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Editors In Chief
Barry Brenner, MD, PHD; Professor; Program Director; Case Western
Reserve University; United States, Cleveland Heights, OH, USA
Martin Huecker, MD; Assistant Professor; Research Director; University
of Louisville; United States, Louisville, KY, USA
Jason An, MD; Emergency Medicine Attending; Associate Program
Director; Riverside Community Hospital/UCRiverside; United States,
Riverside, CA, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Contributing Editors
Ali Abdulkarim, MBBS; Faculty of Medicine, Cairo University; Cairo,
Egypt
Rachel Abrams, MD; Private Practice; Chicago, IL, USA
Aninda Acharya, MD; Associate Professor; Saint Louis University; St
Louis, MO, USA
Adebayo Adeyinka, MD; Assistant Professor; The Brooklyn Hospital
Center; Brooklyn, NY, USA
Oluwaseun Adigun, MBBS, MSc (Human Anatomy); General
Med.Practice/Research; University of Ilorin; Ilorin, Nigeria
Darin Agresti, DO; St Luke's University Hospital; Nazareth, PA, USA
Faisal Akhtar, MD, MPH, MBA; Ochsner Health Systems; Kenner, LA, USA
Sami Akram, MD, MHA; Southern Illinois University; Springfield, IL, USA
Ahmad Al Aboud, MD; Consultant, Assistant Professor; Head Of
Dermatology Department; King Abdullah Medical City; Makkah, Saudi
Arabia
Yasir Al Khalili, MD; Chief Fellow; Drexel University; Philadelphia, PA,
USA
TitilolaAlao, MD; Private Practice; Ossining, NY, USA
Ana Albuja, MD; Chief Resident Child Neurology; University of Kentucky;
Lexington, KY, USA
Mohammed Al-Dhahir, MB, ChB; Neurosurgeon; Sana'a, Yemen
Faysal Alghoula, MBBch; Creighton University; Omaha, NE, USA
Brady Allen, MD; Assistant Professor; Vice-Chief of Staff; University of
Tennessee; Brentwood, TN, USA
William Alley, MD; Assistant Professor; Clerkship Director; Wake Forest
School of Medicine; Winston Salem, NC, USA
Leonardo Alonso, DO; Orange Park Medical Center; Jacksonville, FL, USA
Ubaid ullah Alozai, MBBS; Dr; Allama Iqbal Medical college; Lahore,
Pakistan
Jason An, MD; Emergency Medicine Attending; Associate Program
Director; Riverside Community Hospital/UCRiverside; Riverside, CA, USA
Bradley Anderson, BS Health Science, ASRT; Campbell University School
of Osteopathic Medicine; Salisbury, NC, USA
Catiele Antunes, MD; Private Practice; Philadelphia, PA, USA
Elisa Aponte, MD, RDMS; Attending Physician; Emergency Ultrasound
Director; Kaweah Delta Medical Center; Visalia, CA, USA
John Ashurst, DO, MSc; Program Director; Kingman Regional Medical
Center; Kingman, AZ, USA
Zaza Atanelov, BA, MD; University of Central Florida, North Florida
Regional Medical Center; Gainesville, FL, USA
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Basem Attum, MD, MS; Research Coordinator; Vanderbilt University
Medical Center; Nashville, TN, USA
Usha Avva, MD; Division Chief, Pediatric ED; Joseph M. Sanzari
Children's Hospital; Hackensack, NJ, USA
Folusakin Ayoade, MD; Assistant Professor; University of Miami; Miami,
FL, USA
Muhammad Aziz, MD; University of Kansas School of Medicine; Kansas
City, MO, USA
Mochamad Helmi Aziz, MD, MSc; Private Practice; DKI Jakarta, Indonesia
John Bader, BS Biological Systems Engineering; University of Nebraska
Medical Center; Omaha, NE, USA
Talel Badri, MD; Associate Professor; University of Tunis El Manar;
Tunis, Tunisia
Crystal Bae, MD; Temple University Hospital; Philadelphia, PA, USA
Mark Baker, MD; SIU School of Medicine; Springfield, IL, USA
Katherine Baranowski, MD; Assistant Professor of Pediatric EM; Rutgers
Health Sciences University; Newark, NJ, USA
Amanda Bates, MD; Temple University Hospital; Philadelphia, PA, USA
Amna Batool, MD; University of Kansas; Kansas City, KS, USA
Amanda Battisti, DO; Professor; Grand Strand Medical Ctr; Myrtle
Beach, SC, USA
Brett Baumgartner, DO; Western Michigan University; Cedar City, UT,
USA
Jason Beaman, DO, MS, MPH; Assistant Professor; Chair, Department of
Psychiatry; OSU CHS; Tulsa, OK, USA
Kevin Beier, MD; Associate Program Director; University of Tennessee -
Murfreesboro; Brentwood, TN, USA
Onecia Benjamin, MD, MS, MA; SUNY Upstate; Syracuse, NY, USA
Thomas Bentley, MD; Assistant Professor; Clerkship Director; University
of Central Florida / North Florida Regional Medical Center; Gainesville,
FL, USA
Luke Berry, MD; Zucker School of Medicine; Manhasset, NY, USA
Courtney Bethel, MD, MPH; Assistant Professor; Drexel University
College of Medicine; Media, PA, USA
Danielle Betz, MD; Temple University Hospital; Philadelphia, PA, USA
Karan Bhatti, MD; University of Texas - Houston; Houston, TX, USA
Steve Bhimji, BSci Pharm, MS, MD, PhD; Clinical Instructor (Retired); Un
of Toronto; Toronto, Canada
Benjamin Bloom, MD; Temple University Hospital; Philadelphia, PA, USA
Maria Bokhari, MBBS, FCPS, FRCR; Visiting Faculty; Tulane Hospital ,
Louisiana; New Orleans, _, USA
Sameh Boktor, MD, MPH; Penn State College of Medicine;
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Mechanicsburg, PA, USA
Michael Boniface, MD; Clinical Instructor; Director of Emergency
Ultrasound; Mayo Clinic; Fleming Island, FL, USA
Michael Bono, MD; Professor of Emergency Medicine; Vice Chair,
Department of Emergency Med; Eastern Virginia Medical School;
Suffolk, VA, USA
Gregory Bookout, DO; Grand Strand Medical Center; Ocean Isle Beach,
NC, USA
Christopher Borowy, BS; Midwestern University; Phoenix, AZ, USA
Philip Bouchette, MD; Louisiana State University HSC; Shreveport, LA,
USA
Emily Bounds, MD; University of Illinois COM Peoria; Peoria, IL, USA
Jared Brackenrich, DO; Lewis Gale - Montgomery; Blacksburg, VA, USA
Mark Brady, MD, MPH, MMS, DTM&H; Assistant Professor; University of
Tennessee; Memphis, TN, USA
Bradley Bragg, MD; Mayo Clinic Florida; Saint Johns, FL, USA
Joshua Brinkman, BS; DeBusk College of Osteopathic Medicine; Corbin,
KY, USA
Daniel Brito, MD; Internal Medicine; Universidad Central de Venezuela;
Philadelphia, PA, USA
Falon Brown, DO; CUSOM/Sampson Regional Medical Center;
Wilmington, NC, USA
Kristin Brown, MD; University of Tennessee; Nashville, TN, USA
Casey Brown, MD; Child Advocacy and Protection Services; Medical
College of Wisconsin; Milwaukee, WI, USA
Jerome Buboltz, MD; Practicing Physician; Aurora Medical Center; West
Bend, WI, USA
Liliana Burdea, MD; Lincoln Medical Mental Health Center; Harrison,
NY, USA
Lauren Burton, MD; UTHSC; Murfreesboro, TN, USA
Jeffrey Bush, MD; Assistant Professor; Program Director; Medical
University of South Carolina; Charleston, SC, USA
Christopher Calandrella, DO; Assistant Professor; Associate Chairman;
North Shore Manhasset; Manhasset, NY, USA
Kevin Carter, DO; Transitional Year Residency Director; McLaren
Oakland; Rochester Hills, MI, USA
Murray Casey, MD, MS, MBA, PhD; Professor of Obstetrics and
Gynecology; Creighton University; Omaha, NE, USA
Danny Castro, DO, MEd; Assistant Professor; Dir of Fellow Ed, Med Dir
of Resp Care; Baylor College of Med, TX Children Hosp; Houston, TX,
USA
Deepak Chandra, MBBS, MD; Uni of Nebraska Medical Center; Omaha,
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NE, USA
Arul Chandran, MD, MRCP; Consultant Pulmonologist; Michigan State
University; Grand Blanc, MI, USA
Stanley Chartoff, MD, MPH; Assistant Professor; Attending Physician
Emergency Medicine; Univ of Connecticut, Hartford Hospital;
Woodbridge, CT, USA
Hammad Chaudhry, MBBS; House Officer; Allama Iqbal Med College,
Jinnah Hosp; Mirpur, Pakistan
Krati Chauhan, MD, MPH; Assistant Professor Rheumatology; Southern
Illinois University; Springfield, IL, USA
Apoorva Cheeti, MBBS; Medical Officer; Kamineni Institute of Medical
Sciences; Shreveport, LA, USA
Min Cho, DO; McLaren Greater Lansing; Lansing, MI, USA
Leigha Clarkson, MD; Brooklyn Hospital; Brooklyn, NY, USA
Megan Cochran, DO; Doctors Hospital - Ohio Health; Galloway, OH, USA
Brian Cohagan, MD; Temple University Hospital; Philadelphia, PA, USA
Tim Connelly, MD; Assistant Professor; Associate Program Director;
Mercer University, Memorial Hospital; Savannah, GA, USA
Jeffrey Cooper, MD; Associate Professor; Director; University of
Nebraska Medical Center; Omaha, NE, USA
Carlin Corsino, DO; Carl R. Darnall Army Medical Center; Killeen, TX,
USA
John Costumbrado, MD, MPH; Riverside Community Hospital/UCR EM;
Riverside, CA, USA
Marsha Crader, PharmD; Associate Professor of Pharmacy Practice;
Univ. of Arkansas for Medical Sciences; Jonesboro, AR, USA
Earl Cummings, V, MD; Louisiana State University HSC; Shreveport, LA,
USA
Wael Dakkak, MD; Stroger Hospital of Cook County; Oak park, IL, USA
Rajeev Dalal, BS; NYIT College of Osteopathic Medicine; York, PA, USA
Tarun Dalia, MBBS; Kansas University Medical Center; Kansas, KS, USA
Amina Danishyar, DO; Midwestern University; Kingman, AZ, USA
Sagar Dave, DO; Hartford Hospital; Hartford, CT, USA
Amy Davis, MD; Emergency Medicine Fast Track Director; Magnolia
Regional Health Center; Corinth, MS, USA
Nathan Davis, MD; University of Tennessee; Murfreesboro, TN, USA
David Davis, MD; Orange Park Medical Center; Ponte Vedra, FL, USA
Maureen Davis, MD; Advocate Christ Medical Center; Chicago, IL, USA
Richard de la Cruz, MD, MS; Prof; Orange Park Medical Center; Green
Cove Springs, FL, USA
Justin Deaton, MD; Orange Park Medical Center; Jacksonville, FL,USA
Matthew Deere, DO; McLaren Greater Lansing - MSUCOM; Bath, MI,
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USA
Renee DeNolf, DO; Kaweah Delta Medical Center; Visalia, CA, USA
Bjorn Dijkstra, MD; Emergency Physician; Westfriesgasthuis;
Midddenbeemster, Netherlands
Christopher Dion, MS; Midwestern University; Phoenix, AZ, USA
Arthur Dublin, MD, MBA; Emeritus Clinical Professor of Radiology; UC,
Davis, Medical Center; Sacramento, CA, USA
Stephanie Duckett, DO; Desert Regional Medical Center; Palm Springs,
CA, USA
Noel Dunn, MD; Private Practice; Tacoma, WA, USA
Roberta Dunn, MD; Associate Professor; Riverside Community Hospital;
Riverside, CA, USA
Mary Eberhardt, MD, MSPH; Adjunct Associate Professor; St Lukes
University Health Network; Cherryville, PA, USA
Peter Edemekong, MD, MPH; Faculty; NOVA Southeastern University
College of Osteopathic Medicine; Jupiter, FL, USA
Charles Eifrig, MD; Adjunct Assist Profess, USC EYE; Retina Associates of
Orange County; Newport Beach, CA, USA
Noha EL-Mohandes, MRCPCH; UHND; Sunderland, United Kingdom
Bishoy Emmanuel, DO; Wyckoff Heights Medical Center; Brooklyn, NY,
USA
Joshua Engelsgjerd, MD; University of Nebraska Medical Center; Omaha,
NE, USA
Stacey Ernest, MD; Loma Linda Unversity Medical Center; Rancho
Cucamonga, CA, USA
Jennifer Evans, DO; Private Practice; Dayton, OH, USA
William Farris, MS, MD; Southern Illinois University; Springfield, IL, USA
Thomas Ferreri, MD; Private Practice; Saginaw, MI, USA
Rebecca Fishman, DO; Director of Medical Education; Mercy Medical
Center; Syosset, NY, USA
Thomas Folino, DO; NYIT College Of Osteopathic Medicine; Brooklyn,
NY, USA
Lisa Foris, MD, MSc; St. George's University; Brooklyn, NY, USA
Christopher Foucher, MD; Clinical Assistant Professor; McLaren Greater
Lansing/MSU COM; Lansing, MI, USA
Daniel Francescon, BS; Private Practice; Columbus, CA, USA
Andrew Freeman, DO; Assistant Director Family Practice; Southeastern
Regional Medical Center; Lumberton, NC, USA
Justin Fuehrer, DO; Private Practice; Glen Oaks, NY, USA
Evan Fusco, BS, MD, MHA; Medical Director; Springfield, MO, USA
Kavitha Ganesan, MD; Orange Park Medical Center; Jacksonville, FL, USA
Jonathan Gapp, MD; Creighton University; Omaha, NE, USA
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Emily Garmon, MD; Assistant Professor; Medical Director; Texas A&M
HSC and Baylor Scott & White; Temple, TX, USA
Veronica Garvia, MD; Einstein Medical Center; Philadelphia, PA, USA
Amani Gharbi, MD; La Rabta Hospital; Tunis, Tunisia
Namratta Ghatehorde, BSc, MD; Univeristy of Missouri Columbia;
Columbia, MO, USA
Amanda Gibson, DO; Ohio Health Doctors/Ohio Univ; Columbus, OH,
USA
Jacob Ginglen, DO, BSN; McLaren Oakland Hospital; Rochester, MI, USA
Niklas Glenesk, BS; American University of the Caribbean; Novi, MI, USA
Reshma Golamari, MD; Drexel University; Yeadon, PA, USA
Allen Gold, DO; Northwell Health; Little Neck, NY, USA
Nina Gold, MD; Attending; Hackensack University Medical Center; Fair
Lawn, NJ, USA
Scott Goldstein, DO; Assistant Professor; Dir, Division of EMS, Disaster
Med; Philadelphia, PA, USA
Daphne Joyce Gonzales, MD; Private Practice; Tinton Falls, NJ, USA
Dulce Gonzalez, MD; Lincoln Hospital; New York, NY, USA
Steven Goodfriend, MD; Medical Director; Orange Park Medical Center;
Ponte Vedra, FL, USA
William Gossman, MD; Professor; Creighton University; Elkhorn, NE,
USA
Peter Gotsis, DO; Program Director; University Hospitals; Amherst, OH,
USA
Abhinav Goyal, MD; Private Practice; Philadelphia, PA, USA
Alin Gragossian, DO, MPH; Drexel University; Philadelphia, PA, USA
Charles Graham, MD; Clinical Instructor; Mayo Clinic Florida; Neptune
Beach, FL, USA
Jeremy Graham, DO; Emergency Department Medical Director; Magnolia
Regional Health Center; Corinth, MS, USA
Alexandria Griddine, MD; Medical University South Carolina;
Charleston, SC, USA
Areg Grigorian, MD; Private Practice; Orange, CA, USA
Shamai Grossman, MD, MS; Associate Professor; Vice Chair for Health
Care Quality; HVD Med Sch; Boston, MA, USA
Amanda Guerra, PA-C; Brooklyn, NY, USA
Arun Gulani, MD, MS; Private Practice; Jacksonville, FL, USA
Jalaja Gundrathi, MD; Lanolin Medical Center; Bronx, NY, USA
Gunjan Gupta, MD, MS; IGMC; Shimla, India
Marco Gupton, BS; Campbell University; Salisbury, NC, USA
Kothai Divya Guruswamy Sangameswaran, MD; University of Oklahoma
- Tulsa Campus; Broken Arrow, OK, USA
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Steven Habusta, DO, MEd; Professor; Program Director Orthopedic
Residency; LECOM; Erie, PA, USA
Yamama Hafeez, DO; Campbell University School of Osteopathic
Medicine; Lillington, NC, USA
Wissem Hafsi, MD; University Assistant; Dermatologist and
Venereologist; Faculty of Medicine of Tunis, Tunisia; Bardo, Tunisia
Susan Hageman, BS; University of Nebraska Medical Center; Omaha, NE,
USA
Heather Hager, DNP; Doctorate; Dr.; Ochsner Flight Care; Flowood, MS,
USA
Eryk Hakman, BS; American University of the Caribbean; Novi, MI, USA
Mary Hanley, DO; Associate Professor; Pro Dir Undersea and Hyperbaric;
Un of N En Coll of Osteo Med; Charleston, SC, USA
Sonia Hans, MD; LSU Health Sciences Center - Shreveport; Shreveport,
LA, USA
Aaron Hanyu-Deutmeyer, DO; Private Practice; Chicago, IL, USA
Weston Harkness, DO; Sky Ridge Medical Center; Lone Tree, CO, USA
Micelle Haydel, MD; Clinical Professor; Louisiana State University HSC;
New Orleans, LA, USA
Shireen Hedya, BSc; Private Practice; Cairo, Egypt
Eric Hexdall, BSN, RN, ACHRN; Clinical Nurse Educator; Duke Regional
Hospital; Durham, NC, USA
Jason Hill, MD, MPH; Beth Israel Deaconess Medical Center; Brookline,
MA, USA
Daniel Hilton, DO; McLaren Oakland Hospital; Clawson, MI, USA
Erin Hopkins, BS; Lincoln Memorial University- Debusk College of
Osteopathic Medicine; Corbin, KY, USA
Keahi Horowitz, BM, MM; John A. Burns School of Medicine; Honolulu,
HI, USA
Steven House, MD; Professor; Residency Program Director; University of
Louisville; Glasgow, KY, USA
Robert Howard, MS, MD; Assistant Professor; Drexel University;
Glenside, PA, USA
Theresa Hsiao, DO; Albert Einstein Medical Center; Philadelphia, PA,
USA
Hunter Hsu, DO; Clinical Associate Professor; Orthopedic Surgery
Resident; Michigan State University; Pontiac, MI, USA
Che-wei Hsu, MBBS; Taipei Medical University Hospital; Taipei, Taiwan
Martin Huecker, MD; Assistant Professor; Research Director; University
of Louisville; Louisville, KY, USA
J. Stephen Huff, MD; Professor; University of Virginia; Charlottesville,
VA, USA
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Robert Hughes, PharmD; Private Practice; Lexington, KY, USA
Channing Hui, MD; Private Practice; Highland Park, NJ, USA
Chen-Yu Hung, MD; National Taiwan University Hospital, Beihu Branch;
New Taipei City, Taiwan
Osagie Igiebor, MD; St. George's University; Bronx, NY, USA
Louis Imbriano, MD; Assistant Professor of Clinical Medicine; Winthrop
University Hospital; Mineola, NY, USA
Kimon Ioannides, MD; Temple University Hospital; Philadelphia, PA,
USA
Ashika Jain, MD; Associate Professor; Director- Division of Emergency
Trauma; New York University Langone Health; New York, NY, USA
Rebecca Jeanmonod, MD; Professor; Associate Residency Program
Director; St. Luke's University Health Network; Hellertown, PA, USA
Lindsey Jennings, MD, MPH; Assistant Professor; Assistant Residency
Director; Medical University of South Carolina; Charleston, SC, USA
Jacob Jensen, DO, DiMM, FAWM; OSF St Francis Med Center EM
Residency; Peoria, IL, USA
Kelly Johnson-Arbor, MD; MedStar Georgetown University Hospital;
Washington, DC, USA
Mark Jones, DO; Professor; McLaren Greater Lansing, MSUCOM; East
Lansing, MI, USA
Wesley Jones, DO; Advocate Christ Medical Center; Chicago, IL, USA
Kimberly Jones, MD; Assistant Professor; University of Kentucky;
Lexington, KY, USA
JonathanJourney, MD; Assistant Professor; University of Central
Florida/North Florida Regional Medical Center; Gainesville, FL, USA
Pallavi Juneja, BA; Wake Forest School of Medicine; Winston-Salem, NC,
USA
Nathaniel Justice, MD, MBA; Assistant Professor; East Tennessee State
University; Johnson City, TN, USA
Renu Kadian, MBBS; Great Plains Health; North Platte, NE, USA
Kevin Kammel, MD, MPH; Hahnemann University Hospital; Philadelphia,
PA, USA
Michael Kang, MD; Assistant Clinical Professor; Emergency Medicine
Attending Physician; Riverside Community Hospital/UCRiverside;
Riverside, CA, USA
Laura Kasman, PhD; Associate Professor; Medical University of South
Carolina; Charleston, SC, USA
Mohammed Kassem, MD; SUNY Upstate University Hospital; Syracuse,
NY, USA
Brian Kelly, DO; St. Luke's University Health Network; Perkasie, PA, USA
Kenneth Kennedy, MD; University of Louisville; Louisville, KY, USA
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Erika Kettelhut, DO, MPH; OhioHealth O'Bleness Hospital; The Plains,
OH, USA
Ali Khairat, MD; Weill Cornell Medicine - Qatar; New York, NY, USA
Muhammad Khalid, MD; Drexel Univ College of Medicine; Philadelphia,
PA, USA
John Kiel, DO, MPH; University of Kentucky; Lexington, KY, USA
Kyle Kim, MD; Central Michigan University; Saginaw, MI, USA
Gregory King, PharmD; Clinical Pharmacist; Saint Joseph Hospital;
Lexington, KY, USA
Patrick Kirkland, MD; Harbor-UCLA; Omaha, NE, USA
Matthew Klein, MD, MPH; Northwestern University; Chicago, IL, USA
Thomas Knorr, MD; Beth Israel Deaconess Medical Center; Boston, MA,
USA
Laxmi Kokatnur, MD; Louisiana State University; Shreveport, LA, USA
Noah Kondamudi, MD, MBA; Associate Professor; Medical Director;
Rutgers New Jersey Medical School; West Orange, NJ, USA
Michael Kopstein, DO; Rocky Vista University/Sky Ridge Medical Center;
Lone Tree, CO, USA
Harish Kotipoyina, MD; UCF/North Florida Regional Medical Center;
Gainesville, FL, USA
Rachana Krishna, MD; Private Practice; Rochester, MN, USA
Caitlin Krull, BS, MD; Presence Ressurection Hospital; Skokie, IL, USA
Diann Krywko, MD; Associate Professor; Wellness and Professional Dev.
Director; Medical University of South Carolina; Mount Pleasant, SC, USA
Amy Lagina, OD; Clinical Assistant Professor; Optometrist; University of
Michigan; Dexter, MI, USA
Frank Lane, BS, MD; Temple Medical School; Tampa, FL, USA
Aaron Lawrence, DO; Central Michigan University; Saginaw, MI, USA
Kenny Lee, MD; Private Practice; Visalia, CA, USA
Amy Lee, MD, MS; Resident Physician; Brooklyn Hospital Center;
Brooklyn, NY, USA
Jessica Leek, BS; Midwestern University - AZCOM; Chicago, IL, USA
Stephen Leslie, MD; Associate Professor of Surgery, Urology; MD;
Creighton University Medical Center; Omaha, NE, USA
David Levy, DO; Consultant; Waikato Hospital; Hamilton, New Zealand
Tian Liang, MD; SUNY Downstate Medical Center; Brooklyn, NY, USA
Catherine Linzay, MD; Louisiana State University HSC; Shreveport, LA,
USA
Peter Lopez, MD; Clinical Assistant Professor; MSU; Bloomfield Hills, MI,
USA
Seth Lotterman, MD; Assistant Professor; Hartford Hospital; Hartford,
CT, USA
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T. David Luo, MD; Wake Forest Baptist Medical Center; Winston-Salem,
NC, USA
Christopher Maani, MD; Professor; Attending Anesthesiologist; US
Army; Boerne, TX, USA
Angela Macri, DO, MMS; Sampson Regional Medical Center;
Wilmington, NC, USA
Ajay Mahajan, MD; Royal College of Surgeons in Ireland; Calgary,
Canada
Muddassar Mahboob, MBBS; Private Practice; Riyadh, Saudi Arabia
Kenneth Maniscalco, MD; Louisiana State University Shreveport;
Shreveport, LA, USA
Edward Margolin, MD; Associate Professor; University of Toronto;
Toronto, Canada
Spencer Masiewicz, DO; Grand Strand Medical Center; Myrtle Beach, SC,
USA
Luke Maxfield, DO; Sampson Regional Medical Center; Soddy Daisy, TN,
USA
Christopher McDowell, MD, MEd; Associate Professor; Vice Chair
Emergency Medicine; SIU School of Medicine; Springfield, IL, USA
Ailbhe McGrath, MB, BCh, BAO; Our Lady's Children's Hospital, Crumlin;
Co Meath, Ireland {Republic}
Rita McKeever, MD; Assistant Professor; Drexel University School of
Medicine; Narberth, PA, USA
Kevin McLendon, EMTP, BA, DO; Merit Health Wesley; Hattiesburg, MS,
USA
Oren Mechanic, MD, MPH; Health Policy and Management; Harvard
Medical School/BIDMC; Boston, MA, USA
Suman Medda, MD; Wake Forest Baptist Medical Center; Winston
Salem, NC, USA
Scott Melanson, MD; Professor of Emergency Medicine; Residency
Program Director; St. Luke's University Health Network; Bethlehem, PA,
USA
Richard Menger, MD, MPA; Louisiana State University Health Sciences
Center; Shreveprot, LA, USA
Marcelle Meseeha, MD; Private Practice; Sayre, PA, USA
Alyssa Miceli, DO; Private Practice; Jacksonville, FL, USA
Nicholas Michols, DO, ATC; Medical Officer; Naval Medical Center
Portsmouth; Norfolk, VA, USA
Kayvon Milani, JD; Kern Medical; Bakersfield, CA, USA
Brianna Miner, MD; Advocate Christ Medical Center; Chicago, IL, USA
Justine Moe, MD, DDS; Emory University; Atlanta, GA, USA
Michael Mohseni, MD; Assistant Professor; Mayo Clinic; Atlantic Beach,
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FL, USA
Nathan Moore, MB, BCh, BAO BSc, MRCS; Orthopaedic Specialty
Registrar; Torbay Hospital; Plymouth, United Kingdom
Christine Moore, DO, BA; East Tennessee State University; Johnson City,
TN, USA
Deborah Morris, PA-C, MD; Associate Professor; MD; Methodist
University Physician Assistant Program; Fayetteville, NC, USA
Steven Mountfort, AS, BS; Education Coordinator; Florida Hospital;
Orlando, FL, USA
Xenophon Mucciarone, DO; McLaren Oakland; Waterford, MI, USA
Taif Mukhdomi, MD; University of California Riverside; Columbus, OH,
USA
Pinaki Mukherji, MD; Long Island Jewish Medical Center; New York, NY,
USA
Jeff Mullen, DO; Assocaite Program Director EM; CAMC; Charleston, WV,
USA
Tessa Mullins, DO; Lewis Gale Hospital - Montgomery; Blacksburg, VA,
USA
Sadaf Munir, MBBS, DCH, MCCEE; Clinical Assistant & Case Manager;
Morganville, NJ, USA
Kelly Murphy, MD, MS, LT, MC, NMCP; Naval Medical Center
Portsmouth; Norfolk, VA, USA
Alexandra Murray, DO; Chief Resident; Mercy St. Vincent Medical
Center; Perrysburg, OH, USA
Srividya Naganathan, MD; Clinical Associate Professor; Jersey Shore
University Medical center; Neptune, NJ, USA
Pragya Nair, MD; Professor; Karamsad Gujarat, India
Thomas Nappe, DO; Assistant Professor; Emerg Physician, Medical
Toxicologist; St. Luke's University Health Network; Bethlehem, PA, USA
Usker Naqvi, MD, MS; Univ. of Miami/Jackson Health System; Miami, FL,
USA
Naomi Nardi, DO; Private Practice; Peoria, IL, USA
Gul Nawaz, MBBS; Jinnah Hospital; Lahore, Pakistan
Sara Nehring, DO; Program Director, DME; St Bernards Medical Center;
Jonesboro, AR, USA
Divyesh Nemakayala, MD; Michigan State University; Lansing, MI, USA
Valerie Nemeth, DO; Private Practice; Sandusky, OH, USA
Zeid Nesheiwat, DO; Michigan State University - McLaren Oakland; West
Bloomfield, MI, USA
Matthew Neulander, MD; Assistant Professor; UConn; South
Glastonbury, CT, USA
Ruben Ngnitewe Massa, MD; University of Missouri; Columbia, MO, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Hoang Nguyen, MD; Assistant Professor; Rush University Medical
College; Chicago, IL, USA
Asif Noor, MD; Pediatric Infectious Diseases Physician; Winthrop
University Hospital; Mineola, NY, USA
Kenneth Norman, MD; St. Luke's University Health Network;
Breinigsville, PA, USA
Robert Oelhaf, MD; Emergency Medicine; Elk Regional Health Center;
Saint Marys, PA, USA
Tony Oliver, MD, MRCP, FACP; Assistant Professor; University Of South
Dakota; Sioux Falls, SD, USA
Maria O'Rourke, MD; Assistant Professor; GME EM US Director; Dignity
Health - STMC - Stockton, CA; Gig Harbor, WA, USA
Venu Pararath Gopalakrishnan, MD, MBBS; PrivatePractice; Evanston,
IL, USA
Salvatore Pardo, MD, MBA; Assistant Professor; Vice Chair; Hoftstra
University; Brooklyn, NY, USA
Jai Parekh, MBBS; Creighton University Medical Center; Omaha, NE, USA
Nina Parikh, DO; Touro U of Nev Col of Osteopathic Med; Irvine, CA,
USA
Ronak Patel, BS; SUNY Upstate Medical University; Syracuse, NY, USA
Shivani Patel, BS; NYITCOM; Brooklyn, NY, USA
Juan Patiño, MD; Chief Upper Extremity Unit; Hospital Militar Central;
Buenos Aires, Argentina
John Patterson, MD; Associate Professor; EM Faculty, Former Chair EM;
St. Luke's Univ. Hosp. Bethlehem; Bethlehem, PA, USA
Laryssa Patti, MD; Instructor, Emergency Medicine; Rutgers RWJMS;
Somerset, NJ, USA
Daniel Penrice, BS; University of Nebraska Medical Center; Omaha, NE,
USA
Thomas Perera, MD; Associate Professor; Hofstra Northwell; Manhasset,
NY, USA
Yomayra Perez, MD; Private Practice; Bronx, NY, USA
John Pester, DO; Assistant Professor; Faculty; St. Luke's University
Health Network; Bethlehem, PA, USA
Ryan Peterfy, DO; Private Practice; Palm Springs, CA, USA
Louisdon Pierre, MD, MBA; Assistant Professor Clinical Pediatrics;
Director, Pediatric Critical Care; Ichan School of Medicine at Mount
Sinai; Suffern, NY, USA
Hannah Pile, BSN; Campbell University; Hope Millls, NC, USA
Caleb Pingel, MS, MD; Southern Illinois University SOM; Chatham, IL,
USA
Letitia Pirau, BA; California Northstate University; El Dorado Hills, CA,
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
USA
Michael Plewa, MD; Director of Research; Holland, OH, USA
Shawn Posin, MD; Core Faculty; Simulation Director; Ohio Valley
Medical Center; Wheeling, WV, USA
Ewa Posner, MD; Consultant Pediatrician; University Hospital of North
Durham; Durham, United Kingdom
Jim Powers, DO; Professor; Associate Dean for Clinical Integration;
Campbell Univ. School of Osteopathic Med; Holly Springs, NC, USA
Yana Puckett, MD, MPH; Texas Tech Un Health Sciences Center;
Lubbock, TX, USA
Erion Qaja, DO; Wyckoff Heights Medical Center; Brooklyn, NY, USA
Mohammed Qasswal, MD; Al Quds University School of Medicine,
University of Texas at Houston; Houston, TX, USA
Marc Raj, DO; Bodor Clinic; Napa, CA, USA
Fergie Ramos Tuarez, MD; University of Miami; Wellington, FL, USA
Mark Ramzy, DO; Drexel University; Philadelphia, PA, USA
Chandni Ravi, MD; Rutgers University; Jersey City, NJ, USA
Keith Raymond, MD; CNUCOM; Muckendorf an der Donau, Austria
Alejandro Recio-Boiles, MD; University of Arizona; Tucson, AZ, USA
Mirembe Reed, PharmD; Private Practice; Brighton, MA, USA
Hariharan Regunath, MD; Assistant Professor; University of Missouri;
Columbia, MO, USA
Gage Rensch, BA, BS; University of Nebraska Medical Center; Omaha,
NE, USA
Felix Reyes, MD; State University of New York; Brooklyn, NY, USA
John Richards, MD; Professor; UC Davis Medical Center; Sacramento,
CA, USA
Gilberto Rivera-Dominguez, MD; MD Medical Group; Houston, TX, USA
Erika Robb, MD; Private Practice; Peoria, IL, USA
Mary Rodriguez Ziccardi, MD; Private Practice; Philadelphia, PA, USA
Alexis Rafael Rojas, MD; Assistant Professor; UNAN, Managua; Miami,
FL, USA
Helbert Rondon, MD; Assistant Professor of Medicine; University of
Pittsburgh; Pittsburgh, PA, USA
Adam Ross, MD; Assistant Professor; University of Louisville; Louisville,
KY, USA
Rochelle Rubin, PharmD, BCPS, CDE; Senior Clinical Pharmacy
Coordinator; The Brooklyn Hospital Center; Brooklyn, NY, USA
Lokesh Rukmangadachar, MBBS, MD; Keck School of Medicine of USC;
Los Angeles, CA, USA
Tyler Runde, DO; Un of Illinois College of Medicine; Peoria, IL, USA
Abdolreza Saadabadi, MD; Assistant Professor; Western University/
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Kaweah Delta; Visalia, CA, USA
Ayan Sabih, MBBS; Medical Registrar; Waikato DHB; Hamilton, New
Zealand
Carolyn Sachs, MD, MPH; Health Science Clinical Professor Step 3; UCLA;
Rossmoor, CA, USA
Saema Said, MD; RCH/UCR; Riverside, CA, USA
Karima Sajadi-Ernazarova, MD; Assistant Professor; Associate Residency
Program Director; Drexel University College of Medicine; Merion
Station, PA, USA
Taimur Saleem, MD; Senior Fellow Physician; David Geffen School of
Medicine UCLA; Los Angeles, CA, USA
Dahlia Saleh, DO; Sampson Regional Medical Center; Wilmington, NC,
USA
Philip Salen, MD; Attending; St. Luke's University Hospital; Bethlehem,
PA, USA
Hrishikesh Samant, MD; Assistant Professor; LSUHSC; Shreveport, LA,
USA
Juan Carlos Sánchez-Manso, MD; Consultant; MD; Hospital Virgen de la
Concha (Zamora); Madrid, Spain
Justin Sanders, DO; Orange Park Medical Center; Jacksonville, FL, USA
Livia Santiago-Rosado, MD; Assistant Professor; Vice Chair; Nassau
University Medical Center; Massapequa, NY, USA
Timothy Schaefer, MD; Clinical Professor; Chair; Peoria, IL, USA
Dmitriy Scherbak, DO; Attending; Director of Resident Research; Rocky
Vista University; Greenwood Village, CO, USA
Michael Schick, DO, MA; Assistant Professor; UC Davis Medical Center;
Davis, CA, USA
Pamela Schmidt, MSN, RN-C, WHNP-BC, C-EFM; Perinatal Clinical
Specialist; Sisters of Charity Hospital; Buffalo, NY, USA
Joseph Sciammarella, MD, FACP, FACEP; Medical Director Niagara Falls
Fire Dept; Lindenhurst, NY, USA
Mohammad Selim, MD; Creighton University; Omaha, NE, USA
Rouhin Sen, MD; Creighton University; Omaha, NE, USA
Justin Sevy, MD; Private Practice; Fort Benning, GA, USA
Rushikesh Shah, MD; Emory University Hospital; Decatur, GA, USA
Niraj Shah, MD; Assistant Professor of Medicine; University Of
Mississippi Medical Center; Madison, MS, USA
Faizan Shaikh, MD; St Mary Mercy Hospital; Farmington Hills, MI, USA
Gyanendra Sharma, MBBS, MSc; Private Practice; Monroe, LA, USA
Sandeep Sharma, MD; Adjacent Faculty, Attending; MD; Baptist
Regional Medical Center; London, KY, USA
Abdul Siddiqui, MBBS; MD; Northwell Health SIUH; Staten Island, NY,
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
USA
Michael Silberman, DO; Assistant Professor; Research Director;
University of Tennessee; College Grove, TN, USA
Jason Silberman, MD; UTHSC; Germantown, TN, USA
Leslie Simon, DO; Assistant Professor, Emergency Medicine; Mayo Clinic
Florida; Jacksonville, FL, USA
Kari Simonsen, MD; Associate Professor; University of Nebraska Medical
Center; Omaha, NE, USA
Shashank Singh, MD; Assistant Professor; Louisiana State University
Health Science Center Shreveport; Shreveport, LA, USA
Virteeka Sinha, MD; Assistant Professor; Rutgers New Jersey Medical
School; New York, NY, USA
Subhas Sitaula, MD; SUNY Upstate Medical University; Syracuse, NY,
USA
Gwenn Skar, MD; University of Nebraska Medical Center; Omaha, NE,
USA
Keegan Skidmore, MD; Temple University Hospital; Blue Bell, PA, USA
Sam Slade, DO, MBA; Midwestern University; Kingman, AZ, USA
Matthew Smith, MD; Lieutenant; CBIRF; Indian Head, MD, USA
James Smith, MD; Attending Physician; Bassett Army Community
Hospital; Fort Wainwright, AK, USA
Kaitlyn Smith, DO; Kent Hospital; Pawtucket, RI, USA
Jessica Snowden, MD; Associate Professor; University of Nebraska
Medical Center; Omaha, NE, USA
Ahsan Sohel, DO; University of California, Los Angeles; Orange, CA, USA
Jessica Sop, DO; Associate Professor WVSOM; EM Residency Program
Director; Charleston Area Medical Center; Charleston, WV, USA
Francis Squadrito, MD; Temple University Hospital; Devon, PA, USA
Pranay Srivastava, BD, MD; Nassau University Medical Center; East
Meadow, NY, USA
Michael Stanley, DO; Assistant Professor; Residency Program Director;
Kaweah Delta Hospital; Fresno, CA, USA
Eric Stashko, MD; WakeMed; Apex, NC, USA
Megan Stobart Gallagher, DO; Clinical Instructor; Assistant Program
Director; Philadelphia, PA, USA
Maranda Stokes, BS; Kern Medical Center; Bakersfield, CA, USA
Daniel Chiung Jui Su, MD, RMSK; Visiting staff; Chi Mei Medical Center;
Tainan, Taiwan
Jolee Suddock, DO; University of New Mexico; Albuquerque, NM, USA
Joel Szymanski,DO; McLaren, Michigan State University; Rochester, MI,
USA
Ayesha Tabassom, MD; Bossier City, LA, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Carolina Tapia, MD; Instituto Mexicano del Seguro Social; Guadalajara,
Mexico
Roger Taylor, DO; Conemaugh Memorial Medical Center; Johnstown,
PA, USA
Steven Tenny, MD, MPH, MBA; University of Nebraska Medical Center;
Omaha, NE, USA
Tammy Toney-Butler, AS, RN, CEN, TCRN, CPEN; Clinical
Instructor/Nurse Educator; Naples, FL, USA
Allison Torlincasi, MS, NCCPA; Lincoln Medical Center; Farmingdale, NY,
USA
Klaus Torp, MD; Assistant Professor; Mayo Clinic Florida; Jacksonville,
FL, USA
Jeremy Traylor, DO; Program Director; Grandview Hospital; Waynesville,
OH, USA
Brad Trinidad, MD; University of Arizona Medical Center; Tucson,
Afghanistan
Justina Truong, DO; KRMC; Kingman, AZ, USA
Audrey Tse, MD; NYU Langone Health; New York, NY, USA
Robert Tubben, DO; Associate Professor; Residency Program Director;
McLaren Greater Lansing/ Michigan State; Okemos, MI, USA
William Tucker, BS; ETSU Quillen College of Medicine; Johnson City, TN,
USA
Anisha Turner, MD; Louisiana State University Shreveport; Shreveport,
LA, USA
Jake Turner, BSc; University of Warwick Medical School; Warwick,
United Kingdom
Patrick Tyrrell, DO; Michigan State University College of Osteopathic
Medicine / McLaren Greater Lansing; Alto, MI, USA
Anusha Vakiti, MBBS; Private Practice; Silver Spring, MD, USA
Joel Valencia, MD; University of California Riverside; Riverside, CA, USA
Ngoc Van Horn, MD; Clinical-Educator Instructor; University of Texas-
Southwestern/Dallas Childrens Medical Center; Dallas, TX, USA
Nicole Van Horne, DO; Grandview Medical Center/Kettering Health
Network; Kettering, OH, USA
Danny VanValkinburgh, MD; University of Tennessee HSC COM
Memphis; Memphis, TN, USA
Dona Varghese, MD; Hospitalist; Huggins Hospital; Wolfeboro, NH, USA
Sarayu Vasan, MD, MPH; UCLA - Kern Medical; Bakersfield, NH, USA
Roy Vega, MD; Assistant Professor of Pediatrics; Director, Pediatric ED;
Bronx Lebanon Hospital Center; Bronx, NY, USA
Viliane Vilcant, DO, MBS; Nassau University Medical Center;
Massapequa, NY, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Timporn Vitoonpong, MD; Attending Physician; MD; King Chulalongkorn
Memorial Hospital; Bangrak, Thailand
Josephine Vranick, AAS, BSN, MSN; Nurse Educator; VAMC Northport;
Commack, NY, USA
Nicholas Walker, MD; Winston Salem, NC, USA
J Walker, III, MD, MS; Assistant Professor; University of TN Health
Science Center; Memphis, TN, USA
Heather Wallace, MPAS, MS; Private Practice; Alexandria, VA, USA
Gregory Wanner, DO; Clinical Assistant Professor; Emergency Physician;
Christiana Care Health System; Newark, DE, USA
Matthew Warner, MD, CPE; Vice Chair Dept of EM, Clinical Faculty;
Rowan Univ SOM, Inspira Health Network; Mullica Hill, NJ, USA
Tyler White, MD; Louisiana State University; New Orleans, LA, USA
Adam Wiercinski, DO; Grandview Medical Center; Dayton, OH, USA
Mollie Williams, MD, MPH; Program Director; The Brooklyn Hospital
Center; Brooklyn, NY, USA
Davis Willmann, MD; St. Luke's University Hospital; Allentown, PA, USA
Daniel Willner, MD, MPH; Beth Israel Deaconess Medical Center;
Boston, MA, USA
Micah Wittler, DO, MS; Associate Professor; Western University of
Health Sciences; Redlands, CA, USA
Steve Wolfe, DO; Kaweah Delta Graduate Medical Education; Visalia,
CA, USA
Robert Wolford, MD, MMM; Associate Professor; Un of IL College of
Med, OSF Med Center; Peoria, IL, USA
Michael Wong, BA; Ochsner; River Ridge, LA, USA
Curtis Wong, MD; Instructor; UC Davis School of Medicine; Redding, CA,
USA
Todd Wylie, MD; Assistant Professor; Un of Florida College of Medicine;
Jacksonville, FL, USA
Kathryn Xixis, MD; Assistant Professor; East Tennessee State University;
Johnson City, TN, USA
Niraj Yadav, MBBS; Creighton University Medical Center; Omaha, NE,
USA
Rama Yasaei, MD; Kaweah Delta Medical Center; Pleasant Hill, CA, USA
Ho-Wang Yuen, MD; Attending; Arrowhead Regional Medical Center;
Colton, CA, USA
Lihan Zhang, MBBS, BSc (Hons); Plastic Surgery Registrar; Derriford
Hospital; Plymouth, United Kingdom
Patrick Zito, DO, PharmD; Faculty; Walden University; Fort Lauderdale,
FL, USA
Endrit Ziu, MD, PhD; University of Missouri Columbia; Columbia, MO,
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
USA
Authors
Tony Abdelmaseeh, MD; Private Practice; Bronx, NY, USA
Ali Abdulkarim, MBBS; Faculty of Medicine, Cairo University; Cairo,
Egypt
Rachel Abrams, MD; Private Practice; Chicago, IL, USA
Aninda Acharya, MD; Associate Professor; Saint Louis University; St
Louis, MO, USA
Runa Acharya, MD; Assistant Professor; SUNY Upstate Medical
University; Fayetteville, NY, USA
Heath Ackley; Private Practice; , NY, USA
Adebayo Adeyinka, MD; Assistant Professor; The Brooklyn Hospital
Center; Brooklyn, NY, USA
Oluwaseun Adigun, MBBS, MSc (Human Anatomy); General
Med.Practice/Research; University of Ilorin; Ilorin, Nigeria
Darin Agresti, DO; St Luke's University Hospital; Nazareth, PA, USA
Halleh Akbarnia, MD; Assistant Program Director; Prescience
Resurrection Emergency Med; Glenview, IL, USA
Bobak Akhavan, MD; University of Texas at Houston, McGovern Medical
School; Houston, TX, USA
Faisal Akhtar, MD, MPH, MBA; Ochsner Health Systems; Kenner, LA, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Issaka Akparibo, MBChB, MS, DAv MED; Private Practice; Dayton, OH,
USA
Ahmad Al Aboud, MD; Consultant, Assistant Professor; Head Of
Dermatology Department; King Abdullah Medical City; Makkah, Saudi
Arabia
Yasir Al Khalili, MD; Chief Fellow; Drexel University; Philadelphia, PA,
USA
Titilola Alao, MD; Private Practice; Ossining, NY, USA
Ana Albuja, MD; Chief Resident Child Neurology; University of Kentucky;
Lexington, KY, USA
Mustafa Al-Chalabi, DO; Campbell University School Of Osteopathic
Medicine; Hope Mills, NC, USA
Mohammed Al-Dhahir, MB, ChB; Neurosurgeon; Sana'a, Yemen
Faysal Alghoula, MBBch; Creighton University; Omaha, NE, USA
Abdallah Allam, MD; Assistant Lecturer; Dr; Department of Physical
Medicine,Rheumatology and Rehabilitation.Tanta University School of
Medicine; Tanta, Egypt
Kathrin Allen, MD; Assistant Professor; West Virginia University;
Morgantown, WV, USA
Brady Allen, MD; Assistant Professor; Vice-Chief of Staff; University of
Tennessee; Brentwood, TN, USA
Miranda Allen, DO; Metro Health Hospital University of Michigan
Health; Wyoming, MI, USA
Leonardo Alonso, DO; Orange Park Medical Center; Jacksonville, FL, USA
Mark Aloysius, MD, PhD; Chief Resident; Icahn School of Medicine at
Mount Sinai; Yonkers, NY, USA
Ubaid ullah Alozai, MBBS; Dr; Allama Iqbal Medical college; Lahore,
Pakistan
Jason An, MD; Emergency Medicine Attending; Associate Program
Director; Riverside Community Hospital/UCRiverside; Riverside, CA, USA
Bradley Anderson, BS Health Science, ASRT; Campbell University School
of Osteopathic Medicine; Salisbury, NC, USA
Ali Arif, MD, MBBS; Private Practice; Philadelphia, PA, USA
Tyler Armstrong, MD; University of Tennessee - Nashville; Nashville, TN,
USA
John Ashurst, DO, MSc; Program Director; Kingman Regional Medical
Center; Kingman, AZ, USA
Maximos Attia, MD; Faculty Associate; Guthrie/RPH Family Residency
Program; Sayre, PA, USA
Basem Attum, MD, MS; Research Coordinator; Vanderbilt University
Medical Center; Nashville, TN, USA
Usha Avva, MD; Division Chief, Pediatric ED; Joseph M. Sanzari
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Children's Hospital; Hackensack, NJ, USA
Muhammad Aziz, MD; University of Kansas School of Medicine; Kansas
City, MO, USA
Mochamad Helmi Aziz, MD, MSc; Private Practice; DKI Jakarta, Indonesia
John Bader, BS Biological Systems Engineering; University of Nebraska
Medical Center; Omaha, NE, USA
Crystal Bae, MD; Temple UniversityHospital; Philadelphia, PA, USA
Mark Baker, MD; SIU School of Medicine; Springfield, IL, USA
Subhankar Bandyopadhyay, MD, MBA; Director, Pediatric Emergency
Medicine; Brandon Regional Hospital; Hummelstown, PA, USA
Katherine Baranowski, MD; Assistant Professor of Pediatric EM; Rutgers
Health Sciences University; Newark, NJ, USA
William Barrett, MD; Louisiana State Un Health Science Center;
Shreveport, LA, USA
Amanda Bates, MD; Temple University Hospital; Philadelphia, PA, USA
Amna Batool, MD; University of Kansas; Kansas City, KS, USA
Amanda Battisti, DO; Professor; Grand Strand Medical Ctr; Myrtle
Beach, SC, USA
Brett Baumgartner, DO; Western Michigan University; Cedar City, UT,
USA
Jason Beaman, DO, MS, MPH; Assistant Professor; Chair, Department of
Psychiatry; OSU CHS; Tulsa, OK, USA
Kevin Beier, MD; Associate Program Director; University of Tennessee -
Murfreesboro; Brentwood, TN, USA
Onecia Benjamin, MD, MS, MA; SUNY Upstate; Syracuse, NY, USA
Thomas Bentley, MD; Assistant Professor; Clerkship Director; University
of Central Florida / North Florida Regional Medical Center; Gainesville,
FL, USA
Susan Berg, DNP, MSN, BSN; Associate Professor; University of Tampa;
Gibsonton, FL, USA
Luke Berry, MD; Zucker School of Medicine; Manhasset, NY, USA
Courtney Bethel, MD, MPH; Assistant Professor; Drexel University
College of Medicine; Media, PA, USA
Danielle Betz, MD; Temple University Hospital; Philadelphia, PA, USA
Paawan Bhandari, MBBS; Private Practice; Kathmandu, Nepal
Steve Bhimji, BSci Pharm, MS, MD, PhD; Clinical Instructor (Retired); Un
of Toronto; Toronto, Canada
Edgar Billowitz, MD, MA; Assistant Professor; UMN; Santa Fe, NM, USA
Scott Bjerke, MD; Professor; Research Medical Center, KCUMB;
Leawood, KS, USA
Maria Bokhari, MBBS, FCPS, FRCR; Visiting Faculty; Tulane Hospital ,
Louisiana; New Orleans, _, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Sameh Boktor, MD, MPH; Penn State College of Medicine;
Mechanicsburg, PA, USA
Michael Boniface, MD; Clinical Instructor; Director of Emergency
Ultrasound; Mayo Clinic; Fleming Island, FL, USA
Gregory Bookout, DO; Grand Strand Medical Center; Ocean Isle Beach,
NC, USA
Christopher Borowy, BS; Midwestern University; Phoenix, AZ, USA
Philip Bouchette, MD; Louisiana State University HSC; Shreveport, LA,
USA
Richard Bounds, MD; Associate Professor; Program Director, Emergency
Medicine; University of Vermont Medical Center; Burlington, VT, USA
Emily Bounds, MD; University of Illinois COM Peoria; Peoria, IL, USA
Jared Brackenrich, DO; Lewis Gale - Montgomery; Blacksburg, VA, USA
Mark Brady, MD, MPH, MMS, DTM&H; Assistant Professor; University of
Tennessee; Memphis, TN, USA
Zack Brady, BS, MS, MD; Western Michigan University; Portage, MI, USA
Bradley Bragg, MD; Mayo Clinic Florida; Saint Johns, FL, USA
Joshua Brinkman, BS; DeBusk College of Osteopathic Medicine; Corbin,
KY, USA
Casey Brown, MD; Child Advocacy and Protection Services; Medical
College of Wisconsin; Milwaukee, WI, USA
Kristin Brown, MD; University of Tennessee; Nashville, TN, USA
Jens Brown, DO; McLaren Oakland; Sterling Heights, MI, USA
Falon Brown, DO; CUSOM/Sampson Regional Medical Center;
Wilmington, NC, USA
Jerome Buboltz, MD; Practicing Physician; Aurora Medical Center; West
Bend, WI, USA
Liliana Burdea, MD; Lincoln Medical Mental Health Center; Harrison,
NY, USA
Kevin Burroughs, MD; Associate Professor; Director, Cabarrus Sports
Med Fellowship; Concord, NC, USA
Lauren Burton, MD; UTHSC; Murfreesboro, TN, USA
Kristen Burton-Williams, BSN, MSN; Nursing Quality & Safety Manager;
Rhode Island Hospital; Warwick, RI, USA
David Bury, DO; Assistant Professor; Family Physician; Martin Army
Community Hospital; Fort Benning, GA, USA
Jeffrey Bush, MD; Assistant Professor; Program Director; Medical
University of South Carolina; Charleston, SC, USA
Christopher Calandrella, DO; Assistant Professor; Associate Chairman;
North Shore Manhasset; Manhasset, NY, USA
Avery Callahan, DO; Assistant Professor; Medical Director; Louisiana
State University HSC; Shreveport, LA, USA
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Tim Caporal, CCEMT-P, PMD; Florida Hospital Orlando; Deltona, FL, USA
Kevin Carter, DO; Transitional Year Residency Director; McLaren
Oakland; Rochester Hills, MI, USA
Gabriel Castano, MD; MD; UT Health San Antonio; Irving, TX, USA
Danny Castro, DO, MEd; Assistant Professor; Dir of Fellow Ed, Med Dir
of Resp Care; Baylor College of Med, TX Children Hosp; Houston, TX,
USA
Jesse Charnoff, MD; University of Miami/ JMH; Miami, FL, USA
Stanley Chartoff, MD, MPH; Assistant Professor; Attending Physician
Emergency Medicine; Univ of Connecticut, Hartford Hospital;
Woodbridge, CT, USA
Elizabeth Chase, MD; Private Practice; Danville, PA, USA
Hammad Chaudhry, MBBS; House Officer; Allama Iqbal Med College,
Jinnah Hosp; Mirpur, Pakistan
Shazia Chaudhry, BA; Private Practice; Johnson City, NY, USA
Min Cho, DO; McLaren Greater Lansing; Lansing, MI, USA
Andrew Christiansen, MD; University of Nebraska Medical Center;
Omaha, NE, USA
Casey Ciresi, BSN; Clinical Instructor; University of Louisville; Louisville,
KY, USA
Andrew Clark, BA; University of Missouri; Columbia, MO, USA
Megan Cochran, DO; Doctors Hospital - Ohio Health; Galloway, OH, USA
Shaila Coffey, BS (EMS); University of Nebraska Medical Center; Lincoln,
NE, USA
Brian Cohagan, MD; Temple University Hospital; Philadelphia, PA, USA
John Colling, MD; Methodist Hospital; Omaha, NE, USA
Jeffrey Cooper, MD; Associate Professor; Director; University of
Nebraska Medical Center; Omaha, NE, USA
Carlin Corsino, DO; Carl R. Darnall Army Medical Center; Killeen, TX,
USA
Amanda Corzine, RN, BSN; Director, Kentucky One Safe Services;
Louisville, KY, USA
John Costumbrado, MD, MPH; Riverside Community Hospital/UCR EM;
Riverside, CA, USA
Kathleen Cowling, MS, DO, MBA; Professor; Program Director; Central
Michigan University; Saginaw, MI, USA
Marsha Crader, PharmD; Associate Professor of Pharmacy Practice;
Univ. of Arkansas for Medical Sciences; Jonesboro, AR, USA
Christopher Crismon, MD; Louisiana State University HSC; Shreveport,
LA, USA
Earl Cummings, V, MD; Louisiana State University HSC; Shreveport, LA,
USA
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Wael Dakkak, MD; Stroger Hospital of Cook County; Oak park, IL, USA
Rajeev Dalal, BS; NYIT College of Osteopathic Medicine; York, PA, USA
Tarun Dalia, MBBS; Kansas University Medical Center; Kansas, KS, USA
Sagar Dave, DO; Hartford Hospital; Hartford, CT, USA
Nathan Davis, MD; University of Tennessee; Murfreesboro, TN, USA
Amy Davis, MD; Emergency Medicine Fast Track Director; Magnolia
Regional Health Center; Corinth, MS, USA
David Davis, MD; Orange Park Medical Center; Ponte Vedra, FL, USA
Daniel Dawson, DO, MA; Kingman Regional Medical Center; Kingman,
AZ, USA
Renee DeNolf, DO; Kaweah Delta Medical Center; Visalia, CA, USA
Timothy Depp, MD; Clinical Assistant Professor; University of South
Carolina; Greenville, SC, USA
Bharat Reddy Dhanireddy, MD; Assistant Professor; UAMS; Little Rock,
AR, USA
Bjorn Dijkstra, MD; Emergency Physician; Westfriesgasthuis;
Midddenbeemster, Netherlands
Christopher Dion, MS; Midwestern University; Phoenix, AZ, USA
Chaddie Doerr, BSN, MS, CRNA; Clinical Instructor; Norton Health
Systems; Treasure Island, FL, USA
Emilissa Domingo, DO; Clinical Assistant Professor; Kent Hospital;
Smithfield, RI, USA
Ary Dotiwala, MS; LSUHSC School of Medicine; Shreveport, LA, USA
Arthur Dublin, MD, MBA; Emeritus Clinical Professor of Radiology; UC,
Davis, Medical Center; Sacramento, CA, USA
Stephanie Duckett, DO; Desert Regional Medical Center; Palm Springs,
CA, USA
Scott Dulebohn, MD; Associate Professor; ETSU, Meharry, LMU; Johnson
City, TN, USA
Noel Dunn, MD; Private Practice; Tacoma, WA, USA
Guadalupe Duran, MD; Louisiana State University HSC; Shreveport,LA,
USA
Nicole Durfey, MD; Clinical Assistant Professor; Kent Hospital Warwick
RI; UNECOM; East Greenwich, RI, USA
Mary Eberhardt, MD, MSPH; Adjunct Associate Professor; St Lukes
University Health Network; Cherryville, PA, USA
Joshuah Edwards, PT, DPT; High Point University; High Point, NC, USA
Moavia Ehsan, MBBS; Medical Officer; Allama Iqbal Medical College;
Khushaab, Pakistan
Charles Eifrig, MD; Adjunct Assist Profess, USC EYE; Retina Associates of
Orange County; Newport Beach, CA, USA
Mohamed El Khashab, MD, MS; Northwestern University; Chicago, IL,
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Noha EL-Mohandes, MRCPCH; UHND; Sunderland, United Kingdom
Bishoy Emmanuel, DO; Wyckoff Heights Medical Center; Brooklyn, NY,
USA
Joshua Engelsgjerd, MD; University of Nebraska Medical Center; Omaha,
NE, USA
Stacey Ernest, MD; Loma Linda Unversity Medical Center; Rancho
Cucamonga, CA, USA
Rubina Faizy, MD; KDHCD; Visalia, CA, USA
William Farris, MS, MD; Southern Illinois University; Springfield, IL, USA
Dana Ferguson, BSN, MBA; Emergency Medicine Residency Coordinator;
University of Louisville; Louisville, KY, USA
Thomas Ferreri, MD; Private Practice; Saginaw, MI, USA
Rebecca Fishman, DO; Director of Medical Education; Mercy Medical
Center; Syosset, NY, USA
Thomas Folino, DO; NYIT College Of Osteopathic Medicine; Brooklyn,
NY, USA
Hee Kong Fong, MBBS; University of Missouri, Columbia; Columbia, MO,
USA
Brian Ford, MD; Naval Hospital Camp Pendleton; Encinitas, CA, USA
Lisa Foris, MD, MSc; St. George's University; Brooklyn, NY, USA
David Foster, MD; Assistant Professor; Associate Program Director;
North Shore University Hospital; Brooklyn, NY, USA
Christopher Foucher, MD; Clinical Assistant Professor; McLaren Greater
Lansing/MSU COM; Lansing, MI, USA
Josephine Fowler, MD, MSc; Family Medicine Physician; JPS Health
Network; Arlington, TX, USA
Andrew Freeman, DO; Assistant Director Family Practice; Southeastern
Regional Medical Center; Lumberton, NC, USA
Justin Fuehrer, DO; Private Practice; Glen Oaks, NY, USA
Evan Fusco, BS, MD, MHA; Medical Director; Springfield, MO, USA
Kavitha Ganesan, MD; Orange Park Medical Center; Jacksonville, FL, USA
William Gartlan, DO, MS; Southeastern Regional Medical Center;
Bolivia, NC, USA
Veronica Garvia, MD; Einstein Medical Center; Philadelphia, PA, USA
Uma Gaur, MS, MBBS, BSc; Senior Lecturer; University of The West
Indies; St Thomas, Barbados
Amani Gharbi, MD; La Rabta Hospital; Tunis, Tunisia
Rupendra Ghatak, BS; Private Practice; Henderson, NV, USA
Namratta Ghatehorde, BSc, MD; Univeristy of Missouri Columbia;
Columbia, MO, USA
Ryan Gibbons, MD; Assistant Professor; Assistant Director of EM
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Ultrasound; Temple University Hospital; Philadelphia, PA, USA
William Gibbons, DO; Lower Bucks Hospital; Downingtown, PA, USA
Amanda Gibson, DO; Ohio Health Doctors/Ohio Univ; Columbus, OH,
USA
Jacob Ginglen, DO, BSN; McLaren Oakland Hospital; Rochester, MI, USA
Niklas Glenesk, BS; American University of the Caribbean; Novi, MI, USA
Harry Goett, MD; Associate Professor; Temple University, Temple Univ.
Hospital; Philadelphia, PA, USA
Reshma Golamari, MD; Drexel University; Yeadon, PA, USA
Allen Gold, DO; Northwell Health; Little Neck, NY, USA
Nina Gold, MD; Attending; Hackensack University Medical Center; Fair
Lawn, NJ, USA
Scott Goldstein, DO; Assistant Professor; Dir, Division of EMS, Disaster
Med; Philadelphia, PA, USA
Jeffrey Golightly, MD; Professor; Oklahoma State University; Edmond,
OK, USA
Daphne Joyce Gonzales, MD; Private Practice; Tinton Falls, NJ, USA
Anter Gonzales, MD; Lincoln Medical and Mental Health Center; Tinton
Falls, NJ, USA
Dulce Gonzalez, MD; Lincoln Hospital; New York, NY, USA
Steven Goodfriend, MD; Medical Director; Orange Park Medical Center;
Ponte Vedra, FL, USA
William Gossman, MD; Professor; Creighton University; Elkhorn, NE,
USA
Sherry Gossman, BSN; Clinical Instructor (Retired); Elkhorn, NE, USA
Peter Gotsis, DO; Program Director; University Hospitals; Amherst, OH,
USA
Alin Gragossian, DO, MPH; Drexel University; Philadelphia, PA, USA
Areg Grigorian, MD; Private Practice; Orange, CA, USA
Murray Grossan, MD; Cedars Sinai Medical; Los Angeles, CA, USA
Arun Gulani, MD, MS; Private Practice; Jacksonville, FL, USA
Jalaja Gundrathi, MD; Lanolin Medical Center; Bronx, NY, USA
Gunjan Gupta, MD, MS; IGMC; Shimla, India
Marco Gupton, BS; Campbell University; Salisbury, NC, USA
Dhritiman Gurkha, MD; St. Peter's University Hospital; Somerset, NJ,
USA
Kothai Divya Guruswamy Sangameswaran, MD; University of Oklahoma
- Tulsa Campus; Broken Arrow, OK, USA
Mark Gustafson, DO; Associate Prof; Academic Core Faculty; Charleston
Area Medical Center; Charleston, WV, USA
Kevin Guthmiller, MD; Associate Professor of Anesthesiology;
Anesthesiologist; USC Keck School of Medicine; San Marino, CA, USA
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Patricia Habak, MD; Associate Clinical Professor; Associate PD,
Department Vice Chair; Maricopa Medical Center; Phoenix, AZ, USA
Steven Habusta, DO, MEd; Professor; Program Director Orthopedic
Residency; LECOM; Erie, PA, USA
Yamama Hafeez, DO; Campbell University School of Osteopathic
Medicine; Lillington, NC, USA
Wissem Hafsi, MD; University Assistant; Dermatologist and
Venereologist; Faculty of Medicine of Tunis, Tunisia; Bardo, Tunisia
Susan Hageman, BS; University of Nebraska Medical Center; Omaha, NE,
USA
Heather Hager, DNP; Doctorate; Dr.; Ochsner Flight Care; Flowood, MS,
USA
Mary Hanley, DO; Associate Professor; Pro Dir Undersea and Hyperbaric;
Un of N En Coll of Osteo Med; Charleston, SC, USA
Sonia Hans, MD; LSU Health Sciences Center - Shreveport; Shreveport,
LA, USA
Aaron Hanyu-Deutmeyer, DO; Private Practice; Chicago, IL, USA
Taha Haque, DO; Private Practice; Lorton, VA, USA
Weston Harkness, DO; Sky Ridge Medical Center; Lone Tree, CO, USA
Shireen Hedya, BSc; Private Practice; Cairo, Egypt
Kenadeed Hersi, MD; Rutgers University - NJMS; Manhattan, NY, USA
Eric Hexdall, BSN, RN, ACHRN; Clinical Nurse Educator; Duke Regional
Hospital; Durham, NC, USA
Jason Hill, MD, MPH; Beth Israel Deaconess Medical Center; Brookline,
MA, USA
Daniel Hilton, DO; McLaren Oakland Hospital; Clawson, MI, USA
Michael Hocker, MD, MHS; Chief Emergency Medicine; Duke University;
Durham, NC, USA
Bonnie Hodge, BS; University of Mississippi Medical Center; Jackson,
MS, USA
Brandon Hoffer, MD; Un of IL College of Med, OSF Medical; Peoria, IL,
USA
Erin Hopkins, BS; Lincoln Memorial University- Debusk College of
Osteopathic Medicine; Corbin, KY, USA
Keahi Horowitz, BM, MM; John A. Burns School of Medicine; Honolulu,
HI, USA
Robert Howard, MS, MD; Assistant Professor; Drexel University;
Glenside, PA, USA
Theresa Hsiao, DO; Albert Einstein Medical Center; Philadelphia, PA,
USA
Hunter Hsu, DO; Clinical Associate Professor; Orthopedic Surgery
Resident; Michigan State University; Pontiac, MI, USA
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Tamer Hudali, MD; Assistant Professor; Southern Illinois University;
Springfield, IL, USA
Martin Huecker, MD; Assistant Professor; Research Director; University
of Louisville; Louisville, KY, USA
J. Stephen Huff, MD; Professor; University of Virginia; Charlottesville,
VA, USA
James Hughes, MD; Assistant Professor (Retired); MD; Skokie, IL, USA
Robert Hughes, PharmD; Private Practice; Lexington, KY, USA
Channing Hui, MD; Private Practice; Highland Park, NJ, USA
Chen-Yu Hung, MD; National Taiwan University Hospital, Beihu Branch;
New Taipei City, Taiwan
Phillip Hynes, MD; Radiation Oncology; Lincoln, NE, USA
Osagie Igiebor, MD; St. George's University; Bronx, NY, USA
Kimon Ioannides, MD; Temple University Hospital; Philadelphia, PA,
USA
Alexander Jacobsen, BS, MS; University of South Florida; Tampa, FL,USA
Ashika Jain, MD; Associate Professor; Director- Division of Emergency
Trauma; New York University Langone Health; New York, NY, USA
Rebecca Jeanmonod, MD; Professor; Associate Residency Program
Director; St. Luke's University Health Network; Hellertown, PA, USA
Lindsey Jennings, MD, MPH; Assistant Professor; Assistant Residency
Director; Medical University of South Carolina; Charleston, SC, USA
Mark Jones, DO; Professor; McLaren Greater Lansing, MSUCOM; East
Lansing, MI, USA
Wesley Jones, DO; Advocate Christ Medical Center; Chicago, IL, USA
Jonathan Journey, MD; Assistant Professor; University of Central
Florida/North Florida Regional Medical Center; Gainesville, FL, USA
Steven Joyce, DO, MBA; Resident; Kettering Medical Center; Kettering,
OH, USA
Pallavi Juneja, BA; Wake Forest School of Medicine; Winston-Salem, NC,
USA
Nathaniel Justice, MD, MBA; Assistant Professor; East Tennessee State
University; Johnson City, TN, USA
Michael Kang, MD; Assistant Clinical Professor; Emergency Medicine
Attending Physician; Riverside Community Hospital/UCRiverside;
Riverside, CA, USA
Hoda Karbalivand, MD; PL-2; Bronx, NY, USA
Laura Kasman, PhD; Associate Professor; Medical University of South
Carolina; Charleston, SC, USA
Mohammed Kassem, MD; SUNY Upstate University Hospital; Syracuse,
NY, USA
Brian Kelly, DO; St. Luke's University Health Network; Perkasie, PA, USA
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Erika Kettelhut, DO, MPH; OhioHealth O'Bleness Hospital; The Plains,
OH, USA
Maqsood Khan, BA; Kentucky College of Osteopathic Medicine;
Somerset, KY, USA
John Kiel, DO, MPH; University of Kentucky; Lexington, KY, USA
Kyle Kim, MD; Central Michigan University; Saginaw, MI, USA
Matthew Klein, MD, MPH; Northwestern University; Chicago, IL, USA
Thomas Knorr, MD; Beth Israel Deaconess Medical Center; Boston, MA,
USA
Laxmi Kokatnur, MD; Louisiana State University; Shreveport, LA, USA
Landry Konan, MD; University of Missouri; Columbia, MO, USA
Noah Kondamudi, MD, MBA; Associate Professor; Medical Director;
Rutgers New Jersey Medical School; West Orange, NJ, USA
Michael Kopstein, DO; Rocky Vista University/Sky Ridge Medical Center;
Lone Tree, CO, USA
Harish Kotipoyina, MD; UCF/North Florida Regional Medical Center;
Gainesville, FL, USA
Rachana Krishna, MD; Private Practice; Rochester, MN, USA
Diann Krywko, MD; Associate Professor; Wellness and Professional Dev.
Director; Medical University of South Carolina; Mount Pleasant, SC, USA
Anil Kumar, MD, PhD; Stroke Director; MD; Great Plains Health; North
Platte, NE, USA
Amy Lagina, OD; Clinical Assistant Professor; Optometrist; University of
Michigan; Dexter, MI, USA
Frank Lane, BS, MD; Temple Medical School; Tampa, FL, USA
Aaron Lawrence, DO; Central Michigan University; Saginaw, MI, USA
Angel Lazo, MD; Orange Park Medical Center; Jacksonville, FL, USA
Jacqueline Le, MD; Assistant Medical Director; Desert Regional Medical
Center; Palm Springs, CA, USA
Amy Lee, MD, MS; Resident Physician; Brooklyn Hospital Center;
Brooklyn, NY, USA
Kenny Lee, MD; Private Practice; Visalia, CA, USA
Jessica Leek, BS; Midwestern University - AZCOM; Chicago, IL, USA
Tracy LeGros, MD, PhD; Associate Clinical Professor; Program Director
LSU UHM Fellowship; University Medical Center; New Orleans, LA, USA
Stephen Leslie, MD; Associate Professor of Surgery, Urology; MD;
Creighton University Medical Center; Omaha, NE, USA
Ashley Lessmeier, MD; Carolinas Medical Center; Charlotte, NC, USA
David Levy, DO; Consultant; Waikato Hospital; Hamilton, New Zealand
Michael LeWitt, MD, MPH; Private Practice; Berwyn, PA, USA
Tian Liang, MD; SUNY Downstate Medical Center; Brooklyn, NY, USA
Christopher Libby, MD, MPH; Resident Physician; North Florida Regional
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Medical Center; Gainesville, FL, USA
Janelle Lindow, DO; Private Practice; Fayetteville, NC, USA
Seth Lotterman, MD; Assistant Professor; Hartford Hospital; Hartford,
CT, USA
T. David Luo, MD; Wake Forest Baptist Medical Center; Winston-Salem,
NC, USA
Christopher Maani, MD; Professor; Attending Anesthesiologist; US
Army; Boerne, TX, USA
Angela Macri, DO, MMS; Sampson Regional Medical Center;
Wilmington, NC, USA
Kunal Mahajan, DM Cardiology; IGMC; Shimla, India
Ajay Mahajan, MD; Royal College of Surgeons in Ireland; Calgary,
Canada
Kartikeya Makker, MD, FAAP; Assistant Professor; Un of Florida College
of Medicine; Jacksonville, FL, USA
Kenneth Maniscalco, MD; Louisiana State University Shreveport;
Shreveport, LA, USA
Hemnishil Marella, DO; Private Practice; Memphis, TN, USA
Edward Margolin, MD; Associate Professor; University of Toronto;
Toronto, Canada
Spencer Masiewicz, DO; Grand Strand Medical Center; Myrtle Beach, SC,
USA
Luke Maxfield, DO; Sampson Regional Medical Center; Soddy Daisy, TN,
USA
Christopher McDowell, MD, MEd; Associate Professor; Vice Chair
Emergency Medicine; SIU School of Medicine; Springfield, IL, USA
Ailbhe McGrath, MB, BCh, BAO; Our Lady's Children's Hospital, Crumlin;
Co Meath, Ireland {Republic}
Rita McKeever, MD; Assistant Professor; Drexel University School of
Medicine; Narberth, PA, USA
Oren Mechanic, MD, MPH; Health Policy and Management; Harvard
Medical School/BIDMC; Boston, MA, USA
Suman Medda, MD; Wake Forest Baptist Medical Center; Winston
Salem, NC, USA
Scott Melanson, MD; Professor of Emergency Medicine; Residency
Program Director; St. Luke's University Health Network; Bethlehem, PA,
USA
Richard Menger, MD, MPA; Louisiana State University Health Sciences
Center; Shreveprot, LA, USA
Marcelle Meseeha, MD; Private Practice; Sayre, PA, USA
Kenneth Metcalf, MD, PhD; Professor Emeritus; Dept of Anatomy,
Embryology, & Genetics; UNMC; Omaha, NE, USA
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Eric Metheny, DO; Integris Southwest Medical Center; Edmond, OK, USA
Alyssa Miceli, DO; Private Practice; Jacksonville, FL, USA
Brianna Miner, MD; Advocate Christ Medical Center; Chicago, IL, USA
Justine Moe, MD, DDS; Emory University; Atlanta, GA, USA
Michael Mohseni, MD; Assistant Professor; Mayo Clinic; Atlantic Beach,
FL, USA
Ifeanyi Momodu, MD, MPH; Clinical Instructor; Campbell University
School of Osteopathic Medicine; Fayetteville, NC, USA
Christine Moore, DO, BA; East Tennessee State University; Johnson City,
TN, USA
Nathan Moore, MB, BCh, BAO BSc, MRCS; Orthopaedic Specialty
Registrar; Torbay Hospital; Plymouth, United Kingdom
Deborah Morris, PA-C, MD; Associate Professor; MD; Methodist
University Physician Assistant Program; Fayetteville, NC, USA
Steven Mountfort, AS, BS; Education Coordinator; Florida Hospital;
Orlando, FL, USA
Xenophon Mucciarone, DO; McLaren Oakland; Waterford, MI, USA
Lucy Muinov, MD; Assistant Professor; University of Nebraska Medical
Center; La Vista, NE, USA
Pinaki Mukherji, MD; Long Island Jewish Medical Center; New York, NY,
USA
Jeff Mullen, DO; Assocaite Program Director EM; CAMC; Charleston, WV,
USA
Sadaf Munir, MBBS, DCH, MCCEE; Clinical Assistant & Case Manager;
Morganville, NJ, USA
Kelly Murphy, MD, MS, LT, MC, NMCP; Naval Medical Center
Portsmouth; Norfolk, VA, USA
Heather Murphy-Lavoie, MD; Associate Professor; University Medical
Center/LSU Med Sch; New Orleans, LA, USA
Alexandra Murray, DO; Chief Resident; Mercy St. Vincent Medical
Center; Perrysburg, OH, USA
Pragya Nair, MD; Professor; Karamsad Gujarat, India
Thomas Nappe, DO; Assistant Professor; Emerg Physician, Medical
Toxicologist; St. Luke's University Health Network; Bethlehem, PA, USA
Naomi Nardi, DO; Private Practice; Peoria, IL, USA
Gul Nawaz, MBBS; Jinnah Hospital; Lahore, Pakistan
Valerie Nemeth, DO; Private Practice; Sandusky, OH, USA
Zeid Nesheiwat, DO; Michigan State University - McLaren Oakland; West
Bloomfield, MI, USA
Matthew Neulander, MD; Assistant Professor; UConn; South
Glastonbury, CT, USA
Ruben Ngnitewe Massa, MD; Universityof Missouri; Columbia, MO, USA
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Hoang Nguyen, MD; Assistant Professor; Rush University Medical
College; Chicago, IL, USA
Van Nguyen, MD; Private Practice; Hammond, LA, USA
Adam Nicholson, MD; Assistant Professor; Pediatric Emergency
Medicine Physician; Michigan State University CHM; Byron Center, MI,
USA
Asif Noor, MD; Pediatric Infectious Diseases Physician; Winthrop
University Hospital; Mineola, NY, USA
Tony Oliver, MD, MRCP, FACP; Assistant Professor; University Of South
Dakota; Sioux Falls, SD, USA
Danny Opperman, AAS, BS; EMS Educator/Clinical Coordinator; Atlantic
Cape Community College; Atlantic City, NJ, USA
Maria O'Rourke, MD; Assistant Professor; GME EM US Director; Dignity
Health - STMC - Stockton, CA; Gig Harbor, WA, USA
Anita Pabani, MD; Private Practice; Southfield, MI, USA
Beckie Palmer; Private Practice; Culpeper, VA, USA
Salvatore Pardo, MD, MBA; Assistant Professor; Vice Chair; Hoftstra
University; Brooklyn, NY, USA
Vicky Pardo, PT, MHS, DHS; Assistant Professor; Wayne State Uni,
Detroit Medical Center; McGregor, Canada
Jai Parekh, MBBS; Creighton University Medical Center; Omaha, NE, USA
Nina Parikh, DO; Touro U of Nev Col of Osteopathic Med; Irvine, CA,
USA
Nimesh Patel, FRCS, MRCS, MBBS, BSc; Private Practice; Exeter, United
Kingdom
Nikita Patil, MBBS; Private Practice; Apex, NC, USA
Juan Patiño, MD; Chief Upper Extremity Unit; Hospital Militar Central;
Buenos Aires, Argentina
John Patterson, MD; Associate Professor; EM Faculty, Former Chair EM;
St. Luke's Univ. Hosp. Bethlehem; Bethlehem, PA, USA
Laryssa Patti, MD; Instructor, Emergency Medicine; Rutgers RWJMS;
Somerset, NJ, USA
Jimmy Pearce, MHS; Sergeant, Special Operations Bureau; Manassas,
VA, USA
Thomas Perera, MD; Associate Professor; Hofstra Northwell; Manhasset,
NY, USA
Yomayra Perez, MD; Private Practice; Bronx, NY, USA
Ryan Peterfy, DO; Private Practice; Palm Springs, CA, USA
Louisdon Pierre, MD, MBA; Assistant Professor Clinical Pediatrics;
Director, Pediatric Critical Care; Ichan School of Medicine at Mount
Sinai; Suffern, NY, USA
Hannah Pile, BSN; Campbell University; Hope Millls, NC, USA
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Holly Pilson, MD; Assistant Professor; Wake Forest Baptist Medical
Center; Winston-Salem, NC, USA
Letitia Pirau, BA; California Northstate University; El Dorado Hills, CA,
USA
S Plantz, MD; Associate Professor (Retired); MD; University of Louisville;
Louisville, KY, USA
Michael Plewa, MD; Director of Research; Holland, OH, USA
Shawn Posin, MD; Core Faculty; Simulation Director; Ohio Valley
Medical Center; Wheeling, WV, USA
Ewa Posner, MD; Consultant Pediatrician; University Hospital of North
Durham; Durham, United Kingdom
Pooja Poudel, MD; Suny Upstate Medical University; Syracuse, NY, USA
Jim Powers, DO; Professor; Associate Dean for Clinical Integration;
Campbell Univ. School of Osteopathic Med; Holly Springs, NC, USA
Erion Qaja, DO; Wyckoff Heights Medical Center; Brooklyn, NY, USA
Mohammed Qasswal, MD; Al Quds University School of Medicine,
University of Texas at Houston; Houston, TX, USA
Deborah Raines, PhD, EDS, MSN, BSN; Associate Professor; Univ at
Buffalo; Buffalo, NY, USA
Marc Raj, DO; Bodor Clinic; Napa, CA, USA
Fergie Ramos Tuarez, MD; University of Miami; Wellington, FL, USA
Mark Ramzy, DO; Drexel University; Philadelphia, PA, USA
Kimberly Rathbun, MD, PhD, MPH; Assistant Professor; East Carolina
University; Greenville, NC, USA
Chandni Ravi, MD; Rutgers University; Jersey City, NJ, USA
Keith Raymond, MD; CNUCOM; Muckendorf an der Donau, Austria
Alejandro Recio-Boiles, MD; University of Arizona; Tucson, AZ, USA
Mirembe Reed, PharmD; Private Practice; Brighton, MA, USA
Gage Rensch, BA, BS; University of Nebraska Medical Center; Omaha,
NE, USA
Felix Reyes, MD; State University of New York; Brooklyn, NY, USA
John Richards, MD; Professor; UC Davis Medical Center; Sacramento,
CA, USA
Laura Riley; Private Practice; Jersey City, NJ, USA
Erika Robb, MD; Private Practice; Peoria, IL, USA
Alexis Rafael Rojas, MD; Assistant Professor; UNAN, Managua; Miami,
FL, USA
Adam Ross, MD; Assistant Professor; University of Louisville; Louisville,
KY, USA
Rochelle Rubin, PharmD, BCPS, CDE; Senior Clinical Pharmacy
Coordinator; The Brooklyn Hospital Center; Brooklyn, NY, USA
Lokesh Rukmangadachar, MBBS, MD; Keck School of Medicine of USC;
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Timothy Rupp, MD, MBA; Private Practice; Dallas, TX, USA
Abdolreza Saadabadi, MD; Assistant Professor; Western University/
Kaweah Delta; Visalia, CA, USA
Ayan Sabih, MBBS; Medical Registrar; Waikato DHB; Hamilton, New
Zealand
Saema Said, MD; RCH/UCR; Riverside, CA, USA
Karima Sajadi-Ernazarova, MD; Assistant Professor; Associate Residency
Program Director; Drexel University College of Medicine; Merion
Station, PA, USA
Dahlia Saleh, DO; Sampson Regional Medical Center; Wilmington, NC,
USA
Philip Salen, MD; Attending; St. Luke's University Hospital; Bethlehem,
PA, USA
Hrishikesh Samant, MD; Assistant Professor; LSUHSC; Shreveport, LA,
USA
Nathan Samras, MD, MPH; Assistant Professor; Savannah Memorial
Hosp, Mercer Med Sch; Savannah, GA, USA
Juan Carlos Sánchez-Manso, MD; Consultant; MD; Hospital Virgen de la
Concha (Zamora); Madrid, Spain
Justin Sanders, DO; Orange Park Medical Center; Jacksonville, FL, USA
Livia Santiago-Rosado, MD; Assistant Professor; Vice Chair; Nassau
University Medical Center; Massapequa, NY, USA
Dulaya Santikul, DO; Program Director; Orange Regional Medical Center;
Highland Mills, NY, USA
Timothy Schaefer, MD; Clinical Professor; Chair; Peoria, IL, USA
Dmitriy Scherbak, DO; Attending; Director of Resident Research; Rocky
Vista University; Greenwood Village, CO, USA
Michael Schick, DO, MA; Assistant Professor; UC Davis Medical Center;
Davis, CA, USA
Pamela Schmidt, MSN, RN-C, WHNP-BC, C-EFM; Perinatal Clinical
Specialist; Sisters of Charity Hospital; Buffalo, NY, USA
Erez Schori, MD; Private Practice; Bronx, NY, USA
John Schweitzer, MD; Assistant Professor; East Tennessee State
University; Johnson City, TN, USA
Joseph Sciammarella, MD, FACP, FACEP; Medical Director Niagara Falls
Fire Dept; Lindenhurst, NY, USA
Mohammad Selim, MD; Creighton University; Omaha, NE, USA
Rouhin Sen, MD; Creighton University; Omaha, NE, USA
Justin Sevy, MD; Private Practice; Fort Benning, GA, USA
Rushikesh Shah, MD; Emory University Hospital; Decatur, GA, USA
Niraj Shah, MD; Assistant Professor of Medicine; University Of
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Mississippi Medical Center; Madison, MS, USA
Sandy Shah, DO; Private Practice; Spring, TX, USA
Faizan Shaikh, MD; St Mary Mercy Hospital; Farmington Hills, MI, USA
Gyanendra Sharma, MBBS, MSc; Private Practice; Monroe, LA, USA
Sandeep Sharma, MD; Adjacent Faculty, Attending; MD; Baptist
Regional Medical Center; London, KY, USA
John Shivdat, DO; Clinical Faculty Mercer Medicine; Coliseum Medical
Center; Lizella, GA, USA
Greggory Shubert, MD; Clinical Faculty; Assistant Medical Director -
Finance/PI; Kaweah Delta Medical Center; Visalia, CA, USA
Jamshed Siddique, MBBS; Allama Iqbal Medical College Jinnah Hospital;
Lahore, Pakistan
Abdul Siddiqui, MBBS; MD; Northwell Health SIUH; Staten Island, NY,
USA
Michael Silberman, DO; Assistant Professor; Research Director;
University of Tennessee; College Grove, TN, USA
Jason Silberman, MD; UTHSC; Germantown, TN, USA
Leslie Simon, DO; Assistant Professor, Emergency Medicine; Mayo Clinic
Florida; Jacksonville, FL, USA
Shashank Singh, MD; Assistant Professor; Louisiana State University
Health Science Center Shreveport; Shreveport, LA, USA
Virteeka Sinha, MD; Assistant Professor; Rutgers New Jersey Medical
School; New York, NY, USA
Jacob Sison-Martinez, BS; University of Nebraska;Omaha, NE, USA
Keegan Skidmore, MD; Temple University Hospital; Blue Bell, PA, USA
Rick Slaven, EdD (ABD), MPS; Director; Lincoln Memorial University;
Harrogate, TN, USA
Frank Smeeks, MS, MD, MBA; Private Practice; Hickory, NC, USA
James Smith, MD; Attending Physician; Bassett Army Community
Hospital; Fort Wainwright, AK, USA
Kaitlyn Smith, DO; Kent Hospital; Pawtucket, RI, USA
Jessica Snowden, MD; Associate Professor; University of Nebraska
Medical Center; Omaha, NE, USA
Ahsan Sohel, DO; University of California, Los Angeles; Orange, CA, USA
Daniel Solano, DO; Resident in Ophthalmology; Nova Southeastern
University; Hilliard, OH, USA
Jessica Sop, DO; Associate Professor WVSOM; EM Residency Program
Director; Charleston Area Medical Center; Charleston, WV, USA
Alison Southern, MD, MS; Associate Professor- NEOMED; Attending
physician; Western Reserve Hospital; Clinton, OH, USA
Francis Squadrito, MD; Temple University Hospital; Devon, PA, USA
Pranay Srivastava, BD, MD; Nassau University Medical Center; East
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Meadow, NY, USA
Jennifer Stark, DO; Private Practice; Yonkers, NY, USA
Eric Stashko, MD; WakeMed; Apex, NC, USA
Joshua States, MD; UNMC; Omaha, NE, USA
Megan Stobart Gallagher, DO; Clinical Instructor; Assistant Program
Director; Philadelphia, PA, USA
Maranda Stokes, BS; Kern Medical Center; Bakersfield, CA, USA
Daniel Chiung Jui Su, MD, RMSK; Visiting staff; Chi Mei Medical Center;
Tainan, Taiwan
Sathyaseelan Subramaniam, MBChB; Pediatric Emergency Physician;
Clinical Assistant Instructor; The Children's Hospital of Philadelphia;
Philadelphia, PA, USA
Jolee Suddock, DO; University of New Mexico; Albuquerque, NM, USA
Stephanie Sullivan, MD; Un of IL College of Med, OSF Med Center;
Peoria, IL, USA
Mohamed Sultan; Private Practice; Limerick, FL, USA
Joel Szymanski, DO; McLaren, Michigan State University; Rochester, MI,
USA
Ayesha Tabassom, MD; Bossier City, LA, USA
Christine Tafoya, PharmD; Private Practice; Scottsdale, AZ, USA
Sharven Taghavi, MD, MPH, MS; Brigham and Women's Hospital;
Boston, MA, USA
Preetham Talari, MD; Assistant Professor of Medicine; Medical Director;
University of Kentucky; Lexington, KY, USA
Francisco Talavera, PharmD, PhD; Assistant Professor; University of
Nebraska Medical Center; Omaha, NE, USA
Ankita Taneja, MD, MPH; University Of Florida; Jacksonville, FL, USA
Carolina Tapia, MD; Instituto Mexicano del Seguro Social; Guadalajara,
Mexico
Roger Taylor, DO; Conemaugh Memorial Medical Center; Johnstown,
PA, USA
Steven Tenny, MD, MPH, MBA; University of Nebraska Medical Center;
Omaha, NE, USA
Tammy Toney-Butler, AS, RN, CEN, TCRN, CPEN; Clinical
Instructor/Nurse Educator; Naples, FL, USA
Allison Torlincasi, MS, NCCPA; Lincoln Medical Center; Farmingdale, NY,
USA
Klaus Torp, MD; Assistant Professor; Mayo Clinic Florida; Jacksonville,
FL, USA
Jeremy Traylor, DO; Program Director; Grandview Hospital; Waynesville,
OH, USA
Brad Trinidad, MD; University of Arizona Medical Center; Tucson,
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Afghanistan
Justina Truong, DO; KRMC; Kingman, AZ, USA
Audrey Tse, MD; NYU Langone Health; New York, NY, USA
Robert Tubben, DO; Associate Professor; Residency Program Director;
McLaren Greater Lansing/ Michigan State; Okemos, MI, USA
William Tucker, BS; ETSU Quillen College of Medicine; Johnson City, TN,
USA
Anisha Turner, MD; Louisiana State University Shreveport; Shreveport,
LA, USA
Jake Turner, BSc; University of Warwick Medical School; Warwick,
United Kingdom
Damir Tuyakov, Resident; Astana Medical Hospital; Rudnyy city,
Kazakhstan
Patrick Tyrrell, DO; Michigan State University College of Osteopathic
Medicine / McLaren Greater Lansing; Alto, MI, USA
Anusha Vakiti, MBBS; Private Practice; Silver Spring, MD, USA
Ngoc Van Horn, MD; Clinical-Educator Instructor; University of Texas-
Southwestern/Dallas Childrens Medical Center; Dallas, TX, USA
Danny VanValkinburgh, MD; University of Tennessee HSC COM
Memphis; Memphis, TN, USA
Sarayu Vasan, MD, MPH; UCLA - Kern Medical; Bakersfield, NH, USA
Roy Vega, MD; Assistant Professor of Pediatrics; Director, Pediatric ED;
Bronx Lebanon Hospital Center; Bronx, NY, USA
Nupur Verma, MD; Assistant Professor; University of Florida;
GAINESVILLE, FL, USA
Viliane Vilcant, DO, MBS; Nassau University Medical Center;
Massapequa, NY, USA
Evan Vincent, MD; Private Practice; Westmont, IL, USA
Timporn Vitoonpong, MD; Attending Physician; MD; King Chulalongkorn
Memorial Hospital; Bangrak, Thailand
Josephine Vranick, AAS, BSN, MSN; Nurse Educator; VAMC Northport;
Commack, NY, USA
Nicholas Walker, MD; Winston Salem, NC, USA
J Walker, III, MD, MS; Assistant Professor; University of TN Health
Science Center; Memphis, TN, USA
Heather Wallace, MPAS, MS; Private Practice; Alexandria, VA, USA
Jason Wallen, MD; Assistant Professor; Upstate Medical University;
Syracuse, NY, USA
Gregory Wanner, DO; Clinical Assistant Professor; Emergency Physician;
Christiana Care Health System; Newark, DE, USA
Matthew Warner, MD, CPE; Vice Chair Dept of EM, Clinical Faculty;
Rowan Univ SOM, Inspira Health Network; Mullica Hill, NJ, USA
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Cassandra Wasson, DO; Riverside University Health System; Los
Angeles, CA, USA
Thomas Watson, MD; UPMC -- Pinnacle Harrisburg, PA; Harrisburg, PA,
USA
Tyler White, MD; Louisiana State University; New Orleans, LA, USA
Richard Whitten, MA, MD; Clinical Instructor; MD; Clearwater, FL, USA
Adam Wiercinski, DO; Grandview Medical Center; Dayton, OH, USA
Christopher Williams, MD; Private Practice; Shreveport, LA, USA
Daniel Willner, MD, MPH; Beth Israel Deaconess Medical Center;
Boston, MA, USA
Micah Wittler, DO, MS; Associate Professor; Western University of
Health Sciences; Redlands, CA, USA
Steve Wolfe, DO; Kaweah Delta Graduate Medical Education; Visalia,
CA, USA
Robert Wolford, MD, MMM; Associate Professor; Un of IL College of
Med, OSF Med Center; Peoria, IL, USA
Michael Wong, BA; Ochsner; River Ridge, LA, USA
Curtis Wong, MD; Instructor; UC Davis School of Medicine; Redding, CA,
USA
Todd Wylie, MD; Assistant Professor; Un of Florida College of Medicine;
Jacksonville, FL, USA
Niraj Yadav, MBBS; Creighton University Medical Center; Omaha, NE,
USA
Ho-Wang Yuen, MD; Attending; Arrowhead Regional Medical Center;
Colton, CA, USA
Lihan Zhang, MBBS, BSc (Hons); Plastic Surgery Registrar; Derriford
Hospital; Plymouth, United Kingdom
Patrick Zito, DO, PharmD; Faculty; Walden University; Fort Lauderdale,
FL, USA
Endrit Ziu, MD, PhD; University of Missouri Columbia; Columbia, MO,
USA
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Grammar and Illustration Editors
Susan Oliver, BA
Beata Beaty, BA
Gerson Cordero Rubio
Emergency Medicine
Edited by Barry Brenner; Martin Huecker; Jason An
StatPearls Book ID: MD_EMERGENCY_MEDICINE-2018-05-07
Table of Contents
Introduction
Section 1 ( Questions 1 - 120 )
Section 2 ( Questions 121 - 240 )
Section 3 ( Questions 241 - 360 )
Section 4 ( Questions 361 - 480 )
Section 5 ( Questions 481 - 600 )
Section 6 ( Questions 601 - 720 )
Section 7 ( Questions 721 - 840 )
Section 8 ( Questions 841 - 960 )
Section 9 ( Questions 961 - 1080 )
Section 10 ( Questions 1081 - 1200 )
About StatPearls
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Section 1
Question 1 (Question and Choices)
Question: A 17-year-old female fell and struck her chin on her coffee table,
sustaining a 2 cm laceration to the left side of her chin. The plan is to repair the
laceration and get set up for a mental nerve block. What is the anatomical
location that should be used?
Choices:
1. About 1 cm into the tissue in the longitudinal axis with the right lateral incisor
2. About 1 cm into the tissue in the longitudinal axis with the right canine3. About 1 cm into the tissue in the longitudinal axis with the right first premolar
(bicuspid) tooth
4. About 1 cm into the tissue in the longitudinal axis with the right second
premolar (bicuspid)
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Photo:Contributed by Gray's Anatomy Plates
Question 1 (Answer and Explanation)
Answer: 4 - About 1 cm into the tissue in the longitudinal axis with the right
second premolar (bicuspid)
Explanations:
The mental foramen is typically located halfway between the upper
(alveolar crest) and the lower edge of the mandible in direct line with the
second premolar (bicuspid).
Intra-oral technique for mental nerve block with topical anesthetic applied
for 60 seconds prior to needle use improves discomfort associated with the
procedure.
Be sure to aspirate prior to anesthetic administration.
Avoid intraforaminal injection as there can be nerve damage. This can be
avoided by telling the patient to signal if they experience paresthesias
during needle placement.
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Question 2 (Question and Choices)
Question: In a 46-year-old with pulsatile unilateral tinnitus, what is the most
likely etiology?
Choices:
1. Meningioma
2. Astrocytoma
3. Glomus tumor
4. Otitis media
Question 2 (Answer and Explanation)
Answer: 3 - Glomus tumor
Explanations:
When tinnitus is pulsatile and unilateral, it is important to rule out a Glomus
tumor. Conductive hearing loss is also seen.
They are slow growing, rare, and hypervascular. It is most common in
women in their fifth and sixth decades of life.
They originate from the chief cells of the paraganglia of the jugular bulb.
Glomus Tumors or Tympanicum Jugulare are the most common benign
tumors of the middle ear. They develop from the glomus bodies which are
tiny normal structures in the middle ear which function as baroreceptors.
These baroreceptors sense and regulate the oxygen pressure in the mastoid
and middle ear. Benign tumors of glomus bodies occur within the middle ear
and at other sites including the temporal bone and neck, and within the
jugular vein. Glomus tumors of the middle ear are more common than
glomus tumors of the jugular vein and result from abnormal growth of a
single glomus body. Glomus tumors are highly vascular and are composed
of blood channels flowing through the tumor. They appear as a red ball
behind the eardrum. The eardrum may pulsate if the tumor is touching the the
intact eardrum and is called pulsatile tinnitus. Pulsatile tinnitus may get
worse as the tumor enlarges. Glomus tumors grow large and may grow into
the mastoid or through the wall that divides the middle ear from the mastoid,
and they may then deeply infiltrate the bone. The tumor may also wrap
around and infiltrate areas around the facial nerve. The tumor may become
attached to the jugular vein and carotid artery. With invasion, the tumor is
more difficult to remove. If the tumor fills the middle ear space, hearing loss
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will occur.
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Question 3 (Question and Choices)
Question: A woman presents with her fourth episode of monilial vaginitis in
the past year. Which of the following is appropriate after treatment?
Choices:
1. Weekly prophylaxis with a topical antifungal
2. Weekly prophylaxis with oral fluconazole (Diflucan)
3. A fasting blood sugar
4. Weekly douching with dilute vinegar
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Question 3 (Answer and Explanation)
Answer: 3 - A fasting blood sugar
Explanations:
Recurrent monilial vaginitis can indicate diabetes or immune suppression.
Once other causes are ruled out, maintenance treatment may be appropriate.
Clotrimazole and fluconazole have been used successfully.
Douching is associated with an increased incidence of bacterial vaginosis.
Douching upsets the natural balance of bacterial vaginal flora. These
changes make the environment more favorable for the growth of bacteria.
Women who stopped douching have decreased bacterial vaginosis. Having
bacterial vaginosis can increase the risk of preterm labor and sexually
transmitted infections. Women who douche may have a substantially higher
risk of getting PID.
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Question 4 (Question and Choices)
Question: A 47-year-old African American female with past medical history
of paroxysmal supraventricular tachycardia, coronary artery disease,
hypertension, and type 2 diabetes mellitus presents to the emergency department
with symptoms of dizziness, palpitations, and chest pain. On physical
examination, she has bounding neck veins with a regular heart rate of 174 bpm;
blood pressure is 85/53 mmHg, respiratory rate of 21/minute, and temperature of
98.3 F. Her electrocardiogram shows a regular narrow QRS complex rhythm
with a pseudo-S wave in leads II, III, AVF and pseudo-R' in lead V1. What is the
next step in the management of this patient?
Choices:
1. Obtain in echocardiogram and refer to a cardiologist
2. Perform an urgent electrocardioversion
3. Reassure the patient and schedule a two-week follow-up
4. Treat the patient with intravenous adenosine
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Question 4 (Answer and Explanation)
Answer: 2 - Perform an urgent electrocardioversion
Explanations:
The electrocardiogram is indicative of a type of atrioventricular nodal
reentrant tachycardia, one of the most common paroxysmal supraventricular
tachycardia (PSVT)/SVT as it shows regular narrow QRS complex rhythm
with a pseudo-S wave in leads II, III, AVF and pseudo-R' in lead V1.
This patient is hemodynamically unstable with hypotension and heart rate of
174 bpm. This patient needs to be at the nearest emergency department for
an urgent electrocardioversion. Her PSVT is making her hemodynamically
unstable.
This patient's hypotension might be an indicator that she might be having an
inferior myocardial infarction due to the stress put on her heart from the
PSVT given her history of coronary artery disease.
Intravenous medical therapy with adenosine is not the first line treatment of
patients presentingwith PSVT and who are hemodynamically unstable.
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Question 5 (Question and Choices)
Question: A 65-year-old male presents with a complaint of a bump on his
right eyelid. He has no significant past medical history. He states it has been
there for years and has not changed in size, color, or appearance. It is 5 mm in
diameter, smooth, flesh-colored, and on his lower eyelid skin adjacent and below
the lash line. You notice one eyelash is growing out of the lesion. No ulceration
is appreciated. The patient is not bothered by the lesion but just wants to "make
sure it's not anything dangerous." What is the next best step in management?
Choices:
1. Incisional biopsy
2. Observation
3. Shave excision
4. Cryotherapy
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Question 5 (Answer and Explanation)
Answer: 2 - Observation
Explanations:
Characteristics that make eyelid lesions concerning for malignancy include
distortion of normal anatomy, poliosis (eyelash whitening), madarosis
(eyelash loss), change in the size of the lesion, change in shape of the lesion,
and ulceration. Normal appearing eyelashes growing out of the lesion are a
reassuring sign that the lesion is not destroying surrounding tissue.
Papillomas are benign lesions and excision is not indicated unless the lesion
is causing discomfort or is cosmetically unacceptable to the patient.
An incisional biopsy would be indicated if the eyelid lesion displayed any
characteristics that are suggestive of malignancy.
Cryotherapy can be used to treat verruca vulgaris but is not routinely used to
treat other types of papillomas.
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Question 6 (Question and Choices)
Question: A 17-year-old male is brought to the emergency department after
being found on the streets. A friend states that the patient had attended a party
where illicit drugs and alcohol were being used. The patient is behaving wildly
and complains of hearing voices. He is confused, delirious, and appears
paranoid. His temperature is 99.2F, blood pressure 128/87 mmHg, and heart rate
98 beats/min. Which of the following is the best drug to treat this patient?
Choices:
1. Propranolol
2. Naloxone
3. Flumazenil
4. Haloperidol
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Question 6 (Answer and Explanation)
Answer: 4 - Haloperidol
Explanations:
Amphetamine overdose can produce a psychotic state where the individual
will present with confusion, delirium, confusion, paranoia, and
hallucinations.
Because this patient presents with no life-threatening signs or symptoms, his
amphetamine-induced psychosis is best treated with a high-potency
antipsychotic such as haloperidol.
Agitation can be treated with benzodiazepines such as lorazepam. Beta-
blockers, such as propranolol, can be used to treat elevated blood pressure
and pulse.
Reversal agents are not recommended because they can cause acute
withdrawal. Most cases of amphetamine-induced psychosis are self-
limiting.
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Question 7 (Question and Choices)
Question: A 17-year-old female presents with a severe sore throat. She has
been sick with fever for 4 days. The patient's voice is muffled and she prefers not
to speak secondary to pain. She has not been able to eat solids for 2 days and has
refused to drink for 1 day. Vital signs show a temperature 39.8 C, heart rate 140
beats/min, respiratory rate 20 breaths per minute, and blood pressure of 110/70
mm Hg. Exam shows the tonsils to be four-plus enlarged with airway obstruction
and grey-white exudates. There is anterior cervical lymphadenopathy and
splenomegaly. CBC shows atypical lymphocytes. What is the most appropriate
management?
Choices:
1. Admission for hydration
2. Discharge home on amoxicillin/clavulanate
3. Admission for hydration and corticosteroids
4. Admission for hydration, corticosteroids, and IV antibiotics
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Question 7 (Answer and Explanation)
Answer: 3 - Admission for hydration and corticosteroids
Explanations:
This patient likely has infectious mononucleosis. The clinical presentation
can vary but patients typically have a fever, pharyngitis, and
lymphadenopathy.
The patient is febrile, tachypneic, tachycardic, refusing to eat or drink
secondary to throat pain, and is at risk of airway obstruction. She needs IV
fluids and corticosteroids.
Treatment typically is supportive only, including rest, analgesics, and
antipyretics.
Amoxicillin is not effective against the Epstein-Barr virus and often causes
a rash.
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Question 8 (Question and Choices)
Question: A farmer presents to the emergency department after being sprayed
with a mixed carbamate and organophosphate insecticide while working. Which
of the following symptoms is unlikely to be present?
Choices:
1. Confusion
2. Tachycardia
3. Respiratory depression
4. Urinary retention
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Question 8 (Answer and Explanation)
Answer: 4 - Urinary retention
Explanations:
increased levels of acetylcholine in the central nervous system can cause
symptoms including confusion, hallucinations, seizures, and coma.
Organophosphate and carbamate toxicity is classically associated with the
muscarinic symptoms from the mnemonic DUMBBELS (diarrhea, urination,
bradycardia, bronchorrhea, emesis, lacrimation,and salivation). It is
important to remember that stimulation of sympathetic ganglia via nicotinic
receptors also occurs via increased acetylcholine and can cause adrenergic
stimulation with tachycardia, hypertension, and mydriasis.
Skeletal muscle activation can occur due to increased acetylcholine at
nicotinic receptors, and the most common cause of death in organophosphate
and carbamate toxicity is respiratory muscle failure.
Organophosphate and carbamate toxicity causes increased urination, not
urinary retention.
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Question 9 (Question and Choices)
Question: A patient has flu-like symptoms with a low-grade temperature and
headaches. They complain of pain and stiffness in the neck, shoulders, upper
arms, hips, thighs, groin, and buttocks. Pain is worse in the morning after
sleeping. The patient has increased fatigue and poor appetite. The CBC shows
mild anemia. On physical exam, there is scalp tenderness and distorted vision.
Which of the following is most likely to improve the patient's condition?
Choices:
1. Methotrexate 2.5 mg weekly
2. Prednisone 60 mg a day with a rapid taper
3. Prednisone 20 mg a day and aspirin 81 mg a day
4. Diclofenac 75 mg twice a day
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Question 9 (Answer and Explanation)
Answer: 3 - Prednisone 20 mg a day and aspirin 81 mg a day
Explanations:
Prednisone is the drug of choice for polymyalgia rheumatica and temporal
arteritis, but 20 mg is usually adequate. Low dose aspirin is added to
prevent possible vascular complications.
NSAIDs can decrease symptoms but not prevent the catastrophic
complications.
Prednisone treatment duration is frequently greater than one year. If the
patient does not experience improvement after three days of 10–20 mg oral
prednisone per day, the diagnosis should be reconsidered. Sometimes
symptom relief occurs in a few hours. Nonsteroidal anti-inflammatory drugs
are ineffective in the initial treatment of PMR, but they may be used in
conjunction with the maintenance corticosteroids. Patients should be
encouraged to exercise and eat healthy to maintain a strong immune system
and maintain muscles and bones. A diet of fruits, whole grains, vegetables,
low-fat meat, and dairy products is favored, avoiding foods with high
refined sugars and salt.
About 15% of patients with polymyalgia rheumatica also have temporal
arteritis, and about 50% of people with temporal arteritis have polymyalgia
rheumatica. Symptoms of temporal arteritis may include headaches, scalp
tenderness, jaw or facial soreness, distorted vision, and aching in the limbs
caused by decreased blood flow.
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Question 10 (Question and Choices)
Question: A 2-year-old presents to the emergency department with a barking
cough, inspiratory stridor, and sternal wall retractions at rest. She appears
minimally agitated. Racemic epinephrine is administered via a nebulizer. For
how long is it appropriate to monitor this child for possible rebound of stridor?
Choices:
1. At least 30 minutes
2. At least 4 hours
3. At least 1 hour
4. At least 2 hours
Question 10 (Answer and Explanation)
Answer: 2 - At least 4 hours
Explanations:
This patient has moderately severe croup. Nebulized epinephrine is
associated with a reduction in croup symptoms 30 minutes following
administration.
If epinephrine is given for croup, monitor for at least 4 hours for rebound of
the condition.
Five milliliters of L-adrenaline 1:1000 is considered as safe as the racemic
form.
Epinephrine also is used to treat anaphylaxis, asthma, bradycardia, cardiac
arrest and shock, toxins, and overdoses.
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Epinephrine:
 
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Question 11 (Question and Choices)
Question: Which of the following is not associated with zirconium
granulomas?
Choices:
1. Toxicodendron dermatitis
2. Delayed-type allergic reaction
3. Develop 2 to 3 weeks after exposure
4. May be refractory to therapy
Question 11 (Answer and Explanation)
Answer: 3 - Develop 2 to 3 weeks after exposure
Explanations:
Patients may rarely become allergic to zirconium and develop a granuloma
or collection of granulomas. It may be seen following use of aluminum-
zirconium complexes in deodorants and following use of zirconium
compounds found in the treatment of Toxicodendron dermatitis.
Minute abrasions in the skin may allow penetration of zirconium salts in
deodorants. Zirconium salts used to treat Toxicodendron dermatitis may
penetrate acutely inflamed skin. Zirconium granulomas represent a delayed-
type allergic reaction.
Development of a granuloma 4 to 6 weeks after use of a zirconium
preparation. The granuloma may appear firm, shiny, erythematous papule
and is the color of flesh or apply jelly. Zirconium granuloma may be
solitary, grouped, or coalescent. Eczematous changes may be present. There
may be some pruritus.
Intralesional injection of corticosteroids may treat Zirconium granulomas.
Axillary zirconium granulomas caused by soluble zirconium lactate in
deodorant disappears within a few months. Granulomas caused by insoluble
zirconium oxide used for poison ivy (Toxicodendron) dermatitis are often
refractory to therapy.
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Zirconium Granulomas:
 
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Question 12 (Question and Choices)
Question: A healthy 22-year-old navy seal with no previous medical
conditions experienced extreme fatigue, chest discomfort, dyspnea, and cough
with frothy pink sputum after a 2 km swim. On examination, he was alert andwas
not in respiratory distress. He was also afebrile and hemodynamically stable.
Initial pulse oxygen (O2) 96% on room air. Swimming-induced pulmonary edema
is suspected. What would an echocardiogram show if performed immediately
upon his removal from the water?
Choices:
1. Decreased left ventricle size with thickened septum with decreased motion of
septum
2. Thickened left ventricular wall and diastolic dysfunction
3. Increased right heart and pulmonary artery pressure, and diastolic dysfunction
4. Right atrial systolic collapse
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Question 12 (Answer and Explanation)
Answer: 3 - Increased right heart and pulmonary artery pressure, and diastolic
dysfunction
Explanations:
Decreased left ventricle size with thickened septum with decreased motion
of septum would be consistent with hypertrophic cardiomyopathy. This
could explain the symptoms but would not be consistent with the
pathophysiology of immersion pulmonary edema.
Thickened left ventricular wall and diastolic dysfunction would suggest a
left-sided heart failure secondary to a prolonged increased afterload such as
hypertension.
Increased pulmonary pressure leading to a back up of blood in the right
ventricle leading to distension and acute right-sided failure is consistent
with immersion pulmonary edema
Right atrial collapse would be indicative of increased pressure around the
heart likely from a pericardial effusion causing tamponade.
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Diving, Immersion Pulmonary Edema:
 
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Question 13 (Question and Choices)
Question: A family had a barbeque and everyone become ill. All of them had
a fever and diarrhea, but the 3-year-old had blood in the stool. Over the next 24
hours, the child became lethargic and pale. His urine output dropped and his face
became swollen. A CBC shows a hemoglobin of 8.5 g/dL and a platelet count of
65,000/microliter. There are proteinuria and hematuria. What treatment is
appropriate?
Choices:
1. Trimethoprim/sulfamethoxazole for Salmonella
2. Ampicillin for Shigella
3. Supportive treatment for hemolytic uremic syndrome
4. Corticosteroids for Henoch-Schonlein purpura
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Question 13 (Answer and Explanation)
Answer: 3 - Supportive treatment for hemolytic uremic syndrome
Explanations:
Hemolytic uremic syndrome shows hemolytic anemia, renal insufficiency,
and thrombocytopenia.
Gastrointestinal bleeding, bowel obstruction, and ascites can be seen.
The causative organism is Escherichia coli 0157:H7 and produces
verotoxin.
It is most often due to fecal contamination of undercooked hamburger.
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Question 14 (Question and Choices)
Question: An elderly male with long-standing chronic obstructive pulmonary
disease (COPD) is rushed to the emergency room with exacerbation of his
COPD. He is severely short of breath and gasping. Quick blood work reveals an
arterial blood gas of pH 7.15, PCO2 55, PO2 54 and HCO3 15. He is admitted to
the intensive care unit and the pulmonologist intubates him. He remains on the
mechanical ventilator for 13 days and is eventually extubated. According to the
2015 Global Initiative for Chronic Obstructive Lung Disease, what is the
mortality of such patients at 12 months after discharge?
Choices:
1. Less than 5%
2. 10% to 15%
3. 40% to 60%
4. 90%
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Question 14 (Answer and Explanation)
Answer: 3 - 40% to 60%
Explanations:
COPD carries a high morbidity and mortality.
The GOLD report indicates that patients with COPD who require
mechanical ventilation have a high mortality at 12 months.
Any acute exacerbation should be promptly treated because delays often
result in protracted hospital admissions. The aim is to reduce the burden of
COPD.
Factors associated with negative prognosis include hypercapnia, low body
mass indices, advanced age, low serum albumin, long-term use of
corticosteroids and poor functional status.
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Question 15 (Question and Choices)
Question: A 17-year-old male with AIDS presents with worsening exertional
dyspnea, fever, and a nonproductive cough. His temperature is 102 F, heart rate
120 beats/min, and respiratory rate 19. A physical exam reveals mild crackles
and rhonchi bilaterally. A chest x-ray shows diffuse bilateral infiltrates. He has
no known drug allergies. What is the best initial treatment?
Choices:
1. Intravenous trimethoprim/sulfamethoxazole
2. Intravenous pentamidine
3. Intravenous corticosteroids followed by IV trimethoprim/sulfamethoxazole
4. Intravenous corticosteroids followed by IV levofloxacin
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Question 15 (Answer and Explanation)
Answer: 3 - Intravenous corticosteroids followed by IV
trimethoprim/sulfamethoxazole
Explanations:
Corticosteroids decrease mortality in patients with severe Pneumocystis
jiroveci pneumonia (PCP).
Trimethoprim/sulfamethoxazole is the drug of choice, but pentamidine is
used for those with sulfa allergy.
Levofloxacin does not cover PCP. However, if there are infiltrates, it can be
added for possible bacterial pneumonia.
Adjunctive corticosteroids can decrease the inflammatory response
associated with PCP. Also, they can reduce the decline of oxygenation and
reduce the incidence of respiratory failure.
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Pneumonia, Pneumocystis (Carinii) Jiroveci:
 
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Question: The 42-year-old female presented to the emergency department
with a sudden, painful decrease in visual acuity which was preceded by floaters
in the affected eye for about 24 hours prior to presenting. The third-year medical
student rotating in the emergency department wants to call in the hyperbaric
medicine team to emergently treat the patient for central retinal artery occlusion.
What should she be told?
Choices:
1. She is correct and you will make the phone call immediately
2. The patient has had symptoms for 24 hours and will not benefit from
hyperbaric oxygen this far out from onset of visual loss
3. The patient needs to have an echocardiogram and carotid ultrasound to assess
for an embolic event
4. She is incorrect in her diagnosis, and the patient has symptoms more consistent
with a retinal detachment than central retinal artery occlusion
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Question 16 (Answer and Explanation)
Answer: 4 - She is incorrect in her diagnosis, and the patient has symptoms
more consistent with a retinal detachment than central retinal artery occlusion
Explanations:
The medical student, though enthusiastic, is incorrect in her diagnosis and
treatment plan. The patient has a retinal detachment, and this is treated with
surgery, not hyperbaric oxygen treatment.
The patient needs emergent ophthalmologic consultation for surgical repair
of a probable detached retina.
The patient has no risk factors for an embolic event. Echocardiogram and
carotid ultrasound are not indicated emergently for this patient.
Painful, sudden vision loss in a person less than 60 years of age is more
consistent with a retinal detachment. Central retinal artery occlusion occurs
as sudden, painless monocular vision loss in patients greater than 60 years
of age.
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Question 17 (Question and Choices)
Question: A 28-year old who is 22-weeks pregnant presents to the emergency
room with a headache and general malaise. She has not been feeling well for a
few days. She last saw her obstetrician a month ago and was told that she may be
developing hypertension. Today her blood pressure is 200/110. It is decided to
admit and treat her, as she is symptomatic. Which of the following
antihypertensive drugs would be most appropriate?
Choices:
1. Phentolamine
2. Enalapril
3. Labetalol
4. Esmolol
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Question 17 (Answer and Explanation)
Answer: 3 - Labetalol
Explanations:
For pregnant females with hypertensive crises, the best option from the list
is labetalol. It is dosed at 20 to 40 mg every 15 minutes as needed.
Hydralazine is also used at 5 to 10 mg every 20 minutes as needed.
The goal is to maintain systolic blood pressure between 140 and 160 mmHg
and diastolic pressure between 90 and 110 mmHg.
Nitroprusside is used if needed.
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Question 18 (Question and Choices)
Question: A male was eating cheese and drinking beer. Thirty minutes later, he
developed severe hypertension, diaphoresis, flushing, and muscle rigidity. He
may have been taking which drug?
Choices:
1. Trazodone
2. Phenelzine
3. Nortriptyline
4. Diphenhydramine
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Question 18 (Answer and Explanation)
Answer: 2 - Phenelzine
Explanations:
Phenelzine is a monoamine oxidase inhibitor (MAOI) which is used as an
antidepressant. It is not widely used today because of its adverse event and
interaction profile. This includes dietary restrictions, which if not heeded,
can result in severe or fatal adverse reactions.
Specifically, MAOIs can interact with tyramine-containing foods such as
aged cheese, cured meats, and some red wines.
These drugs can cause a severe hypertensive crisis when they are consumed
with tyramine-containing foods.
MAOIs also have numerous serious drug-drug interactions including with
drugs that increase serotonin, dopamine, or norepinephrine levels. Serotonin
syndrome or hypertensive crisis may result, so many agents are
contraindicated with MAOI use.
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Question 19 (Question and Choices)
Question: A 6-years old boy was for care with symptoms of the marked nasal
blockade. His mother informed that he sustained a nasal injury with badminton
shuttle on the previous day. External nasal examination showed no obvious signs
of injury. Anterior rhinoscopy showed a bilateral cherry red swelling arising
from the nasal septum. This swelling was fluctuant on palpation and did not
regress in size with nasal decongestant spray. Which of the following statement is
not true?
Choices:
1. This is likely to be a case of nasal septal hematoma
2. This is not a case of nasal septal hematoma since there was no obvious sign of
external nasal injury
3. Immediate surgical intervention is required in such cases
4. Children can develop nasal septal hematoma even after a minor injury
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Question 19 (Answer and Explanation)
Answer: 2 - This is not a case of nasal septal hematoma since there was no
obvious sign of external nasal injury
Explanations:
A nasal septal hematoma usually occurs within 24 to 72 hours of nasal
trauma. Atraumatic causes are extremely rare.
Signs of external nasal injury might not be obvious and symptoms can be
non-specific, therefore a high index of suspicion for a septal hematoma is
needed in all the cases of nasal injury.
Immediate surgical intervention is required in all the cases of nasal septal
hematoma to prevent serious infective complications and permanent
sequelae.
In children, the septal cartilage is softer and gets buckled easily, thus
predisposing to hematoma formation even with minor trauma.
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Question 20 (Question and Choices)
Question: A 30-year-old patient has a 3-week history of general malaise and
has had a prolonged upper respiratory tract infection. She now is complaining of
pain in her neck and hoarseness. Her thyroid is diffusely enlarged and tender.
Both the erythrocyte sedimentation rate and T4 levels are elevated. What is the
next step in the management of this patient?
Choices:
1. Treat with non-steroidal anti-inflammatory drugs and rest
2. Ultrasound
3. Fine needle aspiration
4. Surgery referral
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Question 20 (Answer and Explanation)
Answer: 1 - Treat with non-steroidal anti-inflammatory drugs and rest
Explanations:
De Quervain thyroiditis is a common cause of a painful thyroid gland. The
gland can become diffusely tender but usually recovers in a few weeks.
It is believed that the thyroid is inflamed following a viral infection, but
viral inclusion bodies are never seen in the thyroid.
The symptoms may initially mimic hyperthyroid activity and follow a
euthyroid phase. The diagnosis is made clinically and there is no need for
any testing.
Non-steroidal anti-inflammatory drugs and steroids may help recovery.
Symptomatic hypothyroidism can be treated with thyroid hormones and
hyperthyroidism can be treated with beta-blockers.
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Question 21 (Question and Choices)
Question: A 65-year-old female presents with orthopnea, anorexia, and
bilateral lower extremity edema. Physical exam reveals cachexia, jugular venous
distention, a holosystolic, high-pitched, blowing murmur, bilateral rales, and
hepatomegaly. Blood work shows an elevated total bilirubin, aspartate
aminotransferase, and alanine aminotransferase. What is the best treatment for the
suspected condition?
Choices:
1. Metoprolol
2. Digoxin
3. Furosemide
4. Nifedipine
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Question 21 (Answer and Explanation)
Answer: 3 - Furosemide
Explanations:
Diuretics are the first-line option for cardiac cirrhosis.
Aggressive diuresis is often required to reduce the edema.
However, one must treat the primary cause of cardiac failure.
There is no role of the use of beta blockers acutely in the setting of acute
decompensated cardiac cirrhosis, especially if acute heart failure or
cardiogenic shock could be the potential cause of cardiac cirrhosis.
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Question 22 (Question and Choices)
Question: A SWAT officer using a battering ram complains of left shoulder
pain and decreased mobility of the arm after breaking down a door. On exam, the
arm is adducted and internally rotated with sensation intact to light touch but
resisting any range of motion. An anteroposterior view radiograph shows a
lightbulb sign. What is the diagnosis?
Choices:
1. Anterior dislocation
2. Posterior dislocation
3. Inferior dislocation
4. Acromioclavicular separation
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Question 22 (Answer and Explanation)
Answer: 2 - Posterior dislocation
Explanations:
Complications of any shoulder dislocation include fractures of the humerus
and damage to the neurovascular structures in close proximity.
Posterior dislocations can be seen with direct, anterior directed trauma to
the shoulder. The arm is internally rotated and adducted.
The patient resists any range of motion which is common in posterior
dislocations.
The distal sensation is intact. Posterior dislocations are not commonly
associated with neurovascular injuries due to the anterior location of the
neurovascular bundle and the posterior location of the dislocated humeral
head.
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Question 23 (Question and Choices)
Question: A 62-year-old male presents with steatorrhea found to be secondary
to chronic pancreatitis. He reports drinking at least 6 beers a day but has never
had withdrawal symptoms. He has lost 20 pounds and has complaints of
epigastric pain that worsens with eating and improves with taking ibuprofen. CT
scan confirms calcifications of the pancreas and amylase and lipase levels are
normal. What is the appropriate management?
Choices:
1. Low dose narcotic analgesics and discontinuation of alcohol
2. Discontinuation of alcohol and pancreatic enzyme replacement
3. Endoscopic retrograde cholangiopancreatography to rule out pancreatic cancer
4. Metoclopramide to promote gastric emptying
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Question 23 (Answer and Explanation)
Answer: 2 - Discontinuation of alcohol and pancreatic enzyme replacement
Explanations:
Pancreatic enzyme replacement along with fat-soluble vitamin replacement
and frequent, small meals should be considered first-line therapy in the
management of chronic pancreatitis.
Patients should be counseled about discontinuing alcohol use.
Endoscopic retrograde cholangiopancreatography is not needed to rule out
carcinoma but may identify a stricture that could be stented.
Narcotics should be used as a last resort due to the addictive potential.
Metoclopramide would worsen the patient's symptoms.
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Question 24 (Question and Choices)
Question: A 25-year-old woman is diving in Belize for the first time while on
vacation for her honeymoon. She and her husband are diving the Blue Holewith
a guide to 125 fsw using scuba on air. She euphoria and starts to dance in the
water losing track of her depth. Which of the following is the most likely
explanation?
Choices:
1. She's in love and on her honeymoon
2. The echoes of the Blue Hole are rhythmic
3. She has nitrogen narcosis
4. Large amounts of alcohol have been consumed during this trip
© StatPearls, LLC. Licensed To: Leonardo Vieira da Rosa 08-Apr-20 
Question 24 (Answer and Explanation)
Answer: 3 - She has nitrogen narcosis
Explanations:
The effects of nitrogen narcosis are highly variable among divers with all
divers being significantly impaired while breathing air at 180 fsw, whereas
some divers are affected at 100 fsw.
Initial symptoms may include euphoria and lack of inhibition, similar to
alcohol intoxication.
New symptoms develop as a diver descends deeper to greater pressures.
The narcotic symptoms observed are quickly reversible upon ascent.
The symptoms seen in nitrogen narcosis begin first with effects of the higher
function such as judgment, reasoning, short-term memory, and concentration.
Further increases in the partial pressure of nitrogen in the blood from
descending deeper lend to impairments in manual dexterity and further
mental decline including idea fixation, hallucinations, and finally stupor and
coma. This can lead to unsafe actions such as removing the regulator,
descending to dangerous depths, overstaying decompression limits, failing
to follow dive tables, and running out of air.
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Question 25 (Question and Choices)
Question: A 50-year-old male with alcohol use disorder presents to the
emergency department. His medical history includes only alcohol use disorder,
and he is not currently taking any medication. On presentation, he complains of
nausea, vomiting, and abdominal pain. He says that he has been drinking heavily
for several days but over the last day he has been unable to “keep anything
down.” His vital signs show respirations 28, heart rate 126 beats/min, blood
pressure 106/62 mmHg, and temperature of 98.5 F. On physical exam, he has dry
mucous membranes, mild diffuse abdominal tenderness, no peritoneal signs, and
clear lungs. His extremities are without edema. He has a visible resting tremor
which is worsened with finger-to-nose maneuvers. His bedside blood glucose is
70 mg/dL. He has the following arterial blood gas results: pH 7.2, pCO2 25, pO2
98, and bicarbonate 15. His basic metabolic panel shows sodium 138, potassium
4, chloride 100, bicarbonate 15, BUN 29, and creatinine 1.6. Anion gap is 23.
What is the patient’s acid-base status?
Choices:
1. Metabolic acidosis with adequate respiratory compensation
2. Metabolic alkalosis without respiratory compensation
3. Metabolic acidosis without adequate respiratory compensation
4. Metabolic acidosis without respiratory compensation
Question 25 (Answer and Explanation)
Answer: 1 - Metabolic acidosis with adequate respiratory compensation
Explanations:
The patient has metabolic acidosis with respiratory compensation. The
presence of large amounts of ketoacids (beta-hydroxybutyrate) lowers the
pH and causes an increased respiratory rate to decrease the pCO2.
By using Winter's formula one can tell if the patient is adequately
compensating for the metabolic acidosis.
In this case, the lungs are adequately compensating for the metabolic
acidosis.
The patient uses up existing bicarbonate ions by combining them with the
hydrogen ions to make carbonic acid (H2CO3). This is an example of
buffering an acid. At the level of the lungs, the respiratory rate increases to
release carbon dioxide in an attempt to decrease the amount of acid in the
system and bring the pH back up.
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Question 26 (Question and Choices)
Question: An 8-year-old boy presents with his mother with severe itching. His
mother said that the intense itching on the right sole of his skin started two-weeks
ago after they went on holiday to the beach. His mother also notices that on the
itchy area there was redness and a serpiginous rash that advanced in several
days. What is most likely the diagnosis?
Choices:
1. Scabies
2. Tinea pedis
3. Cutaneous larva migrans
4. Impetigo
Question 26 (Answer and Explanation)
Answer: 3 - Cutaneous larva migrans
Explanations:
Cutaneous larva migrans or creeping eruption usually occurs after exposure
to sandy and moist areas that have been contaminated with dog or cat feces.
The most commonly affected areas are those directly exposed to the
contaminated soil, such as hands, feet, and buttocks, although larvae can
penetrate any part of the body.
Patients present with an intensely pruritic, erythematous rash with a
serpiginous pattern.
The serpiginous pattern is the hallmark of cutaneous larva migrans due to
larvae tunneling phenomenon. The serpiginous lesion tract advances due to
larvae movement as much as 1 to 2 cm per day.
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Ancylostoma:
 
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Question 27 (Question and Choices)
Question: A 17-year-old man presents to the emergency department after
accidentally ingesting a mouthful of gasoline while siphoning gas from his lawn
mower. He does not report any vomiting at the time. He is currently
asymptomatic. Vital signs are blood pressure 125/86 mmHg, heart rate 75 beats
per minute, respiratory rate 14 breaths per minute, and temperature 98.8F. How
should this patient be managed?
Choices:
1. Perform gastrointestinal decontamination with activated charcoal and admit
for 24 hours observation
2. Admit for 24 hours observation with continuous pulse oximetry and telemetry
3. Discharge home after 4 hours of observation if patient remains asymptomatic
4. Discharge home after 6 hours of observation if chest x-ray is normal and
patient remains asymptomatic
Question 27 (Answer and Explanation)
Answer: 4 - Discharge home after 6 hours of observation if chest x-ray is
normal and patient remains asymptomatic
Explanations:
Gastrointestinal decontamination is contraindicated in hydrocarboningestion as this may lead to aspiration which could worsen the patient's
symptoms. Supportive care is mainstay of therapy
If a patient begins to exhibit any concerning symptoms or has abnormal vital
signs or imaging, they may require admission for continued monitoring.
Symptoms or chest x-ray changes may be delayed in presentation after
hydrocarbon ingestion or inhalation.
Observation for 6 hours with an asymptomatic patient with normal pulse
oximetry and normal chest x-ray is the appropriate management of the
patient who has ingested or inhaled hydrocarbons.
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Question 28 (Question and Choices)
Question: A 17-year-old male was hiking when he tripped and fell on his
side, landing on the lateral aspect of his left shoulder where you observe a minor
abrasion. He is able to abduct, extend, and flex at the shoulder, but is limited by
pain. He reports a painful lump on the top of the shoulder at the lateral aspect of
the clavicle. His radial pulse is 2+ and sensation to light touch is intact. Which of
the following is the most likely diagnosis?
Choices:
1. Fracture of the clavicle
2. Shoulder dislocation
3. Acromioclavicular joint sprain
4. Tear of the rotator cuff
Question 28 (Answer and Explanation)
Answer: 3 - Acromioclavicular joint sprain
Explanations:
The mechanism of injury, location of pain and swelling, and degree of
symptoms make clavicle fracture less likely. Clavicle fractures more
frequently require greater trauma and symptoms will be at the location of the
fracture along the clavicle, not the acromioclavicular (AC) joint.
His intact but painful range of motion makes a should dislocation less likely.
Shoulder dislocations will have a visible deformity compared to the
contralateral shoulder and have diminished range of motion.
AC joint sprain is the most likely explanation given mechanism of injury and
exam. Patients with AC joint injury usually present with pain and swelling
around the shoulder.
Based on his mechanism of injury and physical exam, a rotator cuff tear is
less likely than an AC joint sprain. Rotator cuff tear is uncommon in younger
patients and requires a significant force with the arm usually in some degree
of external rotation and abduction. This is not consistent with this patient's
mechanism of injury.
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Question 29 (Question and Choices)
Question: A diver with missed decompression presents with vertigo and
tinnitus 4 hours post dive. There was no difficulty in equalizing the ears or any
ear pain. Neurological exam reveals nystagmus and decreased hearing on the left
but is otherwise normal. The diver reports no pain or other symptoms. What is
the most likely diagnosis?
Choices:
1. Otic barotrauma
2. Type 1 decompression sickness
3. Inner ear decompression sickness
4. Cerebral gas embolism
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Question 29 (Answer and Explanation)
Answer: 3 - Inner ear decompression sickness
Explanations:
Otic barotrauma would likely present immediately or in the water.
Neurological decompression sickness (DCS), not otherwise involving the
inner ear, unlikely would present with both hearing and balance issues but
no other neurological findings.
Although inner ear DCS may be a form of arterial gas embolism, cerebral
gas embolism unlikely would present with both hearing and balance issues
but no other neurological issues.
Benign positional vertigo also may present like this. However, the history of
diving and missed decompression makes this unlikely.
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Question 30 (Question and Choices)
Question: A 17-year-old male is brought to the emergency department by
emergency medical services after falling from his bicycle during a mountain bike
ride. The patient was helmeted. C-collar placed by EMS on arrival. He
complains of back, epigastric pain and nausea. Vitals signs are blood pressure
118/78 mmHg, heart rate 101/minute, RR 18, O2 sat of 99%, Temp of 37 C. CT
head and cervical spine are negative. CT of the chest, abdomen, and pelvis
shows L1 chance fracture but no other injuries. Patient given pain medication and
anti-emetics, however, symptoms persist. Which test is most likely going to
provide the diagnosis?
Choices:
1. Deep peritoneal lavage (DPL)
2. Magnetic resonance cholangiopancreatography (MRCP)
3. Focused assessment with sonography test (FAST)
4. Liver function tests
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Question 30 (Answer and Explanation)
Answer: 2 - Magnetic resonance cholangiopancreatography (MRCP)
Explanations:
Blunt abdominal trauma can lead to pancreatic trauma. A sudden localized
impact to the abdomen which results in compression of the intra-abdominal
organs against the vertebral column and can lead to pancreatic injuries.
Examples of mechanisms associated with pancreatic injury include bicycle
handlebar injuries in children, steering wheel injury in adult motor vehicle
collision, or direct kick in an assault.
Computerized tomography (CT) is the test of choice for hemodynamically
stable trauma patient with blunt abdominal injury however it can have
difficulty in identifying pancreatic injury. Twenty to forty percent of
pancreatic injuries appear normal within 12 hours of trauma. The accuracy
of CT identifying traumatic major duct injury is reported as low as 43%.
FAST, DPL, Liver function tests are not diagnostic for traumatic
pancreatitis.
MRCP has become pivotal in the evaluation of traumatic pancreatic injury.
Dynamic secretin-stimulated MRCP is rapid, noninvasive, and competes
with endoscopic resonance cholangiopancreatography (ERCP) for accuracy.
MRCP has the added advantage of being non-invasive.
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Question 31 (Question and Choices)
Question: A patient has been taking paroxetine 20 mg daily for panic attacks
for the past year. She was started on lisinopril for hypertension, but it had to be
discontinued due to hypotension. She is on ibuprofen for headaches that have
been present for a year. She says the panic attacks are associated with headaches
and are getting worse. The patient is flushed and diaphoretic with vital signs of
blood pressure 180/105 mmHg lying and 113/80 mmHg standing, pulse is 110
beats/min, respiratory rate is 20, and she is afebrile. Her examination is
otherwise normal. What is the appropriate diagnostic test?
Choices:
1. CT scan of the abdomen with intravenous contrast
2. MRI of the brain
3. 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
4. 24-hour urine collection for fractionated metanephrines
Question 31 (Answer and Explanation)
Answer: 4 - 24-hour urine collection for fractionated metanephrines
Explanations:
Headaches, palpitations, and sweating are characteristic of
pheochromocytoma.
Panic disorder, essential hypertension, cocaine or methamphetamine abuse,
carcinoid syndrome, intracranial mass, clonidine withdrawal, and factitious
disorder should all be included in the differential diagnoses.
If the urinary metanephrines are elevated, CT of the abdomen, chest, and
pelvis is done to locate the pheochromocytoma.
Carcinoid syndrome would not have the elevation of blood pressure.
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Question 32 (Question and Choices)
Question: A 16-year-old girl presents with painful lumps on her ankles. She is
a long distance cross country runner and has been complaining of painful lumps
on lateral ankles worse after her long runs. On exam, there are several thick,
skin-colored papules which protrude from lateral heel bilaterally while she
stands which disappear after she is seated. What is the most likely diagnosis?
Choices:
1. Lipoma
2. Angiofibroma
3. Piezogenic pedal papules
4. Erythema nodosum
Question 32 (Answer and Explanation)
Answer: 3 - Piezogenic pedal papules
Explanations:
Piezogenic papules painful or asymptomatic papules of the ankles and
wrists.
On exam, these patients present with thick, yellowish to skin colored
papules which protrude from medial, posterior or lateral aspects of the heel.
Risk factors include obesity, pes planus, occupations which require long
periods of standing, and athletes, especially those who partake in long
distance running, high-impact sports or figure skating.
Lipomas should not be painful. Angiofibroma will not be reducible and the
ankle is not a characteristic location. Erythema nodosum though classically
painful occur more often over anterior lower extremities, typically as a
deep nodule and does not typically occur over the ankle.
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Question 33 (Question and Choices)
Question: A 68-year-old female has progressive headaches and worsening
confusion since a fall in the garden one month ago. She takes hydrochlorothiazide
for hypertension and warfarin for atrial fibrillation. Neurologic exam identifies
some confusion and trouble following complex commands but no focal motor
deficits. Laboratory workup is unremarkable except for her INR of 2.1. A urine
analysis is normal. The chest x-ray is normal. There is suspicion for intracranial
hemorrhage. What is the most likely pathology?
Choices:
1. Chronic epidural hematoma
2. Chronic subdural hematoma
3. Chronic subarachnoid hemorrhage
4. Acute subarachnoid hemorrhage
Question 33 (Answer and Explanation)
Answer: 2 - Chronic subdural hematoma
Explanations:
Chronic subdural hematoma can present with headache, nausea, vomiting,
confusion, decreased consciousness, lethargy, motor deficits, aphasia,
seizure or personality changes which may be slowly progressive over time.
A subdural hematoma can occur after minor head injuries, especially in the
elderly where the brain may move more freely within the skull.
A subdural hematoma occurs when a bridging vessel between the brain and
skull is torn and bleeds into the subdural space.
Acute subarachnoid hemorrhage presents as sudden onset of the worst
headache of the life, a thunderclap headache.
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Question 34 (Question and Choices)
Question: A 17-year-old complains of severe pain in her right eye for the past
2 days. She feels like that is a foreign body in the eye. Her vision is blurred and
she has become sensitive to light. She has been wearing contact lenses for over 5
years. Physical exam reveals ciliary injection, pupillary constriction, and an
erythematous eye. Slit lamp exam with fluorescein reveals corneal abrasion.
Which of the following treatment is not recommended for this patient?
Choices:
1. Prescribing a strong cycloplegic agent like cyclopentolate
2. Topical antibiotic
3. Eye patching
4. Oral non-steroidal anti-inflammatory agent for pain relief
Question 34 (Answer and Explanation)
Answer: 3 - Eye patching
Explanations:
Patching the eye is now rarely done. While it may offer mild pain relief it
does not benefit most patients.
Patching is never done in patients deemed at a high risk for an infection,
especially those who wear contacts.
Patching can potentially promote infectious keratitis.
A strong pain medication is usually required for most patients.
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Question 35 (Question and Choices)
Question: A perimenopausal woman presents with orthostatic hypotension,
heavy vaginal bleeding, a negative pregnancy test, and hemoglobin of 9 mg/dL.
What should be the initial treatment?
Choices:
1. A high-dose combination oral contraceptive pill
2. Conjugated estrogen
3. Blood transfusion with 2 units of packed red blood cells
4. Medroxyprogesterone
Question 35 (Answer and Explanation)
Answer: 2 - Conjugated estrogen
Explanations:
Conjugated equine estrogen has traditionally been used to treat an acute
episode of heavy uterine bleeding because it works quickly and will stop
most uterine bleeding, no matter the cause, within 24 to 48 hours.
Although this patient has signs of hypovolemia and anemia, neither is severe
enough to warrant an emergency transfusion.
Prolonged uterine bleeding suggests the uterus epithelial lining has become
denuded. In this setting, a progestin is not likely to control vaginal bleeding.
Estrogen alone can rapidly induce a return to normal endometrial growth.
Hemorrhagic uterine bleeding is treated with high-dose estrogen therapy. If
bleeding fails to stop within 12 to 24 hours, a dilatation and curettage is
indicated. Beginning progestin therapy after initiating estrogen therapy to
prevent a subsequent bleeding episode from treatment with prolonged
unopposed estrogen also is indicated.
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Question 36 (Question and Choices)
Question: A 3-year-old is brought in with a rash present for over a year but
worse for the past few days. The mother has tried many over-the-counter
treatments with intermittent success. The child picks and scratches constantly.
The exam shows dry and excoriated skin that is thickened. There are fissures,
erosions, and crusty exudates. The worst areas are at the antecubital and
popliteal fossa. A cluster of vesicles and lymphadenopathy are noted. What may
be the cause of the vesicles?
Choices:
1. Varicella zoster
2. Contact dermatitis
3. Eczema herpeticum
4. Atopic dermatitis
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Question 36 (Answer and Explanation)
Answer: 3 - Eczema herpeticum
Explanations:
Herpes simplex may cause an infection in a patient with skin barrier
compromise.
This patient has atopic eczema but may also have eczema herpeticum.
The quickest method of diagnosis is the Tzanck preparation. Direct
fluorescent antibody testing is confirmatory.
This may require treatment with antiviral drugs. Acyclovir is dosed at 15
mg/kg/day intravenously.
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Question 37 (Question and Choices)
Question: During a trip to a remote tropical region, you notice a serpentine
migrating rash on the lower leg of a young woman. You are uncertain what the
organism is but you remember that the rate can help distinguish between
hookworms associated with cutaneous larva migrans and other organisms. What
is the classic rate that is distinguishing for cutaneous larva migrans?
Choices:
1. Multiple centimeters per hour
2. Less than 2 cm per day
3. Up to 1 foot per day
4. intermittent movement of 4 cm per hour with pauses and prominence at night
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Question 37 (Answer and Explanation)
Answer: 2 - Less than 2 cm per day
Explanations:
The rate of cutaneous larva migrans is millimeters to 2 cm per day. This
classically is a slower migrating infection distinguishing it from the
similarly presenting larva currens of Strongyloides stercoralis.
Cutaneous larva migrans is diagnosed by the serpiginous rash with a slight
elevation and pruritus. Blood work and biopsy are not required for
diagnosis.
There is no treatment that is required for cutaneous larva migrans if the
disease is limited and symptoms are mild. Topical thiabendazole, oral
albendazole, or ivermectin are the drugs of choice.
Prognosis is excellent among patients with cutaneous larva migrans as
disease is usually self-limited and treatment results in near 100%
resolution.
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Question 38 (Question and Choices)
Question: A 17-year-old female presents with confusion and agitation.
Prescriptions for sumatriptan and phenelzine were discovered. An exam shows a
temperature of 39 C, pulse 110 beats/min, blood pressure 150/100 mmHg, and
respirations of 18. She was tremulous and hyper-reflexive without focal
neurologic findings. Her friends report that she took a recreational drug. Which
drug most likely caused this reaction?
Choices:
1. Heroin
2. MDMA (ecstasy)
3. Marijuana
4. Gamma-hydroxybutyrate (GHB)
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Question 38 (Answer and Explanation)
Answer: 2 - MDMA (ecstasy)
Explanations:
Phenelzine is a monoamine oxidase inhibitor used as an antidepressant and
can cause serotonin syndrome when used in combination with sumatriptan.
This patient tolerated the combination until she added MDMA, or ecstasy,
and developed this potentially life-threatening condition.
Treatment is mainly supportive with fluids, cooling blankets, and
benzodiazepines. In severe cases, a serotonin antagonist is used.
Cocaine, MDMA (ecstasy) and amphetamines may cause serotonin
syndrome.
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Question 39 (Question and Choices)
Question: A 7-year old is seen in the emergency room with a wet cough, fever,
and general malaise. The work-up reveals that he has lobar pneumonia. He has
otherwise been healthy, and he has had all his vaccinations to date. Based on the
2011 guidelines released by the Infectious Disease Society of America, the child
should be treated with which of the following?
Choices:
1. Observation only
2. Ampicillin
3. Ceftriaxone
4. Chloramphenicol
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Question 39 (Answer and Explanation)
Answer: 2 - Ampicillin
Explanations:
According to the 2011 national guidelines released by the PIDS and IDSA
for the treatment of vaccinated children hospitalized with uncomplicated
community-acquired pneumonia, the use of single, narrow-spectrum
antibiotics, such as penicillin or ampicillin was emphasized.
According to experts, the 2011 national guidelines released by the PIDS and
IDSA for the treatment of vaccinated children hospitalized with
uncomplicated community-acquired pneumonia was based on evidence that
Streptococcus pneumoniae most commonly caused the illness and that the
incidence of penicillin-resistant pneumococcal disease has dropped after
the vaccines' introduction.
Community-acquired pneumonia is a serious infection in children and often
requires hospitalization. The diagnosis can be based on the history and
physical examination. Chest radiography and rapid viral testing may be
helpful. Viral and Streptococcus pneumoniae infections are most common in
preschool-aged children. Mycoplasma pneumoniae is more common in
older children. The decision to treat with antibiotics is challenging,
especially with the increasing prevalence of viral and bacterial
coinfections. Preschool-aged children with uncomplicated bacterial
pneumonia should be treated with amoxicillin or ampicillin. Macrolides are
first-line agents in older children. Immunization with the 13-valent
pneumococcal conjugate vaccine is important to reduce the severity of
childhood pneumococcal infections.
Community-acquired pneumonia is a significant cause of respiratory
morbidity and mortality in children, particularly in developing countries. It
is the leading cause of death in children younger than five years. Factors that
increase the severity of pneumonia in children include prematurity,
malnutrition, low socioeconomic status, tobacco smoke exposure, and child
care attendance.
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Question 40 (Question and Choices)
Question: A 17-year-old male with abnormal vital signs and acute psychosis
presents to the emergency department via emergency medical services after
suspected methamphetamine usage. Which of the following diagnoses would not
be considered in addition to methamphetamine intoxication?
Choices:
1. Thyrotoxicosis
2. Acute adrenal insufficiency
3. Heat stroke
4. Pheochromocytoma
Question 40 (Answer and Explanation)
Answer: 2 - Acute adrenal insufficiency
Explanations:
Thyrotoxicosis can be distinguished from methamphetamine intoxication by
clinical signs such as goiter, exophthalmos, and pretibial edema.
Acute adrenal insufficiency causes hypotension, hypoglycemic, and usually
have decreased levels of consciousness. This is not consistent with the
clinical presentation.
A good history of environmental exposure will help differentiate heat stroke
from methamphetamine intoxication. Also, the agitation associated with heat
stroke is less and more resembles confusion.
Pheochromocytoma symptoms are very similar to methamphetamine
intoxication with hypertension, diaphoresis, and other sympathomimetic
symptoms. However, these episodes are episodic and have varying
durations.
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Question 41 (Question and Choices)
Question: A 65-year-old female presents complaining of a left-sided headache
and has a history of brief vision loss in her left eye. Her neurologic and
ophthalmologic exams are normal. She has no carotid bruits. She has tenderness
over her left temple. Blood work reveals an elevated erythrocyte sedimentation
rate. What is the most appropriate management?
Choices:
1. Order C-reactive protein
2. Prescribe oral corticosteroids and plan temporal artery biopsy
3. Prescribe aspirin and plan temporal artery biopsy
4. Order a head CT
Question 41 (Answer and Explanation)
Answer: 2 - Prescribe oral corticosteroids and plan temporal artery biopsy
Explanations:
This case is suggestive of temporal arteritis, or giant cell arteritis, given the
patient's age, headache, temporal artery tenderness, elevated erythrocyte
sedimentation rate, and history of amaurosis fugax.
Other symptoms of temporal arteritis include scalp tenderness, jaw
claudication, and fatigue.
Superficial temporal artery biopsy is the diagnostic standard. High dose
oral corticosteroids should be started immediately while awaiting a
temporal artery biopsy because vision loss can occur.
Temporal arteritis often is associated with polymyalgia rheumatica which
consists of neck, shoulder, and pelvic girdle pain.
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Question 42 (Question and Choices)
Question: A 68-year-old male complains of poor concentration, lethargy, and
inattentiveness. He feels like the Central Intelligence Agency is watching him.
Exam shows ataxia, proximal muscle weakness, edema, pale and coarse skin,
macroglossia, and delayed relaxation of deep tendon reflexes. Which of the
following is the most likely diagnosis?
Choices:
1. Vitamin B12 deficiency
2. Major depressive episode3. Hypothyroidism
4. Normal pressure hydrocephalus
Question 42 (Answer and Explanation)
Answer: 3 - Hypothyroidism
Explanations:
Hypothyroidism can present with neuropsychiatric symptoms including
decreased consciousness, psychosis, dementia, and headache.
Neuromuscular findings can include a delay in the reflex relaxation phase
and myopathic weakness.
Severe cases can result in cerebellar ataxia or myxedema coma
characterized by metabolic disturbances, hypotension, and hypothermia.
Myoedema, the formation of a lump in a muscle after percussion, can occur.
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Thyroid, Hypothyroidism:
 
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Question 43 (Question and Choices)
Question: A 93-year-old male is a nursing home resident and has had a
urinary catheter for the last 2 weeks due to urinary retention. He has had diarrhea
for the last 2 days. His medical history is significant for prostate cancer. The staff
noticed a foul-smelling, concentrated urine and were concerned about a urinary
tract infection. The patient did not report any lower abdominal pain or flank pain
to the staff. He had been unwell with a "stomach bug" for the last 2 days and did
not eat or drink well. The nursing home has had an outbreak of a viral illness,
and he feels that he is now recovering. He has not had any diarrhea today. The
patient's vital signs are pulse 75 beats/min, blood pressure 125/75 mmHg,
respiratory rate 16, temperature 36.8C, and oxygen saturation 98% on room air.
His tongue is slightly dry and he has slightly poor skin turgor. Otherwise, his
exam is normal. He is alert and oriented with no acute cardiac, respiratory,
abdominal, or neurological findings. The prostate exam is unremarkable. The
catheter is draining clear urine. Labs show a normal white cell count. His BUN
and creatinine are slightly elevated, but electrolytes are normal. Urinalysis
shows yeast. What is the most appropriate next step in the management of this
patient?
Choices:
1. Start intravenous amphotericin B for invasive fungal pyelonephritis
2. Start oral ketoconazole for candiduria
3. Replace urine catheter and recheck urine cultures
4. Maintain a fluid balance record and recheck renal functions in 24 hours
Question 43 (Answer and Explanation)
Answer: 4 - Maintain a fluid balance record and recheck renal functions in 24
hours
Explanations:
This patient likely has had a viral gastroenteritis with mild acute kidney
injury (AKI) due to dehydration. He needs to be well hydrated and requires
repeat renal function testing to ensure that his AKI is resolving. He does not
have any clinical features to suggest an active fungal urinary tract infection.
Diagnosis of a urinary tract infection (UTI) in a fully oriented patient
requires the presence of symptoms consistent with a UTI.
Long-term, indwelling urinary catheters frequently get colonized with
candida. Antifungal therapy is not appropriate in a clinically well and
asymptomatic patient.
While the catheter should be replaced and cultures repeated, this is not as
critical as treating his dehydration.
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Dehydration, Adult:
 
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Question 44 (Question and Choices)
Question: A 27-year-old male with asthma presents complaining of pain in
one of his joints. He claims that over the past 2 months the skeletal pain has
steadily increased and is unresponsive to the usual over the counter pain
medications. The pain is continuous and affects his sleep. Over the past few
days, he has been afraid to move the joint because of pain. He brings with him
plain x-rays, which the radiologist notes, has bony sclerosis, multiple areas of
subchondral radiolucent lines (crescent sign), and there is a flattening of bone.
Based on his clinical features and history, this type of pathology is most common
in which bone?
Choices:
1. Wrist
2. Ankle
3. Hip
4. Shoulder
Question 44 (Answer and Explanation)
Answer: 3 - Hip
Explanations:
Avascular necrosis is defined as the death of the cellular component of bone
due to lack of blood.
The disorder presents with pain and loss of joint function. Asthmatics who
take steroids often develop this condition.
Avascular necrosis is most common in the hips, especially the femoral joint.
It has also been associated with the use of bisphosphonates that are known
to jaw necrosis.
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Question 45 (Question and Choices)
Question: A 17-year-old female presents with a “popping sensation” in her
chest that she has had for a long time, but she noticed became worse after a slide
tackle in soccer yesterday. She states it doesn't really hurt. On exam, she can
reproduce it by abducting her arm over 90 degrees. You appreciate a clicking
sensation with palpation of the sternoclavicular joint, but no deformity. What
management is indicated?
Choices:
1. Emergent orthopedic surgical consult
2. Obtain x-rays, if normal, discharge for outpatient follow up
3. CT of the chest
4. Do nothing, advise her to quit playing soccer
Question 45 (Answer and Explanation)
Answer: 2 - Obtain x-rays, if normal, discharge for outpatient follow up
Explanations:
The patient in this question stem is describing a history of multidirectional
instability. Most frequently, this is associated with shoulder pain from
overuse, but may also be related to genetic disorders such as Ehlers-Danlos
or Marfan syndrome. Patient’s may have ligamentous laxity at any joint,
including the sternoclavicular joint. She likely sprained it during her slide
tackle yesterday.
It is standard practice to obtain x-rays in the emergency department. These
are likely to be normal but will help rule out any more nefarious pathology.
This patient does not necessarily need to see an orthopedic surgeon or
sports medicine physician immediately. She can consult with her primary
care provider and be referred to a specialist if she does not improve.
Management includes physical therapy, possibly use of a sling temporarily,
analgesia and a graded return to sports. Therapy is generally directed at
strengthening the muscles of the anterior chestand neck to stabilize the joint
as much as possible.
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Question 46 (Question and Choices)
Question: A patient is brought to the emergency department 20 minutes after
sustaining a chemical burn to his eye from drain cleaner. The eye was irrigated
with tap water for 5 minutes at the time of injury and irrigation was continued in
the emergency department until the pH normalized. Exam of the affected eye
reveals an intraocular pressure of 33 mm Hg. What is the first choice for treating
this patient's intraocular pressure?
Choices:
1. Oral acetazolamide
2. Topical apraclonidine
3. Lateral canthotomy
4. Oral labetalol
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Question 46 (Answer and Explanation)
Answer: 1 - Oral acetazolamide
Explanations:
Alkaline burns can damage the ciliary body and trabecular meshwork
leading to increased intraocular pressure (IOP). Acetazolamide decreases
the rate of aqueous humor formation. Thus, it decreases IOP.
Topical beta-blockers may also be used to treat increased IOP.
Avoid alpha agonists as vasoconstriction may worsen ischemia.
Prompt ophthalmology evaluation should be obtained for all ocular burns.
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Question 47 (Question and Choices)
Question: A 67-year-old female presents with abdominal pain that occurs
minutes to a few hours after every meal. This has been going on for the past 2
months, and she has lost about 15 pounds. She has become afraid to eat. Also,
she has a history of a stroke. The physical exam is unremarkable, and the blood
work is normal. What is the most likely condition?
Choices:
1. Abdominal aortic aneurysm
2. Chronic mesenteric ischemia
3. Gallstones
4. Chronic pancreatitis
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Question 47 (Answer and Explanation)
Answer: 2 - Chronic mesenteric ischemia
Explanations:
Mesenteric ischemia is a rare disorder but carries a high mortality if the
diagnosis is missed.
Chronic mesenteric ischemia typically presents with postprandial
abdominal pain and weight loss. Patients also may develop a fear of eating.
Patients often have a history of vascular disease that involves other organs
including cerebral vascular disease, coronary artery disease, or peripheral
vascular disease.
Arteriography is the gold standard for making the diagnosis. Open or
endovascular revascularization is the treatment of choice.
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Question 48 (Question and Choices)
Question: A 65-year-old male presents to the emergency department with
chest pain and hypotension. Intravenous fluids are started on the patient without
improvement in blood pressure. EKG reveals sinus tachycardia. The decision to
start vasoactive agents is made, and a femoral central venous catheter was
chosen as the best option for central access on this patient. The procedure was
attempted blindly, and only a small amount of blood returned into the syringe
with an associated inability to pass the wire. Which of the following findings on
ultrasound would explain the difficulty with the procedure?
Choices:
1. Identification of the femoral vein directly overlying the femoral artery
2. Anechoic appearance of the lumen of the femoral vein with complete filling
visualized on color flow
3. Minimally pulsatile flow with the flow gates over the center of the femoral
vein and with otherwise linear appearance on Doppler mode
4. Inability to compress the femoral vein
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Question 48 (Answer and Explanation)
Answer: 4 - Inability to compress the femoral vein
Explanations:
Anatomic variation is to be expected when performing an ultrasound of the
femoral vein. While the vein and artery usually are in a side-by-side
configuration, a variation with the vein overlying the artery may occur. This
does not impact the ability to obtain blood from the vein.
An anechoic appearance of the lumen of the femoral vein is associated with
a normal vein. However, not all clots are hyperechoic, making an anechoic
appearance alone unreliable to rule out deep venous thrombosis (DVT).
However, with complete filling on color flow, the presence of a DVT is
much less likely.
Normal venous flow is linear in appearance on Doppler mode. Lower
extremity veins may have a pulsatile flow if there is elevated right atrial
pressures, which may be present if the patient has a massive pulmonary
embolism, which is a possibility in the described patient.
Inability to compress the femoral vein is consistent with a deep venous
thrombosis. This would make it difficult or impossible to easily pass a wire
through the vein to place a central line. A small amount of blood may be
able to be drawn even if a DVT is present, as there may be some lumen
remaining. Evaluation for DVT and evidence of right heart strain on bedside
ultrasonography is a useful way to make a rapid diagnosis and change
management of an unstable patient.
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Question 49 (Question and Choices)
Question: A 32-year-old female who is obese and has a history of migraine
headaches flew from Los Angeles, CA to Aspen, CO and spent a day at a local
spa. While in the sauna, she became dizzy and sluggish and then developed a
dull, moderately severe bilateral frontal headache and nausea. She tried to stand
but fell and was found oriented but lethargic. What is the appropriate treatment?Choices:
1. Acetazolamide, oxygen, and corticosteroids
2. Oral rehydration and bedrest
3. Have the patient take her own sumatriptan
4. Have the patient fly home to Los Angeles
Question 49 (Answer and Explanation)
Answer: 1 - Acetazolamide, oxygen, and corticosteroids
Explanations:
The patient has a high altitude headache with some features of acute
mountain sickness.
The patient ascended from sea level to 7,900 feet of elevation, was likely
dehydrated, and is obese. These are all risk factors.
A high-altitude headache occurs within 24 hours after assent.
Acute mountain sickness can be life-threatening with resulting cerebral
edema. Treatment with acetazolamide, oxygen, and corticosteroids are
indicated.
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Question 50 (Question and Choices)
Question: A diver makes a series of two multilevel dives using 32% nitrox
(N2O2). Dive profiles are as follows: Dive 1, 110 feet/34 meters for 32 minutes.
Surface interval 1 hour 20 minutes. Dive 2, 75 feet/23 meters for 41 minutes. His
computer is set for 32% nitrox. The diver is asymptomatic on surfacing and
remains so during the 60-minute boat ride back to the dock. As he is leaving the
boat, he suddenly experiences severe weakness in both legs. When he arrives at
your facility, he is unable to move his legs and is numb from T11 down. He is
unable to urinate and requires catheterization. His vital signs are all within
normal limits. He denies pain, and his history is negative for traumatic injury.
What is the most likely diagnosis?
Choices:
1. Intervertebral disk herniation
2. Spinal cord decompression sickness
3. Arterial gas embolism
4. Pathologic fracture of the T11 vertebra
Question 50 (Answer and Explanation)
Answer: 2 - Spinal cord decompression sickness
Explanations:
The diver's dives would be considered provocative, that is, more likely to
produce decompression sickness (DCS) symptoms. The US Navy's no-stop
limit for 110 feet is 20 minutes; for 75 feet, the no-stop limit 39 minutes.
However, these limits are for square-profile dives. A dive computer tracks
the diver's depth and bottom time in real-time and constantly recomputes the
no-stop limit and decompression profile. Often, divers start the dive at a
deeper depth and gradually ascend with the bottom topography, so they can
remain within the no-stop limit on their computers while technically
exceeding the no-stop limit for their maximum depth in a printed
decompression table.
The diver experienced a sudden and dramatic onset of severe neurological
symptoms following his dives. Absent another obvious cause and given his
dive profiles, it is likely that he is suffering from spinal cord decompression
sickness.
The sudden onset of severe neurological DCS symptoms following a dive is
suggestive of a right-to-left shunt. Venous gas emboli may not appear
immediately after a dive; in fact, it is possible that venous gas emboli
(VGE) quantity in this diver was peaking at 60 minutes when the boat
docked.
The diver's sudden symptom onset could be explained by shunted VGE,
given the likelihood that he was straining to move heavy diving equipment
as he was debarking the boat. Though it is possible that the VGE shunted
through a PFO, it is also possible that they passed through an intrapulmonary
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shunt. The presence of PFO in this diver may be a red herring, though it
should prompt the practitioner to caution this diver to dive very
conservatively in the future and may influence clearance to dive should this
diver experience a similar incident in the future.
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Question 51 (Question and Choices)
Question: You are responding to an explosion at a nearby park. The first
patient you encounter complains of chest pain and shortness of breath. Her vital
signs are heart rate 100 bpm, blood pressure 115/85 mmHg, respiratory rate
22/minute, and oxygen saturation 95%. On physical exam, you notice that the
patient is coughing frank blood but you do not see any gross deformity or
ecchymosis over the chest wall and notice no jugular venous distension. What is
the most likely diagnosis?
Choices:
1. Blast lung injury
2. Sternal fracture
3. Flail chest
4. Pericardial tamponade
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Question 51 (Answer and Explanation)
Answer: 1 - Blast lung injury
Explanations:
Blast lung injury is a clinical diagnosis made in the field with symptoms of
respiratory distress and hypoxia in the setting of significant chest trauma
after an explosion and usually develops in 24 to 48 hours, though it can be
present immediately after an explosion.
One can expect blast lung Injury in 50% of victims exposed to 70 PSI or
greater.
Patients with great than 10% body surface area (BSA) burns are more likely
to have a concomitant blast lung injury.
Hemodynamic instability related to blast lung injury is thought to be related
to vagal nerve-mediated cardiogenic shock via pulmonary afferent C-fibers
from blast wave energy exertion on the thoracic cavity (Sasser).
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Question 52 (Question and Choices)
Question: A 74-year-old male is brought to the emergency department by
ambulance after his daughter had not heard from the patient in several days and
found him in bed at home unresponsive, with urinary and fecal incontinence. On
arrival, he has sonorous respirations at a rate of 16/min, a heart rate of 51 bpm,
blood pressure of 193/122 mmHg, and temperature of 98.6F. He has no signs of
trauma, withdraws from painful stimuli but will not answer questions or open his
eyes. Pupils are 7 mm bilaterallyand not reactive, with significant retinal
papilledema. What is the most likely underlying cause of this patient’s altered
mental status?
Choices:
1. Epidural hematoma
2. Idiopathic intracranial hypertension
3. Cerebral edema causing fourth ventricle compression
4. Hypertensive urgency
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Question 52 (Answer and Explanation)
Answer: 3 - Cerebral edema causing fourth ventricle compression
Explanations:
This patient is showing signs of elevated intracranial pressure (ICP),
including Cushing reflex of increased blood pressure, bradycardia, and
irregular breathing and papilledema.
His fixed bilateral pupils are indicative of impending or completed
herniation.
This can be caused by fourth ventricle compression due to cerebral edema
in the posterior fossa from a stroke that likely occurred days prior and has
progressively worsened since then along with his mental status as the
patient has stayed in bed without access to care.
In the absence of a history of trauma, an epidural hematoma is unlikely,
especially since the patient was found in bed, not on the ground after a fall.
Hypertensive urgency alone rarely causes neurologic deficits and would not
produce this degree of obtundation. Finally, idiopathic intracranial
hypertension, while also associated with elevated ICP, does not cause canal
obstruction that leads to herniation and focal deficits.
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Cerebellar Infarct:
 
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Question 53 (Question and Choices)
Question: A patient has had several episodes of syncope preceded by blurred
vision, profuse sweating, and lethargy. Blood tests reveal hypoglycemia and
ultrasound shows a mass in the mid-epigastrium. What is the most likely
diagnosis?
Choices:
1. Metastatic brain cancer
2. Insulinoma
3. Type 1 diabetes mellitus
4. Pheochromocytoma
Question 53 (Answer and Explanation)
Answer: 2 - Insulinoma
Explanations:
About 85% of patients with an insulinoma present with diplopia, blurred
vision, palpitations, or weakness.
Other symptoms of insulinoma include confusion, abnormal behavior,
unconsciousness, and amnesia. About 12% of patients have grand mal
seizures.
Laboratory results will reveal high insulin, low glucose, and high levels of
C peptide and proinsulin.
In patients with an insulinoma, diazoxide is used to decrease insulin
secretion, and somatostatin analogs are used to prevent hypoglycemia.
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Insulinoma:
 
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Question 54 (Question and Choices)
Question: A 60-year-old male patient presents with severe multilevel
spondylosis presents with progressive weakens of his upper extremities. He is
not able to lift his both hand above the shoulder and not able to do any fine
activities with his hands. For the past 4 weeks, his weakness has progressed
significantly. He also reports progressive exertional breathlessness. His reports
that when he lays down flat, he gets choking sensation and has to get up from the
bed. His MRI of spine shows severe multilevel cervical cord compression.
Chest x-ray showed elevated left diaphragm. What is the next best step in the
evaluation of this patient?
Choices:
1. MRI of the brain to look for intracranial pathology as strokes are common in
this patient population
2. Echocardiogram to rule out congestive heart failure in view of orthopnea
3. Polysomnography to rule out sleep apnea as patient reports symptoms in the
night
4. Ultrasound of thorax to look for diaphragmatic movements with deep breathing
to rule out diaphragmatic palsy
Question 54 (Answer and Explanation)
Answer: 4 - Ultrasound of thorax to look for diaphragmatic movements with
deep breathing to rule out diaphragmatic palsy
Explanations:
Diaphragmatic palsy is usually detected incidentally on routine chest x-ray
as an elevated diaphragm. Normally the dome of the right diaphragm is at
the level of the anterior end of the fifth rib, and the left diaphragm is one
intercostal space lower than that.
All patient with suspected diaphragmatic palsy should undergo fluoroscopic
evaluation to look for the caudal and outwards movements of the diaphragm
with deep inspiration or sniffing. In the recent times, ultrasound of the chest
is increasing used to detect diaphragmatic movements. It can be done
bedside and also avoids the radiation exposure of fluoroscopic examination.
The diaphragm appears as a thin hypoechoic line when viewed through the
subhepatic or sub splenic view on b mode. On deep inspiration, diaphragm
contacts and moves towered abdomen. This can be easily measured and
tracked in the M mode, and the diaphragmatic excursion can be measured.
In severe paralysis, the normal diaphragmatic contraction on the opposite
side will create negative pressure and sucks the diaphragm into the thorax
during the inspiration causing paradoxical cranial movements of the
diaphragm with inspiration.
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Question 55 (Question and Choices)
Question: A 75-year-old male with a past medical history of diabetes mellitus
type 2, hypertension, peripheral vascular disease, hypothyroidism, and
rheumatoid arthritis presents with significant substernal chest pain and
diaphoresis after acute emotional stress. His electrocardiogram reveals anterior
ST-segment elevations. His cardiac troponin levels are slightly elevated. A
coronary angiogram reveals 40% stenosis of the proximal right coronary artery.
The left anterior descending artery is wrapped around the apex of the heart. Left
ventriculography reveals apical ballooning in the mid, distal, and apical
segments, and a hypercontractile basal segment. What is the treatment for this
disorder?
Choices:
1. Intravenous fluids
2. Inotropic agents
3. Beta-1 blockers, aspirin, angiotensin-converting-enzyme inhibitors,
intravenous diuretics, direct thrombin inhibitors, and glycoprotein IIb/IIa
receptor inhibitors
4. Percutaneous transluminal coronary angioplasty
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Question 55 (Answer and Explanation)
Answer: 3 - Beta-1 blockers, aspirin, angiotensin-converting-enzyme
inhibitors,intravenous diuretics, direct thrombin inhibitors, and glycoprotein
IIb/IIa receptor inhibitors
Explanations:
If Takotsubo cardiomyopathy is diagnosed and there is no co-morbidity in
the patient, medical treatment is supportive. This patient has cardiovascular
and other system comorbidities. Therefore, he should be treated initially as
someone presenting with acute coronary syndrome or myocardial infarction.
If the patient is hypotensive, pressors may be required as well as an intra-
aortic balloon pump and left ventricular assist device. Management should
include continuous ECG monitoring. Echocardiography should be
recommended at approximately 4 to 6 weeks post presentation to document
normalization of left ventricular function.
The patient should be monitored closely if receiving inotropic agents
because these agents can exacerbate symptoms and result in a dynamic left
ventricular mid-cavity obstruction.
If dynamic intraventricular pressure gradient develops, discontinue the
inotropic agent and administer intravenous beta-blockers to increase
diastolic filling time and left ventricular end-diastolic volume.
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Cardiomyopathy, Takotsubo Syndrome (Transient Apical Ballooning, Stress-
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Question 56 (Question and Choices)
Question: A 26-year-old male presents with a 6-week history of pain and
swelling in several joints including his right wrist and left ankle. He also
complains of right eye pain and has had some trouble walking. He does admit to
several unprotected sexual encounters in the past several months. On physical
exam, vital signs are normal. The sclera of the right eye is injected. His right
wrist and left ankle are noted to be slightly swollen, warm, and tender to
palpation. There is also tenderness in bilateral Achilles tendon. What is the most
likely diagnosis?
Choices:
1. Rheumatoid arthritis
2. Osteoarthritis
3. Reactive arthritis
4. Ulcerative colitis associated arthritis
Question 56 (Answer and Explanation)
Answer: 3 - Reactive arthritis
Explanations:
Reactive arthritis can occur after gastrointestinal or genitourinary infections.
The most common triggers are Salmonella, Shigella, Campylobacter, and
Chlamydia.
Patients with reactive arthritis usually present with inflammation of fewer
than 5 joints. Joint pain may be additive or migratory.
The classic mnemonic associated with reactive arthritis is "Can't see, can't
pee, can't climb a tree." This mnemonic describes the triad conjunctivitis,
urethritis, and asymmetric oligoarthritis.
Reactive arthritis is usually self-limited but can be treated with NSAIDs,
glucocorticoids, TNF-inhibitors, or disease-modifying antirheumatic drugs
(DMARDs) such as methotrexate or sulfasalazine.
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Question 57 (Question and Choices)
Question: A 6-year-old child is suspected of being infected with Yersinia
pseudotuberculosis. Which of the following is true?
Choices:
1. Yersinia pseudotuberculosis is associated with a rare Kawasaki disease–like
variant in children. Izumi fever with ECG abnormalities may suggest ischemia if
aneurysms compromise coronary artery circulation.
2. Seventy-five percent or more of patients with Yersinia pseudotuberculosis
infections are associated with the elderly.
3. In Yersinia pseudotuberculosis, expect pronounced diarrhea.
4. Droplet infection transmits Yersinia pseudotuberculosis.
Question 57 (Answer and Explanation)
Answer: 1 - Yersinia pseudotuberculosis is associated with a rare Kawasaki
disease–like variant in children. Izumi fever with ECG abnormalities may
suggest ischemia if aneurysms compromise coronary artery circulation.
Explanations:
Yersinia pseudotuberculosis is a rare Yersinia species. Yersinia
pseudotuberculosis is associated with food-borne infection in humans.
Yersinia pseudotuberculosis is characterized by a self-limited mesenteric
lymphadenitis that mimics appendicitis. Yersinia pseudotuberculosis
survives intracellularly; the primary virulence factor is a plasmid-encoded
protein that causes increased invasiveness. Postinfectious complications
include reactive arthritis and erythema nodosum. The triad for Yersinia
pseudotuberculosis includes abdominal pain, fever, and rash. Rarely, it has
been associated with sepsis.
Seventy-five percent or more of patients with Yersinia pseudotuberculosis
infection are ages five to 15 years.
In the rare Kawasaki disease–like variant, Izumi fever, ECG abnormalities
may suggest ischemia if aneurysms compromise coronary artery circulation.
These abnormalities are more likely to develop in children.
Diarrhea is not a common finding.
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Yersinia, Pseudotuberculosis:
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Question 58 (Question and Choices)
Question: A 54-year-old male presents complaining of "the shakes." He
reports a history of chronic alcohol use of 1 pint of vodka daily. He also has a
history of HIV and prior intravenous drug use but has completely abstained for
the last 5 years. He has a poor appetite due to nausea in the last 2 days with his
last alcohol intake 12 hours ago. His point of care glucose is 235 mg/dL. His
vital signs are temperature 37.9 C, heart rate 110 beats/min and irregular to
palpation, blood pressure 155/90 mmHg, respirations 22, and pulse oximetry
99% on room air. Which of the following is least likely to be a concomitant
diagnosis?
Choices:
1. Atrial fibrillation
2. Alcohol ketoacidosis
3. Hyperosmolar hyperglycemic nonketotic syndrome
4. Alcohol withdrawal
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Question 58 (Answer and Explanation)
Answer: 3 - Hyperosmolarhyperglycemic nonketotic syndrome
Explanations:
Those with alcohol use disorder can present in atrial fibrillation due to both
underlying electrolyte abnormalities from malnourishment as well as the
potential for nonischemic dilated cardiomyopathy.
Alcoholic ketoacidosis is very common due to a diet of "tea and toast" and
overall malnourishment. Patients may have mild hyperglycemia but the
typical symptoms of diabetic ketoacidosis are not present. Therapy for these
patients is actually to give glucose-containing fluids as well as replete
electrolytes and supplement with multivitamins and thiamine.
Hyperosmolar hyperglycemic nonketotic syndrome is very unlikely due to
the patient's appropriate mental status and only mildly elevated glucose.
Alcohol withdrawal is a very likely diagnosis due to the patient's last
known drink, volume of daily utilization, tremors, and vital sign
abnormalities.
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Question 59 (Question and Choices)
Question: A 17-year-old male presents with fever, sore throat, and an
erythematous rash. A social history reveals he commonly has sexual relations
with other males. His rapid antigen test for Group A beta-hemolytic
streptococcus is negative. What is the next best step in the management of this
patient?
Choices:
1. Obtain testing for HIV and gonorrhea
2. Discharge the patient with a prescription for penicillin V and instruct him to
see his primary care provider if not better in 7 days
3. Recommend the patient use frequent gargles and take acetaminophen for pain
and call his primary care provider for an appointment
4. Obtain a complete blood count and blood culture
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Question 59 (Answer and Explanation)
Answer: 1 - Obtain testing for HIV and gonorrhea
Explanations:
Antibiotics for Group A beta-hemolytic streptococcus (GABHS) should not
be prescribed in the setting of a negative culture or rapid GABHS antigen
detection test.
Patients with a history of orogenital sexual contact or high risk of HIV
should be tested for HIV and gonorrhea.
Failure to recognize acute retroviral syndrome may delay appropriate
patient treatment and expose their future sexual partners to infection.
Acute retroviral syndrome and gonococcal pharyngitis should be considered
in a patient without an apparent cause for their symptoms.
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Question 60 (Question and Choices)
Question: A full-term patient is noted to have noisy breathing. Suctioning of
the oropharynx yields copious amounts of secretions that continue to accumulate.
An attempt to feed the infant results in choking. What is the next step in
evaluation?
Choices:
1. Barium swallow
2. Insert a soft radiopaque feeding tube and obtain a chest radiograph
3. Use a laryngoscope to assess the larynx
4. CT of the head to detect choanal atresia
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Question 60 (Answer and Explanation)
Answer: 2 - Insert a soft radiopaque feeding tube and obtain a chest
radiograph
Explanations:
The infant most likely has a tracheoesophageal fistula with a blind
esophageal pouch.
The feeding tube will be coiled in the blind pouch on the chest x-ray.
If there is abdominal distention there may be a connection between the distal
esophagus and the trachea.
If there is not a distal tracheoesophageal fistula there will be no gas in the
abdomen.
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Question 61 (Question and Choices)
Question: A 50-year-old male is transported to the emergency department
after being found down in his apartment. On arrival, he is afebrile but
hypotensive and tachycardic. He is nonresponsive. He has no significant past
medical history. History is limited secondary to his current altered mental status,
but family members note that he has been complaining of back pain for several
weeks. Initial laboratory workup reveals a serum creatinine of 5.7 mg/dL,
potassium 6.2 mmol/L, and sodium 124 mmol/L. A bedside ultrasound reveals
hydronephrosis bilaterally. The patient is hypotensive an tachycardic. What is the
first step necessary for the care of this patient?
Choices:
1. Obtain contrast-enhanced CT scan of the abdomen and pelvis to further
characterize the cause of the patient’s bilateral hydronephrosis
2. Consult interventional radiology for immediate percutaneous nephrostomy tube
placement
3. Immediate cystoscopy with bilateral ureteral stent placement in the operating
room
4. Start the patient on broad-spectrum antibiotics and begin intravenous fluids
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Question 61 (Answer and Explanation)
Answer: 2 - Consult interventional radiology for immediate percutaneous
nephrostomy tube placement
Explanations:
This patient requires acute management of his renal failure and
hyperkalemia. The goal of the initial management of retroperitoneal fibrosis
(RPF) depends on the severity of the disease at the time of diagnosis, with
the primary goal of preserving renal function.
Patient's presenting with acute uremia require immediate decompression
either with cystoscopy and bilateral ureteral stent placement or with
bilateral percutaneous nephrostomy tube placement by interventional
radiology.
This patient is critically ill with anuria and hyperkalemia, therefore
nephrostomy tubes can be placed under ultrasound guidance with local
anesthesia. This can be done quickly and provide the patient immediate
decompression.
The patient will need CT scan of the abdomen and pelvis with contrast
eventually to further characterize the mass, but this is not the most important
first step in the care of this patient.
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Question 62 (Question and Choices)
Question: A 40-year-old female patient with no significant medical history
presents with redness and swelling of the medial aspect of the right orbital
region. He states it started 2 days ago and noticed yellow discharge when he
touches the swollen area. His vitals are temperature of 36.6C, heart rate of 74
bpm, blood pressure of 108/74 mmHg, and oxygen saturation of 98% on room
air. His visual acuity is OD: 20/15, OS: 20/20, and OU: 20/20 which is his
baseline. The conjunctiva is noninjected. He extraocular movements are normal
and nonpainful. His cornea exam is unremarkable. What is the most likely
diagnosis?
Choices:
1. Bacterial conjunctivitis
2. Dacryocystitis
3. Dacryoadenitis
4. Orbital cellulitis
Question 62 (Answer and Explanation)
Answer: 2 - Dacryocystitis
Explanations:
Dacryocystitis is characterized by tenderness, swelling, and redness along
the inferomedial aspect of the eye over the lacrimal sac.
In uncomplicated cases, management consists of warm compresses, oral
antibiotics, and Crigler massage.
Dacryoadenitis is characterized by superolateral redness and swelling of
the lacrimal gland.
Any fever or changes in visual acuity should prompt further workup and
potential admission to the hospital with ophthalmology consultation.
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Question 63 (Question and Choices)
Question: A patient arrives at the emergency department after having been on
the beach for the past 3 days. Ten hours before his arrival, he observed a tiny
puncture wound on the sole of the right foot. Over the past 6 hours, he has noticed
that the foot is painful, swollen, and red, and he has both fevers and chills.
Examination reveals a red, swollen foot with blisters but no crepitus.
Radiological studies appear normal but the white blood cell count is 18
cells/mm3. Which of the following is most appropriate for the management of
this patient?
Choices:
1. Elevate the leg and give intravenous antibiotics
2. Incise the blister, take cultures, and start broad-spectrum antibiotics
3. Immediately take the patient to the operating room
4. Arrange for an MRI to better evaluate the extent of infection
Question 63 (Answer and Explanation)
Answer: 3 - Immediately take the patient to the operating room
Explanations:
This is a classic presentation of a rapidly spreading infection that has all the
markings of either Clostridia or group B Streptococcus necrotizing soft
tissue infection.
The patient needs to be in the operating room for incision and debridement
under broad-spectrum antibiotic coverage.
Any delay increases morbidity and mortality. Imaging, including MRI, is
often not diagnostic and can lead to significant delays.
Any delay in treatment can lead to death. There is no room for conservative
care when necrotizing fasciitis is suspected.
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Question 64 (Question and Choices)
Question: A 28-year-old male military diver presents complaining of shin
pain when ambulating for the past 4 months. Plain x-ray reveals a large,
circumscribed region of bone loss in the tibial shaft involving both cortices.
What should be involved in the next phase of this patient's care?
Choices:
1. Referral to physical therapy
2. Oral bisphosphonate therapy
3. Referral to interventional radiology for biopsy
4. Being made non-weight-bearing and prompt urgent referral to an orthopedic
surgeon
Question 64 (Answer and Explanation)
Answer: 4 - Being made non-weight-bearing and prompt urgent referral to an
orthopedic surgeon
Explanations:
Physical therapy will do little to help this patient's tibial lesion that is likely
causing his pain.
Oral bisphosphonate therapy may have some role in treating osteonecrosis
but is not the most prudent next step.
Biopsy of bony lesions should not be performed relying only on
radiographic workup and should be managed by an orthopedic oncologist.
This is the most prudent next step as the patient is at risk for a fracture
through his tibia and may require prompt surgical intervention to prevent
this complication.
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Question 65 (Question and Choices)
Question: You in the emergency department treating a patient who was
transported after she was removed from a burning house. The senior resident is
managing the patient quite appropriately, and she has secured the airway with an
endotracheal tube, administered the antidote for cyanide poisoning, and she has
consulted the hyperbaric medicine attending as well. You are explaining all this
to a third-year medical student who is starting her rotation today. She points to
the patient's urine which is the color of merlot wine and asks how it is that the
patient developed myoglobinuria so quickly. What should the student be told?
Choices:
1. The antidote for cyanide poisoning, cyanocobalamin will turn the patient's
urine this deep red color, and this is not myoglobinuria
2. Tell the student the catheterization was probably traumatic and that is why the
urine looks dark red.
3. Tell the student that the urine is discolored like this when a patient has had
heavy metal poisoning
4. Tell the student that methylene blue dye will sometimes turn the urine red in
patients with anti-thrombin III deficiency
Question 65 (Answer and Explanation)
Answer: 1 - The antidote for cyanide poisoning, cyanocobalamin will turn the
patient's urine this deep red color, and this is not myoglobinuria
Explanations:
The emergency department resident has correctly administered
cyanocobalamin, the antidote to cyanide poisoning and this will cause the
reddish discoloration of the urine. It is not harmful and will resolve without
further intervention.
Traumatic catheterization may cause transient hematuria, but the deep red
wine color of the urine after the administration of the cyanocobalamine
looks very different.
Heavy metal poisoning is nottreated with cyanocobalamin and therefore the
patient's urine would not have this deep red hue.
Methylene blue dye wound not be indicated to treat this patient with cyanide
poisoning. It turns the urine temporarily blue, not red.
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Question 66 (Question and Choices)
Question: A 17-year-old, male who is HIV-positive presents to your clinic
complaining of bloody discharge and pain during anal intercourse for the past 3
days. His partner had a small, painless penile skin lesion a few weeks ago that
healed. He also had some painful swelling in his groin that is getting better
without treatment. Examination revealed a painless perianal ulcer. Along with
testing for sexually transmitted infections, what would be the next most
appropriate step?
Choices:
1. Report to the health department once tests are back
2. Instruct patient that he does not need to abstain from sexual intercourse
3. Start doxycycline 100 mg orally twice a day for 21 days
4. Anoscopy or Gram stain should be done before starting any treatment
Question 66 (Answer and Explanation)
Answer: 3 - Start doxycycline 100 mg orally twice a day for 21 days
Explanations:
Patients with a clinical syndrome consistent with lymphogranuloma
venereum (LGV) should be reported to the health department without
waiting for diagnostic test results to become available.
The patient should be instructed to abstain from sexual intercourse until he
and his partner(s) have been treated adequately.
Men who have sex with men with acute proctitis, who have bloody
discharge, perianal ulcers, are positive for rectal chlamydia, or are HIV-
positive should be treated presumptively for LGV.
Presumptive therapy should be initiated even when anoscopy or Gram stain
is unavailable.
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Question 67 (Question and Choices)
Question: A patient presents with fever, chills, and extreme pain 48 hours
after cutting his hand. His hand is purplish in color with bullae, putrid discharge,
and decreased sensation. In addition to starting empiric antibiotics, what is the
most appropriate management of this patient?
Choices:
1. CT scan of the hand
2. Serial examinations to assess for progression
3. Surgical exploration
4. Incision and drainage to send specimen for culture and Gram stain
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Question 67 (Answer and Explanation)
Answer: 3 - Surgical exploration
Explanations:
This is a case of necrotizing fasciitis. It is a rapidly spreading infection
along deep fascial planes with subcutaneous tissue necrosis. It typically is
caused by Streptococcus pyogenes or Staphylococcus aureus, but anaerobes
and Clostridium species may also be present.
Urgent surgical exploration is indicated with aggressive debridement and
should not be delayed for culture or radiographic results.
A CT scan will not reveal anything new that can change surgical
management.
The patient must be aggressively resuscitated and undergo aggressive
debridement. A second-look procedure may be required in 24 to 48 hours.
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Question 68 (Question and Choices)
Question: A 26-year old was playing neighborhood football when he fell. He
complains of a painful soft-tissue mass in the anterior aspect of the arm. On
exam, there is decreased strength during flexion and supination of the forearm.
What is the recommended treatment?
Choices:
1. Physical therapy and anti-inflammatory medication
2. Prompt surgical repair
3. Delayed surgical repair
4. Corticosteroid injection
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Question 68 (Answer and Explanation)
Answer: 1 - Physical therapy and anti-inflammatory medication
Explanations:
Conservative treatment for a biceps tendon rupture is indicated unless the
patient does heavy labor, is a young athlete, or is uncomfortable with a
cosmetic defect.
Isolated proximal tears result in a 10% loss of elbow flexion and decreased
supination strength.
Distal ruptures are treated with early surgical repair, as there is a 30% to
40% loss of strength at the elbow.
Disorders of the distal biceps brachii tendon result from partial and
complete muscle tears. Partial tears are characterized by enlargement and
abnormal contour of the tendon. Complete tears generate a soft-tissue mass
in the anterior aspect of the arm, the Popeye sign, which paradoxically
results in decreased strength during flexion and supination of the forearm.
Tears of the biceps brachii may occur in athletic activities.
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Question 69 (Question and Choices)
Question: A male presents with a 3-week history of abdominal pain, nausea,
and bilateral leg pain. He describes a pins and needle sensation in both legs. He
just got a new job in a metal foundry and noticed that his symptoms began soon
after. Physical exam reveals tachycardia and garlic odor from his mouth. On his
chest, he has a rash with hyperkeratosis. Both legs show a symmetrical
neuropathy, and his fingernails show distinct horizontal white lines. To confirm
your suspicion of poisoning, what study is not worthwhile?
Choices:
1. Plasma levels
2. Electrocardiogram
3. Abdominal x-ray
4. Nerve biopsy
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Question 69 (Answer and Explanation)
Answer: 4 - Nerve biopsy
Explanations:Plasma arsenic levels are helpful when available. Arsenic may remain in
the body for months and the toxicity is dose-related.
An abdominal x-ray will reveal the presence of radio-opaque densities that
may resemble an upper gastrointestinal series.
A nerve conduction study may confirm peripheral neuropathy and ECG may
show cardiac arrhythmias. A nerve biopsy is almost never done.
Patients with arsenic poisoning can develop cardiac arrhythmias and hence
an ECG is warranted.
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Question 70 (Question and Choices)
Question: A patient is seen in the emergency department after suffering a
third-degree burn to his right leg several days ago. He was treated at another
facility but the family were unhappy and decided to take him to another facility.
Quick exam reveals a thick band of burnt tissue around the right mid-calf area
and a cold lower extremity which is blue. The proximal leg appears edematous
and swollen. The physician decides to perform an escharotomy. Where is the
most appropriate incision is made?
Choices:
1. Posteriorly and anteriorly
2. Laterally and medially
3. Only anteriorly
4. It does not matter
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Question 70 (Answer and Explanation)
Answer: 2 - Laterally and medially
Explanations:
Whilst escharotomy is simple surgical technique, but it requires an
understanding and knowledge of relevant anatomy so that injuries to
peripheral neurovascular structures are avoided.
It is a time critical procedure, therefore the sooner it is performed, the better
the outcome for the patient. therefore if a senior emergency medicine
physician is available prior to plastic or burn surgeon then it may be
appropriate for them to perform the procedure.
Escharotomy should ideally take place once the patient has been adequately
resuscitated and assessed or discussed with a surgeon.
Ideally, escharotomy should be performed by plastic or burn surgeons as
they will be responsible for patient's care, and will be able to follow up the
patient and review their progress regularly. The incision should be made
laterally and medially to avoid injury to neurovascular structures. When
making a lateral incision, great care should be undertaken at the fibular head
because the common peroneal nerve is close.
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Question 71 (Question and Choices)
Question: Rubbing a brownish macule produces a wheal. This is diagnostic of
what condition?
Choices:
1. Neurofibromatosis
2. Tuberous sclerosis
3. Addison's disease
4. Urticaria pigmentosa
Question 71 (Answer and Explanation)
Answer: 4 - Urticaria pigmentosa
Explanations:
When the pigmented macules of urticaria pigmentosa are rubbed, mast cells
degranulate producing urticaria; this is Darier's sign and is virtually
diagnostic for urticaria pigmentosa.
Urticaria pigmentosa is the most common form of cutaneous mastocytosis. It
is a rare disease caused by excessive mast cells in the skin that produce
hives when irritated. Red or brown spots are often seen on the skin around
the chest and forehead. These mast cells, when irritated produce histamine
triggering an allergic reaction that leads to hives localized to the area of
irritation. Severe itching follows and scratching makes it worse. Symptoms
can be mild (local itching and hives), moderate (diarrhea, tachycardia,
nausea/vomiting, headache, and fainting), or life-threatening (vascular
collapse).
The majority of urticaria pigmentosa is caused by a point mutation at amino
acid 816 of the proto-oncogene c-kit. C-Kit is a transmembrane protein
when bound to Mast Cell Growth Factor signals the cell to divide.
Mutations in position 816 of the c-kit result in a constant division signal
being sent to the mast cells, resulting in abnormal proliferation. Several
factors worsen symptoms including emotional stress, heat, friction, exercise,
bacterial toxins, venom, eye drops containing dextran, NSAIDs, alcohol,
and morphine.
The disease is often diagnosed in infants when parents take their baby in for
what appears to be bug bites. The bug bites are clumps of mast cells.
Clinicians confirm the presence of mast cells by rubbing the baby's skin. If
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hives appear, this suggests urticaria pigmentosa. There is no cure. Most
treatments for mastocytosis can be used to treat urticaria pigmentosa.
Common anti-allergy medications reduce the mast cell's ability to react to
histamine. At least one study suggests that nifedipine may reduce mast cell
degranulation in patients with urticaria pigmentosa. Nifedipine is not
approved by the FDA. Another mast cell stabilizer Gastrocrom, a form of
cromoglicic acid has been used to reduce mast cell degranulation. Urticaria
pigmentosa is a rare disease, affecting fewer than 200,000 people in the
United States.
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Question 72 (Question and Choices)
Question: A patient arrives with a high fever, sweating, diffuse muscle pain,
nausea, vomiting, and diarrhea. On exam, the liver and spleen are palpably
enlarged and tender. The nurse had the patient remove his clothes in the waiting
room because he smelled like wet hay. Which of the following is true?
Choices:
1. Treatment with streptomycin most likely will be helpful
2. Bengal Rose test will be negative
3. Huddleston test will be negative
4. Vaccination of family members is not necessary
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Question 72 (Answer and Explanation)
Answer: 1 - Treatment with streptomycin most likely will be helpful
Explanations:
Signs and symptoms of brucellosis include fever, sweating, foul smell of
wet hay, arthralgia, myalgia, muscular pain, night sweats, nausea, vomiting,
diarrhea, decreased appetite, weight loss, abdominal pain, constipation, an
enlarged liver, liver inflammation, liver abscess, and an enlarged spleen.
Duration of the disease is from a few weeks to years. Blood tests reveal a
low RBC and WBC, elevation of liver enzymes such as aspartate
aminotransferase(AST) and alanine aminotransferase (ALT), and
demonstrate positive Bengal Rose and Huddleston tests. Brucella infection
may cause arthritis, spondylitis, thrombocytopenia, meningitis, uveitis, optic
neuritis, endocarditis, and neurobrucellosis.
Treatment includes tetracycline, rifampin, streptomycin, and gentamicin.
They are effective if given for several weeks as bacteria incubate within
cells. Multiple antibiotics may be necessary. The gold standard treatment is
streptomycin 1 gram for 14 days and oral doxycycline 100 mg twice daily
for 45 days. Another regimen is doxycycline plus rifampin twice daily for 6
weeks. A triple therapy of doxycycline, with rifampin and co-trimoxazole,
has been used successfully to treat neurobrucellosis.
In endemic areas, vaccination is used to reduce the incidence of infection.
Brucella has been weaponized by several countries.
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Question 73 (Question and Choices)
Question: A 17-year-old patient has a sore throat, cough, fever, and general
malaise for 10 days. Examination reveals that he has a thick silvery-greyish
exudate on the tonsils and bilateral cervical adenopathy. Scrapping of the tonsils
leads to bleeding. During the exam, the patient suddenly became hypotensive. A
quick ECG reveals the presence of a 2nd-degree heart block. What is the next
step in his management?
Choices:
1. Intravenous vancomycin
2. Cardiac pacing
3. Mechanical ventilation
4. Intravenous fluids
Question 73 (Answer and Explanation)
Answer: 2 - Cardiac pacing
Explanations:
The description is classic for diphtheria. Diphtheria can cause severe
enlargement of lymph nodes in the neck.
The patients have to be observed as abnormal heart rhythms can occur,
especially atrioventricular (AV) block. If the patient is bradycardic, pacing
is vital.
Classic antibiotic treatment is with erythromycin or procaine penicillin.
Diphtheria antitoxin does not neutralize the toxin that has already attached to
the nerve ending.
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Diphtheria:
 
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Question 74 (Question and Choices)
Question: A 6-month-old male has several comedones on his upper back and
cheeks. The parents request treatment. Which of the following would be most
appropriate?
Choices:
1. Topical erythromycin
2. Topical benzoyl peroxide gel
3. Curettage
4. Obtain DHEA and testosterone levels
Question 74 (Answer and Explanation)
Answer: 2 - Topical benzoyl peroxide gel
Explanations:
Infantile acne is different from neonatal acne and is more common in males.
Testing for androgens is not necessary.
Topical benzoyl peroxide is usually adequate treatment.
Curettage is not recommended.
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Question 75 (Question and Choices)
Question: A 65-year-old male with history of hypertension and
hyperlipidemia presents to the emergency department for sudden onset substernal
chest pain. He was shoveling the sidewalk when the pain occurred but has since
resolved with rest. He is currently chest pain-free. Initial troponin is negative
(less than 0.12 ng/ml), but his EKG shows T wave inversion in V1 and V2 with a
new right bundle branch block. What is the next step in management?
Choices:
1. Consult cardiology for left heart catheterization
2. Admit the patient for repeat troponin and cardiac stress test
3. Administer tPA
4. Discharge the patient home
Question 75 (Answer and Explanation)
Answer: 2 - Admit the patient for repeat troponin and cardiac stress test
Explanations:
T wave inversion in leads V1 and V2 are typical EKG changes in a right
bundle branch block.
A new right bundle branch block is an ischemic equivalent.
Diagnosis of a myocardial infarction is not affected by a right bundle branch
block.
Due to the patient's age and cardiac risk factors, he is at increased risk of a
major adverse cardiac event.
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Question 76 (Question and Choices)
Question: A patient complains of pain and swelling over the third
metacarpophalangeal joint. He reports he was in a fight a day earlier and hit his
opponent, knocking out a couple of teeth. The area is swollen and red with
decreased range of motion secondary to pain. Which of the following is the
greatest cause for concern?
Choices:
1. Boxer fracture
2. Tendon injury
3. Septic joint
4. Clostridium tetani infection
Question 76 (Answer and Explanation)
Answer: 3 - Septic joint
Explanations:
A clenched fist injury from the penetrating teeth of an opponent's mouth can
result in a serious infection, even if the joint is not penetrated.
The patient will need orthopedic consultation for possible dye injection into
the joint.
Admission and intravenous antibiotics may also be necessary.
A boxer fracture occurs at the fourth or fifth metacarpals.
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Question: What is the most reliable method for obtaining an airway in a 1-
year-old patient with facial trauma with excessive intraoral bleed and multiple
facial injuries?
Choices:
1. Surgical cricothyroidotomy
2. Needle cricothyroidotomy
3. Direct laryngoscopy
4. Glideoscope
Question 77 (Answer and Explanation)
Answer: 2 - Needle cricothyroidotomy
Explanations:
Needle cricothyroidotomy is a reliable method of obtaining an airway in a
patient that has obstruction or occlusion of the upper airway.
Surgical cricothyroidotomy is contraindicated in very young children,
particularly under 12 years of age. This is due to the smaller cricothyroid
membrane and more funnel-shaped and compliant larynx.
Direct laryngoscopy and video laryngoscopy are not very useful when
dealing with increased bleeding or secretions that limit visualization and
successful procedure.
Facial trauma in older individuals, with limited visibility and decreased
accessibility benefit from surgical cricothyroidotomy.
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Question 78 (Question and Choices)
Question: A 55-year-old male presents with gynecomastia, spider angiomata,
and testicular atrophy. What is the typical pattern of liver enzymes in the
suspected condition?
Choices:
1. Aspartate aminotransferase (AST) greater than alanine aminotransferase
(ALT)
2. ALT greater than AST
3. Elevated alkaline phosphatase
4. Elevated bilirubin
Question 78 (Answer and Explanation)
Answer: 1 - Aspartate aminotransferase (AST) greater than alanine
aminotransferase (ALT)
Explanations:
The diagnosis of liver disease secondary to alcohol use can be challenging.
Often patients are not forthcoming about intake. Certain physical and
laboratory findings can be helpful. Dependence on alcohol is not found in
all those with alcoholic liver disease. Aspartate aminotransferase (AST) is
double alanine aminotransferase (ALT) in more than 80% of patients with
alcoholic liver disease.
Gamma-glutamyltransferase is the best indicator of recent alcohol intake but
the enzyme is also found in organs other than the liver and can be increased
secondary to other causes.
Elevated alkaline phosphatase is seen in diseases of liver and bone. It is not
specific to alcohol injury.
Elevated bilirubin also is found in many liver diseases. It is not specific to
alcohol injury.
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Question 79 (Question and Choices)
Question: A 46-year-old male with a history of myocardial infarction and
congestive heart failure presents to his local emergency department. The ECG
reveals an ST-elevation myocardial infarction and the provider wants the patient
transported to the percutaneous coronary intervention center. Who is responsible
for choosing the appropriate transport personnel?
Choices:
1. Accepting provider
2. Transport team
3. Emergency medical services dispatch
4. Sending provider
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Question 79 (Answer and Explanation)
Answer: 4 - Sending provider
Explanations:
An accepting provider is necessary for a transport, but only the sending
provider can know what is required of the transporting team.
Neither emergency medical services (EMS) dispatch nor the transport team
is responsible for this, as it would be a conflict of interest to decide what
level of care and who to send. They may recommend a level of transport
based on experience, but cannot make the decision.
The sending provider is the person solely responsible for deciding the
appropriate transport personnel along with the type of equipment based on
the patient's needs.
EMS dispatch can help in the decision and provide information on the level
of care that may be required, but cannot make the decision.
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Question 80 (Question and Choices)
Question: A 13-year-old was hit in the face with a baseball. The nose is not
obviously deformed but there is severe swelling of the nasal septum almost
occluding both nares. Which of the following would be appropriate management?
Choices:
1. Ice packs every hour for the next day
2. Evaluation by an otolaryngologist within a few hours
3. Evaluation by an otolaryngologist in one week
4. Nasal bone radiographs
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Question 80 (Answer and Explanation)
Answer: 2 - Evaluation by an otolaryngologist within a few hours
Explanations:
A septal hematoma is a surgical emergency.
It must be evacuated to prevent compromise of the blood supply.
Failure to do so results in a saddle-nose deformity.
A nasal septal hematoma is purely a clinical diagnosis and no radiological
examination is generally required to make the diagnosis.
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Question 81 (Question and Choices)
Question: A 50-year-old male with a history of two cerebrovascular accidents
presents to the hospital with left-sided weakness. He is found to have another
acute cerebrovascular accident. All previous workups including
electrocardiograms, echocardiograms and a hypercoagulable workup have been
unrevealing. He denies any cardiac-related symptoms. What would be the best
course of action at this point?
Choices:
1. Holter monitor
2. Implantable loop recorder
3. Treat and discharge
4. Observation
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Question 81 (Answer and Explanation)Answer: 2 - Implantable loop recorder
Explanations:
An implantable loop recorder (ILR) is beneficial in identifying
asymptomatic, occult episodes of atrial fibrillation following a stroke.
It also is helpful in assessing the average heart rate and adequacy of rate
control in a patient with atrial fibrillation.
An ILR can record up to 3 years of data and can be helpful when short-term
cardiac monitoring is unrevealing.
Given that patient does not report any cardiac symptoms, but has had
multiple strokes at a relatively young age, it is reasonable to have an ILR
implanted in this patient.
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Question 82 (Question and Choices)
Question: A 1-year-old female presents with episodic abdominal pain for 1
day, anorexia, and loose stools. She has no fever or upper respiratory symptoms.
On physical exam, her abdomen is soft and non-tender but her stools are bloody
and the hemoccult test is positive. Of the following, which radiologic study
would be best used to confirm the suspected diagnosis?
Choices:
1. CT with contrast of the abdomen
2. Ultrasound
3. X-ray
4. MRI of the abdomen, with and without contrast
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Question 82 (Answer and Explanation)
Answer: 2 - Ultrasound
Explanations:
This patient has suspected intussusception given the episodic abdominal
pain and heme-positive stools.
Though CT, MRI, or x-ray could either identify or help identify
intussusception, ultrasound is a much easier, less invasive, and less
expensive modality. The sensitivity and specificity reach nearly 100% in
institutions with well-trained ultrasonographers.
Some surgeons will elect to go with a contrast enema when the suspicion of
intussusception is high. The technique is both diagnostic and therapeutic.
Contrast enema usually is not recommended for children older than 3 years,
as most of these children have a surgical lead point.
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Question 83 (Question and Choices)
Question: You receive a call from local emergency medical services which
are transporting a 17-year old male to your emergency department. The patient
was found inside a burning house by the fire department and non-rebreather from
the building unconscious and unresponsive. He is tachycardic, tachypneic and has
soot around his nares and mouth. He was the only person in the house, and the
fire is believed to have started when he left a cigarette unattended in the living
room. He has full thickness burn injuries to his upper and lower limbs. No
information is available about his past medical history as no family or next of kin
are available at this time. He is being transported by an EMT-1 unit which is
giving the patient oxygen via a nonrebreather mask. They cannot get intravenous
access. What is your priority for treating this patient when he arrives in the
emergency department?
Choices:
1. Prepare to obtain interosseous access to administer fluids and medication
2. Prepare to secure the patient's airway with endotracheal intubation
3. Consult the hyperbaric medicine team to treat the patient's burns
4. Advise the basic EMT unit to divert from your hospital and transport the
patient to the nearest burn center which is approximately 45 miles away
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Question 83 (Answer and Explanation)
Answer: 2 - Prepare to secure the patient's airway with endotracheal
intubation
Explanations:
While this patient may need intraosseous or a central line, this is not the first
priority to care for this patient.
Securing the airway in this patient is the first priority due to the fact that the
presence of soot in the nares and around the mouth indicates he has probably
had a significant inhalation injury as well, and complete airway obstruction
due to edema can occur quickly and catastrophically.
While the patient does have significant burn injuries and hyperbaric oxygen
has been shown to promote healing and decrease the need for surgical
debridement and fasciotomy in burn patients, emergent hyperbaric
consultation for this patient should be for treatment of cyanide and carbon
monoxide poisoning.
The first priority for managing this patient's treatment is to secure his
airway. He may occlude due to edema at any moment, and if transferred
with a basic life support team that cannot intubate, this puts the patient at
even greater risk of death. He needs to come to the closest emergency
department for airway management, and if transport is later deemed
necessary, the patient can go with the airway secured and with appropriate
critical care transport.
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Question 84 (Question and Choices)
Question: A 17-year-old male with a history of frequent perianal abscesses,
previously treated with incision and drainage, presents with the same complaints
of perianal pain and subjective fever and chills. He also has been recently
complaining of abdominal pain and some diarrhea. Physical exam identifies
circumferential fullness of the anal verge. MRI of the pelvis identifies perianal
horseshoe abscess. Which initial referral should this patient receive in addition
to an immediate surgical consultation?
Choices:
1. Gastroenterology referral
2. No further referral is needed
3. Endocrinology referral
4. Immunology referral
Question 84 (Answer and Explanation)
Answer: 1 - Gastroenterology referral
Explanations:
Initial immediate consultation to surgical services is key because this
patient needs adequate drainage in an operating room setting for posterior
drainage with counter incisions if necessary.
All patients with recurrent or complex abscesses without an underlying
cause should be evaluated for Crohn disease.
Referral to gastroenterology services is appropriate for evaluation,
diagnosis, and treatment for Crohn disease.
Although usually well versed in the symptoms of a perianal abscess, these
patients should be educated to return to the emergency and not to dismiss
their symptoms. Prompt diagnosis and treatment can avoid further sequelae
of this disease.
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Question 85 (Question and Choices)
Question: A 3-year-old child presents to the emergency department by way of
emergency medical services with lethargy. Vital signs are temperature 37C, heart
rate 60 beats/min, systolic blood pressure 70 mmHg, respiratory rate 16, and
oxygen saturation 99% on room air. He has small pupils, hyporeflexia, and is
arousable with physical stimuli. The child's sibling is being treated for attention-
deficit/hyperactivity disorder. The child was given naloxone prehospital without
response. What is the best next step in management?
Choices:
1. Give a larger dose of naloxone
2. Administer a 20 mL/kg IV bolus of normal saline
3. Check blood glucose
4. Set up for intubation
Question 85 (Answer and Explanation)
Answer: 3 - Check blood glucose
Explanations:
This is likely an accidental ingestion of the sibling's central alpha-2 agonist
used for the treatment of attention-deficit/hyperactivity disorder. But,
immediate causes of presentation need to be ruled out first.
The child is ventilating and oxygenating appropriately, and more immediate
causes of central nervous system depression need to be ruled out.
Hypoglycemia should be ruled out immediately in any patient with altered
mental status. Given the hypotension, a 20 mL/kg IV bolus of normal saline
is necessary for this child.
A larger dose of naloxone is not needed because the child is not having
significant respiratory depression. Naloxone is indicated for respiratory
depression in the setting of opioid toxicity and is not a proven antidote for
alpha-2 agonism toxicity.
If the patient's glucose is normal, and clinical status does not respond to IV
fluids and tactile stimulation, then a norepinephrine drip is indicated.
Patients with alpha-2 agonist toxicity respond very well to repletion of
catecholamines.
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Question 86 (Question and Choices)
Question: A 15-year-old female presents with increased snoring and difficulty
articulating, which she attributes to her tongue. She states that her tongue has
slowly enlarged over the last 5 weeks. Her tongue appears to be enlarged,
although it does not protrude from her mouth and has no visually obvious lesions.
She denies trauma to the tongue. Given her presentation, which of the following
is the most likely etiology for her enlarging tongue?
Choices:
1. Down syndrome
2. Hyperthyroidism
3. Lymphangioma
4. Lymphoma
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Question 86 (Answer and Explanation)
Answer: 3 - Lymphangioma
Explanations:
Lymphangioma is a rare cause of macroglossia, and physical examination
clues the provider into its likely presence. There can be diffuse enlargement
with or without vesicles.
The patient's history is consistent with the presence of lymphangioma but is
not detailed enough to necessarily rule out all of the other choices.
Intraoral lymphangiomas occur more frequently on the dorsum of the tongue,
followed by palate, buccal mucosa, gingiva, and lips.
The anterior two-thirds on the dorsal surface of the tongue is the most
common site for intraoral lymphangiomas leading to macroglossia.
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Question 87 (Question and Choices)
Question: A young male has a solitary indurated penile ulcer with fairly clean
margins, no obvious raised granulomatous areas, and no discoloration. It began
as a hard, nonpainful nodule. Regional lymphadenopathy is present. What is the
most likely etiologic agent?
Choices:
1. Haemophilus ducreyi
2. Human papillomavirus, serotype 11
3. Streptococcus pyogenes
4. Treponema pallidum
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Question 87 (Answer and Explanation)
Answer: 4 - Treponema pallidum
Explanations:
Only Haemophilus ducreyi and Treponema pallidum produce nodular penile
lesions that ulcerate.
T. pallidum causes a hard nodule or chancre with no pain.
H. ducreyi produces soft, painful chancres.
Human papillomavirus produces warts that do not ulcerate.
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Question 88 (Question and Choices)
Question: A 10-year-old female presents to the emergency room with a 3-hour
history of swelling of the face. She reports that 1 hour prior the onset of the
swelling, she felt numbness in that area. She denies past episodes. At the 8 years
of age, she had an appendectomy due to abdominal pain however the pathology
report came back as normal. Her father mentions that he had episodes of swelling
of his hands and feet when he was a teenager which resolved by itself in a couple
of days. Her vital signs are normal, and her physical exam is remarkable for
nonpitting nontender swelling of her cheeks and lips with no erythema. What is
the most reliable and cost-effective screening test to be done?
Choices:
1. ESR
2. C3
3. C4
4. CH50
Question 88 (Answer and Explanation)
Answer: 3 - C4
Explanations:
This patient has hereditary angioedema. It can present in childhood with
75% of patients experiencing symptoms before 15 years of age. It has an
autosomal dominant inheritance. Symptoms include a prodrome of tingling
that precedes the swelling by 1-2 hours. Symptoms worsen over 12 to 24
hrs with resolution within 72 hours. The edema is unresponsive to
antihistamines. Attacks can recur with the most feared complication being
laryngeal edema. This may require emergent intubation or even a surgicalairway. Elevated ESR or eosinophilia is not usually present. If either is
present the one should consider a coexisting or different diagnosis.
C3 and C1q levels are normal in patients with hereditary angioedema
regardless of the clinical status. Some diseases associated with low C3
levels include SLE and membranoproliferative glomerulonephritis.
The most reliable and cost-effective screening test for HAE is C4 level. It is
almost always decreased during attacks and is low in between them. If C4
level is normal but suspicion for angioedema is high, the test should be
repeated.
CH50 (total serum hemolytic complement) is typically decreased during
attacks with the return to normal with recovery. It is nonspecific because a
decrease in any of the components of the complement system can cause low
CH50 levels. Hereditary angioedema is caused by C1 inhibitor (C1 INH)
deficiency. While some patients may have low levels, others may have
normal C1 INH, but due to mutation in the protein, it may be dysfunctional.
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Question 89 (Question and Choices)
Question: A 36-year-old pilot went flying after scuba diving for 3 hours, at an
altitude of 20,000 feet and then started having pain in his right knee. He describes
the pain as a dull ache and not made worse with movement. Upon landing, the
pain in the knee resolved but he started to feel numbness in his feet and
thoracoabdominal pain. Which of the following is true for this patient?
Choices:
1. He has the bends, hence type 1 decompression sickness (DCS)
2. He has spinal cord DCS and is classified as type 1 DCS
3. He has spinal cord DCS and is classified as type 2 DCS
4. He has the creeps and classified as type 1 DCS
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Question 89 (Answer and Explanation)
Answer: 3 - He has spinal cord DCS and is classified as type 2 DCS
Explanations:
Decompression sickness (DCS) is classified as type 1 and type 2.
According to United States Navy classification, type 1 is mild, composed of
joint pains, the "bends," and skin manifestations, the "creeps." Type 2 DCS
involves the neurological and cardiopulmonary system.
Spinal cord DCS is type 2 DCS. In most cases, the first symptom of spinal
DCS is numbness or paresthesia of the feet.
The sensory symptoms move upward in a dermatomal pattern.
The spinal cord lesions are due to bubble embolization in the paraspinal
venous plexus.
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Question 90 (Question and Choices)
Question: A 45-year-old female was at the grocery store shopping when she
reportedly grabbed her head then collapsed to the ground. At the hospital, she
had a Glasgow coma score (GCS) of 7. CT of the head showed diffuse acute
blood in the subarachnoid spaces and cisterns with hydrocephalus. What is the
most likely etiology of her intracranial hemorrhage?
Choices:
1. Hemorrhagic stroke from a lenticulostriate vessel
2. Rupture of an intracranial aneurysm
3. Slow leakage of blood from a bridging vein
4. Trauma from hitting her head after she fell
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Question 90 (Answer and Explanation)
Answer: 2 - Rupture of an intracranial aneurysm
Explanations:
Rupture of an intracranial aneurysm can cause sudden, severe subarachnoid
hemorrhage with sudden loss of consciousness.
Hemorrhagic stroke typically results in intraparenchymal hemorrhage which
may extend into the intraventricular region and less often is subarachnoid
space.
A chronic subdural hematoma occurs when there is slow leakage of blood
from a bridging vein.
Trauma can cause numerous types of intracranial hemorrhage including
epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and
intraparenchymal hemorrhage. Traumatic subarachnoid hemorrhage
typically is not as diffuse as aneurysmal subarachnoid hemorrhage.
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Question 91 (Question and Choices)
Question: A 17-year-old football player presents with complaints of a 3-day
history of progressive right knee pain. He states that he was running when he felt
a pop in his knee following a sudden change of direction. He continued to play
the rest of the game. The next day, his knee began to swell. He admits to diffuse
knee swelling and pain over the medial joint line as well as occasional popping
and clicking through the knee with running and climbing up stairs. On physical
exam, the patient has a positive McMurray and Apley compression test.
Lachman, anterior and posterior drawer, and valgus and varus stress tests are
negative. What is the most likely diagnosis?
Choices:
1. Anterior cruciate ligament tear
2. Patellar subluxation
3. Patellar tendonitis
4. Meniscal tear
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Question 91 (Answer and Explanation)
Answer: 4 - Meniscal tear
Explanations:
Although anterior cruciate ligament (ACL) tears can present as a pop with a
change in movement, they most likely present with immediate pain and
swelling. The patient likely would not be able to continue to play with a
torn ACL. The patient also would have positive Lachman and anterior
drawer signs on physical exam.
Patellar subluxation usually occurs with a sudden displacement of the
patella either medially or laterally with spontaneous relocation. This is
prominent in young female athletes with genu valgus or with vastus medialis
weakness. Pain and tenderness are usually located in the prepatellar region.
An effusion may be present. There would not be a positive McMurray or
Apley compression test. A diagnostic test shows patellar grinding.
Also known as jumper's knee, the pain from patellar tendonitis usually is
chronic and results from microtears of the patellar tendon. Pain is located
over the inferior pole patellar tendon. Usually, there is no effusion.
Meniscal injury is the most likely diagnosis for his complaints. Common
presenting symptoms of meniscal tears include an initial "pop" with a
sudden change of movement, pain and swelling developing over the
following days, and complaints of popping and clickingof the knee.
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Question 92 (Question and Choices)
Question: A mother brings in her 5-year old girl because the girl has had
swollen lymph nodes in her neck for approximately 2 weeks. The mother denies
any exposure to tuberculosis but does not know about possible exposure to cats.
A small papule is noted on the child's forearm. Bilateral cervical
lymphadenopathy and tender lymphadenopathy of the right axilla are also noted.
The child is afebrile, and fluctuation appears to be absent. What is the most
likely causative organism?
Choices:
1. Staphylococcus aureus
2. Bartonella henselae
3. Afipia felis
4. Bartonella clarridgeiae
Question 92 (Answer and Explanation)
Answer: 2 - Bartonella henselae
Explanations:
The child likely has cat scratch disease (CSD). This is one of the most
common causes of chronic lymphadenopathy in children.
Although B clarridgeiae and A felis are possible causes, B henselae and B
quintana are the organisms most often implicated in CSD.
The disorder resolves spontaneously in the majority of people in about 2 to
4 weeks.
Rarely immunocompromised individuals will develop encephalitis,
osteomyelitis, pneumonia, arthritis and oculoglandular syndrome.
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Question 93 (Question and Choices)
Question: A 68-year-old African American male with poorly-controlled
diabetes mellitus presents with new onset of bilateral swelling in his feet. He is
insulin dependent and takes an ACE inhibitor. On exam, there is three-plus pitting
edema of his lower extremities bilaterally. Blood work reveals a creatinine of
2.6 mg/dL and potassium 6 mg/dL. Past medical records indicate that his
creatinine has been the same over the last 2 years. What is the most appropriate
next step in management?
Choices:
1. Start immediate hemodialysis
2. Administer furosemide
3. Start calcium acetate
4. Potassium restricted diet and sodium polystyrene sulfonate
Question 93 (Answer and Explanation)
Answer: 4 - Potassium restricted diet and sodium polystyrene sulfonate
Explanations:
The most critical issue is this patient's hyperkalemia which should be
treated by giving sodium polystyrene sulfonate and restricting potassium
intake.
With diabetic nephropathy, it is important to continue the ACE inhibitor to
prevent further damage.
This patient has moderate chronic kidney disease rather than acute kidney
injury and does not require dialysis.
Patients who take sodium polystyrene sulfonate for hyperkalemia should not
take any other oral drugs 3 hours before or after taking this medication.
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Question 94 (Question and Choices)
Question: A 68-year-old male with a history of hypertension presents to the
emergency department with a sudden onset headache, nausea, vomiting, and
dizziness. A CT scan of the head is unremarkable with no intracranial
hemorrhage and no acute ischemic lesions seen. He has a non-focal neurologic
exam while lying down. As soon as he stands up, he has severe unsteadiness and
falls to the floor. He is unable to walk. What is the most appropriate next step in
the management of this patient?
Choices:
1. Discharge the patient with an anti-emetic and follow up with his primary care
provider the next day
2. Order an MRI brain and MR angiogram of the intracranial and neck vessels
3. Admit him under "observation" with a diagnosis of vertigo, with neurological
evaluation every 8 hours
4. Perform an urgent lumbar puncture looking for a subarachnoid hemorrhage
Question 94 (Answer and Explanation)
Answer: 2 - Order an MRI brain and MR angiogram of the intracranial and
neck vessels
Explanations:
The patient has symptoms suggestive of either an acute vestibular disorder
or an acute cerebellar ischemic event, for which a CT is commonly
unrevealing.
An MRI brain with diffusion-weighted imaging and an MR angiogram are
the best way of imaging the posterior fossa and posterior circulation when
there is a negative CT.
Lumbar puncture is contraindicated in cases where the posterior fossa
pressure gradient is likely to be increased, as in ischemic vertebrobasilar
stroke. The risk of herniation of the edematous cerebellum in this context is
high.
This patient should be admitted, with frequent neurological evaluations to
observe for mental status changes from obstructive hydrocephalus.
However, the best initial step is ordering an MRI brain and MR angiogram.
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Question 95 (Question and Choices)
Question: A 17-year-old falls while skiing, gripping the ski pole with his left
hand as he fell. He has swelling and tenderness over the ulnar aspect of the left
thumb metacarpophalangeal joint. Plain films reveal a large, displaced avulsion
fracture of the base of the left proximal phalanx, ulnar cortex, which involves the
joint surface. Which of the following is the best management?
Choices:
1. Immobilize the patient in a spica cast for 1 month
2. Perform stress testing to rule out instability
3. Begin immediate range of motion therapy to avoid stiffness in this particular
fracture
4. Explore and fixate the fracture fragment and attached ulnar collateral ligament
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Question 95 (Answer and Explanation)
Answer: 4 - Explore and fixate the fracture fragment and attached ulnar
collateral ligament
Explanations:Displaced fragments of bone at the ulnar collateral ligament insertion
require direct reinsertion to restore proper ligament length and tension and
restoration of the articular surface.
Gamekeeper's, skier's thumb, or ulnar collateral ligament (UCL) tear is a
UCL injury to the thumb. In the vast majority of cases, the UCL may be torn
or avulsed from its insertion site into the thumb's proximal phalanx.
Gamekeeper's and skier's thumb are similar conditions; both involve
insufficiency of the ulnar collateral ligament (UCL) of the thumb. Skier's
thumb is considered an acute condition acquired after a fall or abduction
injury to the metacarpophalangeal joint of the thumb. Gamekeeper's thumb is
considered a chronic condition which has developed as a result of
repetitive low-grade hyperabduction over time. Gamekeeper's thumb is
more difficult to treat due to the UCL being lengthened and becoming
thinner. Approximately 50% of UCL disruptions are caused by a fall onto an
outstretched hand. Sports injuries account for most of the remaining injuries.
The UCL is a stabilizer of the thumb. Thumb instability resulting from
disruption of the UCL impairs the overall function of the involved hand.
Because of this, it is critical for these injuries to receive appropriate
treatment. In some cases of a complete tear, the aponeurosis of the adductor
pollicis muscle is interposed between the bones of the metacarpophalangeal
joint and the torn ligament. When this occurs adequate healing of the tear is
prevented. This is referred to as a Stener lesion. When approaching the
evaluation of this injury, first determine whether there is an incomplete or
complete rupture of the UCL. If the UCL is complete, then determine
whether there is an interposition of the adductor aponeurosis or simply a
complete rupture of the UCL with the anatomic or near-anatomic position.
Radiographs are helpful in determining if an avulsion fracture of the
proximal phalanx involves the insertion site of the ulnar collateral ligament.
Stress examination done under fluoroscopic guidance can determine the
integrity of the ligament.
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Question 96 (Question and Choices)
Question: A 17-year-old, previously healthy, female presents with an acute
flu-like illness, fever, myalgias, shortness of breath, and chest pain. Her ECG
shows sinus tachycardia. Her labs show elevated white blood cells and an
abnormally elevated troponin. Her chest x-ray shows mild pulmonary edema
with findings consistent with congestive heart failure. What is her likely
diagnosis?
Choices:
1. Hypertrophic obstructive cardiomyopathy
2. Brugada syndrome
3. Acute myocarditis
4. Prolonged QT
Question 96 (Answer and Explanation)
Answer: 3 - Acute myocarditis
Explanations:
Hypertrophic obstructive cardiomyopathy is an inherited, usually autosomal
dominant, cardiac disorder that may lead to sudden death, typically in young
people. The chief abnormality found is left ventricular hypertrophy with
asymmetrical thickening of the anterior interventricular septum. Classically,
patients will present with exertional syncope caused by acute left
ventricular outlet obstruction and ventricular dysrhythmias with the potential
for sudden death.
Brugada syndrome is a well-known cause of sudden death secondary to a
genetic mutation in cardiac sodium channels. Also known as a sodium
channelopathy, over 60 mutations have been described. Classic ECG
findings include the "Brugada sign" in type 1 Brugada syndrome with a
coved ST-segment elevation greater than 2 mm in more than one of V1-V3
followed by a negative T wave. Other types have been described as well.
This abnormal sodium channel with corresponding ECG findings can lead to
sudden death. It presents as ventricular dysrhythmias such as ventricular
fibrillation and ventricular tachycardias.
Myocarditis, by definition, is an inflammatory process of the myocardium
that is caused mostly by viruses. Patients typically will present with a flu-
like illness, with symptoms including fever, malaise, myalgias, vomiting,
and even diarrhea. Adults typically will present with dyspnea, chest pain,
and arrhythmias. Vital signs typically are abnormal, including fever,
tachycardia, tachypnea, and sometimes hypotension. No single sign or
symptom is specific to make the diagnosis, but a presentation with chest
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pain or congestive heart failure often indicates a poor prognosis.
The QT interval is measured from the beginning of the Q wave to the end of
the T wave. The corrected QT or QTc interval is considered long if greater
than 440 milliseconds in men and 460 milliseconds in women. Any QTc
greater than 500 milliseconds poses a significantly increased risk for
torsades de pointes. Causes of prolonged QT include hypokalemia,
hypomagnesemia, hypocalcemia, certain drugs, and congenital prolonged
QT syndrome. Patients often are asymptomatic but also may present with
syncope or ventricular dysrhythmias such as torsades de pointes.
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Question 97 (Question and Choices)
Question: A middle-aged male presents to the emergency room with
exacerbation of his chronic obstructive pulmonary disease. He has been coughing
and has been moderately short of breath for the past 2 days. He complains of
general malaise and says that his inhalers do work but he ran out of supplies.
After your exam, you decide to start him on antibiotics. Based on the 2015
Global Initiative for Chronic Obstructive Lung Disease, which of the following
is a sufficient indication for starting the antibiotic?
Choices:
1. Temperature greater than 99.5
2. Foul breath
3. Purulent sputum
4. Wet cough
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Question 97 (Answer and Explanation)
Answer: 3 - Purulent sputum
Explanations:
The decision to start antibiotics depends primarily on the presence of
purulent sputum.
If there is no purulence, antibiotics should not empirically be started as this
only increases drug resistance.
For an uncomplicated infection, one may start the patient on a macrolide
other than erythromycin), a third-generation cephalosporin, or doxycycline.
Erythromycin is not active against Haemophilus influenzae.
If the exacerbation is complicated than the choices include
amoxicillin/clavulanate or fluoroquinolones like levofloxacin or
gemifloxacin.
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Question 98 (Question and Choices)
Question: A 17-year-old previously healthy female develops fever, chills,
pharyngitis, muscle pain, scleral injection, headache, cervical lymphadenopathy,
and photophobia lasting 7 days and was improving. The patient then seemed to
relapse with additional symptoms of nausea, headache, emesis, and moderate
neck stiffness. Lumbar puncture showed 180 WBCs per microliter that were all
monocytes and elevated protein. Which of the following is true?
Choices:
1. More than half of cases are severe
2. Involvement of the central nervous system is common
3. Hepatic and renal involvement is common
4. The most common vector is the mosquito
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Question 98 (Answer and Explanation)
Answer: 2 - Involvement of the central nervous system is common
Explanations:
The patient has leptospirosis, a disease acquired from rats, livestock, cats,
dogs, or other pets.
Most patients have anicteric courses but 50% to 90% have meningeal
involvement.
Fewer than 10% of cases are icteric and these patients may also have renal
involvement.
Both anicteric and icteric illnesses start with the septicemic phase as
described in the question.
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Question 99 (Question and Choices)
Question: A 6-year-old male has a 10-day history of a rash and sore throat.
The patient has had no fevers or upper respiratory symptoms. The patient has
erythema of the posterior pharynx and 1- to 10-millimeter erythematous plaques
over the trunk in a random pattern. A rapid strep screen is positive, and the
patient is treated with antibiotics. What should the parents be told about the rash?
Choices:
1. It will clear within 2 weeks and not recur
2. It will improve but may persist for life
3. It is contagious and the rest of the family will need to watch for signs of the
rash
4. There will be post inflammatory depigmentation
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Question 99 (Answer and Explanation)
Answer: 2 - It will improve but may persist for life
Explanations:
The small lesions with random distribution are most characteristic of guttate
psoriasis.
This condition can flare in response to streptococcal pharyngitis.
The condition may require topical steroids and occasionally phototherapy.
These patients are at risk for psoriasis vulgaris as they age.
Guttate psoriasis is most common in people under 30 years of age and often
follows an oropharyngeal or perianal streptococcal infection. The sudden
onset of papular lesions following a streptococcal infection can be the
exacerbation of long-standing plaque psoriasis or the initial presentation of
guttate psoriasis. Guttate psoriasis is nonscarring and often runs a limited
course over a few months.
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Question 100 (Question and Choices)
Question: A 65-year-old female presents with a headache, dizziness, and
confusion. She has no history of smoking and is taking no medication. On exam,
she is tachycardic, hypotensive, confused, and agitated. Blood work reveals an
elevated carboxyhemoglobin, which remains elevated with 100% oxygen therapy
for 4 hours. What is the treatment of choice?
Choices:
1. Hyperbaric oxygen
2. Ethylenediaminetetraacetic acid (EDTA)
3. Dialysis
4. Non-rebreathing mask
Question 100 (Answer and Explanation)
Answer: 1 - Hyperbaric oxygen
Explanations:
Hyperbaric oxygen therapy is the fastest way to eliminate carbon monoxide
from the blood.
Hemoglobin has a very high in affinity for carbon monoxide.
Hyperbaric oxygen causes the carbon monoxide to be displaced from the
hemoglobin molecule faster than it would occur under normobaric or sea
level conditions.
Normobaric oxygen via face mask should be initiated as soon as possible.
However, hyperbaric oxygen treatment is the treatment of choice for a
significant carbon monoxide poisoning.
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Question 101 (Question and Choices)
Question: A 25-year-old female has an upper respiratory tract infection and
decides to go diving anyway. She has some trouble clearing her ears and surfaces
with vertigo. Approximately 10 minutes later she is able to clear her ears and the
vertigo subsides. What is the most likely diagnosis?
Choices:
1. Middle ear barotrauma
2. Round window rupture
3. Perilymphatic fistula
4. Alternobaric vertigo
Question 101 (Answer and Explanation)
Answer: 4 - Alternobaric vertigo
Explanations:
Vertigo, particularly in diving, should be taken seriously as the differential
ranges from the benign to the highly morbid. Briefly, causes of vertigo in
settings of changing pressure can be delineated according to the persistence
of symptoms: Transient vertigo that lasts less than 1 minute and typically is
benign; alternobaric vertigo caused by a difference in pressures between the
middle ear spaces; and caloric vertigo experienced by a difference in
temperature between the left and right ear.
Vertigo that lasts more than 1 minute and is concerning for a more serious
condition such as inner ear barotrauma, vestibular decompression sickness,
or arterial gas embolism. Inner ear barotrauma can occur if there is a
significant failure of equalization of the middle ear chambers. Increased
pressure within the middle ear chamber causes damage to the inner ear, such
as a round window rupture or perilymphatic fistula.
Vestibular decompression sickness is the result of the formation of air
bubbles in circulation and tissue as the air that became dissolved at depth
reconstitutes from solution as small air bubbles. If this is the causeof
vertigo, the presentation may be accompanied by other neurologic deficits
that do not necessarily follow a classic distribution pattern. This is an
emergency and requires immediate administration of oxygen with transfer to
the nearest hyperbaric facility.
Arterial gas embolism is similar to decompression sickness. It is the result
of an air bubble forming in circulation preventing blood flow and
essentially causing a stroke. This can be due to the reconstitution of
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dissolved air or secondary to another process such as lung barotrauma. This
is also an emergency requiring hyperbaric treatment.
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Question 102 (Question and Choices)
Question: A 58-year-old female with no prior history presents with a
complaint of bilateral hand pain for several weeks that is worse in the morning
and improves with activity. She has warmth and mild tenderness of both hand
proximal interphalangeal joints. The remainder of her exam is normal. What is
the most likely diagnosis?
Choices:
1. Septic arthritis
2. Osteoarthritis
3. Rheumatoid arthritis
4. Reiter syndrome
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Question 102 (Answer and Explanation)
Answer: 3 - Rheumatoid arthritis
Explanations:
Rheumatoid arthritis affects mostly women and onset typically is under 40
years of age. Usually, there is symmetric involvement of the proximal
interphalangeal and metacarpophalangeal joints and morning stiffness.
Associated systemic symptoms include depression, myalgias, pericarditis,
myocarditis, and pleuritis.
Septic arthritis patient's often are systemically ill and have a monoarticular
presentation.
Osteoarthritis onset is most common after 50 years of age in women.
Features include weight-bearing and distal interphalangeal joint pain, pain
is worse with activity and better with rest, Heberden nodes at distal
interphalangeal joints, and Bouchard nodes at proximal interphalangeal
joints.
Reiter syndrome or reactive arthritis is an acute asymmetric arthritis
affecting a few joints, occurs 2 to 6 weeks after an infectious illness
(Chlamydia, Salmonella, Shigella), usually involves the lower extremities,
and has the classic triad of arthritis, uveitis, conjunctivitis.
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Question 103 (Question and Choices)
Question: Paramedics respond to an industrial fire at a paper manufacturing
plant. A 54-year-old male self-extricated from a building filled with smoke. The
patient was started on 100% FiO2 by non-rebreather. Hydroxocobalamin
treatment should be initiated as soon as the patient exhibits which of the
following signs or symptoms?
Choices:
1. Almond breath
2. Pulse oximetry reading of 80%
3. Supraventricular tachycardia
4. Cherry-red skin
Question 103 (Answer and Explanation)
Answer: 3 - Supraventricular tachycardia
Explanations:
There is no sensitive or specific constellation of signs and symptoms of
cyanide gas toxicity. Providers must maintain a high threshold for giving the
antidote in the correct clinical setting.
Almond breath and cherry-red skin are not sensitive signs of toxic gas
exposure and cannot be relied on for guiding treatment. Depending on the
concentration levels and time of carbon monoxide and cyanide exposure,
patients may present clinically on a broad spectrum. Patients may complain
of headaches, nausea, vomiting, dizziness, lethargy, confusion, chest pain,
shortness of breath, loss of consciousness, or even cardiac arrest
Hydroxocobalamin is relatively well tolerated. Treatment should be
initiated early on in a patient's care to reduce morbidity and mortality
secondary to cyanide gas exposure.
Indications for giving hydroxocobalamin are altered mental status, seizures,
respiratory depression/arrest, or a cardiac dysrhythmia.
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Question 104 (Question and Choices)
Question: What occurs with induction of anesthesia using only nitrous oxide?
Choices:
1. Increased intracranial pressure
2. Decreased cerebral blood flow
3. Decreased intracranial pressure
4. Cerebrovascular dilatation
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Question 104 (Answer and Explanation)
Answer: 1 - Increased intracranial pressure
Explanations:
Induction with nitrous oxide is associated with elevated cerebral blood
flow and intracranial pressure.
The effects of Nitrous Oxide are based on several factors, including settings
and individual differences. It induces intoxication, euphoria, dysphoria,
spatial disorientation, temporal disorientation, and reduced pain sensitivity.
Some users will have uncontrolled vocalizations and muscle spasms. These
effects disappear within minutes after removal of the nitrous oxide. Nitrous
oxide also has anxiolytic and analgesic effects.
The major safety hazards of nitrous oxide is asphyxiation risk and a
dissociative anesthetic. Nitrous oxide is a significant hazard for surgeons,
dentists, and nurses. It can cause an intoxicating and prolonged exposure
hazard to the clinic staff if the room is poorly ventilated. Exposure causes
short-term decreases in mental performance, audiovisual ability, and manual
dexterity. If pure nitrous oxide is inhaled without oxygen, this can result in
oxygen deprivation resulting in loss of blood pressure, fainting, and heart
attacks.
Long-term exposure may cause vitamin B12 deficiency. It inactivates the
cobalamin form of B12 by oxidation. Symptoms of vitamin B12 deficiency
include sensory neuropathy, myelopathy, and encephalopathy, which may
occur within days or weeks of exposure to nitrous oxide in people with
subclinical vitamin B12 deficiency. Symptoms are treated with high doses
of vitamin B12, but recovery can be incomplete. Vitamin B12 levels should
be checked in patients with risk factors for vitamin B12 deficiency prior to
using nitrous oxide anesthesia.Reduced fertility among those exposed to
high levels of nitrous oxide may have adverse effects on a developing fetus.
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Question 105 (Question and Choices)
Question: A 30-year-old, previously good health, non-smoker, triathlete is
helped out of the water due to extreme exhaustion and dyspnea. While being
examined, he begins coughing up blood-tinged sputum. He is transported to the
local emergency room on 100% oxygen due to oxygen saturation of 91%. All
other vitals are stable. What is expected on chest x-ray when he arrives at the
hospital?
Choices:
1. Cardiomegaly
2. Unilateral pleural effusion
3. Widened mediastinum
4. Kerley B lines
Question 105 (Answer and Explanation)
Answer: 4 - Kerley B lines
Explanations:
While there is some component of heart failure in immersion pulmonary
edema (IPE) it may or may not be significant enough to show up on chest x-
ray.
Pleural effusions may be seen with IPE but it would be bilateral.
While there is a redistribution of blood centrally during submersion which
may lead to increased diameter of the inferior vena cava, it may not be
radiographically significant, and there is a rapid redistribution after
removal from the water.
Kerley B lines are indicative of pulmonary edema.
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Question 106 (Question and Choices)
Question: An 8-month old previously healthy male who is fully vaccinated is
brought to the emergency department for lethargy. The vital signs are temperature
99.6 F, respiratory rate 9/minute, pulse 106 bpm, blood pressure 95/50 mmHg,
and pulse oximetry 75% on room air. His eyes are dilated and his breathing is
shallow. There are no rashes or signs of trauma. The parents deny that he could
have gotten into anything but do state that they recently gave the child some
canned peaches from last year’s harvest. The patient has minimal response to
painful stimuli and when he has a weak gag reflex. While waiting to perform a
rapid sequence intubation (RSI) and pre-oxygenating the patient, you notice what
other clinical findings?
Choices:
1. Decreased rectal tone and a large amount of stool in the rectal vault
2. Generalized tonicity
3. Absent reflexes
4. Retinal hemorrhages
Question 106 (Answer and Explanation)
Answer: 1 - Decreased rectal tone and a large amount of stool in the rectal
vault
Explanations:
This patient has a diagnosis of infantile botulism that is due to the
contaminated canning process of the peaches.
The gram-positive anaerobic Clostridium botulinum spore causes decrease
release of acetylcholine in the presynaptic cleft caused flaccid paralysis
causes infantile botulism.
Symptoms are consistent with increased lethargy, constipation, depressed
respiration, poor feeding, and suck. As a result, it would not be uncommon
to see decreased rectal tone with a large amount of stool in the rectal vault.
Retinal hemorrhages are consistent with non-accidental trauma. General
tonicity would be consistent with a seizure. Diminished or absent reflexes is
consistent with myasthenia gravis.
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Question 107 (Question and Choices)
Question: A 38-year-old commercial diver is diving on a mixture of helium
and oxygen to 190 feet of salt water (fsw), with a gas switch at 40 fsw to air.
Two hours after the dive he notes vertigo, nausea, and vomiting. He did not have
any trouble clearing his ears and has no signs of barotrauma on exam. He is
treated with a United States Navy Table 6 with extensions and has complete
resolution of his symptoms. When can he be returned to dive?
Choices:
1. 24 hours
2. One week
3. 28 days
4. 4 to 6 months
Question 107 (Answer and Explanation)
Answer: 4 - 4 to 6 months
Explanations:
The Association of Diving Contractors International (ADCI) recommends 4
to 6 months prior to returning to dive following an episode of vestibular
decompression sickness (DCS).
A round window rupture, or perilymphatic fistula, also can present with
vertigo, nausea, and vomiting. These divers must wait 6 months after repair
of the fistula.
Vestibular DCS is seen more commonly with gas switching from a mixture
of helium and oxygen to air due to isobaric counter diffusion.
Neurologic symptoms with decompression sickness must be completely
resolved prior to consideration for return to dive of a commercial diver.
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Question 108 (Question and Choices)
Question: A 37-year-old patient with alcohol use disorder presents with 2
weeks of stomach pain and fatigue. Physical findings are confusion, jaundice,
normal bowel sounds, right upper quadrant tenderness without rebound or
guarding, liver edge 7 cm below the costal margin at the midclavicular line,
splenomegaly, and asterixis. Labs show a marked white blood cell count without
left shift and elevated transaminases. The patient has a calculated Maddrey
discriminant function of 48. An ultrasound of the liver shows hepatomegaly,
increased echogenicity, gallstones, and no ascites. A chest x-ray and urinalysis
are normal. Which of the following is false?
Choices:
1. This presentation could reflect concomitant hepatitis C infection
2. Lactulose therapy is indicated
3. This patient can be managed as an outpatient
4. Morbidity and mortality can be decreased by IV methylprednisolone
Question 108 (Answer and Explanation)
Answer:3 - This patient can be managed as an outpatient
Explanations:
This patient's severe acute alcoholic hepatitis must be managed as an
inpatient. A Maddrey discriminant function score above 32 suggests
increased disease severity and mortality.
Encephalopathy is an indication for lactulose therapy.
Concomitant hepatitis C infection increases morbidity synergistically.
This patient's 30-day mortality rate of 30% to 50% can be reduced with IV
corticosteroids.
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Question 109 (Question and Choices)
Question: A 17-year-old female is a frequent hiker and camper. She presents
complaining of fever, chills, headache, and rash for the past few days. On exam,
she is febrile and has a maculopapular rash on her extremities including her
palms and soles. What is the most likely diagnosis?
Choices:
1. Lyme disease
2. Rocky Mountain spotted fever
3. Ehrlichiosis
4. Contact dermatitis
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Question 109 (Answer and Explanation)
Answer: 2 - Rocky Mountain spotted fever
Explanations:
Rocky Mountain spotted fever is an infection caused by Rickettsia rickettsii,
a gram-negative intracellular coccobacillus. It is spread by American dog
ticks. It is characterized by fever with relative bradycardia, malaise,
headache, and rash within a week following the tick bite.
The rash begins as a maculopapular rash involving the distal extremities and
spreads centripetally becoming more petechial and involves the palms and
soles.
It is most common in south-central and southeastern United States,
especially North Carolina and East Tennessee. It is treated with
doxycycline.
Ehrlichiosis is spread by ticks and causes shaking chills, severe headache,
and myalgias but rarely causes a rash. Lyme disease is spread by ticks and
causes a "bull's eye" rash at the site of the bite that spreads outward.
Contact dermatitis is confined to the area of exposure and is not associated
with chills, fever, or headache.
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Question 110 (Question and Choices)
Question: You are seeing a 64-year-old obese male who was admitted with
some chest pain. He says that the chest pain lasted a few minutes and he was
admitted to ensure that he had not suffered a myocardial infarction. The cardiac
enzymes turned out to be normal and the ECG is normal sinus rhythm. Today, you
are asked to do the easy thing first. Measure the blood pressure. You measure the
blood pressure and notice that it is 90/80 mmHg in the right arm and 95/75
mmHg in the left arm. You measure the blood pressure three more times and get
the same result. What is the most likely cause of this patient's pathology?
Choices:
1. Smoking
2. Diabetes
3. Degenerative calcification
4. Rheumatic fever
Question 110 (Answer and Explanation)
Answer: 3 - Degenerative calcification
Explanations:
When the pulse pressure is narrow, think of heart failure, significant blood
loss, or severe aortic stenosis.
A low pulse pressure is commonly seen in shock and cardiac tamponade
The most common cause of aortic stenosis is degenerative, meaning that
calcium starts to deposit on the valves.
Other things that can cause low pulse pressure include reduced preload and
dehydration.
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Question 111 (Question and Choices)
Question: A 21-year-old male saw a shark while diving. He panicked and
rapidly ascended to the surface. He is found to be very short of breath and
describes a pleuritic chest pain. Examination reveals decreased breath sounds on
the left with auscultation. What is the most likely diagnosis?
Choices:
1. Air embolism
2. Pneumonia
3. Water aspiration
4. Pneumothorax
Question 111 (Answer and Explanation)
Answer: 4 - Pneumothorax
Explanations:
Symptoms occur immediately on ascent with air embolism. This patient's
history and physical exam are consistent with pneumothorax.
Pneumothorax occurs due to over-pressurization in scuba diving when one
holds their breath on ascent.
Due to Henry's law and Boyle's law, if one fills one's lungs at a depth of 20
meters then rapidly ascends without properly exhaling or holding one's
breath, the volume of the gas in the lungs will rapidly expand. This
contributes to a pneumothorax.
Symptoms of pneumonia will not cause this same constellation of symptoms.
Confirmatory studies of pneumothorax are chest x-ray or CT of the chest and
treatment is high flow oxygen and chest tube as indicated.
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Question 112 (Question and Choices)
Question: It is winter in the United States when a 3-year-old previously
healthy child is brought to the emergency department after the parents witness a
5- to 10-minute episode of shaking of the arms and legs. The shaking stopped
while on route to the emergency department. The child is now sleepy and not
responsive to questions but responds during the exam. His temperature is 103.1
F. There is minimal nasal congestion, the throat is erythematous, the neck is
supple, and bilateral anterior cervical adenopathy is present. The spleen tip is
palpable. Heart exam is normal, and lungs are clear. What is a rapid and
sensitive method to make the diagnosis?
Choices:1. Viral culture of nasopharyngeal specimen
2. Influenza A enzyme immunoassay antigen detection on throat specimen
3. Influenza A direct fluorescent antibody on nasopharyngeal specimen
4. Influenza A IgG serology on acute serum
Question 112 (Answer and Explanation)
Answer: 3 - Influenza A direct fluorescent antibody on nasopharyngeal
specimen
Explanations:
The rapid antigen tests commercially available for identification of
influenza A or B have variable sensitivity and specificity compared to viral
culture.
The direct fluorescent antibody is more sensitive than the rapid antigen
tests, and its sensitivity is high (90%) when compared with culture.
Serologic testing with acute and convalescent serum can identify children
with influenza not detected by other methods but is not helpful for rapid
diagnosis.
According to the Centers for Disease Control and Prevention, "During
periods when influenza activity is high and influenza viruses are circulating
among persons in the community, the positive predictive value of a test
result is high."
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Question 113 (Question and Choices)
Question: Examination of a 67-year-old female complaining of chest pain
when climbing stairs reveals yellow plaques over both sets of eyelids. She
denies any symptoms associated with the plaques. A familial history includes
paternal coronary artery disease and a sibling with the same kind of lesion on her
eyelids. Which laboratory test would be most helpful in determining the origin of
the lesions?
Choices:
1. Comprehensive metabolic profile
2. Complete blood count
3. Hepatic profile
4. Lipid profile
Photo:Contributed by DermNetNZ
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Question 113 (Answer and Explanation)
Answer: 4 - Lipid profile
Explanations:
This patient has xanthelasma palpebrarum, a xanthelasma found on the
eyelids.
Approximately 50% of patients with xanthelasma palpebrarum have
hyperlipidemia.
Decreased high-density lipoprotein may be associated with xanthelasma
palpebrarum.
Xanthelasma are soft or semisolid yellowish deposits that are commonly
found along the corners of the upper and lower eyelids. Xanthelasma are not
common skin lesions, but when they are observed, they may be a predictor
of ischemic heart disease, myocardial infarction, or systemic
atherosclerosis. These lesions are often seen in the fourth to fifth decade of
life. Once xanthelasma has developed, it will not spontaneously disappear
but will remain the same or increase in size. The majority of people come to
attention because of cosmetic concerns.
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Question 114 (Question and Choices)
Question: It is early winter in the United States and a 78-year-old female
complains of fever, dry cough, a runny nose, malaise, and achiness for 1 day. Her
oxygen saturation is normal and her lungs are clear. What is the most appropriate
next step in management?
Choices:
1. A chest radiograph to determine therapy
2. Oseltamivir 75 mg twice a day for 5 days
3. Moxifloxacin 400 mg daily for 5 days
4. Amantadine 100 mg twice a day for 5 days
Question 114 (Answer and Explanation)
Answer: 2 - Oseltamivir 75 mg twice a day for 5 days
Explanations:
The recommended treatment for influenza is oseltamivir. Rapid in-office
testing is available but is only 50% to 70% sensitive. Treatment should be
started without waiting for the test results.
Amantadine is active against influenza A viruses, but not influenza B
viruses. There is a high level of resistance to amantadine. Therefore, it is
not recommended for antiviral treatment or prophylaxis.
Starting antiviral treatment early in the course of infection decreases
morbidity and mortality caused by influenza infection.
A chest radiograph would be indicated if there were lung findings or
purulent sputum.
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Question 115 (Question and Choices)
Question: A 38-year-old male with no significant past medical history
presents to the emergency department with sudden onset fever, dysuria, and
malaise. Upon presentation, his vitals are T 101.5, HR 85, RR 14, BP 129/73,
SaO2 98%. He has a soft and non-tender abdomen with no costovertebral
tenderness. Prostate exam demonstrates a tender and enlarged prostate. His post-
void residual is 10 cc. He is sexually active with one long-term partner and has
no history of sexually transmitted infections. He denies urethral discharge, and
none is noted on exam. Midstream urinalysis is nitrite positive with large
leukocyte esterase, 3+ bacteria, 30 WBCs, and 3 RBCs. The patient's serum
WBC is 8, and his lactic acid is 0.4. Laboratory evaluation is otherwise
unremarkable. Urine gram stain shows gram-negative rods. Urine culture is
pending. What are the most appropriate treatment and disposition for this patient?
Choices:
1. Admission to the hospital and treatment with intravenous
piperacillin/tazobactam
2. Admission to the hospital and treatment with intravenous levofloxacin and
gentamicin
3. Discharge on 2 to 4 weeks of oral nitrofurantoin
4. Discharge on 2 to 4 weeks of oral ciprofloxacin
Question 115 (Answer and Explanation)
Answer: 4 - Discharge on 2 to 4 weeks of oral ciprofloxacin
Explanations:
This patient does not meet criteria for inpatient treatment. He is not septic,
he does not have urinary retention, and he has no risk factors for atypical
organisms or treatment-resistant acute bacterial prostatitis.
Ciprofloxacin achieves therapeutic levels in the prostate and treats most
causative organisms.
Nitrofurantoin is an appropriate treatment for uncomplicated cystitis. It does
not, however, reach appropriate levels in the prostate and is therefore
inadequate in this case.
Treatment with intravenous levofloxacin and gentamicin may be an
appropriate treatment for certain patients who require admission.
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Question 116 (Question and Choices)
Question: A 17-year-old male with no past medical history presents to the
emergency department severely intoxicated after reportedly ingesting a bottle of
isopropyl alcohol. His labs are remarkable for a creatinine of 1.8 mg/dL and a
BUN of 10 mg/dL. Ketones are detectable in urine. He vomited twice and
urinated in his hospital bed. What is the most appropriate management?
Choices:
1. Observe until clinically well and discharge with a responsible adult
2. Admit to the intensive care unit
3. Administer fomepizole and admit to the intensive care unit
4. Consult nephrology for dialysis
Question 116 (Answer and Explanation)
Answer: 1 - Observe until clinically well and discharge with a responsible
adult
Explanations:
Isopropyl is known to cause severe intoxication, hemorrhagic gastritis, and
falsely elevated creatinine due to acetone (Jaffe reaction).
Most patients improve with supportive care, including hydration, and can be
discharged if ingestion was not a self-harm attempt.
Fomepizole is not required to treat isopropyl alcohol ingestion because its
metabolite does not cause acidosis or any specific end-organ toxicity.
Dialysis is not necessary as the creatinine is falsely elevated. This requires
a repeat basic metabolic panel when clinically improved to reassess
creatinine, but the normal blood urea nitrogen does not correlate with the
elevated creatinine, raising the concern for a falsely elevated creatinine.
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Toxicity, Isopropanol:
 
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Question 117 (Question and Choices)
Question: A 60-year-old male presents with severe, left shoulder pain. He
denies any recent injury. He reports that he has been dropping things held in his
left hand. His left eyelid is drooping and the pupil is smaller compared to the
right pupil. The patient has a 40 pack-year history of smoking. An exam reveals
tenderness in the mid-scapular area on the left. What is the most likely diagnosis?
Choices:
1. Rotator cuff tear
2. Cervical disc disease
3. Pancoast tumor
4. Brain tumor
Question 117 (Answer and Explanation)
Answer: 3 - Pancoast tumor
Explanations:
A lung cancer at the apex can cause compression of the axillary structures
and the sympathetic ganglion. This is called a Pancoast tumor.
Patients often present with severe pain in the shoulder region which radiates
toward the axilla and scapula.
The Pancoast tumor occurs in the superior sulcus of the lung and is locally
destructive. It often invades the lower brachial plexus and causes pain in the
ulnar nerve distribution.
When it involves the stellate ganglion, it causes Horner syndrome
characterized by ipsilateral anhidrosis, ptosis, miosis, and enophthalmos.
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Cancer, Lung, Pancoast (Superior Sulcus Tumor):
 
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Question 118 (Question and Choices)
Question: A patient presents to the emergency department following an
overdose of her antihypertensive medications. She is noted to have profound
bradycardia and hypotension. Which of the following statements is true when
differentiating calcium channel blocker toxicity from beta-blocker toxicity?
Choices:
1. The electrocardiogram findings in each of the poisonings are completely
different
2. An elevated serum calcium is indicative of calcium channel blocker poisoned
patients
3. A normal mental status suggests calcium channel blocker overdose
4. A reliable marker for beta blocker overdose is an elevated serum glucose
Question 118 (Answer and Explanation)
Answer: 3 - A normal mental status suggests calcium channel blocker
overdose
Explanations:
The vital signs and the EKG findings are not particularly helpful in
differentiating between the two classes of drugs in overdose.
In calcium channel overdose, the patient typically maintains a normal mental
status. This may be due to the neuroprotective features of calcium channel
blockers.
In calcium channel overdose, the serum glucose is typically elevated, with
beta blocker overdose, the serum glucose may be high, low, or normal so
this is not a reliable marker.
One of the first line treatments for calcium channel blocker overdose
includes intravenous calcium.
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Calcium Channel Blockers:
 
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Question 119 (Question and Choices)
Question: A 48-year-old female with past medical history of B cell lymphoma
colitis on pembrolizumab presents with bilateral perianal abscesses. Patients
states she was here 1 week ago with the same and now increase in pain and
erythema. What is the appropriate treatment for this patient?
Choices:
1. Incision and drainage with a surgeon at the bedside
2. Addition of ciprofloxacin for recurrence of infection.
3. Obtain an endoanal ultrasound
4. Obtain blood cultures, start intravenous antibiotics and admit to the hospital
for imaging and possible surgical drainage
Question 119 (Answer and Explanation)
Answer: 4 - Obtain blood cultures, start intravenous antibiotics and admit to
the hospital for imaging and possible surgical drainage
Explanations:
Patients with recurrent or bilateral abscesses should be evaluated by
surgery for intraoperative drainage, including cases where internal draining
may be necessary.
Ciprofloxacin should be combined with metronidazole for appropriate
antibiotic coverage.
CT should be obtained in patients with significant comorbidities, complex
suppurative anorectal conditions, and when surgical consultation is not
immediately available.
Patients who are immunocompromised with bilateral and recurrent
abscesses should be started on intravenousantibiotics after cultures are
obtained and have a prompt surgical evaluation for intraoperative drainage.
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Abscess, Perirectal:
 
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Question 120 (Question and Choices)
Question: An otherwise healthy male presents with a history of athlete's foot
complaining of the sudden onset of fever and pain in his right foot and leg and is
found to have a well-defined red, indurated area on his right leg that appears to
be progressing as well as inguinal lymphadenopathy. What is the most likely
diagnosis in this case?
Choices:
1. Tinea pedis
2. Staphylococcus aureus
3. Streptococcus pyogenes
4. Staphylococcus epidermidis
Question 120 (Answer and Explanation)
Answer: 3 - Streptococcus pyogenes
Explanations:
This is classic erysipelas caused by Streptococcus pyogenes, which is a
superficial skin infection with distinct margins that involves cutaneous
lymphatics.
Cellulitis due to Staphylococcus aureus would not have the lymphatic
involvement and would lack definitive margins. It often causes abscesses.
A route of entry such as a cut or fungal infections such as tinea pedis
precedes the infection.
First line treatment would be penicillin.
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Erysipelas:
 
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Section 2
Question 121 (Question and Choices)
Question: A 72-year-old woman presents after a ground level fall with right
hip pain. Her right leg is shortened and externally rotated. AP pelvis and a right
hip lateral x-ray show what appears to be an intertrochanteric fracture of the
femur. Which is the best next imaging study that should be ordered to further
delineate the fracture pattern and help guide treatment?
Choices:
1. Standing low AP pelvis
2. Provider assisted AP traction view of the right hip
3. Right knee AP and lateral views
4. Right hip CT scan
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Question 121 (Answer and Explanation)
Answer: 2 - Provider assisted AP traction view of the right hip
Explanations:
Provider assisted AP traction views of proximal femur fractures can help
delineate fracture pattern, as well as determine the need for open or closed
reduction techniques.
Standing radiographs should not be ordered for acute fractures.
It is important to visualize the entire affected femur on x-ray, to rule out any
distal hardware or deformity which may alter the plan of treatment
Advanced imaging such as CT or MRI is only indicated in the setting of hip
pain with normal x-rays.
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Question 122 (Question and Choices)
Question: A 54-year-old female complains of upper leg weakness that has
been present for several months. Her past medical history is only significant for
psoriasis, which was diagnosed 2 years ago because of a rash on her hands and
elbows. She takes no medication, smokes half a pack of cigarettes a day, and
drinks socially. The patient's exam is only remarkable for bilateral decreased
strength in the hip flexors and quadriceps. Reflexes and sensation are normal.
What is the first diagnostic test that should be ordered?
Choices:
1. Antinuclear antibody
2. Creatine phosphokinase and aldolase
3. Thyroid stimulating hormone
4. Electromyography
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Question 122 (Answer and Explanation)
Answer: 2 - Creatine phosphokinase and aldolase
Explanations:
The patient has evidence of weakness with neurologic deficits.
Myositis can be secondary to polymyositis or dermatomyositis.
Electromyography would be premature before labs are drawn.
Muscle enzymes, if elevated, should prompt a muscle biopsy.
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Question 123 (Question and Choices)
Question: A 23-year-old female presents to the emergency department with
severe pelvic pain, vaginal spotting, and believes she is approximately 7 weeks
pregnant. She has a history of pelvic inflammatory disease. Her vital signs are
temperature 37.1 C, heart rate 115 bpm, blood pressure 95/50 mmHg, respiratory
rate 22/minutes, and oxygen saturation 99% on room air. Which of the following
descriptions of ultrasound would be consistent with an ectopic pregnancy?
Choices:
1. Intrauterine pregnancy is identified with an estimated 7w3d gestational age.
Both ovaries appear normal and are symmetric. There is no free fluid noted
outside the uterus
2. No intrauterine pregnancy identified. Ovaries are visualized bilaterally and
appear normal. There is a small amount of free fluid in the right adnexa
surrounding a mass with high blood flow
3. No intrauterine pregnancy is identified. The left ovary measures 5 cm x 3 cm
and the right ovary measures 3 cm x 2 cm. The left ovary does not appear to have
blood flow and has a cyst present near the pole
4. An intrauterine pregnancy is identified without a heartbeat. The estimated
gestational age is 5w 3d. No other masses are visualized
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Question 123 (Answer and Explanation)
Answer: 2 - No intrauterine pregnancy identified. Ovaries are visualized
bilaterally and appear normal. There is a small amount of free fluid in the right
adnexa surrounding a mass with high blood flow
Explanations:
In a pregnant patient in the first trimester, any abdominal pain should
warrant workup to exclude ectopic pregnancy if the pregnancy has not
previously been identified as intrauterine. Identification of a live
intrauterine pregnancy in a patient that conceived by natural conception
makesthe diagnosis of ectopic pregnancy extremely unlikely.
A patient who is believed or known to be pregnant that has an adnexal mass,
especially with surrounding free fluid, is highly likely to have an ectopic
pregnancy.
Transabdominal ultrasonography is a rapid tool to utilize at the bedside for
potentially unstable patients. If a mass is identified between the bladder and
the uterus on transabdominal ultrasound, this is highly suspicious for an
ectopic pregnancy.
The most common location for ectopic pregnancy is the Fallopian tubes in
both patients who conceive by natural conception or by assisted
reproductive technologies. However, in patients having conceived by
assisted reproductive technology, 11% of ectopic pregnancies will be found
to be heterotopic, with one pregnancy being found in the uterus. In these
patients, it is important not to stop searching once the intrauterine pregnancy
has been identified.
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Question 124 (Question and Choices)
Question: A 75-year-old female with a 50-pack-year history of tobacco use
presents with a 2-week history of worsening dyspnea on exertion. She has had a
dry cough but no fever, night sweats, or chills. Her neck shows no jugular venous
distention. Heart tones are distant but regular without murmurs. A lung exam
reveals right lower lung dullness to percussion and decreased breath sounds. A
chest radiograph shows a pleural effusion but no infiltrates or lymphadenopathy.
Laboratories are normal. What is the appropriate management?
Choices:
1. Broad-spectrum antibiotics
2. CT of the chest
3. Bronchoscopy
4. Thoracentesis
Question 124 (Answer and Explanation)
Answer: 4 - Thoracentesis
Explanations:
There is no evidence of infection, so antibiotics would not be appropriate.
CT of the chest may have a small yield, but thoracentesis will provide the
most rapid diagnosis.
Sampling the pleural fluid by thoracentesis will determine if the fluid is
exudate or transudate in nature and aids in diagnosis.
Thoracentesis also will provide symptomatic relief.
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Question 125 (Question and Choices)
Question: An emergency medical services call was placed for possible
hazardous materials indecent. Upon arrival to the scene, a 78-year-old female is
found confused, diaphoretic, with vomitus on her clothes and decreased heart
rate. The area is immediately quarantined using an incident command system.
Where should the patient be taken?
Choices:
1. The closest emergency department for decontamination and stabilization
2. The cold zone for decontamination
3. The hot zone for decontamination
4. The warm zone for decontamination
Question 125 (Answer and Explanation)
Answer: 4 - The warm zone for decontamination
Explanations:
Emergency departments should be equipped to handle any decontamination
if necessary. However, if identified, decontamination should always occur
prehospital to not contaminate your personnel or equipment. Safety of
emergency personnel is of paramount importance.
An incident command system utilizes three zones for decontamination
procedure, the hot, warm and cold zones. The cold zone is the farthest from
the hazardous materials incident where the emergency can be directed and
supported. The patients and personnel in this zone should have been
decontaminated before entering.
The hot zone is the immediate area surrounding the suspected hazardous
material. This zone should only be entered by emergency personnel wearing
the proper personal protective equipment with the primary goal of removing
the patient.
The warm zone is just outside the hot zone where the decontamination
process takes place. In a hazardous materials incident, all contaminated
patients must be thoroughly decontaminated in the warm zone, prior to
further triage.
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EMS, Hazardous Waste Response:
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Question 126 (Question and Choices)
Question: A 72-year-old female nursing home resident is transferred to the
emergency department with fever, diarrhea, and hypotension. She had been
treated with ciprofloxacin the previous week for a urinary tract infection.
Symptoms started 3 days ago but the patient became lethargic and was found to
have a blood pressure of 75/45 mmHg, heart rate of 125 beats/min, and a
temperature of 38.7 C. On exam, her abdomen is distended with decreased bowel
sounds. A rectal exam shows no masses but is hemoccult positive. Abdominal
films showed no free air but the colon is dilated to 7 cm. Colonoscopy shows
pseudomembranes. What is the most likely diagnosis?
Choices:
1. Ischemic colitis
2. Clostridium difficile enterocolitis
3. Enterotoxigenic Escherichia coli
4. Diverticulitis
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Question 126 (Answer and Explanation)
Answer: 2 - Clostridium difficile enterocolitis
Explanations:
The patient has pseudomembranous enterocolitis that is caused by
Clostridium difficile.
It most often is seen after broad-spectrum antibiotics but can develop
without these medications.
Pseudomembranes can be seen with ischemic colitis but the recent antibiotic
use makes this diagnosis less likely.
The initial treatment for mild to moderate Clostridium difficile enterocolitis
is metronidazole. Treatment of more severe manifestations of Clostridium
difficile or recurrent infection is with oral vancomycin, fidaxomicin, or
rifaximin.
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Question: A 17-year-old female presents with a 6-month history of recurring
"bumps around my vagina." She tells you that she has noticed that she has flu-like
symptoms before the "bumps" appear. On exam, you observe several vesicular
lesions on the vulva. What is the appropriate treatment?
Choices:
1. Ofloxacin
2. Penicillin
3. Mupirocin
4. Acyclovir
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Question 127 (Answer and Explanation)
Answer: 4 - Acyclovir
Explanations:
Acyclovir treats a herpes infection.
It can be given orally, topically, or intravenously.
Acyclovir is an antiviral agent that is incorporated into viral DNA and
inhibits DNA synthesis and viral replication after it is converted to
acyclovir triphosphate by cellular enzymes. Acyclovir is used to treat
infections caused by the herpes simplex virus (HSV), and it is FDA
approved to treat genital herpes and HSV encephalitis. Some off-label uses
include cold sores, shingles, and chicken pox.
Acyclovir may be administered orally or intravenously. When taken orally,
acyclovir may be taken with or without food 2 to 5 times a day for 5 to 10
days. To prevent outbreaks of genital herpes, acyclovir is usually taken 2 to
5 times a day for up to 12 months. Intravenous acyclovir is used to treat
severe localized infections, including severe genital herpes, chickenpox,
and encephalitis. In patients with HIV, acyclovir can be used to treat eczema
herpeticum and to prevent infections of the skin, eyes, nose, and mouth.
Also, acyclovir treats oral hairy leukoplakia. Acyclovir should be taken
with plenty of fluids. Some of the common side effects include a headache,
malaise, nausea, vomiting, and diarrhea. The Centers for Disease Control
and Prevention has declared that in cases of severe recurrent or first
episodes of genital herpes, acyclovir may be used during pregnancy. For the
treatment of varicella, it also may be used during pregnancy, especially
during the second and third trimesters. Acyclovir does not cure herpes and
may not stop the spread of genital herpes to other people, but it may lessen
the symptoms of the infection.
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Question 128 (Question and Choices)
Question: A 65-year-old male is found at home febrile and unresponsive. He
is brought to the emergency department. His blood pressure is 60/40 mmHg,
pulse 45 beats/min, temperature 38.4C, and respiratory rate 22/min. Upon
administering fluids, a physical exam is conducted. There is marked tenderness at
the costovertebral angle. Urinalysis is positive for leukocyte esterase and WBCs.
Which of the following is the best medication to resuscitate him?
Choices:
1. Dobutamine
2. Epinephrine
3. Dopamine
4. Lidocaine
Question 128 (Answer and Explanation)
Answer: 2 - Epinephrine
Explanations:
Epinephrine is FDA-approved in adults with hypotension associated with
septic shock.
Pyelonephritis leading to septic shock is a medical emergency and needs to
be treated as soon as possible.
Epinephrine stimulates the body's sympathetic nervous system and plays a
role in acute stress response.
Another treatment for septic shock is norepinephrine.
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Question 129 (Question and Choices)
Question: A 32-year-old man presents after a 12 ft fall from a roof with a
highly comminuted fracture of the distal tibia (pilon fracture). He has no medical
comorbidities and smokes 1/2 pack of cigarettes per day. What is the next
appropriate imaging study that should be considered on initial evaluation in the
emergency department?
Choices:
1. Traction x-ray of the ankle to better delineate the fracture pattern
2. X-rays of the lumbar spine
3. CT scan of the ankle for pre-operative planning
4. Chest x-ray for pre-operative optimization
Question 129 (Answer and Explanation)
Answer: 2 - X-rays of the lumbar spine
Explanations:
Pilon fractures typically occur from high energy mechanisms that cause
significant axial loading.
In patients whose mechanism involves a fall from a significant height,
careful attention should be placed on evaluation of associated injuries,
particularly to the lumbar spine.
CT scan is preferred over traction x-ray views after spanning the ankle in an
external fixator to better delineate the fracture pattern and determine
surgical approach and fixation strategies.
Without a history of cardiopulmonary disease, or potential injury to the
thoracic cavity, a chest x-ray is no routinely needed in the pre-operative
optimization of pilon fractures.
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Question 130 (Question and Choices)
Question: An elderly patient with a history of dementia and falls presents to
the emergency department with a type III odontoid fracture noted on x-ray
imaging. A full history cannot be obtained, and physical exam is unreliable. What
is the best modality to determine, with the greatest accuracy, the acuteness of the
fracture?
Choices:
1. MRI with and without contrast
2. CT scan with contrast
3. CT scan with and without contrast
4. MRI without contrast
Question 130 (Answer and Explanation)
Answer: 4 - MRI without contrast
Explanations:
MRI without contrast will show T2 signal hyperintensities, mostly seen on
STIR imaging, with an acute fracture. The benefits and risks of obtaining an
MRI possible with sedation must be discussed.
This is especially relevant if no operative intervention or decision-making
will be altered.
CT without contrast will illustrate the fracture and can give some imaging
related information regarding the age of the fracture due to cortification of
the fracture line.
CT with contrast and MRI with contrast are unnecessary to evaluate the age
of the fracture.
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Question 131 (Question and Choices)
Question: A patient with diabetes mellitus presents with diabetic
ketoacidosis. She complains of a headache, nasal congestion, mild epistaxis,
visual disturbances, and lethargy. She is febrile. Nasal endoscopy is performed
with biopsy of a necrotic-appearing area. Slides stained with potassium
hydroxide reveal broad irregularly shaped hyphae with right-angle branching.
Bacterial and fungal cultures are negative. A CT of the sinuses reveals tissue
invasion. Which of the following is not true?
Choices:
1. The cause of these signs and symptoms frequently spreads to adjacent organ
systems near the sinuses with associated risk of cavernous sinus thrombosis,
bones with associated osteomyelitis, and ocular globe leading to blindness
2. Aggressive surgical debridement of the affected tissue should be performed
quickly while correcting associated metabolic abnormalities such as
hyperglycemia, ketoacidosis, and neutropenia
3. Fungal culture results are usually positive
4. The mortality rate is as high as 85%
Question 131 (Answer and Explanation)
Answer: 3 - Fungal culture results are usually positive
Explanations:
Zygomycosis is a rare infection caused by the fungi Zygomycetes. The term
mucormycosis is often used to designate this infection. The fungus that
causes mucormycosis is found in the environment and in decaying organic
matter.
Zygomycosis is associated with a 50% mortality. Rhinocerebral
zygomycosis has a mortality rate of 85%. It is more common in males.
Laboratory findings are nonspecific. Microscopic slides with potassium
hydroxide may reveal broad irregularly shaped hyphae with right-angle
branching. A fungal culture obtained during tissue biopsy may be beneficial
but are frequently negative despite positive histopathology. Fungal cultures
are positive in 15% to 25%. CT scan can reveal the extent of infection and
destruction of other adjacent organs.
Aggressive surgical debridement of the affected tissue should be performed
quickly. Correct associated metabolic abnormalities such as hyperglycemia,
ketoacidosis, and neutropenia. Discontinue immunosuppressive agents and
administer antifungal medications such as amphotericin B and
isavuconazole. Hyperbaric oxygen therapy has been reported as a useful
adjunct and is FDA approved for this condition.
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Question 132 (Question and Choices)
Question: An 18-month-old male presents with a burn of the left oral
commissure after chewing through an electrical cord. Loss of consciousness is
suspected. The commissure is not bleeding, and no burns of the feet or buttocks
are apparent. The child has normal ECG results, and immunizations are
confirmed to be up-to-date. He is drinking liquids quite well. Which of the
following medications is most appropriate?
Choices:
1. Oral amoxicillin-clavulanate for 14 days
2. Topical bacitracin to the commissure until the eschar is replaced by epithelium
3. Topical silver sulfadiazine cream until the wound heals
4. Tetanus toxoid and topical bacitracin
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Question 132 (Answer and Explanation)
Answer: 2 - Topical bacitracin to the commissure until the eschar is replaced
by epithelium
Explanations:
Empiric broad-spectrum antibiotics have not proven useful for routine
burns.
Silver sulfadiazine should not be used on mucous membranes because of
possible systemic absorption and toxicity.
If this child has up-to-date immunizations, he should have adequate tetanus
coverage, and a booster is unnecessary.
Burns to the oral commissure may result in immediate or delayed labial
artery bleeding if the eschar breaks down. As a result, these patients should
be observed.
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Question 133 (Question and Choices)
Question: You are seeing a patient with dislodged G-tube. The tube was
placed 4 years ago for stroke-related dysphagia by the gastroenterology service.
The tube has been replaced 6 times in last 4 years due to accidental
dislodgement. You consulted gastroenterology service who came and replaced
G-tube at the bedside and asked to confirm placement in the stomach prior to use.
What is the preferred and most cost-effective way to confirm placement in the
stomach?
Choices:
1. Flush the G-tube with air-filled syringe while auscultating over stomach
2. Obtain a KUB to see if the tube is in stomach
3. Inject water-soluble contrast through the tube and obtain KUB
4. Reconsult gastroenterology to do upper endoscopy to confirm placement in the
stomach
Question 133 (Answer and Explanation)
Answer: 3 - Inject water-soluble contrast through the tube and obtain KUB
Explanations:
The most accurate and cost-effective method to confirm G-tube placement in
the stomach is KUB after water-soluble contrast injection through the G-
tube.
Endoscopic G-tube placement confirmation in the stomach although is most
accurate but is not cost-effective.
If G-tube is replaced at bedside blindly, it should not be used without
confirming placement in the stomach. However, this might change depending
upon institutional policy.
If upon restarting feeding through recently replaced G-tube, the patient starts
complaining of abdominal pain, develops a fever or has physical exam
concerning for acute abdomen, peritonitis due to accidental intraperitoneal
tube placement should be considered.
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Question 134 (Question and Choices)
Question: A 17-year-old male presents after exposure to methomyl poisoning
after spraying it on their crop field. Vital signs are heart rate 40 bpm, respiratory
rate 12/minute, blood pressure mmHg, temperature 36.5 C, and oxygen saturation
96% on 10 L by a nonrebreather mask. His Glasgowcoma scale is 15; he has
increased lacrimation and salivation, with profound coarse expiratory wheezes
bilaterally. 2 mg of atropine is administered 2 mg intravenously, and 5 minutes
later he is less tearful. He continues to have coarse expiratory wheezes, and
oxygen saturation is still 96%. Which of the following is the appropriate next
step in pharmacotherapy?
Choices:
1. Continuous nebulized albuterol 10mg over 1 hour and reassessment for
treatment response
2. Increase dose to 4 mg IV of atropine with doubling of dose every 5 minutes
until respiratory secretions and bronchoconstriction improves
3. Start maintenance rate intravenous infusion of atropine to decrease lacrimation
and hypersalivation
4. Administer pralidoxime and bolus 2 mg of atropine IV every 15 minutes
Question 134 (Answer and Explanation)
Answer: 2 - Increase dose to 4 mg IV of atropine with doubling of dose every
5 minutes until respiratory secretions and bronchoconstriction improves
Explanations:
Atropine is administered in carbamate poisoning to clear respiratory
secretions. Dosing strategies are recommended to start with 1 to 3 mg IV in
adults and 0.05 mg/kg in pediatrics with a minimum dose of 0.1 mg.
Response to therapy with an emphasis on clearing respiratory secretions
and relieving bronchoconstriction should be reassessed every five minutes.
The previous dose should be doubled every five minutes until respiratory
symptom improvement.
The endpoint of atropine therapy is to clear respiratory secretions and
relieve bronchoconstriction. Former goals of "atropinization" with slowing
gastrointestinal motility and decreasing hypersalivation are no longer
recommended as it is not a meaningful endpoint of therapy.
Albuterol plays little role in the treatment of carbamate toxicity as
symptoms are related to increased muscarinic receptor stimulation, and
atropine directly inhibits these effects in the respiratory system.
Pralidoxime is not indicated in known single agent carbamate toxicity as
symptoms are shorter lived and carbamates reversibly bind to
acetylcholinesterase.
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Question 135 (Question and Choices)
Question: A patient with diabetes mellitus presents with pain around his right
ear and facial weakness. He says the illness started 3 days ago and his ear is
very tender to touch. He has a low-grade fever. Examination reveals a swollen
right ear, which is red and tender to touch. What should be done?
Choices:
1. Treat for Pseudomonas aeruginosa
2. Topical antibiotics
3. CT scan of head
4. Treat for Staphylococcus aureus
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Question 135 (Answer and Explanation)
Answer: 1 - Treat for Pseudomonas aeruginosa
Explanations:
Malignant otitis externa is diagnosed most commonly in patients with
diabetes mellitus and the immunocompromised.
It is caused by Pseudomonas aeruginosa and starts with external otitis.
Microvessel pathology and defective defenses result in spread into deeper
tissues.
It spreads along the floor of the ear canal medially. Spread outside of the
canal involves the osseocartilaginous junction and the fissures of Santorini.
There can be involvement of the facial nerve, mastoid, and the base of the
skull. It is potentially fatal.
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Question 136 (Question and Choices)
Question: A 16-year-old has returned from a mission trip. He has been home
for 30 days. He has developed a fever, abdominal pain, constipation, and
weakness. On physical exam, a rose-colored rash is seen on the chest. Which of
the following is the most likely cause of the patient's condition?
Choices:
1. Typhoid fever
2. Hepatitis
3. Measles
4. Chicken pox
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Question 136 (Answer and Explanation)
Answer: 1 - Typhoid fever
Explanations:
Typhoid fever is a bacterial infection.
Typhoid fever is a bacterial infection due to Salmonella typhi. Symptoms
usually begin six to thirty days after exposure and often start with a gradual
onset of a high fever. Weakness, abdominal pain, constipation, and
headaches develop. Diarrhea is uncommon, and vomiting is not usually
severe. Some patients develop a skin rash with rose-colored spots. The
patient may develop confusion. Without treatment, symptoms may last weeks
or months.
Patients may carry the bacterium without being affected; however, they are
still able to spread the disease to others. The cause is Salmonella enterica
serotype Typhi which grows in the intestines and blood. Typhoid is spread
by food or water contaminated with infected feces. It is associated with
poor sanitation and poor hygiene. Diagnosis is by culturing the bacteria or
detecting the bacterium's DNA in the blood, stool, or bone marrow.
Culturing the bacterium may be difficult. Bone marrow testing is the most
accurate.
Typhoid vaccine may prevent about 30% to 70% of cases during the first
two years. The risk is reduced by clean drinking water, better sanitation,
and handwashing. Until it has been confirmed that a patient's infection is
cleared, the individual should not prepare food for others. Treatment is with
antibiotics such as azithromycin, fluoroquinolones, or third-generation
cephalosporins. Resistance to these antibiotics has been developing.
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Question 137 (Question and Choices)
Question: A 25-year-old male football player presents for evaluation of
shoulder pain after another player tackled him and fell on his shoulder. He did
not feel a "pop" and was able to play the rest of the day. However, the pain has
progressively worsened. On general inspection, there is no acute abnormality,
deformity, or dislocation. There is pain to palpation at the acromioclavicular
joint. Adduction of the arm across the body elicits pain. Radiographs of the
shoulder show no fractures or dislocation. According to the Rockwood
classification, what type of acromioclavicular injury does this patient have?
Choices:
1. Type I
2. TypeIII
3. Type II
4. Type V
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Question 137 (Answer and Explanation)
Answer: 1 - Type I
Explanations:
In type I injuries, the acromioclavicular ligament is sprained, and the
coracoclavicular ligament is intact. There are no radiographic
abnormalities.
In type II injuries, the acromioclavicular is torn, and the coracoclavicular
ligament is sprained. The clavicle is elevated superiorly but not above the
acromion.
In type III injuries, the acromioclavicular and coracoclavicular ligaments
are torn. The clavicle is elevated superiorly above the border of the
acromion.
In type IV injuries, the acromioclavicular and coracoclavicular ligaments
are torn. The clavicle is displaced posteriorly into the trapezius.
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Question 138 (Question and Choices)
Question: A 1-year-old girl presents with episodic abdominal pain, drawing
the legs up to the abdomen and kicking the legs in the air for 1 day, anorexia, and
loose stools. She has no fever or upper respiratory symptoms. On physical exam,
her abdominal exam is soft and non-tender, but her stools are stool guaiac test
positive. Of the following, which radiologic study would be recommended for
screening?
Choices:
1. CT with contrast of the abdomen
2. Ultrasound
3. Air enema
4. MRI of the abdomen with and without contrast
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Question 138 (Answer and Explanation)
Answer: 2 - Ultrasound
Explanations:
This patient has suspected intussusception given the episodic abdominal
pain and heme-positive stool.
Though CT, MRI, or plain film could either identify or help identify
intussusception, ultrasound is a much easier, less invasive, and less
expensive modality. The sensitivity and specificity reach nearly 100% in
institutions with well-trained ultrasonographers.
Air enema can be used to diagnose intussusception. It often successfully
treats the condition. There is a risk of perforation with this procedure, and
the patient must be cleared for surgery and surgical backup available before
performing. Ultrasound is non-invasive and does not require preoperative
evaluation.
Ultrasound can identify both small and large bowel intussusception.
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Question 139 (Question and Choices)
Question: A 62-year-old male is seen in the emergency department with a
chief complaint of "heart racing" and feeling "hot." The patient states this began
four hours ago while he was sitting on his couch watching TV. The patient has a
past medical history of hypertension, depression, hyperlipidemia, and seasonal
allergies for which he takes lisinopril, amitriptyline, atorvastatin, and over the
counter allergy medication. Vital signs are blood pressure of 110/70 mmHg, heart
rate of 125 bpm, respiratory rate of 18, and temperature of 101F. On physical
exam, the patient appears flushed, he is warm to the touch, but his skin is dry. His
pupils are dilated and equally reactive to light, heart sounds are tachycardic
without murmurs, lungs are clear to auscultation, and his lower abdomen is
tender to palpation. What is the most likely cause of this patients symptoms?
Choices:
1. Medication noncompliance
2. Acute coronary syndrome
3. Adverse drug reaction
4. Illicit drug use
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Question 139 (Answer and Explanation)
Answer: 3 - Adverse drug reaction
Explanations:
Concurrent use of tricyclic antidepressants and antihistaminic medications
can potentiate the likelihood of anticholinergic toxicity symptoms.
Elder populations are more at risk for experiencing anticholinergic
symptoms and proper review of medications should be done to decrease the
risk of adverse drug reaction.
This vignette describes the commonly known profile of anticholinergic
poisoning of "red as a beet, dry as a bone, hot as a hare, blind as a bat, mad
as a hatter, and full as a flask." Although this patient did not describe
symptoms of visual changes or hallucinations, he appeared flushed, had
dilated pupils, hyperthermic, and had physical exam findings significant for
urinary retention.
Treatment of this patient should first include proper laboratory testing, ECG,
and monitoring for any agitation or seizures. Conservative management and
observation are indicated unless there is widening of QRS complexes or
seizing.
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Question 140 (Question and Choices)
Question: A 17-year-old male is brought to the emergency department by his
family after seizure-like activity. He reports that he was out with his friends and
"smoked some weed" about an hour prior to seeing his family. The family reports
that when he returned from his friend's house, he was very agitated, hard to
restrain, and was cursing at all of his family members. Approximately 10 minutes
prior to arrival, he became unresponsive and had 3 minutes of seizure-like
activity. In the ambulance, he was diaphoretic and difficult to arouse but no
further seizure-like activity was noted. On your exam, he is tachycardic,
hypertensive, and tachypneic. His pupils are 3 millimeters and reactive with mild
nystagmus. Which is the most likely explanation for his symptoms?
Choices:
1. The marijuana was likely a synthetic cannabinoid
2. Marijuana is the likely culprit as seizures are a common side effect
3. The patient had an allergic reaction to marijuana
4. The patient likely had concomitant marijuana and alcohol use
Question 140 (Answer and Explanation)
Answer: 1 - The marijuana was likely a synthetic cannabinoid
Explanations:
The presentation is not typically found in marijuana toxicity. Although vital
sign abnormalities are not always present, the expected abnormalities are
cannabis-induced tachycardia, postural hypotension, and central nervous
system and respiratory depression.
Similar to this case, the typical marijuana toxicity results in somnolence,
mild euphoria, and occasional agitation. Although agitation may be present,
patients typically do not present with aggressive behavior,