Board Review Questions

[pbruss]

    A few questions for your review. Same tng as last time, no internet and you have 2 weeks to post answers. winner gets a prize. Lets get some more people invalid: beat the whopping 2 people that participated last time. And i know the question numbers skip a bit.      


 1. A 29-year-old woman with a history of gout presents with a diffuse rash consisting of erythematous target lesions as well as oral sores for several days (Fig. 11-1). She recently started a course of medication for a urinary tract infection the week prior but cannot remember the name. Which of the following is the most likely cause?    
      (A)  Ciprofloxacin      
    (B)  Cefdinir     
     (C)  Cephalexin    
      (D)  Trimethoprim-sulfamethoxazole   
       (E)  Macrodantin  

   2. A 35-year-old woman presents after a fall from a fourth-story window. She was initially moaning, but then became completely unresponsive. Her pupils were initially miotic and equal, but then became dilated and unreactive. She exhibits decorticate posturing in response to pain. Which of the following is the most likely mechanism?    
      (A)  Skull fracture     
     (B)  Uncal herniation     
     (C)  Basilar artery dissection  
        (D)  Subarachnoid hemorrhage    
      (E)  Brain death   

  3. Which of the following cardiac findings is expected in hypothermic patients?   
       (A)  QT interval prolongation      
    (B)  Sinus bradycardia     
     (C)  Atrial fibrillation    
      (D)  J waves      
    (E)  All of the above   

  4. In patients with tibial shaft fractures, which of the following is the most common associated finding?     
     (A)  Fibular fracture    
      (B)  Common peroneal nerve injury   
       (C)  Posterior tibial nerve injury     
     (D)  Dorsalis pedis artery injury      
    (E)  Posterior tibial artery injury  

   5. A 14-year-old boy presents with intermittent bilateral hip pain for several weeks. Physical examination demonstrates decreased internal rotation of both hips. Radiographs show slippage of the femoral epiphysis. Which of the following is the most common associated condition?   
       (A)  Hyperthyroidism      
    (B)  Diabetes mellitus  
        (C)  Obesity        
  (D)  Renal failure


    6. Which of the following is the most common organ affected by Francisella tularensis?      
    (A)  Skin  
        (B)  Liver
         (C)  Kidney
         (D)  Heart
         (E)  Lungs

    7. A 19-year-old man presents with fevers, chills, malaise, and rash for 5 days. He recently returned from a camping trip. The rash is macular and located on the wrists, ankles, palms, and soles. Routine laboratory work including lumbar puncture is normal. Which of the following is the most appropriate medication at this time?    
      (A)  Watchful waiting   
       (B)  Doxycycline    
      (C)  Acyclovir       
   (D)  Clindamycin      
    (E)  TMP-SMX   

  8. What is the primary risk factor for uterine rupture among pregnant women?   
       (A)  Vaginal delivery after a prior cesarean-section     
     (B)  Diabetes        
  (C)  Large for gestational age fetus
         (D)  Prolonged use of oxytocin
        (E)  Maternal collagen vascular disease  

   9. A 67-year-old female with diabetes, hypertension and a history of an aortoiliac bypass graft presents with abdominal pain and dark, “funny-smelling” stools. She states the symptoms started 2 days ago and seem to have gone away as she had a “near normal” bowel movement this morning and no longer has pain. On examination, she has guaiac positive, dark brown, but not melenic stool. Which of the following must be excluded as a cause of hemorrhage?  
        (A)  Acute mesenteric ischemia   
       (B)  AAA       
   (C)  Aortoenteric fistula  
        (D)  Duodenal ulcer   
       (E)  Ischemic colitis  

 10. A 25-year-old woman presents with progressively worsening right eye vision loss and pain with extraocular movements over the last 3 days. An afferent papillary defect is present on the right, and direct fundoscopic examination reveals a swollen optic disc. You make the diagnosis of optic neuritis. The patient is very concerned that her vision loss may be an early sign of MS. You tell her that her risk of developing MS within 5 years is approximately:  
        (A)  5%   
       (B)  25%  
        (C)  50%   
       (D)  75%    
      (E)  100%   

11. Which of the following is the most appropriate test in a patient with an intermediate probability of a PE by Wells criteria?  
        (A)  Lung scintigraphy (ventilation-perfusion [V/Q] scan)   
       (B)  D-dimer        
  (C)  CT pulmonary angiography
         (D)  Lower extremity Doppler ultrasonography  
        (E)  ABG


  13. A 72-year-old man without any past medical history presents to the ED after a fall from standing height with accompanying head trauma. A CT scan of the brain is ordered. Which of the following is the most likely abnormal finding on CT scan?     
     (A)  Epidural hematoma    
      (B)  Subdural hematoma   
       (C)  Subarachnoid hemorrhage
         (D)  Cerebral contusion        
  (E)  Cerebellar hematoma

  14. The combination of ceftriaxone and azithromycin is a common dual-antibiotic regimen used in the empiric treatment of community-acquired pneumonia. For which of the following organisms is azithromycin included?   
       (A)  Haemophilus influenzae   
       (B)  Staphylococcus aureus   
       (C)  Legionella pneumophila   
       (D)  Streptococcus pneumoniae
         (E)  Moraxella catarrhalis   

15. Fracture of which of the following structures is readily identified by oblique views of the cervical spine?  
        (A)  Spinous process    
      (B)  Lamina      
    (C)  Pedicle        
  (D)  Vertebral body   
       (E)  Dens  

 16. Which of the following is the most common metabolic abnormality causing adynamic ileus?   
       (A)  Lactic acidosis
         (B)  Hypokalemia
         (C)  Hypomagnesemia
         (D)  Hypercalcemia
         (E)  Uremia

  17. A 28-year-old man with a history of asthma is brought to the resuscitation room in your ED with a chief complaint of wheezing, dyspnea, and cough. Your ED has an asthma “protocol” in which all severe asthmatics receive an immediate portable chest x-ray. Which of the following is true of chest x-rays in asthma?          (A)  All asthmatics who present to the ED with wheezing should receive a chest x-ray.
         (B)  Chest x-rays reveal an infiltrate in 50% of patients experiencing an asthma exacerbation.
         (C)  Approximately 50% of patients not responding to optimal therapy have unsuspected pulmonary complications evident on chest x-ray.
         (D)  Chest x-rays are most useful to detect the pulmonary complications of asthma exacerbations.
         (E)  Chest x-rays should only be used if an asthma patient is febrile, with symptoms suggestive of pneumonia.

  18. A 44-year-old cancer patient with known chemotherapy-induced neutropenia is sent by her oncologist to the ED with a fever of 101.5°F. Which of the following is the most appropriate initial empiric antibiotic regimen?
         (A)  Doxycycline
         (B)  Cefepime
         (C)  Clindamycin
         (D)  Metronidazole + gentamicin
         (E)  Metronidazole + aztreonam

  19. A 23-year-old woman presents with fever, chills, and right flank pain. She just completed treatment for pyelonephritis with a 2-week course of ciprofloxacin. The patient states that the symptoms are very similar to when she had pyelonephritis and she cannot understand why she did not get better with the antibiotics. She admits to having waited “longer than usual” before seeking care for the pyelonephritis during the first visit, but swears that she took all the antibiotics as directed. The initial urine culture revealed E. coli that was sensitive to ciprofloxacin. Which of the following is the most appropriate next step in management?          (A)  Continue ciprofloxacin for 3 more days
         (B)  Continue ciprofloxacin for 7 more days
         (C)  Start trimethoprim-sulfamethoxazole (TMP-SMX) for 3 days
         (D)  Start metronidazole for 3 days
         (E)  CT scan of the abdomen/pelvis

  20. A 3-day-old female neonate is brought to the ED with a chief complaint of rectal bleeding. A guaiac test of the stool is positive. Which of the following tests can help to determine whether the blood in the stool is of fetal origin?
         (A)  KBT
         (B)  Meckel’s scan
         (C)  Rosette test
         (D)  Apt test
         (E)  All of the above

  21. Women are affected by gout:
         (A)  Very rarely
         (B)  Most commonly in childhood
         (C)  Most commonly during their adult years
         (D)  Most commonly in their postmenopausal years
         (E)  Mostly in the hip joints

  22. Which of the following is true regarding cerebral edema after head trauma?
         (A)  Vasogenic edema usually occurs in the gray matter
.          (B)  Vasogenic edema occurs because of membrane pump failure.
         (C)  Cytotoxic edema develops when cerebral blood flow is reduced.
         (D)  Cytotoxic edema rarely occurs in the absence of vasogenic edema.
         (E)  The presence of cerebral edema mandates operative management.

  23. A 5-year-old boy is brought by his mother for a rash on his lower abdomen (Fig. 11-3). You suspect contact dermatitis from the metal on his jean button. Which of the following is the most likely cause?
         (A)  Silver
         (B)  Platinum
         (C)  Copper
         (D)  Nickel
         (E)  Zinc

  24. Which of the following is an indication for replantation after amputation?
         (A)  Amputation of the thumb in the nondominant hand.
         (B)  Ring finger amputation distal to the distal interphalangeal (DIP) joint.
         (C)  A 58-year-old diabetic factory worker with an amputation of his index finger at the metacarpophalangeal (MCP) joint.
         (D)  A 23-year-old laboratory worker with a middle finger amputation at the level of his middle phalanx who stored his finger packed in dry ice for the last 12 hours.
         (E)  All of the above.

  25. A 27-year-old man is brought to the ED after being stabbed in the neck with a knife and robbed. Upon examination, you note a 3-cm wound to zone II of the neck with an intact platysma. Which of the following is the next best step in management?
         (A)  Local wound care, reassurance, and discharge  
        (B)  Admission for 23 hours of observation
         (C)  Soft tissue x-ray of the neck
         (D)  Carotid angiography
         (E)  CT of the neck

  26. A 34-year-old women presents to the ED with increasing low abdominal pain. She was seen by a colleague a week ago and diagnosed with an early ectopic pregnancy in her left fallopian tube. Her OB was consulted at that time and the patient was started on methotrexate therapy. What is the most likely cause of her abdominal pain?
         (A)  Treatment failure and increasing size of the ectopic pregnancy
         (B)  Tubal rupture
         (C)  Appendicitis
         (D)  Normal “separation pain” from methotrexate use
         (E)  PID

  27. Patients with which of the following are most likely to develop superimposed septic arthritis:
         (A)  Osteoarthritis
         (B)  Rheumatoid arthritis
         (C)  Reactive arthritis
         (D)  Systemic lupus erythematosus
         (E)  Gout

Attachments:

[Bjs04f]

1-d
2-d
3-e
4-e
5-c
6-a
7-b
8-a
9-c
10-d
11-c
12-there is no 12
13-d
14-e
15-b
16-b
17-e
18-e
19-e
20-d
21-a
22-a
23-d
24-c
25-a
26-a
27-b
Felt better about the last board review

[kemple]

1) D, 2) A, 3) E, 4) E 5) C, 6) A, 7) B, 8) A, 9) C, 10) C, 11) C, 12) N/A, 13) B, 14) A, 15) C, 16) A, 17) E, 18) B, 19) E, 20) D, 21) D, 22) A, 23) D, 24) A, 25) A, 26) A, 27) B

Well at this rate I at least got second again!

[afemdoc]

1-d
2-b
3-e
4-a
5-c
6-e
7-b
8-a
9-c
10-b
11-c
13-b
14-c
15-a
16-b
17-e
18-b
19-e
20-e
21-d
22-a
23-d
24-a
25-a
26-a
27-b

[pbruss]

answers till to come, lets see who else steps up but stransky already in first place with matrix like answer of "there is no 12".

is there no 12 stansky? or does the absent 12 represent an existential challenge for all of you to obtain the highest level of self awareness and knowledge. Was there not the 12 great labors of Hercules? Was there not 12 knights of the round table? The Lex Duodecim Tabularum  was the 12 tables of ancient Roman law that sustained an Empire for centuries an cultivated the foundation of civilized culture on Earth. The fate of any man or woman in America ultimately rests in the hands of 12 jurors. the 12 Jyotirlingas in Hindu Shaivism are held with the highest respect. Were there not 12 Olympians that sat atop mount Olympus? The chief Norse god, Odin, had 12 sons. In the Bible Jacob had 12 sons, who were the progenitors of the Twelve Tribes of Israel. After Judas Iscariot was disgraced, there remained 12 faithful apostles. In the Catholic Church a crown with 12 stars sits upon the Virgin Mary's head. The prophet Muhammad had 12 Imams or successors to his blood line. 
In the Tarot cards twelve is the card of the hanged man - the symbolic of self-sacrifice and meditation. Reversed it represents selfishness
. there are 12 letters in my name p-a-t-r-i-c-k-b-r-u-s-s. so i ask again, is the no 12?

sorry - i just read 12 dan brown novels. and please forgive any cultural or religious inaccuracies.

[Bjs04f]

great odins raven hes right. There is a 12, we just havent obtained enough medical greatness to see it yet. Wait nope I can see it 12-b.

[Bjs04f]

annnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnd closed. Congrats we have 1 more person with us on proboards. I assume based on the name afem doc its tyson

[pbruss]

  winner- afemdoc with 19 correct. who is afemdoc by the way. answers below 

 1. Answer D. The patient likely has Stevens–Johnson syndrome (SJS), most commonly caused by certain drug exposures. Sulfa drugs, allopurinol, carbamazepine, and phenytoin are usually implicated, though many other drugs have been known to cause SJS. SJS exists on the same spectrum as toxic epidermal necrolysis and can exhibit multiorgan involvement, though most cases are restricted to the skin and mucous membranes. Diagnosis is clinical, and treatment revolves around good supportive care, especially adequate IV hydration. Corticosteroid use is controversial. (Figure courtesy of Robert Hendrickson, MD. Reprinted from Hendrickson R. Greenberg’s Text-Atlas of Emergency Medicine. Lippincott Williams & Wilkins; 2004:51, with permission.)   

  2. Answer B. Cerebral herniation syndromes are a result of severely increased ICP, usually because of trauma. Herniation occurs when the increased ICP causes movement of various parts of the brain across fixed structures, such as the falx cerebri (dividing left from right), tentorium cerebella (dividing the cortex from the brainstem and cerebellum), or foramen magnum (dividing intracranial from extracranial structures). Mortality is virtually 100% in untreated patients. Uncal herniation is the most common type, in which the ipsilateral temporal lobe is compressed against the tentorium cerebella and subsequently puts pressure on the underlying brainstem. The initial clinical manifestation is oculomotor nerve injury, causing ipsilateral ptosis, oculomotor dysfunction, and mydriasis. As herniation progresses, contralateral hemiparesis occurs and the contralateral uncus is compressed, leading to bilateral decorticate posturing. Ultimately, uncal herniation often progresses further until the brainstem herniates, causing respiratory failure and death.    

 3. Answer E. Though a transient tachycardia may occur, sinus bradycardia develops and the heart progressively slows as the body cools. In fact, the finding of a relative tachycardia in a hypothermic patient should trigger a search for a cause. The PR, QRS, and QT intervals may all become prolonged although this finding is most common in the QT segment and also correlates with the degree of hypothermia. J waves, or Osborn waves, are the most discussed EKG feature in hypothermia. They are additional waves at the junction of the QRS complex and the ST segment and tend to be upright in aVL, aVF, and the lateral precordial leads. Any atrial or ventricular dysrhythmia may occur, but atrial fibrillation is the most common and it usually spontaneously converts to sinus rhythm upon rewarming.   

  4. Answer A. Patients with tibial shaft fractures usually have concomitant fibular fractures as well, due to the close proximity of the two bones. Mechanism of injury usually involves direct trauma; only rarely do pathologic fractures occur in the tibia. Due to the sparse soft tissue surrounding the anterior surface of the tibia, fractures are often open and require emergent operative repair. The most common site for compartment syndrome is in the leg, due to tibial fracture. The common peroneal nerve is the most common nerve to be injured in tibial fractures, but this does not occur in most patients. Vascular compromise with tibial fractures is rare, but when present, mandates aggressive management.

    5. Answer C. The patient has evidence of SCFE. The most common presenting age is early adolescence, it is more common in boys, and African Americans are the highest risk population. Obesity is the most common associated condition, but hypothyroidism may also be involved. Patients typically present with unilateral or bilateral hip or knee pain, which is intermittent and worse on activity. Physical examination may demonstrate progressive loss of internal rotation, muscle atrophy, and leg length discrepancy. Lateral, AP, and frog-leg radiographs show the femoral epiphysis slipping inferiorly and posteriorly off the femoral neck. Emergency management includes non–weight-bearing and orthopedic consultation.  

   6. Answer A. Tularemia is a tick-borne illness caused by the spirochete, F. tularensis. Rabbits, rodents, and cats are the common vectors. Human-to-human transmission rarely occurs. The most common manifestation of disease is cutaneous, with formation of skin ulcers and painful lymphadenopathy. Systemic, pharyngeal, pulmonary, and ocular disease may also occur. Diagnosis is made by clinical suspicion and confirmed with antibody titers. Treatment is with intramuscular streptomycin, although tetracyclines, aminoglycosides, and chloramphenicol may be used with lower efficacy. Pulmonary tularemia may be caused by aerosolization from a bioterrorist attack, due to the organism’s extremely infectious properties.  

   7. Answer B. With the history of a recent camping trip, tick-borne illness should be suspected. In this case, the patient likely has Rocky Mountain spotted fever, caused by the intracellular bacterium, Rickettsia rickettsii. The organism causes endothelial cell damage, resulting in diffuse vasculitis and multiple organ microinfarctions and failure. Acute respiratory distress syndrome, DIC, and shock all may occur in serious cases. Rash on the wrists and ankles following a nonspecific viral-like syndrome is characteristic. Laboratory work is usually normal, though thrombocytopenia may occur. Treatment is with doxycycline or chloramphenicol. Choices A, C, D, and E will not adequately treat the rickettsial infection.   

  8. Answer A. Uterine rupture may occur as a result of substantial maternal trauma. However, among typical pregnant women, the primary risk factor for uterine rupture is a prior cesarean delivery (c-section), particularly with a “classic” vertical incision. Patients may present with significant abdominal pain and vaginal bleeding or they may be relatively asymptomatic if only minor dehiscence has occurred. A more recent meta-analysis suggests that only the risk of dehiscence is increased among women with a prior cesarean section (excluding women with a classic vertical incision). Oxytocin did not increase the risk of rupture. Emergent cesarean-section is indicated in all cases of uterine rupture.  

   9. Answer C. This patient has an aortoenteric fistula until proven otherwise. The classic presentation is abdominal pain and GI bleeding that resolves spontaneously (the so-called herald bleed) in a patient with a prior history of aortic graft. The initial bleeding is thought to stop when splanchnic pressure drops and allows adequate clot to form. However, the initial bleed is often followed by a massive and often fatal hemorrhage days or possibly weeks later. The fistula is caused by S. aureus or Escherichia coli infection of the prior graft and typically forms between the aorta and the distal duodenum. Therefore, all patients with a history of aortic graft and GI bleeding should undergo esophagogastroduodenoscopy to search for a fistula in the distal duodenum. Most of these patients, however, have an alternative, more common cause of GI bleeding.

  10. Answer B. The lifetime risk of developing MS in a patient with acute optic neuritis is 25% to 30%. Although administration of intravenous steroids reduces the duration of acute ocular symptoms, it is unclear whether it reduces the risk of development of MS. Up to half the number of patients with MS will develop optic neuritis over the course of their illness. The classic historic triad of optic neuritis is eye pain, loss of vision, and defects in color vision. White patients of northern European descent are at the highest risk demographically. Bilateral optic neuritis and recurrent optic neuritis each occur in approximately one-third of patients. Recurrent disease is more common in patients who are ultimately diagnosed with MS.  

 11. Answer C. Although a high-probability V/Q scan can “rule in” a PE in the setting of a patient with an intermediate pretest probability, and a completely normal scan can rule out the disease, any other result will require further testing by CT pulmonary angiography or direct pulmonary angiography. Furthermore, most patients undergoing V/Q scanning will fall into this intermediate group. Therefore, the best test in a patient with an intermediate probability for PE is a CT pulmonary angiogram. d-dimer assays are only useful in the evaluation of patients with very low probability of having a PE. Elevated d-dimer levels cannot confirm a diagnosis of PE, and normal levels can only rule out disease in very low risk individuals. Lower extremity Doppler ultrasonography has been advocated by some as a means to evaluate the presence of venous thrombosis in the setting of inconclusive studies for PE. Regardless of their findings, however, lower extremity ultrasonography cannot prove nor refute the presence of a PE. ABG has no role in the evaluation of PE, as PEs may be present regardless of the findings on an ABG.  

13. Answer D. The most common abnormal finding on CT scan in elderly patients with head trauma is cerebral contusion. Most of these patients have mild intraparenchymal capillary damage and are usually managed nonoperatively, with serial CT scans and neurologic examinations to assess for deterioration. Epidural hematomas are less common in the elderly than in younger adults, as the dura is tightly adherent to the skull and does not usually expose arteries to shear forces. Subdural hematomas become much more common as patients get older because of brain atrophy, which stretches cranial bridging veins. Subarachnoid hemorrhage and cerebellar hematomas are less commonly seen in this population.

  14. Answer C. Legionella spp., along with Chlamydia spp. and Mycoplasma spp. all respond to macrolide therapy. The remaining organisms are usually treated with cephalosporins or fluoroquinolones.  

 15. Answer B. Oblique views of the cervical spine do not generally add significant sensitivity to the standard three-view cervical spine series (lateral, AP, odontoid). Their primary utility is in identifying fractures of the lamina and better characterizing unilateral facet dislocations. Both these injuries may also be identified with CT scan, rendering oblique views less useful in current trauma evaluations of the cervical spine. Spinous process and pedicle fractures are best seen on the lateral view. Vertebral body fractures are seen well on the AP and lateral views. Dens fractures are the primary reason for obtaining the open-mouth odontoid view of the cervical spine.  

 16. Answer B. Postoperative ileus is a common, expected outcome after laparotomy. However, multiple electrolyte abnormalities may also cause or exacerbate the condition. Hypokalemia is the most common electrolyte abnormality responsible for ileus, though hypomagnesemia, hyponatremia, hypocalcemia, and uremia may also contribute.

  17. Answer D. Chest x-rays are commonly ordered but rarely useful in the evaluation of patients with acute asthma. They are indicated, however, when there is clinical evidence of pneumonia, a complication of asthma, such as pneumothorax or pneumomediastinum, or a pulmonary disorder that mimics asthma (e.g., a first-time adult wheezer who fails to respond to typical asthma therapy). Approximately 15% of patients who fail to respond to optimal therapy will have an unsuspected pulmonary complication evident on x-ray. Fewer than 10% of patients with asthma exacerbations will have some kind of infiltrate on chest x-ray. Most of these abnormalities are slight increases in interstitial markings of unknown significance.  

 18. Answer B. Neutropenic fever patients are at considerable risk for serious bacterial infection and require broad-spectrum antibiotics. Either gram-positive (Streptococcus or Staphylococcus species) or gram-negative (Pseudomonas, E. coli, and others) organisms can be responsible for infection. Cefepime monotherapy is an appropriate initial antibiotic choice, covering all organisms except for some strains of methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin may be added to any antibiotic regimen to adequately cover MRSA in hospitals with a high incidence of this pathogen. Doxycycline covers some gram-positive organisms and atypicals but does not adequately cover gram negatives. Clindamycin does not cover gram-negative organisms. The combination of metronidazole and either gentamicin or aztreonam leaves out adequate gram-positive coverage.  

 19. Answer E. The patient has failed outpatient therapy for pyelonephritis. The possible reasons for this include antibiotic noncompliance, antibiotic resistance, a concomitant kidney stone, or a renal abscess. The patient has had two weeks of appropriate antibiotic therapy for pyelonephritis, which should be adequate for clinical cure unless a kidney stone or renal abscess is present. CT is recommended if such a complication is suspected. Initiating treatment with a more narrow-spectrum antibiotic such as TMP-SMX or metronidazole is not indicated, especially if no urine culture is performed beforehand. In this patient’s case, the urine culture suggests that ciprofloxacin should normally be adequate therapy. However, given the resistance rates in many communities, the best empiric choice for outpatient treatment of pyelonephritis is a third generation oral cephalosporin such as cefixime. Extending the course of ciprofloxacin beyond 2 weeks is only indicated in cases of male prostatitis.

  20. Answer D. Swallowed maternal blood is a common cause of factitious GI bleeding in young neonates. The apt test involves the application of alkali to a small sample of bloody stool. Owing to its different composition from adult hemoglobin, fetal hemoglobin (which is composed of two α and two γ subunits instead of two α and two β subunits as in adult hemoglobin) is resistant to denaturation by this application. After the application of alkali, fetal hemoglobin will remain pinkish red upon microscopic examination whereas adult hemoglobin will appear brownish. Both the Rosette test and the KBT are used to detect the presence of fetal maternal hemorrhage.

  21. Answer D. Because estrogens increase the renal excretion of uric acid, women have a decreased risk of developing gout until menopause. Postmenopausal women affected by gout are more often taking diuretic therapy and often have underlying renal insufficiency. Gout is primarily a disease of the lower extremities, although the hip joints are very rarely affected.  

 22. Answer C. Cerebral edema refers to an increase in brain water content (rather than an increase in cerebral blood flow) after head trauma. CT can define the extent of cerebral edema, but the appearance on imaging may not correlate with clinical severity. The two types of cerebral edema are vasogenic and cytotoxic. Vasogenic edema is due to dysfunction of the endothelial tight junctions which maintain the blood–brain barrier. It usually occurs in the white matter from a focal injury. Cytotoxic edema results from cerebral ischemia, which causes cellular membrane pump dysfunction and cellular death. Either form of edema may occur with any traumatic injury. Management of cerebral edema is handled on a case-by-case basis and operative treatment is usually based on extent of increased ICP and clinical findings rather than the specific degree of edema observed on CT scan.  

 23. Answer D. Nickel is the most common overall cause of contact dermatitis in the world and the second most common cause in the United States (after poison ivy/oak). Nickel is found in many metals on clothes, and many silver and gold chains use nickel as a filler metal. Notably, “sterling silver” chains do not contain significant amounts of nickel. Symptoms of allergic contact dermatitis include a pruritic, maculopapular rash. Treatment involves avoiding nickel substances and mild topical corticosteroids. (Figure courtesy of Robert Hendrickson, MD. Reprinted from Hendrickson R. Greenberg’s Text-Atlas of Emergency Medicine. Lippincott Williams & Wilkins; 2004:51, with permission.)

  24. Answer A. In general, indications for replantation include multiple digit amputations, thumb amputations, wrist and forearm amputations, single digit amputations between the PIP and DIP joints, and any pediatric amputation. Amputations distal to the DIP joint are typically debrided and closed along with amputations proximal to the PIP. Amputations that are between the PIP (distal to the flexor digitorum superficialis insertion) and DIP joints tend to do well. However, single digit amputations are often considered unnecessary to replant. In addition, patients with underlying vascular disease, diabetes, congestive heart failure, or other medical problems may not have a good outcome even when the characteristics of the amputation are encouraging for replantation. Finally, all patients with amputation should wrap the amputated digit in saline-soaked gauze, place the gauze in a ziplocked bag, and place the bag on ice or in an ice-water bath. Freezing the digit should be avoided as it results in irreversible damage to cellular structures due to ice crystal formation.  

 25. Answer A. The platysma is the most superficial muscular layer of the neck, as it is sandwiched between the superficial and deep fascia of the neck. There are no vital structures superficial to the platysma. Therefore, patients with penetrating trauma who have an intact platysma can be given local wound care and discharged for routine follow-up. However, although neck wounds may be carefully examined to determine whether the platysma is intact, wounds should never be probed outside of the OR. If, after shallow examination, there is any uncertainty regarding platysma integrity, a surgeon should be consulted for further evaluation and treatment.  

 26. Answer D. A large percentage of women, estimated to be from 30% to 60%, experience abdominal pain approximately 1 week after starting methotrexate for ectopic pregnancy. This is known as separation pain as it is thought to result from tubal distension as a result of tubal abortion or hematoma formation. However, all women with a history of methotrexate treatment for ectopic pregnancy who present with abdominal pain merit further investigation by ultrasonography to explore the possibility of tubal rupture. Interestingly, the size of the ectopic mass may actually increase before involution, but this finding has not been shown to be associated with treatment failure. However, if patients have an increase in the amount of pelvic free fluid or a decrease in their hemoglobin, a presumptive diagnosis of tubal rupture should be made and an OB should be urgently consulted. Although it is a risk factor for ectopic pregnancy, active PID at the same time as pregnancy (ectopic or intrauterine) is extremely rare.

  27. Answer B. Any patient with underlying joint disease is more likely to develop septic arthritis. However, patients with underlying rheumatoid arthritis are most likely to develop concurrent septic arthritis. The diagnosis is usually delayed because patients are often afebrile, the presentation is frequently indolent and the symptoms are initially attributed to an exacerbation of the patient’s chronic condition. The case-fatality rate is 30% to 50%. Therefore, any patient with an underlying connective tissue or joint disease who develops sudden inflammation in one or two joints should be presumed to have septic arthritis until proved otherwise. Reactive arthritis is the name which is now given to arthritis, urethritis, and conjunctivitis that occurs after an infection (thus, “reactive”) and which was formerly called Reiter syndrome.   

Aldeen, Amer Z.; Rosenbaum, David H. (2012-07-12). 1200 Questions to Help You Pass the Emergency Medicine Boards (p. 354). Lippincot (Wolters Kluwer Health). Kindle Edition.