Category: Mock Oral Boards (Page 2 of 4)

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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

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Shock – A state of deranged physiology characterized by systemic, widespread hypoperfusion

• Hypovolemic Shock
  • Hemorrhage
  • Volume Loss (vomiting/diarrhea, dehydration)
• Cardiogenic Shock
  • ACS, Myocarditis, CHF, Valve failure, Endocarditis, etc
• Obstructive Shock
  • Massive PE, Tension Pneumothorax, Cardiac Tamponade
• Distributive Shock
  • SIRS (Septic Shock, Pancreatitis, Severe Burns)
  • Anaphylactic Shock
  • Neurogenic Shock
  • Adrenal Crisis

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You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision”

Initial Vitals:

HR: 65

BP: 88/50

Temp: 97.0F

RR: 20

O2: 96% Room Air

Critical Actions:

1. Apply Cervical Collar
2. Treat the Patient’s Pain
3. Give Antibiotics for Open Fracture
4. Identify and Prioritize Etiologies of Shock in Trauma
5. Start Vasopressors for Neurogenic Shock

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• Differential
  • Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter
  • Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors
• Work-up
  • XRay
  • Labs to evaluate for septic arthritis – CBC BMP ESR CRP
• Kocher Criteria
  • Non-weight bearing
  • Fever >38.5C
  • ESR >40
  • WBC >12
• Kocher Criteria Statistics
  • 0 points: 0.2% (or 2% in prospective studies)
  • 1 point: 3% (or 9% in prospective studies)
  • 2 points: 40%
  • 3 points:93%
  • 4 points: 99%
• Septic Arthritis DX
  • >50,000 WBC
    • Age 0-3mo : group B strep
    • Age 3mo – 12 years: Staph Aureus
    • Age 12-18 years: Gonorrhea
    • Sickle Cell Disease: Salmonella

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You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury.

Initial Vitals:

HR: 112

BP: 97/67

Temp: 99.2F

RR: 20

O2: 97% Room Air

Critical Actions:

1. Consider Non-Accidental Trauma
2. Evaluate for Septic Arthritis
3. Treat the Childs Pain
4. Diagnose Lyme Disease
5. Prescribe Antibiotics (Avoid Doxycycline)

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• Focused Physical Exam
  • Tachypnea and Hypoxemia
  • Able to speak in complete sentences
  • Accessory muscle use/retractions
  • Moving air or quiet on auscultation
• Basic Treatment Algorithm
  • Albuterol Inhaler
  • Albuterol/Ipratropium Nebulized (Duoneb)
  • Steroids
  • IV Magnesium
  • Non Invasive Ventilation (CPAP or BiPAP)
    • Decreases Work of Breathing
  • Epinepherine
• Less Common Treatments
  • Benzodiazepines
  • Ketamine
  • Heliox
• Intubation (Last resort)
  • Use a large ETT (8.0)
  • Increase the Expiratory Time
• “Permissive Hypercapnea”
  • Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK
• Air Trapping
  • Results in decreased preload, obstructive shock and pneumothorax
  • Suspect with high airway pressures and when waveform doesn’t return to zero (see media)
  • Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air
• Ventilator Settings
  • Decrease the respiratory rate (ex 10)
  • Increase the tidal volume (although some hypercapnia is permitted)
  • Increase I:E ratio (1:4 or greater)

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You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes”

Initial Vitals:

Critical Actions:

1. Give Albuterol, Steroids, and Magnesium
2. Give either Epinephrine or Terbutaline
3. Post Intubation Checklist: Sedation, Tubes, and Xray
4. Choosing Appropriate Vent Settings
5. Allow permissive hypercapnia

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The 6 STEMI Equivalents:

1. Posterior MI
   • ST Depression V2/V3 (or STE in V7-V9)
2. Right Ventricular MI
   • STE V1 associated with inferior MI ; or STE V4R-V6R
3. Wellens Syndrome
   • Type A: Biphasic T-waves V2/3
   • Type B: Deep Symmetric T-wave Inversion V2/V3
4. De Winter’s T Wave
   • ST Depression with a large, symmetric, upright T wave
5. STE avR with diffuse ST-Depression
   • Usually a strain pattern due to underlying pathology, in correct clinical context can represent a left main or proximal LAD coronary occlusion
6. Modified Sgarbossa Criteria in LBBB
   • Concordant STE in any lead
   • Concordant ST Depression in V1-V3
   • Excessive Discordance (ST/S ratio >0.25)

Other atypical ischemic EKG findings:

1. Isolated TWI in avL – early sign of inferior MI
2. Hyperacute TWave
3. NTTV1 (New Tall T-wave in V1)

Further Reading (see photos in the article):

ECG Diagnosis of Life-Threatening STEMI Equivalent’s: Journal of the American College of Cardiology

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You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain.

Initial Vitals:

Critical Actions:

1. Give Aspirin, Nitroglycerin, and Heparin
2. Identify Posterior STEMI
3. Assess for Thrombolytic Contraindications and Consent
4. Transfer for PCI
5. Diagnose Accelerated Idioventricular Rhythm (AIVR)

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1. The MILDLY agitated patient : verbal de-escalation or PO benzo/antipsychotic
2. The MODERATELY agitated patient : IM benzo/antipsychotic
3. The SEVERELY agitated patient : IM Ketamine 5mg/kg

Consider removing the terminology “Agitated Delirium” from your vocabulary, as there is significant racial bias behind this term.

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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 an agitated and combative 30 year old male, we’ll see you in 5 minutes.”

Initial Vitals:

Critical Actions:

1. Administer Sedation for Patient/Staff Safety
2. Intubate the Patient and Obtain Chest Xray
3. Diagnose Intracranial Hemorrhage
4. Treat Patients Hypertension
5. Diagnose Rhabdomyolysis and Give Fluids

Dangerous Actions:

1. Giving Succinylcholine
2. Giving B-Blocker (Controversial)

Check Out:

Procrastinators Guide to Emergency Medicine

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Indications for LP: CNS infection, SAH, Guillian Barree, IIH

Contraindications for LP: Space occupying lesion with mass effect ; severe thrombocytopenia and coagulopathy; cellulitis over LP site or concern for epidural abscess ; traumatic injury to spine

Complications for LP: Post LP Headache, spinal hematoma, brainstem herniation

Technique for LP: Positioning is everything.  Use US if necessary.  Check for CSF early and often.  

When to CT before LP?: AMS; focal neuro deficit; new onset seizures, known CNS lesions; immunosuppression; papilledema 

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You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…”

Initial Vitals:

BP: 68/40

HR: 128

RR: 22

O2: 99% (Room Air)

Temp: 103.5F

Critical Actions:

1. Diagnose Meningitis and Perform Lumbar Puncture
2. Give Empiric Antibiotics
3. Treat Septic Shock
4. Give Steroids
5. Give Prophylaxis to Close Contacts

Check Out:

Pearson Ravitz Webinar – “Disability Insurance 101 for Residents”

https://us06web.zoom.us/webinar/register/1416806357023/WN_ziYRNc0kT8yAyOOJZ-Xk2g

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• Two Types of Priapism
  • Low Flow “Ischemic” (Most Common >95% of Cases)
    • Urologic Emergency
      • Results in Erectile Dysfunction
    • Painful
    • Common Etiologies
      • Idiopathic
      • Erectile Dysfunction Drugs (ex. sildenafil)
      • Sickle Cell Disease
      • Trazodone (“TrazoBONE”)
      • Cocaine/Meth
  • High Flow
    • Caused by Trauma and AV Fistulas
• Management
  • Analgesia
    • Dorsal Penile Nerve Block
  • Aspiration
    • Can intermittently irrigate with normal saline to dilute the clot
  • Injection
    • Phenylepherine
      • Recommend cardiac monitor

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You are working at Clerkship General on an overnight shift when the next chart is handed to you. It’s a 35 year old male with a chief complaint of groin pain.

Initial Vitals:

BP: 150/90

HR: 107

RR: 20

O2: 99% (Room Air)

Temp: 98.0F

Critical Actions:

1. Diagnose Ischemic/Low Flow Priapism
2. Perform Penile Nerve Block
3. Aspirate Blood and Irrigate with Saline
4. Inject Intracavernous Phenylepherine
5. Diagnose and Treat Ventricular Tachycardia

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Obtain IV Access – get two large bore IVs (18g or larger)

Resuscitate – un-crossmatched blood at first, don’t forget type and screen!

Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated

Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB

Consult – GI if unstable / if variceal bleeding

Disposition – based on amount of bleeding and hemodynamic stability

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You are working at Clerkship General when the charge nurse grabs you – “hey we got a real sick one, a 57yo Male who I just put in the resuscitation bay, he is vomiting blood”.

Initial Vitals:
BP: 77/34

HR: 135

RR: 24

O2%: 95%

Temp: 98.8F

Critical Actions:

1. Place two large bore IVs
2. Transfuse emergency uncross matched blood
3. Administer IV Pantoprazole
4. Administer IV Ceftriaxone and IV Octreotide
5. Consult GI

Further Reading: EMDocs – GI Bleed

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Aortic Dissection – when there is a tear in the intima layer of the aorta and the blood dissects the intima away from the media creating a false lumen in the aorta

1. Historical Features
   • Be VERY suspicious with ABRUPT onset of chest/back pain that reaches MAXIMAL SEVERITY immediately after onset of pain.
   • Chest pain or Back pain with a neurologic deficit
   • Pain “above and below the diaphragm”
2. Diagnosis
   • CT Angiography of chest abdomen and pelvis is gold standard
   • Can see widened mediastinum on CXR or dissection flap on POCUS
3. Treatment
   • Pain control first
   • Heart rate control second (goal <60bpm, use esmolol)
   • Blood pressure control third (goal 100-120SBP, use nicardipine/clevidipine)
   • CT Surgery consult (should go directly to OR with a Type A dissection)
   • Arterial Line placement

Further Reading:

Core EM – Aortic Dissection

LITFL – Aortic Dissection

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You are working at Clerkship General when the base command phone rings –

“Hey doc just wanted to give you a heads up on this stroke alert we’re bringing you – we have a 70yo M with sudden onset left arm numbness and weakness, last known well 2 hours ago, we’ll be there in about 5 minutes”

Initial Vital Signs:

HR 120

BP 180/90

RR 22

O2 97%

Temp 97.7F

Critical Actions:

1. Check a blood glucose

2. Diagnose Aortic Dissection

3. Give Esmolol first, titrate to HR<60

4. Give Nicardipine/Clevidipine second, titrate for SBP 100-120

5.   Consult cardiothoracic surgery for type A dissection

Further Reading:

EMCrit – Aortic Dissection