PEM Source

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PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) You are triaging patients from a multi-casualty incident. The following patients are seen: Patient A: Approximately 2 years old, ambulatory, crying, large 8cm parietal hematoma, obvious right humeral deformity Patient B: Approximately 5 years old, unresponsive, apneic after airway positioning and 5 rescue breaths, weak palpable pulse Patient C: Approximately 3 years old, responsive to painful stimuli, breathing at 40 breaths per minute, very weak palpable pulse Patient D: Approximately 7 years old, unresponsive, breathing at 30 breaths per minute, weak palpable pulse [yop_poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child recently brought from a third world country with PMH of an unrepaired hole in the heart and mild cyanosis is brought in to the ED. The patient fed in the AM, then began to cry and became unconsolable, hyperpneic, and deeply cyanotic. On arrival, the patient has a temp of 37.6, HR 180, RR 60, BP unobtainable, O2 sat 40% on room air. [yop_poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED. [yop_poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are evaluating the electrocardiogram of a 2 year old boy. The patient presented for fever and the ECG was inadvertently ordered on him instead of another patient. [yop_poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) You receive word that the clinic is rushing over a patient with a genetic syndrome and respiratory distress. You have a few moments to look in the electronic chart of the patient and set up the resuscitation room. Which of the following syndromes would make you concerned for a potential difficult airway scenario? [yop_poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy presents after taking 3-4 of grandma’s pills about an hour prior. It is unknown what Grandma takes, but she has “chronic pain, a heart condition, high blood pressure, and sugar problems”. He is altered, but arousable to stimuli and answers questions. He says he took the pills because he was “curious.” His vital signs are: Temp 36.6, HR 49, RR 12, BP 80/40, O2 sat 98% on room air. Physical exam is significant only for miosis, bradycardia, and somewhat weak pulses. Bedside glucose is 100. [yop_poll id="18"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is true about erythema multiforme major, Stevens-Johnson syndrome, and toxic epidermal necrolysis? [yop_poll id="17"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
Impetigo http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
Which of the following cervical spine findings would you expect to be less common in a young child as compared to an adolescent or adult? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="11"]  
Jellyfish en.wikipedia.org (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="10"]
A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
A 3 year old comes in after falling 3 feet from the top of a kiddie slide onto cement, hitting his head. His only +PECARN symptom is 2 episodes of vomiting in the 2 hours since the fall. The medical student seeing him states to you that he is PECARN+ and he has discussed CT with the parents. What is the approximate risk of clinically important traumatic brain injury in this patient? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="7"]
A 10yo girl comes home from a family vacation to Florida in June, where she swam in the ocean. She has an itchy rash in the area covered by her bathing suit that started soon after swimming in the ocean and is still present 3 days later. Seabathers   http://www.medicinenet.com (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="6"]
A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]
A 19yo man presents with progressively worsening extremity numbness in a glove and stocking distribution and ataxia x 1 month. He has areflexia, weakness, and a wide-based gait on exam. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="4"]
NEW! Vote your answer and see what others voted for. Correct answer will be in Comments in a few days. A 14yo female soccer player comes to the ED complaining of bilateral knee pain x 1 month, right greater than left. She does not recall a specific traumatic injury or fall, nor of any knee swelling, popping, or locking. The pain is worse after soccer practice or a game, and after getting up from sitting for a prolonged period such as her 2-hour block classes. The pain is described as behind the knee cap. There is no knee effusion, and there is full active range of motion. She has been afebrile throughout the course. [yop_poll id="1"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
A 16yo boy just returned from a vacation to the U.S. Virgin Islands. On the flight, he developed abdominal pain, nausea, vomiting, which he initially attributed to airsickness. He came straight from the airport to the ED, and now he also complains of lingual and circumoral paresthesias, painful paresthesias of his hands and feet, feeling as though his teeth feel “loose”, and generalized weakness. Another classic symptom of this entity is: A. Urticaria and flushing B. Tachycardia C. Profuse watery diarrhea D. Paralysis E. Temperature reversal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
You are conducting a study to compare the efficacy of a new bronchodilator against standard albuterol therapy in patients with acute asthma exacerbations. To reduce the possibility of selection bias in your study, the key element in your study design is: A. Blinding study participants so that they do not know which treatment has been selected for them, and do not change their subjective assessment of improvement in asthma symptoms B. Enrolling sufficient numbers of study participants to ensure an accurate estimate of the difference in treatment effects C. Randomizing study participants to ensure that the two groups studied are equivalent in potential confounding factors D. Only enrolling study participants > 2 years old, to avoid selecting bronchiolitis patients instead of asthma patients Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition? Septal hematoma http://rhinitis.hawkelibrary.com/album09/83_G A. Change antibiotics to amoxicillin-clavulanate B. Attempt removal of foreign body C. Incision and drainage and nasal packing D. Referral to otorhinolaryngologist for polyp removal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here
A 10yo girl is sitting lapbelted in the rear of an SUV that is involved in a rear-end collision at 40mph. She complains of abdominal pain, and has an ecchymosis from the lapbelt going across her lower abdomen. Of the following, which is the LEAST likely injury the patient may have: A. Small bowel injury B. Kidney injury C. Horizontal vertebral body fracture in lower spine D. Spinal cord injury Check back in a few days for my answer and others' comments Also if you're interested in the Peds ID question of the week, go here
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments
You are seeing a 12yo child with right ear pain for 2 days. He has been swimming recently. On examination, he has pain when you pull on the pinna of the ear to straighten the canal, and the canal is swollen and full of purulent discharge. He is afebrile and has no previous history of ear infection. Which of the following is FALSE regarding the management of this patient? A. Systemic antibiotics play no role B. If the patient had a history of pressure equalization tubes, neomycin + polymyxin B + hydrocortisone (cortisporin) drops would be contraindicated C. The patient should be advised not to swim while undergoing treatment D. Pain can be treated with antipyrine + benzocaine (auralgan) drops E. Fluoroquinolone drops are the most commonly used antibiotic therapy
Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C
A 14yo boy presents with fever and chest pain for 2 days. The chest pain is pleuritic and worse with leaning back. On examination, lung sounds are clear bilaterally, heart is regular with no murmurs, but a friction rub is heard. Which of the following is true of this condition? A. Treatment of choice is NSAID therapy B. All patients must be admitted to the hospital on a cardiac monitor C. CXR is always abnormal D. Electrocardiogram most commonly shows ST elevation isolated to leads II, III, and aVF E. Pain is rarely referred to shoulder or back
A 5yo uncircumcised boy comes in because his parents are unable to retract the foreskin of his penis. They have not been able to retract it ever, but now note also that he is having ballooning of the foreskin when he urinates. On exam, the opening of the foreskin is very tight. Appropriate treatment includes: A. Forceful retraction of the foreskin to break any adhesions B. Topical steroid cream and close follow-up C. Topical estrogen cream and close follow-up D. Emergent consultation with a urologist for immediate circumcision E. Reassurance that the condition will resolve by age 10 years
A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is: A. 60 cc/hr B. 75 cc/hr C. 120 cc/hr D. 135 cc/hr E. 150 cc/hr
What is the difference between Enhanced 911 and 911? A. With Enhanced 911, operators are able to give instructions on how to perform CPR in the field B. With Enhanced 911, EMS response times are under 10 minutes C. With Enhanced 911, ALS units are available, whereas with 911 only BLS units are available D. With Enhanced 911, the caller’s location and phone number is automatically transmitted to the operator E. With Enhanced 911, calls are routed by type to specific specialized call centers
A 6yo child is brought in after rescue from a housefire. He is unconscious, and has soot in his nares. You perform rapid sequence intubation. Vital signs are: Temp 37.5, HR 120, BP 68/40, O2 saturation 100%. You note a cherry red color to his skin. What is the antidote most indicated? A. Methylene blue B. 2-PAM C. Hydroxocobalamin D. Sodium bicarbonate E. Naloxone
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis
According to the Belmont report, the 3 main ethical principles for conducting research involving human subjects are: A) Beneficence, nonmaleficence, justice B) Respect for persons, beneficence, justice C) Respect for persons, beneficence, nonmaleficence D) Beneficence, justice, informed consent E) Nonmaleficence, justice, informed consent
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection
A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV
All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed
A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen
Which of the following is true of EMT scopes of practice (EMT-B = EMT-Basic, EMT-I = EMT-Intermediate, EMT-P = Paramedic)?
  1. Only EMT-I and Paramedic level EMT’s can administer oxygen
  2. Training to become an EMT-B is usually 100-150 hours
  3. Training to become a Paramedic is an additional 250 hours of training
  4. IV therapy may be given by EMT-I and EMT-P
A. 1 and 3 B. 2 and 4 C. 1, 2, and 3 D. 4 only E. All of the above
A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
  1. Anterior cord syndrome
  2. Brown-Sequard cord syndrome
  3. Central cord syndrome
  4. Chance fracture
17yo boy with long legs and arms, h/o scoliosis and mild pectus excavatum, hyperextensibility of the thumbs, presents with sudden onset ripping quality chest pain and feeling lightheaded. On exam, patient is anxious appearing, afebrile, HR 105, BP 98/45, RR 14, pulse ox 98% RA, alert, HEENT non-revealing, Lungs BCTA, Cor RRR with mid-systolic click followed by a late systolic murmur at the apex, Abd soft ND NT, Extremities and Skin non-contributory.  Of the following, which diagnostic study is the best choice? A) POC troponin B) Arterial blood gas C) Bedside ultrasound looking for lung sliding D) CT angiogram E) CT abdomen
For aeromedical transport, transport mode transitions from helicopter to fixed wing aircraft when the distance from base station to patient pick-up location exceeds how many miles? A) 70 miles B) 150 miles C) 200 miles D) Distance is not a factor
A child is brought in with a stab wound to the right neck just superior to the cricoid cartilage. What zone of the neck is this? What is the significance of the zones?
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?
In a population of 1,000 people, 100 have a disease. A test is positive in 95 people with the disease and 100 people without the disease. What is the sensitivity, specificity, and positive predictive value of this test?

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