In-Training Exam Prep Emergency Medicine Question Sets #1-5 Second Edition
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In-Training Exam Prep Emergency Medicine Question Sets #1-5 Second Edition Editors Michael Gottlieb, MD Rochelle Zarzar, MD Philippe Bierny, BA From the ALiEM Chief Resident 5 PracticeIncubator Tests ASSOCIATE EDITORS Foreword Dorothy Habrat, DO We would like to thank the many medical students, residents, Margaret Sheehy, MD, MSc and attending physicians for their contributions to this book. Samuel Zidovetzki, MD We would also like to thank the Academic Life in Emergency Medicine group with special thanks to Derek Sifford for their Adaira Chou, MD, MEd (c) support and assistance with the creation of this book. Finally, Nikita Joshi, MD we would like to thank Dorothy Habrat, Margaret Sheehy, Samuel Zidovetzki, and Adaira Chou for all of their efforts in Michelle Lin, MD editing the first edition of this book. Michael Gottlieb, MD Published by Academic Life in Emergency Medicine San Francisco, California, USA Rochelle Zarzar, MD Second edition, November 2016 Philippe Bierny, BA Available for usage under the Creative Commons Attribution- NonCommercial-NoDerivs 3.0 Unported License Book cover image: Creative Commons Attribution 2.0 by Alberto G on Flickr.com ISBN: 978-0-9907948-8-2 1 Contributing Authors Layla Abubshait, MD Joseph Bradley, DO Ryan Duhe, MD Eddie Garcia, MD Central Michigan University University of Arizona Sinai Grace Hospital Rutgers University Helen Adams, MD Holly Caretta-Weyer, MD Sean Dyer, MD Stephen Gau, MD Oregon Health & Science University of Wisconsin Cook County Hospital Central Michigan University Carmen Alcala, MD Iris Chandler, MD Daniel Eggeman, MD Thomas H. Gildea, MD Cook County Hospital Yale University University of Illinois Stanford University Dina Al-Joburi, DO Aoko Crain, MD Peter England, MD Puja Gopal, MD Drexel University University of Chicago Mount Sinai Medical Center University of Illinois Annie Laurie Auden, MD Erin Dalka, MD Michelle Feltes, MD Stephen Gore, MD University of Illinois Cook County Hospital George Washington University University of Illinois Abdullah Bakhsh, MD Leah Davis, MD Liz Fierro, MD Stanislaw Haciski, MD Emory University University of Illinois Loma Linda University George Washington University Claudia Barthold, MD Brendan Devine, MD Brandon Firestone, MD Justin Hall, DO University of Nebraska Cook County Hospital UCLA-Olive View University of Nebraska Nicole Battaglioli, MD Kayla Donnawell, MD Jessica Folk, MD James Hassel, MD York Hospital Sinai Grace Hospital Cook County Hospital SUNY Downstate Maria Bevilacqua, MD Steve Ducey, MD Analysa Gallegos, MD Chris Heberer, DO University of Illinois University of Nebraska Hackensack University Central Michigan University 2 Amy Ho, MD Christie Lech, MD James S. Morrison, MD Megha Rajpal, MD University of Chicago New York University Mount Sinai Medical Center Mount Sinai Medical Center Angela Hou, BS Eric Lee, MD Sreeja Natesan, MD Zachary Risler, MD New York University Mount Sinai Medical Center Duke University Drexel University Kevin Hu, MD Andrew Little, DO Mary Naughton, MD Toni Riveros, MD Mount Sinai Medical Center Doctors Hospital University of Illinois Cook County Hospital Angela Hua, MD Alfred Liu, DO Shana Nelson, DO Daniel Robinson, MD Mount Sinai Medical Center University of Illinois University of Illinois University of Illinois Bilal Khan, MD Theresa Mead, DO Louisa Ng, MD Novneet Sahu, MD Cook County Hospital Central Michigan University University of Illinois Christiana Care Health Jeremy Kim, MD Kasebaoth Mekonnen, MD Morgan Oakland, MD Liz Samuels, MD Mount Sinai Medical Center Highland Hospital Thomas Jefferson University Brown University Jung Kim, MD Daniel Migliaccio, MD Patrick Olivieri, MD Audrey Sanford, MD Stony Brook University Stanford University St. Luke’s-Roosevelt Hospital University of Illinois Laura Kwoh, MD Shivani Mody, DO Gregory Patek, MD Kraftin Schreyer, MD University of Illinois Baystate Medical Center Louisiana State University Temple University Steven Lai, MD Pablo Moreno, MD John Rague, MD Sameed Shaikh, DO UCLA-Olive View University of Illinois Denver Health Sinai Grace Hospital 3 Jenna Shenk, DO Lindsay Taylor, MD Aria Health Sinai Grace Hospital Rachel Shively, MD Sean Thrush, DO Mount Sinai Medical Center Aria Health Sukhdeep Singh, MD Paul Trinquero, MD Baystate Medical Center Northwestern Kimberly Sokol, MD Anisha Turner, MD UC-Irvine Louisiana State University Jordan Spector, MD Gregory Wanner, DO Boston Medical Center Thomas Jefferson University Britni Sternard, MD Jordan Warchol, MD Louisiana State University University of Nebraska Noah Sugerman, MD Stephanie Wilsey, MD UCLA-Olive View Cooper University Victor Szeto, MD Fareen Zaver, MD University of Illinois George Washington University Emily Taub, MD Xiao Chi Zhang, MD Mount Sinai Medical Center Brown University 4 Board Review Questions 5 2. Which of the following populations is INCORRECTLY paired with Practice Test #1 its most likely infectious cause of osteomyelitis? 1. A 28-year-old female presents with lateral knee pain. She has no A. Children - Staphylococcus aureus past medical history and runs 20 miles per week. She has never had pain like this before. On exam, there is no medial or lateral B. Patients in developing countries - Mycobacterium tuberculosis joint line tenderness, however Ober’s test is positive. Her knee x- C. Patients with diabetes mellitus - Staphylococcal and Streptococcal species rays are normal. Which of the following is the most likely diagno- sis? D. Patients with human bite wounds - Streptococcal and anaerobic species E. Patients with sickle cell disease - Streptococcal species A. Baker's cyst B. Iliotibial band syndrome Click here for the correct answer. C. Lateral meniscal injury D. Pes anserine bursitis E. Popliteus tendonitis Click here for the correct answer. 6 3. A 22-year-old female presents to the Emergency Department com- 4. Which of the following is a component of the correct manage- plaining of dizziness for one day. She endorses three days of nasal ment of acute pancreatitis? congestion and rhinorrhea. This morning she awoke with con- stant, severe dizziness and decreased hearing in the left ear. She has never experienced anything like this before. Her vital signs are A. Give an H2 blocker to decrease secretin release by inhibition of unremarkable. Physical examination reveals normal tympanic gastric acid membranes without evidence of infection. Her neurologic exami- nation is significant only for rightward-directed horizontal nystag- B. Give glucagon in severe pancreatitis to directly suppress pancre- mus. What is the most likely diagnosis? atic exocrine secretion C. Keep the patient nothing by mouth for at least 48 hours before starting a clear liquid diet A. Acoustic neuroma D. Place the patient on an insulin drip for severe hyperglycemia B. Benign paroxysmal positional vertigo E. Replace calcium with calcium gluconate if ionized calcium is low C. Cerebellar infarct D. Labyrinthitis Click here for the correct answer. E. Meniere's disease Click here for the correct answer. 7 5. A 46-year-old female with past medical history of renal transplant Urinalysis with microscopy is positive for mild proteinuria but nega- presents with progressively worsening fatigue x 3 days. The trans- tive for leukocyte esterase, nitrites, or bacteria. Immunosuppressant plant was performed two months prior. The patient has been do- levels are normal. In addition to consulting the patient’s transplant ing well since the transplant until the onset of fatigue three days team, what is the next best step in the evaluation or management of ago. Her vital signs are within normal limits. Her physical exam is this patient? remarkable for bi-basilar rales and a well-healed incision site with- out erythema or fluctuance. The laboratory findings are provided below. A. Blood cultures and broad-spectrum antibiotics B. Doppler ultrasound of the kidney To d ay Two weeks ago WBC 9.8 8.3 C. High-dose glucocorticoids Hgb 9.7 10.1 D. Intravenous fluids Plt 143 132 E. Renal biopsy of donor kidney Na 140 142 Cl 102 104 K 4.9 4.2 Click here for the correct answer. CO2 22 22 BUN 33 24 Cr 2.8 2.0 8 6. A 42-year-old female with hypertension, hyperlipidemia, mi- 7. A 29-year-old male presents with dental pain and facial redness graines, and anxiety presents to the emergency department with for the past 4 days. Today, he began to notice double vision. On fever, diarrhea, and a headache. On physical examination, she is exam, he has extensive erythema along his right face, as well as ip- agitated, diaphoretic, and tachycardic. Her vital signs are other- silateral facial asymmetry and a cranial nerve 3 palsy. Which of wise normal. Her neurological exam reveals hyperreflexia and the following is the most likely etiology of his exam findings? rhythmic muscle spasms without rigidity. CT head and lumbar puncture are unremarkable. What is the most likely diagnosis? A. Cavernous sinus thrombosis A. Bacterial meningitis B. Diabetic neuropathy B. Malignant hyperthermia C. Ludwig's angina C. Neuroleptic malignant syndrome D. Optic neuritis D. Serotonin syndrome E. Vestibular abscess E. Substance abuse Click here for the correct answer. Click here for the correct answer. 9 8. A 5-year-old girl with a history of congenital hydrocephalus and a 9. A 55-year-old male presents to the emergency department com- ventriculoperitoneal (VP) shunt presents with irritability, nausea plaining of bilateral weakness with associated paresthesias of his and severe headache. The shunt was placed 3 years ago and has arms for the past 2 weeks. The weakness is progressively worsen- not been revised since. Her vital signs are unremarkable, and her ing, and now he is having trouble gripping objects. The patient physical examination is unrevealing. While awaiting neurosurgical had diarrhea one month prior, which took a week to resolve. On consultation, what is the next most appropriate step in the manage- physical exam, the patient is afebrile, with a respiratory rate of 22 ment of this patient? breaths per minute. He has 3 out of 5 strength in his bilateral up- per extremities with decreased upper extremity sensation and 1+ brachioradialis reflexes bilaterally.