RoshCast EM Board Review

  A champion is defined not by their wins but by how they can recover when they fall. -Serena Williams Welcome back to RoshCast for Episode 51! For those of you taking the initial certification exam, you’re at the home stretch. Remember to listen to this episode and old episodes as you get closer to the end for more review. Good luck from us at the RoshCast team! We have a great episode for you to get you prepped in your final studies! Question 1 A 46-year-old man presents with a progressive dull headache over the past 3 weeks. It is worse in the morning and with bending over or coughing. He denies any fever or congestion. For the last two days, he has had associated nausea and three episodes of vomiting. Which of the following characteristics seen on neuroimaging would be most consistent with a glioblastoma? A. Heterogenous mass with central necrosis B. Lack of enhancement with administration of contrast C. Presence of calcifications D. Well circumscribed margins Teaching Image Question 2 A 16-year-old African American boy presents with a scalp rash. On examination, it is a 5 x 5 cm boggy and thickened area of the right parietal cap with an overlying scaly and crusty plaque and hair loss. The lesion appears yellowish-green under a Wood’s lamp. What is the treatment of choice for this lesion? A. Clotrimazole ointment B. Ketoconazole shampoo C. Oral amphotericin B D. Oral griseofulvin Teaching Image Question 3 A 22-year old man recently diagnosed with schizophrenia presents to the ED with altered mental status. His blood pressure is 160/80 mm Hg, pulse 130 beats per minute, and temperature is 39.5°C. He is noted to be confused and diaphoretic. He has muscle rigidity and a tremor in his hands. What is the most likely diagnosis? A. Malignant hyperthermia B. Neuroleptic malignant syndrome C. Serotonin syndrome D. Tyramine reaction Teaching Image Question 4 A 21-year-old woman presents with painful urination. She has no vaginal discharge and is not sexually active. Which of the following is most sensitive for a urinary tract infection on urine dipstick testing? A. Bacteria B. Blood C. Leukocyte esterase D. Nitrites Teaching Image Question 5 Which of the following findings would be consistent with a diagnosis of Tetralogy of Fallot? A. Bounding pulses and a continuous machine-like murmur B. Decreased pulses in lower extremities C. Increased pulmonary vascular markings on chest radiography D. Loud, single second heart sound with a harsh systolic murmur Teaching Image Question 6 A 73-year-old man presents with painless vision loss in the right eye. Which of the following on funduscopic examination is most characteristic of central retinal vein occlusion? A. Cherry red fovea B. Pale retina C. Papilledema D. Retinal hemorrhages Teaching Image Teaching Image Teaching Image

  A hero is someone who has given his or her life to something bigger than oneself. -Joseph Campbell Welcome back to RoshCast for Episode 50! Wow!! We can’t believe we’re already at Episode 50. It’s been a real journey building this podcast from the original concept two years ago. And in the last year, we have seen some pretty big changes, including Megha joining the team. We are excited to see how RoshCast continues to evolve over the next fifty episodes and two years. None of this would be possible without you, our listeners. Your listenership and feedback is what drives us to keep delivering high quality content! We value every moment you give your attention to us, and we try our best to design the episode to maximize your learning. We have a pretty involved process for choosing questions to present to you and for how we manipulate and deliver the content before we get it to your ears. With that, let’s kick off to a great episode! Question 1 A 70-year-old woman with history of coronary artery disease, hypertension, and diabetes presents to the emergency department with chest pressure and shortness of breath. Her exam is notable for a new holosystolic murmur best heard over the midaxillary line as well as diffuse bilateral rales. Which of the following is most likely to be seen on this patient’s ECG? A. Biventricular tachycardia B. S1Q3T3 pattern C. ST-depressions in I, V6, and aVL without ST-elevations D. ST elevations in II, III, aVF Teaching Image Question 2 A 26-year-old woman with no medical history presents with bleeding gums after brushing her teeth for the last 3 days. Her complaint was preceded 2 weeks ago by a URI. Her examination is unremarkable except for oozing from the gums. Labs show a platelet count of 23,000. Which of the following is the most appropriate next step in management? A. IV immunoglobulin B. Platelet transfusion C. Steroids, IV immunoglobulin D. Steroids, IV immunoglobulin and platelet transfusion Teaching Image Question 3 Which of the following is most suggestive of measles infection? A. A prodrome of fever, lymphadenopathy, and conjunctivitis followed by a maculopapular rash that starts on the face and spreads to the trunk and limbs B. Diffuse maculopapular rash with white spots on the buccal mucosa C. High fever for 3 days followed by the appearance of a pink maculopapular rash after defervescence D. Presence of shallow ulcers on oral mucosa and vesicular lesions on the palms and soles Teaching Image Question 4 A 23-year-old man who has unprotected, receptive anal intercourse presents to the ED with two weeks of worsening rectal pain and dyschezia. On exam, he has numerous ulcers in the anorectal area and a crop of grouped vesicles containing clear fluid on an erythematous base. The surrounding skin shows no sign of cellulitis or abscess. Which of the following is the most appropriate next step? A. Refer the patient to a surgeon for operative intervention B. Send a serology test C. Send a Tzanck smear D. Treat with acyclovir Question 5 A 5-year-old boy with von Willebrand’s disease presents with persistent bleeding after he lost a tooth 4 hours ago. Vital signs are unremarkable. Physical exam reveals oozing at the site of the tooth which persists despite pressure. Which of the following is the most appropriate treatment? A. Desmopressin B. Factor VIII concentrate C. Fresh Frozen Plasma D. Vitamin K

  Life is like riding a bicycle. To keep your balance, you must keep moving. -Albert Einstein Welcome back to RoshCast for Episode 49! We have a lot of exciting material in this episode. Definitely don’t skip this one! For those taking the initial certification exam, it’s just around the corner. Go back and listen to old episodes and review. Question 1 A 14-year-old boy developed an itchy, painful, erythematous rash on his hands, forearms, and face about a day after hiking in nearby woods with some friends. Your exam shows linear erythematous papules over his forearms with similar swelling and erythema around his eyes (including eyelids), cheeks, and forehead. You suspect poison ivy that he reports he has had in the past. Which of the following is most likely to improve the course of his illness? A. Oral diphenhydramine every six hours B. Three week prednisone taper C. Topical 1% hydrocortisone three times daily D. Topical calamine lotion twice daily Teaching Image Question 2 Which of the following patients will benefit most from receiving tissue plasminogen activator for acute pulmonary embolism detected in the emergency department? A. 55-year-old man with a history of hypertension with vital signs showing HR 100, BP 80/40, R 24, and oxygen saturation 92% B. 55-year-old man with a history of hypertension with vital signs showing HR 145, BP 136/86, R 24, and oxygen saturation 92% C. 55-year-old woman with a history of hypertension and systemic lupus erythematosus with vital signs showing HR 100, BP 116/86, R 24, and oxygen saturation 85% D. 55-year-old woman with a history of hypertension with vital signs showing HR 110, BP 122/80, R 24, and oxygen saturation 92% with evidence of right ventricular dysfunction on echocardiogram Teaching Image Question 3 A 55-year-old woman presents to the Emergency Department unresponsive. She and her friend had finished eating sixty minutes earlier when she collapsed to the floor while talking. Which of the following foods is most likely the cause? A. Apricot kernels B. Fava beans C. Peanuts D. Poppy seeds Teaching Image Question 4 Which of the following is due to the intense thermal radiation seen in lightning strikes? A. Cataract formation B. Hypertension and tachycardia C. Mydriasis D. Tympanic membrane rupture Teaching Image Question 5 A 32-year-old woman with no past medical history presents to the emergency department with a four-day history of bloody diarrhea and abdominal cramping. She states that her boyfriend is having similar symptoms but did not want to come to the hospital. Their symptoms started two days after they shared a meal at their favorite fried chicken restaurant. The patient’s vital signs are 37.4℃, HR 89, BP 112/70, RR 17. Physical examination is significant for moist mucus membranes with brisk capillary refill and mild diffuse tenderness to palpation of the abdomen. Which of the following is the most appropriate management of this patient’s illness? A. Admit for IV azithromycin and rehydration B. Admit for IV rehydration and observation for resolution of diarrhea C. Discharge home with ciprofloxacin D. Discharge home with metronidazole Teaching Image...

  Success is not final, failure is not fatal: it is the courage to continue that counts. – Winston Churchill Welcome back to RoshCast for Episode 48! We’re going to jump right into questions this week. Remember to send us feedback for any changes you would like to see at roshcast@roshreview.com. Question 1 An 8-year-old previously healthy boy presents with back pain and fever for 4 days. He complains of pain in the low back, which is increased with bending or twisting. The pain radiates down into his left leg. He denies trauma. Physical exam is remarkable only for tenderness to palpation over the lumbar spine. What management is indicated A. Ibuprofen and follow up with his pediatrician B. MRI of the lumbar spine C. Plain radiographs of the lumbar spine D. Urinalysis Teaching Image Question 2 A 40-year-old man is brought to the Emergency Department after being assaulted during a bar fight. He has proptosis of the right eye with a measured intraocular pressure of 50 mm Hg. A lateral canthotomy is started. Once the Kelly clamp is released from the lateral canthus, what is the appropriate next step? A. Clamp the medial canthus B. Cut the inferior crus of the lateral canthal tendon C. Cut the superior crus of the lateral canthal tendon D. Recheck intraocular pressure Teaching Image Question 3 A 25-year-old man presents to the emergency department after sustaining burns to the hands, legs and chest after falling into a bonfire. On physical examination, there are partial thickness burns on the upper half of the anterior torso along with the bilateral palms of the hands, and bilateral anterior legs. He weighs 70 kg. You begin to initiate fluid resuscitation using the Parkland formula. How much fluid should this patient receive in the first eight hours? A. 10,640 mL B. 4,060 mL C. 5,320 mL D. 8,120 mL Teaching Image Question 4 A 64-year-old man presents to the emergency department with cough and shortness of breath that has progressively been worsening over the last several weeks. He has also been more fatigued and is unable to get around the house anymore. He denies fever and night sweats. He has a past medical history of hypertension and takes lisinopril daily. He is an immigrant from Argentina where he used to work as a miner. He denies tobacco use. What is the most likely diagnosis based on this chest radiograph? A. Histoplasmosis B. Miliary tuberculosis C. Pneumoconiosis D. Sarcoidosis Teaching Image Teaching Image Teaching Image Teaching Image Question 5 A 53-year-old man presents with numbness to his right hand for three to four months. He states that he has numbness with waking up in the morning, which gets better when he shakes his hands. The patient indicates numbness to his first, second, and third digits on the right hand. Which of the following tests is most sensitive for this diagnosis? A. Finkelstein’s test B. Median nerve compression test

  If you fell down yesterday, stand up today. -H. G. Wells Welcome back to RoshCast for Episode 47! Let’s kick off this episode with a review of Neisseria Meningitides. An important topic for clinical practice and personal safety. Neisseria meningitides is highly contagious and antibiotic prophylaxis is indicated for close contacts of an infected patient, including those in contact with secretions as well as members of the same household or daycare center. Healthcare workers with close contact with the patient’s secretions should also receive prophylaxis. There are three options for prophylaxis: * Rifampin is administered at a dose of 10mg/kg with a max dose of 600mg every 12 hours for four doses and this is 100% effective as far as we know. * Ceftriaxone 250mg IM can be given for one dose, which is 97-100% effective. * The least effective option is Ciprofloxacin 500mg PO for one dose, and that’s 90-95% effective. Even though rifampin is the most effective, be wary of its side effects which include turning secretions like tears and urine orange. Contact lens wearers should be warned of permanent staining. Teaching Image Now onto this week’s podcast Question 1 A 33-year-old woman presents to the ED with agitation and severe respiratory distress. She has been taking a significant amount of “pain medication” for low back pain according to her son. The patient is screaming about her “ears ringing.” Vital signs are BP 100/60 mm Hg, HR 140 beats per minute, RR 35 breaths per minute, and T 100.1°F. Which of the following complications is she at risk of developing? A. Hemodynamically significant lower gastrointestinal bleeding B. Increased intracranial pressure C. Noncardiogenic pulmonary edema D. Urinary retention requiring catheterization Teaching Image Question 2 Which of the following is associated with carbon monoxide poisoning? A. Bilateral basal ganglia hypodensities B. Elevated pH C. Low PO2 D. Odor of bitter almonds Teaching Image Question 3 A 62-year-old woman presents to the emergency department with dizziness. She describes the events as a spinning sensation that is worse with position changes. The dizziness is associated with hearing loss as well as tinnitus and vomiting. She notes It started three days ago and that she has had multiple episodes all lasting less than a day since that time. On physical examination, horizontal nystagmus is present as is decreased hearing on the left. The remainder of the ear and neurologic examination is within normal limits. A head CT and brain MRI are performed and are negative. Which of the following is the most likely diagnosis? A. Acoustic neuroma B. Labyrinthitis C. Meniere disease D. Vestibular neuritis Teaching Image Teaching Image Teaching Image Question 4 A 28-year old woman presents with several painful ulcers she has developed in the vaginal area. Examination reveals multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity.

  Only those who dare to fail greatly can ever achieve greatly. -Robert F. Kennedy Welcome back to RoshCast for Episode 46! Let’s kick off this episode with a rapid review of molluscum contagiosum. * Molloscum contagiosum is caused by poxvirus. It is seen in children, sexually active adults, and immunocompromised patients like those with HIV. The rash presents as painless, pearly, umbilicate papules, and it is spread by direct skin-to-skin contact. Children present with lesions on the face, trunk, and extremities, whereas sexually active adults can present with lesions in the genital regions, lower abdomen, and thighs. The rash tends to spare the palms and soles. Most patient will not require therapy with spontaneous resolution occurring in months. Those with extensive lesions may benefit from cryotherapy. HIV positive patients with a CD4 count less than 100 are at greater risk for developing molluscum contagiosum. Teaching Image Now onto this week’s podcast Question 1 Which of the following organisms is one of the most commonly implicated in the development of a lung abscess? A. Klebsiella pneumoniae B. Peptostreptococcus C. Staphylococcus aureus D. Streptococcus pneumoniae Teaching Image Question 2 A 26-year-old man presents to the ED after being hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head? A. A collection of blood layering in the basilar cisterns B. A crescent-shaped frontal hematoma crossing suture lines C. A lenticular-shaped hematoma in the temporal region D. An intraparenchymal hemorrhage within the frontal lobe Teaching Image Question 3 A 55-year old man who is taking several antihypertensive medications presents to the ED with nausea, vomiting, shortness of breath, and a rash after eating a home-cooked Thai meal at a friend’s house about 1 hour ago. The symptoms began within seconds of the first bite of his meal. Despite the patient being administered 2 doses of intramuscular epinephrine, diphenhydramine, dexamethasone, and crystalloid fluids, his blood pressure remains at 75/38 mm Hg. Which other medication should be considered in this patient? A. Cimetidine B. Glucagon C. Noreepinephrine D. Octreotide Question 4 A 36-year-old man presents to the ED after having a seizure. He has a folder full of medical records dating back 15 years. Several of the records are from other cities and states. It is now 11:00 pm on a Friday night. His primary care physician, neurologist, and psychiatrist are “out of town” and he believes that he needs to be admitted for the duration of the weekend. He has another episode in the ED and immediately following this he returns to his baseline. He is now awake and alert. You immediately draw a serum lactate and it is normal. Which of the following diagnoses should be strongly considered in this patient? A. Conversion disorder B. Hypochondriasis C. Munchausen syndrome D. Somatization Teaching Image Question 5 A 4-year-old is brought to the emergency department by his parents after they found him in the backyard shed choking and gagging. Before this event, he was otherwise healthy.

  There is only one corner of the universe you can be certain of improving, and that’s your own self. – Aldous Huxley Welcome back to RoshCast for Episode 45! Let’s start out with a review of rabies before getting to core content Q&A. * The most common wild reservoirs of rabies are raccoons, skunks, bats, foxes, and coyotes. Domestic animals like cats, dogs, and cattle can also get rabies. Rodents, reptiles, and birds on the other hand are not carriers and cannot transmit rabies. * One important factor in deciding if you get rabies postexposure prophylaxis is whether the animal can be found and held for observation. * The rabies post-exposure prophylaxis has two parts: the immunoglobulin and the vaccine. * When giving rabies post-exposure prophylaxis, inject the immunoglobulin into the wound and start the rabies vaccine series which the patient will receive on days 1, 3, 7, 14, and 28. Now onto this week’s podcast Question 1 Which of the following is true regarding acute respiratory distress syndrome? A. Define as PaO2:FiO2 > 300 B. Empiric corticosteroids should be given C. Positive end expiratory pressure should be increased with increases in FiO2 D. Tidal volume should be started at 10 mL/kg in intubated patients Teaching Image Question 2 A 35-year-old man presents to the ED after being assaulted in a bar fight. He has signs of significant facial trauma. On physical exam, you note a tooth fracture through the enamel and dentin but does not involve the pulp. Which of the following is the most appropriate next step in management of his dental injury?   A. Calcium hydroxide paste B. Extract the tooth C. Immediate dental consult D. Pencillin VK Teaching Image Question 3 A 62-year-old man presents with acute onset of chest pain with radiation to the shoulders and nausea while walking his dog. On examination, he is diaphoretic with heart rate 94 bpm, respiratory rate 20 bpm, blood pressure 92/59 mm Hg, and oxygen saturation 96% on room air. His ECG reveals 2 mm elevation in aVR. Occlusion of which coronary artery is most likely responsible for this patient’s presentation? A. Left anterior descending artery B. Left circumflex artery C. Left main coronary artery D. Right coronary artery Teaching Image Question 4 A 62-year-old man presents for evaluation of chest pain. Approximately three weeks ago the patient had a myocardial infarction with stent placement. Last evening he developed pleuritic chest pain and fever. He has no cough and does not feel short of breath. His ECG is shown above. Which of the following is the most likely diagnosis? A. Dressler syndrome B. Infarct pericarditis C. Left ventricular aneurysm D. ST segment elevation myocardial infarction Teaching Image Question 5 A 45-year-old man with a history of hypercholesterolemia presents with acute onset of anterior chest pain, nausea, and diaphoresis. His ECG is distinct for upsloping ST elevation in AVR (≥ 1 mm) with ST depressions and tall T waves in the precordial leads. What is the most likely diagnosis? A. Occlusion of the left circumflex artery B. Occlusion of the left main coronary artery C. Occlusion of the proximal left anterior descending artery D.

  By failing to prepare, you are preparing to fail. -Benjamin Franklin Welcome back to RoshCast for Episode 44! We are back to an every other week schedule covering core content. Let’s start out with a rapid review of neonatal conjunctivitis. * The three dangerous causes of neonatal conjunctivitis that you need to consider in the ED are gonorrhea, chlamydia, and herpes. * Gonorrhea is the most aggressive bacteria associated with neonatal conjunctivitis. It presents in the first week of life with purulent drainage and ulcerations, and it can disseminate to cause gonococcal sepsis. Culture the drainage for confirmation, and treat the baby with cefotaxime. * Chlamydia neonatal conjunctivitis, which presents in the first month of life, can disseminate into the lungs. Treat with oral erythromycin. * The third and least dangerous cause of neonatal conjunctivitis is herpetic. In this case you may see vesicles in the eye. Treat this with IV acyclovir. Now onto this week’s podcast Question 1      A 21-year-old man presents was bitten by a spider. He has a picture of the spider on his phone (shown above). Which of the following is a potential complication of a bite by this spider? A. Abdominal rigidity B. Autonomic instability C. Coagulation abnormalities D. Pancreatitis Teaching Image Question 2 A 66-year-old man with hypertension and hyperlipidemia presents after an episode of severe chest pain while walking to work. He is currently asymptomatic. His vitals are T 36.27°C, HR 76, BP 143/85, RR 18, and oxygen saturation 99%. A 12-lead ECG is performed as seen above. Which of the following is the most appropriate next step in management? A. Give 325mg of aspirin, and activate the cardiac catherization lab B. Give 325mg of aspirin, and admit for serial troponin testing and stress test C. Give 325mg of aspirin, and discharge home with cardiology follow up in 24-48 hours D. Send d-dimer, and consider CTpulmonary angiogram if elevated Teaching Image Question 3 A 17-year-old boy from New Jersey presents with a 3-day history of rash and a 1-day history of facial droop. He also complains of a headache. The images above represent the physical examination findings. In addition you note mild nuchal rigidity. A non-contrast head CT is performed and is normal. Which of the following is the next best step for this patient? A. Acyclovir and corticosteroids B. Lumbar puncture C. MRI brain D. Serologic testing for lyme diseases  Teaching Image Question 4 A 52-year-old man presents with decreased sensation in the upper extremities and chronic neck pain. He states that the loss of sensation has been progressive for months. On physical examination, he has decreased sensation to pain over the upper back, shoulders and arms with intact proprioception and light touch. What disorder does this patient exhibit? A. Anterior cord syndrome B. Brown sequard syndrome C. Central cord syndrome D. Syringomyelia Teaching Image Question 5 What is the most frequently seen oculomotor sign in patients with Wernicke’s encephalopathy? A. Lateral nystagmus B. Lateral rectus palsy C. Miosis D. Ptosis

Always do your best. What you plant now, you will harvest later. -Og Mandino Welcome back to RoshCast for Episode 43! After a long pause, we are back with new episodes and a lot of announcements. A lot has happened in the past few months. Jeff had a baby and moved to Pittsburg to start his EMS fellowship. In doing so, he is taking a break from Roshcast to focus on fellowship and his new baby. Megha Rajpal, a fourth year resident at Mount Sinai, will be taking over as co-host. * For epiglottitis, the patient will usually have a rapid onset fever and dysphagia. On exam, they could be leaning forward, drooling, and even have inspiratory stridor. * The typical radiographic finding for epiglottitis is thumbprint sign, which is seen on a lateral neck film. * The most common bacteria associated with epiglottitis are H. influenzae and Streptococcus. * For management in epiglottitis, airway is the crucial piece. Patients may need to be intubated immediately. Don’t forget to start the patient on antibiotics to treat for the common pathogens. Now onto this week’s podcast Question 1 Which of the following is the most common presenting vital sign abnormality seen in patients presenting with a pulmonary embolism? A. Fever B. Hypoxia C. Tachycardia D. Tachypnea Teaching Image Question 2 A 72-year-old man presents with pain in the right knee. It has increased over the last 24 hours with redness and swelling. Joint aspiration reveals negative birefringent crystals. He reports an allergy to NSAIDs and is a brittle diabetic. Colchicine is prescribed. Which side effect limits its usefulness due to a narrow therapeutic window? A. Headache B. Nausea and vomiting C. Rash D. Sore throat Teaching Image Question 3 A patient presents to the ED after waking up and finding that he was drooling while drinking his coffee. When he looked in the mirror he noticed that the left side of his face was drooping. Which of the following findings is suggestive of a central process? A. Hyperacusis of the left ear B. Inability to close the left eye completely C. Loss of taste sensation D. Preserved ability to raise the eyebrows Teaching Image Question 4 Which of the following is considered a stable cervical spine injury? A. Bilateral facet dislocation B. Clay-shoveler’s fracture C. Hangman fracture D. Teardrop fracture Teaching Image Question 5 A 28-year-old male presents to the Emergency Department via ambulance after a terrorist set off a large bomb in an airport. On physical exam, he has bilateral tympanic membrane ruptures. Chest X-ray shows bilateral pulmonary contusion. These injuries are most consistent with which category of blast injury? A. Primary B. Quaternary C. Secondary D. Tertiary Teaching Image Question 6 A 19-year-old man presents with eye pain and photophobia in his left eye after being punched there two days ago. He describes blurry vision. On exam, you note consensual photophobia.

The secret of change is to focus all of your energy, not on fighting the old, but on building the new.  -Socrates Welcome back to RoshCast for Episode 42! With the in-training exam around the corner, go back and power through old episodes during commutes to pick up as many points as possible. Good luck! * Patent ductus arteriosus (or PDA) closes, the neonate will present in heart failure and shock. * Turner’s Syndrome is associated with Coarctation. Turner’s is also associated with webbed neck, short stature, and low-set ears. * Individuals with Turner’s syndrome are missing an X chromosome as well, making it a 45 XO chromosomal condition. * A blood pressure differential between the arms and legs — specifically, the pressure in the arms is higher than the legs. Depending on the specific anatomy, you might even note a difference in the pressures between both arms. * Classic EKG and chest x-ray findings associated with coarctation of the aorta include left ventricular hypertrophy and rib notching, respectively. Now onto this week’s podcast Question 1 Which of the following is typically seen in Korsakoff syndrome? A. Cerebellar dysfunction B. Long-term memory impairment C. Ophthalmoplegia D. Recent memory impairment Teaching Image  Question 2 Which of the following is the most common physical exam finding in an abdominal aortic aneurysm? A. Abdominal bruit B. Diminished femoral pulses C. Duodenal obstruction D. Pulsatile abdominal mass Teaching Image Question 3 A 24-year-old woman at full term presents with rupture of membranes and contractions. Sterile exam reveals a crowning infant with a visible cord. After elevating the fetal head, what management is indicated? A. Clamp and cut cord and proceed with delivery B. Continue with standard delivery C. Emergent cesarean section D. Intravenous tocolytics Teaching Image  Question 4 You suspect a 35-year-old man has epiglottitis with impending airway compromise. Which of the following is the best method for confirming the diagnosis? A. Computed tomography of the neck B. Frontal cervical soft tissue radiograph C. Indirect laryngoscopy D. Lateral cervical soft tissue radiograph Teaching Image Question 5 A 21-year-old man presents with a stab wound to the right chest. His vitals are HR 157, BP 81/43, RR 28, and oxygen saturation 91%. The patient is intubated and packed red blood cells are started. Physical examination reveals a bleeding wound to the right chest, a midline trachea and decreased breath sounds on auscultation of the right hemithorax. Which of the following should be performed next? A. Application of a pelvic binder B. Placement of a right thoracostomy tube C. Right chest thoracotomy D. Transfer to operating room Teaching Image  Question 6 A 65-year-old man with a history of hypertension presents with left sided weakness beginning two hours prior to arrival. Vitals are BP 155/85 mm Hg, HR 102, RR 12, oxygen saturation 100% on RA. His CT scan is shown above. Which of the following therapies is appropriate? A. Antihypertensives to lower mean arterial pressure by 25% B.

We are what we repeatedly do. Excellence, then, is not an act, but a habit.  -Aristotle Welcome back to RoshCast for Episode 41! As we get closer and closer to the in-training, now would be a great time to go back and listen to old episodes to brush up on some of the core EM knowledge that you may not come across regularly on shift. Let’s get started with a rapid review and our regular mixed content of questions, answers, and high-yield review. * Staph aureus is the most common bacterial cause of septic arthritis in adults. * In a patient with splenic dysfunction, the strep species are more likely to cause septic arthritis. * Septic arthritis classically presents with fever, monoarticular joint pain, and a decreased range of motion. * Joint aspirates with a white count > 50,000 with more than 75% PMNs are indicative of septic arthritis. Now onto this week’s podcast Question 1 Which of the following hematological disorders is characterized by intermittent venous and arterial thrombosis, splenomegaly, and abnormal proliferation of all three myeloid cell lines? A. Aplastic anemia B. Chronic myelogenous leukemia C. Disseminated intravascular coagulopathy D. Polycythemia vera Teaching Image  Question 2 Which of the following pairs are matched correctly? A. Elevated direct bilirubin – Gilbert’s syndrome B. Elevated indirect bilirubin – Cholestasis C. Elevated transaminases with ALT/AST ratio > 2:1 – Alcoholic hepatitis D. Elevated transaminases with AST and ALT > 10,000 IU/L – Ischemic hepatitis Teaching Image  Question 3 Which of the following conditions can result in refractory hypokalemia that is not correctable by the administration of potassium? A. Hypermagnesemia B. Hypernatremia C. Hypomagnesemia D. Hyponatremia Teaching Image Question 4 A 29-year-old male is brought to the ED for a gunshot wound to the right chest. He is diagnosed with a right-sided hemopneumothorax. A tube thoracostomy is subsequently performed with immediate drainage of 250 cc of blood. The nurse connects the chest tube to a commercial suction device, and a chest radiograph is performed that confirms proper placement. You note an absence of respiratory fluctuation of the fluid level in the drainage tube. A repeat chest X-ray shows the right-sided hemothorax remains. Which of the following is true regarding this finding? A. An air leak is present B. The lung is still collapsed C. There is a blockage of the drainage tube D. This is an expected finding Question 5 Which of the following is true regarding Ranson’s Criteria? A. A score of 0-3 on admission constitutes a high-risk population B. Glucose > 200 mg/dL on admission is associated with a higher mortality rate C. Hematocrit < 35% at 48 hours is predictive of mortality D. WBC < 10,000 is associated with a higher mortality rate Teaching Image  Question 6 The Emergency Medical Treatment and Active Labor Law of 1986, or EMTALA, requires hospitals to provide which of the following? A. Care to all patients B. Interpreters for all patients in a timely manner C. Screening exam, competent ED physicians and appropriate stabiliza...

Dreams and dedication are a powerful combination. -William Longgood Welcome back to Roshcast for Episode 40! After a quick detour last week to talk with Dr. Rosh, we are back at it with our regular routine. But before we get going, if you have any thoughts or feedback on last week’s episode, or even if you have any unanswered questions, make sure you send them our way to RoshCast@RoshReview.com, so that we can get them answered either individually by email or on another special episode. This week, we are going to cover a few pediatric respiratory questions to parallel the EM Clerkship podcast’s most recent episode in addition to some bread and butter emergency medicine. Before we begin, let’s get warmed up with a rapid review covering environmental emergencies, since these are things we see less frequently in our day to do practice but ALWAYS appear on the in-training exam.  * Pit viper bites cause local swelling and oozing from the wound. Severe envenomations can lead to a DIC like coagulopathy and hemorrhagic bullae. * Brown recluse spider bites cause a papule that later blisters and may necrose. Systemic symptoms include renal failure, pulmonary edema, and shock. * Black widow spider bites cause a local papule with a halo. Severe systemic symptoms include a peritonitic abdomen, muscle fasciculations, and diaphoresis. Remember that you can identify a black widow spider by the red hourglass on their abdomen. * Frostbite should be treated with immersion in a warm water bath set at 37-39 degrees Celsius. Now onto this week’s podcast Question 1 Let’s get right into with a pediatric respiratory question: A 3-year-old girl presents to the ED with 1 hour of a barking cough and inspiratory stridor at rest. On exam, she has mild retractions but is not hypoxic. Which of the following interventions has been shown to reduce hospital length of stay in moderate to severe croup? A. Dexamethasone B. Heliox C. Humidified air D. Racemic epinephrine Teaching Image Question 2 A 33-year-old woman presents with intermittent, intense shooting pain to the left side of the face. She states that the pain begins near her ear and radiates to her chin. The pain is often brought on by chewing and brushing her teeth. Which of the following managements is most likely indicated? A. Carbamazepine B. Dental X-rays C. Mandible CT scan D. Prednisone Teaching Image Question 3 Which of the following cervical spine fractures is considered stable? A. Bilateral facet dislocation B. Flexion teardrop fracture C. Jefferson fracture D. Type I odontoid fracture Teaching Image  Question 4 You are working in a busy pediatric ED in December. During your shift you evaluate and treat 4 children with moderate croup by administering oral dexamethasone and aerosolized epinephrine. You re-evaluate each child 2 hours after the initial racemic epinephrine treatment. Which of the following children can most safely be discharged home? A. A 1-year-old boy with persistent stridor at rest B. A 2-year-old uninsured boy with clinical improvement, but no primary care physician C. A 3-month-old girl with a history of tracheomalacia who has clinical improvement D. A 4-year-old girl with retractions that have since resolved

“The person who creates structure the soonest, is the person who is most comfortable in residency the soonest.”  -Adam Rosh, MD Welcome back to RoshCast episode number 39!  As we mentioned at the end of episode 38, this won’t be a regular old RoshCast. Instead of our regularly scheduled content, we put together an interview with Dr. Adam Rosh – the namesake of the Rosh Review, former program director, and most importantly an emergency physician who has dedicated the last 20 years of his life to education. While this episode will not contain our usual board review content, it will include tactical advice on preparing for and taking your board exam. This episode provides a gold mine of actionable information, tools, strategies, and tactics that you can use not only for your upcoming Shelf exam, In-Training exam, or ABEM Certification exam, but any high stakes endeavor.  Some of the topics Dr. Rosh talked about include: * The biggest studying challenges going from medical school to residency * The best advice Dr. Rosh received when he was an intern * A system to 10X your medical knowledge during residency * How to implement a study strategy called “layering” to build deep medical knowledge * How a “notebook system” made all the difference in the world to building confidence as a resident * An opportunity to aggregate Post-it Pearls  * A system to capture mistakes to improve clinical practice * How studying material like the leads of an ECG looking at the heart can lead to improved understanding  * Using interleaving to improve preparation for the actual exam * What do you do if you answered all of the questions in the Qbank? * How forgetting leads to improved recall * Avoiding the illusion of knowing * Choosing the right study material * Making sure you prevent people from stealing your time * The importance of exercise or simply taking a break to go for a walk to improve recall * Upcoming releases within Rosh Review  * And much more… Items referenced during the interview Flip notebook How to Increase Your In-Training Exam Score by 10 Points An Emergency Medicine Resident’s Clinical Experience That’s wraps up RoshCast Episode 39. Don’t forget to follow us on Twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write “RoshCast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. And let us know if you’d like us to do a Part 2 with Dr. Rosh.  Until next time, Jeff and Nachi

  Believe you can and you’re halfway there. -Theodore Roosevelt Welcome back to Roshcast Episode 38, the last episode of 2018! Before we jump into this week’s episode, we have a few people to recognize. First, congrats to Zain who won the trauma ring tone challenge last episode and will be receiving a Rosh Review subscription. Special mention goes out as well to Clark, David, and Ryker who all responded soon after Zain. We should also recognize Sarah, who won the EM Clerkship-RoshCast crossover challenge and won a free copy of Case Files Emergency Medicine. Stay tuned for more contests to come! Let’s head back to the Rosh Blog and start out with a recent Rapid Review. * Central cord usually presents with sensory and motor deficits, with the upper extremities being affected more than the lower extremities. It’s most commonly caused by an extension injury. * Anterior cord syndrome presents with complete loss of motor, pain, and temperature below the level of the injury, but you would retain proprioception and vibration sensation. Anterior cord is most often caused by a flexion or vascular injury. * Brown Sequard classically occurs after penetrating trauma. It results in ipsilateral loss of motor, vibration, and proprioception with contralateral loss of pain and temperature. Now onto this week’s podcast Question 1 A 3-day-old girl presents with decreased feeding and is found to be limp and minimally responsive. After intubation, at what rate should breaths be delivered? A. 10-16 per minute B. 20-30 per minute C. 40-60 per minute D. 70-80 per minute Teaching Image  Question 2 In a malnourished patient, which of the following sources of megaloblastic anemia is expected to develop first? A. Folic acid deficiency B. Hypothyroidism C. Liver disease D. Vitamin B12 deficiency Teaching Image  Question 3 What medication should be first line treatment in moderate musculoskeletal back pain? A. Acetaminophen B. Cyclobenzaprine C. Diazepam D. Oxycodone Question 4 An 18-year-old male presents to the ED with a 4 cm laceration to the right side of his chin. Which of the following nerve blocks is most appropriate? A. A mental nerve block B. A posterior superior alveolar nerve block C. A stellate ganglion block D. An apical nerve block Teaching Image  Question 5 A previously healthy 5-year-old girl presents to the ED with left lower extremity pain and an inability to bear weight for 1 day. Mom denies any recent trauma. On exam, the patient has a T 37.9°C, HR 130, and RR 28. Her left lower extremity is slightly flexed and externally rotated. Lab evaluation reveals a WBC of 8,000, a C-reactive protein of 1 mg/dL, and an erythrocyte sedimentation rate (ESR) of 7 mm/hr. Radiographs are negative for fracture. The patient’s range of motion has improved following administration of ibuprofen. What is the most appropriate course of action in this patient? A. Intravenous antibiotics and admission to the hospital B. MRI to rule out osteomyelitis or septic arthritis C. Orthopedic consultation for arthrocentesis D. Treatment with NSAIDs and discharge with follow-up arranged for ...

  The most difficult thing is the decision to act, the rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life; and the procedure, the process is its own reward.   -Amelia Earhart Welcome back to Roshcast Episode 37! This week, we’re continuing our collaboration with the EM Clerkship podcast. We’ll cover 3 EKG related questions in addition to 3 randomly generated questions. Maybe we’ll even get to a trauma question… As a reminder, listen closely for the trauma ring tone during this episode and the next episode. And e-mail us at roshcast@roshreview.com or tweet us at roshcast the exact time of the ring tone to win a subscription. With the in training exam right around the corner this will certainly help get you ready for February 28th. Let’s get going with a rapid review from a recent post on the Rosh Review Blog. * Supracondylar fracture is the most common type of pediatric elbow fracture. Typically caused by falling on an outstretched hand — or a FOOSH.  * In a posterolaterally displaced supracondylar humeral fracture you should be concerned for the median nerve. This can be tested by asking the patient to make an “OK” sign and checking sensation at the volar tip of the index finger * For a posteromedially displaced supracondylar fracture you should be concerned about the radial nerve. Have the patient try to make a “thumbs up” sign. And check sensation along the dorsal web space of the hand.  Now onto this week’s podcast Question 1  A previously healthy patient who presents with leg pain is found to have a clot within the tibial vein. Which of the following treatments is most likely indicated? A. Aspirin for 6 months B. Heparin and warfarin C. Repeat ultrasound in 2-5 days D. Warfarin alone Question 2 Which of the following is associated with a shortened PR interval?  A. Brugada Syndrome B. Mobitz 2° AV Block C. Wellens Syndrome D. Wolff-Parkinson-White syndrome Teaching Image Question 3 A 29-year old man presents after a syncopal episode. His ECG reveals an epsilon wave, a small positive deflection buried in the end of the QRS complex. Which of the following tests will likely identify the cause of the patient’s syncope? A. Cardiac catheterization B. Cardiac MRI C. Electrophysiology study D. Stress testing Teaching Image Question 4 A 12-year-old boy is brought to the ED after being struck in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition? A. Asystole B. Supraventricular tachycardia C. Ventricular fibrillation D. Ventricular tachycardia Teaching Image Question 5 A 57-year-old man with hypertension presents complaining of a 6-hour history of a “floater” in the right eye. He states that he has had increasing difficulty reading as the cloudy area blocks his visual field. Additionally, he complains of decreased vision in his right eye. Which of the following represents the appropriate management? A. Administer timolol drops and emergently consult ophthalmology B.