Virtual Web Photography Emergency Medicine Tutorial

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Title: Virtual Web Photography Emergency Medicine Tutorial

1
Virtual Web PhotographyEmergency
MedicineTutorial

UCONN Emergency Medicine
Eric Kendall, M.D.
Senior Project
May 3, 2006

An elderly man presents the findings above.
Which of the following answers are the most
accurate?
A Incidence rate of hip fracture is greater in
men than women
B Physical exam shows leg to be shortened and
internally rotated
C Incidence of hip fracture is 2-3X higher in
whites than nonwhites
D Traction should not be applied to the
extremity
E This type of fracture is commonly associated
with avascular necrosis

An elderly man presents the findings above.
Which of the following answers are the most
accurate?
A Incidence rate of hip fracture is greater in
men than women
False, the incidence is higher in women due to
greater osteoporosis
B Physical exam shows leg to be shortened and
internally rotated
False, this would be the position for a posterior
hip dislocation.
The hip is held in external rotations with a
intertrochanteric fracture
C Incidence of hip fracture is 2-3X higher in
whites than nonwhites
True, due to the higher rate of osteoporosis
D Traction should not be applied to the
extremity
False, traction should be applied early for pain
relief and vascular concerns
E This type of fracture is commonly associated
with avascular necrosis
False, a femoral neck fracture rather than a
intertrochanteric fracture is the greatest
concern due to the blood supply to the femoral
head.

After a busy trauma you are cleaning up and stick
yourself with a used needle. Appropriate
intervention includes which of the following?
A Blame the nurse for leaving an open needle on
the floor
B Go to occupational services for evaluation and
treatment
C Just pretend like nothing ever happened
D Inform the attending, request permission to
test the patient blood, and go to
occupational services for additional testing and
treatment
E Look at the patients records to see if they
are HIV or Hepatitis positive

After a busy trauma you are cleaning up and stick
yourself with a used needle. Appropriate
intervention includes which of the following?
A Blame the nurse for leaving an open needle on
the floor
False, this will not solve the problem and only
create a negative relationship among the ED staff
B Go to occupational services for evaluation and
treatment
False, the patient needs to be tested to help
guide treatment
C Just pretend like nothing ever happened
False, there needs to be an account of the
incident and further documentation will be
important for health insurance claims if you
contract a blood born pathogen
D Inform the attending, request permission to
test the patient blood, and go to
occupational services for additional testing and
treatment
True, the attending needs to be aware of the
incident, permission should be asked of the
patient, and you should receive immediate testing
and treatment if indicated from occupational
services
E Look at the patients records to see if they
are HIV or Hepatitis positive
False, this will only provide false assurance if
negative. The period from infection until
positive testing can take months

Based on the injury seen above, all of the
anatomic structures are at risk except?
A Radial artery
B Radial nerve
C Median nerve
D Extensor carpi radialis
E Abductor pollicus longus

Based on the injury seen above, all of the
anatomic structures are at risk except?
A Radial artery
B Radial nerve
C Median nerve
False, all the answers listed are in the
anatomical region of the injury except the median
nerve which runs along the volar surface of the
wrist in the midline passing thru the carpal
tunnel
D Extensor carpi radialis
E Abductor pollicus longus

A patient presents with pain at the distal aspect
of the middle finger. Appropriate intervention
and treatment includes which of the following?
A Pressure relief by removing nail bed with
scalpel after local anesthesia
B Discharge home for follow up with PMD
C Pressure relief by inserting sterile needle
under nail
D Pressure relief by electrocautery thru nail
E Antibiotics and next day follow up

A patient presents with pain at the distal aspect
of the middle finger. Appropriate intervention
and treatment includes which of the following?
A Pressure relief by removing nail bed with
scalpel after local anesthesia
False, there is no need to damage the nail bed in
this injury
B Discharge home for follow up with PMD
False, the pressure needs to be relieved or
permanent damage to the nail bed will result
C Pressure relief by inserting sterile needle
under nail
False, this would not be recommended in this
situation
D Pressure relief by electrocautery thru nail
True, this is the recommended method for treating
these injuries. Other acceptable methods are a
sterile needle or heated paperclip
E Antibiotics and next day follow up
False, these need to be drained because of the
severe pain and damage to the underlying nail bed
if not relieved

A female presents to the ED with the clinical
picture seen above. All of the following signs
or symptoms would be consistent with anaphylaxis
except?
A Lip swelling
B Urticaria
C Hypotension
D Bronchospasm
E Hypoxia

A female presents to the ED with the clinical
picture seen above. All of the following signs
or symptoms would be consistent with anaphylaxis
except?
A Lip swelling
False, this is related to an allergic reaction
but not true anaphylaxis which is IGE mediated
release of mast cells causing all of the signs
and symptoms below and can be life threatening.
B Urticaria
C Hypotension
D Bronchospasm
E Hypoxia

An elderly man presents with fever and complaint
of rash to his legs. All of the following
increase the risk of the condition he is
experiencing except?
A Steroids
B Diabetes
C Hypothyroidism
D AIDS
E Varicella

An elderly man presents with fever and complaint
of rash to his legs. All of the following
increase the risk of the condition he is
experiencing except?
A Steroids
True, steroids decrease skin thickness and
predispose patients to trauma
B Diabetes
True, patients with DM have peripheral vascular
disease leading to poor circulation and decreased
response to skin infection leading to increased
risk for cellulitis
C Hypothyroidism
False, hypothyroidism does not increase the risk
for cellulitis
D AIDS
True, immunocompromised patients have increased
risk of infections including cellulitis
E Varicella
True, the pruritis from chickenpox leads to
increased risk of cellulitis in patients and must
be closely watched for because varicella is viral
but if underlying skin infection is present then
antibiotics should be administered

An intoxicated male presents after falling down
several steps. Complications from this injury
include all of the following except?
A Osteomyelitis
B Compartment Syndrome
C Medial malleoli skin breakdown
D Common peroneal nerve injury
E Tibial nerve injury

An intoxicated male presents after falling down
several steps. Complications from this injury
include all of the following except?
A Osteomyelitis
True, this is a tri-malleolar fracture caused by
significant force and has a high complication
rate including osteomyelitis
B Compartment Syndrome
True, with this injury significant swelling can
result leading to compartment syndrome in
selected cases
C Medial malleoli skin breakdown
True, the skin tending on the medial side can
cause tenting and even breakthrough if not
reduced in a timely manner
D Common peroneal nerve injury
False, the common peroneal nerve is found in the
upper aspect of the fibia and does not reach the
foot
E Tibial nerve injury
True, the tibial nerve supplies the bottom of the
foot and runs thru the ankle causing it to be
affected in this injury

A man presents to the ED with a frontal/temporal
depressed skull fracture and GCS of 5.
Appropriate RSI medications and stomach
decompression includes which of the following?
A RSI with (ketamine succ), NG tube
B RSI with (ketamine succ), OG tube
C RSI with (lidocaine, etomidate and succ), NG
tube
D RSI with (lidocaine, etomidate and succ), OG
tube
E RSI with (versed and succ), NG tube

A man presents to the ED with a frontal/temporal
depressed skull fracture and GCS of 5.
Appropriate RSI medications and stomach
decompression includes which of the following?
A RSI with (ketamine succ), NG tube
False, ketamine causes increased ICP and should
be avoided in head injury
B RSI with (ketamine succ), OG tube
False, ketamine causes increased ICP and should
be avoided in head injury
C RSI with (lidocaine, etomidate and succ), NG
tube
False, RSI meds are appropriate but and NG should
never be placed with a frontal depressed fracture
due to concern of placement into the brain
D RSI with (lidocaine, etomidate and succ), OG
tube
False, RSI meds are appropriate but and NG should
never be placed with a frontal depressed fracture
due to concern of placement into the brain
E RSI with (versed and succ), NG tube
False, pt needs pretreatment with lidocaine and
NG should be avoided in this situation

The above patient is in no apparent distress and
is able to give a detailed history without
difficulty. Carbaceous sputum is noted.
Appropriate management includes which of the
following?
A Oxygen, IVF, EKG, CXR, Cardiac Enzymes and
admission
B Oxygen, IVF, EKG, CXR, Cardiac Enzymes and if
negative discharge
C Oxygen, IVF, intubation, and admission to ICU
D Oxygen, IVF, and transfer to ICU with close
monitoring for intubation
E IVF, Silver Cream to face, pain control and
discharge

The above patient is in no apparent distress and
is able to give a detailed history without
difficulty. Carbaceous sputum is noted.
Appropriate management includes which of the
following?
A Oxygen, IVF, EKG, CXR, Cardiac Enzymes and
admission
False, with carbaceous sputum pt needs
prophylactic intubation for airway control
B Oxygen, IVF, EKG, CXR, Cardiac Enzymes and if
negative discharge
False, even if patient appears to be in no
distress this can be misleading
C Oxygen, IVF, intubation, and admission to ICU
True, with the singed hair and carbaceous sputum
pt should immediately be intubated for impending
airway edema
D Oxygen, IVF, and transfer to ICU with close
monitoring for intubation
False, pt needs to be intubated before she
becomes symptomatic which would make the airway
difficult at best and may necessitate a surgical
airway
E IVF, Silver Cream to face, pain control and
discharge
False, pt needs admission and airway control

A 46 y/o male presents with distended abdomen
and admits to being Hep C positive. Which of the
following are chronic complications of his
disease.
A Cirrhosis, esophageal varices, hemorrhoids,
caput medusa, coagulopathy
B Liver cancer, encephalopathy, coagulopathy,
ascites, diabetes
C Gastric cancer, encephalopathy, coagulopathy,
ascites
D Coagulopathy, hemorrhoids, systemic
hypertension, caput medusa
E Cirrhosis, gastric varices, diabetes,
hemorrhoids

A 46 y/o male presents with distended abdomen
and admits to being Hep C positive. Which of the
following are chronic complications of his
disease.
A Cirrhosis, esophageal varices, hemorrhoids,
caput medusa, coagulopathy
True, all of the above are associated with
cirrhosis
B Liver cancer, encephalopathy, coagulopathy,
ascites, diabetes
False, hepatitis and cirrhosis are not directly
associated with diabetes
C Gastric cancer, encephalopathy, coagulopathy,
ascites
False, there is no direct association between
gastric ca and cirrhosis
D Coagulopathy, hemorrhoids, systemic
hypertension, caput medusa
False, cirrhosis leads to portal hypertension,
low albumin and systemic hypotension
E Cirrhosis, gastric varices, diabetes,
hemorrhoids
False, there is no association with diabetes

Which of the following chronic conditions is this
patient likely to get from this devastating
injury?
A Reflex sympathetic dystrophy
B Dermatomyositis
C Scleroderma
D Rheumatoid arthritis
E Reiter Syndrome

Which of the following chronic conditions is this
patient likely to get from this devastating
injury?
A Reflex sympathetic dystrophy
True, this is a very painful condition associated
with post trauma seen most often in the upper
extremity
B Dermatomyositis
False, this is an idiopathic systemic myopathy
C Scleroderma
False, this a a systemic disease of collagen not
induced by local trauma
D Rheumatoid arthritis
False, this is a chronic systemic inflammatory
disease not due to specific trauma
E Reiter Syndrome
False, this is associated with HLA b27 and is a
triad of arthritis, urethritis, and
conjunctivitis

A patient prevents with the findings seen above.
Patients vitals are T 99, P 110, R 20, BP 118/76.
Initial work up includes which of the following?
A Blood cultures and antibiotics for skin
infection
B CXR for underlying bony trauma
C CT angiogram for pulmonary embolism
D Mammogram for breast cancer detection
E Ultrasound for breast abscess

A patient presents with the findings seen above.
Patients vitals are T 99, P 110, R 20, BP 118/76.
Initial work up includes which of the following?
A Blood cultures and antibiotics for skin
infection
False, the patient is afebrile and breast
findings are classic for peau d orange a sign of
inflammatory breast cancer
B CXR for underlying bony trauma
False, pt has no evidence of trauma
C CT angiogram for pulmonary embolism
True, with breast cancer, tachycardia and
tachypnea the physician must have a high index of
suspicion for PE
D Mammogram for breast cancer detection
False, the patient has clear evidence of existing
breast cancer
E Ultrasound for breast abscess
False, the patient needs more aggressive
diagnostic intervention for PE and there is no
fever or other signs of infection

A FAST exam is most likely to show free fluid in
which compartment?
A RUQ
B LUQ
C RLQ
D Cardiac
E Pelvis

A FAST exam is most likely to show free fluid in
which compartment?
A RUQ
True, the patient has a wound in his RUQ with
mesenteric extrusion and the most common site of
free fluid on the fast exam is always the RUQ
B LUQ
C RLQ
D Cardiac
E Pelvis

A gang member is transferred from another
facility with this x-ray. All of the following
are true statements except?
A Liberal use of angiography is indicated with
these wounds
B Review ABC upon arrival to trauma room and
give tetanus shot
C Type II injuries are worse than type III
injuries
D Shotgun injuries have the highest mortality of
any firearm in civilians
E Aggressive volume resuscitation should be
initiated

A gang member is transferred from another
facility with this x-ray. All of the following
are true statements except?
A Liberal use of angiography is indicated with
these wounds
True, each pellet should be treated as a low
velocity gunshot wound and with multiple injuries
to the chest the incidence of vessel injury is
high
B Review ABC upon arrival to trauma room and
give tetanus shot
True, after transfer one should always review the
ABC to see if tube position has changed while in
transport or that no PTX has developed from
aggressive bagging. Buckshot wounds are not
sterile and with any ballistic a tetanus shot is
indicated
C Type II injuries are worse than type III
injuries
False, with shotgun injuries there are three
types of grading
Type I injuries are long range greater than 7
yards and usually do not penetrate the fascia
Type II injuries are 3-7 yards and involve injury
to organs deep to the fascia
Type III injuries are sustained at less than 3
years and involve massive tissue destruction
D Shotgun injuries have the highest mortality of
any firearm in civilians
True, the fact that most are used at close range
with tremendous spread and tissue destruction
leads them to have the highest mortality of an
civilian firearm
E Aggressive volume resuscitation should be
initiated
True, although the clinical exam and CXR may seem
mild every pellet should be considered an
individual GSW and prophylactic volume
resuscitation should be initiated before the
patient develops hemorrhagic shock

Which of the following statement is most accurate
concerning this patient?
A Gout is caused by calcium pyrophosphate
crystals
B Pseudogout is caused my monosodium urate
crystals
C Acute phase treatment of both inflammations
differs
D Prophylactic therapy for pseudogout exists
E Pseudogout is associated with metabolic
disorders

Which of the following statement is most accurate
concerning this patient?
A Gout is caused by calcium pyrophosphate
crystals
False, gout is caused by monosodium urate
crystals
B Pseudogout is caused my monosodium urate
crystals
False, pseudogout is caused my calcium
pyrophosphate crystals (CPPD)
C Acute phase treatment of both inflammations
differs
False, acute treatment of both disorders is
identical
D Prophylactic therapy for pseudogout exists
False, there is no known therapy for psedogout
E Pseudogout is associated with metabolic
disorders
True, both pseudogout and gout are associated
with metabolic disorders

Elderly gentleman presents with this head injury
after falling down a flight of stairs the night
before. Which of the following statements are
most accurate?
A High ICP is characterized by hypotension,
bradycardia, and irregular respirations
B ICP is lowered by elevating HOB, mannitol,
hypoventilation, and sedation
C Epidurals are usually convex shaped and do not
outline the sulci on CT
D Epidurals are caused by tearing of the
bridging veins during trauma
E Subdurals are caused by damage to the middle
meningeal artery

Elderly gentleman presents with this head injury
after falling down a flight of stairs the night
before. Which of the following statements are
most accurate?
A High ICP is characterized by hypotension,
bradycardia, and irregular respirations
False, Cushings response in head injury is a
triad of hypertension, bradycardia, and irregular
respirations
B ICP is lowered by elevating HOB, mannitol,
hypoventilation, and sedation
False, HOB should be elevated to 30 degrees,
mannitol can be given to decrease ICP at
0.5-1gm/kg IV, hyperventilation to keep the PCO2
at around 35, and sedation is important to
decrease ICP
C Epidurals are usually convex shaped and do not
outline the sulci on CT
True, they do not outline the sulci on CT like a
characteristic SAH
D Epidurals are caused by tearing of the
bridging veins during trauma
False, subdurals are caused by tearing of the
bridging veins
E Subdurals are caused by damage to the middle
meningeal artery
False, epidurals are usually caused by direct
blows of the temporal bone and laceration to the
middle meningeal artery

Which of the following answers most likely caused
this problem?
A Ascaris lumbricoides
B Taenia solium
C Trichinella spiralis
D Wuchereria bancrofti
E Strongyloides stercoralis

Which of the following answers most likely caused
this problem?
A Ascaris lumbricoides
False, this is an intestinal roundworm causing
pulmonary and GI symptoms not elephantiasis
B Taenia solium
False, this is found in undercooked pork mean and
is the causative agent in neurocystercicosis
C Trichinella spiralis
False, this is the agent that causes trichinosis
which causes intramuscular cysts leading to
myalgia and fever
D Wuchereria bancrofti
True, this is a nematode parasite of the order
Filariidae and specifically of the lymphatic
subgroup known to cause elephantiasis as seen in
this picture
E Strongyloides stercoralis
False, this is an enteric parasite that usually
causes mild GI symptoms and not elephantiasis

Hispanic man presents with concern over possible
stroke. Which of the following is the best
management for this patient?
A Pt needs stat CT of the head followed by
lumbar puncture
B Pt has a poor prognosis and steroids should be
started immediately
C Pt can be discharged home with neurological
follow up and eye tears
D Pt needs stroke team activation immediately
E Patient has no neurological deficits and
should be sent home

Hispanic man presents with concern over possible
stroke. Which of the following is the best
management for this patient?
A Pt needs stat CT of the head followed by
lumbar puncture
False, after careful history and physical exam
this patient can be diagnosed with bells palsy
and further diagnostic workup is not indicated
B Pt has a poor prognosis and steroids should be
started immediately
False, this patient has an 85 chance of full
recovery from bells palsy and only a 5 chance
of permanent neurologic sequelae
C Pt can be discharged home with neurological
follow up and eye tears
True, this patient may be discharged home with
timely follow up, but the important thing to
remember is judicious use of artificial tears or
lubricants to protect the eye since the 7th
cranial nerve affects eye closure
D Pt needs stroke team activation immediately
False, this patient needs no further diagnostic
imaging
E Patient has no neurological deficits and
should be sent home
False, this patient has a 7th cranial nerve palsy
and clear neurological deficits as seen in this
picture manifesting as slurred speech, facial
drooling, facial asymmetry, and inability to
fully close the affected eye

What is the proper name and treatment for the
condition that this patient has?
1 Tinea barbae -- A 1 4
2 Tinea capitis -- B 1 5
3 TInea manuum -- C 2 4
4 Griseofulvin -- D 2 6
5 Monistat -- E 3 5
6 Amphotericin B

What is the proper name and treatment for the
condition that this patient has?
1 Tinea barbae -- A 1 4 Answer
2 Tinea capitis -- B 1 5
3 TInea manuum -- C 2 4
4 Griseofulvin -- D 2 6
5 Monistat -- E 3 5
6 Amphotericin B
Tinea barbae is a fungal infection of the face in
the distribution of facial hair hence the term
barbae or barber
Tinea capitis is a fungal infection involving the
scalp
Tinea manuum is a fungal infection involving the
hands whereas tenia pedis involves the feet
Griseofulvin is a medication used extensively in
the past, however it can cause liver dysfunction
so newer agents are more commonly used like
ketoconazole
Monistat is generally not recommended for the
facial areas
Amphotericin B is a antifungal agent for serious
infections and is toxic to kidneys therefore it
would not be used in a simple case of tinea

After falling off a 20 ft ladder this injury is
seen in the ED. Other injuries one might look
for include all of the following except?
A Acetabular fracture
B Humerus fracture
C Calcaneal fracture
D Lumbar fracture
E Femoral fracture

After falling off a 20 ft ladder this injury is
seen in the ED. Other injuries one might look
for include all of the following except?
A Acetabular fracture
B Humerus fracture
False this is not a common fracture that is
associated with high falls/jumps landing on your
feet. The other answers are all characteristic
of this high energy mechanism starting with a
calcaneal fracture, femoral fracture, acetabular
fracture, and lumbar fracture as the energy is
transferred up the bony axis of the skeletal
system
C Calcaneal fracture
D Lumbar fracture
E Femoral fracture

A young female presents with rash and 1st degree
AV block. Which of the following statements is
most correct?
A Arthritis is common and always bilateral
B A pacemaker is usually required if block
naturally progresses
C Development of meningitis is always a concern
D Often a fatal disease
E No antibiotics are needed

A young female presents with rash and 1st degree
AV block. Which of the following statements is
most correct?
A Arthritis is common and always bilateral
False, this is the classical rash erythema
migrans from lyme disease and common
complications if untreated are arthritis which is
usually unilateral
B A pacemaker is usually required if block
naturally progresses
False, once heart block is identified and
appropriate treatment is given most case are
reversible and rarely require a pacemaker
C Development of meningitis is always a concern
True, a physician must always keep lyme
meningitis in the differential
D Often a fatal disease
False, there is an excellent prognosis if
promptly identified and treated. If patient
presents later in the course there is higher
incidence of morbidity but only select cases of
mortality
E No antibiotics are needed
False, antibiotics should be initiated even
without confirmation of the disease if clinical
suspicion is high enough. Doxycycline is the
first agent of choice for children with permanent
teeth (gt8yrs) and alternatives are amoxicillin or
rocephin if considering lyme meningitis

Appropriate diagnostic studies and work up
includes which of the following?
A CT angiogram of the neck
B Barium swallow
C Bronchoscopy
D All of the above
E None of the above

Appropriate diagnostic studies and work up
includes which of the following?
A CT angiogram of the neck
B Barium swallow
C Bronchoscopy
D All of the above
True, this patient has sustained a stab wound to
zones I and II of the neck.
Penetrating neck trauma is divided into 3 zones
and are differentiated as follows
Zone I injury is the thoracic inlet inferiorly
and cricoid cartilage superiorly
Zone II injury is from the cricoid cartilage to
the angle of the mandible superiorly
Zone III injury is from angle of the mandible to
the base of the skull
Zone I injuries are associated with the highest
morbidity and mortality
Because this patient has stab wounds to zones I
and II he should be carefully evaluated by all
three diagnostic test to evaluate for vessel,
esophageal, and airway injury
E None of the above

Appropriate questions to ask this patient include
which of the following?
A Do you feel safe in your current relationship?
B What did you do to deserve this?
C Why dont you just leave him?
D Were you using drugs or drinking?
E Why did you allow this to happen to you?

Appropriate questions to ask this patient include
which of the following?
A Do you feel safe in your current relationship?
True, this woman has evidence of domestic
violence by the injury pattern which is seen in
the above picture. The marks are all linear from
a stick that the abuser used on the patient.
In DV an easy approach to the victim is to ask
the SAFE questions
Do you feel safe in your current relationship or
have you ever felt stressed?
Have you ever been afraid or abused in your
current relationship?
Do you have friends and family that would be
willing to support you and are they aware of the
situation?
Do you have an emergency plan including money,
location, means of travel?
B What did you do to deserve this?
C Why dont you just leave him?
D Were you using drugs or drinking?
E Why did you allow this to happen to you?

Which of the following is best management plan
for this patient?
A Perform an immediate canthotomy
B Perform a stat CT scan of the head
C Instill steroid drops in the affected eye
D Consult ophthalmology for stat surgical repair
E Send patient home with ophthalmology follow up

Which of the following is the best management
plan for this patient?
A Perform an immediate canthotomy
False, this would only be indicated in a
retrobulbar hemorrhage with significant
intraocular pressure and concern of loss of
vision
B Perform a stat CT scan of the head
False, a head ct scan might only be indicated if
the patient fell and you were worried about an
intracranial injury, but for a spontaneous
conjunctival hemorrhage this would play no role
C Instill steroid drops in the affected eye
False, steroids would not be indicated in this
setting
D Consult ophthalmology for stat surgical repair
False, although the picture is very worrisome
looking these patients will do fine with time and
holding their anticoagulants
E Send patient home with ophthalmology follow up
True, the patient deserves some education about
what to watch for but can be safely discharged
home with proper eye care and outpatient
ophthalmology follow up

The above patient may also have which of the
following other dermatologic findings?
A Keloid lesions
B Café au lait lesions
C Angiofibroma lesions
D Collagenoma lesions
E Shagreen patch lesions

The above patient may also have which of the
following other dermatologic findings?
A Keloid lesions
False, keloid lesions occur most commonly in
black races and are characterized by hypertrophic
scarring from previous trauma
B Café au lait lesions
True, café au lait lesions are characteristic of
neurofibromatosis which this patient is
exhibiting. They generally develop within the
first 3 years of life. It is an autosomal
dominant disease with 2 different subtypes
C Angiofibroma lesions
False, an angiofibroma is a benign neoplastic
lesions of microvasculature found all over the
body
D Collagenoma lesions
False, a collagenoma is growth of fibrous
collagen usually manifesting as a plaque and
associated with tuberous sclerosis
E Shagreen patch lesions
False, orange peel type lesions found on the back
or neck and also associated with tuberous
sclerosis

Appropriate fluid resuscitation based on the
parkland formula for this patient weighing 80kgs
with 30 body surface area over 24hrs is?
A 16.1 liters
B 12.5 liters
C 9.6 liters
D 8.2 liters
E 6.5 liters

Appropriate fluid resuscitation based on the
parkland formula for this patient weighing 80kgs
with 30 body surface area over 24hrs is?
A 16.1 liters
B 12.5 liters
C 9.6 liters
True, the parkland formula is calculated below
4ml/kg X BSA 4(80) X 309600
Total fluids for 24 hrs would be 9.6 liters
Half should be given in the first 8 hours and the
other half over 16hrs
4.8 liters in the first 8 hours and the rest at
300cc/hr for 16hrs
D 8.2 liters
E 6.5 liters

Symptoms this patient may be experiencing include
all of the following except?
A Fever
B Weight loss
C Diaphoresis
D Palpitations
E Hair loss

Symptoms this patient may be experiencing include
all of the following except?
A Fever
B Weight loss
C Diaphoresis
D Palpitations
E Hair loss
False, all of the above are true and
characteristic of hyperthyroidism which often
presents with these symptoms along with a
palpable or visible goiter as this patient has.
Hair loss is associated with hypothyroidism
rather than hyperthyroidism

During immediate trauma management using ATLS
guidelines, which of the following answers would
be the most appropriate for this patient?
A Chest CT
B Oxygen, repeat x-ray
C Chest tube insertion
D Needle thoracotomy
E 2 units of PRBC then OR

During immediate trauma management using ATLS
guidelines, which of the following answers would
be the most appropriate for this patient?
A Chest CT
False, this may be indicated later on with this
patient but is not the first step in management
in a patient with a tension pneumothorax
B Oxygen, repeat x-ray
False, this patient has a clearly evident tension
pneumothorax with deviation of the mediastinal
structures to the right side and needs immediate
decompression
C Chest tube insertion
False, although this is the definitive treatment
and should be placed after needle decompression,
it is not the best answer per ATLS guidelines
D Needle thoracotomy
True, this patient needs immediate decompression
and should have a needle placed in the left 2nd
intercostal space
E 2 units of PRBC then OR
False, although the patient may need blood
depending on the overall clinical presentation
the immediate indication is for chest
decompression

Which of the following answers most accurately
describes the process shown in this x-ray?
A Chest tubes should be placed anterior into the
apex
B This tube is fully inserted into the chest
cavity
C Perform blunt dissection with clamp under the
desired rib
D Place incision into the 4th intercostal space
in the mid axillary line
E A 36 French tube is smaller than a 34 French
tube

Which of the following answers most accurately
describes the process shown in this x-ray?
A Chest tubes should be placed anterior into the
apex
False, chest tubes should be placed posterior and
directed toward the apex
B This tube is fully inserted into the chest
cavity
False, the tube is longer than the chest cavity
and should only be inserted 10-14cm in most
patients so that the radiopaque line is within
the chest cavity but the end of the tube should
not be inserted to far and end up damaging the
mediastinum
C Perform blunt dissection with clamp under the
desired rib
False, the dissection should always be over the
rib so as not to damage the intravascular bundle
that runs under the rib and thereby prevent
intracostal bleeding
D Place incision into the 4th intercostal space
in the mid axillary line
True, the line should generally be directly
lateral to the nipple line or inframammary line
in women and in the mid axillary line
E A 36 French tube is smaller than a 34 French
tube
False, the 36 French is bigger than the 34 French
tube

These elderly hands are classic for which of the
following?
A Scleroderma
B Rheumatoid Arthritis
C Chronic Trauma
D Mallet Finger
E Reiters Syndrome

These elderly hands are classic for which of the
following?
A Scleroderma
False, these hands do not show tuberous sclerosis
which is characterized by taunt skin that appears
stretched
B Rheumatoid Arthritis
False, RA is known for the classical swan neck
deformity of the MCP or PIP joints with ulnar
deviation and usually spares the DIP joints
C Chronic Trauma
True, in this picture the patient has multiple
DIP joint abnormalities with both ulnar and
radial deviation. On further history he was a
carpenter with a chronic history of hitting his
fingers with his hammer over the years
D Mallet Finger
False, mallet finger is usually a DIP phenomenon
whereby the extensor tendon is separated from the
bone and leads to an inability to fully extend
the DIP joint
E Reiter's Syndrome
False, there is no evidence in this picture or
history that the patient has the triad of
conjunctivitis, urethritis, or arthritis

A man presents with the following rash. Which of
the following is true?
A Most common among children
B Associated with pruritis or burning sensation
but no pain
C Acyclovir decreases pain but does not shorten
duration of illness
D Rash does not follow a dermatome distribution
E Symptoms may persist for months after
resolution of lesions

A man presents with the following rash. Which of
the following is true?
A Most common among children
False, about 80 of cases occur in patients older
than 2Oyrs of age
B Associated with pruritis or burning sensation
but no pain
False, Herpes Zoster can be very painful and
narcotics are commonly given
C Acyclovir decreases pain but does not shorten
duration of illness
False, acyclovir not only shortens the duration
of illness but has also been reported to decrease
the pain of herpes zoster
D Rash does not follow a dermatome distribution
False, the rash always follows a dermatomal
pattern because the reactivation of the herpes
virus occurs in the dorsal root ganglion
E Symptoms may persist for months after
resolution of lesions
True, this is known as post herpetic neuralgia
and is quite common in patients suffering from an
outbreak of herpes zoster

A man is brought into the ED unresponsive after
being found in his garage. The only physical
evidence is shown above. Which of the following
is true?
A Skin, brain , and fat are most susceptible to
injury
B Renal failure is usually a result of direct
injury to kidney
C With significant injury dysrthymia usually
develops 24-48hrs after contact
D Even with minor cutaneous involvement major
internal injury can occur
E Rhabdomyolysis is a common finding after
lightening injuries

A man is brought into the ED unresponsive after
being found in his garage. The only physical
evidence is shown above. Which of the following
is true?
A Skin, brain , and fat are most susceptible to
injury
False, the path of least resistance are the
nerves and blood vessels
B Renal failure is usually a result of direct
injury to kidney
False, renal failure is usually due to the high
amount of muscle breakdown and elevated levels of
CK and myoglobin
C With significant injury dysrthymia usually
develops 24-48hrs after contact
False, dysrthymia occurs at the time of
electrical injury or immediately after and only
rarely presents later during episodes of
extensive cardiac injury
D Even with minor cutaneous involvement, major
internal injury can occur
True, the ED physician must have a high index of
suspicion for underlying injury as electrical
injury usually causes damage to the path of least
resistance which are the nerves and blood vessels
making diagnosis difficult
E Rhabdomyolysis is a common finding after
lightening injuries
False, lightening rarely causes elevation in CK
levels. Electrical injuries rather can have
extensive muscle injury which sometimes leads to
rhabdomyolysis

A women presents with acute onset of swelling.
Immediate ED management includes which of the
following?
A Immediate endotracheal intubation
B Observation with airway backup
C Call anesthesia stat
D Nasotracheal blind intubation
E Fiberoptic guided nasotracheal intubation

A women presents with acute onset of swelling.
Immediate ED management includes which of the
following?
A Immediate endotracheal intubation
False, although airway consideration is of utmost
importance, the majority of the time these
patients do not involve their post pharynx and
expectant management with admission will prevent
the complications of intubation
B Observation with airway backup
True, these patients should closely be observed
and standard and back up airways readily
available
C Call anesthesia stat
False, anesthesia only needs to be called when a
airway has already been attempted and failed
D Nasotracheal blind intubation
False, again the best answer is observation
however due to the large tongue swelling the only
viable option is nasotracheal either blind or
fiberoptic assisted
E Fiberoptic guided nasotracheal intubation
False, see answer D

All of the following are true statements except
which one?
A Most infections are caused by staph and strep
bacteria
B Finger is often held in slight flexion
C Joint is usually fully swollen
D Pain with passive flexion of the digit
E Tenderness along the palmer aspect of the
tendon

All of the following are true statements except
which one?
A Most infections are caused by staph and strep
bacteria
True, these are the most common infections and
should be treated by both opening of the tendon
and appropriate antibiotics
B Finger is often held in slight flexion
True, this is the most comfortable position and
creates less pressure on the infected tendon
sheath
C Joint is usually fully swollen
True, known as sausage digit
D Pain with passive flexion of the digit
False, the Kanavel signs of flexor tenosynovitis
are otherwise stated in the other answers and
include pain with passive extension of the
affected digit rather than flexion. These 4
signs are characteristic of flexor tenosynovitis
and are an orthopedic emergency!
E Tenderness along the palmer aspect of the
tendon
True, the pain gradually ascends up the tendon
sheath and can go into the mid palmer aspect of
the hand

All of the following are true except which of the
following?
A Prehns sign is reliable for distinguishing
torsion from epididymitis
B Often caused by STDs or coliform bacteria
from urinary dysfunction
C Patients have a greater risk of transmitting
HIV
D Epididymitis is a risk factor for orchitis
E Progression is usually gradual in nature
peaking within 24 hrs

All of the following are true except which of the
following?
A Prehns sign is reliable for distinguishing
torsion from epididymitis
False, although the Prehn sign is helpful in
diagnosis of epididymitis by causing relief of
pain with the scrotum is elevated, it is not
sensitive and specific enough to be a reliable
sign to differentiate the two disease entities
B Often caused by STDs or coliform bacteria
from urinary dysfunction
True, epididymitis is often caused by STD in the
younger age groups and urinary dysfunction
including BPH is associated with the older
patients, however both of these may overlap
depending on the patient
C Patients have a greater risk of transmitting
HIV
True, patients have a 2-5X greater risk of
transmitting and contacting HIV when infected
D Epididymitis is a risk factor for orchitis
True, the infection can spread from one region to
another
E Progression is usually gradual in nature
peaking within 24 hrs
True, unlike torsion which is usually acute in
onset, epididymitis usually has a more gradual
course

A young female unbelted passenger s/p MVC
presents with the x-ray above. She had some blood
in the perineal area, but admits to currently
having her period. Which of the following
statements are correct?
A Injury is most likely from bony fragment
perforation
B Gross hematuria is an indication for a
cystogram
C Injury is almost always intraperitoneal in
origin
D A catheter needs to be placed immediately to
diagnose etiology of injury
E The ability to urinate excludes bladder injury

A young female unbelted passenger s/p MVC
presents with the x-ray above. She had some blood
in the perineal area, but admits to currently
having her period. Which of the following
statements are correct?
A Injury is most likely from bony fragment
perforation
False, although this was thought to be the
mechanism, current literature in urologic trauma
is that the rupture is from direct burst injury
or shearing forces rather than bony perforation
B Gross hematuria is an indication for a
cystogram
True, a physician should proceed first with a
urethrogram and then perform a cystogram to
evaluate the lower GU tract for injury
C Injury is almost always intraperitoneal in
origin
False, the injury is usually extraperitoneal in
high speed MVC associated with traumatic pelvic
fractures 90-100 of the time
D A catheter needs to be placed immediately to
diagnose etiology of injury
False, placing a foley catheter can cause further
injury if there is an urethral tear and a
urethrogram