XII. Emergency QUESTIONS WITH 100% CORRECT ANSWERS

XII. Emergency 1. A 40-year-old man is brought to the emergency room after his wife found him alone in a confused state. He admits to overdosing in a suicide attempt, but does not specify the drug taken. En route to t ...

XII. Emergency 1. A 40-year-old man is brought to the emergency room after his wife found him alone in a confused state. He admits to overdosing in a suicide attempt, but does not specify the drug taken. En route to the hospital, he is drowsy and ataxic with blurred vision. His past medical history is significant for asthma, insomnia, depression, and substance abuse. His temperature is 38.3C (100F), blood pressure is 130/80mm Hg, pulse is 100/min, and respirations are 22/min. Examination shows dry mucus membranes and skin; pupils are 8mm bilaterally. There is no neck stiffness. Lungs are clear to auscultation. Heart sounds are within normal limits. Abdominal examination shows reduced bowel sounds with no tenderness. A Foley catheter is placed in the ER and 600 ml of urine is collected over one hour. Which of the following is the most likely diagnosis? A. Salicylate intoxication B. Serotonin syndrome C. Cocaine intoxication D. Diphenhydramine poisoning@ E. Phencyclidine poisoning 2. A 46-year-old male is admitted to the hospital because of right hand cellulitis. He has a history of intravenous drug use, hepatitis C infection and septic arthritis of the knee. He smokes one pack of cigarettes and drinks one pint of vodka daily. He is started on vancomycin. On the following day, the swelling and redness of his arm decreases. However, he complains of bugs crawling on his skin. His temperature is 38.3C (100.9 F), blood pressure is 160/90 mm Hg, pulse is 110/min, and respirations are 18/min. Examination shows mild hand tremors and diaphoresis Which of the following is the most appropriate next step in management? A. Start chlordiazepoxide@ B. Give haloperidol C. Start propranolol D. Stop vancomycin E. Start methadone 3. A 35-year-old woman is brought to the emergency room after an apparent suicide attempt. Her current prescription of imipramine was found at her bedside along with a suicide note. En route to the hospital, she suffered a seizure. She has been treated with many different anti-depressants over the past several years without improvement. Her temperature is 38.3C (101F), blood pressure is 90/50 mm Hg, pulse is 120/min and respirations are 24/min. EKG shows QRS widening (0.18sec). She is given sodium bicarbonate along with supportive treatment. Which of the following is the most likely mechanism that explains the beneficial effects of sodium bicarbonate? A. Alkalinization of urine will promote diuresis of the antidepressants B. Acidification of urine will promote diuresis of the antidepressants C. Sodium load of sodium bicarbonate will alleviate depressant action on sodium channels@ D. Sodium load of sodium bicarbonate will alleviate depressant action on potassium channels E. Sodium load of sodium bicarbonate will alleviate depressant action on calcium channels 4. A 32-year-old male is admitted to the hospital because of confusion. He was recently diagnosed with schizophrenia His temperature is 38.6C (101.6F), blood pressure is 160/100 mm Hg, pulse is 116/min, and respirations are 22/min. He is not oriented to time, place or person. Mucus membranes are dry. Profuse diaphoresis is present. Lungs are clear to auscultation. Abdominal, neck and extremity muscles are rigid. Muscle tone is increased. Deep tendon reflexes are 2+. Laboratorystudies show a serum CK of 50,000 IU/L. CSF fluid analysis shows a total white blood cell count of 5/microL. Which of the following is the most appropriate next step in management? A. Risperidone B. Dantrolene@ C. L-Dopa D. Prednisone E. Antibiotics 5. A 38-year-old homeless man is brought to the emergency room. He is obtunded and unable to speak. No previous medical history is known. His temperature is 34.0C (93.2F), blood pressure is 90/60 mm Hg, pulse is 60/min and respirations are 6/min. Oxygen saturation is 86% on room air. Pupils are 5 mm in size, bilaterally. Oropharynx is dry. Lungs are clear to auscultation. Abdomen is soft; bowel sounds are decreased; there is no organomegaly. Extremities reveal several needle marks. Babinski sign is negative. Deep tendon reflexes are 2+ throughout. Which of the following is the most appropriate next step in management? A. CT scan of the head B. Glucagon C. Methadone D. Naloxone@ E. Flumazenil 6. A mother brings her 16-year-old daughter to the ER after she had two episodes of coffee ground emesis. The mother reports that for the past two weeks, the teen has not been acting like herself; she has been especially isolated and has had a poor appetite and poor sleep. Her medical history is significant for anemia, for which she takes iron sulfate and folic acid. She also takes acetaminophen for occasional back pain. Presently, the patient's blood pressure is 110/70 mmHg and heart rate is 120/min. Which of the following is most likely to establish the diagnosis? A. Liver function tests B. Upper Gl endoscopy C. Serum iron level@ D. CT scan of the head E. Serum acetaminophen level 7. A 47-year-old man is brought to the ED by EMS after being found wandering in the street mumbling. His BP is 150/75 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 16 breaths per minute, oxygen saturation is 99% on room air, and fingerstick glucose is 98 mg/dL. On examination, the patient is confused with mumbling speech. His pupils are dilated and face is flushed. His mucous membranes and skin are dry. Which of the following toxic syndromes is this patient exhibiting? a. Sympathomimetic syndrome b. Anticholinergic syndrome@ c. Cholinergic syndrome d. Opioid syndrome e. Ethanol syndrome 8. A 25-year-old man is carried into the ED by two of his friends who state that he is not breathing. The patient has a history of heroin abuse. His vital signs are BP 115/70 mm Hg, HR 99 beats per minute, temperature 98.9°F, RR 3 breaths per minute, and oxygen saturation 87% on room air. You notice fresh needle marks and miotic pupils. You begin bag-valve mask ventilation and his oxygen saturation increases to 99%. Which of the following is the most appropriate next step in management? a. Continue bag-valve-mask ventilation until he breathes on his own. b. Perform endotracheal intubation of the patient.c. Evaluate response to administration of naloxone.@ d. Put the patient on supplemental oxygen. e. Place a nasogastric tube and administer activated charcoal. 9. A 42-year-old man who is actively seizing is brought to the ED by EMS after a massive ingestion of an unknown substance. The man is known to have a history of acquired immunodeficiency syndrome (AIDS). An intravenous (IV) line is established and anticonvulsant therapy is administered. After high doses of diazepam, phenobarbital, and phenytoin, it is determined that the seizures are refractory to standard anticonvulsant therapy. Which of the following substances did this patient most likely ingest? a. Cocaine b. Diphenhydramine c. Tricyclic antidepressant (TCA) d. Haloperidol e. Isoniazid (INH)@ 10. A 26-year-old man is brought to the emergency room by police with depressed mental status. Out of fear of arrest, he swallowed a handful of pills as the police officers approached him. On examination, he responds to painful stimuli but is somnolent. His respiratory rate is 8/min and after naloxone bolus infusion increases to 12/min. Lungs are clear to auscultation. Which of the following additional findings is most likely to be present in this patient? A. Miosis, bradycardia, hypertension B. Miosis, tachycardia, hypotension C. Miosis, bradycardia, hypotension@ D. Miosis, tachycardia, hypertension E. Mydriasis, tachycardia, hypertension 11. A 29-year-old male is brought to the emergency room because of sudden onset confusion and fever. He was recently admitted to the hospital for hallucinations and was discharged in stable condition. His temperature is 38.6C (101.6 F), blood pressure is 150/100 mm Hg, pulse is 112/min, and respirations are 24/min. Mucus membranes are dry. Profuse diaphoresis is present. Lungs are clear to auscultation. Abdominal muscles are rigid. Muscle tone is increased; "lead pipe rigidity" is noted in all four extremities. Deep tendon reflexes are 2+. Tremor is noted. Which of the following is the most likely diagnosis? A. Tetanus B. Meningitis C. Drug induced idiosyncratic reaction@ D. Cocaine intoxication E. Lithium intoxication 12. A 26-year-old man is brought to the emergency room after an attempted suicide by medication overdose. For the past hour, he has suffered two seizures. His temperature is 38.8C (102F), blood pressure is 110/85 mmHg, pulse is 90/min, and respirations are 22/min. He is not oriented to time, place, and person. Pupils are dilated, but reactive to light and accommodation; skin is flushed and dry. Abdominal examination shows reduced bowel sounds. EKG shows prolonged QRS complexes (0.19 sec). Toxicology studies are pending. Which of the following is the most appropriate indicator of severity of intoxication? A. Serum drug levels B. Urine drug levels C. Duration of QRS complex@ D. Pupillary sizeE. Bowel sounds 13. A 42-year-old male is admitted to the hospital with fever and shortness of breath. He has HIV infection, hepatitis C infection, and alcohol induced cardiomyopathy. His temperature is 38.6 C (101.5 F). Thrush is noted in the oropharynx. Chest x-ray reveals right lower lobe consolidation. He is started on fluconazole and moxifloxacin. His pneumonia and thrush improve over the next 2 days. However, on the third day, he develops palpitations. His EKG strip is shown below: Which of the following is the most appropriate next step in management? A. Calcium gluconate B. Magnesium sulphate@ C. Sotalol D. Amiodarone E. Adenosine 14. A 34-year-old homeless man is brought to the emergency room in a confused state. He complains of epigastric pain, vomiting and blurred vision. His temperature is 36.8C (98.2F), blood pressure is 110/60 mm Hg, pulse is 110/min and respirations are 22/min. Physical examination shows poor oral hygiene and dry mucous membranes. Lungs are clear to auscultation. Abdominal exam shows mild epigastric discomfort. Funduscopic examination reveals optic disc hyperemia. Laboratory studies show: Serum sodium 136 mEq/L Serum potassium 3.0 mEq/L Chloride 93 mEq/L Bicarbonate 6 mEq/L Blood urea nitrogen (BUN) 30 mg/dL Serum creatinine 0.8 mg/dL Blood glucose 80 mg/dL Serum ketones negative Plasma lactate 2.2 mEq/L Which of the following is the most likely cause of his symptoms? A. Ethylene glycol poisoning B. Mesenteric ischemia C. Septic shock D. Diabetic ketoacidosis E. Methanol poisoning@ 15. You receive notification from EMS that they are bringing in a 17-yearold adolescent boy who was found unconscious by a police officer. The police officer at the scene states that he snuck up on a group of kids that he thought were using drugs. Two of them got away and one just fell to the ground seconds after standing up. Lying on the ground next to the adolescent were plastic bags. The emergency medical technician (EMT) states that the patient was in ventricular fibrillation. He was shocked in the field and is now in a sinus rhythm. The EMT also administered IV dextrose, thiamine,and naloxone without any change in mental status. Which of the following substances was the patient most likely abusing? a. Butane@ b. Ethanol c. Heroin d. Cocaine e. PCP 16. A 61-year-old man with a history of depression and hypertension is brought to the ED by EMS for altered mental status. The patient’s wife states that he stopped taking his fluoxetine 1 month ago and now only takes metoprolol for his hypertension. The patient’s BP is 75/40 mm Hg, HR is 39 beats per minute, RR is 14 breaths per minute, oxygen saturation is 99% on 100% oxygen, and fingerstick glucose is 61 mg/dL. The patient is awake and moaning, responding only to deep stimuli. His extremities are cool to the touch. You suspect an overdose of metoprolol. You endotracheally intubate the patient for airway control. Which of the following is the most appropriate next step in management? a. Normal saline bolus, administer atropine, administer 1-g calcium gluconate bolus, then insert a transvenous cardiac pacer b. Put the patient on pacer pads, then administer norepinephrine drip c. Cardioversion with 200 J, then administer atropine d. Normal saline bolus, atropine, norepinephrine e. Normal saline bolus, atropine, glucagon@ 17. A 22-year-old woman presents to the ED by ambulance from a dance club. The paramedics report that the patient was agitated in the club and had a generalized seizure. Her BP is 165/100 mm Hg, HR is 119 beats per minute, temperature is 101.9 °F, RR is 17 breaths per minute, oxygen saturation is 98% on room air, and fingerstick glucose is 92 mg/dL. On examination, the patient is hyperactive and appears to be hallucinating. Her pupils are dilated to 6 mm bilaterally and reactive. Her neck is supple. Examination of the heart is unremarkable except for tachycardia. Her lungs are clear and abdomen is soft and nontender. The patient moves all four extremities. Laboratory results are as follows: Sodium 109 mEq/L WBC 12,000/mm 3 Potassium 3.5 mEq/L Hct 49% Chloride 83 mEq/L Platelets 350/μL Bicarbonate 20 mEq/L BUN 10 mg/dL Creatinine 1 mg/dL Glucose 103 mg/dL Which of the following substances did this patient most likely consume? a. Cocaine b. Heroin c. 3,4-Methylenedioxymethamphetamine (MDMA)@ d. Ketamine (special K) e. PCP 18. A 32-year-old woman is brought to the emergency department by her husband because of slurred speech and difficulty walking. She has also been very drowsy for the past several hours, a non-typical behavior for a very active woman. She has a history of bipolar disorder, insomnia, migraineheadaches, seizures and hypothyroidism. Her temperature is 37(98.6F), blood pressure is 110/70 mm Hg, pulse is 76/min, and respirations are 16/min. She is lethargic and falls asleep during the interview and physical examination. Pupils are 5 mm in size and reactive to light. Neck is supple. Oropharynx is clear. Chest auscultation is unremarkable. Abdomen is soft and non-tender; bowel sounds are normal. Limited neurologic examination shows 1+ deep tendon reflexes in all four extremities; there is no Babinski sign; strength is 5/5 throughout. There is no nystagmus or hand tremor. Blood sugar is 130 mg/dl. Which of the following is the most likely cause of her symptoms? A. Cerebrovascular accident B. Phenytoin toxicity C. Benzodiazepine overdose@ D. Ethanol intoxication E. Lithium toxicity 19. A 31-year-old woman with a known psychiatric history presents to the ED after ingesting an unknown quantity of pills from her medication vial. In the ED, she complains of nausea, abdominal cramping, and feels unsteady on her feet. On physical examination, you observe that she is tachycardic and ataxic. Which of the following substances will best be treated by activated charcoal that could present like this? a. Phenobarbital b. Carbamazepine@ c. Lye (sodium hydroxide) d. Lithium e. Acetaminophen 20. A 27-year-old man presents to the ED extremely agitated complaining of mild chest pain and dyspnea. He states that he was snorting cocaine all afternoon. You place him on a monitor and get his vital signs. His BP is 215/130 mm Hg, HR is 112 beats per minute, temperature is 100.1°F, RR is 17 breaths per minute, and oxygen saturation is 98% on room air. An ECG reveals sinus tachycardia at a rate of 116. Which of the following is the most appropriate medication to administer? a. Haloperidol b. Labetalol c. Esmolol d. Diltiazem e. Diazepam@