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PEER VIII: Physician’s Evaluation and Educational Review in Emergency Medicine, Volume 8, Print Edition

PEER VIII: Physician’s Evaluation and Educational Review in Emergency Medicine, Volume 8, Print Edition

Product code :590000

Emergency medicine's gold standard for content review and self-assessment!  The Print Edition comes with separate books for questions and answers.  Please note - the online testing site and CME credit for PEER VIII access expired on October 14, 2016. 

PEER VIII includes:

  • 450 questions 
  • More than 60 images for visual stimuli, many in color
  • A subject index for the "Answers" book
  • A handy "Where's that question about ..." index for the "Questions" book
  • Reference ranges for selected laboratory tests

Frequently Asked Questions

   
"Why didn't you group the questions by category in the book?"
We want PEER VIII to be the closest thing to a real board exam, so we mixed questions from all 20 categories together. But if you want to know which questions are in which categories, and if you want to practice one category at a time using paper answer sheets, go to the "Testing Information" tab below and download the "key" and practice answer sheets.
 
 
 
"How close is PEER to the real exam?"
People who bought PEER VII told us that it was the closest thing to the board exams. PEER is multiple-choice questions. We went from five possibles to four this time because that's the direction ABEM is moving. The questions are based on topics from the "EM Model," and the number of questions in each of the 20 categories reflects the percentages ABEM uses. For example, "Signs, Symptoms, and Presentations" is 9% in the "EM Model," so 40 of the 450 PEER VIII questions are based on topics in that category. You'll also notice that the questions are positively worded, none of those " ... all of the following except ..." constructions, where the right answer is the wrong thing to do (except for the occasional "which of the following is contraindicated ..." question). And all of the possibles really are, well, possible -- no goofy choices or trick questions.
 
PEER likely has more case-based questions than the board exam does, and we're fine with that. PEER is an educational activity, not a test, so it's good to help you apply what you know to a real-life patient encounter. And the explanations in the "Answers" book cover all the possibles, not just the correct answer.
 
Some users have wondered if the same people who write PEER also write the board exams, and some people think that ACEP and ABEM somehow collaborate on the process. Not true. PEER VIII is not affiliated with ABEM. The people who write PEER -- the PEER VIII Editorial Board -- are educators and practicing physicians who are very good at the art and science of item-writing (it's hard), and they've all certainly answered their share of MCQs, but they don't have an inside track on the ABEM exams.

(Based on 4 vote(s))
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Mary Jo Wagner, MD, FACEP, is in her third term as Editor-in-Chief of the PEER content review and self-assessment series.

Dr. Wagner is program director of the emergency medicine residency program for Synergy Medical Education Alliance in Saginaw, Michigan, and a full professor in the Division of Emergency Medicine at Michigan State University College of Human Medicine. Dr. Wagner also practices emergency medicine in two community hospitals. She earned her doctor of medicine degree from Boston University School of Medicine and completed her residency training at St. Vincent Medical Center/The
Toledo Hospital Emergency Medicine Residency Program in Toledo, Ohio. She has been board certified by the American Board of Emergency Medicine since 1992. In addition to the two previous editions of PEER, Dr. Wagner has edited Last
Minute Emergency Medicine, Emergency and Primary Care of the Hand, Foresight, and Critical Decisions in Emergency Medicine. She is on the editorial board for AccessEmergency Medicine.com.

Dr. Wagner has chaired the national ACEP Education Committee, the Educational Meetings Subcommittee, and the Federal Government Affairs Committee and has also served on the Academic Affairs Committee, the Focused Meetings Task Force,
and several other work groups both nationally and locally. She is a past president of the Council of Emergency Medicine Residency Directors.

In 2005, Dr. Wagner was among a group of emergency physicians who worked on Capitol Hill to secure new or extra funding for residency positions after Congress passed the residency redistribution provision. And in 2009, Dr. Wagner received one of the College’s highest honors, the Outstanding Contribution in Education Award, in recognition of her work on behalf of excellence in emergency medicine clinical practice, teaching, and research.

PEER VIII Editorial Board

The American College of Emergency Physicians gratefully acknowledges the contributions of the PEER VIII Editorial Board in the development and writing of the PEER VIII questions and answer explanations.

Mary Jo Wagner, MD, FACEP
Editor-in-ChiefProgram Director
Synergy Medical Education Alliance
Emergency Medicine Residency Program
Saginaw, Michigan
Professor
Division of Emergency Medicine
Michigan State University College of Human Medicine
East Lansing, Michigan

Fredrick M. Abrahamian, DO, FACEP
Associate Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles, California
Director of Education
Department of Emergency Medicine
Olive View-UCLA Medical Center
Sylmar, California

Christopher S. Amato, MD, FAAP, FACEP
Assistant Professor
Department of Emergency Medicine
Mount Sinai School of Medicine
Director, Pediatric Emergency Medicine Fellowship
Medical Director, Pediatric Advanced Life Support, Atlantic
Attending Physician, Pediatric Emergency Medicine
Morristown, New Jersey

John Bailitz, MD, RDMS, FACEP
Emergency Ultrasound Director
Cook County Hospital (Stroger)
Assistant Professor of Emergency Medicine
Rush University Medical School
Chicago, Illinois

Lance Brown, MD, MPH, FACEP
Chief, Division of Pediatric Emergency Medicine
Associate Professor of Emergency Medicine and Pediatrics
Loma Linda University Medical Center and Children’s Hospital
Loma Linda, California

Lynda Daniel-Underwood, MD, MS, FACEP
Assistant Dean for Clinical Site Recruitment
Loma Linda University, School of Medicine
Loma Linda, CaliforniaMichele Dorfsman, MD, FACEP
Associate Professor of Emergency Medicine
University of Pittsburgh Medical Center, Presbyterian Hospital
Assistant Program Director
University of Pittsburgh Residency in Emergency Medicine
Pittsburgh, Pennsylvania

Jonathan Fisher, MD, MPH, FACEP
Assistant Professor
Harvard Medical School
Director of Undergraduate Education
Harvard Affiliated Emergency Medicine Residency
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Boston, MassachusettsHans

Hans Roberts House, MD, FACEP, MAM, DTMH
Associate Chair for Education
Assistant Professor of Emergency Medicine
University of Iowa Carver College of Medicine
Iowa City, Iowa

Linda Regan, MD, FACEP
Associate Director
Emergency Medicine Residency
Johns Hopkins Medical Institutions
Baltimore, Maryland

Tracy Sanson, MD, FACEP
Education Director
University of South Florida Emergency Medicine Program
Associate Professor, University of South Florida
Director, University of South Florida Division of
Global and Emergency Medical Sciences
Director, TeamHealth Professional Emergency
Medicine Liaison Division
Tampa, Florida

Aaron Schneir, MD, FACEP, FACMT
Associate Professor
Division of Medical Toxicology
Department of Emergency Medicine
University of California, San Diego Medical Center
San Diego Division, California Poison Control System
San Diego, California

Jeffrey Tabas, MD, FACEP
Professor
Department of Emergency Medicine
Office of Continuing Medical Education
UCSF School of Medicine
San Francisco, California

Katren R. Tyler, BMBS, FACEM, FACEP
Assistant Professor of Emergency Medicine
University of California, Davis
Sacramento, California

Andrew R. Zinkel, MD
Assistant Professor of Emergency Medicine
University of Minnesota Medical School
Director, Medical Quality Management and Patient
Safety Fellowship
Emergency Medical Director of Quality
Regions Hospital
St. Paul, Minnesota 

Contributors

Dr. Wagner and the PEER VIII Editorial Board gratefully acknowledge the following individuals and organizations who contributed to PEER VIII by donating images, participating in item testing, and providing and reviewing information.

Joshua Broder, MD, FACEP
Esther H. Chen, MD
Antonio Cummings, MD
David Duong, MD
Mark A. Hostetler, MD, MPH, FACEP
Christian Jacobus, MD
Timothy H. Kaufman, MD
Tina Latimer, MD, MPH
Edwin Lopez, MD
Amal Mattu, MD, FACEP
Kelly P. O’Keefe, MD, FACEP
Rianne Page, MD
Robert A. Rosen, MD, FACEP
Christopher Ross, MDRobert C. Satonik, MD, FACEP
Loren Yamamoto, MD, MPH, MBA, FAAP, FACEP

 

EMS Fellow from the University of Pittsburgh Department of Emergency Medicine
Adam Z. Tobias, MD

Resident from the Denver Health Medical Center Emergency Medicine Residency Program
Todd Guth, MD

Resident from the Johns Hopkins Medical Institutions Residency Program
Sneha Shah, MD

Resident from the Loma Linda University Medical Center Residency Program
Vi Am Dinh, MD

Resident from the Naval Medical Center (San Diego) Emergency Medicine Residency Program
Steve Tantama, MD

Resident from the Regions Hospital Emergency Medicine Residency Program
Autumn Erwin, MD

 

Resident from the University of Maryland Emergency Medicine Residency Program
Joshua Moskovitz, MD, MPH

Residents from the Cook County Emergency Medicine Residency Program
Tamara Espinoza, MD
Roderick Roxas, MD
Michael Nelson, MD
Rachel Weiselberg, MD

Residents from the Synergy Medical Education Alliance/Michigan State University Emergency Medicine Residency Program
Edris Afzali, MD*Abdulaziz Alburaih, MD
Adel Alghamdi, MD*
Khaled Alghamdi, MD
William A. Bishop, MD
Thomas Charlton, MD
Mathias Christianson, MD*
Stacey Clark, MD
Jonathon Deibel, MD
Angela Gregory, MD
Roman Hill, MD
Marisa Homer, MD*
Ervin Hunt, MD
Charles Keersmaekers, MD*
Corrine Kvamme, MD
Neil Malhotra, MD
Nicole McCadie, DO
Heather Merrill, MD
Eric Minnihan, MD*
James Mlejnek, MD
Adam Nofziger, MD
Dilnaz Panjwani, MD
Peri Penman, DO
Sameh Sejiney, MD
Saleem Sheikh, DO*
Philip Sloan, MD
Kristy Smith, MD*
Dalkeith Tucker, DO
Tiffany Weiss-Feldkamp, DO*
Diana Yandell, MD*
*Additionally developed Questions book index.

Residents from the University of Iowa Emergency Medicine Residency Program
Sara Burnham, DO
David Dierks, DO
Kathryn Szajna, DO
Amy Walsh, MD


Residents from the University of South Florida Emergency Medicine Residency Program
Nadia Abrahamsen, MD
James Bartlett, MD
Phillip Ryan Coker, MD
Matthew Daniel Fucarino, MD
Tamas Gaspar, MD
Nicholas Nathaniel Healy, DO
Melinda Henry, MD
Lindsay A. Lyon, MD
Molly McIntyre, MD
Raymond Lee Merritt, DO
Deborah Marie Luiken Repaskey, MD
John Elliott Reynolds IV, DO
Nathaniel Ronning, MD
Kant Shah, MD
Kristopher Ryan Sutherly, MD
Sarah Temple, MD
Kimberly Norman Thivierge, MD
Veronica Theresa Tucci, MD
Andrew Brent Wilson, MD

 

Thank you very much for purchasing the eighth edition of the Physician’s Evaluation and Educational Review in Emergency Medicine (PEER) series. This self-assessment educational publication has been used by tens of thousands of emergency physicians since 1974 to review the clinical practice of emergency medicine. For more than 30 years, it has served as a guide to physicians studying for the national board examinations, including the in-training, qualifying, and continuous certification exams.

Over the past 5 years, the emergency medicine board examinations and the technology used to study and take these exams have been changing. As we strive to continue to model PEER after the American Board of Emergency Medicine (ABEM) examinations, we have made changes throughout the text. The questions now contain only four selections for answers, a change that has already been made on the ABEM in-training exam and is being implemented over time for the qualifying and continuous certification examinations. When selecting topics, the Editorial Board chose conditions, presentations, and physician tasks from “The Model of the Clinical Practice of Emergency Medicine,” as well as from the “Table of Specificity”  developed by the American Osteopathic Board of Emergency Medicine. With only a few exceptions, all answer explanations in PEER VIII are supported by and then referenced to at least two of the most up-to-date resources, including textbooks, journal articles, and guidelines developed by national organizations. Although we have worked very hard to ensure that the answers and explanations are as accurate as possible, information in this publication should not be used to make decisions regarding standard of care.

New guidelines from the Accreditation Council for Continuing Medical Education for obtaining CME credit helped guide the development of a different method of using PEER VIII as a testing tool. To obtain up to 55 AMA PRA Category 1 Credit™, you will first have to take a 90-question pretest to establish a baseline score and determine your topic-specific study needs. After that, you will use the books and the practice tests by category to study, and when you are ready, you will take the full 450-question post-test. If you score 75% correct or better, you can generate your CME certificate. If you do not, then you can continue practicing and studying and take the post-test again to achieve the passing grade. You will do the pretest, practice tests, and post-tests via computer, with the format being a close match to the real ABEM computer-based qualifying and certification examinations.

PEER VIII comprises 450 questions, which is 40 more than we developed for PEER VII. As with the last edition of PEER, all questions and images are completely new to allow those of you who used PEER VII to find this edition a new experience. This is a major undertaking for the Editorial Board, but I hope you agree with us that it is well worth the effort. As emergency medicine becomes more facile and dependent on advanced imaging modalities, the national boards and associations are expecting more competence in reading basic pathology on both CT cans and ultrasound images. These have been included here, with explanations in the answers to help identify key image components.

Finally, we have redesigned all the answers so that the discussion of the key component of the topic appears within the first few sentences of the answer explanation. We hope this will help you use the answer book during a quick review before an examination and focus your learning. This will also help us as we move forward in the future with other electronic formats for PEER such as smartphone and other mobile device applications.

We hope this edition of PEER continues to provide a comprehensive format for reviewing the essentials of emergency medicine. As our residents have praised in the past, the Editorial Board and all our contributors have worked hard to make this “the closest thing to taking the Boards.”

Mary Jo Wagner, MD, FACEP
Editor-in-Chief
September 2011
The print edition of PEER VIII is two books, “Questions” and “Answers.” It is designed to help you review the emergency medicine knowledge base and then demonstrate your cognitive expertise on a written board certification examination. We continue to publish PEER VIII in print because it is the format more than 70% of previous users prefer for reading and studying; online and other mobile device formats are in development.

Send questions, comments, or corrections to kEncEmailQFFSWJJJFejupsAbdfq/psh
kEncEmailQFFSWJJJFejupsAbdfq/psh.

 

The following changes have been made to PEER VIII since its October 2011 release:

Question 35 (eff. Fourth Printing)

The following sentence in the question has been revised to, “A 21-year-old woman presents with her third episode of urinary symptoms in the past 6 weeks.”

Question 46 (eff. Fourth Printing)

The following sentence has been deleted from the question: “Physical examination reveals weakness in the left facial muscles, including the forehead."

Question 46 (eff. Fourth Printing)

In the answer explanation, the following bullet was added: “Topical pilocarpine drops should be used to improve aques humor outflow by constricting the pupil only after the IOP is less than 50 mm Hg.”

Question 50 (eff. Third Printing)

In the answer explanation, the sentence that reads, “These are treated with azithromycin” has been changed to, “These are treated with metronidazole.”

Question 60 (eff. Fourth Printing)

In the answer explanation, the following bullet was added: “Topical pilocarpine drops should be used to improve aques humor outflow by constricting the pupil only after the IOP is less than 50 mm Hg.”

Question 61 (eff. Fourth Printing)

In the answer explanation, the sentence that reads “Gonorrhea is treated with a single-dose regimen, either ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally,” has been revised so that the ceftriaxone dose is “250 mg.”

Question 68 (eff. Fourth Printing)

The question has been revised to “When assessing brainstem function in an unconscious patient using the oculovestibular response using cold water, which of the following indicates an intact cortical response?”

Question 82 (eff. Fourth Printing)

The following sentence in the question has been revised to “Vital signs are blood pressure 180/94, pulse 115, respirations 18, temperature 36.9°C (98.4°F), and oxygen saturation 92% on room air.”

Question 103 (eff. Fourth Printing)

In the answer explanation, the sentence that reads, “The infusion of 1 unit of factor VII/kg increases the level by approximately 2%" has been revised to, “The infusion of 1 unit of factor VIII/kg increases the level by approximately 2%."

Question 116 (eff. Fourth Printing)

In the answer explanation, the sentence that reads, “It can diminish the left-to-right shunting and improve overall circulation," has been revised to, “It can diminish the right-to-left shunting and improve overall circulation."

Question 122 (eff. Fourth Printing)

In the answer explanation, the following sentence, "The cornea is injected, but there is no foreign body visualized…” has been revised to "The conjunctiva is injected, but there is no foreign body visualized…”

Question 123 (eff. Fourth Printing)

In the answer explanation, in the sentence that reads “It can be present in a variety of vesiculobullous dermatologic disorders, including bullous pemphigoid, pemphigous vulgaris, staphylococcal scalded skin syndrome, Stevens-Johnson syndrome, and toxic epidermal necrolysis,” “bullous pemphigoid” was deleted.

Question 134 (eff. Fourth Printing)

In the question, the following sentence, "In the intestines, the mebic cysts transform into trophozoites, invade…" has been revised to "In the intestines, the amebic cysts transform into trophozoites, invade…"

Question 140 (eff. Fourth Printing)

In the answer explanation, “synovial” was added so that the sentence reads “The synovial WBC count is significantly elevated (>50,000 WBC/mm3) with greater than 95% PMNs.” Also, the following sentence was added to follow the previous sentence “The significance of the elevation of the synovial WBC count is related to the likelihood of septic arthritis, so levels can be lower than this in early infections of the joints.”

Question 142 (eff. Fourth Printing)

In the answer explanation, the following sentence, "Patients with severe respiratory acidosis such as pH of 7 are likely to fail NPPV…" has been revised to "Patients with severe respiratory acidosis such as pH of 7.0 are likely to fail NPPV…”

Question 159 (eff. Fourth Printing)

The answer explanation was revised to read “The 2010 guidelines from the American Heart Association provide a class I recommendation (level of evidence B) for early invasive therapy (diagnostic angiography with revascularization) for patients with unstable angina/non-ST-segment elevation MI (UA/NSTEMI) who have refractory angina. The patient in this question presents with UA/NSTEMI based on his symptoms and ECG findings of inferolateral ST-segment depression (leads II, III, and aVF, I, aVL, and V4 through V6). If serial troponin levels remain negative, especially if the ST-segment changes resolve with anti-ischemic therapy, then the diagnosis of UA can be made. If a troponin elevation occurs, then NSTEMI can be diagnosed. Appropriate treatment for a patient with UA/NSTEMI includes either a conservative approach with medical therapy and early risk stratification or an immediate invasive strategy. Therefore, activation of the cardiac catheterization laboratory is an acceptable approach, especially in a patient like the one in this question who has persistent pain despite medical management. The ECG shows ST elevation in aVR, that in the setting of ST depression in multiple other leads is consistent with ischemia due to tight stenosis of the left main or 3 vessels. There is high risk for sudden occlusion and death and therefore, these findings are indications for immediate or at least urgent cardiac catheterization with anticipated coronary artery bypass grafting. Because these findings usually do not represent acute ST elevation MI (unless ST elevation is found in the right or posterior leads), thrombolytics are not indicated. An NSAID should not be used in the setting of acute coronary syndrome because of the associated increased risk of death, reinfarction, hypertension, heart failure, and myocardial rupture. Nitroglycerin is of theoretic benefit for cardiac ischemia given that it reduces myocardial oxygen demand while enhancing myocardial oxygen delivery, although a positive mortality benefit from treatment has not been shown. This patient, however, has an absolute contraindication to treatment with nitroglycerin therapy: nitrate use within 24 hours after sildenafil or vardenafil use, or within 48 hours of tadalafil use, has been associated with profound, refractory hypotension, MI, and even death. This patient lacks indications for thrombolytic therapy, which include 1 mm of ST-segment elevation due to MI in two contiguous leads or presumed new left bundle-branch block and ongoing symptoms of less than 12 hours' duration.”

Question 167 (eff. Second Printing)

The question and answer explanation have been replaced as follows:

In which of the following presentations would succinylcholine administration for rapid sequence intubation be the safest?

A. Hemiplegia from a stroke 1 month earlier
B. Major injuries from a burn 1 week earlier
C. Peaked T waves on ECG
D. Renal failure with serum potassium 4.2 mEq/L

The answer is D, Renal failure with serum potassium 4.2 mEq/L.

(Marx, 13-14; Nelson, 992)

Renal failure alone does not predispose to an exaggerated hyperkalemic response; if serum potassium is normal, succinylcholine can be used safely. Agonism of the nicotinic neuromuscular receptor usually leads to a slight (about 0.5 mEq/L) rise, even in renal failure. With hyperkalemia (peaked T waves), the rise can be clinically significant. With certain myopathies and denervation problems, there can be an exaggerated, potentially life-threatening hyperkalemic response. With crush injury, major burn injury, stroke, and spine injury, the predisposition to hyperkalemia from succinylcholine does not occur for approximately 5 days; it resolves when the injury heals or, with stroke or spine injury, in about 6 months. With certain preexisting disorders such as amyotrophic lateral sclerosis, muscular dystrophy, and multiple sclerosis, succinylcholine should not be used. Nondepolarizing neuromuscular blockers are safe in all the presentations described.

Question 172 (eff. Fourth Printing)

In the answer explanation, the following bullet point has been deleted: “Older than 75 years.”

Question 201 (eff. Fourth Printing)

In the answer explanation, the following sentence, "Findings can include cells and flare on slit lamp examination, a swollen optic disc, and an afferent pupillary defect” has been revised to "Findings can include a swollen optic disc on slit lamp examination and an afferent pupillary defect.”

Question 222 (eff. Fourth Printing)

In the answer explanation, “but is generally not tender” was added to the last sentence so that it reads “If she then rubbed her eye, a contact dermatitis could have developed around the eye that is difficult to distinguish from periorbital cellulitis but is generally not tender.”

Question 230 (eff. Fourth Printing)

The question was revised to read “Which of the following diagnostic tests would most likely provide a specific diagnosis to the emergency physician?”

Question 250 (eff. Fourth Printing)

The question was revised to read “What is this a classic presentation of?”

Question 256 (eff. Fourth Printing)

In the answer explanation, “(centrifugal)” and “(centripetally)” has been removed from the following sentences, "From the limbs, they spread centrally (centrifugal)" and "…and the rash spreads from the trunk to the limbs (centripetally).”

Question 260 (eff. Fourth Printing)

In the answer explanation, “umphoelitis” has been revised to “omphalitis.”

Question 263 (eff. Fourth Printing)

In the answer explanation, the following sentence, “Laboratory tests are of limited value…or metabolic alkalosis from profuse diarrhea” has been revised to “Laboratory tests are of limited value…or metabolic alkalosis from prolonged diarrhea.”

Question 264 (eff. Third Printing)

In the answer set, C has been changed from “Intersphincteric abscess” to “Ischiorectal abscess.” The correct answer has been changed to “Ischiorectal abscess,” and the first word of the answer explanation has been changed to “Ischiorectal.”

Question 269 (eff. Fourth Printing)

In the answer explanation, “avoiding loop diuretics (furosemide).” was deleted from the sentence that read “Edema and hypertension are best treated with diuretics, avoiding loop diuretics (furosemide).” Also, the following sentence was revised to read “Patients with significant peripheral edema and hypertension, with pulmonary edema and cardiac failure require aggressive treatment and hospitalization.”

Question 282 (eff. Fourth Printing)

In the answer explanation, “synovial” was added and “100,000/mcL” was revised to “50,000” so that the sentence now reads “Typically, synovial WBC counts are greater than 50,000/mcL and mostly PMNs.”

Question 285 (eff. Fourth Printing)

In the answer explanation, the second sentence that reads, “Most of these fractures heal well with pain control and immobilization with either a simple sling or a figure-of-eight harness” has been revised to “Most of these fractures heal well with pain control and immobilization.”

Question 288 (eff. Fourth Printing)

In the answer explanation, the sentence that reads, “The PERC rule includes the following: age younger than 50 years; heart rate lower than 10 beats/min…” has been changed to, “The PERC rule includes the following: age younger than 50 years; heart rate lower than 100 beats/min...” This change took effect in the third printing.

In the answer explanation, the last sentence that reads, “This patient should undergo D-dimer testing because she is low risk for PE but positive for one of the PERC (tachycardia)” has been revised to “This patient should undergo D-dimer testing because she is low risk for PE but positive for two of the PERC (tachycardia and oral hormone use).”

Question 296 (eff. Third Printing)

In the answer explanation, the sentence that reads, “...pulse less than 125 or respiratory rate greater than 30; and systolic blood pressure less than 90” has been changed to “…pulse less than 125 or respiratory rate less than 30; and systolic blood pressure greater than 90.”

Question 298 (eff. Fourth Printing)

 In the answer explanation, the last sentence that reads, “Blood from the lungs and pulmonary tree appears dark red” has been revised to “Blood from the lungs and pulmonary tree appears bright red.”

Question 299 (eff. Fourth Printing)

In the answer explanation, the last sentence that reads, “Radiographs of malrotation demonstrate air-fluid levels and occasionally a double bubble sign” was revised to read “Radiographs of malrotation demonstrate air-fluid levels over the liver with a paucity of gas distally in the small bowel and occasionally a double bubble sign.”

Question 315 (eff. Fourth Printing)

 In the answer explanation, the sentence that reads, “Any patient with a nasal pack should be given antibiotic prophylaxis to prevent streptococcal infection and…” has been revised to “Any patient with a nasal pack should be given antibiotic prophylaxis to prevent staphylococcal infection and….”

Question 317 (eff. Fourth Printing)

The question and answer explanation have been replaced as follows:

A 20-year-old man is brought to the emergency department by ambulance. He was the unrestrained driver in a single-car crash and was ejected after the car hit a tree. There is an odor of alcohol on his breath. He does not remember what happened and complains of chest and abdominal pain. Vital signs include blood pressure 78/48, pulse rate 122, respiratory rate 16, and temperature 37.5°C (99.5°F). His neck veins are flat. What is the most likely cause of the hypotension?

A.        Cardiac tamponade
B.        Hypovolemia
C.        Spinal shock
D.        Tension pneumothorax

The answer is B, Hypovolemia.

(Marx, 244-250, 373, 393-396, 403-406; Tintinalli, 1671-1676)

This trauma patient presents with uncompensated shock identified secondary to tachycardia and hypotension. Hemorrhagic shock should be assumed to be present in any hypotensive trauma patient until proved otherwise. With chest and abdominal complaints and the history of significant trauma, therefore, the most likely cause of this patient’s hypotension is hypovolemia. Other causes of hypotension include spinal shock and hypotension due specifically to decreased venous return to the heart from a tension pneumothorax or cardiac tamponade. Spinal shock presents with bradycardia and hypotension and is the result of autonomic tone and paralysis caused by a spinal cord injury; it is not due to head injury or intracranial bleeding as might be suspected in a patient with altered sensorium. Tension pneumothorax presents with distended neck veins and tracheal deviation and can present with tachypnea and decreased breath sounds over the side of the pneumothorax. Cardiac tamponade presents with distended neck veins unless the patient has profound concomitant hypovolemia. This patient's neck veins are collapsed, consistent with hypovolemia or hemorrhagic shock.

Question 321 (eff. Fourth Printing)

In the answer explanation, the sentence that reads, “…includes broad-spectrum antibiotics (aminoglycoside and second-generation cephalosporin), fluid….” has been revised to “…includes broad-spectrum antibiotics, fluid…”

Question 328 (eff. Fourth Printing)

In the answer explanation, the sentence that reads, “Side effects related to increasing doses of dopaminergic agents include nausea, vomiting, orthostatic, dysrhythmias, and acute psychosis” has been revised to “Side effects related to increasing doses of dopaminergic agents include nausea, vomiting, orthostatic hypotension, dysrhythmias, and acute psychosis.”

Question 363 (eff. Fourth Printing)

In the answer explanation, the word “Anterior” has been deleted from the first sentence.

Question 390 (eff. Fourth Printing)

Foil A was changed to “Intravenous macrolide.” In the answer explanation, the sentence that read “The answer is A, Intravenous erythromycin” has been changed to read “The Answer is A, Intravenous macrolide.” Also, the sentence that read “Nonetheless, intravenous administration of a macrolide antibiotic such as erythromycin is recommended to minimize…” has been revised to “Nonetheless, intravenous administration of a macrolide antibiotic such as erythromycin or azithromycir is recommended to minimize…”

Question 395 (eff. Fourth Printing)

In the answer explanation, the sentence that reads “The treatment of choice is doxycycline 100 mg twice daily for 7 to 10 days” has been replaced with “The CDC recommends doxycycline for children, as the staining of teeth has not been seen with the recommended dose and duration.”

Question 413 (eff. Fourth Printing)

In the answer explanation, the first sentence that reads “When a digit is amputated at multiple levels or is in many pieces, crushed, contaminated, or otherwise compromised…” has been revised to “When a digit is amputated at multiple levels (ie, from the hand and in more than one piece) or is in many pieces, crushed, contaminated, or otherwise compromised...”

Question 433 (eff. Fourth Printing)

Foil A was revised to “Blindly clamping a vessel is the best way to gain control of active bleeding.”

Question 436 (eff. Fourth Printing)

In the answer explanation, the sentence that reads “On plain radiographs, malrotation is associate with paucity of small bowel air, and NEC is characterized by diffusely dilated loops of small bowel” has been revised to read “On plain radiographs, malrotation is associate with a paucity of distal small bowel gas with dilated loops proximally over the liver.”

Question 440 (eff. Fourth Printing)

In the answer explanation, the sentence that reads “Petechiae can be seen of the soft palate in patients with pharyngitis from several causes and does not distinguish one etiology from another” has been revised to read “Petechiae can be seen of the soft palate in patients with pharyngitis from several causes, most commonly a beta-hemolytic streptococcus, but do not distinguish one etiology from another.”



Publisher :  ACEP 
Published   2011 
Pages :  Questions 170
Answers 282 
Format :  Spiral bound, 2 book set
Dimensions :  8.5 x 11

The print edition of PEER VIII is two books, “Questions” and “Answers.” It is designed to help you review the emergency medicine knowledge base and then demonstrate your cognitive expertise on a written board certification examination.

We published PEER VIII in print first because it is the format more than 70% of users prefer for reading and studying. 

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Case Study #1

A 48-year-old prison inmate is brought in for evaluation of what he thinks is a spider bite, as shown in the picture. What is the best course of treatment?

A.  Contact the poison center to arrange for Loxosceles reclusa antitoxin

B. Request a surgical consultation for wide excision of the lesion

C.  Start oral dapsone and topical antibiotic therapy and refer to general surgery

D.  Start oral trimethoprim-sulfamethoxazole with routine local wound care

The answer is D, Start oral trimethoprim-sulfamethoxazole with routine local wound care.

(Liu, 1-38; Marx, 753, 1837; Moran, 666-674)

 

This patient likely has an abscess with surrounding cellulitis from MRSA infection rather than a spider bite. Complicated abscesses and cellulitis can be managed with oral trimethoprim-sulfamethoxazole or clindamycin and close followup care. For more severe infections or when close observation is not possible, admission for intravenous vancomycin treatment is indicated. Simple abscesses, even those caused by MRSA, can be adequately treated with incision and drainage alone. Many patients with MRSA skin infections assume that they have been bitten by spiders. In fact, in a multivariate logistic regression analysis of 422 patients with MRSA skin infection, the three historical factors most strongly associated with positive cultures for MRSA were close contact with a person with a similar infection, history of MRSA infection, and reported spider bite. A history of incarceration or participation on a sports team is considered a risk factor for MRSA infections as well. The ulcerating, progressive abscess common in MRSA skin infections can resemble the necrotic, volcanic ulcer caused by the bite of the brown recluse spider (Loxosceles reclusa). But skin infections with MRSA are far more common than brown recluse spider bites and tend to be associated with multiple small furuncles near the main lesion, whereas a brown recluse spider bite is almost always solitary. True brown recluse spider bites pose a management challenge. There are several suggested regimens available, but immediate wide surgical excision is not recommended. Routine wound care with close followup care is a reasonable initial approach. Dapsone has been shown to reduce systemic symptoms of the bite and limit the size of the lesion at the bite location. An antivenin for Loxosceles is produced in Brazil but is not available in the United States.

 

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gregg From EBYMZ
online version shows the right answer with the question
April 06, 2016
I was looking for an online version of PEER VIII that would show me the question and force me to answer it so that I could assess my performance & areas of weakness. It doesn't seem like this product actually does that.

My understanding is that the online version displays the correct answer & explanation at the same time it shows the question. It's not a true online self-assessment test. It would be nice if future versions of Peer VIII online allowed for a more realistic test-taking experience.
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