EM Case Studies II

48. (D) Persistent and repetitive use of topical α-adrenergic decongestant sprays (such as oxymetazoline) for more than 5 to 7 consecutive days is associated with rebound nasal congestion after withdrawal. This phenomenon is termed rhinitis medicamentosa. Extensive use of these over-the-counter sprays can cause inflammatory mucosal hypertrophy and chronic congestion. The patient should discontinue using the topical decongestant, which will resolve the problem. This can be difficult for patients. Use of steroidal nasal sprays can be helpful. (Quillen and Feller, 2006, 1583-1590)

48. A 45-year-old man presents with chronic nasal congestion. He has been using a topical 12-hour- duration nasal decongestant for the last several weeks, which has, up until recently, been very effective. Initially, he used it only a couple of times per day. Now, he states that he has to use it every 2 to 3 hours. If he does not use the nasal spray, he feels very congested and cannot breathe. He denies purulent drainage or epistaxis. What is your diagnosis? (A) deviated septum (B) allergic rhinitis (C) nasal polyps (D) rhinitis medicamentosa (E) chronic sinusitis

1. (C) This is the classic history of an epidural hematoma. The typical presentation is that of a child who sustains a hard blow to the head and experiences a brief loss of consciousness, followed by a lucid interval, when the child is awake and alert. As the hematoma expands, the patient experiences a headache followed by vomiting, lethargy, and hemiparesis and may progress to coma if left untreated. This injury usually results from a temporal bone fracture with a laceration of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Epidural hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel. Spinal cord transection should not present initially as a loss of consciousness and will affect distal motor and sensory function. Chronic subdural hematomas present more than 20 days after the trauma. Subarachnoid hemorrhage typically presents as a generalized headache without associated trauma. A grade III concussion usually involves continued improvement after consciousness is gained. The lucid period followed by worsening symptoms in this question is worrisome of more severe intracranial pathology. (Aminoff et al., 2005, p. 329)

1. A 6-year-old boy is struck by a car while riding his bicycle. He is reported to be unconscious for 2 minutes following the accident. He is conscious and alert upon arrival to the emergency department, but within 45 minutes he begins to vomit and shortly thereafter he becomes completely unresponsive. Which of the following most likely explains this child's injury? (A) spinal cord transection (B) chronic subdural hematoma (C) acute epidural hematoma (D) acute subarachnoid hemorrhage (E) grade III concussion

1. (C) Melissa's symptoms (fever, pharyngitis, and conjunctivitis) and findings on examination, particularly nontender preauricular lymphadenopathy, are characteristic of a viral conjunctivitis. This condition is found more commonly in children, and contaminated swimming pools are sometimes the source of infection. There is no specific treatment, but the conjunctivitis is self- limited, usually lasting about 10 days. Symptomatic treatment would include antipyretics such as acetaminophen. Application of topical antibiotics is occasionally recommended to prevent secondary infection. Penicillin, indicated for streptococcal pharyngitis, would not be appropriate because there are no physical examination findings such as pharyngeal erythema, tonsillar exudate, or tender cervical adenopathy to support the diagnosis. Acyclovir may be helpful in the treatment of herpes simplex virus conjunctivitis, which is a disease characterized by unilateral injection, irritation, mucoid discharge, pain, and mild photophobia. A mast cell stabilizer would be helpful in allergic conjunctivitis to alleviate symptoms of itching, a symptom that Melissa did not complain of. (Ehlers et al., 2008, pp. 102-104)

1. Melissa is a 7-year-old girl who is brought to her pediatrician by her mother for evaluation of a 2-day history of fever (temperature, 101°F), sore throat, and redness and tearing in both eyes. She denies any cough, nasal congestion, or any pain or photophobia in her eyes. Melissa has been taking swimming lessons 2 days a week for the past month. Findings on physical examination include copious watery discharge and scanty exudate in both eyes, prominent follicles present on both her conjunctiva and pharyngeal mucosa, and nontender preauricular lymphadenopathy. The most appropriate treatment for Melissa at this time is which of the following? (A) penicillin to be taken four times a day by mouth (B) topical or systemic antiviral such as acyclovir (C) only symptomatic treatment required (D) instillation of a mast cell stabilizer to each eye (E) culture of ocular exudate

10. (C) The medial ankle support comprises the deltoid ligaments, which include tibionavicular, anterior tibiotalar, tibiocalcaneal, and posterior tibiotalar parts. The most common mechanism of injury is an external rotational force. The lateral portion of the ankle is supported by the anterior talofibular, anterior inferior tibiofibular, interosseous, posterior tibiofibular, and the calcaneofibular ligaments. Approximately two-thirds of all ankle injuries are isolated anterior talofibular ligament injuries. About 20% involve both anterior talofibular and calcaneofibular ligament injuries. Less than 5% of the ankle injuries are isolated deltoid ligament sprains. (Ho and Abu-Laban, 2006, pp. 808-820)

10. A 16-year-old long-distance runner suffered an external rotation injury to the ankle. Which of the following ligaments is most likely injured? (A) anterior talofibular (B) posterior talofibular (C) deltoid (D) calcaneofibular (E) tibiofibular

10. (C) The anterior chest and abdomen are 18%, the entire right leg is 18%, and the entire right arm is 9%, for a total of 45% body surface area. (Latenser, 2010, p. 1121)

10. Using the "rule of nines" to calculate body surface area, what would the percentage of burned area be in an adult patient with second-degree burns involving the entire right arm, the anterior chest and abdomen, and the entire right leg? (A) 27 (B) 36 (C) 45 (D) 52

105. (C) Crotaline or pit viper venomous poisoning is noted by the following clinical findings: localized pain, the spreading of edema in the affected area, and the presence of at least one fang mark. The development of compartment syndrome of a snake-bitten extremity is a noted complication. The clinical symptoms of the compartment syndrome are noted by severe localized pain that is unrelieved with narcotic medications. Delayed serum sickness after Fab AV antivenom treatment occurs only in 5% of patients and is treated with oral steroids. Dislodged teeth contaminating a wound are often associated with bites from the midwestern Gila monsters. Delayed absorption of the antivenom is not an expected complication as intramuscular injection in not recommended in lieu of venom-induced hypovolemia in the snake-bitten patient. Intravenous infusion of the Fab AV antivenom is the recommended method of therapy. Rapid collapse and death are associated with the bite of the Australian brown snake (elapids) as its venom causes severe cardiovascular depression. (Dart and Daly, 2004, pp. 1200-1205)

105. Which of the following complications has a high likelihood of developing in ED management of venomous snakebites to the extremities? (A) delayed serum sickness (B) dislodged teeth contaminating the wound (C) compartment syndrome (D) delayed absorption of antivenom (E) immediate death after venomous snakebite

12. (D) Perform a special fluorescein dye examination of the eye. Since there is a possibility of globe penetration, the Seidel test should be performed. A moistened fluorescein dye strip is gently applied directly to the site of the injury. Slit-lamp examination is performed with cobalt blue light. If a perforation or leak is present, the fluorescein dye will be diluted by aqueous fluid from the injured site. It will appear as a dark (ie, diluted) stream within a pool of bright green (ie, concentrated) dye. This is known as the Seidel sign or a positive Seidel test. If globe rupture is suspected or confirmed, an eye shield should be immediately placed over the affected eye and further direct examination should be deferred to avoid putting pressure on the eye. Computed tomography of the head and orbits (coronal and axial views) is recommended. (Pokhrel and Loftus, 2007, pp. 829-836)

12. A 40-year-old man presents with a history of having a fleck of metal getting into the eye while the patient was pounding on a piece of metal scrap. There is a significant subconjunctival hemorrhage with a central abrasion on the sclera. How can you rule out a perforation of the globe? (A) Apply gentle pressure to the globe to see if there is extrusion. (B) Perform a magnetic resonance imaging test. (C) Perform a Schiotz tonometry test. (D) Perform a test using fluorescein dye. (E) Do nothing until cleared by an ophthalmologist.

13. (A) Emergency referral to an ophthalmologist is the most appropriate disposition for this patient. Patients with retinal detachment often complain of unilateral photopsia (ie, sensation of flashing light), an increasing number of floaters in the affected eye signifying posterior vitreous detachment, decreased visual acuity, and metamorphopsia (ie, wavy distortion of an object). Floaters may move in and out of central vision. Vision loss may be curtain-like, filmy, or cloudy. If the macula or the central vision is involved, the patient may lose the ability to read, have loss of light perception, or may not be able to see a hand waved in front of his or her face. If retinal detachment is suspected from patient history alone, immediate referral to an ophthalmologist is warranted, especially for persons with known risk factors. (Pokhrel and Loftus, 2007, pp. 829- 836)

13. A 65-year-old woman fell down and bumped her head earlier in the evening. She now presents with a sensation of flashing lights and floaters in her right eye. She has a history of diabetic retinopathy. She now has decreased visual acuity and feels that there is a curtain over her visual field. Funduscopic examination is difficult and, therefore, nondiagnostic since the patient is on eye drops for glaucoma. What is the most appropriate disposition for this patient? (A) emergency referral to an ophthalmologist (B) fasting blood glucose level (C) CT scan of the head (D) neurologic evaluation (E) admission to the hospital for head injury observation

14. (E) Everting the upper eyelid will help discover a foreign body. Conjunctival foreign bodies are very painful. Irrigation is important to remove debris from the eye. However, sometimes a speck of material can become lodged under the upper eyelid. The persistent presence of the foreign body continues to damage the cornea each time the patient blinks. The eyelid should be everted by using a cotton-tipped applicator. Carefully examine the area under the upper eyelid. Foreign bodies are usually 2 to 3 mm from the lid margin and are easily removed with a moistened cotton-tipped applicator. This should be done before applying analgesic drops or even staining the eye. (Sullivan, 2008, p. 341)

14. A 24-year-old man is working in a factory and felt a speck of material get into his eye, which was quite painful. He flushed out his eye at work but still complains of pain. He states that blinking makes the pain worse. The eye is very red. What is your next step? (A) patch the eye and refer to the ophthalmologist (B) flourescein staining (C) cycloplegics to reduce the patient's pain (D) slit-lamp examination (E) evert the upper eyelid

2. (B) The central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain with radiculopathy. (Hauser and Ropper, 2008, p. 2580)

2. A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? (A) anterior cord syndrome (B) central cord syndrome (C) Brown-Séquard syndrome (D) complete cord transection (E) cauda equina syndrome

24. (D) Flumazenil competitively blocks the effects of benzodiazepines on GABAnergic pathway- mediated inhibitors in the central nervous system (CNS). Naloxone HCl (Narcan) is a narcotic antagonist. Ketamine is a rapidacting general anesthetic. Flutamide is a nonsteroidal, antiandrogenic agent used for prostate carcinoma. (Bosse, 2004, pp. 1055-1056)

24. Which of the following drugs represents the most appropriate antidotal agent for benzodiazepine overdose? (A) naloxone (B) activated charcoal (C) ketamine (D) flumazenil (E) flutamide

28. (A) The evaluation of septic arthritis is best accomplished with synovial fluid analysis and culture. Radiological imaging can be normal. Ultrasound evaluation can demonstrate fluid in the joint but is not specific to the diagnosis. CT scan and MRI of the joint are not specific to the diagnosis. (Tay et al., 2006, p. 1199)

28. Which of the following is most diagnostic of a septic joint? (A) synovial fluid analysis (B) plain radiograph (C) ultrasound of the joint (D) CT scan of the joint (E) MRI of the joint

28. (A) The acute onset of pain seen with ischemia in an acute arterial occlusion is associated with the time of occlusion in 80% patients. Pain is often followed by paresthesias, pallor, and paralysis. (Rapp, 2006, p. 806)

28. Which symptom associated with an acute arterial occlusion to the lower extremities is most associated with the time of occlusion? (A) Pain (B) Pallor (C) Paresthesias (D) Paralysis

29. (B) This patient's scenario is consistent with a torus fracture of the radius. Torus fractures commonly present as a "buckle" of the cortex and are due to force or compression of the bone. This type of fracture is more common to occur in a pediatric patient because of the "softer" nature of the bone. Torus fractures usually do not create alignment issues and heal within 3 weeks with simple immobilization. A greenstick fracture involves disruption of one side of the cortex with angulation of the bone; this type of fracture does not separate the ends of the bone. Plastic deformation is the change in the natural shape of the bone with a detectable suture line; there is no "buckle" with this type of fracture. Radial neck fracture would present with angulation of the radial head and is proximally located. Monteggia fracture refers to an ulnar fracture with associated radial head dislocation from the capitulum. (Polousky and Eilert, 2009, p. 759)

29. An 8-year-old boy presents with complaint of a painful right wrist of 2 days' duration. The mother of the child reports that the child jumped off of a swing landing on his outstretched arms. He immediately complained of pain in the right wrist and now has some mild swelling on the radial aspect of the wrist. Radiographic evaluation of the wrist presents an area of impaction on the distal radius, with a slight bend in the opposing cortex. Which of the following best describes this type of pediatric fracture? (A) greenstick fracture (B) torus fracture (C) plastic deformation (D) radial neck fracture (E) Monteggia fracture

30. (C) Foreign bodies within the nose quickly create an unusually foul-smelling unilateral purulent drainage. The nose should be carefully decongested and anesthetized with topical solution. Care should be taken not to push the foreign body into the nasopharynx, where it can be aspirated. It is unusual to have unilateral sinusitis (such as from the maxillary or ethmoid sinuses) with purulent drainage just from one side. Acute viral rhinitis is typically thin serous drainage. Nasal polyps can create sinusitis. However, the main problem would be nasal congestion instead of purulent drainage. (Wilson, 2004, p. 130)

30. A 3-year-old boy presents with a 2-week history of purulent rhinorrhea from his right nostril. Mother complains that the child's nose has a bad odor. What is the most likely diagnosis? (A) maxillary sinusitis (B) ethmoid sinusitis (C) foreign body (D) nasal polyp (E) acute viral rhinitis

31. (C) Boxer fracture refers to a fracture of the fifth metacarpal. This is the most common fracture of the hand and is seen with injuries associated with a closed fist striking an object. With all of the potential fractures, the patient will typically have a history of trauma, local tenderness, swelling, deformity, and/or decreased range of motion. (Tay et al., 2006, p. 1129)

31. A 17-year-old boy presents with complaints of pain located in his fifth digit. He was involved in an altercation and states that his hand was injured from punching someone. On physical examination of the patient's hand, there is tenderness, swelling, and pain with extension. The patient is diagnosed with a "boxer fracture." What radiographic finding would be present to diagnose this patient? (A) spiral fracture of the third metacarpal (B) fracture of the fourth metacarpal (C) fracture of the fifth metacarpal (D) comminuted fracture of the distal phalanx of the fifth digit (E) comminuted fracture of the distal phalanx of the fourth digit

34. (A) Anterior septal bleeding from Kiesselbach plexus is by far the most common site of epistaxis in children and adults. Often, there is a history of trauma (picking the nose) or hay fever. In adults, it is important to rule out clotting disorders, aspirin use, and a family history of epistaxis. Pinching the nose firmly, sitting upright, and leaning slightly forward is often helpful in stopping epistaxis. The site of bleeding should then be sought with a nasal speculum, topical nasal decongestant, and effective light source. Once the bleeding site is located, it could be cauterized with a silver nitrate stick. (Wilson, 2004, pp. 146-147)

34. Which is the most common site of epistaxis in adults? (A) anterior septum (B) posterior septum (C) inferior turbinate (D) superior nasal vault (E) floor of nose

35. (D) The thoracic T4 dermatome runs across the nipple line. T2 dermatome involves the upper medial bicep region. T3 runs just above the nipple line, and T5 runs just below the nipple line. (Ferri, 2005, pp. 5-6)

35. A 28-year-old man presents to the ED with a back injury following an all-terrain vehicle (ATV) crash. The examination reveals a sensory deficit at the nipples. The spinal cord injury level is most likely at which of the following levels? (A) T1 (B) T2 (C) T3 (D) T4 (E) T5

35. (E) Stop the bleeding! Epistaxis can be life-threatening. Fortunately, most nosebleeds are mild and simple to treat; however, patients can still die from a severe nosebleed. While all of the other answers can be appropriate in the right setting, it is critical to stop a vigorous nasal bleed as soon as possible. This patient is at risk of a posterior arterial bleed because of being elderly, being a hypertensive, and taking blood thinners. If a nasal tampon or nasal packing is used, it should stay in place (as long as the bleeding is controlled) for at least 3 days. It should be removed by an ENT specialist in case bleeding recurs. Be sure to place the patient on a broad- spectrum antibiotic to prevent sinusitis (because of the blocked sinus ostia) or toxic shock syndrome from S aureus. (Bhattacharya, 2009, pp. 1383-1386)

35. An elderly patient with a history of hypertension, diabetes mellitus, and supraventricular tachycardia presents with a brisk episode of epistaxis from the left nostril and a mild amount of bleeding from the right nostril. The bleeding first occurred last night and lasted for about 10 minutes and then stopped. It has now been continuously bleeding for about 20 minutes. You are in the emergency department and are unable to visualize the bleeding site because of the extent of bleeding from the left nostril. What is the most appropriate next step in your evaluation? (A) Get a detailed history of medications, prior surgery, prior episodes of epistaxis, and possible nasal disease. Review prior medical records if available. (B) Perform diagnostic laboratory work including complete blood cell counts and hemoglobin, hematocrit, and clotting factor levels. Prepare the patient for vitamin K administration. (C) Assess the hemodynamic state of the individual by obtaining blood pressures including a "tilt" test to rule out hypovolemia, pulse, and electrocardiogram and cardiac monitoring. (D) Start a large bore intravenous (IV) line and provide at least 1 L of lactated Ringer's solution. Start oxygen by mask with a flow of at least 2 L/min. (E) Focus your attention on the bleeding. Carefully insert a cotton pledget soaked in a topical vasoconstricter (eg, oxymetazoline) and pinching the nose. If this fails to slow down the bleeding, insert a nasal tampon or one of the many commercially prepared emergency nasal packs.

35. (B) Up to 75% of subarachnoid hemorrhages can be attributed to the rupture of an intracranial aneurysm. Because of cerebrovascular anatomy, the blood is usually confined to the subarachnoid space. Blood from a ruptured arteriovenous malformation can be intraparenchymal and cause focal neurologic symptoms. Trauma is more likely to cause epidural or subdural hematoma. (Aminoff et al., 2005, pp. 74-76)

35. Which of the following is the most common etiology for a subarachnoid hemorrhage? (A) trauma (B) ruptured aneurysm (C) bleeding arteriovenous malformation (D) embolic stroke (E) primary intracerebral hemorrhage

96. (C) In the emergency medicine setting, treatment of small dental abscess or periapical abscess with oral antibiotics is warranted. The most appropriate antimicrobial agents include Penicillin VK 500 mg PO QID, clindamycin 300 mg PO QID, or erythromycin 500 mg QID. Small periodontal abscess may respond to antibiotic therapy as described earlier along with the application of warm saline rinses. Larger abscesses warrant incision and drainage. It is crucial to provide sufficient analgesic therapy for dental abscesses. Analgesic therapy may include NSAIDs and/or short courses of opioid medications. Definitive therapy for dental abscesses is provided by a dentist. (Beaudreau, 2004, pp. 1484-1485)

96. In addition to dental referral, which of the following represents the most appropriate standard therapy for a routine periodontal abscess in the ED setting? (A) intravenous penicillin and topical analgesics (B) intravenous penicillin and incision and drainage (I/D) (C) oral penicillin and oral analgesics (D) oral penicillin and saline rinses (E) oral clindamycin and topical analgesics

36. (E) Glucose is present in cerebrospinal fluid (CSF) and can be detected with a urine glucose dipstick (50 to 80 mg/dL). Injuries in the region of the nasal bones and nasal process of the frontal bone may lead to a fracture through the cribiform or ethmoid bones. CSF drainage is most commonly unilateral and may be intermittent, coming in short, rapid gushes, or may present as a steady flow. A clue to a CSF leak can be gained from the characteristic "bull'seye" test when the fluid is mixed with blood and allowed to dry on a white sheet. This is not helpful after the bleeding has stopped. Often, these leaks can seal off spontaneously by having the patient on bed rest, with the head elevated. Leaks that do not stop require more elaborate evaluation and surgical intervention. (Wilson, 2004, pp. 155-156)

36. A 26-year-old healthy-appearing man presents with rhinorrhea since having a nondisplaced nasal fracture 3 weeks prior. According to the patient, his nose has completely healed and feels fine now. He complains of a short gushes of a clear salty tasting liquid out his right nostril several times a day. He states that he can sometimes precipitate the drainage by leaning his head forward. Which test should you run on this liquid? (A) "bull's-eye" test (B) specific gravity (C) Gram stain (D) culture and sensitivity (E) glucose dipstick

4. (B) Distal radius fractures are commonly associated with falls, especially falls on an outstretched hand. Middle-aged and elderly patients, especially those with osteoporosis, are susceptible to these injuries. A Colles fracture is classically described as dorsally angulated and displaced distal radius metaphysical fracture. A Smith fracture, sometimes referred to as a reverse Colles fracture, is an extra-articular metaphysical fracture of the radius with volar angulation and displacement. Barton fracture is a displaced unstable articular fracture- subluxation of the distal radius with volar displacement. A boxer fracture classically involves the fifth metacarpal bone and is associated with a closed hand trauma. (Tay et al., 2006, p. 1124)

4. A 73-year-old woman presents to the emergency department following a fall in her home. She tripped over a throw rug, fell forward, and landed with her arms extended and hands outstretched. She presents complaining of left wrist pain. Radiographs reveal a dorsally angulated and displaced distal radius metaphyseal fracture. What is the most likely diagnosis? (A) Barton fracture (B) Colles fracture (C) Smith fracture (D) boxer fracture

42. (C) Antibacterial ear drops is the most appropriate initial treatment. The most common cause of pain in the external ear is acute otitis externa. Infections can be caused by bacteria or fungi. Water can macerate the skin of the auditory canal and raise the pH allowing for bacterial or fungal overgrowth. When a bacterial organism is suspected, treatment should include debridement of the canal and use of an antibacterial ear drop with or without steroids. The most common bacteria would be Pseudomonas aeruginosa, which is responsive to neomycin sulfate or fluoroquinolone drops. Neomycin preparations should not be used if there is a chance of a perforated tympanic membrane since it can be neuro-ototoxic. (Lustig and Schindler, 2010, pp. 181-182)

42. A patient presents with swelling and mild edema of the right ear canal after swimming. What is the most appropriate initial treatment? (A) oral antibiotics to prevent further swelling (B) insert an otowick into the canal to prevent the canal from closing (C) antibacterial ear drops (D) vigorous irrigation with saline to clean the ear (E) self-limited disorder requiring no treatment

43. (C) An immediate emergency referral to an ENT surgeon is essential. Extension of the infection from the middle ear space into the mastoid air cells can lead to acute mastoiditis. The facial nerve courses through the middle ear and can become inflamed, leading to neuropraxia and facial paresis. An emergent ENT consult is essential for the treatment of this child. Besides requiring high-dose intravenous antibiotics, the child will probably require the insertion of a tympanostomy tube for drainage and perhaps an emergent mastoidectomy. (Kelly et al., 2008, pp. 447-448)

43. A child with a history of a recent episode of acute otitis media presents with a painful swelling of the area behind the right ear. There is protrusion of the ear. The child is febrile and looks very ill. You notice that he has a right facial paresis. Your examination shows a hyperemic and bulging right tympanic membrane (TM) with a purulent effusion. The TM is immobile to pneumatic testing. What is your next step? (A) Insert an otowick and start the child on antibiotic otic drops to prevent further extension of the infection. (B) Admit the child to a pediatric service to watch and wait for additional CNS extension. (C) Consult ENT immediately for an emergent consult. (D) Prescribe high-dose amoxicillin (80 mg/kg/day in divided doses for 10 days). (E) Perform close outpatient follow-up the following day after prescribing oral antibiotics.

46. (E) A peritonsillar abscess often presents with trismus, "hot potato" voice, painful swallowing, and fever. Examination of the oral cavity will demonstrate protrusion of the lateral pharynx and unilateral tonsil with deviation of the uvula away from the mass lesion. A computed tomography (CT) scan is sometimes used to differentiate between a phlegmon (inflamed tissue) and a coalesced abscess. Treatment consists of steroids, intravenous antibiotics, and surgical drainage. (Lustig and Schindler, 2010, p. 205)

46. A febrile, 18-year-old boy presents with a 4-day history of sore throat that has suddenly become much worse. He complains of pain when attempting to eat or drink and has difficulty opening his mouth. He has a "hot potato" voice. On the basis of this clinical presentation, what is your diagnosis? (A) epiglottis (B) retropharyngeal abscess (C) croup (D) tonsillitis (E) peritonsillar abscess

47. (E) The focused abdominal sonography for trauma (FAST) has most notably been useful in evaluation of trauma patients utilizing the noninvasive diagnostic modality of ultrasonography. The FAST examination consists of four standard views. It is helpful in identifying those patients in need of emergent laparotomy as it is able to detect blood in the peritoneal cavity. Retroperitoneal bleeding may not be visualized with FAST evaluation. Ultrasonography is useful in evaluating patients in the first trimester of pregnancy; however, the FAST examination approach is not typically applied when assessing pathology of the extremity venous system and the right upper quadrant of the abdomen. (Melanson and Heller, 2004, pp. 1874-1876)

47. Which of the following clinical conditions would the focused assessment sonography for trauma (FAST) be most useful in confirming the suspected diagnosis? (A) suspected ectopic pregnancy (B) right upper quadrant pain (C) suspected retroperitoneal bleeding (D) right calf swelling and pain (E) blunt abdominal injury

49. (A) Button battery ingestion may cause significant complications in as little as 4 to 6 hours due to the rapid action of alkaline in the battery. Severe burns of the esophagus or perforation may occur. A plain radiograph of the abdomen should be obtained first to localize the battery. A battery lodged in the esophagus should be removed emergently with endoscopy. A surgical consult may be indicated for symptomatic ingestions past the esophagus. (Gaasch and Barish, 2006, pp. 515-516)

49. A 2-year-old child was brought to the ED after swallowing a button battery from a watch. Which of the following statements is true regarding button battery ingestion? (A) A button battery lodged in the esophagus is a true emergency because of the extremely rapid action of the alkaline substance on the mucosa. (B) Button battery ingestion is essentially a benign ingestion because of the unlikelihood of the battery dissolving. (C) Button battery ingestion is a minor emergency that can often be treated with a Foley balloon technique extraction. (D) Most button batteries, even if symptomatic, can be left to pass through the GI tract naturally by peristalsis. (E) Surgical removal of the button battery is always indicated, even if the patient is asymptomatic.

5. (C) A history of facial/orbital trauma that results in diplopia is suggestive of an orbital blowout fracture causing entrapment. As a result, one would expect to find restriction of extraocular movements. Although plain radiographs may be helpful in the initial identification of bony injury, CT scanning with axial and coronal views provides the best assessment of orbital trauma. A hyphema is a possible abnormal finding in this patient as well but would not require radiographs or tonometry. (Ehlers et al., 2008, pp. 28-30)

5. A 38-year-old man presents to the emergency department complaining of persistent double vision after being hit in the left eye during a fistfight the night before. On physical examination, his left perioribital area is markedly edematous and ecchymotic. On the basis of his history, what other abnormal finding might you expect to find as you complete your ophthalmic examination, and what diagnostic study would you order to best confirm your diagnosis? (A) hyphema; Schiotz tonometer (B) hyphema; plain radiograph (C) restricted ocular movement; CT scan (D) restricted ocular movement; plain radiograph (E) ruptured globe; retinal angiography

50. (E) Infectious mononucleosis caused by Epstein-Barr virus is often associated with pharyngitis. Tonsils are often covered with exudates, and there is prominent anterior and posterior cervical adenopathy. Generalized lymphadenopathy and splenomegaly are frequently seen. An evaluation for the presence of heterophile antibodies (eg, monospot test) will confirm the diagnosis. Patients should be cautioned against sports activities if they have mononucleosis since this can cause a life-threatening splenic rupture. Also, be aware that primary human immunodeficiency virus seroconversion illness can present with a similar fashion. A high index of suspicion is essential, because this diagnosis is often missed in clinical practice. (Corrales-Medina and Shandera, 2010, pp. 1243-1244)

50. A 15-year-old boy presents with an exudative tonsillitis. Anterior and posterior cervical lymph nodes are enlarged and tender. The rapid antigen test for strep is negative for group A β- hemolytic streptococcus. What is the most appropriate step in treating this disease? (A) Treat presumptively with penicillin. (B) Check for a history of recurrent tonsillitis. (C) Wait for confirmation of the disease with a formal culture. (D) Assume it is viral and, therefore, self-limited. (E) Perform a serum assay for mononucleosis.

53. (C) A crystalloid fluid bolus of 20 mg/kg is recommended for initial resuscitation in hypovolemic pediatric trauma patients. If 40 mg/kg of crystalloid fluids does not lead to improvement of the hypovolemic state, administration of packed red blood cells should be initiated. (Cantor, 2006, p. 331)

53. A 6-year-old child (20 kg) presents to the ED after being struck by a car. The child suffered chest, head, and abdominal trauma. The vital signs demonstrate a blood pressure of 80/40 mm Hg, a pulse of 170/min, and a respiratory rate of 40/min. After the airway is managed, which is the most appropriate initial fluid therapy? (A) dextrose 5% water at 100 mL/h (B) normal saline 5 mL/kg bolus, then 100 mL/h (C) lactated Ringer's 20 mL/kg bolus (D) lactated Ringer's at 20 mL/h (E) normal saline 200 mL bolus

6. (D) The scaphoid bone is based in the proximal row of carpal bones but extends into the distal row, making it more vulnerable to injury when a patient falls on an outstretched hand. The scaphoid bone is the most frequently injured carpal bone, accounting for 60% to 70% of all carpal fractures. At the time of initial injury, 10% to 15% of scaphoid fractures may not be visible on plain radiographs. Patients with pain in the anatomical snuffbox to palpation or axial loading, even with normal radiographs, should be treated as though they have a scaphoid fracture and placed in a thumb spica splint. Repeat radiographs should be taken after 2 to 3 weeks. If radiographs are still normal but tenderness over the scaphoid bone persists, a bone CT scan or MRI can be ordered. Fractures of the scaphoid have a high incidence of nonunion and osteonecrosis because the major blood supply enters in the distal segment of the bone and can be disrupted with injury/fracture and thus conservative management is warranted. (Griffin, 2005, pp. 358-361)

6. A 22-year-old female person was playing basketball when she tripped and landed on the pavement with her hands outstretched. She presents complaining of abrasions on the right thenar eminence and "wrist pain." Physical examination reveals tenderness to palpation between the extensor pollicis longus and the extensor pollicis brevis. Assessment of the median, ulnar, and radial nerves reveals no sensor or motor changes when compared with the left hand. Radial and ulnar pulses are 2+ bilaterally with capillary refill less than 2 seconds on all five fingers of the right hand. Posterior-anterior view radiographs of the wrist and posterior-anterior wrist radiographs with the wrist in ulnar deviation reveal no fractures or dislocations. What is the appropriate management for this patient at this time? (A) immediate orthopedic referral (B) cock-up splint until symptoms resolve (C) physical therapy referral for assessment and treatment (D) thumb spica splint and repeat radiographs in 3 weeks (E) No further treatment is necessary because the radiographs were negative and no vascular or neurological abnormalities were noted on examination.

6. (E) The patient's symptoms, abnormal findings noted on the eye examination, and her significantly elevated intraocular pressure of 70 mm Hg (normal range of intraocular pressure is 10-24 mm Hg) are all consistent with a diagnosis of acute angle closure glaucoma. This type of glaucoma is an ophthalmic emergency requiring immediate reduction in the intraocular pressure. Primary open angle glaucoma is the most common form of glaucoma; it is a chronic condition that is often asymptomatic until the disease is far advanced. Both retinal detachment and retinal artery occlusion are painless disorders with abnormal findings on examination that are different than those stated. (Ehlers et al., 2008, pp. 198-202)

6. A 45-year-old woman presents with sudden onset of excruciating pain in the right eye, blurred vision, nausea, and vomiting. Physical examination reveals decreased visual acuity, intraocular pressure of 70 mm Hg, shallow anterior chamber, steamy cornea, and a moderately dilated right pupil. Which of the following is the most likely diagnosis? (A) retinal detachment (B) retinal artery occlusion (C) uveitis (D) primary open angle glaucoma (E) primary acute angle closure glaucoma

62. (A) Congenital cerebral aneurysms or Berry aneurysms account for 75% to 80% of nontraumatic subarachnoid hemorrhages (SAHs). Poorly controlled hypertension and anticoagulant use are more commonly associated with intracerebral hemorrhages (ICH). AVMs can cause either SAH or ICH. (Heuer, 2006, p. 21)

62. Which of the following etiologies is the most common cause of nontraumatic subarachnoid hemorrhage (SAH)? (A) Cerebral aneurysm (B) Poorly controlled hypertension (C) Anticoagulant use (D) Arteriovenous malformation

62. (B) The most beneficial maneuver in evaluating a patient with an Achilles tendon injury is the Thompson-Doherty test or the Thompson test. This maneuver is performed by squeezing the patient's calf of the affected lower extremity while the patient is lying in a prone position. An intact Achilles is noted by visualizing plantar flexion of the foot while applying the preceding described maneuver. The Lachman test is the more sensitive and specific for establishing anterior cruciate ligament (ACL) injuries. Anterior drawer test and the pivot shift test are also used to evaluate ACL injuries. The posterior drawer test is used to evaluate injuries to the posterior cruciate ligament. (Haller, 2004, 1735-1737; Steele and Glaspy, 2004, pp. 1729-1730)

62. Which of the following maneuvers would be the most helpful in diagnosing an Achilles tendon rupture? (A) pivot shift (B) Thompson-Doherty test (C) Lachman test (D) anterior drawer test (E) posterior drawer test

63. (B) The initial study to diagnose a subarachnoid hemorrhage is a noncontrast CT scan of the head. If the CT scan is nondiagnostic for a SAH and the clinical suspicion is high, then proceed with a lumbar puncture for the presence of red blood cells in the cerebrospinal fluid; xanthochromia can be seen with an old SAH. (Heuer, 2006, p. 21)

63. A 58-year-old man presents with to the emergency department with the acute onset of the "worst headache of his life," which was associated with a brief loss of consciousness. The patient is complaining of increased pain with movement of his neck as well as photophobia. What is the recommended first-line study to evaluate this patient? (A) Lumbar puncture (B) Noncontrast CT scan of the head (C) Magnetic resonance imaging (MRI) of the brain (D) Four-vessel angiogram

64. (B) Le Fort I fractures involve the maxilla at the level of the nasal bones. A Le Fort II fracture involves several facial bones, including the maxilla, the nasal bones, and the medial aspects of the orbits. A Le Fort III fracture includes aspects of the maxilla, zygoma, nasal bones, ethmoids, vomer, and lesser bones of the cranial base. It can also be described as a craniofacial dysfunction. (McKay, 2006, pp. 393-394)

64. Le Fort I facial fracture is best described as (A) a fracture involving the maxilla, the nasal bones, and the medial aspects of the orbits (B) a fracture involving the maxilla at the level of the nasal fossa (C) a fracture involving the maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base (D) A fracture involving frontal bones and bones of the midface

65. (E) The source of facial injuries varies by city or rural settings. There is a high incidence of domestic violence associated with a female patient presenting with an orbital fracture. Statistics reports that about 25% of facial injuries seen in the ED are associated with domestic violence. Facial injuries associated with falls are seen more frequently with the elderly and pediatric populations. Rural hospitals see higher rates of facial trauma associated with MVC and sports- related injuries. (Hasan and Colucciello, 2004, p. 1583)

65. Maxillofacial trauma in a 35-year-old woman is most likely associated with (A) falls (B) motor vehicle collision (MVC) (C) work related (D) sports related (E) domestic violence

67. (D) Direct and compressive forces to the eye may cause a blowout fracture to the orbital floor with herniation of the contents into the maxillary sinus. Blowout fractures may produce enophthalmos, diplopia, impaired ocular motility, and infraorbital hypoesthesias. Many orbital floor fractures resolve spontaneously and require only close follow-up with consultants. A decision to operate may be delayed 10 to 14 days, depending on persistent diplopia or enophthalmos. (McKay, 2006, p. 393)

67. A 42-year-old man presents to the ED with a right-sided facial injury after an assault with a wooden club. The patient complains of diplopia and pain to the right side of the face. The examination reveals enophthalmos, impaired ocular motility, and infraorbital hypoesthesias. What is the most likely diagnosis? (A) maxilla fracture involving the superior orbital ridge (B) orbital blowout fracture with herniation of contents into the frontal sinus (C) maxillary blowout fracture with herniation into the soft palate (D) orbital blowout fracture with herniation of contents into the maxillary sinus (E) orbital blowout fracture without herniation

68. (E) An unstable, hyperextension fracture through the pedicles of C2 is known as a hangman fracture. Fortunately, cord damage is usually minimal because the anteroposterior diameter of the neural canal is greatest at the C2 level. Furthermore, less neurological damage occurs because bilateral pedicle fractures tend to decompress themselves, allowing more space for the spinal cord. A Jefferson fracture of C1 is produced by an axial loading injury to the cervical spine, transmitting a force through the occipital condyles to the superior articular surfaces of the lateral masses of the atlas. A clay-shoveler fracture is an avulsion fracture of the spinous process of the lower cervical vertebrae. This oblique fracture of the base of the spinous process, classically C7, derived its name in the 1930s when Australian miners lifted a heavy shovelful of clay causing an abrupt flexion of the head, in opposition to the stabilizing force of the strong supraspinous muscle, resulting in an avulsion fracture of the spinous process. An extension teardrop fracture involves a hyperextension injury in which the anterior longitudinal ligament avulses the inferior portion of the anterior vertebral body at its insertion. The second cervical vertebra is the most common location for an extension teardrop fracture. (Hockberger et al., 2006, pp. 401-413)

68. A patient is involved in a motor vehicle accident and suffered a fractured neck. The fracture lines extend through the pedicles of C2. Which of the following describes this unstable hyperextension fracture to the cervical spine? (A) Jefferson fracture (B) extension teardrop fracture (C) clay-shoveler fracture (D) Johnson fracture (E) hangman fracture

69. (D) The most severe neurological dysfunction, as a result of inadequate or delayed treatment of disk herniation, is cauda equina syndrome. The most common presenting symptoms are saddle anesthesia, bilateral leg pain, urinary incontinence or retention, and fecal incontinence or retention. Most cases of cauda equina syndrome and cord compression develop over a matter of hours. If the symptoms are delayed, these patients are at high risk for chronic neurological deficits. (Stettler and Pancioli, 2006, pp. 1678-1679)

69. A 68-year-old woman presents to the ED with an exacerbation of chronic low-back pain. Which of the following indicates the patient has developed cauda equina syndrome? (A) lower leg weakness, paresthesias to both legs, and incontinence (B) loss of deep tendon reflexes bilaterally and urinary retention (C) bilateral leg weakness, loss of peripheral pulses, and incontinence (D) bilateral leg pain, saddle anesthesia, urinary incontinence, and fecal incontinence (E) anesthesia to entire leg, bilateral leg weakness, and loss of deep tendon reflexes

7. (C) The clinical scenario reveals contamination of the abdomen at the time of injury with a potential source of gram-negative bacteria. Causes of septic shock may include traumatic injuries, infections, and systemic inflammatory response syndrome. Vasoactive mediators that are released cause a decrease in vascular tone, which leads to a relative hypovolemia resulting in hypotension and decreased cardiac output. Therapy will require empiric antibiotic use guided by knowledge of the source of infection and most likely pathogens. Although hypovolemic or hemorrhagic shock is the most commonly encountered clinical cause of shock in the surgical/trauma patient, the timelines and clinical presentation rule it out. Cardiogenic shock represents pump failure and is inconsistent with the clinical presentation. Neurogenic shock is usually found in association with spinal cord injuries at the cervical or high thoracic region. (Jackson, 2006, p. 266)

7. A 35-year-old man is postoperative day 4-status post exploratory laparotomy for a gunshot wound to the abdomen. At the time of exploration, a perforation to the left colon was found and he underwent repair with proximal colostomy. He now is confused, agitated, and has developed oliguria over the past 8 hours. His vital signs are temperature 104°F, respiratory rate 24/min, heart rate 134/min, blood pressure 85/60 mm Hg. Which of the following types of shock is most likely in this situation? (A) Hypovolemic (B) Cardiogenic (C) Septic (D) Neurogenic

70. (A) Acute narrow-sangle glaucoma should be recognized as an ophthalmic emergency. It is characterized by a sudden onset of severe pain localized to the affected eye. Common associated visual symptoms include halos around lights, blurriness, and scotomas. Other associated symptoms include nausea and vomiting. The typical physical examination findings reveal a red eye with fixed, mid-dilated pupil, corneal clouding, and a shallow anterior chamber. Anterior uveitis is inflammation of the anterior segment of the eye. Anterior uveitis includes iritis (inflammation that involves only the iris) and iridocyclitis (inflammation of both the iris and ciliary body). Physical examination findings include ciliary flush (ie, circumcorneal perilimbal injection of the episcleritis and scleral vessels) conjunctival injection, and cells may be present in the anterior chamber. The pupil on the affected side is often small and irregular. Direct and consensual light reflex will cause pain on the affected side to increase. Orbital cellulitis is recognized as a soft tissue infection that extends deep into the fascia and eye orbit. Clinical findings include ocular pain, limitation of eye movement, lid edema, and proptosis, tenderness of the globe, decreased visual acuity, increased ocular pressure, and pupillary paralysis. Allergic conjunctivitis is most common signs and symptoms include red or injected conjunctiva, chemosis, eye drainage, and pruritus. It is mediated by a hypersensitivity exposure. Episcleritis is the inflammation of the connective tissue between the sclera and the conjunctiva. Episcleritis is commonly described as an irritation rather than a true pain. In addition, the orbital vessels blanch with topical neosynephrine. (Dutton, 2008, pp. 1460-1461; Forster, 2008 pp. 783-788; Goldstein and Tessla, 2008, p. 255; Rubenstein and Virasch, 2008, pp. 237-240; See and Chew, 2008, pp. 1164-1167)

70. A 64-year-old man presents to the ED with decreased visual acuity, red eye, and a "steamy" or hazy cornea. What is the most likely diagnosis? (A) acute narrow-angle glaucoma (B) iritis/uveitis (C) orbital cellulitis (D) allergic conjunctivitis (E) episcleritis

73. (D) Third-space fluid losses that occur with inflammatory conditions such as peritonitis result in an isotonic volume depletion; the recommended intravenous fluid used to replace those losses is lactated Ringer's solution, which is a balanced salt solution that contains 130 mEq/L of sodium, 109 mEq/L of chloride, 4.0 mEq/L of potassium, 3.0 mEq/L of calcium, and 28 mEq/L of lactate. (Kaiser, 2006, p. 48)

73. A patient with peritonitis secondary to a ruptured appendix was admitted to the intensive care unit with hypotension and tachycardia. Which of the following crystalloid solutions would be recommended for the fluid resuscitation of this patient? (A) 5% Dextrose water (B) 5% Dextrose water with 0.45% sodium chloride (C) 0.9% Sodium chloride (D) Lactated Ringer's solution

74. (B) The most objective means of assessing the adequacy of volume replacement for fluid losses is by following the urinary output, which should be at a minimum of 0.5 mL/kg/h. Other objective measures include normalization of hemoglobin and hematocrit values as well as BUN and creatinine levels. Following the patient weight as well as intake and output can provide valuable information about the patient's volume status over time. (Kaiser, 2006, p.51)

74. A patient is admitted to the intensive care unit in hypovolemic shock secondary to a splenic injury sustained in a motor vehicle collision. What is the most objective means of assessing that the intravascular volume is being adequately replaced during fluid resuscitation? (A) Measurement of patient weight (B) Maintenance of urinary output (C) Resolution of orthostatic changes (D) Normalization of peripheral perfusion

75. (E) A retrograde urethrogram should be performed prior to invasive interventions such as urethral catheterization if there is any possibility of urethral disruption. Signs of urethral disruption include a high riding prostate and the presence of blood at the tip of the meatus. Sixty milliliters (or 0.6 mL/kg) of full-strength or half-strength iothalmate meglumine (Conray II) is injected over 30 to 60 seconds. A radiograph is taken during the last 10 mL of contrast material. Retrograde flow through the urethra and into the bladder without extravasation ensures continuity of the urethra and absence of urethral injury. (Schneider, 2006, pp. 517-520)

75. A patient presents to the ED after suffering a significant pelvic injury following a fall. The patient has a grade III pelvic fracture and blood at the tip of the urethral meatus. How should one proceed in evaluating urethra and/or bladder injuries? (A) Gently pass a 14- or 16-Fr Foley catheter. (B) Gently pass a 14- or 16-Fr Coudé catheter. (C) Notify the urologist for immediate cystoscopy. (D) Gently pass a 10- or 12-Fr (pediatric) Foley catheter. (E) Perform a retrograde urethrogram and rectal exam.

76. (D) The initial evaluation of blunt abdominal trauma is by the performance of a FAST (focused assessment with sonography for trauma) ultrasound, which is performed by an emergency department physician or surgeon. CT scan remains an adjunct test in hemodynamically stable patients or in patients in whom further assessment of solid intra-abdominal organs is required. (Cothren, 2010, p. 155)

76. A 23-year-old man, unrestrained driver, is brought to the emergency department by ambulance after having been involved in an automobile accident. His vitals are BP: 99/54 mm Hg, P: 112/min, R: 18/min, oxygen saturation: 99%, T: 99.8°F. Examination reveals mild abdominal tenderness with pain radiating to the right shoulder. What is the most appropriate diagnostic test to order initially? (A) Computed tomography of the abdomen and pelvis (B) Diagnostic peritoneal lavage (C) Flat and upright abdominal radiographs (D) Diagnostic ultrasound

77. (C) Mallet finger is a disruption of the distal tendon, resulting in a flexion deformity at the Distal interphalangeal joint (DIP). It is the most common zone I injury. Bennett fracture is a combination of a dislocated carpometacarpal joint and the thumb's metacarpophalangeal joint (MCP) that is fractured intra-articularly. Rolando fracture is defined as a comminuted fracture involving the base of the thumb's MCP. A Boutonniere deformity involves deformity of the index finger. The swan neck deformity does not represent an acute finding but rather is associated with an untreated mallet finger. (Lyn and Antosia, 2006, pp. 599-607)

77. A 41-year-old man injures his finger while playing basketball. He is unable to extend the distal interphalangeal (DIP) joint. The radiograph shows an avulsion fracture to the proximal dorsal region of the distal phalanx. What is the diagnosis? (A) Bennett fracture (B) Rolando fracture (C) mallet finger fracture (D) swan neck deformity

78. (A) The developing bones of the child are more pliable and flexible than an adult mature bone. In a torus fracture, there is a buckling of the cortex of the bone without complete disruption of the cortical segment. Multiple radiographic views may be necessary to make the diagnosis in small, nondisplaced fractures. (Woolfrey and Eisenhaver, 2006, pp. 644-645)

78. A child falls on an outstretched hand. She complains of pain and swelling to the wrist. The radiograph demonstrates a buckling of the cortex to the distal radius. What is your diagnosis? (A) torus fracture (B) greenstick fracture (C) complete fracture (D) plastic deformation

79. (B) The most common nerve injured with a humeral shaft fracture is the radial nerve. The radial nerve runs in close proximity to the posterior midhumeral shaft. A radial nerve injury is evident by a wrist drop. (Geiderman, 2006a, p. 655)

79. A 40-year-old man slips on the ice, injuring his left arm. He complains of pain and swelling to the midshaft humeral region. The physical examination reveals a wrist drop on the injured side. Which nerve is most likely injured? (A) ulnar (B) radial (C) median (D) axillary (E) subclavian Figure 17-1. Elbow dislocation

8. (B) 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. A left tube thoracostomy may be indicated in this patient but would not relieve symptoms. Fluid resuscitation though applied to all trauma patients would help stabilize the patient until more therapeutic interventions could be completed. Immediate intubation, even if indicated, would require a prophylactic tube thoracostomy to prevent the development of tension pneumothorax in the event of an unrecognized lung injury. Emergency thoracotomy will relieve the signs and symptoms associated with cardiac tamponade and allow for repair of any underlying cardiac injuries. (Dolich, 2006, p. 191)

8. 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? (A) Left tube thoracostomy (B) Pericardiocentesis (C) Fluid resuscitation (D) Immediate intubation

81. (E) Retropharyngeal abscess is an infected fluid collection in the fascial plane between the posterior pharyngeal muscles and the paraspinous muscles. Primarily, retropharyngeal abscess is a pediatric problem because there are lymph nodes in the retropharyngeal space that can become suppurative. Clinical manifestations include an ill-appearing child with fever, sore throat, neck pain, and voice changes (ie, "duck-like voice"). A CT scan with IV contrast of the soft tissues of the neck and upper chest is the best diagnostic test. Peritonsillar abscess is an infected fluid collection in the pharyngeal pillar. The most common etiology is β-hemolytic streptococcus. Symptoms include fever, sore throat (unilateral), and odynophagia. In addition, the patient drools and finds it hard to handle his/her own secretions. Streptococcal pharyngitis is an infection of the pharynx and tonsils due to group A β-hemolytic streptococci. Clinical features include sudden onset of fever and sore throat with enlargement of the cervical lymph nodes. Headache, vomiting, abdominal pain, meningismus, and torticollis can occur as well. Epiglottitis is an inflammatory disorder of the supraglottic laryngeal region. Etiologies of epiglottitis include bacterias, viruses, chemical damage (eg, aspiration of fuel), and mechanical damage (eg, trauma, burns). Symptoms include sore throat, fever, a muffled voice, dysphagia, and respiratory distress. Clinical features include drooling, dyspnea, tachypnea, inspiratory stridor, tripod position (ie, patient leans forward, supporting himself/herself with both hands), and toxic appearance. Ludwig angina is an abscess formation of the submaxillary, sublingual, and submental spaces accompanied by elevation of the tongue. The cause is due to an infection of the lower second and third molars usually due to β-hemolytic streptococcus, staphylococcus, and mixed anaerobic and aerobic infections. Patients commonly present with swelling beneath the chin. The tongue is displaced up and posteriorly. Trismus often makes opening the mouth for examination difficult. (Manno, 2006, pp. 2522-2523, 2530; Melio, 2006, pp. 1109-1110)

81. A 7-year-old child presents to the ED with fever, neck pain, and a "duck-like" voice. Which of the following is the most likely diagnosis? (A) peritonsillar abscess (B) streptococcus pharyngitis (C) epiglottitis (D) Ludwig angina (E) retropharyngeal abscess

85. (D) Treatment priorities of acetaminophen toxicity consist of supportive care, gastrointestinal decontamination, and the use of the antidote N-acetylcysteine (NAC). No additional therapies are recognized for intervention in acetaminophen overdoses. If given early (less than 8 hours after ingestion), NAC can prevent toxicity by inhibiting the binding of the toxic metabolite N-acetyl-p- benzoquinoneimine to hepatic proteins. In acetaminophen toxicity, more than 24 hours after ingestion, NAC diminishes hepatic necrosis by nonspecific mechanisms. The standard 72-hour oral NAC regimen used in the United States is a loading dose of 140 mg/kg followed by maintenance doses of 70 mg/kg every 4 hours for 17 doses. (Hung and Nelson, 2004, pp. 1091- 1093)

85. A 20-year-old man presents to the ED following a lethal overdose of acetaminophen. What is the antidote for acetaminophen toxicity? (A) flumazenil (B) narcan (C) vitamin K (D) N-acetylcysteine (NAC) (E) ethanol

86. (D) Periorbital cellulits is characterized by warmth, redness, swelling, and tenderness over the affected eye, along with conjunctival injection, eyelid swelling, chemosis, and fever. Orbital cellulitis includes all the symptoms of periorbital (preseptal) cellulitis with the addition of ocular pain and limitation of eye movement. Other physical examination findings may include lid edema, proptosis, marked tenderness to the globe, decreased visual acuity, and pupillary paralysis. (Meislin and Guisto, 2006, pp. 2197-2198)

86. Which of the following clinical findings differentiates periorbital from orbital cellulitis? (A) erythema (B) fever (C) lid edema (D) worsening pain with eye movements (E) development of a rash on the face

88. (C) Mild hypothermia is defined as a temperature from 32°C to 35°C (89.6°F-95°F). In mild hypothermia, the body responds by increasing metabolic activity to produce heat. This is known as the excitation or the responsive phase. When the temperature drops to less than 32°C (89.6°F), bodily functions slow down, giving way to the adynamic phase. As metabolism slows, there is a decrease in both oxygen utilization and carbon dioxide production. As the body temperature falls to less than 30°C to 32°C (86°F-89.6°F), shivering will cease. Hypothermia may induce life- threatening dysrhythmias and ECG changes. A characteristic, but not pathognomonic, ECG finding in hypothermia is the Osborne (J) wave. This abnormal wave is a slow, positive deflection at the end of the QRS complex. (Bessen, 2004, pp. 1179-1180)

88. A 58-year-old man presents to the ED hypothermic after an environmental exposure to cold weather and snow. The patient's core temperature is 85.5°F. Which of the following is the most accurate statement regarding this scenario? (A) Shivering is common. (B) An Osborne (J) wave is pathognomic for hypothermia. (C) Rough handling can produce serious dysrhythmias. (D) A nasogastric tube should be inserted to protect the airway from regurgitation. (E) The patient is in an excitation phase of hypothermia.

91. (B) The answer is 44% burn. The rule of nines to estimate percentage of burns is as follows: head 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, each arm 9%, and perineum 1%. (Schwartz and Balakrishnam, 2004, pp. 1221-1222)

91. A patient presents to the ED after being trapped in a house fire. The patient suffered partial thickness burns over the entire anterior chest and abdomen, entire right arm, and the entire right leg. Using the rule of nines, what is the estimated percentage of burn? (A) 36% (B) 45% (C) 48% (D) 54% (E) 72%

93. (D) An L4 injury may present as weakness or paralysis to the quadriceps and thigh adductor muscles, sensory loss to the medial leg, and loss of the patellar reflexes. An injury to C7 may manifest as decreased sensation in the middle finger and the loss of the triceps reflexes and thumb extension. An injury to L1 would involve loss of the cremasteric reflex, decreased sensation in groin area, and loss of hip flexion. An injury to S1 would more likely be indicated by loss of sensation of the lateral dorsal and plantar aspect of the foot, loss of Achilles reflex, and loss plantar flexion. S4 deficits may present with a loss of the anal reflex (wink), loss of perineal area sensation, and loss of voluntary control of the pelvic floor. (Cleveland and Rock, 2008, pp. 391-398)

93. A 29-year-old logger was struck in the back with a load of logs. The evaluation reveals absence of patellar reflexes. This finding is consistent with an injury at which of the following dermatome levels? (A) C7 (B) L1 (C) L4 (D) S1 (E) S4