NCCPA Emergency Medicine 2 — Questions and Answers
Question 1: A 45-year-old male presents with sudden onset severe headache described as 'the worst headache of his life.' CT head is negative. What is the next best step?
- Discharge with ibuprofen
- Lumbar puncture for xanthochromia (Correct answer)
- MRI brain with contrast
- Neurology consult only
Correct answer: Lumbar puncture for xanthochromia
A negative CT with thunderclap headache requires lumbar puncture to rule out subarachnoid hemorrhage via xanthochromia detection.
Question 2: Which ECG finding is most associated with hyperkalemia requiring immediate treatment?
- ST depression in lateral leads
- Peaked T waves progressing to sine wave pattern (Correct answer)
- Delta waves with short PR interval
- Prolonged QT interval
Correct answer: Peaked T waves progressing to sine wave pattern
Progressive hyperkalemia causes peaked T waves, widened QRS, and ultimately a sine wave pattern requiring urgent calcium gluconate and potassium-lowering therapy.
Question 3: A 28-year-old with sickle cell disease presents with chest pain, fever, and new pulmonary infiltrate. What is the priority treatment?
- Hydroxyurea initiation
- Simple blood transfusion and antibiotics
- Exchange transfusion and antibiotics (Correct answer)
- Bronchodilators and steroids only
Correct answer: Exchange transfusion and antibiotics
Acute chest syndrome (ACS) in sickle cell disease is managed with exchange transfusion to rapidly reduce HbS percentage plus broad-spectrum antibiotics.
Question 4: A patient presents after ingesting a unknown substance and has a calculated osmol gap of 25 mOsm/kg. What toxic ingestion is most likely?
- Acetaminophen
- Aspirin
- Ethylene glycol (Correct answer)
- Benzodiazepines
Correct answer: Ethylene glycol
An elevated osmol gap (>10 mOsm/kg) suggests ingestion of an unmeasured osmole such as ethylene glycol, methanol, or isopropanol.
Question 5: Which intervention is contraindicated in the initial management of a tension pneumothorax?
- Needle decompression at 2nd ICS midclavicular line
- Chest tube insertion
- Waiting for CXR confirmation before treatment (Correct answer)
- High-flow oxygen
Correct answer: Waiting for CXR confirmation before treatment
Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression — delaying for imaging risks cardiovascular collapse and death.
Question 6: A 70-year-old on warfarin presents with INR 8.2 and active GI bleeding. What is the most appropriate reversal agent?
- Fresh frozen plasma alone
- Vitamin K alone
- 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K (Correct answer)
- Protamine sulfate
Correct answer: 4-factor prothrombin complex concentrate (4F-PCC) plus vitamin K
Active life-threatening bleeding with supratherapeutic INR requires 4F-PCC for rapid reversal plus IV vitamin K for sustained effect.
Question 7: Which feature best distinguishes cardiac syncope from vasovagal syncope?
- Loss of consciousness duration >1 minute
- Syncope occurring during or immediately after exertion (Correct answer)
- Prodrome of nausea and diaphoresis
- Recovery taking several minutes
Correct answer: Syncope occurring during or immediately after exertion
Syncope during or immediately after exertion is a red flag suggesting cardiac etiology such as hypertrophic cardiomyopathy or aortic stenosis.
NCCPA Emergency Medicine 2
A 45-year-old male presents with sudden onset severe headache described as 'the worst headache of his life.' CT head is negative.
What is the next best step?