ER: PA easy Part B, Questions and answers 2022, 100% pass rate, graded A+

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ER: PA easy Part B, Questions and answers 2022, 100% pass rate, graded A+ A 2-year-old baby girl is brought to the ED with a history of abdominal pain and diarrhea. Mother states that the child w... as playing normally and then "doubled over" with what appears to be abdominal pain. The abdomen appears slightly distended and is tender to palpation. While in the ED the child has a bloody, diarrheal bowel movement. Which of the following is the most likely diagnosis? - ✔✔Intussusception is the most frequent cause of intestinal obstruction in the first 2 years of life. The patient develops paroxysms of pain followed by bloody bowel movements. Pyloric stenosis typically presents prior to the age of 6 months with vomiting but not with diarrhea. Hirschsprung disease results from an absence of ganglion cells in the colon and typically presents early in life with failure to pass meconium, followed by vomiting and abdominal distension. The typical age of onset is later in adolescence in Crohn disease and in the elderly in mesenteric ischemia. A 39-year-old man presents to the emergency department with massive hematemesis. His physical examination reveals slight jaundice, palmar erythema, spider angiomas, and marked ascites. Vitals at the time of presentation are as follows: BP: 85/44 mm Hg, P: 122/min, R: 16/min, oxygen saturation: 96%, and T: 99.8°F. Which of the following is the most likely cause of the massive hematemesis? - ✔✔The most common cause of massive upper gastrointestinal bleeding in patients with cirrhosis is esophageal varices. Although 20% of patients with portal hypertension will have bleeding from other causes (peptic ulcer disease, Mallory-Weiss tears, or gastritis), endoscopic evaluation in patients with portal hypertension is necessary for diagnosis and initial therapy. 1. What is the initial treatment for a patient who is having an acute episode of supraventricular tachycardia? - ✔✔1. The initial treatment that should be attempted is a simple vagal maneuver to break the reentry tachycardia. If this is unsuccessful, pharmacologic therapy is indicated. A 3 year-old boy is brought to the emergency department due to acute onset of cough and wheezing. Physical exam reveals focal wheezing in the right lower lobe. Which of the following should be ordered to confirm the suspected diagnosis? - ✔✔The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift (B) on chest x-ray. ABG (A) results will vary depending on the severity of airway obstruction. PA and lateral chest x-rays (C) are typically normal. PEFR (D) and Spirometry (E) are not typically able to accurately assess this localized airway obstruction. 1. the best way to confirm FB aspiration 2. CC of intrinsic AKI 3. CC of pre renal AKI 4. CC of post renal AKI - ✔✔1. The patient most likely has aspirated a foreign body. This is best evaluated through the demonstration of inspiratory localized hyperinflation and expiratory mediastinal shift 2. CC of intrinsic AKI: sepsis, ischemia, nephrotoxins 3. CC of pre renal AKI: hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), impaired renal autoregulaiton (due to NSAID use, ACE/ARB, cyclosporine) 4. CC of post renal AKI:bladder outlet obstruction, bladder stones and BPH A 32 year-old male presents to the emergency department in Acute Renal Insufficiency (AKI). Which of the following conditions would be most likely observed in intrinsic AKI? - ✔✔Septic shock; The most common causes of intrinsic AKI are sepsis, ischemia, and nephrotoxins, both endogenous and exogenous. Prerenal acute kidney injury can be caused from hypovolemia, decreased cardiac output, decreased circulation of blood volume (CHF, liver failure), and impaired renal autoregulation (NSAIDs, ACE-I/ARB, cyclosporine)---(E), (D), and (B). Postrenal causes include bladder outlet obstruction including bladder stones and BPH (C). A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency room complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted with over 200 mL of pericardial fluid described. Which of the following is the most appropriate next step in management? - ✔✔Choice E, emergent pericardiocentesis, should be considered when patients exhibit symptoms suggestive of severe cardiac tamponade, such as described above, with confirmatory echocardiographic findings of a large pericardial effusion, as this can be fatal if not treated promptly. Choice A is inappropriate, as this could lead to worsening of cardiac tamponade if it is secondary to bleeding into the pericardial space, such as with trauma or postoperatively. Choice B could provide additional confirmation of the diagnosis if a reduction in amplitude of QRS complexes is demonstrated, and electrical alternans of the P, QRS, and T waves, but would not provide any therapeutic benefit. Choice C could be the next appropriate step in management of myocardial infarction, but not in cardiac tamponade. Choice D represents appropriate therapy for patients with acute rheumatic fever, but not for patients with cardiac tamponade. what is pulses paradoxus; what does abnormal pulses paradoxus caused by - ✔✔Pulsus paradoxus (PP), also paradoxic pulse or paradoxical pulse, is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg or 10 torr. When the drop is more than 10mm Hg, it is referred to as pulsus paradoxus. Pulsus paradoxus has nothing to do with pulse rate or heart rate. The normal variation of blood pressure during breathing/respiration is a decline in blood pressure during inhalation and an increase during exhalation. Pulsus paradoxus is a sign that is indicative of several conditions, including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease A 42-year-old woman with a history of migraine cephalgia and Raynaud's phenomenon comes to the emergency department with complaints of severe chest discomfort that occurs at rest every morning (at approximately 10 AM). An EKG performed during an episode of chest discomfort demonstrates transient ST segment elevation, which is relieved with sublingual nitroglycerin. There is no troponin elevation. Cardiac catheterization is performed, and reveals coronary artery spasm, which corresponds with ST segment elevation, and no significant coronary artery stenosis. Which of the following is the most appropriate treatment regimen? - ✔✔Choice D, calcium channel blockers, and long-acting nitrate therapy have been proven to be effective for preventing recurrences of episodes of Prinzmetal angina, with short-acting sublingual or IV nitroglycerin useful for relieving acute episodes. Choice A, 24-hour nitroglycerin dermal patch, is inappropriate, as patients can develop nitrate tolerance, and thus need a 12-hour nitrate-free period every day. Choices B and C, thiazide and loop diuretics, have no proven benefit in patients with Prinzmetal angina. Aspirin, choice E, may worsen episodes of prinzmetal angina, and thus is not recommended. A 45-year-old male who presents to the emergency department with sudden onset of lip swelling, which began shortly after awakening this morning. He denies any history of allergies and denies any new medications. His current medications include hydrochlorothiazide (HCTZ), captopril, atenolol, atorvastatin, and fexofenadine. What is the most likely cause of this gentleman's symptoms? - ✔✔The correct answer is (B). ACE inhibitor angioedema is a potentially life-threatening known side effect of captopril. The patient may need emergency intubation to ensure that his airway remains patent. Patients with a history of ACE inhibitor angioedema should not be placed on any ACE inhibitor or an ARB due to the possibility of similar reaction. HCTZ (a diuretic) and atenolol (a beta blocker) are antihypertensives that are generally unlikely to be associated with angioedema. Atorvastatin (a statin) and Fexofenadine (an antihistamine) are unlikely to present with angioedema. A 75-year-old man with type 2 diabetes presents to the emergency department with a 2-day history of confusion and lethargy. On physical exam, notable dehydration, tachycardia, and confused mental state is noted. Serum sodium, potassium, magnesium, and chloride levels are normal. The arterial blood gases are normal and serum ketones are negative. The abnormal laboratory findings are as follows: - ✔✔A hyperglycemic hyperosmolar state is characterized by dehydration, significant hyperglycemia, and an elevated serum osmolality with an insignificant or negative ketosis. Because of the lack of ketosis, the patient may present with a gradual onset of symptoms, and it can go unnoticed until the dehydration becomes more severe than in ketoacidosis. A 70-year-old man, with a history of pulmonary hypertension and obstructive sleep apnea, presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension is noted. Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur. The murmur is heard over the second and third left intercostal spaces. An S3 is appreciated. Abdominal exam reveals hepatomegaly and splenomegaly. Which of the following maneuvers would be the most appropriate to choose for better identification of the murmur? - ✔✔Choice D, inspiration, will increase the intensity of the murmur of pulmonic regurgitation/insufficiency. The Valsava maneuver will diminish the intensity of the murmur. Choice B, standing, will cause the mid-systolic click associated with mitral valve prolapsed to move toward S1 or become more audible. Choice A, rolling the patient to the left lateral decubitus position, is most useful in identification of the murmur of mitral stenosis. Choices B, C, and E, have no effect on the Graham Steell murmur of pulmonic regurgitation. best way to hear the following and what specific, distinguishing sound you hear for 1. pulmonic regurgitation 2. mitral prolapse 3. mitral stenosis - ✔✔1. Choice D, inspiration, will increase the intensity of the murmur of pulmonic regurgitation/insufficiency (Graham steel). The Valsava maneuver will diminish the intensity of the murmur. 2. Choice B, standing, will cause the mid-systolic click associated with mitral valve prolapsed to move toward S1 or become more audible. 3. Choice A, rolling the patient to the left lateral decubitus position, is most useful in identification of the murmur of mitral stenosis. increasing dyspnea; increased lower extremity edema; jugular venous distension is noted; Auscultation of the chest demonstrates a high-pitched blowing diastolic murmur; The murmur is heard over the second and third left intercostal spaces. An S3 is appreciated. Abdominal exam reveals hepatomegaly and splenomegaly. - ✔✔pulmonic regurgitation 1. what is a Graham steel murmur 2. A blowing holosystolic murmur at the left lower sternal border 3. systolic ejection murmur 4. exertional dyspnea; auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. 5. diastolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex. - ✔✔1. high-pitched diastolic blowing murmur (Graham Steell murmur), Choice D is the most likely of the choices offered. 2. A blowing holosystolic murmur at the left lower sternal border is characteristic for tricuspid regurgitation, 3. aortic stenosis, presents with a systolic ejection murmur. 4. An atrial septal defect, Choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. 5. mitral stenosis, presents with a diastolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex. • A 27-year-old African American female presents to the emergency department with low blood pressure of 100/40, palpitations, and shortness of breath. She is currently under treatment for Wolff-Parkinson-White syndrome and has been taking procainamide for the last two years. An electrocardiogram is obtained on the monitor and reveals the rhythm strip shown. What is the treatment of choice for this patient? (looks like twisted ribbon) - ✔✔The rhythm strip reveals ventricular tachycardia in the form of torsades de pointes. In this case, the primary medical intervention is to administer magnesium sulfate to counter the irregular activity. Antiarrhythmics, antidepressants, and some antibiotics can be responsible for this arrhythmia. In addition to the magnesium, administration of beta-blockers can also be helpful. During a hospitalization for acute exacerbation of COPD, troponin levels are drawn on a 62-year-old man with a history of hypertension, hyperlipidemia, and chronic tobacco use, and found to be elevated above the 99th percentile of normal. Which of the following choices would qualify this patient for the most recent ACC/AHA consensus guideline's definition of myocardial infarction? - ✔✔o Ischemic symptoms o Choice A is the most appropriate choice, as troponin elevation may occur in the setting of patients who do not suffer from acute coronary syndrome. Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." ACC/AHA consensus guidelines for definition of MI - ✔✔Therefore, the 2007 consensus guidelines recommended that the definition of myocardial infarction be applied to those patients who not only had troponin elevation above the 99th percentile, but also met one of the following criteria: "ischemic symptoms, new left bundle branch block (not right bundle branch-block as in choice B), new ST and T-wave changes, new Q waves, or imaging evidence of a new loss of viable myocardium or new regional wall-motion abnormality." A patient with severe hemophilia A is brought into the emergency department following an automobile accident. Concern is for hemorrhage. What is the best intervention to raise factor VIII levels to hemostatic levels? - ✔✔o Recombinate factor VIII o While fresh frozen plasma and cryoprecipitate have been used in the past for hemophilia A hemostatis, volumes may be too large or unable to reach levels to achieve hemostasis in severe hemophilic A patients. Recombinate is a commercial lyophilized factor VIII concentrate that can case factor VIII levels to reach hemostasis in smaller volumes, and do not have the disadvantages of plasma or cryopreciptate. DDAVP is not used in severe hemophilics. EACA is used to enhance hemostasis, but is not able to achieve initial hemostasis seen with recombinate therapy. 1. What is the most common blood gas abnormality in patients with a pulmonary embolism? 2. characteristic of absence seizure 3. lenox gastaut syndrome 4. juvenile myoclonic epilepsy - ✔✔1. Respiratory alkalosis occurs as a result of the hyperventilation. 2. Absence seizures are generalized seizures characterized by a loss of consciousness without motor involvement, typically seen in older children. 3. Lenox-Gastaut syndrome presents in childhood as well but is usually associated with developmental delay and seizures of akinetic and myoclonic nature (referred to as drop attacks). 4. Juvenile myoclonic epilepsy evolves in the teenage years and is characterized by repeated episodes of myoclonic seizure activity. A 33-year-old woman treated with trifluoperazine for the past 3 months is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? - ✔✔Neuroleptic malignant syndrome is an uncommon but serious complication with therapeutic doses of antipsychotic drug therapy, particularly the first-generation (typical) class. Cardinal signs and symptoms include a body temperature above 100.4°F, altered state of consciousness, autonomic dysfunction, and rigidity. A 78-year-old woman with known diabetes mellitus type 2 is brought to the emergency room after a neighbor became concerned when newspapers began piling up on her doorstep and called the police. In the emergency department, she is found to be lethargic and disoriented, with tenting of the skin, sunken eyes, and dry mucous membranes. She is hypotensive and has a rapid pulse. She is wearing a diaper that apparently has been in place for several days, but is barely moist. What is the most appropriate fluid therapy for them to initiate? - ✔✔This woman is severely dehydrated so 0.9% saline is indicated. If she were less dehydrated, 0.45% saline (A) would be appropriate because of likely hyperosmolality. Once her glucose has dropped to 250 mg/dL, she should receive dextrose in water (C) or 0.45% saline (D) to prevent her glucose level from dropping too low. Lactated Ringers i is contraindicated in patients who are likely to have severe acidosis or alkalosis. What fluid resuscitation to use when: 1. severe dehydration 2. hyperosmolality 3. when glucose drop to 250mg/dL 4. when to use lactate ringers; when CI - ✔✔1. This woman is severely dehydrated so 0.9% saline is indicated. 2. If she were less dehydrated, 0.45% saline (A) would be appropriate because of likely hyperosmolality. 3. Once her glucose has dropped to 250 mg/dL, she should receive dextrose in water (C) or 0.45% saline (D) to prevent her glucose level from dropping too low. 4. Lactated Ringers i is contraindicated in patients who are likely to have severe acidosis or alkalosis. * Ringers Lactate solution is often used for fluid resuscitation after a blood loss due to trauma, surgery, or a burn injury.[citation needed] It has been used to induce urine output in patients with renal failure.[citation needed] *Ringers Lactate solution is used because the by-products of lactate metabolism in the liver counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or renal failure.[1] LRS is not suitable for maintenance therapy (i.e., maintenance fluids) because the sodium content (130 mEq/L) is considered too low, particularly for children, and the potassium content (4 mEq/L) is too low, in view of electrolyte daily requirement. Moreover, since the lactate is converted into bicarbonate longterm use will cause patients to become alkalotic A 19-year-old woman presents to the emergency department complaining of headache. The headaches are generalized and increasing in intensity. They have not responded to over-the-counter (OTC) medications. She complains of approximately 1 week of blurred vision, intermittent diplopia, and vague dizziness. Her medical history includes obesity and acne. She takes Accutane and oral contraceptives. She is found to have bilateral papilledema, visual acuity of 20/30 on physical examination, and a normal MRI of the brain. The next most appropriate step would be - ✔✔o Lumbar puncture o The presence of headache associated with papilledema raises the concern for a brain tumor. The MRI excluded a mass lesion, raising a strong [Show More]

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