The Real-Life Quiz for Real-Life EM
I recently lectured pre-med students, and most mentioned their apprehension about taking the MCAT. I explained that this test is only the beginning of a series of flaming hoops they will have to jump through on the way to becoming a physician. The testing seems never-ending, and the problems only become more difficult.
I understand the rationale for asking questions about rare diseases and uncommon worst-case scenarios, but the mundane and common clinical scenarios we encounter every day are underrepresented on board exams. I would love to get some points on my re-cert for knowing how to handle vital ED scenarios such as those in the following questions:
- A 55-year-old man presents with a history of alcohol intoxication and the inability not to curse loudly. He was discharged eight hours earlier, and he has normal vital signs, hasn't eaten in four days, and has no trauma. He has no complaints, but is unsteady on his feet. You should:
- Do a panculture, a full blood panel, and convince the medical service to admit.
- Bring him a turkey sandwich and a Powerade, and take him to the urinal.
- Bring him a ham sandwich and a Powerade, and take him to the urinal.
- Find him the bed next to a board member's kid who has a broken ankle.
- Prescribe Haldol, Ativan, and Benadryl, and sign out to the next provider.
- A 48-year-old woman presents with abdominal pain, which feels similar to her previous 241 episodes. Her pain doctor told to her to come see him, but she came to the ED instead. She has 14 allergies, is wearing sunglasses and eating cool ranch Doritos, and says her pain is 1000/10. Her vitals are normal, and she vaguely gestures to her entire abdomen while not looking up from Facebook on her phone. You should:
- Run an MRA and some labs, and consult GI and surgery.
- Ask her for some Doritos, friend her on Facebook, and send her ironic memes.
- Give her a list of pain medications that don't start with “D.”
- Contact her pain specialist. (P.S. It's an out-of-service number.)
- Give her Dilaudid, Phenergan, and a Press Ganey survey to fill out.
- A 99-year-old man presents with hypertension and “dizziness.” He is AOX2, and calmly states that he's not dizzy and is a World War II vet. Nursing home records indicate that he is AOX2 at baseline and confirm that he is a vet. Paperwork shows he is not to be transported because he is in palliative care. You should:
- Discharge him back to the nursing home.
- Do a full workup, and call out-of-town family to clarify palliative care specifics.
- Call the nursing home, berate the staff, and question them about patient's transfer in the first place.
- Do a full workup to keep your room occupied so you won't get more patients.
- Sit down and ask him about World War II. Hear first-hand historical accounts of the war from one of the few remaining who actually lived it. Shake his hand, reassure him his blood pressure is fine, and discharge him back to his nursing home.
- A 44-year-old patient with end-stage bladder cancer and uterine involvement comes to the ED for passing stool from her vagina. Her oncologist at the Big Academic Center across the state told her to go immediately to the ED for evaluation. CT shows a new enterovaginal fistula. You should:
- Discharge the patient and tell her to drive to the Big Academic Center.
- Ask OB/GYN to see the patient.
- Ask general surgery to see the patient.
- Ask urology to see the patient, realize the patient has had a cystectomy, and thank urology for their time.
- Call the Big Academic Center, fight the phone prompts, and talk to her actual oncologist.
- A 35-year-old man presents with high blood pressure. He was at his aunt's friend's house and took his blood pressure because she had a cuff and why not? His girlfriend is a licensed essential oil therapist, who said he could have had a stroke. The cuff read either 139/80 or OB/GEI, depending on which side was up, and they are very concerned. His current BP is 129/79. You should:
- Complete an electrolyte panel, an ECG, a head CT, and a fundoscopic exam.
- Try to escape the room during the girlfriend's dissertation on essential oil use in penetrating trauma.
- Say “thank goodness, you came, but I'm afraid it's too late,” and walk out of the room.
- Use a mixture of a thistle, gumma root, and guttural chanting. Then make a poultice and apply to your own eyeballs. Continue chanting in the room until the patient leaves.
- Provide new PCP information, recheck BP, and discharge the patient.
- A 22-year-old patient arrives waving his arms in the air like he just doesn't care. He says, “I think this might be my pseudoseizures again.” He has had multiple negative seizure workups in the past, and is on no meds. He says Ativan, Dilaudid, and Benadryl work best for this while he dances to “YMCA.” You should:
- Repeat full workup, labs, CT of the head, and a urine drug screen.
- Provide IV Ativan, Dilaudid, and Benadryl on top of a Press Ganey survey.
- Consult the Village People.
- Have your own pseudoseizure so one of your partners has to see the patient.
- Teach the patient the Macarena.
Special thanks to Steve Dehorn, MD; Thomas Witham, MD; and Adam Oostema, MD, for their help with this article.Wolters Kluwer Health, Inc. All rights reserved.