Emergency EOR Rosh

Erythromycin (D) oral and ophthalmic ointment is the treatment for chlamydial ophthalmia neonatorum, or chlamydial conjunctivitis, caused by the bacteria Chlamydia trachomatis. In contrast to gonococcal conjunctivitis, it presents between 5 days and 5 weeks of age.

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Anal fissure

45-year-old man with severe rectal pain when he defecates, lasts for several hours, and subsides until the next bowel movement. He has been constipated for the past 6 months and when he does have a bowel movement the stool is covered with bright red blood. A sentinel pile is noted on the physical exam.

Impetigo Tx: - Mupirocin tid and retapamulin bid x5 days are first-line topical treatments - Cephalexin 500 mg QID and dicloxacillin 500 mg QID are appropriate first-line oral treatments

5-year-old girl with crusting facial lesions present for 3 days. The mother reports that prior to the development of the facial lesions her daughter was scratching at insect bites. Examination reveals a red facial rash with a golden "honey-colored crust" and pruritus. Diagnosis? Tx?

Correct Answer ( D ) Explanation: Nasal suctioning is the first step in management for a child presenting with bronchiolitis. Bronchiolitis is a viral infection of the lower airways most commonly caused by respiratory syncytial virus respiratory. Inflammation of the lower respiratory tracts leads to edema, bronchospasm, and increased mucus production within the bronchioles. The resulting increase in airway resistance leads to respiratory distress and increase work of breathing. Since infants are obligate nasal breathers, and the nasal passages account for 50% of airway resistance, nasal suctioning is essential in helping decrease work of breathing. In addition to nasal suctioning, supplemental oxygen should be administered for oxygen saturation below 90%.

A 1-year-old boy presents to the ED with shortness of breath and cough. Vital signs are BP 90/60 mm Hg, HR 110 beats per minute, RR 40 breaths per minute, oxygen saturation of 91% on room air, and T 97.5°F. Physical exam reveals intercostal retractions, rhinorrhea, and wheezing. Which of the following is the most appropriate next step in management? · A Administer nebulized albuterol · B Administer racemic epinephrine · C Endotracheal intubation · D Nasal suctioning

Correct Answer ( B ) Explanation: This patient's presentation is consistent with acute bacterial parotitis. Risk factors for parotitis include old age, sialoliths, neoplasms, Sjögren's syndrome, HIV, anorexia, and bulimia. This patient's fever is an indicator of severe infection that is unlikely to respond to oral antibiotics. Other indicators include leukocytosis and significant comorbidity (e.g. immunosuppressed). Additionally, the patient's degree of swelling is concerning for possible extension into the deeper structures of the neck. Notable complications of parotitis include airway compromise, Lemierre's syndrome, and facial nerve palsy. Bacterial causes are often polymicrobial with Staphylococcus aureus, Streptococcus viridans, and Eikenella corrodens compromising commonly cultured pathogens. Antibiotic choice must cover for Staphyloccocus with consideration for MRSA coverage if the patient has any risk factors (e.g. prior MRSA infection or nursing home resident). Ampicillin/sulbactam is available in IV formulation, has broad spectrum coverage, and is first-line therapy for bacterial parotitis.

A 13-year-old girl presents complaining of sudden onset right-sided facial swelling associated with a foul taste in her mouth. Physical exam reveals an underweight teenage girl. She has difficulty opening her mouth and the oropharynx is clear without swelling or exudates. There is swelling and tenderness to the right preauricular space, extending beyond the angle of the mandible. Temperature is 39.7°C, blood pressure is 114/64 mm Hg. Which of the following is the most appropriate treatment for this patient? · AAmoxicillin/clavulanate · BAmpicillin/sulbactam · CCephalexin · DMoxifloxacin

Correct Answer ( B ) Explanation: This patient is exhibiting signs and symptoms consistent with black widow spider envenomation. The black widow spider can be identified by the red hourglass shape on its ventral abdomen. Signs and symptoms of envenomation include autonomic instability with hypertension and tachycardia, nausea, vomiting, muscle cramps, severe abdominal pain with rigidity mimicking a surgical abdomen, fasciculations, ptosis, and headache.

A 14-year-old boy presents to the ED with severe abdominal pain. You notice a painful papule on his right arm where he said he was "bit by something when he was working in the garage." On physical exam, his abdomen is rigid. Vital signs are BP 140/90 mm Hg, HR 120 beats per minute, RR 18 breaths per minute, and T 98.4℉. Which of the following is the most appropriate next step in management? · A Administer intravenous antivenin · B Administer intravenous lorazepam · C Consult general surgery · D Obtain computed tomography of the abdomen

Correct Answer ( D ) Explanation: The patient has an injury to the ulnar collateral ligament, also known as "gamekeeper's thumb" named after Scottish gamekeepers who developed this injury pattern from repeatedly twisting the necks of hares. It is also known as "skier's thumb" since skiing is now the most common cause of this injury. The injury occurs when the thumb gets stuck in the pole straps during a fall. The mechanism of injury is a forceful radial abduction of the thumb with a subsequent partial or complete tear in the ulnar collateral ligament at the insertion into the proximal phalanx of the thumb. Patients present with pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb and a weak pincer grasp. Greater than 35 degrees of laxity of thumb abduction or additional 15 degrees of laxity beyond the uninjured side suggests a complete rupture. Radiographs may show a small associated avulsion fracture. Patients should be immobilized in a thumb spica splint and referred to orthopedics. A partial ulnar collateral ligament rupture will often heal well with immobilization alone, but a complete rupture often requires surgical repair.

A 24-year-old woman presents with right thumb pain. She recently fell while skiing. On examination, she has swelling and tenderness over the base of the thumb on the ulnar side. She has weakness when pinching an object between her thumb and index finger. Which of the following structures is most likely to be injured? AExtensor pollicis brevis BExtensor pollicis longus CRadial collateral ligament DUlnar collateral ligament

Correct Answer ( B ) Explanation: This patient's presentation is consistent with a peritonsillar abscess. Patients typically present with sore throat, fever, odynophagia or dysphagia, and examination will reveal unilateral swelling and displacement of the tonsil and uvula deviation. Peritonsillar abscess can be differentiated from peritonsillar cellulitis by the presence of tonsillar swelling and uvula deviation, which is an important distinction in order to choose appropriate management. Ultrasonography or computed tomography can be used in equivocal cases to help differentiate, although the diagnosis of peritonsillar abscess is typically clinical. It can occur spontaneously due to an obstructed gland or as a sequela of progressive tonsillitis. Treatment for peritonsillar abscess consists of drainage and the preferred initial method is needle aspiration. The patient should be anesthetized and a sheathed needle with 1 cm of exposed needle (to prevent overshooting and causing injury to the internal carotid artery) should be used to aspirate from the superior tonsillar pole, halfway between the uvula and maxillary alveolar ridge until pus returns. Well-appearing patients who are tolerating fluids can then be discharged with amoxicillin-clavulanate or clindamycin orally to treat any associated cellulitis.

A 25-year-old healthy man presents to the emergency department with several days of sore throat associated with fever and voice change. Examination is significant for a temperature of 101.5°F, HR 110 bpm, oxygen saturation 99% on room air, right tonsillar erythema and swelling with uvula deviation to the left, no pooling of oral secretions, and tender anterior cervical lymphadenopathy. Which of the following is the most appropriate management of this patient's condition? · A Clindamycin orally · B Needle aspiration · C Otolaryngology consult · D Penicillin intramuscular injection

Correct Answer ( D ) Explanation: Papilledema is the hallmark funduscopic finding of idiopathic intracranial hypertension and is typically bilateral and symmetric. Papilledema is a reflection of elevated intracranial pressure. Due to the elevated pressure on intracranial structures, patients with this disease can also present with loss of vision or sixth cranial nerve palsy. Idiopathic intracranial hypertension primarily affects overweight women of childbearing age and has been associated with polycystic ovary syndrome. Symptoms include intermittent visual changes, headache (most common), and pulsatile tinnitus. Diagnosis of idiopathic intracranial hypertension consists of signs and symptoms of elevated intracranial pressure, unremarkable neuroimaging, and elevated opening pressures on lumbar puncture with normal cerebrospinal fluid studies.

A 26-year-old woman with a history of polycystic ovary syndrome presents with five days of diffuse headache that has not responded to over-the-counter medications. She also reports one day of intermittent blurring and "blacking out" of vision with positional changes. Temperature is 37°C (98.6°F), pulse rate is 78/min, respirations are 20/min, blood pressure is 135/90 mm Hg, and SaO₂ is 99%. The physical exam is notable for an obese, uncomfortable-appearing woman who is moving all extremities and answering you appropriately. Her visual fields are intact, but visual acuity is 20/40 OD and 20/70 OS, and she tells you that she has never had vision issues. What is an additional physical exam finding that is likely to be associated with the condition? · A Intraretinal hemorrhages and dilated tortuous retinal veins · B Mid-dilated poorly reactive pupils and elevated intraocular pressures · C Nuchal rigidity · D Papilledema

Correct Answer ( C ) Explanation: This patient is presenting with symptoms suggestive of a diagnosis of influenza, which is best treated with rest and oral rehydration in this patient. Influenza typically presents with fever, fatigue, malaise, headache, nausea, vomiting, arthralgias, and myalgias. It is a viral illness that is often debilitating and can be fatal for the elderly or immunocompromised. In healthy patients, it typically presents with a self-limited course of illness that only requires treatment with oral rehydration, rest, and sometimes antiemetics if the patient is unable to eat or drink. Oseltamivir is an antiviral agent that can be effective in treating influenza if administered within the first 48 hours of illness. It is typically indicated for patients with progressive or severe illness, elderly patients (age 65 or greater), in pregnancy, in patients with underlying lung disease, in neurologic and neurodevelopmental conditions, and in immunosuppressed patients.

A 27-year-old man presents to the emergency department in January with a nonproductive cough, fever, headache, myalgias, weakness, nausea, and vomiting for the past three days. His temperature is 102°F (38.9°C), blood pressure is 127/68 mm Hg, pulse is 110/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air. Physical exam is notable for a fatigued-appearing young man. Lungs are clear to auscultation. Which of the following is the best treatment for this patient? · A Azithromycin · B Moxifloxacin · C Oral rehydration and rest · D Oseltamivir

Correct Answer ( C ) Explanation: Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. While it can rarely occur with a normal ovary, the majority of cases are associated with some type of ovarian pathology (e.g., tumor, cyst, hyperstimulation syndrome secondary to infertility treatments). Patients present with acute onset of unilateral pelvic pain often accompanied by nausea and vomiting. They may relate previous episodes of similar pain due to intermittent torsion. Ultrasound is the test of choice for diagnosing ovarian torsion. The most common finding is ovarian enlargement due to venous and lymphatic engorgement. Complete arterial obstruction is unlikely due to the dual blood supply to the ovary from both the uterine and ovarian arteries. Therefore, in cases of high clinical suspicion, the finding of arterial flow does not eliminate the possibility of torsion. Gynecology consultation is warranted for all cases of confirmed or suspected ovarian torsion.

A 27-year-old woman presents with acute onset of right pelvic pain and nausea that started six hours ago. She reports two prior episodes that were similar, but symptoms with those episodes resolved within one hour. On examination, she appears uncomfortable and is mildly tachycardic. She has tenderness to palpation of the right adnexa. A transvaginal ultrasound is ordered. What is the most common ultrasound finding in ovarian torsion? · A Complete arterial obstruction · B Heterogeneous appearance of the ovarian stroma · C Ovarian enlargement · D Whirlpool sign

Correct Answer ( C ) Explanation: This patient's presentation is most consistent with a pilonidal abscess. Pilonidal cysts form in the midline of the superior natal cleft due to granuloma formation after an ingrown hair penetrates the skin and forms a sinus tract. Patients may chronically have a pilonidal cyst that is nontender. However, this cyst may become infected, leading to a painful, inflamed, and swollen abscess. Pilonidal abscesses can be diagnosed clinically due to their classic location in the upper midline of the natal cleft, and they do not communicate with the anorectal canal. For an acutely infected cyst, incision and drainage with outpatient surgery follow-up is the recommended treatment. Incision should be performed in the cranial-caudal axis lateral to the midline. Antibiotics are only required if there are signs of surrounding cellulitis,and packing the incision is not recommended. Patients should follow up with a surgeon approximately 1 week after drainage (once surrounding inflammation has resolved) for removal of the cyst to prevent recurrence.

A 30-year-old healthy woman presents to the emergency department for a painful mass. Examination is significant for normal vital signs and a 3 cm inflamed abscess in the midline superior natal cleft with no surrounding erythema. The patient states she has had nontender swelling in the same location previously, but now it is very painful for her to lay down. Which of the following is the most appropriate management of this patient's condition? · A Emergent surgical consultation · B Incision and drainage and discharge with cephalexin orally · C Incision and drainage and outpatient surgery follow-up · D Outpatient surgery follow-up

Correct Answer ( B ) Explanation: This patient's clinical presentation is consistent with a thrombosed external hemorrhoid. Hemorrhoids occur when veins become engorged due to increased abdominal pressure, leading to displacement into the anal canal. Constipation, increasing age, liver disease, and pregnancy are all related to increased risk of hemorrhoids.

A 30-year-old healthy woman presents to the emergency department for severe perianal pain and difficulty with defecation for one day, which is not associated with fever, bleeding, or decreased oral intake. Examination is significant for a purple-colored mass external to the anal verge that is firm and tender. Which of the following is the best management of this patient's condition? · A Anesthetize the lesion and evacuate with cruciate incision · B Anesthetize the lesion and evacuate with elliptical incision · C Discharge with recommendations for stool softeners, sitz baths, and primary care follow-up · D Surgery consult for drainage in the operating room

Correct Answer ( D ) Explanation: This child is presenting with evidence of foreign body aspiration. Signs and symptoms of foreign body aspiration include coughing, gagging, choking, or cyanosis. This is an easy-to-miss diagnosis as patients are often well-appearing on presentation. It should be considered in all toddlers who present with respiratory symptoms. Children may have stridor, wheezing, or unequal breath sounds depending upon where the aspirated object is located. Delayed diagnosis often presents with postobstructive pneumonia. Chest radiographs may be normal if the foreign body is not radiopaque. Decubitus or forced expiratory radiographs will detect air trapping as the lung will remain hyperinflated on the affected side. Pulmonology will need to be consulted for bronchoscopy. This should be done based upon clinical suspicion alone even if radiographs are normal.

A 32-month-old girl presents to the ED with her mother after an episode of choking and "turning blue." Her mother notes that she was playing with her brother's toys when she choked and turned blue. After coughing, she seems to be back to normal. On physical exam, you note wheezing on the right side. Which of the following will aid in confirming the diagnosis? · A Abdominal radiograph · B Direct laryngoscopy · C Lateral soft tissue neck radiograph · D Right lateral decubitus chest radiograph

Correct Answer ( B ) Explanation: This patient most likely has acute bronchitis. The most common causes of acute bronchitis are respiratory viruses such as influenza The pathophysiology behind acute bronchitis is a bronchial epithelial infection that results in inflammation and thickening of the bronchial and tracheal mucosa. This leads to airflow obstruction and bronchial hyperresponsiveness, manifesting as a cough, dyspnea, and wheezing. Patients may also acutely present with a fever. The cough due to acute bronchitis may be with or without sputum production and last anywhere from 5 days up to 4 weeks, a distinguishing clinical feature that is used to differentiate acute bronchitis from an acute upper respiratory infection. Patients with acute bronchitis may also have abnormal pulmonary function testing, such as a reversible decrease in forced expiratory volume in 1 second, attributed to bronchial hyperresponsiveness. Diagnosis is made clinically, and treatment is focused on symptomatic relief with expectorants, antihistamines, mucolytics, and antitussives such as dextromethorphan.

A 32-year-old healthy man presents to the emergency department with 10 days of a cough productive of green sputum. He was seen in the emergency department 1 week ago for fever, dyspnea, and a similar cough. At that time, a chest X-ray was negative and he was diagnosed with an upper respiratory infection. Today, his vital signs are unremarkable, a cardiopulmonary exam is benign, and a repeat chest X-ray is negative for acute pulmonary disease. Which of the following is the best management for this patient? · A Albuterol as needed · B Dextromethorphan as needed · C Oral amoxicillin · D Oral prednisone

Correct Answer ( A ) Explanation: This patient is exhibiting signs and symptoms of acute angle closure glaucoma. Acute angle closure glaucoma is defined by increased intraocular pressure caused by obstruction of aqueous humor drainage via the canal of Schlemm. The anterior chamber "angle" refers to the angle formed by the cornea and the iris. The ciliary body produces aqueous humor and is located posterior to the iris. The canal of Schlemm is located in the angle of the anterior chamber and serves to drain the aqueous humor in the anterior chamber. Contact between the iris and cornea due to anterior movement of the iris obstructs the canal of Schlemm. This happens when either there is increased pressure in the posterior chamber or pupillary dilation occurs causing narrowing of the anterior chamber and thus obstruction of the canal. Signs and symptoms of acute angle closure glaucoma include ocular pain, nausea and vomiting, unilateral blurring of vision, photopsia or colored halos around lights, elevated intraocular pressure (often 30 mm Hg or higher), conjunctival injection, a cloudy or steamy cornea due to corneal edema, and a mid-dilated nonreactive pupil. Management of acute angle closure glaucoma includes several treatment modalities. First, you need to reduce the production of aqueous humor using oral or intravenous acetazolamide, a topical beta blocker such as timolol, and a topical alpha agonist such as apraclonidine. These are typically given one hour after the start of treatment and require two doses 15 minutes apart. Additionally, administration of topical pilocarpine, a miotic, should be used with caution and only after initial reduction in intraocular pressure due to the concern over possible shallowing of the anterior chamber thereby propogating further closure of the chamber's angle. Adjuncts, including hyperosmotic agents like intravenous mannitol, may be needed to further reduce the intraocular pressure two hours after the initiation of treatment if not adequately controlled. Ophthalmology should be consulted as soon as this diagnosis is suspected for definitive laser iridotomy.

A 34-year-old woman presents to the ED with severe right eye pain. The pain began after she entered a dark movie theatre. On physical exam, you note a mid-dilated pupil (4 mm) and corneal edema. Which of the following is the correct combination of medications in the treatment for this process? A Acetazolamide IV, topical apraclonidine, topical timololCorrect Answer B Mannitol IV, topical timolol, prednisolone IV C Topical prednisolone, mannitol IV, topical timolol D Topical timolol, topical apraclonidine, topical prednisoloneYour Answer

Correct Answer ( A ) Explanation: Myasthenia gravis is a rare disorder known for a bimodal onset, with the first peak among women 20 to 40 years of age and a second peak among men 50 to 70 years old. It involves autoimmune destruction of acetylcholine receptors on the postsynaptic membrane at the neuromuscular junction. This results in complement-mediated destruction of the total number of receptors along with autoantibodies competing with acetylcholine to bind to the remaining receptors. Therefore, with repeated stimulation and fewer sites available, fatigue develops.

A 35-year-old woman presents to the emergency department with complaints of fatigue, weakness, and shortness of breath. Symptoms started about a month ago when she began to have trouble keeping her eyes open towards the end of the day. Over the last few days she has noted overall weakness and shortness of breath. Vital signs including a respiratory rate of 16 breaths/minute and 96% SpO2. You note bilateral ptosis and clear lung sounds. Ice bags were applied to the eyes for two minutes. After the ice bags were removed, the distance between her upper and lower eyelids had improved by greater than 2 mm. Which of the following describes the pathophysiology of the most likely underlying diagnosis? · A Autoimmune destruction of acetylcholine receptors on the postsynaptic membrane · B Neurodegenerative lesion formation in the anterior horn cells · C Toxin irreversibly bound to presynaptic membrane preventing acetylcholine release · D Toxin reversibly bound at the presynaptic membrane preventing acetylcholine release

Correct Answer ( C ) Explanation: The most common risk factor for the development of placental abruption is hypertension. In this scenario, the patient is most likely experiencing a placental abruption, which is the premature separation of a normally implanted placenta. Patients will generally complain of sudden onset, constant abdominal pain and vaginal bleeding that is generally darker in color. They may have uterine firmness on examination. Depending on the degree of abruption, the patient may be hemodynamically unstable.

A 36-year-old woman presents to the ED with sudden onset lower abdominal pain and vaginal bleeding. She is 35-weeks pregnant. She reports constant lower abdominal pain and vaginal bleeding for the last 4 hours. On examination, her cervix is closed and she has dark blood coming from the cervical os. Her uterus is firm to the touch. What is the most common risk factor associated with this condition? · AAdvanced maternal age · BCocaine use · CHypertension · DTobacco use

Correct Answer ( C ) Explanation: Acute mesenteric ischemia is a small bowel vascular catastrophe that needs early diagnosis and management to prevent mortality, which remains around 60% to 80% despite advances in diagnostic imaging and disease characterization. The four types of acute mesenteric ischemia include arterial embolism (most common), arterial thrombosis, venous thrombosis, and venous embolism. Patients typically present with acute severe abdominal pain out of proportion to physical exam findings. Symptom onset and clinical deterioration can occur rapidly. Initially, only the ischemic visceral structures cause pain. Later, when the parietal peritoneum becomes ischemic, abdominal peritonitis occurs. Laboratory testing is of limited utility but may aid somewhat in diagnosis. An elevated serum lactate level, though nonspecific, is useful when the diagnosis is considered. A serum lactate is readily available, quickly results, and can be repeated to check serial levels to determine if ongoing ischemia is occurring.

A 37-year-old woman with a history of hypertension, depression, and intravenous heroin use presents with sudden-onset abdominal pain and vomiting. Symptoms began one hour prior to arrival. Her vital signs are temperature 98.9°F, HR 126 beats/minute, RR 32 breaths/minute, BP 89/50 mm Hg, and oxygen saturation 98% on room air. She appears distressed and is writhing on the bed. Her abdomen is soft without ecchymosis or guarding. Which of the following studies is most useful to aid in the diagnosis of her condition? · A Kidney, ureter, bladder series · B Serum D-dimer · C Serum lactate · D Upright chest X-ray

Correct Answer ( B ) Explanation: The most common cause of upper gastrointestinal (GI) bleeding is an ulcer in the upper GI tract with duodenal ulcers being most common. Sixty to eighty percent of all ulcers are caused by infection with H. pylori. The second most common cause of peptic ulcer formation is the chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin. Other causes include smoking, alcohol use, and steroid use. Classically, gastric ulcers cause pain immediately after meals, whereas food relieves the pain caused by duodenal ulcers.

A 45-year-old previously healthy man presents to the emergency department with a chief complaint of epigastric burning and gnawing pain. While in the waiting room, he has an episode of dark, coffee-ground emesis and continues to vomit while being wheeled to the resuscitation bay. Which of the following is the most likely cause of the patient's symptoms? · A Duodenal ulcer due to chronic nonsteroidal antiinflammatory drug use · B Duodenal ulcer due to H. pylori infection · C Gastric ulcer due to chronic nonsteroidal antiinflammatory drug use · D Gastric ulcer due to H. pylori infection

Correct Answer ( D ) Explanation: Stevens-Johnson syndrome (SJS) is a severe mucocutaneous reaction characterized by extensive necrosis and detachment of the epidermis. It is more common in women than men and occurs in any age group. Drugs are the most common cause and trigger of SJS or toxic epidermal necrolysis (TEN) in all age groups. Drugs commonly known to cause SJS (remembered by the mnemonic PEC SLAPP) include penicillin, ethosuximide, carbamazepine, sulfa medications, lamotrigine, allopurinol, phenytoin, and phenobarbital. The next most common cause after medications is Mycoplasma pneumoniae infections

A 38-year-old man presents to the emergency department with a new-onset rash. He has a past medical history significant for epilepsy and hypertension, for which he currently takes levetiracetam and lisinopril. The patient was feeling well until two days ago when he started developing fevers, chills, malaise, and body aches. Yesterday, he noticed a rash had started on his face and trunk. He states the rash has since spread to all four extremities. A review of systems is positive for recently completing a course of azithromycin for walking pneumonia. Vital signs are remarkable for a temperature of 40°C, HR 138, BP 90/60, RR 29, and pulse oximetry 98%. Physical examination is remarkable for a toxic-appearing man with blisters and erythematous macules with a purple core covering the trunk, face, and extremities. Mucositis is noted on examination as well as a positive Nikolsky sign. Which of the following is most related to his likely diagnosis of Stevens-Johnson syndrome? · A Azithromycin · B Levetiracetam · C Lisinopril · D Mycoplasma infection

Correct Answer ( C ) Explanation: The clinician should recognize that the patient in this question is presenting with an acute dystonic reaction related to medication use. Dystonic reactions are characterized by involuntary contractions of muscles of the extremities, face, neck, or pelvis that lead to abnormal movements or postures. Acute reactions usually affect the head and face where chronic dystonia, such as tardive dyskinesia, can affect the entire body. A wide range of abnormal movements can be found, including twisting of the tongue, smacking of the lips, bulging of the cheeks, blepharospasm, spreading finger movements, extensor posturing of the toes, shoulder shrugging, torticollis, rocking and swaying movements, and hip thrusts. The most commonly described causative agents include first-generation antipsychotics and antiemetic medications. These reactions usually occur shortly after initiation of the offending agent or after the dose has been increased. Other medications that have been implicated include antimalarials, antidepressants, and anticonvulsants. The abnormal movements are generally attributed to an imbalance in the dopaminergic and cholinergic effects in the basal ganglia. Offending agents are dopamine receptor antagonists. The antagonism leads to a deficit in central dopamine transmission, which leads to excess release of acetylcholine. Acetylcholine has inhibitory effects on movement, leaving patients with twisting, tight dyskinetic movements. Primary treatment is with anticholinergic medications such as diphenhydramine or benztropine. Benzodiazepines are also used to help relax the patient. After administration of an anticholinergic agent, symptoms usually improve within 30 minutes but will return since the half-life of most antipsychotics is much longer than anticholinergics. Patients who develop dystonic reactions need to stop taking the offending agent or switch medications.

A 38-year-old man with a history of underlying psychiatric disease presents to the emergency department with strange facial and tongue movements. He was recently started on a new medication, but he cannot remember the name. He has difficulty describing his exact underlying psychiatric problem, and the friend with him also does not know the details regarding the patient's chronic medical issues. On exam, the patient is smacking his lips periodically and twisting his tongue in and out of his mouth. He is also holding his head stiffly and tilted to the left. What neurotransmitter imbalance is responsible for the development of this syndrome? · A Altered calcium-channel gating leading to an excess accumulation of calcium and, thus, hypermetabolism · B Decreased circulating dopamine and gamma-aminobutyric acid leading to a surplus of acetylcholine and glutamate · C Dopamine receptor blockade leading to increased cholinergic activity · D Excess circulating serotonin

Correct Answer ( A ) Explanation: This neonate most likely has gonococcal ophthalmia neonatorum, also known as gonococcal conjunctivitis, caused by the bacteria Neisseria gonorrhoeae. Patients present with copious bilateral purulent discharge, severe chemosis, and lid edema within the first 5 days of life. Diagnosis is made via Gram stain, revealing gram-negative diplococci. Gonococcal conjunctivitis is potentially life-threatening, and patients should undergo a full septic workup to evaluate for other sources of infection. Treatment of isolated gonococcal conjunctivitis is with the third-generation cephalosporin, cefotaxime.

A 4-day-old neonate born at 38 weeks gestation following an uncomplicated pregnancy and delivery presents to the emergency department with his father due to bilateral eye redness and discharge. On exam, the patient has bilateral conjunctivitis and copious amounts of purulent discharge from both eyes. What is the treatment for the most likely diagnosis? · A Cefotaxime · B Cephalexin · C Ciprofloxacin · D Erythromycin

Correct Answer ( D ) Explanation: Sciatica is a lumbosacral radiculopathy that is caused by compression of the spinal nerve root(s).

A 40-year-old man presents to the emergency department with sudden-onset back pain after lifting a box. The pain radiates down to the mid-thigh and is worse with bending and walking. Physical exam reveals left para-lumbar muscular tenderness without spasm. Which of the following exam maneuver(s) has the highest sensitivity and specificity for sciatica, respectively? · A Crossed straight leg alone · B Crossed straight leg raise, straight leg raise · C Straight leg raise alone · D Straight leg raise, crossed straight leg raise

Correct Answer ( C ) Explanation: The treatment for most cases subacute thyroiditis is nonsteroidal anti-inflammatory drugs (NSAIDs). Subacute thyroiditis is suspected to be caused by a viral infection or a post-viral inflammatory process. Common symptoms include fever, myalgias, fatigue, and malaise. Patients will complain of anterior neck pain, which is often localized over the area of the thyroid but can radiate to the jaw, throat, upper neck, or ears. The pain may be exacerbated by swallowing, coughing, or neck movement. The hallmark physical exam finding is tenderness over the thyroid gland. If tenderness is absent, another diagnosis should be considered. Subacute thyroiditis is ultimately a clinical diagnosis, but thyroid studies will reveal a suppressed thyroid-stimulating hormone with an elevated T3 and T4 in the early phases in illness.

A 40-year-old woman presents to the ED complaining of neck pain. For the past three days, she has had a fever, myalgias, and increasing fatigue. Vital signs are BP 130/90 mm Hg, HR 100 beats per minute, RR 14 breaths per minute, oxygen saturation of 97% on room air, and T 100.4°F. On physical exam, she has tenderness over her anterior, midline neck. Which of the following is the most appropriate treatment? · A Levothyroxine · B Methimazole · C Nonsteroidal anti-inflammatory drugs · D Propranolol

Correct Answer ( B ) Explanation: Meningitis is due to meningeal infection and inflammation, and the diagnosis should be considered in patients with headache who present with an associated triad of fever, altered mentation, and neck stiffness. However, the entire triad is rarely seen, and thus a high index of suspicion should be maintained in patients presenting with any combination of these. Meningitis can be viral, bacterial, and less commonly, fungal or parasitic. A lumbar puncture (LP) for analysis of the cerebrospinal fluid should be obtained in patients with features concerning for meningitis. Bacterial meningitis will demonstrate a low glucose, high protein, and a significant elevation of WBCs in the CSF that is often > 100 WBCs/µL. In patients presenting with features concerning for elevated ICP, such as altered mental status, neurological deficits, seizures, or papilledema, a CT scan of the head should be obtained prior to LP due to the risk of herniation. If a CT scan is required, antibiotics should be administered first, as a delay worsens the prognosis and mortality risk. The recommended antibiotics include ceftriaxone and vancomycin in patients beyond the neonatal period and up to the age of 50. In neonates and in patients greater than 50 years old, ampicillin should also be administered to cover Listeria monocytogenes. This recommendation should also be provided to patients who have alcohol use disorder or are immunocompromised, including those with HIV/AIDS, hematologic malignancies, end-stage renal disease, diabetes mellitus, and those being treated with tumor necrosis factor medications.

A 45-year-old man presents to the emergency department for a headache. He has a history of diabetes mellitus type 1, hypertension, and alcohol use disorder. He states he started feeling unwell 3 days ago, and the headache started this morning. He also reports having blurred vision and nausea without vomiting and no chest pain or shortness of breath. Vital signs are remarkable for a temperature of 39°C, HR 115 bpm, BP 100/60 mm Hg, RR 23 breaths/min, and SpO2 of 97%. Physical examination is remarkable for a man who appears lethargic. Upon passively flexing the patient's neck, he flexes at the hips and knees. Which of the following sequences is the best next step in this patient's management? · A Administer ceftriaxone and vancomycin; CT head; lumbar puncture · B Administer ceftriaxone, ampicillin, and vancomycin; CT head; lumbar puncture · C CT head; lumbar puncture; administer ceftriaxone, ampicillin, and vancomycin · D Lumbar puncture; administer ceftriaxone, ampicillin, and vancomycin

Correct Answer ( A ) Explanation: A pleural effusion is an abnormal fluid collection in the pleural space, commonly caused by congestive heart failure, malignancy, and pneumonia in Western nations. Patients with small effusions are asymptomatic. Larger effusions can cause shortness of breath or pleuritic chest pain. Infectious etiologies, including parapneumonic effusions, may present with fever or history of fever. Five to ten percent of parapneumonic effusions develop into an empyema. Physical examination findings include decreased breath sounds, decreased tactile fremitus, and dullness to percussion; however, these findings are dependent on the size of the effusion.

A 48-year-old woman presents to the emergency department with a chief complaint of shortness of breath and cough for three weeks. She states she initially had fevers, but they stopped one week ago. She has had progressive dyspnea on exertion since that time. On examination, she has a temperature of 99.5°F, heart rate of 105 beats per minute, blood pressure of 110/60 mm Hg, respiratory rate of 14 breaths per minute, and pulse oximetry of 95% on 2 liters of oxygen. Lung sounds are diminished at the left base, and there is a normal S1 and S2 but with mild tachycardia. Which of the following additional physical examination findings is expected? · A Decreased tactile fremitus · B Distended neck veins · C Tracheal shift to the right · D Tympany to percussion

Correct Answer ( D ) Explanation: This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. The most common precipitating factor is infection. Signs and symptoms of thyroid storm include bilateral ocular proptosis, anxiety, tremulousness, psychosis, obtundation, seizure, coma, fever, tachycardia (out of proportion to fever), high-output heart failure, circulatory collapse, diarrhea, and vomiting. Thyroid storm is a clinical diagnosis. Management of thyroid storm occurs in a stepwise fashion. Adrenergic blockade is the most important initial component of therapy. Propranolol, a nonspecific beta-blocker, is used to decrease sympathetic hyperactivity and partially block peripheral conversion of T4 to T3. Antithyroid drugs should then be initiated. Propylthiouracil and methimazole are both options, as both block the synthesis of thyroid hormone, however, propylthiouracil has the added benefit of decreasing conversion of T4 to T3 and works faster than methimazole. One hour after antithyroid drug administration, iodine should be given to inhibit the release of stored thyroid hormone. Steroids also serve as an adjunct to decrease peripheral conversion of T4 to T3.

A 54-year-old woman with a history of hyperthyroidism presents to the ED with fever, vomiting, palpitations, and tremors. Which of the following would you expect to find on physical exam? A Dry, scaling skinYour Answer B Loss of eyebrow hair C Maculopapular rash D Ocular proptosisCorrect Answer

Correct Answer ( B ) Explanation: This patient presents with signs and symptoms concerning for hepatic encephalopathy. In the setting of liver failure, ammonia that is normally produced by bacteria in the gut accumulates. Encephalopathy is thought to be the result of this accumulation, as well as the presence of other metabolites of ammonia, such as glutamine. Risk factors for development of encephalopathy in the setting of liver disease include infection, gastrointestinal bleeding, constipation, high protein intake, sedatives, dehydration and electrolyte abnormalities. Patients can present with a range of symptoms, from mild confusion and irritability to frank coma. Physical examination may reveal stigmata of chronic liver disease, such as caput medusae, ascites, spider angiomata, and jaundice. Asterixis, alternating flexion and extension at the wrist when the wrist is held in extension, is a classic finding in hepatic encephalopathy. Laboratory tests will show evidence of liver dysfunction including hypoalbuminemia and elevated prothrombin time. Ammonia is typically elevated, although the level of elevation does not correlate consistently with the degree of encephalopathy. Management depends on decreasing the ammonia level as well as finding and treating the underlying cause. The regimen of choice includes lactulose and rifaximin. Lactulose is a nonabsorbable disaccharide that decreases absorption of ammonia and alters the colonic pH to trap ammonia as ammonium in the stool. It can be given orally, via nasogastric tube or as an enema, with the goal of producing several loose stools per day. Rifaximin is an oral antimicrobial agent that reduces ammonia-producing enteric bacteria. It has fewer systemic side effects than neomycin. Ceftriaxone, vancomycin, and ampicillin (A) would be the empiric regimen of choice for a patient with alcohol use disorder and presumed meningitis. While meningitis can present with altered mental status, there is no history of fever or headache. There are also no signs of meningismus noted on exam. Metronidazole (C) can also be used in the management of hepatic encephalopathy, although it is not the treatment of choice. Thiamine (D) would be the treatment of choice for Wernicke encephalopathy. These patients also present with altered mental status but, in addition, have findings of ocular motor dysfunction (e.g. nystagmus, gaze palsies) and ataxia.

A 56-year-old man with a history of chronic alcohol use disorder presents with confusion. His wife notes that he has been progressively more confused in the last few days and sleeping much more than usual. There has been no fever, headache, cough, vomiting, or abdominal pain but she noticed that his stool was almost black when she helped him in the bathroom earlier today. On examination, he is lethargic and confused but able to answer a few simple questions. There is mild scleral icterus. The abdomen is soft without tenderness, guarding, or rebound. On rectal exam, there is dark, tarry stool in the rectal vault that is hemoccult positive. There are no focal neurologic deficits, although when asked to hold his arms up to test his strength, asterixis is noted. In addition to management of his gastrointestinal hemorrhage, which of the following is the best choice for treatment of his altered mental status? · A Ceftriaxone, vancomycin, and ampicillin · B Lactulose and rifaximin · C Metronidazole · D Thiamine

Correct Answer ( B ) Explanation: Pertussis is a highly contagious acute respiratory infection caused by the gram-negative rod Bordetella pertussis. Infection is spread by respiratory droplets. Childhood vaccination and natural immunity do not confer lifelong immunity against pertussis. School-aged children are usually affected, but adults may be carriers. Three clinical phases exist: catarrhal, paroxysmal, and convalescent. The catarrhal phase, during which infectivity is highest, lasts one to two weeks and is characterized by cough, low-grade fever, rhinitis, and anorexia. The paroxysmal phase lasts two to six weeks and is characterized by defervescence, increased coughing, and paroxysms of coughing with inspiratory "whooping" and posttussive emesis. The convalescent phase may include a cough lasting several months. The diagnosis is often clinical but is commonly missed due to atypical presentations and misdiagnosis as bronchitis. A polymerase chain reaction of nasopharyngeal secretions, nasopharyngeal culture or serological antibodies may be used for definitive diagnosis. Diagnostic workup may reveal lymphocytosis and radiographic evidence of peribronchial thickening, atelectasis or pulmonary consolidation. Treatment is with azithromycin, although trimethoprim-sulfamethoxazole may be used in macrolide-intolerant patients. Treatment is best if started during the first week of the illness and may have limited utility after the catarrhal phase.

A 6-year-old boy with a past medical history of glucose 6-phosphate dehydrogenase deficiency presents to the Emergency Department for a cough associated with vomiting. His parents state that he has been coughing every day for the last week. He is unimmunized but otherwise healthy. He appears well on exam with a dry cough and occasional wheezes. His laboratory workup reveals a leukocytosis with lymphocytic predominance and a chest X-ray with peribronchial thickening. Based on the suspected diagnosis, which of the following is the most appropriate therapy at this time? AAmpicillin-sulbactam BAzithromycin CErtapenem DTrimethoprim-sulfamethoxazole

Correct Answer ( A ) Explanation: This patient's presentation is consistent with anterior cord syndrome, an incomplete spinal cord syndrome caused by hyperflexion of the spine or thrombosis of the anterior spinal artery. This presentation leads to damage to the corticospinal and spinothalamic tracts while not damaging the posterior columns. Findings on examination include loss of motor function and pain and temperature sensation below the level of the injury with preservation of position and vibratory sensation. Neuroimaging should be used to diagnose any associated fractures, although most incomplete cord injuries will not be apparent on computed tomography scans. Magnetic resonance imaging and neurosurgical evaluation will be required in these patients.

A 60-year-old man presents to the emergency department after a fall in which he hit his head, causing severe neck flexion. On examination, he has 4/5 strength and normal sensation of his upper extremities but has 0/5 strength of his lower extremities and absent sensation to pain below his clavicles, but he is able to sense vibration and tell which direction his toes are pointed. Which of the following is the most likely cause of this patient's symptoms? · A Anterior cord syndrome · B Brown-Séquard syndrome · C Central cord syndrome · D Spinal shock

Correct Answer ( C ) Explanation: Cellulitis is a bacterial infection of the deep dermis and subcutaneous fat tissue, which manifests with localized skin erythema, edema, warmth, and pain. The most common pathogens implicated in cellulitis are beta-hemolytic streptococci and Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA). The treatment of cellulitis is based on whether or not there is associated purulence. Patients with purulent cellulitis should receive empiric coverage for MRSA. Oral antibiotics with MRSA coverage include doxycycline, trimethoprim-sulfamethoxazole, clindamycin, and linezolid. Patients with systemic symptoms requiring admission should receive parenteral antibiotics with coverage for MRSA, which include vancomycin, clindamycin, telavancin, daptomycin, and linezolid.

A 65-year-old man presents with left leg pain. He reports progressive erythema and pain of his left lower leg after cutting it while working on his car. His examination is notable for a 5 x 5 cm area of induration and erythema with yellow purulent drainage. The area is warm to touch and tender to palpation. Which of the following is the most appropriate medication for outpatient management of this patient's condition? · A Amoxicillin-clavulanate · B Cephalexin · C Doxycycline · D Levofloxacin

Correct Answer ( C ) Explanation: Cellulitis is a bacterial infection of the deep dermis and subcutaneous fat tissue, which manifests with localized skin erythema, edema, warmth, and pain. The most common pathogens implicated in cellulitis are beta-hemolytic streptococci and Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA). The treatment of cellulitis is based on whether or not there is associated purulence. - Patients with purulent cellulitis should receive empiric coverage for MRSA. Oral antibiotics with MRSA coverage include doxycycline, trimethoprim-sulfamethoxazole, clindamycin, and linezolid. - Patients with systemic symptoms requiring admission should receive parenteral antibiotics with coverage for MRSA, which include vancomycin, clindamycin, telavancin, daptomycin, and linezolid.

A 65-year-old man presents with left leg pain. He reports progressive erythema and pain of his left lower leg after cutting it while working on his car. His examination is notable for a 5 x 5 cm area of induration and erythema with yellow purulent drainage. The area is warm to touch and tender to palpation. Which of the following is the most appropriate medication for outpatient management of this patient's condition? · AAmoxicillin-clavulanate · BCephalexin · CDoxycycline · DLevofloxacin

Correct Answer ( A ) Explanation: Glaucoma is a group of disorders characterized by increased intraocular pressure that causes optic neuropathy and vision loss. An acute attack is usually precipitated by pupillary dilation, which classically occurs after a patient enters a room or building with dim illumination. Abrupt onset of severe pain located in the eye or a frontal or supraorbital headache is usually described. Associated symptoms include blurred vision, nausea, and vomiting. Examination often reveals conjunctival injection, a mid-sized and fixed pupil, a hazy cornea, and a globe that is rock hard to touch. The features above are essentially diagnostic, however, measurement of the intraocular pressure often exceeds 60 to 80 mm Hg, but pressures greater than 30 mm Hg should be worrisome.

A 66-year-old woman presents for acute headache. She has a history of hypertension and migraines. She states the headache started suddenly after walking into a movie theater. She has associated nausea and vomiting and states she has never had anything like this in the past. Physical examination is remarkable for the finding noted above. What is the best first step in the treatment of the patient above? · A Apraclonidine · B Laser iridotomy · C Mannitol · D PilocarpineYour

B

A 76-year-old man presents to the emergency department with acute onset of left sided hemiparesis. Symptoms started abruptly 45 minutes prior to arrival. He has a history hypertension and type II diabetes mellitus. Stat imaging suggests an acute ischemic stroke. Which of the following is considered an absolute contraindication for thrombolytic therapy? · A Age greater than 75 years · B Blood glucose of 325 mg/dL · C Gastrointestinal or genitourinary bleeding within the past three months · D Ischemic stroke within the past three months

Correct Answer ( C ) Explanation: In general, symptoms associated with lower UTIs are limited to the genitourinary system and include dysuria, urgency, frequency, hematuria, and suprapubic abdominal pain. In addition to lower urinary symptoms, patients with upper UTIs (pyelonephritis) also develop constitutional symptoms such as fever, vomiting, and malaise and may also have back and flank pain. Nontoxic patients may be treated as an outpatient. Toxic or pregnant patients and those with urologic abnormalities, immunocompromised, or inability to tolerate oral intake should be placed on parenteral antibiotics. Ceftriaxone has excellent coverage of E. coli and is generally considered the first line for parenteral treatment of uncomplicated pyelonephritis, but local resistance patterns should be considered when selecting specific agents. Fluoroquinolones are another option.

A 78-year-old woman is brought to the ED by her daughter with concern for altered mentation and somnolence over the past three days. The patient has a history of hypertension and elevated cholesterol, both well controlled with medication. Her vitals are significant for a blood pressure of 148/72 mm Hg, heart rate of 82 beats per minute, oxygen saturation of 99% on room air, and a temperature of 100.58°F (38.1°C). Physical exam reveals a well-appearing elderly female who is sleeping but easily arousable. Laboratory values show a WBC of 8.2/microL with 2% bands, hemoglobin of 13.6 g/dL, platelets of 120,000/microL, sodium of 136 mEq/L, potassium of 3.4 mEq/L, a BUN of 12 mg/dL, and a creatinine of 0.8 mg/dL. Urinalysis is positive for leukocyte esterase, nitrites, and 15 WBC/HPF. Which of the following statements best describes the diagnosis and next step of management? · A The patient has cystitis; start oral levofloxacin and discharge · B The patient has cystitis; start oral trimethoprim-sulfamethoxazole and discharge · C The patient has pyelonephritis; start parenteral ceftriaxone and admit · D The patient has pyelonephritis; start parenteral trimethoprim-sulfamethoxazole and admit

Correct Answer ( A ) Explanation: The patient has multifocal atrial tachycardia (MAT). MAT occurs when at least three different atrial ectopic foci depolarize to pace the heart. These are seen on an ECG as an irregular rhythm with P waves with at least three distinct morphologies. The QRS complex is narrow unless an underlying bundle branch block is present. Because of the irregular rhythm, MAT is easily confused with atrial fibrillation. However, in MAT, distinct P waves should be visible. MAT is most commonly seen in elderly patients with chronic lung disease. MAT can also be seen in heart failure and sepsis. The treatment of MAT is directed at treating the underlying disorder. In a patient with symptomatic lung disease, oxygen and bronchodilators improve pulmonary function and oxygenation and therefore decrease atrial ectopy. Cardioversion is ineffective for MAT.

A 79-year-old man presents to the ED complaining of dyspnea. His rhythm strip is shown above. What is the most likely underlying process? A Chronic obstructive pulmonary disease B Crohn disease C Pericardial effusion D Ventricular aneurysm

Correct Answer ( A ) Explanation: Coma or central nervous system depression with essentially normal vital signs and midposition pupils are characteristic findings in isolated benzodiazepine toxicity, making chlordiazepoxide the most likely culprit in this case. Similar findings would be expected with other benzodiazepines such as diazepam and lorazepam. Unlike phenobarbital and other barbiturates, benzodiazepines require endogenous GABA to open the chloride channel and exert clinical effects.

An 18-year-old man presents to the emergency department after overdosing on medication. He is somnolent, only arousing to noxious stimuli. His vital signs are normal and his pupils are midposition and briskly reactive. You are unable to elicit nystagmus. He is not tremulous, his reflexes are normal, and he displays no clonus. Toxicity from which of the following agents is most likely responsible for his presentation? · AChlordiazepoxide · BLithium · CMethadone · DQuetiapine

1. Mesenteric angiography 2. CT angiography 3. Fluid resuscitation, cardiac monitoring, blood pressure correction, and antibiotics 4. Dobutamine, milrinone, and low-dose dopamine 5. Ceftriaxone or ciprofloxacin in addition to metronidazole

Acute mesenteric ischemia ___1.___ is the gold standard imaging modality for diagnosis, but ___2.___ has largely replaced this due to its better availability to emergency providers. Goals of treatment are to restore mesenteric blood flow, reduce vasospasm, mitigate further clot propagation, and treat the underlying cause. ___3.___ are all integral to early therapy. ___4.___ are preferred pressors due to less mesenteric vasoconstriction. ___5.___ is recommended for enteric coverage. A surgeon should be consulted promptly if perforation or peritonitis are present. Most patients require intensive care unit admission.

1. anesthetizing the lesion and evacuating with an elliptical incision 2. not have excision performed in the emergency department 3. better evacuation of the clot

Acutely thrombosed hemorrhoids (for less than 48 hours) with severe symptoms in healthy patients can be treated by ___1.___. Immunocompromised patients, pregnant women, those with coagulopathies, and patients with symptoms for greater than 48 hours should ___2.___. Anesthesia should be performed with local anesthetic such as bupivacaine, either into the dome of the hemorrhoid or as a perianal block. - Once anesthetized, an elliptical incision should be made. This is preferred to other types of incision, as it allows ___3.___ than straight or cruciate incisions. - Gauze should be tucked into the evacuated hemorrhoid and left for several hours to help control bleeding. - Patients may be discharged with surgical outpatient follow-up for definitive treatment of the hemorrhoid.

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 of 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 two to five days. Management involves supportive care.

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? ABordetella pertussis BHaemophilus influenzae CParainfluenza virus DRespiratory syncytial virus

Correct Answer ( D ) Explanation: This patient has acute otitis externa, which most commonly presents with ear pain, pruritus, purulent discharge, and hearing loss. Physical exam findings include an edematous, erythematous external auditory canal with debris present. Tenderness with tragal pressure or when the auricle is manipulated or pulled may also be present. Risk factors for development of otitis externa include trauma and swimming or other water exposure. The most common pathogens responsible for causing otitis externa are Pseudomonas aeruginosa and Staphylococcus aureus. Diagnosis is made clinically, and treatment depends upon the severity of the external otitis. The first step in treatment is to clean the external ear canal using suction, irrigation, or gentle curettage. For mild otitis externa, which is characterized by minor discomfort and pruritus with minimal canal edema, otic acetic acid with hydrocortisone may be used. Moderate disease is characterized by an intermediate degree of pain and pruritus, along with a partially occluded ear canal. Otic ciprofloxacin with hydrocortisone would be appropriate treatment for moderate infection. In severe cases, the canal is completely occluded by edema; in this case, a wick should be inserted in the external canal with the topical antibiotic applied to it. The patient in question has moderate otitis externa and should be treated with otic ciprofloxacin with hydrocortisone.

An 18-year-old man presents to the emergency department with ear pain. He states that pain started after he went swimming in a local pond several days ago. He also reports purulent drainage from his ear. Physical examination reveals an erythematous, edematous external auditory canal. The tympanic membrane is partially visible, and tenderness with tragal pressure is also present. Which of the following is the best treatment for this patient? · A Oral amoxicillin · B Oral ciprofloxacin · C Otic acetic acid with hydrocortisone · D Otic ciprofloxacin with hydrocortisone

Correct Answer ( C ) Explanation: This patient's history of sore throat, tonsillar exudates, fever, and a diffuse rash that started after initiation of amoxicillin is consistent with a diagnosis of infectious mononucleosis caused by Epstein-Barr virus. It typically affects adolescents and young adults and presents with fever, sore throat, fatigue, and headache. On examination, tonsillar exudates and lymphadenopathy will be present. Lymphadenopathy is primarily noted in the posterior cervical chains bilaterally, but may also become generalized. Splenomegaly is present in half of patients. Nearly all patients who have infectious mononucleosis who are given amoxicillin or ampicillin will develop a diffuse maculopapular rash. The mechanism of this is unknown but it is not thought to represent an allergic reaction. Laboratory studies will show an atypical lymphocytosis and elevated aminotransferases. Diagnosis is confirmed with a positive heterophile antibody test. Treatment is supportive. The use of corticosteroids is controversial but can be considered in patients with significant posterior pharyngeal edema and impending airway obstruction. Patients should refrain from contact sports for three weeks after diagnosis.

An 18-year-old woman presents with a diffuse erythematous rash that started yesterday. She was seen recently at a local urgent care three days ago for a sore throat, fatigue, and low-grade fever. She was told her strep screen was negative but because she was found to have "pus on my tonsils," she was started on amoxicillin pending the results of her throat culture. On examination, she has posterior pharyngeal erythema with tonsillar exudates and a diffuse maculopapular rash. Vital signs are unremarkable for her age other than a temperature of 38.1°C. Which of the following is most likely to be found on exam? · A Anterior cervical lymphadenopathy · B Positive Nikolsky sign · C Splenomegaly · D Wheezing

Correct Answer ( D ) Explanation: This patient has Reye syndrome, characterized by encephalopathy and fatty degeneration of the liver. It has been associated with aspirin exposure in the setting of a viral illness. Its major cause of morbidity and mortality is cerebral edema leading to increased intracranial pressure. There is no specific cure, and management is supportive.

An 8-year-old boy presents with his mother to the ED via EMS following six days of rhinorrhea, cough, and nasal congestion. He has been taking an over-the-counter medication for fever. Two days ago, he started having multiple bouts of vomiting, despite restricting his oral intake, and on the day of arrival, he became disoriented and confused. On exam, he has T 37.16°C, BP 110/70 mm Hg, HR 155 bpm, RR 28/min, and glucose 78 mg/dL. He is altered and stuporous, has a palpable liver edge but no jaundice or icterus, and has no meningeal signs or focal neurologic deficits. His labs reveal elevated levels of AST, ALT, lactate, and ammonia. Which of the following is the most appropriate treatment for this condition? · A High-dose barbiturates · B Hyperosmolar agents · C Hyperventilation · D Supportive care

Beta-lactam + Macrolide OR Resp. FQ monotherapy

CAP IP tx (Standard)?

Amoxicillin (HD) Or Doxycycline Or Macrolide

CAP OP tx (no comorbidities)?

Amoxicillin (HD) Or Cephalosporin And Doxycycline Or Macrolide

CAP OP tx (with comorbidities)?

1. recent Abx use (clinda most common) 2. nucleic acid amplification test (NAAT) 3. · Nonsevere or severe: oral vancomycin or oral fidaxomicin · Fulminant: oral vancomycin with parenteral metronidazole

Clostridioides difficile Colitis (Pseudomembranous Colitis) · History of ___1.___ · Frequent watery stools, abdominal pain · Diagnosis is made by ___2.___ · Treatment: ___3.___

1. calcium pyrophosphate (CPP) 2. pain, stiffness, tenderness, redness, warmth, and swelling in some joints 3. knee or wrist 4. Chondrocalcinosis

Pseudogout: accumulation of crystals of ___1.___ in the connective tissues. Clinical manifestations of pseudogout: - Causes ___2.___. It can affect one or several joints at once. Pseudogout commonly affects the ___3.___. Less often, it can involve the hips, shoulders, elbows, finger joints, toes, or ankles ___4.___ - linear radiodensities on x-ray

Postrenal Acute Kidney Injury Ultrasound

Diagnosis? Outflow obstruction BUN to Cr 10-20:1

1. - Blood cultures (before abx are started) 3 sets at least 1 hour apart - EKG at regular intervals - LABS: CBC, ESR, RF - A transesophageal echocardiogram is the gold standard 2. 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria Major clinical criteria - Positive blood culture: 2 sep blood cx or persistently positive cx - Single positive blood culture for C. burnetii - Positive echocardiogram: presence of vegetation, abscess, or new partial dehiscence of a prosthetic valve - New valvular regurgitation Minor criteria (FROM JANE) - Predisposing heart condition or IV drug use - Fever ≥38.0°C (100.4°F) - Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, Janeway lesions - Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor (RF) - Microbiologic evidence: positive blood culture, but not a major criterion (excluding single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis) or serologic evidence of infection likely to cause IE

Endocarditis Diagnosis requires: ___1.___ Modified Duke Criteria for Diagnosis of Infectious Endocarditis: ___2.___

Management - treatment consists of prolonged antimicrobial treatment and sometimes surgery IV antibiotics (based on the organism and its susceptibility) Sometimes valve debridement, Typically, patients with native valves and no IV drug abuse receive: (NAG) - ampicillin 500 mg/h continuous IV infusion plus - nafcillin 2 g IV q 4 h plus - gentamicin 1 mg/kg IV q 8 h. Patients with a prosthetic valve receive: (VRG) - vancomycin 15 mg/kg IV q 12 h plus - gentamicin 1 mg/kg q 8 h plus - rifampin 300 PO q 8 h. IV drug abusers receive: - nafcillin 2 g IV q 4 h Antibiotic prophylaxis to prevent recurrent endocarditis is recommended: 2 g of Amoxicillin 30-60 minutes before procedure

Endocarditis Tx? patients with native valves and no IV drug abuse? Patients with a prosthetic valve receive? IV drug abusers? Abx ppx?

1. Thrombosis 2. Valsalva maneuver

External hemorrhoids occur due to dilation of veins distal to the anal verge and, due to their sensory innervation, can become exquisitely painful and tender. ___1.___ in these veins due to hemostasis can occur, leading to the blue-purplish discoloration, pain, and swelling. Additionally, hemorrhoids will increase in size and prominence during ___2.___ as intra-abdominal pressure increases.

1. These patients should be started on antiviral therapy regardless of the duration of illness.: - Children under age 5 but especially under age 2 - Adults over age 65 - Pregnant women up to 2 weeks postpartum - Residents of nursing homes and long-term care facilities - Americans Indians - Chronic asthma, chronic lung disease, coronary artery disease, congenital heart disease, diabetes, renal insufficiency, chronic liver disease, extreme obesity, and immunocompromised individuals. 2. less than 48 hours

Influenza The Infectious Diseases Society of America also recommends treating high-risk outpatients with oseltamivir. These populations include: ___1.___ Other patients who might see some benefit from antiviral therapy but do not fall into this high-risk category include those with symptoms for ___2.___, those with symptomatic household contacts who are at high risk for complications from influenza, and health care providers who routinely care for patients at high risk for complications from influenza. Keeping these indications in mind.

Treatment acronym WASH Warm sitz baths: which can relax the anal sphincter and improve blood flow to the anal mucosa.During a sitz bath, the anus is immersed in warm water for approximately 10 to 15 minutes two to three times daily or showers immediately after every bowel movement Analgesics: - 2% lidocaine jelly - Topical vasodilator:topical 0.4% nitroglycerin rectal ointment (Rectiv) twice daily - topical 0.2 to 0.3% nifedipine ointment two to four times daily in patients who have access to a compounding pharmacy Stool softeners (Colace) High Fiber: the recommended dietary fiber intake is between 20 and 35 grams per day - fiber supplements, such as psyllium seed (Metamucil), methylcellulose (Citrucel), wheat dextrin (Benefiber), and calcium polycarbophil (Fibercon) Second-line therapy Topical Ca channel blocker (Diltiazem 2% rectal gel is applied three times daily for eight weeks), or botulinum toxin type A injection

For patients with a typical a, treatment consists of a combination of...?

1. - NSAIDS drug of choice - Indomethacin, Naprosyn (NO ASPIRIN = increased serum uric acid) - Colchicine is 2nd line treatment - Steroids (prednisone) reserved if no response to NSAIDs or colchicine 2. - Allopurinol: reduces uric acid production by inhibiting xanthine oxidase - take with meals to prevent gastric irritation - Uricosuric drugs: probenecid (promotes renal uric acid secretion)

GOUT: Acute management: ___1.___ Chronic management: ___2.___

A topical beta-blocker and alpha-agonist, such as timolol and apraclonidine, respectively, along with acetazolamide, should be given immediately. Emergency consultation with ophthalmology should occur, as patients will likely require more definitive care.

Glaucoma tx?

1. negatively birefringent needle-shaped urate crystals 2. "mouse/rat bite" "punched-out" erosions 3. "p"ositively birefringent, rhomboid-shaped CPP crystals

Gout - Arthrocentesis shows: ___1.___ - X rays: ___2.___ - Increased serum uric acid, increased ESR and WBC Pseudogout - Arthrocentesis shows: ___3.___

1. uric acid 2. purine-rich foods (alcohol, liver, oily fish, yeasts) 3. Diuretics (thiazides and loop), ACEI, pyrazinamide, aspirin 4. monoarthropathy with joint erythema, swelling, and stiffness 5. Podagra 6. tophi deposition

Gout involves the accumulation of ___1.___ in the soft tissue of joints and bone - Attacks are secondary to ___2.___ causing rapid changes in uric acid concentration. - Medications: ___3.___, ARB's most common in men > 30 years old and postmenopausal women. Clinical manifestations of gout: - Acute Gouty Arthritis: 80% ___4.___ (often extends past the joint). - ___5.___ (attack of MTP of the great toe ~ 70% of cases) is often first affected. - In chronic gout = ___6.___: a collection of solid uric acid in soft tissue (helix of ear, eyelids, and Achilles tendon) - Uric acid nephrolithiasis and nephropathy: uric acid stones associated with low urine volume and acidic PH

You can distinguish between Left Bundle Branch Block and Right Bundle Branch Block simply by looking at the QRS morphology in V1 and V6. If the QRS looks like W in V1 and M in V6 it is LBBB. ( WiLLiam) If the QRS looks like M in V1 and W in V6 it is RBBB. ( MoRRow)

How can you tell if a bundle branch block is left or right?

Two spontaneous episodes of rotational vertigo lasting >20 min Audiometric confirmation of sensorineural hearing loss Tinnitus or perception of aural fullness or both

How do you diagnose Menieres Dz?

· Medial to lateral rotation

How to manually detorse Testicular Detorsion?

Correct Answer ( A ) Explanation: The mechanism of injury causing an acute subdural hematoma is a sudden acceleration-deceleration of brain parenchyma relative to the dural structures, which causes tearing of vessels called the bridging veins, connecting veins from the cortical surface to the dural sinus, or much less commonly tearing a small cortical artery. The blood dissects the plane between the dura mater and the arachnoid.

Injury to which vessel or vessels is likely responsible for this patient's abnormal computed tomography scan? · ABridging veins · BIntracerebral arterioles · CMiddle meningeal artery · DSubarachnoid veins

Analgesia and benzodiazepines such as lorazepam for cramping. Antivenin should be reserved only for the most severe symptoms due to the risk of anaphylaxis and serum sickness as it is derived from equine serum.

Management of black widow spider envenomation is almost universally supportive with ...?

1. supportive care (e.g., cardiac monitoring, end-tidal CO2 measurements, pulse oximetry, measures to prevent aspiration such as head of bed elevation) 2. six

Most benzodiazepine overdoses are best treated with ___1.___, exclusion of other coingestants, and investigations into other possible coexisting diagnoses such as trauma, hypoglycemia, rhabdomyolysis, and aspiration pneumonitis. A ___2.___-hour ED observation period is reasonable in these patients, with subsequent admission to a monitored unit if they remain symptomatic.

1. Fatigue and muscular weakness 2. Ocular symptoms 3. Myasthenic crisis

Myasthenia gravis ___1.___ are the hallmarks of myasthenia gravis. ___2.___ are often the first manifestation, with ptosis worsening by the end of the day. Muscular weakness can also affect respiration along with the bulbar muscles causing dysarthria or dysphagia. The diagnosis is based on clinical findings and a combination of serologic testing, electromyographic testing, and the bedside edrophonium (tensilon) or ice bag tests. ___3.___ is defined as respiratory failure leading to mechanical ventilation. Overall mortality has declined dramatically due to treatments with plasmapheresis, intravenous immunoglobulin, and corticosteroids.

Corticosteroids are 1st line, NSAIDs, Colchicine (prophylaxis)

PSEUDOGOUT: Management?

Optic Neuritis MRI IV methylprednisolone

Patient presents with acute monocular vision loss, pain worse with eye movements, loss of color (red) vision, and transient worsening of vision with increased body temperature (Uhthoff phenomenon) Diagnosis is made clinically. ___?___ will confirm demyelination Most commonly caused by multiple sclerosis Treatment is ___?___

Hypercalcemia shortened QT interval IV fluids, bisphosphonates, calcitonin

Patient presents with bone pain (bones), kidney stones (stones), abdominal pain (groans), lethargy, psychosis (psychiatric overtones) ECG will show ___?____ Most common causes: - Malignancy (most common inpatient cause) - Primary hyperparathyroidism (most common outpatient cause) Treatment is ____?____

Scabies · Most commonly caused by Sarcoptes scabiei var. hominis Diagnosis is made by microscopic visualization Treatment is permethrin 5%

Patient presents with severe pruritus that is worse at night PE will show small papules, vesicles, and burrows in the webbed spaces of the fingers and toes Diagnosis? Dx? Tx?

Placental abruption is a life-threatening condition for both the mother and fetus. Large bore IV access should be obtained IV fluids should be given Patient should be typed and crossed for blood. The patient and fetus should have continuous cardiac monitoring. The patient's OB should be emergently consulted.

Placental abruption tx?

1. 200 ml 2. Thoracic ultrasound

Pleural effusion Chest radiographs can detect pleural effusions on an anteroposterior or posteroanterior upright film with a volume of ___1.___, with obscuration of the costophrenic angle. ___2.___ is more sensitive than chest radiograph, detecting fluid as low as 50 mL, and will show hypoechoic fluid above the diaphragm. Lateral and decubitus radiographs can help elucidate if the pleural fluid is loculated, indicating possible empyema or abscess formation. Pleural effusions are characterized as exudative or transudative based on thoracentesis analysis. However, most patients with pleural effusions do not need emergency thoracentesis in the emergency department, unless a massive effusion impedes respiratory or circulatory function. A patient with an empyema will do best with timely ED tube thoracostomy or operative intervention.

1. hypertension, hematuria, and periorbital edema 2. proteinuria and red blood cell casts 3. group A beta-hemolytic Streptococcus 4. furosemide

Poststreptococcal Glomerulonephritis PE will show ___1.___ Labs will show ___2.___ in the urine Most commonly caused by ___3.___ Management includes mainly supportive measures, e.g., salt and water restriction - If edema present, ___4.___ can help.

1. Patient will be a woman > 50 years old 2. Monocular visual loss, unilateral headache, jaw claudication 3. tender temporal artery 4. > 50 mm/hour 5. temporal artery biopsy 6. steroids

Temporal Arteritis (Giant Cell Arteritis) · Demographics: ___1.___ Sx:___2.___ PE will show a ___3.___ Labs will show ESR ___4.___ Diagnosis is made by ___5.___ Treatment is high-dose ___6.___ ASAP Associated with polymyalgia rheumatica

1. emergent surgical decompression to medical management 2. size and type of the hematoma, the effect on the underlying brain tissue, and any associated brain injury

The definitive treatment for subdural hematomas ranges from ___1.___, and treatment varies greatly depending on the ___2.___.

1. airway protection, resuscitation with blood products, and emergent GI consultation for endoscopy 2. proton pump inhibitor 3. gastric or duodenal perforation

The emergency management of a patient with an upper GI bleed includes ___1.___. A ___2.___ is typically given IV twice daily as it may decrease transfusion requirements. Another complication of peptic ulcer disease is ___3.___. This is a surgical emergency that requires immediate surgical consultation.

1. 1 to 4 days 2. fever and respiratory symptoms 3. pneumonia, worsening chronic respiratory disease, myocarditis, meningitis

The incubation period for influenza is typically ___1.___. Patients complain of ___2.___, which usually resolve within about 1 week. Complications from the illness can include ___3.___, and bacterial superinfection.

Correct Answer ( A ) Explanation: The image represents impetigo, a pustular eruption most commonly seen in preschool children. Acute poststreptococcal glomerulonephritis results from an antecedent infection of the skin or throat caused by nephritogenic strains of group A beta-hemolytic streptococci. Acute poststreptococcal glomerulonephritis usually occurs 1-2 weeks after pharyngitis and 3-6 weeks after skin infection. The incidence is decreasing in the United States but is still common in some rural areas. It appears to results from the deposition of circulating immune complexes in the kidney. This results in decreased glomerular filtration, allowing proteins to flow freely into the urine. Urinalysis shows significant blood and protein with RBC casts in 60% of cases. Pyuria with granular or hyaline casts also may be found.

The rash seen above is associated with which one of the following conditions? A Acute glomerulonephritis B Arthritis C Clostridioides difficile colitis D Secondary syphilis

Dextromethorphan is a cough suppressant. It affects the signals in the brain that trigger cough reflex. Dextromethorphan is used to treat a cough. It is available over-the-counter alone and is also present in many over-the-counter and prescription combination medications.

What is Dextromethorphan?

Postictal paralysis that follows a generalized or complex partial seizure and is a focal motor deficit that may persist up to 24 hours.

What is Todd paralysis?

· Carpal spasm while checking blood pressure - Hypocalcemia

What is Trousseaus sign and what does it indicate?

Apply only in 2nd and 3rd degree burns Vol of Ringer lactate soln: - 4mL x Tot body surface area of burn (%) x body weight (kg) - First half of soln over 8 hours; Second half over next 16 hours

What is the Parkland formula?

Phimosis: Inability to retract the foreskin proximally Paraphimosis: inability to reduce foreskin back to anatomical position

What is the difference between phimosis and paraphimosis?

Posterior midline (comparatively low blood flow)

What is the most common site of an anal fissure?

Glucose-6-phosphate-dehydrogenase deficiency (x-linked recessive) Antimalarials, sulfonylureas, quinolones, nitrofurantoin, fava beans Heinz bodies, presence of bite cells on the smear

What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis? History of taking? Labs will show?

Episodic vertigo (spinning sensation) Sensorineural hearing loss Tinnitus

What is the triad for Menieres Dz?

TMP-SMX

What medication can not be prescribed for a child with G6PD deficiency?

Correct Answer ( D )

Which of the following dysrhythmias can be triggered by premature ventricular contractions? · A Atrial fibrillation · B Atrial flutter · C Supraventricular tachycardia · D Ventricular tachycardia

Correct Answer ( B ) Explanation: Mitral valve prolapse (MVP) is billowing of one or both mitral leaflets into the left atrium by increasing pressure in the ventricle during systole. Mitral valve regurgitation may or may not be present. MVP is caused by myxomatous degeneration of the valve and is the most common cause of primary valvular disease in industrialized countries. Most patients are asymptomatic, and the condition is diagnosed by incidental auscultation of the classic midsystolic click, which may be associated with a late systolic crescendo murmur. The midsystolic click is moved earlier in systole by maneuvers that decrease preload, such as Valsalva and standing. Maneuvers that increase preload (such as squatting) or afterload (such as hand grip) move the click later in systole. Although most patients with MVP are asymptomatic, symptoms can include nonexertional chest pain, palpitations, dyspnea, and anxiety.

Which of the following moves the midsystolic click of mitral valve prolapse later into the systolic phase? · A Prone position · B Squatting · C Standing · D Valsalva maneuver

Correct Answer ( B ) Explanation: Influenza is a highly contagious orthomyxovirus that is transmitted through aerosolized respiratory secretions and large droplets. Individuals at greatest risk for these complications include the very young, the very old, and those with chronic medical conditions such as chronic obstructive lung disease, congestive heart failure, chronic renal insufficiency, and an immunocompromised state. Influenza can be diagnosed clinically, but testing is available with rapid antigen testing. Unfortunately, the sensitivity is low, but the specificity of the test is high. Symptomatic treatment is the mainstay with antipyretics, decongestants, and oral hydration. However, antiviral medications are available to help prevent disease complications and shorten the duration of symptoms. There are two types of antivirals: the neuraminidase inhibitors and the adamantines. - The use of a neuraminidase inhibitor, such as oseltamivir, is the recommended first-line therapy for patients requiring treatment with antivirals. - Adamantine medications are active only against influenza A, and high rates of resistance have already occurred, so they are not indicated for treatment.

Which of the following patients may obtain the most benefit from treatment with oseltamivir twice a day for 5 days during influenza season? · A A 50-year-old man with a history of hypertension and high cholesterol diagnosed with influenza A after 3 days of symptoms · B A 73-year-old woman with a history of arthritis diagnosed with influenza A after 3 days of symptoms · C A 9-year-old healthy boy diagnosed with influenza A after 3 days of symptoms · D An asymptomatic 35-year-old woman with two children at home who are ill with influenza A for 1 day