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SAEM 241 – 390 /150 Questions And Answers (A+)
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SAEM 241 – 390 /150 Questions And Answers (A+)Quiz :A 32 year old male, intravenous heroin abuser, presents with a one-day
history of mid-back pain, progressive weakness of his legs, and an inability to
urinate. He has a temperature of 38.3° C (100.8° F). On exam, absent patellar
deep tendon reflexes are noted, he cannot stand or walk, a distended bladder is
palpable, and he has tenderness to palpation over his T10 and T11 vertebrae.
Which of the following is not an acceptable next step?
A. MRI of the spine
B. Analgesia
C. Foley catheter to drain the bladder
D. Hospital admission for neurosurgical consultation in the morning
E. Antibiotics to cover a broad spectrum of organism - √Answer :D. Hospital
admission for neurosurgical consultation in the morning
he answer is D. A spinal epidural abscess is a neurosurgical emergency, with
the outcome being dependent on the speed of diagnosis and surgical
decompression. Consequently, urgent neurosurgical evaluation is required.
Although an uncommon disease, intravenous drug abuse, diabetes mellitus,
chronic renal failure, and immunosuppression are risk factors for its
development. Antibiotics to cover Staph. aureus, the most common cause, gram
negative bacteria, and anaerobes are needed. Bladder decompression for
symptomatic relief is important, as is analgesia
Quiz :Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral nervous
system.
B. A myasthenic crisis involves an exacerbation of weakness, especially of
respiratory muscles, often necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The "atropine test" is diagnostic when 0.5 mg of atropine is given
intravenously and the patient's symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them. - √Answer :B.
A myasthenic crisis involves an exacerbation of weakness, especially of
respiratory muscles, often necessitating intubation.
The answer is B. Myasthenia gravis is an autoimmune disease that results from
antibodies directed against the acetylcholine receptor (AChR) at the
neuromuscular junction. Destruction of the AchR leads to fewer receptors
available to bind acetylcholine, with a resulting muscle weakness. Ocular
symptoms are usually the first to occur, with diplopia and ptosis being common.
The disease typically worsens as the day progresses because of repeated use of
the muscles involved. Diagnosis is made with the tensilon test, where
,edrophonium is given and the patient's symptoms are observed to transiently
improve. The administration of atropine is not a diagnostic test. Cooling helps
the symptoms and heat exacerbates them. A myasthenic crisis is a feared
complication. Patients develop respiratory failure requiring intubation,
frequently for prolonged periods.
Quiz :A 36 year old woman on chronic cyclosporine treatment for bilateral lung
transplantation visits the emergency department complaining of extreme
headache, nausea and vomiting. Her exam is notable for BP 239/165, normal
cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG
showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to
acutely control her blood pressure, which of the following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing afterload
and would not be useful in this setting
B. Nitroprusside would be contraindicated in this patient due to its relatively
slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac output
D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade -
√Answer :C. Nitroglycerin decreases BP by decreasing venous return and
cardiac output
The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an
extremely rapid onset of action. Although rare, long-term nitroprusside
treatment may lead to cyanide toxicity in renal failure patients secondary to the
presence of cyanide as an intermediate metabolite. A history of long-term
cyclosporine treatment suggests this patient likely has some degree of renal
insufficiency.
Quiz :A 14 year-old child presents to the emergency department. His blood
pressure is 210/140. He complains of a headache, nausea, and recent blurred
vision. Of the following choices, the best goal for lowering his mean arterial
blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour - √Answer :C. 25% in the first hour
The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or
greater, defines hypertensive urgency. With end-organs symptoms, as above,
the presumptive diagnosis is hypertensive emergency. In hypertensive
emergencies, the goal is to decrease mean arterial blood pressure by 10-25%
,within the first hour, thereby alleviating symptoms while not compromising
cerebral perfusion.
Quiz :A 2 year old male is brought to the ED in status epilepticus. He has not
responded to adequate doses of benzodiazepines. Which of the following
possible causes of a seizure must be evaluated for in the emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for - √Answer :E. All of
the above possible causes must be evaluated for
The answer is E. Seizures have a number of secondary causes, which must be
identified and corrected before the seizure will end. Hypoxemia and
hypoglycemia are easily detected by pulse oximetry and bedside measurement
of glucose, respectively. Toddlers may ingest many toxins accidentally, such as
INH, tricyclic antidepressants, and camphor. Trauma must be considered, too,
including child abuse. Sickle cell disease, SLE, and leukemia are some of the
medical causes of seizures and status epilepticus.
Quiz :Shock is defined as:
A. tachycardia
B. hypotension
C. altered mental status
D. hypovolemia
E. inadequate tissue and organ perfusion - √Answer :E. inadequate tissue and
organ perfusion
The answer is E. Shock is defined as inadequate tissue and organ perfusion.
Hypovolemia, tachycardia, hypotension and altered mental status are all signs
and symptoms of shock.
Quiz :The four classic types of shock include all of the following EXCEPT:
A. Distributive
B. Obstructive
C. Hypovolemic
D. Cardiogenic
E. Traumatic - √Answer :E. Traumatic
The answer is E. Shock is divided into four mechanistic classifications:
hypovolemic (inadequate circulatory volume); cardiogenic (inadequate cardiac
pump function); distributive (maldistribution of blood flow); and obstructive
, (extracardiac obstruction to blood flow). Trauma may lead to various shock
states (usually hypovolemic, but also distributive in the case of pericardial
tamponade), but there is no "traumatic" shock subtype.
Quiz :An early sign and symptom of shock is:
A. Cyanosis
B. Decreased respiratory rate
C. Tachycardia
D. Hypotension
E. Bradycarda - √Answer :C. Tachycardia
The answer is C. Hypotension is a late finding in shock; narrowing of pulse
pressure tends to occur earlier (and is due to increased sympathetic tone). Early
signs of shock include tachycardia and increased respiratory rate, which occur
as the body attempts to maintain perfusion.
Quiz :All patients with shock should receive as the first priority:
A. Supplemental oxygen
B. Packed red blood cells
C. Trendelenburg positioning
D. Antibiotics
E. Intravenous fluids - √Answer :A. Supplemental oxygen
The answer is A. The fundamental issue in shock is tissue hypoperfusion and
hypoxia. All patients in shock should receive supplemental oxygen initially.
Steps to improve oxygenation range from nasal cannula to endotracheal
intubation.
Quiz :As compared to adults, children with shock usually:
A. Have more reliable signs and symptoms
B. Have similar epidemiology (i.e. causes for shock states)
C. Are able to maintain their blood pressure better
D. Have different treatment priorities
E. Do not need specialized care - √Answer :C. Are able to maintain their blood
pressure better
The answer is C. While the treatment priorities for pediatric and adult shock are
similar, there are some differences; thus, a specialized approach to care is often
required. The epidemiology is different, since in children shock tends to be
caused by trauma and infections. Children's signs and symptoms may be more
subtle than those of adults in shock, rendering the physical examination less
reliable in pediatrics. One of the key differences is a child's ability to maintain
blood pressure despite presence of shock.
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