PANRE Emergency Medicine 2 — Questions and Answers
Question 1: A 55-year-old male presents with crushing chest pain radiating to the left arm. ECG shows ST elevations in leads V1-V4. What is the most appropriate immediate management?
- Administer IV heparin and arrange emergent PCI (Correct answer)
- Give aspirin 325mg and nitroglycerin only
- Order a stress test for further evaluation
- Administer thrombolytics and discharge home
Correct answer: Administer IV heparin and arrange emergent PCI
STEMI with anterior wall involvement requires immediate reperfusion via primary PCI within 90 minutes of first medical contact, with anticoagulation.
Question 2: A 30-year-old woman presents with sudden-onset severe headache described as 'the worst headache of my life.' CT head is negative. What is the next best step?
- Reassure and discharge with analgesics
- Perform lumbar puncture to evaluate for xanthochromia (Correct answer)
- Order an MRI brain
- Start empiric antibiotics for meningitis
Correct answer: Perform lumbar puncture to evaluate for xanthochromia
A thunderclap headache with negative CT requires lumbar puncture to detect xanthochromia, which indicates subarachnoid hemorrhage.
Question 3: An 8-year-old child presents with inspiratory stridor, drooling, and prefers to sit in a tripod position. Temperature is 39.5°C. What is the most likely diagnosis?
- Croup
- Epiglottitis (Correct answer)
- Foreign body aspiration
- Anaphylaxis
Correct answer: Epiglottitis
Epiglottitis presents with the classic triad of drooling, dysphagia, and distress along with high fever and a tripod posture to maintain airway patency.
Question 4: A 70-year-old man on warfarin presents after a fall with a GCS of 12 and INR of 3.8. CT shows a subdural hematoma. What reversal agent should be administered?
- Vitamin K alone
- Fresh frozen plasma alone
- 4-factor prothrombin complex concentrate (4F-PCC) (Correct answer)
- Protamine sulfate
Correct answer: 4-factor prothrombin complex concentrate (4F-PCC)
4F-PCC provides rapid reversal of warfarin anticoagulation and is preferred over FFP for emergent reversal due to faster onset and lower volume.
Question 5: A 45-year-old presents with acute scrotal pain of 2 hours duration. The testicle is tender, elevated, and the cremasteric reflex is absent. What is the priority action?
- Order a scrotal ultrasound and wait for results before acting
- Administer antibiotics for epididymitis
- Arrange immediate surgical exploration (Correct answer)
- Apply ice and re-examine in 4 hours
Correct answer: Arrange immediate surgical exploration
Absent cremasteric reflex with acute scrotal pain is testicular torsion until proven otherwise; surgical detorsion within 6 hours is critical to salvage the testicle.
Question 6: A patient presents with altered mental status, fever of 40°C, muscle rigidity, and autonomic instability after starting a new antipsychotic. What is the diagnosis?
- Serotonin syndrome
- Neuroleptic malignant syndrome (Correct answer)
- Malignant hyperthermia
- Heat stroke
Correct answer: Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is characterized by hyperthermia, lead-pipe rigidity, autonomic instability, and altered consciousness following antipsychotic use.
Question 7: A 25-year-old presents with a deep laceration over the MCP joint after punching someone in the mouth. How should this wound be managed?
- Irrigate, close primarily, and discharge
- Irrigate, leave open, splint, and prescribe antibiotics covering oral flora (Correct answer)
- Close primarily and prescribe antifungals
- Apply a pressure dressing only and reassure
Correct answer: Irrigate, leave open, splint, and prescribe antibiotics covering oral flora
Fight bites over the MCP joint carry a high risk of septic arthritis from oral flora; the wound must be left open, irrigated, splinted, and treated with antibiotics such as amoxicillin-clavulanate.
PANRE Emergency Medicine 2
A 55-year-old male presents with crushing chest pain radiating to the left arm.
ECG shows ST elevations in leads V1-V4.
What is the most appropriate immediate management?