EM 2 - Answers PDF - National Board of Medical Examiners Emergency Medicine Self-Assessment

Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment...

Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment I 1. A 67-year-old woman comes to the emergency department 60 minutes after the sudden onset of shortness of breath. She also has had a 2-day history of swelling of her abdomen and legs. She received the diagnosis of carcinoma of the rig ht breast 6 years ago and underwent lumpectomy followed by radiotherapy and chemotherapy. She has type 2 diabetes mellitus well controlled with diet. On arrival, she is in severe respiratory distress. Her pulse is 122/m in, respirations are 28/min, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows jugular venous distention. Heart sounds are distant. A pericardia! rub is heard best at the second to fourth left intercostal spaces. The abdomen is distended and nontender. The liver is enlarged. There is 2+ edema of the lower extremities. An ECG shows sinus tachycardia and ST-segment elevations throughout all leads. An x-ray of the chest is shown. Which of the following is the most appropriate next step in diagnosis? A) Bedside cardiac ultrasonograph~ B) Cardiac catheterization C) CT scan of the chest.... ~, https://t.me/USMLENBME2CK ~ ~ r, Next Score Report Lab Values Calculator Help Pause Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment... 1. A 67-year-old woman comes to the emergency department 60 minutes after the sudden onset of shortness of breath. She also has had a 2-day history of swelling of her abdomen and legs. She received the diagnosis of carcinoma of the rig ht breast 6 years ago and underwent lumpectomy followed by radiotherapy and chemotherapy. She has type 2 diabetes mellitus well controlled with diet. On arrival, she is in severe respiratory distress. Her pulse is 122/m in, respirations are 28/min, and blood pressure is 94/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows jugular venous distention. Heart sounds are distant. A pericardia! rub is heard best at the second to fourth left intercostal spaces. The abdomen is distended and nontender. The liver is enlarged. There is 2+ edema of the lower extremities. An ECG shows sinus tachycardia and ST-segment elevations throughout all leads. An x-ray of the chest is shown. Which of the following is the most appropriate next step in diagnosis? A) Bedside cardiac ultrasonograph~ B) Cardiac catheterization C) CT scan of the chest D) Dopamine infusion E) Hepari n infusion F) Noninvasive ventilation G) Orotracheal intubation H) Thrombolytic infusion Correct Answer: A. Bedside cardiac ultrasonography is the most appropriate next step in diagnosis. This patient has a history of breast cancer and now presents with tachycardia, jugular venous distention, pulmonary edema, and hypotension with a pericardia! friction rub , hepatomegaly, and ST elevations on ECG. Together this is concerning for pericardia! tamponade, likely secondary to malignancy. Further assessment with bedside ultrasonography should be the next step. Characteristic findings on echocardiography include a pericardia! effusion, col lapse of the right atrium at the end of diastole, and a collapse of the right ventricle in the early part of diastole. Additionally, pulsus paradoxus, which is a clinical finding defined by a drop in the systolic blood pressure of greater than 10 mm Hg with inspiration can also be visualized on echocardiography as changes in the volume of the left and right ventricles with respiration. As a result of increased diastolic filling pressures and equalization of diastolic pressures between the left and right heart, other potential findings include congestive hepatopathy and tender hepatomegaly from flow reversal within the hepatic veins, and pulmonary edema. Incorrect Answers: B, C, D, E, F, G, and H. Cardiac catheterization (Choice B) is appropriate for patients with ST-elevation myocardial infarction (STEMI). This patient may also have acute coronary syndrome, but an echocardiography should be performed prior to catheterization as decompression of the pericardium via a pericardiocentesis should be performed first..... ~, https://t.me/USMLENBME2CK ~ ~ r, Next Score Report Lab Values Calculator Help Pause Exam Section : Item 1 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment Correct Answer: A. Bedside cardiac ultrasonography is the most appropriate next step in diagnosis. This patient has a history of breast cancer and now presents with tachycardia , jugular venous distention, pulmonary edema , and hypotension with a pericardia! friction rub , hepatomegaly, and ST elevations on ECG. Together this is concerning for pericardia! tamponade, likely secondary to malignancy. Further assessment with bedside ultrasonography should be the next step. Characteristic findings on echocardiography include a pericardia! effusion, collapse of the right atrium at the end of diastole, and a collapse of the right ventricle in the early part of diastole. Additionally, pulsus paradoxus, which is a clinical finding defined by a drop in the systolic blood pressure of greater than 10 mm Hg with inspiration can also be visualized on echocardiography as changes in the volume of the left and right ventricles with respiration. As a result of increased diastolic filling pressures and equalization of diastolic pressures between the left and right heart, other potential findings include congestive hepatopathy and tender hepatomegaly from flow reversal within the hepatic veins, and pulmonary edema. Incorrect Answers : B, C, D, E, F, G, and H. Cardiac catheterization (Choice B) is appropriate for patients with ST-elevation myocardial infarction (STEMI). This patient may also have acute coronary syndrome, but an echocardiography should be performed prior to catheterization as decompression of the pericardium via a pericardiocentesis should be performed first. CT scan of the chest (Choice C) is not appropriate in a borderline unstable patient with a presumed diagnosis of cardiac tamponade as the diagnosis can easily be made at bedside with ultrasonography. Dopamine infusion (Choice D) is appropriate in instances of cardiogenic shock, but this patient's hemodynamic status is more likely secondary to obstruction from pericardia! tamponade, which should first be diagnosed and managed before beginning vasopressors. Heparin infusion (Choice E) is appropriate for acute coronary syndrome, but this patient will likely require pericardiocentesis, and the initiation of anticoagulation prior to this procedure may increase the risk for significant bleeding. Noninvasive ventilation (Choice F) with bilevel positive pressure ventilation is sometimes used in patients with acute heart failure and pulmonary edema. This patient's pulmonary edema is likely to improve with treatment of her pericardia! effusion. Orotracheal intubation (Choice G) is reserved for patients who are unable to protect their airway as a result of altered mental status or for those with respiratory failure. This patient is awake and talking and does not require intubation. Thrombolytic infusion (Choice H) is incorrect. This patient has findings consistent with cardiac tamponade. Thrombolytics are reserved for the treatment of STEMI in patients who do not have immediate access to a catheterization laboratory. Educational Objective: Malignant pericardia! effusion can result in cardiac tamponade, which presents with hypotension, tachycardia , jugular venous distension , and pulsus paradoxus. Diagnosis can be made immediately with bedside echocardiography, which will ~, ~ F' ,., Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment Bedside cardiac ultrasonography is the most appropriate next step in diagnosis. This patient has a history of breast cancer and now... presents with tachycardia, jugular venous distention, pulmonary edema, and hypotension with a pericardia! friction rub, hepatomegaly, and ST elevations on ECG. Together th is is concerning for pericardia! tamponade, likely secondary to malignancy. Fu rther assessment with bedside ultrasonography should be the next step. Characteristic findings on echocardiography include a pericardia! effusion, collapse of the right atrium at the end of diastole, and a collapse of the right ventricle in the early part of diastole. Additionally, pulsus paradoxus, which is a clinical finding defined by a drop in the systolic blood pressure of greater than 10 mm Hg with inspiration can also be visualized on echocardiography as changes in the volume of the left and right ventricles with respiration. As a result of increased diastolic filling pressures and equalization of diastolic pressures between the left and right heart, other potential findings include congestive hepatopathy and tender hepatomegaly from flow reversal within the hepatic veins, and pulmonary edema. Incorrect Answers: B, C, D, E, F, G, and H. Cardiac catheterization (Choice B) is appropriate for patients with ST-elevation myocardial infarction (STEMI). This patient may also have acute coronary syndrome, but an echocardiography should be performed prior to catheterization as decompression of the pericardium via a pericardiocentesis should be performed first. CT scan of the chest (Choice C) is not appropriate in a borderline unstable patient with a presumed diagnosis of cardiac tamponade as the diagnosis can easily be made at bedside with ultrasonography. Dopamine infusion (Choice D) is appropriate in instances of cardiogenic shock, but this patient's hemodynamic status is more likely secondary to obstruction from pericardia! tamponade, which should first be diagnosed and managed before beginning vasopressors. Heparin infusion (Choice E) is appropriate for acute coronary syndrome, but this patient will likely requ ire pericardiocentesis, and the initiation of anticoagulation prior to this procedure may increase the risk for significant bleeding. Noninvasive ventilation (Choice F) with bilevel positive pressure ventilation is sometimes used in patients with acute heart failu re and pulmonary edema. This patient's pulmonary edema is likely to improve with treatment of her pericardia! effusion. Orotracheal intubation (Choice G) is reserved for patients who are unable to protect their airway as a result of altered mental status or for those with respiratory failure. This patient is awake and talking and does not requ ire intubation. Thrombolytic infusion (Choice H) is incorrect. This patient has findings consistent with cardiac tamponade. Thrombolytics are reserved for the treatment of STEMI in patients who do not have immediate access to a catheterization laboratory. Educational Objective: Malignant pericardia! effusion can result in cardiac tamponade, which presents with hypotension, tachycardia, jugular venous distension, and pulsus paradoxus. Diagnosis can be made immediately with bedside echocardiography, which will demonstrate right atrial and right ventricular collapse during diastole in addition to interventricular dependence and pericardia! fluid accumulation..... ~, https://t.me/USMLENBME2CK ~ ~ r, Next Score Report Lab Values Calculator Help Pause Exam Section: Item 2 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment 2. A 14-month-old girl is brought to the emergency department 20 minutes after having a generalized tonic-clonic seizure at home. The seizure began after she awoke from a nap and lasted approximately 3 minutes. She was drowsy afterward. This morning, her parents noted that she had mild rhinorrhea. She was born at term following an uncomplicated pregnancy and delivery. Development has been appropriate for age. On examination, she is alert and responsive. Her tem perature is 39.8°C (103.6°F), pulse is 140/min, respirations are 24/min, and blood pressure is 90/60 mm Hg. There are copious nasal secretions. The neck is supple. The lungs are clear to auscultation. Muscle strength is normal. Which of the following is the most appropriate next step in management of this patient's seizure? A) Reassurance B) CT scan of the head C) Beg in anticonvu lsant therapy D) EEG E) Lumbar puncture Correct Answer: A. This infant's generalized tonic-clonic seizure, which occurred in the setting of a febri le, upper respiratory ill ness, is consistent with a diagnosis of simple febrile seizure. Febri le seizures typically occur in children between the ages of 6 months and 6 years and may be simple (generalized and lasting for less than 15 minutes) or complex (focal, recurrent, or lasting longer than 15 minutes). The majority of febrile seizures are simple, and neither require treatment nor carry a significantly increased risk for future epilepsy. A careful history and physical examination are necessary to distinguish benign, febrile seizures from complex seizures resulting from viral or bacterial central nervous system infections. Incorrect Answers: B, C, D, and E. CT scan of the head (Choice B) is useful for identifying an intracranial mass lesion or hemorrhage. This child does not display focal neurologic signs or altered mental status to suggest an underlying intracranial pathology. Anticonvulsant therapy (Choice C) is useful in the management of epilepsy. Simple febri le seizures are typically self-limited and do not carry a significantly increased risk for future epilepsy. EEG (Choice D) is useful for the diagnosis of epilepsy. Generalized tonic-clonic seizures lasting less than 15 minutes in the setting of a febri le il lness do not require evaluation with an EEG. Recurrent seizures or those occurring outside of a period of febrile illness should be evaluated with an EEG. Lumbar puncture (Choice E) may be useful for the diagnosis of meningitis or encephalitis. This child lacks symptoms suggestive of.... - - - - - - - - - - - - - - - - - - - - - -- - - - - - - -- - - - - - -- - - --- - - - - - - - -- - - -- - r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 2 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment... A) Reassurance B) CT scan of the head C) Beg in anticonvu lsant therapy D) EEG E) Lumbar pu nctu re Correct Answer: A. This infant's generalized tonic-clonic seizure, which occurred in the setting of a febrile, upper respiratory illness, is consistent with a diagnosis of simple febrile seizure. Febrile seizures typically occur in children between the ages of 6 months and 6 years and may be simple (generalized and lasting for less than 15 minutes) or complex (focal, recurrent, or lasting longer than 15 minutes). The majority of febrile seizures are simple, and neither require treatment nor carry a significantly increased risk for future epilepsy. A careful history and physical examination are necessary to distinguish benign, febrile seizures from complex seizures resulting from viral or bacterial central nervous system infections. Incorrect Answers: B, C, D, and E. CT scan of the head (Choice B) is useful for identifying an intracranial mass lesion or hemorrhage. This child does not display focal neurologic signs or altered mental status to suggest an underlying intracranial pathology. Anticonvulsant therapy (Choice C) is useful in the management of epilepsy. Simple febrile seizures are typically self-limited and do not carry a significantly increased risk for future epilepsy. EEG (Choice D) is useful for the diagnosis of epilepsy. Generalized tonic-clonic seizures lasting less than 15 minutes in the setting of a febrile illness do not require evaluation with an EEG. Recurrent seizures or those occurring outside of a period of febrile illness should be evaluated with an EEG. Lumbar puncture (Choice E) may be useful for the diagnosis of meningitis or encephalitis. This child lacks symptoms suggestive of these diagnoses, such as altered mental status, meningismus, or focal neurologic symptoms. Educational Objective: Febrile seizures typically occur in children between the ages of 6 months and 5 years in the setting of a febrile illness and may be simple (generalized and lasting for less than 15 minutes) or complex (focal, recurrent, or lasting longer than 15 minutes). Simple febrile seizures do not require treatment or invasive testing..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 3-4 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer. A 71-year-old woman is broug ht to the emergency department by her fami ly because of a 1-day history of intermittent ag itation and confusion. Du ring the past 2 days, she has had a cough and has felt cold. She has hypertension, coronary artery disease, and Graves disease; she takes lisinopril, methimazole, and lovastatin. She has no known allergies. On arrival , she is oriented to person but not to place or time. Her temperatu re is 39.4 °C (103°F), pulse is 150/min and regular, respi rations are 26/min, and blood pressu re is 114/52 mm Hg. Pulse oximetry on room ai r shows an oxygen satu ration of 92%. The skin is warm and moist to the touch. Card iac exam ination shows no murmur or gallop. Rhonchi are heard in the right lung base. The abdomen is soft and nontender. Cranial nerves, motor function, sensation, and cerebellar function appear to be intact, but patient ag itation prevents a detailed neurolog ic exami nation. Patellar reflexes are 3+ bilaterally. 'I 3. Item 1 of 2 In add ition to x-ray of the chest, which of the following is most likely to confi rm the diag nosis? A) Blood cultu re B) Complete blood count with differential C) CT scan of the head D) Measurement of serum calcium and magnesium concentrations E) Thyroid fun ction testing Correct Answer: E. Thyroid storm is a serious potential complication of hyperthyroidism. It typically occurs in a patient with a known diagnosis of hyperthyroidism following physiologic stress from surgery or trauma, or in the setting of infection, such as in this patient who presents with signs and symptoms of pneumonia. Signs and symptoms of thyroid storm include hyperthermia, tachycardia, tachypnea, hypertension, diaphoresis, agitation, tremor, hyperreflexia, nausea, and diarrhea, and may progress to high-output heart failure, obtundation, seizure, or coma. The initial diagnosis of thyroid storm is made through a combination of clinical features and thyroid function testing, which shows increased serum concentrations of triiodothyronine (T 3) and thyroxine (T 4), and a decreased concentration of thyroid-stimulating hormone (TSH). Management requires supportive care, treatment of the underlying provocative stress, as well as intravenous corticosteroids, ~-adrenergic blockers, propylthiouracil, and potassium iodide. Incorrect Answers: A, B, C, and D. Blood culture (Choice A) is an appropriate step for the diagnosis of bacteremia and sepsis. This patient's altered mental status, hyperreflexia, and known history of Graves disease is more concerning for thyroid storm..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 3-4 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment --....... B) Complete blood count with differential C) CT scan of the head D) Measurement of serum calcium and magnesium concentrations E) Thyroid function testing Correct Answer: E. Thyroid storm is a serious potential complication of hyperthyroidism. It typically occurs in a patient with a known diagnosis of hyperthyroidism following physiologic stress from surgery or trauma, or in the setting of infection, such as in this patient who presents with signs and symptoms of pneumonia. Signs and symptoms of thyroid storm include hyperthermia, tachycardia, tachypnea, hypertension, diaphoresis, agitation, tremor, hyperreflexia, nausea, and diarrhea, and may progress to high-output heart failure, obtundation, seizure, or coma. The initial diagnosis of thyroid storm is made through a combination of clinical features and thyroid function testing, which shows increased serum concentrations of triiodothyronine (T 3) and thyroxine (T 4), and a decreased concentration of thyroid-stimulating hormone (TSH). Management requires supportive care, treatment of the underlying provocative stress, as well as intravenous corticosteroids, ~-adrenergic blockers, propylthiouracil, and potassium iodide. Incorrect Answers: A, B, C, and D. Blood culture (Choice A) is an appropriate step for the diagnosis of bacteremia and sepsis. This patient's altered mental status, hyperreflexia, and known history of Graves disease is more concerning for thyroid storm. Complete blood count with differential (Choice B) may disclose neutrophilia in the setting of pneumonia or leukocytosis in the setting of thyroid storm. These findings are relatively nonspecific and are less useful for the diagnosis in comparison to thyroid function testing. CT scan of the head (Choice C) is useful for excluding the presence of intracranial mass lesions prior to performing a lumbar puncture in patients with meningitis. Meningitis presents with fever, headache, photophobia, phonophobia, and neck stiffness, with possible Kernig or Brudzinski signs on examination. Measurement of serum calcium and magnesium concentrations (Choice D) may be useful for assessing potential causes of hyperreflexia. However, this patient's vital signs and her known history of Graves disease suggest thyroid storm rather than electrolyte derangement as the most likely cause of her hyperreflexia. Educational Objective: Thyroid storm is a serious potential complication of hyperthyroidism. It typically occurs in patients with a known diagnosis of hyperthyroidism fol lowing physiologic stress, such as infection (eg, pneumonia), surgery, or trauma. Thyroid storm presents with vital sign instability, mental status changes including agitation, obtundation, or coma, tremor, seizures, hyperreflexia, diaphoresis, nausea, diarrhea, and potential high-output heart failure..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 3-4 of 50 National Board of Medical Examiners Mark Emergency Medicine Self-Assessment... 4. Item 2 of 2 Acetaminophen and 0.9% saline (2 L) are administered , and supplemental oxygen via nasal cannu la is initiated. One hour later, her temperature is 38.2°C (100.8°F), pulse is 145/min, respirations are 22/min, and blood pressure is 135/65 mm Hg. Oxygen saturation is 97%. Laboratory stud ies show: Leukocyte count 17,000/mm 3(17 x 10 9/L) Segmented neutrophils 85% Bands 3% Lymphocytes 10% Monocytes 2% Serum Na + 145 mEq/L (145 mmol/L) Creatin ine 1.3 mg/dL (114.9 µmol/L) Thyroid -stim ulating hormone 0.01 µIU/mL (0.01 mlU/L) Lactic acid 2.4 mEq/L (2.4 mmol/L) [N