PaEasy Emergency Medicine,
Emergency Medicine EOR Practice,
Emergency Medicine EOR Exam, ER
Final, ER
A 59-year-old woman presents to the accident and emergency department by ambulance
with second- and third-degree burns to her head and neck, and the anterior surfaces of her
upper extremities, right leg, and trunk including her genital area.
Question
Which of the following represents a reasonable estimation of the extent of her burns?
Answer Choices
1 36%
2 37%
3 46%
4 45%
5 55% - correct answer-The correct answer is 55%. This estimation is based on the "rule of
9s". Body surface area is estimated at 9% for each arm, the head and neck, anterior surface
of upper torso, anterior surface of lower torso, posterior surface of upper torso, posterior
surface of lower torso, anterior surfaces of each leg, posterior surfaces of each leg and an
additional 1% for the groin area for a total of 100%. In this case, 9% for her head and neck,
9% for the anterior surface of each arm, 9% for the anterior surface of her right leg, 9% for
her anterior upper torso, 9% for her anterior lower torso, and 1% for the genital area for a
total of 55%.
The other answers are incorrect using the estimation by the "rule of 9s".
A 45-year-old man presents with hematemesis. He has had 2 episodes of vomiting
'coffee-ground'-appearing material; the vomiting began 45 minutes prior to presentation.
Additionally, he reports passing black, sticky stools for the past 3 or 4 days. Past medical
history is positive for occasional headaches; they have been coming more frequenly lately.
Social history reveals alcohol use (1 case of beer each weekend) and tobacco (1 pack per
day). Medications include ibuprofen as needed for headaches; he has been taking 800 mg 3
times a day for the past week. You place a nasogastric tube and find bright red blood that
fails to clear with saline irrigation. Hemoglobin is 8.9 g/dL. Evaluation of his blood pressure
and pulse reveals orthostatic changes that resolve with an intravenous fluid bolus of 500 cc
of Lactated Ringer's solution. What should you do next?
Answer Choices
1 Transfuse 2 units of packed red blood cells an - correct answer-refer for emergency
endoscopy
He should be referred for an emergency upper endoscopy.
,This patient is most likely bleeding from a gastric ulcer. His recent NSAID use, as well as his
alcohol and tobacco habits, make him at risk for peptic ulcer disease. His symptoms of
melena and hematemesis, along with his anemia, make the diagnosis quite straightforward.
It appears that this patient is still actively bleeding based on the results of the nasogastric
tube irrigation; therefore, the priority should be getting the ulcer to stop bleeding. Upper
endoscopy should be performed so that the bleeding site can be identified and treated with
electrocautery, coagulation, or injection of epinephrine or a sclerosing agent. If the bleeding
cannot be stopped with endoscopic interventions, angiographic embolization should also be
tried. If these interventions do not succeed, the patient has rapid deterioration, or if he
requires more than 6 units of blood in a 24-hour period, then emergency surgery may be
indicated.
The other choices are not the best options for immediate management. This individual
cannot be followed simply with transfusions and serial CBC's because he appears to still be
actively bleeding.
Helicobacter pylori infection may very well be playing a part in the etiology of this man's
ulcer, but evaluation for H. pylori can be done with a biopsy at the time of his endoscopy; it
will not help in his immediate management.
A barium esophagram will not identify actively bleeding ulcers and cannot treat active
bleeding.
While NSAID, alcohol, and tobacco use may have precipitated this man's GI bleed,
counseling about his use of these substances will not sufficiently treat his immediate bleed.
A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked
swelling is noted externally to the left eye. There was no loss of consciousness. Upon
physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is
noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate
an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this
information, what is the most likely diagnosis?
A Zygomatic arch fracture
B Orbital blowout fracture
C Le Fort I fracture
D Le Fort II fracture
E Le Fort III fracture - correct answer-orbital blow out fracture
B Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus
and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling
of the infraorbital nerve. A Le Fort I fracture describes a transverse fracture separating the
body of the maxilla from the pterygoid plate and nasal septum. A Le Fort II fracture describes
a pyramidal through the central maxilla and hard palate. Movement of the hard palate and
nose occurs, but not the eyes. A Le Fort III fracture describes a craniofacial disjunction,
wherein the entire face is separated from the skull due to fractures of the frontozygomatic
,suture line, across the orbit and through the base of the nose, and ethmoids. The entire face
shifts, with the globes held in place only by the optic nerve.
What is the most common ECG abnormality in patients with a pulmonary embolism (PE)?
A Atrial fibrillation
B Sinus tachycardia
C Ventricular ectopy
D Sinus bradycardia - correct answer-sinus tachycardia
B In most cases, sinus tachycardia is the only abnormality in patients with a PE. You may
also find some ECGs that will have non-specific ST-T wave changes. Sinus bradycardia and
AV blocks are not common findings that are associated with PE.
In the emergency department, you are asked to evaluate a 77-year-old man with a history of
HTN who had a syncopal episode while chasing after his dog. He admits to recent episodes
of chest discomfort, also associated with activity, as well as dyspnea at lower levels of
activity including walking up one flight of stairs. On physical exam, a grade III/IV
crescendo-decrescendo systolic ejection murmur can be heard best over the right upper
sternal border. His EKG demonstrates NSR @ 80 bpm, with evidence of left ventricular
hypertrophy. His troponin levels are negative for ischemia. What is the next most appropriate
test or procedure?
A Echocardiography
B VQ scan
C CT scan of the head
D Serum D-dimer levels - correct answer-echo
A This patient exhibits all the signs of progression of aortic stenosis, thus echocardiography
is the next most appropriate test. A determination of severity can then be made, with
possible cardiac catheterization if severe aortic stenosis is suspected, in preparation for
surgical intervention if necessary. A VQ scan is appropriate if pulmonary embolism were
suspected. A CT scan of the head could be considered if a head injury was suspected, but
would not be the next step in the management of this patient. Serum D-dimer levels might be
used to rule out pulmonary embolism, although it is a fairly nonspecific test. An MRI of the
heart is not considered standard of care for aortic stenosis
A 56-year-old male, with history of hyperlipidemia and non-insulin-dependent diabetes
mellitus (NIDDM) presents to the emergency department with a history of increasing
peripheral edema over the past week. On examination he is noted to have periorbital,
scrotal, and +2 pretibial edema. His lungs are CTAB. He denies any chest pain or shortness
of breath. Urine dipstick reveals 4+ protein. Urine microscopic reveals Maltese crosses
consistent with lipiduria. Labs include a decreased serum albumin of 2 g/dl, decreased total
protein of 5.5 g/dl, and normal glomerular filtration rate (GFR). What is the most likely
diagnosis?
A pyelonephritis
B congestive heart failure (CHF)
C nephrotic syndrome
D prostatitis - correct answer-Nephrotic syndrome
, C The correct answer is (C). This patient has typical symptoms of nephrotic syndrome,
which includes significant proteinuria, hypoalbuminemia, and typical presentation of edema.
He also has a history of hyperlipidemia and laboratory findings of lipiduria, which is also
common in nephrotic syndrome. Furthermore, his history of diabetes mellitus is also a
potential cause of nephrotic syndrome. Pyelonephritis and prostatitis would present with
urine WBCs and is not consistent with the laboratory findings or edema. CHF would more
likely present with dyspnea, rales on exam, and peripheral edema but would unlikely involve
the periorbital area. DVT would likely present with unilateral swelling of the LE, and
discomfort and is not consistent with the laboratory findings above.
Out of all cervical vertebrae, which two are responsible for the greatest amount of rotation?
A C1 & C2
B C2 & C3
C C3 & C4
D C4 & C5
E C5 & C6 - correct answer-C1 & C2
A Approximately 50% of cervical rotation takes place between the C1 (atlas) and C2 (axis)
vertebrae. These first two cervical vertebrae have a different shape from the other cervical
vertebrae that allow for this greater range of motion. The remaining 50 % of cervical rotation
is split fairly evenly between the remaining vertebrae. Approximately 50 % of flexion and
extension occurs between the occiput at the base of the skull and C1 with the remaining
50% distributed fairly evenly between the remaining vertebrae with a slightly higher
percentage occurring at the C5 & C6 level.
A 15-year-old boy suddenly collapses on the basketball court; his sports physical conducted
at the beginning of the year did not elicit any abnormal findings. Basic life support initiated at
the scene, however, is unsuccessful in resuscitation. Which of the following is the most likely
etiology of his sudden death?
A mitral valve prolapse
B surgically corrected aortic stenosis
C hypertrophic cardiomyopathy
D rheumatic heart disease - correct answer-hypertrophic cardiomyopathy
C Hypertrophic cardiomyopathy in adolescence is typically due to familial hypertrophic
cardiomyopathy with an incidence of 1:500. Many patients are asymptomatic until a sporting
event, which may cause symptoms, specifically sudden cardiac death. Examination may
demonstrate a palpable or audible S 4 , an LV (left ventricular) heave, systolic ejection
murmur (may need to stimulate cardiac activity), and/or a left precordial bulge.
Echocardiography is the gold standard for diagnosis but family history should be assessed.
Stress testing is indicated to assess for ischemia and arrhythmias. Strenuous activities are
prohibited for these patients. The other cardiomyopathies (dilated and restrictive) are next
but are not as common. Congenital structural abnormalities of the coronary arteries are the
next most common cause. Valvular disorders, including surgically repaired aortic stenosis,
are typically not causes of sudden death, but these patients should be screened for
symptoms and stress tested as necessary.
