. Placement of a needle decompression device, followed by repeat CXR - ✔✔D.
Placement of a needle decompression device, followed by repeat CXR
This patient needs emergent chest decompression and this is rapidly done by needle
thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal
chest tube will be placed, but placement may not be rapid enough and he may
decompensate in the meantime. Transfusion of blood does nothing to correct the
physiology of a tension pneumothorax
✔✔The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination - ✔✔E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and
should be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves
placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of
wrinkling indicates the nerve is intact.
✔✔Which is *not* part of the Ottawa ankle rules?
A. inability to walk 4 steps at the time of the injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus
E. tenderness over the talus - ✔✔E. tenderness over the talus
The Ottawa ankle rules are a validated (for adults) set of physical exam findings to
determine if an ankle X-ray is needed after an injury. If any of the first 4 answers is
present or if there is *tenderness over the navicular or base of the 5th metatarsal*, an X-
ray should be obtained. If the correct answer to all questions is no, then an X-ray is not
needed.
✔✔Choose the INCORRECT statement regarding thoracentesis from the anterior
approach (needle decompression):
A. An upright chest X-ray should always be performed following a thoracentesis to
confirm the successful relief of a tension pneumothorax and the absence of hemothorax
or other complications.
