Emergency Medicine

Emergency medicine books

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Chest Pain and Cardiac
Dysrhythmias
Questions
1. A 59-year-old man presents to the emergency department (ED) complaining
of new-onset chest pain that radiates to his left arm. He has a history
of hypertension, hypercholesterolemia, and a 20-pack-year smoking
history. His electrocardiogram (ECG) is remarkable for T-wave inversions
in the lateral leads. Which of the following is the most appropriate next
step in management?
a. Give the patient two nitroglycerin tablets sublingually and observe if his chest
pain resolves.
b. Place the patient on a cardiac monitor, administer oxygen, and give aspirin.
c. Call the cardiac catheterization laboratory for immediate percutaneous intervention
(PCI).
d. Order a chest x-ray; administer aspirin, clopidogrel, and heparin.
e. Start a β-blocker immediately.
2. A 36-year-old woman presents to the ED with sudden onset of leftsided
chest pain and mild shortness of breath that began the night before.
She was able to fall asleep without difficulty but woke up in the morning
with persistent pain that is worsened upon taking a deep breath. She
walked up the stairs at home and became very short of breath, which made
her come to the ED. Two weeks ago, she took a 7-hour flight from Europe
and since then has left-sided calf pain and swelling. What is the most common
ECG finding for this patient’s presentation?
a. S1Q3T3 pattern
b. Atrial fibrillation
c. Right-axis deviation
d. Right-atrial enlargement
e. Tachycardia or nonspecific ST-T–wave changes
1
3. A 51-year-old man with a long history of hypertension presents to the
ED complaining of intermittent chest palpitations lasting for a week. He
denies chest pain, shortness of breath, nausea, and vomiting. He recalls
feeling similar episodes of palpitations a few months ago but they resolved.
His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 130 beats per
minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation
is 99% on room air. An ECG is seen below. Which of the following is
the most appropriate next step in management?

Emergency Medicine books
a. Sedate patient for immediate synchronized cardioversion with 100 Joules
b. Prepare patient for the cardiac catheterization laboratory
c. Administer Coumadin
d. Administer amiodarone
e. Administer diltiazem
4. A 54-year-old woman presents to the ED because of a change in behavior
at home. For the past 3 years she has end-stage renal disease requiring
dialysis. Her daughter states that the patient has been increasingly tired and
occasionally confused for the past 3 days and has not been eating her usual
diet. On examination, the patient is alert and oriented to person only. The
remainder of her examination is normal. An initial 12-lead ECG is performed
as seen below. Which of the following electrolyte abnormalities best
explains these findings?
Emergency Medicine books
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypercalcemia
e. Hyponatremia
` A 29-year-old tall, thin man presents to the ED after feeling short of breath
for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR
is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is
98% on room air. Cardiac, lung, and abdominal examinations are normal. An
ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small
right-sided (less than 10% of the hemithorax) spontaneous pneumothorax.
A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which
of the following is the most appropriate next step in management?
a. Discharge the patient with follow-up in 24 hours
b. Perform needle decompression in the second intercostal space, midclavicular
line
c. Insert a 20F chest tube into right hemithorax
d. Observe for another 6 hours
e. Admit for pleurodesis
6. A 42-year-old man found vomiting in the street is brought to the ED by
emergency medical services (EMS). He has a known history of alcohol abuse
with multiple presentations for intoxication. Today, the patient complains of
acute onset, persistent chest pain associated with dysphagia, and pain upon
flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is
18 breaths per minute, and oxygen saturation is 97% on room air. As you
listen to his heart, you hear a crunching sound. His abdomen is soft with
mild epigastric tenderness. The ECG is sinus tachycardia without ST-T–wave
abnormalities. On chest x-ray, you note lateral displacement of the left mediastinal
pleural. What is the most likely diagnosis?
a. Aspiration pneumonia
b. Acute pancreatitis
c. Pericarditis
d. Esophageal perforation
e. Aortic dissection

7. A 65-year-old man with a history of chronic hypertension presents to the
ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is
205/110 mm Hg, HR is 90 beats per minute, RR is 20 breaths per minute,
and oxygen saturation is 97% on room air. He appears apprehensive. On
cardiac examination you hear a diastolic murmur at the right sternal border.
A chest x-ray reveals a widened mediastinum. Which of the following is the
preferred study of choice to diagnose this patient’s condition?
a. Electrocardiogram (ECG)
b. Transthoracic echocardiography (TTE)
c. Transesophageal echocardiography (TEE)
d. Computed tomography (CT) scan
e. Magnetic resonance imaging (MRI)
8. A 47-year-old man with a history of hypertension presents to the ED
complaining of continuous left-sided chest pain that began while snorting
cocaine 1 hour ago. The patient states he never experienced chest pain in
the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per
minute, RR is 18 breaths per minute, and oxygen saturation is 98% on
room air. The patient states that the only medication he takes is alprazolam
to “calm his nerves.” Which of the following medications is contraindicated
in this patient?
a. Metoprolol
b. Diltiazem
c. Aspirin
d. Lorazepam
e. Nitroglycerin

9. A 32-year-old woman presents to the ED with a persistent fever of
101°F over the last 3 days. The patient states that she used to work as a
convenience store clerk but was fired 2 weeks ago. Since then, she has been
using drugs intravenously daily. Cardiac examination reveals a heart murmur.
Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph
reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal
white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%,
and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart
block. Which of the following is the most appropriate next step in management?
a. Obtain four sets of blood cultures, order a transthoracic echocardiogram (TTE),
and start antibiotic treatment.
b. Order a monospot test and recommend that the patient refrain from vigorous
activities for 1 month.
c. Administer a nonsteroidal anti-inflammatory drug (NSAID) and inform the
patient she has pericarditis.
d. Administer isoniazid (INH) and report the patient to the Department of Health.
e. Order a Lyme antibody and begin antibiotic therapy.

10. A 61-year-old woman was on her way to the grocery store when she
started feeling chest pressure in the center of her chest. She became
diaphoretic and felt short of breath. On arrival to the ED by EMS, her BP is
130/70 mm Hg, HR is 76 beats per minute, and oxygen saturation is 98%
on room air. The nurse gives her an aspirin and an ECG is performed as
seen below. Which of the following best describes the location of this
patient’s myocardial infarction (MI)?

Emergency Medicine
a. Anteroseptal
b. Anterior
c. Lateral
d. Inferior
e. Posterior
11. A 31-year-old man who works for a moving company presents to the
ED because he thought he was having a heart attack. He does not smoke, and
jogs 3 days a week. His father died of a heart attack in his sixties. He
describes a gradual onset of chest pain that is worse with activity and resolves
when he is at rest. His HR is 68 beats per minute, BP is 120/70 mm Hg, and
RR is 14 breaths per minute. On examination, his lungs are clear and there is
no cardiac murmur. You palpate tenderness over the left sternal border at the
third and fourth rib. An ECG reveals sinus rhythm at a rate of 65. A chest
radiograph shows no infiltrates or pneumothorax. Which of the following is
the most appropriate next step in management?
a. Administer aspirin and send for a troponin.
b. Administer aspirin, clopidogrel, and heparin and admit for acute coronary
syndrome (ACS).
c. Administer ibuprofen and reassure the patient that he is not having a heart
attack.
d. Inject corticosteroid into the costochondral joint to reduce inflammation.
e. Observe the patient for 6 hours.
12. A 21-year-old woman presents to the ED complaining of lightheadedness.
Her symptoms appeared 45 minutes ago. She has no other symptoms
and is not on any medications. She has a medical history of mitral valve
prolapse. Her HR is 170 beats per minute and BP is 105/55 mm Hg. Physical
examination is unremarkable. After administering the appropriate medication,
her HR slows down and her symptoms resolve. You repeat a 12-lead
ECG that shows a rate of 89 beats per minute with a regular rhythm. The PR
interval measures 100 msec and there is a slurred upstroke of the QRS complex.
Based on this information, which of the following is the most likely
diagnosis?
a. Ventricular tachycardia
b. Atrial flutter with 3:1 block
c. Atrial fibrillation
d. Lown-Ganong-Levine (LGL) syndrome
e. Wolff-Parkinson-White (WPW) syndrome

13. A 55-year-old man presents to the ED with worsening weakness, muscle
cramps, and paresthesias. His past medical history is significant for hypertension
and diabetes. He smokes one pack of cigarettes per day. On examination,
the patient is alert and oriented and diffusely weak. An ECG is seen below.
Which of the following is the most important next step in management?
Emergency Medicine
a. Administer calcium gluconate.
b. Administer insulin and dextrose.
c. Administer aspirin and call the catheterization laboratory.
d. Order an emergent head CT scan and get a neurology consult.
e. Collect a sample of his urine to test for ketones.

14. While eating dinner, a 55-year-old man suddenly feels a piece of steak
“get stuck” in his stomach. In the ED, he complains of dysphagia, is drooling,
and occasionally retches. On examination, his BP is 130/80 mm Hg,
HR is 75 beats per minute, RR is 15 breaths per minute, and oxygen saturation
is 99% on room air. He appears in no respiratory distress. Chest x-ray
is negative for air under the diaphragm. Which of the following is the most
appropriate next step in management?

a. Administer 1-mg glucagon intravenously while arranging for endoscopy.
b. Administer a meat tenderizer such as papain to soften the food bolus.
c. Administer 10-mL syrup of ipecac to induce vomiting and dislodge the food bolus.
d. Perform the Heimlich maneuver until the food dislodges.
e. Call surgery consult to prepare for laparotomy.

15. A 59-year-old man presents to the ED with left-sided chest pain and
shortness of breath that began 2 hours prior to arrival. He states the pain is
pressure-like and radiates down his left arm. He is diaphoretic. His BP is
160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute.
ECG reveals 2-mm ST-segment elevation in leads I, aVL, V3 to V6. Which of
the following is an absolute contraindication to receiving thrombolytic
therapy?

a. Systolic BP greater than 180 mm Hg
b. Patient on Coumadin and aspirin
c. Total hip replacement 3 months ago
d. Peptic ulcer disease
e. Previous hemorrhagic stroke

16. A 67-year-old woman is brought to the ED by paramedics complaining
of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is
139 beats per minute, and RR is 20 breaths per minute. Her skin is cool
and she is diaphoretic. Her lung examination reveals bilateral crackles and
she is beginning to have chest pain. Her ECG shows a narrow complex
irregular rhythm with a rate in the 140s. Which of the following is the most
appropriate immediate treatment for this patient?

a. Diltiazem
b. Metoprolol
c. Digoxin
d. Coumadin
e. Synchronized cardioversion

17. A 61-year-old woman with a history of congestive heart failure (CHF)
is at a family picnic when she starts complaining of shortness of breath. Her
daughter brings her to the ED where she is found to have an oxygen saturation
of 85% on room air with rales halfway up both of her lung fields.
Her BP is 185/90 mm Hg and pulse rate is 101 beats per minute. On examination,
her jugular venous pressure (JVP) is 6 cm above the sternal angle.
There is lower extremity pitting edema. Which of the following is the most
appropriate first-line medication to lower cardiac preload?

a. Metoprolol
b. Morphine sulfate
c. Nitroprusside
d. Nitroglycerin
e. Oxygen

18. A 27-year-old man who is otherwise healthy presents to the ED with a
laceration on his thumb that he sustained while cutting a bagel. You irrigate
and repair the wound and are about to discharge the patient when he asks
you if he can receive an ECG. It is not busy in the ED so you perform the
ECG, as seen below. Which of the following is the most appropriate next
step in management?

Emergency Medicine
a. Admit the patient for placement of a pacemaker.
b. Admit the patient for a 24-hour observation period.
c. Administer aspirin and send cardiac biomarkers.
d. Repeat the ECG because of incorrect lead placement.
e. Discharge the patient home.

19. A 56-year-old woman with a history of ovarian cancer presents to the
ED with acute onset of right-sided chest pain, shortness of breath, and
dyspnea. Her BP is 131/75 mm Hg, HR is 101 beats per minute, respirations
are 18 breaths per minute, and oxygen saturation is 97% on room
air. You suspect this patient has a pulmonary embolism (PE). Which of the
following tests is most likely to be abnormal?

a. Arterial blood gas
b. Oxygen saturation
c. ECG
d. Chest radiograph
e. D-dimer

(Reproduced, with permission, from Tintinalli J, Kelen G, Stapczynski J. Emergency Medicine
A Comprehensive Study Guide. New York, NY: McGraw-Hill, 2004:193)

20. A 61-year-old woman with a history of diabetes and hypertension is
brought to the ED by her daughter. The patient states that she started feeling
short of breath approximately 12 hours ago and then noticed a tingling
sensation in the middle of her chest and became diaphoretic. An ECG
reveals ST-depression in leads II, III, and aVF. You believe that the patient
had a non–ST-elevation MI. Which of the following cardiac markers begins
to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and
returns to baseline in 7 to 10 days?
a. Myoglobin
b. Creatinine kinase (CK)
c. Creatinine kinase-MB (CK-MB)
d. Troponin I
e. Lactic dehydrogenase (LDH)

21. A 27-year-old man complains of chest palpitations and lightheadedness
for the past hour. He has no past medical history and is not taking any
medications. He drinks a beer occasionally on the weekend and does not
smoke cigarettes. His HR is 180 beats per minute, BP is 110/65 mm Hg, and
oxygen saturation is 99% on room air. An ECG reveals a HR of 180 beats per
minute with a QRS complex of 90 msec with a regular rhythm. There are no
discernable P waves. Which of the following is the most appropriate medication
to treat this dysrhythmia?
a. Digoxin
b. Lidocaine
c. Amiodarone
d. Adenosine
e. Bretylium

22. A 59-year-old man presents to the ED with left-sided chest pain and shortness
of breath that began 1 hour ago. Initial vital signs are BP 85/45 mm Hg,
HR 105 beats per minute, RR 20 breaths per minute, and oxygen saturation
94% on room air. An ECG is seen below. Which of the following is the most
appropriate definitive treatment?
Emergency Medicine
a. Administer metoprolol or diltiazem
b. Electrical cardioversion
c. Administer calcium gluconate
d. Thrombolytic therapy
e. Percutaneous angioplasty

23. A 55-year-old man presents to the ED at 2:00 AM with left-sided chest
pain that radiates down his left arm. He takes a β-blocker for hypertension,
a proton-pump inhibitor for gastroesophageal reflux disease, and an
antilipid agent for high cholesterol. He also took sildenafil the previous
night for erectile dysfunction. His BP is 130/70 mm Hg and HR is 77 beats
per minute. Which of the following medication is contraindicated in this
patient?

a. Aspirin
b. Unfractionated heparin
c. Nitroglycerin
d. Metoprolol
e. Morphine sulfate

24. A 31-year-old kindergarten teacher presents to the ED complaining of
acute onset substernal chest pain that is sharp in nature and radiates to her
back. The pain is worse when she is lying down on the stretcher and
improves when she sits up. She smokes cigarettes occasionally and was told
she has borderline diabetes. She denies any recent surgeries or long travel.
Her BP is 145/85 mm Hg, HR is 99 beats per minute, RR is 18 breaths per
minute, and temperature is 100.6°F. Examination of her chest reveals clear
lungs and a friction rub. Her abdomen is soft and nontender to palpation.
Her legs are not swollen. Chest radiography and echocardiography are
unremarkable. Her ECG is shown below. Which of the following is the most
appropriate next step in management?

Emergency Medicine
a. Anticoagulate and CT scan to evaluate for a PE
b. Prescribe a NSAID and discharge the patient
c. Aspirin, heparin, clopidogrel, and admit for ACS
d. Administer thrombolytics if the pain persists
e. Prescribe antibiotics and discharge the patient

25. A 71-year-old man is playing cards with some friends when he starts
to feel a pain in the left side of his chest. His fingers in the left hand become
numb and he feels short of breath. His wife calls the ambulance and he is
brought to the hospital. In the ED, an ECG is performed. Which of the following
best describes the order of ECG changes seen in an MI?

a. Hyperacute T wave, ST-segment elevation, Q wave
b. Q wave, ST-segment elevation, hyperacute T wave
c. Hyperacute T wave, Q wave, ST-segment elevation
d. ST-segment elevation, Q wave, hyperacute T wave
e. ST-segment elevation, hyperacute T wave, Q wave

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