help with a couple questions for my EM assignment

[sweetlenovo88]

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We have an assignment and there a couple I am not sure about, the sampling below. Maybe some EM residents can help out. Some are very vague and annoying.

Here goes:

1. 70 y/o comes to ED with a ST elevation inferior wall MI with classic symptoms of MI, etc, he is on vasotec and ASA 81mg.

Vital: 220/110, HR-105, resp-22, 02 sat 96

diaphoretic clutching chest, RRR, +S4, clear lungs no pulm edema.

The ED doctor gave ASA 163mg, Nitro SL 1/150 q 5 minutes X3, Lopressor 5mg IV, morphine 4mg

this should be followed by:

A. 1/2" nitropaste ACW
B. Emergent Cardiac Cath with placement of LAD stent
C. Plavix 325mg PO
D. Reopro as definitive re-perfusion strategy
E. Retavase

I am thinking Retavase, a clot buster as with STEMI, he needs busting or cardiac cath. Could it be choice B though?


2. What will administer the greatest amounts of O2 to a patient?

A. nonrebreather
B. Bipap Mask
C. NC
D. Partial NRB
E. Venturi

I think A, what about B though?

3. AA gradient- 7.33/36/65/24/92%

I get 40, right?

4. An 84 y/o male from a nursing home is sent to the ED for eval of a change in mental status. Hx of dementia and today is confused on exam. Which of the following is the INITIAL treatment?

A. Blood Ammonia
B. Complete neurological exam
C. EEG
D. MRI of the head
E. Psych consult

I am thinking B, but could it be A?

5. The patient above while being evaluated becomes increasingly lethargic and develops snoring respirations. The patient is immediately intubated and neuro function(So B for choice above?) is revaluated. The next diagnostic step is:

A. Bedside EEG
B. CT Head without contrast
C. CT Head with contrast
D. LP
E.MRI

I am thinking a stroke, so choice B. Is that right?

6. The most reliable diagnostic sign when examining an ear for ottitis media is:

A. Erythematous ear canal
B. Fluid behind the ear drum with air fluid level
C. Lack of movement of tympanic membrane with insufflation
D. Pearly gray tympanic membrane with defined core of light
E. Retraction of pars flaccida and malleus

Uhm, half of these are common for acute ottitis media. I am thinking A. could it be B or C? I hate this question

7. Suicide attempt with Benadryl OD. Two hours later the patient will have:

A. Bradycardia
B. Diarrhea
C. Dry Mouth
D. Excessive Lacrimation
E. Meiosis

I am thinking C. right?

7. MVA with head on collision, patient wearing seatbelt, patient brought in with C collar and on longboard. Primary survey includes:

A. Airway Assessment with C-spine control
B. C-spine xray, cxr, ap pelvis xray.

I am thinking A, ABCs, right?

8. Mix and match suture size with location

locations: Arms/Legs, Face, Scalp, Secure Central Line, Tongue
suture size: 4-ethilon (mistake should this have been 4-0?, 4 is huge), 4-0 silk, 5-0 vicryl, 6-0 ethilon, staples.

I think:

Face-6-0 ethilon
Scalp-Staples
Arms/Legs-4 (-0?) ethilon??
Tongue-5-0 vicryl
Central Line-4-0 Silk

Does this sound right to everyone?

9. A patient with increased bleeding that started this AM with an ectopic pregnancy, 10 weeks, dizzy and weak, pale and diaphoretic, BP: 68/46, 99.4, HR 128, RR 20. The most appropriate INITIAL treatment is:

A. 2 large bore IVs with NS
B. IV floroquinolone
C. O-negative blood transfusion
D. Pack the vagina with surgical sponges
E. Pressor Agents

I am thinking C, but would you first give fluids for the BP drop or just put in blood?

10. A 44 y/o man brought to ED by police after found wandering in the park. Admits to a 'few beers.' He denies drug use. Admits to a past history of 'a lot of alcohol use.' On exam, he has slurred speech and you not the smell of alcohol. Your INITIAL Eval should be:

A. CT Head
B. Fingerstick Blood Sugar
C. Hepatitis Screen
D. LP
E. Stat Serum Ammonia

I am not sure at all on this one. Is it A, because maybe he fell, help?



Thanks for all your help

 

[Rendar5]

I'm not gonna directly answer your questions, but your thinking is on the right track for these questions. I'll just try and provide guiding comments when I can

1. Generally, cath is preferred to tpa for acute MI's. I'm not exactly sure the reasons as the initial data doesn't show a huge mortality difference between the two. I'm sure someone else could explain the reasons for this.

2. The point here is that nonrebreathers can deliver 100% O2 if they have both valves (the thing green circles) are in place preventing atmospheric air intake. They don't always though because a lot of models only have 1 of 2 valves in place (so they don't suffocate if the O2 stops). I'm told in that case that FiO2 ends up being 70% in reality. I don't know how accurate it is, it's just what I've been told. I'll leave it to you to figure out the rest.

4. You're on the right track. I don't know what they want, but I'd put the H & P before labs.

5. Don't really have anything to add

6. I'll let you look this one up. Keep in mind that you're examining for OM not OE.

7. Mad as a Hatter, Blind as a Bat, Dry as a Bone, Hot as a Hare??? I forget the rest... but in real life, they'll be picking at themselves (dunno why, it's not in the textbook, but it is textbook) and delirious.

7. ABC(DE)s are the first commandment of EM.


8. Good Job

9. She's in hypovolemic shock. She needs volume resuscitation before everything else (assuming A's and B's are ok). What're you gonna be able to do first for her?

10. Y'know, I'll be honest, I'm not sure what they're looking for here. You've got someone who admits to drinking, acting like a drunk, smelling like a drunk, who is a chronic drunk...Yeah, it's an AMS workup, but unless they respond that they're looking to get some help and want to stop drinking (in which case work them up, get them some benzo's, and contact addiction services), I have a feeling the risk:benefit ratio is in favor of them leaving to get more booze when they start shaking. Of all those answers there, I would pick fsg because it's cheap, will change management, and is relatively non-invasive. If I were suspecting Wernicke or Korsakoff, I'd also get them some thiamine +/- CT. The short answer? you may be right or you may be wrong I dunno.

 

[sweetlenovo88]

thanks for the guidance. yeah, the last question could not be more vague

I'm not gonna directly answer your questions, but your thinking is on the right track for these questions. I'll just try and provide guiding comments when I can

1. Generally, cath is preferred to tpa for acute MI's. I'm not exactly sure the reasons as the initial data doesn't show a huge mortality difference between the two. I'm sure someone else could explain the reasons for this.

2. The point here is that nonrebreathers can deliver 100% O2 if they have both valves (the thing green circles) are in place preventing atmospheric air intake. They don't always though because a lot of models only have 1 of 2 valves in place (so they don't suffocate if the O2 stops). I'm told in that case that FiO2 ends up being 70% in reality. I don't know how accurate it is, it's just what I've been told. I'll leave it to you to figure out the rest.

4. You're on the right track. I don't know what they want, but I'd put the H & P before labs.

5. Don't really have anything to add

6. I'll let you look this one up. Keep in mind that you're examining for OM not OE.

7. Mad as a Hatter, Blind as a Bat, Dry as a Bone, Hot as a Hare??? I forget the rest... but in real life, they'll be picking at themselves (dunno why, it's not in the textbook, but it is textbook) and delirious.

7. ABC(DE)s are the first commandment of EM.


8. Good Job

9. She's in hypovolemic shock. She needs volume resuscitation before everything else (assuming A's and B's are ok). What're you gonna be able to do first for her?

10. Y'know, I'll be honest, I'm not sure what they're looking for here. You've got someone who admits to drinking, acting like a drunk, smelling like a drunk, who is a chronic drunk...Yeah, it's an AMS workup, but unless they respond that they're looking to get some help and want to stop drinking (in which case work them up, get them some benzo's, and contact addiction services), I have a feeling the risk:benefit ratio is in favor of them leaving to get more booze when they start shaking. Of all those answers there, I would pick fsg because it's cheap, will change management, and is relatively non-invasive. If I were suspecting Wernicke or Korsakoff, I'd also get them some thiamine +/- CT. The short answer? you may be right or you may be wrong I dunno.

 

[spyderdoc]

1. 70 y/o comes to ED with a ST elevation inferior wall MI with classic symptoms of MI, etc, he is on vasotec and ASA 81mg.

Vital: 220/110, HR-105, resp-22, 02 sat 96

diaphoretic clutching chest, RRR, +S4, clear lungs no pulm edema.

The ED doctor gave ASA 163mg, Nitro SL 1/150 q 5 minutes X3, Lopressor 5mg IV, morphine 4mg

this should be followed by:

A. 1/2" nitropaste ACW
B. Emergent Cardiac Cath with placement of LAD stent
C. Plavix 325mg PO
D. Reopro as definitive re-perfusion strategy
E. Retavase

I am thinking Retavase, a clot buster as with STEMI, he needs busting or cardiac cath. Could it be choice B though?

I think this is a bit of a trick question. Cath is definitely preferred if available, but in the question part, it is noted that he is having acute IWMI, which is RCA territory, so taking him for emergent LAD stent is not technically the right answer......No Plavix for STEMI in case they need rescue CABG (and dose is wrong anyhow). No nitropaste to chest wall (start drip). Reopro is not a definitive re-perfusion strategy in STEMI.....So I guess since they named the wrong artery to stent (LAD instead of RCA), I would be inclined to mark thrombolytics in this particular question......

 

[sweetlenovo88]

I think this is a bit of a trick question. Cath is definitely preferred if available, but in the question part, it is noted that he is having acute IWMI, which is RCA territory, so taking him for emergent LAD stent is not technically the right answer......No Plavix for STEMI in case they need rescue CABG (and dose is wrong anyhow). No nitropaste to chest wall (start drip). Reopro is not a definitive re-perfusion strategy in STEMI.....So I guess since they named the wrong artery to stent (LAD instead of RCA), I would be inclined to mark thrombolytics in this particular question......

thanks for the crystal clear answer.

 

[southerndoc]

I think this is a bit of a trick question. Cath is definitely preferred if available, but in the question part, it is noted that he is having acute IWMI, which is RCA territory, so taking him for emergent LAD stent is not technically the right answer......No Plavix for STEMI in case they need rescue CABG (and dose is wrong anyhow). No nitropaste to chest wall (start drip). Reopro is not a definitive re-perfusion strategy in STEMI.....So I guess since they named the wrong artery to stent (LAD instead of RCA), I would be inclined to mark thrombolytics in this particular question......

FWIW, EMS now gives Plavix in my area for C-PORT patients. Not sure why the cardiologists wanted this. We don't give Plavix in the ER for our C-PORT patients.