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SAEM test missed questions and answers already passed 1 An elderly female presents to the emergency department with vomiting and abdominal pain. She has a history of a cholecystectomy about 5 year... s ago. On exam, she is significantly uncomfortable and nauseated. Lung and cardiovascular exam is normal. Abdominal exam shows diffuse tenderness, some distention with tympany, and an empty rectal vault. Vital signs are: HR 102 BP 145/86 RR 24 SpO2 96% RA Temp 99.9F You order an acute abdominal series, which is read by the radiologist as "nonspecific bowel gas pattern, no perforation." What is your management plan? A. IV fluids, pain medication, consult vascular surgery for serial exams B. IV fluids, pain medication, CT abdomen C. IV fluids, pain medication, consult vascular surgery D. IV fluids, pain medication, discharge if improved ✔✔B A 70 year old female presents to the Emergency Department with 3 days of intermittent rightsided abdominal pain. The patient has had associated symptoms of nausea and vomiting. On physical examination, the patient is exquisitely tender in the right side of the abdomen with mild distension. Xray films of the abdomen show pneumobilia and multiple air-fluid levels. What of the following is the most likely diagnosis? A. Ascending cholangitis B. Gallstone ileus C. Cecal volvulus D. Acalculous cholecystitis ✔✔B A 38 year old man with sudden severe central abdominal pain for the last hour presents to the ED. He is ill appearing, febrile and has a rigid board-like abdomen. A bedside ultrasound reveals no fluid collections or aneurysm and a plain upright portable chest xray reveals no pneumoperitoneum. Your surgical consultant wants to take the patient for a laparotomy. What percentage of patients have no pneumoperitoneum who go to the operating room with this entity: A. 10% B. 25% C. 50% D. 75% ✔✔C A 25 year old previously healthy male presents 7 hours after a rattlesnake bite to his right lower leg. You confirm it is a pit viper based on a photo taken by his friend. Exposing the affected leg reveals a grossly edematous, tender, ecchymotic and tense calf with small bullae forming near the bite. There are preserved pulses and paresthesias in his foot. There is intense pain with passive ranging of the ankle. Which of the following is the most appropriate management of this patient's condition? A. Immediate decompressive fasciotomy in the OR, along with administration of FabAV antivenin B. Immediate application of a proximal tourniquet to prevent systemic spread of toxin, FabAV antivenin, and surgical consult in the Emergency department C. IV mannitol and elevation of the extremity with ICU admission D. Immediate administration of the FabAV antivenin with ICU admission and surgical consult ✔✔A An unconscious 8 year old boy was pulled out of a freshwater lake. It was unknown how long he had been submerged in the water or how much water he had aspirated. The water temperature was 20C at the time he was pulled out of the water. He was found to be hypoxic upon removal and quickly given 100% oxygen. Which of the following is correct with regards to this drowning scenario? A. Adults develop hypothermia more quickly than children in cold water B. Initial treatment of fresh water and salt water drowning are different C. Significant ingestion of freshwater will cause hypernatremia D. Hypoxia is based on volume of water aspirated and not water content ✔✔D A 65 year old male with a history of COPD presents to the emergency department with increasing dyspnea, rhinorrhea, cough, and sputum production over the last three days. He denies fever or chest pain. His last acute health visit was 6 months ago. His vital signs are as follows: BP 135/75, HR 85, RR 19, SpO2 95%, Oral temp 98.0 °F. His exam is significant for a diffuse expiratory wheeze and prolonged expiratory time. His chest X-ray and EKG are unchanged from baseline and your patient responds to your ED medical therapy. In addition to an inhaled beta agonist your patient's recommended outpatient pharmacotherapy includes: A. A mucokinetic such as guaifenesin B. A methylxanthine such as theophyline C. A high-dose oral corticosteroid such as prednisone D. An antibiotic such as doxycycline ✔✔D A 39-year-old diabetic man with hypertension and cirrhosis, presents to the ED with an infected tattoo resulting in cellulitis encompassing his entire left arm and forearm. His vital signs are 40.0 C, pulse 140, respirations 28, blood pressure 120/50. His last admission reveals his usual blood pressures to be systolic values of 180-190. To which level of care should he be admitted? A. Intensive care unit with IV antibiotics B. Observation unit until vital signs normalize and can tolerate oral antibiotics C. Discharge home with daily ED wound checks and oral antibiotics D. General medical/surgical ward with IV antibiotics ✔✔A A 17 year old male presents to the emergency department complaining of excruciating groin pain that woke him from sleep. This pain is associated with nausea and radiation into the abdomen. On examination his right testicle is firm, exquisitely tender, and there is unilateral absence of the cremasteric reflex. A bedside diagnostic and therapeutic maneuver would be to: A. Rotate his right testicle in a medial to lateral rotation (540 degrees) B. Perform a bedside scrotal ultrasound C. Transilluminate the right testicle D. Elevate the left testicle ✔✔A A child presents after falling off the monkey bars onto an outstretched hand. What type of pediatric radius fracture is seen in the Figure? [image] A. Salter I B. Salter II C. Salter III D. Salter IV E. Salter V ✔✔The correct answer is B. The Salter-Harris classification system describes a pediatric fracture and its location relative to the growth plate. Growth plate injuries are important because injury to them can cause arrest of that bone's growth. Salter I fractures extend through the growth plate only. Salter II fractures extend through the growth plate and the metaphysis of the bone (above the growth plate) as seen in the radiograph. Salter III fractures extend through the growth plate and the epiphysis (below the growth plate). Salter IV fractures involve both metaphysis and epiphysis and travel through the growth plate. Salter V fractures are those in which epiphysis and metaphysis are pushed onto one another, obscuring the growth plate. A patient (see Figure) presents with right shoulder pain after a wrestling match. He has difficulty elevating his arm. What is the most likely diagnosis? [image] A. acromio-clavicular separation B. clavicle fracture C. deltoid rupture D. humerus dislocation E. proximal humerus fracture ✔✔The correct answer is A. Acromioclavicular joint injuries are usually the result of a direct blow on the scapula while the arm is adducted. This causes injury by driving the scapula downward and medially. Most can be treated conservatively with sling immobilization. More severe injuries require close orthopaedic follow up (within 72 hours). -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 591-592. What other injury(s) may be associated with calcaneal fracture after a fall? A. C-1 fracture B. closed head injury C. lumbar compression fracture D. pelvis fracture E. spleen injury ✔✔c A 46 year old woman was wearing high heels and tripped stepping off a curb. She thinks she inverted her left ankle. She complains of pain on the lateral side of her foot. On exam she has tenderness and swelling with ecchymosis on the lateral aspect of her left foot. Her X-ray shows: [image] A. 5th metatarsal tuberosity fracture B. fifth phalanx fracture C. Jones fracture D. ligamentous injury only E. no fracture, just a sesamoid bone ✔✔The correct answer is A. This is a fracture of the tuberosity of the base of the fifth metatarsal usually due to an inversion of a plantar-flexed foot. This fracture is usually managed non-operatively. This fracture has been erroneously called a Jones Fracture. A Jones' fracture is a transverse fracture at least 15mm distal to the proximal end of the fifth metatarsal and may require operative fixation by an orthopaedic specialist. -- For further reading, see Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th edition, pages 728-730. A hemodynamically stable patient presents with pain in the forearm after isolated trauma. The neurovascular examination is normal. A single X-ray is taken, and appears as is shown in the Figure. Of the following choices, which is the best next step? [image] A. CT scan of the radius and ulna B. MRI to assess for nerve damage C. X-ray of the contralateral arm to assess for symmetry D. splinting of the forearm with Orthopedic follow-up E. obtain another view of the forearm, and also X-ray the elbow and wrist ✔✔he correct answer is E. This patient has an ulnar fracture, which like any other fracture should be imaged in at least two planes. Additionally, views of the wrist and elbow are indicated to assess for fractures or dislocations to joints adjacent to the injury. An intoxicated 30-year old male, unable to give any history other than "knee pain," had an X-ray ordered from triage (see Figure) before being seen by a physician. Based upon the X-ray results (see Figure), which of the following would be the most likely physical finding? [image] A. limited ability to extend the leg B. palpable defect in the quadriceps tendon, superior to the patella C. loss of sensation in the thigh D. diminished popliteal pulse E. tenderness over the fibular head ✔✔The correct answer is A. The X-ray demonstrates patella alta, or a high-riding patella. This X-ray finding, which is associated with patellar tendon rupture, is defined as being present when the ratio of the patellar height to the (apparent) length of the patellar tendon exceeds 1:1.2. Patella baja, a low-riding patella, is the finding when the quadriceps tendon is ruptured (in these cases there will often be a palpable defect superior to the patella). Patellar tendon rupture is less common than quadriceps tendon rupture, and patellar tendon rupture is more likely in younger patients (<40 years) while quadriceps rupture more frequently occurs in older patients. Regarding the figure below, which of the following statements is true? [image] Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving A. A Salter-Harris I fracture runs through the bony area marked "C". B. The area of bone indicated by "C" is the metaphysis. C. A Salter-Harris IV fracture extends to the area of the bone indicated by "A". D. A Salter-Harris V fracture occurs when there is compression of the bony area marked "C" towards the bony area marked "B". E. The area of bone indicated by "B" is the epiphysis. ✔✔The answer is D. In the diagram, the letters A, B, and C refer to the diaphysis, metaphysis, and epiphysis. Salter-Harris fractures in pediatric patients are those involving the growth plate. --For further reading, see Hamilton et al, Emergency Medicine: An approach to clinical problemsolving (Chapter 46: Closed injuries of the upper extremity) A CT of the abdomen reveals air surrounding the duodenum and under the diaphragm in a 45 year old man in the ED. Your surgeon has taken him to the OR after rapid IV fluid resuscitation and antibiotics were started in the ED. His family arrives after he already went to the theater and wants to know his risk of dying. You can tell them even with advances in surgery, antibiotics and ICU care his risk of mortality is: A. 1-5% B. 5-20% C. 30-50% D. 50-70% ✔✔C A 45 year old female patient presents to the emergency department in the care of her husband with a complaint of agitation and anxiety. Her husband states that she has been acting "strangely" for the past several days. She's been hyperactive, "agitated", and sometimes delusional. She is previously healthy but has allergies to penicillins, iodine, and morphine. On exam, the patient is clearly anxious and frustrated with the visit. She's diaphoretic and on cardiovascular exam a harsh systolic murmur is heard as well as an irregularly irregular rhythm. Vital signs show a temperature of 101.5, HR 123, BP 175/98, RR 27, and SpO2 98% on RA. An EKG shows rapid atrial fibrillation. What is the definitive treatment for her condition? A. Diltiazem, benzodiazepines, IV fluids B. Aspirin, benzodiazepines, fluids C. Lithium, propranolol, acetaminophen D. Acetaminophen, haloperidol, atenolol ✔✔C A 20 year-old man presents to the Emergency Department with right-sided chest pain and dyspnea. His symptoms started while walking his dog five hours ago. He describes the pain as sharp, pleuritic, and diffuse throughout his right chest. He has a history of asthma for which he takes albuterol as needed. He took four puffs of his inhaler today without relief. He has no surgical history, and reports occasional cigarette and alcohol use. He denies trauma. On exam, he appears uncomfortable. He has a heart rate of 105 beats/minute, a blood pressure of 145/85, a respiratory rate of 22 breaths/minute, a temperature of 98.9 degrees Fahrenheit and a pulse oximeter reading of 93% on room air. He has decreased breath sounds heard over his right chest. A triage chest x-ray is shown. What is the most appropriate next step in managing this patient? A. Administer prednisone B. Insert a tube thoracostomy C. Administer empiric antibiotics D. Perform a chest computed tomography (CT) angiogram ✔✔B A 73 year old woman is brought in by BLS after witnessed collapse. They found the patient unresponsive and provided CPR until arrival in the Emergency Department. In the Emergency Department the EKG demonstrates a wide-complex, regular rhythm and there is no palpable carotid pulse, consistent with PEA arrest. The patient is intubated and CPR is continued. According to ACLS guidelines, what is the next step in this patient's management? A. Heparin B. Nitroglycerine C. Epinephrine D. Defibrillation ✔✔C A 5 year old male is bitten by a snake while playing along a ditch. The child is brought to the ED by his parents with complaint of fang marks to the right index finger. On physical exam, you note absence of swelling to the right hand or fingers. He does appear to have 2 small superficial fang marks, but no bleeding or oozing is present. Vital signs are normal. What is the next most appropriate step in the management of this patient? A. Discharge home in 8 hours if patient's exam remains unchanged B. Admit for observation of potential compartment syndrome C. Administer prophylactic antibiotics with gram positive sensitivity D. Administer weight based antivenom in pediatric patients ✔✔A [Show More]

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