SAEM (2023 – 2024) Questions With Complete Solution, Exams of Advanced Education

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SAEM (2023 – 2024) Questions With

Complete Solution

Management of Large Subungual Hematoma - Drainage (18-Gauge) or Hot Micro- Cauterization Reason to Avoid Suction in Ear Foreign Body Removal - Perforation of Tympanic Membrane Management of Skin Abscess - Linear Incision for Non-Face vs. Needle Drainage for Face Catheter for Bartholin Cyst - Word Grading of Laryngeal Opening - Cormack-Lehane Preferred Induction Agent in Reactive Airway Disease for Dilation Effects - Ketamine Induction Agent Avoided in Sepsis Due To Adrenal Suppression - Etomidate Sudden-Onset Back Pain Worsened by Coughing Soon After Epidural Anesthesia - Epidural Hematoma Presentation of Adhesive Arachnoiditis - Progressive Neuropathy Tom, Dick, and Very Nervous Harry - Anterior to Posterior of Medial Ankle: Tibialis Posterior, Digitorum Longus, Vein, Nerve, Hallucis Longus Absolute Contra-Indication to Crico-Thyrotomy - Age Under 5 Anesthesia for Suturing D.I.P. of Finger in Patient with Underlying Vascular Disease - Lidocaine (2%) Without Epinephrine Around Digital Nerve for Fingers, Toes, Penis, Nose Earliest Sign of Lidocaine Toxicity (Over 5 mg/kg) - Lightheadedness (Also Peri-Oral Numbness, Tinnitus, Visual and Auditory Disturbances, Shivering, Twitching, and Generalized Tonic-Clonic Seizures) (1) Avoid Vertical Mattress Sutures. (2) Avoid Topical Skin Adhesives (Risk of Dehiscence from Sweating). - Palm Glottis Spasm and Chest Wall Rigidity from Sedative (Rapid High Dose of IV Form) - Fentanyl (Effects Not Always Reversed by Naloxone)

Management of Long-Lasting L.P. Headache - Autologous Blood Patch Timing of Tetanus Prophylaxis - Within First Few Days (Suture Within First 24 Hours) Normal C.S.F.-to-Blood Glucose Ratio - 0. Size of Needle Decompression Needle - 14 Gauge (2nd Intercostal at Midclavicular Line) Large Paronychia and Cellulitis - Removal of Affected Nail Under Digital Block; Start Antibiotics Signs of Acute Appendicitis - 1. Rovsing: Right Lower from Left Lower.

2. Psoas: Extension.
3. Obturator: Rotation. Suggested by Abdominal Pain Preceding Nausea and Vomiting - Surgery (Small Bowel Obstruction) Peak of Gastric Acid Secretion at Rest - 2 A.M. Timing of Presentation of Hypertrophic Pyloric Stenosis (Non-Bilious) vs. Intussusception (Bilious) - 4 Weeks vs. 8 Months Over 95% Sensitive and Specific for Renal Stones - Helical C.T. Intermittent Left Lower Quadrant Pain (Afebrile), Loose Stools (Non-Bloody); Good Follow-Up - Discharge on High-Fiber Diet (Consider Laxatives and Stool Softeners) Abdominal Wall Condition in Anti-Coagulated Patient with Trauma or Coughing - Rectus Sheath Hematoma (1) Age 30. (2) Prior Abdominal Surgery or Pregnancy. (3) Marathons. - Risk Factors for Cecal (Cross-Country) Volvulus Possible Chest X-Ray Finding of Hepatic Abscess - Right-Sided Effusion and Elevated Hemi-Diaphragm Referred Pain from Ureteral Colic - Inguinal (Ovarian Torsion Does Not Cause Sacral Pain) Elderly Patient, Diverticulitis Without Perforation (Without Peritonitis) - I.V. Fluids (Elderly), Antibiotics, and Bowel Rest (Peritonitis Requires Surgery)

Proximal vs. Distal Esophageal Perforation - Iatrogenic vs. Spontaneous Rigidity; Elevated Temperatures, Altered Mental Status, Choreo-Athetosis, Autonomic Dysfunction (Diaphoresis, Incontinence, Arrhythmia) - Dantrolene (Or Bromocriptine, Amantadine, Lorazepam) for Neuroleptic Malignant Syndrome Indicated by Temperature Over 105 - Non-Infectious Extra-Pyramidal: Involuntary Periodic Movements of Tongue, Lips, or Mouth - Tardive Dyskinesia Extra-Pyramidal: Torticollis, Fixed Upper Gaze (Oculogyric Crisis), or Arching of Back (Opisthotonus) - Benztropine (2mg Cogentin) or Benadryl (25mg) for Dystonia from Typical Anti-Psychotics Extra-Pyramidal: Restlessness - Beta-Blocker for Akathisia E.C.G. Finding of Haloperidol Toxicity - Long Q.T. Illicit Drug Causing Vertical Nystagmus - Phencyclidine (PCP) Controls Agitation Without Respiratory Depression (Negligible Anticholinergic Side Effects) - Haloperidol (5mg IM q30); B-52 is Benadryl (50 Milligrams), 5 Milligrams of Haloperidol, and 2 Milligrams of Lorazepam Risk of Protracted Struggle in Restraints - Metabolic Acidosis Risk of Flumazenil in Chronic Benzodiazepine User - Withdrawal Seizures Altered Chronic Alcoholic, Non-Gap Metabolic Acidosis - Isopropyl Alcohol Glucose and Magnesium Recommendations for Altered Alcoholic - 1. Thiamine Before Glucose; and,

2. Give Magnesium Regardless of Magnesium Level (Low Stores). Waxing and Waning Global Inability to Relate to Environment and Process Sensory Input (Increased Alertness and Psychomotor Activity) - Delirium Most Common Dementia - Alzheimer More Common Than Vascular Dementia Management of Seizures in Eclampsia - Magnesium; Consider Labetalol or Hydralazine for Diastolic Over 110 After Seizure Stops Relationship Between Alcohol and Seizures - Direct Toxicity vs. Withdrawal vs. Head Injury from Fall

Most Common Cause of Delirium in Elderly - Medications Tooth Fracture of Enamel and Dentin, Yellowish Tinge, No Blood - Ellis 2 Dental Fracture Requires Consultation to Prevent Abscess Formation Obvious Nasal Bone Deformity After Blunt Trauma, Bleeding Controlled by Pressure; No Bone Tenderness, Cranial Nerves Intact; Swollen and Bruised Tender Unilateral Septum - Incision and Drainage of Septal Hematoma Followed by Nasal Packing Eye Blunt Trauma; Pain, Double Vision from Upward Gaze - Entrapment of Inferior Rectus from Inferior Orbital Wall Fracture Head Blunt Trauma, Loss of Consciousness, Currently Seizing; Previous Confusion, Vomiting, and Headache - R.S.I. with Paralytic (Before Addressing Intracranial Pressure) Tension Pneumo-Thorax; Hemodynamically Unstable - Needle in 2nd Intercostal Mid-Clavicular (Anterior) or 4th Intercostal Mid-Axillary (Lateral), Before X-Ray (Chest Tube Takes Too Long) Most Sensitive Bedside Test for Finger Nerve Injury - Two-Point Discrimination O'Riain Test - Wrinkling of Digit in Warm Water Indicates Intact Nerve Ottawa Ankle Rules (Any Positive Requires X-Ray) for Pain in Malleolar Zone - 1. Inability to Walk 4 Steps At Time of Injury and Currently.

2. Tenderness Over Posterior Edge of Either Malleolus.
3. Tenderness Over Navicular or Base of 5th Metatarsal. Suspected Globe Rupture (Enophthalmos and Leakage of Vitreous Humor) - Broad- Spectrum Antibiotics (Tetanus If Necessary); Visual Acuity Assessment Before Consultation (Avoid Pressure Tonometry) Trauma; Unilateral Eye Pain with Extra-Ocular Movement, Proptosis, Decreased Visual Acuity - Lateral Canthotomy for Retro-Bulbar Hematoma Blunt Trauma; Unilateral Epistaxis (Maxillary), Subcutaneous Emphysema, or Anesthesia of Ipsilateral Infra-Orbital Region (V2) - Orbital Blowout Fracture (No Proptosis) Anterior Chamber Meniscus - Hyphema (Blood) vs. Hypopion (Pus) Management of Subconjunctival Hemorrhage - Resolves Without Intervention

Gravid Female, Pulseless and Apneic for 2 Minutes; Detectable Fetal Heart Tones - Emergency C-Section (More Viable Than Gravid GSW with Undetectable Fetal Heart Tones) Elderly Extension Injury; Decreased Bilateral Grip Strength - Steroids and Cervical M.R.I. for Central Cord Syndrome (Contusion from Buckling of Ligamentum Flavum) Affected by L.X.-L.Y. Herniation - Y (1) Jefferson Fracture of C1 (Image). (2) Hangman Fracture of C2. (3) Flexion Teardrop Fracture. (4) Bilateral Facet Dislocation. - Unstable Fractures Penetrating Trauma to Zone 1 (Sternal Notch to Cricoid Cartilage) - Angiography (4- Vessel CT), Triple Endoscopy, and Observation Management of Hemodynamically-Stable Liver Laceration from Trauma - Conservative Management; No Emergency Laparotomy Trauma Patient with Bloody Foley - C.T. with I.V. and Trans-Urethral Contrast Chest G.S.W., Unconscious and Pulseless, Systolic of 60 - Emergency Thoracotomy (Lower Success Rates for Blunt Trauma) In Breast, Out Axilla; Hemodynamically-Stable and Clear Breath Sounds Bilaterally; I.V. Access Obtained - (1) Bedside Ultrasound. (2) Intubation and Chest Tube. (3) Portable X-Ray; and, (4) Admit to I.C.U. Stab Wound in 10th Intercostal Space, Absent Breath Sounds; Dyspnea But Hemodynamically-Stable - (1) Chest Tube. (2) Portable X-Ray. (3) Abdominal C.T. Decreased Sensation Over Lateral Palm - Median Nerve Injury from Distal Radius Fracture Leg Externally-Rotated (And Abducted) - Femoral Neck Fracture (ER = RE) Leg Internally-Rotated - Posterior Hip Dislocation Popliteal Pain After Impact on Planted Foot; Pale Cold Foot, No Distal Pulses - Sedate and Reduce Without X-Rays

Eikenella - Aggressive Mouth Flora Requiring Prophylactic Lactam-Lactamase After Human Bite Definitively Determines Entry and Exit Points - Forensic Specialist (Emergency Department Must Describe Wounds But Never Speculate) Small Pneumo-Thorax on Chest C.T.; Hemodynamically-Stable - 100% Oxygen Flexion and Compression of Vertebral Body, Resulting in Paralysis and Loss of Pain and Temperature Sensation Below - Anterior Cord from Anterior Spinal Artery Injury (From Anterior Flexion) Severe Burns of Hands (Or Skull) and Heels; Risk of Cardiac Arrest or Loss of Consciousness - Deep Burns Distinguish Electrical Injury from Lightning Hepatitis C Medication With Risk of Depression - S.S.R.I. Pretreatment for Interferon Alpha Psychiatric Risk Associated with Breast Implants - Suicide SAD PERSONS - 1. Male (Caucasian).

2. Age Under 20 or Over 50.
3. Depression.
4. Previous Attempt.
5. Ethanol or Drugs.
6. Rational Thought Loss (Psychosis).
7. Social Support Issues.
8. Organized Plan.
9. No Spouse or Significant Other (1 Point, All Others 2 Points).
10. Sickness or Injury. Psychiatric Disorder With Greatest Risk of Suicide - Panic Disorder Silent vs. Occult Suicide - Self-Neglect (Starvation) vs. Recurrent Accidents 2 Hours Post-Acetaminophen (Suicide Attempt), Refuses to Drink Activated Charcoal

• N.G. Tube Avoids Pneumonitis Contra-Indicated for Hydro-Carbon (Oil) Ingestions - Gastric Lavage Belladonna Toxicity - Stigmine (Anti-Cholinesterase) for Anti-Cholinergic Poisoning: Hot (Hades), Blind (Bat), Red (Rose), and Mad (Hatter) 3 Contra-Indications for Activated Charcoal - 1. Bivalent Metal (Unable to Bind).

2. Unprotected Airway (Aspiration).
3. Caustic Ingestions Awaiting Endoscopy (Black Color).

Mechanism of Q.R.S. Prolongation (And Right Axis Deviation) vs. Sinus Tachycardia from Tri-Cyclic Anti-Depressant - Sodium Channel Blockade vs. Anti-Muscarinic Management of Benzodiazepine Overdose - Intubate; Risk of Seizures from Flumazenil (Indicated for Iatrogenic Oversedation) Treatment of Agitation and Sympathetic Tone from Cocaine - Benzodiazepine A.B.G. 2 Hours After Aspirin Overdose - Slightly Alkalotic (Later Mixed), High Oxygen (Activation of Respiratory Centers) Toxic Single Dose of Acetaminophen - 140 Milligrams Per Kilogram (Over 140 at 4 Hours Requires 140 mg/kg NAC) Management of Acetaminophen Overdose - Early Charcoal; Rumack-Matthew Nomogram At Least 4 Hours Post-Ingestion Vomiting, Diarrhea, Fatigue, and Yellow-Green Halos - Digoxin Mimics Clonidine Toxicity - Opioid Toxicity (Hypotension, Bradycardia, Bradypnea, Miosis) Vin Rose Urine - De-Feroxamine (I.V. or I.M.) for Iron Toxicity Antidote for Isoniazid vs. Beta-Blocker (Also CCB or Insulin) - Pyridoxine vs. Glucagon (1) Brain Damage (Encephalopathy, Seizure, Sleep Disturbance, or Memory Deficits). (2) Paresthesias or Wrist Drop. (3) Colicky Abdominal Pain. - Lead Toxicity; Check for Lead Lines Chocolate Brown Blood After Nitrites, Local Anesthetics, Dapsone (Dermatitis Herpetiformis), or Phenazopyridine (UTI) - Methylene Blue for Met-Hemoglobinemia (1) Tall and Young. (2) Smoking. (3) Asthma. (4) C.O.P.D. (5) Interstitial Lung Disease. (6) Connective Tissue Disease. (7) Lung Cancer. - Risk Factors for Spontaneous Pneumo-Thorax Endo-Tracheal Tube Depth (Lip Line) - 23 Centimeters for Males (Jordan) and 22 for Females

Populations At Higher Risk for Asthma - Male Children, Female Adults, and African- Americans 10 Millimeter Fall in Systolic Pressure During Inspiration (Pulsus Paradoxus) - Severe Asthma vs. Pericardial Tamponade (External Compression of Heart) Steroid Route for Asthma Exacerbation - I.V. Steroids Effect of Mucokinetic Agent (N-Acetylcysteine) on C.O.P.D. Exacerbation - Increases Work of Breathing Pathogen Coverage Required for Community-Acquired Pneumonia - Co-Infection of Gram-Positive (Streptococcus) and Gram-Negative (Chlamydia) Common (1) Malignancy. (2) Alcohol. (3) Diabetes or Immune Suppression. (4) Cardiovascular Disease. (5) Age Over 65. (6) Sickle Cell. (7) Splenectomy. - Risk Factors for Streptococcus Pneumonia Manifestation of Varicella Zoster in Adult Smokers or Pregnant Women (Contrast to Rash in Children) - Pneumonia Currant Jelly Sputum, Empyema or Abscess - Klebsiella Pneumonia Chest X-Ray Findings of Food Aspiration - Right Middle Lobe Atelectasis or Right Lung Hyperinflation Percentage of P.E. Patients with D.V.T. vs. Percentage of D.V.T. Patients with Asymptomatic P.E. - 33% vs. 50% Cancers Most Associated with Pulmonary Embolism - Ovarian and Colon (Think OCPs) Most Common E.C.G. Finding of Pulmonary Embolism - Tachycardia (S1Q3T Suggestive But Not Diagnostic) Describe S1 Q3 T3 of P.E. - S in 1, Q and Inverted T in 3 Young Adult, Pneumonia, Bullous Myringitis (Inflammation and Bullae of Tympanic Membrane) - Mycoplasma Elderly; Pneumonia, Diarrhea, Relative Bradycardia - Legionella

Ventricular Fibrillation, Refractory to Multiple Shocks and Epinephrine - Amiodarone (15 Milligrams Per Minute for 1st 10 Minutes) or Procainamide Management of Torsades from Low Potassium (Long QT) or Magnesium - Overdrive Pacing If Magnesium Fails Endo-Tracheal Dosing of Epinephrine, Compared to I.V. - Double A.C.L.S. Epinephrine Dose - 1 Milligram (1-to-10000) Every 5 Minutes Management of Asystole - Check Second Lead Before Compressions and Epinephrine (Or Vasopressin) or Atropine Dissociation of P and R Waves (Wide QRS from Ventricular Focus) After Ischemia or Infarction - Complete Heart Block Contra-Indication for Chin Lift Maneuver - C-Spine Status Total Body Water Deficit in D.K.A. - 70 Milliliters Per Kilogram (5 Liters for 70 Kilograms) 2 Electrolytes Appearing Normal On D.K.A. Labs Despite Total Body Depletion, In Addition to Potassium - 1. Magnesium.

2. Phosphorous. Contra-Indicated During Hyperglycemic Seizures Due to Impairment of Endogenous Insulin Release - Phenytoin Timing of Fluid Resuscitation for Hyper-Glycemic Hyper-Osmolar State - Half of Deficit in 1st 8 Hours (2 L in 1st Hour); Other Half Over 24 Hours (Switch to Half- Normal Saline Once BP and UOP Normalize) Risk of Rapid Correction of Hyper-Osmolarity, Especially in Children (20 mL/kg) - Cerebral Edema; Change in Mental Status During D.K.A. Treatment Requires Mannitol (Avoid Glucogenic Steroids) (1) Ineffective for Alcoholic Hypoglycemia (Inadequate Glycogen Stores). (2) Dangerous In Unexplained Pediatric Hypoglycemia (Possible Glycogen Storage Disease). - Glucagon Glucose Level Required for Symptoms of Hypoglycemia - Under 50 (Seek Other Causes Otherwise) Observation Period for Overdose on Oral Hypoglycemic - 24 Hours

Contrast Physical Exam of Moderate Hypothermia and Mild Hypothermia - Below 32 Degrees, Altered Mental Status and Loss of Shivering (Bradycardia and Bradypnea) Management of Frostbite - Warm Immersion (Pain Returns) Seasonal Timing of Presentation of Hypo-Thyroidism - Winter Due To Cold Intolerance C.B.C. and B.M.P. Findings Supporting Diagnosis of Hypo-Thyroidism - Normo-Cytic Anemia and Hypo-Natremic Respiratory Acidosis from Hypo-Ventilation (Also Hypercholesterolemia) Calcium Level in Adrenal Insufficiency - Normal or High (Unknown Etiology) Management of Suspected Adrenal Insufficiency - Dexamethasone (4 Milligrams IV q6) Before A.C.T.H. Stimulation Test (Not Affected by Dexamethasone) (1) Untreated Pneumo-Thorax (Including C.O.P.D. Blebs). (2) Doxorubicin, Cisplatin, Bleomycin, Disulfiram, and Mafenide Acetate. (3) Otitis Media. - Contra-Indications for Hyperbaric Oxygen Therapy (1) Decompression Sickness. (2) Necrotizing Fasciitis. (3) Air or Gas Embolism. (4) Carbon Monoxide Poisoning. (5) Crush Injury. (6) Compartment Syndrome. - Indications for Hyperbaric Oxygen Management of Mild Acute Mountain Sickness (Not Life-Threatening) - 1. Avoid Higher Altitudes.

2. Acetazolamide, Oxygen, and Ibuprofen (Headache) for Current Altitude. (1) Alcohol. (2) Thyroid. (3) Rheumatic Heart. (4) Ischemia. (5) Atrial Myxoma. (6) Lung (PE or Emphysema). (7) Pheochromocytoma. (8) Infection. (9) Blood Pressure. - Causes of Atrial Fibrillation (ATRIAL PhIB) Management of Thyroid Storm - P.T.U. and Propranolol, Followed by Iodine (5 Drops K-I q6 or Na-I Drip q8) After 1 Hour

Effect of Acetaminophen (Anti-Pyretic) on Thyroid Storm - Worsens by Displacing Thyroid Hormone from Binding Globulin Presentation of Scorpion Bite in Children vs. Adults (Symptoms Resolve Without Anti-Venom) - Restlessness, Jerking, Roving Eye Movements, and Drooling (Anaphylaxis Requires Anti-Venom) in Children vs. Pain and Paresthesia in Adults Risk of Scorpion Anti-Venom - Allergy (Type 1) or Serum Sickness (Type 3) American Scorpion Causing Systemic Symptoms - Centruroides Observation Period for Asymptomatic Snake Bite - 8 Hours Core Body Temperature Over 40.5 Celsius and Hot Dry Skin; Risk of Seizure, Respiratory Failure, Low Blood Pressure, or Rhabdomyolysis - Altered Mental Status Suggests Heat Stroke; Conduction and Evaporation Cooling Severe Hypothermia, Mental Status Changes and Arrhythmia - Warm I.V. Fluids (1) Red Fruits or Meats. (2) Methylene Blue. (3) Chlorophyll. (4) Iodide or Bromide. (5) Cupric Sulfate. - False Positive Guaiac Test (1) Bile. (2) Ingestion of Magnesium-Containing Antacids. (3) Ascorbic Acid (Vitamin C). - False Negative Guaiac Test Thumbprinting on X-Ray - Submucosal Edema and Hemorrhage 2 Most Common Causes of Lower G.I. Bleeding in Adults - Diverticulosis and Angiodysplasia 2 Most Common Causes of Upper G.I. Bleeding in Adults (Higher Mortality Than Lower GI Bleeding) - PUD (Gastric Erosions) or Varices Most Common Cause of Upper G.I. Bleed in Children - Esophagitis Painful Hemorrhoids - External Most Common Cause of Food Poisoning in U.S. - Clostridium (CDC Shows Salmonella, Campylobacter, and Giardia More Common After Viruses) 2, 3, and F - Inferior from Right Coronary Artery

Criteria for Acute Myocardial Infarction - 2 of 3: 20 Minutes Duration, E.C.G, or Positive Enzymes Management of Acute Myocardial Infarction Before Catheterization or Thrombolytics

• 1. Nitroglycerin, and Morphine Increases Oxygen Delivery.

2. Aspirin and Clopidogrel.
3. Beta-Blocker Decreases Myocardial Oxygen Requirement.
4. Heparin Once Dissection Ruled Out. V1, More Elevation in 3 Than 2 - Confirmed by S.T. Elevation in V3R to V6R on Right- Sided E.C.G.; Give Fluids and Avoid Dilators (Nitroglycerin) M.I. Symptoms, E.C.G. Shows No S.T. Elevation, But Right Bundle Branch Block and Fascicle Block - Pacemaker Prevents Complete Block S.T. Elevation in V5 and V6 - Lateral M.I. from Left Circumflex Perfusion of S.A. Node - Right Coronary Artery Management of Likely Aortic Dissection - Beta-Blocker Decreases Shearing Forces on Aorta (Systole) and Sodium Nitro-Prusside Lowers Pressure (More Titratable Than Nitroglycerin); Consult Cardiothoracic Surgery and Consider Morphine Second-Degree Type 1 - Widening Wenckebach Management of Pheo-Chromocytoma - Phenoxybenzamine for 2 Weeks Until Surgical Resection High Blood Pressure and Optic Disc Edema (Or Encephalopathy, Intracerebral Hemorrhage, Retinopathy, Heart Failure, ACS, Acute Renal Failure, Aortic Dissection, and Eclampsia) - Malignant or Emergent Hypertensive Crisis (1) Valsalva. (2) Baro-Trauma. (3) Asthma. (4) Cocaine Inhalation from Positive Pressure Devices. - Risk Factors for Pneumo- Pericardium; Check for Hamman's Sign (Mediastinal Crunch Over Precordium) (1) Cardiac Arrhythmia. (2) Artery Spasm (MI or Mesenteric Ischemia). (3) Dissection or Encephalopathy from Hypertension. (4) Seizures. (5) Rhabdomyolysis. - Cocaine Complications PERC Criteria (Low Risk Only) - (1) Bloody Hemoptysis. (2) Room Air Saturation Under 95%.

(3) Estrogen. (4) Age Over 50. (5) Thrombosis History. (6) Heart Rate Over 100. (7) Surgery or Trauma Within 4 Weeks. Type of Stroke After T.I.A. - Thrombotic (Not Embolic) Sudden-Onset Severe Occipital Headache and Nausea; History of Migraines (Frontal); No Neurological Deficits; Normal Head C.T. - L.P. Excludes Sub-Arachnoid Population At Lowest Risk for Epidural Hematoma - Infants Have Elastic Skulls and Dura Attaches Close to Peri-Osteum Indicated by Hemo-Tympanum and Epidural Hematoma - Basilar Skull Fracture History of Hypertension (Diabetic African-American), Unilateral Arm and Leg Motor Deficits - Lacunar Infarct of Internal Capsule Complete Unilateral Facial Droop (Inability to Raise Forehead) - Acyclovir and Prednisone (Bell Palsy); Suggest Eye Patch and Moisturizing Drops for Lacrimal Gland Dysfunction Contrast Presentation of Vestibular Neuronitis to Labyrinthitis - No Sensori-Neural Hearing Loss from Vestibular Neuronitis Suggested by Cranial Nerve Deficit (Diplopia) in Vertigo Patient - Central Etiology (Stroke) Pharmacologic Management of Vertigo from Benign Positional Vertigo (In Addition to Epley Maneuver) - Benzodiazepine (Sedation of Limbic System and Thalamus) or Anti-Cholinergic (Diphenhydramine, Meclizine, or Promethazine) Mid-Back Pain (Urinary Retention) and Progressive Leg Weakness; Fever, Absent Reflexes, Tenderness to Palpation - Start Broad-Spectrum Antibiotics and Consult Neuro-Surgery for Epidural Abscess; Foley and Analgesics to Relieve Pain Initial Management of Myasthenic Crisis (Previously Diagnosed by Edrophonium Test) - Intubation Risk of Nitro-Prusside in Renal Failure Patients or Pregnancy - Cyanide Toxicity Management of Hypertensive Emergency (Urgency + End-Organ Damage) - 25% in First Hour by I.V. (Esmolol 100 to 500 Micrograms / Kilogram Load) 1st Step in Management of Atrial Fibrillation - Rate Control Before Anti-Coagulation

Termination of A.V. Nodal Re-Entry Tachycardia - Adenosine (99% Effective) Location of Second-Degree Type 2 Block (Requires Pacing) - His-Purkinje System Location of Second-Degree Type 1 Block from Vagal Tone or Drug Effect - A.V. Node Long Q.R.S., Terminal R Wave in V1 and Slurred S in 1 and V6 - Right Bundle Branch Block Linear or Flame-Shaped Hemorrhages, Cotton-Wool Patches, Copper or Silver Discoloration of Arterioles, Hard (Lipid) Exudates from Abnormal Vascular Permeability - Longstanding Hypertension (Optic Disk Edema Indicates Emergent Malignant Hypertensive Crisis)

Beta-Blocker That Also Blocks Alpha Receptors - Labetalol Reason to Avoid Beta-Blocker in Pheo-Chromocytoma or Cocaine Toxicity - Blood Pressure Increase from Alpha-Mediated Vasoconstriction Management of Shingles - Analgesic and Acyclovir (Prevents Post-Herpetic Neuralgia) Umbilicating Vesicles Covering Body and Fever; Recent (Days Ago) Papules on Extremities and Face; Started As Oral Rash and Severe Febrile Headache and Backache One Week Ago - Smallpox; Isolate for Weeks and Monitor Corneas; Vaccinate Exposures Skin Sloughing After Target Macules on Palms and Soles from Penicillin or Sulfa Drugs (Also Barbiturates, Immunization, or Mycoplasma) - Erythema Multiforme vs. Stevens-Johnson vs. Toxic Epidermal Necrolysis Cellulitis Treatment in Diabetic; History of Recurrent Cellulitis - Gram-Positive and Gram-Negative (Ampicillin-Sulbactam) Management of Seborrheic Dermatitis (Tinea-Like Erythema and Waxy Scaling on Hairy Surfaces Before Infancy or After Puberty) - Shampoo Containing Zinc Pyrethrin, Selenium, Salicylic Acid, or Tar Contrast Color Under Wood's Light of Tinea Versicolor vs. Erythrasma - Yellow-Green vs. Red (Erythrasma Pictured) Indicated by Potency of Topical Steroid - Ability to Vaso-Constrict (Drug Holidays for Topical Steroids Avoid Tachyphylaxis)

Two Options for Diffuse Allergic Pruritis in Adult - Diphen-Hydramine or Hydroxyzine (Both 25 to 50 Milligrams PO q6) More Expensive Due To Less Frequent Dosing and Less Sedative Adverse Effects - 2nd-Generation Anti-Histamines End in -adine or -zine Chronic Use Dries Out Skin vs. Used for Dry Skin Lesions - Creams vs. Ointments (Grease) or Alcohol-Free Gels Detected by Tzanck Smear - H.H.V. 1 to 3 Management of Tzanck-Positive Eczema Herpeticum, Mistaken for Impetigo - Acyclovir and Dermatology Consultation (10% Mortality) Palm-Sole Rashes - Kawasaki, Coxsackie A, RMSF, Syphilis (Kawasaki CARS); Also Neisseria and Scabies Reason Scabies (Sarcoptes) Does Not Penetrate Dermis - Aerobic (Permethrin 5% Twice Daily) Periodic Muscle Paralysis and Areflexia vs. Tetany and Weakness - Low Potassium vs. Low Calcium Dry Scaly Sharply-Marginated and Brightly-Red Eczematous Dermatitis on Peri-Oral and Ano-Genital Regions (Progresses to Vesicles Throughout Body); Diffuse Alopecia and Nail Manifestations; Red Glossy Tongue; Photophobia, Irritability, and Depression - Zinc Supplementation (1) Dermato-Myositis. (2) Pruritis. (3) Erythema Nodosum. (4) Acanthosis Nigricans. - Para-Neoplastic Syndromes Black Eschar; Vesicles 1 Week Ago (20% Lower Mortality Compared to Pulmonary Type) - Oral Doxycycline Prevents Dissemination of Dermatological Anthrax (Bacillus) Management of Drug-Induced Urticaria - Stop Drug, Start Anti-Histamine; Steroids Not Indicated Unless Anaphylaxis Develops Poorly-Controlled Glucose, New Mucosal Red Dots; Normal P.T. - Steroids Prevent Platelet Drop Below 20,000 in I.T.P.; Platelet Transfusions Contra-Indicated Is Stroke or Trauma More Likely To Cause Fever? - Stroke

Indicates Response to Infection, No Indication of Severity - White Count Management of Suspected Croup (Barking Cough) - Racemic Epinephrine and Steroids (Consider Cool Mist) Toxic-Appearing Child, Stridor, High Fever, Drooling - Lateral X-Ray and Call E.N.T. or Anesthesia for Epiglottitis Suspicion for Infective Endocarditis - Blood Cultures, I.V. Antibiotics, Admit Kidney Infection in Children, Pregnant Women, Elderly, or Those With Co- Morbidities - Reasons for Admission Endemic for R.M.S.F. - Southeast Management of Purulent Infected Open Laceration At Joint, Possible Glass; No Fever, Painful Range of Motion - X-Ray, I.V. Antibiotics, and Consult Surgery Infection in Smokers, Rapid-Onset Begets Rapid Deterioration; Adult Incidence Increasing While Pediatric Incidence Decreasing - Epiglottitis Fever, Stiffness, and Drooling After Foreign Body Ingestion - Retro-Pharyngeal Abscess Infection of Deep Space (Pulp) of Fingertip - Incision (Medial for 2-4 and Lateral for End) for Felon Cat Bite; Finger Held in Slight Flexion (Fusiform Swelling), Tenderness, Pain With Passive Extension - I.V. Antibiotics for Teno-Synovitis, Elevation, and Hand Consult Tick Removal - Forceps (No Great Literature) Contrast Presentation of Intra-Ocular vs. Extra-Ocular Foreign Body - Vision Loss (Or Endophthalmitis) Likely from Intra-Ocular Foreign Body (Requires Ophthalmology Consult) Management of Suspected Ocular Foreign Body - Moist Cotton Swab for Removal Before Fluorescein (Avoid Contact Lenses Over Corneal Abrasions) Aqueous Humor Leakage or Vitreal Hemorrhage Through Defect in Sclera or Cornea - Globe Rupture Presentation of Keratitis from Ultraviolet Exposure - Painful Conjunctival Injection (Red Eye) and Photophobia

Corneal Injury from Foreign Body in Conjunctiva of Upper Eyelid - Parallel Vertical Abrasion from Eyelid Opening and Closing Causes Dendritic (Branching) Corneal Abrasions - Herpes Abbreviation for Left Eye vs. Right Eye - O.S. vs. O.D. (Derecho) Topical Ester (Acceptable for Anesthetic Amide Allergy) Not for Home Use (Corneal Toxicity) - Proparacaine Pain, Vision Loss, and Edematous Cornea After Entering Darkness - Call Ophthalmology for Acute Angle Closure Glaucoma Management of Optic Neuritis (Cranial Nerve 2 Deficits in Female) - Follow-Up for M.S. Work-Up (Avoid Oral Steroids) Maximum Delay Between Steroids and Biopsy for Suspected Temporal Arteritis (Elderly Woman with Associated Poly-Myalgia Rheumatica) - 1 Week (Prednisone 100mg PO Daily) Unilateral Facial Paralysis (Including Forehead) - Bell Palsy Contrast Central Retinal Artery Occlusion to Optic Neuritis or Acute Angle Closure Glaucoma - No Pain from Artery Occlusion Normal Intra-Ocular Pressure - 10 to 21 Management of Corneal Ulcer - Fluoroquinolone and Close Ophthalmology Follow-Up (24 Hours) Contrast Orbital (Posterior to Orbital Septum) Cellulitis to Pre-Septal Cellulitis; Both Have Fever, Edema, Erythema, and Tenderness - (1) Pain with Extra-Ocular Movements (Risk of Sub-Periosteal Abscess or Cavernous Sinus Thrombosis) and Vision Impairment. (2) Proptosis. (3) Inpatient I.V. Antibiotics (Outpatient Antibiotics for Pre-Septal). (1) Pregnancy or Oral Contraceptives. (2) Steroids. (3) Vitamin A. - Risk Factors for Pseudo-Tumor Cerebri (Risk of Reduction of Visual Fields) Last Feature of Horner Syndrome, In Addition to Ptosis, Anhidrosis, and Miosis (Loss of Sympathetic Innervation) - Enophthalmos Work-Up for Suspected Horner Syndrome - (1) Chest X-Ray for Pancoast Tumor.

(2) C.T. of Brain and Neck. (3) Carotid Angiogram for Dissection. (1) Acetazolamide (Carbonic Anhydrase Inhibitor) or Topical Beta-Blockers (Production). (2) Cholinergic Miotic Drops. (3) Mannitol (Pressure). (4) Iridectomy. - Options for Acute Angle Closure Glaucoma Tropicamide vs. Pilocarpine - Dilator (Sunny Tropics = Anti-Cold) vs. Constrictor (Muscarinic) Fracture of Neck of 4th or 5th Metacarpal - Boxer Fracture Oblique Fracture Through Base of Thumb, Dislocation of Radial Articular Surface - Bennett Fracture Distal Radius Fracture and Dorsal Displacement (Volar Angulation) - Colles Fracture; Unstable Ulnar Fracture Requires Long Arm Cast (Short Arm Cast or Surgery for Others) Intra-Articular Comminuted Fracture at Base of Thumb - Rolando Fracture (Comminuted Bennett Fracture) Salter Classification - 1. Slipped.

2. Above: Through Plate Into Metaphysis.
3. Lower: Through Plate Into Epiphysis.
4. Through Both Sides.
5. Reduced (Crushed Plate). Direct Blow On Scapula (Down and Medial) While Arm Adducted - Sling for A.C. Joint Injury and Orthopedic Follow-Up in 3 Days Fracture Resulting in Multiple Pieces - Comminuted Greenstick vs. Torus Fracture - Incomplete Break (Sticks Break) vs. Buckle Sprain (Ligament Tear) Grading - 1. Mild Hemorrhage and Swelling.
6. Tenderness and Loss of Function.
7. Grossly Abnormal Joint Movement. Management of Sprain - Immobilize for 3 Days, Non-Steroidals; Ice and Elevate for 1 Day Bohler Angle - Smaller Than 20 Degrees Suggests Calcaneus Fracture

Management of 5th Metatarsal Tuberosity Fracture from Inversion Injury - Non- Operative Transverse Fracture of Metaphysis-Diaphysis Junction of 5th Digit - Orthopedic Consultation for Jones Fracture High-Riding Patella vs. Low-Riding Patella - Patellar Tendon (Pediatric) vs. Quadriceps Tendon (Elderly) 4 Types of Hip Fractures, Proximal to Distal - (1) Subcapital. (2) Basilar Neck. (3) Inter-Trochanteric. (4) Sub-Trochanteric. Improves Symptoms of Gout or Pseudogout; Contra-Indicated in Renal Failure (Gout from Cyclosporine) - Colchicine Reason 80% of Pediatric Trauma Deaths Result from Head Trauma - Disproportionately Large Head Produces More Torque on Cervical Spine Contrast Epidural Hematoma in Adult vs. Child - Venous in Children Management of Supracondylar Humerus Fracture - Surgery for High Risk of Nerve Injury Management of Radial Head Subluxation (Nursemaid Elbow) - Push Radial Head While Curling (Flexion + Supination) Most Common Complication of Anterior Shoulder Dislocation - Compression Fracture of Postero-Lateral Humeral Head (Hill-Sachs Deformity) More Common Than Avulsion Fracture of Greater Tuberosity Most Common Heart Rhythm in Pediatrics, Resulting from Hypoxemia - Brady-Cardia Progresses to A-Systole (1) Acidosis by Fetal Scalp Monitoring. (2) Thick Meconium in Amniotic Fluid. (3) Prematurity. (4) Intra-Uterine Growth Failure. (5) Multiple Gestation. - Risk Factors for Neonatal Resuscitation; Dry, Warm, Position, Suction, and Stimulate Before Oxygen Management of Heart Rate Under 60 in Infant - Oxygen (Adequate Ventilation) Before Chest Compressions

Drugs Amenable to Endo-Tracheal Route for Children, Up to 10 Times I.V. Dose with Positive Pressure Ventilation - LEAN: Lidocaine, Epinephrine, Atropine, Naloxone Management of Post-Arrest Hypotension in Child - Epinephrine (Dopamine in Adults) Because Coronary Artery Disease Unlikely in Children Decreased p.H. (Oxygen Consuption), Glucose, and Ventilation - Consequences of Hypothermia in Pediatrics Considered Bradycardia in Neonate - Under 100 (1) Tibial Fracture (Procedure Contra-Indicated for Known Fracture). (2) Anterior Compartment Syndrome. (3) Fat or Marrow Embolus. - Complications of Intra-Osseous Access Unilateral Purulent Nasal Discharge or Recurrent Epistaxis in Child - Speculum Examination for Foreign Body Before C.T. Scan (1) Swallowed in Breast Milk. (2) Toxin Ingestion. (3) Milk Allergy. (4) Dyes in Foods. (5) Occult Trauma. (6) Munchhausen by Proxy. - Incomplete List of Causes of G.I. Bleeding in Children Child, Episodic Abdominal Pain; Currant-Jelly Stool - Consult Pediatric Surgery (Risk of Procedural Perforation) Before Barium Enema for Diagnosis and Treatment of Intussusception Endo-Tracheal Tube Size for Children - 16 Plus Age, Divided by 4 Most Common Tracheo-Esophageal Fistula - Proximal Atresia and Distal Fistula Management of Choking Infant - 4 Back Blows in Prone (Interscapular) Followed by 4 Chest Thrusts in Supine (Avoid Heimlich or Blind Finger Sweep) Requires Apgar Score Check in 5 Minutes - Score Under 7 (Repeat Up To 4 Times) 3 Differences in Pediatric Intubation Technique - (1) More Anterior with Straight Blade (Larger Tongue). (2) Atropine Before Succinylcholine. (3) Uncuffed. Prevents Increase in Intra-Cranial Pressure During Intubation - Lidocaine Highest Risk Foreign Body Aspiration or Ingestion - Large Object in Upper Airway

Most Common Type of Shock in Pediatrics - Hypovolemic Most Common Cause of Fatal Anaphylactic Reaction - Penicillin (More Common Than Stings) High Blood Pressure and Edema or Proteinuria During Pregnancy - Magnesium and Labetalol for Pre-Eclampsia; Induce for Term or Near-Term Pregnancy (1) Refractory Headache. (2) Visual Disturbance. (3) Diastolic Pressure Over 110. (4) Pulmonary Edema. (5) High Liver Enzymes. (6) 2+ Proteinuria. (7) Oliguria or High Creatinine. (8) Hemolysis. (9) Intra-Uterine Growth Restriction. - Severe (Pre-Eclampsia); Admit for I.V. Access (Magnesium and Labetalol) and Fetal Monitoring Ripens Cervix for Induction of Labor - Prostaglandin Effect of Terbutaline on Uterus - Tocolytic (Prevents Pre-Term Delivery) Prevention of Seizures in Pre-Eclampsia (HTN and 0.3 grams in 24-Hour Specimen or Protein/Creatinine Ratio of 0.3 or Dipstick Protein of 1+) With Severe Features Before 34 Weeks - Magnesium (4 Gram LD Over 10 Minutes Followed By 1 Gram Hourly) (1) Under 20. (2) First Time Pregnancy. (3) Twin or Molar Pregnancy. (4) High Cholesterol. (5) Smoker. - Risk Factors for Pre-Eclampsia Long-Term Maternal Complication of Pre-Eclampsia - Gestational Diabetes (Results in Increased Risk for Diabetes Mellitus) Respiratory or Cardiac Failure After Treatment of Pre-Eclampsia with Renal Failure - Supra-Therapeutic Magnesium Levels (Loss of Deep Tendon Reflexes) Management of Hypertension and Acute Pulmonary Edema - Nitroglycerin Causes 95% of Duodenal Ulcers and 85% of Gastric Ulcers - Helicobacter

Two Populations At Highest Risk for Pyelo-Nephritis - Indigent Population and Diabetics With Bacteriuria Management of Esophageal Foreign Body Trapped by Crico-Pharyngeus, Aortic Arch, or Lower Sphincter - Glucagon Before Endoscopy Management of Superior Vena Cava Syndrome from Mass - Elevate Head of Bed and Consult for Radiation or Chemotherapy Extremity Pain Disproportionate to Initial Injury (No Nerve Injury) Extending Beyond Distribution of Single Nerve; Edema, Allodynia (Hyperalgesia), and Sweating

• Venous Doppler Excludes D.V.T. Before Diagnosing Complex Regional Pain Syndrome Pre-Hospital Care Based on Protocols and Standing Orders, Not Direct Contact with Physicians - Off-Line Medical Control E.M.S. Management of Hypo-Glycemia vs. Cardiac Arrest or Anaphylaxis vs. Severe Asthma Exacerbation vs. Seizure Activity - Dextrose vs. Epinephrine vs. Albuterol vs. Benzodiazepine More Important Than Fluid Resuscitation for Traumatic Hemorrhage - Surgical Hemo-Stasis 2 Reasons for Intubation and Gastric Decompression Prior to Flight, Instead of Mid- Air - Difficult to Hear Breath Sounds Over Helicopter Noise and Prevention of Vomiting from Turbulence Pre-Hospital Ventilation in Critically-Ill Neonates Until ECMO Center - Nitric Oxide Diffuse Abdominal Tenderness, Distension and Tympany, Empty Rectal Vault; Hemo- Dynamically Unstable; Normal X-Ray - C.T. After I.V Fluids and Pain Management Days of Right-Sided Abdominal Pain; Exquisite Tenderness; Pneumo-Bilia and Multiple Air-Fluid Levels - Gallstone Ileus Hypothermic Patient, Respiratory Rate of 4; Ventricular Tachycardia; Defibrillation Unsuccessful - Continue Compressions and Warming Determines Level of Hypoxia in Drowning Patient - Volume of Water (Not Fresh vs. Salt) Unilateral Stroke Symptoms for 45 Minutes; Systolic 150, Negative C.T. - Thrombolytics Management of Suspected Ectopic Pregnancy; Systolic 90; H.C.G. Over 4000 - Surgery

Breathing Support for C.H.F. Exacerbation - BiPAP Liver Failure, Upper Extremity Cellulitis; Fever, Fast Rates; Previous Admissions Show Systolics Over 180 - I.C.U. for I.V. Antibiotics Bedside Management of Likely Testicular Torsion - Medial to Lateral Rotation, One- and-a-Half Turns (540 Degrees)