LMCC Emergency Medicine 2 — Questions and Answers
Question 1: A 55-year-old hypertensive man presents with blood pressure of 210/130 mmHg, papilledema, and serum creatinine rising from 90 to 180 μmol/L over 3 days. What defines this as a hypertensive emergency vs. urgency?
- The absolute blood pressure level above 200 mmHg systolic
- The presence of acute end-organ damage (retina, kidney, brain) (Correct answer)
- Symptoms of headache and visual blurring alone
- Diastolic pressure exceeding 130 mmHg
Correct answer: The presence of acute end-organ damage (retina, kidney, brain)
Hypertensive emergency is defined by severely elevated blood pressure accompanied by acute end-organ damage, not by blood pressure level alone.
Question 2: A 30-year-old man with known epilepsy presents with continuous tonic-clonic seizures lasting 8 minutes. What is the first-line pharmacologic treatment?
- IV phenytoin 20 mg/kg loading dose
- IV lorazepam 0.1 mg/kg (Correct answer)
- IM diazepam 10 mg
- Oral levetiracetam 500 mg
Correct answer: IV lorazepam 0.1 mg/kg
IV benzodiazepines (lorazepam preferred) are first-line for status epilepticus due to their rapid onset, efficacy, and safety profile in acute seizure termination.
Question 3: A 68-year-old COPD patient on home oxygen presents in acute respiratory failure with pH 7.28, PaCO2 72 mmHg, and PaO2 52 mmHg. He is conscious and can cooperate. What is the preferred initial ventilatory support?
- High-flow oxygen via non-rebreather mask
- Non-invasive positive pressure ventilation (NIPPV/BiPAP) (Correct answer)
- Immediate endotracheal intubation
- Heliox (helium-oxygen mixture)
Correct answer: Non-invasive positive pressure ventilation (NIPPV/BiPAP)
NIPPV/BiPAP is the preferred initial intervention for acute hypercapnic respiratory failure in cooperative COPD patients, reducing intubation rates and mortality.
Question 4: A 22-year-old university student presents with fever, severe headache, neck stiffness, and a non-blanching petechial rash. What is the most critical immediate action?
- Perform lumbar puncture before administering antibiotics
- Administer IV ceftriaxone immediately, before CT or LP if meningococcal meningitis is suspected (Correct answer)
- Order CT head and await results before any treatment
- Administer IV dexamethasone and wait for culture results
Correct answer: Administer IV ceftriaxone immediately, before CT or LP if meningococcal meningitis is suspected
In suspected bacterial meningitis with a petechial rash (meningococcemia), antibiotics must be given immediately without waiting for CT or lumbar puncture, as delay increases mortality.
Question 5: A 28-year-old woman with 7 weeks of amenorrhea presents with right lower quadrant pain, vaginal bleeding, and a positive urine hCG. Her blood pressure is 90/60 mmHg and heart rate is 118 bpm. What is the priority?
- Transvaginal ultrasound to confirm ectopic pregnancy before any intervention
- IV access, fluid resuscitation, type and crossmatch, and urgent surgical/gynecology consultation (Correct answer)
- Serial serum beta-hCG levels to confirm diagnosis
- Administer methotrexate and observe in the emergency department
Correct answer: IV access, fluid resuscitation, type and crossmatch, and urgent surgical/gynecology consultation
Hemodynamic instability in a pregnant patient with these findings suggests a ruptured ectopic pregnancy, requiring immediate resuscitation and emergent surgical intervention.
Question 6: A 45-year-old man presents with 12 hours of periumbilical pain that has migrated to the right iliac fossa, anorexia, and low-grade fever. WBC is 14.5 × 10⁹/L. What is the most likely diagnosis and appropriate management?
- Mesenteric adenitis; treat with antibiotics alone
- Acute appendicitis; surgical consultation for appendectomy (Correct answer)
- Ovarian torsion; urgent gynecology referral
- Renal colic; analgesics and outpatient urology follow-up
Correct answer: Acute appendicitis; surgical consultation for appendectomy
The classic migration of pain from periumbilical to the right iliac fossa with leukocytosis is characteristic of acute appendicitis, which requires surgical consultation for appendectomy.
Question 7: A firefighter is brought in after 20 minutes in a burning building. He has a headache, nausea, and confusion. Oxygen saturation reads 98% on pulse oximetry. What is the most likely diagnosis and treatment?
- Smoke inhalation with normal oxygenation; supportive care only
- Carbon monoxide poisoning; administer 100% oxygen via non-rebreather mask (Correct answer)
- Cyanide poisoning; administer hydroxocobalamin
- Psychogenic hyperventilation; reassurance and rebreathing
Correct answer: Carbon monoxide poisoning; administer 100% oxygen via non-rebreather mask
Pulse oximetry cannot distinguish carboxyhemoglobin from oxyhemoglobin, so normal SpO2 is falsely reassuring in CO poisoning; 100% oxygen accelerates CO elimination.
LMCC Emergency Medicine 2
A 55-year-old hypertensive man presents with blood pressure of 210/130 mmHg, papilledema, and serum creatinine rising from 90 to 180 μmol/L over 3 days.
What defines this as a hypertensive emergency vs. urgency?