Questions

Board Review Questions: October 2018

PEER (Physician’s Evaluation and Educational Review in Emergency Medicine) is ACEP’s gold standard in self-assessment and educational review. These questions are from PEER, updated continually on its digital platform. Order PEER to prepare!

1. A 31-year-old woman presents with severe pelvic pain 1 week after delivering a healthy baby. She passed a large, foul-smelling clot just before arrival. She reports chills. Vital signs include BP 115/74, P 84, T 38°C (100.4°F). Which of the following is a risk factor for the development of this condition?
A. Advanced maternal age
B. Cesarean delivery
C. External fetal monitoring
D. Precipitous delivery

2. Which of the following conditions can falsely lower a B-type natriuretic peptide level?
A. Advanced age
B. Obesity
C. Pulmonary disease
D. Renal disease

3. A 56-year-old woman presents after an episode of near syncope. Vital signs are BP 93/40, P 104, R 20, T 36.1°C (97°F); Spo2 is 95% on room air. Blood glucose is 94. She recently received a diagnosis of idiopathic pulmonary hypertension; an ECG is unchanged from her most recent one. She denies fever, chest pain, and recent illness. Her dyspnea is slightly increased from baseline. Auscultation of the chest yields a loud split S1 but no murmurs. There is no jugular venous distention, hepatomegaly, or lower extremity swelling. Lungs are clear. Chest x-ray shows moderate cardiomegaly. After placing the patient on supplemental oxygen, what is the next treatment goal?
A. Decrease left ventricular afterload
B. Decrease pulmonary artery pressures
C. Maintain adequate right ventricular filling pressure
D. Maintain pulmonary vascular resistance

4. In the setting of chronic digoxin poisoning, which of the following findings is the best indication for administering digoxin-specific antibody fragments?
A. Bidirectional ventricular tachycardia
B. Serum digoxin concentration 2.4 ng/mL
C. Serum potassium 5.6 mEq/L
D. Vomiting

5. A 26-year-old man presents with pain, swelling, and ecchymosis of the right eye. He says he was attacked the night before and struck in the face with an unknown object. On examination, his orbital rim is tender to palpation. Which of the following additional signs would be most concerning for an orbital blowout fracture?
A. Ecchymosis
B. Enophthalmos
C. Exophthalmos
D. Photophobia

Answers: 1. B; 2. B; 3. C; 4. A; 5. B


Answers

1. The correct answer is B, Cesarean delivery.

Why is this the correct answer?
This patient is suffering from endometritis, a polymicrobial infection of the uterus following delivery. Risk factors for its development include retained products of conception or placenta, cesarean delivery, young maternal age, premature rupture of membranes, frequent vaginal examinations, and the use of intrauterine monitoring devices. The history of a cesarean delivery is the risk factor most frequently associated with endometritis, which might be associated with a concomitant wound infection. Complications of endometritis include parametrial abscesses, pelvic abscesses, and septic thrombophlebitis of the pelvic veins. Obese and diabetic patients are at risk for developing necrotizing fasciitis of the pelvis if their infections are not controlled aggressively. Endometritis typically begins 3 to 5 days following delivery and is characterized by foul lochia, fever, pelvic pain, and uterine tenderness. The ultrasonographic examination can be normal, or it can show a thickened endometrium with increased vascularity. In severe cases, gas might be identified within the uterus. In all but the mildest of cases, these patients should be treated as inpatients with intravenous, broad-spectrum antibiotics (typically, third-generation cephalosporins or clindamycin plus gentamicin).

Why are the other choices wrong?

  • Younger maternal age and lower socioeconomic status are risk factors for endometritis.
  • Internal fetal monitors, any instrumentation, and repeated digital examinations are risk factors for the development of endometritis.
  • Any condition that prolongs the period of exposure of the unprotected endometrium to the vaginal canal can lead to endometritis, such as the premature rupture of membranes and a prolonged period of active labor.

REFERENCES
Adams JG, Barton ED, Collings JL, et al, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Elsevier; 2013:1061-1068.e1.

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012: 644-652.

 

2. The correct answer is B, Obesity.

Why is this the correct answer?
The B-type natriuretic peptide (BNP) is a counter-regulatory hormone produced by cardiac myocytes in response to increased end-diastolic pressure and volume, as occurs in the setting of heart failure. ProBNP is released into the circulation and cleaved into biologically active BNP and an inactive N-terminal fragment, NT-proBNP, which has a half-life up to six times that of BNP. Patients with a high body mass index tend to have lower levels of BNP and NT-proBNP. Plasma levels of BNP and NT-proBNP correlate with the degree of left ventricular overload, severity of clinical heart failure, and both short-term and long-term cardiovascular mortality rates. Acutely dyspneic patients with BNP lower than 100 pg/mL or NT-proBNP levels lower than 300 pg/mL are very unlikely to have acute decompensated heart failure, whereas those with BNP levels higher than 500 pg/mL or NT-proBNP levels higher than 1,000 pg/mL are very likely to have it. Intermediate levels must be interpreted in the clinical context.

Why are the other choices wrong?

  • Patients of advanced age tend to have higher levels of BNP and NT-proBNP, not lower.
  • Patients with pulmonary disease resulting in cor pulmonale and patients with right heart stretch from PE have slightly elevated BNP levels.
  • As with advanced age, renal insufficiency can falsely elevate BNP slightly; any more significant increases in BNP are the result of heart disease.

REFERENCES
Adams JG, Barton ED, Collings J, et al, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Saunders; 2013: 476-486.

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014: 1075-1090.

 

3. The correct answer is C, Maintain adequate right ventricular filling pressure.

Why is this the correct answer?
Maintaining high right ventricular filling pressures by ensuring adequate intravascular volume status is the mainstay of emergency therapy for pulmonary hypertension; parenteral fluid hydration with normal saline is recommended. Primary, or idiopathic, pulmonary hypertension is rare. It often presents as exercise intolerance, syncope or near syncope, dyspnea on exertion, and shortness of breath, making it difficult to distinguish from a variety of other more common cardiopulmonary disease processes such as asthma, COPD, left ventricular heart failure, and PE. Syncope occurs in up to half of patients with pulmonary hypertension and is typically related to dysrhythmia. There are many secondary causes of pulmonary hypertension, most notably congenital heart disease with unrepaired cardiac shunt.

Why are the other choices wrong?

  • Decreasing afterload through diuresis is beneficial in left-sided heart failure and, judiciously, in right-sided heart failure, but in this patient without clear evidence of right-sided heart failure and pulmonary hypertension, fluid resuscitation is indicated.
  • Medications such as prostacyclin analogues and phosphodiesterase inhibitors can decrease pulmonary artery pressure; however, this should be initiated and managed by or in collaboration with a cardiologist. The initial management of pulmonary hypertension should focus on intravascular volume resuscitation to maintain right ventricular filling pressure and ensure adequate cardiac output.
  • There are no benefits to maintaining pulmonary artery resistance, and the emergency physician should focus on maintaining adequate cardiac output by maintaining preload.

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014: 135-141; 1075-1090.

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012: 409-412.

 

4. The correct answer is A, Bidirectional ventricular tachycardia.

Why is this the correct answer?
Digoxin-induced ventricular tachycardia is life-threatening and should be managed by administration of digoxin-specific antibody fragments. Bidirectional ventricular tachycardia is an unusual rhythm caused by toxicity from very few agents, digoxin being one. Digoxin inhibits the Na+-K+-ATPase pump, leading to increased intracellular calcium concentrations. In toxicity, this inhibition causes increased myocardial automaticity and excitability and/or vagally mediated bradycardic and conduction problems. Ventricular tachycardia, ventricular fibrillation, a wide variety of bradyarrhythmias, and various degrees of heart block can all be seen with digoxin toxicity. Digoxin toxicity can cause nearly every arrhythmia, with the exception of rapidly conducted atrial tachyarrhythmias (such as atrial fibrillation with rapid ventricular response).

Why are the other choices wrong?

  • In the setting of chronic digoxin toxicity, the clinical status of the patient, predominantly the presence or absence of cardiac arrhythmias, not the digoxin concentration or hyperkalemia, should be the principal determinant of whether to administer digoxin-specific antibody fragments. In acute poisoning, the presence of hyperkalemia and very elevated digoxin concentrations (>10 ng/mL) can guide the administration of digoxin-specific antibody fragments before arrhythmias develop.
  • The presence of hyperkalemia in chronic digoxin poisoning typically reflects underlying renal insufficiency and corresponding decreased potassium elimination. Renal insufficiency with the corresponding decreased clearance of digoxin is a common cause of chronic digoxin toxicity. In acute poisoning, hyperkalemia reflects poisoning of Na+-K+-ATPase, precedes the onset of arrhythmias, and is an indication for digoxin-specific antibody fragments, but hyperkalemia alone is not an indication to administer the antidote in chronic digoxin poisoning.
  • Vomiting is a symptom, albeit a very nonspecific one, of digoxin toxicity. Vomiting alone is not an indication to administer the antidote.

REFERENCES
Hoffman RS, Howland MA, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill; 2010: 898-899.

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012: 1284-1287.

 

5. The correct answer is B, Enophthalmos.

Why is this the correct answer?
Enophthalmos occurs when the globe is posteriorly displaced within the orbit and a “sunken eye” can be seen on physical examination. This can occur as the result of an orbital blowout fracture of the affected eye or a loss of orbital contents. Another concerning physical examination finding for an orbital blowout fracture is binocular diplopia, which can occur due to extraocular muscle entrapment in the fracture. An additional concerning examination finding is infraorbital numbness of the cheek or lip due to infraorbital nerve involvement. Subcutaneous emphysema can also occur and can indicate a concomitant sinus fracture. Obvious displacement of the globe or a palpable step-off of the orbit is also indicative of a fracture. A maxillofacial CT scan should be obtained if there is any concern for an orbital or facial fracture on physical examination.

Why are the other choices wrong?

  • Ecchymosis can occur with or without a fracture. The periorbital tissues are very susceptible to distention that can occur with blunt trauma, so swelling and ecchymosis are common even when a fracture is not present. Ecchymosis is not specific for an orbital blowout fracture.
  • Exophthalmos occurs when the globe is displaced anteriorly. This can occur with a retrobulbar hematoma, or it can occur insidiously due to nontraumatic causes such as an orbital tumor or Graves disease. Exophthalmos is not specific for an orbital blowout fracture.
  • Photophobia can occur for many reasons. The most common reason in trauma is traumatic iritis, resulting in ciliary spasm.

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014: 909-910.

Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014: 160-161, 176-179.

Related Articles

Board Review Questions: June 2014

EM Resident 06/13/2014
Board Review Questions: June 2014 Provided by PEER VIII. PEER (Physician's Evaluation and Educational Review in Emergency Medicine) is ACEP's Gold Standard in self-assessment and educational review.

Board Review Questions: October 2014

EM Resident 10/21/2014
Board Review Questions: October 2014 Provided by PEER VIII. PEER (Physician's Evaluation and Educational Review in Emergency Medicine) is ACEP's gold standard in self-assessment and educational revie
CHAT NOW
CHAT OFFLINE