EM EOR

In infants, the eyes should move in parallel without deviation by the age of

6 months Notes: Intermittent alternating convergent strabismus is frequently noted for the first 6 months of life, but referral is indicated if it persists beyond 6 months.

Which of the following patients presenting to the emergency department with suicidal ideation would be considered highest risk for suicide if released from the department?

A 50-year-old white man who works as a physician and has been diagnosed with severe depressive disorder Of the patients presented, the 50-year-old white man who is a physician with major depressive disorder is at highest risk for suicide. His risk factors include being a white man with age greater than 45 years, a high-risk occupation, and severe depression. He carries four risk factors that make him at highest risk for suicide. Suicide Protective factors: marriage, pregnancy Risk factors (SAD PERSONS = mnemonic) -Sex (male) -Age (teenager or ≥ 45 years) -Depression -Previous attempt -Ethanol or drug use -Rational thinking loss -Separated, divorced, or widowed -Organized plan -No social support -Stated future attempt Most completed suicides involve firearms Most attempted suicides involve ingestions (MC: antidepressants) All overdose patients: obtain acetaminophen level

A 26-year-old man presents to the ED after briefly losing consciousness when hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head?

A lenticular-shaped hematoma in the temporal region Notes: This patient's presentation and physical examination are consistent with a traumatic acute epidural hematoma, a collection of blood between the skull and the dura. The diagnosis is made with a non-contrast CT of the head. This characteristically shows a hyperdense lenticular-shaped hematoma in the temporal region that is sharply defined and does not cross suture lines. Epidural Hematoma: History of a head injury with a loss of consciousness followed by a lucid interval CT will show a biconvex opacity Most common artery ruptured is the middle meningeal artery Treatment is emergent evacuation

A 34-year-old woman presents to the ED with severe right eye pain. The pain began after she entered a dark movie theatre. On physical exam, you note a mid-dilated pupil (4 mm) and corneal edema. Which of the following is the correct combination of medications in the treatment for this process?

Acetazolamide IV, topical apraclonidine, topical timolol Notes: Acute angle closure glaucoma is defined by increased intraocular pressure caused by obstruction of aqueous humor drainage via the canal of Schlemm. First, you need to reduce the production of aqueous humor using oral or intravenous acetazolamide, a topical beta blocker such as timolol, and a topical alpha agonist such as apraclonidine. Acute Angle-Closure Glaucoma: Patient will be entering a dark room or movie theater Acute unilateral painful vision loss, vomiting, and seeing halos around lights PE will show cloudy cornea and fixed mid-dilated pupil Testing will show IOP ( > 21 mm Hg) Treatment is topical beta-blockers, topical alpha-agonists, carbonic anhydrase inhibitors, miotics Iridotomy is definitive treatment but not used for initial management

*Image of Impetigo* The rash seen above is associated with which one of the following conditions?

Acute glomerulonephritis Notes: Acute poststreptococcal glomerulonephritis results from an antecedent infection of the skin or throat caused by nephritogenic strains of group A beta-hemolytic streptococci. Impetigo: Patient will often be a child < 6 years (can affect any age) Nonpainful, pruritic lesions on the face PE will show honey-colored, weeping lesions Most commonly caused by Staphylococcus aureus, Streptococcus pyogenes Treatment: - Limited number of lesions: topical mupirocin Numerous lesions or involvement of more than one area: oral antibiotics (cephalexin or dicloxacillin) Complications: poststreptococcal glomerulonephritis

A 68-year-old man with a history of severe chronic obstructive pulmonary disease presents with altered mental status. His oxygen saturation is 90% on 4 liters of oxygen via nasal cannula. A venous blood gas is obtained with the following results: pH: 7.15 pO2: 45 mm Hg pCO2: 100 mm Hg HCO3: 38 mEq/L The patient has which of the following acid-base disturbances?

Acute on chronic respiratory acidosis Notes: Acute Respiratory and Metabolic Acidosis and Alkalosis (Normal ABG values pH: 7.35-7.45; PaCO2: 35-45; HCO3: 22-26)

A 45-year-old woman presents to the emergency department with palpitations. She is placed on the monitor which shows a rapid narrow-complex tachycardia. Her heart rate is 160 bpm and blood pressure is 120/70 mm Hg. Vagal maneuvers are attempted and fail. Next, adenosine 6 mg IV is given intravenously without a change in her rhythm. Repeat vitals show a heart rate 165 bpm and blood pressure 120/70 mm Hg. What is the most appropriate next step in management?

Adenosine 12 mg intravenous Notes: In a stable patient, after vagal maneuvers and a single dose of adenosine 6 mg have been attempted and fail, it is most appropriate to give adenosine 12 mg intravenously. Supraventricular Tachycardia (SVT) or Paroxysmal Supraventricular Tachycardia (PSVT) PE will show abrupt onset of tachycardia with a ventricular rate of 120 to 200 bpm Most commonly caused by a reentrant pathway in the atrioventricular node Dx: ECG (stress testing or ambulatory monitoring may be needed) Treatment is vagal maneuvers, drug therapy (adenosine), and cardioversion

A 52-year-old man with a history of diabetes mellitus and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 150 beats/minute, blood pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His electrocardiogram is shown above. Which of the following is the most appropriate initial management?

Administer intravenous diltiazem Notes: Patients who are stable can be treated with rate control with beta blockers or calcium channel blockers (e.g., diltiazem), and consideration of rhythm control, either with pharmacologic agents or via synchronized cardioversion. Atrial Fibrillation Rate will be irregular Rhythm will be irregular Notable feature: No defined P waves Treatment Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) > 48 hours: anticoagulate for 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-VASc score Most common sustained dysrhythmia in adults

A 27-year-old previously healthy man comes to the ED with chest pain. He had a viral syndrome with a low-grade fever a few days earlier. He describes the chest pain as sharp, retrosternal in location, with radiation to the left trapezius ridge. It improves with sitting forward and worsens when he lays down. Vital signs are normal. His electrocardiogram is shown above. His initial cardiac biomarkers are negative. Which of the following treatments is most appropriate?

Administration of ibuprofen and colchicine and discharge home Notes Pericarditis Patient presents with pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE will show tachycardia and pericardial friction rub ECG will show PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Most commonly caused by idiopathic then viral (coxsackie) Treatment is NSAIDs, colchicine

A 22-year-old woman presents with lower abdominal pain that started two days ago. Today, she had three episodes of vomiting but denies any diarrhea or dysuria. On examination, her temperature is 38.8°C, heart rate 105 beats per minute, and blood pressure 128/72 mm Hg. She is ill-appearing with bilateral lower quadrant tenderness. Pelvic examination reveals moderate yellow discharge and uterine tenderness. There are no adnexal masses appreciated. Pregnancy test is negative. What is the next step in the management of this patient?

Admission for intravenous cefotetan and doxycycline Notes: Pelvic inflammatory disease comprises a spectrum of disorders involving the female upper genital tract including endometritis, salpingitis, and tubo-ovarian abscess. Patients with mild-to-moderate disease can be treated as an outpatient with ceftriaxone 500 mg IM and doxycycline 100 mg BID for 14 days. This patient is ill-appearing with vomiting and a high fever making her a candidate for inpatient management with intravenous cefotetan and doxycycline.

Which of the following is the major pathogenetic mechanism that causes asthma?

Airway inflammation is the major pathogenetic mechanism that leads to the development of asthma.

A patient presents with occasional wheezing and chest tightness that occurs approximately once a week and at night only about once a month. Peak expiratory flow is 85% of predicted. Which of the following is the most appropriate initial treatment?

Albuterol (Proventil) inhaler Notes: This patient has mild intermittent asthma which is initially treated with inhaled beta 2-agonists as needed. No long-term control medications are indicated.

A 17 year-old male who is trying out for the track team notes excessive coughing with chest tightness when running. Which of the following is the most appropriate preventive agent for this patient?

Albuterol inhaler (Proventil) Albuterol is a beta-2 agonist that results in bronchodilation that makes this a useful agent in a patient with exercise-induced asthma when used just prior to exercise.

A 20-year-old male presents with a mass in the groin. On examination with the patient standing, a mass is noted that extends into the scrotum. The patient denies any trauma. The most likely diagnosis is

An indirect inguinal hernia is caused by a patent processus vaginalis and the hernial contents may be felt in the ipsilateral scrotum.

What is the most common site of compartment syndrome?

Anterior compartment of the lower leg Notes: Compartment Syndrome PE will show paresthesias, pallor, pulselessness, poikilothermia, paralysis, and pain out of proportion to exam (6 Ps) Most commonly caused by tibia fracture If delta pressure < 30 mm Hg, treatment is fasciotomy Most common sites: forearm, lower leg Pain is usually the first symptom

A 56-year-old woman with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents with acute substernal chest pain that is worse with exertion and associated with nausea and shortness of breath. Her sister and her mother both had "heart attacks" before age 55 years. Which of the following offers a proven mortality benefit in acute coronary syndrome?

Aspirin Notes: Aspirin is the prototypical antiplatelet agent for acute coronary syndrome and irreversibly inhibits platelet activity for the entire platelet life cycle (approximately eight to ten days). Aspirin has been proven to reduce mortality in patients with acute myocardial infarction by 25-50% both independently and with the use of fibrinolytic therapy.

A 3 year-old girl is diagnosed with atopic dermatitis. Which of the following disorders is this child at risk for in the future?

Athma Notes: Up to 50% of patients with atopic dermatitis develop asthma and/or allergic rhinitis in the future.

A 50-year-old woman presents to the emergency department following a syncopal episode. On physical exam she is diaphoretic. She is alert and oriented. Her blood pressure is 90/50 mm Hg and respirations are 12 per minute. Her rhythm strip is shown above. What is the most appropriate pharmacologic treatment for this patient's condition?

Atropine Since this patient presents with both a syncopal episode and diaphoresis, she is unstable and atropine is the appropriate therapy. After an initial dose of atropine, infusions of epinephrine or dopamine may also be considered, and for more emergent cases transcutaneous pacing may be necessary.

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

Azithromycin Notes: Pertussis (Whooping Cough) History of nasal congestion, cough, and low-grade fever Rapid-fire repetitive coughing followed by an inspiratory whoop and post-tussive emesis Most commonly caused by Bordetella pertussis Treatment is a macrolide: azithromycin

Which of the following is a common symptom associated with laryngotracheobronchitis (viral croup)?

Barking cough Notes: Viral croup is characterized by a history of upper respiratory tract symptoms followed by the onset of a barking cough and stridor. Treatment with nebulized racemic epinephrine and glucocorticosteroids is indicated for patients with stridor at rest. Croup is most often caused by parainfluenza virus.

A 34 year-old female with a history of asthma presents with complaints of increasing asthma attacks. The patient states she has been well-controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals greater than 85% predicted value. Which of the following is the most appropriate intervention at this time?

Beclomethasone (Qvar)inhaler Notes: This patient has progressed to mild persistent asthma. In addition to her inhaled beta2-agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control.

A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time?

Beclomethasone inhaler This patient has progressed to mild persistent asthma. In addition to her inhaled beta2- agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control. Other options may include cromolyn or nedocromil.

A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test?

Bedside echocardiography Notes Pericardial Tamponade Patient presents with dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck triad), pulsus paradoxus ECG will show low-voltage QRS, electrical alternans EchocardiographyDiastolic collapse of RA (highly sensitive and specific)Early diastolic collapse of RV (less sensitive but very specific) Treatment is pericardiocentesis

A 28-year-old woman is brought to the clinic by her sister, who is concerned about her recent reckless behavior. The patient has been spending money excessively, acting sexually promiscuous, speaking delusionally, and has not slept for three days. The patient is visibly irritated by her sister's comments. The patient reports periods of depression in the past, which were untreated, but now feels "absolutely great." She is extremely talkative, easily distracted in her thought process, and reports several different grand new ideas, which she explains within the space of a ten-minute discussion. What is the most likely diagnosis?

Bipolar disorder Notes: Bipolar Disorder Lifelong, recurrent mood episodes of either mood pole Mania, hypomania Inflated self-esteem Decreased need for sleep Pressured speech Flight of ideas Excessive pleasurable activity

What is the most common symptom of hemorrhoids?

Bleeding with defecation Notes: Hemorrhoids Patient presents with discomfort and itching in the anal regionIf thrombosed may also report pain PE will showInternal: proximal to the dentate lineExternal: distal to the dentate line Treatment is lifestyle modifications, sitz baths, analgesic creams, or surgical excision

Which of the following conditions has a negative Nikolsky sign?

Bullous pemphigoid Notes: Bullous Pemphigoid Patient will be > 60 years old Intensely pruritic papules that became large, tense blisters or bullae PE will show tense and firm blisters that do not extend with lateral pressure (Nikolsky sign negative)Nikolsky sign: slippage of the epidermis from the dermis when slight rubbing pressure is applied to the skin Most commonly caused by chronic autoimmune blistering disease Treatment is wound care, corticosteroids, doxycycline, and immunosuppressants

A 79-year-old man presents to the ED complaining of dyspnea. His rhythm strip is shown above. What is the most likely underlying process?

COPD Notes: Multifocal Atrial Tachycardia Associated with older patients and those with COPD Rate will be 100-200 beats/min PR interval will differ Notable feature: at least three different P wave forms Treatment is to treat the underlying cause, calcium channel blockers

A 75-year-old man with a history of renal colic presents with right flank pain radiating to the right groin. During triage, the patient has a syncopal event. Urinalysis shows no red cells. His blood pressure is 110/60 mm Hg. What is the best management indicated for this patient?

CT abdomen and pelvis with contrast The patient presents with signs and symptoms concerning for an abdominal aortic aneurysm (AAA) and should have a CT scan of the abdomen and pelvis with contrast to confirm the diagnosis. Abdominal Aortic Aneurysm (AAA) Risk factors: male sex, older patients, smoking, HTN Abdominal pain or asymptomatic Physical exam will show pulsatile abdominal mass If ruptured: hypotension Diagnosis is made by US: excellent screening tool Management: Monitor progression (Society for Vascular Surgery guidelines) - 4.0-4.9 cm: US annually - 5.0-5.4 cm: US every 6 months, can also use CT or MRI (MRI is preferred over time due to less radiation) Surgical repair would be indicated if the patient is symptomatic - > 5.5 cm or aneurysms with rapid expansion rate: elective surgery The USPSTF recommends one-time screening for AAA by ultrasonography in men aged 65-75 who have ever smoked

A 61-year-old man presents with intermittent shock-like spasms of pain in his right cheek. The pain only lasts a few seconds at a time but recurs frequently. He notes that shaving each morning causes intense spasms of pain, as does chewing. What is the first-line treatment for his likely diagnosis?

Carbamazepine Trigeminal Neuralgia (Tic Douloureux) Patient presents with sudden unilateral electric shock-like pains in gums, cheek, chin, temporal forehead PE will show pain in V2 and V3 distributions, not V1 Treatment is carbamazepine

A 77-year-old woman presents to the ED with acute painless vision loss. On funduscopic exam, you note the above. Which of the following is the most likely diagnosis?

Central retinal artery occlusion Central Retinal Artery Occlusion Patient presents with sudden, painless monocular vision loss Funduscopy will show boxcar look or cherry red spot Treatment is globe massage, ↓ IOP, ophthalmology consultation

A 23-year-old man with a history of insulin-dependent diabetes presents to the ED with vomiting and shortness of breath. He recently became homeless and has not been using his insulin. On physical exam, he has a fruity odor to his breath. After two hours of treatment in the ED, his serum labs include glucose 190 mg/dL, sodium 133 mEq/L, chloride 101 mEq/L, and bicarbonate 12 mmol/L. Which of the following is the most appropriate next step in management?

Change to dextrose-containing intravenous fluid Notes: Diabetic Ketoacidosis Patient will have diabetes History of infection, ischemia (cardiac, mesenteric), iatrogenic (e.g. steroids), insulin deficit (poor control), intoxication/illegal (cocaine abuse) (five I's) Abdominal pain, vomiting, and fatigue PE will show fruity-smelling breath, dehydration, and AMS Labs will show hyperglycemia, ketonemia, and an anion gap metabolic acidosis ManagementTreat precipitating causeCorrect volume depletion with NS, add dextrose to fluids once glucose is < 250 mg/dLReplete K+ deficit (usually falsely elevated), do not start insulin if K+ < 3.3 mEq/LIV insulin drip until anion gap closes Corrected sodium: add 1.6 mEq/L for each 100 mg/dL in serum glucose HHS = hyperglycemic hyperosmolar syndrome

A 32-year-old man presents with severe, acute left knee pain that occurred while wrestling with his brother. He is unable to bear weight. His knee is held in flexion and he is unable to actively extend it. His leg is shown above. Which of the following is the best next step in management?

Closed reduction Notes: Patellar Dislocation Patient will be an adolescent girl, dancer, or athlete PE will show the patella displaced laterally over the lateral condyle Diagnosis is made by clinical exam and X-ray to rule out fracture Most commonly caused by a twisting injury, valgus stress combined with flexion and external rotation Most common type is lateral dislocation Treatment is reduction, knee immobilizer

A 61-year-old previously healthy man presents with three days of gross hematuria and clots in his urine. He denies any dysuria, flank pain, fever, or trauma. On examination, his heart rate is 78 beats per minute, blood pressure 142/72 mm Hg, and temperature 37.4°C. He has no abdominal tenderness or fullness on palpation. Genitourinary exam is unremarkable. Urinalysis is negative for leukocyte esterase and nitrites. There are > 100 red blood cells/hpf and 6 white blood cells/hpf. Creatinine is 1.1. What is the next step in the management of this patient?

Computed tomography of the abdomen and pelvis with intravenous contrast Notes: Bladder Cancer Patient will be older History of smoking Painless hematuria Diagnosis is made by cystoscopy Most common type is urothelial (transitional cell) carcinoma

Which of the following conditions would cause a positive Kussmaul's sign on physical examination?

Constrictive pericarditis Notes: Kussmaul's sign is an increase rather than the normal decrease in the JVP during inspiration. It is most often caused by severe right-sided heart failure; it is a frequent finding in patients with constrictive pericarditis or right ventricular infarction.

A 65-year-old patient with steroid-dependent chronic obstructive lung disease presents with a headache that has been increasing in severity over the past week, accompanied by nausea and vomiting. He denies fever but has had photophobia and a stiff neck. Which of the following is the most likely diagnosis?

Cryptococcus Notes: Cryptococcus is an opportunistic fungal infection that affects immunocompromised patients, including those with HIV, chronic steroid use, organ transplants, diabetes mellitus, and chronic renal or liver disease. The most common clinical presentation is that of meningitis; fever is present in only about half of patients. Initial treatment of cryptococcal meningitis is amphotericin B with flucytosine and lifelong prophylaxis with fluconazole is needed after treatment of the episode or until the CD4 count is > 100 cells/mm^3.

Small grayish vesicles and punched-out ulcers in the posterior pharynx in a child with pharyngitis is representative of which organism?

Coxsackievirus Notes: Hands, foot, and mouth

A 3-year-old boy is seen in the office with a 5-day history of fever, erythema, edema of the hands and feet, a generalized rash over the body, bilateral conjunctival injections, fissuring and erythema of the lips, and cervical adenopathy. Antistreptolysin O (ASO) titer and throat culture are negative. The most serious systemic complication associated with this disorder is

Cradiac Notes: The patient most likely has Kawasaki syndrome. The major complication with this disorder is coronary artery aneurysms, which are reported in up to 20% of affected children. The etiology of this disorder is uncertain, although a bacterial toxin with super antigen properties may be involved.

A 21-year old female comes to you with complaint of low grade fever, sore throat, malaise, anorexia, and body rash. Physical examination reveals cervical lymphadenopathy, generalized maculopapular rash, enlarged tonsils, exudative pharyngitis and soft palatal petechiae. Monospot test shows positivity for Heterophile antibody. Which of the following would be helpful in the treatment of this patient?

Corticosteroids Management of Infectious mononucleosis is mostly symptomatic. Corticosteroids may be helpful for the tonsillar enlargement.

A 12-month-old child with tetralogy of Fallot is most likely to have which of the following clinical features?

Cyanosis is very common in tetralogy of Fallot.

A 49-year-old woman presents with chest pain and shortness of breath. Her pain is constant, non-exertional and does not radiate into the back. She denies hemoptysis, history of previous venous thromboembolism, trauma or surgery within the last four weeks or unilateral leg swelling. She takes no medications. She smokes a half pack of cigarettes per day. Her vital signs at triage are temperature 98.6°F, blood pressure 120/80 mm Hg, and heart rate 108 bpm. Her heart rate improves to 97 bpm upon reevaluation. Her physician decides to evaluate her for a pulmonary embolism. In addition to an ECG and a chest X-ray, which of the following is the most appropriate next step in the diagnosis of pulmonary embolism?

D-dimer followed by a CT pulmonary angiogram if positive Notes: If the patient has any one of the following, D-dimer testing should be performed: age ≥ 50 years, HR ≥ 100 bpm at any time in the emergency department, room air oxygen saturation < 95%, prior history of venous thromboembolism, trauma or surgery within four weeks, hemoptysis, exogenous estrogen use, or unilateral leg swelling. This patient is low risk for pulmonary embolism but had a heart rate greater than 100 bpm at triage, and therefore, should be evaluated by a D-dimer followed by a CT pulmonary angiogram if positive.

Which of the following tests is used to diagnose benign paroxysmal positional vertigo?

Dix-Hallpike maneuver Notes: Question: What is the recommended treatment for benign paroxysmal positional vertigo? Epley Maneuver Benign paroxysmal positional vertigo (BPPV): Patient presents with sudden onset of sensation of room spinning in connection with positional changes of the head, lasting seconds to minutes Diagnosis is made by Dix-Hallpike Most commonly caused by the presence of an otolith in the labyrinth system Treatment is Epley maneuver

A 41-year-old man with a long history of alcohol use disorder presents to the ED with several weeks of worsening shortness of breath and lower extremity edema. An echocardiogram shows biventricular chamber enlargement, increased systolic and diastolic volumes, and an ejection fraction of 35 percent. What is the most likely diagnosis?

Dilated cardiomyopathy notes: Dilated Cardiomyopathy: MCC: idiopathic > alcohol use disorder Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea PE will show an S3 gallop on auscultation Echo will show four dilated chambers (ventricles > atria) Management includes abstaining from alcoholRx options: ACEI and diureticsFor refractory disease to maximum medical therapy, consider cardiac transplantation or LVAD (for those who are not candidates for transplantation) Most common cardiomyopathy

A 46-year-old woman without significant past medical history presents with drooping of the left side of her face which she noticed this morning when she looked into the mirror. She is unable to completely close her left eye and cannot raise her eyebrows on the left side. Her vision is intact. When asked to puff out her cheeks, air leaks out the left side. The rest of her neurologic exam is normal. Which of the following is the most appropriate initial management?

Discharge home with prednisone and eye lubricant and patch at night Notes: Weakness of the facial muscles is a sign of Bell palsy, which refers to unilateral cranial nerve VII weakness Bell Palsy: History of viral prodrome Waking up with unilateral facial nerve paralysis, hyperacusis, and taste disturbance PE will show CN VII palsy that does NOT spare the forehead Most commonly caused by HSV Treatment is prednisone, artificial tears, tape eyelid shut, antivirals (for severe cases) Bilateral: Lyme disease, infectious mononucleosis

A 32-year-old woman presents with dysuria and lower abdominal discomfort. She is sexually active with one male partner and uses condoms inconsistently. She denies vaginal bleeding or discharge, and her pelvic examination is unremarkable. Urinalysis shows 10 WBC/hpf with positive nitrites. Which of the following is the most likely causative organism?

E. coli Notes: Cystitis Patient presents with low-grade fever, increased urinary frequency, dysuria, and suprapubic or abdominal pain Labs will show positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age - adult, adolescents or pediatric Pregnancy: asymptomatic bacteriuria should be treated Complications: ↑ risk of preterm birth, low birth weight, perinatal mortality

A 51-year-old man with a history of diabetes mellitus and hypertension presents with approximately 60 minutes of left-sided jaw pain that began while he was shoveling snow. Which of the following tests should be ordered?

Electrocardiogram Notes: This presentation is concerning for acute coronary syndrome (ACS) and the patient should have an immediate electrocardiogram (ECG) performed Additional features which are predictive of acute coronary syndrome include radiation to the jaw, right arm, left arm, or both arms. It is important to be aware that some patients, particularly the elderly, women, and patients with diabetes, may not present with classic ACS symptoms and may instead complain of generalized weakness, fatigue, epigastric discomfort or "indigestion," and nausea.

A 22-year-old woman presents with symmetric lower extremity weakness. She recently had a diarrheal illness. Which of the following might you expect on further workup?

Elevated protein of the cerebrospinal fluid Notes: lumbar puncture is abnormal, showing a markedly elevated CSF protein with a mild pleocytosis. Guillain-Barré Syndrome Risk Factors: recent minor respiratory or GI illness Sx: Symmetric, progressive ascending muscle weakness, can lead to respiratory failure PE: lack of deep tendon reflexes, symmetric weakness Lumbar puncture: increased CSF protein but a normal cell count Most commonly caused by Campylobacter jejuni Treatment is supportive, plasmapheresis, or IVIG

A 32-year-old G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last six months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but denies any vaginal discharge. On examination, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are felt. Her pregnancy test is negative. What is the most likely diagnosis?

Endometriosis Endometriosis Patient presents with pre- or mid-cycle dysmenorrhea, dyspareunia, dyschezia (painful bowel movement) PE may show uterosacral nodularity or a fixed or retroverted uterus or adnexal mass Definitive diagnosis is made by laparoscopy Most common site is ovaries Tx: NSAIDs, COCs, depot medroxyprogesterone acetate, GnRH agonists, surgery

A 59-year-old woman presents with pain and swelling of the face that began yesterday. She states that the symptoms began abruptly with a fever and chills. Physical exam reveals well-demarcated bright red, indurated skin in a malar distribution. The skin has a peau d'orange appearance. What is the most likely diagnosis?

Erysipelas Notes: Erysipelas Patient presents with malaise, fever, chills, or nausea PE will show intense and deeply erythematous, sharply demarcated elevated shiny patch Most commonly caused by Streptococcus pyogenes infection (group A beta strep) Treatment Infections with systemic compromise: parenteral cefazolin, ceftriaxone, or flucloxacillin Mild infections: oral amoxicillin or cephalexin

A 5-year-old boy presents to the emergency department complaining of right hip pain. He is febrile and refuses to bear weight on the right foot. There is no history of trauma. X-rays are obtained and are unremarkable. Which of the following diagnostic tests would best exclude a diagnosis of osteomyelitis?

Erythrocyte sedimentation rate Notes: Pediatric patients with underlying osteomyelitis almost universally have an elevated erythrocyte sedimentation rate (ESR). An elevated ESR and C-reactive protein have a 98% sensitivity for osteomyelitis in children. The two most common symptoms of osteomyelitis in children are fever and joint pain. Osteomyelitis X-ray will show periosteal elevation or bony erosions Diagnosis is made by bone scan or MRI Most common organism: - General: S. aureus - Sickle cell: Salmonella, S. aureus - Cat or dog bites: Pasteurella multocida Treatment is long-term Abx Adults: contiguous spread Children: hematogenous spread

A 58-year-old man presents with two days of fever and lower back pain. Digital rectal exam reveals a swollen and tender prostate. His urinalysis reveals 100 WBC/hpf, leukocyte esterase, and nitrites. What is the most likely pathogen causing this condition?

Escherichia coli Acute Bacterial Prostatitis Sx: fever, chills, perineal or pelvic pain, and dysuria PE: firm and exquisitely tender prostate Most common causes< 35 years old: N. gonorrhoeae, C. trachomatis> 35 years old: E. coli Treatment< 35 years old: ceftriaxone IM and doxycycline> 35 years old: fluoroquinolone or TMP-SMX for 4 weeks Avoid vigorous prostatic massage, which can lead to septicemia

A 22-year-old woman who is sexually active with multiple partners presents with dysuria for two days. Urine pregnancy test is negative. Her urinalysis reveals 36 WBC/hpf and is nitrite and leukocyte esterase positive. She is diagnosed with cystitis. What is the most likely bacterial pathogen?

Escherichia coli Cystitis Patient presents with low-grade fever, increased urinary frequency, dysuria, and suprapubic or abdominal pain Labs will show positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age - adult, adolescents or pediatric Pregnancy: asymptomatic bacteriuria should be treatedComplications: ↑ risk of preterm birth, low birth weight, perinatal mortality

A 65-year-old man with a past medical history of hypertension presents to the emergency department with "tearing" chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first?

Esmolol Notes: Rate-controlling medication (e.g. esmolol) should be given before vasodilators to prevent reflex tachycardia and subsequent increase in aortic shearing forces.

A 25-year-old woman with a history of hypertension presents to the emergency department after a syncopal event. She is complaining of lower abdominal pain. Her heart rate is 132 beats/minute and her blood pressure is 85/41 mm Hg. Her urine pregnancy test is positive. Which of the following is the most appropriate next step in management?

Establish intravenous access Notes: This patient likely has significant hemorrhage from a ruptured ectopic pregnancy and requires fluid resuscitation and possible blood transfusion Ectopic Pregnancy: Risk factors include prior ectopic, PID, tubal surgery, IUD Symptoms include abdominal pain, pelvic pain, amenorrhea, or vaginal bleeding Labs will show positive pregnancy test and lower than expected serum beta-hCG levels Diagnosis is made by ultrasound Gestational sac with a yolk sac or embryo outside of the uterine cavity Free fluid with debris is suggestive to ruptured ectopic Most commonly located in a fallopian tube Treatment is methotrexate or surgery

A 32-year-old Nigerian man presents to the emergency department for blurry vision. He immigrated to the United States six months ago. He was diagnosed with a "lung disease" and was prescribed several medications in Nigeria. Which of the following agents is most likely responsible for his symptoms?

Ethambutol Notes: "Lung disease" aka TB Ethambutol Use: usually in combination with other tuberculosis drugs (e.g. RIPE: rifampicin, isoniazid, pyrazinamide, ethambutol) MOA: bacteriostatic against actively growing TB bacilli ADR: optic neuritis, red-green color blindness, hepatotoxicity Side effects: optic neuritis and red-green color blindness.

An 8-year-old girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right-sided facial droop, and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management?

Exchange transfusion Pediatric Sickle Cell Disease: Life-long disease, with initiation of symptoms in first 6-8 months of life Genetic mutation of hemoglobin gene, leading to sickling of red blood cells, easy red cell destruction, chronic anemia, vaso-occlusive crises, and multiorgan failure Patients are often asplenic by early childhood Patients are hundreds of times more likely to have sepsis, with the period of risk highest between 6 months and 5 years old Prophylactic antibiotics are often given when patients have fever until blood and urine cultures are deemed negative

A 28-year-old woman presents to the ED following a finger injury while playing flag football. She states that she sustained a direct blow to the pointer finger when the ball struck her fingertip. On physical exam, the patient has swelling and tenderness at the distal interphalangeal joint. The fingertip rests in 45 degrees of flexion. She is unable to demonstrate active extension of the distal interphalangeal joint but has full passive extension. The skin is intact. X-ray of the finger is obtained, which shows soft tissue swelling but no fracture or dislocation. Which of the following is the most appropriate management for this patient?

Extension splinting of the distal interphalangeal joint Notes: Mallet Finger Patient will be a basketball or volleyball player History of forced hyperflexion of the DIP Inability to extend the DIP Treatment is volar splinting of DIP in extension If untreated, swan neck deformity can result

Which of the following clinical manifestations is common in candidal vulvovaginitis?

Extreme valvular irritation Notes: Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous.

Which of the following oral hypoglycemic agents when used as monotherapy is most likely to cause hypoglycemia?

Glipizide (Glucotrol) Notes: Sulfonylureas increase insulin levels and predispose patients to hypoglycemia.

A 38-year-old man presents to the emergency department with low back pain that began this morning when he rolled over in bed. Throughout the day, he tried ibuprofen and acetaminophen without relief, which prompted him to come to the Emergency Department for further evaluation. Which of the following historical findings is an indication for further investigation?

Fever Notes: Investigation for infection should include spinal imaging, urinalysis, complete blood count, C-reactive protein, and erythrocyte sedimentation rate. Back Pain: Night pain, weight loss: malignancy Back pain + fever + neurological deficits: epidural abscess Acute bony tenderness: fracture Young, morning stiffness: seronegative spondyloarthropathy Urinary retention: cauda equina syndrome Pain with extension, relief with flexion: spinal stenosis Image if red flags present

A 34-year-old man presents to the emergency department with left arm pain after a fall on an outstretched hand while walking his dog. He has tenderness and swelling of the forearm as well as wrist pain with attempted pronation and supination. An X-ray is obtained as seen above. What eponym is associated with this fracture?

Galeazzi fracture Galeazzi Fracture: X-ray will show fracture of middle to distal radius + disruption of distal radioulnar joint Treatment is immediate ORIF Risk of anterior interosseous nerve injury Mnemonic: GRUesome MURder - Galeazzi: radius fracture, ulna (radioulnar joint) dislocation - Monteggia: ulna fracture, radial head dislocation

A 42-year-old man with a history of heavy alcohol use presents with severe abdominal pain and vomiting following an alcohol binge. Lab values are as follows: WBC 14,000, Hgb 10, platelets 98,000, lipase 9,000, AST 200, ALT 107, T. bill 1.6, Na 134, K 5.1, Cr. 3.1, and glucose 313. Which of the following lab values is associated with increased mortality according to the Ranson Criteria?

Glucose of 313 Notes: Ranson criteria on admission: Age > 55 Glucose > 200 WBC > 16,000 AST > 250 LDH > 350 Acute Pancreatitis Patient presents with epigastric pain radiating to the back, nausea, and vomiting PE will show flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amylase Ranson criteria and APACHE II are used to predict the severity (Note: they are difficult to apply and have limitations) Most commonly caused by gallstones > alcohol Treatment is IV fluids, analgesics Pancreatic pseudocyst complication in adults

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

Glucose-6-phosphate-dehydrogenase deficiency Notes: This patient most likely has hemolytic anemia caused by oxidative stress in the setting of G6PD deficiency Without G6PD, the RBC membrane is subject to hemolysis when exposed to oxidative stressing agents, including aspirin, antimalarials, nitrofurantoin, sulfa drugs, fava beans, and methylene blue. G6PD Deficiency History of taking antimalarials, sulfonylureas, quinolones, nitrofurantoin, fava beans Infection is also a cause for the hemolysis Labs will show Heinz bodies, presence of bite cells on the smear Consider testing prior to starting potential agents in patients who may be at risk X-linked recessive

Which of the following correctly describes electrocardiographic features of second-degree type I atrioventricular block?

Grouped beats Second-Degree Heart Block (Mobitz I, Wenckebach): Rhythm will be irregular PR interval will be progressively lengthening Notable feature: progressive lengthening of the PR interval until QRS complex fails to appear after a P wave (dropped beat)

During a baseball game, a 22-year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen?

Hematoma of the orbit Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma.

A 35-year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis?

Herpes Simplex Virus (HSV) The presentation seen on the Tzanck preparation is characteristic of HSV.

A 42-year-old man presents to the ED with racing heart rate and difficulty breathing. On physical exam, you note bilateral ocular proptosis and 3+ non-pitting edema of the bilateral lower extremities. His electrocardiogram is shown above. Which of the following complications of this disease is this patient most likely experiencing?

High output heart failure Notes: This patient is exhibiting signs and symptoms consistent with thyroid storm. Thyroid storm is a rare, life-threatening hypermetabolic state caused by severe thyrotoxicosis. The most common precipitating factor is an infection

A 65-year-old man presents to the ED with diffuse bone pain, abdominal cramping, and severe constipation. He is currently undergoing dialysis for end-stage renal disease but has not been to dialysis this week. Physical exam reveals a lethargic man with diffuse abdominal tenderness without rebound or guarding. Which of the following is the most likely etiology for his symptoms?

Hypercalcemia Notes: In a patient with chronic renal failure, is classically caused by tertiary hyperparathyroidism. The parathyroid gland secretes parathyroid hormone, which typically acts on the kidney to decrease calcium clearance (thus increasing serum calcium) and to decrease phosphate reabsorption (thus lowering serum phosphate). Hypercalcemia: Sx: bone pain (bones), kidney stones (stones), abdominal pain (groans), lethargy, psychosis (psychiatric overtones) ECG: shortened QT interval Most common causes: Malignancy (most common inpatient cause) Primary hyperparathyroidism (most common outpatient cause) Treatment: IV fluids, bisphosphonates, calcitonin

A 23-year-old professional soccer player collapses during a match. He is pulseless, and cardiopulmonary resuscitation is initiated. Which of the following is the most common cause of sudden death in competitive athletes?

Hypertrophic cardiomyopathy

A 23-year-old male presents with syncope. On physical examination you note a medium-pitched, mid-systolic murmur that decreases with squatting and increases with straining. Which of the following is the most likely diagnosis?

Hypertrophic cardiomyopathy is characterized by a medium- pitched, mid-systolic murmur that decreases with squatting and increases with straining.

A 72-year-old man presents to the emergency department with left eye pain. Earlier this evening he was involved in a fistfight. He reports getting punched in the eye with no loss of consciousness. He now has eye pain and blurry vision. On physical exam his visual acuity is 20/50 in the left eye and 20/20 in the right eye. His intraocular pressure is 14 on the left. His left eye is shown above. What is the most likely diagnosis?

Hyphema Notes: Hyphema History of blunt or penetrating trauma Blurry vision PE will show unequal pupils, injected conjunctiva or sclera, and blood in anterior chamber Treatment is with eye protection, limitation of activity, and head elevation of 30-45 degrees

A 55-year-old man presents with fever and right upper quadrant pain. On examination, you note that the patient is jaundiced and slightly altered. Clinically you make the diagnosis of cholangitis. Which of the following is the final component of Reynold's pentad?

Hypotension Notes: Acute Cholangitis Patient presents with right upper quadrant pain, jaundice, fever (Charcot triad) Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (gold standard) Most commonly caused by choledocholithiasis that leads to bacterial infection, E. coli Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction

A 39-year-old man presents to the emergency department with left hand pain. He denies recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes mellitus and tobacco abuse. His examination is shown above. Which of the following is the most appropriate initial therapy for this patient?

Incision and drainage Notes: Pt has a felon, which is a pyogenic infection of the digital subcutaneous tissue and pulp. Staphylococcus aureus is the most common causative organism. Incision and drainage is the recommended initial treatment if the finger is swollen and tense with palpable fluctuance. Felon Most commonly caused by Staphylococcus aureus Treatment is incision and drainage Oral antibiotics covering Staphylococcus aureus, Streptococcus pyogenes, and anaerobes (e.g., trimethoprim-sulfamethoxazole) are recommended as most felons are accompanied by cellulitis.

You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility?

Increase in FEV1 Notes: In asthma, the airway obstruction should be at least partially relieved be a short-acting bronchodilator. This would be reflected in an increased forced expiratory volume in 1 second (FEV1).

A 62-year-old woman was walking her dog when she began to experience intense substernal chest pressure. She became very diaphoretic and felt nauseated. She called 911 and was brought to the ED. Her electrocardiogram is shown above. Which of the following best describes the location of the patient's myocardial infarction?

Inferior Notes: In this case, the patient has ST elevation in leads II, III, and aVF and reciprocal ST depression in leads I and aVL. This is diagnostic of an inferior wall myocardial infarction. The coronary artery that supplies the inferior portion of the heart in most patients is the right coronary artery. ACS: Location: Leads: Artery Anterior and septal: V1-V4: left anterior descending (LAD) Inferior: II, III, aVF: 70+% right coronary artery (RCA) or left circumflex (LCX) Lateral: I, aVL, V5-V6: left circumflex (LCX), diagonal of left anterior descending

A 63-year-old female presents with a complaint of chest pressure for one hour, noticed upon awakening. She admits to associated nausea, vomiting, and shortness of breath. 12 lead EKG reveals ST segment elevation in leads II, III, and AVF. Which of the following is the most likely diagnosis?

Inferior wall myocardial infarction Notes: Myocardial infarction often presents with chest pressure and associated nausea and vomiting. ST segment elevation in leads II, III, and AVF are classic findings seen in acute inferior wall myocardial infarction.

A 25 year-old male with a history of asthma presents complaining of increasing episodes of evening and daytime symptoms. He is on a short acting inhaled beta agonist prn. He is presently using his short acting beta agonist on a daily basis. Which of the following is the most appropriate addition to this patient's regimen?

Inhaled Corticosteroid Notes: According to the stepwise approach for managing asthma by the National Asthma Education and Prevention Program, inhaled corticosteroids are indicated for mild to moderate persistent asthma.

A 44-year-old woman presents to the emergency department with one week of crampy abdominal pain that is worse after she eats. She denies alcohol consumption or tobacco abuse. On physical examination, she is overweight and has epigastric and right upper quadrant abdominal tenderness to palpation. Which of the following examination findings is most consistent with cholecystitis? A.) Epigastric rebound tenderness B.) Grey-Turner sign C.) Inspiratory arrest with right upper quadrant palpation D.) Right scapular tenderness

Inspiratory arrest with right upper quadrant palpation Notes: Colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: USGold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy Epigastric rebound tenderness (A), or any rebound tenderness, is considered a sign of peritoneal irritation and warrants surgical consultation for possible surgical etiologies of pain. It is nonspecific and does not necessarily indicate gallbladder pathology. Grey-Turner sign (B) is flank ecchymosis that indicates retroperitoneal hemorrhage. Right scapular tenderness (D) is not a specific finding for gallbladder disease. However, diaphragmatic irritation from an inflamed gallbladder may cause radiation pain via the phrenic nerve to the right scapula or shoulder. Epigastric rebound tenderness (A), or any rebound tenderness, is considered a sign of peritoneal irritation and warrants surgical consultation for possible surgical etiologies of pain. It is nonspecific and does not necessarily indicate gallbladder pathology. Grey-Turner sign (B) is flank ecchymosis that indicates retroperitoneal hemorrhage. Right scapular tenderness (D) is not a specific finding for gallbladder disease. However, diaphragmatic irritation from an inflamed gallbladder may cause radiation pain via the phrenic nerve to the right scapula or shoulder.

A 28-year-old woman presents with pain and swelling of her left breast, fever, and myalgias. She had a full-term vaginal delivery one week ago and is breastfeeding her infant. On examination, she has a temperature of 38.1°C. The superior lateral quadrant of the left breast is erythematous, warm, and tender to palpation. There is no fluctuance appreciated. What is the next step in management of this patient?

Instruct her to continue breastfeeding and start oral cephalexin

A 45-year-old man with a history of alcoholic cirrhosis presents to the emergency department for confusion. His family brought him. They deny recent trauma, infection, bloody emesis, or stool. He is unable to give a coherent history but seems pleasantly confused. He denies pain. Family report that he no longer drinks alcohol and has not used any medications or drugs recently. On exam, he is drowsy and delirious. His hands flap when held up, and his tongue gyrates back and forth when protruded. Guaiac testing is negative. His abdomen is distended, but soft and nontender. A noncontrast computed tomography scan of the head shows no evidence of bleeding. His renal function is normal, sodium levels are within normal ranges, liver function tests are within his normal ranges, and blood counts are normal. His ammonia level is elevated at 114 µmol/L. What therapy should be initiated?

Lactulose Notes: Hepatic Encephalopathy History of infection, dehydration, medications, GI bleed, hypoxia, hypoglycemia Presents with confusion PE will show scleral icterus and asterixis Most commonly caused by toxin accumulation due to liver dysfunction Treatment is lactulose, rifaximin CSF glutamine correlates with severity

A 61-year-old woman with no past medical history or family history of heart disease presents with a trimalleolar ankle fracture after a fall. As part of her preoperative workup, an electrocardiogram is obtained. A portion of the rhythm strip is shown above. Which of the following is the most appropriate next step?

Reassure the patient and the orthopedic surgeon that no treatment is necessary Notes: The patient has first-degree atrioventricular (AV) block evidenced by a prolonged PR interval but no other abnormalities.

A 35-year-old woman presents to the ED with facial swelling. On physical exam, you note the above. Which of the following medications is most likely the cause of this process?

Lisinopril This patient is exhibiting signs and symptoms of drug-induced angioedema. Angioedema is defined as edema of cutaneous and subcutaneous tissue secondary to capillary dilation. Common triggers of drug-induced angioedema include ACE inhibitors like lisinopril which inhibit bradykinin degradation. Angioedema Patient presents with swelling of the tongue, face, and neck in the absence of hives Most common causes: Idiopathic Drug-induced: ACE inhibitors (most common) Hereditary: C1 esterase inhibitor deficiency Treatment is airway management Hereditary: C1 esterase inhibitor replacement or FFP

A 74-year-old woman with a history of hypothyroidism presents to the ED with confusion, rigors, and lightheadedness. Vital signs are BP 110/64 mm Hg, HR 48 beats per minute, RR 12 breaths per minute, and T 95.2°F. Her electrocardiogram is shown above. Which of the following is the most likely diagnosis?

Myxedema coma This patient is exhibiting signs and symptoms consistent with myxedema coma. Myxedema coma is defined as severe hypothyroidism resulting in a decompensated metabolic state and mental status change. It is classically characterized by thickened, non-pitting edema of the skin diffusely associated with severe chronic hypothyroidism.

A 6 year-old boy is brought to the pediatric clinic by his mother for an evaluation of his asthma. He coughs about 3 days out of the week with at least 2-3 nights of coughing. Which of the following would be the most appropriate treatment for this patient?

Low dose inhaled corticosteroids are the preferred treatment for mild persistent asthma.

A 44-year-old man with systemic lupus erythematosus presents to the ED with chest pain and dyspnea. Vital signs are notable for tachycardia and hypotension with a narrow pulse pressure. Bedside ultrasound confirms a large pericardial effusion with collapse of the right ventricle during diastole. Which classic electrocardiogram findings are associated with this disease process?

Low voltage and electrical alternans Notes: Classic ECG findings of cardiac tamponade include low voltage QRS complexes and electrical alternans, where there is beat-to-beat variation in the amplitude of the R waves.

An 80-year-old woman, with a history of type 2 diabetes mellitus, presents with slowly worsening vision. Her vision is worse in low-intensity light and she has blurring in the center of her vision. Physical examination shows intact peripheral visual fields with a positive Amsler grid distortion. Fundoscopic exam reveals drusen located in the macula of the retina. What is the most likely diagnosis?

Macular degeneration Notes: Macular degeneration is characterized by central vision loss caused by atrophy of the cells in the central macular region of the retinal pigment epithelium. Risk factors are multifactorial and include advanced age, tobacco abuse, genetic predisposition, race, obesity, and existing cardiovascular disease. Symptoms include wavy or distorted central vision and central blind spots. An Amsler grid will be perceived as distorted by the patient on exam Macular Degeneration Patient will be older Bilateral, gradual central field vision loss PEDry (85% of cases): atrophic changes and yellow retinal deposits (drusen spots) Wet: vascular changes Diagnosis is made by characteristic findings on dilated eye examination Most common cause of blindness in the older population

A 46-year-old man with a history of diabetes mellitus and chronic alcohol use presents to the emergency department with lower back pain that has progressively worsened over the last five days. He denies a history of trauma. On examination, he has a temperature 37.9oC, heart rate 87 beats/minute, and blood pressure 146/75 mm Hg. He has tenderness with percussion over the midline lower lumbar spine. Achilles and patellar reflexes are intact. He has mild decreased sensation of both feet, but his strength is intact. What is the next best step in management?

Magnetic resonance imaging of the lumbosacral spine Notes: Spinal Epidural Abscess History of diabetes or IVDA Back pain, fever, and neurological deficits Labs will show elevated ESR Diagnosis is made by MRI Most commonly caused by S. aureus

Which of the following is the most common cause of status epilepticus in a patient with known epilepsy?

Medication noncompliance Status Epilepticus: PE will show ≥ 5 minutes of continuous seizure activity or more than one seizure without recovery from the postictal state between episodes Most commonly caused by a change in the medication regimen of someone with a seizure disorder Treatment: -First-line: benzodiazepines (e.g., lorazepam) -Second-line: phenytoin or fosphenytoin, valproic acid, levetiracetam -Third-line: pentobarbital, propofol, phenobarbital

A 30-year-old man presents to the ED with three weeks of diarrhea. He reports colicky abdominal pain associated with frequent episodes of pale, loose, foul-smelling stools. He returned from a camping trip in New Hampshire one month prior. His vital signs are temperature 37.1°C, heart rate 85 bpm, and blood pressure 125/80 mm Hg. Which of the following is the most appropriate treatment for this condition?

Metronidazole 250 mg tid for seven days Giardiasis History of camping and drinking lake water Sudden onset of explosive, foul-smelling, and nonbloody diarrhea Classic symptoms include explosive diarrhea, colicky abdominal pain, and pale, loose, foul-smelling stools. Labs will show flagellated protozoan Most commonly caused by Giardia lamblia Treatment is metronidazole The most common cause of parasitic diarrheal infection in the United States.

Which of the following is the most effective way for patients with persistent asthma to monitor the severity of their symptoms?

Monitor peak flow Notes: Monitoring peak flow is the most effective way for the patients and healthcare providers to manage symptoms and guide treatment.

A 32-year-old woman presents with progressive fatigue, shortness of breath, and chest discomfort that has worsened over the last 2 days. She had a mild upper respiratory infection last week but otherwise reports no significant past medical history. She does not take any medications and reports no illicit drug use. On examination, she has a T 37.9°C, HR 132 bpm, RR 16/min, and oxygen saturation 98% on room air. Lungs are clear to auscultation. Chest radiograph demonstrates mild cardiomegaly without infiltrates. Electrocardiogram shows sinus tachycardia with nonspecific ST segment and T wave changes. Troponin is 0.25 ng/mL. What is the likely cause of her symptoms?

Myocarditis Myocarditis Patient presents with fatigue, fever, chest discomfort, dyspnea, and palpitations PE will show tachycardia disproportionate to fever or discomfort Echocardiogram will show decreased ventricular ejection fraction with hypokinesis and wall motion abnormalities Gold standard for diagnosis is an endomyocardial biopsy

A 25-year-old man presents to the emergency department after a gunshot wound to the chest. He is awake and following commands. His vital signs are T 97.5°F, BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and oxygen saturation 87% on a nonrebreather face mask. Jugular venous distension is present and he has diminished breath sounds on the left. Which of the following is the next best step in management?

Needle decompression of the chest Notes: Needle decompression of the chest in the second intercostal space in the midclavicular line is recommended for emergent management of a tension pneumothorax. Tension Pneumothorax History of chest trauma PE will show diminished or absent breath sounds, tracheal deviation away from the side of the injury, hypotension, jugular venous distension Diagnosis is made clinically Treatment is needle decompression of the chest in the second intercostal space in the midclavicular line or fifth intercostal space in the midaxillary line followed by chest tube insertion

Which of the following is a known complication of chronic lithium toxicity?

Nephrogenic diabetes insipidus Notes: Chronic lithium ingestion may cause nephrogenic diabetes insipidus, a concentrating defect in the kidneys due to a resistance of antidiuretic hormone. Nephrogenic Diabetes Insipidus: History of taking lithium Diagnosis is made by water deprivation test: no change in urine osmolality Most commonly caused by kidney unresponsiveness to ADH Treatment is HCTZ, amiloride, indomethacin

Treatment of Bell's palsy includes which of the following?

Reassurance of the patient's recovery Notes: Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy.

Which of the following is more consistent with the diagnosis of encephalitis rather than meningitis?

New psychiatric symptom

A 58-year-old man presents with chest pain. His electrocardiogram is shown above. A right-sided electrocardiogram is also performed and shows elevated ST segments in V4R and V5R. Which of the following medications is contraindicated?

Nitroglycerin Notes: Treatment of right ventricular infarction, in addition to early reperfusion, includes using fluids to maintain adequate preload, reducing right ventricular afterload, and using inotropes like dobutamine, if needed, to support the failing right ventricle. Nitroglycerin, which is commonly used in acute myocardial for its preload and afterload reducing effects, should not be used in right ventricular infarction because it can precipitate critical hypotension and cardiovascular collapse. Right Ventricular Infarction Hypotension, JVD Clear lungs ST elevation in V4R-V6R ST elevation lead III > lead II Preload dependent Impaired filing of left ventricle Reperfusion, IVF

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F, blood pressure 220/110 mm Hg, heart rate 125 beats/minute, and respiratory rate 30 breaths/minute. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment?

Nitroglycerin Notes: Nitroglycerin can be administered sublingually and intravenously to achieve rapid and titratable improvement in hypertension via vasodilation with a reduction in preload and afterload. Acute Pulmonary Edema Crackles, jugular venous distension CXR: cephalization, Kerley B lines, effusions Initial RxBPAP: ↑ oxygenation, ↓ work of breathing, ↓ preload, ↓ afterload Nitroglycerin: ↓ preload, ↓afterload Furosemide: diuresis Second-line Rx:Hypotension without signs of shock: dobutamine (may worsen hypotension)Severe hypotension with signs of shock: norepinephrine (↑ systemic vascular resistance, ↑ HR, ↑ BP, ↑ myocardial O2 demand)

A 60-year-old man with a history of chronic obstructive pulmonary disease presents by EMS in respiratory distress. He is diaphoretic and is sitting up in bed leaning forward. His vital signs are T 100.1°F, HR 95 beats/minutes, RR 30 breaths/minute, BP 150/90 mm Hg, and oxygen saturation 79% on room air. There is poor air movement with prolonged expiratory wheezes. A nonrebreather face mask is placed, but his work of breathing and oxygen saturation are not improving. In addition to intravenous glucocorticoid and nebulized beta-agonist medications, which of the following is most appropriate next step in management?

Noninvasive positive pressure ventilation Chronic Obstructive Pulmonary Disease (COPD) Pink puffer, blue bloater Excessive O2 → ↓ respiratory drive Bronchodilators, anticholinergics, steroids, NIPPV, smoking cessation Antibiotic options include azithromycin or doxycycline. Noninvasive positive pressure ventilation (NIPPV) is beneficial for patients with severe acute exacerbations

A 54-year-old woman with a history of hyperthyroidism presents to the ED with fever, vomiting, palpitations, and tremors. Which of the following would you expect to find on physical exam?

Ocular proptosis Signs and symptoms of thyroid storm include bilateral ocular proptosis, anxiety, tremulousness, psychosis, obtundation, seizure, coma, fever, tachycardia (out of proportion to fever), high-output heart failure, circulatory collapse, diarrhea, and vomiting.

Which of the following drugs is first-line therapy for schizophrenia?

Olanzapine (Zyprexa) Initial pharmacologic therapy of schizophrenia should begin with one of the newer, "atypical" antipsychotic drugs, such as olanzapine, risperidone, quetiapine, and ziprasidone because their side effect profile is significantly better than the older drugs, and they may be more effective for negative psychotic symptoms.

Which of the following causes acute painful loss of vision?

Optic neuritis Notes: Optic Neuritis Patient presents with acute monocular vision loss, pain worse with eye movements, loss of color (red) vision, and transient worsening of vision with increased body temperature (Uhthoff phenomenon) Diagnosis is made clinically. MRI will confirm demyelination Most commonly caused by multiple sclerosis Treatment is IV methylprednisolone Although often idiopathic, approximately 30% of patients will develop multiple sclerosis (MS) within five years.

A 27-year-old woman presents with chest pain. The patient reports that she was about to give a presentation at her job and suddenly had a feeling of impending doom. In addition to chest pain, she had palpitations and sweating. Which of the following is the most likely diagnosis?

Panic Attack Notes: Panic Attack Sudden onset Intense apprehension, fearfulness, terror Peaks in 10 minutes Concern about future attacks

An 18-year-old presents to the emergency department with severe pain in his penis. He indicates he has had some mild irritation to the glans and foreskin areas recently. After intercourse tonight he was unable to reduce the foreskin and now has severe pain in the tip of his penis. On examination, the penis is flaccid and the foreskin is retracted proximally. There is swelling to the tip of the penis with mild erythema. What is the most likely diagnosis?

Paraphimosis Paraphimosis Patient presents with penile pain PE will show foreskin that, once retracted, cannot be brought to the usual position Treatment is manual reduction or dorsal slit if reduction unsuccessful

A 55-year-old woman presents with right finger pain. She reports she habitually bites her nails. On examination, the lateral nail fold and cuticle of the right ring finger is erythematous, fluctuant and tender to palpation. Which of the following is the most likely diagnosis?

Paronychia Notes: Paronychia PE will show an infection of lateral nail fold Most commonly caused by S. aureus Treatment is Abx, warm soaks, I&D

A 5-year-old boy with a history of sickle cell anemia presents with dyspnea and fatigue. His mother notes that 1 week prior, he had a fever, headache, and bright red rash on his cheeks, which has since resolved. Laboratory studies show a decrease in his baseline hemoglobin by 30%. Infection with which virus likely precipitated his current symptoms?

Parvovirus B19 Notes: Pediatric Sickle Cell Disease Life-long disease, with initiation of symptoms in first 6-8 months of life Genetic mutation of hemoglobin gene, leading to sickling of red blood cells, easy red cell destruction, chronic anemia, vaso-occlusive crises, and multiorgan failure Patients are often asplenic by early childhood Patients are hundreds of times more likely to have sepsis, with the period of risk highest between 6 months and 5 years old Prophylactic antibiotics are often given when patients have fever until blood and urine cultures are deemed negative

A 6-week-old infant presents with decreased appetite. The child is underweight for her age, and her mother says that she is not eating well. Physical exam reveals a continuous heart murmur in the left infraclavicular space and a thrill in the suprasternal notch. Which of the following findings would be expected on echocardiogram?

Patent ductus arteriosus Notes: PDA is a congenital heart defect that occurs when the fetal ductus arteriosus fails to close after birth Patent Ductus Arteriosus - Patient presents with failure to thrive, poor feeding, tachycardia, and tachypnea - PE will show continuous, rough, machine-like murmur, heard best in the first interspaces of the LSB - Diagnosis is made by echo - Management includes indomethacin, conservative observation, surgical ligation, or percutaneous transcatheter occlusion

A 23-year-old female with a history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well-controlled until 2 days ago. Since yesterday, she has been using her albuterol inhaler every 4 to 6 hours. She is normally very active, however yesterday she did not complete her 30-minute exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries, or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment?

Peak flow Notes: A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

A 45-year-old woman, who works as a day laborer, presents with epigastric abdominal pain that began one hour prior to arrival. She has been having abdominal discomfort after meals for the past several weeks. Today, she developed sudden onset, severe abdominal pain far worse than what she has been experiencing. She denies back pain, nausea, and vomiting. On exam, she is tachycardic but has otherwise normal vital signs. Her abdomen is significantly tender in the epigastric region with rebound and guarding. Chest X-ray is as above. What is the most likely diagnosis?

Perforated gastric ulcer Notes: Peptic Ulcer Disease Patient presents with gnawing epigastric painDuodenal ulcer: pain is alleviated by ingesting food (mnemonic: DUDe, give me food)Gastric ulcer: pain is exacerbated by ingesting food Diagnosis is confirmed by endoscopy Diagnosis of H. pylori infection is made by H. pylori fecal antigen or urea breath test Most commonly caused by H. pylori infection or nonsteroidal anti-inflammatory use Most common cause of upper GI bleed Increases risk of perforation

A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from 4-week summer camp one week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae, surrounding scattered erythematous papules. Which of the following is the most appropriate treatment?

Permethrin This patient has scabies, a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabiei var. hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus, especially when exposure to others with similar symptoms is reported. Scabies Sx: severe pruritus that is worse at night PE: small papules, vesicles, and burrows in the webbed spaces of the fingers and toes Diagnosis is made by microscopic visualization Most commonly caused by Sarcoptes scabiei var. hominis Treatment is permethrin 5%

A 22-year-old healthy man presents with acute onset pleuritic, left-sided chest pain and mild dyspnea. Social history includes smoking a pack of cigarettes a week. Vital signs include blood pressure 142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation 97% on room air. He is in no acute distress. His chest radiograph is shown above. Which of the following is the best next step in management?

Place patient on 100% oxygen and repeat chest radiograph in six hours Notes: Spontaneous Pneumothorax Patient will be a young, tall, thin, man PE will show decreased breath sounds, decreased fremitus, hyperresonance to percussion CXR will show the absence of lung markings along lung periphery Treatment< 20% in a healthy patient: observation with oxygen administration> 20%: chest tube thoracostomy

A 32-year-old woman, who is at 20 weeks gestational age, presents to the ED after a seizure. Her vital signs are BP 115/70 mm Hg, HR 105 bpm, RR 16/min, T 38.5°C, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/µL. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition?

Plasmapheresis The pt has Thrombotic Thrombocytopenic Purpura (TTP): Patient will be a woman Fever, confusion, difficulty speaking, headache, seizure, nausea, vomiting, diarrhea Labs will show elevated LDH, elevated indirect bilirubin, normal coagulation studies, microangiopathic hemolytic anemia, and thrombocytopenia Most commonly caused by severely decreased protease ADAMTS13 activity Treatment is plasma exchange with intravenous corticosteroids The mainstay of treatment for TTP is plasmapheresis (plasma exchange).

A 67-year-old man with a history of bronchogenic carcinoma presents with fever and shortness of breath. His vital signs are T 101.5°F, HR 112 bpm, RR 22 breaths/minute, BP 100/60 mm Hg, and oxygen saturation 92% on room air. He has right basilar crackles on auscultation and dullness to percussion. A chest X-ray demonstrates a right lower lobar consolidation with costophrenic angle blunting. Which of the following values suggests the presence of an exudative pleural effusion?

Pleural fluid lactate dehydrogenase twice that of serum lactate dehydrogenase Notes: The Light criteria for the diagnosis of a pleural exudative effusion include the presence of at least one of the following: pleural fluid lactate dehydrogenase (LDH) to serum LDH ratio > 0.6, pleural fluid to serum protein ratio > 0.5, or pleural fluid LDH greater than two-thirds the upper limit of normal for serum LDH. Therefore, a pleural fluid LDH twice that of serum LDH would suggest the presence of an exudative effusion

Which of the following is the most common pulmonary complication of influenza?

Pneumonia secondary to superimposed bacterial infection Notes: The most frequent complication of influenza is pneumonia secondary to a superimposed bacterial infection. Streptococcus pneumoniae is the most frequently implicated pathogen, with Staphylococcus aureus and Haemophilus influenzae being cited as well. Influenza Patient presents with sudden onset of fever, headache, cough, myalgia, sore throat, fatigue Diagnosis is made clinically, can be confirmed with reverse transcription polymerase chain reaction (RT-PCR) or viral culture Treatment is mainly supportive or oseltamivir for high-risk patients Start oseltamivir as early as possible, after 48 hours it may not confer any benefit Most common cause of viral pneumonia In adults New vaccine needed yearly Monitor patients for postinfluenza pneumonia

Which of the following is a cause of prerenal azotemia?

Poor renal perfusion Notes: Renal hypoperfusion is the cause of prerenal azotemia, which may be rapidly reversible when renal blood flow and glomerular ultrafiltration pressure are restored

A 38-year-old man with a past medical history of hypertension and stage III chronic kidney disease presents with severe left foot pain that began in the middle of the night. He appears comfortable but has exquisite tenderness to palpation of the left, first metatarsophalangeal joint. The joint is erythematous and warm. His vital signs include a temperature of 99.1°F, BP 132/85 mm Hg, RR 16 breaths/minute, and oxygen saturation 99% on room air. Arthrocentesis of the involved joint is performed and synovial fluid analysis reveals negatively birefringent crystals. Which of the following is the most appropriate therapy at this time?

Prednisone Gout Patient will be a middle-aged man Acute onset of pain in the first MTP (podagra) Labs will show needle-shaped crystal with negative birefringence Most commonly caused by uric acid crystals TreatmentAcute: NSAIDs, steroids, colchicineChronic: allopurinol (first line) or probenecid Can be triggered by loop and thiazide diuretics

Which of the following treatment strategies is best for the condition seen in the image above? Image: pediculosis capitis (head lice)

Pregnant women should be treated with permethrin Permethrin is first-line therapy for treatment of pediculosis capitis (head lice) in all populations, including pregnant and lactating women as well as infants greater than or equal to 2 months of age.

Which of the following is one of the most helpful signs to rule out testicular torsion?

Presence of the cremasteric reflex Notes: Testicular Torsion Bimodal distribution: infants and young men Sx: intense scrotal pain PE: exquisite tenderness of the testicle and no cremasteric reflex Diagnosis is made by ultrasound with Doppler Treatment: urgent surgery, manual detorsion if surgery delayed

A 53-year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam, she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals sinus tachycardia. Which of the following is the most likely diagnosis?

Pulmonary Embolism Notes: This patient's risk factors for pulmonary embolism include advanced age, surgery, and prolonged bed rest. While the diagnosis of pulmonary embolism is difficult to make due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

Which of the following is the most common injury seen in a child with severe blunt chest trauma such as being struck by a motor vehicle?

Pulmonary contusion Notes: Pulmonary Contusion Vascular leak causes local parenchymal injury and edema Ventilation-perfusion mismatch Tachypnea and hypoxia are common on initial presentation > 80% of children with pulmonary contusion will have extrathoracic injuries Radiographic findings are often delayed Good lung should be positioned down (good to ground) to improve V/Q matching and oxygenation Exceptions: bad lung in the dependent position (down)Massive hemoptysis (to prevent blood from filling the good lung)Large pulmonary abscesses (to prevent pus from filling the good lung)Unilateral emphysema (to prevent hyperinflation)

A 22-year-old man presents with upper extremity weakness. He notes that he was drinking heavily last night and when he woke up this morning he was unable to move his hand. On examination, he has normal strength in the biceps and triceps but weakness of the wrist extensors, finger extensors, and brachioradialis. Injury to what nerve accounts for his symptoms?

Radial nerve Notes: Radial Nerve Palsy (Saturday Night Palsy) History of a night of heavy drinking PE will show a weakness of the wrist extensors, wrist drop, and weakness of the finger extensors Treatment is splinting the wrist, physical therapy, and pain management Remember: radial nerve is formed from nerve roots C5 through T1

Which of the following types of traumatic events has the highest probability of resulting in post-traumatic stress disorder?

Rape sexual relationship violence, such as rape or childhood sexual assault, has the highest probability of causing PTSD. Post-Traumatic Stress Disorder (PTSD) Sx duration > 1 month Persistently reexperiencing of event Persistently ↑ arousal Avoidance of stimuli ↑ risk for suicide, substance use

A 65-year-old woman presents to the emergency department with acute onset vertigo. She denies associated decreased hearing or tinnitus. Vital signs are normal. Horizontal head impulse test shows a corrective saccade when the head is turned to the left. Dix-Hallpike maneuver elicits a leftward rotary nystagmus that is fatigable. Which of the following mechanisms will provide the most definitive treatment of this condition?

Relocation of free floating otoconia Notes: Benign paroxysmal positional vertigo (BPPV) Patient presents with sudden onset of sensation of room spinning in connection with positional changes of the head, lasting seconds to minutes Diagnosis is made by Dix-Hallpike Most commonly caused by the presence of an otolith in the labyrinth system Treatment is Epley maneuver

An 18-month-old boy presents to the emergency department with worsening shortness of breath. The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms?

Respiratory syncytial virus notes: Pt has bronchiolitis, which is the most common lower respiratory tract infection in patients less than two years of age. Bronchiolitis Patient will be an infant Difficulty breathing PE will show respiratory distress, polyphonic wheezing, and rales Diagnosis is made by history and physical exam Most commonly caused by respiratory syncytial virus (RSV) Treatment is supportive care

A 67-year-old man with a history of hypertension and diabetes mellitus presents to the emergency department with sudden onset of left leg weakness. His examination is notable for 3/5 strength in his left lower extremity as well as diminished sensation over his left toes, foot, and leg. He has a flat affect and appears slow in his speech. Which of the following vascular territories is most likely affected in this patient?

Right anterior cerebral artery (ACA) Notes: Symptoms of an ACA infarction include contralateral lower extremity weakness and sensory loss with sparing of the upper extremity and face. Ischemic Stroke Anterior cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper) Middle cerebral artery: contralateral paralysis (upper > lower), aphasia Posterior cerebral artery and VBI: LOC, nausea or vomiting, CN dysfunction, ataxia, visual agnosia Rule out hypoglycemia CT reveals loss of gray-white interface, acute hypodensity Thrombolytics

A 31-year-old man presents to the emergency department in police custody after he was found unclothed, confused, and running down a snowy street. His urine drug test is positive for phencyclidine (PCP). Which of the following ocular findings is most likely present on physical examination?

Rotary nystagmus Notes: Phencyclidine (PCP) Intoxication HTN, tachycardia, hyperthermia Vertical, horizontal, or rotatory nystagmus Variable pupil size Combative behavior Complications: rhabdomyolysis, seizures BZDs, cooling, IVF, charcoal

An 18-year-old man presents complaining of fever, right-sided abdominal pain, anorexia, and vomiting. When you palpate his left lower quadrant, he complains of pain in his right lower quadrant. Based on this information, which of the following signs is considered positive?

Rovsing sign Appendicitis Patient presents with fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show psoas sign (RLQ pain on extension of right hip), obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (RLQ pain when the LLQ is palpated) Diagnosis is made by CT (adults), ultrasound (pediatric or pregnant patients), MRI (pregnant patients with nondiagnostic ultrasound) Most commonly caused by fecolith Treatment is surgery, in some case Abx

A 25-year-old man is brought to the emergency department by police for bizarre behavior. His family arrives and states that his behavior changed about eight months ago. He does not abuse drugs or alcohol. On examination, he has a flat affect and appears to be responding to internal stimuli. His speech is disorganized and he says, "I've been running from the Russians who are trying to steal my thoughts." His laboratory and urine studies are unremarkable. What is the most likely diagnosis?

Schizophrenia Notes: The most common psychotic disorder is schizophrenia (meaning "split mind") Schizophrenia Two or more symptoms Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms Brief psychotic disorder: < 1 month Schizophrenia: > 6 months Schizophreniform disorder: 1-6 months Schizoaffective disorder: psychosis + mania or depression

A 56-year-old woman with a history of lung cancer presents to the emergency department with confusion, nausea, and vomiting. She is unable to provide much history due to her confusion. She is dehydrated and is oriented only to self. She is afebrile. Her renal function is normal. Her serum calcium level is 14 mg/dL. What is the most likely mechanism for her hypercalcemia?

Secretion of parathyroid hormone related protein from the tumor Hypercalcemia of Malignancy Most common cause is secretion of parathyroid hormone-related protein (PTHrP) Management: IVF, calcitonin, bisphosphonates (denosumab if bisphosphonates are contraindicated)May need HD if refractory to medical treatment

A 39-year-old woman presents to the emergency department with right leg pain and mild swelling. She denies any previous medical history or trauma. She does not take any medication. Examination is remarkable for tenderness along the right calf venous distribution and minimal swelling of the right lower leg. What is the most appropriate diagnostic workup of this patient?

Send a D-dimer. If negative, the patient may be discharged. Deep Vein Thrombosis (DVT): History of smoking, long-distance travel, surgery, oral contraceptive use Unilateral leg edema, leg pain, tenderness, and warmth Physical exam may show a positive Homans sign Diagnosis is made by ultrasound, gold standard is venography Most commonly caused by stasis, hypercoagulable state, endothelial dysfunction (Virchow triad) Treatment is anticoagulation Warfarin is contraindicated in pregnancy Pretest probability by modified Wells score

A 33-year-old man presents with pain and swelling in his left knee since yesterday. He has also had a fever with a maximum temperature of 100.9°F. Physical exam reveals swelling of the left knee with erythema and warmth noted. There is pain with passive range of motion. What is the most likely diagnosis?

Septic arthritis Notes: Septic Arthritis Patient may present with fever, monoarticular pain with decreased ROM Labs from arthrocentesis: WBC > 50,000/µL with > 75% PMNs Diagnosis is made by arthrocentesis Most commonly caused byAge < 35: N. gonorrheaOverall: S. aureus Treatment is IV Abx, joint drainage, surgical washout

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 leukocytes, low glucose level, and no crystals. Which of the following would be the most likely diagnosis?

Septic arthritis presents with a large number of WBCs, predominantly polymorphonuclear, and with glucose levels much lower than serum levels.

A 43-year-old asymptomatic diabetic female is found to have an elevated total calcium level of 12.4 mg/dL. Which of the following tests must be assessed in order to evaluate this laboratory abnormality?

Serum albumin Notes: Since approximately 50% of calcium is protein bound, total calcium levels should be interpreted relative to albumin levels.

A 17-year-old patient presents to the emergency department with agitation and hallucinations, and has one seizure. He admits to using "some drugs" but does not know what they were. On physical examination, temperature is 103 degrees F, BP 140/90, pulse 120, respirations 20. Remainder of the examination is unremarkable. Which of the following diagnostic studies will be of most help in managing this patient?

Serum creatinine kinase Notes: Serum creatinine kinase is the most sensitive test to detect rhabdomyolysis, a serious complication of seizures and hyperthermia related to drug abuse.

A 75-year-old man with a long-standing history of constipation presents complaining of abdominal pain for the last two days. He is now experiencing abdominal distention, constipation, and inability to pass gas for the last 12 hours. On examination, his abdomen is distended and tympanitic to percussion. You obtain an upright abdominal X-ray as seen above. What is the most likely diagnosis?

Sigmoid volvulus Notes: An intestinal obstruction that resulted when a non-fixed, redundant loop of the sigmoid colon twisted and obstructed the lumen. Sigmoid volvulus is more common in elderly, debilitated patients with a history of chronic constipation.

A 93-year-old man on aspirin presents to the ED with epistaxis. On physical exam, you note bleeding from bilateral nares and down the posterior pharynx. You are unable to visualize the source of bleeding. Which of the following vessels is most likely the source of bleeding in this patient?

Sphenopalatine artery Notes: Posterior epistaxis is less common than anterior epistaxis and is most commonly due to bleeding from the sphenopalatine artery, located at the posterior aspect of the middle nasal turbinate. Patients with posterior epistaxis typically complain of bleeding from both nostrils. Epistaxis Most common source: - Anterior bleeds: Kiesselbach plexus - Posterior bleeds: sphenopalatine artery Treatment: - Anterior bleeding: direct pressure, topical vasoconstriction (oxymetazoline), chemical cautery (if vessel visualized), packing - Posterior bleeding: packing (Foley, gauze pack, intranasal balloon device) Admit patients with posterior packing to a monitored bed

A 52-year-old female comes to the office because of black stools for the past 3 days. She is afebrile and she has no pertinent physical examination abnormalities. Which of the following is the most appropriate initial diagnostic study?

Stool for occult blood Notes: To start: what are the black stools? Are they blood or not?

A 35-year-old woman with a history of migraines and polycystic kidney disease presents to the Emergency Department with a severe, diffuse headache. The onset was abrupt approximately one hour prior to arrival. Her vital signs are within normal limits. She has photophobia and phonophobia, as well as pain with extraocular movements. Which of the following is the most likely diagnosis?

Subarachnoid hemorrhage (SAH) Notes: Subarachnoid Hemorrhage Patient presents with abrupt onset of "worst headache of life" or thunderclap headache Diagnosis is made by noncontrast CT scan, blood will appear white on the CT - If CT negative and suspicion high, lumbar puncture Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

An 18-month-old boy presents with his father for a cough and difficulty breathing. The father states that the child has had nasal congestion and coryza for the last two days. On exam, he has a barking cough, inspiratory stridor, and a prolonged inspiratory phase. Which of the following would you expect to see on radiographic evaluation?

Subglottic narrowing Notes: Laryngotracheitis (Croup) Patient will be a nontoxic-appearing child, 6 months to 3 years old URI symptoms with barky seal-like cough, inspiratory stridor, low-grade fever X-ray will show steeple sign on PA view Most commonly caused by parainfluenza virus Treatment is steroids, aerosolized epinephrine

An HIV-positive patient presents with worsening dementia, fever, headache, and right hemiparesis. MRI of the brain reveals six lesions throughout the brain that show ring enhancement and surrounding edema. Which of the following is the treatment of choice?

Sulfadiazine and pyrimethamine

An 81-year-old man with a history of atrial fibrillation presents with abdominal pain. He fell two weeks ago and was advised to stop his anticoagulation medication after the fall. He reports diffuse, severe abdominal pain but is minimally tender on examination. He has symmetric pulses in his extremities. What is the most likely anatomic location of his pathology?

Superior mesenteric artery Mesenteric Ischemia History of dysrhythmias (AF), recent MI, or CAD Abdominal pain out of proportion to exam Labs will show lactic acidosis Diagnosis is made by CTA, angiography (gold standard)

A 51-year-old man with a history of alcohol use presents with three days of anorexia, nausea, vomiting, and right upper quadrant abdominal pain. Vital signs are HR 115, BP 114/83, RR 20, and oxygen saturation 96% on room air. On physical examination, he appears jaundiced and tender hepatomegaly is noted. Liver function tests are notable for AST 433 IU/L, ALT 206 IU/L, and total bilirubin 8.0 mg/dL. INR is prolonged at 1.6. Which of the following is the appropriate treatment for this condition?

Supportive care Notes: Treatment for alcoholic hepatitis is supportive, including intravenous hydration, thiamine, glucose supplementation, correction of electrolyte disturbances, nutritional support, and control of alcohol withdrawal symptoms with benzodiazepines.

A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate?

Suprapatellar bursa Notes: A knee effusion is defined as fluid within the knee joint. Symmetric peripatellar or suprapatellar swelling will be present. Traumatic effusions may result from ligamentous, bony, or meniscal injuries or overuse syndromes. Atraumatic etiologies of knee effusions include osteoarthritis, crystal arthropathies (e.g. gout and pseudogout), and septic arthritis. When a knee effusion or hemarthrosis is present, fluid can freely flow into and distend the suprapatellar bursa.

Which muscle is most commonly involved with rotator cuff injuries?

Supraspinatus Notes: Question: What are two primary physical exam techniques used to diagnose shoulder impingement? The Neer test (passively flexing the glenohumeral joint while simultaneously preventing shoulder shrugging) and the Hawkins test (internally rotating the shoulder while the shoulder is forward flexed 90 degrees and the elbow is flexed at 90 degrees).

A 54-year-old man presents with abdominal pain, vomiting, and fever. Physical examination reveals an ill-appearing man with a mass in the right groin as seen above. Which of the following is the most immediate next step required?

Surgical consultation Notes: Inguinal Hernias Bimodal: < 1 and > 40 years old - Direct: Protrudes directly through Hesselbach triangle and medial to the inferior epigastric artery (IEA)Bulge decreases upon reclining - Indirect​​: Most common type Protrudes through internal ring, lateral to IEA Mnemonic: MDs don't lie​ - Medial to IEA: direct - Lateral to IEA: indirect Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation

A 30-year-old man presents to the emergency department with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging?

Swelling over the lateral malleoli Ankle Sprain History of ankle inversion PE will show pain and swelling Imaging will show partial or complete tearing of ligaments Most commonly injured anterior talofibular ligament (ATFL) Treatment is RICE therapy Ottawa Ankle Rules to determine imaging

What is the mechanism of action of salmeterol (Serevent) in the treatment of asthma?

The mechanism of action for salmeterol is the relaxation of bronchial smooth muscle.

Which of the following is correct when estimating an adult burn patient's percent of total body surface area affected?

The perineum is approximately 1% Notes: The rule of nines is used to estimate the percentage of body surface area burned. Only second-degree burns or greater are used in this estimation. However, a few areas do not fit into the rule of Nines, such as the perineum, which accounts for approximately 1% of the total body surface area.

A 7-year-old girl presents to the ED with noisy breathing, fever, and drooling. On physical exam, she is in obvious respiratory distress with audible stridor at rest. Vital signs are BP 90/60 mm Hg, HR 150 beats/minute, RR 40 breaths/minute, and T 103.8°F. Which of the following are you likely to see on a lateral radiograph of the soft tissues of the neck?

Thumbprint sign Notes: Epiglottitis Patient presents with rapid onset of fever and dysphagia PE will show patient leaning forward, drooling, inspiratory stridor Imaging will show thumbprint sign Most commonly caused by H. influenzae (decrease since Hib vaccine), Strep. and Staph. species Treatment is IV antibiotics and airway management

A 21-year-old woman presents with pain, tearing, photophobia, and left eye redness. She has been wearing her contact lenses continuously for the last two weeks. A slit lamp examination reveals a white, hazy opacity on the cornea at the 3 o'clock position of the cornea with associated limbal flush. Which of the following is the most appropriate pharmacotherapy?

Topical ciprofloxacin Notes: Topical ciprofloxacin is first-line treatment for a corneal ulceration. Corneal Ulcer Patient will have a history of trauma, incomplete closure, or extended contact lens use PE will show oval ulcer with ragged edges, severe conjunctival inflammation Most commonly caused by Staphylococcus, Pseudomonas(contact lens wearers), Streptococcus pneumoniae Treatment is emergent ophthalmology consult

A 32-year-old man presents to the emergency department with complaints of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A chest radiograph is obtained and shown above. Which of the following abnormalities is likely to be noted on echocardiogram?

Tricuspid valve vegetations Notes: Tricuspid valve vegetations are the most likely abnormalities seen on echocardiogram. This patient has endocarditis affecting his tricuspid valve.

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

Ulnar collateral ligament Notes: Gamekeeper's Thumb, Skier's Thumb History of skiing Pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb Most commonly caused by the forceful radial abduction of the thumb Treatment is thumb spica splint

A 25-year-old G1P0 woman at 38 weeks gestation presents to the ED after feeling a gush of fluid. On tocometry you note variable decelerations of the fetal heart rate. You perform a sterile vaginal exam and feel a pulsating mass protruding from the cervical os. Which of the following appropriately matches the diagnosis with the next step in management?

Umbilical cord prolapse, elevate presenting part Notes: umbilical cord prolapse, which is defined by delivery of the umbilical cord prior to the delivery of the fetus. Umbilical Cord Prolapse History of malpresentation, PROM Cord precedes presenting part, increasing cord pressure and leading to fetal anoxia Treatment is emergent C-sectionIf delay in C-section: Trendelenburg position, knee-chest position, bladder filling, elevation of presenting fetal part

A 32-year-old woman presents to the emergency department with dysuria, back pain, and fever for two days. She indicates she has had urinary tract infections in the past but never this severe. She denies other past medical history and does not take any medications. Vital signs show HR 114, BP 132/80, R 16, T 102.2°F. Examination shows a moderately ill-appearing woman with right costovertebral angle tenderness. What test or tests are required in making an appropriate diagnosis in this patient?

Urinalysis Notes: Clinical syndrome of fever, chills, flank pain, and nausea or vomiting in conjunction with a urinalysis that is consistent with infection. The majority of patients with acute pyelonephritis do not need emergency imaging to secure the diagnosis of pyelonephritis. Acute Pyelonephritis Sx: fever, dysuria, and flank pain PE: CVA tenderness Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing Most commonly caused by Escherichia coli Treatment depends on infection severity and community/host risk factors for resistant pathogens, options include fluoroquinolones, 3rd/4th gen cephalosporins, TMP-SMX. Critical illness or risk for multidrug resistant organisms: consider coverage for MRSA, VRE

Which of the following is the most sensitive finding in cauda equina syndrome?

Urinary retention Notes: Cauda Equina Syndrome History of trauma, malignancy, epidural abscess, or hematoma Acute onset of lower back pain with weakness and numbness PE will show urinary retention, saddle anesthesia, decreased rectal tone Diagnosis is made by MRI or CT myelogram Most commonly caused by a herniated disc Treatment is operative decompression

A 24-year-old woman presents to the emergency department with a headache and receives a lumbar puncture. She is eventually discharged home in improved condition, but returns 24 hours later with a worsened headache, now throbbing in nature, which is worse in the standing position and relieved in the supine position. Which of the following reduces the risk of post-lumbar puncture headache?

Using a higher gauge needle Notes: Post-Lumbar Puncture Headache Due to persistent CSF leak 24-48 hours after LP Worsened by sitting and standing, improved by lying flat Preventive measures: small-caliber needle, blunt needle, stylet replacement before needle removal Management: hydration, IV caffeine, epidural blood patch Question: What spinous process level corresponds to the pelvic brim? Answer: L4.

A 30-year-old woman presents complaining of vaginal itching and irritation. She also complains of vaginal discharge. Which of the following supports a diagnosis of uncomplicated candidal vaginitis?

Vaginal pH < 4.5 Notes: Vulvovaginal Candidiasis History of diabetes, HIV, recent Abx use Pruritus, dysuria, dyspareunia PE will show white, cottage cheese-like discharge Labs will show pH < 4.5, pseudohyphae, spores Most commonly caused by Candida Treatment is fluconazole

In adults and intravenous drug abusers, which of the following bones is most commonly affected with acute osteomyelitis?

Vertebral Spine Notes: The bones of the vertebral spine are most commonly affected in a patient with osteomyelitis. Organisms reach the well-perfused vertebral body of adults via spinal arteries and quickly spread from the end plate into the disk space and then to the adjacent vertebral body. The infection may originate in the urinary tract and intravenous drug use carries an increased risk of spinal infection.

A 57-year-old man presents to the ED with headache, blurred vision, and fatigue. His wife notes he has a "blood problem" that his doctor is monitoring. Which of the following underlying conditions is most frequently complicated by hyperviscosity syndrome?

Waldenstrom macroglobulinemia Notes: What blood smear abnormality is associated with Waldenstrom macroglobulinemia? Answer: Rouleaux formation. Hyperviscosity Syndrome Sludging → ↓ perfusion MM, Waldenström macroglobulinemia, PV, leukemias ↑ WBC, ↑ RBCs Dysproteinemias: plasmapheresis Blast transformations: leukapheresis

When performing a rectal examination, prostatic massage is contraindicated in

acute bacterial prostatitis Notes: Vigorous manipulation of the prostate during rectal examination may result in septicemia. This is contraindicated in the presence of fever, irritative voiding symptoms, and perineal/sacral pain.

A 19-year-old female presents with a sore throat for nearly two weeks. She complains of fatigue and a low-grade fever. On physical examination, there is cervical, axillary, and inguinal lymphadenopathy, and mild splenomegaly. On review of the blood smear, which of the following would be expected?

atypical lymphocytes Notes: The hallmark of infectious mononucleosis is the presence of lymphocytosis with atypical large lymphocytes seen in the blood smear. These are larger than normal mature lymphocytes, stain more darkly, and frequently show vacuolated, foamy cytoplasm, and dark chromatin in the nucleus.

A 15-year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is

mycoplasma pneumonia The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely. Bacterial Pneumonia: S. Pneumoniae - Rust-colored sputum - common in patients with splenectomy S. Aureus - Salmon colored sputum - MRSA treat with vancomycin Pseudomonas - Ventilators, patients become sick fast - treat with 2 antibiotics Legionella - low NA+ (hyponatremia), GI symptoms (diarrhea), and high fever Mycoplasma - Young people living in dorms, (+) cold agglutinins, bullous myringitis Klebsiella - currant jelly sputum, drinkers, aspiration

A 14 year-old male presents to the ED experiencing a severe asthma attack. His respiratory effort is shallow and he is using accessory muscles to breathe. Auscultation of his chest reveals no audible wheezing. Vital signs include BP 90/60 mmHg, P 160 bpm, RR 52. An arterial blood gas (ABG) is ordered. Normal ABG values at your institution are pH 7.35-7.45, CO2 35-45, pO2 80-95. Which of the following ABG findings suggests the poorest prognosis?

pH = 7.27 pCO2 = 46 pO2 = 56 Notes: pH = 7.27 pCO2 = 46 pO2 = 56 is associated with the poorest prognosis in this patient. The clinical presentation of asthma is a respiratory alkalosis with high RR, low pCO2, and decreased pO2. The fact that the pCO2 is elevated despite the high respiratory rate suggests profound air trapping and respiratory failure.