Practice Questions
A 54-year-old male comes to the emergency room with right sided groin pain, swelling, colicky abdominal pain and abdominal distension, nausea and 2 episodes of vomiting. He had been having intermittent pain and swelling in the right groin for 2 years, always triggered by straining at stool. He recalls that on all previous occasions, the swelling had reduced with gentle finger massage. However, finger massage was ineffective this time. He has a 20 pack-year smoking history. Examination reveals an overweight male with abdominal distension. There is a red, tender swelling in his right groin, descending into his right scrotum. Radiographs reveal dilated small bowel loops. What's most likely diagnosis?
incarcerated, obstructed indirect right inguinal hernia
A 75-year-old man with type 2 diabetes presents to the emergency department with a 2-day history of confusion and lethargy. On physical exam, notable dehydration, tachycardia, and confused mental state is noted. Serum sodium, potassium, magnesium, and chloride levels are normal. The arterial blood gases are normal and serum ketones are negative. The abnormal laboratory findings are as follows: Glucose = 700 osmolality = 380
A hyperglycemic hyperosmolar state is characterized by dehydration, significant hyperglycemia, and an elevated serum osmolality with an insignificant or negative ketosis. Because of the lack of ketosis, the patient may present with a gradual onset of symptoms, and it can go unnoticed until the dehydration becomes more severe than in ketoacidosis.
A 14-year-old boy presents to ED with acute scrotal pain and vomiting for past 2 hours. His left testicle is in extreme pain and he states pain started while playing basketball in gym class. On physical exam of the affected testicle, which of the following findings would suggest testicular torsion?
abnormal transverse lie Absence of ipsilateral cremasteric reflex
A 69-year-old male with atrial fibrillation on warfarin had a syncopal episode and struck his head on the stairs. Shortly thereafter, he because unconscious. Treatment?
burr hole
63yo male complains of acute vision loss in R eye that lasted about 2-3min and completely resolved. He denies pain, blurriness & motor deficits. What dx study would be most helpful?
carotid doppler U/S --> TIA
A 70-year-old male with atrial fibrillation presents to the emergency department with sudden onset of severe abdominal pain despite relatively benign findings on physical exam.
mesenteric ischemia
A 22-year-old man is brought to the emergency department by paramedics after having sustained a single stab wound along the left sternal border at the fourth intercostal space. Upon arrival to the emergency department, he was hypotensive and tachycardic. The neck veins were distended and heart sounds were muffled. Which of the following interventions is the most appropriate first-line management of this patient?
Cardiac tamponade is classically described by the triad of jugular venous distension (JVD), arterial hypotension, and muffled heart sounds. In the emergency department, suspicion of this clinically entity is usually confirmed by ultrasonography and is acutely treated by pericardiocentesis, which will be diagnostic, therapeutic, and buy time until a definitive procedure can be done.
27yo G1P0 presents complaining of painless spotting since this morning. She's known to be 12wk pregnant. Pelvic exam reveals presence of blood within vagina w/ closed cervical os. Uterus consistent with 10-12wk gestation & nontender to palpation. Imaging?
U/S - threatened
A 72-year-old man presents to the ED complaining of worsening abdominal pain over the last few hours. He also reports nausea, but denies fever, vomiting, or changes in the appearance of his bowel movements. His medical history is significant for type 2 diabetes mellitus, hypertension, coronary artery disease, stroke, atrial fibrillation, and peptic ulcer disease. Due to his recurrent bleeding peptic ulcers, he does not take warfarin. His surgical history is significant for an appendectomy as a child. His medications include metformin, lisinopril, metoprolol, and omeprazole. He has a 50-pack-year history of smoking. His temperature is 37.6 C (99.7 F), blood pressure is 146/80 mm Hg, pulse is 115/min, and respiratory rate is 20/min. On physical exam, he is in acute distress due to the pain. Pulmonary auscultation reveals scattered wheezes and decreased air entry. His heart rate is irregularly irregular, with no murmurs, rubs or gallops. Abdominal exam is significant for decreased bowel sounds and diffuse tenderness. What is the most likely diagnosis in this patient?
mesenteric ischemia
Otherwise healthy 30yo female complains of RLQ abd pain & vaginal spotting x1day. Her LMP was 6mo ago & describes it as lighter than normal. She's afebrile & has localized RLQ tenderness on exam. Transvaginal U/S reveals empty uterus & right adnexal mass <2cm in diameter. What's apt management?
methotrexate - folic acid antagonist; used to treat small, unruptured ectoic preg
A 45-year-old man is brought to the ED following a motor vehicle accident. He was not wearing a seatbelt and was ejected from the car through the windshield. On physical exam he was noted to have retroauricular ecchymosis, as seen in the image. What imaging?
noncontrast CT - Basilar Skull Fracture
74yo female treated w/ mild HTN. Found at home w/ right hemiparesis & brought to ED. Pt fell 2days ago, but had no complaints at that time. Her daughter said her mother sounded a little confused this morning. Pt's left pupil's dilated. What imaging?
noncontrast CT - subdural hematoma
A 28 year-old female, who has experienced occasional painful migratory arthralgias, complains now of a tender, swollen, and hot left ankle. The joint was aspirated and the synovial fluid showed 55,000 WBCs, 75% polymorphonuclear lymphocytes, low glucose level, and no crystals.
septic arthritis
A 59-year-old man returns to the hospital with chest pain and difficulty breathing a couple of weeks after being discharged following a myocardial infarctation requiring immediate cardiac catheterization. He has been coughing up frothy sputum for the past three days. On CXR, you see blunting of costophrenic angles. What would be the best diagnostic test?
thoracentesis - pleural effusion
a 43yo male complaining of R eye pain after treating his yard w/ fertilizer & lime. He attempted to flush his eye at home w/o relief of pain. Which of following's most appropriate initial step in managing this pt's sx? A. Double evert to look for remaining foreign bodies B. Fluorescein stain c. Instill proparacaine D. irrigate E. opthalmologist
C
43yo female w/ h/o cholelithiasis presents w/ moderate boring epigastric pain that came on suddenly 3hr ago. Pain radiates to back & somewhat relieved by leaning forward. She's nauseous & has vomited twice. Exam reveals abdominal distention & tenderness w/o rigidity or rebound. Best initial imaging?
CT
A 38-year-old man presents to the emergency department complaining of acute onset, 10/10 stabbing pain in his chest radiating to the area between his scapulae. He has a history of hypertension for which he is noncompliant with treatment but no other medical problems. He has no allergies. His vital signs are T 37.2C, P 100, BP 240/110 in the right arm, 200/90 in the left arm, RR 16, SaO2 99%. The patient is clearly distressed. Radial and pedal pulses are present and equal bilaterally, and the remainder of the physical exam reveals no abnormalities. The patient's EKG is shown in Image A. What is the most appropriate next diagnostic test?
CTA --> Aortic aneurysm
A 43-year-old woman presents complaining of a "pins and needles" sensation that started bilaterally in her feet 2 days ago. The sensation now extends up to her mid-thighs. On physical examination, she is noted to have mild sensory loss, weakness, and absent reflexes bilaterally in her legs.
Guillain-Barre
A 28-year-old male presents with hypotension, marked tachypnea, and severe dyspnea following a fistfight. A physical exam reveals ecchymoses over the lateral left rib cage, hyperresonance on the left, and tracheal shift to the right. Which of the following is the most appropriate next step for management of this patient?
The diagnosis for this patient is a traumatic tension pneumothorax, a true medical emergency. Diagnosis can be made based on physical exam findings. Although definitive treatment with a properly placed tube thoracostomy is preferred, choice E has the position incorrect. Needle decompression in the second intercostal space, midclavicular line is the correct choice, with this remaining in place until a chest tube is properly in place.
A 45-year-old male presents to the emergency department with complaints of fever, shortness of breath, and productive cough over the past 3 days. His medical history is significant for HIV and hypertension. The patient's last course of anti-viral therapy concluded 6 months ago, with a documented CD4 T-cell count of 550 cells/uL at that time. He denies any recent international travel. His vital signs today are as follows: T 39.2 C, HR 99, BP 143/89, RR 22, O2 Sat 94% on RA. Physical exam is significant for crackles auscultated over the lower lobe of the left lung. A chest radiograph is obtained and is shown in Figure A. Which of the following is the most common causative organism responsible for this patient's presentation?
This HIV-positive patient has community-acquired pneumonia. The most common cause of pneumonia in HIV-positive patients is Streptococcus pneumoniae.
A 65-year-old man presents to the emergency department with an acute ischemic stroke. His CT scan is normal. His blood pressure is 180/100 mm Hg. What is the most appropriate treatment for his hypertension?
Blood pressure is typically elevated at the time of presentation in acute ischemic stroke. It will decline without medication in the first few hours to days. Aggressively lowering blood pressure in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. This potentially salvageable brain tissue is referred to as the penumbra. Decreasing blood flow to the ischemic penumbra by acutely lowering blood pressure may result in eventual infarction of this brain tissue. Treatment of previously undiagnosed hypertension should be deferred for several days. Blood pressure should be treated if there are other indications, such as angina or heart failure. Control of blood pressure is appropriate in patients who are receiving tissue plasminogen activator (t-Pa) for their stroke. Blood pressure should be lowered cautiously to a systolic of less than 185 mm Hg and a diastolic of less than 110 mm Hg. This is thought to decrease the incidence of intracerebral hemorrhage in these patients.
A 68-year-old female presents to the emergency department due to exertional dyspnea and increased cough for the past week. The patient states that this has happened in the past, but she cannot recall which medication helped her. Physical exam reveals a sustained left ventricular impulse, an S3 gallop, and mild JVD. What do you expect to see on CXR?
CHF
A 68-year-old woman underwent a hip replacement surgery two weeks ago. The post-operative period was complicated by a pneumonia, and the patient has been bed-ridden ever since. A nurse calls you to the patient's room due to vital sign abnormalities and complaints of chest pain. The patient's HR is 105 bpm, BP is 90/60 mmHg, RR is 35 rpm, and T is 100.2F. You note jugular venous distension and profound dyspnea. What's best diagnostic test?
CT w/ IV contrast
A 76 year-old female presents to the ED with the worst abdominal pain in her life. The pain began following a large meal and is located periumbilically. Although she is writhing in pain, she does not have an exacerbation of the pain on palpation of the abdomen. She has a history of coronary artery disease, asthma, and atrial fibrillation. What's best imaging?
CTA - mesenteric ischemia
A 16-year-old male was hit on the left side of his face by a line drive baseball. Marked swelling is noted externally to the left eye. There was no loss of consciousness. Upon physical exam, he complains of diplopia during extraocular motion testing. Enophthalmos is noted, as well as decreased sensation of the left cheek. Plain x-rays of the face demonstrate an air-fluid level in the left maxillary sinus, and a fracture of the orbit. Based on this information, what is the most likely diagnosis?
Diplopia is common in an orbital blow out fracture, due to entrapment of the inferior rectus and inferior oblique muscles. Loss of infraorbital sensation occurs from disruption or swelling of the infraorbital nerve.
26yo brought to ED stating that her legs have become weak & tingling causing progressively worsening difficulty walking for 2days. She's also been severely fatigued. Exam reveals tachycardia, irregular rhythm, & hypoTN. She also experiences urinary incontinence.
Guillain-Barre
A 70-year-old woman who was found barely responsive at home by her daughter is brought to the emergency department. Evaluation reveals that she is in a hyperglycemic hyperosmolar state with a severe fluid deficit. Treatment is initiated with vigorous saline rehydration and a continuous infusion of insulin. At what point should her glucose be added to her treatment?
In hyperglycemic hyperosmolar states, the serum glucose rapidly corrects with fluid administration alone. However, with vigorous rehydration, glucose may fall precipitously and lead to severe hypoglycemia. To avoid this, glucose should be added to water, half-normal, or normal saline as soon as the patient's blood glucose is less than or equal to 250mg/dL.
A 42-year-old healthy male presents to the emergency department with the complaint of a progressively worsening sore throat, and difficulty swallowing over the past 48 hours. He also complains of a subjective fever, but denies any headaches, nausea, or vomiting. On exam, the patient is afebrile and in mild distress, with a presentation of leaning forward on the exam table. His TM examination is normal, there is no rhinorrhea, and the oropharynx is patent without signs of stridor. His lungs are clear, and he has a regular rhythm on cardiac exam. What diagnostic test is indicated for a definitive diagnosis?
Lateral neck XR - epiglottitis
A 23-year-old G1P0 presents to the office complaining of headache, nausea, swelling, and generally not feeling well. She is at 33 weeks gestation. A physical exam reveals a 5-pound weight gain in 2 weeks, BP 148/90, P 84, T 98.1°F, and UA concentrated with 1+ protein. What is the management?
bed rest - preeclampsia
A 68-year-old female presents to the emergency department with signs and symptoms of an acute ischemic stroke. The initial CT scan is normal. Her blood pressure is 164/105. What is the most appropriate treatment for the blood pressure of this patient?
close monitoring --> ischemic stroke
A 55-year-old woman with a history of emphysema, who is undergoing chemotherapy for lung cancer, comes to the emergency room complaining of a sudden increase in dyspnea, with exertion and fatigue. On physical exam, hypotension, pulsus paradoxus, and muffled heart sounds are noted. On transthoracic echocardiography, cardiac tamponade is noted with over 200 mL of pericardial fluid described. Which of the following is the most appropriate next step in management?
emergent pericardiocentesis, should be considered when patients exhibit symptoms suggestive of severe cardiac tamponade, such as described above, with confirmatory echocardiographic findings of a large pericardial effusion, as this can be fatal if not treated promptly.
A 34-year-old man is brought to the ER by his wife because she believes her husband is very ill. The patient initially had a headache that progressed to neck stiffness and an inability to look at bright lights. His temperature is 103.1 deg F (39.5 deg C), blood pressure is 130/85 mmHg, and respirations are 20/min. Extreme pain is elicited upon flexion of the patient's neck and the patient's legs.
meningitis
32yo female 6wk postpartum complains of double vision that appears midmorning & worsens thruout day. She's been easily fatigued & has had difficulty swallowing. Exam reveals ptosis & limited EOM movement. Pupillary reflexes & deep tendon reflexes are normal. What's next imaging?
• CT (faster) Thymoma
A 26 year-old female reports progressive distal to proximal spread of extremity weakness over the last 36 hours without fever, headache or syncope. Examination reveals symmetrical, paresis of the hands and feet with loss of the brachioradialis and Achillis reflexes. Biceps and knee reflexes are present but diminished. Sensory exam is normal. What treatment?
• IV Immunoglobulin IgG Plasma exchange
A 30 year-old female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On physical examination you note the presence of bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. What's treatment?
• Thymectomy • Anticholinesterase drgs Pyridostigmine (Mestinon)
G1P0 at 36wk gestation p/w blurred vision & increased dependent edema. BP= 160/100 & 3+ proteinuria noted on urine dipstick. Fetal heart tones strong & regular, fetal movement present & fundal height 36cm. Maternal fundi w/o retinal hemorrhages; DTR 3+ & equal bilaterally. Denies seizures. What's next step in management?
- Severe preeclampsia --> admit, place on MgSO4 & induce labor Delivery indicated in pt w/ preeclampsia & >34wk gestation or if fetal lung maturity's confirmed
A teenage girl presents to the emergency department with her parents. She has had symptoms of a urinary tract infection for the last two days, but did not tell her parents until today. She is not sexually active. Today, the girl also has diffuse abdominal pain with vomiting, general malaise, and difficulty breathing. She has no significant past medical history. Her physical exam reveals sinus tachycardia and deep fast respirations with no localization of abdominal pain or rebound tenderness. Initial lab test results reveal a plasma glucose = 378 mg/dL and serum bicarbonate = 14 mEq/L. What is the most likely diagnosis?
Classic signs and symptoms of this disorder include polyuria, polydipsia, marked fatigue, nausea, vomiting, signs of dehydration, fruity breath odor, postural hypotension, Kussmaul respirations, and possibly mental stupor or coma. Patients with type 1 diabetes mellitus may present for the first time in DKA. DKA is commonly precipitated by a recent infection.
60yo female w/ 2month h/o slowly increasing dysphagia, weakness in extremities, ptosis & diplopia. What diagnostic test could you do?
Edrophonium (Tensilon) test: MG • Serology Acetylcholine receptor Ab assay
28yo female p/w complaints of "prickly sensation" that started bilaterally in her feet 2days ago & difficulty walking. She now has 4/5 dyesthesia from her mid-thigh down to her toes. On PE: diminished pain & temp sensation, absent reflexes, loss of proprioception in her legs bilaterally & muscle strength 1+/5+ UE.
Guillain-Barre
A 76-year-old man, is brought to the emergency department by his niece after she found him wandering around his yard in the cold wearing only a tee shirt and jeans. When she set up his pill container about 36 hours earlier, he seemed his usual self but, in retrospect, possibly a little more confused than usual. The niece says that he has "high blood," treated with a "white fluid pill," "sugar diabetes," treated with an oral medication, and early "old timer's" dementia treated with "a memory pill." Vital signs include an oral temperature of 100.8F, pulse 100 beats per minute, respirations 24 and somewhat shallow, and blood pressure of 88/52. Initial examination reveals a slightly dehydrated, stuporous man appearing older than his stated age, who smells strongly of urine. He has no lateralizing signs. What is the most likely cause of the mental status changes?
HHS
A 27-year-old man comes to the emergency department complaining of extreme pain in his left calf. He is a surfer and cut his leg on a reef over the weekend. He says he cleaned the wound himself and bandaged it, but has been having worsening pain. On exam, T is 101.8 F, HR is 108 bpm, RR 18 rpm, and BP 115/75 mmHg. You note crepitus on palpation. Which of the following is most appropriate next step?
He needs empiric broad antibiotic coverage and surgical debridement of necrotic tissues.
A 57 year-old male presents with episodic diplopia over the past two months. Symptoms progressed over the last two days with the onset of bilateral facial weakness made worse with repetitive use. Weakness improves somewhat with rest. He denies fever, headache or areas of pain. Exam reveals a nasal voice, drooping eyelids and a normal sensory exam.
MG
A 56-year-old insulin dependent diabetic has been under your evaluation for his diabetes for several years. The patient has a 3-year history of diabetic neuropathy to the right foot, and may have suffered an injury to the foot without knowing due to loss of sensation. The patient now presents with a tender, reddened, and swollen right foot for the last 10 days that is also warm to the touch. You suspect that this patient may have an acute case of osteomyelitis. Based on this history, what bacterial organism is most commonly the cause of osteomyelitis?
Osteomyelitis is an infection in a bone and can occur in patients of all ages. The most common organism implicated in osteomyelitis across all age groups is Staphylococcus aureus. It can enter the bone through multiple mechanisms including by direct inoculation during an open fracture or during surgical intervention following a fracture (most common mechanisms for adults) or by hematogenous spread from another source (the usual cause in children).
55-year-old woman with history of hypertension and hyperlipidemia, presents with sudden onset slurred speech at noon time while eating with friends, immediately brought to ED within the hour, where her symptom spontaneously resolved. DWI sequence on MRI unrevealing for acute stroke. However, multiple punctate hypodensities isodense to CSF present on CT indicating old infarcts.
TIA
A 45-year-old woman presents to the emergency room with a stiff neck, photophobia, and an extremely severe headache that began while she was enjoying a glass of sweet Alabama southern tea. She states her symptoms came on immediately and she is in severe distress.
Subarachnoid hemorrhage (SAH)
A 54-year-old man with a history of chronic alcohol abuse presents to the emergency department with complaints of a subjective fever and severe epigastric pain radiating to the back. The pain has been present for the past 8 hours and is associated with nausea and vomiting, which has not relieved the pain. Laboratory data reveal a WBC of 14,000/mm 3 and a serum amylase of 500 U/L (reference range 0-286 U/L). Plain films of the abdomen were unremarkable. Management?
Supportive - IV fluids & analgesia
A 75-year-old man with type 2 diabetes presents to the emergency department with a 2-day history of confusion and lethargy. On physical exam, notable dehydration, tachycardia, and confused mental state is noted. Serum sodium, potassium, magnesium, and chloride levels are normal. The arterial blood gases are normal and serum ketones are negative. The abnormal laboratory findings are as follows: glucose = 700
A hyperglycemic hyperosmolar state is characterized by dehydration, significant hyperglycemia, and an elevated serum osmolality with an insignificant or negative ketosis. Because of the lack of ketosis, the patient may present with a gradual onset of symptoms, and it can go unnoticed until the dehydration becomes more severe than in ketoacidosis.
A 77-year-old male with hypertension and a 46 pack year history presents to the Emergency Department from an extended care facility with acute onset headache, nausea, vomiting, and neck pain which began 2 days prior. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. Eye examination reveals that his left pupil is smaller than the right and the right eyelid is lower than the left. His vision, however, appears intact, and he is able to track an "H in space" without limitation. On ophthalmoscopy he has no retinal hemorrhages and his optic discs are normal. He is immediately sent for an urgent head CT, which is normal. What is the most appropriate next step in his management?
In a patient with high pre-test probability of aneurysmal subarachnoid hemorrhage with a normal head CT, a lumbar puncture is indicated to assess for xanthochromia.
A 62-year-old man with a history of hypertension, diabetes mellitus type 2, hyperlipidemia, and chronic tobacco use presents to the office with complaints of a retrosternal chest pressure associated with diaphoresis, nausea, and dyspnea, radiating down his left arm for the last 45 minutes after mowing his lawn. The patient's vital signs are stable, and on physical examination a new systolic murmur is appreciated. His EKG demonstrates evidence of acute anterolateral myocardial infarction on EKG, with ST segment elevation across the precordial leads, indicative of left anterior descending coronary artery stenosis. Which of the following is the most appropriate next step in management of this patient?
In patients suffering from acute ST elevation myocardial infarction (STEMI), cardiac catheterization with percutaneous coronary intervention within 90 minutes substantially decreases morbidity and mortality outcomes
An 18-year-old woman is transferred to your emergency department from a local college infirmary. She presented yesterday with a complaint of headache but became confused and is now febrile. You notice a petechial rash on physical examination and her cerebrospinal fluid comes back with increased WBCs, increased protein, and decreased glucose. What is the most likely organism responsible for her meningitis?
Neisseria meningitidis and Streptococcus pneumoniae are the most common etiologic agents for bacterial meningitis in this patient's age group.
A 30-year-old woman presents to the university emergency department complaining of sudden-onset dyspnea and pleuritic chest pain. It is found out that the patient has recently started a new oral contraceptive pill within the past six months. Physical examination elicits tachypnea and tachycardia. How would treat this patient's suspected diagnosis?
Parenteral anticoagulation 1 wk --> oral anticoagulation (Warfarin/Lovenox) 3-6mo
A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Best imaging?
Pelvic U/S - ectopic empty uterus, free fluid & adnexal mass
A 65-year-old female is evaluated by her primary hospital team for the evaluation of a new rash. Approximately 1 week ago she was admitted for an exacerbation of chronic bronchitis and given trimethoprim/sulfamethoxazole (Bactrim). While her respiratory symptoms have improved, two days ago she developed a low-grade fever, a headache, and her eyes became red. Today she has a red rash on her face and chest. Additionally, she has numerous ulcers on her lips that were not there yesterday. On exam, she has scattered, irregularly shaped, dusky macules on her trunk and face - some are targetoid in nature. She also has mucosal involvement, with erosions and ulcers on her lips, inside her mouth, and around her eyes. What is the most likely diagnosis?
SJS
A young boy is sent to the emergency room by his primary care physician who noted erythematous lesions all over his body and ulcerations of the mucosal membranes of the mouth and eyes. He recently started antibiotic treatment for an upper respiratory infection.
SJS
72yo h/o HTN & a. fib p/w episodes of weakness, numbness & paresthesias in right arm. At same time, she notes speech difficulty & loss of vision in L eye. Sx come on abruptly & clear within minutes
TIA
A 25-year-old male with no significant past medical history is brought to the emergency room after a skiing accident. His friend reports that the patient tumbled into a tree and briefly lost consciousness. He then regained consciousness and appeared normal for the rest of the day, but became progressively more confused that evening. A non contrast CT of his head is shown in Figure A. What is the most appropriate next step?
The patient has an acute epidural hematoma causing depressed consciousness and requires urgent surgical evacuation.
A 74-year-old male smoker with a history of type II diabetes presents to the emergency room complaining of sudden-onset, painless vision loss in his left eye. He describes the feeling as if things went black in his left eye. Vital signs are within normal limits and stable. Physical exam reveals 20/800 vision in the left eye with eccentric fixation and a normal right eye. Fundoscopic exam of the left eye reveals a cherry red spot on the macula. Which of the following is the best next step in management?
The patient presents with signs and symptoms of central retinal artery occlusion. Emergent treatment includes ocular massage, CO2 rebreathing, and decompression of the anterior chamber.
A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the best test to definitively diagnose this medical problem?
This patient is exhibiting a history and physical examination that is consistent with a thoracic aneurysm. The patient's history of hypertension, along with the "ripping" sensation in his back and hypotension give a clinical presentation that is suggestive of a thoracic aneurysm dissection. Given this clinical situation, the best test to evaluate for a potential dissection is by computed tomography
A 48-year-old man presents to the emergency department with 30 minutes of severe chest pain radiating to the back. He has no history of angina or known cardiac disease. His uncle died suddenly of an unknown cause at age 50. Vitals include T 37.3 C, BP 160/60 mmHg, HR 100/min, RR 20/min. On physical exam, he is 6'6" tall and has a high-arched palate. The appearance of his chest and fingers are shown in Figures A and B, respectively. Cardiac auscultation reveals a decrescendo diastolic murmur at the third left intercostal space. The rest of the physical exam is within normal limits. What is the next best step in the management of this patient?
This patient with Marfan syndrome and a family history of possible sudden death from aortic disease most likely has a thoracic aortic dissection, which should be evaluated with CT angiography of the aorta.
A 55-year-old right-hand dominant man presents with a 4-hour history of weakness and tingling of his right hand and numbness of the right side of his mouth. Mild difficulty was noted with word finding. His symptoms have improved since onset but have not fully resolved. There is no significant medical history. Physical examination revealed flat right nasolabial fold, subjective numbness of the right hand, right pronator drift, clumsiness of finger tapping on the right hand, increased deep tendon reflexes on the right, as well as a present Babinski. What is the most likely etiology for this patient's problem?
Three key features of a transient ischemic attack include sudden onset and complete reversal of symptoms within 24 hours, usually within 15 minutes. The symptoms are usually in the anatomical distribution of a single blood vessel.
A 54-year-old man presents to the emergency department with crampy abdominal pain, nausea, and vomiting. The patient has not passed gas or had a bowel movement for at least 10 hours. On examination, the abdomen is distended and there are high-pitched bowel sounds with rushes. A plain radiograph of the abdomen reveals cecal distension to 12 cm. What's diagnosis?
bowel obstruction
A 28-year-old snow skier strikes a tree and was not wearing a helmet. He loses consciousness for several minutes but later regains consciousness and reports feeling fine. Several hours later his neurological state decompensates acutely.
epidural hematoma
