Questions

Board Review Questions: April 2019

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 73-year-old man presents with painless intermittent gross hematuria. He smokes cigarettes daily and uses ibuprofen frequently for back pain. Urinalysis reveals 3+ blood and 1+ protein with 30 RBCs/hpf and no WBCs on microscopic examination. Which of the following disposition plans is most appropriate?
A. CT scanning of the abdomen and pelvis followed by urgent urology follow-up
B. Manual irrigation of the bladder by catheter until the urine is clear and then admission
C. Reassurance and consideration of prostate hypertrophy therapy
D. Urine culture and empiric antibiotic coverage for Escherichia coli

 

2.Which of the following findings is most suggestive of myocarditis?
A. Disproportionate tachycardia
B. Fever with night sweats
C. Paroxysmal nocturnal dyspnea
D. Pleuritic chest pain

 

3. A 52-year-old man presents by ambulance with shortness of breath and hoarseness, following a fire in an industrial plant. Examination reveals a very hoarse voice, difficulty speaking, occasional audible stridor, and significant wheezing in all lung fields. Vital signs are BP 102/54, P 108, R 28, T 37.1°C (98.8°F); SpO2 is 90% on room air. What is the next most appropriate step in the management of this patient?
A. Administer albuterol 5 mg by nebulizer
B. Administer decadron 10 mg IV
C. Initiate BiPAP
D. Perform immediate RSI

 

4. A 19-year-old man presents with his mouth open in a fixed position with his tongue protruding and his neck twisted to the side. He has had nausea, mild headache, vomiting, and diarrhea for 2 days, for which his primary care physician prescribed promethazine and loperamide. Vital signs are normal. What is the best next step in management?
A. Administer diphenhydramine
B. Administer tetanus immunoglobulin
C. Obtain a lateral soft tissue neck x-ray
D. Perform RSI 

 

5. A 72-year-old woman presents by ambulance following cardiac arrest. She received good quality chest compressions for about 10 minutes in the field and 2 rounds of defibrillation before return of spontaneous circulation. Paramedics established a supraglottic airway and started bag-mask ventilation. Bilateral coarse breath sounds were noted. Vital signs on arrival include BP 105/62 and P 87; oxygen saturation is 94%. Several minutes later, BP is 85/67, P is 114, and oxygen saturation drops to 83%. The monitor shows sinus tachycardia. The respiratory therapist says the patient is becoming increasingly difficult to ventilate. Breath sounds are present on the left but severely diminished on the right. What other new findings might be expected?
A. Distended right atrium and ventricle on ultrasound
B. Jugular venous distention and subcutaneous emphysema on examination
C. Muffled heart sounds and an enlarged, globular cardiac silhouette on chest x-ray
D. Significant respiratory variation in diameter of the inferior vena cava on ultrasound

 

 

1. The correct answer is A, CT scanning of the abdomen and pelvis followed by urgent urology follow-up.
Why is this the correct answer?
The presentation of an older patient with painless intermittent hematuria should prompt suspicion for a urinary tract carcinoma, most often bladder or renal cell cancer. Patients with this complaint should undergo CT imaging of the abdomen and pelvis, which is likely to reveal a complex mass in the kidneys if the patient has renal cell cancer. Bladder cancer, however, may not be detectable on CT in its early stages. Therefore, regardless of the imaging results, the patient should be urgently referred to a urologist for appropriate screening by cystoscopy and, if necessary, biopsy. Risk factors for bladder cancer include tobacco use, excessive analgesic use, radiation to the pelvis, exposure to cyclophosphamide, and occupational exposure to aromatic amines or benzenes. For patients in tropical areas, especially Africa, infection with Schistosoma haematobium is associated with an increased rate of bladder cancer. The strongest risk factors for renal cell cancer are tobacco use, obesity, and hypertension. 

 

Why are the other choices wrong?

 

  • Patients with large amounts of gross hematuria with visible clots are prone to develop a urinary obstruction from a blood clot in the urethra. Typically, a patient with a urinary tract structural abnormality or surgery who is taking anticoagulants can develop this complication. The intermittent, mild (only 30 RBCs/hpf) bleeding of the patient in this case is unlikely to cause an acute obstruction.
  • Painless intermittent hematuria with blood appearing at the conclusion of the stream can be caused by benign prostate hypertrophy. Although initiating therapy for prostate enlargement can be reasonable, patients with this complaint and multiple risk factors for neoplastic disease should undergo imaging and then be referred. Reassurance only is not the ideal management.
  • Older men with prostate enlargement and incomplete bladder emptying can develop UTIs, which present with hematuria and dysuria. They do not typically complain of painless, intermittent bleeding. Initiating antibiotic therapy and sending a urine culture may be reasonable for the patient in this case, but he should undergo advanced imaging first because of the high risk of cancer.

 

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:1326-1354.

 

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:609-613.

 

2. The correct answer is A, Disproportionate tachycardia.
Why is this the correct answer?
Myocarditis is an inflammatory condition that causes myocardial damage, usually as a result of infectious, immunologic, or toxin-mediated conditions. It can manifest as mild constitutional symptoms, moderate cardiopulmonary symptoms, or fulminant cardiopulmonary decompensation leading to death. The notable physical examination findings are low-grade fever, tachypnea, and tachycardia. Classically, the tachycardia is out of proportion to the fever. In most adult cases, the myocardial damage is thought to be autoimmune and triggered by a virus (most commonly Coxsackievirus) or other infections. In neonates and infants, injury to myocytes is believed to occur more often because of direct injury by the pathogen itself. The clinical manifestations of myocarditis usually begin days to weeks after the acute infection, especially when viruses are implicated as the cause. Only 50% of patients report a recent upper respiratory or GI viral type of infection. The initial symptoms are nonspecific and constitutional: low fever, fatigue, malaise, myalgia, and arthralgia. These mild symptoms are often the reason for initial misdiagnosis or delays in proper diagnosis of this condition. Cardiopulmonary symptoms such as chest pain and dyspnea are also commonly seen. The most common abnormalities on ECG are sinus tachycardia and nonspecific ST-segment or T-wave changes. Chest xrays may reveal signs of congestive heart failure (cardiomegaly, pulmonary vascular redistribution, interstitial edema, frank pulmonary edema). Close attention should be paid to the ABCs of resuscitation because patients with fulminant myocarditis can decompensate rapidly. The mainstay of treatment of myocarditis is primarily supportive with a focus on hemodynamic support and management of complications. 

 

Why are the other choices wrong?

 

  • A low-grade fever can be seen in patients who develop myocarditis, but it is not the most suggestive or classic finding of the disease. Fever with night sweats is characteristic of TB. In fact, only 50% of patients report a recent viral-type upper respiratory or GI infection.
  • Paroxysmal nocturnal dyspnea is a symptom seen in patients with decompensating heart failure: They wake from sleep to sit upright due to sudden increasing shortness of breath. Although patients with myocarditis can have paroxysmal nocturnal dyspnea with heart failure, it is not the most suggestive symptom of myocarditis.
  • Pleuritic chest pain is a common symptom of acute pericarditis but is less commonly associated with myocarditis. The progression of myocarditis involves necrosis of the myocardial cells with inflammatory cells leading to fibrosis. This does not lead to the irritation or pleuritic pain associated with pericarditis. 

 

REFERENCES
Pericarditis, pericardial tamponade, and myocarditis. In: Adams JG, Barton ED, Collings J, et al, eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Saunders; 2013.

 

Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:1106-1112. 

 

3. The correct answer is D, Perform immediate RSI.
Why is this the correct answer?
In this case, the patient has been exposed to a pulmonary irritant that is causing bronchospasm and stridor from laryngeal edema. Regardless of what the underlying irritating agent is, he requires immediate rapid sequence induction (RSI) and intubation because of his increasing laryngeal edema and the risk of developing ARDS. In particular, water-soluble irritants can irritate both the upper and lower airways, and if edema is present, early airway control is indicated. Symptoms of ARDS may not develop for 24 to 36 hours from these pulmonary irritants, but because of the stridor, direct visualization and control of the airway are warranted. 

 

Why are the other choices wrong?

 

  • Inhalation injury is the leading cause of death from burns, given the significant improvement in fluid management. Bronchospasm is a prominent symptom due to the particles in smoke and the edema from the inflammatory process. Albuterol is indicated as a potential stabilizing measure, but delaying definitive airway management to provide an albuterol treatment is not the right next step for this patient with stridor and impending airway closure.
  • Corticosteroids have not been shown to be effective at mitigating the symptoms this patient has, and even if they did have an effect, it would take hours.
  • The contraindications for BiPAP include upper airway obstruction that can be bypassed by endotracheal intubation (as in this case), facial deformity from trauma or other causes that do not allow seal of the mask, decreased respiratory effort from an altered level of consciousness, and vomiting or increased secretions. There is no role for BiPAP in this patient with upper airway stridor.

 

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:2036-2043.

 

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:1307-1310. 

 

4. The correct answer is A, Administer diphenhydramine.
Why is this the correct answer?
The presentation described in this case is an acute dystonic reaction secondary to the administration of the dopamine antagonist metoclopramide, so the patient should receive an antimuscarinic medication such as diphenhydramine. Complications from a single dose of a dopamine antagonist include akathisia (inability to sit still, restlessness), dystonia, and neuroleptic malignant syndrome. Acute dystonic reactions manifest with sustained, involuntary muscular contractions that are often localized to the head and neck. The contractions are often, but not always, static. Acute dystonic reactions typically occur soon after the offending drug is administered and respond rapidly to appropriate treatment. Characteristic physical findings, temporal association following administration of a dopamine antagonist, and rapid resolution of symptoms with treatment are helpful in distinguishing dystonic reactions from other more serious disorders.

 

Why are the other choices wrong?

 

  • Administering tetanus immunoglobulin would be correct if the patient had tetanus. The involuntary muscular contractions that occur with tetanus often involve the face but are typically recurrent and episodic and occur in response to trivial stimuli. In contrast, this patient has classic symptoms of an acute dystonic reaction: sustained, involuntary muscular contractions localized to the head and neck soon after being administered a dopamine antagonist (metoclopramide). These findings help distinguish an acute dystonic reaction from other more serious disorders.
  • Radiographic imaging is not necessary. The patient is experiencing an acute dystonic reaction and should be administered an antimuscarinic agent to reverse it.
  • An acute dystonic reaction often involves the head and neck and can manifest with signs that provoke concern for the airway. However, response to appropriate treatment with an antimuscarinic agent is rapid, and it should be administered before invasive interventions are considered.

 

REFERENCES
Hoffman RS, Howland MA, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies. 10th ed. New York, NY: McGraw-Hill; 2010:964-965.

 

Wolfson AB, Hendey GW, Ling LJ, et al, eds. Harwood-Nuss’ Clinical Practice of Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014:1451-1453.

 

5. The correct answer is B, Jugular venous distention and subcutaneous emphysema on examination.
Why is this the correct answer?
The risk of causing traumatic injuries while performing chest compressions is significant. These injuries include rib fracture, subsequent lung parenchymal damage, and a pneumothorax. When a patient is also given positive-pressure ventilation, intrapleural pressure increases, and a tension pneumothorax can result as air continues to enter the pleural cavity but is unable to escape. This patient is beginning to show evidence of a tension pneumothorax, specifically tachycardia, hypotension, hypoxia, increased central venous pressure, difficulty ventilating, and unilateral decreased or absent breath sounds. Other findings include jugular venous distention (from decreased right heart filling due to increased intrathoracic pressure), subcutaneous emphysema (from air being trapped beneath the skin), and tracheal deviation (from deviation of the mediastinum away from the involved side). If a tension pneumothorax is clinically suspected, the patient should be immediately stabilized by performing a needle thoracostomy at the second intercostal space at the midclavicular line, using a large-bore needle (at least 14 gauge). Alternatively, the needle can be placed laterally at the fourth or fifth intercostal space, which may allow for easier access to the intrapleural space, particularly in obese patients (when the needle is not long enough for an anterior approach). This intervention should not be delayed for radiographic confirmation.

 

Why are the other choices wrong?

 

  • Sonographic evidence of right heart distention suggests right heart failure from a primary cardiac process or obstructive source such as a PE. Although these conditions could be consistent with the patient’s vital sign abnormalities and should be in the differential diagnosis, they do not explain the unilateral decrease in breath sounds or difficulty in ventilating.
  • Muffled heart sounds and an enlarged globular cardiac silhouette in a patient with tachycardia and hypotension suggest pericardial effusion with cardiac tamponade. This can be caused by thoracic trauma but is more likely in penetrating trauma than blunt trauma. Although pericardial effusion can cause these vital sign abnormalities, it does not cause a unilateral decrease in breath sounds or difficulty in ventilating.
  • Respiratory variation in the diameter of the inferior vena cava can be seen when central venous pressure is low, as is the case in hypovolemia or distributive shock. In this case, central venous pressure is likely elevated because the right heart cannot expand and fill properly due to the high intrathoracic pressure. Instead, the effect would be distention of the inferior vena cava and lack of variability throughout the respiratory cycle.

 

REFERENCES
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. St. Louis, MO: Elsevier; 2014:437-440.

 

Tintinalli JE, Stapczynski JS, Ma OJ, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2012:1750-1752.

Related Articles

Sounding the Bowel

Sounding the Bowel Using Point-of-Care Ultrasound in Small-Bowel Obstruction Case 1. A 72-year-old male with no past medical history presents to the ED with two days of vomiting and severe abdominal

Why Does EMRA Membership Matter?

Why Does EMRA Membership Matter? Hey there EMRA! This is my first letter to you as this year's president, and I honestly could not be more excited to write it. EMRA is an incredible organization. We