01-10-2007, 07:55 PM
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1. A 75-year-old retired landscape architect is brought to the emergency department after the police found him wandering around the city. He was unable to tell them who he was or where he lived. He has a long history of poorly controlled hypertension. He had two strokes several months ago from which he partially recovered. He can walk but his left arm remains weak. Pertinent family history indicates that his father, a successful businessman, committed suicide at age 72 years. Which of the following is the most likely diagnosis?
A) Bipolar disorder, manic episode
B) Major depressive disorder
C) Vascular dementia
D) Dementia, Alzheimer type
E) Schizophrenia
2. A 37-year-old woman comes to the emergency department because of a 2-day history of weakness in her left foot which has caused her to accidentally stub the toes of her left foot several times. She reports no other symptoms and is otherwise generally healthy. Medical history is unremarkable except for an episode of blurred vision 1 year ago that resolved on its own. She takes no medications and does not smoke cigarettes or drink alcoholic beverages. Physical examination shows a left footdrop but is otherwise noncontributory. Neurologic examination shows hyperreflexia of the deep tendon reflexes in all extremities. CT scan of the head shows no abnormalities. Lumbar puncture is done. Examination of this patient's cerebrospinal fluid is most likely to show which of the following?
A) Elevated glucose
B) Elevated IgG
C) Elevated neutrophil count
D) Elevated protein
E) Positive VDRL
3. A 55-year-old African-American woman is transported to the emergency department by paramedics. She was sitting at the dinner table, and suddenly said to her husband, "I have a terrible headache." She then dropped her fork and slumped in her chair. The husband went to her aid, and she said, "I can't move my right side." He then called emergency medical services. On arrival the patient is alert and oriented. She is holding her head and is in obvious distress. Vital signs are: pulse 101/min, respirations 28/min and blood pressure 190/118z mm Hg. The patient's husband tells you that she has been treated for hypertension for the past 10 years and that she has a 25-year history of simple migraines that occur every 3 to 4 months. On physical examination the patient has an obvious right hemiparesis with an associated hemisensory deficit and hyperreflexia. Blood is drawn for laboratory studies, electrocardiography is done and CT scan of the head is ordered. Her husband asks, "What do you think happened, Doctor?" Based on her clinical presentation and past medical history, which of the following is the most likely cause?
A) Cerebellar hemorrhage
B) Complicated migraine
C) Embolic cerebral infarct
D) Intracerebral hemorrhage
E) Subarachnoid hemorrhage
4. A 36-year-old firefighter is trapped in a burning building when his air supply runs out. When the rescuers find him 15 minutes later, he is breathing spontaneously and has a pulse, but he is unresponsive. There is no evidence of acute traumatic injury. He is resuscitated with 100% oxygen via a nonrebreathing face mask. He gradually becomes conscious, and by the time he reaches the emergency department, he is awake, alert and complains only of a headache. On arrival in the emergency department arterial blood gas values while breathing 100% oxygen show:
PO2
493 mm Hg
PCO2
29 mm Hg
pH
7.53
Carboxyhemoglobin
30%
Which of the following is the most appropriate management at this time?
A) Admit the patient for careful monitoring of his airway
B) Begin phenytoin therapy by intravenous loading
C) Have the patient rebreathe 100% oxygen at 10 L/min
D) Intubate the patient in order to allow controlled mechanical ventilation
E) Measure the concentration of carbon monoxide in his blood
5. A 23-year-old rugby player is brought to the emergency department by his teammates after sustaining blunt trauma to the left infra-orbital area during a game. The patient complains of significant periorbital pain and says, "I'm seeing flashing lights." Physical examination discloses periorbital swelling. Pupils are equal and reactive. Visual acuity is 20/20 in the right eye and 20/40 in the left eye. Which of the following is the most appropriate step?
A) Discharge and follow-up with an ophthalmologist within 24 hours
B) Discharge with a nonsteroidal anti-inflammatory drug (NSAID) and an eye patch
C) Discharge with corticosteroid eyedrops and a nonsteroidal anti-inflammatory drug (NSAID)
D) Discharge with pain medication and application of ice packs
E) Immediate consultation with an ophthalmologist
6. A 19-year-old white college student is brought to the emergency department by her two roommates because of shortness of breath. The roommates tell you that her symptoms came on suddenly about one hour after they picked her up at the airport where she had arrived after a 6-hour flight from visiting her parents. The patient has rapid and shallow breathing, and with difficulty she tells you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something. Do something!" She says she has never had an experience like this before. She always has been healthy and she takes no medications except for combination oral contraceptive therapy. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show:
PO2
99 mm Hg
PCO2
30 mm Hg
pH
7.44
Which of the following is the most appropriate long-term pharmacotherapy?
A) Bupropion
B) Gabapentin
C) Lorazepam
D) Metoprolol
E) Paroxetine
The following vignette applies to the next 2 items.
A 58-year-old white man comes to the emergency department because of chest heaviness for the past 45 minutes associated with shortness of breath and a sense of doom. He has not seen a physician since he was 18 years old. He smokes approximately two packs of cigarettes per day. He takes no prescription medications. He has had increasing heartburn recently and he has been taking eight to twelve antacid tablets daily during the past 3 weeks. He is mildly nauseated and diaphoretic. Vital signs are: temperature 37.2°C (99.0°F), pulse 98/min, respirations 20/min and blood pressure 160/96 mm Hg. Electrocardiogram shows that ST-T segment changes are indeterminate. You are aware of a new blood test, CQ, that can diagnose an acute myocardial infarction (MI) more quickly than the creatine kinase isoenzymes. The receiver operating characteristic (ROC) curve for CQ is shown in the exhibit for four cut-off points. You believe the likelihood of an acute MI is high in this patient and you want to minimize the chance of a false negative.
Item 1 of 2
7. Which of the following is the most appropriate cut-off point on the ROC curve?
A) A
B) B
C) C
D) D
E) It cannot be determined with the data provided
Item 2 of 2
8.
The cut-off point at which the test performance for CQ is most accurate in the detection of an acute MI is which of the following?
A) A
B) B
C) C
D) D
E) It cannot be determined from an ROC curve
End of Set
9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared dead when defibrillation fails after which of the following?
A) Rapid endotracheal intubation and administration of 100% oxygen
B) Restoration of a normal core temperature
C) Restoration of a normal oral temperature
D) 1 hour of core rewarming
E) 20 minutes of warming, externally
10. A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain, heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component. Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin. Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation for cardiac decompensation and renal failure in this patient?
A) Bulimic cardiomyopathy
B) Cocaine intoxication
C) Hypothyroidism
D) Myocardial ischemia
E) Myocarditis
11. A 73-year-old recently widowed African-American woman comes to the emergency department because of abdominal pain, nausea and constipation for the past 3 days. She says the pain has been intermittent and she has had severe nausea and left-sided stomach cramps. She alternates between being constipated and having diarrhea but she has not had a bowel movement in the past 36 hours. She admits to smoking one pack of cigarettes per day, and she has diabetes mellitus that is poorly controlled with diet and glyburide. Vital signs now are: temperature 37.8°C (100.8°F), pulse 100/min, respirations 28/min and blood pressure 180/90 mm Hg. Abdomen is distended and tender; rectal examination is positive for occult blood. X-ray film is shown. Which of the following is the most appropriate management at this time?
A) Discharge home with clear fluids
B) Exploratory laparotomy
C) Nasogastric tube
D) Oral antibiotics
E) Rectal tube
12. A 10-day-old female neonate with Down syndrome is brought to the emergency department by her mother because she has been vomiting for the past 2 days. The vomitus is bile-stained. She was initially breast-fed, but she has been drinking cow milk-based formula for the past week. Physical examination shows slight fullness in the left upper quadrant without obvious tenderness. Test of the stool for occult blood is negative. Which of the following is the most likely diagnosis?
A) Allergy to cow milk protein
B) Duodenal obstruction
C) Hypertrophic pyloric stenosis
D) Peptic ulcer with pyloric obstruction
E) Small-bowel volvulus
The following vignette applies to the next 2 items.
A 49-year-old homeless white man comes to the emergency department and says, "I began vomiting 2 to 3 hours ago, and then started to throw up blood." He reports vomiting "about half a cup" of red blood. He had epigastric discomfort after several episodes of emesis, but no preceding abdominal pain. The patient says that he drinks about a half pint of bourbon per day, and he does not use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). He has no previous history of similar symptoms. Vital signs now are: temperature 37.0°C (98.6°F), pulse 105/min and blood pressure 150/77 mm Hg. On physical examination he is alert, oriented and disheveled, and he has the odor of alcohol on his breath. No scleral icterus is present. Abdomen is soft, with mild epigastric tenderness. Liver edge is palpated 2 cm below the right costal margin and is nontender. Bowel sounds are present. Stool is negative for occult blood. An intravenous line is started. Endoscopy confirms a tear of the gastroesophageal junction. Laboratory studies show:
Serum
Amylase
135 U/L
BUN
10 mg/dL
Creatinine
0.7 mg/dL
Na+
137 mEq/L
K+
3.3 mEq/L
Cl-
97 mEq/L
HCO-3
22 mEq/L
Blood
Hematocrit
37%
Hemoglobin
12 g/dL
WBC
12,100/mm3
Platelet count
317,000/mm3
Item 1 of 2
13. The patient says, "What are you going to do, Doc?"
Which of the following is the most appropriate next step?
A) Cimetidine, intravenously
B) Observation and supportive care
C) Octreotide, intravenously
D) Sclerotherapy
E) Selective arterial vasopressin
Item 2 of 2
14. After 1 hour the patient's condition has stabilized. Despite your urging him to stay for further evaluation, he insists on leaving.
At this time which of the following is most appropriate to tell the patient?
A) An elective operation should be scheduled
B) He is at immediate risk for major gastrointestinal hemorrhage
C) His symptoms might indicate severe alcoholic liver disease
D) Omeprazole would help prevent further episodes
E) The risk for rebleeding from this episode is relatively small
The following vignette applies to the next 2 items.
A 17-year-old African-American boy is brought to the emergency department by his mother and two of his friends at 2:00 AM on Sunday morning. His friends had taken him home from a party after he began to act strangely. They were aware that the patient had recently been treated for marijuana abuse, and they believe that he has significantly cut back on his drug use. His friends began to worry when he insisted that several peers at the party were talking about him behind his back and were plotting to harm him. On the way to the hospital, he was adamant that the same individuals were following them and that they were all in great danger. Now, the patient is unable to walk a straight line, and his speech is slurred. Vital signs are: temperature 38.1°C (100.5°F), pulse 130/min, respirations 20/min, and blood pressure 150/105 mm Hg. Physical examination discloses vertical and horizontal nystagmus. The remainder of the physical examination and neurologic examination is normal.
Item 1 of 2
15. The most likely cause of the patient's current symptoms is intoxication with which of the following?
A) Alcohol
B) Cannabis
C) Heroin
D) Nitrous oxide
E) Phencyclidine
Item 2 of 2
16. Which of the following is the most appropriate pharmacotherapy?
A) Diphenhydramine
B) Fluoxetine
C) Haloperidol
D) Hydroxyzine
E) Phentolamine
The following vignette applies to the next 2 items.
A 4-year-old girl is brought to the emergency department by her mother because of severe wrist pain. The girl was playing with her friends in her backyard and fell, breaking the fall with her outstretched hand. On physical examination there is slight swelling over the dorsal aspect of the wrist. X-ray films of the wrist are shown.
Item 1 of 2
17. The findings are most consistent with which of the following?
A) Carpal navicular fracture
B) Cortical fracture of the radius
C) Fracture of the distal radius and ulnar growth plates
D) Fracture of the distal radius growth plate
E) Perilunate dislocation of the wrist
Item 2 of 2
18. Which of the following is the most appropriate management?
A) Apply an elastic bandage and apply ice packs to the wrist
B) Do closed reduction of the fracture
C) Do closed reduction of the fracture and report the case to child protective services
D) Immobilize the forearm and hand in situ in a cast
E) Prepare for open reduction and internal fixation
The following vignette applies to the next 3 items.
A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.
Item 1 of 3
19. Which of the following is the most important first step in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values
Item 2 of 3
20. After 10 minutes there is no change in his condition.
At this time, the most appropriate next step is to administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally
Item 3 of 3
21. The patient improves with treatment. In 30 minutes his urticaria, dyspnea and hoarseness are resolved and his vital signs are normal. As you prepare to discharge the patient you recommend that he be evaluated by an allergist.
The patient's mother asks you what should be done until he can be seen by the allergist. Which of the following is the most appropriate recommendation?
A) Avoid all outdoor activity
B) Take diphenhydramine, orally, every 4 hours while awake
C) Take oral prednisone once daily
D) Use an albuterol metered-dose inhaler after any insect sting
E) Use an epinephrine autoinjector if he is stung again
22. A 3-year-old girl is brought to the emergency department by her father because of vomiting. He reports that her medical history is unremarkable except for a viral infection 1 month ago, during which she had a mild fever and was irritable for 2 days. She recovered quickly and was well until 3 days ago, when she seemed more thirsty than usual and did not eat as much solid food as she had before. She began vomiting last night and was lethargic today. She is afebrile, pulse is 180/min and respirations are 40/min and deep. On physical examination she is lethargic but responds to touch. Which of the following abnormalities is most likely on further physical examination?
A) Acetone-smelling breath
B) Hepatomegaly
C) Multiple bruises of various stages of healing
D) Nuchal rigidity
E) An olive-sized mass in the right upper abdominal quadrant
23. A 71-year-old retired oil refinery worker comes to the emergency department at 2:00 AM because of inability to urinate for the past 6 hours. He says he is having abdominal discomfort and that he has had a decreased urinary stream and urinary dribbling for the past 4 months. Vital signs are: temperature 36.5°C (97.7°F), pulse 103/min and blood pressure 140/90 mm Hg. His lower abdomen is mildly tender and the urinary bladder can be percussed at 2 cm below the umbilicus. Rectal examination shows an enlarged, firm, smooth prostate. Neurologic examination is normal. Which of the following is the most appropriate initial management?
A) Admit the patient to the short-stay unit for observation
B) Do a suprapubic cystostomy and drain the bladder
C) Insert an indwelling urinary catheter
D) Order pelvic ultrasonography
E) Order retrograde cystourethrography
24. A 15-year-old girl is brought to the emergency department by her sister. The patient is 36 weeks pregnant and is very upset. She says, "I don't feel the baby move like I used to. Something's wrong!" She has had no prenatal care. A fetal nonstress test is obtained and is nonreactive. Which of the following is the most appropriate first step?
A) Assess biophysical profile
B) Determine her hemoglobin concentration
C) Determine her serum glucose concentration
D) Induce labor
E) Order amniocentesis to determine fetal maturity
The following vignette applies to the next 2 items.
A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:
Blood
Urine
Hematocrit 21%
WBC 0/hpf
Hemoglobin 5.6 g/dL
RBC 10-20/hpf
WBC 2000/mm3
MCV 102 μm3
Partial thromboplastin time 26 sec
Platelet count 20,000/mm3
Prothrombin time 12.8 sec
INR 1.3
Bone marrow biopsy shows marked hypocellularity.
Item 1 of 2
25. Which of the following is the most appropriate management?
A) Administer granulocyte colony-stimulating factor
B) Administer high-dose short-term corticosteroids
C) Administer parenteral broad-spectrum antibiotics
D) Begin transfusion with whole blood
E) Discontinue sulfamethoxazole-trimethoprim
Item 2 of 2
26. Supportive measures are provided for the patient.
Which of the following is the most appropriate treatment recommendation for this patient at this time?
A) Chemotherapy
B) Follow-up evaluation in 1 week
C) Glucocorticoid therapy
D) Hematopoietic growth factor therapy
E) Stem cell transplant
27. An 87-year-old woman is brought to the emergency department by ambulance. Her friend found her lying in bed in her home about one-half hour ago. She had been incontinent of urine and had also vomited. The patient has a history of degenerative joint disease, hypertension and chronic obstructive pulmonary disease. The paramedics brought in her medications, which include felodipine, naproxen, albuterol inhaler, ipratropium inhaler, prednisone, theophylline and ciprofloxacin. On questioning the woman she says she has a headache and nausea, but she is not able to give a more coherent history. She appears restless, tremulous and agitated. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 26/min and blood pressure 110/65 mm Hg. Physical examination is normal except for mild expiratory wheezing. Chest x-ray film is normal. Which of the following is the most likely cause of her symptoms?
A) Exacerbation of chronic obstructive pulmonary disease
B) Gastroenteritis
C) Migraine
D) Stroke
E) Theophylline toxicity
28. A 53-year-old white man is brought to the emergency department by emergency medical services after he crashed his car into a tree. He was not wearing a seatbelt. Upon arrival in the emergency department the patient is clearly drunk but he is cooperative during the examination. Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min, respirations 18/min and blood pressure 110/75 mm Hg. Physical examination shows generalized tenderness over the lower abdomen and pelvis. Neurologic examination is normal. X-ray films of the cervical spine, chest and pelvis are normal, as is CT scan of the head. On reexamination 3 hours later, no urinary output has been recorded. The patient is unable to produce a urine sample. He has received 1400 mL of lactated Ringer solution since the accident. Foley catheter is placed and yields 5 mL of bloody urine. X-ray film obtained after placement of the Foley catheter is shown. Which of the following is the most appropriate next step?
A) Foley catheter drainage for 10 days
B) Observation only
C) Percutaneous nephrostomy
D) Suprapubic catheter drainage
E) Surgical repair
29. A 17-year-old white girl is brought to the emergency department after she was struck by a car while riding her bicycle. She was wearing a helmet. She is awake, alert, and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 18/min, and blood pressure 107/60 mm Hg. Pulse oximetry shows an oxygen saturation of 96% while breathing room air. Physical examination shows no cervical spine tenderness. Breath sounds are clear. Abdominal, pelvic, and neurologic examinations are normal. Screening x-rays of the lateral cervical spine and pelvis are normal. Chest x-ray is shown. Which of the following is the most likely diagnosis?
A) Aortic rupture
B) Flail chest
C) Hemothorax
D) Perforated viscus
E) Pulmonary contusion
The following vignette applies to the next 3 items.
You are notified that your patient, a 26-year-old pregnant woman, has been brought by ambulance to the emergency department after she was in an automobile accident. The vehicle in which she was a passenger was broad-sided by another car. She was in the front passenger seat and was wearing a lap/shoulder belt. You have known the patient for 10 years. She is at 34 weeks' gestation with her second pregnancy; she has one child. The nurses attach an external fetal monitor immediately upon the patient's arrival. When you arrive, the patient's vital signs are: pulse 110/min, respirations 18/min and blood pressure 120/80 mm Hg. The fetal heart rate is 150/min with occasional accelerations to 160/min and no decelerations. The monitor shows uterine contractions about every 7 minutes. The patient states that her only discomfort is from the contractions. She says, "They feel like the hard ones from the end of labor with my other baby." On physical examination, the abdomen is very tender to palpation. On speculum examination, there is a small amount of bright red blood oozing from the cervix, which is long and closed. The patient asks you how long she will have to stay in the hospital.
Item 1 of 3
30. Which of the following is the most appropriate response at this time?
A) "We need to monitor both you and the baby and do some additional tests before I can answer your question."
B) "You are in preterm labor from the accident. We will try to stop the contractions with medication, and you can go home later today."
C) "You seem a little shaken up, but the baby is fine. I want you to go home but remain in bed the rest of the day."
D) "You seem a little shaken up. Even though the baby seems fine, I would like to keep you overnight for observation."
E) "You will need to stay here until the baby is delivered."
Item 2 of 3
31. While you are talking with the patient, she has a severe contraction that lasts for 5 minutes. Fetal heart tones decrease to 60/min. Which of the following is the most appropriate action at this time?
A) Determine fetal scalp pH
B) Give the mother oxygen by face mask and magnesium sulfate by slow intravenous push
C) Prepare for immediate cesarean delivery
D) Place an internal fetal scalp electrode
E) Rupture the membranes artificially for vaginal delivery
Item 3 of 3
32. The appropriate action is undertaken. The patient asks you if she would have been better off if she had not been wearing a seatbelt. Which of the following is the most appropriate answer?
A) "If your car has an air bag, you should not use the seat belt when you are pregnant. But if your car does not have an air bag, we still recommend you use the seat belt."
B) "We prefer that pregnant women not wear seat belts because, in case of accidents, the belt can cause more harm than it prevents."
C) "Pregnant women should use seat belts until about 28 weeks' gestation. After that, the abdomen is so large that the belt can cause the kind of problem you experienced."
D) "The problem you had was caused from the forces of the accident. You might have been injured more seriously without a seat belt."
E) "Your problem was that you were sitting in the front passenger seat, which is the most dangerous seat in the car. If you had sat in a different seat, this would not have happened."
33. A 47-year-old man is brought to the emergency department because of the sudden onset of chest pain. On cardiac examination, which of the following physical findings is suggestive of ischemia?
A) Early diastolic murmur at the base
B) A late systolic murmur at the apex
C) Mid-systolic click
D) Pericardial knock
E) Pulsus paradoxus
34. A 23-year-old woman comes to the emergency department because of fever. She was diagnosed with acute lymphoblastic leukemia 2 weeks ago, and chemotherapy was initiated 3 days later. She has received all of the chemotherapy as an outpatient. Several hours prior to admission she developed a single episode of shaking chills, which spontaneously resolved. Vital signs are temperature 38.4°C (101.1°F), pulse 108/min, respirations 16/min, and blood pressure 120/80 mm Hg. She is in mild distress. Partial alopecia is noted, and a Hickman catheter is in place. Results of stat complete blood count are obtained and shown:
Blood
Hemoglobin
8.5 g/dL
WBC
950/mm3
Platelet count
80,000/mm3
Urinalysis shows no abnormalities. Two sets of blood cultures are obtained. Which of the following is the most appropriate next step?
A) Administer a single dose of antibiotics and discharge with oral antibiotics
B) Admit her to the hospital
C) Discharge her on G-CSF (filgrastim)
D) Monitor vital signs in the emergency department
E) Remove the Hickman catheter and discharge with oral antibiotics
The following vignette applies to the next 2 items.
An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3-5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.
Item 1 of 2
35. Which of the following is the most accurate statement?
A) An epidural abscess has developed
B) The epidural block has worn off
C) The original injection was subdural
D) A radiculopathy has developed at a different level
E) She is having a reaction to the anesthetic
Item 2 of 2
36. Which of the following is the most appropriate next step?
A) Administer an analgesic and diphenhydramine
B) Administer an analgesic, intravenously, and arrange myelography
C) Contact the anesthesiologist about repeating the epidural block
D) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
E) Request an emergency MRI of the spine
1. A 75-year-old retired landscape architect is brought to the emergency department after the police found him wandering around the city. He was unable to tell them who he was or where he lived. He has a long history of poorly controlled hypertension. He had two strokes several months ago from which he partially recovered. He can walk but his left arm remains weak. Pertinent family history indicates that his father, a successful businessman, committed suicide at age 72 years. Which of the following is the most likely diagnosis?
A) Bipolar disorder, manic episode
B) Major depressive disorder
C) Vascular dementia
D) Dementia, Alzheimer type
E) Schizophrenia
2. A 37-year-old woman comes to the emergency department because of a 2-day history of weakness in her left foot which has caused her to accidentally stub the toes of her left foot several times. She reports no other symptoms and is otherwise generally healthy. Medical history is unremarkable except for an episode of blurred vision 1 year ago that resolved on its own. She takes no medications and does not smoke cigarettes or drink alcoholic beverages. Physical examination shows a left footdrop but is otherwise noncontributory. Neurologic examination shows hyperreflexia of the deep tendon reflexes in all extremities. CT scan of the head shows no abnormalities. Lumbar puncture is done. Examination of this patient's cerebrospinal fluid is most likely to show which of the following?
A) Elevated glucose
B) Elevated IgG
C) Elevated neutrophil count
D) Elevated protein
E) Positive VDRL
3. A 55-year-old African-American woman is transported to the emergency department by paramedics. She was sitting at the dinner table, and suddenly said to her husband, "I have a terrible headache." She then dropped her fork and slumped in her chair. The husband went to her aid, and she said, "I can't move my right side." He then called emergency medical services. On arrival the patient is alert and oriented. She is holding her head and is in obvious distress. Vital signs are: pulse 101/min, respirations 28/min and blood pressure 190/118z mm Hg. The patient's husband tells you that she has been treated for hypertension for the past 10 years and that she has a 25-year history of simple migraines that occur every 3 to 4 months. On physical examination the patient has an obvious right hemiparesis with an associated hemisensory deficit and hyperreflexia. Blood is drawn for laboratory studies, electrocardiography is done and CT scan of the head is ordered. Her husband asks, "What do you think happened, Doctor?" Based on her clinical presentation and past medical history, which of the following is the most likely cause?
A) Cerebellar hemorrhage
B) Complicated migraine
C) Embolic cerebral infarct
D) Intracerebral hemorrhage
E) Subarachnoid hemorrhage
4. A 36-year-old firefighter is trapped in a burning building when his air supply runs out. When the rescuers find him 15 minutes later, he is breathing spontaneously and has a pulse, but he is unresponsive. There is no evidence of acute traumatic injury. He is resuscitated with 100% oxygen via a nonrebreathing face mask. He gradually becomes conscious, and by the time he reaches the emergency department, he is awake, alert and complains only of a headache. On arrival in the emergency department arterial blood gas values while breathing 100% oxygen show:
PO2
493 mm Hg
PCO2
29 mm Hg
pH
7.53
Carboxyhemoglobin
30%
Which of the following is the most appropriate management at this time?
A) Admit the patient for careful monitoring of his airway
B) Begin phenytoin therapy by intravenous loading
C) Have the patient rebreathe 100% oxygen at 10 L/min
D) Intubate the patient in order to allow controlled mechanical ventilation
E) Measure the concentration of carbon monoxide in his blood
5. A 23-year-old rugby player is brought to the emergency department by his teammates after sustaining blunt trauma to the left infra-orbital area during a game. The patient complains of significant periorbital pain and says, "I'm seeing flashing lights." Physical examination discloses periorbital swelling. Pupils are equal and reactive. Visual acuity is 20/20 in the right eye and 20/40 in the left eye. Which of the following is the most appropriate step?
A) Discharge and follow-up with an ophthalmologist within 24 hours
B) Discharge with a nonsteroidal anti-inflammatory drug (NSAID) and an eye patch
C) Discharge with corticosteroid eyedrops and a nonsteroidal anti-inflammatory drug (NSAID)
D) Discharge with pain medication and application of ice packs
E) Immediate consultation with an ophthalmologist
6. A 19-year-old white college student is brought to the emergency department by her two roommates because of shortness of breath. The roommates tell you that her symptoms came on suddenly about one hour after they picked her up at the airport where she had arrived after a 6-hour flight from visiting her parents. The patient has rapid and shallow breathing, and with difficulty she tells you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something. Do something!" She says she has never had an experience like this before. She always has been healthy and she takes no medications except for combination oral contraceptive therapy. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show:
PO2
99 mm Hg
PCO2
30 mm Hg
pH
7.44
Which of the following is the most appropriate long-term pharmacotherapy?
A) Bupropion
B) Gabapentin
C) Lorazepam
D) Metoprolol
E) Paroxetine
The following vignette applies to the next 2 items.
A 58-year-old white man comes to the emergency department because of chest heaviness for the past 45 minutes associated with shortness of breath and a sense of doom. He has not seen a physician since he was 18 years old. He smokes approximately two packs of cigarettes per day. He takes no prescription medications. He has had increasing heartburn recently and he has been taking eight to twelve antacid tablets daily during the past 3 weeks. He is mildly nauseated and diaphoretic. Vital signs are: temperature 37.2°C (99.0°F), pulse 98/min, respirations 20/min and blood pressure 160/96 mm Hg. Electrocardiogram shows that ST-T segment changes are indeterminate. You are aware of a new blood test, CQ, that can diagnose an acute myocardial infarction (MI) more quickly than the creatine kinase isoenzymes. The receiver operating characteristic (ROC) curve for CQ is shown in the exhibit for four cut-off points. You believe the likelihood of an acute MI is high in this patient and you want to minimize the chance of a false negative.
Item 1 of 2
7. Which of the following is the most appropriate cut-off point on the ROC curve?
A) A
B) B
C) C
D) D
E) It cannot be determined with the data provided
Item 2 of 2
8.
The cut-off point at which the test performance for CQ is most accurate in the detection of an acute MI is which of the following?
A) A
B) B
C) C
D) D
E) It cannot be determined from an ROC curve
End of Set
9. A 67-year-old man is brought to the emergency department in ventricular fibrillation. His rectal temperature is 26.7°C (80.0°F). Among the following criteria, the patient should be declared dead when defibrillation fails after which of the following?
A) Rapid endotracheal intubation and administration of 100% oxygen
B) Restoration of a normal core temperature
C) Restoration of a normal oral temperature
D) 1 hour of core rewarming
E) 20 minutes of warming, externally
10. A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain, heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component. Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin. Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation for cardiac decompensation and renal failure in this patient?
A) Bulimic cardiomyopathy
B) Cocaine intoxication
C) Hypothyroidism
D) Myocardial ischemia
E) Myocarditis
11. A 73-year-old recently widowed African-American woman comes to the emergency department because of abdominal pain, nausea and constipation for the past 3 days. She says the pain has been intermittent and she has had severe nausea and left-sided stomach cramps. She alternates between being constipated and having diarrhea but she has not had a bowel movement in the past 36 hours. She admits to smoking one pack of cigarettes per day, and she has diabetes mellitus that is poorly controlled with diet and glyburide. Vital signs now are: temperature 37.8°C (100.8°F), pulse 100/min, respirations 28/min and blood pressure 180/90 mm Hg. Abdomen is distended and tender; rectal examination is positive for occult blood. X-ray film is shown. Which of the following is the most appropriate management at this time?
A) Discharge home with clear fluids
B) Exploratory laparotomy
C) Nasogastric tube
D) Oral antibiotics
E) Rectal tube
12. A 10-day-old female neonate with Down syndrome is brought to the emergency department by her mother because she has been vomiting for the past 2 days. The vomitus is bile-stained. She was initially breast-fed, but she has been drinking cow milk-based formula for the past week. Physical examination shows slight fullness in the left upper quadrant without obvious tenderness. Test of the stool for occult blood is negative. Which of the following is the most likely diagnosis?
A) Allergy to cow milk protein
B) Duodenal obstruction
C) Hypertrophic pyloric stenosis
D) Peptic ulcer with pyloric obstruction
E) Small-bowel volvulus
The following vignette applies to the next 2 items.
A 49-year-old homeless white man comes to the emergency department and says, "I began vomiting 2 to 3 hours ago, and then started to throw up blood." He reports vomiting "about half a cup" of red blood. He had epigastric discomfort after several episodes of emesis, but no preceding abdominal pain. The patient says that he drinks about a half pint of bourbon per day, and he does not use aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). He has no previous history of similar symptoms. Vital signs now are: temperature 37.0°C (98.6°F), pulse 105/min and blood pressure 150/77 mm Hg. On physical examination he is alert, oriented and disheveled, and he has the odor of alcohol on his breath. No scleral icterus is present. Abdomen is soft, with mild epigastric tenderness. Liver edge is palpated 2 cm below the right costal margin and is nontender. Bowel sounds are present. Stool is negative for occult blood. An intravenous line is started. Endoscopy confirms a tear of the gastroesophageal junction. Laboratory studies show:
Serum
Amylase
135 U/L
BUN
10 mg/dL
Creatinine
0.7 mg/dL
Na+
137 mEq/L
K+
3.3 mEq/L
Cl-
97 mEq/L
HCO-3
22 mEq/L
Blood
Hematocrit
37%
Hemoglobin
12 g/dL
WBC
12,100/mm3
Platelet count
317,000/mm3
Item 1 of 2
13. The patient says, "What are you going to do, Doc?"
Which of the following is the most appropriate next step?
A) Cimetidine, intravenously
B) Observation and supportive care
C) Octreotide, intravenously
D) Sclerotherapy
E) Selective arterial vasopressin
Item 2 of 2
14. After 1 hour the patient's condition has stabilized. Despite your urging him to stay for further evaluation, he insists on leaving.
At this time which of the following is most appropriate to tell the patient?
A) An elective operation should be scheduled
B) He is at immediate risk for major gastrointestinal hemorrhage
C) His symptoms might indicate severe alcoholic liver disease
D) Omeprazole would help prevent further episodes
E) The risk for rebleeding from this episode is relatively small
The following vignette applies to the next 2 items.
A 17-year-old African-American boy is brought to the emergency department by his mother and two of his friends at 2:00 AM on Sunday morning. His friends had taken him home from a party after he began to act strangely. They were aware that the patient had recently been treated for marijuana abuse, and they believe that he has significantly cut back on his drug use. His friends began to worry when he insisted that several peers at the party were talking about him behind his back and were plotting to harm him. On the way to the hospital, he was adamant that the same individuals were following them and that they were all in great danger. Now, the patient is unable to walk a straight line, and his speech is slurred. Vital signs are: temperature 38.1°C (100.5°F), pulse 130/min, respirations 20/min, and blood pressure 150/105 mm Hg. Physical examination discloses vertical and horizontal nystagmus. The remainder of the physical examination and neurologic examination is normal.
Item 1 of 2
15. The most likely cause of the patient's current symptoms is intoxication with which of the following?
A) Alcohol
B) Cannabis
C) Heroin
D) Nitrous oxide
E) Phencyclidine
Item 2 of 2
16. Which of the following is the most appropriate pharmacotherapy?
A) Diphenhydramine
B) Fluoxetine
C) Haloperidol
D) Hydroxyzine
E) Phentolamine
The following vignette applies to the next 2 items.
A 4-year-old girl is brought to the emergency department by her mother because of severe wrist pain. The girl was playing with her friends in her backyard and fell, breaking the fall with her outstretched hand. On physical examination there is slight swelling over the dorsal aspect of the wrist. X-ray films of the wrist are shown.
Item 1 of 2
17. The findings are most consistent with which of the following?
A) Carpal navicular fracture
B) Cortical fracture of the radius
C) Fracture of the distal radius and ulnar growth plates
D) Fracture of the distal radius growth plate
E) Perilunate dislocation of the wrist
Item 2 of 2
18. Which of the following is the most appropriate management?
A) Apply an elastic bandage and apply ice packs to the wrist
B) Do closed reduction of the fracture
C) Do closed reduction of the fracture and report the case to child protective services
D) Immobilize the forearm and hand in situ in a cast
E) Prepare for open reduction and internal fixation
The following vignette applies to the next 3 items.
A 10-year-old boy is brought to the emergency department because he developed hives and shortness of breath 10 minutes after being stung by an insect. His father tells you that he had a similar episode of dyspnea and urticaria 2 years ago. Physical examination now shows a frightened child who appears out of breath, has generalized urticaria and asks for help in a hoarse voice. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 36/min and blood pressure 70/40 mm Hg.
Item 1 of 3
19. Which of the following is the most important first step in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values
Item 2 of 3
20. After 10 minutes there is no change in his condition.
At this time, the most appropriate next step is to administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally
Item 3 of 3
21. The patient improves with treatment. In 30 minutes his urticaria, dyspnea and hoarseness are resolved and his vital signs are normal. As you prepare to discharge the patient you recommend that he be evaluated by an allergist.
The patient's mother asks you what should be done until he can be seen by the allergist. Which of the following is the most appropriate recommendation?
A) Avoid all outdoor activity
B) Take diphenhydramine, orally, every 4 hours while awake
C) Take oral prednisone once daily
D) Use an albuterol metered-dose inhaler after any insect sting
E) Use an epinephrine autoinjector if he is stung again
22. A 3-year-old girl is brought to the emergency department by her father because of vomiting. He reports that her medical history is unremarkable except for a viral infection 1 month ago, during which she had a mild fever and was irritable for 2 days. She recovered quickly and was well until 3 days ago, when she seemed more thirsty than usual and did not eat as much solid food as she had before. She began vomiting last night and was lethargic today. She is afebrile, pulse is 180/min and respirations are 40/min and deep. On physical examination she is lethargic but responds to touch. Which of the following abnormalities is most likely on further physical examination?
A) Acetone-smelling breath
B) Hepatomegaly
C) Multiple bruises of various stages of healing
D) Nuchal rigidity
E) An olive-sized mass in the right upper abdominal quadrant
23. A 71-year-old retired oil refinery worker comes to the emergency department at 2:00 AM because of inability to urinate for the past 6 hours. He says he is having abdominal discomfort and that he has had a decreased urinary stream and urinary dribbling for the past 4 months. Vital signs are: temperature 36.5°C (97.7°F), pulse 103/min and blood pressure 140/90 mm Hg. His lower abdomen is mildly tender and the urinary bladder can be percussed at 2 cm below the umbilicus. Rectal examination shows an enlarged, firm, smooth prostate. Neurologic examination is normal. Which of the following is the most appropriate initial management?
A) Admit the patient to the short-stay unit for observation
B) Do a suprapubic cystostomy and drain the bladder
C) Insert an indwelling urinary catheter
D) Order pelvic ultrasonography
E) Order retrograde cystourethrography
24. A 15-year-old girl is brought to the emergency department by her sister. The patient is 36 weeks pregnant and is very upset. She says, "I don't feel the baby move like I used to. Something's wrong!" She has had no prenatal care. A fetal nonstress test is obtained and is nonreactive. Which of the following is the most appropriate first step?
A) Assess biophysical profile
B) Determine her hemoglobin concentration
C) Determine her serum glucose concentration
D) Induce labor
E) Order amniocentesis to determine fetal maturity
The following vignette applies to the next 2 items.
A 56-year-old white executive is admitted to the hospital from the emergency department following a severe nosebleed. One month ago he had a brief viral illness after being exposed to an exanthem eruption of one of his grandchildren. At that time the patient was also referred to a urologist because of fatigue, low back pain, and urinary frequency. He was diagnosed with prostatitis, for which he has been taking sulfamethoxazole-trimethoprim for the past 12 days. He does not take any other medications. On arrival in the emergency department vital signs were: temperature 36.8°C (98.2°F), pulse 100/min, respirations 16/min, and blood pressure 120/66 mm Hg. The patient appeared pale with scattered areas of bruising on his limbs and body and a few petechiae. No lymphadenopathy or organomegaly was found. Results of laboratory studies obtained in the emergency department are shown:
Blood
Urine
Hematocrit 21%
WBC 0/hpf
Hemoglobin 5.6 g/dL
RBC 10-20/hpf
WBC 2000/mm3
MCV 102 μm3
Partial thromboplastin time 26 sec
Platelet count 20,000/mm3
Prothrombin time 12.8 sec
INR 1.3
Bone marrow biopsy shows marked hypocellularity.
Item 1 of 2
25. Which of the following is the most appropriate management?
A) Administer granulocyte colony-stimulating factor
B) Administer high-dose short-term corticosteroids
C) Administer parenteral broad-spectrum antibiotics
D) Begin transfusion with whole blood
E) Discontinue sulfamethoxazole-trimethoprim
Item 2 of 2
26. Supportive measures are provided for the patient.
Which of the following is the most appropriate treatment recommendation for this patient at this time?
A) Chemotherapy
B) Follow-up evaluation in 1 week
C) Glucocorticoid therapy
D) Hematopoietic growth factor therapy
E) Stem cell transplant
27. An 87-year-old woman is brought to the emergency department by ambulance. Her friend found her lying in bed in her home about one-half hour ago. She had been incontinent of urine and had also vomited. The patient has a history of degenerative joint disease, hypertension and chronic obstructive pulmonary disease. The paramedics brought in her medications, which include felodipine, naproxen, albuterol inhaler, ipratropium inhaler, prednisone, theophylline and ciprofloxacin. On questioning the woman she says she has a headache and nausea, but she is not able to give a more coherent history. She appears restless, tremulous and agitated. Vital signs are: temperature 37.0°C (98.6°F), pulse 120/min, respirations 26/min and blood pressure 110/65 mm Hg. Physical examination is normal except for mild expiratory wheezing. Chest x-ray film is normal. Which of the following is the most likely cause of her symptoms?
A) Exacerbation of chronic obstructive pulmonary disease
B) Gastroenteritis
C) Migraine
D) Stroke
E) Theophylline toxicity
28. A 53-year-old white man is brought to the emergency department by emergency medical services after he crashed his car into a tree. He was not wearing a seatbelt. Upon arrival in the emergency department the patient is clearly drunk but he is cooperative during the examination. Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min, respirations 18/min and blood pressure 110/75 mm Hg. Physical examination shows generalized tenderness over the lower abdomen and pelvis. Neurologic examination is normal. X-ray films of the cervical spine, chest and pelvis are normal, as is CT scan of the head. On reexamination 3 hours later, no urinary output has been recorded. The patient is unable to produce a urine sample. He has received 1400 mL of lactated Ringer solution since the accident. Foley catheter is placed and yields 5 mL of bloody urine. X-ray film obtained after placement of the Foley catheter is shown. Which of the following is the most appropriate next step?
A) Foley catheter drainage for 10 days
B) Observation only
C) Percutaneous nephrostomy
D) Suprapubic catheter drainage
E) Surgical repair
29. A 17-year-old white girl is brought to the emergency department after she was struck by a car while riding her bicycle. She was wearing a helmet. She is awake, alert, and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 100/min, respirations 18/min, and blood pressure 107/60 mm Hg. Pulse oximetry shows an oxygen saturation of 96% while breathing room air. Physical examination shows no cervical spine tenderness. Breath sounds are clear. Abdominal, pelvic, and neurologic examinations are normal. Screening x-rays of the lateral cervical spine and pelvis are normal. Chest x-ray is shown. Which of the following is the most likely diagnosis?
A) Aortic rupture
B) Flail chest
C) Hemothorax
D) Perforated viscus
E) Pulmonary contusion
The following vignette applies to the next 3 items.
You are notified that your patient, a 26-year-old pregnant woman, has been brought by ambulance to the emergency department after she was in an automobile accident. The vehicle in which she was a passenger was broad-sided by another car. She was in the front passenger seat and was wearing a lap/shoulder belt. You have known the patient for 10 years. She is at 34 weeks' gestation with her second pregnancy; she has one child. The nurses attach an external fetal monitor immediately upon the patient's arrival. When you arrive, the patient's vital signs are: pulse 110/min, respirations 18/min and blood pressure 120/80 mm Hg. The fetal heart rate is 150/min with occasional accelerations to 160/min and no decelerations. The monitor shows uterine contractions about every 7 minutes. The patient states that her only discomfort is from the contractions. She says, "They feel like the hard ones from the end of labor with my other baby." On physical examination, the abdomen is very tender to palpation. On speculum examination, there is a small amount of bright red blood oozing from the cervix, which is long and closed. The patient asks you how long she will have to stay in the hospital.
Item 1 of 3
30. Which of the following is the most appropriate response at this time?
A) "We need to monitor both you and the baby and do some additional tests before I can answer your question."
B) "You are in preterm labor from the accident. We will try to stop the contractions with medication, and you can go home later today."
C) "You seem a little shaken up, but the baby is fine. I want you to go home but remain in bed the rest of the day."
D) "You seem a little shaken up. Even though the baby seems fine, I would like to keep you overnight for observation."
E) "You will need to stay here until the baby is delivered."
Item 2 of 3
31. While you are talking with the patient, she has a severe contraction that lasts for 5 minutes. Fetal heart tones decrease to 60/min. Which of the following is the most appropriate action at this time?
A) Determine fetal scalp pH
B) Give the mother oxygen by face mask and magnesium sulfate by slow intravenous push
C) Prepare for immediate cesarean delivery
D) Place an internal fetal scalp electrode
E) Rupture the membranes artificially for vaginal delivery
Item 3 of 3
32. The appropriate action is undertaken. The patient asks you if she would have been better off if she had not been wearing a seatbelt. Which of the following is the most appropriate answer?
A) "If your car has an air bag, you should not use the seat belt when you are pregnant. But if your car does not have an air bag, we still recommend you use the seat belt."
B) "We prefer that pregnant women not wear seat belts because, in case of accidents, the belt can cause more harm than it prevents."
C) "Pregnant women should use seat belts until about 28 weeks' gestation. After that, the abdomen is so large that the belt can cause the kind of problem you experienced."
D) "The problem you had was caused from the forces of the accident. You might have been injured more seriously without a seat belt."
E) "Your problem was that you were sitting in the front passenger seat, which is the most dangerous seat in the car. If you had sat in a different seat, this would not have happened."
33. A 47-year-old man is brought to the emergency department because of the sudden onset of chest pain. On cardiac examination, which of the following physical findings is suggestive of ischemia?
A) Early diastolic murmur at the base
B) A late systolic murmur at the apex
C) Mid-systolic click
D) Pericardial knock
E) Pulsus paradoxus
34. A 23-year-old woman comes to the emergency department because of fever. She was diagnosed with acute lymphoblastic leukemia 2 weeks ago, and chemotherapy was initiated 3 days later. She has received all of the chemotherapy as an outpatient. Several hours prior to admission she developed a single episode of shaking chills, which spontaneously resolved. Vital signs are temperature 38.4°C (101.1°F), pulse 108/min, respirations 16/min, and blood pressure 120/80 mm Hg. She is in mild distress. Partial alopecia is noted, and a Hickman catheter is in place. Results of stat complete blood count are obtained and shown:
Blood
Hemoglobin
8.5 g/dL
WBC
950/mm3
Platelet count
80,000/mm3
Urinalysis shows no abnormalities. Two sets of blood cultures are obtained. Which of the following is the most appropriate next step?
A) Administer a single dose of antibiotics and discharge with oral antibiotics
B) Admit her to the hospital
C) Discharge her on G-CSF (filgrastim)
D) Monitor vital signs in the emergency department
E) Remove the Hickman catheter and discharge with oral antibiotics
The following vignette applies to the next 2 items.
An 81-year-old Chinese-American woman is brought to the emergency department by her husband because of back pain. She says, "My back hurts and the pain is getting worse." The patient tells you that 2 days ago, an epidural block was done by a staff anesthesiologist because of a chronic, painful left L5 radiculopathy. She obtained temporary relief immediately after the procedure, but about 24 hours ago she began having midline low back pain without radiation that has increased in severity. She was unsuccessful today in contacting the orthopedist who arranged the procedure. Vital signs now are: temperature 38.5°C (101.3°F), pulse 101/min and blood pressure 140/85 mm Hg. On physical examination there is tenderness over the L3-5 area in the midline, which is slightly swollen. Straight leg-raising test is negative bilaterally. Anal sphincter tone is normal. There is decreased sensation over the left lateral calf, an absent left ankle reflex and moderate weakness of left great toe extension. The remainder of the neurologic examination of the leg is normal.
Item 1 of 2
35. Which of the following is the most accurate statement?
A) An epidural abscess has developed
B) The epidural block has worn off
C) The original injection was subdural
D) A radiculopathy has developed at a different level
E) She is having a reaction to the anesthetic
Item 2 of 2
36. Which of the following is the most appropriate next step?
A) Administer an analgesic and diphenhydramine
B) Administer an analgesic, intravenously, and arrange myelography
C) Contact the anesthesiologist about repeating the epidural block
D) Reassure the patient and have her make an appointment with the orthopedist for tomorrow
E) Request an emergency MRI of the spine