CEN Exam 1
A 2-year-old is brought to the emergency department with mild fever, persistent restlessness,
crying, and pulling his left ear. He has had a cold for about a week. Examination of the ear
reveals a distorted light reflex and slight bulging of the tympanic membrane. What is the proper
diagnosis and treatment?
a.otitis externa and antibiotics
b.otitis media and antibiotics
c.otitis media and myringotomy
d.acute labyrinthitis and antivertigo drug - ANS-B: Ear infections may cause severe and
persistent pain, especially in children in the 6-month to 3-year age group and are a frequent
cause of emergency department visits. Loss or distortion of the light reflex and bulging of the
tympanic membrane are cardinal signs of otitis media, usually caused by bacteria such as
Streptococcus Influenza or Haemophilus Influenza. Sinusitis and purulent rhinitis may
accompany the otitis. Antibiotics to cover these organisms, topical warmed otic analgesics, and
antipyretics are the usual treatment modalities. Otitis externa or swimmer's ear also causes
otalgia and frequently follows swimming in contaminated water or a foreign body in the ear.
Keeping the ear dry and using otic analgesics and antibiotics are indicated. Ear plugs while
swimming or ear drying agents after swimming or showering are the usual preventive measures.
Myringotomy is a surgical procedure to keep the middle ear draining in chronic otitis media and
hopefully prevent such complications as mastoiditis, meningitis, ruptured tympanic membrane,
or permanent hearing loss. Labyrinthitis is an infection of the inner ear and usually causes
severe vertigo, most commonly in adults.
A 30-year-old man comes to the emergency department with the acute onset of left flank pain
radiating to the groin. Microscopic hematuria is present on urinalysis. What is the most likely
diagnosis?
a.ureteral calcium oxalate calculus
b.ureteral cystine calculus
c.testicular torsion
d.cystitis - ANS-A: Ureteral calculi are a quite common cause of acute emergency evaluation,
usually causing flank pain with radiation to the back and/or groin. About 75% of these are
calcium oxalate or phosphate; less common are struvite, uric acid, or cystine calculi. While KUB
or ultrasound may show the stone, helical CT is now the preferred diagnostic method. Additional
workup includes CBC, chemistry panel, urinalysis, and straining of urine to catch a passed
stone for chemical analysis. Nursing attention should be directed to intravenous hydration with
input and output recording and narcotic or narcotic plus NSAID (e.g., ketorolac) administration
for pain. Some patients may be discharged with analgesics and instructions for hydration and
calculus capture. Testicular torsion is most common in adolescents and usually presents with
testicular and groin pain with abdominal radiation; increasing pain by lifting the scrotum to the
level of the pubic symphysis causes exacerbation of the pain (Prehn sign). Cystitis may be
, infectious or drug-induced, but cystitis usually causes dysuria and pyuria and shows positive
urine cultures.
A 7-year-old child is brought to the emergency department after multiple bee stings about 30
minutes previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing and
stridor are heard. What is the most immediate treatment required?
a.epinephrine 0.1 mg intramuscularly
b.intravenous corticosteroid
c.intravenous antihistamine
d.broad-spectrum antibiotic - ANS-Answer: A
The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is
potentially life-threatening. The onset of symptoms within 1 hour after exposure to the allergen
is particularly worrisome as are the laryngeal and pulmonary signs. The airway must be
established with intubation often necessary; high-flow oxygen, cardiac monitoring, and
intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting agent
and should be given as soon as possible after the diagnosis of anaphylaxis and every 5 to 15
minutes thereafter as needed. Steroids and antihistamines are slower acting than epinephrine
but are often given to alleviate itching, angioedema, and hives. There is no indication for
antibiotics in this clinical situation unless further signs and symptoms develop.
A 75-year-old man has a history of several episodes of transient right-sided arm and hand
weakness lasting an hour or two but with full recovery. He is diabetic and hypertensive and is
taking medication for both conditions. This time the episode does not resolve and he is taken to
the emergency department some 2 hours after the onset of symptoms. He is awake and able to
answer questions and give a medical history. His chest is clear and no bruits are heard over the
carotids. There is drift of the right arm on examination and his speech is slightly garbled. His
blood pressure is 160/95 mm Hg and his pulse is irregular at 80 beats per minute. A CT of the
brain reveals a small left-sided occlusion in a branch of the middle cerebral arterial circulation
without hemorrhage. What should be the next step in his management?
a.start nitroprusside to reduce his blood pressure to normal
b.begin fibrinolytic therapy with altep - ANS-B: This patient had several transient ischemic
attacks prior to his clear-cut signs of a stroke, shown to be nonhemorrhagic in nature. Such
strokes may be caused by local thrombosis, especially in arteriosclerotic vessels, or by emboli
arising in the carotid artery (usually at the bifurcation of the internal and external vessels) or the
heart, most often in atrial fibrillation patients with clots in the atrial appendage. Because this
patient arrived in the emergency department within 3 hours from the onset of symptoms, the
current recommendation is to begin fibrinolytic therapy with recombinant tissue plasminogen
activator (r-TPA). Some recent studies indicate benefit from this therapy may be achieved up to
4.5 hours after the onset of symptoms. Blood pressure management in stroke patients is tricky.
Most would agree with slow reduction if the value is greater than 220 systolic or 120 diastolic or
the stroke is hemorrhagic in nature. For patients treated with a fibrinolytic agent, significantly
elevated blood pressure should be lowered to prevent reperfusion problems. If noninvasive
carotid scanning shows marked stenosis, neurosurgical consultation for endarterectomy or
angioplasty with stent placement is reasonable. Subsequent warfarin treatment may be
appropriate if atrial fibrillation is present.
A 2-year-old is brought to the emergency department with mild fever, persistent restlessness,
crying, and pulling his left ear. He has had a cold for about a week. Examination of the ear
reveals a distorted light reflex and slight bulging of the tympanic membrane. What is the proper
diagnosis and treatment?
a.otitis externa and antibiotics
b.otitis media and antibiotics
c.otitis media and myringotomy
d.acute labyrinthitis and antivertigo drug - ANS-B: Ear infections may cause severe and
persistent pain, especially in children in the 6-month to 3-year age group and are a frequent
cause of emergency department visits. Loss or distortion of the light reflex and bulging of the
tympanic membrane are cardinal signs of otitis media, usually caused by bacteria such as
Streptococcus Influenza or Haemophilus Influenza. Sinusitis and purulent rhinitis may
accompany the otitis. Antibiotics to cover these organisms, topical warmed otic analgesics, and
antipyretics are the usual treatment modalities. Otitis externa or swimmer's ear also causes
otalgia and frequently follows swimming in contaminated water or a foreign body in the ear.
Keeping the ear dry and using otic analgesics and antibiotics are indicated. Ear plugs while
swimming or ear drying agents after swimming or showering are the usual preventive measures.
Myringotomy is a surgical procedure to keep the middle ear draining in chronic otitis media and
hopefully prevent such complications as mastoiditis, meningitis, ruptured tympanic membrane,
or permanent hearing loss. Labyrinthitis is an infection of the inner ear and usually causes
severe vertigo, most commonly in adults.
A 30-year-old man comes to the emergency department with the acute onset of left flank pain
radiating to the groin. Microscopic hematuria is present on urinalysis. What is the most likely
diagnosis?
a.ureteral calcium oxalate calculus
b.ureteral cystine calculus
c.testicular torsion
d.cystitis - ANS-A: Ureteral calculi are a quite common cause of acute emergency evaluation,
usually causing flank pain with radiation to the back and/or groin. About 75% of these are
calcium oxalate or phosphate; less common are struvite, uric acid, or cystine calculi. While KUB
or ultrasound may show the stone, helical CT is now the preferred diagnostic method. Additional
workup includes CBC, chemistry panel, urinalysis, and straining of urine to catch a passed
stone for chemical analysis. Nursing attention should be directed to intravenous hydration with
input and output recording and narcotic or narcotic plus NSAID (e.g., ketorolac) administration
for pain. Some patients may be discharged with analgesics and instructions for hydration and
calculus capture. Testicular torsion is most common in adolescents and usually presents with
testicular and groin pain with abdominal radiation; increasing pain by lifting the scrotum to the
level of the pubic symphysis causes exacerbation of the pain (Prehn sign). Cystitis may be
, infectious or drug-induced, but cystitis usually causes dysuria and pyuria and shows positive
urine cultures.
A 7-year-old child is brought to the emergency department after multiple bee stings about 30
minutes previously. He complains of itching, swollen lips, and difficulty breathing. Wheezing and
stridor are heard. What is the most immediate treatment required?
a.epinephrine 0.1 mg intramuscularly
b.intravenous corticosteroid
c.intravenous antihistamine
d.broad-spectrum antibiotic - ANS-Answer: A
The clinical picture of this patient is that of an anaphylactic reaction to bee stings which is
potentially life-threatening. The onset of symptoms within 1 hour after exposure to the allergen
is particularly worrisome as are the laryngeal and pulmonary signs. The airway must be
established with intubation often necessary; high-flow oxygen, cardiac monitoring, and
intravenous fluids are basics. Epinephrine given intramuscularly is the most rapidly acting agent
and should be given as soon as possible after the diagnosis of anaphylaxis and every 5 to 15
minutes thereafter as needed. Steroids and antihistamines are slower acting than epinephrine
but are often given to alleviate itching, angioedema, and hives. There is no indication for
antibiotics in this clinical situation unless further signs and symptoms develop.
A 75-year-old man has a history of several episodes of transient right-sided arm and hand
weakness lasting an hour or two but with full recovery. He is diabetic and hypertensive and is
taking medication for both conditions. This time the episode does not resolve and he is taken to
the emergency department some 2 hours after the onset of symptoms. He is awake and able to
answer questions and give a medical history. His chest is clear and no bruits are heard over the
carotids. There is drift of the right arm on examination and his speech is slightly garbled. His
blood pressure is 160/95 mm Hg and his pulse is irregular at 80 beats per minute. A CT of the
brain reveals a small left-sided occlusion in a branch of the middle cerebral arterial circulation
without hemorrhage. What should be the next step in his management?
a.start nitroprusside to reduce his blood pressure to normal
b.begin fibrinolytic therapy with altep - ANS-B: This patient had several transient ischemic
attacks prior to his clear-cut signs of a stroke, shown to be nonhemorrhagic in nature. Such
strokes may be caused by local thrombosis, especially in arteriosclerotic vessels, or by emboli
arising in the carotid artery (usually at the bifurcation of the internal and external vessels) or the
heart, most often in atrial fibrillation patients with clots in the atrial appendage. Because this
patient arrived in the emergency department within 3 hours from the onset of symptoms, the
current recommendation is to begin fibrinolytic therapy with recombinant tissue plasminogen
activator (r-TPA). Some recent studies indicate benefit from this therapy may be achieved up to
4.5 hours after the onset of symptoms. Blood pressure management in stroke patients is tricky.
Most would agree with slow reduction if the value is greater than 220 systolic or 120 diastolic or
the stroke is hemorrhagic in nature. For patients treated with a fibrinolytic agent, significantly
elevated blood pressure should be lowered to prevent reperfusion problems. If noninvasive
carotid scanning shows marked stenosis, neurosurgical consultation for endarterectomy or
angioplasty with stent placement is reasonable. Subsequent warfarin treatment may be
appropriate if atrial fibrillation is present.
