Emergency Med NBME Form 1
CT angio of chest: BL PE
ED: pt inc resp distress
145/min
30/min
80/50 mmHg
POx: 86% RA
most app next step in mgnt?
Correct Answer:
intravenous administration of alteplase
hemodynamically unstable PE patients are candidates for treatment with IV
thrombolysis or mechanical thrombectomy
> streptokinase, urokinase (also known as urinary plasminogen activator), and
alteplase
if pt stable/stabilizes - can give other anticoagulants (like unfractionated
heparin and enoxaparin mentioned in the answer choices)
remember this is ED - so need to stabilize the pt before doing anything else
> make sure they're alive and well lol
can think surg options as well
> IVC filter - for those w/ CIs to anticoagulation
> embolectomy - for those w/ bad prognosis
28 yo male - prog SOB past 4 hrs
> 3 days of chest congestion and cough (yellow sputum)
> 6 months ago: hospitalized 2 days for similar symptoms
,PMHx: asthma, NKDA
med: albuterol by metered-dose inhaler
> using this more freq past 2 days
ED: mild resp distress, accessory muscles
BMI: 23
100.6F
106/min, reg
18/min
132/86 mmHg
POx: 96% RA
PE: exp wheezes BL
give him supplemental O2 therapy - most app next step in mgnt?
Correct Answer:
administration of nebulized albuterol
remember that w/ asthma (unlike COPD) - you have to give ICS after SABA,
before LABA
> SABA > ICS > LABA > inc ICS > oral steroids
just think what we give in the hospital - BIOMES
> Beta agonists, Ipratropium, O2, Mg sulfate, Epi, Steroids
> duonebs babyyy
severe exacerbation: use of accessory muscles, tripod position, hypoxia,
tachypnea, impending resp failure
32 yo female - 30 min after onset of dizziness, numbness, neck pain
> vigorous aerobics class
> sharp pain on R.side of neck that spread to back of head
> sens of spinning
> L.sided numbness
,ED: AOx3
99.7F
90/min, reg
130/80 mmHg
PE: mild narrowing of R. palpebral fissure; R.pupil 2 mm; L.pupil 4 mm; both
reactive to light; EOCM; fundo exam gucci; palate does not elevate on R.;
tongue protrudes midline; DTRs 2+; muscle strength gucci; Babinski absent;
sens to pinprick dec over L.side of body and R.side of face; sens to
vib/proprioception intact; intention tremor RUE; gait mildly ataxic; speech
mildly slurred
most likely dx?
Correct Answer:
vertebral artery dissection
seen a previous case from UWorld - young guy skiing and presented w/ similar
symptoms
I guess homegirl has lat medullary syndrome aka Wallenberg syndrome 2/2
occlusion or dissection of intracranial vertebral artery or PICA
in young adults - MC causes of stroke = arterial dissection and cardiogenic
embolism
previously reported following minor head and neck trauma
> cervical spine manipulation
68 yo male - 2 wks of abd cramps after eating
> 5 lb weight loss
> occ loose stools - no blood
PMHx: HTN, CHF, NKDA
meds; metoprolol, digoxin, amlodipine
6 months ago: LV EF 20%
98.6F
96/min
, 18/min
138/72 mmHg
POx: 97%
PE: S3; BL basilar crackles; abd - soft w/ minimal gen tenderness to palp
next step in dx?
Correct Answer:
CT angiography
homeboy has mesenteric ischemia
> usually presents w/ severe acute abd pain out of proportion
~ pt will complain of severe pain but not very tender on PE
RFs: > 50 yo; CHF; atherosclerotic heart dz; diuretics/vasoconstrictive drugs;
AFib; recent MI
dx made late bc elderly don't get severe acute abdomens
sudden onset = art vascular occlusion
> sup mesenteric art
insidious onset = venous thrombosis or nonocclusive infarction (intestinal
angina)
> presents like angina but after eating, instead of exercise
peritoneal signs aka "acute abdomen"
do angiography - dx/tx
x-rays: dilated loops of bowel; air-fluid level; irregular thickening of bowel wall
(thumbprinting); pneumatosis intestinalis (gas in bowel wall)
35 yo male - prog redness/swelling of R.knee for past 3 days
98.6F
84/min
16/min
134/74 mmHg
CT angio of chest: BL PE
ED: pt inc resp distress
145/min
30/min
80/50 mmHg
POx: 86% RA
most app next step in mgnt?
Correct Answer:
intravenous administration of alteplase
hemodynamically unstable PE patients are candidates for treatment with IV
thrombolysis or mechanical thrombectomy
> streptokinase, urokinase (also known as urinary plasminogen activator), and
alteplase
if pt stable/stabilizes - can give other anticoagulants (like unfractionated
heparin and enoxaparin mentioned in the answer choices)
remember this is ED - so need to stabilize the pt before doing anything else
> make sure they're alive and well lol
can think surg options as well
> IVC filter - for those w/ CIs to anticoagulation
> embolectomy - for those w/ bad prognosis
28 yo male - prog SOB past 4 hrs
> 3 days of chest congestion and cough (yellow sputum)
> 6 months ago: hospitalized 2 days for similar symptoms
,PMHx: asthma, NKDA
med: albuterol by metered-dose inhaler
> using this more freq past 2 days
ED: mild resp distress, accessory muscles
BMI: 23
100.6F
106/min, reg
18/min
132/86 mmHg
POx: 96% RA
PE: exp wheezes BL
give him supplemental O2 therapy - most app next step in mgnt?
Correct Answer:
administration of nebulized albuterol
remember that w/ asthma (unlike COPD) - you have to give ICS after SABA,
before LABA
> SABA > ICS > LABA > inc ICS > oral steroids
just think what we give in the hospital - BIOMES
> Beta agonists, Ipratropium, O2, Mg sulfate, Epi, Steroids
> duonebs babyyy
severe exacerbation: use of accessory muscles, tripod position, hypoxia,
tachypnea, impending resp failure
32 yo female - 30 min after onset of dizziness, numbness, neck pain
> vigorous aerobics class
> sharp pain on R.side of neck that spread to back of head
> sens of spinning
> L.sided numbness
,ED: AOx3
99.7F
90/min, reg
130/80 mmHg
PE: mild narrowing of R. palpebral fissure; R.pupil 2 mm; L.pupil 4 mm; both
reactive to light; EOCM; fundo exam gucci; palate does not elevate on R.;
tongue protrudes midline; DTRs 2+; muscle strength gucci; Babinski absent;
sens to pinprick dec over L.side of body and R.side of face; sens to
vib/proprioception intact; intention tremor RUE; gait mildly ataxic; speech
mildly slurred
most likely dx?
Correct Answer:
vertebral artery dissection
seen a previous case from UWorld - young guy skiing and presented w/ similar
symptoms
I guess homegirl has lat medullary syndrome aka Wallenberg syndrome 2/2
occlusion or dissection of intracranial vertebral artery or PICA
in young adults - MC causes of stroke = arterial dissection and cardiogenic
embolism
previously reported following minor head and neck trauma
> cervical spine manipulation
68 yo male - 2 wks of abd cramps after eating
> 5 lb weight loss
> occ loose stools - no blood
PMHx: HTN, CHF, NKDA
meds; metoprolol, digoxin, amlodipine
6 months ago: LV EF 20%
98.6F
96/min
, 18/min
138/72 mmHg
POx: 97%
PE: S3; BL basilar crackles; abd - soft w/ minimal gen tenderness to palp
next step in dx?
Correct Answer:
CT angiography
homeboy has mesenteric ischemia
> usually presents w/ severe acute abd pain out of proportion
~ pt will complain of severe pain but not very tender on PE
RFs: > 50 yo; CHF; atherosclerotic heart dz; diuretics/vasoconstrictive drugs;
AFib; recent MI
dx made late bc elderly don't get severe acute abdomens
sudden onset = art vascular occlusion
> sup mesenteric art
insidious onset = venous thrombosis or nonocclusive infarction (intestinal
angina)
> presents like angina but after eating, instead of exercise
peritoneal signs aka "acute abdomen"
do angiography - dx/tx
x-rays: dilated loops of bowel; air-fluid level; irregular thickening of bowel wall
(thumbprinting); pneumatosis intestinalis (gas in bowel wall)
35 yo male - prog redness/swelling of R.knee for past 3 days
98.6F
84/min
16/min
134/74 mmHg
