PEER=eVIT Physician’s Evaluation and Educational Review in Emergency MedicineHow to Use PEER VII ‘Thank you for purchasing PEER VIL: Physician’ Evaluation and Educational Review in Emergency Medicine, Volume 7. We hope you will ind st to be a valtable tool for cantent review and selL-assessment. And we welcome your opinions. If you have comments or suggestions, please e-mail us at ACEPBookstore@acep org. Please read all of the information on pages vii-x before you begin PEER VII. Why do emergency physicians need PEER VII? Emergency medicine is a patient-driven “24/7” specialty practiced in small, rural hospitals, ‘community and suburban medical centers, large, urban, university-based tertiary care centers, and. other facilites to which patients present for emergency medical care. The emergency medicine “body of knowledge” crosses all other specialties, and the patients come from all age groups and sociceconomtc backgrounds, presenting with conditions that range from primary care to life threatening. For these reasons, emergency physicians must be prepared to care for patients of any age at any time with any condition at any acuity. Continuing medical education (CME) helps ensure that emergency physicians are knowledgeable and skilled in the diagnosis and treatment of essentially any emergency medical condition. Additionally, all emergency physicians who are certified by the American Boatd of Emergency Medicine (ABEM) must participate in the Emergency Medicine Continuous Cemification program to maintain their certification. One component of this program is the continuous certification examination (“ConCert exam”), which. ‘most ABEM diplomates take in the tenth year of their certification cycles. Although emergency physicians typically complete enough CME programs every year to meet their state licensure requirements and stay up-to-date on information they need to provide quality patient care, most accelerate their study programs to prepare for the ConCert exam. These study programs, ideally would provide an overall review of the emergency medicine body of knowledge and a mechanism for self-assessment that identifies areas of weakness for additional study. How does PEER VII meet this need? PEER VIlis designed to establish a “baseline” score using a pretest, to provide materials for study, and to improve cognitive expertise as evidenced by post-test scores. It isa self-contained, portable (CME program that can be completed as designed in about 25 hours. It is wo books—Questions, and Answers. Each question is designed to assess emergency physicians’ cognitive expertise related. toa topic from “The Model of the Clinical Practice of Emergency Medicine” (the “EM Model”). The number of PEER VII questions per EM Model category (eg, Cardiovascular, Trauma, Procedures and Skills, and so on) reflects the “weight” each category is assigned within the EM Model. So for example, Cardiovascular Disorders, with weight of 10% within the EM Model, comprises 41 of the 410 questions in PEER Vl A category with a smaller weight, such as Cutaneous Disorders, comprises fewer questions. All 410 PEER VII questions are answered in the Answers book. Each answer has an explanation of the correct answer—and the incorrect answers—and. provides additional information related to the tepic. The answer explanations are drawn from. major emergency medicine textbooks, key journal articles, and other selected readings. And because PEER VII was developed in accordance with the guidelines of the Accreditation Council for Continuing Medical Education, physicians who complete it as designed can receive CME cenificates for Category 1 credit Who should use PEER VII? PEER VIL is designed for all emergency physicians at any time of their careers, whether for overall content review and self-assessment or to prepare for the ConCert exam. I is also of value to emergency mecicine residents, especially as they prepare for the annual in-training examination and the board certification qualifying examination, However, all health care professionals who care for patients in emergency departments will benefit from reading and studying PEER VII because it reflects the “core content” of emergency medicineMethod of Participation ‘To complete PEER VII as designed and receive a CME certificate and a report of your scores, complete te following steps of the PEER Vil Pretest, Assessmert, Study, and Post-Test and Evaluation process: Pretest + Read the PEER VII questions starting on page 1 + Choose your answers to the questions “closed book’ firs (without referring to the Answers book} + Record your answers on one of the twa pretest answer sheets, as follows The answer sheet on pages x-xii has spaces to record your answers in the same order that the questions appear in the hook. This isthe more efficient way to complete the pretest and calculate your overall pretest score © The answer sheet on pages xiii-xvi has spaces to record your answers grouped by EM Mosel category: If you use this answer sheet, you'll be jumping around in the Questions book more, but ‘you'l also be able to see how you performed in each of the 20 EM Model categories and calculate ‘your overall pretest score, Assess + Check your answers against the correct answers in the Answers book + Caleulate your pretest score. Keep in mind: this score is simply a measure of your cognitive expertise atthe beginning of this CME activity: You will not report this score to ACEP, and it has ro bearing on your receiving a CME certificate. Study + Read and stady the answer explanations in the Answers book, + You'l see that each correct answer is explained and that supposting references are cited. + You'll see that the “foils” are addressed as well. So each answer explanation is a “mini-essay” on cone of the EM Model topics, + PEER VIL is designed this way to expand or refresh your knowledge well beyond a specific answer to aspecific question. For example, many of the questions that ask you to identify a diagnosis are answered and explained with additional information on diagnostic testing and ‘management. Many questions on appropriate management of @ condition include explanations of pahophysiology and differential diagnosis. And many describe accepted choice of antimicrobial therapy with information on both first-line and second-line choices + Finally a laige percentage of the questions in PEER VII are case-based—most likely a larger percentage than would appear on a certification exam, The questions are designed this way because PEER VII is an educational activity, not atest, and as such should be practical and problem-centered. There are, of course, some “level 1” questions in PEER VIJ, those that requie basic recall of facts. But the majority of PEER VII questions are designed to capitalize on your knowledge and experience and ask you to apply them to realistic patient care scenarios. Post-Lest and Evaluation + When you'e finished studying, go back to the Questions book, + Answer the questions again, but this time, record your answers on the purple Scantron answer sheet, as follows: Print your name and address clearly in the indicated area, We'll use this information to mail you your score report and CME certificate + Record your 6-digit ACEP ID number in the spaces provided. You can find this number on your packing list or, i you're an ACEP member, on your ACEP member ID card. Please be ‘sure to use “0” when appropriate. Do not include the “A.” © Use a No, 2 pencil to mark your answers to the questions on the Scantron form. Do not put marks outside the grids. Erase all changes completely © Mail your completed Scantron form unfolded in the enclosed preaddressed envelope. © Resure to answer all 410 FM Model questions and the 18 evaluation questions (411-428) ACEP carnot award you a CME certificate unless you answer all 428 questions on the Scantron form. + When we receive your completed Scantron form. we will score it and generate a score report for you. It will show your overall score, along with your score in each of the 20 categories—all of ‘which shovld reflect improvernent over your pretest score. Please allow at least 6 weeks for your score repor to be mailed to you willContinuing Medical Education Credit Information Release date: October 15, 2008 Expiration date: Ociober 15, 2009 Learner Objectives (On completion of PEER Vil, you should be able to: + Describe typical and atypical presentations of conditions listed in “The Model of the Clinical Practice of Emergency Medicine.” + List the differential diagnoses for these conditions and develop appropriate plans for diagnostic testing, treatment, and disposition + Explan key procedures and skills that are use in the treatment of emergency department patients. + Discuss a variety of administrative issues related to the practice of emergency medicine. + Assess your cognitive expertise related to topics listed in “The Model of the Clinical Practice of Emergency Medicine” and address areas that require additional study. + Demonstrate that expertise by successful performance on a knowledge-based examination of the emergency medicine core content. Designation Statement ‘The American College of Emergency Physicians (ACEP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide contin:uing medical education for physicians. ACEP designates PEER VII: Physician’ Evaluation and Educational Review in Emergency Medicine, Volume 7, for a maxinrum of 50 AMA PRA Category 1 credits". Physicians should only claim credit commensurate with the extent of their participation in the activity Approved by ACEP for 50 hours of ACEP Category I credit. Application has been made to the American Osteopathic Association for AOA Category 1-B credit. Disclosures The names and affiliations of the editor-in-chief, all editorial board members, contributors, and staff are listed on pages iii and iv Please note that, in accordance with ACCME Standards and ACEP policy, all persons wio are in a position to control the content of this educational activity ‘must disclose to participants the existence of significant financial interests in or relationships with ‘manufacturers of commercial products that might have a direct interes: in the subject matter. Dr. Brown discloses that he isa co-editor of a pediatric emergency medicine textbook for Elsevier, In. Dr. Abrahamian, Dr. Blankenship, Dr. Daniel-Underwood, Dr. Dorfsman, Dr Effron, Ms. Foster, Dr. House, Dr. Michelson, Dr. Saionik, Dr. Schneir, Dr. Sokolove, Dr. Tyler, and Dr. Wagner have no significant financial interests or relationships to disclose.Disclosures (continued) ACEP expects all authors and editors to present information in an objective, unbiased manner ‘without endorsement or criticism of specific products or services. ACEP also expects that the relationships contributors disclose will not influence their contributions, In PEER VI, in most cases, drugs and devices are referred to by their generic names, in accordance with ACCME and ACEP policy. Ina few cases, however, brand names do appear for the sole purpose of clanfication or easier recognition or more realistic description of a scenario. In no instance isa drug or device listed by a brand name for a commercial purpose, No person who was ina position to control the content of PEER VII disclosed a relationship with a manufacturer of any nig or device referred to by its brand name. Finally, no member of the PEER Vil Editorial Board or any person who was in a position to control the content of PEER VIl is afiiated with ABEM as an item writer or examiner or in ary other capacity related to the development of the ConCert exam. Any similarities between questions and answers in PEER VII and those that appear on the ConCert exam are purely coincidental.PEER VII Pretest je 35, 6a fre’ 36 70L_ pay 4 38. Pin Fees Sa, HLS 6 4H — Ae BH fea Bo TM a a No 6 MH Be. fix, BL. Bo 7 Bh a a ae ee Wo BI 16.___ 50, 8t___ _ SL 85.__ 18. Su, = BOL, Wes Sinn Bis 20, a 21, 558 Me S625 BO 2 7 24 5B 9 25 a a: a a MW 6H Bo 6H Bao B38 HLL 3 $B 3 5 Re.” Ba, AL Bo Si, Hig 34. 68. 302. 103,__ lot 105, 106._ a 108, 109, uo, Wis 172. 173. 174. 175.__ 176.__ WW. 178. 179.__ 180. 181 182 183, 184, 185. 180, 187. 188, 189. 190. 191.__ 192. 193. 194. 195. 196. 197, 198. 199. 200,__ Hi 202. 203. 204,205. 206. 207. 240,_ 241 242. 243. 244, 245. 246.__ 247, 248, 249, 250, 251 252.__ 253. 254, 255, 256 257. 258. 259.__ 260. 261, 262.___ 263, 264, 265._ 266, ter. 208, 269. 270.___ 2 272,__ 273, 274, 345 346. 347. 348, 349, 350, jn 392, 353, 354 395, 356. 387, 358, 359,__ 360, 361 362. 363, 364 365. 366. 367, 368. 309, 370. 371 372, 373, 374, 375, 376, 377. 378, 379, 406,__ 407, 408, 409,__ #10,PEER VII Pretest by Category 0, Signs, Symptoms, and Present: 1 MO 238 324K ST 1 6857329 373.___ 36. Bln Be So» 374 90. a a No 8 HHT 8 WKB 8K 2.0, Abdominal and Gastrointestinal Disorders 2 ML _39,___ 20. MLB 82 HH 37. 6850 34 wo 2303325, 254 n 24299 330.88 a1 96258 80TH 382 3.0, Cardiovascular Disorders 3 br 249 ___ 359. 300. 38. WH 368293 55 wr 826 370.__ 294, 92 We. Bias Bi, Hes Wa, 93. Bi BW) Bee Biles, Bs 26.30 BKB 40. W385. 387___ 4.0, Cutaneous Disorders Me Bh Gi. Mo 56. Si Sk 5.0, Endocrine, Metabolic, and Nutritional Disorders 4 39. m, 128 158. 184. 22.__ 7. SB 481. xilt6.0, Environmental Disorders 5 40, 7, 13, 14 185 23, 58, 96, 129, 159. 198, 7.0, Head, Ear, Eye, Nose, Throat Disorders Sse 7 8828, Mo 20. 250288. 52 30,200. 7145, 2Bl___—_268, 301 8.0, Hematologic Disorders 1 41 7. 1s, 25, 60. 98, 146 9.0, Immune System Disorders 8 42, 78, BI 26, 61 99. 200, 10.0, Systemic Infectious Disorders a | a | a 2, 100 61__— 232,289, Bo M6295, ou, 186. 2ol___— 302 11.0, Musculoskeletal Disorders (Nontraumatic) 10. 80. 133. In. 406. 28 101 148, 187 63. uy. 162 213 xiv12.0, Nervous System Disorders i 81. 149,__ 214. 262. 407. 29 ton 1B 33, 270 oe 118. 188,__ 242. 271 Cn > 13.0, Obstetrics and Gynecology Ro 6s 2m 30. 82 3 46. 103. 174. 234. 263. 14.0, Psychobehavioral Disorders Bo 4 8 8, 360. 391 a 66. 104. 365. 386, 409. 15.0, Renal and Urogenital Disorders 4 84 151 190 372 Wa a : | 164.__ Ole s 48 no 175, 215. 16.0, Thoracic-Respiratory Disorders 5120 ne aes 323, 347 a 135. Cees 290. 327, 351. APs 152. 244 296, 332, 375. 1s 234. 303.__ 336 85 191 264. 340 W208 KL xv11.0, Toxicologic Disorders 6. 107 312, 225 50. 121 165 204 236 86. B67 ar 245 18.0, Traumatic Disorders : 154 255, 319. 366 401 33, 166. 337. 378. 402. 5 178 341 385, 403 195 344 388 405, 205291 348 380 408, 218 297 392 302 122. 226. 304 356 396, br 246, 314 360, 398 Appendix 1, Procedures and Skills 109 199. wr 309 32, 123 206 256. 9 138, 219 266 72, 179. 227. 276. 88, 194. Br, 286. Appendix 2, Other Components 18 33 89 139, 167, 207 35 7 at 155 180, 410PEER VIL A 52-yearold woman presents complaining of generalized fatigue and weakness for the past week, She admits to a 40-pack-year history of smoking and occasional alcohol use. Over the past several weeks she has noticed that her clothes have become loose fitting and that she has lost 20 pounds. Physical examination is unremarkable except for an intermittent, hacking cough. A chest radiograph demonstrates a mediastinal mass, and serum clecirolytes are as follows: sodium, 116 mEq/L; potassium, +.7 mEq/L; chloride, 90 mEq/L; bicarbonate, 18 mEq/L; BUN, 10 mEq/L; and creatinine, 0.6 mEq/L. What is the most appropriate initial management? A. Demeclocycline Fluid restriction Hospital admission Hypertonic saline Intravenous furosemide moos A 46-yearold woman presents with constant abdominal pain with associated nausea that started 8 hours earlier. She appears nontoxic and is lying still on the bed. Blood pressure is normal; pulse rate is 95, respiratory rate is 16, and temperature is 37.8°C (100°F). Physical examination is remarkable for RUQ and epigastric tenderness 1o palpation without rebound or guarding. Laboratory test resulls reveal elevated ALT, AST, and alkaline phosphatase, normal lipase and total bilirubin, and a negative urine hCG. The next most appropriate management step is: A. Acute abdominal series B. CT scan C. General surgery consultation D. Oral cholecystography FE, RUQuttrasonography