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May House Staff Quiz
Poisoning/Hazardous Substances
1.
The parents of a 12-year-old boy bring him to the emergency department after
finding him unresponsive in bed when they tried to wake him for school. They report that
he has had no recent illnesses and was in his usual state of health when he went to bed
last night. Of note, he has enuresis, treated with imipramine. On physical examination, he
is responsive only to pain, his heart rate is 120 beats/min, respiratory rate is 6
breaths/min, and blood pressure is 60/40 mm Hg. His pupils are 6 mm, equal, and
sluggishly reactive. All other findings are within normal parameters. He is endotracheally
intubated, ventilated with 100% oxygen, placed on a cardiac monitor, and given a 20mL/kg bolus of normal saline. Electrocardiography demonstrates sinus tachycardia, PR
interval of 130 msec, and QRS duration of 140 msec.
Of the following, the next MOST appropriate step is to:
A. administer adenosine
B. administer amiodarone
C. administer sodium bicarbonate
D. begin external pacing
E. perform synchronized cardioversion at 0.5 J/kg
2. You receive a call from the emergency department at 11:00 PM on New Year's Eve. Five
patients have presented with foreign body ingestions.
Of the following, the foreign body that is MOST appropriate to be removed first is a
A. 1999 penny in the stomach of an 18-month-old
B. AAA battery in the stomach of a 4-year-old
C. button battery in the mid-esophagus of a 2-year-old
D. quarter in the esophagus of a 3-year-old who vomited twice and is refusing solids
E. toothbrush in the stomach of an asymptomatic 16-year-old, which she swallowed 2 hours
ago
3. A father brings his 2-year-old son to the emergency department in status epilepticus.
He reports that the boy spent several hours in the garage with him while he was repairing
the car. On questioning, the father states that over the course of the afternoon the child
seemed sleepier than usual, then became lethargic, vomited, and seemed like he was
"drunk." On the way to the hospital he began having seizures. In the emergency
department, the boy is given a dose of lorazepam to stop the seizure and is endotracheally
intubated because of respiratory depression. His initial laboratory results are:
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Sodium, 138 mEq/L (138 mmol/L)
Potassium, 4.9 mEq/L (4.9 mmol/L)
Chloride, 100 mEq/L (100 mmol/L)
Bicarbonate, 6 mEq/L (6 mmol/L)
Glucose, 120 mg/dL (6.7 mmol/L)
Blood urea nitrogen, 10 mg/dL (3.6 mmol/L)
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Calcium, 5.5 mEq/L (5.5 mmol/L)
Serum osmolality, 335 mOsm/kg (335 mmol/kg)
Of the following, the MOST likely cause of this child's clinical condition is ingestion of
A. ethylene glycol
B. gasoline
C. motor oil
D. organophosphate insecticide
E. turpentine
4. A 10-year-old boy is brought to the emergency department after he struck a boulder
while riding his all-terrain vehicle, causing the vehicle to roll over on him. He was not
wearing a helmet. Bystanders reported that he had a brief loss of consciousness, but he is
now alert and answers questions appropriately. He reports that he is nauseous, has a
severe headache, and is unable to hear with his left ear. On physical examination, his
heart rate is 120 beats/min, respiratory rate is 20 breaths/min, and blood pressure is
130/80 mm Hg. He has multiple facial abrasions, a 6-cm laceration on his forehead, and
bloody drainage from his left ear. His midface is stable to palpation, his extraocular
movements are normal, and there is no deformity of his nasal bone.
Of the following, his clinical presentation is MOST consistent with a(n)
A. diffuse axonal injury
B. occipital skull fracture
C. orbital skull fracture
D. subdural hematoma
E. temporal bone fracture
5. You are treating a 20-kg, 4-year-old boy who was admitted to the pediatric intensive
care unit 3 days ago after being endotracheally intubated and resuscitated in the
emergency department for septic shock. Over the past 2 days, he has required increasing
ventilator settings, progressive opacification of his lung fields has been apparent on chest
radiography, and he now fulfills the clinical criteria for acute respiratory distress
syndrome (ARDS). His current ventilator settings are a respiratory rate of 25 breaths/min,
tidal volume of 300 mL, positive end-expiratory pressure (PEEP) of 12 mm Hg with an
FiO2 of 0.6, and a resultant oxygen saturation (SpO2) of 90%. His most recent arterial
blood gas assessment shows a pH of 7.30, a PaCO2 of 50 mm Hg, and a PaO2 of 65 mm
Hg.
Of the following, the MOST effective treatment strategy to decrease ARDS-associated
mortality risk in this patient is
A. adjustment of the respiratory tidal volume to 6 mL/kg
B. administration of corticosteroids
C. administration of surfactant
D. decrease of PEEP to 5 mm Hg
E. increase in oxygen to ensure an SpO2 greater than 95%
6. A 2-year-old boy is brought to the emergency department after his father found him
with the leaf from a foxglove plant in his mouth. He has had one episode of emesis and is
complaining of abdominal pain. On physical examination, his heart rate is 140 beats/min,
respiratory rate is 24 breaths/min, blood pressure is 100/60 mm Hg, and oxygen
saturation is 100%. His pupils are 4 mm and briskly reactive to 2 mm. The remainder of
his examination findings are normal.
After administering activated charcoal, the MOST appropriate next step is
A. abdominal radiography
B. electrocardiography
C. serum creatine phosphokinase assessment
D. serum sodium assessment
E. urine toxicology screening
7. When an 11-year-old boy attempts to pet a stray dog in the park, he is bitten on the
dorsum of his right hand, sustaining several breaks in the skin. The parents clean the
wounds with soap and water. The dog is located and captured by animal control officers.
Forty-eight hours later, the child presents to your office with painful swelling of the hand,
erythema, and purulent discharge. The boy is allergic to penicillin.
Of the following, the BEST choice for antibiotic therapy for this child is
A. amoxicillin-clavulanate
B. azithromycin and trimethoprim-sulfamethoxazole
C. cefdinir
D. clindamycin and trimethoprim-sulfamethoxazole
E. doxycycline
8. A 9-year-old boy is admitted to the hospital because of altered consciousness and
fever. A lumbar puncture, performed because of a stiff neck and altered mentation,
reveals cerebrospinal fluid protein of 100 mg/dL; cytologic findings of 100 white cells,
95% lymphocytes, and 10 red blood cells; and glucose of 40 mg/dL. Additional serum
laboratory findings include:
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Glucose, 70 mg/dL (3.9 mmol/L)
Sodium, 124 mEq/L (124 mmol/L)
Potassium, 3.2 mEq/L (3.2 mmol/L)
Chloride, 93 mEq/L (93 mmol/L)
Bicarbonate, 18 mEq/L (18 mmol/L)
Results of serum cortisol and adrenocorticotrophic hormone concentrations are pending.
Broad-spectrum antibiotic therapy is initiated.
Of the following, the MOST appropriate next step is to
A. administer an initial bolus dose of hydrocortisone hemisuccinate 2 mg/kg
intravenously
B. administer 0.9% saline with 10% dextrose 10 mL/kg intravenously over 4 hours
C. administer 3% saline 10 mL/kg intravenously over 4 hours
D. initiate sodium polystyrene phosphonate per rectum every 8 hours
E. restrict fluids to half of the maintenance requirement
9. A 16-month-old girl is brought to the emergency department because of persistent
crying for several hours. She has had clear rhinorrhea, cough, and an undocumented fever
for 3 days. She has had adequate oral intake, has vomited twice, and has had no diarrhea.
She has no underlying medical conditions and no exposures. Current medications include
acetaminophen and an over-the-counter cough and cold medicine. Physical examination
reveals an agitated, crying child, who is inconsolable. Her temperature is 37.8°C, heart
rate is 192 beats/min, respiratory rate is 36 breaths/min, blood pressure is 122/78 mm Hg,
and oxygen saturation is 98%. The remainder of physical examination findings are
normal. Complete blood count, electrolytes, urinalysis, and cerebrospinal fluid studies
yield normal results. Electrocardiography shows sinus tachycardia.
Of the following, the MOST likely cause of this child’s symptoms is
A. acetaminophen overdose
B. early meningitis
C. intussusception
D. myocarditis
E. reaction to cold and cough medicine
10. A 6-year-old boy comes to the emergency department after falling off of the monkey
bars onto his left arm. His left elbow is swollen, ecchymotic, and painful. You splint his
arm, administer parenteral morphine sulfate for pain, and obtain a radiograph. On return
from radiology, his left hand is pale and he complains of worsening pain. He can move
all of his fingers. His symptoms do not improve after you loosen the splint.
Of the following, the MOST likely cause of this boy's findings is
A. anterior interosseous nerve injury
D. cubitus varus
B. brachial artery injury
E. Volkmann contracture
C. compartment syndrome