► 1. A 17-year-old teenaged boy presents with flushed skin, dilated pupils, dry mouth, agitation, confusion, and urinary retention. Vital signs are: heart rate, 115 beats/min; blood pressure (BP), 140/90 mm Hg; temperature, 99°F; respiratory rate, 18 breaths/min. His medical history is unremarkable. Which of the following substances is not likely to be the cause for the patient's symptoms?

1. Jimson weed
2. Ecstasy (methylenedioxymethamphetamine)
3. Diphenhydramine
4. Amanita muscaria
5. Benztropine mesylate (Cogentin)

► 2. A 29-year-old woman presents to the emergency department after having a 5-minute generalized tonic-clonic seizure. She is postictal and unable to provide a history. Vital signs are: temperature, 98.6°F; pulse, 112 beats/min; BP, 160/105 mm Hg; respiratory rate, 14 breaths/min; oxygen saturation, 97%. Primary examination reveals that her pupils are equal and are reactive to light. She moves her extremities purposefully to stimulation. Her husband states the patient is generally healthy and had an uncomplicated pregnancy that resulted in a vaginal delivery 2 weeks ago. What would be the first-line treatment for her condition?

1. Lorazepam (Ativan)
2. Magnesium
3. Phenytoin (Dilantin)
4. Labetalol HCl (Trandate)

► 3. You are evaluating a 28-year-old man whose chief complaint is left-sided chest pain that began while he was lifting weights at the gym this morning. Vital signs are: temperature, 99.5°F; heart rate, 101 beats/min; BP, 129/77 mm Hg; respiratory rate, 28 breaths/min; oxygen saturation, 94% on room air. Examination shows his trachea is midline, and no jugular venous distention is evident. Cardiopulmonary examination is remarkable for diminished breath sounds on the left side. Deep inspiration exacerbates his chest pain. You perform a bedside thoracic ultrasound while the patient is waiting for the chest x-ray you ordered. You place the linear transducer in the midclavicular line over the left third intercostal space, and obtain B-mode (Figure 1A) and M-mode (Figure 1B) images. Both lung sliding and comet-tail artifact are absent on the B-mode image. The M-mode images of the left chest differ significantly from the right chest. What is the diagnosis?

1. Pulmonary embolus
2. Pneumothorax
3. Musculoskeletal strain
4. Myocardial infarction (MI)
5. Foreign body aspiration

► 4. A 75-year-old man is brought to the emergency department by his family because of mental status changes associated with fever. He had a prodromal illness consisting of cough, congestion, and myalgias. The family is concerned about West Nile virus infection, which they heard about on the evening news. Which of these statements regarding West Nile virus is NOT true?

1. Mosquitoes serve as the primary amplifying hosts
2. West Nile virus infection has been transmitted through blood transfusions
3. Less than 1% of patients develop severe neurologic disease
4. Advanced age is the most important risk factor for death
5. Treatment for West Nile virus encephalitis is mainly supportive

► 5. A 6-year-old, asymptomatic, previously healthy girl presents 2 hours after ingesting 4 of her mother's captopril (Capoten) tablets. What is the appropriate treatment?

1. Discharge the patient home if she is stable after 4 hours of observation
2. Admit the patient to the intensive care unit to monitor for hemodynamic instability
3. Administer intravenous (IV) hydration, and evaluate renal function
4. Initiate gastric lavage
5. Admit the patient, and notify social services to evaluate for possible child abuse or neglect

► 6. Which of these statements concerning primary coronary angioplasty and fibrinolytic therapy for patients with acute MI with ST-segment elevation is NOT true?

1. Primary angioplasty is superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities
2. For patients who arrive at a hospital that does not have an invasive treatment center, onsite fibrinolysis is superior to transfer and primary angioplasty, as long as the transfer takes 1 hour or less
3. Patients who receive angioplasty have a reduced rate of reinfarction when compared with those who receive fibrinolytic therapy
4. The benefit of primary angioplasty depends on the volume of procedures performed and the level of expertise of the physician

► 7. An 89-year-old man presents with abdominal pain that has been increasing over the past 24 hours. He has a history of seasonal allergies and has been using increasing doses of diphenhydramine HCl (Benadryl) for symptomatic relief. The patient's BP is 210/98 mm Hg, and his heart rate is 102 beats/min. His abdomen is distended and diffusely tender to palpation. The transabdominal bedside ultrasound reveals the diagnosis (Figure 4). What should you do next?

1. Perform a paracentesis
2. Call for an emergent vascular consult
3. Administer IV labetalol (Normodyne)
4. Insert a Foley catheter
5. Order a computed tomography (CT) scan of the abdomen and pelvis

► 8. A 75-year-old woman taking warfarin sodium (Coumadin) long-term for atrial fibrillation presents 12 hours after tripping and falling. She is currently asymptomatic and denies loss of consciousness, headache, or vomiting. Physical examination is unremarkable, except for a small, nonbleeding abrasion on her forehead. CT of the head shows no acute traumatic lesions. The international normalized ratio (INR) is elevated, at 6.5. What is the next step in management?

1. Omit warfarin dose and administer 1 mg vitamin K subcutaneously
2. 24-hour INR check; administer 1 mg vitamin K orally
3. Omit 1-2 warfarin doses; administer 1 mg vitamin K subcutaneously; 24-hour INR check
4. Omit 1-2 warfarin doses; administer 1 mg vitamin K orally; 24-hour INR check
5. Stop warfarin therapy altogether

► 9. A 50-year-old, right-handed woman comes to the emergency department after being stung on her right middle finger by her pet lionfish. She is experiencing severe pain in that finger. Examination reveals fusiform swelling and mild erythema of the distal half of the finger. What is the most appropriate next step?

1. Obtain radiographs to evaluate for a retained spine
2. Consult a hand surgeon for extraction of a possible retained spine
3. Administer a nonsteroidal antiinflammatory drug
4. Soak the finger in hot water
5. Apply acetic acid to inactivate the toxin

► 10. A 16-year-old teenaged boy presents to your emergency department because of a 2-hour acute right inguinal pain. He says that he had similar pain earlier in the day that resolved spontaneously. He has not had any fever or urinary symptoms but did have nausea and vomiting. He denies any antecedent trauma or sexual activity. Physical examination reveals a swollen, tender, right hemiscrotum. All the following statements are correct, except:

1. This is a classic presentation of testicular torsion
2. Scrotal support and antibiotics are not indicated
3. Absence of a cremasteric reflex is typical to his condition
4. Color Doppler ultrasound is the initial diagnostic test of choice
5. Manual detorsion of the testicle is the definitive treatment

► 11. A 35-year-old man is brought in by emergency medical services (EMS) after he was found unresponsive outside of a downtown bar. Witnesses told EMS workers that he had been involved in a large bar brawl minutes before EMS arrived. In the ambulance bay, the patient goes into pulseless electrical activity, as shown on the monitor. As your team attempts to secure his airway and establish IV access, you perform a quick parasternal cardiac ultrasound (Figure 5). What is the next best step in this patient's management?

1. Place bilateral chest tubes
2. Administer 5 mg epinephrine down the endotracheal tube
3. Emergent thoracotomy
4. Order a CT scan of his chest
5. Perform an emergent pericardiocentesis

► 12. A 25-year-old man with a known history of bipolar disorder and substance abuse presents with mild lethargy after ingesting an unknown amount of lithium. His BP is 110/70 mm Hg; pulse, 108 beats/min; temperature, 97.8°F; and lithium level, 2.5 mEq/L (therapeutic range, 0.6-1.2 mEq/L). What would be the most appropriate next step?

1. Administer activated charcoal
2. Initiate whole-bowel irrigation
3. Determine the time and amount of ingestion
4. Arrange for urgent hemodialysis
5. Initiate forced saline diuresis

► 13. A young woman presents to your emergency department complaining of pain after "twisting" her knee in a basketball game. Which statement about the Ottawa Knee Rules is not correct?

1. Radiographs are required for patients with acute knee injuries who are 55 years or older
2. Radiographs are required for patients with knee injuries who cannot bear weight on the affected leg, either immediately after injury or in the emergency department
3. Radiographs are required for patients with tenderness to palpation of the tibial plateau
4. The Ottawa Knee Rules have been validated prospectively in children aged 5 to 16 years
5. The Ottawa Knee Rules are 100% sensitive for detecting clinically significant fractures in adults with acute knee injuries

► 14. An 18-month-old girl presents obtunded, with poor respiratory effort, after she fell on her head. A large ecchymosis is seen in the right temporal region. The child was difficult to intubate and experienced hypoxic episodes with 60% oxygen saturation, but the capnometer shows sustained color change, and you notice tube fogging after placement. Despite attaching a breathing mask, you are unable to raise the oxygen saturation above 86% with a good waveform. Other vital signs are stable, but diminished breath sounds are evident on the left. What is the next step in management?

1. Needle decompression of left chest
2. Replace existing endotracheal tube
3. Change placement of the pulse oximeter
4. Check tube positioning

► 15. You are evaluating an 8-year-old girl for complaints of a pruritic rash that has progressed during the past 2 days. The lesions consist of a vesicular eruption on an erythematous base. The rash was preceded by a few days of cough and sore throat. The child has a history of renal transplantation and is taking high-dose immunosuppressive therapy. Other than a low-grade fever, she appears well. All the following statements about this patient's condition are correct, except:

1. Immunocompromised patients manifest a shorter incubation and longer infectivity period than other patients
2. Complications include encephalitis, pneumonia, hepatitis, and bacterial superinfection of skin lesions
3. The patient should be started on IV acyclovir, and varicella-zoster immune globulin should be administered
4. The diagnosis can be confirmed with tissue cultures, direct fluorescent antibody testing, Tzanck smears, and polymerase chain reaction (PCR) testing

► 16. A 16-year-old girl presents with right shoulder pain and nausea for the past 2 days. She thinks that she injured her shoulder when she was lifting heavy boxes last week. She has been taking ibuprofen, without much relief. On further questioning, she reports mild, intermittent, crampy lower abdominal pain for the past few days. She denies fever, dysuria, vaginal bleeding, or discharge. She is sexually active and thinks that her last menstrual period was 4 or 5 weeks ago. She is not taking any medications.

Vital signs are: BP, 105/70 mm Hg; heart rate, 97 beats/min; respiratory rate, 20 breaths/min. Physical examination findings are unremarkable, except for mild tenderness in the right lower quadrant, but no rebound or guarding. Her right shoulder examination is normal. During preparations for a pelvic examination, the patient becomes hypotensive and tachycardic. A quick bedside ultrasound is performed (Figure 6). What is the most likely diagnosis?

1. Right rotator cuff injury
2. Ruptured ovarian cyst
3. Appendicitis
4. Ruptured ectopic pregnancy
5. Renal colic

► 17. A 69-year-old woman is brought to your emergency department after having pulseless ventricular tachycardia arrest. Defibrillation in the prehospital setting resulted in the return of spontaneous circulation. Her vital signs are stable on arrival, but she remains comatose. Which of the following statements about initiating therapeutic hypothermia for this patient is not true?

1. Therapeutic hypothermia is a Class IIa recommendation in the unconscious adult who exhibits a return of spontaneous circulation after ventricular fibrillation and pulseless ventricular tachycardia cardiac arrest
2. Therapeutic hypothermia works by decreasing metabolic demands
3. Modalities for cooling the patient include cooling blankets, ice packs, iced saline gastric lavage, cooled IV fluids, and endovascular cooling catheters
4. Patients treated with traditional normothermia have a higher rate of sepsis
5. Target temperature is 32°C-34°C for 12-24 hours

► 18. A 45-year-old man with a history of hypertension comes to the emergency department agitated and combative after smoking cocaine. Vital signs are: BP, 240/120 mm Hg; pulse, 110 beats/min; temperature, 99.2°F; respiratory rate, 24 breaths/min. Among the following IV therapies, which one would be the most appropriate for initial control of his hypertension?

1. Lorazepam
2. Metoprolol (Lopressor)
3. Verapamil HCl
4. Furosemide
5. Labetalol

► 19. You have been evaluating a 42-year-old woman who is complaining of leg cramps that began after she underwent liposuction 3 days ago. During your evaluation, she suddenly becomes diaphoretic and dyspneic and starts complaining of sharp pleuritic chest pain. What bedside ultrasound finding would arouse suspicion for a large, acute pulmonary embolus?

1. Increased diastolic diameter of the right ventricle
2. Increased diastolic diameter of the left ventricle
3. Decreased diastolic diameter of the right ventricle
4. Increased aortic root diameter
5. Rightward bowing of the septum

► 20. A 26-year-old man presents to your emergency department with an acute onset of severe, left-sided pleuritic chest pain of 3 hours' duration. His vital signs, including respiratory rate and oxygen saturation, are normal. The patient does not appear to be in acute distress. The patient denies antecedent trauma but acknowledges a remote history of a "collapsed lung." Chest radiography reveals a small pneumothorax. Which of the following strategies would be appropriate in this case?

1. Emergent chest tube placement
2. Discharge home after a period of observation
3. Evaluation by a thoracic surgeon
4. Allow travel by air without restrictions