Page | 1
EMERGENCY MED NBME FORM 1
QUESTIONS AND ANSWERS.
52 yo man - 6 hrs after onset of severe, epigastric abd pain
> began at cocktail party
> was there for 4 hrs - 3 martinis, lot of food
PMHx: HLD (statin)
100.4F
104/min
150/92 mmHg
PE: diffuse tenderness over upper quadrants BL - esp epigastrium; no
guarding/rebound
labs: WBC WNL, BR 3 (direct 2.4), alk phos 210, AST 325, ALT 360,
amylase 1200, lipase 600
most likely cause of symptoms? -correct answer - common bile duct
obstruction
choledocholithiasis = stone in CBD
lipase high so think pancreatitis
2 MC causes: alcohol and gallstones
if alcoholic cause - the AST should be higher than ALT (A Scotch and
Tonic)
abd pain that started right after eating a lot of food > think gallstones
he also has PMHx of HLD - another RF for pancreatitis
42 yo man - 30 min after onset of gen weakness, SOB, severe abd cramps,
sweating
, Page | 2
> began while gardening
99.2F
52/min
RR: 24/min
98/60 mmHg
POx: 98% RA
PE: diaphoresis, excessive lacrimation, 2 mm pupils reactive to light;
diffuse wheezes; abd - no tenderness; muscle strength 4/5 in ext - muscle
fasciculations; DTRs 2+; no Babinski; intact sens
after decontamination - most app tx to immediately relieve current
symptoms? -correct answer - administration of atropine
homeboy was gardening - exposure to spray insecticides (aka
organophosphates - AChE inhibitors)
> these can cause acute cholinergic toxicity = DUMBBELLS (diarrhea,
urination, miosis/muscle weakness, bradycardia/bronchorrhea, emesis,
lacrimation, sweating/salivation)
pralidoxime regenerates AChE at musc/nic receptors - only peripheral
> useless once aging of bonded complex has occurred
atropine reverse peripheral and central musc toxicity
54 yo - 2 hrs of chest pain, SOB, nausea
> began while sitting/working at desk
> 1 episode of vomiting
> pain 7/10, radiates to shoulders, "pressure"
3 similar episodes during past 3 months
> occurred on exertion, resolved after 15 min of rest
, Page | 3
PMHx: HTN, T2DM
meds: ASA, metformin, enalapril
SHx: smokes 1 pack qd 30 yrs
98.6F
90/min
20/min
154/85 mmHg
POx: 99%
PE: gucci
labs: WNL (including trop)
ECG, CXR: gucci
ED course: ASA, NTG, morphine administered > 15 min later, pain is now
2/10; pt being observed; repeat trop 4 hrs later WNL; symptoms have
resolved
most app next step in mgnt? -correct answer - myocardial perfusion testing
within 3 days
trops aren't elevated and pt is stable - okay to d/c him and f/u really soon
he has RFs for CAD and has had similar episodes of chest pain in the past
this episode is diff bc occurred w/o exertion - suggesting the etiology has
gotten worse
2014 AHA guidelines:
1. for patients with possible ACS who have *normal serial ECGs and
cardiac troponin levels*: it is reasonable to obtain a treadmill ECG (level of
evidence: A), stress myocardial perfusion imaging, or stress
echocardiography before discharge or within 72 hours after discharge (level
of evidence: B).
> our guy falls under this category due to his prior episodes
, Page | 4
2. in patients with possible ACS and a normal ECG, normal cardiac
troponin levels, and no history of coronary artery disease (CAD): it is
reasonable to initially perform (without serial ECGs and troponin levels)
coronary computed tomography angiography to assess coronary artery
anatomy (level of evidence: A) or rest myocardial perfusion imaging with a
technetium-99m radiopharmaceutical to exclude myocardial ischemia (level
of evidence: B)
47 yo - 1 hr after can of gas exploded 5 ft from him
> pain/loss of hearing in R.ear
ED: mild distress
98.8F
90/min
14/min
120/80 mmHg
PE: abrasions over R.face/neck/upper chest; blood in ext auditory canal;
swelling/ecchymosis of R.pinna; can't hear whispered voices; L.ear - gucci
most likely explanation of symptoms? -correct answer - rupture of the
tympanic membrane
blast injuries - potential cause of barotrauma
barotrauma = results from the air pressure wave generated by an explosion
> rapid pressure change allows no time to equalize the pressure
> potential injuries: bruising of the eardrum, bleeding into the drum and
middle ear, eardrum rupture, ossicular disruption, and inner ear injury
resulting in dizziness and tinnitus
13 yo - 30 min after fell off sailboat into freshwater lake
EMERGENCY MED NBME FORM 1
QUESTIONS AND ANSWERS.
52 yo man - 6 hrs after onset of severe, epigastric abd pain
> began at cocktail party
> was there for 4 hrs - 3 martinis, lot of food
PMHx: HLD (statin)
100.4F
104/min
150/92 mmHg
PE: diffuse tenderness over upper quadrants BL - esp epigastrium; no
guarding/rebound
labs: WBC WNL, BR 3 (direct 2.4), alk phos 210, AST 325, ALT 360,
amylase 1200, lipase 600
most likely cause of symptoms? -correct answer - common bile duct
obstruction
choledocholithiasis = stone in CBD
lipase high so think pancreatitis
2 MC causes: alcohol and gallstones
if alcoholic cause - the AST should be higher than ALT (A Scotch and
Tonic)
abd pain that started right after eating a lot of food > think gallstones
he also has PMHx of HLD - another RF for pancreatitis
42 yo man - 30 min after onset of gen weakness, SOB, severe abd cramps,
sweating
, Page | 2
> began while gardening
99.2F
52/min
RR: 24/min
98/60 mmHg
POx: 98% RA
PE: diaphoresis, excessive lacrimation, 2 mm pupils reactive to light;
diffuse wheezes; abd - no tenderness; muscle strength 4/5 in ext - muscle
fasciculations; DTRs 2+; no Babinski; intact sens
after decontamination - most app tx to immediately relieve current
symptoms? -correct answer - administration of atropine
homeboy was gardening - exposure to spray insecticides (aka
organophosphates - AChE inhibitors)
> these can cause acute cholinergic toxicity = DUMBBELLS (diarrhea,
urination, miosis/muscle weakness, bradycardia/bronchorrhea, emesis,
lacrimation, sweating/salivation)
pralidoxime regenerates AChE at musc/nic receptors - only peripheral
> useless once aging of bonded complex has occurred
atropine reverse peripheral and central musc toxicity
54 yo - 2 hrs of chest pain, SOB, nausea
> began while sitting/working at desk
> 1 episode of vomiting
> pain 7/10, radiates to shoulders, "pressure"
3 similar episodes during past 3 months
> occurred on exertion, resolved after 15 min of rest
, Page | 3
PMHx: HTN, T2DM
meds: ASA, metformin, enalapril
SHx: smokes 1 pack qd 30 yrs
98.6F
90/min
20/min
154/85 mmHg
POx: 99%
PE: gucci
labs: WNL (including trop)
ECG, CXR: gucci
ED course: ASA, NTG, morphine administered > 15 min later, pain is now
2/10; pt being observed; repeat trop 4 hrs later WNL; symptoms have
resolved
most app next step in mgnt? -correct answer - myocardial perfusion testing
within 3 days
trops aren't elevated and pt is stable - okay to d/c him and f/u really soon
he has RFs for CAD and has had similar episodes of chest pain in the past
this episode is diff bc occurred w/o exertion - suggesting the etiology has
gotten worse
2014 AHA guidelines:
1. for patients with possible ACS who have *normal serial ECGs and
cardiac troponin levels*: it is reasonable to obtain a treadmill ECG (level of
evidence: A), stress myocardial perfusion imaging, or stress
echocardiography before discharge or within 72 hours after discharge (level
of evidence: B).
> our guy falls under this category due to his prior episodes
, Page | 4
2. in patients with possible ACS and a normal ECG, normal cardiac
troponin levels, and no history of coronary artery disease (CAD): it is
reasonable to initially perform (without serial ECGs and troponin levels)
coronary computed tomography angiography to assess coronary artery
anatomy (level of evidence: A) or rest myocardial perfusion imaging with a
technetium-99m radiopharmaceutical to exclude myocardial ischemia (level
of evidence: B)
47 yo - 1 hr after can of gas exploded 5 ft from him
> pain/loss of hearing in R.ear
ED: mild distress
98.8F
90/min
14/min
120/80 mmHg
PE: abrasions over R.face/neck/upper chest; blood in ext auditory canal;
swelling/ecchymosis of R.pinna; can't hear whispered voices; L.ear - gucci
most likely explanation of symptoms? -correct answer - rupture of the
tympanic membrane
blast injuries - potential cause of barotrauma
barotrauma = results from the air pressure wave generated by an explosion
> rapid pressure change allows no time to equalize the pressure
> potential injuries: bruising of the eardrum, bleeding into the drum and
middle ear, eardrum rupture, ossicular disruption, and inner ear injury
resulting in dizziness and tinnitus
13 yo - 30 min after fell off sailboat into freshwater lake
