ROSH Review ER | Questions & Answers (100 %Score) Latest Updated 2024/2025
Comprehensive Questions A+ Graded Answers | With Expert Solutions
A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and
between his fingers after returning home from summer camp 1 week ago. He reports
several other campers had similar symptoms. On exam, you note excoriations in the
inguinal region and axillae surrounding scattered, erythematous papules. Which of the
following is the most appropriate treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - Correct Answer ( C )
Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the
mite Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and
should be considered in patients with generalized pruritus, especially when exposure to
others with similar symptoms is reported. The rash of scabies involves papules, which
are often excoriated. Burrows are pathognomonic but not uniformly present. Unless
previously infected, pruritus generally takes 3-6 weeks to develop because symptoms
are due to delayed (Type IV) sensitivity reaction. The pruritus is classically worse at
night and affects the web spaces of the fingers, flexor aspect of the wrists, axillae, groin,
nipples, and the periumbilical region. Except in cases involving an immunocompromised
host, the scalp and face are generally spared. Diagnosis is clinical but can be confirmed
by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic
examination. The treatment of choice for primary scabies infection is the application of
topical scabicidal agents, with repeat application in 7 days. The treatment of choice is
permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact
with others. Patients with typical scabies may return to school or work 24 hours after the
first treatment.
Should family members of an infected individual also be treated for scabies? - Yes,
family members and sexual contacts.
Scabies - Sarcoptes scabiei
Pruritic rash worse at night
Linear burrows
Interdigital spaces of hands/feet, penis, breasts
Permethrin (first line)
Ivermectin
**head and back are sparred
(head involved in children)
,An 18-month-old boy presents to the emergency department with worsening shortness
of breath. The parents report he has had a cough, runny nose, and fussiness for the
past five days. On exam, the patient demonstrates subcostal retractions, tachypnea,
and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any
improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the
following organisms is the most likely cause of his symptoms?
Bordetella pertussis
Haemophilus influenzae
Parainfluenza virus
Respiratory syncytial virus - Correct Answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection
in patients less than two years of age. It remains the leading cause for hospitalization in
infants under one year of age. Bronchiolitis is most commonly caused by respiratory
syncytial virus (RSV), but may be caused by other viral agents. Bronchiolitis is
inflammation of the lower respiratory tract, which involves edema, epithelial cell
necrosis, bronchospasm, and increased mucus production. The resultant lower airway
obstruction causes increased work of breathing and wheezing. Bronchiolitis is a clinical
diagnosis based on age under two years old, rhinorrhea, tachypnea, and wheezing.
Unlike asthma or reactive airway disease, there is often no significant improvement with
albuterol. There is often a history of several days of upper respiratory symptoms, such
as rhinorrhea, mild cough, and mild fever. Rapid antigen tests, blood work, and
radiographs are not usually needed. Radiographs may demonstrate hyperinflation and
atelectasis, but do not show any focal infiltrates like with pneumonia. Bronchiolitis is
usually self-limited, with respiratory status typically improving over 2-5 days.
Management involves supportive care.
Bronchiolitis -
What months of the year contain the peak incidence of RSV in North America? -
November to March.
A 76-year-old man presents to the emergency department with shortness of breath and
lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124
beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has
distended neck veins and occasional dropped radial beats. His lungs are clear to
auscultation, but his heart sounds are distant. He has some fullness to palpation of the
right upper quadrant of his abdomen. Which of the following is the most appropriate
diagnostic test?
Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - Correct Answer ( A )
Explanation:
,This patient presents with a clinical picture consistent with obstructive shock. His
distended neck veins, full right upper quadrant, muffled heart sounds, and hypotension
are all consistent with pericardial tamponade. A pericardial sac slowly accumulating fluid
can stretch without obstructing cardiac function. Tamponade occurs when rapid fluid
accumulation results in elevated pressures that inhibit venous return. This is a dynamic
process over the course of the cardiac cycle, therefore bedside echocardiography is the
diagnostic test of choice. Fluid around the heart with evidence of right atrial
compression and right ventricular diastolic collapse are diagnostic of pericardial
tamponade.
Pericardial Effusion -
What is the emergent treatment of pericardial tamponade? - Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with
diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency
department, she develops acute onset headache, right sided facial droop and right arm
weakness. A CT scan confirms the diagnosis. Which of the following is the next best
step in management?
Alteplase
Exchange transfusion
MRI brain
Tranexamic acid - Correct Answer ( B )
Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient
developed symptoms concerning for acute ischemic stroke. For pediatric patients with
acute ischemic stroke in the setting of sickle cell disease, exchange transfusion is the
treatment of choice. Transfusion goals include decreasing hemoglobin S levels to less
than 30% and obtaining a total hemoglobin level of 10 g/dL. For adults with acute
ischemic stroke in the setting of sickle cell disease, consider tissue plasminogen
activator (tPA). tPA is not indicated or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage.
Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric
hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell -
What is the most common bacterial cause of acute chest syndrome in adults with sickle
cell disease? - Atypical bacteria such as Chlamydia pneumoniae, Mycoplasma
pneumoniae, Mycoplasma hominis.
Correct Answer ( B )
Explanation:
, The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results
when multiple areas of the atrial myocardium simultaneously depolarize and contract.
As a result, the atrial walls do not contract in a coordinated fashion, but rather "quiver"
or "fibrillate." The electrocardiographic hallmarks of atrial fibrillation are a narrow,
complex, irregularly irregular rhythm and no discernible P waves. The rate may be slow,
normal, or fast. Atrial fibrillation is usually associated with ischemic or valvular heart
disease, and can also be seen in cardiomyopathies, myocarditis, and thyrotoxicosis.
Patients with atrial fibrillation may be asymptomatic, or may complain of palpitations,
dizziness, lightheadedness, chest pain, or dyspnea. Patients in whom atrial fibrillation
results in a rapid ventricular rate may develop clinical heart failure due to inadequate
ven - A 52-year-old man with a history of diabetes mellitus and hypertension presents to
the ED with palpitations and dyspnea that have been present intermittently over the past
week. His vital signs include HR 135 beats/minute, blood pressure 136/87 mm Hg, RR
15 breaths/minute, and oxygen saturation of 97% on room air. His electrocardiogram is
shown above. Which of the following is the most appropriate initial management?
Administer intravenous adenosine
Administer intravenous diltiazem
Sedate the patient and perform synchronized cardioversion with 100 joules
Transport the patient to the cardiac catheterization suite
Afib Image -
What are options for outpatient anticoagulation for atrial fibrillation? - Warfarin or new
oral anticoagulant drugs (e.g., dabigatran, rivaroxaban, apixaban).
A 65-year-old man with a past medical history of hypertension presents to the
Emergency Department with "tearing" chest and abdominal pain radiating towards his
back. His blood pressure is 185/98 mm Hg. Which of the following medications should
be administered first?
Aspirin
Esmolol
Heparin
Nitroprusside - Correct Answer ( B )
Explanation:
Esmolol is the first line treatment for a hypertensive patient with an aortic dissection.
Rate-controlling medication (e.g. esmolol) should be given before vasodilators to
prevent reflex tachycardia and subsequent increase in aortic shearing forces. An aortic
dissection occurs when the intima tears allowing blood to cause a false channel and
intramural hematoma. If this extends to the heart it can precipitate myocardial infarction,
severe aortic regurgitation, or pericardial tamponade leading to death. Risk factors
include a history of hypertension, collagen vascular disease or aortic aneurysm, as well
as current pregnancy and cocaine use. Based on the Stanford classification, a
dissection is classified as type A if it involves the ascending aorta while a type B
dissection is limited to the descending aorta. Treatment of a type A dissection requires
surgical management while type B dissections are typically managed medically
