Category: Mock Oral Boards (Page 1 of 4)

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Introduction:

You are working at Clerkship General when the next chart is handed to you. It’s a 35-year-old female with a chief complaint of dizziness and fatigue. She is here accompanied by her husband.

Initial Vitals:

HR: 118

BP: 150/91

Temp: 100.4F

RR: 20

O2: 99% Room Air

Critical Actions:

1. Check pregnancy test
2. Check hemolysis labs
3. Diagnose TTP
4. Consult hematology
5. Initiate treatment for TTP

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You are working at Clerkship General when you hear a woman screaming from triage… It’s baby time!

Initial Vitals:

HR: 120

RR: Shallow

O2: 58%

Critical Actions:

1. Place neonate in warmer
2. Administer positive pressure ventilation
3. Obtain pre-ductal pulse ox
4. Check blood glucose
5. Place umbilical vein catheter
6. Administer dextrose

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Transcript coming soon!

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You are working at Clerkship General when the nurse comes up to you and says, “Hey doc, EMS dropped off this guy named Randy from the memory care unit at the nursing home down the street. He’s in the hall bed outside of room 7. EMS says he’s here for confusion, we will get him in a room once we can get one clean.

Initial Vitals:

HR: 118

BP: 109/55

Temp: 102.5 F

RR: 22

O2: 99% Room Air

Critical Actions:

1. Check a blood glucose
2. Obtain a full set of vitals
3. Diagnose necrotizing soft tissue infection
4. Consult surgery before a CT scan
5. Correct antibiotic coverage

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Episode summary coming soon!

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You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General, we are bringing you a 3 year old female with complaints of altered mental status. We are pulling in now.”

Initial Vitals:

HR: 129

BP: 98/66

Temp: 99.7F

RR: 35

O2: 99% Room Air

Critical Actions:

1. Check blood glucose
2. Check ingestion labs
3. Start bicarbonate drip
4. Call nephrology
5. Check venous blood gas

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Guillain-Barre Syndrome (GBS) – Autoimmune polyneuropathy that results in widespread demylination of peripheral nerves

Typically occur 1 week after a triggering infection

Paresthesias/Neuropathic Pain -> Ascending symmetric paralysis -> Respiratory Failure

Major Diagnostic Criteria

1. Progressive limb weakness in multiple limbs that is relatively symmetric
2. Diminished/Absent deep tendon reflexes in affected limbs
3. No alternative diagnosis
4. CSF studies have false-negatives – May see albuminocytologic dissociation (Elevated protein with normal cell counts)

Treatment – IVIG and monitor respiratory status

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Critical Actions:

1. Treat the Patient’s Pain
2. Perform a detailed neurologic exam (including reflexes)
3. Perform LP
4. Administer IVIG
5. Check NIF or FVC and intubate prior to transfer

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Orbital Compartment Syndrome – needs to be diagnosed CLINICALLY

On exam, LOOK for: Proptosis, Ophthalmoplegia, Afferent Pupillary Defect, Vision Loss

On exam, FEEL for: Rock hard globe, tense eyelids, resistance to retropulsion

IOP > 40 means immediate canthotomy is indicated!

Don’t perform if open globe is present

Lateral Canthotomy Procedure: Anesthetize, Devascularize, Canthotomy, Cantholysis (inferior crus first)

Paperclip Eyelid Retractors

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You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen.

Initial Vitals:

HR: 101

BP: 138/85

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

1. Diagnose Retrobulbar Hematoma
2. Diagnose Subdural Hematoma
3. Reverse Anticoagulation
4. Perform a Lateral Canthotomy Procedure
5. Administer Tetanus Shot
6. Elevate the Head of Bed

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Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.  

The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags. 

Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  

Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment). 

Remember that time is brain, so move fast! 

AAEM tPA Infographic

AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

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You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.”

Initial Vitals:

HR: 51

BP: 201/98

Temp: 98.0F

RR: 18

O2: 99% (Room Air)

Critical Actions:

1. Check a Blood Glucose
2. Activate a Stroke Alert
3. Assess Contraindications to tPA
4. Consent for tPA
5. Transfer via Air for Thrombectomy

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• Common during the first year of life as well as during puberty
• Presents with nausea/vomiting, abdominal pain, and/or testicular pain
• ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)
• Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex
• Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound
• Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US
• Attempt manual detorsion if there will be a significant delay to surgery

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You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting

Initial Vitals:

HR: 119

BP: 104/63

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

1. Finger Stick Blood Glucose
2. Treat Patient’s Pain
3. Diagnose Testicular Torsion
4. Immediate Urology Consult
5. Perform Manual Detorsion

References:

Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

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Phase One: CNS

• Ataxia, Slurred Speech, Confusion, N/V, Seizures

Phase Two: Cardiopulmonary

• CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS

Phase Three: Renal

• Flank pain, Hematuria, Oliguria, Renal Failure

Diagnosis:

• HIGH INDEX OF SUSPICION
• Ethylene Glycol Serum Level
• Elevated Osmolar Gap
• Serial Anion Gap Measurements

Treatment:

• Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid
• Hemodialysis
• Consider Bicarb drip, pyridoxine, and thiamine

Further Reading:

EMCrit Toxic Alcohols

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You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again

Initial Vitals:

HR: 116

BP: 150/70

Temp: 98.8

RR: 26

O2: 85% (Room Air)

Critical Actions:

1. Recognize Hypoxemia
2. Diagnose Toxic Alcohol Ingestion
3. Consult Nephrology Emergent Dialysis
4. Administer Fomepizole
5. Workup Anion Gap Metabolic Acidosis

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Hypertensive Emergencies of Pregnancy

PreEclampsia, Eclampsia, HELLP syndrome

Diagnosis: BP >140/90 plus end organ dysfunction

• Acute Kidney Injury
• Proteinuria
• Thrombocytopenia
• Transaminitis
• Hemolysis
• Pulmonary Edema
• Cerebral Edema / Hemorrhage
• Headache refractory to tylenol
• Visual Changes
• RUQ Pain not attributable to another diagnosis

Treatment

• Loading Dose: IV Magnesium 4-6g over 20-30 min OR 5g IM in each buttock
• Maintenance Dose: 1g/hr IV
• Antihypertensives (goal 20% reduction): Labetalol, Nicardipine, Hydralazine
• Delivery of fetus and placenta

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You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache.

Initial Vitals:

HR: 56

BP: 172/93

Temp: 98.8F

RR: 18

O2: 97%

Critical Actions:

1. Check a Blood Glucose
2. Diagnose Preecclampsia/Ecclampsia
3. Administer Magnesium
4. Treat the Hypertension
5. Discuss with OBGYN and Admit

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Diagnosing PE:

Step 1: Consciously consider the diagnosis

Step 2: Risk Stratify into low, intermediate, and high risk

Step 3: Choose appropriate testing based on pre-test probability

Classification of PE

1. High Risk/Massive PE: Hemodynamic Instability
2. Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+
3. Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2)

Treatment of PE

1. High Risk/Massive PE: Thrombolytics and often thrombectomy
2. Intermediate Risk/Submassive PE: Heparin and sometimes intervention
3. Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

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You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.”

Initial Vitals:

HR: 122

BP: 75/40

Temp: 100.1

RR: 24

O2: 74%

Critical Actions:

1. Obtain full set of vital signs
2. Treat the patient’s pain
3. Diagnose PE without imaging
4. Stabilize patient prior to imaging
5. Transfer the patient for thrombectomy