SPEX Emergency Medicine 4 — Questions and Answers
Question 1: A patient with atrial fibrillation presents with rapid ventricular response (HR 160) and hemodynamic instability. What is the immediate treatment?
- IV metoprolol
- IV diltiazem
- Synchronized cardioversion (Correct answer)
- IV amiodarone
Correct answer: Synchronized cardioversion
Hemodynamically unstable tachyarrhythmias require immediate synchronized cardioversion regardless of the rhythm.
Question 2: Which physical exam finding is MOST specific for cardiac tamponade?
- Jugular venous distension
- Muffled heart sounds
- Pulsus paradoxus >10 mmHg (Correct answer)
- Hypotension
Correct answer: Pulsus paradoxus >10 mmHg
Pulsus paradoxus greater than 10 mmHg is the most specific physical exam finding for cardiac tamponade, reflecting impaired ventricular filling with inspiration.
Question 3: A 25-year-old female presents with right lower quadrant pain, missed period, and a positive pregnancy test. The uterus is empty on ultrasound. What is the most concerning diagnosis?
- Ovarian cyst
- Ectopic pregnancy (Correct answer)
- Appendicitis
- Pelvic inflammatory disease
Correct answer: Ectopic pregnancy
A positive pregnancy test with an empty uterus on ultrasound and abdominal pain must be presumed ectopic pregnancy until proven otherwise due to risk of rupture.
Question 4: Which maneuver should be performed when shoulder dystocia is encountered during delivery?
- McRoberts maneuver and suprapubic pressure (Correct answer)
- Fundal pressure
- Forceps application
- Emergent C-section immediately
Correct answer: McRoberts maneuver and suprapubic pressure
McRoberts maneuver (hyperflexion of maternal thighs) combined with suprapubic pressure is the first-line intervention for shoulder dystocia.
Question 5: What is the most common cause of distributive shock?
- Anaphylaxis
- Sepsis (Correct answer)
- Adrenal insufficiency
- Neurogenic shock
Correct answer: Sepsis
Sepsis is the most common cause of distributive shock, characterized by vasodilation, decreased SVR, and initially elevated cardiac output.
Question 6: A patient presents with fever, neck stiffness, and photophobia. Before lumbar puncture, what imaging is required?
- CT head is always required
- CT head only if papilledema, focal neuro deficits, immunocompromised, or seizure (Correct answer)
- MRI brain is preferred
- No imaging needed; proceed to LP
Correct answer: CT head only if papilledema, focal neuro deficits, immunocompromised, or seizure
CT head before LP is indicated only in specific high-risk features (papilledema, focal deficits, immunocompromise, new-onset seizure) to avoid herniation risk.
Question 7: A 60-year-old presents with acute onset unilateral facial droop, arm weakness, and speech difficulty starting 2 hours ago. CT head is negative. What is the next step if no contraindications exist?
- Aspirin 325mg and admission
- tPA (alteplase) administration (Correct answer)
- MRI brain before any treatment
- Heparin infusion
Correct answer: tPA (alteplase) administration
Acute ischemic stroke within the 4.5-hour window with no contraindications warrants IV tPA (alteplase) after CT rules out hemorrhage.
SPEX Emergency Medicine 4
A patient with atrial fibrillation presents with rapid ventricular response (HR 160) and hemodynamic instability.
What is the immediate treatment?