Category: Mock Oral Boards (Page 1 of 2)

Round 21 (MW) Geriatric Fall

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

Round 20 (MW) Stroke Symptoms

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

Round 19 (MW) Tummy Ache in Child with Diabetes

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.

Round 18 (MW) Drunk Man Wants Pizza

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

Round 17 (MW) Headache

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

Round 15 (MW) MVA

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

Round 14 (MW) Leg Pain

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)

Asthma (Deep Dive R13 MW)

  • 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)

Round 13 (MW) Respiratory Distress

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:

HR: 123

BP: 142/78

Temp: Unknown

RR: 36

O2: 97% (NonRebreather)

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

Organophosphate Poisoning (Deep Dive R12 MW)

Introduction

  • Used as pesticides
  • Used as weapons (nerve agents)
    • Sarin Gas, VX Gas, Novichok
  • Transdermal, Inhalation, Ingestion

Clinical Presentation

  • Muscarinic Activation (Dumbels Mnemonic)
    • Defication
    • Urination
    • Myosis
    • Bradycardia, Bronchospasm, and Bronchorrhea
      • “The Killer B’s”
    • Emesis
    • Lacrimation
    • Salivation and Sweating
  • Nicotinic Activation
    • Muscle weakness and paralysis
  • CNS Activation
    • Respiratory Depression
    • Altered Mental Status
    • Seizures

Treatment

  • Atropine
    • Reverses Dumbels
    • Keep giving and doubling the dose until brochorrhea and bradycardia resolve
  • Pralidoxime
    • Only works before ‘aging’ occurs
  • Diazepam
    • Stops the seizures

Round 11 (MW) Chest Pain

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:

BP: 156/97

HR: 110

RR: 22

O2: 98% (Room Air)

Temp: 98.8F

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)

Round 10 (MW) Agitation

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:

BP: 192/105

HR: 134

RR: 22

O2: 99% (Room Air)

Temp: 98.8 F

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

Round 9 (MW) Altered Mental Status

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

Priapism (Deep Dive R8 MW)

  • 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

Round 8 (MW) Groin Pain

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

Round 24 (Altered Mental Status)

CAUTION: THESE NOTES CONTAIN SPOILERS!!

Case Introduction

You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive.

Initial Vitals

  • Temp 98.0F
  • HR 97
  • RR 16
  • BP 120/80
  • O2 98%

Critical Actions

  • Obtain collateral history from EMS/friends
  • Administer Naloxone as needed for respiratory depression
  • Obtain 0-hour and 4-hour acetaminophen levels
  • Administer N-acetyl-cystine
  • Obtain psychiatry consult for suicidal ideation

Further Reading

Acetaminophen Toxicity (EMCrit)

Torsades de Pointes (Deep Dive R21)

Torsades de Pointes (TdP)

A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired.

Treatment

  1. Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in real life, the defibrillator often isn’t able to “sync” with TdP, forcing you to perform unsynchronized cardioversion (aka defibrillation).
  2. IV Magnesium – treats and prevents TdP, even when magnesium levels are normal
  3. Overdrive Pacing – by preventing bradycardia, we help prevent TdP (bradycardia prolongs the QT interval).
    • Electrical Overdrive Pacing – transcutaneous or transvenous pacemaker
    • Chemical Overdrive Pacing – beta agonist therapy (isoproterenol)
  4. Lidocaine – anti-arrhythmic therapy that does not prolong QTc.
  5. Fix underlying cause – congenital long QT syndrome, hypokalemia, hypocalcemia, medication induced (psych meds, anti-emetics, methadone, fluoroquinolones, many more)

Defibrillation and IV Magnesium are used for patients who are ACTIVELY in TdP. Once you shock/mag them into a stable rhythm, you can use Overdrive Pacing / Lidocaine / Treat Underlying Cause to PREVENT them from going back into TdP.

Round 20 (Dehydration)

CAUTION: THESE NOTES CONTAIN SPOILERS!!!

Case Introduction

You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration.

Initial Vitals

  • Temp 100.4F
  • HR 132
  • RR 22
  • BP 98/64
  • O2 98%

Critical Actions

  • Identify key historical findings (fever >= 5 days)
  • Identify abnormal physical exam findings (Conjunctivitis, Rash, Adenopathy, Strawberry Tongue)
  • Diagnose Kawasaki Disease Clinically
  • Administer Aspirin
  • Administer IVIG

Final Diagnosis

Kawasaki Disease

Tips and Tricks

  • Remember the CRASH & BURN mnemonic
  • Always have a high index of suspicion for this diagnosis
  • Remember the diagnosis is CLINICAL!

Further Reading

EMDocs – Kawasaki Disease

Beta Blocker Overdose (Deep Dive R19)

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine

Treatment of Beta Blocker OD

  1. Activated Charcoal – Only if ingestion time was <1 hour ago, and only if patient is protecting their airway (or intubated).  

2. Glucagon – the best answer for the exam, unlikely to work in real life

3. Epinephrine Drip

4. Calcium 

5. High Dose Insulin Therapy

Round 19 (Bradycardia)

CAUTION: THESE NOTES CONTAIN SPOILERS!!!

Case Introduction

You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS.

Initial Vitals

  • Temp 98.0F
  • HR 43
  • RR 18
  • BP 60/40
  • O2 98%

Critical Actions

  • Diagnose the etiology for the bradycardia (BB overdose)
  • Administer Atropine
  • Administer Glucagon
  • Administer Epinephrine drip
  • Attempt transcutaneous/transvenous pacing
  • Administer high-dose Insulin therapy

Final Diagnosis

Beta Blocker Overdose

Tips and Tricks

  • Keep in mind the broad differential for severe bradycardia – ischemia, ingestion, electrolyte abnormalities, intrinsic arrhythmia/heart block, hypothyroidism, hypothermia, hypoglycemia, hypoxia, increased intracranial pressure, neurogenic shock.

Further Reading

High Dose Insulin Therapy (EMCRIT)

Low and Slow Poisoning (EMCASES)

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