Episode 59: Emergency Medicine EOR – The Audio PANCE and PANRE Board Review Podcast

Answer: C. Hematoma of the orbit

Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma.

A. Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema, and epistaxis.
B. Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor.
D. Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis.

Blowout fractures are covered as part of the NCCPA EENT Content Blueprint which accounts for 9% of your exam.

Answer: D. Indomethacin

Indomethacin, a nonsteroidal anti-inflammatory medication, is the treatment of choice in a patient with acute pericarditis.

A. Pericardiocentesis is the treatment of choice in a patient with a pericardial effusion and cardiac tamponade, there is no evidence of either of these in this patient.
B. Nitroglycerin is indicated in the treatment of chest pain related to angina.
C. Percutaneous coronary intervention is the treatment of choice in a patient with an acute myocardial infarction.

Acute pericarditis is covered the NCCPA Cardiology Content Blueprint which accounts for 16% of your exam.

Answer: A. Atypical lymphocytes

The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus.

B. Hypersegmented neutrophils are seen in vitamin B12 deficiency.
C. Anemia, if seen in mononucleosis, is normocytic and normochromic.
D. Schistocytes are noted in hemolytic anemias.

Mononucleosis as part of the NCCPA Infectious Disease Content Blueprint which accounts for 3% of your exam.

Answer: D. Serum creatinine kinase

Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.

A. Although a drug screen may identify specific drugs, the results will not alter the care of this patient.
B. Urine dipstick is not sensitive for myoglobinuria.
C. This patient is at risk for myoglobinuria, and a complete blood count will not alter the treatment.

Answer: B. mycoplasma pneumonia.

The insidious onset of symptoms, the interstitial infiltrates on chest x-ray, and elevated cold hemagglutinin titer makes this diagnosis the most likely.

A. Most children with pulmonary tuberculosis are asymptomatic with few physical examination findings. The results of the diagnostic studies do not support tuberculosis as the most likely diagnosis.
C. The clinical presentation of bacterial pneumonia in children is variable, but usually involves fever of acute onset. The WBC count is also usually elevated, making this a less likely diagnosis.

Mycoplasma pneumonia is covered as part of the NCCPA Pulmonary Content Blueprint and accounts for 12% of the exam

Answer:  A. Extreme vulvar irritation 

Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous.

B. A firm painless ulcer is seen in syphilis.
C. Tender lymphadenopathy is associated with bacterial infections and is not a feature of candidal vulvovaginitis.
D. Purulent discharge is noted in gonorrhea.

Vaginitis is covered as part of the NCCPA Reproductive System Content Blueprint and accounts for 8% of the exam

Answer: B. Inferior wall myocardial infarction 

Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST-segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.

A. A patient with aortic dissection will complain of tearing, ripping pain. EKG is often normal but may reveal left ventricular strain pattern.
C. Acute pericarditis presents with atypical chest pain and diffuse ST-segment elevation.
D. Pulmonary embolism often presents with either no EKG changes or sinus tachycardia. Classically described, rarely seen findings include a large S wave in lead I, a Q wave with T wave inversion in lead III, ST-segment depression in lead II, T wave inversion in leads V1-V4 and a transient right bundle branch block.

Acute myocardial infarction is covered as part of the NCCPA Cardiology Content Blueprint and accounts for 16% of the exam

Answer: C. Coxsackievirus

Coxsackievirus presents with small grayish vesicles and punched-out ulcers in the posterior pharynx.

A. Epstein-Barr virus presents with enlarged tonsils with exudates and petechiae of the palate.
B. Group C Streptococcus presents with a red pharynx and enlarged tonsils with a yellow, blood tinged exudates
D. Neisseria gonorrhea of the pharynx may be asymptomatic

Coxsackievirus is covered as part of the NCCPA Dermatology Content Blueprint which accounts for 5% of your exam.

Answer: B. Risperidone (Risperdal)

There are numerous options used in the management of acute psychosis including benzodiazepines and antipsychotics such as haloperidol (first generation – typical -antipsychotic), risperidone or aripiprazole (second Generation – atypical – antipsychotics). Antidepressants and lithium have no benefit in the treatment of acute psychosis.

Schizophrenia is covered as part of the NCCPA psychiatry Content Blueprint which accounts for 6% of your exam.

Answer: B. Monteggia fracture

A Monteggia fracture is a fracture of the proximal ulna with anterior dislocation of the radial head.

A. A Galeazzi fracture is a fracture along the length of the radius with an injury to the distal radioulnar joint.
C. A Colles’ fracture is a fracture of the distal radius with dorsal displacement of the radial head.
D. A Smith fracture is a fracture of the distal radius with a ventral displacement of the radial head.

Monteggia fracture is covered as part of the NCCPA Musculoskeletal Content Blueprint which accounts for 10% of your exam.