PANCE Review: ER Medicine Questions and Answers on Shock, Cardiology, and Trauma, Exams of Medicine

Download PANCE Review: ER Medicine Questions and Answers on Shock, Cardiology, and Trauma and more Exams Medicine in PDF only on Docsity! PANCE Review: ER Medicine Questions And Answers Hypovolemic Shock is defined as: - correct answer Shock caused by loss of blood volume. Examples include: - Blood loss - Plasma loss - Third-spacing Cardiogenic Shock is defined as: - correct answer Shock caused by dysfunction of the heart causing decreased blood flow. Examples include: - AMI - Heart failure - Myocarditis Obstructive Shock is defined as: - correct answer Shock caused by obstruction in the vascular system causing decreased blood flow. Examples include: - Pneumothorax - Pericardial tamponade - Large thrombus Distributive Shock is defined as: - correct answer Shock caused by poor distribution of blood to organs, most often due to inadequate vessel tone. Examples include: - Septic shock PANCE Review: ER Medicine Questions And Answers - SIRS - Anaphylaxis - Neurogenic shock What are the common presenting signs of shock? What are considered late findings of shock? - correct answer Presenting: Hypotension (relative), oliguria, orthostatic changes Late: AMS, skin mottling, weak/thready pulses, cool extremities 4 y/o female presents to ER w/ parents w/ 4 days of diffuse, watery diarrhea, low fever, fatigue. On exam pt is hypotensive, tachycardic, w/ thread pulses. Mentation appears altered per parents. What type of shock is this most likely, and what initial treatment would be most appropriate? - correct answer This is hypovolemic shock due to fluid loss from diarrhea. Initial care should include fluid resuscitation via IVF. 44 y/o male presents to ER post MVA, having suffered blunt trauma to the sternum from the steering wheel. On exam he appears confused/drowsy, his pulses are weak, heart sounds are muffled, and he has significant JVD. He is tachycardic and hypotensive. What form of shock is this, what is the underlying etiology, and what should PANCE Review: ER Medicine Questions And Answers ST changes in what leads could indicate an anterolateral MI? - correct answer V4, V5, V6 What cardiac enzyme rises first during an AMI, but is not specific to heart tissue? - correct answer Myoglobin What cardiac enzyme rises 3-12 hrs after onset of chest pain in AMI, and is often checked serially to determine course of ischemia? - correct answer Cardiac Troponin T (or I) What cardiac enzyme rises 3-12 hrs after onset of chest pain in AMI, stays elevated for as long as 72 hrs, and may be used to monitor for new infarct in patients s/p cardiac surgery or catheterization? - correct answer CK-MB 48 y/o male presents w/ 3 hrs of crushing, left-sided chest pain, diaphoresis, dyspnea. ECG shows clear ST elevation, Troponin is 1.20. What steps should be taken acutely to improve his prognosis? - correct answer Mantra: IV, O2, Monitor (of course) Antiplatelet: ASA+Clopidogrel Morphine or benzos may be appropriate for sedation (MONA) PANCE Review: ER Medicine Questions And Answers Activate cardiac cath team or transfer to capable facility immediately 82 y/o female diabetic presents w/ 6 hrs of fatigue, N/V, dyspnea. ECG shows NSR, Troponin <0.02. Assuming that you are worried about NSTEMI ACS, what steps should be taken to improve prognosis in this patient? - correct answer Mantra: IV, O2, Monitor Antiplatelet: ASA+Clopidogrel (MONA) Consider Beta-blockers Pt's w/ NSTEMI should be risk-stratified to determine how appropriate coronary angiography is. If indeterminate, it is appropriate to hold and monitor these patients. In this instance, the gender of the patient, her age, and her status as a diabetic make the possibility of a "silent" or atypical MI more likely. What does the acronym MONA stand for in ACS? - correct answer Morphine Oxygen Nitroglycerin Aspirin PANCE Review: ER Medicine Questions And Answers These medications are all generally used for ACS, chest pain. What are the 3 components of the Glasgow Coma Scale? - correct answer Eye opening Verbal response Motor response 42 y/o male arrives to ER post MVA. GCS shows: no opening of eyes to stimuli, mumbling and groaning with painful stimuli, and withdraws from noxious stimuli. What is his score? - correct answer Eye: 1 Verbal: 2 Motor: 4 Total: 7 22 y/o male presents w/ police after being picked up for public intoxication. GCS shows: eyes open to painful stimuli, speech is confused/jumbled, brushes away examiners hand on pinching. What is his score? - correct answer Eye: 2 Verbal: 3 Motor: 5 PANCE Review: ER Medicine Questions And Answers to improve and is released, but returns to the ER the next day with similar sx's, EKG now showing some slight ST elevation. What unusual ischemic event could be happening? What is the treatment? - correct answer Prinzmetal angina - occurs most often in young females, pain is very similar to ACS cases, occurs at rest, is not provoked by stress or exercise. ST changes occur intermittently and are difficult to capture on an EKG. Pain is typically relieved by nitro. Long-term management includes CCB's to prevent CA vasospasm, as well as nitro if needed. 68 y/o male smoker w/ Ehlers-Danlos presents to ER via EMS w/ hx of brief syncope today, followed by gradually worsening chest pain. Pt describes the pain as 10/10, and radiating to the back. Pt BP was initially 144/90, now 105/43. What are you most concerned about in this scenario, and how would you confirm your suspicions? - correct answer Dissecting thoracic aortic aneurysm. As the dissection expands, pain worsens and BP drops. CT chest would be the best way to confirm this Dx, although CXR could show the "3 sign" of the expanding aorta, while a D-Dimer could be absurdly elevated (50,000+). 72 y/o male smoker w/ DMII presents via EMS from SNF w/ 6 hr hx of cold, pale L leg. On exam the limb is cool to the touch, pale, TP/DP pulses non-palpable. What is most likely occurring, and how would you confirm it? - correct answer Arterial occlusion of the LLE, from the sound of PANCE Review: ER Medicine Questions And Answers things likely in the L external iliac. Dx could be confirmed w/ CT abd/limb w/ contrast or doppler U/S (probably a better choice as this guy's kidneys are probably shite) 25 y/o male presents w/ "tingling and numbness" in his R hand x1 hr. He states that while playing rugby earlier today he blocked a hit with that forearm, and although he did not sustain a fracture, the site bruised badly and "hurt like a mother." On exam the R forearm is exquisitely TTP, the skin is tight, there is an area of ecchymosis on the volar and lateral aspect. The R hand is somewhat cool to the touch, radial pulse difficult to palpate. Pt reports no sensation of pain or touch in the hand, although he is able to tell whether his fingers are pointed up or down. What is occurring here, and what treatment should be considered? - correct answer Compartment syndrome. The swelling from his previous injury has occluded the major vessels of this arm, restricting bloodflow to the distal areas. An emergency fasciotomy of the forearm should be considered. 19 y/o male w/ long hx ov IV drug use presents to ER w/ 1 week of fevers, chills, fatigue. On exam, he has multiple small, non-painful nodular lesions in both hands including the palms, and several others scattered over the rest of his body, as well as many small subconjunctival hemorrhages. A new, blowing systolic murmur can be appreciated on auscultation, most apparent in the superior left sternal border. What is likely occurring here, PANCE Review: ER Medicine Questions And Answers and what would a reasonable initial treatment be? - correct answer Infective endocarditis. Because of his hx of IVD use, the likely agent is staph, however starting both IV Vancomycin and Ceftriaxone would be prudent. 45 y/o male presents w/ "the worst sore throat ever," which he states began today and has gotten much worse throughout the day. On exam he is sitting leaning forward with his face tilted up, and seems unwilling to speak or close his mouth. He has a fever of 103. What is likely occurring here, what is the likely etiology, what could be done non-invasively to confirm the dx, and what would initial tx consist of? - correct answer This is acute epiglottitis. It is typically caused by H. influenza, and so is more common in kids, or in middle to older adults whose immunity has waned. A lateral x-ray of the neck would show the "thumbprint sign" of the inflamed epiglottis. Initial tx would include securing the airway, IV CTS's and broad-range antibiotics. 52 y/o male trucker presents w/ cough "for about a day." He reports no other sx's other than some L calf pain. He recently returned from a 20-hour delivery out of state. His EKG shows sinus tachycardia w/ distinct S-waves in I, and Q-waves in III w/ inverted T's. What are you most worried about in this scenario? - correct answer Pulmonary embolism. Granted, none of his sx's are diffinative proof of a PE. In fact, even the S1Q3T3 finding on EKG is only PANCE Review: ER Medicine Questions And Answers breakfast, staring off into space for several minutes. Eventually she came back to her senses, but was confused for several hours after. On exam now she is pleasant, cooperative, and A&Ox4 w/o any neurological deficit. CT brain shows some evidence of chronic microvascular disease, consistent w/ advanced age, but no other abnormal findings. What has most likely happened? What treatment is warranted? - correct answer This bears the appearance of a TIA, as the sx's had all resolved within 24 hrs w/o any permanent deficit. Further workup is warranted to evaluate the vascular status of the pt, including BP, arrhythmias, lipid panel, and possibly carotid U/S. Depending on the findings, antiplatlet, statin, antiarrhythmic or other therapies could be started. 64 y/o male w/ DMII reports to ER via EMS w/ confusion, slurred speech, and weakness. On exam he appears lethargic, he is able to speak fluently, however his speech is a jumbled mix of unrelated words. CN's II-XII are intact. MRI brain shows evidence of acute infarction. What section of the brain is most likely affected? - correct answer Considering his sx's (confusion, jumbled but fluent speech) this infarct is most likely in the L parietal lobe, in or near Werniche's area. If the infarct had been instead in Broca's area, the aphasia would have presented as an inability to form coherent words. PANCE Review: ER Medicine Questions And Answers 72 y/o female w/ HTN reports to ER w/ severe dizziness, N/V, weakness upon waking early this AM. On exam she is afebrile, w/ significant horizontal and vertical nystagmus, dizziness which is mildly alleviated by laying flat and exacerbated by turning the head. Dix-Hallpick test is negative. MRI brain shows evidence of acute infarct. What section of the brain is most likely affected? - correct answer This is most likely a cerebellar infarct, which typically present w/ severe dizziness and nystagmus w/ a negative Dix-Hallpike. 80 y/o male smoker presents w/ 12 hrs of facial immobility. On exam, his L face appears flaccid, although he still raises the ipsilateral eyebrow when surprised. He also reports a recent viral illness, w/ sore throat, cough, ear ache, and neck pain. What is most likely occurring here? - correct answer Given the fact that he is experiencing unilateral flaccid paralysis, but can still raise the eyebrow on that side, this is most likely an acute infarct to the L, superior motor cortex. If he was unable to raise the ipsilateral eyebrow, his sx's might also represent Bell's Palsy. 48 y/o male presents to ER w/ severe unilateral headache. On exam, pt is pacing back and forth with his hand over his R forehead, and reports that the pain feels like it is "right behind the eyeball." He describes the pain as 10/10 and stabbing in character. He states that he had a similar episode of this pain yesterday which lasted PANCE Review: ER Medicine Questions And Answers about 20 minutes then went away on his own. What type of headache is this, and what initial treatment is warranted? - correct answer This is most likely a cluster headache. Other than being a middle-age male, other risk factors include alcohol use. Initial treatment typically consists of 100% O2 via NC, with addition of abortive drugs such as triptans if necessary. 14 y/o female presents to ER w/ FOC w/ 2 hrs of severe HA, N/V, photo/phonophobia. Pt states that she noticed blurred vision, "blinking lights" in the periphery of her vision before the pain began. She describes the pain as R unilateral, throbbing, and "really bad." Her father states that he believes there is some hx of migraine on her mother's side. What initial treatment is most appropriate? - correct answer This is a pretty classic migraine. Initial treatment would most likely consist of a triptan. Prophylactic treatment could consist of beta-blockers, TCA's, CCB's, valproic acid, etc. 62 y/o male w/ hx of HTN and stable abdominal aortic aneurysm reports to ER w/ "the worst headache of (his) life," rating his pain as a 10/10. The HA started this AM, has gotten worse throughout the day, and is now accompanied by N/V and lethargy. On exam, he is hypertensive at 195/100, pt appears neurologically intact, however Kernig and Brudzinski signs are positive. CSF shows elevated ICP, frankly bloody tap w/o signs of bacterial or viral infection. What has occurred here, and PANCE Review: ER Medicine Questions And Answers 22 y/o male presents via EMS w/ GSW to neck. Pt appears to be largely hemodynamically stable, w/ minimal bleeding, however he states that his arms and legs feel "funny." On exam his upper and lower extremities are flaccid w/ hyperreflexia. In addition, priapism is noted. How severe is this pt's spinal cord injury? - correct answer This is likely a very severe injury, possibly a full transection, as indicated by the loss of any voluntary movement in the upper and lower extremities, as well as hyperreflexia indicating damage to the corticospinal pathways. Spontaneous priapism in neck injuries can also be an indicator of spinal cord damage. 48 y/o male diabetic presents w/ 4 days of redness, pain and swelling to upper arm. Pt states that he is not sure exactly when the pain began, but thinks he was "bit by a bug." On exam, pt is mildly febrile at 101.3, L lateral arm w/ large area of erythema w/ distinct border, edema, skin is diffusely TTP, no crepitus is noted, no other lesions or marks are noted on skin. Pt's white count is elevated, w/ increased bands. What is likely occurring here, and what treatment is appropriate? - correct answer This is most likely a cellulitis. Treatment should include IV antibiotics w/ staph coverage, such as Vancomycin. During treatment, care should be taken to outline the erythema in marker to track the progress of the infection and treatment. PANCE Review: ER Medicine Questions And Answers 16 y/o male presents w/ very painful "bug bite." Pt states that he was reaching for something in the loft of the garage, and suddenly experienced intense pain in his R hand. On exam, the R hand is diffusely edematous, erythematous, and TTP. On the dorsum of the hand, a small puncture wound is noted. While in the ER, pt complains that he has begun experiencing severe abdominal cramps. What kind of bite is this, and what treatment is warranted? - correct answer This is most likely a black widow bite. Pt's will typically c/o intense pain at the site of the bite immediately, often followed by malaise and abdominal cramps. IV calcium can alleviate abdominal cramps. Treatment is often otherwise supportive, with anti-venom conserved for the very young or infirm. 38 y/o male presents w/ 2 days of abdominal pain, fatigue, as well as vomiting x3, which he states was dark or black in color. Pt states that he recently twisted his ankle, and has been taking Motrin 800mg TID for "about a week" to help with the pain. CBC shows moderate anemia. What are you most suspicious of here, and what treatment is warranted? - correct answer This is a fairly obvious upper GI bleed. Treatment would consist of admission, upper endoscopy, and potentially transfusion if warranted. 45 y/o male w/ hx of alcoholism presents w/ 4 days of "dark stool," nausea, fatigue. While in the ER, he begins PANCE Review: ER Medicine Questions And Answers to cough up a moderate amount of blood, and c/o new chest pain. What are you most concerned about in this scenario, and what is the underlying etiology? - correct answer The most concerning outcome here would be ruptured esophageal varices. The underlying etiology in that case would involve portal hypertension from alcoholic hepatitis, causing stagnation of blood in the portal system, and varicosities in areas with additionally increased pressure because of their association with the caval return system, at the rectum and the distal esophagus. 50 y/o female w/ hx of alcoholism presents w/ 12 hrs of intense abdominal pain, anorexia, nausea. She localizes the pain primarily to the epigastrum and states that it radiates to the back. Her lipase level is noted to be extremely elevated. Assuming that she has had several episodes of pancreatitis in the past, what possible long- term sequella would you be concerned about, and how could you check for them? - correct answer Sequella of recurrent pancreatitis can include pancreatic necrosis and pancreatic pseudocyst. CT abdomen would demonstrate these abnormalities. Another possible short-term sequella of pancreatitis would be ARDS.