ROSH ENP REVIEW

Which of the following is classified as an esophageal motility disorder? A Achalasia B Esophageal web C Schatzki ring D Zenker diverticulum

Achalasia is the most common esophageal motility disorder producing dysphagia. Its exact etiology is unknown, but it is thought to be due to loss of Auerbach plexus in the esophagus. It is associated with impaired swallowing-induced relaxation of the lower sphincter and the absence of esophageal peristalsis. Onset is usually between 20 and 40 years of age.

In a patient with otitis media, the development of which sign is an indication for emergent myringotomy?

Acute facial paralysis.

What is the most common complication of sickle cell disease?

Acute painful episode (formerly called sickle cell crisis).

Causes of NEW Rightward Axis Deviation on ECG (ED)

Acute pulmonary hypertension (e.g., PE) Na+channel blocker toxicity Hyperkalemia Ventricular ectopy Lead misplacement / dextrocardia

What antibiotics are associated with the development of a morbilliform rash in a patient with infectious mononucleosis?

Ampicillin and amoxicillin. Infectious Mononucleosis Patient presents with low-grade fever, headache, malaise, severe fatigue PE will show mildly tender lymphadenopathy involving the posterior cervical chain, hepatosplenomegaly Diagnosis is made by heterophile antibody test (mononuclear spot test) or a generalized maculopapular rash following administration of amoxicillin Most commonly caused by Epstein-Barr virus Treatment is self-limiting, refrain from contact sports for 4 weeks postinfection

What is a typical radiographic finding that supports a diagnosis of a Lisfranc dislocation-fracture?

An AP view which reveals lateral shift of the second metatarsal off the middle cuneiform Lisfranc Injuries History of a motor vehicle collision, fall, or playing sports Severe foot pain and inability to bear weight PE will show tenderness of the tarsometatarsal joint Post-traumatic arthritis is the most common complication

What class of medication is cyproheptadine?

An antihistamine with anti-serotonergic properties.

What lab marker helps to distinguish primary from secondary adrenal insufficiency?

An elevated ACTH level in a patient with adrenal insufficiency is consistent with primary adrenal insufficiency. Primary Adrenal Insufficiency (Addison Disease) Patient presents with abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE will show hyperpigmentation of skin and mucus membranes and hypotension Labs will show hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Treatment is hydrocortisone or other glucocorticoid

yeast infection

An infection of the vagina causing itching and discharge most often caused by Candida albicans and results in dysuria, vulvar irritation and itching, and a thick white vaginal discharge. It is diagnosed by the presence of yeast or pseudohyphae on wet mount.

Activated Charcoal

An oral medication that binds and adsorbs ingested toxins in the gastrointestinal tract for treatment of some poisonings and medication overdoses. Interrupts the entero-hepatic cycle with multiple dose. Indications: Non-specific poisons except cyanide, iron, lithium, caustics and alcohol.

sniffing position

An upright position in which the patient's head and chin are thrust slightly forward to keep the airway open.

What spinal cord syndrome is suggested by complete paralysis and loss of temperature and pain perception with preserved proprioception below a given spinal cord level?

Anterior cord syndrome.

What serum test can be used to establish HBV immunity?

Anti-hepatitis B surface antigen (anti-HBsAg) antibody (IgG) is the best marker of HBV immunity

Which antibiotics are appropriate first line therapy for appendicitis?

Antibiotics that cover gram-negative aerobes and anaerobes. The most common regimens include: a single dose of cefoxitin or cefotetan, or the combination of cefazolin PLUS metronidazole, or, in patients allergic to penicillins and cephalosporins, clindamycin PLUS one of the following: ciprofloxacin, levofloxacin, gentamicin, or aztreonam.

Optic nerve compression may be the result of aneurysmal mass effect at which artery junction?

At the bifurcation of the middle and anterior cerebral arteries. 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 CTIf CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled outIf CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

Differential diagnosis for narrow-complex irregularly irregular tachycardia

Atrial fibrillation No distinct regular atrial activity Fibrillatory waves usually coarse (bumpy with higher voltage) early on, then fine (lower voltage) Atrial rate > 350 bpm Commonly over diagnosed in patients with irregular rhythms from PACs Atrial flutter with variable conduction Regular atrial activity (F-waves) present Flutter waves may be mapped out with calipers Atrial rate = 250-350 Multifocal atrial tachycardia (MAT) P-waves present, but irregular and with 3 or more different P-wave morphologies Variable PP, PR, and RR intervals

Antiphospholipid Antibody Syndrome

Autoimmune disorder characterized by thromboembolic events and fetal loss Primary disorder or associated with lupus or other rheumatologic diseases Arterial, venous, or small vessel thrombosis Repeated spontaneous abortions Labs Antiphospholipid antibodies: anticardiolipin, anti-beta2 glycoprotein, lupus anticoagulant, Thrombocytopenia Tx: anticoagulation

What kidney disorder puts an individual at higher risk for cerebral aneurysm and potentially spontaneous subarachnoid hemorrhage?

Autosomal dominant polycystic kidney disease

Which organism is the likely etiology of pneumonia in a patient with hyponatremia and diarrhea? AHaemophilus influenzae BKlebsiella pneumoniae CLegionella species DStreptococcus pneumoniae

C. Legionella species Pneumonia is the seventh leading cause of death overall and the leading infectious cause of death in the United States. The microbial etiology of pneumonia can only be identified in half of cases. Laboratory testing is relatively nonspecific for a specific organism. There are 19 species of Legionella that cause infection in humans. The organism lives in aquatic environments and does not have person-to-person transmission. The infection is associated with hyponatremia, mild elevation in the transaminases, and gastrointestinal symptoms. A urinary antigen is available to detect Legionella infection. Treatment includes fluoroquinolones, macrolides, and tetracyclines.

Transplant Related Problems

Cyclosporine toxicity: hyperkalemia, nephrotoxicity Azathioprine toxicity: BM suppression, hepatotoxicity, pancreatitis Hyperacute rejection: minutes to hours post-transplant, irreversible graft destruction, due to preformed antibodies Acute rejection: 1-12 weeks post-transplant, humoral or T-cell mediated Chronic rejection: months to years post-transplant, tissue fibrosis GVHD: after allogeneic BMT, rash, diarrhea Kidney transplant rejection: increased creatinine, tenderness, decreased urine output Lung transplant rejection: cough, chest tightness Heart transplant rejection: fatigue, HF, no angina or CP Liver transplant rejection: fever, abnormal LFTs, RUQ pain Transplant rejection Rx: steroids

A 45-year-old woman with a history of Graves disease presents to the ED with a one-day history of dyspnea, fever, and agitation. Her husband believes that she stopped taking her medications one week ago. Her vital signs are BP 185/75 mm Hg, HR 141 bpm, R 24 breaths/min, and T 38.9°C. On exam, you note tremulous hands and bounding peripheral pulses. Her ECG shows a sinus tachycardia, and a chest radiograph reveals increased interstitial markings. You administer 2 L of normal saline, but her vital signs are unchanged. Which one of the following is the most appropriate therapy to administer next? A Cefepime B Dantrolene C Potassium iodide D Propranolol

D Propranolol Hyperthyroidism refers to disorders that result from the overproduction of hormone from the thyroid gland. Thyrotoxicosis refers to any cause of excessive thyroid hormone concentration. Thyroid storm represents the extreme manifestation of thyrotoxicosis. The point at which thyrotoxicosis transforms into thyroid storm is controversial, but attempts have been made by Burch and Wartofsky to standardize the diagnosis of thyroid storm. This patient has thyroid storm, a condition predominantly seen in patients with Graves disease. There are many precipitants of thyroid storm, but infection and sepsis are the most common. Clinically, patients often present with fever, diaphoresis, tachycardia, altered mental status, restlessness, agitation, abdominal pain, and vomiting. The presentation mimics many other hyperadrenergic states such as cocaine intoxication or ethanol withdrawal. It can also be confused with heatstroke and neuroleptic malignant syndrome. Prompt recognition and treatment of thyroid storm are crucial for patient survival. If untreated, the condition is uniformly fatal. Propranolol is the first-line treatment for patients with symptomatic thyrotoxicosis or thyroid storm because it blocks peripheral hyperadrenergic activity and the conversion of T4 to T3. This should be immediately followed by administration of propylthiouracil (PTU) to further block the conversion of T4 to T3. Iodine (after PTU administration), corticosteroids, fluid resuscitation, rapid cooling, and the treatment of any precipitating illness follows. After administering propranolol, the management of thyroid storm should proceed with the initiation of propylthiouracil to inhibit the production of thyroid hormone. Once primary measures are taken, and there is concern that the inciting event may be due to sepsis, then cefepime (A) should be administered. Inorganic iodine (potassium iodide) (C) blocks the release of thyroid hormone that is still stored in the thyroid gland, but its administration should be delayed until at least 60 minutes after propylthiouracil is administered. It is important to first inhibit the synthesis of thyroid hormone, otherwise, the administered iodine will be incorporated into new hormone. Dantrolene (B) is a muscle relaxant that acts by abolishing excitation-contraction coupling in muscle cells, probably by action on the ryanodine receptor. It is the only specific and effective treatment for malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia.

A 72-year-old woman presents to the ED with an acute onset of dyspnea and palpitations that began 4 hours before arrival. Vital signs include an HR of 144 bpm, BP of 80/50 mm Hg, RR of 28/min, T of 98.6°F (37.0°C), and SpO2 of 92% on room air. The above 12-lead ECG is obtained. What is the most appropriate next step in management? A Anticoagulation with enoxaparin followed by warfarin B Chemical cardioversion using procainamide C Rate control using diltiazem D Rate control using esmolol E Synchronized cardioversion

E Synchronized cardioversion This patient has atrial fibrillation with a rapid ventricular rate and is hemodynamically unstable (BP 80/50 mm Hg). This dysrhythmia needs to be emergently corrected in order to stabilize the patient. Not doing so could result in sudden cardiac death. In such circumstances, emergent synchronized cardioversion is required.

What is the Parkland formula?

Fluids for first 24hrs = 4 (pt weight in kg x %BSA) - 50% over 8hrs - 50% over next 16hrs 4 x weight in kg x %TBSA (total body surface area) burned (excluding first-degree burns).

When are patients contagious with measles?

From five days before the rash and four days after the rash appears. Measles (Rubeola) Patient will be an unvaccinated young child History of maculopapular rash that started on head and spread toward feet High fever, cough, conjunctivitis, coryza PE will show red spots with blue or white center on buccal mucosa (Koplik spots) Diagnosis is made clinically Treatment is supportive care plus vitamin A if signs of vitamin A deficiency, severe symptoms, or child < 2

Nasogastric Tube (NGT) Summary

GI decontamination Diaphragmatic injury: NGT coiling on CXR TEF: coiling of NGT in proximal esophagus Facial trauma: NGT may enter cranium or facial soft tissues Radiograph to confirm placement

What is the most serious complication of acute cholecystitis?

Gangrene of the gallbladder Cholecystitis Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods, fever PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: U/SGold standard: HIDA Most commonly caused by obstruction by a gallstone Acalculous disease can occur in critically ill Treatment is cholecystectomy, antibiotics; percutaneous cholecystostomy tube in critically ill

Simple febrile seizures

Generalized tonic-clonic seizure lasting < 15 minutes Associated with a fever in a child 6 months to 5 years of age Occurring only once in a 24 hour period. If lasting > 5 min, a dose of diazepam gel, nasal, buccal, or suppository can be used

Should you order serologic testing to diagnose toxoplasmosis?

Generally, no, because antibodies are fairly prevalent in the general population. Toxoplasmosis Caused by the protozoan parasite Toxoplasma gondii In immunocompetent adults typically asymptomatic and self-limited Reactivation in HIV positive (CD4 < 100 cells/microL) Encephalitis: fever, headache, focal neurologic deficitsToxoplasma IgG +CT: multiple ring-enhancing lesions Pneumonitis: dyspnea, nonproductive cough Chorioretinitis: eye pain, decreased vision Tx: pyrimethamine, sulfadiazine

Which of the following is an expected finding in a patient with a tube thoracostomy connected to a chest drainage system?

Gentle bubbling in the suction control chamber is an expected finding as air is being removed. A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly

What is the most common human enzyme defect?

Glucose-6-phosphate dehydrogenase (G6PD) deficiency History of taking antimalarials, sulfonylureas, quinolones, nitrofurantoin, fava beansInfection 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

Antibiotic Coverage

Gram (+): Vancomycin, Linzeolid, Daptomycin, First Gen Cephalosporins Gram (-): Zosyn, Carbapenems, 4th Gen Cephalosporins, Fluroquinolones, Aminoglycosides Anaerobic: Metronidazole, Clindamycin, Carbapenems, 2nd Gen Cephalosporins, Moxifloxacin

In neutropenic fever patients with a bacterial infection, what bacteria are the most common source?

Gram positives. Neutropenic Fever One oral temperature of ≥ 38.3°C or ≥ 38°C for ≥ 1 hour + neutropenia Leading cause of cancer death: infection Obtain cultures Rx: empiric antibiotics, admission as needed

What are the most common etiologic agents responsible for urinary tract infections?

Gram-negative aerobic bacilli that arise from the GI tract, such as E. coli, account for approximately 80% of cases. 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

Greater than what total body surface area (TBSA) is diagnostic of toxic epidermal necrolysis?

Greater than 30%.

What is the time frame in which delirium tremens typically develops?

Greater than 72 hours. Withdrawal: Patient presents with visual and tactile hallucinations, seizures PE will show autonomic hyperactivity (↑ HR, ↑ BP, diaphoresis) Treatment is benzodiazepines Progression: tremulousness → hallucinations → seizures → delirium tremens Delirium tremens: autonomic hyperactivity, psychosis, peaks 2-5 days after cessation

Bacterial Pneumonia Pathogens

HAP: starts ≥ 48 hrs after admission VAP: ≥ 48 hrs after endotracheal intubation Pathogens: Streptococcus pneumoniae: most common, rust-colored sputum, rigors, gram-positive paired lancets Klebsiella: chronic alcohol use, currant-jelly sputum, bulging fissures Staphylococcus aureus: intravenous drug use, postinfluenza, older adults, gram-positive cocci in clusters Haemophilus influenzae: COPD, gram-negative pleomorphic rods Pseudomonas: cystic fibrosis, nursing home residents, cyanosis Treatment Follow 2019 IDSA guidelines for CAP, 2016 IDSA/ATS for HAP/VAP in adults

Acute Hepatitis Summary

HAV: fecal-oral, shellfish, alone (no carrier), asymptomatic, acute HBV: HBsAg: active infection Anti-HBs: recovered or immunized Anti-HBc IgM: early marker of infection, positive in window period Anti-HBc IgG: best marker for prior HBV HBeAg: high infectivity Anti-HBeAb: low infectivity HCV: IVDU, chronic, cirrhosis, carcinoma, carrier HDV: dependent on HBV coinfection HEV: fecal-oral (enteric), high mortality rate among pregnant (expectant) patients, epidemics HAV and HEV are fecal-oral: "The vowels hit your bowels" HAV and HBV have preventative vaccine available Autoimmune hepatitis: young women Alcoholic hepatitis: moderate transaminase elevation, AST > ALT (2:1) Supportive Rx

Acute Hepatitis

HAV: fecal-oral, shellfish, alone (no carrier), asymptomatic, acute HBV:HBsAg: active infection Anti-HBs: recovered or immunized Anti-HBc IgM: early marker of infection, positive in window period Anti-HBc IgG: best marker for prior HBV HBeAg: high infectivity Anti-HBeAb: low infectivity HCV: IVDU, chronic, cirrhosis, carcinoma, carrier HDV: dependent on HBV coinfection HEV: fecal-oral (enteric), high mortality rate among pregnant (expectant) patients, epidemics HAV and HEV are fecal-oral: "The vowels hit your bowels" HAV and HBV have preventative vaccine available Autoimmune hepatitis: young women Alcoholic hepatitis: moderate transaminase elevation, AST > ALT (2:1) Supportive Rx

What are the common causes of pericarditis?

HIV, viruses, kidney failure, systemic lupus erythematous ,hypothyroidism Uremic, post-traumatic, post-myocardial infarction, neoplastic, radiation-induced, connective tissue disorder related, infectious, and idiopathic. Sx: pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE: tachycardia and pericardial friction rub, distant heart sounds ECG: PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Causes: idiopathic, viral Tx: NSAIDs, colchicine

Was the most prevalent cause of epiglottitis before routine vaccination against this bacteria was started

Haemophilus influenzae

Which vasculitis is associated with intussusception?

Henoch-Schönlein Purpura. Intussusception (Telescoping Bowel) Patient will be a child 6 months to 3 years old Colicky abdominal pain, vomiting, and bloody stools (currant jelly) Diagnosis is made by ultrasound (target sign) Most common cause is idiopathic Although less common, it is important to be vigilant for pathologic lead points in children of any age Treatment is air or hydrostatic (contrast or saline) enema

What is the current thought about the long-feared lumbar puncture complication of brain herniation?

Herniation related to lumbar puncture is now known to be very rare and, when it does occur, is thought to more likely be related to the underlying pathology itself rather than the procedure. 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 CTIf CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled outIf CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

What is the most common infectious precipitating factor for erythema multiforme?

Herpes simplex virus.

What antibiotics are recommended for outpatient treatment of community-acquired pneumonia in patients without comorbidities?

High-dose amoxicillin, doxycycline, or a macrolide (if local resistance < 25%). Bacterial Pneumonia HAP: starts ≥ 48 hrs after admission VAP: ≥ 48 hrs after endotracheal intubation PathogensStreptococcus pneumoniae: most common, rust-colored sputum, rigors, gram-positive paired lancetsKlebsiella: chronic alcohol use, currant-jelly sputum, bulging fissuresStaphylococcus aureus: intravenous drug use, postinfluenza, older adults, gram-positive cocci in clustersHaemophilus influenzae: COPD, gram-negative pleomorphic rodsPseudomonas: cystic fibrosis, nursing home residents, cyanosis Treatment Follow 2019 IDSA guidelines for CAP, 2016 IDSA/ATS for HAP/VAP in adults

Rheumatic Fever

History of GAS infection Fever, red skin lesions on the trunk and proximal extremities, and small, nontender lumps located over the joints PE: Jones criteria: joints, oh no—carditis!, nodules, erythema marginatum, Sydenham chorea (jerky, uncontrollable and purposeless movements of the hands, arms, shoulder, face, legs, and trunk) Labs: antistreptolysin O, anti-DNase B, positive throat culture, or positive rapid antigen test Treatment is antibiotics, NSAIDs Modified Jones criteria for a first episode of acute rheumatic fever: need two major or one major and two minor plus evidence of recent GAS infection

Epidural Hematoma Summary

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

Pityriasis Rosea Summary

History of a larger lesion 1 week prior, herald patch Rash on the back PE will show diffuse papulosquamous rash on the trunk, pine tree-like distribution Treatment is self-limiting disease, topical corticosteroids, or oral antihistamines for itching

Lymes Disease

History of being in the woods, hiking, or camping Presentation Stage 1: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache) Stage 2: myocarditis, bilateral Bell palsy Stage 3: chronic arthritis, chronic encephalopathy PE will show slightly raised red lesion with central clearing, erythema migrans (bull's-eye) rash Most commonly caused by Borrelia burgdorferi carried by Ixodes tick Treatment is doxycycline Children: amoxicillin or doxycycline (if used for < 21 days) Pregnant: amoxicillin Bilateral facial nerve palsy is virtually pathognomonic for Lyme disease

Hyphema Summary

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

Tension Pneumothorax Summary

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

Hypokalemia

History of diuretics use, diarrhea, vomiting Weakness, hyporeflexia, cramping, paresthesias ECG will show U waves, T wave flattening, ST depression, QT prolongation Treatment is potassium replacement along with magnesium

Cystic Fibrosis Summary

History of multiple recurrent respiratory infections or failure to thrive Diagnosis is made by elevated quantitative sweat chloride test Most commonly caused by autosomal recessive disorder in CFTR gene that results in the abnormal production of mucus Pseudomonas aeruginosa most common infecting bacteria in recurrent pulmonary infections

Pelvic Inflammatory Disease (PID)

History of multiple sexual partners or unprotected intercourse Lower abdominal pain, cervical motion tenderness, painful sexual intercourse PE will show mucopurulent cervical discharge Commonly caused by Chlamydia trachomatis or Neisseria gonorrhoea Outpatient treatment is ceftriaxone + doxycycline + metronidazole Fitz-Hugh-Curtis syndrome: perihepatitis + PID

Pertussis (Whooping Cough) Summary

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

Small Bowel Obstruction Summary

History of prior abdominal or pelvic surgery Bilious vomiting PE will show high-pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NGT, surgery

Otitis Externa Summary

History of swimming or moisture exposure Malodorous discharge and pruritus PE will show pain with palpation of tragus or pinna Most commonly caused by Pseudomonas aeruginosa Treatment is topical antimicrobials with or without steroids Necrotizing otitis externa: a complication seen in those with diabetes or immunocompromise

G6PD deficiency Summary

History of taking antimalarials, sulfonylureas, quinolones, nitrofurantoin, fava beans G6PD causes nonimmune hemolytic anemia and thus has a negative Coombs test. 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

Cauda Equina Syndrome Summary

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

Bell Palsy Summary

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

Transplant Rejection

Hyperacute rejection: minutes to hours post-transplant, irreversible graft destruction, due to preformed antibodies Acute rejection: weeks to months post-transplant, humoral or T-cell mediated Chronic rejection: months to years post-transplant, tissue fibrosis Kidney transplant rejection: increased creatinine, tenderness, decreased urine output Lung transplant rejection: cough, chest tightness Heart transplant rejection: fatigue, HF, no angina or CP Liver transplant rejection: fever, abnormal LFTs, RUQ pain Transplant rejection Rx: steroids

What concurrent electrolyte abnormalities are often seen with hypomagnesemia?

Hypocalcemia (from interference with parathyroid hormone) and hypokalemia Hypomagnesemia Malnutrition, alcohol use Hypocalcemia Hypokalemia ↑ QT interval, dysrhythmias Neuromuscular symptoms (e.g., tremor, tetany)

Dialysis Complications

Hypotension Bleeding Disequilibrium: due to osmolality decrease and fluid shifts Peritonitis: Staphylococcus or Streptococcus, Rx: intraperitoneal Abx Vascular access: bleeding, fistula, thrombosis Patient who comes to the ED with a stenosed or thrombosed graft or fistula ==> can be discharged home and be treated within 24 hours by angiographic clot removal or angioplasty.

What is the most common cause of respiratory acidosis?

Hypoventilation/apnea. Acute Respiratory and Metabolic Acidosis and Alkalosis (Normal ABG values pH 7.35-7.45; PaCO2 35-45 mm Hg; bicarbonate 22-26 mEq/L) Respiratory Acidosis pH < 7.35; PaCO2 > 45 mm Hg; bicarbonate normal Respiratory Alkalosis pH > 7.45; PaCO2 < 35 mm Hg; bicarbonate normal Metabolic Acidosis pH < 7.35; PaCO2 normal; bicarbonate < 22 mEq/L Metabolic Alkalosis pH > 7.45; PaCO2 normal; bicarbonate > 26 mEq/L

Thiamine (Vitamin B1)

INDICATIONS: coma of unknown origin, alcoholism, delirium tremens, Adjunctive in ethylene glycol, Wernicke-Korsakoff Syndrome Reverses acute thiamine deficiency

What is the treatment for anticholinergic associated hyperthermia?

Ice water immersion, evaporative cooling, and benzodiazepines for shivering Anticholinergic Ingestion Antipsychotics, antihistamines, jimson weed, deadly nightshade Mad as a hatter, red as a beet, dry as a bone, blind as a bat, hot as a hare Physostigmine, BZDs, cooling

What is the effect of hypothermia on the oxyhemoglobin dissociation curve?

In a left shift condition (alkalosis, hypothermia, etc.) oxygen will have a higher affinity for hemoglobin. SaO2 will increase at a given PaO2, but more of it will stay on the hemoglobin and ride back through the lungs without being used. This can result in tissue hypoxia even when there is sufficient oxygen in the blood. A right shift decreases oxygen's affinity for hemoglobin. In a right shift (acidosis, fever, etc.) oxygen has a lower affinity for hemoglobin. Blood will release oxygen more readily. This means more O2 will be released to the cells, but it also means less oxygen will be carried from the lungs in the first place.

Right bundle branch blocks (RBBB)

In typical RBBB, leads V1-V3 can have mild discordant ST segment depression which is a normal finding RBBB should have no ST segment elevation in any lead ==> Any ST elevation in RBBB is abnormal and must be explained Beware STEMI's in RBBB...often missed by the computer and the clinician. Don't trust the computer to make the diagnoses when the STE is subtle, especially STE in V1-V2 in subtle anterior STEMI Be wary of the intervals! Look at all the leads and trace out where the QRS ends and where the J-point begins to evaluate for ST-segment deviations

Macrocytic Anemia

Includes megaloblastic anemia, alcohol or liver disease, nutrient deficiency, reticulocytosis, drug-induced macrocytosis Sx: fatigue, weakness PE: pallor, glossitis Labs: MCV > 100 fL and hypersegmented neutrophils Most commonly caused by vitamin B12 (cobalamin), folate deficiency, direct ethanol toxicity Only vitamin B12 deficiency results in neurological symptoms

What is the most common cardiac complication associated with truncus arteriosus?

Increased pulmonary blood flow resulting in heart failure and cyanosis within the first few weeks of life. DiGeorge Syndrome Most commonly caused by 22q11 deletion Congenital heart disease, recurrent infections, velopharyngeal insufficiency, neonatal seizures PE: hypoplasia of thymus and parathyroids, cleft palate, heart murmur Labs: hypocalcemia CXR: absent thymic shadow

Benzylpenicillin Antidote

Indication: Amanita phalloides (Death cap mushroom) Mode of Action: Not known; partial protection against acute hepatic failure; may displace amatoxin from protein-binding sites allowing increased renal excretion; may also inhibit penetration of amatoxin to hepatocytes.

atropine sulfate or pralidoxime

Indication: Anticholinesterase MOA: Competitive inhibition of muscarinic receptors.

Pyridoxine (B6) as Antidote

Indication: Isoniazid, theophylline, monomethyl hydrazine. Adjunctive therapy in ethylene glycol poisoning. Reverses acute pyridoxine deficiency by promoting GABA synthesis. Promotes the conversion of toxic metabolite glycolic acid to glycine.

Orbital Cellulitis Summary

Infection involving orbital fat and ocular muscles - complications include orbital abscess, vision loss, intracranial infection Risk factors: sinusitis, orbital trauma or surgery Sx: eyelid swelling, pain with eye movement PE: proptosis, ophthalmoplegia,, decreased vision Dx is made clinically, confirmed with CT scan Most commonly caused by S. aureus, streptococci Treatment is ophthalmology evaluation, broad spectrum antibiotics

vulvovaginitis

Inflammation of the vulvar and vaginal tissues. Most common gynecological condition in prepubertal children

What is the most common type of hernia in adults?

Inguinal hernia, which represents 75% of all hernias 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

epidural hematoma

Injury to the middle meningeal artery, causing an epidural hematoma, would result in a lens-shaped hyperdense lesion that does not cross suture lines on a noncontrast CT

Diaphragm Important Info

Innervation: C3, C4, C5 Structures perforating diaphragm: T8: IVC T10: esophagus, vagus nerve T12: aorta, thoracic duct, azygos vein Kehr sign: diaphragmatic irritation → left shoulder pain

Head Trauma: AIRWAY MANAGEMENT SUMMARY

Intubate with GCS ≤ 8 Remove C-collar and hold inline cervical stabilization for intubation Hyperventilation → cerebral vasoconstriction → ↓ ICP The use of prophylactic hyperventilation therapy (PaCO2 < 30 mm Hg) during the first 24 hours after severe traumatic brain injury should be avoided (except in cases of acute herniation) because it can compromise cerebral perfusion pressure

What is the Hunt and Hess Clinical Grading Scale?

It is a scoring scale for cerebral aneurysms and subarachnoid hemorrhage. The scale ranges from 0 (unruptured aneurysm) to 5 (deep coma, decerebrate posturing). 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 CTIf CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled outIf CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

How long after symptoms cease do patients with genital herpes stop shedding virus?

It is suspected that patients with a history of herpes can shed virus continuously, whether symptoms are present or not. Herpes Simplex HSV-1: oral, keratitis HSV-2: genital, neonatal Grouped lesions on an erythematous base Multinucleated giant cells Most common cause of encephalitis HSV keratitis: dendrites with fluorescein stain Rx: acyclovir

What is peak airway pressure?

It is the maximum amount of pressure in the ventilator circuit and is measured during inspiration

Is the cremasteric reflex typically present in testicular torsion?

It is typically absent.

Which tick is responsible for the spread of Lyme disease?

Ixodes tick.

What is the reaction that can occur during the treatment of syphilis that causes fever, chills, rash, and myalgias?

Jarisch-Herxheimer reaction.

LVH (left ventricular hypertrophy) + Strain

LVH results in: = high voltage R waves in the left sided leads (I, aVL, V4-V6) and = high voltage S waves in the right sided leads (III, aVR, V1-V3) Voltage criteria Limb leads Lead I (R wave) + lead III (S wave) > 25 mm aVL (R wave) > 11 mm aVF (R wave) > 20 mm aVR (S wave) > 14 mm Precordial Leads V4, V5, or V6 (R wave) > 26 mm V5 or V6 (R wave) + V1 (S wave) > 35 mm Highest voltage precordial R wave + highest precordial S wave > 45 mm Non-voltage criteria R wave peak time > 50 ms in V5 or V6 Presence of a strain pattern will increase specificity. Strain pattern: repolarization abnormalities resulting in ST segment depression & asymmetric T wave inversion in left sided leads. ST depression and asymmetric T wave inversions (in leads I, aVL, V4-V6 [+/- II & aVF]) Appropriately discordant ST segment elevation in leads V1-V3 (and often aVR) QRS widening (non-specific IVCD)

What lab abnormalities are associated with osteosarcoma?

Laboratory studies are generally not useful in diagnosis of osteosarcoma, but the most common lab abnormalities include elevated alkaline phosphatase, lactate dehydrogenase (LDH), and erythrocyte sedimentation rate (ESR). Osteosarcoma Patient will be 10 to 20 years old or > 65 Pain, swelling that awakens at night X-ray will show Codman triangle, sunburst pattern Most common location: long bone metaphyses Most common malignant bone tumor

One small block and one large block correspond to what amount of time? 0.2 seconds on an ECG is one small or one large block?

Large = 0.2 seconds and small = 0.04 seconds.

Causes of Diffuse ST Elevation

Large Acute MI ​± reciprocal ST-segment depression with active symptoms Evolving changes (especially with treatment) Acute Pericarditis ​No reciprocal ST-segment depression (except aVR, V1) PR-segment depression (not specific) PR elevation in aVR Early repolarization ​No reciprocal ST-segment depression No PR-segment depression Fishhooks, J-waves Ventricular aneurysm ​No reciprocal ST-segment depression + Q-waves from previous MI

Renal Calculi and Colic Summary

M > F Calcium oxalate: most common Struvite: staghorn calculi, urease producing bacteria Uric acid: radiolucent on X-ray, gout Cystine: children with metabolic diseases Flank pain radiating to groin, unable to lie still Hematuria Ultrasound: hydronephrosis Helical CT < 5 mm: likely to pass spontaneously > 8 mm: unlikely to pass Admission: intractable pain, infected stone, single kidney, new kidney dysfunction Prevention: increase fluid intake, thiazide, citrate, allopurinol NSAIDs for first-line pain control

Clavicular Fractures Summary

MC fracture in children MC location: middle third Medial third: possible vascular injury Distal third: possible coracoclavicular ligament injury Initial management for nondisplaced fracture: sling

Hydroxocobalamin (Cyanokit)

MOA: precursor of vitamin B12 -> reacts with cyanide (doesn't produce methemoglobin). Forms cyanocobalamin, a non-toxic metabolite that is easily excreted through the kidneys. USE: Cyanide poisoning

Which classes of antimicrobials can lead to acquired long QT syndrome?

Macrolide and fluoroquinolone antibiotics and azole antifungals. Prolonged QT Syndrome Patient presents with syncope, seizure, palpitations ECG Men: QT interval > 440 msec Women: QT interval > 460 msec More commonly caused by medications > familial prolongation, low Mg, K, Ca Treatment Congenital: beta-blocker, cardiology consult, consider genetic testing and counseling Acquired: stop offending medications, correct electrolyte disturbances, IV magnesium or pacing for torsades de pointes

What is the cause of tinea versicolor?

Malassezia furfur (aka pityrosporum ovale)

What is the most common cause of a massive pleural effusion (> 1.5-2 L)?

Malignancy Pleural Effusion PE will show ↓ breath sounds + dull percussion + ↓ tactile fremitus CXR will show blunting of the costophrenic angle Can also use CT or US to diagnose Most common causes Transudate: heart failure Exudate: infection > malignancy, PE Management includes treating underlying cause, therapeutic thoracentesis, tube thoracostomy Light criteria are used to differentiate between transudative and exudative effusions

What is the most common cause of intussusception in adults?

Malignancy.

Pharyngitis Summary

Most commonly caused by viral > bacteria (GAS, S. pyogenes) Centor criteria: estimates probability pharyngitis is streptococcal based on PE and Sx: cervical lymphadenopathy, tonsillar exudate, fever, absence of cough Treatment Viral: supportive Bacterial: Penicillin (first line). -Patients with Penicillin allergy: Cephalexin, cefadroxil (avoid in individuals with immediate-type hypersensitivity to penicillin), Clindamycin, Azithromycin, clarithromycin (resistance of group A strep to these agents is known well and varies geographically and temporally)

Pharyngitis

Most commonly caused by viral > bacteria (GAS, S. pyogenes) Centor criteria: estimates probability pharyngitis is streptococcal based on PE and Sx: cervical lymphadenopathy, tonsillar exudate, fever, absence of cough Treatment Viral: supportive Bacterial:Penicillin (first line)Patients with Penicillin allergy Cephalexin, cefadroxil (avoid in individuals with immediate-type hypersensitivity to penicillin) Clindamycin Azithromycin, clarithromycin (resistance of group A strep to these agents is known well and varies geographically and temporally)

What is "ice rink sign"?

Multiple linear corneal abrasions resulting from an embedded foreign body under the upper lid.

What is the most common cause of viral sialoadenitis?

Mumps parotitis, which, in contrast to bacterial parotitis, is usually bilateral.

What are three organisms responsible for "atypical" pneumonia?

Mycoplasma, Chlamydia, and Legionella

What are three organisms responsible for "atypical" pneumonia?

Mycoplasma, Chlamydia, and Legionella.

What is the most common complication of meningococcemia?

Myocarditis with heart failure or conduction abnormalities. Meningococcemia Patient will be a military recruit or student Fever, HA, arthralgias, rash PE will show petechiae, skin lesions with gray necrotic centers Diagnosis is made clinically and can be confirmed by blood cultures and Gram stain, as well as lumbar puncture Most commonly caused by Neisseria meningitidis, an aerobic, gram-negative diplococcus Treatment is ceftriaxone Waterhouse-Friderichsen syndrome: bilateral adrenal hemorrhage + meningococcemia

Which cause of peripheral vertigo is due to an increased amount of endolymph within the cochlea and labyrinth?

Ménière syndrome. -Thiazide diuretics inhibit reabsorption of sodium from the distal convoluted tubules. This is a treatment for Ménière's syndrome but does not have any efficacy in the treatment of BPPV.

Should asymptomatic bacteriuria be treated in the elderly?

NO Cystitis Sx: increased urinary frequency, dysuria, and suprapubic pain Labs: positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age and risk of MDR infection Pregnancy: asymptomatic bacteriuria should be treated Complications: ↑ risk of preterm birth, low birth weight, perinatal mortality

What is the name of a long-acting mu receptor antagonist?

Naltrexone, which has an effect for up to 72 hours. Opioid Toxicity PE: decreased respiratory rate, sedation, miosis, hyporeflexia, bradycardia, hypotension, hypothermia Labs: glucose to rule out hypoglycemia EKG - prolonged QTc interval may be seen with methadone Tx: respiratory support, opioid antagonist - naloxone Prolonged observation after naloxone if overdose with long-acting opioid Initiating opioid agonist therapy and/or take home naloxone reduce overdose mortality

Pediatric Airway Summary

Narrowest portion of airway: cricoid ring Larynx: more anterior and superior Shorter trachea Endotracheal (uncuffed) tube diameter size for those > 2 yrs (in mm): 4 + (age / 4)May use fifth digit fingernail diameter or Broselow tape Endotracheal tube depth (in cm): (3 × tracheal tube size or age in years) / 2 + 12 Straight laryngoscope blade may allow for better visualization by lifting the epiglottis in infants and young children

What birefringence on arthrocentesis is acute gout associated with?

Negative birefringence.

What causative organism of pharyngitis also is the most common cause of septic arthritis in young patients?

Neisseria gonorrhea

What is the normal respiratory rate of newborn and 1-year-old children?

Newborn: 50 breaths per minute, 1-year-old: 30 breaths per minute

Back Pain DDx Summary

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

Why is nitrofurantoin not used in the treatment of pyelonephritis?

Nitrofurantoin is excreted unchanged in the urine, only reaching effective concentrations in the bladder Cystitis Sx: increased urinary frequency, dysuria, and suprapubic pain Labs: positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age and risk of MDR infection Pregnancy: asymptomatic bacteriuria should be treated Complications: ↑ risk of preterm birth, low birth weight, perinatal mortality

Do scheduled antipyretics prevent febrile seizures?

No

Does the presence of Prehn sign rule out testicular torsion?

No

Is the content of the water (salt versus fresh) clinically relevant?

No, the fluid medium is clinically insignificant. Submersions induce pulmonary injury based on the amount of water aspirated and duration of submersion Management of Drowning - Adult ABCs, resuscitation, intubate if necessary Evaluate for cervical spine injury Monitor core body temperature Admit symptomatic patients Asymptomatic patients with stable vitals and normal imaging can be discharged, with return precautions, after 6 hours of monitoring

Is there a vaccine for Lyme disease?

No, the manufacturer discontinued production of the vaccine due to poor sales, so it is no longer available. Lyme Disease History of being in the woods, hiking, or camping Presentation Stage 1: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache) Stage 2: myocarditis, bilateral Bell palsy Stage 3: chronic arthritis, chronic encephalopathy PE will show slightly raised red lesion with central clearing, erythema migrans (bull's-eye) rash Most commonly caused by Borrelia burgdorferi carried by Ixodes tick Treatment is doxycycline Children: amoxicillin or doxycycline (if used for < 21 days) Pregnant: amoxicillin Bilateral facial nerve palsy is virtually pathognomonic for Lyme disease

Is atrioventricular block always pathological?

No. First degree atrioventricular block may be present in healthy individuals with high vagal tone

Is hypothermia the most common cause of death in cold water immersion?

No. Victims more commonly die from drowning during the cold shock and cold incapacitation phases, prior to the onset of hypothermia, unless they are wearing personal flotation devices. Hypothermia Core body temp < 35°C Metabolic excitation followed by slowing phase Initial increase in BP, HR, CO followed by decrease ECG: Osborn (J wave) < 30°C: patient appears dead, cardiac dysrhythmias Oxyhemoglobin dissociation curve shifts (O2 delivery) Kidney concentrating ability cold diuresis Treat only life-threatening dysrhythmias (VF, asystole) Treatment Mild: passive rewarming Severe without cardiovascular instability: active external rewarming Severe with cardiovascular instability: invasive core rewarming

What fluid should be used to resuscitate a hypothermic patient?

Normal saline because Lactated Ringer is poorly metabolized by the cold liver. Hypothermia Core body temp < 35°C Metabolic excitation followed by slowing phase Initial increase in BP, HR, CO followed by decrease ECG: Osborn (J wave) < 30°C: patient appears dead, cardiac dysrhythmias Oxyhemoglobin dissociation curve shifts (O2 delivery) Kidney concentrating ability cold diuresis Treat only life-threatening dysrhythmias (VF, asystole) Treatment Mild: passive rewarming Severe without cardiovascular instability: active external rewarming Severe with cardiovascular instability: invasive core rewarming

What is the most accurate imaging modality for the diagnosis of cholecystitis?

Nuclear scintigraphy (HIDA) scan.

What is OS OD OU?

O.D.- This is oculus dexter, meaning right eye. O.S.- This is oculus sinister, meaning left eye. O.U.- This is oculus uterque, meaning both eyes.

What are some risk factors for pilonidal disease?

Obesity, sedentary lifestyle, deep natal cleft, and family history.

Third-Degree Atrioventricular Block (Complete Heart Block)

Observed on an electrocardiogram as a complete dissociation of P waves with QRS complexes, as well as bradycardia. Patients may complain of fatigue, dizziness and syncopal episodes. Permanent pacing is the treatment of choice for symptomatic patients with third-degree atrioventricular block.

Superior Vena Cava Syndrome

Obstruction of blood flow in the SVC resulting in impaired drainage from the head, neck, upper extremities Risk factors: mediastinal tumors, thrombosis due to indwelling catheter, aortic aneurysm Sx: dyspnea, headache, hoarseness PE: facial swelling, plethora (purple skin), upper extremity swelling, JVD Dx: CT chest Rx: diuretics and steroids alleviate laryngeal or cerebral edema Depending on cause: radiation therapy, chemotherapy, thrombolytics, anticoagulation, stenting

How should octreotide be dosed in upper GI bleed?

Octreotide should be given as a bolus of 50 mcg followed by an infusion of 50 mcg/hour.

What additional management is indicated in a patient with a bite wound from a dog with unknown immunization status?

On initial presentation, the patient should have rabies immunoglobulin administered and should have the rabies vaccination series started. Dog Bites Sepsis most commonly caused by Capnocytophaga canimorsus Treatment is amoxicillin-clavulanate Prophylactic antibiotic treatment indication: Deep puncture wounds Wounds associated with crush injury Wounds with venous or lymphatic impairment Wounds involving the hand, genitalia, or face Wounds close to bone or joints (e.g., in the hand) Wounds that require closure Wounds in patients who Are immunocompromised, Have impaired or absent spleen function, Have diabetes

Pneumocystis jiroveci pneumonia (PCP)

Opportunistic infection seen in patients with HIV and a CD4 count below 200. Additionally, it is seen in other immunocompromised patients like transplant recipients. On X-ray, PCP causes perihilar haziness classically described as the bat wing appearance. It does not cause discreet lesions as shown in this case.

Appendicitis Summary

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 (fecalith) Treatment is surgery, in some case Abx

Peptic Ulcer Disease Summary

Patient presents with gnawing epigastric pain Duodenal 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

Epididymitis

Patient presents with gradual-onset unilateral scrotal pain PE will show increased color flow on Doppler, relief with testicular elevation (Prehn sign) Most commonly caused by < 35 years old: C. trachomatis, N. gonorrhoeae > 35 years old: E. coli, Pseudomonas Treatment < 35 years old: ceftriaxone-doxycycline > 35 years old: fluoroquinolones

Erysipelas Summary

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

Bacterial Vaginosis (BV)

Patient presents with malodorous vaginal discharge PE will show thin, gray or white discharge Labs will show pH > 4.5, clue cells Diagnosis is made by potassium hydroxide smear → fishy odor, whiff test, Amsel criteria Most commonly detected bacteria is Gardnerella vaginalis (usually due to decrease in Lactobacillus sp) Treatment is metronidazole

Cor Pulmonale (Right Sided HF)

Patient presents with peripheral edema, dyspnea, fatigue, and signs of right-sided heart failure PE will show pulmonary HTN + RVH Most common chronic cause: COPD Most common acute cause: PE Diagnosis is made by right heart catheterization

Acute Otitis Media Summary

Patient will be an infant or young child Ear pain, fever, URI symptoms PE will show TM erythema and decreased mobility of TM Most common bacteria isolated: H. influenza (nontypable) (previously S. pneumoniae but has decreased post-PCV13 vaccination) Treatment is amoxicillin; consider amoxicillin-clavulanate in otitis-conjunctivitis syndrome or adults due to drug resistance Consider period of observation if ≥ 2 years and immunocompetent with mild symptoms

Corneal Ulcer Summary

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 Immunosuppressed individuals at risk for developing fungal corneal ulcerations

What is the primary indication for glycoprotein inhibitors in acute coronary syndrome?

Planned percutaneous coronary intervention

Antiplatelet therapy in acute coronary syndrome is focused on treating which pathophysiologic process?

Plaque thrombosis.

Malaria summary

Plasmodium falciparum (deadliest), P. ovale, P. vivax, P. malariae P. ovale, P. vivax: hepatic phase Anopheles mosquito Immigrant, traveler Irregular fevers, diaphoresis P. falciparum: cerebral malaria, blackwater fever Uncomplicated, chloroquine-sensitive areas Rx: chloroquine Uncomplicated, chloroquine-resistant areas Rx: atovaquone-proguanil Complicated, chloroquine-resistant areas Rx: artesunate IV

What pulmonary infection is associated with pneumothorax in AIDS patients?

Pneumocystis jirovecii pneumonia.

What other disease do up to 50% of patients with temporal arteritis also have?

Polymyalgia rheumatica, which manifests as proximal muscle pain and stiffness, often involving the upper > lower extremities. Temporal Arteritis (Giant Cell Arteritis) Risk factors: age > 50, female sex Sx: new headache, jaw claudication, monocular visual loss PE: tender temporal artery Labs: ESR > 50 mm/hour, ↑CRP Dx: temporal artery biopsy Treatment is high-dose steroids, do not wait for bx if strong suspicion Associated with polymyalgia rheumatica

sulfa allergy

Popular FACTSSS: probenecid, furosemide, acetazolamide, celecoxib, thiazides, sulfonamides, sulfasalazine, sulfonylureas

Where does one palpate the posterior tibial artery pulse?

Posterior and inferior to the medial malleolus

Which perforation related to peptic ulcer disease classically will not show on X-ray?

Posterior duodenal perforation

What medication is used for the nicotinic effects of nerve gas poisoning?

Pralidoxime chloride (2-PAM).

Anaphylaxis

Preexisting IgE antibodies → mast cell degranulation → shock, airway compromise Leading cause of fatal anaphylaxis: penicillin Epinephrine Adults: 0.3 to 0.5 mL 1:1,000 (1 mg/mL) solution IM q5-15 minutes Children: 0.01 mg/kg 1:1,000 (1 mg/mL) solution IM q5-15 minutes ​Refractory hypotension in a patient on beta-blockers: glucagon Adjunctive medicines include: histamine H1 and H2 antagonists, corticosteroids, beta-2 agonists, and glucagon

Achilles Tendon Rupture

Presents due to "pop" or "snap" and sudden pain in the calf area PE will show absent plantar flexion upon calf squeeze (Thompson test) Treatment is posterior splint in plantar flexion, orthopedic consult

nalmefene or naloxone

Prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension. Naloxone is believed to antagonize opioid effects by competing for the µ, κ and σ opiate receptor sites in the CNS, with the greatest affinity for the µ receptor.

What is the most common cause of superior vena cava syndrome? A Goiter B Indwelling central venous catheter C Malignancy D Thrombosis

C Malignancy Malignancy accounts for the majority of cases of superior vena cava (SVC) syndrome, which results when the SVC is compressed by other mediastinal structures. Centrally located tumors (squamous cell carcinoma and small cell carcinoma) account for 65% of cases. The clinical presentation of SVC syndrome includes periorbital edema, conjunctival suffusion, and facial swelling, which are most evident in the early morning hours Nonmalignant causes account for less than 25% of cases of SVC syndrome, including thoracic aortic aneurysm, goiter, complications from indwelling central venous catheters, thrombosis, aortitis, and mediastinitis Most common presenting symptom of superior vena cava syndrome is Dyspnea from mediastinal compression

A 23-year-old man with no past medical history presents with an episode of blood-tinged vomitus. He states that he drank heavily last night and had been vomiting all morning. Vital signs are unremarkable. Which of the following is the most likely cause of the patient's symptoms? A Boerhaave syndrome B Esophageal varices C Mallory-Weiss tear D Peptic ulcer disease

C Mallory-Weiss tear A Mallory-Weiss tear is a partial thickness tear in the esophagus typically seen after recurrent episodes of vomiting. Upper gastrointestinal bleeding can be the result of a number of sources. Peptic ulcer disease (PUD) is the most common cause accounting for about 45% of all cases. Mallory-Weiss tear should be suspected in patients presenting with minimal bleeding in the setting of acute vomiting. Patients are typically otherwise healthy and will not appear ill on presentation. Treatment should focus on supportive care mainly with relief of nausea and vomiting. The majority of patients can be discharged home. Those with recurrent hematemesis, risk factors for other causes of upper GI bleeding, and unclear diagnosis should have further work up performed.

What is the most common symptom of anaphylaxis?

Skin symptoms (e.g., urticaria, itching, flushing).

During which normal physiologic state can sinus bradycardia be seen?

Sleep

What is the classic mnemonic for the symptoms of hypercalcemia?

Stones, bones, groans, and psychiatric overtones Hypercalcemia Sx: bone pain (bones), kidney stones (stones), abdominal pain (groans), lethargy, psychosis (psychiatric overtones) ECG: shortened QT interval Most common causesMalignancy (most common inpatient cause)Primary hyperparathyroidism (most common outpatient cause) Treatment: IV fluids, bisphosphonates, calcitonin

Common causes of a retropharyngeal abscess

Streptococcus viridans

What phase of Kawasaki disease is the risk greatest for developing coronary artery thrombosis?

Subacute phase (days 11-20), when thrombocytosis peaks Kawasaki Disease Children < 5 years old History of high fever x 5 days Conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, fever #1 cause of pediatric acquired heart disease, risk for coronary artery aneurysm Mnemonic: CRASH and burn: conjunctivitis, rash, adenopathy, strawberry tongue, hand or foot edema, uncontrolled high fever Tx: IVIG + aspirin

Central retinal vein occlusion

Sudden painless unilateral loss of vision in pt with Hx of HTN: DISC SWELLING, RETINAL HEMM and COTTON WOOL SPOTS Associated with varying degrees of severity of monocular vision loss. Central retinal vein occlusion usually has a slower onset than arterial occlusion.

Bacterial Meningitis (Adult) Summary

Sx: headache, neck stiffness, photophobia, phonophobia, fever PE: meningismus, jolt accentuation, Brudziński sign (flexing neck causes hips and knees to flex), Kernig sign (resistance and pain with knee extension while hip is flexed at 90 degrees) Mnemonic: Brudziński: bend the brain, Kernig: extend knees Most commonly caused by Streptococcus pneumoniae Treatment is empiric antibiotics by age 18-50 years: ceftriaxone + vancomycin > 50 years: ceftriaxone + vancomycin + ampicillin (to cover Listeria) Empiric Abx if LP delayed for CT HIV patients: Cryptococcus Consider chemoprophylaxis for close contacts

Cystitis Summary

Sx: increased urinary frequency, dysuria, and suprapubic pain Labs: positive leukocyte esterase and nitrites Definitive diagnosis is made by urine culture Most commonly caused by Escherichia coli Treatment varies on age and risk of MDR infection Pregnancy: asymptomatic bacteriuria should be treated Complications: ↑ risk of preterm birth, low birth weight, perinatal mortality

Pericarditis Summary

Sx: pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE: tachycardia and pericardial friction rub ECG: PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Most common causes: idiopathic then viral (coxsackie) Tx: NSAIDs, colchicine

Psoriasis Summary

Sx: rash on extensor surfaces of arms and legs PE: bilateral sharply marginated papules or plaques with silvery scales, Auspitz sign (scale removal produces blood droplets), nail pitting Treatment: topical corticosteroids, emollients, phototherapy, biologic agents

Boerhaave syndrome

Sx: severe chest pain PE: Hamman crunch (mediastinal crackling with each heartbeat) Chest X-ray: pneumomediastinum Diagnosis is made by esophagram with water-soluble oral contrast Caused by a full-thickness esophageal rupture due to iatrogenic > forceful vomiting Most common location is left posterolateral distal esophagus Treatment is emergent surgical consult and broad-spectrum antibiotics

Iron Deficiency Anemia

Sx: weakness, dizziness, and fatigue PE: pallor, tachycardia, atrophic glossitis, or koilonychia (spoon nails) Labs: microcytic, hypochromic red blood cells, decreased serum iron level, an increase in the total iron binding capacity (TIBC), and decreased serum ferritin levels Most common cause of microcytic anemia

What dermatome covers the nipple area?

T4. Clinical Reflexes Biceps: C5-6 Triceps: C7 Patella: L4 Achilles: S1

Overdose ECGs

TCA: Tx with BiCarb Sinus Tachycardia Tall R wave in aVR Rightward axis Prolongation of the QRS interval Digoxin: Paroxysmal atrial tachycardia/atrial flutter with variable conduction ==> ventricular rate will usually be very slow Slow "regularized" atrial fibrillation "dig-effect" may be seen without digoxin toxicity CCB/BB: Slow junctional (regular) rhythm

True or false: Shock may occur with a normal blood pressure

TRUE

What are the indications for physostigmine in anticholinergic poisoning?

Tachycardia uncontrolled with standard therapy and agitation uncontrolled with sedatives PE will show hyperthermia, tachycardia, mydriasis, and dry skin Treatment is supportive care alone or in combination with antidotal therapy with physostigmine Classes of medications with anticholinergic properties include antihistamines, tricyclic antidepressants, and sleep aids Mnemonic: Mad as a hatter (AMS), blind as a bat (mydriasis), red as a beet (flushed skin), hot as a hare (anhidrosis), and dry as a bone (dehydration)

TACO (transfusion associated circulatory overload)

Reactions to blood component transfusion can range from mild to potentially fatal. Transfusion-associated circulatory overload (TACO) is a common transfusion reaction in which pulmonary edema develops primarily due to volume excess or circulatory overload. TACO typically occurs in patients who receive a large volume of a transfused product over a short period of time, especially those with underlying cardiovascular or renal disease Definitive TACO - New onset or exacerbation of three or more of the following within 12 hours of the end of a transfusion without another explanation: •Respiratory distress (acute or worsening) •Evidence of pulmonary edema on examination or radiographs •Elevated brain natriuretic protein (BNP) or N-terminal pro-hormone BNP (NT-pro BNP) •Other unexplained cardiovascular changes (elevated central venous pressure)

What is rhinitis medicamentosa?

Rebound vasodilation and nasal obstruction resulting from prolonged use of topical nasal decongestants.

What are the three types of rectal prolapse?

Rectal mucosa only (< 2 years old), all layers of rectum, and intussusception through rectum. Precipitated by defecating, coughing, and sneezing No vascular compromise: manual reduction in ED Vascular compromise: emergency surgery consultation and reduction Consider CF in pediatric patient Types Mucosal prolapse (hemorrhoids and children) All layers prolapse Intussusception

Paroxysmal nocturnal hemoglobinuria

Red urine in the morning, fragile RBCs stem cell defect in which there is an abnormal sensitivity to complement-mediated destruction of RBCs. This destructive process is a result of a defect in the formation of surface proteins on the red blood cell, which normally functions to inhibit immune reactions. For this reason, blood transfusion can be fatal, and only washed blood cells should be given to patients with PNH.

Name the 5 anatomic locations in which renal stones become impacted.

Renal calyx, ureteropelvic junction, pelvic brim, ureterovesicular junction, and vesicle orifice. Renal Calculi and Colic M > F Calcium oxalate: most common Struvite: staghorn calculi, urease producing bacteria Uric acid: radiolucent on X-ray, gout Cystine: children with metabolic diseases Flank pain radiating to groin, unable to lie still Hematuria Ultrasound: hydronephrosis Helical CT< 5 mm: likely to pass spontaneously> 8 mm: unlikely to pass Admission: intractable pain, infected stone, single kidney, new kidney dysfunction Prevention: increase fluid intake, thiazide, citrate, allopurinol NSAIDs for first-line pain control

Ankylosing Spondylitis (Radiographic Axial Spondyloarthritis) Summary

Risk factors: male sex, age < 40 Sx: low back pain that's most severe at night and morning stiffness that improves with exercise PE: limited spinal mobility, decreased lumbar lordosis X-ray: squared vertebral bodies, multiple vertebral fusions (bamboo spine) Labs: increased ESR, positive HLA-B27 Treatment options include NSAIDs, physical therapy, TNF-alpha blockers Associated with: uveitis, aortitis, IBD, psoriasis, apical pulmonary fibrosis Diseases associated with HLA-B27: PAIRPsoriatic arthritisAnkylosing spondylitisInflammatory bowel diseaseReactive arthritis

Carpal Tunnel Syndrome Summary

Risk factors: repetitive hand and wrist use, female sex, obesity, pregnancy, hypothyroidism Pain and numbness in the first, second, and third digits, especially at night Caused by median nerve compression PE:Phalen sign: reproduction of symptoms with wrist hyperflexion Tinel sign: reproduction of symptoms with percussion over the carpal tunnel Carpal compression test: reproduction of symptoms within 30 seconds of applying direct pressure to the carpal tunnel Hand elevation test: reproduction of symptoms after raising hands above the head for 1 min Tx: wrist splint in neutral position, glucocorticoid injection, oral glucocorticoids, surgical decompression Classically associated with prolonged computer use, recent studies show moderate-quality evidence that computer use was not associated with CTS

Chancroid Summary

Risk factors: sexually active Sx: painful genital ulcers PE: papule evolves to a pustule which ulcerates, ulcers on an erythematous base covered by a gray or yellow purulent exudate and painful lymphadenopathy (bubo) Caused by Haemophilus ducreyi Tx: ceftriaxone 250 mg IM or azithromycin 1 g oral

Rhabdomyolysis

Risk factors: trauma, heat, alcohol or drugs, exercise CPK more than five times ULN Urine: tea-colored, positive for blood, negative for RBCs, myoglobinuria Hypocalcemia (most common), hyperkalemia, hyperphosphatemia Immediate ECG Rx: IVF, bicarbonate Complications: DIC, ARF, compartment syndrome

Sickle Cell Disease (SCD)

Sickling → vaso-occlusive ischemia Hydroxyurea increases fetal hemoglobin (HbF) production, reduces chance of sickling ↓ O2, dehydration, acidosis → sickling Crizanlizumab -> to reduce frequency of vaso-occlusive crises Newborns: initially asymptomatic (due to ↑ HbF) Most common presentation in infants: dactylitis Aplastic crisis: ↓ Hgb + reticulocytopenia, parvovirus B19 Acute chest syndrome - Most common cause of death in adults Fever, CP, CXR: pulmonary infiltrate Splenic sequestration crisis: rapid splenic sequestration of RBCs → splenomegaly + severe anemia Stroke Aseptic necrosis of the femoral head Dysfunctional spleen → ↑ infection riskSalmonella osteomyelitis S. pneumoniae sepsis: most common cause of death in children

Sickle Cell Disease Summary

Sickling → vaso-occlusive ischemia Hydroxyurea increases fetal hemoglobin (HbF) production, reduces chance of sickling ↓ O2, dehydration, acidosis → sickling Crizanlizumab -> to reduce frequency of vaso-occlusive crises Newborns: initially asymptomatic (due to ↑ HbF) Most common presentation in infants: dactylitis Aplastic crisis: ↓ Hgb + reticulocytopenia, parvovirus B19 Acute chest syndrome = Most common cause of death in adults Fever, CPCXR: pulmonary infiltrate Splenic sequestration crisis: rapid splenic sequestration of RBCs → splenomegaly + severe anemia Stroke Aseptic necrosis of the femoral head Dysfunctional spleen → ↑ infection riskSalmonella osteomyelitis S. pneumoniae sepsis: most common cause of death in children

Cushing's triad

Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirations

Esophageal Foreign Body Summary

Site of obstruction: C6 > T4 > T11 AP, PA view: flat side of coin appears Esophageal necrosis → perforation Most FBs that pass pylorus pass spontaneously Observe most esophageal FBs for 24 hours Emergent endoscopy indicated if FB is a battery, is sharp, or has signs of obstruction

Esophageal Foreign Body

Site of obstruction: C6 > T4 > T11 AP, PA view: flat side of coin appears Esophageal necrosis → perforation Most FBs that pass pylorus pass spontaneously Observe most esophageal FBs for 24 hours Emergent endoscopy indicated if FB is a battery, is sharp, or has signs of obstruction

What is the most common side effect of beta-adrenergic drugs?

Skeletal muscle tremor

How long should a deer tick be attached before prophylactic treatment to prevent Lyme disease is recommended?

Typically, longer than 36 hours. Lyme Disease History of being in the woods, hiking, or camping PresentationStage 1: erythema migrans (pathognomonic), viral-like syndrome (fever, fatigue, malaise, myalgia, headache)Stage 2: myocarditis, bilateral Bell palsyStage 3: chronic arthritis, chronic encephalopathy PE will show slightly raised red lesion with central clearing, erythema migrans (bull's-eye) rash Most commonly caused by Borrelia burgdorferi carried by Ixodes tick Treatment is doxycyclineChildren: amoxicillin or doxycycline (if used for < 21 days)Pregnant: amoxicillin Bilateral facial nerve palsy is virtually pathognomonic for Lyme disease

What percent of iatrogenic pneumothoraces will be missed on the initial post-procedure chest radiograph?

Up to one-third.

What diagnostic procedure is classically associated with iatrogenic Boerhaave syndrome?

Upper endoscopy (EGD)

Causes of Wide-Complex Regular Tachycardias on Board Exams

Ventricular tachycardia Ventricular tachycardia Ventricular tachycardia Ventricular tachycardia Ventricular tachycardia Sinus tachycardia with aberrant conduction SVT with aberrant conduction? Key point: On board exams, don't be fooled by a history or ECG slightly suggestive of SVT with aberrant conduction when VT remains in your differential. Consider and treat for VT when dealing with wide complex regular tachycardias! However, if the ventricular rate is less than 130 bpm, do NOT diagnose ventricular tachycardia! Consider the following in your differential for "slow VT": Accelerated idioventricular rhythm (AIVR) Hyperkalemia TCA overdose Type 1A antiarrhythmic overdose

Hyperkalemia treatment

albuterol inhaler, insulin & glucose, NaHCO3, kayexalate

Trichomoniasis

an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder the most common nonviral sexually transmitted disease in the world. It is caused by Trichomonas vaginalis, a flagellated protozoan. Fifty percent of those affected are asymptomatic, but others may present with dysuria, vulvar irritation or itching, and vaginal discharge. The diagnosis is confirmed by the presence of flagellated organisms on a wet mount.

Hemophilia A

an X-linked recessive bleeding disorder resulting from low or absent factor VIII. Patients develop bleeding after minor trauma and, in severe deficiency, spontaneous bleeding can occur. Hemarthrosis, retroperitoneal hemorrhage, and hematomas of deep muscles are common. Intracranial bleeding is a major cause of death. The treatment for hemophilia-related bleeding is administration of factor VIII

ECG Artifacts

an abnormal signal that does not reflect electrical activity of the heart during the cardiac cycle Artifact is not uncommon and can be misdiagnosed as polymorphic ventricular tachycardia (PVT), torsades, or ventricular fibrillation (VF) Always correlate with clinical condition PVT, torsades, and VF patients usually appear sick! If unstable/unconscious, check pulse and don't delay shock If patient is stable, look for evidence of regular organized activity buried within artifact!

Reactive Arthritis [Reiter's syndrome]

an inflammatory arthritis occurring in a joint geographically separate from a site of infection elsewhere on the body. The arthritis is sterile and typically begins several weeks after resolution of the antecedent infection. Gastrointestinal infections are most commonly associated with reactive arthritis.

Sacroilitis

an inflammatory disorder of the SI joint and is associated with ankylosing spondylitis. Ankylosing spondylitis is a seronegative arthropathy associated with the HLA-B27 genotype. In addition to the sacroiliac joints, the axial skeleton is often involved. Joints become inflamed and are susceptible to fracture even from minor trauma

pulsus paradoxus

beats have weaker amplitude with respiratory inspiration, stronger with expiration RF: Asthma, constrictive pericarditis, pulmonary embolism and COPD.

Greenstick fracture

bending and incomplete break of a bone; most often seen in children have cortical disruption on one side with intact periosteum on the compression side. Despite being an incomplete fracture, those with > 10 degrees of angulation require reduction and immobilization

Greenstick Fracture

bending and incomplete break of a bone; most often seen in children incomplete angulated fracture of a long bone. Typically, only one side of the cortex is fractured. This results in a bowing appearance of the bone

Meningioma

benign tumor of the coverings of the brain (the meninges) Usually asymptomatic when less than 2.0 cm in size. It is typically an incidental finding on neuroimaging that is located near the inner surface of skull or tentorial dura.

Antisocial personality disorder

blatant disregard for the rights of others, frequently violate social norms and display a lack of remorse.

Vitamin B12 deficiency

cyanocobalamin, is a water-soluble vitamin. Dietary deficiencies can cause megaloblastic anemia, pancytopenia, and neuropsychiatric symptoms. Because of the size of the B12 molecule, deficiencies typically result from issues with absorption (such as pernicious anemia), rather than from poor dietary intake Risk Factors: vegan diet, metformin use Sx: fatigue, weakness, and peripheral neuropathy PE: pallor and glossitis Labs: MCV > 100 fL, hypersegmented neutrophils, elevated homocysteine, elevated methylmalonic acid Tx: parenteral vitamin B12, oral considered if no neurologic sx or malabsorption Neuropathy is more common with vitamin B12 deficiency (as opposed to folate deficiency) Pernicious anemia: autoimmune destruction of cells that produce intrinsic factor (IF), resulting in vitamin B12 deficiency

Brugada syndrome

disorder characterized by sudden death associated with one of several electrocardiographic (ECG) patterns characterized by incomplete right bundle-branch block and ST elevations in the anterior precordial leads -Autosomal dominant disorder most common in Asian males. -ECG pattern of pseudo-right bundle branch block and ST elevations in V1-V3. -⬆️risk of ventricular tachyarrhythmias and SCD. Prevent SCD with implantable cardioverter-defibrillator (ICD).

Prinzmetal angina

drop in blood flow through the coronary arteries caused by a vasospasm in the artery, not by atherosclerosis Also known as Vasospastic angina, is due to coronary artery spasm. This condition can truly be diagnosed only after visualization of the coronary arteries reveals no or minimal fixed lesions. Vasospastic angina occurs at rest and is usually relieved by nitroglycerin or exercise. It is more common in young women and can be associated with smoking and a circadian pattern of symptoms (such as chest pain at night). It can also occur when abusing drugs that can cause vasospasm (such as cocaine or amphetamines). It can be associated with ST elevations on the ECG that cannot be differentiated from a STEMI. Calcium channel blockers (such as diltiazem) can alleviate symptoms.

primary blast injuries

due entirely to the blast, damage is caused by the pressure wave generated by the explosion, disruption of major blood vessels and organ rupture - Blast Lung - TM Rupture/Middle Ear Damage - Abdominal Hemorrhage/Perforation - Eye Rupture - TBI

kinetic energy

energy due to motion

Myxedema Coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure Hypothyroidism exacerbation → ↓ metabolic state + AMS PE: stupor, hypoventilation, hypotension, bradycardia Rx: IV thyroid hormone replacement, glucocorticoids High mortality

Charcot triad of cholangitis

fever, right upper quadrant pain, and jaundice

Reynold's pentad of Cholangitis

fever, right upper quadrant pain, jaundice, hypotension and altered mental status

Cyanide poisoning

presents with primarily neurologic symptoms ranging from headaches to comas and seizures. Treatment is with hydroxycobalamin

beta-hydroxybutyrate lab

primary ketone body produced in the body

Mobitz type 1 second degree atrioventricular block

progressive lengthening of PR interval until a beat is 'dropped' (P wave not followed by a QRS complex) usually asymptomatic Characterized by a progressive increase in the duration of the PR interval with an eventual blocked sinus impulse. This block is most commonly located in the atrioventricular node. Patients may be asymptomatic or complain of irregular heartbeats. Clinicians should be aware that digoxin, calcium channel blockers, and beta blockers can cause or exacerbate atrioventricular block.

Zenker Diverticulum

progressive out-pouching of the esophageal mucosa just above the upper esophageal sphincter. It most commonly occurs in the elderly population.

Sinusitis

refers to inflammation of the mucous membranes lining the paranasal sinuses. Patients present complaining of cough, facial tightness, headache, reduced ability to smell, and nasal congestion with purulent nasal and postnasal discharge lasting 7-10 days. Sinusitis is usually caused by a virus, leading to decreased clearance of secretions within the mucosa and entrapment of bacteria which may lead to secondary bacterial infection. The three most common bacterial agents involved in sinusitis are Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Treatment of viral sinusitis is supportive. Antibiotics are indicated only if the clinical course strongly suggests bacterial infection

A chest tube thoracostomy is indicated in what cases?

rge spontaneous pneumothorax, evidence of enlargement during observation, tension pneumothorax, trauma, positive pressure ventilation, and significant underlying lung disease.

Slit ventricle syndrome

seen in 5-10% of all patients with shunts. The ventricles are overdrained, resulting in occlusion of the proximal shunt orifice, which limits drainage and causes ICP to rise. As fluid reaccumulates in the ventricle, the occlusion is relieved, allowing drainage to resume. This presents as cyclical, episodic symptoms of raised ICP.

Kehr's sign

severe left shoulder pain in patient with splenic rupture (referred pain due to diaphragmatic irritation)

Epiglottitis

severe, life-threatening infection of the epiglottis and supraglottic structures that occurs most commonly in children between 2 and 12 years of age Thumbprint sign = seen on a lateral soft tissue neck radiograph is characteristic of epiglottitis Streptococcus, Staphylococcus, and Bacteroides are the most common pathogens.

Gram positive bacilli (rods)

should raise concern for possible pulmonary anthrax. Gram positive lancet shaped (Streptococcus pneumoniae) is also commonly associated with post-influenza pneumonia

Mallory-Weiss tear

tear that occurs in the esophageal mucosa at the junction of the esophagus and stomach caused by severe retching and vomiting and results in severe bleeding.

Delirium tremens

the most severe manifestation of alcohol withdrawal symptoms. It is a rapid onset of confusion caused by withdrawal from alcohol. It occurs as early as 48-72 hours after the cessation of alcohol and can last for 2-3 days. The hallmark of delirium tremens is severe agitation, global confusion, disorientation, visual and auditory hallucinations, formication (tactile hallucinations of something crawling on the skin), fever, heavy sweating, and autonomic hyperactivity (tachycardia and hypertension). Treatment is with benzodiazepines.

Body Dysmorphic Disorder (BDD)

the preoccupation with an imagined physical defect or a real, although minor, defect that is exaggerated (such as a large nose).

Newton's First law of motion

the scientific law that states that an object at rest will stay at rest and an object in motion will stay in motion with a constant speed and direction unless acted on by a force

Jarisch-Herxheimer reaction

transient worsening of symptoms in the first 24 hours secondary to immune response to antigens released from dying spirochetes. It is common with treatment of any spirochetal infection, including Lyme disease and syphilis. While the reaction is self-limited, symptoms can be severe and can be controlled with antipyretics.

Lymes disease

transmitted by the bite of an Ixodes scapularis tick and is the most common vector-borne disease in the United States. Early infection is associated with the classic erythema migrans rash, a circular lesion with central clearing or erythema at the site of a tick bite.

Gallstone pancreatitis

can occur if a gallstone lodges in the common bile duct causing epigastric abdominal pain, nausea, and vomiting. Cholecystitis and gallstone pancreatitis are not associated with viscous perforation and free air under the diaphragm.

Erythema Infectiosum (Fifth Disease)

caused by parvovirus B19, is a nonfebrile illness that affects children ages 4-10 years old. Children will have a bright erythematous rash on the cheeks ("slapped cheek" appearance) followed by a lacy rash on the trunk

Colorado tick fever (B)

caused by the coltivirus and transmitted by the wood tick in the western United States. Patients present with sudden fever, headache, myalgias, and photophobia 3-6 days after a bite. A transient petechial rash may occur. In 50% of cases, symptoms resolve and then recur after 3 days.

Wernicke's syndrome

characterized by a triad of neurologic symptoms (ophthalmoplegia, ataxia, and confusion) caused by the deficiency of thiamine. Treatment is with thiamine repletion, which should occur prior to any glucose administration due to the risk of further neuronal damage.

Rubeola (measles)

characterized by cough, coryza, conjunctivitis, and fever followed by a maculopapular rash on the head which spreads to the body. Patients with rubeola are typically still febrile when the rash appears.

borderline personality disorder

characterized by unstable interpersonal relationships, impulsivity, and a distorted self-image

systemic lupus erythematosus (SLE)

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs associated with a malar rash as well; however, it is not typically abrupt in onset, indurated, or associated with sudden onset of fever and chills

Thrombotic Thrombocytopenic Purpura (TTP)

classically present with some combination of the pentad that includes fever, anemia, thrombocytopenia, renal failure, and neurologic problems. Rarely are all five seen on presentation. Platelet transfusion is associated with rapid deterioration and should not be administered in patients with TTP.

TTP (thrombotic thrombocytopenic purpura)

classically present with some combination of the pentad that includes fever, anemia, thrombocytopenia, renal failure, and neurologic problems. Rarely are all five seen on presentation. Platelet transfusion is associated with rapid deterioration and should not be administered in patients with TTP.

Chlamydia pneumonia

common cause of atypical pneumonia in young adults. In infants, a staccato-like cough may be present but not the characteristic inspiratory whoop seen with pertussis.

Inferior alveolar nerve block

commonly used but difficult nerve block that anesthetizes all of the mandibular teeth to midline with the exception sometimes of the buccal aspect of the molars. It also numbs the lower lip and chin through blockade of the mental nerve branch. The lingual nerve runs near the inferior alveolar nerve and is often blocked coincidentally, providing anesthesia to the anterior 2/3 of the tongue and the floor of the oral cavity.

Choledocholithiasis

condition of stones in the common bile duct This is not usually seen sonographically. However, choledocholithiasis will cause the common bile duct to dilate (> 6 mm), which can be measured sonographically.

Newton's Third Law of Motion

when one object exerts a force on a second object, the second object exerts an equal force in the opposite direction on the first object

Disseminated intravascular coagulation (DIC)

widespread activation of the coagulation and fibrinolytic cascade, leading to a life-threatening bleeding disorder. It is associated with a prolonged aPTT/PT, low platelet count, low fibrinogen level, elevated fibrin degradation products, elevated D-dimer, increased thrombin time, and decreased antithrombin III levels. Microangiopathic hemolytic anemia is invariably present and, accordingly, schistocytes are commonly seen on peripheral blood smear

Cellulitis

will typically present as a painful, erythematous area of an extremity with extension proximally. It is normally indurated, and unless it has an accompanying abscess, it is not fluctuant

ECG findings in patients on digoxin

"Digoxin effect" - Down sloping ST-segment depression with a characteristic sagging appearance (a.k.a Salvador Dali moustache) The presence of digoxin effect pattern on the ECG is not a marker of supra-therapeutic digoxin levels or toxicity, but merely suggests that the patient is taking digoxin Digoxin toxicity causes a multitude of dysrhythmias due to increased automaticity and decreased AV conduction Most common finding is frequent PVC's, Sinus bradycardia and AV blocks may be seen Slow "regularized" atrial fibrillation is a classic finding ==> Regularized due to complete heart block and junctional or ventricular escape rhythm Bidirectional VT (rare)

Digoxin toxicity

-Cholinergic—nausea, vomiting, diarrhea, blurry yellow vision (think van Gogh), arrhythmias, AV block. -Can lead to hyperkalemia, which indicates poor prognosis.

What is the risk of acquiring HIV from a blood transfusion?

1 per 2-3 million.. . Transfusion Complications Massive transfusion: coagulopathy, hypothermia, hypocalcemia Febrile reaction: most common complication, fever or chills Hemolytic reaction: ABO incompatibility, immediate fever or chills, HARx: stop transfusion, IVF, diuretics Allergic reaction: urticaria or hives TRALI: like ARDSRx: stop transfusion Delayed reaction: 3-4 weeks after transfusion, decreased Hgb GVHD: immunocompromised, rash, pancytopenia, increased LFTs Prevention: irradiated blood products in immunocompromised

What is the dose of intravenous magnesium sulfate for torsade de pointes?

1-2 g IV.

What are the 4 cluster B personality disorders?

1. Antisocial 2. Borderline 3. Histrionic 4. Narcissistic

Sodium Bicarbonate Indications

1. Cardiopulmonary arrest with: a. unsuccessful drug therapy and defibrillation b. suspected hyperkalemia (elevated potassium in dialysis patients. 2. Crush Syndrome or crush injury greater than 4 hours. 3. Iron - Prevents convertion of ferrous to ferric. 4. Cardiotoxic drug affecting fast sodium channel (TCA, cocaine) - Decreases affinity of cardiotoxic drugs to the fast sodium channel. 5. Weak acids - Promotes ionization of weak acids 6. Chlorine gas inhalational poisoning - Neutralization of hydrochloric acid formed when chlorine gas reacts with water in the airways.

Primary Immune Thrombocytopenia - Pediatric

2-6 years old Antiplatelet autoantibodies H/o recent viral infection Non-blanching petechiae/purpura, gingival bleeding Labs: platelets < 100,000/µL, normal WBC, normal hematocrit Tx: activity restriction, observation, glucocorticoids and IVIG or IV anti-D if severe

What are the maximum doses of bupivacaine with and without epinephrine?

2.5 mg/kg without epinephrine and 3 mg/kg with epinephrine.

What is the average rate of alcohol clearance in a typical intoxicated individual?

20 mg/dL per hour. Chronic alcoholism leads to a megaloblastic anemia secondary to folate deficiency and iron deficiency anemia secondary to blood loss in the GI tract. The measured platelet survival time and qualitative platelet function is impaired in chronic ethanol abuse

Crytpococcal Meningitis

3 subspecies starts as lung infection spread via bloodstream occurs in 10% of patients with HIV infection, but most commonly in those with CD4 cell counts less than 100 cell/µL. Headache and fever commonly occur, but there are no cutaneous manifestations. Treatment includes amphotericin B plus 5-flucytosine

Cardiac output (Q)

= stroke volume (SV) x heart rate (HR).

In which of the following conditions is uveitis the most common extra-articular manifestation? A Ankylosing spondylitis B Fibromyalgia C Psoriatic arthritis D Reactive arthritis

A Ankylosing spondylitis Seronegative spondyloarthropathies share the characteristics of sacroiliac involvement, peripheral inflammatory arthropathy, an absence of rheumatoid factor, ligamentous and tendinous changes, and a genetic component related to the HLA-B27 marker. Patients with ankylosing spondylitis typically have back discomfort, with radiographic evidence of sacroiliitis. Uveitis is the most common extra-articular manifestation. Aortic root disease may also occur Symmetrical squaring of the margins of the vertebral bodies that over time develops into a "bamboo spine."

You are working in the ED when the police bring in a 26-year old man who was involved in a bar fight. The patient is well known to staff, as he frequently seeks treatment in the ED for injuries related to fights and alcohol use. He has been caught smoking cigarettes in the ED bathroom, has urinated on the floor, and been known to steal food trays and other patients' belongings. As you enter his examination room, you overhear him giving the registration clerk a false identity. Which of the following personality disorders best fits with this patient's behavior? A Antisocial B Borderline C Paranoid D Schizoid

A Antisocial Individuals with antisocial personality disorder have a blatant disregard for the rights of others (e.g. stealing food trays and other people's belongings) and violate social norms (e.g. urinating on the floor, smoking in a hospital bathroom) and have a lack of remorse for their actions. They often lie and manipulate situations (e.g. give a false identity). They are often aggressive (e.g. get into frequent altercations), irritable, and impulsive, which leads to frequent encounters with law enforcement. This personality can be difficult for emergency physicians, however it is best to set limits, avoid becoming angry, and focus on the chief concern.

An 83-year-old woman with a history of constipation presents to the ED complaining of a rectal mass. On exam, you note the mass seen in the image above. What is the most appropriate next step in management? A Attempt manual reduction B Consultation to a colorectal surgeon C Immediately begin broad-spectrum antibiotics D Inject local anesthesia and perform an excisional thrombectomy

A Attempt manual reduction Rectal prolapse is a disease of the very young and the very old. In adults, it is most commonly seen in older women and is most often associated with excessive straining while defecating, coughing, or sneezing. This is due to laxity of attachment structures and is often accompanied by prolapse of the bladder (cystocele) and uterus. Often, bloody mucous discharge will be seen along with fecal incontinence and dull pain. Manual reduction is usually sufficient for most cases and should be attempted in the ED.

Which of the following is the most common cause of acute pancreatitis? A Biliary tract pathology B Endoscopic retrograde cholangiopancreatography C Ethanol ingestion D Medication side effect

A Biliary tract pathology Biliary tract pathology (gallstones) is the leading cause of acute pancreatitis, accounting for approximately 45% of cases. The incidence may be as high as 66% in some regions. Stones from the bile duct, pancreatic duct, or common bile duct can obstruct the pancreatic duct, resulting in bile reflux, increased pancreatic secretions, and activation of pancreatic enzymes. Patients classically present following ingestion of a fatty meal or after binge drinking and complain of epigastric pain, nausea, and vomiting. The epigastric pain is constant in nature with radiation directly into the back and is often eased when the patient leans forward. Because of the retroperitoneal location of the pancreas, however, rebound is generally absent.

A patient presents 90 minutes after acute severe headache, nausea, and vomiting. He states it began during sexual intercourse. He has no fever or focal neurologic signs. Which of the following abnormalities would you most likely find on a non-contrast CT of the brain? A Bright, high-attenuation density within the subarachnoid space B Bright, low-attenuation density within the brainstem C Dark, high-attenuation density within the epidural space D Dark, low-attenuation density within the ventricles

A Bright, high-attenuation density within the subarachnoid space Aneurysmal rupture is the fourth most common cause of cerebrovascular disease and, if large enough, can be fatal. Aneurysms arise from a congenital defect of the vessel wall's internal elastic lamina and media. The majority of all aneurysms occur on the internal carotid artery or its branches. Other locations include the basilar or vertebral arteries or their branches. The most common site is the anterior half of the circle of Willis at a bifurcation of a branching distal artery off of the circle. Most brain aneurysms are recognized only when they rupture, commonly between the ages of 35-65 years, resulting in subarachnoid hemorrhage and presenting as acute onset of severe headache, nausea, vomiting, and meningeal signs without fever. Rupture is not necessarily related to chronic hypertension. Sometimes rupture follows a Valsalva maneuver, intense physical effort, or sexual intercourse. Diagnosis is confirmed with CT scanning (depending on the time of symptom onset) or the presence of blood on a lumbar puncture or an aneurysm on CT angiography in the setting of a normal noncontrast head CT. On a noncontrast brain CT, fresh subarachnoid hemorrhage appears as a bright, white, high-attenuating, amorphous substance within the normally dark CSF-filled subarachnoid spaces (noncontrast CT bright = bone, clotted blood; dark = air, fluid, fat; gray = brain). Complications include mass effect, vasospasm, and cerebral infarction but also hydrocephalus and the syndrome of inappropriate antidiuretic hormone secretion. Definitive treatment is built on early diagnosis, defining the vasculature with angiography, and neurosurgical clipping.

Quaternary blast injury

A blast injury that falls into one of the following categories: - burns - crush injuries - toxic inhalation - Angina - Hyperglycemia, HTN - Skin Burn

What is Left Bundle Branch Block (LBBB)?

A block in the electrical conduction through the left bundle; evidenced by a wide QRS in lead 1 and V6 Bundle branch blocks are abnormal conduction abnormalities (not rhythm disturbances) in which the ventricles depolarize in sequence, rather than simultaneously, thus producing a wide QRS complex (> 120 msec) and a ST segment with a slope opposite that of the terminal half of the QRS complex. A left bundle branch block is a bifascicular block in which ventricular activation is by way of the right bundle branch. The impulse travels down the right bundle, activating the septum and the free wall of the right ventricle, and then continues on in the same direction to activate the free wall of the left ventricle. Because the dominant forces are traveling in the same direction, there is a tendency toward monophasic QRS complexes. The ECG in a LBBB will show a large wide R wave in lead I and a negative wave (QS or rS) in lead V1.

Rubella (German Measles)

A highly contagious viral disease, especially affecting children, that causes swelling of the lymph glands and a reddish pink rash; may be harmful to the unborn baby of a pregnant woman who contracts it associated with a maculopapular rash that first appears on the face and spreads downward to involve the trunk and extremities (similar to measles). The rash on the face fades on day two, and the rash on the trunk becomes coalescent. By day three, the rash disappears, which is why rubella is also called three-day measles.

What size pneumothorax can be successfully managed with oxygen supplementation 100% oxygen nonrebreather mask and observation alone?

A pneumothorax involving less than 20% of the hemithorax.

What is the most common infectious etiology of conjunctivitis in adults? A Adenovirus B Enterovirus C Staphylococcus aureus D Streptococcus pneumoniae

A. Adenovirus Viral conjunctivitis is the most common type of conjunctivitis in adults and is most often caused by adenovirus. Patients present with symptoms of redness, watery or mucoserous discharge, and irritation. It is typically bilateral (but may initially affect only one eye) and there is often a preceding or concomitant upper respiratory illness. Physical examination findings include preauricular lymphadenopathy, diffuse conjunctival injection, and enlarged follicles on the inferior palpebral conjunctiva. Visual acuity, examination of the cornea and anterior chamber, and intraocular pressures are normal. Treatment consists of supportive care with cool compresses. Some patients may get relief from an over-the-counter topical antihistamine or ocular decongestant but this treats only the symptoms and not the cause. Topical antibiotics are reserved for those patients in whom the etiology is unclear or if there is concern for a superimposed bacterial infection.

A 22-year-old woman presents to the emergency department with right ankle pain after twisting her ankle while playing soccer. What is the most likely ligament involved in her injury? A Anterior talofibular ligament B Calcaneofibular ligament C Lateral talocalcaneal ligament D Posterior talofibular ligament

A. Anterior talofibular ligament Normal functioning of the ankle depends on the integrity of three sets of ligaments - the lateral collateral ligaments, the medial collateral ligaments, and the syndesmotic ligaments. Most ankle sprains occur from inversion and plantar flexion of the ankle making injury to the lateral collateral set of ligaments most likely. The anterior talofibular ligament, which connects the anterior fibular malleolus to the talus, is usually the first ligament injured and responsible for two-thirds of ankle sprains. With sufficient force, the calcaneofibular ligament, which connects the tip of the lateral malleolus to the lateral calcaneus, will also be injured.

A 29-year-old man presents to the ED with right eye pain, tearing, and photophobia. After instilling fluorescein into the affected eye, you see the above on slit lamp exam. Which of the following is the most likely prognosis with appropriate treatment of this condition? A Complete resolution within 24-72 hours B Corneal erosion and perforation C Diminished unilateral visual acuity D Recurrent lesions with viral reactivation

A. Complete resolution within 24-72 hours This patient's exam is consistent with a corneal abrasion. The prognosis for a corneal abrasion is generally good with most completely resolving within 24-72 hours. Most corneal abrasions are caused by ocular trauma or a foreign body. Patients characteristically present with unilateral ocular pain, photophobia, tearing, conjunctival injection, and a foreign body sensation. Diagnosis is made by fluorescein staining examination, which demonstrates a staining defect within the cornea revealing the epithelial injury. Vertical abrasions of the cornea on fluorescein staining exam are indicative of a foreign body beneath the eyelid. Eversion of the eyelid is required to evaluate for retained foreign body and removal. Management of corneal abrasions includes topical antibiotics, typically erythromycin ointment, or ciprofloxacin drops. If the patient is a contact-lens wearer, it is recommended to utilize topical antibiotics that cover for Pseudomonas aeruginosa. Patients with corneal abrasions should follow up with ophthalmology. Tetanus vaccination status should be discussed with the patient and updated as indicated.

Which of the following is more common in ulcerative colitis than in Crohn disease? A Development of malignancy B Fissures C Intestinal obstruction D Small intestine involvement

A. Development of malignancy Ulcerative colitis leads to inflammation and ulceration along the rectum and colon, typically in a continuous pattern. Clinical features include abdominal pain, cramping, tenesmus, and diarrhea. Patients with ulcerative colitis are 15 times more likely to develop malignancy than the general population.

A 55-year-old woman with a history of obesity presents with right upper quadrant abdominal pain, fever, nausea, and vomiting. She reports that her symptoms started 6 hours ago after eating a cheeseburger and french fries. Which physical exam finding would support the suspected diagnosis? A Murphy sign B Obturator sign C Psoas sign D Rovsing sign

A. Murphy sign The suspected diagnosis is cholecystitis. Risk factors for cholecystitis include advanced age, female sex, parity, obesity, rapid weight loss, family history, and oral contraceptive use. Patients will commonly present with right upper quadrant or epigastric abdominal pain, fever, nausea, and vomiting. Often, there is a history of ingestion of a fatty meal prior to the onset of symptoms. Physical exam may reveal tachycardia, fever, and tenderness in the right upper quadrant or epigastrium. Murphy sign is frequently present. To test for Murphy sign, the examiner firmly places their hand at the costal margin in the right upper quadrant and instructs the patient to take a deep inspiration. If the patient experiences increased pain and transiently stops inhaling, this constitutes a positive Murphy sign

DDx for Syncope + ECG

ACS Dysrhythmia (tachy- or brady-) Brugada syndrome Hypertrophic cardiomyopathy Pulmonary embolism Prolonged QT/Torsades de pointes WPW

What part of the cardiac conduction system conducts electricity the slowest?

AV Node

What is typically responsible for diplopia in IIH?

Abducens nerve (cranial nerve VI) palsy.

What is the maximum dose of 0.5% bupivacaine with epinephrine for an average adult?

About 42 mL for a 70 kg adult, using 5 mg/mL and a maximum dose of 3 mg/kg with epinephrine. (1.5 mg/kg is the maximum dose for bupivacaine without epinephrine). Facial and Dental Nerve Blocks Supraorbital: ipsilateral forehead and scalp Infraorbital: area between lower eyelid and upper lip Posterior superior alveolar: ipsilateral maxillary molars Inferior alveolar: ipsilateral mandibular teeth, lower lip, chin Mental: ipsilateral lower lip and chin

What medication can be used for prophylaxis against acute mountain sickness?

Acetazolamide. High Altitude Pulmonary Edema (HAPE) Patient presents with dyspnea at rest, dry cough at first then cough with copious clear secretions, 2-4 days after arrival Treatment is immediate descent (most effective), supplemental oxygen Descent not required if symptoms mild and relieved with rest and oxygen Most life-threatening high altitude illness

What classic eye findings are present in patients with a posterior communicating artery aneurysm?

Acute cranial nerve III palsy with ipsilateral pupillary dilation.

Why should beta-blockers be avoided in the treatment of patients with cocaine-related chest pain or hypertension?

Administration of a beta-blocker can cause unopposed alpha effects leading to worsening symptoms and blood pressure.

What are the Centor criteria for streptococcal pharyngitis?

Age and history of fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough Pharyngitis Most commonly caused by viral > bacteria (GAS, S. pyogenes) Centor criteria: estimates probability pharyngitis is streptococcal based on PE and Sx: cervical lymphadenopathy, tonsillar exudate, fever, absence of cough TreatmentViral: supportiveBacterial:Penicillin (first line)Patients with Penicillin allergy: cephalexin, cefadroxil (avoid in individuals with immediate-type hypersensitivity to penicillin), Clindamycin, Azithromycin, clarithromycin (resistance of group A strep to these agents is known well and varies geographically and temporally)

Pancytopenia Causes

Aplastic anemia Chloramphenicol Leishmania donovani Megaloblastic anemia Paroxysmal nocturnal hemoglobinuria (PNH) Radiation sickness Transfusion-associated GVHD

Spodick's Sign

Appears in Stage I of Pericarditis and is a down sloping of the TP line ie., the baseline. It is said to be present in some 80% of cases of acute pericarditis and is best visualised in lead II and the lateral precordial leads

What aortic branch supplies the lower two thirds of the spinal cord via the anterior spinal artery?

Artery of Adamkiewicz.

Which fungal species is the most common cause of fungal otitis externa?

Aspergillus.

Which medication has the greatest mortality reduction in acute myocardial infarction?

Aspirin.

Which medication has the greatest mortality benefit in acute coronary syndrome?

Aspirin. ST Segment Elevation Myocardial Infarction (STEMI) Patient presents with substernal chest pain that radiates to the neck and arm Labs will show elevated troponin I or troponin T and CK, ST segment elevations > 1 mm in more than two contiguous leads TreatmentPCI (percutaneous coronary intervention): gold standardThrombolytic therapyAspirinP2Y12 receptor blockerBeta blockerAnticoagulation Anterior wall ST elevation in leads V1 through V4 Inferior wall ST elevation in leads II, III, and AVF Lateral wall ST elevation in leads I, AVL, V5, and V6 Posterior wall ST depressions in leads V1 through V3 and elevations in leads V8 and V9

Wernicke Encephalopathy

Associated with chronic alcohol use Ataxia and confusion PE will show nystagmus, lateral rectus palsy Most commonly caused by thiamine (B1) deficiency Treatment is aggressive thiamine repletion Replace thiamine BEFORE glucose Korsakoff (irreversible memory loss)

Asthma in Adults and Adolescents

Asthma: airway inflammation + bronchial hyperresponsiveness + reversible airflow obstruction NAEPP Classifications: Intermittent Symptoms ≤ 2 days/week≤ 2 nighttime awakenings/monthFEV1 > 80% of predicted Mild persistent Symptoms > 2 days/week but < daily> 3-4 nighttime awakenings/monthFEV1 ≥ 80% of predicted Moderate persistent Symptoms daily> 1 nighttime awakening/week but not nightlyFEV1 60-80% of predicted Severe persistent Symptoms throughout the dayNightly awakenings commonFEV1 < 60% of predicted Management depends on factors such as asthma classification, level of control, and patient factors (such as age) Treatment options may include SABAs, ICS, combination ICS-formoterol, LAMAs, and LTRAs Step-up or step-down therapy based on asthma control

Mycoplasma pneumoniae

Atypical bacterial causes of pneumonia. It is often referred to as "walking pneumonia," where the patient tends to look better than you would expect, given the diffuse interstitial pattern commonly seen on chest X-ray. Associated with extrapulmonary manifestations such as conjunctivitis, pharyngitis, rash, and pericarditis.

A 64-year-old woman with a history of hypertension arrives by EMS with mental status changes. Paramedics orotracheally intubated the patient after she was found to be unresponsive. Her vital signs are T 37.7°C, BP 222/98 mm Hg, HR 130 bpm, and RR 16/min, assisted. Glucose is 100 mg/dL. Her pupils are pinpoint, but are sluggishly reactive to a strong light source. The neurologic exam is unobtainable secondary to pharmacologic paralysis. Continuous EEG monitoring shows no acute seizure activity. CT scan of her head shows a large hemorrhage in the region of the pons. Which of the following is the most appropriate next step in management? A Administer mannitol B Administer nicardipine C Administer phenytoin D Administer recombinant factor VIIa E Hyperventilate to pCO2 < 30 mm Hg

B Administer nicardipine Nicardipine is a quick-acting calcium channel blocker commonly used for hypertension in the setting of acute intracranial hemorrhage. Persistently elevated BP in patients with intracranial hemorrhage contributes to hematoma expansion and is associated with poorer outcomes. For patients presenting with intracerebral hemorrhage and a systolic blood pressure of 150-220 mm Hg, the latest guidelines recommend lowering to a goal systolic blood pressure of 140 mm Hg. For those presenting with an initial systolic blood pressure > 220 mm Hg, a continuous intravenous infusion of antihypertensive medication is recommended to acutely lower the systolic blood pressure to 140-160 mm Hg. When BP reduction is indicated, intravenous medications such as nicardipine (by continuous infusion) or labetalol (by intermittent bolus) are recommended. Mannitol (A) is an osmotic diuretic that shifts water across the blood-brain barrier. It has been used clinically to reduce intracranial pressure with varying success. Many patients with intracranial hemorrhage present after a seizure or have a seizure during hospitalization. Seizures have not been associated with worsened outcome or mortality. Several studies have shown that treatment with prophylactic phenytoin (C) in the absence of seizure led to a worse outcome. Despite plausible utility based on physiologic understanding of the coagulation cascade, activated factor VIIa (D) has not been shown to be of any clinical benefit in patients with acute intracranial hemorrhage. Carbon dioxide causes the cerebral vasculature to dilate, leading to increased intracranial blood volume and increased intracranial pressure. Hyperventilation (E) leads to decrease in the carbon dioxide levels and has been tested as an adjunct to intracranial hemorrhage management. Unfortunately, this treatment can lead to decreased cerebral perfusion pressures and increased ischemia, so it is not recommended.

A 3-year-old girl presents to the Emergency Department after swallowing a foreign body. A chest X-ray was obtained and shows lodged button battery. What is the best initial management step? A Activated charcoal B Endoscopic removal C Gastric lavage D Repeat chest X-ray in 3 hours

B. Endoscopic removal She has a button battery in her esophagus that requires emergent endoscopic removal. Button battery ingestion occur most frequently in children under the age of six with a peak incidence at one to two years old. The batteries most commonly come from hearing aids, toys, and calculators. Damage from a button battery occurs when they become stuck against the gastrointestinal mucosa. Over the course of hours the electrical discharge can cause mucosal damage and may lead to perforation. Other risks include leakage of the battery's content and exposure to harmful heavy metals. Any button battery found in the esophagus requires emergent endoscopic removal.

Which of the following findings is most consistent with a diagnosis of viral conjunctivitis? A Chemosis B Follicular changes on the inferior palpebral conjunctiva C Purulent drainage that continues throughout the day D Unilateral eye involvement

B. Follicular changes on the inferior palpebral conjunctiva Viral conjunctivitis, frequently caused by adenovirus, is the most common type of conjunctivitis and is highly contagious. Infection is often preceded by or concomitant with a viral upper respiratory illness. Symptoms of watery discharge, irritation, and redness may start in one eye but spreads to the other eye within days. Patients may complain of crusting on the eyelids in the morning. Eye pain, photophobia and change in visual acuity are typically absent. Examination shows diffuse conjunctival injection and enlarged follicles on the inferior palpebral conjunctiva. Preauricular lymphadenopathy may also be present. In simple viral conjunctivitis, there should not be corneal uptake of fluorescein or any abnormalities in the anterior chamber

Which of the following findings in acute pancreatitis contributes to a higher mortality rate? A AST > 150 units/L on admission B Glucose > 200 mg/dL on admission C Hematocrit < 35% at 48 hours D WBC < 10,000 on admission

B. Glucose > 200 mg/dL on admission In a patient with acute pancreatitis, a glucose > 200 mg/dL on admission to the hospital is associated with a higher mortality rate. Ranson criteria are a two-step list of laboratory parameters that can be used to predict a patient's risk of mortality during their hospitalization. The scores should be performed on admission to the hospital and again at 48 hours of hospitalization. As the number of Ranson criteria increase, mortality increases as well.

A 7-year-old girl presents to the ED with fever, mouth and eye pain, and a rash. Past medical history is unremarkable outside of recent prolonged cough. On physical exam, you note the above. Nikolsky sign is positive. Which of the following are the most common infectious etiologies of this disease process? AChlamydia pneumoniae and adenovirus BMycoplasma pneumoniae and herpes simplex virus CStaphylococcus aureus and coxsackievirus DStreptococcus pneumoniae and varicella zoster virus

B. Mycoplasma pneumoniae and herpes simplex virus This patient is exhibiting symptoms and physical exam findings consistent with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). SJS and TEN are variants of a disease spectrum with life-threatening mucocutaneous manifestations. SJS is the formal diagnosis when the lesions involve < 10% total body surface area while TEN involves > 30%. It is more common in males and older patients. It is caused by the autoimmune detachment of the epidermis and mucous membranes that result in widespread erythema and bullous lesions. Most cases are medication-related. Infectious causes are more likely in children and younger adults. The most common infectious causes of SJS and TEN are Mycoplasma pneumoniae and herpes simplex virus.

Scorpion Sting

Bark scorpion in SW USA Roving eye movements, muscle spasms, excessive secretions BZDs for neuromuscular symptoms Atropine for excessive secretions Antivenom

What are some complications of GERD?

Barrett esophagus, esophageal strictures, and esophageal adenocarcinoma

Hyperacute T waves

Be wary of hyper-acute T waves...get serial ECGs! Will be the first sign of evolving occlusion MI in many cases Look out for T waves that are larger than their preceding QRS complex Early infarction - T waves get larger, QRS complexes (R waves) get smaller Don't trust the computer interpretation!

What are three other treponematoses (conditions caused by Treponema pallidum)?

Bejel (endemic syphilis), pinta, and yaws.

How many cm H2O should cuff pressures be kept below to avoid tracheal mucosal ischemia when using cuffed endotracheal tubes?

Below 20 cm H2O.

Flumazenil (Romazicon)

Benzodiazepine antidote Reverses the effects of benzodiazepines by competitive inhibition at the benzodiazepine binding site on the GABAA receptor.

What is the appropriate medication for treatment of seizures in patients with sodium channel blocker toxicity?

Benzodiazepines.

What medications are used for an acute COPD exacerbation?

Beta-agonists, anticholinergics, and corticosteroids.

What is the best laboratory test to confirm the presence of CSF in nasal fluid?

Beta2-transferrin.

At what age do children begin to present with allergic contact dermatitis similar to adults?

Between three to eight years of age. It is rare before this due to an impaired ability to react to allergens.

What personality disorder is associated with substance abuse and "drug seeking" behavior?

Borderline personality disorder.

What nerve root is mainly responsible for the triceps reflex? A C5 B C6 C C7 D C8

C C7 The C7 nerve root is responsible for the triceps reflex. The motor function of C7 is also associated with elbow extension.

Which of the following is an appropriate treatment of a patient with acute rheumatic fever that has a severe penicillin allergy? A Cephalexin B Ciprofloxacin C Clindamycin D Trimethoprim/sulfamethoxazole

C Clindamycin Nearly all patients with acute rheumatic fever have evidence of an antecedent group A streptococcal (GAS) pharyngitis infection either by history or serology. Diagnosis is made using two major or one major and two minor Jones criteria. The five major Jones criteria include carditis, polyarthritis, erythema marginatum, subcutaneous nodules, and chorea. The Jones criteria were updated in 2015 to include subclinical carditis based on echocardiography. The four minor criteria were also updated and include arthritis (monoarthralgia in high-risk populations), fever, elevated erythrocyte sedimentation rate or C-reactive protein, and a prolonged PR interval on ECG. There must be evidence of prior group A streptococcal infection for diagnosis. All patients with rheumatic fever should receive antibiotics to treat group A streptococcal infection of the pharynx, usually with penicillin, amoxicillin, or cephalexin. For patients that are allergic to penicillin, azithromycin, clarithromycin, or clindamycin are recommended. BOTH skin and respiratory streptococcal infections can lead to acute glomerulonephritis.

A 65-year-old man presents to the ED with a known history of heart failure. He complains of progressive shortness of breath over the preceding month to the point that he now has to rest even when he walks from his bed to the bathroom. These symptoms resolve at rest. What is this patient's New York Heart Association classification? A I B II C III D IV

C III The New York Heart Association functional classification scheme is used to assess the severity of functional limitations in patients with chronic heart failure and correlates fairly well with prognosis. Patients in class III have moderate limitations and have symptoms of heart failure with minimal activity such as walking across a room.

Which of the following is the most common cause of an esophageal perforation? A Acid ingestions B Alkaline ingestions C Iatrogenic D Vomiting

C Iatrogenic Most esophageal perforations are iatrogenic and often result from complications of instrumentation (about 60% of all cases). The rigid endoscope is the most common offender. Injuries tend to occur near the cricopharynx or the cervical esophagus as the endoscope is inserted

What blood test helps identify factitious hypoglycemia?

C-peptide level

A 20-year-old man presents with chest pain and dyspnea for the past day. He also reports fever and palpitations. He does not have any significant past medical history but relates that he did have a viral illness 1 week ago. Physical exam reveals a young man in mild respiratory distress with rales appreciated on auscultation and mild pedal edema. His temperature is 100.6℉, and his heart rate is 130 beats per minute. His chest X-ray reveals mild pulmonary edema, and his erythrocyte sedimentation rate and troponin I are elevated. Which of the following is the most effective management for this patient? A Administer antibiotics and discharge to home B Administer intravenous steroids and admit to the hospital C Admission with cardiac monitoring D Prescribe furosemide and discharge with outpatient cardiology follow-up

C. Admission with cardiac monitoring The suspected diagnosis is myocarditis. Myocarditis is an inflammation of the cardiac muscle that may be the result of numerous infectious and noninfectious conditions, including viral, bacterial, or parasitic infections, systemic disorders, and drug hypersensitivities. Patients will often present with fever and chest pain. Symptoms may also include fatigue, palpitations, myalgias, and dizziness. In more severe cases, patients may also have symptoms of heart failure. Myocarditis most commonly affects patients between 20 and 50 years of age and often follows a recent viral illness. Common physical exam findings include rales, peripheral edema, jugular venous distention, pericardial friction rub, and sinus tachycardia disproportionate to the degree of fever. ECG changes may vary from sinus tachycardia to ST changes or QRS widening. Chest X-ray may be normal, but may show cardiomegaly or pulmonary edema in some cases. Echocardiography should be performed to assess ventricular and valvular function and identify other possible causes of cardiac dysfunction. Cardiac catheterization can distinguish from an acute coronary syndrome. Commonly, laboratory studies show mild to moderate leukocytosis, an elevated erythrocyte sedimentation rate, and elevated cardiac enzymes. Patients suspected to have myocarditis should be admitted to the hospital. Standard heart failure treatment should be initiated for patients presenting with heart failure, and cardiac monitoring is needed as patients with myocarditis are at risk for developing dysrhythmias.

Which of the following antibiotics is associated with spontaneous tendon rupture? A Amoxicillin B Doxycycline C Levofloxacin D Sulfamethoxazole

C. Levofloxacin Fluoroquinolone drugs, including levofloxacin, have been associated with spontaneous tendon ruptures. Fluoroquinolones are a commonly prescribed antibiotic class. The class includes ciprofloxacin, moxifloxacin, and levofloxacin. The fluoroquinolone class of drugs has a number of side effects, the most serious of which are prolongation of the QTc and spontaneous tendon rupture. Tendon rupture appears to be more common in older patients. The overall risk is between 0.1 - 0.4%. These drugs are discouraged for use in pregnant women and children secondary to their effect on cartilage.

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? A Topical acyclovir B Topical amphotericin B C Topical ciprofloxacin D Topical cyclopentolate

C. Topical ciprofloxacin Topical ciprofloxacin is first-line treatment for a corneal ulceration. This is because of the necessary coverage against Pseudomonas aeruginosa. A corneal ulcer is a bacterial infection that develops secondary to a break in the corneal epithelium. Risk factors for developing a corneal ulcer include incomplete lid closure (e.g. secondary to Bell's palsy) and soft contact lenses use. Symptoms include redness, swelling of the lids, foreign body sensation, and photophobia. Physical exam may reveal a round or an irregular ulceration with a white or hazy base. A secondary iritis can develop and cause ciliary flush or a limbal injection. Treatment includes topical antibiotics and emergent ophthalmologic consultation. Cultures can be obtained of the ocular drainage to guide antibiotic therapy. Cycloplegic drops can be used to help with the pain from the secondary iritis. Complications include corneal scarring, corneal perforation, and secondary glaucoma.

Compression or damage to which nerve roots can lead to compromise in the ulnar nerve distribution?

C8-T1

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany, spasms and stridor Can be seen in renal failure, hypoparathyroidism, pancreatitis, or chronic malabsorption syndromes. Neurologic symptoms include paresthesias, carpopedal spasm (Trousseau sign), contraction of the ipsilateral facial muscles when tapping on the facial nerve just anterior to the ear (Chvostek sign), and hyperreflexia. Cardiovascular signs include hypotension, heart failure, dysrhythmias, and prolonged QT interval.

Malrotation

Can result in midgut volvulus which presents with symptoms of abdominal pain and distension, bilious vomiting and hematochezia.

What is the most common surgical procedure complicated by endophthalmitis?

Cataract Surgery

Procidentia (rectal prolapse)

Circumferential, full-thickness protrusion of the rectal wall through the anal orifice. typically encountered in extremely old individuals. The condition is typically painless and associated with bloody or mucoid discharge.

Pseudomonas aeruginosa

Common cause of pneumonia in patients with cystic fibrosis which presents with meconium ileus (in the newborn), pancreatic insufficiency, failure to thrive, and chronic/repeat pulmonary infections.

Uterine Fibroids (Leiomyomas)

Common during reproductive-ages Menorrhagia and dysmenorrhea PE will show a enlarged, asymmetric, and nontender uterus Diagnosis is made by pelvic ultrasound Majority do not require surgical or medical treatment Severe cases: myomectomy (fertility can be preserved) or hysterectomy most frequently occurring pelvic tumor in women

What is a grade III ankle sprain?

Complete ligamentous tearing; joint unstable with no definite endpoint to ligamentous stressing

Other than rebleeding, what are possible complications related to a hyphema?

Corneal blood staining, acute or chronic glaucoma, and synechia formation.

What is the most common viral etiology for myocarditis?

Coxsackievirus.

Acute Pulmonary Edema Summary

Crackles, jugular venous distension CXR: cephalization, Kerley B lines, effusions Initial Rx ==> BPAP: ↑ 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)

What is the typical imaging appearance of a subdural hematoma on non-contrast CT head?

Crescent-shaped hematoma that may cross suture lines.

In which case is an orogastric tube preferred over a nasogastric tube? A Alkali ingestion B Esophageal strictures C Esophageal varices D Facial fracture

D Facial fracture Nasogastric (NG) and orogastric (OG) tubes are most commonly used to aspirate or decompress stomach contents in the emergency department, either for diagnostic or therapeutic purposes. In patients with facial trauma (cribriform plate fractures), a blindly placed NG tube may enter the cranium or facial soft tissues. Therefore, a tube placed through the mouth is preferred in these situations.

A 22-year-old man presents with a sore throat. On examination, the pharynx is erythematous without tonsillar enlargement or exudate. There is no cervical adenopathy. The patient is not sexually active. Which of the following is likely to provide the most improvement? A Acetaminophen PO B Amoxicillin PO C Ceftriaxone IM D Ibuprofen PO

D Ibuprofen PO The patient likely has viral pharyngitis. The examination demonstrates an erythematous pharynx without exudates and without adenopathy. In this case, the patient needs supportive care. NSAIDs, such as ibuprofen, will provide the most symptomatic relief.

A 32-year-old woman presents with abdominal pain, nausea, vomiting, and change in skin color for 6 days. She states that she had unprotected intercourse 4 weeks ago. Which one of the following tests indicates acute infection with hepatitis B as the cause of the patient's symptoms? A Antibody to hepatitis B e antigen (Anti-HBe) B Antibody to hepatitis B surface antigen (Anti-HBs) C IgG antibody to B core antigen (Anti-HBc-IgG) D IgM antibody to B core antigen (Anti-HBc-IgM)

D IgM antibody to B core antigen (Anti-HBc-IgM) This patient presents with symptoms consistent with acute Hepatitis B virus (HBV) infection. HBV is primarily transmitted through parenteral exposure (needle stick, intravenous drug use) or through unprotected intercourse. Transmission through blood transfusion is rare due to advances in screening techniques. Acute viral hepatitis presents with malaise, fever, anorexia, nausea, vomiting, abdominal discomfort, and diarrhea. Often, jaundice leads patients to consult a physician. Fulminant hepatitis is characterized by the acute onset of hepatic failure and encephalopathy over a short period of time (usually days). Measurement of hepatic enzymes can demonstrate 10- to 100-fold elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. ALT is usually elevated to a greater degree than AST in viral hepatitis (the reverse is usually true in alcoholic hepatitis). Hyperbilirubinemia can be moderate (5-10 mg/dL) or severe (15-25 mg/dL) and usually presents days to weeks after the onset of symptoms. Both direct and indirect bilirubin will be elevated in viral hepatitis. Serum testing can also be used to diagnose the type of viral hepatitis. Acute hepatitis B is characterized by the presence of IgM antibody to B core antigen (Anti-HBc-IgM).

A 60-year-old man with a history of chronic heart failure, diabetes, and hypertension presents to the ED with a fever and productive cough. Vital signs are BP 80/40 mm Hg, HR 110 bpm, RR 18/min, T 38.4°C, and pulse oximetry 94% on room air. You note rales in the right lower lung field on exam. His chest radiograph shows right middle and lower lobe infiltrates. After a 2-liter crystalloid fluid bolus, he remains hypotensive with a mean arterial pressure less than 65 mm Hg. A bedside long-axis inferior vena cava ultrasound is performed during inspiration, as seen above. What is the most appropriate next step in management? A Initiate a dobutamine drip B Initiate a norepinephrine drip C Initiate a phenylephrine drip D Initiate another liter bolus of crystalloid fluid

D Initiate another liter bolus of crystalloid fluid The hypovolemic patient should be adequately volume resuscitated before starting vasopressor or inotropic support. Numerous techniques exist to assess fluid responsiveness, which is defined as an improvement in stroke volume after a fluid bolus. Ultrasound analysis of inferior vena cava (IVC) diameter variation is a technique that can help predict cardiac filling pressure and the likelihood of fluid responsiveness. The IVC is a thin-walled compliant vessel that returns blood from the lower systemic circuit to the right atrium. IVC diameter can be measured 1-2 centimeters caudal to the hepatic vein inlet while visualizing the IVC in the long axis. With inspiration, blood is drawn into the heart, reducing the IVC diameter. Variation in the IVC diameter during respiration depends on a number of factors, including circulating blood volume, cardiac performance, and pulmonary vascular resistance. IVC collapse of 50% or greater with inspiration indicates a decrease in blood volume and predicts fluid responsiveness. As shown in the image, this patient has a slit-like or flat IVC with inspiration, a finding that strongly supports the need for aggressive volume resuscitation.

A 23-year-old woman presents with concerns of tender breast enlargement. She gave birth to a healthy newborn 2 weeks ago, and she currently breastfeeds. Examination reveals subjective fevers, myalgias, and general malaise, warmth, and edema of the right breast. There is mild overlying erythema, but no other superficial abnormalities, palpable masses, or purulent nipple discharge present. The left breast appears normal. Which of the following is the most likely diagnosis? A Breast abscess B Breast engorgement C Inflammatory breast cancer D Lactation mastitis

D Lactation mastitis Mastitis generally refers to breast inflammation, which can be infectious, noninfectious, or associated with inflammatory breast cancer. Of the infectious subclass, lactation mastitis is the most common and occurs within a few weeks postpartum. Typical symptoms include general body ache, fever, malaise, and tender breast engorgement (almost always unilateral) with erythema and induration. More serious disease may present with purulent nipple discharge.

Which of the following medications can be given to a 6-year-old in cardiac arrest via the endotracheal tube? A Amiodarone B Calcium gluconate C Dextrose D Naloxone

D Naloxone Naloxone can safely be given to a pediatric patient in cardiac arrest via the endotracheal tube (ETT) if intravenous or intraosseous access is unavailable. Endotracheal drug administration is infrequently used but has the potential to be therapeutic in patients without intravenous access. A number of medications can be given via the ETT, including atropine, naloxone, lidocaine, and epinephrine.

A 45-year-old man presents to the ED in police custody for acting obscenely in a nearby grocery store. He is intoxicated and has slurred speech and impaired extraocular movements. He also seems to be fabricating stories about his behavior earlier in the day. Which of the following should be administered at this time? A Dextrose B Pralidoxime C Pyridoxine D Thiamine

D Thiamine Confusion, confabulation, ataxia, ophthalmoplegia, and nystagmus suggest Wernicke-Korsakoff encephalopathy. Although Wernicke syndrome and Korsakoff syndrome are clinically distinct, they are both caused by thiamine deficiency. Wernicke encephalopathy is often underdiagnosed and carries a mortality rate of 10% to 20%. It is diagnosed clinically with two of the following findings: oculomotor abnormalities (most commonly nystagmus), dietary deficiencies, cerebellar dysfunction, and altered mental status (e.g., lethargy, inattentiveness) or memory impairment. Korsakoff psychosis, also referred to as alcohol-induced persisting amnestic disorder, is an untreatable form of dementia that involves recent retrograde amnesia, anterograde amnesia (inability to learn new information), apathy, and confabulation. Confabulation (Fabrication of facts or events as a compensation for lapses or loss in memory) is not essential to the diagnosis. Treatment is with thiamine followed by dextrose administration, along with an adequate diet and abstinence of alcohol. Ocular manifestations usually respond well to thiamine within days, but ataxia and mental changes usually do not improve as rapidly and portend a worse prognosis. Dextrose (A) should be given after thiamine for the theoretical prevention of Wernicke-Korsakoff syndrome. Older literature suggests that prolonged treatment with hypertonic IV glucose "precipitated" Wernicke encephalopathy, but this did not occur with single or repeated bolus of IV glucose. Pralidoxime (B) is an antidote for cholinergic toxicity, as it regenerates acetylcholinesterase. Pyridoxine (C), or vitamin B6, is not the cause of Wernicke-Korsakoff syndrome and has no role in its prevention or treatment.

Which of the following diseases is characterized by the presence of a delta wave on an electrocardiogram? A Charcot-Marie-Tooth disease B Parkinsonism C Parkinson's disease D Wolff-Parkinson-White syndrome

D Wolff-Parkinson-White syndrome Wolff-Parkinson-White (WPW) syndrome is a congenital cardiac condition in which there is an abnormal conduction pathway (accessory bundle) between the atria and ventricles other than the atrioventricular node. This pathway provides the basis for a reentrant circuit which bypasses the typical delay thru the AV node, typically resulting in premature ventricular depolarization and supraventricular tachyarrhythmia. The premature depolarization of some of the ventricle produces a "slurring" of the normal depolarization wave thru the AV node. This is seen as a gradual upsloping of the QR segment, called a delta wave, which creates an illusion of PR interval shortening and QRS lengthening Definitive treatment is radiofrequency ablation The Bundle of Kent. = accessory bundle in WPW syndrome

Which of the following gastrointestinal foreign body ingestions is an indication for urgent endoscopy? A Circular structure at the level of the clavicles in sagittal plane on chest radiograph B Ingestion of a button battery that is localized past the pylorus on abdominal radiograph C Multiple packages of presumed narcotics in the stomach on abdominal radiograph D Witnessed ingestion of toothpicks just prior to arrival now located in stomach

D Witnessed ingestion of toothpicks just prior to arrival now located in stomach Stomach foreign bodies are most commonly unintentional and in patients who are young or who have cognitive disorders. Diagnosis is suspected during history gathering and confirmed with imaging. The most commonly used imaging technique is plain radiographs; however, wooden foreign bodies may not appear, so high clinical suspicion needs to be maintained for these types of foreign bodies. Children with an unwitnessed ingestion commonly had access to small objects and had an episode of coughing, gagging, or vomiting after presumed ingestion. Otherwise, patients with stomach foreign bodies are usually asymptomatic. Those with ingestion of small, rounded objects have a high likelihood of passing the object without intervention. Indications for urgent endoscopy for stomach foreign bodies include ingestion of sharp or long objects (e.g., toothpicks, needles), co-ingestion of a button battery and magnet, objects wider than 2 cm, objects longer than 6 cm, and localization proximal to the pylorus over 24 hours after ingestion. For objects that do not meet these criteria, close observation with radiographic follow-up and stool checks to evaluate for passage is indicated Foreign bodies with orientation in the sagittal plane at the level of the clavicles (A) are most likely in the trachea and require emergent bronchoscopy, not urgent endoscopy. Body packers (C) without evidence of impaction or obstruction should be watched closely. Routine endoscopy for removal should not be performed as iatrogenic rupture of the packets may prove fatal. Button batteries that have passed the pylorus (B) have a high likelihood of passage without intervention required. Urgent endoscopy is required when localized in the esophagus or co-ingested with a magnet. What food most commonly causes food impaction requiring urgent endoscopy? Meat

A 25-year-old man presents for evaluation of fever and cough. He reports last week that he was diagnosed with influenza. In the last two days he developed a worsening cough productive of large amounts of sputum. Vital signs are T 101°F, HR 98, BP 120/60, RR 18, and 95% oxygen saturation on room air. His chest X-ray demonstrates a lobar infiltrate in the left lower lobe. Which of the following would you most likely expect to see on the patient's Gram stain? A Gram negative bacilli B Gram negative diplococci C Gram positive bacilli D Gram positive cocci in clusters

D. Gram positive cocci in clusters The patient had a recent influenza infection and now presents with a lobar infiltrate. Staphylococcus aureus pneumonia is classically associated with causing post-influenza bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in clusters.

A 25-year-old man presents to the ED with chest pain, shortness of breath, and fever. Vital signs include BP 98/50 mm Hg, HR 136 beats/minute, RR 26 breaths/minute, and T 102.4°F. On auscultation, you hear rales to the mid-thorax bilaterally. Bedside cardiac ultrasound shows global hypokinesis and a small pericardial effusion. Which of the following organisms is the most common cause of this condition worldwide? ACoxsackievirus B BMycobacterium tuberculosis CPlasmodium falciparum DTrypanosoma cruzi

D. Trypanosoma cruzi This patient presents with signs and symptoms of myocarditis accompanied by pericarditis. Myocardial injury results from inflammation of the myocardium. The most common etiology worldwide is Chagas disease, caused by the protozoan Trypanosoma cruzi. The protozoan is spread by the reduviid bug, also known as the kissing bug as it feeds on the faces of those affected. Unfortunately, in many patients, the cause of myocarditis is idiopathic. Other noninfectious causes include connective tissue disorders such as scleroderma, toxins such as chemotherapy, cocaine, and heavy metals, and peripartum myocarditis. Symptoms often include a viral prodrome with fever, myalgias, and generalized weakness. Patients may present with chest pain, symptoms of acute heart failure, tachycardia, dysrhythmias, syncope, cardiogenic shock, or even sudden cardiac death. Diagnosis can be very difficult and patients often present to the ED multiple times prior to being diagnosed. An ECG may show global or segmental ST elevation, nonspecific ST segment and T wave changes, dysrhythmias, or conduction delays. Troponin and creatinine phosphokinase are often elevated. Echocardiography classically shows global hypokinesis. Management is primarily supportive; however, patients with new left bundle branch block or low ejection fraction may require a left ventricular assist device as a bridge to cardiac transplantation in some cases as these are poor prognostic indicators. The most common long-term sequelae of myocarditis is dilated cardiomyopathy.

A 31-year-old man presents with a rash. He first noticed a 3 cm erythematous lesion on his left shoulder two weeks ago. Today, he woke up with pruritic lesions on his trunk as shown above. He denies fever. What is the most likely etiology of his symptoms? A Autoimmune reaction B Bacterial infection C Fungal infection D Viral infection

D. Viral infection Pityriasis rosea is a self-limiting papular rash that affects children and young adults. It is thought to be viral in etiology. Patients present with multiple pink, oval 1-2 cm papules or plaques on the trunk that run parallel to the ribs forming a Christmas tree distribution. Typically, the generalized rash is preceded by a single larger lesion, the herald patch, that is similar in appearance to the multiple small lesions. Patients are typically well appearing and complain only of mild pruritus which can be managed with oral antihistamines. Symptoms resolve in 2-3 months.

What is the late complication of rhabdomyolysis associated with thrombocytopenia, hypofibrinogenemia, and an elevated D-dimer?

DIC = RIP Disseminated intravascular coagulopathy may occur and is a result of muscle necrosis with liberation of activating substances from injured cells. Rhabdomyolysis Risk factors: trauma, heat, alcohol or drugs, exercise CPK more than five times ULN Urine: tea-colored, positive for blood, negative for RBCs, myoglobinuria Hypocalcemia (most common), hyperkalemia, hyperphosphatemia Immediate ECG Rx: IVF, bicarbonate Complications: DIC, ARF, compartment syndrome

Bulimia Nervosa Summary

DSM-5: recurrent episodes of binge eating followed by inappropriate compensatory behavior via self-induced vomiting, laxative misuse, excessive exercise, or caloric restriction (occurring at least once per week for 3 months) Sense of lack of control during eating episodes Self-evaluation is unduly influenced by body shape or weight PE: body weight usually within or above normal range, dental erosions, parotid gland swelling, callused knuckles Tx options: cognitive behavioral therapy, fluoxetine or other SSRIs, or combined CBT/pharmacotherapy

secondary blast injuries

Damage to the body resulting from being struck by flying debris. Some objects can travel up to 3,000mph when propelled by explosions. - Closed/Open Head/Brain Injury - Eye Penetration - Penetrating/Ballistic/Blunt Injuries

Acute Tubular Necrosis (ATN)

Damage to the renal tubules due to presence of toxins in the urine or to ischemia. Results in oliguria.

Why is dexamethasone administered with antibiotics for suspected meningitis?

Decrease in mortality and long-term morbidity (e.g. hearing loss).

What is the mechanism of aspirin in acute coronary syndrome?

Decreases platelet aggregation by irreversibly inhibiting cyclooxygenase, which catalyzes the thromboxane enzymes.

What are Heinz bodies?

Denatured globin chains attached to the red blood cell membrane

What are the nodular deposits seen in gout?

Deposits of uric acid crystals, or tophi, which can be seen in subcutaneous tissues, tendons, cartilage, and bone. Gout Mono or oligo-articular arthritis caused by uric acid crystals Risk factors: male sex, age > 30 Sx: podagra (acute onset of pain in the first MTP) PE: hot, red, tender joint, tophi Labs: needle-shaped crystal with negative birefringence, uric acid can be low, normal or elevated Treatment Acute: NSAIDs, steroids, colchicine Chronic: allopurinol (first line), febuxostat, probenecid Can be triggered by loop and thiazide diuretics

Which psychiatric illness is commonly misdiagnosed as a somatic symptom disorder?

Depression

Prognosis of melanoma depends primarily on what clinical feature?

Depth

Does nitrogen narcosis occur with ascent or descent while scuba diving?

Descent, typically to depths greater than 70 ft. Arterial Air Embolism Expanding gas ruptures alveoli → air enters circulation Divers: most common cause of stroke, LOC, ACS Rx: supine position, O2, immediate hyperbaric chamber recompression

What should be a consideration in recurrent fungal infections?

Diabetes alters the urogenital flora making fungal infections more common and can be screened with historical information of polyuria or point of care testing with a finger-stick blood test for glucose.

Diaphysis, metaphysis, epiphysis of bone

Diaphysis: Shaft, middle region, of long bone Metaphysis: flares portion of bone. Epiphysis: each end only long bone

What midline abdominal defect in elderly and pregnant patients is often mistaken as a ventral hernia?

Diastasis recti.

What is the most common cause of Ludwig angina?

Direct spread from a dental infection.

What is Cullen sign?

Discoloration around the umbilicus indicative of hemorrhagic pancreatitis Grey Turner sign = flank ecchymosis

What is the first line treatment of neuroleptic malignant syndrome?

Discontinue offending medication, supportive care (lower fever, maintain euvolemic state), and benzodiazepines adverse effects 2 weeks after initiating antipsychotic or antiemetic Rx Sx: FEVER: fever, encephalopathy, vitals unstable, elevated CK, rigidity

What is the classic finding of hypertrophic cardiomyopathy on echocardiogram?

Disproportionate septal hypertrophy.

Which class of medication prevents calculation of an accurate FENa?

Diuretics, which alter the amount of urinary sodium

What is the classic triad of aortic stenosis?

Dyspnea, chest pain, and syncope.

What are the most common organisms responsible for cholangitis of the biliary tract?

E. coli, Klebsiella, Enterococcus, and Bacteroides

Left Bundle Branch Block

ECG findings:Wide QRS > 0.12 secBroad, slurred R in I, aVL, V5 and V6Absent q waves in I, V5 and V6ST and T waves opposite direction to QRS New LBBB + chest pain = MI until proven otherwise

In addition to antibiotics, what is the treatment of choice for cholangitis?

ERCP

For which tick-borne illness is doxycycline the recommended treatment regardless of age?

Ehrlichiosis and Rocky Mountain spotted disease. Doxycycline can be used to treat Lyme disease in children < 8 years if given < 21 days

Which patients are at greatest risk of developing myxedema coma?

Elderly female patients Myxedema Coma Hypothyroidism exacerbation → ↓ metabolic state + AMS PE: stupor, hypoventilation, hypotension, bradycardia Rx: IV thyroid hormone replacement, glucocorticoids High mortality

Causes of prolonged QT interval (greatest concern when QTc > 500ms)

Electrolytes Hypokalemia (U waves) Hypomagnesemia Hypocalcemia Hypothermia ACS / cardiac ischemia Elevated intracranial pressures Medications (e.g., sodium channel blocking drugs, Type 1a anti-arrhythmics, TCAs, etc.) Congenital

What type of dental injury involves the enamel, but spares the dentin and pulp?

Ellis class I fracture.

What is the Ellis classification system?

Ellis classes describe the degrees of dental fractures. Ellis class I is a fracture involving the enamel only, class II involves the enamel and the dentin, and III involves pulp exposure.

What is the term for acute cholecystitis when gas-forming organisms create air in gall bladder wall?

Emphysematous cholecystitis caused by Clostridial species. This has a 5 times greater operative mortality.

From what type of bacteria are sickle cell patients at particularly high risk for infection?

Encapsulated organisms due to functional asplenia.

Fomepizole (Antizol)

Ethylene glycol toxicity - raw material in the manufacture of polyester fibers and for antifreeze formulations. It is an odorless, colorless, flammable, viscous liquid A competitive inhibitor of the enzyme alcohol dehydrogenase found in the liver. This enzyme plays a key role in the metabolism of ethylene glycol and methanol.

What is the most common complication of otic foreign body removal?

External auditory canal abrasion or laceration.

What is the most common cause of hyperkalemia in the emergency department?

Extravascular hemolysis.

What are the common risk factors for development of accidental hypothermia?

Extremes of age, heavy alcohol and substance use, mental disorders, and poverty. Hypothermia Core body temp < 35°C Metabolic excitation followed by slowing phase Initial increase in BP, HR, CO followed by decrease ECG: Osborn (J wave) < 30°C: patient appears dead, cardiac dysrhythmias Oxyhemoglobin dissociation curve shifts (O2 delivery) Kidney concentrating ability cold diuresis Treat only life-threatening dysrhythmias (VF, asystole) Treatment Mild: passive rewarming Severe without cardiovascular instability: active external rewarming Severe with cardiovascular instability: invasive core rewarming

ENP F&G Additional Criteria

Facilitate Family Presence/FULL VS Give Adjuncts/comfort (LMNOP)

What conditions are associated with an increased incidence of berry aneurysms?

Family history, coarctation of the aorta, polycystic kidney disease, Marfan syndrome, and Ehlers-Danlos syndrome.

What kinds of casts seen on microscopic examination of urine can proteinuria and nephrotic syndrome lead to?

Fatty casts. Urinalysis: Causes of False Negatives Protein: dilute, acidic Leukocytes: Abx, glycosuria, proteinuria Nitrite: ascorbate Bilirubin: ascorbate, aged sample, rifampicin, UV light exposure Glucose: ascorbate

Which two medication classes increase an individual's risk for Achilles tendon rupture?

Fluoroquinolones and corticosteroids.

Where is the typical location for chest tube placement?

Fourth or fifth intercostal space at the anterior or mid axillary line directed above the rib. Enter above rib Finger sweep Advance tube toward apex Do not advance tube after placement

At what serum hCG level would you expect to see a gestational sac on transvaginal ultrasound?

From 1,500-2,000 IU/L.

What ultrasound findings support the diagnosis of cholecystitis?

Gallstones, gallbladder wall thickening or edema, pericholecystic fluid, and sonographic Murphy sign

What hematologic test should be sent to the lab if suspecting malaria?

Giemsa-stained thick and thin smears to identify the plasmodial parasites

What score helps identify patients with upper GI bleeding who are candidates for outpatient therapy?

Glasgow-Blatchford Bleeding Score

What sexually transmitted infection can commonly cause pharyngitis?

Gonococcal pharyngitis (Neisseria gonorrhoeae).

Peutz-Jeghers syndrome

Hamartomatous (benign) polyps throughout GI tract and mucocutaneous hyperpigmentation (freckle-like spots) on lips, oral mucosa, and genital skin; autosomal dominant disorder Often presents with hyperpigmentation (freckle like spots) on the oral mucosa. However, it is not associated with intracranial arteriovenous malformations. The disease is associated with an increased risk for colorectal, breast, and gynecologic cancers.

GERD summary

History of nocturnal cough or asthma Retrosternal burning sensation radiating upward (heartburn) usually after eating Most commonly caused by LES dysfunction Lifestyle modifications: weight loss, elevate head of bed during sleep, avoid certain foods (caffeine, alcohol, acidic foods) H2 receptor antagonists for mild or intermittent symptoms, PPIs (most effective) for frequent (two or more times weekly) or debilitating symptoms Consider surgery for refractory cases

What is most common cause of croup?

Human parainfluenza virus.

Which condition is associated with hyperemesis, gravid uterus larger than expected for dates, and high quantitative beta hCG levels?

Hydatidiform mole, or molar pregnancy

What medication, commonly used in patients with sickle cell disease, is associated with megaloblastic anemia?

Hydroxyurea.

What are the three categories of transplant rejection?

Hyper-acute (occurs minutes to hours after surgery) Acute (occurs 1-12 weeks post-transplant) Chronic (progressive with an insidious decline)

Myocardial Infarction: ECG findings

Hyperacute T waves: earliest finding ST elevation Reciprocal ST depression T wave inversions Sgarbossa criteria for STEMI with LBBB = Concordant ST elevation > 1 mm in leads with a positive QRS (5) Concordant ST depression > 1 mm in V1-V3 (3) Discordant ST elevation > 5 mm in leads with a negative QRS (2) 3 = STEMI

What is the most common condition resulting in hypercalciuria and subsequent renal stone formation?

Hyperparathyroidism

What is the most common gastrointestinal complication of Henoch-Schonlein purpura?

Ileoileal intussusception

Cocaine intoxication

Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid ideations, angina, sudden cardiac death. Treatment: α-blockers, benzodiazepines. β-blockers not recommended. can present in a similar manner to MDMA, with sympathomimetic symptoms such as agitation and tachycardia, and may have the following complications: seizures, dysrhythmias, ischemia, and rhabdomyolysis.

Sgarbossa criteria

In setting of LBBB, the criteria for calling AMI is >3 points: >1mm concordant STE (OR 25, 5 points) >1mm STD in v1, v2, v3 (OR 6, 3 points) >5mm discordant STE (OR 4.3, 2 points) Also look at ST (baseline to T) / S (top of S to baseline) ratio <-0.25

What pulmonary function test findings are expected in a patient with emphysema?

Increased residual volume, increased total lung capacity, and a decreased FEV1/FVC

What CSF study should be performed if cryptococcal meningitis is suspected?

India ink stain.

Glucagon as Antidote

Indication: Toxicity of Beta blockers and calcium channel blockers Stimulates the formation of adenyl cyclase causing intracellular increase in cycling AMP and enhanced glycogenolysis and elevated serum glucose concentration.

phyostigmine or NaHCO3

Indication: Tricyclic antidepressants toxicity A reversible anticholinesterase which effectively increases the concentration of acetylcholine at the sites of cholinergic transmission.

Cholinergic Toxicity

Insecticides, drugs, sarin DUMBBELS: 1. Diarrhea 2. Urination 3. Miosis 4. Bronchospasm 5. Bradycardia 6. Excessive sweating 7. Lacrimation 8. Salivation -Possible flaccid paralysis due to the flooding of Ach at the NMJ SLUDGE: salivation or sweating, lacrimation, urination, defecation, gastrointestinal distress, emesis Killer Bs: bradycardia, bronchorrhea, bronchospasm Rx: atropine Organophosphate Rx: pralidoxime

Glucose (Dextrose 50%) Antidote

Insulin reaction Dextrose (the monosaccharide glucose) is used, distributed and stored by body tissues and is metabolized to carbon dioxide and water with the release of energy.

What size pneumothorax can be observed in patients with stable vital signs?

Isolated pneumothoraces less than 20% can be observed

What findings are seen in keratoconjunctivitis?

Keratoconjunctivitis is infection of the cornea in addition to the conjunctiva. Findings include eye pain and redness, photophobia, conjunctival injection and diffuse, fine, fluorescein uptake on the cornea.

What is the induction agent of choice when performing rapid sequence intubation in an asthmatic patient?

Ketamine

Which organism is responsible for currant jelly sputum?

Klebsiella pneumoniae

Diagnosing STEMI in patients with LVH with strain pattern

LVH may mimic anterior coronary occlusion and is known to be a common cause of "false-positive" cath lab activations Like the anterior ST segment elevation seen in LBBB, it is thought that ST segment elevation that exceeds 25% of the preceding QRS is excessively discordant for LVH, and this may be a useful method for identifying occlusion

What diseases are associated with Streptococcus bovis endocarditis?

Large bowel pathologies including colon cancer, polyps, and diverticula.

What is the Somogyi phenomenon?

Largely discredited theory of counter-regulatory, hormone-induced morning hyperglycemia following nighttime hypoglycemia induced by a dose of evening insulin that is too high

Which of the following is true regarding uterine fibroids? A Increase in size during menopause B More common in Caucasian women than African American women C Surgical removal is associated with a 25% to 30% rate of recurrence D Typically occur as a single fibroid

Leiomyomas (uterine fibroids) are benign tumors of muscle cell origin that cause pain and abnormal bleeding. Uterine fibroids are associated with severe pain when part of the fibroid undergoes torsion or degeneration (due to rapid growth and loss of blood supply, most common in early pregnancy). Diagnosis is made by ultrasound. The treatment depends on size and symptoms. Initial management usually includes NSAIDs, medroxyprogesterone, and gonadotropin-releasing hormone agonists. Surgical removal is associated with a 25% to 30% rate of recurrence and significant bleeding complications. most frequently occurring pelvic tumor in women

Low voltage ECG tracing

Low Voltage Definition Sensitive Definition QRS amplitudes in leads I+II+III < 15 mmOr QRS amplitudes in leads V1+V2+V3 < 30 mm Specific Definition QRS amplitudes in limb leads all < 5 mmOr QRS amplitude in all precordial leads < 10 mm Low Voltage QRS Differential "Low Power" = Myxedema (severe hypothyroidism), Infiltrative diseases (Amyloid, Sarcoid, etc.), Connective tissue diseases, End stage cardiomyopathy​ Conduction blockage = Fluid/Effusion (pericardial or pleural), Fat (obesity), Air (COPD) Take home Points Patients with LVADs may present with significant dysrhythmias (ventricular fibrillation, ventricular tachycardia, electrical storm) with minimal or no active symptoms as their circulation is mechanically supported Consider myxedema in patients with bradycardia and low voltage QRS complexes Pay special attention to the rhythm diagnosis in patients with STEMI who can present with subtle complete heart blocks

Maximum allowable dose Concentration of local anesthetic

Maximum Safe Doses: Lidocaine: with epinephrine = 7mg/kg without epinephrine = 3mg/kg Bupivocaine: with or without epinephrine = 2mg/kg

Sulfonylurea Toxicity

Mechanism: increase insulin secretion Can cause hypoglycemia 24 hrs after ingestion Can cause severe hypoglycemia in children Rx: charcoal, dextrose, octreotide

Phytomenadione (Vitamin K.)

Mechanism: warfarin antagonist, Bypasses inhibition of Vitamin K epoxide reductase enzyme. Indication: bleeding due to warfarin. Adverse effects: hypotension; neonatal jaundice.

Are prophylactic antibiotics indicated in patients with indwelling urinary catheters placed for acute urinary retention?

NO

Can esophageal or gastric injury from caustic ingestion be ruled out if no oral lesions are seen?

NO Caustic Ingestions Chest pain, dysphagia, drooling Alkali: corrosive damage with liquefactive necrosis Acid: coagulation necrosis NPO, endoscopy, monitor airway Monitor children with history of possible ingestion

WPW Syndrome with SVT

Narrow complex rhythm (orthodromic AVRT) - looks like other types of paroxysmal SVT, treat like usual SVT Wide complex rhythm (antidromic AVRT) - looks like ventricular tachycardia, treat like ventricular tachycardia

What is the name of the sign in staphylococcal scalded skin syndrome when gentle pressure causes the upper epidermis to slide off?

Nikolsky sign.

What topical therapies are available for the treatment of anal fissures?

Nitroglycerin, nifedipine, lidocaine

What is the most common presenting symptom of frostbite?

Numbness. Frostbite Do not rewarm if possibility of refreezing Rx: address hypothermia first, rapid rewarming of affected part in 37-39°C water

ECG findings in Hypothermia

Onset of ECG findings can vary, but resolve with warming: Early sinus tachycardia Shivering artifact Bradycardia: sinus, junctional rhythms, slow atrial fibrillation J-waves/Osborn waves (positive deflections at the J-point) "Classic" textbook finding, but not sensitive Can cause pseudo-ST segment elevation or depression Slow irregular atrial fibrillation Prolongation of all intervals Long QT due to lengthening of the ST segment Ventricular fibrillation Asystole

Why should a patient not be sent home with proparacaine drops after a corneal injury?

Ophthalmologic proparacaine overuse can result in corneal opacification leading to blindness.

Trauma Process

PREPARATION and TRIAGE Activate the Trauma Team, Prepare the trauma Room, PPE On Arrival: Assess for uncontrolled Hemorrhage: Consider Reprioritizing to C of ABC PRIMARY ASSESSMENT A. AIRWAY / ALERTNESS (AVPU) / C-SPINE : Must assess 4: Vocalization , Tongue obstruction, Loose teeth, Foreign objects, Vomit / Secretions, Edema, Posture, Drooling, Dysphagia, Abnormal sounds INTERVENE and REASSESS: Suction, NPA/OPA, BVM, Definitive Airway? B. Breathing: Must Assess 4:Spontaneous respirations, rate and depth, Symmetrical chest rise, quality of respirations, color, Bony deformities, Work of Breathing, JVD VENTILATION: Breathing is present, is Ventilation adequate? INTERVENE and REASSESS: O2 or BVM ETT: Confirm tube, secure, and mechanically ventilate C. Circulation: Must assess all 3: Central pulse, Skin: color, Temp., Condition, Uncontrolled bleeding IV ACCESS: Inspect pre-hospital IV's, Start IV's PRN and state rate of infusing fluid D. Disability: GCS, Pupils. If needed, anticipate CT Scan E. Expose & Environmental Control: Warm fluids, ambient temp, warm blankets, etc ==================================================== RESUSCITATION ADJUNCTS F Full set of VS, Family presence G Get Resuscitative Adjuncts: L: Labs: Blood Typing, H&H, ABGs, Lactate, CBC, Chem7 M: Cardiac monitoring: ECG, Adjust for Pediatric settings N: Naso vs Orogastric Tube O: Pulse Oximetry and Capnography P: PAIN: Pharmacologic and Non Pharmacologic SECONDARY ASSESSMENT H. History: MIST: ( Mechanism of Injury, Injuries sustained, Signs and Sx, Treatment ) , Pt/Family Generated I. Inspection: Head to Toe: Inspect AND palpate, Auscultate Lung, Heart, and Bowel Sounds Inspect posterior Surfaces: Log roll, Inspect and palpate, State the need to remove the backboard REEVALUATION ADJUNCTS Identify All Simulated injuries Expected Reevaluation Adjuncts: Must list 3: CT, Xray, Labs, Tetanus, Antibiotics, Consults, Psychosocial, Wound Care, etc........ What will you Reevaluate? VIPP = VS, Injuries, Primary Assessment, Pain and Effectiveness of interventions -Consider the Need for transport DOPE= Displacement, Obstruction, Pneumothorax, Equipment Failure FOCA= Fluctuations, Output, Color, Airleak

Angioedema Summary

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

What patient population is most at-risk for developing erysipelas?

Pediatric and elderly patients.

What is Fitz-Hugh-Curtis syndrome?

Perihepatitis caused by pelvic inflammatory disease

What is Cullen sign?

Periumbilical ecchymosis caused by subcutaneous intra- or retroperitoneal hemorrhage, rarely seen in acute hemorrhagic pancreatitis. Sx: epigastric pain radiating to the back, worse when lying down and better when leaning forward, nausea, and vomiting PE: flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs: 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) Caused by gallstones > alcohol, hypertriglyceridemia, drugs Treatment is IV fluids, analgesics Complications: necrotizing pancreatitis, pancreatic pseudocyst

Which pediatric pneumonia is classically associated with a shaggy right heart border?

Pertussis pneumonia.

What imaging modality can show abnormalities in patients with concussion in the acute setting?

Positron emission tomography scan.

Should a primate bite be sutured?

Primate bites, along with cat bites, typically should not be sutured, unlike dog bites, which can be repaired if they are uncomplicated.

Protamine sulfate MOA

Protamine that is strongly basic combines with acidic heparin forming a stable complex and neutralizes the anticoagulant activity of both drugs.

Ventriculoperitoneal Shunt Obstruction

Proximal > distal obstruction Proximal obstruction often due to choroid plexus or ↑ CSF protein in catheter Distal obstruction often due to thrombus Bulging fontanelle (infants), setting-sun eye (patient unable to look up), HA, nausea Neurosurgical consultation

Arthrocentesis Summary

Relative contraindications: overlying skin infection, bleeding diathesis, bacteremia Ankle: medial to the anterior tibial tendon and directed toward the anterior edge of the medial malleolus Elbow: lateral aspect distal to the lateral epicondyle and directed medially Knee: midpoint or upper portion of patella and directed beneath the posterior surface of patella into joint Shoulder: inferior and lateral to the coracoid process and directed posteriorly toward the glenoid rim

Ear Foreign Body Summary

Removal via curette, forceps, or irrigation Removal requires a cooperative or restrained patient Irrigation is contraindicated if tympanic membrane may be violated Irrigation is contraindicated if the material is organic and can swell Prior to removal, any live insects should be killed with alcohol, mineral oil, or lidocaine Otitis externa prophylaxis with ototopical antibiotics is indicated if the EAC or TM has been excoriated during the FB removal

Rh Isoimmunization

Rh-negative mothers exposed to Rh-positive blood → anti-Rh antibodies Subsequent pregnancies: jaundice, anemia, fetal hydrops, fetal death Prevention: anti-D globulin at 28 weeks (and within 72 hrs of delivery if infant is Rh+)

Spontaneous Pneumothorax Summary

Risk factors: tall, thin, male, ages 10-30, Marfan syndrome, cigarette smoking, COPD, TB, CF, ILD, PCP pneumonia Sx: acute dyspnea and pleuritic chest pain PE: decreased breath sounds, decreased fremitus, hyperresonance to percussion Dx:Upright CXR: absence of lung markings along lung peripheryPleural U/S: absence of lung sliding Tx:< small ≤3 cm in a healthy patient: observation with oxygen administration> large >3 cm: needle aspiration or chest tube thoracostomy

Subdural Hematoma Summary

Risk factors: traumatic head injury, advancing age, anticoagulant use, coagulopathy, thrombocytopenia Caused by tearing of the bridging veins between arachnoid and dura Sx: acute or subacute neuro sx, headache, mental status changes, seizures, or focal deficits Dx: crescent-shaped hematoma on noncontrast CT (suB = Banana) Management includes neurosurgical consultation, blood pressure control, reversal of anticoagulation

Name two common viral causes of prenatal hearing loss?

Rubella and cytomegalovirus.

Cardiac Electrical Conduction System

SA node → AV node → bundle of His → bundle branches → Purkinje fibers

What typically occurs first in compartment syndrome: loss of pulses or sensory deficits?

Sensory deficits occur before loss of pulses. The loss of pulses is usually the last finding 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

What are the most common ECG findings in hypercalcemia?

Shortening of the QTc interval, PR prolongation, and QRS widening

What is a Stener lesion?

Soft tissue interposition from the adductor aponeurosis associated with ulnar collateral ligament rupture

What red blood cell disorder has a characteristic increase in mean corpuscular hemoglobin concentration?

Spherocytosis.

What condition causes lower back pain that is worse with walking but improves with rest and bending forward?

Spinal stenosis.

Pediatric Fractures

Spiral or Toddler fracture = Torsional injury. Minimally or nondisplaced Distal tibial metaphysis Casting x 3 weeks Bowing = Longitudinal compression Orthopedic consultation Greenstick = Axial compression with twisting Cortex fractured on one side Casting and reduction Torus = Axial compression Wrinkling or buckling of cortex Distal radius (most common)Casting

What is the most common cause of septic arthritis?

Staphylococcus aureus is the most common cause of septic arthritis in adults. 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 common cause overall: S. aureus Infants < 3 mo: Group B Streptococcus (Streptococcus agalactiae) N. gonorrhoeae is a common cause in young, sexually active individuals Tx: IV Abx, joint drainage, surgical washout

What is the most common bacterial cause of external shunt infection?

Staphylococcus epidermidis.

What is the common mnemonic associated with hypercalcemia?

Stones, bones, moans, groans and psychiatric overtones

What organisms are most commonly implicated in mediastinitis?

Streptococcus and Bacteroides species are most common.

Species of Gram-positive bacteria that in humans is associated with endocarditis and colorectal cancer

Streptococcus bovis

What is tabes dorsalis?

Syphilitic damage to the posterior columns and dorsal roots of the spinal cord with impairment of position and vibration sense. May result in broad-based gait ataxia and a positive Romberg test

How can axillary nerve sensory function be tested?

Test for sensation over the lateral aspect of the shoulder.

What is the best marker of immunosuppression in patients who are HIV-positive?

The CD4 cell count is the best predictor of susceptibility to opportunistic infection and immunologic dysfunction. HIV Clinical course: exposure → acute HIV syndrome → seroconversion → asymptomatic period → symptomatic period Dx: 4th generation HIV-1/2 combination antigen and antibody immunoassay followed by HIV-1/HIV-2 differentiation immunoassay Dx tests become positive during seroconversion (3-12 weeks after exposure) Chronic watery diarrhea: Cryptosporidium White cottage-cheese lesions: Candida Irremovable white lesions on lateral tongue: hairy leukoplakia (EBV) Pneumonia, CD4 < 200/mm3: PCP TB: CD4 < 200/mm3, may have negative CXR or PPD Ring-enhancing intracranial lesions + focal neurologic deficits: Toxoplasma gondii Ring-enhancing intracranial lesions + AMS: primary CNS lymphoma Meningitis, CD4 < 100/mm3: Cryptococcus Focal neurologic deficits, nonenhancing white matter lesions, CD4 < 200/mm3: PML (JC virus) Retinitis, cotton-wool spots: CMV Dark purple skin or mouth nodules: Kaposi sarcoma Cutaneous: HSV, zoster reactivation

Newton's Second Law of Motion

The acceleration of an object depends on the mass of the object and the amount of force applied.

What is Bell phenomenon?

The defense mechanism for the eyes in which they move outward and upward while closing the eyelids to avoid injury.

What is the initial pediatric defibrillation dose?

The dose is 2-4 J/kg.

What nerve may be injured by an orbital blowout fracture?

The infraorbital nerve.

What nerve branch can be compressed in severe anterior superior iliac spine avulsion fractures, leading to paresthesias over the lateral thigh (meralgia paresthetica)?

The lateral femoral cutaneous nerve.

V fib

The most common life-threatening arrhythmia is ventricular fibrillation. This is an erratic, disorganized firing of impulses from your heart's ventricles (lower chambers). When this happens, your heart is unable to pump blood. Without treatment, you can die within minutes. *SHOCK* on R wave chaotic rapid rhythm fatal if not treated in 3-5 mins CPR, defib, O2, antidysrhythmics

Mycobacterium avium complex

The most common of the atypical mycobacteria, causing disseminated disease. This is seen primarily in the immunocompromised patient, especially with AIDS.

Esophageal web

Thin structures of mucosa and submucosa located most commonly in the proximal or middle esophagus. They are associated with Plummer-Vinson syndrome and iron deficiency anemia.

What organisms cause serious bacterial infection in neonates?

Those found in the vaginal canal: group B Streptococcus, Escherichia coli, and Listeria monocytogenes

Why are corticosteroids recommended in thyroid storm?

To inhibit conversion of T4 to T3, block the release of hormone from the gland, and treat relative adrenal insufficiency. Thyroid Storm History of thyrotoxicosis Sx: tachycardia, hyperpyrexia, agitation, anxiety PE: goiter, lid lag, hand tremor, and warm, moist skin Labs: low TSH and high free T4 or T3 Most commonly caused by an acute event (infection, trauma) Tx: Beta-blocker (propranolol) Thioamide (propylthiouracil or methimazole) Iodine solution Glucocorticoids

Why should you limit prostatic palpation in patients with acute bacterial prostatitis?

To prevent precipitation of bacteremia and sepsis.

Prior to electrical cardioversion in a hemodynamically stable patient with atrial fibrillation that has been present for > 48 hrs, what test needs to be done to assess for atrial clot formation?

Transesophageal echocardiogram.

What imaging study is preferred for the identification of endocarditis?

Transesophageal echocardiogram.

Spinal Cord Injury Without Radiographic Abnormalities (SCIWORA)

Trauma patient, usually a child Neurological deficits CT or X-ray negative Obtain MRI or MRA Neurosurgical consultation

What is it called when the patient stands on one leg and the pelvis droops on the unaffected side due to weakened gluteal muscles?

Trendelenburg sign

What is the treatment for H. pylori infection?

Triple therapy with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole

True or False: Any oral antibiotic can lead to diarrhea?

True

True or false: visual hallucinations are more common in organic (medical) psychoses than functional (psychiatric) psychoses.

True

What is the most common cause of large bowel obstruction?

Tumor.

Inverted U waves

U waves are normally small deflections that occur right after the T wave (typically in the same direction as the T wave and best seen in leads V2-V3) Normal U wave amplitude is generally ~ 10% of its associated T wave amplitude and tends to be inversely related to the heart rate (best seen in bradycardia and difficult to appreciate when heart rate is > 90 bpm) U wave inversion, or negative U waves ( ≥ 0.5 mm depth) are abnormal in leads with upright T waves Inverted U waves usually occur in antero-lateral leads and are highly specific for the presence of heart disease Most associated with: Hypertensive heart disease Aortic and mitral valvular disease Ischemic heart disease Unstable angina Variant angina During exercise testing, U wave inversion was 93% specific (but only 21% sensitive) as a marker for LAD stenosis In the setting of cardiac ischemia...Inverted U waves are a specific sign of myocardial ischemia and may be an early marker for unstable angina and evolving MI Association with LAD (or LMCA?) stenosis and the presence of LV dysfunction. May occur during pain or painless state Take-home Points: Inverted U waves in the antero-lateral leads = Not normal! Very predictive of heart disease Ischemic heart disease ==> Can predict LAD disease (or LMCA), During pain or painless state

Is a large amount of diarrhea more common in ulcerative colitis or Crohn disease?

Ulcerative colitis.

What test is diagnostic for pyloric stenosis?

Ultrasound

What is the relationship between cluster headaches and smoking?

Up to 85% of cluster headache sufferers are chronic cigarette smokers. Unfortunately, quitting smoking has no effect on the disease once a patient develops symptoms.

What percentage of patients with DVT have a concomitant pulmonary embolism?

Up to fifty percent.

What is the most common symptom (aside from back pain) seen in cauda equina syndrome?

Urinary retention.

What is Tullio sign?

Vertigo resulting from loud sounds, seen in superior canal dehiscence

How soon after potential exposure to Rh-positive fetal blood does an Rh-negative mother need to receive RhoGAM for it to be effective?

Within 72 hours Rh Isoimmunization Rh-negative mothers exposed to Rh-positive blood → anti-Rh antibodies Subsequent pregnancies: jaundice, anemia, fetal hydrops, fetal death Prevention: anti-D globulin at 28 weeks (and within 72 hrs of delivery if infant is Rh+)

Which population is at greatest risk for a heterotopic pregnancy?

Women with fertility-assisted pregnancies. ==> co-existing ectopic and intrauterine pregnancies

What is a possible complication of positive-pressure ventilation?

Worsening pneumothorax

Adult Asplenia - Vaccinations

Yearly influenza Hib Pneumonia (start with PCV13 and then later administer PPSV23) Meningitis (conjugate and serogroup B) Zoster (age > 60)

Can the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score be used for benzodiazepine withdrawal?

Yes

Does cefepime provide antipseudomonal coverage?

Yes

Is a scalp hematoma predictive of a skull fracture in infants?

Yes, if the scalp hematoma is overlying the parietal or temporal bones. Frontal hematomas are not predictive of underlying fracture.

Tyramine reaction

a drug-food interaction that occurs when a patient taking an MAOI inhibitor ingests a tyramine containing food. Symptoms start immediately following ingestion and include headache, hypertension, flushing, and diaphoresis.

Polycystic kidney disease

a genetic disorder characterized by the growth of numerous fluid-filled cysts in the kidneys Associated with ruptured berry aneurysms that may yield a similar patient presentation. However, it is more likely to occur in an older patient.

Secondary Survey H&I

a head-to-toe physical assessment; an additional assessment of a patient to determine the existence of any injuries other than those found in the primary survey History/SAMPLE Head to Toe Survey Inspect Posterior

Viral labyrinthitis (Vestibular Neuritis/Labryrinthitis)

an infection of the labyrinth within the inner ear and affects the vestibular nerve and cochlear nerve, resulting in vertigo and hearing loss. It is associated with mumps and measles. Tinnitus, headache, and vision changes are not common.

Acetylcysteine (Mucomyst)

antidote for Acetaminophen/ Tylenol/ Paracetamol Restores depleted glutathione stores and protects against renal and hepatic failure.

Posterior Shoulder dislocation

associated with forceful trauma such as high-speed motor vehicle collisions, seizures, and electric shock. Subtle to detect on radiographs, these injuries are commonly missed. On exam, the patient's arm will be in adduction with internal rotation, and they will be unable to externally rotate it.

Aortic Stenosis Summary

calcification of aortic valve cusps that restricts forward flow of blood during systole Risk factors: advancing age, diabetes, hypertension Sx: dyspnea, chest pain, syncope PE: crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop. Murmur decreases with Valsalva Most commonly caused by degenerative calcification Treatment: aortic valve replacement

Sternoclavicular joint dislocation

can be either anterior or posterior and involves complete rupture of the sternoclavicular and costoclavicular ligaments. Anterior dislocations are mainly cosmetic, while posterior dislocations have the potential to cause serious complications such as pneumothorax, laceration of the superior vena cava, occlusion of the subclavian artery, and rupture of the trachea.

Babesiosis

carried by Ixodes tick; Babesia are intraerythrocytic parasites; hemolytic anemia

Somatic Symptom Disorder

characterized by excessive worry and behaviors related to one or more (often multiple) somatic symptoms. Unlike illness anxiety disorder, patients are not focused on a particular illness. Symptoms may vary over time, but the disorder is persistent.

fibromyalgia syndrome

characterized by idiopathic widespread pain with no associated extra-articular manifestations

Borderline Personality Disorder (BPD)

characterized by unstable interpersonal relationships, impulsivity and a distorted self-image

Hereditary Spherocytosis (HS)

congenital intrinsic membrane abnormality in which RBCs are shaped like spheres. Clinical sequelae can range from compensated hemolysis to aplastic crisis. Diagnosis is made via blood smear and osmotic fragility testing. Splenectomy is the definitive treatment

Hamman sign

crunching sound heard over the mediastinum in the presence of mediastinal air.

Obturator hernia

develop in the obturator foramen and are more common in elderly women, usually in the setting of significant weight loss. As they do not produce an external or palpable mass, diagnosis is very challenging. Patients can present with pain and decreased sensation along the medial thigh to the knee or symptoms associated with small bowel obstruction if the hernia becomes incarcerated.

PCP intoxication

dissociative anesthetic that causes agitated behavior and CNS stimulation. Nystagmus, rhabdomyolysis, renal failure, and traumatic injuries can all occur, but serotonergic effects and hyponatremia are not common.

Nephrotic syndrome

form of glomerular proteinuria characterized by significant proteinuria (3.5 g/24 hrs), hypoproteinemia, hyperlipidemia, and peripheral edema. It may be caused by a primary glomerular process (i.e., minimal change disease, focal segmental glomerulosclerosis) or secondary to diabetes or lupus.

Burkitt's lymphoma

form of non-Hodgkin lymphoma. It is considered the fastest growing human tumor and unlikely to grow slowly over the course of four months. Although neck masses can occur, in the United States the intra-abdominal form of the disease is most common What virus is most commonly associated with Burkitt lymphoma? Epstein-Barr virus.

What is the trauma triad of death?

hypothermia, acidosis, coagulopathy

Preiser disease

idiopathic (no previous fracture) avascular necrosis of the scaphoid

Roseola (Sixth Disease)

illness common in children from birth to 2 years of age; symptoms begin with a high fever followed by a red-colored skin rash; caused by herpesvirus 6 (HHV-6) and possibly herpesvirus 7 (HHV-7) typically seen in children between 6 months and 2 years of age and presents with a history of high fever of three days' duration and mild symptoms. The fever abates abruptly, followed by the appearance of a macular rash on the trunk and thighs. It is caused by Human herpesvirus 6

TRALI (transfusion related acute lung injury)

immune-mediated reaction causing acute lung injury and resultant pulmonary capillary leak. Signs and symptoms include respiratory distress, fever, hypotension, and noncardiogenic pulmonary edema. It develops within 2 to 8 hours after a transfusion, and can be life-threatening. TRALI is thought to occur due to cytokines in the donor blood or interactions between host and donor blood antigens and antibodies causing pulmonary vascular permeability. Treatment is supportive. A patient with TRALI will have evidence of pulmonary edema on chest radiograph and have abnormalities in vital signs.

Gram negative diplococci

include Neisseria sp., Moraxella sp., Acinetobacter sp., and Brucella sp

Gram negative bacilli (rods)

include a number of organisms common in pneumonia including Klebsiella, Pseudomonas, and Haemophilus sp

Quadriceps tendon rupture

include the inability to extend the knee, inferior patellar displacement, indentation superior to the patella, and tenderness superior to the patella. Quadriceps tendon rupture is more common in individuals over 40 years of age with systemic comorbidities that place them at risk for underlying tendon weakness.

Immediate irrigation using Morgan lens

indicated for chemical burns, but will not help in the treatment of corneal abrasions.

Narcissistic

individuals have a distorted sense of self-importance and believe they deserve special treatment.

Mononucleosis

infection caused by Epstein-Barr virus and is most common in 15 to 24 year-olds. Patients usually experience a several day prodrome of fever, chills, malaise, and anorexia followed by the onset of throat pain, fever, and lymphadenopathy. The diagnosis is supported by heterophile (Monospot) antibody testing. Treatment is supportive and the illness is generally self-limited, though some patients may experience residual symptoms of malaise and fatigue for months following initial diagnosis.

Optic neuritis

inflammation of the optic nerve, causing a decrease in visual acuity and changes in color perception Can also cause acute vision loss with pain, but the latter is typically associated with extraocular movements. In addition, an afferent pupillary defect is usually present

Phosgene Gas

interferes with oxygen diffusion across the alveoli, leading to respiratory distress. It smells like freshly cut hay or grass, commonly causing victims to inhale deeper, allowing for more widespread pulmonary effects. Treatment is supportive.

Babesiosis

malaria-like illness caused by the protozoan Babesia microti. It is transmitted by Ixodes ticks in the northeastern United States. It also has been acquired by transfusion. Like malaria, the protozoan infects red blood cells, causing fever, drenching sweats, myalgias, and headache. It is occasionally associated with a rash.

Patella Fracture

manifests as pain, swelling, and ecchymosis over the patella. It is most commonly a transverse fracture, in which the quadriceps tendon pulls the superior patella upward and causes a wide displacement of the fracture fragments.

First-Degree Atrioventricular Block

manifests on ECG as a PR interval which is greater than 200 milliseconds. The PR interval will be consistent and each P wave will have an associated QRS. This conduction deficit occurs at the level of the atrioventricular node. Patients are often asymptomatic and require no treatment, although drugs that prolong the PR interval should be avoided in these patients.

Are inguinal hernias more common in men or women?

men

Salicylate toxicity

metabolic acidosis + respiratory alkalosis, hyperthermia, tinnitus, vertigo Patients who present with salicylate overdose will generally have tachypnea, nausea, vomiting, vertigo, and altered mental status. They do not present with signs of liver failure. The potassium level is important in patients presenting with salicylate toxicity as alkalinization of the urine with sodium bicarbonate can lead to life-threatening hypokalemia. A venous blood gas would be useful in salicylate toxicity to monitor the patient's acid-base status during treatment with sodium bicarbonate for progress and to prevent over-alkalinization of the serum.

Paranoid Personality Disorder

pattern of distrust and suspiciousness; others' motives are interpreted as malevolent

Rumpel-Leede phenomenon

phenomenon seen in Rocky Mountain spotted fever when petechiae form after blood pressure cuff inflation

Herpes keratitis

presents on fluorescein exam with dendritic lesions with or without the classic clear vesicles on the eyelid or conjunctiva. It is treated with a topical antiviral, like trifluridine, cycloplegics, and an emergent ophthalmologic evaluation.

Scarlet fever symptoms

presents with fever, malaise, and sore throat followed by a fine sandpaper-like rash.

Slipped Femoral Capital Epiphysis (SFCE)

refers to apparent posterior and inferior slippage of the proximal femoral epiphysis on the metaphysis, and it is most common in overweight adolescent males between 12 and 16 years of age. Patients with SCFE present with a progressive limp and pain localized to the groin, thigh, or knee. Most common in boys 12-16 yo -obese with underdeveloped sexual characteristics (most common) or -tall, slender, rapid growing

Duodenal atresia

result of failure of the small bowel to recanalize during early development. Infants will present with gastric distension and vomiting. It is often associated with other gastrointestinal and cardiac malformations. A quarter of patients with duodenal atresia have Down syndrome.

Left sided heart failure

results from an abnormality in systolic or diastolic cardiac function. Chronically increased left heart pressures in poorly controlled heart failure can lead to cor pulmonale, but in most patients, this does not occur.

What is an anaphylactoid reaction?

same clinical effects as anaphylaxis but *NOT IgE mediated*... more common in *Pts taking beta blockers* or NSAIDS, exercise

Esophageal Varices

swollen, twisted veins in the esophagus that are especially susceptible to ulceration and hemorrhage Nasogastric Tube (NGT) GI decontamination Diaphragmatic injury: NGT coiling on CXR TEF: coiling of NGT in proximal esophagus Facial trauma: NGT may enter cranium or facial soft tissues Radiograph to confirm placement What is the most reliable method to confirm correct placement of a nasogastric tube? Radiographic evidence that the tube is in the stomach.

Uhthoff phenomenon (MS)

transient worsening of vision with increased body temperature (Seen with Optic Neuritis, MS)

Ascending cholangitis

true emergency - reynold's pentad -fever, jaundice, ruq pain, MS changes, hypotension not a sonographic diagnosis, but one made clinically in patients with abdominal pain, fever, and jaundice.

paranoid personality disorder

type of personality disorder characterized by extreme suspiciousness or mistrust of others

SCORTEN Score for SJS/TEN

used to determine prognosis and clinical setting for treatment

Pellagra

vitamin B3 (niacin) deficiency, characterized by diarrhea, dermatitis, and dementia. Desquamation, keratosis, and erythema of sun-exposed skin are the common cutaneous findings

Acute Pericarditis ECG

​No reciprocal ST-segment depression (except aVR, V1) PR-segment depression (not specific) PR elevation in aVR

Isoniazid (INH): Toxicity

↓ B6 (pyridoxine) → ↓ GABA → refractory seizures with anion gap metabolic acidosis Antidote: B6

How are button batteries differentiated from coins on X-ray?

Button batteries appear as a double-ring or halo.

Tinea cruris

"jock itch", most commonly affects adolescent and young adult males, and involves the upper thigh and groin. The scrotum itself is usually spared in Tinea cruris, but involved in candidiasis

Tinea corporis

"ringworm"; typically presents as a red, annular, scaly, pruritic patch with central clearing and an active border. Lesions may be single or multiple and the size generally ranges from 1 to 5 cm, but larger lesions and confluence of lesions can also occur. Tinea corporis may be mistaken for many other skin disorders, especially eczema, psoriasis, and seborrheic dermatitis. A potassium hydroxide (KOH) preparation is often helpful when the diagnosis is uncertain based on history and visual inspection

Acute Respiratory and Metabolic Acidosis and Alkalosis

(Normal ABG values pH 7.35-7.45; PaCO2 35-45 mm Hg; bicarbonate 22-26 mEq/L) Respiratory AcidosispH < 7.35; PaCO2 > 45 mm Hg; bicarbonate normal Respiratory AlkalosispH > 7.45; PaCO2 < 35 mm Hg; bicarbonate normal Metabolic AcidosispH < 7.35; PaCO2 normal; bicarbonate < 22 mEq/L Metabolic AlkalosispH > 7.45; PaCO2 normal; bicarbonate > 26 mEq/L

Stevens-Johnson Syndrome

(SJS) is an acute life-threatening mucocutaneous reaction characterized by extensive necrosis and epidermal detachment involving < 10% of total body surface area. A hallmark of SJS is that the positive Nikolsky sign, vesiculobullous lesions are most often found on mucosal surfaces, including the mouth, eyes, vagina, urethra, and anus. Medications most often associated with SJS are antibiotics and anticonvulsants. Two drugs of note are sulfamethoxazole/trimethoprim and lamotrigine due to their classic association with SJS. Unfortunately, the inciting agent is not identified in about half of all cases.

Thiamine Deficiency (B1)

(vitamin B1), is a water-soluble vitamin not stored in the body to any significant extent, and is, therefore, subject to deficiencies in patients with poor diet, including alcoholics, pregnant women suffering from hyperemesis gravidarum, and patients with anorexia nervosa. Thiamine deficiency may result in neurologic consequences such as Wernicke encephalopathy. It is not associated with macrocytic anemia

Digibind (digoxin immune fab)

-treatment for digoxin toxicity -dosage determined by serum digoxin level -side effects: low cardiac outputs, anaphylaxis Binds molecules of digoxin, making them unavailable for binding at their site of action on cells in the body.

What age group is most affected by both pre- and postseptal cellulitis?

< 10 years of age Preseptal Cellulitis (Periorbital Cellulitis) Anterior portion of eye, does NOT involve the globe More common in children May follow trauma or bites Pain, swelling, erythema on exam Clinical diagnosis, consider CT if unsure of orbital involvement Treat with oral antibiotics, usual duration is 5-7 days

How many colony-forming units are necessary for a positive urine culture?

> 100,000.

Eye Chemical Burn

Alkaline burns Liquefaction necrosis → damage to cornea, iris, lens Penetrates faster and deeper than acidic burns Acidic burns Coagulation necrosis Limited depth of injury Immediate irrigation (NS or LR) until pH is 7.0-7.2

What fluid does the U.S. military currently recommend to use for decontamination after mustard gas exposure?

Alkaline hypochlorite solution or diluted household bleach. Mustard Gas (Sulfur Mustard) Vesicant Remove from source Decontamination Systemic toxicity (eyes, lungs, mucosal membranes, skin) May cause bone marrow suppression

What is the disposition for patients with known colchicine ingestion but limited symptoms?

All symptomatic patients should be admitted to the hospital due to an elevated risk of sudden cardiac death within the first 24-48 hours. Colchicine Poisoning GI distress Pancytopenia Multisystem organ failure, sudden cardiac death

Torus fracture

A deformity in children caused by the longitudinal compression of the soft bone in either the radius or ulna, or both, and characterized by localized bulging most common pediatric radial fractures. Complications are rarely seen, likely because there is no true cortical disruption. These fractures usually heal in two to four weeks with immobilization

How does immersion in a 5% acetic acid solution help with pain control in patients stung by jellyfish?

By inactivating the nematocysts still embedded in the skin. (Not recommended for Portuguese man-of-war stings.) Marine Animals with Stingers Stingrays, venomous fish, sea urchins, cone shells Local Sx Systemic Sx rare Rx: stinger removal, hot water immersion

Myocarditis Summary

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

What is the most common site of foreign body aspiration?

The right main-stem bronchus Foreign Body Aspiration Sudden episode of coughing PE: asymmetric decreased breath sounds, wheezing, stridor Most common site is the right mainstem bronchus CXR: inspiratory/expiratory films show hyperinflation Tx: rigid bronchoscopy

Contact Dermatitis Summary

Allergic Contact Dermatitis Most commonly caused by nickel, poison ivy, soaps, and topical meds (neomycin) Dx: patch testType IV cell-mediated hypersensitivity reaction "Id" reaction - generalized cutaneous reaction in areas not exposed to allergen Irritant Contact Dermatitis Caused by prolonged contact with water, detergents, solvents, acids, alkali Tx: avoid causative agents, emollients, topical corticosteroids

What is the sensitivity of ultrasound for detecting pneumothorax?

The sensitivity approaches 100% when performed by an experienced operator. Ultrasound: Pneumothorax Sagittal plane at second intercostal space Absent pleural sliding = pneumothorax Stratosphere or barcode sign More sensitive than supine CXR

Schatzki ring

A fibrous ring located at the LES causes only large diameter foods to get stuck. most common cause of intermittent dysphagia with solids. It is due to the development of a fibrous stricture near the gastroesophageal junction. It is associated with "steakhouse syndrome"—food impaction in the esophagus due to poorly chewed meat This will be a very episodic (months in between) dysphagia with odynophagia. A barium swallow will show a narrowed lumen and an EGD will yield definitive diagnosis with visualization and biopsy. Breaking the ring will alleviate symptoms.

What is the choroidal tubercle?

A granuloma in the choroid of the retina that is specific for disseminated TB

What newer therapeutic intervention for abscesses can be considered to decrease incision size and need for packing changes?

A loop drain

Myocarditis signs and symptoms

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

V-tach

*SHOCK* synchronized on R wave 140-250 can lead to cardiac arrest bigeminy-every other beat trigeminy-every 3rd beat give O2 if stable unstable: shocks, CPR, O2, antidysrhytmics, cardioversion

Mobitz Type II

- Dropped beats that are not preceded by a change in the length of the PR interval - Often found as a 2:1 block, where there are 2 or more P waves to 1 QRS complex. - Treatment: pacemaker Atrioventricular block occurs when there is a delay in conduction of impulses at the level of the atrioventricular node, the His-Purkinje fibers or lower regions of the heart's conduction system. This delay in conduction can be visualized on an ECG. In Mobitz type 2 second degree atrioventricular block, there is a blockage of conduction in the His bundle or lower regions of the cardiac conduction system. This conduction defect will manifest on ECG as consecutively conducted beats with the same PR interval, followed by a blocked P wave. The QRS is usually wide, and the heart rate is usually bradycardic. Patients may be asymptomatic or may complain of an irregular heartbeat, dizziness, lightheadedness, or syncope. Patients with Mobitz type 2 second degree atrioventricular block who complain of chest pain may be suffering myocarditis or ischemia. Mobitz type 2 block is likely to progress to complete heart block, and therefore symptomatic patients often need placement of an implanted pacemaker.

First degree AV block

- PRI >5 boxes/.20 sec - Fixed but prolonged PRI (consistent but long) - normally get bradycardia here recognized by a prolonged PR interval without any dropped beats

Basilar Skull Fracture Signs/Symptoms

- Petrous portion of temporal bone fracture most common - Battle sign, raccoon eyes, hemotympanum, CSF otorrhea and rhinorrhea - CN VII, VIII entrapment - CT

Brown Recluse Spider

- TX: supportive - Antibiotics - Anti-inflammatories - Swelling - Dapsone - [Used to treat leprosy)

What is the "Hamman crunch"?

-Found in pneumomediastinum. -Crackling, crunching, rasping sound, synchronous with the heartbeat, heard over the precordium during systole -Caused by the movement of air in the mediastinum

What percentage of children will have a recurrent febrile seizure?

50% of children < 12 months and 30% of children > 12 months. Overall, the risk of epilepsy in children is ~1%, with a slight increase post febrile seizure. Febrile Seizure Age: 6 months to 5 years Simple Number of seizures: 1 Duration: < 15 mins Type: generalized Simple: no further workup, reassurance Complex Number of seizures: > 1 in 24 hrs Duration: > 15 mins Type: focal or generalized Complex: further workup depending on age and clinical picture

What percentage of patients with a tick-borne illness recall a tick bite?

50-70%. Rocky Mountain Spotted Fever (RMSF) History of recently being in the woods, hiking, or camping Abrupt onset of severe headache, photophobia, vomiting, diarrhea, and myalgia PE will show maculopapular eruption on palms and soles Most commonly caused by Rickettsia rickettsii Empiric treatment based on clinical presentation Diagnosis confirmed by serologic testing Treatment is ALWAYS doxycycline, even in children

To reduce the risk of secondary cases of meningococcemia, chemoprophylaxis with oral rifampin is necessary for household contacts and anyone who has had direct exposure to an index case's oral secretions up to how many days before the index case's onset of illness?

7 days Meningococcemia Patient will be a military recruit or student Fever, HA, arthralgias, rash PE will show petechiae, skin lesions with gray necrotic centers Diagnosis is made clinically and can be confirmed by blood cultures and Gram stain, as well as lumbar puncture Most commonly caused by Neisseria meningitidis, an aerobic, gram-negative diplococcus Treatment is ceftriaxone Waterhouse-Friderichsen syndrome: bilateral adrenal hemorrhage + meningococcemia

How many days after chemotherapy is the predicted nadir of the absolute neutrophil count (ANC)?

7-10 days after chemotherapy. Neutropenic Fever One oral temperature of ≥ 38.3°C or ≥ 38°C for ≥ 1 hour + neutropenia Leading cause of cancer death: infection Obtain cultures Rx: empiric antibiotics, admission as needed

Which of the following patients with a renal stone should be considered for admission? A A 24-year-old man with a 5 mm stone at the ureterovesicular junction who presents with intractable nausea and vomiting B A 33-year-old pregnant woman with a 2 mm stone at the ureteropelvic junction who is tolerating oral intake and has 2+ hematuria C A 37-year-old man with a 3 mm stone at the pelvic brim whose ultrasound shows no hydronephrosis and urinalysis shows 2+ blood and 5-10 WBCs D A 45-year-old man with a 7 mm renal stone at the ureterovesicular junction who required a single dose of pain medication to resolve his pain

A A 24-year-old man with a 5 mm stone at the ureterovesicular junction who presents with intractable nausea and vomiting Most patients with renal stones may be safely discharged home from the ED. A patient with intractable nausea and vomiting, should be admitted to the hospital for symptomatic treatment relief and fluid resuscitation. Sepsis and renal damage are risks in the presence of obstruction and infection. These patients require immediate urologic consultation to evaluate the need for drainage and for relief of the obstruction by ureteral stenting. If infection is present, patients require fluid resuscitation and antibiotics.

Which of the following patients has a positive Mantoux test? A A 32-year-old man, who is immunocompetent, with 15 mm induration B A 36-year-old woman, with HIV, with 6 mm of erythema but no induration C A 42-year-old man, who previously received bacillus Calmette-Guérin immunization against tuberculosis, with 9 mm induration D A 51-year-old woman, who uses intravenous drugs, with < 5 mm induration

A A 32-year-old man, who is immunocompetent, with 15 mm induration The Mantoux test is used to screen for tuberculosis (TB) exposure. Tests are administered to individuals at high risk for latent TB infection, including health care workers. Testing is performed by injecting 0.1 mL of purified protein derivative (PPD) into the forearm. At 48-72 hours, this injection site is assessed for induration. Induration is the result of a delayed hypersensitivity reaction. Positive results vary depending upon the individual's risk factors for tuberculosis. Patients with ≥ 5 mm induration are considered positive if they have HIV, have close contact with someone with active infection, have previous chest X-ray findings suggestive of healed infection, or have organ transplants and are on immunosuppressive agents. Patients with ≥ 10 mm induration are considered positive if they use intravenous drugs, have immigrated from endemic areas of the world, reside in long-term care facilities, or are under the age of 4 years. Patients with ≥ 15 mm induration in otherwise healthy, immunocompetent adults are considered positive. What is the next step in care for a patient who presents with a positive purified protein derivative (PPD) test? A posteranterior and lateral chest X-ray to evaluate for active disease

A 19-year-old man presents with multiple painful ulcers on his penis. He also reports painful urination. Genital examination reveals multiple purulent-based, sharply defined, circular ulcers on the shaft of the penis and tender, enlarged, inguinal lymph nodes. Which of the following is the most appropriate treatment regimen? A A single dose of oral azithromycin B A single intramuscular injection of benzathine penicillin G C A three day course of oral nitrofurantoin D Weekly intramuscular injections of benzathine penicillin G for three weeks

A A single dose of oral azithromycin The patient has chancroid. This is a sexually transmitted infection caused by the gram-negative bacteria Haemophilus ducreyi. Painful ulcers with purulent bases develop one week after inoculation. Painful inguinal lymphadenopathy often develops and this can progress to a bubo, a large unilateral fluctuant lymph node. If the ulcers contact the urethra, the patient may experience dysuria. Chancroid should be distinguished from syphilis, which is characterized by a clean-based, painless, and usually solitary chancre. Treatment is with a single dose of oral azithromycin, a single intramuscular injection of ceftriaxone, or a single dose of oral ciprofloxacin.

A 67-year-old woman presents complaining of dark urine. Over several months she has had increased fatigue and weight loss. There has not been any fever or night sweats. On physical examination, her abdomen is soft, non-distended with a palpable mass in the right upper quadrant that is non-tender. Her laboratory values are notable for a total bilirubin of 6.4 mg/dl and a direct bilirubin of 5.0 mg/dl. Which of the following imaging studies is the next best step in the workup? A Abdominal CT scan B Endoscopic retrograde cholangiopancreatography C Right upper quadrant ultrasound D Upper GI series

A Abdominal CT scan The patient's symptoms are concerning for pancreatic cancer. This patient has developed fatigue, weight loss, and an abdominal mass, a classic presentation of someone with a mass at the head of the pancreas compressing the bile duct. Patients will often also complain of weight loss typically due to loss of appetite. The imaging study of choice in this situation is an abdominal CT scan. What is the name of the mass palpable in the right upper quadrant in a patient with pancreatic cancer? Courvoisier sign: an enlarged, painless, palpable gallbladder.

A 2-year-old boy presents to the emergency department with his mother for abdominal pain that started just prior to arrival. He has no significant past medical history other than a mild upper respiratory illness last week which resolved. She describes him as screaming in pain and inconsolable for about 15 minutes. He had one episode of nonbilious vomiting. On examination, he is afebrile and sleeping comfortably in his mother's arms. His abdomen is soft, with no significant tenderness to palpation and no masses appreciated. Shortly after your first interaction with the patient, the nurse notifies you that the child is screaming in pain again. What is the most appropriate test to determine the diagnosis? A Abdominal ultrasound B Acute abdominal series C Computed tomography scan of the abdomen and pelvis D Upper gastrointestinal series

A Abdominal ultrasound This child presents with symptoms concerning for intussusception. The most common cause of intestinal obstruction in children under 2 years of age, it results from telescoping of one point of intestine into another. Ileocolic intussusception is most frequently seen. In younger children, the lead point is often the result of enlarged Peyer's patches from a recent viral illness. Older children are more likely to have an underlying lesion, such as a Meckel's diverticulum. The classic triad of symptoms includes cyclic abdominal pain, nonbilious vomiting, and bloody diarrhea. During the periods of abdominal pain, the child is often inconsolable. When the pain subsides, the child initially is often well appearing, but may become more lethargic as symptoms progress. Currant jelly stool, diarrhea mixed with blood and mucus, is often associated with intussusception but infrequently encountered. Occasionally, a sausage-like mass in the right lower quadrant can be palpated. Abdominal ultrasound is the diagnostic modality of choice and will show a target sign on transverse view

A 5-week-old male infant presents to the ED with nonbilious emesis. Per parents, the patient seems hungry, but 5-10 minutes after drinking 3 ounces of formula, he spits up. This was initially sporadic, but it now occurs with every feeding. His mother describes the vomiting as forceful. On exam, the patient appears well hydrated with a temperature of 37.4°C, pulse of 150 bpm, and respiratory rate of 30/min. His abdomen is nondistended with no masses or palpable organomegaly. The patient has a strong suck and symmetrical Moro reflex. Which of the following diagnostic tests should be ordered to confirm the diagnosis? A Abdominal ultrasound B Abdominopelvic CT scan C Basic metabolic panel D Nasogastric tube insertion E Upper GI series

A Abdominal ultrasound This patient has pyloric stenosis, the most common cause of gastric obstruction in infants. It is characterized by progressive postprandial, nonbilious vomiting that steadily increases in frequency and amount due to hypertrophy of the pyloric musculature and edema of the pyloric canal, producing gastric outlet obstruction. Infants typically present with symptoms at 2-8 weeks, but they may occur up to 5 months of age. Due to persistent vomiting, hypochloremic hypokalemic metabolic alkalosis with dehydration is commonly noted. Failure to thrive may also be seen if the diagnosis is not made early in the course. -Males (4 to 1 predominance) Up to 90% of infants exhibit the pathognomonic pyloric olive, which is due to hypertrophy of the antral and pyloric musculature and is best palpated in the epigastrium or right upper quadrant. If a palpable mass is detected, no imaging is indicated and direct surgical consultation is warranted. However, if the diagnosis is less certain and there is no palpable mass detected, an ultrasound should be obtained.

Which of the following is considered a hard sign in penetrating neck trauma? A Absent radial pulse B Dysphagia C Minor hematemesis D Subcutaneous emphysema

A Absent radial pulse Hemodynamically stable patients with penetrating neck trauma should be evaluated for the presence of soft and hard signs of aerodigestive or neurovascular injury. Most patients with hard signs benefit from surgical intervention. An absent radial pulse is a hard sign suggestive of significant injury.

A 23-year-old man presents to an emergency department in Connecticut with one week of fevers, night sweats, fatigue, and generalized body aches. On exam, there is a 20 cm targetoid rash in the right popliteal fossa that he notes has been slowly enlarging over the past four days. The patient was started on the appropriate antibiotic yesterday for the most likely diagnosis. Which of the following adjunctive treatments can be used to manage common complications of this antibiotic? A Acetaminophen and sunscreen B Diphenhydramine C Prednisone D Whitening toothpaste

A Acetaminophen and sunscreen This patient is presenting with signs of symptoms consistent with early localized lyme disease. Lyme disease is a spirochetal infection caused by Borrelia burgdorferi and is transmitted by bite of an Ixodes tick. It is the most common tick-borne disease in the United States and is primarily found in the northeast and upper midwest. There are three stages of Lyme disease. 1. Early localized Lyme disease usually occurs within seven to 14 days of infection and is characterized by systemic nonspecific symptoms (fatigue, anorexia, headache, neck stiffness, myalgias, and arthralgias) and erythema migrans. Erythema migrans is characterized by a slowly expanding pruritic or burning rash that develops central clearing then a targetoid appearance. It is typically in the axilla, popliteal fossa, or inguinal region. 2. Early disseminated Lyme disease is characterized by the early development of multiple erythema migrans rashes with delayed neurologic or cardiac sequelae and may not be preceded by early localized Lyme disease. Neurologic manifestations include peripheral neuropathies and cranial nerve palsies, including bilateral Bell's palsy. Cardiac manifestations include atrioventricular nodal block and myopericarditis. 3. Late Lyme disease is characterized by large-joint arthritis and mild encephalopathy. Treatment of early localized Lyme disease includes doxycycline or amoxicillin. Doxycycline is generally preferred as it also treats anaplasmosis, which is caused by coinfection with Anaplasma phagocytophilum. Pregnant women should be treated with amoxicillin. Recent guidelines suggest that doxycycline should be used in children < 8 as long as the duration of treatment is < 21 days. Common side effects of doxycycline therapy include photosensitivity, which can be managed with sunscreen, and the Jarisch-Herxheimer reaction.

A 69-year-old diabetic man presents to the ED after a witnessed seizure-like event at a family reunion. His family states that his behavior has changed and he has been having auditory hallucinations. His vital signs are T 103.1°F, HR 120 beats/minute, RR 14 breaths/minute, BP 132/84 mm Hg, and oxygen saturation 97% on room air. He is awake and follows most commands. He is fully exposed and a crusting vesicular rash is seen on his groin. A noncontrast head CT is ordered. Which of the following should be administered at this time? A Acetaminophen orally and acyclovir IV B Ceftriaxone IV and azithromycin IV C Cyproheptadine and a crystalloid bolus D Vancomycin, ceftriaxone, and dexamethasone

A Acetaminophen orally and acyclovir IV The clinical presentation of encephalitis can be variable, but the classic presenting features include fever, headache, and altered mental status. Encephalitis should be considered in any patient with these findings plus the addition of new behavioral changes such as psychiatric symptoms (e.g., hallucinations), cognitive decline, or seizures. The presence of a vesicular rash suggests herpes simplex virus (HSV) encephalitis. In the setting of fever, a vesicular rash, and neurocognitive changes, acetaminophen orally and acyclovir IV should be initiated without delay. Encephalitis can have many other causes including herpes zoster virus, cytomegalovirus, rabies, and Epstein-Barr virus. HSV accounts for up to half of all known cases. The diagnostic workup includes neuroimaging with CT or MRI along with a lumbar puncture. HSV encephalitis classically shows hyperattenuation of the temporal lobes and insular cortex on CT. Antiviral therapy should not be delayed and should be given empirically if viral encephalitis is suspected. Cytomegalovirus encephalitis should be treated with ganciclovir IV. Rabies is usually fatal despite aggressive treatment. Herpes Encephalitis Patient presents with HA, fever, behavioral changes CSF will show ↑ RBCs MRI will show temporal lobe edema Treatment is acyclovir Most common cause of nonepidemic encephalitis in the US What are three viral causes of encephalitis traveling in a retrograde fashion within nerve axons from a distal site to the central nervous system? Rabies, herpes simplex virus, and herpes zoster virus

Assuming no contraindications or medication allergies, what is the first-line recommended treatment regimen for acute pain in an emergency department patient presenting with an isolated musculoskeletal injury? A Acetaminophen orally plus nonsteroidal anti-inflammatory drug orally or intravenously B Fentanyl 50-100 mcg intravenously C Hydromorphone 0.5-1 mg intravenously D Morphine 6-10 mg intravenously

A Acetaminophen orally plus nonsteroidal anti-inflammatory drug orally or intravenously A combination of acetaminophen 1,000 mg orally plus a nonsteroidal anti-inflammatory drug (NSAID) equivalent to 400-600 mg of oral ibuprofen has been shown to provide superior pain relief when compared to standard doses of intravenous opiate analgesics for acute pain. This combination treatment should be considered in all patients who are able to take oral medications. Opiate analgesics should be avoided when possible to decrease the risk of respiratory depression, sedation, and dependence. How much intravenous ketorolac is therapeutically equivalent to 400-600 mg of oral ibuprofen? 7.5-15 mg.

A 26-year-old man presents with two days of left ear pain. He notes that the symptoms started with an itchy ear that progressed to pain, discharge, and mild hearing loss. On examination, there is tenderness with manipulation of the auricle, with edema, erythema, and narrowing of the auditory canal. Which of the following is useful in treating this condition? A Acetic acid otic washes B Antihistamines C Oral amoxicillin D Tympanostomy tubes

A Acetic acid otic washes This patient has otitis externa, also called "swimmer's ear." This infection is characterized by pruritus, pain, and tenderness of the external canal. Trauma and excessive moisture are common precipitants of this condition. Patients may present with otorrhea, otalgia, and tenderness with manipulation of the pinna (especially the tragus). With progression, pain may be present with mastication or any movement of the periauricular skin. When chronic, narrowing of the tympanic canal and hearing impairment may occur. There are many different treatment modalities for otitis externa. Though topical antibiotics are typically administered, acetic acid drops are effective and may be used, particularly in patients who cannot afford prescription medications

A 50-year-old man presents to the emergency department with left ankle pain that started last night after a tennis match. He heard a pop when trying to change directions quickly. On exam, the patient's left posterior ankle is swollen. There is no focal bony tenderness; however, the Thompson test is positive. Which of the following is the most likely diagnosis? A Achilles tendon rupture B Medial deltoid ligament sprain C Peroneal tendon subluxation D Tibiofibular syndesmotic ligament injury

A Achilles tendon rupture Achilles tendon rupture is an acute ankle injury that is often misdiagnosed as an ankle sprain. It is commonly seen in older athletes during recreational sports. The mechanism of injury is forceful plantar flexion against resistance. Patients will typically have tenderness and swelling to an area 2 to 6 cm proximal to the insertion site of the Achilles tendon. Usually, this is easily diagnosed clinically by an abnormal calf squeeze test or Thompson test. To perform this test, the patient should be lying prone. As the clinician squeezes the gastrocnemius, an intact Achilles tendon will cause plantar flexion of foot. If there is absence of plantar flexion, this indicates a rupture of the Achilles tendon. Once diagnosed, the patient's leg should be splinted with the ankle in moderate plantar flexion and referred to orthopedics.

A 3-year-old girl was walking on the sidewalk with her parent when she fell onto the street. In a panicked state, her parent picked up the child by her arm. Immediately after, the child refused to move her right arm, reporting that it hurt. In the emergency department, the girl is holding her right arm in a flexed, pronated, and adducted position. There is no crepitus, swelling, or point tenderness along the entire right arm or clavicle. Which of the following is the next step in the management of this patient's condition? A Actively supinate and flex the elbow while applying pressure over the radial head B Consult orthopedics for casting C Obtain an ultrasound D Perform a skeletal survey

A Actively supinate and flex the elbow while applying pressure over the radial head This child has a pulled elbow that is due to subluxation of the annular ligament rather than dislocation of the radial head. The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn. It occurs in toddlers due to traction via pulling on a pronated and extended arm. The child immediately refuses to move the arm and often cradles the affected arm. Parents often give a history of a young child with no history of trauma who suddenly refuses to use an arm. The diagnosis is clinical, and imaging studies are generally not needed. If reduction is unsuccessful after two to three attempts, imaging studies may be warranted. Treatment is manual reduction via supination and flexion or hyperpronation. A palpable click may be felt, and the child usually regains immediate movement of the arm and relief of discomfort Pulled Elbow (Radial Head Subluxation, Nursemaid Elbow) Patient will be a child 1-4 years old History of being pulled up by the wrist PE will show the affected arm held close to the body in a flexed and pronated position Most commonly caused by longitudinal traction on a pronated forearm while the elbow is extended Treatment Hyperpronation method: apply pressure to the radial head and hyperpronating the forearm Supination-flexion method: supinate and fully flex the elbow while applying pressure to the radial head and pulling with gentle traction

A 55-year-old woman presents to the ED with acute loss of vision in her right eye. She describes cloudiness in her visual field associated with eye pain and a headache. On examination, her visual acuity is markedly decreased in the affected eye, and she has a mid-dilated and sluggishly reactive pupil. What is the most likely diagnosis? A Acute angle-closure glaucoma B Central retinal artery occlusion C Central retinal vein occlusion D Optic neuritis

A Acute angle-closure glaucoma This patient has acute angle-closure glaucoma, which is associated with painful vision loss, headache, nausea, and vomiting. It is caused by an outflow obstruction of aqueous humor from the anterior chamber to the canal of Schlemm. As a result, intraocular pressure (IOP) rises and the pupil becomes mid-dilated with sluggishness or nonreactivity to light. There is often ciliary flush, and the cornea appears steamy or hazy. Patients often describe blurry vision with halos around lights. Mydriatics can precipitate acute angle glaucoma and should be avoided in patients with narrow anterior chambers.

In which setting is initiating allopurinol not appropriate in the treatment of gout? A Acute attack of gout B History of alcohol use disorder C Hyperuricemia greater than 8.0 mg/dL D In combination with colchicine

A Acute attack of gout Allopurinol therapy should never be initiated until the acute attack of gout has subsided. Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production but also produces a more soluble metabolite. Therefore, it is effective regardless of the cause of the hyperuricemia. Gout is caused by deposition of uric acid crystals in the synovium, bursae, tendon sheaths, skin, heart valves, and kidneys, which can lead to arthritis, tophi, renal stones, and gouty nephropathy. Typically, patients present with acute, exquisitely tender, monoarticular arthritis. The joint is usually warm and erythematous. The first metatarsophalangeal joint is most commonly affected. Detecting negatively birefringent, needle-like crystals in the synovial fluid from an arthrocentesis confirms the diagnosis. First-line treatment are NSAIDs. Indomethacin has traditionally been the NSAID of choice, but any NSAID can be used with similar efficacy. Colchicine (D) can be used in combination with allopurinol to help decrease the likelihood of a gouty flare while the uric acid level is decreasing after an acute attack has subsided. Colchicine decreases inflammation associated with lactic acid production and phagocytosis of urate. It terminates most gouty attacks within 6 to 12 hours but is limited by GI side effects.

A 56-year-old man presents to the ED with decreased urine output. His medical history is significant for hypertension and end-stage renal disease, for which he received a kidney transplant one month ago. He is taking mycophenolate for immunosuppression. On physical exam, he is febrile. The area over his graft is tender to palpation. His creatinine on discharge one month ago was 1.2 mg/dL. Today, it is 3.5 mg/dL. Urinalysis demonstrates 2+ protein, but no leukocyte esterase or nitrites. A renal ultrasound demonstrates good flow to the graft. What is the most likely etiology of this patient's renal failure? A Acute graft rejection B Drug toxicity from mycophenolate C Nephrotic syndrome D Renal artery thrombosis

A Acute graft rejection The patient in this scenario has acute graft rejection. Acute renal allograft rejection is characterized by decreased urine output, fever, pain over the graft site, and an increase in serum creatinine 20% or more above baseline. It is important to evaluate the patient for other potential causes of graft failure, such as thrombosis and infection. Rejection is mediated by an immune-mediated inflammatory reaction against the graft. Treatment is with high-dose immunosuppressant therapy in conjunction with the patient's transplant team. Mycophenolate is an immunosuppressant commonly used to prevent rejection after kidney transplant. Unlike other immunosuppressants, such as cyclosporine, nephrotoxicity is rarely associated with mycophenolate. When transplant patients present with graft failure, their medication list should be reviewed for nephrotoxic drugs. Renal artery and vein thrombosis rarely occur after the first month of transplant. An ultrasound of the kidney should be obtained to assess flow to the graft. The patient in this scenario is one month post-transplant and has normal blood flow to the kidney on ultrasound, making this diagnosis less likely.

A 25-year-old animal laboratory worker presents with paresthesias on his forearm. While at work 2 days ago, he was bitten on the arm by a monkey. Physical examination does not reveal any abnormalities other than the bite mark on his forearm. Which of the following is the most appropriate agent to administer? A Acyclovir B Ampicillin C Fluconazole D Vancomycin

A Acyclovir Primate bites are rare outside of research and zoo settings in the United States. Bites by primates are highly infectious although infecting bacterial organisms are not well identified. Monkeys carry Cercopithecine herpesvirus 1, also called Herpesvirus simiae or more simply, B virus, which is fatal to humans if not treated early. Treatment is with acyclovir. Humans can develop infections after bites or scratches. Following an incubation period of 2 days to 5 weeks, symptoms begin with paresthesias and subsequent development of vesicles. Untreated infection may lead to encephalitis and coma. Treatment with intravenous acyclovir improves survival, especially when started early.

A 72-year-old woman presents to the emergency department for evaluation of vomiting. Over the last 24 hours, she developed increasing abdominal pain. She is afebrile. On examination, she has a distended and diffusely tender abdomen without peritoneal signs. A plain film of the abdomen is shown above. What is the most likely etiology of her condition? A Adhesions B Hernia C Hypokalemia D Malignancy

A Adhesions Small bowel obstructions (SBOs) are a common diagnosis in the emergency department. The most common cause of an SBO is adhesions from a previous operation (60% of cases). Approximately 25% of patients who had intraperitoneal surgery and develop adhesions will have an SBO at some point in their lives. Patients present with abdominal pain, distention, nausea, and often vomiting. Frequently patients will describe the inability to pass flatus or have a bowel movement. In some cases, patients may have a small bowel movement or even diarrhea depending on the site and duration of obstruction. Plain radiographs will demonstrate dilated loops of small bowel, and on the upright image air-fluid levels within the dilated loops are visualized. Plain radiographs identify only 50% to 60% of obstructions and therefore are not considered definitive testing. Most patients will have a CT scan in order to identify the exact site of obstruction as well as to assess the integrity of the bowel for any ischemia.

A 46-year-old man presents to the emergency department in status epilepticus. He recently emigrated from South America. His family reports he has a history of type II diabetes mellitus and a "lung problem" for which he takes medications. Upon arrival, the patient is actively seizing and continues to seize despite aggressive treatment with diazepam, phenobarbital, and phenytoin. His glucose is 86 mg/dL, pH 7.16, and anion gap is 22 mEq/L. What is the most appropriate management for this patient? A Administer pyridoxine B Begin to titrate phenobarbital C Correct acidosis with sodium bicarbonate D Provide supplemental glucose E Treat potential alcohol withdrawal seizures with thiamine and folic acid

A Administer pyridoxine The patient is presenting with refractory seizures, acidosis, and an elevated anion gap suggestive of isoniazid (INH) toxicity. This is further supported by the history that the patient is from South America (an area with a much higher prevalence of tuberculosis) and has a history of an unknown lung disease. As such, he is likely to be taking isoniazid. INH alters the metabolism of pyridoxine, inhibiting its biologic actions. INH also interferes with the metabolism of the neurotransmitter GABA, predisposing patients to seizures. For this reason, patients taking INH and showing evidence of toxicity such as seizures and metabolic acidosis should be treated with pyridoxine (vitamin B6). Patients with INH toxicity often have seizures that are refractory to multiple anticonvulsive medications. Such refractory seizures produce lactic acid, which leads to the metabolic acidosis of INH toxicity; in the absence of seizures, this metabolic acidosis does not develop. The empiric dose of pyridoxine is 5 g IV slow IV push. In general, benzodiazepines (lorazepam, diazepam) are first-line agents for drug-induced seizures. Second-line agents include phenobarbital and Propofol. Patients with severe metabolic acidosis in the setting of INH toxicity may require sodium bicarbonate to help correct the acidosis, however, this does not address the underlying pathophysiology. Stopping the seizures with pyridoxine is the most critical action because status epilepticus may cause permanent neurological sequelae and even death.

A 32-year-old man presents to the ED with facial and mouth pain after being kicked in the face. On physical exam, you note significant swelling and deformity of the left inferior face, misalignment of the inferior premolars, and an associated intraoral laceration. Which of the following is the most appropriate management of this patient? A Admission and intravenous cephalosporin B Admission and intravenous metronidazole C Discharge with amoxicillin-clavulanic acid and close dental follow-up D Discharge with oxycodone and close dental follow-up

A Admission and intravenous cephalosporin This patient has signs and symptoms consistent with an open mandibular fracture. Management of mandibular fractures is variable depending upon location and whether the fracture is open or closed. Open fractures require admission and administration of intravenous antibiotics, such as a cephalosporin. Closed fractures may be discharged with dental follow-up. Many fractures will require open reduction and internal fixation. For this patient, he will require early operative intervention and, depending upon your institutional practice, otolaryngology, oromaxillofacial surgery, or plastic surgery will need to be consulted to manage his injury. The mandible is the second most commonly fractured facial bone behind the nasal bone. Signs and symptoms of a mandibular fracture include trismus, tooth misalignment, malocclusion of the bite, intraoral lacerations, and missing teeth. The tongue blade test is a way of detecting even subtle mandibular fractures. The patient bites the blade while the examiner attempts to break it. Inability to stabilize the blade is an indication that the patient may have a mandibular fracture and should undergo imaging. Plain mandibular X-rays and panoramic radiographs are appropriate screening tests for mandibular fractures; however, CT of the facial bones is the gold diagnostic standard for this injury. Most commonly in condyle, angle, or body of mandible

Post MVC, the restrained passenger of an automobile presents to the ED with lower abdominal pain. There is blood at the urethral meatus. A FAST examination is negative for free fluid in the abdomen. Vital signs are stable. A CT scan of the abdomen-pelvis with CT cystography is thus obtained, revealing an extraperitoneal bladder rupture and fractures of the left inferior and superior pubic rami. Which of the following should be part of the management plan for this patient? A Admission to the trauma service for continued observation B Application of a pelvic binder C Diagnostic peritoneal lavage (DPL) D Immediate consultation to urology for placement of a suprapubic catheter E Surgical repair of the bladder rupture within 24 hours

A Admission to the trauma service for continued observation Greater than two-thirds of bladder injuries result from blunt trauma. Most occur from motor vehicle collisions, with severe abdominal injury such as that which occurs with ejection from the vehicle or excessive compressive force from the seat belt on a distended bladder. Bladder injuries are classified as contusions, intraperitoneal ruptures, extraperitoneal ruptures, or a combination of intraperitoneal and extraperitoneal ruptures. The management of extraperitoneal bladder rupture is nonsurgical with Foley catheter urine drainage for one to two weeks to allow for spontaneous healing (assuming urethral injury has also been ruled out). None of the injuries sustained by this patient require an emergent procedure. However, given the reported mechanism and associated findings, it is reasonable to admit the patient for observation, serial exams, and urology consultation.

A 30-year-old military recruit presents to the emergency department during the summer with concerns of a heat-related illness. Which of the following exam findings best differentiates heat stroke from heat exhaustion? A Altered mental status B Anhidrosis C Temperature > 104 degrees F D Vomiting

A Altered mental status Heat stroke is an acute life-threatening illness that has a high morbidity and mortality, especially during the summer months. Patients are at risk for heat stroke if they are not properly acclimated to their environment. There are two types of heat illness: classic and exertional. These occur when the body's thermoregulatory mechanisms are overwhelmed causing damage to organ tissues. The most defining feature that differentiates heat stroke from heat exhaustion is altered mental status. The central nervous system is particularly vulnerable to extreme temperatures and can cause virtually any neurologic abnormality including ataxia, confusion, seizures, hallucinations, and coma. The extent of neurologic injury and mortality is directly related to the peak temperature and duration of the hyperthermia. Thus, cooling is by far the most important treatment. This should be done rapidly and as soon as possible, including cooling prior to transport to a hospital if feasible. Cold water immersion (ice water bath) is the most effective but may not be tolerated by some patients. Other means of cooling are ice packs, evaporative cooling, and cooling blankets. The goal of treatment is to get the patient to a temperature of 102.2oF or 39oC as quickly as possible. There are multiple overlapping signs and symptoms between heat exhaustion and heat stroke. However, patients with heat exhaustion will not have signs of neurologic impairment. Heat exhaustion is usually associated with volume depletion and causes vomiting (D), headache, fatigue, and muscle cramping. It is classically thought that patients with heat stroke will have anhidrosis (B) and will not be sweating. However, this clinical feature is inconsistent. In fact, over half of patients with heat stroke are found to be sweating. Thus, this should not be used to differentiate heat exhaustion versus heat stroke. It is true that a temperature > 104oF (C) is more frequently associated with heat stroke than heat exhaustion; however, heat exhaustion can potentially have temperatures above 104oF. What medications will increase the risk of a heat-related illness? Anticholinergic agents, beta-blockers, and sympathomimetic drugs can all interfere wit

A 27-year-old G1P0 woman at 12 weeks gestation presents to the emergency department with the above physical exam finding after hiking through the woods in Wisconsin. What is the most appropriate therapy? A Amoxicillin 500 milligrams orally three times daily B Ceftriaxone 1 gram intravenously every 12 hours C Doxycycline 100 milligrams orally two times daily D Rifampin 600 milligrams orally once daily

A Amoxicillin 500 milligrams orally three times daily This patient is exhibiting erythema migrans, a hallmark of Lyme disease. Lyme disease is the most common vector-borne disease in the United States. It is endemic to New England, the mid-Atlantic states, and the upper Midwest. It is caused by the spirochete Borrelia burgdorferi and transmitted by the Ixodes scapularis tick, more commonly known as the deer tick. The tick must be attached for more than 48 hours for transmission to occur. There are three stages of clinical Lyme disease. -Early Lyme disease is characterized by erythema migrans, an erythematous blanching patch that may have central clearing and classically has a bull's-eye appearance. Hematogenous spread leads to diffuse erythema migrans, which spares the palms and soles. -Acute disseminated Lyme disease occurs approximately 4 weeks after initial infection and can include meningoencephalitis, Bell palsy (which may be bilateral), or carditis, which often manifests with atrioventricular block. -Late Lyme disease develops greater than 1 year after initial infection and includes chronic arthritis with or without chronic subtle encephalopathy. Only 50% of patients remember a tick bite; thus, diagnosis may be difficult. Erythema migrans is diagnostic, but not all patients present with this finding. Initial screening involves enzyme-linked immunosorbent assay (ELISA) testing with western blot and PCR to confirm the diagnosis. If the diagnosis is suspected, empiric treatment should be administered. Treatment for early Lyme disease and mild acute disseminated Lyme disease in pregnant patients is amoxicillin 500 mg PO three times daily

What is the most common location of extrapulmonary tuberculosis?

Lymph nodes.

A 26-year-old woman presents to the ED after finding a tick attached to her right flank. She believes it has been there since she went hiking four days prior. On exam, you notice a red annular rash on her right flank with mild central clearing. A urine beta-hCG test is positive. Her last menstrual period was six weeks prior to this visit. What antibiotic prescription should this patient receive? A Amoxicillin, 14 days B Doxycycline, 7 days C Erythromycin, 7 days D Trimethoprim-sulfamethoxazole, 14 days

A Amoxicillin, 14 days This patient has a history and physical exam consistent with Lyme disease. Her rash is classic for erythema migrans, seen in 60-80% of those with Lyme disease, usually in the first several days after a tick bite. This first stage of Lyme disease needs to be treated before it progresses to more serious symptoms affecting the neurological and cardiovascular systems. The presence of erythema migrans requires she be treated with a 14-day course of amoxicillin given she is also pregnant. Doxycycline (B) is the first-line therapy for Lyme disease in the general population. It is safe to use in children if used for less than 21 days. Although adverse bone and teeth effects to the fetus due to doxycycline use are extremely rare, amoxicillin is still the first drug of choice in pregnant women. When used in nonpregnant patients, doxycycline should be given for 14-21 days.

An 18-year old woman is diagnosed with a spontaneous first trimester complete abortion at 10 weeks. Her blood type is found to be O-negative. She does not know the father's blood type. Which of the following is true? A Anti-D immune globulin must be administered within 72 hours to be effective in preventing Rh-isoimmunization B Subsequent Rh-positive fetuses are not at risk for complications after Rh-isoimmunization C The patient is not at risk for Rh-isoimmunization D The patient should be given a minimum of 300 micrograms of anti-D immune globulin in order to prevent Rh-isoimmunization

A Anti-D immune globulin must be administered within 72 hours to be effective in preventing Rh-isoimmunization Anti-D immune globulin must be administered within 72 hours to be effective in preventing anti-Rh antibody formation secondary to Rh-isoimmunization. Rh-isoimmunization occurs when an Rh-negative woman is exposed to Rh-positive fetal blood. This transplacental hemorrhage can occur during term delivery, threatened miscarriage, spontaneous miscarriage, termination of pregnancy, amniocentesis, following abdominal trauma, or during surgery for treatment of an ectopic pregnancy. To prevent this from occurring, patients are given anti-D immune globulin (Rho-GAM®). The patient is at risk for Rh-isoimmunization after a spontaneous abortion because she is known to be Rh-negative and the father's blood type is unknown. For a spontaneous abortion less than 12 weeks, the minimum dose is 50 micrograms of anti-D immune globulin to prevent Rh-isoimmunization. The 300 micrograms dose is given after 12 weeks of gestation. All subsequent Rh-positive fetuses are at risk for complications once the mother has developed anti-Rh antibodies

A 25-year-old man with sickle cell disease presents with dyspnea on exertion and pleuritic chest pain. His vital signs include heart rate 105 beats per minute, blood pressure 138/88 mm Hg, respiratory rate 20 breaths per minute, temperature 100.6°F, and oxygen saturation 95% on room air. Initial lab results include hemoglobin 10.2 mg/dL and a chest X-ray shows a right lower lobe infiltrate. What is the next best step in management of this patient? A Antibiotics B Blood transfusion C Computed tomography pulmonary angiogram of the chest D Oxygen

A Antibiotics This patient shows signs of acute chest syndrome, a common complication in sickle cell disease. Acute chest syndrome is clinically defined by the combination of a new pulmonary consolidation involving at least one lung segment and a pulmonary symptom such as chest pain, fever, tachypnea, wheezing or cough. It is the most common cause of admission to an intensive care unit and the most common cause of premature death in sickle cell disease. The most common cause of acute chest syndrome is infection by a community-acquired pathogen, followed by an excessive inflammatory lung injury response. Therefore, empiric antibiotics are part of the routine treatment of all patients with acute chest syndrome. Antibiotic coverage should include typical and atypical organisms, as most sickle cell patients are functionally asplenic and vulnerable to encapsulated organisms. In addition to antibiotic coverage, patients with acute chest syndrome often require exchange transfusion to help improve gas exchange. Pain control is also indicated with opioids, if necessary, to help prevent hypoinflation secondary to splinting.

A 31-year-old man with sickle cell disease presents with several weeks of pain in the lower extremity. He reports a history of fever at home. An X-ray is obtained which shows a periosteal reaction of the tibia. Which of the following is an appropriate plan? A Antibiotics that include coverage for Salmonella B Hyperbaric oxygen therapy C Outpatient work-up D Splint immobilization

A Antibiotics that include coverage for Salmonella Patients with sickle cell disease are at increased risk of osteomyelitis through hematogenous spread of infection. Radiographs may show a periosteal reaction supporting the diagnosis of osteomyelitis. This is an early plain film finding of osteomyelitis before cortical disruption occurs. Salmonella spp. are a common pathogen identified in sickle cell patients with osteomyelitis. It is theorized that chronic microinfarcts in the bowel allow translocation of Salmonella into the bloodstream seeding other sites in the body. Patients with sickle cell are at risk for bone infarct as well. However, fever and significant elevation of inflammatory markers like ESR and CRP are more common in osteomyelitis than bone infarction

A 31-year-old woman is diagnosed with her sixth spontaneous abortion. Which of the following is the most likely underlying diagnosis? A Antiphospholipid antibody syndrome B Hemophilia A C Thrombotic thrombocytopenic purpura D Von Willebrand disease

A Antiphospholipid antibody syndrome Antiphospholipid antibody syndrome is an autoimmune disorder that is a well-recognized cause of acquired hypercoagulability. Affected patients produce antibodies to a host of various proteins which predispose to thrombosis in a manner that is not well understood, but may involve interference with normal hemostasis pathways. The generally accepted "1 in 5 rule" states that 1 in 5 patients younger than age 45 with stroke, 1 in 5 patients with deep vein thromboses (DVT), and 1 in 5 patients with recurrent pregnancy loss will test positive for antiphospholipid antibodies. Antiphospholipid antibody syndrome should be suspected in patients with recurrent DVTs, recurrent spontaneous abortions, or recurrent cerebrovascular events, particularly in young people. Approximately 1% of patients with antiphospholipid antibody syndrome develop a rapidly progressive form known as catastrophic antiphospholipid antibody syndrome. This life-threatening condition involves widespread simultaneous small vessel occlusions in multiple organs. Despite treatment, the mortality of catastrophic antiphospholipid antibody syndrome is 50%

Which of the following statements is true regarding giant cell arteritis? A Aortic involvement can lead to valvular disease and dissection B Corticosteroid therapy should be initiated only when biopsy confirms the disease C Histologic findings of inflammation are irreversible D It is associated with sudden, painful binocular vision loss

A Aortic involvement can lead to valvular disease and dissection Temporal arteritis is a chronic segmental vasculitis of medium and large vessels. Although it most commonly affects one or more branches of the carotid artery (temporal artery, ophthalmic artery, and posterior ciliary artery), the aorta can also be involved. Aortic involvement can lead to valvular insufficiency, aortic arch syndrome, and dissection. The carotid and vertebrobasilar arteries can also be affected, which can lead to neurologic complications. The condition is associated with a markedly elevated erythrocyte sedimentation rate (50-100 mm/hr). Histologic findings are rapidly reversed with steroid therapy. Temporal arteritis is a sight-threatening disease, but timely administration of high-dose corticosteroids can prevent blindness. For this reason, if the diagnosis is suspected, corticosteroids should be administered immediately while awaiting the results of temporal artery biopsy. Symptoms suggestive of temporal arteritis include headache, jaw claudication, and visual disturbances. Temporal arteritis is associated with a sudden painless monocular loss of vision due to vascular occlusion of the ophthalmic or posterior ciliary artery with infarction of the optic nerve or retina

A 74-year-old woman with a history of heart failure presents to the ED with shortness of breath. Her vital signs are notable for heart rate 105 beats/minute, blood pressure 180/90 mm Hg, and oxygen saturation of 87 percent on room air. Chest X-ray shows pulmonary edema. You are considering starting nitrates. Which of the following underlying conditions puts the patient at risk of developing nitrate-induced hypotension? A Aortic stenosis B Myocardial infarction involving the left ventricle C Pulmonary edema D Volume overload

A Aortic stenosis This patient's clinical presentation is suggestive of a heart failure exacerbation. In heart failure, ventricular filling or ejection of blood is impaired, leading to clinical effects of pulmonary edema, in the case of a failing left ventricle, and peripheral edema, in the case of a failing right ventricle. Reducing cardiac afterload, thereby decreasing strain on the heart and improving cardiac output, is a critical aspect of the treatment of heart failure. Nitrates are vasodilators, which decrease mean arterial pressure by reducing preload and afterload, and are first-line therapy for hypertensive acute heart failure. However, due to their vasodilatory effects, nitrates can precipitate or worsen hypotension and should not be used if hypotension is present. In addition, in preload-dependent states, in which cardiac output depends on an adequate preload to the heart, administration of nitrates can result in critical hypotension. These preload-dependent states include aortic stenosis, volume depletion, right ventricular infarction, and hypertrophic obstructive cardiomyopathy.

A 54-year-old man presents complaining of epigastric pain that started several hours ago. The pain is moderate and sharp but does not radiate. He has a history of hypertension and an exploratory laparotomy 20 years ago. His vital signs on presentation include T 37°C, HR 95 bpm, and BP 136/80 mm Hg. His exam reveals a firm, mildly tender protruding mass in the epigastric region with no overlying skin changes. Which of the following is the best next step? A Apply gentle steady pressure to the mass B Obtain computed tomography scan of the abdomen C Perform bedside abdominal aortic ultrasound D Perform incision and drainage of the mass

A Apply gentle steady pressure to the mass This patient is presenting with a ventral hernia through the incision site from his exploratory laparotomy. Incisional hernias account for up to 20% of all abdominal wall hernias. They are often the result of excess wall tension or inadequate wound healing. Risk factors for the development of incisional hernias include obesity, age, wound infection, and certain medical conditions that increase the intra-abdominal pressure. All hernias fall into one of three categories: reducible, incarcerated, or strangulated. Reducible hernias are soft and easy to replace through the hernia defect. Incarcerated hernias are firm, often painful, and non-reducible by direct manual pressure. Strangulation occurs as a consequence of incarceration and results in impaired blood flow, leading to ischemia, necrosis, and obstruction. Skin changes overlying the hernia site may be seen, and patients are often toxic in appearance. A strangulated hernia is a true surgical emergency. Abdominal aortic aneurysm should be considered in this patient and that would be an indication to perform a bedside abdominal aortic ultrasound (C). However, this condition generally presents as a pulsatile mass in patients with chronic hypertension. An incision and drainage (D) is appropriate for an abscess. This mass is firm, whereas an abscess is fluctuant. To reduce the potential for ischemia and necrosis, there should be no delay at reduction, which would be caused by obtaining a computed tomography scan of the abdomen (B).

A 75-year-old ill-appearing man presents with high fevers and heavy sweats eight days after returning from a trip to sub-Saharan Africa. He received neither vaccines nor chemoprophylaxis before his travel. Vital signs are T 40.1°C, HR 125 bpm, and BP 120/65 mm Hg. On exam, patient has hepatomegaly, scleral icterus, and bilateral lower extremity pitting edema and appears lethargic. Which of the following is the most appropriate treatment? A Artesunate B Chloroquine phosphate C Primaquine D Pyrimethamine plus sulfadiazine

A Artesunate Malaria is transmitted from the bite of the female Anopheles mosquito. Plasmodium falciparum, P. ovale, P. vivax, and P. malariae are the species responsible for human malaria. The clinical hallmark of malaria is periodic fevers with a prodrome of malaise, myalgia, headache, fevers, and chills. After several hours, fever can abate and the patient will develop diaphoresis. Over time, the paroxysms of malaria may occur at nearly regular intervals that correspond to the length of asexual erythrocytic cycles of the particular protozoan infection. The classic paroxysms of malaria are often lacking in patients infected with P. falciparum or in persons who received some form of chemoprophylaxis. Complicated disease can present with hepatosplenomegaly, icterus, jaundice, respiratory failure due to acute respiratory distress syndrome, renal failure, profound hypoglycemia, hemolytic anemia, coma, seizures, or altered mental status. P. falciparum is the deadliest and is known to cause complicated malaria (severe organ system damage), as in the patient in this clinical scenario. P. falciparum is also endemic to sub-Saharan Africa and is known to exhibit resistance to chloroquine. These patients should be treated with intravenous artesunate

Which of the following is a common complication of scaphoid fracture? A Avascular necrosis B Kienböck disease C Thenar eminence atrophy D Ulnar nerve injury

A Avascular necrosis Avascular necrosis (AVN) is a process of ischemic bone death. It is also known as aseptic necrosis, ischemic necrosis, and osteonecrosis. Over time, the ischemia will lead to collapse of the bone, causing pain, swelling, and decreased range of motion. The patient populations most affected by AVN are men and Black individuals. The average age at the time of diagnosis is 37. Causes include trauma, chronic corticosteroid use, chronic alcohol use, and an underlying hemoglobinopathy (sickle cell anemia). However, AVN may be deemed idiopathic in up to 20% of patients. Treatment ranges from supportive treatment (observation, immobilization, physical therapy, and anti-inflammatory drugs) to surgical procedures. If the cause is thought to be iatrogenic, then eliminating the source should lessen the progression of boney destruction. The X-ray above demonstrates a scaphoid fracture, which is the most commonly fractured carpal bone. Due to the distal blood supply to the scaphoid, it is at risk for AVN following a fracture.

What are the main components of initial management of contact dermatitis? A Avoidance of the source agent, protection of involved skin, treatment of inflammation B Identification of the source agent, protection of involved skin, systemic steroids C Low protein diet, avoidance of the known or suspected agent, acetaminophen D Use of topical moisturizer and triple antibiotic ointment, allergy testing

A Avoidance of the source agent, protection of involved skin, treatment of inflammation Avoidance of the source agent, protection of involved skin, and treatment of inflammation is the correct answer. Because contact dermatitis is defined as patterns of skin reaction resulting from topical contact with external agents it is reasonable to begin management with measures that minimize continued or recurrent exposure to the known or suspected causative agent. The agent may be an irritant (such as solvents, caustics, and detergents) or an allergen (such as nickel in jewelry, soaps, cosmetics, rubber compounds, latex, and poison ivy, oak, or sumac). The cause may be readily identifiable via a detailed history and physical examination or may require eventual skin testing. Contact dermatitis may develop from brief but intense or repetitive low levels of exposure. Avoidance of continued or recurrent exposure may include measures such as substituting a different brand or type of a topical agent, avoiding the location of exposure, or even changing occupation. Protection of involved skin may include wearing gloves or clothing or use of a barrier cream when exposure is possible. The other initial component is treatment of inflammation. Oral antihistamines may be effective for control of itching, low to moderate potency topical steroids can be used on erythematous areas, and cool compresses with aluminum acetate solutions can be used on oozing or vesiculated skin to treat inflammation. Steroid use can sometimes be delayed until patient follow-up to ascertain whether avoidance and protective measures alone have been adequate.

A 19-year-old woman presents with complaints of vaginal discharge. She has a history of chlamydia in the past. Pelvic examination reveals a thin, white, foul-smelling discharge. There is no cervical motion tenderness or adnexal fullness. Clue cells are seen on wet mount. Pregnancy test is negative. What is the most likely diagnosis? A Bacterial vaginosis B Pelvic inflammatory disease C Trichomoniasis D Yeast infection

A Bacterial vaginosis Bacterial vaginosis is due to a shift in vaginal flora from the normal Lactobacillus to a polymicrobial group resulting in an elevated pH from 4.5 to as high as 7. Bacterial vaginosis most often presents with malodorous vaginal discharge, however, up to 50% of women are asymptomatic. Diagnosis can be made by the Amsel criteria, where three out of four criteria must be present: (1) thin, white discharge, (2) presence of clue cells in microscopic examination, (3) pH of vaginal fluid greater than 4.5, and (4) a fishy odor before or after the addition of 10% KOH (positive "whiff test"). All women with symptomatic disease should be treated, because it can result in an acute upper genital tract infection, including pelvic inflammatory disease, endometritis, and vaginal cuff cellulitis, following invasive procedures (e.g. endometrial biopsy, intrauterine device placement, hysterectomy). Bacterial vaginosis during pregnancy is associated with premature rupture of membranes, preterm labor, preterm birth, and postpartum endometritis. Treatment of bacterial vaginosis includes oral metronidazole or clindamycin. Only oral treatment should be used in pregnancy. In those who are not pregnant, appropriate topical medications include metronidazole gel or clindamycin cream

A 48-year-old man with a history of diabetes mellitus presents to the ED with scrotal and perineal pain, fevers, chills, and fatigue. He reports the onset of his symptoms several hours ago with lower abdominal pain. On exam, he has T 39.6°C, BP 104/80 mm Hg, HR 112 bpm, RR 22/min, and oxygen saturation 100% on room air. He appears ill, and there is darkened discoloration with crepitus throughout his perineum and part of his scrotum. Which of the following pairs represents the most likely causative organisms? A Bacteroides fragilis, Escherichia coli B Chlamydia trachomatis, methicillin-resistant Staphylococcus aureusYour Answer C Staphylococcus aureus, Streptococcus pyogenes D Staphylococcus epidermidis, viridans streptococci

A Bacteroides fragilis, Escherichia coli This is a patient with Fournier gangrene, a necrotizing infection of the subcutaneous tissue of the perineum. It spreads rapidly and often features discoloration of the skin along with crepitus, which is indicative of subcutaneous gas. The infection is polymicrobial. The causative organisms are mostly bacteria from the distal colon with aerobic and anaerobic bacteria. The most common are Bacteroides fragilis and Escherichia coli. Treatment of Choice: Emergent surgical debridement to remove necrotic tissue and broad-spectrum antibiotics

A 19-year-old man presents for evaluation after a fall. The patient was rollerblading and fell backward onto the pavement. There was no loss of consciousness, and his only concern is a headache. On physical examination, the patient has a Glasgow Coma Scale score of 15. There is no scalp hematoma. His cervical spine is nontender. On inspection of the ear canal, you see blood behind the tympanic membrane. What injury is associated with this physical exam finding? A Basilar skull fracture B Depressed skull fracture C Intracerebral contusion D Traumatic subarachnoid hemorrhage

A Basilar skull fracture The physical examination of this patient demonstrates hemotympanum, which is blood behind the tympanic membrane. This finding is associated with a basilar skull fracture which is a linear fracture often through the temporal bone causing bleeding in the middle ear. Patients with this finding need a CT scan of the brain, with attention paid to the temporal bone area. Basilar skull fractures may be associated with dural tears which may be a portal of entry for infection requiring prophylactic antibiotics.

What is the etiology for cardiovascular compromise related to intravenous phenytoin administration?

Although phenytoin is a class Ib antiarrhythmic, it is the propylene glycol diluent that produces cardiovascular compromise when the medication is given by rapid infusion. Propylene glycol is not present in fosphenytoin, enabling bolus administration. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Begins 2-6 weeks after initiation of drug Facial edema, fever, rash, internal organ involvement Rash initially spares mucous membranes Eosinophilia Steroids, immunoglobulin

A 55-year-old woman with end stage renal disease on hemodialysis presents with shortness of breath. Her temperature is 98.8°F, blood pressure is 70/30 mm Hg and heart rate is 152 bpm. She has jugular venous distension. An ECG is performed and is shown above. Which of the following is the most appropriate diagnostic test? A Bedside cardiac ultrasound B Brain natriuretic peptide C CT angiography D Electrolyte panel

A Bedside cardiac ultrasound Pericardial tamponade occurs when enough fluid or air builds up in the pericardial space to cause external pressure on the heart, leading to decreased ventricular filling and hemodynamic compromise. Patients with end stage renal disease and cancer are at greater risk of developing pericardial effusions and tamponade. Signs of tamponade include hypotension, jugular venous distension and diminished heart sounds. Pulsus paradoxus is a decrease in systolic blood pressure > 10 mm Hg with inspiration and is seen in tamponade. The ECG can demonstrate low QRS voltage and electrical alternans (beat to beat variability in the axis or voltage of the P and QRS complexes). A bedside cardiac ultrasound should be performed to confirm the diagnosis of tamponade as the patient is unstable and will require an emergent pericardiocentesis if tamponade is present.

A 73-year-old man presents to the ED with progressive shortness of breath for two days without chest pain. The patient has a history of hypertension controlled with hydrochlorothiazide, but has been noncompliant with his medications. In the ED, his vital signs are BP 186/102, HR 108, RR 34, and oxygen saturation 90% on room air. On exam, the patient has pulmonary crackles midway up both lung fields, jugular venous distension, and pitting edema of his lower extremities. A chest X-ray depicts increased interstitial markings and an enlarged cardiac silhouette. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in management? A Begin non-invasive positive pressure ventilation B Give the patient aspirin and activate the cath lab C Intubate the patient D Restart his hydrochlorothiazide

A Begin non-invasive positive pressure ventilation This patient is in acute heart failure with pulmonary edema. The clinical presentation of heart failure includes shortness of breath, jugular venous distension, crackles and rales, peripheral edema, S3 gallop, orthopnea, and paroxysmal nocturnal dyspnea. A chest X-ray may show an enlarged cardiac silhouette, Kerley B lines suggesting pulmonary edema, and pulmonary vessel cephalization. Labs may show an elevated plasma brain natriuretic peptide (BNP). Management of heart failure with acute pulmonary edema begins with addressing the ABCs. Noninvasive respiratory therapy, such as bilevel positive airway pressure (BPAP) or continuous positive airway pressure (CPAP) is the most appropriate next step in management. Noninvasive positive pressure ventilation increases oxygenation, decreases the work of breathing, and decreases preload and afterload. In addition to BPAP, adjunctive medications include nitrates, diuretics, and positioning the patient sitting up. Nitrates act as venous and arterial vasodilators and help to reduce preload and afterload. Morphine sulfate is thought to decrease oxygen consumption by decreasing catecholamine release, decreasing preload from mild vasodilatory effects, and decreasing pain and anxiety. However, there are some studies that link the use of morphine sulfate to an increased mortality. Furosemide can be used in patients with evidence of fluid retention (JVD, extremity edema).

A 21-year-old man presents to the emergency department for a penile lesion. He is sexually active and reports unprotected intercourse with multiple women over the last few months. He reports no fever, testicular pain, penile discharge, or extremity rash. On physical examination, he has a painless ulcerative lesion on the shaft of his penis with no inguinal adenopathy. Which of the following is the most appropriate treatment? A Benzathine penicillin G B Clotrimazole cream C Intramuscular ceftriaxone and oral doxycycline D Oral acyclovir

A Benzathine penicillin G Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum and is characterized by painless, indurated genital ulcers with a clean base, referred to as a chancre. These are found on the penis, vulva, or other areas of sexual contact. Nontender, firm regional adenopathy may be present. Lesions typically appear after an incubation period of approximately 21 days. These chancres usually resolve spontaneously. Positive screening tests for syphilis such as the Venereal Disease Research Laboratory (VDRL) test or rapid plasma reagin (RPR) test should be confirmed with a treponemal antibody-specific immunoassay. Treatment for primary syphilis is with a single intramuscular dose of benzathine penicillin G 2.4 million units. For penicillin-allergic patients, doxycycline may be used twice daily for 2 weeks. Treatment of sexual partners within 90 days of exposure is recommended.

A 29-year-old man presents to the ED with oral and nail bed cyanosis after undergoing a recent procedure. His triage pulse oximetry is 85% and remains so despite supplemental oxygen. Which of the following is the most likely cause of this patient's toxicity? A Benzocaine B Isoflurane C Nitrous oxide D Propofol

A Benzocaine This patient is exhibiting signs and symptoms of methemoglobinemia. Methemoglobinemia is most commonly caused by medications including amyl nitrite, benzocaine, dapsone, nitroglycerin, nitroprusside, phenazopyridine, quinines, and sulfonamide. It can also be secondary to chemical agents such as aniline dye derivatives or foods containing nitrites. Finally, it should always be considered in fire victims due to inhalation of nitrogen oxide in smoke or due to heat-induced denaturation of hemoglobin. Methemoglobin forms when hemoglobin becomes oxidized to the ferric (Fe3+) state. Methemoglobin cannot bind oxygen. It also impairs oxygen release from normal hemoglobin causing a leftward shift of the oxyhemoglobin dissociation curve. Signs and symptoms of methemoglobinemia primarily manifest as cyanosis due to impaired oxygen delivery to the tissues. Diagnosis of methemoglobinemia stems from a high clinical suspicion in patients whose cyanosis does not improve with supplemental oxygen and is typically out of proportion to clinical signs and symptoms. An oxygen saturation gap is present - the oxygen saturation measured by the pulse oximeter is often 85% while the blood gas demonstrates a normal oxygen saturation. If you suspect methemoglobinemia, a co-oximeter will measure the methemoglobin in the blood. Management of methemoglobinemia is via 100% supplemental oxygen and methylene blue. What is the classic appearance of the blood in a patient with methemoglobinemia? Chocolate brown.

Which of the following is most characteristic of a complex febrile seizure? A Convulsions are focal in nature B Convulsions lasting 12 minutes C Second seizure occurs with second febrile illness D Single seizure that occurs at a temperature of 40°C

A Convulsions are focal in nature Complex febrile seizures are diagnosed when multiple seizures occur during the same febrile illness, seizures are prolonged (> 15 minutes), or the seizures have a focal component. Not all criteria are needed to diagnose a complex febrile seizure (i.e., a focal seizure would be considered complex even if it only lasted 5 minutes). Simple febrile seizures are associated with generalized convulsions. Seizures lasting under 15 minutes (B) are associated with simple febrile seizures. When multiple seizures occur within the same febrile illness, the seizures are classified as complex. However, a patient may have a febrile seizure during a subsequent febrile illness (C) and still be classified as a simple febrile seizure. A febrile seizure can occur at any elevated temperature (D), but almost 50% of children have a documented temperature of < 39.0°C

A 19-year-old man presents with headache and a peripheral cranial nerve VII palsy. He states that he was recently hiking in Connecticut and had numerous tick bites. What CSF finding is most sensitive for Lyme meningitis? A Borrelia burgdorferi antibody B Decreased glucose level C Decreased protein level D Positive PCR assay

A Borrelia burgdorferi antibody B. burgdorferi antibody is the most sensitive test for Lyme meningitis and will be present in 80-90% of patients. Lyme disease is the most common tick borne illness in the US. The disease is caused by Borrelia burgdorferi, a spirochete. After a bite from the Ixodes scapularis tick and transmission of the spirochete, patients typically develop a non-specific viral illness accompanied by the erythema migrans rash. The rash appears at the site of the tick bite and spreads outwards eventually with central clearing. Early disease can progress to the acute disseminated form where hematogenous spread can cause multiorgan involvement. Neurologic signs develop about four weeks after the initial infection. The most common presentation of neurologic involvement is a fluctuating meningoencephalitis with accompanying cranial and peripheral neuropathies. The most common cranial neuropathy is a seventh nerve palsy. CSF samples should be obtained and sent for B. burgdorferi antibodies (IgG or IgA) since this is the most sensitive test.

A 70-year-old woman presents to the emergency department with a report of blisters on her abdomen for the past month. Initially, the rash was composed of small pruritic papules that developed into bullae after 3 weeks. Some of the blisters recently broke and are now tender eroded lesions, as shown in the above image. There is no mucosal involvement. When lateral pressure is applied, the bullae do not enlarge. She reports no trauma, exposure to new chemicals, starting new medications, or recently hiking outdoors. What is the most likely diagnosis? A Bullous pemphigoid B Pemphigus vulgaris C Pustular psoriasis D Stevens-Johnson syndrome

A Bullous pemphigoid Bullous pemphigoid is the most common bullous autoimmune disease in older patients. The age of onset is between 60-80 years old, and it affects men and women equally. The lesions begin as pruritic papules, which early in the disease course can be easily confused with urticaria. However, unlike urticaria, they do not change position. The papules coalesce into large tense bullae over weeks to months and exhibit a negative Nikolsky sign (they do not easily extend when lateral pressure is applied). The bullae appear on normal or erythematous skin and eventually rupture, leaving tender eroded lesions. The underlying cause is the production of autoantibodies to basement membrane proteins, basal keratinocyte hemidesmosomal antigens, which cause a detachment at the basement membrane between the epidermis and dermis. Commonly affected body regions include the axilla, medial aspect of the thigh, groin, abdomen, forearm flexors, and lower extremities. They may also be generalized. Mucous membranes are almost never involved. The painful eroded lesions crust and eventually heal spontaneously. Oral steroids are the mainstay of treatment and help to hasten resolution. Recurrence is rare but can occur.

A previously healthy 18-year-old woman presents with sore throat and pain with swallowing. Her vital signs are T 102.7°F, HR 124 bpm, BP 123/76 mm Hg, RR 22/min, and oxygen saturation 97%. On examination, she has trismus, pain with neck extension, and difficulty swallowing her saliva. Her oropharyngeal examination is unremarkable. Which of the following is the most appropriate next step in management? A CT scan of the neck with contrast and ENT consultation B Ibuprofen, dexamethasone, and a rapid strep test C Oral antibiotics and ENT follow-up D Peritonsillar needle aspiration

A CT scan of the neck with contrast and ENT consultation This patient is suffering from a retropharyngeal abscess and will need advanced imaging (CT scan of the neck with IV contrast) to further delineate the extent of the disorder, along with emergent ENT consultation for possible operative intervention. Historically, this was a disease of children under 6 years of age, but adults are increasingly affected. A number of infectious processes, including nasopharyngitis, otitis media, peritonsillar abscess, and dental infections, as well as iatrogenic procedures, including endoscopy and dental instrumentation, have been associated with retropharyngeal abscess formation . The infection is most commonly polymicrobial with both aerobes and anaerobes, requiring broad antibiotic coverage. Patients typically present with sore throat, odynophagia, dysphagia, drooling, muffled voice, neck stiffness, fever, and trismus. In severe cases, the patient may hold the neck in extension in order to increase airway diameter by distracting the posterior pharynx from the airway. CT scan and MRI are diagnostic, but in unstable patients, lateral neck X-ray can demonstrate retropharyngeal swelling, supporting the diagnosis. Additionally, if the patient is unable to lie flat for advanced imaging, direct visualization with an upper airway scope can be diagnostic. Normal width of the retropharyngeal space on lateral neck X-ray? 7 mm (at C2) in both children and adults.

A 33-year-old man presents with right eye pain, swelling, and fever for 2 days. Physical examination reveals upper and lower lid erythema and swelling. The patient has difficulty opening his eyelid and is unable to move the right eye laterally. What management should be initiated? A CT scan of the orbit and intravenous antibiotics B Oral antibiotics and ophthalmology follow-up C Topical antibiotics and ophthalmology follow-up D Warm compresses

A CT scan of the orbit and intravenous antibiotics This patient presents with signs and symptoms of orbital cellulitis and should receive imaging looking for an abscess and intravenous antibiotics to treat the infection. Patients with orbital cellulitis present with systemic symptoms, proptosis, pain, and limitation of extraocular movements. In the presence of these findings, patients should have a CT scan of the orbits and brain performed to look for an abscess near the orbit and other intracranial complications. Intravenous antibiotics should be started and the patient should be admitted to the hospital with an emergent ophthalmologic consultation. The most common bacterial organisms implicated in orbital cellulitis are Streptococcus and Staphylococcus species Orbital Cellulitis Infection involving orbital fat and ocular muscles - complications include orbital abscess, vision loss, intracranial infection Risk factors: sinusitis, orbital trauma or surgery Sx: eyelid swelling, pain with eye movement PE: proptosis, ophthalmoplegia, decreased vision Dx is made clinically, confirmed with CT scan Most commonly caused by S. aureus, streptococci Treatment is ophthalmology evaluation, broad spectrum antibiotics What are the serious sequelae associated with orbital cellulitis? Vision loss, cavernous sinus thrombosis, and meningitis.

A 3-month-old boy presents to the ED actively seizing. His parent tells you that he has a known congenital heart defect. While examining the patient, it is noted that he has a cleft palate. Which electrolyte is likely abnormal in this patient? A Calcium B Magnesium C Potassium D Sodium

A Calcium Approximately 40% of patients with truncus arteriosus have DiGeorge syndrome. DiGeorge syndrome results from a deletion in chromosome 22q11.2 and is characterized by thymic aplasia, arch abnormalities, and hypoparathyroidism resulting in hypocalcemia. Hypocalcemia can result in seizure. Other classic findings include abnormal facial features (including a cleft palate) and thymic hypoplasia. These patients often experience recurrent infections.

A 20-year-old man presents to the ED with an isolated stab wound to the chest. His BP is 80/40 mm Hg, heart rate is 120 bpm, respiratory rate is 32/min, and oxygen saturation is 93%. Which of the following is the most likely cause of his hypotension with a FAST image showing pericardial effusion A Cardiac tamponade B Cardiogenic shock C Hemorrhagic shock D Septic shock

A Cardiac tamponade Given the clinical scenario of a stab wound to the chest and hypotension along with these ultrasound findings, cardiac tamponade is the likely cause of his hypotension. Cardiac tamponade occurs when blood accumulates in the pericardium and causes elevated intrapericardial pressure. This causes decreased right ventricular (RV) and left ventricular (LV) filling during diastole. If enough fluid accumulates, the myocardial septum will deviate and further decrease LV filling. This results in decreased cardiac output. The classic physical exam findings are hypotension, muffled heart sounds, and jugular venous distention, which are referred to as the Beck triad. Other physical exam findings include tachycardia, elevated central venous pressures, and pulsus paradoxus. The patient should be resuscitated according to ATLS protocol and prepped for possible ED pericardiocentesis, and he ultimately will require definitive surgical repair by a trauma surgeon. Which chamber is most commonly injured in penetrating cardiac trauma? Right ventricle. Ultrasound: Cardiac Tamponade Pericardial effusion Diastolic right ventricular collapse (high specificity) Systolic right atrial collapse (earliest finding) Plethoric IVC

In the work up of priapism, what test is used to differentiate low-flow priapism from high-flow priapism? A Cavernosal blood gas B Complete blood count C Reticulocyte count D Urine drug screen

A Cavernosal blood gas There are three main types of priapism: ischemic (low-flow) priapism, nonischemic (high-flow) priapism, and recurrent ischemic priapism. Ischemic priapism results from trapping of mixed venous blood within the corpus cavernosum. Nonischemic priapism is caused by unregulated arterial flow into the cavernosal sinusoids. Ischemic priapism is a true urologic emergency whereas nonischemic priapism is less urgent and can be further evaluated in a urology clinic. The two types can be differentiated by blood gas analysis of cavernosal blood. Ischemic cavernosal blood is dark, hypoxemic and acidemic. Nonischemic cavernosal blood would be more consistent with an arterial blood gas with a normal pH and pO2 > 90 mm Hg.

A 65-year-old woman undergoing chemotherapy for breast cancer presents with a fever. Her absolute neutrophil count is 300/µL. Urinalysis is suggestive of infection. Vital signs are otherwise normal. Which of the following is the most appropriate initial treatment? A Cefepime B Fluconazole C Trimethoprim-sulfamethoxazole D Vancomycin

A Cefepime Based on the need for broad-spectrum antibiotics to cover multiple potential pathogens, including Staphylococcus aureus, S. epidermidis, Escherichia coli, Pseudomonas, and Klebsiella species, the Infectious Diseases Society of America guidelines recommend initiation of an antipseudomonal beta-lactam, such as cefepime, a carbapenem, or piperacillin-tazobactam in patients with fever and neutropenia.

A 24-year old woman presents with UTI symptoms. She is 34 weeks pregnant. As part of her work-up, you order a urinalysis, which shows 2+ bacteria with no WBCs or squamous epithelial cells. Two days later, the lab calls you and informs you that the urine culture is positive. You call the patient back and she denies symptoms of urinary tract infection. With regards to the urine culture results, what treatment is indicated? A Cephalexin 500 mg QID for 7 days B Ciprofloxacin 500 mg QID for 7 days C No treatment is necessary D Trimethoprim-sulfamethoxazole 1 DS tablet BID for 3 days

A Cephalexin 500 mg QID for 7 days The patient has asymptomatic bacteriuria of pregnancy confirmed by a positive urine culture and should be treated with an oral antibiotic that is known to be safe in pregnancy, such as cephalexin 500 mg QID for 7 days. Asymptomatic bacteriuria is common in the general population and in most scenarios does not require therapy. However, due to the high risk of complication seen during pregnancy, it should be treated with antibiotics. It is commonly due to E. coli. Pregnant women have an increased risk of developing urinary tract infections due to the pressure that the enlarged uterus exerts on the ureters and bladder, incomplete emptying during voiding, and impaired ureteral peristalsis from progesterone-induced relaxation of the ureteral smooth muscle. Complications of untreated asymptomatic bacteriuria include development of a lower urinary tract infection, pyelonephritis, renal abscess, renal failure, bacteremia, sepsis, intrauterine growth retardation, premature labor, and neonatal death. Treatment options generally include cephalosporins (such as cephalexin), amoxicillin (or amoxicillin-clavulanate), and nitrofurantoin. All of these antibiotics are recognized as Category B by the Food and Drug Administration; meaning that animal studies have failed to show a risk to the fetus. Treatment duration should be for 7-10 days.

A 19-year-old boy presents with scrotal pain and fever. Examination reveals a tender, swollen testicle. Scrotal Doppler ultrasonography shows increased blood flow to the testicle. Elevation of the scrotum lessens the patient's pain. Which of the following organisms is the most common cause of this condition in this patient? A Chlamydia trachomatis B Escherichia coli C Group A Streptococcus D Staphylococcus epidermidis

A Chlamydia trachomatis Epididymitis occurs most commonly in men between the ages of 14 and 35 years. Epididymitis is characterized by a gradual onset of scrotal pain, fever, urinary urgency, frequency, dysuria, pyuria, or hematuria. Examination usually reveals localized epidydimal edema and tenderness (posterior aspect of scrotum), possible testicular tenderness, and a normal cremasteric reflex. Pain may be relieved with testicular elevation (positive Prehn sign). Scrotal pain should be initially evaluated with a color Doppler ultrasound test, and in the case of epididymitis, the typical findings are an enlarged, thickened epididymis with increased blood flow. The most common organism responsible for epididymitis in those 14 to 35 years-of-age are Neisseria gonorrhoeae and Chlamydia trachomatis. In older individuals (traditionally > 35 years of age), the gram-negative rod bacteria (Escherichia, Klebsiella, Enterobacter, and Citrobacter species) are most common

A 57-year-old man presents with abdominal pain and fever. He is focally tender in the left lower quadrant without rebound or guarding. His white blood cell count is 12,000 cells/mm3. Which is the most appropriate diagnostic test? A Computed tomography scan of the abdomen and pelvis B Flexible sigmoidoscopy C Ultrasound D Water soluble contrast enema

A Computed tomography scan of the abdomen and pelvis This patient has diverticulitis, which in the uncomplicated form is pericolonic inflammation as a result of obstruction of diverticula within the colon. Diverticular disease occurs most commonly in the sigmoid colon and is typically asymptomatic. Once the disease extends beyond pericolonic fat inflammation (e.g., phlegmon, abscess, gross perforation), the patient has complicated diverticulitis. A computed tomography scan of the abdomen and pelvis is the diagnostic test of choice.

A 41-year-old previously healthy woman presents to the ED with gingival bleeding and epistaxis over the past four days. She takes no medications and has no recent travel. You note scattered petechiae, but otherwise physical exam is normal. Her hemoglobin is 12.5 g/dL, international normalized ratio 1.1, PTT 25 seconds, and platelets 14,000/µL. A peripheral blood smear shows few large, well-granulated platelets. Which of the following is the most appropriate initial treatment? A Corticosteroids and immunoglobulin B Observation C Platelet transfusion D Splenectomy

A Corticosteroids and immunoglobulin Immune thrombocytopenia (ITP) is an acquired autoimmune disease that results in rapid destruction of platelets. It is characterized by thrombocytopenia, the presence of purpura or petechiae, normal bone marrow, and no other identifiable cause for the thrombocytopenia. It is more common in children than in adults. The physical exam may reveal petechiae, epistaxis, gingival bleeding, and menorrhagia. The presence of lymphadenopathy, hepatosplenomegaly, pallor, or hyperbilirubinemia should suggest an alternative diagnosis such as leukemia, lymphoma, lupus, mono, or hemolytic anemia. Management is predicated primarily on the severity of thrombocytopenia and bleeding. Drugs that interfere with platelet function are discontinued. In general, asymptomatic patients with platelet counts > 20,000/µL require no treatment. When the platelet count is < 20,000/µL or the patient is symptomatic, corticosteroid treatment is indicated. Intravenous (IV) immunoglobulin may be coadministered in more severe cases

A 19-year-old man presents to the clinic after losing his job a month ago. During your interview, the patient reports he drinks daily. You suspect the patient has alcohol use disorder. Which of the following is a criterion for the diagnosis of alcohol use disorder? A Craving or strong urge to use alcohol B Drinking at least six alcoholic beverages per day C Having legal problems related to alcohol use D Symptoms lasting at least 6 months

A Craving or strong urge to use alcohol Alcohol abuse and alcohol dependence were replaced by alcohol use disorder in the DSM-5 update. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, alcohol dependence is approximately comparable to substance use disorder, moderate to severe subtype, while alcohol abuse is similar to the mild subtype. Alcohol use disorder is classified based on severity, mild, moderate, or severe, which correlates to how many DSM-5 criteria are present. Mild severity includes two to three symptoms, moderate severity includes four to five symptoms, and severe includes six or more symptoms. DSM-5 criteria for alcohol use disorder include recurrent drinking resulting in not fulfilling major role obligations, recurrent drinking in hazardous situations, continued drinking despite alcohol-related social or interpersonal problems, evidence of tolerance, evidence of alcohol withdrawal or use of alcohol for relief or avoidance of withdrawal, drinking in larger amounts or over longer periods than intended, persistent desire or unsuccessful attempts to stop or reduce drinking, great deal of time spent obtaining, using, or recovering from alcohol, important activities given up or reduced because of drinking, continued drinking despite knowledge of physical or psychological problems caused by alcohol, and craving or having a persistent urge to drink alcohol. There are higher rates of alcohol use associated with young people, men, and people of American Indian ancestry.

You are taking part in a bioterrorist attack simulation. Your simulated patient was exposed to nerve gas. What is the end point of your treatment with atropine? A Decreased respiratory secretions B Normal pupil size C Resolution of bradycardia D Resolution of muscle fasciculations

A Decreased respiratory secretions Nerve gases are organophosphates. These agents inhibit acetylcholinesterase leading to accumulation of acetylcholine at both the nicotinic and muscarinic receptors. Stimulation of the muscarinic receptors leads to miosis, salivation, rhinorrhea, lacrimation, bronchorrhea, bronchospasm, vomiting, and defecation. The nicotinic stimulation leads to muscle fasciculations, flaccid paralysis, tachycardia, and hypertension. Atropine blocks the acetylcholine receptors and is used in large quantities in the treatment of these poisonings. Mortality is linked with ventilatory failure from severe secretions and bronchoconstriction. Treatment with atropine continues until respiratory secretions decrease. The preferred dose and route of administration for atropine in these patients is 2-4 mg IM as the IV route has been associated with ventricular fibrillation in hypoxic patients.

A 55-year-old woman presents with four days of gradually progressive monocular loss of central vision with associated right eye pain which worsens with movement of the eye. She also notes difficulty with color perception. A right afferent pupillary defect is noted on examination and the optic disk appears edematous. Examination of the left eye is unremarkable. What is the most likely cause of her symptoms? A Demyelination of the optic nerve B Inhibition of outflow of aqueous humor C Occlusion of the central retinal artery D Occlusion of the central retinal vein

A Demyelination of the optic nerve Optic neuritis is the result of an inflammatory demyelination of the optic nerve. It is most commonly associated with multiple sclerosis (MS), with half of patients with MS having optic neuritis at some point during the course of illness. It can also be the result of infection (e.g., syphilis, herpes simplex) and other autoimmune disorders such as lupus or sarcoidosis. Patients present with monocular vision loss which typically progresses over hours to days, with a peak in symptoms at one to two weeks. Eye pain, often worse with movement of the eye, is also seen in the majority of patients. A central scotoma is the most frequently described visual field defect, although almost all types of defects can be seen. A finding specific to optic nerve pathology is the loss of color vision out of proportion to the loss of visual acuity. In addition to decreased visual acuity and visual field defects, the optic disk will appear edematous and hyperemic and an afferent pupillary defect is usually present. Diagnosis is made clinically based on the history and physical examination findings. Magnetic resonance imaging with gadolinium can confirm the diagnosis and is helpful in evaluating for multiple sclerosis in patients without a known history. Intravenous glucocorticoids are typically indicated as there is some evidence that they delay the onset of multiple sclerosis and may hasten visual recovery. Glucocorticoids have not been shown to alter long-term visual outcomes Acute angle closure glaucoma is the result of anterior chamber angle closure which inhibits outflow of aqueous humor (B) and results in increased intraocular pressure. Patients present with sudden onset of eye pain and decreased visual acuity with "halos," as well as nausea, vomiting, and headache. The pupil is often mid-range in size and the cornea appears hazy. Patients with acute angle closure glaucoma do not typically have visual field defects or change in color perception. Occlusion of the central retinal artery (C) presents with sudden, painless, monocular loss of vision. The retina will appear pale with a cherry red spot on the fovea. Occlusion of the central retinal vein (D) also presents with painless

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? A Dilated cardiomyopathy B Hypertrophic cardiomyopathy C Pericardial effusion D Pulmonary embolism

A Dilated cardiomyopathy Dilated cardiomyopathy is the most common cardiomyopathy. Most cases of dilated cardiomyopathy are idiopathic, but they can also occur in a familial pattern and can result from alcohol abuse or due to medications, such as chemotherapeutic agents. Infections that attack the cardiac tissue (coxsackievirus, Lyme disease) can also result in dilated cardiomyopathy. Postpartum cardiomyopathy usually manifests as a dilated cardiomyopathy. In dilated cardiomyopathy, there is systolic and diastolic dysfunction, resulting in decreased left ventricular contractile force, low cardiac output, and increased end-systolic and end-diastolic ventricular volumes. This leads to dilation of the left ventricle, and often the right ventricle. Patients with dilated cardiomyopathy present with typical findings of heart failure, including dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, and dependent edema. ECG often shows LV hypertrophy and left atrial enlargement, as well as poor R wave progression. Atrial fibrillation and ventricular ectopy are also common. Chest radiographs may show an enlarged cardiac silhouette, but an echocardiogram is needed to confirm the diagnosis, showing decreased ejection fraction, increased systolic and diastolic volumes, and chamber enlargement. Patients are treated with standard heart failure therapy, and those with low ejection fractions may be implanted with a cardioverter-defibrillator. In severe cases, a left ventricular assist device may be used as a bridge to heart transplantation.

An 18-year-old woman presents after extramural delivery on the ambulance en route to the hospital. The baby has normal Apgar scores and is well-appearing on exam. However, the mother has heavy bleeding and pallor. Which of the following may worsen her condition? A Magnesium B Methylergometrine C Misoprostol D Oxytocin

A Magnesium Postpartum hemorrhage is the most common cause of maternal mortality worldwide and remains a common cause of maternal death in the United States. Uterine atony is the most common cause of postpartum hemorrhage. Magnesium can cause muscle relaxation, which can worsen this condition. If magnesium is given prior to delivery, it can lead to poor fetal tone as well. Oxytocin is frequently given to stimulate uterine contraction or to increase tone in patients with postpartum hemorrhage. This uterotonic agent is considered first-line treatment for such patients Methylergometrine is an ergot derivative that can produce sustained contraction in uterine smooth muscle. It is contraindicated in patients with hypertension or preeclampsia. Misoprostol is a prostaglandin E1 analog that can cause uterine contractions. It is sometimes used (off label) for patients with postpartum hemorrhage.

A 44-year-old man presents to the ED with facial pain after being struck in the face by an errant golf ball at the driving range. On physical exam, you note the above. Which of the following sign or symptom is associated with this injury? A Diplopia B Photophobia C Tinnitus D Vertigo

A Diplopia This patient has signs and symptoms consistent with an orbital blowout fracture. Orbital blowout fractures are typically caused by direct trauma, resulting in an orbital floor fracture. Patients frequently complain of diplopia, which is caused by inferior rectus muscle entrapment between the bony fragments of the orbital floor causing upward gaze limitation, as seen above. The misalignment of the eyes on upward gaze is what causes the patient to have double vision. A possible significant complication of orbital blowout fracture is infraorbital nerve palsy and neuropraxia. This may lead to upper lip, maxillary teeth, or cheek paresthesia. Diagnosis of orbital blowout fracture includes a thorough ophthalmologic examination including visual acuity and fluorescein staining. Plain X-rays and CT are frequently helpful and show a teardrop sign, radiographic visualization of periorbital fat and inferior rectus muscle protruding into the maxillary sinus. CT of the orbits will show the anatomy of the fracture and is helpful if operative repair is necessary. Management of orbital blowout fracture includes analgesics, prophylactic antibiotics if the sinuses are disrupted, and follow-up with ophthalmology. Ophthalmology should be seen within 48 hours if there is evidence of inferior rectus entrapment as the patient may require operative management of the fracture. Orbital blowout fractures do not generally cause photophobia unless there is another injury to the globe itself. An orbital blowout fracture is not associated with tinnitus or vertigo

You diagnose a 43-year-old man with alcohol withdrawal. Lab results reveal a hemoglobin of 12 g/dL and an MCV of 115 fL. Which of the following is the most likely cause of these findings? A Direct ethanol toxicity B Pyridoxine deficiency C Thiamine deficiency D Vitamin B12 deficiency

A Direct ethanol toxicity Ethanol affects practically every organ system in the body. This patient is suffering from a macrocytic anemia, most likely as a result of chronic alcohol abuse. Chronic ethanol intake directly suppresses bone marrow by impairing protein synthesis, causing anemia or even pancytopenia. Although patients who have heavy alcohol use often have concomitant nutritional deficiencies that contribute to the development of megaloblastic anemia, the most likely cause of macrocytic anemia is due to direct ethanol toxicity. Macrocytosis is present in the majority of patients with heavy alcohol use even before significant anemia appears. This is typically reversed after several months of abstinence from alcohol. In addition to the harmful effects of ethanol itself, its metabolite, acetaldehyde, is inherently toxic to biologic systems. Patients presenting with acute ethanol intoxication also commonly have decreased serum ionized magnesium concentrations. Total body magnesium may be depleted due to poor dietary intake, decreased GI absorption, and renal wasting.

A 47-year-old woman with no significant past medical history and no hospitalizations, presents with cough, green sputum, and fever. Her vitals are T 100.7°F, HR 94 bpm, BP 123/76 mm Hg, RR 18/min, and oxygen saturation 97%. She is well appearing, and her blood work (CBC and BMP) is unremarkable. A chest X-ray shows a left lower lobe infiltrate. Which one of the following answer choices represents the best management for this patient? A Discharge home with oral antibiotics and follow-up B Draw blood cultures and discharge home on oral antibiotics C Order a chest CT scan D Start IV antibiotics, draw blood cultures, and admit

A Discharge home with oral antibiotics and follow-up This otherwise healthy, well-appearing patient presents with community-acquired pneumonia (CAP), which affects 2-4 million US patients every year. There are a number of prognostic tools for pneumonia to help guide disposition. Among these are the Pneumonia Severity Index (PSI) and CURB-65, both of which would classify this patient as low risk. She can be managed as an outpatient with oral antibiotics and follow-up

A 16-year-old boy presents after acute onset of right leg pain while playing soccer. The patient was sprinting toward the ball when he felt something "pop" in his right hip and fell. He denies loss of consciousness or head trauma, but needed assistance to ambulate to the sideline. He has 3/5 strength with right hip flexion and 4/5 strength with right hip abduction, both movements limited by pain. He also complains of pain with lateral compression of the pelvis. The patient is able to ambulate with an antalgic gait. An anterior-posterior X-ray of the pelvis is obtained and shown above. What is the most appropriate next step in management? A Discharge the patient with crutches and symptomatic treatment B Extremity traction and emergent orthopedic surgery consult for repair C Frog-leg X-ray to visualize possible femoral head fracture D Pelvic binding for two weeks with gradual return to activity

A Discharge the patient with crutches and symptomatic treatment Anterior superior iliac spine (ASIS) avulsion fractures usually occur in young athletes as a result of a sudden hip extension, usually in the context of jumping or running (e.g. pole vaulting, sprinting, or soccer). In adolescents, the tendons of the sartorius and tensor fascia are often stronger than the developing bone and can avulse from the pelvic brim when subjected to high stress. Patients endorse substantial pain with hip flexion and knee flexion, but can often bear weight on the affected extremity. X-ray findings are often subtle and patients can be misdiagnosed as suffering from acute muscular strain. MRI can also be used to distinguish between musculo-ligamentous injury and fracture. Most ASIS avulsion fractures can be managed conservatively, with crutches and partial weight bearing followed by physical therapy. Patients should have a referral to orthopedic surgery to monitor for malunion. Indications for surgery include neurologic symptoms (e.g. paresthesias over the lateral hip), large avulsions, and bony separation > 3 cm. Such injuries may require internal screw fixation. Prognosis is very good in both surgically and non-surgically managed patients. Surgical intervention allows for earlier mobility and weight bearing, but functional status is identical at one year regardless of treatment.

A 3-year-old boy presents with bleeding from his mouth after a fall. On examination, he has a completely avulsed front tooth. His mom has the tooth in her hand. The patient is otherwise well appearing, and the bleeding has stopped. What management is indicated? A Do not replace the tooth and arrange follow-up B Place the tooth in water and send to dentist in the morning C Replacement of the tooth into the socket D Scrub the tooth thoroughly and replace into socket

A Do not replace the tooth and arrange follow-up This boy presents with a completely avulsed primary tooth and requires urgent dental referral for further care. Avulsed teeth are a true dental emergency in adults but not in young children with primary teeth. For every minute that a permanent tooth remains out of the socket, the chance of successful reimplantation goes down by 1%. Thus rapid replacement is indicated. Primary teeth, however, should not be placed back into the socket. Reimplanted primary teeth may ankylose or fuse to the bone leading to dentofacial complex abnormalities. Additionally, a reimplanted primary tooth may interfere with eruption of the permanent tooth. Either way, cosmetic deformity results. Typically, primary teeth are present from 6 months to 6 years. Patients with avulsion of a primary tooth should be urgently referred to a dentist for further care.

Which of the following is true of Guillain-Barré syndrome? A Elderly patients have a more severe clinical course B It is associated with hyperreflexia C Lumbar puncture will reveal low protein D Rapid onset of Guillain-Barré syndrome tends to have a benign recovery

A Elderly patients have a more severe clinical course Guillain-Barré syndrome (GBS) is an acute polyneuropathy characterized by immune-mediated peripheral nerve myelin sheath destruction. The classic GBS syndrome is preceded by a viral illness, followed by the subacute onset of ascending symmetric weakness or paralysis and loss of deep tendon reflexes. The clinical course of GBS is more severe in the elderly. There is typically a more rapid recovery in children GBS is associated with normal or diminished deep tendon reflexes (B). Lumbar puncture results show high protein (C) (> 45 mg/dL). Those patients with a rapid onset of symptoms (D) usually have a poorer prognosis

A 67-year-old man presents to the ED with complaints of generalized abdominal pain that began four hours prior to arrival. The pain started after eating a hamburger and fries at a local restaurant. He has nausea and vomiting but denies diarrhea, chest pain, dyspnea, and dysuria. His medical history is significant for hypertension, heart failure, and atrial fibrillation. Vital signs are HR 89 beats per minute, RR 22 per minute, BP 145/70 mm Hg, temperature 100.0°F (37.8°C), and oxygen saturation 97% on room air. On exam, the patient appears very uncomfortable with mild, diffuse abdominal tenderness to palpation. An electrocardiogram reveals atrial fibrillation. Which of the following is most likely the cause of this patient's pain? A Embolism in the superior mesenteric artery B Thrombosis in the celiac artery C Vasoconstriction in the inferior mesenteric artery D Venous thrombosis

A Embolism in the superior mesenteric artery This patient's history and clinical picture are consistent with acute mesenteric ischemia, a life-threatening condition that most commonly affects patients who are > 50-years-old and have a history of cardiovascular disease. Acute mesenteric ischemia is caused by embolic obstruction of the superior mesenteric artery (SMA) in approximately 50% of cases. Patients typically have a history of dysrhythmia (most commonly atrial fibrillation), myxoma, or valvular heart disease. The classic presentation of mesenteric ischemia is abdominal pain out of proportion to exam. A persistently elevated lactate without an apparent underlying cause should also prompt consideration of the diagnosis. What is the gold standard for diagnosis of acute mesenteric ischemia? Angiography

A 27-year-old man presents after accidentally injuring his left hand at work while cleaning a paint gun. On examination, there is a pinpoint wound on the volar aspect of the distal phalanx of the second digit. There is minimal surrounding edema and mild tenderness with palpation. He has full range of motion at the distal interphalangeal joint. An X-ray is negative for fracture. What is the next best step in management? A Emergent hand service consultation B Immobilize the finger and discharge on oral cephalexin C Irrigate the wound and discharge home with oral analgesics D Wound exploration after performing a digital block

A Emergent hand service consultation High-pressure injection injuries, while often benign appearing initially, can result in significant morbidity, including amputation in nearly 50% of cases. The extent of injury is dependent on the type and volume of material injected, the velocity of injection, and location of injury. Injection of paints and solvents are more likely to result in a significant inflammatory response compared with grease and other viscous materials. Injection into distal sites is typically worse than injection into more proximal sites. Initial findings are often subtle, with a very small entrance wound and minimal erythema, edema and pain. Within hours, patients will develop increased pain, erythema, pallor, and pain with palpation and attempted range of motion. While a clinical diagnosis, radiographs of the affected area are done to rule out an associated bony injury, as well as to help identify the extent of subcutaneous air or radioopaque material. Emergent hand service consultation is indicated for all high-pressure injection injuries, including those that appear benign. While definitive treatment typically involves surgical decompression and debridement, broad-spectrum antibiotics, elevation, tetanus prophylaxis and pain control are also indicated in the emergency department

What is the correct order of the six cardinal movements of fetal descent during labor and delivery? A Engagement, descent, flexion, internal rotation, extension, external rotation B Engagement, extension, descent, external rotation, flexion, internal rotation C Engagement, extension, descent, internal rotation, flexion, external rotation D Engagement, flexion, descent, external rotation, extension, internal rotation

A Engagement, descent, flexion, internal rotation, extension, external rotation Normal Labor and Delivery First stage: cervical dilation to full dilation (10 cm) Latent phase: slow cervical change to ~5 cm dilation Active phase: rapid cervical change from 6-10 cm dilation Second stage: 10 cm dilation to delivery of baby Third stage: delivery of placenta Fourth stage: postpartum Delivery stages (six cardinal movements): engagement, descent, flexion, internal rotation, extension, external rotation. Anterior shoulder delivered first

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? A Erysipelas B Rosacea C Scarlet fever D Systemic lupus erythematosus

A Erysipelas Erysipelas is an infection of the skin that is characterized by an abrupt onset of fever, chills, and malaise followed by the development of a bright red, well-demarcated, indurated area of the skin. The skin can develop a peau d'orange appearance and classically involves the face in a malar distribution. The diagnosis is clinical. Treatment is elevation and antibiotics. Infections with systemic compromise: parenteral cefazolin, ceftriaxone, or flucloxacillin Mild infections: oral amoxicillin or cephalexin In patients that develop bullae, crepitus, or pain out of proportion to the exam, a necrotizing infection must be considered and a surgical consult may be warranted. Most common pathogen that causes erysipelas- Strep. pyogenes.

A 63-year-old man presents with chest pain radiating to his back. Vital signs are HR 123, BP 193/104, and oxygen saturation 95% on room air. A chest X-ray is shown. What therapy should be immediately initiated? A Esmolol B Hydralazine C Nitroglycerin D Sodium nitroprusside

A Esmolol This patient presents with an aortic dissection and should have aggressive control of blood pressure and heart rate started. Treatment is often referred to as "anti-impulse" therapy or decreasing the rate of rise of the arterial pulse (dP/dt). The goal is to rapidly achieve a heart rate < 60 bpm and a systolic blood pressure < 120 mm Hg. Esmolol is an ideal drug as it has a rapid onset of action and is easily titratable. Additionally, esmolol can lower both the heart rate and the blood pressure. Labetalol has been used as an alternative to esmolol but is more difficult to titrate and its effects are delayed in comparison. Provision of opiates relieve pain and in turn, may decrease the heart rate and blood pressure Hydralazine (B) should be avoided in aortic dissection because it is long-acting and difficult to titrate. Nitroglycerin (C) and sodium nitroprusside (D) can be used as alternatives to esmolol but are not ideal as they often cause reflex tachycardia in response to changes in blood pressure and should be combined with a beta blocker.

Which of the following clinical scenarios in a patient with chronic ethanol use should prompt admission to the hospital? A Fever, tachycardia, hypertension B Intoxication with vomiting C Mild tachycardia, tongue fasciculations D Normal vital signs, one seizure six hours ago

A Fever, tachycardia, hypertension The spectrum of illnesses related to chronic alcohol use is quite broad and frequently encountered in the ED. Acutely intoxicated patients are common in urban settings and require monitoring for clinical sobriety and safety prior to discharge. Patients may request admission for detoxification in the setting of cessation of alcohol use. When alcohol use is abruptly stopped or markedly decreased, patients may develop alcohol withdrawal with mild symptoms, alcohol related seizures, or in the most serious and life-threatening form of withdrawal, delirium tremens. The patient described here has several abnormal vital signs (fever, tachycardia, hypertension). These abnormalities are concerning for major alcohol withdrawal which is a constellation of symptoms which may include anxiety, irritability, tremors, tachycardia, fever, hypertension, decreased seizure threshold, and both auditory and visual hallucinations. In its most severe form, patients develop delirium tremens, which is a severe, hyper-adrenergic state with confusion, hallucinations, and hemodynamic instability. This condition is life-threatening and requires aggressive treatment with benzodiazepines and possibly antipsychotics. Intoxication with vomiting (B) is a common presentation in both chronic alcohol users and binge drinkers. It is important to recognize that alcohol intoxication is a diagnosis of exclusion as the cause of a patient's altered mental status. Routine investigations include fingerstick glucose, careful history, and an assessment for trauma. In most cases of intoxication, patients are monitored for clinical sobriety or metabolization until sober. Attention is paid to the ability of a patient to maintain an adequate airway, especially in the context of vomiting. A patient with mild tachycardia and tongue fasciculations (C) is consistent with mild alcohol withdrawal. Patients may also develop nausea, a coarse tremor, insomnia, and some hypertension. With treatment and observation for 4 to 6 hours in the ED, patients may be eligible for discharge. A patient with normal vital signs and a seizure 6 hours ago (D) is unlikely to have seizures related to severe alcohol withdrawal. Alcohol-related seizures are common. First time seizures should have the usual seizure evaluation including measurement of electrolytes and neuroimaging. If a patient had an isolated seizure and is seizure-free for a period of 6 hours without signs of ongoing withdrawal, they are eligible for discharge from the ED.

A 23-year-old man presents in status epilepticus by EMS. They have given multiple doses of benzodiazepines without response. Which of the following tests is most important at this time? A Fingerstick glucose B Lumbar puncture C Noncontrast head CT D Serum sodium level

A Fingerstick glucose Hypoglycemia is a common and easily treated cause of seizures that is frequently overlooked. Seizures are defined as episodes of abnormal neurologic functioning caused by an excess activation of neurons. They are common with over 10% of the general population experiencing at least one seizure during their lifetime. Seizures have a number of causes and are typically separated into primary (epilepsy) and secondary. Secondary seizures may be provoked by trauma, intoxication, toxin exposure, organ failure, metabolic disturbances, tumors, and secondary to drug effects. Hypoglycemia is a common metabolic disturbance that can cause a host of neurologic symptoms including confusion, coma, seizures, and focal neurologic deficits. Because hypoglycemia can be rapidly identified, rapidly treated, and potentially fatal, fingerstick glucose should be part of the immediate workup of any patient who presents with altered mental status. What medication should be given to a patient with status epilepticus and a possible isoniazid overdose? Pyridoxine.

A 19-year-old man presents after an intentional ingestion of an unknown substance. He reports visual disturbances. He has an elevated anion gap acidosis and an elevated osmolar gap. Vital signs are within normal limits. Serum ethanol, lactic acid, and salicylate levels are normal. Which of the following is the correct antidotal therapy? A Fomepizole B Hydroxocobalamin C Naloxone D Physostigmine

A Fomepizole Methanol is a compound found in antifreeze, windshield washer fluid, cleaning agents, formalin, and embalming fluid. It is also a byproduct of illicit alcohol production. Methanol is converted in the liver to formaldehyde and formic acid. Formic acid is the primary cause of toxicity. It causes a metabolic acidosis by inhibiting mitochondrial cytochrome oxidase. An osmolar gap (the difference between the calculated and measured serum osmolarity) is caused by elevated levels of methanol in the serum. Autopsy studies suggest that retinal cells have unique enzymes which convert formic acid to formate, an especially toxic compound. Therefore, visual impairment in a patient with a toxic ingestion is highly suggestive of methanol poisoning. This patient most likely ingested methanol. Fomepizole is the antidotal therapy for methanol (and ethylene glycol) poisoning. It inhibits alcohol dehydrogenase, slowing the conversion of methanol into toxic metabolites. The unmetabolized methanol is then renally excreted. Other therapies include sodium bicarbonate, folinic acid and hemodialysis. Antifreeze, windshield washer fluid, paint thinners Methanol → formic acid (toxic metabolite) Visual Sx (snowstorm) Anion gap metabolic acidosis, increased osmolar gap Rx: fomepizole (first line), folinic acid, bicarbonate, hemodialysis Hydroxocobalamin (B) is the antidote for cyanide toxicity. It binds cyanide to form cyanocobalamin (vitamin B12) which is then eliminated in the urine. Naloxone (C) is the antidote for opioid overdose. It is a competitive antagonist which inhibits opioid binding at receptors. Physostigmine (D) is a reversible inhibitor of acetylcholinesterase and is the antidote for anticholinergic delirium.

A 23-year-old woman presents to the ED two hours after an intentional ingestion of a "painkiller". She is complaining of nausea and vomiting. Physical exam is unremarkable. Vital signs are BP 110/70 mm Hg, HR 90 beats per minute, RR 14 breaths per minute, and T 98.2°F. Which of the following is necessary to direct your treatment? A Four-hour acetaminophen level B Four-hour salicylate level C Potassium level D Venous blood gas

A Four-hour acetaminophen level This patient is exhibiting signs and symptoms of acetaminophen toxicity. A key to treatment of acetaminophen overdoses is to predict the risk of toxicity. A reliable time of ingestion and amount ingested should be obtained. The typical toxic dose is greater than 150 mg/kg. A serum acetaminophen level should be obtained at 4 hours after ingestion or as soon as possible thereafter based on time of presentation. The Rumack-Matthew nomogram can be used to determine potential toxicity and whether to treat. Signs and symptoms of acetaminophen toxicity vary based on the time of presentation from time of ingestion. If a patient presents within the first 24 hours, they may present with nausea, vomiting, and anorexia or no symptoms at all. Between 24 and 72 hours, the initial GI symptoms resolve. The patient may develop right upper quadrant abdominal pain in addition to elevated liver enzymes and prolonged INR. Between 72 and 96 hours, hepatic encephalopathy, coagulopathy, acidosis, jaundice, renal failure, cerebral edema, and death will occur. If the patient survives, hepatic dysfunction may resolve over 4 to 14 days. The treatment for acetaminophen toxicity is N-acetylcysteine (NAC). It may be given orally or intravenously. A four-hour salicylate level (B) would not be appropriate as this patient's presentation does not match that of someone with salicylate toxicity. Patients who present with salicylate overdose will generally have tachypnea, nausea, vomiting, vertigo, and altered mental status. They do not present with signs of liver failure. The potassium level (C) is important in patients presenting with salicylate toxicity as alkalinization of the urine with sodium bicarbonate can lead to life-threatening hypokalemia. A venous blood gas (D) would be useful in salicylate toxicity to monitor the patient's acid-base status during treatment with sodium bicarbonate for progress and to prevent over-alkalinization of the serum.

A 4-year-old boy who has not received routine childhood vaccinations presents with fever, cough, coryza, and conjunctivitis for three days. Today his mother noted an erythematous macular rash over his face, trunk, and extremities. Which of the following is the most likely diagnosis? A Measles B Mumps C Roseola D Rubella

A Measles Measles (rubeola) is spread by direct contact with infectious droplets or airborne dissemination. From exposure to the onset of symptoms takes 8-12 days, with the onset of the rash about 14 days. Clinically, measles is associated with fever, conjunctivitis, coryza, and cough (the 3 Cs). The rash is a discrete red maculopapular rash that first appears on the forehead, becoming coalescent as it spreads down the trunk to the feet. The rash fades in the same head-to-feet pattern as it appeared. Measles is also associated with Koplik spots. These are 1-3 mm bluish-white spots on a bright red surface that appear first on the buccal mucosa opposite the lower molars. They are a pathognomonic enanthem of measles and appear approximately within 48 hours after the onset of symptoms.

A 45-year-old man presents with altered mental status. On arrival, his finger stick is 35 mg/dL. He is given dextrose leading to the return of a normal mental status. On history, he reports he may have unintentionally taken extra medication. Which of the following medications requires prolonged observation in the hospital? A Glipizide B Insulin aspart C Metformin D Sitagliptin

A Glipizide In most adults, symptomatic hypoglycemia occurs when glucose levels reach 40 to 50 mg/dL. Mechanism: increase insulin secretion Can cause hypoglycemia 24 hrs after ingestion Can cause severe hypoglycemia in children Rx: charcoal, dextrose, octreotide Glipizide is a sulfonylurea oral hypoglycemic drug. This class of medication is associated with hypoglycemic episodes through their action as an insulin secretagogue. In a sulfonylurea overdose, patients should be observed for 24 hours. When the etiology is unclear, laboratory testing including renal function is indicated. In situations without large ingestions, patients may be discharged if no additional episodes of hypoglycemia occur after an observation period. In cases of severe, prolonged, or recurrent episodes of hypoglycemia from sulfonylureas, additional therapy with octreotide as an inhibitor of insulin release is indicated.

What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis? A Glucose-6-phosphate-dehydrogenase deficiency B Hereditary spherocytosis C Paroxysmal nocturnal hemoglobinuria D Pyruvate kinase deficiency

A Glucose-6-phosphate-dehydrogenase deficiency This patient most likely has hemolytic anemia caused by oxidative stress in the setting of G6PD deficiency. Pneumocystis pneumonia prophylaxis is most commonly initiated with trimethoprim-sulfamethoxazole, an agent known to be associated with hemolysis in patients with G6PD deficiency. Up to 85% of the energy generated by RBCs to sustain membrane stabilization occurs via anaerobic glycolysis. At least eight known enzymatic deficiencies are found in the glycolytic pathway, including pyruvate kinase deficiency, a cause of hemolytic jaundice, usually diagnosed in infants. The other 15% of energy comes from the production of nicotinamide adenine dinucleotide phosphate (NADPH) via the hexose monophosphate shunt pathway. NADPH is necessary for the reduction of oxidized glutathione, an antioxidant that contributes significantly to membrane stabilization. The first enzyme in the hexose monophosphate pathway is G6PD. 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 is diagnosed by enzymatic screening. G6PD Deficiency History of taking antimalarials, sulfonylureas, quinolones, nitrofurantoin, fava beansInfection 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 What finding on peripheral blood smear is characteristic of G6PD deficiency?Heinz bodies, which are clumps of denatured hemoglobin.

A 60-year-old woman with a history of diabetes presents to the ED with altered mental status and a blood glucose level of 35 mg/dL. She receives 50 g of dextrose, and her mental status improves. She is then given something to eat. One hour later, she is confused and diaphoretic, and her blood glucose is 40 mg/dL. Which of the following agents is most likely responsible for her condition? A Glyburide B Metformin C Regular insulin D Rosiglitazone

A Glyburide Glyburide is a commonly prescribed sulfonylurea for type II diabetes. Sulfonylureas are oral agents that stimulate the beta cells of the pancreas to produce insulin and increase the sensitivity to insulin in peripheral tissues. Sulfonylureas have a relatively long duration of action and can cause hypoglycemia 24 hours after ingestion. Glyburide is one of these sulfonylureas with a long half-life. After the patient received dextrose, she became hypoglycemic again. This recurrent hypoglycemia is life-threatening, therefore, the patient requires hospitalization. She should be placed on a dextrose drip. Octreotide, a somatostatin analog, can be administered to limit the effect of native insulin. Octreotide works by inhibiting glucose-stimulated insulin release. In severe overdoses, activated charcoal should be considered for decontamination.

Which of the following statements is true regarding septic arthritis? A Gonococcal arthritis is the most common type of monoarticular septic arthritis in sexually active adults under 35 years of age B Infection occurs most commonly by direct inoculation C There is a unimodal distribution D Widening of the joint space is an early sign seen on X-ray

A Gonococcal arthritis is the most common type of monoarticular septic arthritis in sexually active adults under 35 years of age Septic arthritis is defined as an infection of a joint by bacterial or fungal organisms. Classically, septic arthritis presents with fever, joint pain, and effusion, typically in the large joints. Fever is usually present but may be absent in immunocompromised individuals. Gonococcal arthritis remains the most common form of joint infection in adults under 35 years of age. Acute nongonococcal septic arthritis in adults is most often caused by gram-positive organisms (Staphylococcus aureus). Overall, Staphylococcus aureus is the most common cause of septic arthritis with an increasing frequency of methicillin resistance.

Which of the following statements is true regarding the diagnosis of Epstein-Barr virus infection? A Guillain-Barré syndrome is a possible complication B Neutrophilia predominates C Splenomegaly occurs in 10% of patients D The virus is transmitted via respiratory droplets

A Guillain-Barré syndrome is a possible complication The Epstein-Barr virus (EBV) is implicated in a variety of human illnesses. It is associated with infectious mononucleosis, B-cell lymphoma, Hodgkin disease, Burkitt lymphoma, and nasopharyngeal carcinoma. EBV can affect nearly all organ systems. Neurologic complications such as encephalitis, meningitis, and Guillain-Barré have been reported. EBV is associated with lymphocytosis (B) with > 50% lymphocytes. Atypical lymphocytes are found on examination of the peripheral blood smear. Splenomegaly (C) occurs in > 50% of patients. Therefore, patients should be advised to avoid all contact sports for a minimum of four weeks after illness onset to avoid splenic injury. EBV is transmitted via salivary secretions (D) and requires close contact for transmission (hence lay application of the term "kissing disease"). The infection is usually contracted from an asymptomatic individual who sheds the virus. After infecting the oropharyngeal epithelium, it disseminates through the blood stream. The virus infects B lymphocytes and causes an increase in T lymphocytes, which results in enlargement of lymphoid tissue. In immunocompromised patients with decreased T-cell function, B cells continue to proliferate, and proliferation may lead to neoplastic transformation

Transient aplastic crisis

A clinical manifestation of parvovirus Sickle cell disease/hemolytic anemia syndromes Arrest in red cell production Lasts 7-10 days Contagious until a week after onset Clinically, patients develop pallor, lethargy, and shock. The bone marrow suppression leads to an absence of reticulocytosis, so an inappropriately low (or nonexistent) reticulocyte count is seen.

In a patient that is not alert or has polytrauma, what compartment measurement should lead the clinician to consider fasciotomy regardless of symptoms?

A compartment pressure > 30 mm Hg should always prompt consideration for a fasciotomy regardless of symptoms.

A 21-year-old woman presents to the emergency department with painful genital lesions and vaginal discharge. She is sexually active with multiple partners and sometimes uses protection. Her last menstrual period was two weeks ago. She has a history of chlamydia infection but does not think her symptoms are the same. On physical examination, you find genital vesicular lesions. What diagnostic test is most likely to be positive in this patient? A Herpes simplex virus polymerase chain reaction test B Human papillomavirus testing through a Pap smear C Potassium hydroxide preparation D Rapid plasma reagin test

A Herpes simplex virus polymerase chain reaction test The patient in this question is presenting with a herpes simplex virus outbreak. Patients generally present with painful genital ulcers, dysuria, fever, tender inguinal lymphadenopathy, and headache. Patients will have multiple shallow, tender, vesicular ulcers on an erythematous base. The diagnosis is usually made clinically. The diagnosis can be confirmed with either a viral culture or polymerase chain reaction assay of the vesicular fluid. Viral cultures are approximately 50% sensitive in detecting virus and require several days before a result is complete. Therefore, polymerase chain reaction tests, which are more sensitive, have become the tests of choice. Alternatively, a Tsanck smear can be performed and may demonstrate multinucleated giant cells, but this test has a low sensitivity and specificity and is only helpful if it is positive.

A patient presents after a chemical splash to the eye. What management is immediately indicated? A High-volume irrigation B Pupil dilation and slit lamp examination C Referral to ophthalmology D Topical antibiotics and ophthalmology consultation

A High-volume irrigation Patients who present with chemical exposure to the eye should undergo immediate irrigation with normal saline prior to the initiation of any other management. A rapid assessment of the pH of the conjunctiva with pH paper and application of a topical anesthetic may be rapidly performed prior to initiation of irrigation, but no procedure or intervention should delay irrigation. Irrigation should continue for a minimum of 30 minutes, followed by a check of the pH. Irrigation should be continued until the pH normalizes. Once the pH normalizes, application of cycloplegics and a complete ocular assessment should be performed. After immediate management, focus should be placed on identifying the substance the patient was exposed to and obtaining ophthalmologic consultation for any significant injuries. Typically, alkaline substances with a pH less than 12 and acidic substances with a pH greater than 2 are not thought to cause significant injury. This may be altered if the duration of contact was prolonged. Long-term complications include perforation, scarring, and neovascularization of the cornea. Glaucoma and cataracts can also occur.

Which of the following techniques for shoulder reduction is associated with a high incidence of complications? A Hippocratic technique B Scapular manipulation C Stimson method D Traction-countertraction method

A Hippocratic technique The shoulder is the most commonly dislocated major joint in the body. The vast majority of dislocations are anterior, representing 95 to 97% of cases. Anterior dislocations result from a combination of abduction, extension, and external rotation forces on the shoulder. In younger people, this often occurs during athletic activities, while in the elderly, dislocation more commonly results from a fall. Individuals with recurrent dislocations can suffer a dislocation from seemingly innocuous movements, such as rotating the arm to put on a jacket. On physical examination, the patient is in severe pain and holds the arm in slight abduction and external rotation. A defect in the normally rounded contour of the shoulder is present. Adduction or internal rotation usually causes severe pain. Radiographs are confirmatory, revealing the abnormal position of the humeral head with respect to the glenoid fossa. A patient with a confirmed shoulder dislocation should undergo prompt reduction since the risk of neurovascular injuries increases over time. Several methods are available to reduce a dislocated shoulder. Procedural sedation and intra-articular injection of an analgesic medication is often used in the ED to facilitate reduction. In the traction-countertraction technique, the provider applies traction to the abducted arm while an assistant provides countertraction using a sheet wrapped across the patient's chest. The Stimson method positions the patient in the prone position and utilizes a hanging weight on the affected arm to reduce the dislocation. In the scapular manipulation technique, the provider rotates the inferior tip of the scapula medially while stabilizing the superior and medial edges of the scapula with the opposite hand. The Hippocratic method is no longer recommended due to increased risk of axillary nerve injury. In this method, traction is applied to the arm while the provider's foot is positioned in the ipsilateral shoulder.

A 36-year-old man presents after an assault with the eye as seen in photo. What is the most likely diagnosis? A Hyphema B Iritis C Retrobulbar hematoma D Subconjunctival hemorrhage

A Hyphema This patient has evidence of a traumatic hyphema on ocular exam. A hyphema is defined as blood in the anterior chamber of the eye. A hyphema is most commonly caused by ocular trauma. It is the result of contusive forces causing mechanical tearing or shearing of the vasculature of the iris or ciliary body. Spontaneous hyphema is also possible, but far less common. Symptoms often include blurring of vision, ocular pain, photophobia, and tearing. Diagnosis is made on physical examination of the eye by visualizing blood in the anterior chamber. Management includes elevating the head of the bed and cycloplegics to decrease the activity of the iris and decrease the incidence of rebleeding. Increased intraocular pressure can be managed by topical beta blockers, mannitol, or acetazolamide. Patients should be admitted if the hyphema is > 33% of the anterior chamber or if the intraocular pressure is > 30 mm Hg. Grade 4 hyphemas require surgical management. Ophthalmology should be consulted for all hyphemas of grade 2 or higher. The most important complication to prevent is rebleeding, which is caused by disruption of the initial clot typically three to five days after the initial bleed. Aspirin and NSAIDs are contraindicated in the treatment of pain.

Which of the following variables are significant independent predictors of pneumonia in nursing home patients? A Increased pulse rate and respiratory rate > 30/min B Pleuritic chest pain and increased leukocyte count C Respiratory rate > 30/min and productive cough D Wheezing and productive cough

A Increased pulse rate and respiratory rate > 30/min Nursing home patients with pneumonia are less likely than those living independently to have a productive cough or pleuritic chest pain but more likely to be confused and have poorer functional status. There are eight variables that are significant independent predictors of pneumonia in nursing home patients, as seen in the table below. A patient with one of these variables has a 33% chance of having pneumonia, whereas three or more variables suggest a 50% likelihood of pneumonia

Peritonsillar abscess (PTA)

A complication of acute tonsillitis. The infection spreads from the tonsil to the surrounding tissue, which forms an abscess. The most common cause of PTA is group A beta-hemolytic Streptococcus.

What is splenic sequestration crisis?

A condition seen in children with sickle cell disease when there is rapid sequestration of RBCs in the spleen causing splenomegaly and severe anemia

A 3-year-old boy presents to the emergency department after a high-speed motor vehicle collision. Paramedics report that he had paralysis of all four extremities on scene. Your primary and secondary surveys, including a full neurologic exam, are normal. He has normal head and cervical spine CTs. Which of the following is most likely to be found on magnetic resonance imaging (MRI) of his cervical spine? A Injury to spinal cord at C3-C4 B Injury to spinal cord at C6-C7 C Injury to spinal cord at T4-T5 D Normal MRI

A Injury to spinal cord at C3-C4 Pediatric patients are at an increased risk of spinal cord injury without radiographic abnormalities (SCIWORA) as compared to adults. SCIWORA was originally defined as clinical evidence of a spinal cord injury (e.g., neurologic deficits, including transient deficits) without abnormalities on cervical spine CT or flexion-extension X-rays. More recently, with the use of MRI, we have found that most SCIWORA patients have visible acute spinal cord injuries, including those with transient symptoms and normal neurologic exams by presentation. Pediatric patients are at higher risk for SCIWORA secondary to larger head-to-body ratios, more elastic spinal ligaments, shallow vertebral facets that predispose to subluxation, as well as higher spinal canal diameter-to-spinal cord diameter, allowing movement of the cord within the canal. As such, it is important to maintain a high index of suspicion for spinal cord injuries in pediatric patients with significant mechanism (e.g., axial loading, high-risk motorized vehicle collision), or those with neurologic symptoms and normal preliminary spine imaging. Pediatric patients are also at higher risk for higher-level cervical spine injuries. As the head-to-body ratio decreases with age, the cervical spine fulcrum moves from C2-C3 at birth to C5-C6 by approximately 8 years of age.

The Health Insurance Portability and Accountability Act (HIPAA) was issued in 1996 for the protection of patient privacy. Which of the following is an acceptable reason to share or to access a patient's protected health information? A Insurance company billing inquiry B Media inquiries C Mother's inquiry regarding her 21-year-old son D Preparation for a teaching lecture not involving morbidity and mortality

A Insurance company billing inquiry The Health Insurance Portability and Accountability Act (HIPAA) encompasses all guidelines related to the privacy of patient information and the appropriate management of protected health information (PHI). The Office for Civil Rights oversees the execution of federal privacy rules. PHI includes any information related to the medical or psychiatric care of a patient. The information is linked to specific patients by pieces of information that could help to identify the individual patient including: date of birth, social security number, address, name, medical record number, and other unique identifiers. It is the job of all health care professionals to maintain strict privacy standards inside and outside the workplace. Certain scenarios are protected under HIPPA. This includes communication with other healthcare professionals who have direct patient care responsibilities. Additionally, information is shareable with the patient's insurer for billing and payment processing. What are the penalties for HIPAA violations? Financial and possible imprisonment. HIPAA - Health Insurance Portability and Accountability Act of 1996 Privacy and security for health information PHI can be used for insurance and billing purposes Minimize transfer of information to only what is necessary Possible fines for breaches

A 51-year-old woman presents with pain and swelling of the face that began yesterday. Her symptoms began abruptly with a high fever and chills. Physical exam reveals bright red, indurated skin in a well-demarcated malar distribution. Which of the following is the most appropriate pharmacologic treatment? A Intravenous ceftriaxone B Oral amoxicillin C Oral prednisone D Topical metronidazole

A Intravenous ceftriaxone Intravenous ceftriaxone is the best initial treatment for patients presenting with erysipelas and systemic symptoms. Once the patient has clinically improved, the patient can be discharged with oral antibiotics. Erysipelas is an infection of the skin typically caused by beta-hemolytic streptococci (S. pyogenes) that is characterized by an abrupt onset of fever, chills, and malaise followed by the development of a bright red, well demarcated, indurated area of the skin. The skin can develop a "peau d'orange" appearance and classically involves the face in a malar distribution or the legs. The diagnosis is clinical. In patients that develop bullae, crepitus, or pain out of proportion to the exam, a necrotizing infection must be considered and a surgical consult may be warranted.

A 6-year-old boy presents with a limp for the last several months. He reports pain in his groin that is worse at the end of the day. He has not had trauma. On examination, the patient is afebrile and well appearing. His height and weight are within normal limits for age. Pain is elicited with internal rotation and abduction of the right hip. There is no effusion, redness, or warmth over the hip joint. Which of the following is the most likely diagnosis? A Legg-Calvé-Perthes disease B Osgood-Schlatter disease C Septic arthritis of the hip D Slipped capital femoral epiphysis

A Legg-Calvé-Perthes disease Legg-Calvé-Perthes disease, or idiopathic avascular necrosis of the proximal femoral epiphysis, most commonly occurs in male children between the ages of 4 and 10 years with a peak between 5 and 7 years of age. It often presents with a limp that has an insidious or stuttering onset. The associated pain is generally mild, refers to the groin or anteromedial aspect of the thigh or knee, is relieved by rest, and generally worse at the end of the day. Early in the disease, patients tend to have pain and restriction with abduction and internal rotation of the hip due to synovitis and muscle spasm. As the disease progresses, the limited abduction becomes permanent due to bony changes in the femoral head. Patients may also exhibit a positive Trendelenburg sign; thigh, calf, and buttock muscle atrophy; or limb-length discrepancy from the collapse of the femoral head. Legg-Calvé-Perthes disease is diagnosed using plain films with AP and frog-leg views, bone scan, and MRI. Initial treatment involves non-weight bearing and orthopedic referral, as medical or surgical treatment may be necessary based on clinical and radiographic findings. The goal is to improve range of motion, limit growth disturbance, and prevent chronic degenerative changes Patient will be a boy 4-10 years old Unilateral, intermittent limp Most commonly caused by osteonecrosis of the proximal femoral head

A 58-year-old man with diabetes presents to the ED with a concern about right knee pain and swelling. On examination, his right knee is tender, erythematous, and swollen. He experiences intense pain with passive movement of the knee. You are concerned that he has a septic joint and perform an arthrocentesis. Which of the following synovial fluid results most supports this diagnosis? A Low glucose B Low protein C Polymorphonuclear leukocytes of 25% D WBC count of 200/mm3

A Low glucose Low synovial fluid glucose level is consistent with a diagnosis of septic arthritis. Septic arthritis is a true orthopedic emergency and accurate diagnosis requires a high index of suspicion. Patients who present with monoarticular arthritis should be considered to have a septic joint until the diagnosis is ruled out. A delay in diagnosis leads to increased morbidity and higher complication rates. Arthrocentesis is a common ED procedure that can yield valuable information to aid in the diagnosis of a septic joint. It is generally a well-tolerated procedure and can be therapeutic.

Which of the following risk factors has the strongest association for cellulitis? A Lymphedema B Obesity C Skin breakdown D Venous insufficiency

A Lymphedema Certain host factors predispose to cellulitis. Elderly and immunocompromised individuals are at risk for more severe disease. Patients with diabetes, immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral arterial disease, and chronic kidney disease appear to be at a higher risk for recurrent infection, owing to an altered host immune response. While other factors that affect host immunity such as concurrent intravenous or subcutaneous "skin popping" drug use predispose to development of infection, the risk factor that is most strongly associated with cellulitis is lymphedema. The odds ratio (OR) is 71.2.

A pH of 7.1, HCO3 of 15 mEq/L, and PCO2 of 30 mm Hg is best described by which of the following primary acid-base disorders? A Metabolic acidosis B Metabolic alkalosis C Respiratory acidosis D Respiratory alkalosis

A Metabolic acidosis Acidosis and alkalosis are processes that lead to acidemia (pH < 7.40) and alkalemia (pH > 7.40), respectively. Primary metabolic disorders result from a change in bicarbonate, while primary respiratory disorders result from a change in partial pressure of carbon dioxide. Compensation occurs when other system alterations bring the blood gas toward a normal pH of 7.35. Metabolic acidosis is present in patients with a pH of < 7.35 and bicarbonate < 24 mEq/L. Causes of an increased anion gap acidosis [Na+ - (Cl- + HCO3-)] > 20 can be remembered by the MUDPILES mnemonic (Methanol, Metformin, Uremia, Diabetic (or alcoholic) ketoacidosis, Paraldehyde, Propylene glycol, Isoniazid, Iron, Lactic acidosis, Ethylene glycol, Salicylates). Normal anion gap acidosis is caused by renal losses (tubular acidosis, acetazolamide), GI losses (diarrhea, malabsorption), and adrenal insufficiency. Compensation for an acid-base disorder never completely normalizes the pH. A pH of 7.45 in a patient with low bicarbonate indicates a second disorder (such as a primary respiratory alkalosis). Metabolic alkalosis (B) is caused by increased bicarbonate, leading to a pH > 7.35. This occurs secondary to gastric acid loss from vomiting or nasogastric tube suctioning, diuretic use, and adrenocortical hormone excess. Most common benign cause of a primary respiratory alkalosis - HYPERVENTILATION Respiratory acidosis (C) is caused by an increase in the partial pressure of carbon dioxide > 40 mm Hg leading to a pH < 7.35. This is primarily a result of inadequate ventilation or increased dead space. Causes include head or chest trauma, over sedation, obtundation, neuromuscular disorders, Pickwickian syndrome (obesity-hypoventilation syndrome), and COPD. Respiratory alkalosis (D) is caused by a decrease in the partial pressure of carbon dioxide < 40 mm Hg, leading to a pH > 7.35. In this condition, carbon dioxide ventilation outpaces production.

Which of the following is characteristic of pemphigus vulgaris? A Mucous membrane involvement B Negative Nikolsky sign C Primarily affects patients over 60 years of age D Tense bullae

A Mucous membrane involvement Pemphigus vulgaris is a dermatologic disease characterized by bullous lesions. It is most commonly seen in patients ages 40-60 years and affects men and women equally. It is thought to be autoimmune in origin. Most patients develop mucous membrane lesions initially, sometimes months prior to the onset of skin lesions. Like the skin lesions, the oral lesions present on the gums and vermilion border of the lips, are bullous and break, leaving painful and superficial ulcerations. The skin lesions can involve any site on the body and are small, flaccid bullae that break easily. Nikolsky sign, extension or new bullae formation when lateral pressure is placed on intact skin in the next 24 hours, is positive. Diagnosis is made clinically and confirmed by serum immunofluorescence. A Tzanck test will also be positive, but is not specific to pemphigus vulgaris. Treatment consists of pain control, wound care, and oral glucocorticoids. Prior to the use of steroids, the mortality rate was over 90%. With steroid management and appropriate wound care, the mortality rate is now less than 15%.

Which of the following is the earliest finding in compartment syndrome? A Pain with passive stretch B Pallor C Paresthesias D Pulselessness

A Pain with passive stretch Pain with passive stretch of the affected compartment is the most common symptom early in compartment syndrome. Compartment syndrome develops when pressure builds within a confined anatomical space. Increasing pressure leads to decreased perfusion compromising tissue. Tissue ischemia eventually leads to death of muscle, nerve, and bone tissue. Although it is typically associated with major trauma and crush injuries, it can develop after a relatively minor injury. Any compartment that is prescribed by fascial planes can develop compartment syndrome. However, the lower extremities are the most common location due to their higher risk for injury and their relatively low-volume compartments. Long-bone fractures account for 75% of all traumatic compartment syndromes. Patients will present with pain that is often out of proportion to examination

A 32-year-old woman presents with scleroderma. Which of the following is she most likely to also have? A Raynaud phenomenon B Reactive arthritis C Sacroiliitis D Systemic lupus erythematosus

A Raynaud phenomenon Scleroderma is also known as progressive systemic sclerosis. This disease is much more common in women than men. It is an autoimmune disease of unclear etiology affecting the connective tissue causing thickening and tightening. The disease covers a clinical spectrum of isolated skin disease to progressive involvement of multiple internal organs. CREST syndrome is a variant of scleroderma with most involvement distal to the elbows and knees although there may be some involvement of the face and neck. The components of CREST syndrome are Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasias. Most treatments are aimed at symptomatic relief although there is some evidence for the use of methotrexate as an immunosuppressive agent

Which of the following groups of lab results is most consistent with a toxic-appearing adult patient with known sickle cell disease who was exposed to a child with a recent febrile illness characterized by the rash seen above? A Reticulocyte count decreased, Coombs negative, haptoglobin normal B Reticulocyte count decreased, Coombs positive, haptoglobin decreased C Reticulocyte count increased, Coombs negative, haptoglobin decreased D Reticulocyte count increased, Coombs positive, haptoglobin normal

A Reticulocyte count decreased, Coombs negative, haptoglobin normal This patient is suffering from an aplastic crisis. In patients with sickle cell disease (SCD), certain viruses, parvovirus B19 being the best known, are cytotoxic to host cells and can cause suppression of erythrogenesis and subsequent aplastic crisis. Although all cell lines are typically affected, the severe anemia has the greatest clinical impact because these patients are chronically anemic due to sickle cell disease. Clinically, patients develop pallor, lethargy, and shock. The bone marrow suppression leads to an absence of reticulocytosis, so an inappropriately low (or nonexistent) reticulocyte count is seen. The Coombs test detects immunoglobulins or complement on the surface of red blood cells in autoimmune hemolytic anemia. Therefore, this patient will be Coombs negative. Haptoglobin binds to free hemoglobin in hemolytic anemia. Because this patient is experiencing marrow suppression, rather than a hemolytic crisis, the haptoglobin is expected to be normal.

Which one of the following groups of lab results is most consistent with a complication that commonly occurs 6-12 weeks after acute hepatitis? A WBC decreased, RBC decreased, platelets decreased B WBC decreased, RBC increased, platelets increased C WBC increased, RBC decreased, platelets decreased D WBC increased, RBC increased, platelets increased

A WBC decreased, RBC decreased, platelets decreased Aplastic anemia is a known complication of acute hepatitis. This affects up to 2% of all patients after their initial illness. Hepatitis-associated aplastic anemia most often affects adolescent boys and young men, is most commonly seen 6-12 weeks after hepatitis, and can be fatal if untreated. Its etiology is unclear. There is no known association with blood transfusions, drugs, or toxins. Most patients have been seronegative for hepatitis A, B, and C, but it is believed to be the result of autoimmune bone marrow failure. Lab findings show a decrease in the WBC, RBC, and platelet counts.

myocardial infarction (MI)

A myocardial infarction occurs when rupture of atherosclerotic plaque and subsequent platelet aggregation and thrombosis lead to occlusion of a coronary artery, compromising blood supply to the heart. The left side of the heart is primarily supplied by the left coronary artery, which divides into the left anterior descending artery and left circumflex artery. . The left anterior descending branch travels down the anterior aspect of the heart and provides the main blood supply to the anterior and septal regions of the heart. Infarction of this region is seen on ECG with ST elevation in leads V1-V4. In addition, reciprocal ST depressions are often seen in leads II, III, and aVF. The circumflex artery supplies blood to a portion of the anterior wall and the majority of the lateral wall of the heart. Acute myocardial infarction involving the circumflex artery is characterized by ST elevation in lead V5, V6, I and aVL, and ST depressions in leads V1-V3. The right coronary artery supplies blood to the right side of the heart, and provides some perfusion to the inferior aspect of the left ventricle. Infarction involving the right coronary artery is evidenced by ST elevation in leads II, III and aVF. Reciprocal ST depressions are often seen in leads I and aVL. The most effective treatment for an ST-elevation myocardial infarction is immediate reperfusion via cardiac catheterization. If cardiac catheterization is not available, thrombolysis with tissue-plasminogen activator is another appropriate option

What is the normal ocular pH?

A pH of 6.5 - 7.5 is normal for the eye.

What size pneumothorax can be successfully managed with oxygen supplementation and observation alone?

A pneumothorax involving < 20% of the hemithorax. Spontaneous Pneumothorax Risk factors: tall, thin, male, ages 10-30, Marfan syndrome, cigarette smoking, COPD, TB, CF, ILD, PCP pneumonia Sx: acute dyspnea and pleuritic chest pain PE: decreased breath sounds, decreased fremitus, hyperresonance to percussion Dx: Upright CXR: absence of lung markings along lung periphery Pleural U/S: absence of lung sliding Tx: small ≤3 cm in a healthy patient: observation with oxygen administration large >3 cm: needle aspiration or chest tube thoracostomy

Functional Neurological Symptom Disorder

A rare somatoform disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found. previously known as conversion disorder, is characterized by abnormalities or deficits of motor or sensory function that are not medically explained, such as blindness, seizure, paresis, paralysis, tremors, aphonia, or anesthesia. Classically, symptoms occur suddenly following a psychosocial stressor and are nonpainful.

non-Hodgkin lymphoma (NHL)

A widespread malignant disease of lymph nodes that involves lymphocytes. It differs from Hodgkin disease in that giant Reed-Sternberg cells are absent. most common in children between 2 and 12 years of age. Extranodal involvement as well as lymphadenopathy below the clavicles are frequently seen. Multiple, peripheral nodes; noncontiguous spread Extranodal involvement HIV and autoimmune association Most common hematopoietic neoplasm Associated with EBV

Which lab marker elevation has the highest positive predictive value for a biliary etiology in patients diagnosed with acute pancreatitis? A Alanine aminotransferase B Alkaline phosphatase C Lipase D Total bilirubin

A. Alanine aminotransferase (ALT) Elevation in liver enzymes may result from biliary-induced pancreatitis. Alanine aminotransferase (ALT) has a high specificity/positive predictive value for a biliary etiology of pancreatitis. Levels three times greater than baseline support the diagnosis of biliary pancreatitis. The higher the level of ALT, the greater the specificity and predictive value for gallstones. ALT levels more than 150 IU/L have 96% specificity and 95% positive predictive value for gallstone pancreatitis. Elevated lipase is specific for acute pancreatitis. At values five times the upper limit of normal, lipase is 60% sensitive and 100% specific

A 45-year-old woman with a history of panic disorder and depression presents with palpitations, shortness of breath, diaphoresis, and tingling in her fingers for one hour. Yesterday, she took an hour car ride. She states that her symptoms feel like her previous panic attacks. She is breathing at a rate of 24 breaths per minute and her heart rate is 102 beats per minute. She has trace pitting edema of the bilateral ankles. She takes conjugated estrogen tablets for post-menopausal symptoms. What is her score using Wells Clinical Prediction Rule for pulmonary embolism? A 1.5 B 3 C 6 D 7.5

A. 1.5 Wells Clinical Prediction Criteria is a clinical prediction and risk stratification tool used to quantify a patients pre-test probability of pulmonary embolism (PE). The criteria should be applied only after a history and physical suggests that venous thromboembolism is a diagnostic possibility. It should not be applied to all patients with chest pain/dyspnea or to all patients with leg pain or swelling. While there have been modified versions since its first publication in 2000, the original scoring systems involves 7 risk factors. These factors include: (1) Clinical signs and symptoms of deep vein thrombosis (DVT); (2) An alternative diagnosis is less likely than PE; (3) HR > 100; (4) Immobilization at least 3 days or surgery in the previous 4 weeks; (5) Previous objectively diagnosed PE or DVT; (6) Hemoptysis; and (7) Malignancy with treatment within 6 months or palliative. The patient in the above clinical scenario only has a heart rate greater than 100 beats per minute which constitutes a Wells score of 1.5. She has no further risk factors according to Wells Criteria. This risk stratification tool has been validated in several studies since its publication and is widely used for stratifying patients who may need further evaluation for PE with a D-dimer or CT angiogram. Patients with a low or moderate risk Wells score should be further evaluated using a high sensitivity D-dimer assay. Those with a Wells score > 6 should be further evaluated with CT angiography. It is important to note that Wells criteria have not been validated for use in pregnant females or patients less than eighteen years of age. The scoring system stratifies patients into low risk (1.3% chance of PE), moderate risk (16.2% chance of PE), and high risk (40.6% risk of PE).

A 26-year-old man without significant past medical history presents with left sided headache that woke him from sleep. He has tearing of the left eye and rhinorrhea. Neurologic exam is non-focal although the patient appears restless and is pacing around the room. What is the treatment of choice for his acute symptoms? A 100% oxygen B Intranasal lidocaine C Intravenous prochlorperazine D Oral verapamil

A. 100% oxygen This patient presents with symptoms consistent with a cluster headache. The cause of cluster headaches is not completely understood, but is thought to be due to hypothalamic activation with secondary activation of the trigeminal-autonomic reflex. Young to middle-aged men are much more commonly affected than women. Patients present with acute onset of severe unilateral orbital or temporal pain accompanied by autonomic phenomena or agitation and restlessness. The typical autonomic symptoms include ptosis, miosis, lacrimation, and rhinorrhea and they occur on the same side as the pain. Attacks are usually short-lived, but can recur multiple times a day for a cluster of days to weeks. Patients will then have periods when they are completely asymptomatic. The episodic nature of symptoms is the more typical course although some patients suffer from a chronic form of the disease and have symptoms daily for over a year. Diagnosis is made based on history and clinical exam findings. On initial presentations, neuroimaging (e.g. non-contrast CT or MRI of the brain) may be indicated to rule out a structural cause for the symptoms. Oxygen therapy (100% at 12-15 L/min) is first-line treatment for acute symptoms. Symptoms may improve in a matter of minutes, but oxygen should be continued for at least 15 minutes to prevent recurrence. Triptans (e.g. subcutaneous or intranasal sumatriptan or intranasal zolmitriptan) have also been found to be effective in relieving symptoms in patients who do not respond or cannot tolerate high flow oxygen therapy. Triptans should be avoided in patients with cardiovascular disease, stroke, uncontrolled hypertension, and pregnancy. Intranasal lidocaine has been used in the treatment of cluster headaches although the benefit is not as great as that seen with either oxygen therapy or triptans. Intravenous prochlorperazine can be used in the treatment of migraine headaches, but has not been found to be effective with cluster headaches. Oral verapamil is first-line treatment for prevention of cluster headaches, but is not effective in the management of acute symptoms

A 29-year-old kindergarten teacher presents with palpitations and lightheadedness, which began 30 minutes ago. Her vital signs are notable for HR 175 beats/minute and blood pressure of 111/82 mm Hg. The rhythm strip of her electrocardiogram is shown above. Which of the following is the most appropriate management? A Administration of intravenous adenosine B Administration of intravenous diltiazem C Defibrillation D Procedural sedation with synchronized cardioversion

A. Administration of intravenous adenosine The patient has paroxysmal supraventricular tachycardia (SVT). On the ECG, SVT manifests as a fast, regular rhythm with a narrow QRS complex without regular P waves. SVT results from a sustained re-entry loop emanating from the AV node, or in some cases, from an ectopic atrial focus. Because the depolarization does not come from the sinoatrial node, P waves do not precede each QRS complex. P waves may be buried within or seen immediately after each QRS complex, known as "retrograde" P waves. Paroxysmal SVT has a peak incidence in the late teenage and young adult years, and is more common in females than males. Typical symptoms include palpitations, lightheadedness, and dyspnea. Patients with SVT are usually hemodynamically stable. Vagal maneuvers, such as valsalva and carotid sinus massage, are easy to perform and are sometimes successful in terminating SVT. By increasing vagal tone, these maneuvers slow conduction through the AV node, breaking the re-entrant loop, and terminating the dysrhythmia. If unsuccessful, the next step is administration of intravenous adenosine. The mechanism is to slow conduction through the AV node and is usually successful in terminating the dysrhythmia. The initial dose of adenosine is 6 mg rapid intravenous push, followed by a dose of 12 mg if the first dose is ineffective. Patients receiving adenosine should always have pacer pads attached since adenosine may cause a brief period of asystole. Alternative agents include beta blockers and calcium channel blockers Administration of intravenous diltiazem is a second-line agent after adenosine Defibrillation is indicated for pulseless ventricular tachycardia or ventricular fibrillation, which are forms of cardiac arrest Synchronized cardioversion may be necessary if the SVT is refractory to the above measures or if the patient becomes clinically unstable.

A 72-year-old man with a history of diabetes mellitus and hypertension presents with acute onset of facial pain and swelling anterior to the right ear. He denies any trauma or vomiting. On examination, he has a temperature of 38.7°C, heart rate 105 beats/minute, and blood pressure 148/78 mm Hg. There is marked edema and erythema anterior to the right ear with tenderness to palpation, and moderate trismus. Pus is expressed from Stensen's duct. What is the next best step in management? A Admission for hydration and intravenous ampicillin-sulbactam B Discharge home with sialagogues and amoxicillin-clavulanate C Incision and drainage D Non contrast maxillofacial computed tomography scan

A. Admission for hydration and intravenous ampicillin-sulbactam Acute suppurative parotitis typically occurs when salivary stasis allows for retrograde migration of oral bacteria. Obstruction from calculi or tumor can also predispose to stasis and infection. Risk factors for development of infection include advanced age, dehydration, recent hospitalization or surgery, and use of drugs that decrease salivation (e.g. anticholinergics). Symptoms include acute swelling, erythema, and tenderness over the parotid gland which lies just anterior to the external auditory canal and superior to the angle of the mandible. There may be associated fever, trismus, and dysphagia. Over half the patients are found to have purulent drainage from Stensen duct which drains opposite the upper second molar. Diagnosis is primarily clinical although ultrasound and CT may help differentiate suppurative parotitis from frank abscess. As most patients present acutely ill, admission for intravenous hydration and antibiotics (e.g. nafcillin/clindamycin or ampicillin-sulbactam) is indicated. The infection is typically polymicrobial with S. aureus the most frequently isolated organism. Recommended antibiotic regimens: include ampicillin-sulbactam or a first-generation cephalosporin with metronidazole or clindamycin. Vancomycin should be added to patients at risk for MRSA. Incision and drainage is not indicated initially, but may be necessary if there is evidence of frank abscess formation or no improvement after 48 hours of antibiotics.

A 45-year-old man with a significant history of chronic alcohol use presents to the emergency department by ambulance with confusion and agitation. Paramedics report that he has not had a drink for 24 hours. His vital signs are HR 125 bpm, BP 160/100 mm Hg, RR 24/min, T 99.5°F, and oxygen saturation 100% on room air. On exam, he appears hyperalert and very anxious. He has a tremor in both of his hands, and he is diaphoretic. He does not have nystagmus and is able to walk without difficulty. Which of the following is the most likely diagnosis? A Alcohol withdrawal B Delirium tremens C Korsakoff syndrome D Wernicke encephalopathy

A. Alcohol withdrawal Alcohol withdrawal symptoms occur after abrupt cessation or significant reduction in ethanol intake in patients with a history of heavy and prolonged alcohol consumption. The physical manifestations exist as a continuum from uncomplicated and mild to moderate and severe. They may begin as early as 2 to 6 hours after the reduction in alcohol consumption and last up to 2 weeks. The spectrum of signs and symptoms include hand tremors, headache, loss of appetite, nausea and vomiting, diaphoresis, insomnia, tachycardia, hypertension, fever, psychomotor agitation, hyperarousal, craving, and anxiety. Additionally, more serious manifestations include seizures, hallucinations, and delirium. The abrupt withdrawal of alcohol is thought to reduce inhibitory neurotransmission through γ-aminobutyric acid (GABA) and enhance excitatory neurotransmission through glutamate. The severity of symptoms can be ascertained by a revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score, a 10-item validated assessment tool that can be used to quantify the severity of alcohol withdrawal symptoms. Scores < 8 correspond with mild symptoms, 9-15 with moderate symptoms, and > 15 with severe symptoms such as delirium tremens and withdrawal seizures. Treatment is with benzodiazepines

A 37-year-old man presents with burning in his rectum. Earlier today, he had severe, sudden pain while having a bowel movement and noted a small amount of bright red blood on the toilet paper while wiping. What is the most likely etiology of his symptoms? A Anal fissure B Anorectal fistula C Procidentia D Thrombosed external hemorrhoid

A. Anal fissure Anal fissures happen when a superficial tear occurs as a result of hard stool passing through the canal typically in the setting of constipation. Patients reports acute, severe pain sometimes associated with a small amount of bleeding. Fissures typically occur in the posterior midline where the skeletal muscles surrounding the anus are the weakest. Fissures outside of this location should prompt investigation for underlying diseases such as leukemia, inflammatory bowel disease, HIV, tuberculosis, and syphilis. Fissures not identified and treated can lead to ulceration and skin tags. Treatment includes warm baths, debulking agents, and some topical therapies (e.g. nitroglycerin)

A 29-year-old man presents with progressive back pain and stiffness that started 2 months ago. The pain is worse at night and when he wakes up in the morning and improves with exercise. In the last week he has also noted pain and stiffness in the hips and ankles. Neurological examination is unremarkable. What is the likely diagnosis? A Ankylosing spondylitis B Lumbar radiculopathy C Rheumatoid arthritis D Spinal stenosis

A. Ankylosing spondylitis Ankylosing spondylitis is a chronic inflammatory condition primarily affecting the spine and pelvis. There is a strong association between the presence of human leukocyte antigen (HLA) B-27 and AS. Patients often present in their 20s to 30s with a 3:1 male predilection. Symptoms consistent with ankylosing spondylitis include an insidious onset of pain and stiffness (often present for 3 months or more) that is worse at night and the morning, but improves with mild activity. Pain typically affects the lower spine and hips, but can involve peripheral joints as well, most notably the ankles and knees. Another classic finding is pain, stiffness, and tenderness at the insertion sites of ligaments and tendons to the bone (enthesitis). This is most commonly seen at the achilles tendon attachment to the calcaneus and the plantar fascia. Diagnosis is made based on history and physical findings, presence of HLA B-27, and radiographs consistent with disease (e.g. erosions or fusion of sacroiliac joints). First-line treatment is nonsteroidal anti-inflammatory medications

A 29-year-old man presents with progressive back pain and stiffness that started 2 months ago. The pain is worse at night and when he wakes up in the morning and improves with exercise. In the last week he has also noted pain and stiffness in the hips and ankles. Neurological examination is unremarkable. What is the likely diagnosis? A. Ankylosing spondylitis B. Lumbar radiculopathy C. Rheumatoid arthritis D. Spinal stenosis

A. Ankylosing spondylitis. Ankylosing spondylitis is a chronic inflammatory condition primarily affecting the spine and pelvis. There is a strong association between the presence of human leukocyte antigen (HLA) B-27 and AS. Patients often present in their 20s to 30s with a 3:1 male predilection. Symptoms consistent with ankylosing spondylitis include an insidious onset of pain and stiffness (often present for 3 months or more) that is worse at night and the morning, but improves with mild activity. Pain typically affects the lower spine and hips, but can involve peripheral joints as well, most notably the ankles and knees. Another classic finding is pain, stiffness, and tenderness at the insertion sites of ligaments and tendons to the bone (enthesitis). This is most commonly seen at the achilles tendon attachment to the calcaneus and the plantar fascia. Diagnosis is made based on history and physical findings, presence of HLA B-27, and radiographs consistent with disease (e.g. erosions or fusion of sacroiliac joints). First-line treatment is nonsteroidal anti-inflammatory medications.

A 78-year-old man presents to the emergency department with generalized weakness and confusion. His blood pressure is 82/51 mm Hg. While transcutaneous pacing is being prepared, which of the following is the most appropriate initial drug therapy? A Atropine B Glucagon C Procainamide D Verapamil

A. Atropine Sinus bradycardia refers to a discharge rate from the sinoatrial node of < 60 beats/minute. Sinus bradycardia has multiple causes. Hypoxia, cardiac ischemia, hypothyroidism, and hypothermia can all cause sinus bradycardia. Sinus bradycardia may result from increased vagal tone (as seen in well-conditioned athletes), severe pain, intraperitoneal bleeding, and inferior wall myocardial infarction. Medications also cause sinus bradycardia, including beta blockers, calcium channel blockers, digoxin, and opioids. Individuals with sinus bradycardia may be asymptomatic, or they may complain of lightheadedness, chest pain, exercise intolerance, or syncope. The treatment of sinus bradycardia hinges on whether or not the patient is clinically stable. A patient with hypotension or other signs of hypoperfusion (e.g., ischemic chest pain or altered mental status) should undergo cardiac pacing. Transcutaneous pacing is used as bridge until transvenous pacing can be arranged. While the pads are being placed on the chest for transcutaneous pacing, intravenous atropine 1 mg should be administered. Atropine, by blocking vagal tone, enhances automaticity of the sinoatrial node and improves conduction through the AV node, increasing heart rate. It is most effective in sinus bradycardia and junctional rhythms. Atropine is unlikely to be effective for patients with an escape rhythm at or below the bundle of His since the more distal conducting system is not as sensitive to vagal activity. Dopamine and epinephrine infusions can also be used to increase heart rate until a transvenous pacer can be placed.

An 18-year-old man with sickle cell anemia presents with atraumatic left hip pain that increases with weight bearing for the last week. He has no fever. His painful crises typically involve his lower back and legs. An X-ray of the hip is shown above. Which of the following is the most likely diagnosis? A Avascular necrosis B Demineralization C Fracture of the femoral neck D Osteomyelitis

A. Avascular necrosis Sickle cell disease (SCD) is a genetic defect of the hemoglobin gene causing a change in the structure of hemoglobin in deoxygenated states and subsequent sickling of the cells. Sickled cells lead to increased viscosity and sludging of the blood. On a microvascular level, this leads to vaso-occlusive events. Multiple vaso-occlusive events may lead to avascular necrosis or osteonecrosis of the femoral head. The prevalence increases with age and may be seen as early as age 5. Treatment is supportive until advanced stages at which time surgical options are available. These include core decompression to remove the necrotic tissue and arthroplasty to replace the joint. The humeral head is also affected by osteonecrosis in sickle cell patients.

A 32-year-old man presents with fever and sore throat for two days. Vital signs are HR 133, BP 110/70, T 103.2°F. Examination reveals an ill-appearing man who is sitting up with his neck extended forward. There is audible stridor on examination. You are unable to visualize the posterior pharynx as he is unable to fully open his mouth. What management is indicated? A. Awake fiberoptic intubation B CT scan of the neck with contrast C Muscle relaxant administration to aid visualization D X-ray of the neck

A. Awake fiberoptic intubation This patient presents with signs and symptoms concerning for a deep space infection of the neck and airway compromise and should have awake fiberoptic intubation performed by a trained clinician. Deep space infections of the lower face and neck include peritonsillar abscess, Ludwig angina, and retropharyngeal and parapharyngeal abscess. Patients with these disorders can decompensate rapidly and thus, rapid diagnosis and appropriate management is vital. Patients will often present with fever and sore throat and will be ill-appearing. Because these abscesses can compromise the airway, patients may exhibit signs of respiratory compromise including stridor and tachypnea. Trismus may be present if the infection irritates the TMJ and muscles of mastication. Airway distortion is common and intubation should not be taken lightly. The safest approach is typically awake intubation with fiberoptics.

A 10-year-old boy presents with a two day history of sore throat, fever, and headache. He denies cough, significant rhinorrhea, or head congestion. Physical exam is remarkable for enlarged, erythematous tonsils with a pharyngeal whitish exudate. He has marked lymphadenopathy over his anterior and posterior cervical lymphoid chain. Which of the following is the most likely diagnosis? A Bacterial pharyngitis B Mononucleosis C Sinusitis D Tonsillolithiasis

A. Bacterial pharyngitis "Strep throat" caused by Group A beta-hemolytic Streptococcus (Streptococcus pyogenes or GAS), is a common etiology of acute pharyngitis especially in children ages 5 to 15. It is characterized by inflammation of the pharynx or tonsils (tonsillar exudates) associated with symptoms of fever, malaise, and sore throat, as well as the absence of other URI symptoms such as nasal congestion and cough. Cervical lymphadenopathy is often found on exam, as is a whitish exudate over the pharynx and tonsils. A rapid streptococcal antigen test is recommended in order to determine if treatment with antibiotics is warranted, as other conditions which do not require antibiotic treatment may mimic streptococcal pharyngitis. A throat culture to rule-out GAS infection is recommended in children if rapid antigen testing is negative (90% sensitivity), in order to limit transmission and prevent complications such as rheumatic fever. Other complications of strep throat may include acute glomerulonephritis, peritonsillar abscess, bacteremia, sinusitis, and pneumonia. Penicillin-based antibiotics (benzathine penicillin IM or oral penicillin VK) are the treatment of choice. For penicillin allergic patients, azithromycin is an alternative.

A 34-year-old woman presents to the emergency department after being physically assaulted by her boyfriend. She has bilateral periorbital edema, a nasal bridge deformity, and postauricular ecchymosis. There is blood-tinged fluid coming from her right nostril. You are concerned for cerebrospinal fluid rhinorrhea and send a sample of the fluid to the laboratory for testing. The presence of which of the following is most likely to confirm this diagnosis? A Beta-transferrin B Glucose concentration of 75 mg/dL C Lactate dehydrogenase D Monocytes

A. Beta-transferrin A basilar skull fracture may create a cerebrospinal fluid (CSF) leak. This commonly presents as CSF otorrhea or rhinorrhea. Clinical signs of basilar skull fractures include periorbital ecchymosis ("raccoon eyes"), mastoid ecchymosis (Battle sign), hemotympanum, vertigo, cranial nerve VII palsy, and decreased hearing or deafness. Fluid from the nose or ear may be collected and sent for analysis. The presence of beta-transferrin, particularly the beta-2 isoform, confirms the diagnosis as this is only found in CSF and not in blood, mucus, or tears.

A 34-year-old woman presents to the emergency department after being physically assaulted by her boyfriend. She has bilateral periorbital edema, a nasal bridge deformity, and postauricular ecchymosis. There is blood-tinged fluid coming from her right nostril. You are concerned for cerebrospinal fluid rhinorrhea and send a sample of the fluid to the laboratory for testing. The presence of which of the following is most likely to confirm this diagnosis? A. Beta-transferrin B. Glucose concentration of 75 mg/dL C. Lactate dehydrogenase D. Monocytes

A. Beta-transferrin A basilar skull fracture may create a cerebrospinal fluid (CSF) leak. This commonly presents as CSF otorrhea or rhinorrhea. Clinical signs of basilar skull fractures include periorbital ecchymosis ("raccoon eyes"), mastoid ecchymosis (Battle sign), hemotympanum, vertigo, cranial nerve VII palsy, and decreased hearing or deafness. Fluid from the nose or ear may be collected and sent for analysis. The presence of beta-transferrin, particularly the beta-2 isoform, confirms the diagnosis as this is only found in CSF and not in blood, mucus, or tears. Glucose concentration of 75 mg/dL (B) and lactate dehydrogenase (C) can be present in body fluids other than CSF (e.g., blood). Therefore, their presence on fluid analysis does not confirm CSF as the source. Monocytes (D) are found in blood, which may be present in a traumatic CSF leak. The presence of monocytes on fluid analysis does not rule in or rule out the diagnosis of CSF otorrhea or rhinorrhea.

A 20-year-old man presents with a sore throat that has been worsening over the last two days. Physical exam reveals trismus and a muffled voice. Exam of the posterior oropharynx reveals a swollen uvula that is displaced toward the left. There is inferior and medial displacement of the right tonsil. His temperature is 102.8°F. A needle aspiration is performed. Which of the following is the most likely causative pathogen? A Group A Streptococcus B Haemophilus influenzae C Streptococcus bovis D Streptococcus viridans

A. Group A Streptococcus Group A Streptococcus is the most common cause of a peritonsillar abscess (PTA). A PTA is a fluid collection between the tonsillar capsule and the superior constrictor and palatopharyngeus muscles. It is most common in young adults in the spring and winter months and symptoms include trismus, muffled voice, sore throat, and dysphagia. Patients sometimes complain of pain radiating toward the ear on the affected side. Physical exam reveals displacement of the tonsil and uvula, lymphadenopathy, and drooling. The diagnosis can be confirmed with a needle aspiration of the purulent material. If the diagnosis is uncertain, a CT scan of the neck will demonstrate a fluid collection. Treatment depends on clinical symptoms, but typically includes needle aspiration or incision and drainage. Appropriate antibiotic treatment includes ten days of amoxicillin/clavulanic acid or clindamycin. Intravenous and oral steroid administration can reduce the severity of pain.

A 35-year-old man with a history of HIV and recurrent anemia presents to the ED with increasing fatigue after being started on dapsone. He is noted to have scleral icterus on physical exam. Which of the following laboratory findings would be expected? A Heinz bodies on peripheral smear B Low lactate dehydrogenase C Positive direct Coombs test D Positive indirect Coombs test

A. Heinz bodies on peripheral smear Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency will have a low hemoglobin concentration level and Heinz bodies on peripheral smear when exposed to oxidative stress. G6PD deficiency is an inherited disorder found mainly in patients with African, Asian, or Mediterranean ancestry. Glutathione is responsible for protecting red blood cells from harmful oxidative metabolites. Impairment in this protective mechanism results in hemolytic anemia when red blood cells are exposed to oxidative stress. Certain drugs, such as dapsone, phenazopyridine, nitrofurantoin, primaquine, rasburicase, and methylene blue, have been implicated in precipitating acute hemolysis in patients with G6PD deficiency. Patients can present with symptoms related to anemia, such as fatigue or dyspnea. They may also present with jaundice from an increase in indirect bilirubin from the breakdown of red blood cells.

A 65-year-old man who does not have housing presents to your emergency department with a report of fever, productive cough, and shortness of breath. He has a 40 pack-year history of smoking and daily alcohol consumption. His chest radiograph demonstrates a right upper lobe lung infiltrate with an air-fluid level. What is the most likely etiology for this finding? A Klebsiella pneumoniae B Legionella pneumophilia C Mycoplasma pneumoniae D Pseudomonas aeruginosa

A. Klebsiella pneumoniae Klebsiella pneumoniae is a gram-negative encapsulated organism. It occurs most commonly in patients who chronically use alcohol or are chronically debilitated. Patients with Klebsiella pneumonia commonly present with shaking chills, cyanosis, pleuritic chest pain, and a productive cough with characteristic currant-jelly sputum. Chest radiography reveals an infiltrate that is often in the upper lobes (most commonly the right) and is associated with a bulging fissure. If untreated, the infiltrate will progress into a necrotizing lesion with air-fluid levels, and can ultimately lead to development of an empyema. Note that in patients with aspiration who chronically use alcohol, infection with Streptococcus pneumoniae is still a more common cause of pneumonia overall.

A 45-year old man presents to the ED with a complaint of left flank pain, nausea, and vomiting. A non-contrast CT scan of the abdomen and pelvis confirms the diagnosis of a renal calculus. Which of the following factors would necessitate hospital admission? A4 mm calculus with associated mild hydronephrosis and urinalysis shows evidence of a urinary tract infection B4 mm calculus without associated hydronephrosis and urinalysis shows evidence of urinary tract infection C6 mm calculus with associated mild hydronephrosis and urinalysis shows no evidence of urinary tract infection D6 mm calculus without associated hydronephrosis and urinalysis shows no evidence of urinary tract infection

A4 mm calculus with associated mild hydronephrosis and urinalysis shows evidence of a urinary tract infection Concomitant obstruction and infection is an absolute indication for hospital admission and should prompt emergency consultation with urology. The decision to admit or discharge a patient with renal calculi is based on the clinical scenario, as well as the laboratory results and imaging studies. Absolute indications for hospital admission include: concomitant obstruction and infection, intractable vomiting, uncontrollable pain, urinary extravasation, and hypercalcemic crisis. Relative indications for admission include: solitary kidney, intrinsic renal disease, significant comorbid conditions (e.g. immunosuppression), high-grade obstruction, leukocytosis, and psychosocial factors affecting ability to follow-up or be managed in the outpatient setting. Stones less than 5 mm in size pass spontaneously 90% of the time. Stones 5-8 mm in size pass 15% of the time whereas stones greater than 8 mm become impacted 95% of the time. Stone size (D) alone does not necessitate admission particularly when there is no associated obstruction or infection. Generally patients with mild to moderate hydronephrosis can safely be managed in the outpatient setting, as long as there is no concurrent infection (C). Patients with mild infections can also be managed in the outpatient setting as long as there is no concurrent obstruction (B).

When should an asymptomatic AAA be referred for repair?

AAA greater than or equal to 5.5 cm should be referred to a surgeon for elective repair 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

Endolymphatic Hydrops (Meniere's Disease)

AKA: Meniere's Disease ==> characterized by the triad of vertigo, tinnitus, and hearing loss Probably from abnormality in the inner ear fluids.

PECARN Cervical spine Injury

AMS, Focal Neurologic Deficits, Neck Pain, torticollis, Injury to torso, MVA high Speed, diving Injury

What is the most common symptom in patients with a deficit in one of the nerves that control extraocular nerve functions?

Diplopia. Descending flaccid paralysis, dysarthria, dysphagia, diplopia: botulism Limitation of upward gaze → binocular diplopia: orbital blowout fracture Young women with obesity: idiopathic intracranial hypertension Painful, ↓ EOM, diplopia: orbital cellulitis CN III dysfunction: posterior circulation stroke, diabetes, myasthenia gravis CN IV dysfunction: vertical diplopia Diplopia on lateral gaze: CN VI dysfunction Vertebral artery dissection MS

Eye Chemical Burn Summary

Alkaline burns Liquefaction necrosis → damage to cornea, iris, lens Penetrates faster and deeper than acidic burns Acidic burns Coagulation necrosis Limited depth of injury Immediate irrigation (NS or LR) until pH is 7.0-7.2

What formula is used to calculate the true sodium level in the setting of hyperglycemia without hypertriglyceridemia?

Add 1.6 mEq/L to the sodium value for every 100 mg/dL glucose over normal 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 Management Treat precipitating cause Correct volume depletion with NS, add dextrose to fluids once glucose is < 200 mg/dL Replete 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

Early passive shoulder range-of-motion exercises are utilized in clavicle fracture to reduce the risk of what complication?

Adhesive capsulitis (frozen shoulder).

What is the "asthma triad?"

Airway inflammation, bronchial hyperresponsiveness, intermittent reversible airway obstruction.

ENP ABCDE Criteria

Airway/Alertness/Across Room Assessment Breathing/Ventilation Circulation and Control of Hemorrhage Disability - GCS, BG, Pupils Exposures/Environmental Control

Which state does not have any black widow spiders?

Alaska Black Widow Spider Yellow-red hourglass on abdomen of spider Venom releases ACh and NE Diffuse muscle cramps Mimics acute abdomen Sympathomimetic symptoms Opioids, benzodiazepines, antivenin (only if severe Sx)

A 73-year-old man with a history of arthritis presents with complaints of a low-grade fever and severe right knee pain for the past three days, with an inability to bear weight since this morning. On exam, you note exquisite right knee tenderness and a large effusion. There is limited range of motion both actively and passively, and he refuses to ambulate. You perform an arthrocentesis and drain 20 mL of turbid fluid. Laboratory analysis of the joint fluid reveals the following: WBC of 55,000/µL with 95% neutrophils and a glucose level of 60 mg/dL (serum glucose is 140 mg/dL). Gram stain and crystal analysis are not immediately available. Which of the following is the most likely diagnosis? A Acute gout B Osteoarthritis C Rheumatoid arthritis D Septic arthritis

Any patient with an acute monoarticular arthritis should be considered to have septic arthritis until proven otherwise. Patients at increased risk for septic arthritis include the elderly, those with prosthetic joints, IV drug users, and the immunocompromised. Septic arthritis often occurs in patients with a history of chronic arthritis, complicating the diagnosis. In healthy adults, the knee is the most commonly affected joint, but in IV drug users, common sites include the sacroiliac, sternoclavicular, and intervertebral joints. In children, the knee and hip are most commonly affected. Synovial fluid results in this case are consistent with a bacterial rather than inflammatory etiology (see table below). Fluid culture will help confirm the diagnosis of septic arthritis, but such results take time to complete. Empiric treatment should be initiated.

How frequently should a patient have recurrent outbreaks of herpes simplex virus infection before chronic suppressive therapy is recommended?

At least six episodes per year. Sx: painful genital rash, may be asymptomatic PE: grouped erythematous shallow cluster of vesicles and lymphadenopathy Labs: multinucleated giant cells on Tzanck smear (poor sensitivity) Dx: tissue PCR or viral culture Most commonly caused by herpes simplex virus (HSV) type 2, but HSV-1 infections are increasing in frequency Tx: acyclovirPregnancy: acyclovir or valacyclovir for 7-10 days after primary infection and from 36 weeks to delivery

A 45-year-old man presents to the ED with an unknown opioid toxicity. He initially required 0.3 mg of naloxone for stabilization. Ninety minutes later, you are called to the bedside due to decreased respirations and responsiveness. You administer another 0.3 mg of naloxone with improved respiratory status and decide to start a naloxone drip. What is the recommended starting infusion rate? A 0.1 mg/hr B 0.2 mg/hr C 0.3 mg/hr D 0.6 mg/hr

B 0.2 mg/hr Naloxone is a competitive opioid antagonist that blocks the receptor (mu) responsible for respiratory depression. When repeated doses of naloxone are needed to treat recurrent cycles of respiratory depression, a continuous infusion can be started by preparing 2/3 of the bolus dose of naloxone that resulted in symptom reversal (i.e., 0.2 mg/hr if, as in this case, the reversal dose was 0.3 mg). Respiratory depression may occur despite the use of a naloxone drip, therefore, continued monitoring (ideally in an ICU setting) is important with uptitration of the drip or establishment of a definitive airway as necessary.

An 8-year-old girl presents to the ED in status asthmaticus. The decision is made to perform endotracheal intubation. What is the appropriate cuffed endotracheal tube size? A 4.5 mm B 5.5 mm C 6 mm D 7 mm

B 5.5 mm Cuffed and uncuffed endotracheal tubes (ETTs) have been shown to have similar complication rates in infants and children. However, there are certain circumstances in which cuffed ETTs may be advantageous, such as patients with severe lung disease who may require high ventilator pressures (e.g., status asthmaticus). The following formulas have shown 99% accuracy for the determination of ETT size (internal diameter). Therefore, in this clinical scenario: (8/4) + 3.5 = 5.5 mm.

A 92-year-old man presents after falling down stairs and hitting his head. He opens his eyes to voice and intermittently makes sounds. He does not have any purposeful movement and periodically displays extension of this arms and legs with plantar flexion of the feet and toes. What is his Glasgow Coma Scale score? A 6 B 7 C 8 D 9

B 7 The patient's total Glasgow Coma Scale (GCS) score is 7. Assessment of the patient's eye opening, verbal response, and motor response make up the score. The chart below indicates how the GCS is calculated. This patient receives the following scores: eye movement 3, verbal response 2, and motor response 2. Eye opening and verbal responses are straightforward in the scoring system. For the motor response calculation, knowledge of the difference between decerebrate and decorticate posturing is essential. Decerebrate posturing receives a lower score because it is associated with a worsened neurologic outcome, often associated with uncal herniation. In decerebrate posturing, the arms become extended at the elbow and adducted. The wrists and fingers are flexed and the entire arm is internally rotated. Similarly, the legs become extended and internally rotated with plantar flexion of the feet and toes. Decorticate posturing involves flexion of the upper extremity with extension of the lower extremity. The leg also internally rotates with plantar flexion of the feet and toes as in decerebrate posturing. Decorticate posturing is associated with injuries above the midbrain. Cryptococcus neoformans Sx: patient with HIV presents with headache, fever, stiff neck, photophobia, vomiting Labs: CD4 < 100/mm3 Dx:LP: ↑ opening pressure, ↓ glucose, ↑proteinIndia ink stain of CSF shows round encapsulated yeastcryptococcal antigen (CrAg) in CSF or serum Imaging: "cannon-ball" lesions, hydrocephalus on CT or MRI Tx: amphotericin B (fungicidal) + flucytosine (fungicidal)fluconazole (fungistatic) for mild lung disease Comment: severely immunocompromised patients may have minimal symptoms and bland CSF What finding on lumbar puncture increases the suspicion of cryptococcal meningitis? Clear CSF with a high opening pressure.

Which of the following patients should be classified as having unstable angina? A A 51-year-old woman who had chest pain three days ago but now is chest pain free and is found to have a positive troponin with Q waves in leads II, III, and aVF, without ST elevations B A 55-year-old woman with a history of hypertension but no prior cardiac disease who complains of one episode of chest pressure that began while pushing her grocery cart and lasted 30 minutes C A 65-year-old man with a known history of coronary artery disease who gets chest pain and shortness of breath every time he climbs the steps to his bedroom D A 71-year-old man who underwent a coronary catheterization one month ago for early morning chest pain that showed minimal coronary artery disease with no fixed lesions presents with recurrent early morning chest pain that is relieved by nitroglycerin

B A 55-year-old woman with a history of hypertension but no prior cardiac disease who complains of one episode of chest pressure that began while pushing her grocery cart and lasted 30 minutes Acute coronary syndrome is a spectrum of entities that includes asymptomatic coronary artery disease, stable angina, unstable angina, acute myocardial infarction, and sudden cardiac death. Unstable angina is broadly defined as angina new in onset that occurs at rest or with minimal exertion, or a worsening change in a previously-diagnosed stable angina. Unstable angina should be considered a possible harbinger of acute myocardial infarction. A myocardial infarction (A) is acute, evolving, or recent and, unlike anginal syndromes, involves myocardial cell death and necrosis. These patients exhibit a rise and gradual fall in cardiac biomarkers associated with at least one of the following: ischemic symptoms; development of pathologic Q waves on the ECG; ECG changes indicative of ischemia; or coronary artery intervention. Stable angina (C) is transient, episodic chest pain or discomfort, predictable and reproducible with familiar symptoms that occur from a characteristic stimulus. Symptoms improve with rest or nitroglycerin within a few minutes.

A 45-year-old woman presents to the emergency department with a one week history of diarrhea. Which of the following increases the risk of Clostridioides difficile colitis? A A course of ciprofloxacin four months ago B A two-day hospital admission last month C Her age of 45 years D History of diverticulitis

B A two-day hospital admission last month Clostridioides difficile colitis results when there is exposure to C. difficile in the setting of disruption of the normal bacterial flora of the colon. Once colonized, the C. difficile organism releases toxins leading to mucosal damage with significant inflammation. Patients develop watery diarrhea associated with abdominal cramping. The diagnosis is made with confirmation of the organism by culture or identification of the toxin using PCR. Laboratory testing often demonstrates serum leukocytosis. Risk factors include advanced age, antibiotic use in the preceding three months (most commonly cephalosporins, fluoroquinolones, amoxicillin/clavulanic acid, clindamycin), recent hospitalization, and immunosuppression.

A mother brings her 11-month-old infant into a rural ED for inconsolable crying. You note the infant is lying in the stretcher, crying with his knees drawn to his chest. You perform a physical exam and leave the room to order blood work. When you return to the examination room, you note the infant now appears lethargic. An abdominal radiograph is obtained and interpreted by the radiologist as nonspecific. Which of the following diagnostic tests should be performed next? A Abdominal CT scan B Abdominal ultrasound C Nasogastric tube lavage D Upper GI series

B Abdominal ultrasound In patients with suspected intussusception, ultrasound is a quick, noninvasive diagnostic modality commonly used for the diagnosis of intussusception. One study reported that the overall sensitivity and specificity of ultrasonography for detecting ileocolic intussusception was 97.9% and 97.8%, respectively. The authors concluded that ultrasonography should be used as a first-line examination for the assessment of possible pediatric intussusception. Ultrasonography eliminates the risk of exposure to ionizing radiation and can help to depict lead points and residual intussusceptions. It also helps to rule out other possible causes of abdominal pain. On the transverse ultrasound scan, the intussusception appears as a multilayered or wrapped complex mass. Longitudinally, it appears as a tube within a tube.

A laboratory report after an arthrocentesis returns with a finding of calcium pyrophosphate crystals that are rhomboid shaped. What is the most likely diagnosis? A Cellulitis B Gout C Pseudogout D Rheumatoid arthritis

C Pseudogout Mono or oligo-articular arthritis caused by deposition of calcium pyrophosphate crystals Labs: rhomboid-shaped crystals, weakly positive birefringence X-ray: chondrocalcinosis Tx options: intra-articular steroid injection (one or two joints), NSAIDs, colchicine, systemic corticosteroids Notes: can be associated with hemochromatosis, hyperparathyroidism, hypomagnesemia, hypophosphatemia

An obese 52-year-old woman presents with right upper quadrant abdominal pain, fever, nausea, and vomiting. She reports that her symptoms started last night after eating a large piece of birthday cake. Which of the following is the most likely next step in diagnosis? A Abdominal CT B Abdominal ultrasound C Endoscopy D Hepatobiliary (HIDA) scan

B Abdominal ultrasound The suspected diagnosis is cholecystitis. Risk factors for cholecystitis include advanced age, female sex, parity, obesity, rapid weight loss, family history, and oral contraceptive use. Patients will commonly present with right upper quadrant or epigastric abdominal pain, fever, nausea, and vomiting. Often, there is a history of ingestion of a fatty meal prior to the onset of symptoms. Physical exam may reveal tachycardia, fever, and tenderness in the right upper quadrant or epigastrium. Abdominal ultrasound is the most useful initial test for imaging the gallbladder. It is noninvasive, quick, and can often establish the diagnosis. Ultrasonography can identify thickness of the gallbladder wall (> 3 mm is considered abnormal), gallstones, common duct stones, dilated common bile duct, and pericholecystic fluid. Cholecystitis Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods, fever PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) DiagnosisInitial: U/SGold standard: HIDA Most commonly caused by obstruction by a gallstone Acalculous disease can occur in critically ill Treatment is cholecystectomy, antibiotics; percutaneous cholecystostomy tube in critically ill

A patient presents to you as a transfer from an outside facility with the radiograph seen above. Which of the following exams will evaluate for the most commonly associated nerve injury in this type of fracture? A Ability to make a "thumbs up" sign B Ability to make an "OK" sign C Sensation to the index finger D Sensation to the little finger

B Ability to make an "OK" sign This is a Galeazzi fracture, which involves injury to the middle to distal third of the radius and dislocation or subluxation of the distal radioulnar joint (DRUJ). Consequently, the anterior interosseous nerve, a branch of the median nerve, is at risk of injury with this type of fracture. The anterior interosseous nerve is purely a motor nerve and can cause paralysis of the flexor pollicis longus and flexor digitorum profundus to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger ("OK" sign). This fracture is an orthopedic emergency and requires immediate consultation with open reduction and internal fixation in most cases. Patients are at risk for compartment syndrome. 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 The ability to make a "thumbs up" sign (A) tests the motor function of the radial nerve. Sensation to the index finger (C) tests function of the median nerve. The ulnar nerve supplies sensation to the little finger (D) and the adjacent half of the ring finger.

A previously healthy 17-year-old boy is brought to the ED by ambulance. He became very ill over the past few hours. His vital signs are T 39.4°C, HR 142 bpm, BP 90/52 mm Hg, RR 20/min, and oxygen saturation of 94% on room air. On physical exam, he is slow to respond, has a stiff neck, and a rash noted on his leg, as seen above. You establish an intravenous line, draw blood cultures, order a complete blood count and electrolyte assessment, and administer a fluid bolus. Which of the following is the most appropriate next step? A Administer hydrocortisone to treat hemorrhagic adrenalitis (Waterhouse-Friderichsen syndrome) B Administer intravenous ceftriaxone C Perform a CT scan of the head D Perform a lumbar puncture

B Administer intravenous ceftriaxone This patient is presenting with severe meningococcal septicemia caused by the aerobic gram-negative diplococcus Neisseria meningitidis, a natural organism living in the nasopharynx of humans, its only host. Patients with this infection may progress rapidly. The lumbar puncture may be deferred until the patient is stable and should not delay antibiotic administration. Although N. meningitidis continues to be sensitive to penicillin, ceftriaxone should be administered for CNS coverage.

A 47-year-old woman with a history of hypertension presents to the ED with a severe headache that began suddenly three hours prior to arrival. She has a history of recurrent frontal headaches for the last month and is currently being treated for migraine. Today, she also complains of blurry vision, diplopia, nausea, vomiting, and confusion. Her vital signs are BP 95/45 mm Hg, HR 118 bpm, RR 23/min, T 36.7°C, and pulse oximetry of 98% on room air. Neurologic exam reveals a dilated and minimally reactive left pupil, a globe deviated inferiorly, and bitemporal hemianopsia. Lab results reveal only hyponatremia of 129 mEq/L. Normal saline is administered. A CT scan reveals an intrasellar mass. Which of the following is an appropriate step in the management of this patient? A Administer intravenous 3% saline B Administer intravenous hydrocortisone C Administer intravenous mannitol D Arrange for rapid radiation therapy

B Administer intravenous hydrocortisone The patient has pituitary apoplexy from a pituitary tumor. The initial symptoms of pituitary apoplexy are related to the increased pressure in and around the pituitary gland. The most common symptom, in more than 95% of cases, is a sudden-onset headache located behind the eyes or around the temples. It is often associated with nausea and vomiting. The patient's clinical presentation is also consistent with acute (secondary) adrenal insufficiency due to inadequate ACTH production from the pituitary gland. Adrenal insufficiency manifests in this patient as hypotension, fatigue, abdominal pain, and hyponatremia. It is also associated with hyperkalemia and hypoglycemia. Hydrocortisone is the preferred steroid to administer because it provides both glucocorticoid and mineralocorticoid effects. Clinical improvement is usually seen within a few hours of steroid administration

Of the following, which is the most common infectious etiology of diarrhea in patients with AIDS? A Candida B Cryptosporidium C Cytomegalovirus D Mycobacterium avium complex

B Cryptosporidium As the CD4 count drops, patients with AIDS are at risk for opportunistic infections of the gastrointestinal tract. Worldwide, diarrhea is a source of significant morbidity and mortality of HIV-positive patients because of poor access to antiretroviral therapy. HIV infects and damages the gut-associated lymphoid tissue (GALT) which leads to frequent infection in those with poorly controlled disease and lower CD4 counts. HIV medications also cause diarrhea as a side effect. Additionally, patients with longstanding disease develop malabsorption syndromes from the chronic inflammatory changes of the intestinal tract. In patients with AIDS, Cryptosporidium is a common cause of diarrhea when the CD4 count falls below 100 cells/mm3.

A 23-year-old man presents to the emergency department with a tender, fluctuant, nonpulsatile mass to his right inner thigh with surrounding erythema. Which of the following is the most likely diagnosis? A Cellulitis B Cutaneous abscess C Lipoma D Neuroma

B Cutaneous abscess

A 45-year-old man with a history of schizophrenia comes to the ED after a syncopal event at his group home. His electrocardiogram shows a prolonged QT interval. Initial troponin is normal. The nurse caring for him suddenly alerts you that he is having chest pain. The above rhythm is seen on the cardiac monitor. Which of the following is the most appropriate initial management? A Administer intravenous isoproterenol B Administer intravenous magnesium sulfate C Administer oral aspirin D Prepare for overdrive pacing

B Administer intravenous magnesium sulfate The patient has torsade de pointes, a variant of polymorphic ventricular tachycardia (VT). In torsade de pointes, which is French for "twisting of the points," the ventricles depolarize in a circular fashion, which produces the characteristic ECG pattern of progressively changing QRS complex amplitude and direction. Torsade can develop when depolarization is delayed, seen with a prolonged QT interval. If the QRS complex of a subsequent beat falls on the T wave, known as "R on T phenomenon," it can induce torsade. Conditions associated with a prolonged QT interval include inherited disorders (e.g. congenital long QT syndrome) and acquired conditions (primarily drug toxicity and electrolyte disorders). Drugs that prolong the QT interval and can predispose to torsade include cardiac medications like sotalol, quinidine, and amiodarone, numerous psychiatric drugs, including haloperidol, fluoxetine, and lithium, and antibiotics like azithromycin, clarithromycin, and ciprofloxacin. In this clinical scenario, it is likely that this individual is on psychiatric medications, which resulted in a prolonged QT interval, predisposing him to development of torsade. Torsade usually terminates spontaneously but can occur in a sustained fashion and degenerate into ventricular fibrillation. The treatment for torsade includes administration of intravenous magnesium sulfate and discontinuing medications that prolong the QT interval. For patients who do not respond to magnesium, overdrive pacing may be required. In overdrive pacing, a transvenous pacemaker is used to increase the heart rate from 90 to 120 beats per minute, which has the effect of reducing the QT interval and preventing a recurrence of torsade. Unstable patients should undergo unsyncronized cardioversion.

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? A Administration of aspirin and emergent cardiac catheterization B Administration of ibuprofen and colchicine and discharge home C Hospital admission for cardiac monitoring and serial cardiac enzymes D Prescription for azithromycin and discharge home

B Administration of ibuprofen and colchicine and discharge home The patient has acute pericarditis. Pericarditis refers to inflammation of the pericardial sac. Classic symptoms include precordial or retrosternal sharp and stabbing chest pain, sometimes with radiation to the trapezius ridge or left arm. Patients may report that pain is worsened in the supine position and improved by sitting up and leaning forward. Associated symptoms may include low-grade fever, dyspnea, and cough. A pericardial friction rub is specific for pericarditis, but often absent. Characteristic ECG changes of pericarditis include diffuse ST segment elevation and PR segment depression. Pericarditis can be caused by infections (viral, bacterial, and fungal), systemic inflammatory disorders (rheumatoid arthritis, systemic lupus erythematosus, scleroderma, etc.), uremia, malignancies (particularly leukemia, lymphoma, and metastatic breast and lung cancer), or iatrogenic or idiopathic. The treatment of pericarditis depends on the underlying cause. When viral infection is suspected, treatment is supportive with nonsteroidal anti-inflammatory medications. Therefore, administration of ibuprofen and discharge home is appropriate. Colchicine is also recommended to reduce the risk of recurrent pericarditis. Hospitalization is not usually necessary unless myocarditis or a very large pericardial effusion is present.

A 23-year-old man with acute lymphoblastic leukemia presents with generalized weakness and muscle cramps. The patient states he started chemotherapy 3 days ago. A basic metabolic panel shows serum potassium 6.5 mEq/L, calcium 6.3 mg/dL, and creatinine 11.1 mg/dL. What management is indicated? A Aggressive fluids and admit B Aggressive fluids and emergent dialysis C Sodium polystyrene sulfonate and admit D Urine alkalinization

B Aggressive fluids and emergent dialysis This patient presents with symptoms and signs of tumor lysis syndrome and multiple electrolyte and metabolic abnormalities requiring dialysis. Tumor lysis syndrome occurs secondary to increased cell death in a rapidly growing tumor. It frequently occurs hours to a few days after the initiation of chemotherapy or radiation therapy. Tumor lysis syndrome is commonly seen in hematologic malignancies (acute lymphoblastic leukemia, non-Hodgkin lymphomas) and in some solid tumors like small cell lung carcinoma. Patients will present with symptoms and signs that reflect their electrolyte abnormalities and can be nonspecific, depending on severity. With hyperkalemia, ECG changes are common and can be exacerbated by concomitant hypocalcemia. Hyperphosphatemia and hyperuricemia are also common. Kidney function is a critical factor in the development and treatment of metabolic abnormalities, as it is responsible for the removal and resorption of the various electrolytes involved. Initial therapy should include stopping chemotherapy or radiation and starting fluids. Further care depends on the electrolyte abnormalities present. With severe metabolic derangements, hemodialysis is required. The figure below contains the six indications for emergent hemodialysis:

A 24-year-old man with a history of AIDS presents to the ED with fever and headache. His head CT scan is unremarkable. Cerebrospinal fluid results from lumbar puncture shows: WBC: 300/mm3 RBC: 3/mm3 Glucose: 35 mg/dL Protein: 209 mg/dL Gram stain: negative India ink: positive Which of the following is the most appropriate treatment at this time? A Acyclovir B Amphotericin B + flucytosine C Fluconazole D Itraconazole

B Amphotericin B + flucytosine This patient has fungal meningitis, most likely due to Cryptococcus neoformans, which is an opportunistic infection in AIDS patients. The most common presenting signs are fever and headache, followed by nausea, altered mental status, and focal neurologic deficits. Meningismus is uncommon. India ink staining of the cerebrospinal fluid (CSF) has a sensitivity of 60-80%. Identifying cryptococcal antigen in the CSF has a sensitivity and specificity near 100%. Amphotericin B is the cornerstone of antifungal therapy for cryptococcal meningitis. The addition of flucytosine has been shown to enhance the mycologic and clinical effectiveness Cryptococcus neoformans Sx: patient with HIV presents with headache, fever, stiff neck, photophobia, vomiting Labs: CD4 < 100/mm3 Dx:LP: ↑ opening pressure, ↓ glucose, ↑proteinIndia ink stain of CSF shows round encapsulated yeastcryptococcal antigen (CrAg) in CSF or serum Imaging: "cannon-ball" lesions, hydrocephalus on CT or MRI Tx: amphotericin B (fungicidal) + flucytosine (fungicidal)fluconazole (fungistatic) for mild lung disease Comment: severely immunocompromised patients may have minimal symptoms and bland CSF

A 65-year-old man presents to the ED with chest pain that radiates to the left arm and is associated with diaphoresis and shortness of breath. His ECG reveals ST elevation in leads II, III, and aVF. A point-of-care troponin test is positive. Which of the following is required to confirm the diagnosis of an ST elevation myocardial infarction (STEMI)? A A history and physical exam with cardiac biomarkers B An ECG alone C An ECG and cardiac biomarkers D Cardiac biomarkers alone

B An ECG alone Unlike most medical conditions, a STEMI can be diagnosed with a single test before a patient's evaluation is complete. The diagnosis of STEMI is made by ECG alone and must meet the following criteria: Myocardial Infarction: ECG findings Hyperacute T waves: earliest finding ST elevation Reciprocal ST depression T wave inversions Sgarbossa criteria for STEMI with LBBB Concordant ST elevation > 1 mm in leads with a positive QRS (5)Concordant ST depression > 1 mm in V1-V3 (3)Discordant ST elevation > 5 mm in leads with a negative QRS (2)3 = STEMI

Pericardial effusion on ECG

Classic teaching Electrical alternans = Only present in <30% of patients Tachycardia = May be blunted in patients taking cardiac medications Low voltage Cardiomegaly in CXR - Sensitive but not specific Always consider pericardial effusions in patients with low voltage and tachycardia - Especially if new low voltage Electrical alternans is "classic" ...so don't rely on it! (Seen in <1/3 of cases) Avoid anticoagulants/lytics until pericardial effusion is ruled out Large pericardial effusions often are misdiagnosed as ACS Right sided Diastolic collapse on Echo -= with Tamponade

A 55-year-old woman presents to the ED after a trip and fall. On exam, you note a fracture of the right upper lateral incisor with both dentin and pulp exposed. Which of the following is the most appropriate next step in management? A Apply a splint using periodontal paste B Apply calcium hydroxide paste to the exposed dentin and pulp C Perform an emergency department pulpectomy D Reassure the patient and discharge with dental follow-up within 24 hours

B Apply calcium hydroxide paste to the exposed dentin and pulp Dental fractures are commonly classified in the ED by the Ellis classification system. An Ellis I fracture involves only the dental enamel. No immediate treatment is necessary, although the tooth may be filed with an emery board for patient comfort. The patient may follow up with a dentist on an elective basis. An Ellis II fracture involves the enamel and dentin, visible by its yellow tint. Dental pulp, which is pink, may be visible through dentin. This fracture is at risk for infection because dentin is porous and bacteria may pass through into the pulp chamber. Ellis III fracture, which occurs when the fracture extends through the enamel, dentin, and pulp (often distinguished by the appearance of blood within the fractured tooth). The goal in dental fractures is to prevent pulp infection and necrosis. Thus in Ellis II and III fractures, the fracture site should be protected using calcium hydroxide paste. Ellis III fractures are usually associated with significant pain or bleeding, thus, the physician may first use local vasoconstrictors and anesthesia (topically or by local infiltration). The area must be dried thoroughly prior to application of the paste. The patient should be instructed to eat a soft diet. An antibiotic regimen (e.g., penicillin) directed at oral flora should be prescribed, and the patient should be referred for urgent dental follow-up where more definitive treatment such as pulpectomy or root canal can be performed.

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? AAmlodipine BAspirin CMorphine DNitroglycerin

B Aspirin 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). It also inhibits thromboxane A2 synthesis and has indirect antithrombotic activity. 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. The standard dose is 324 mg of non-enteric coated aspirin that is chewed and swallowed.

A 28-year-old woman with a history of alcohol use is brought to the ED after being found unresponsive in her car by bystanders at 9 AM. She was last seen walking out to her vehicle at 2 AM. She is unresponsive, with a GCS of 3 and has a rectal temperature of 24°C. You proceed with passive and active rewarming measures. In which of following scenarios, should resuscitative efforts be stopped? A Arterial blood gas pH of 6.3 B Asystole and core temperature of 32°C C Serum lactate of 10 mg/dL D Serum potassium of 6 mmol/L

B Asystole and core temperature of 32°C Hypothermic patients that present in cardiac arrest should be warmed to a minimum of 32°C preferably via extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass. However, if a hypothermic patient has been warmed to 32°C and remains in asystole, recovery is unlikely and resuscitative efforts should be terminated.

A 55-year-old woman presents to the ED with swelling of her tongue and lips. She recently started a new antihypertensive medication. Which of the following is the direct mediator for her condition? A Angiotensin B Bradykinin C C1-esterase inhibitor D Histamine

B Bradykinin Angioedema is the clinical manifestation of transient, localized, nonpitting swelling of the subcutaneous layer of the skin or submucosal layer of the respiratory or gastrointestinal tracts. There are many causes of angioedema, but the condition is usually divided into hereditary, acquired, and drug-induced etiologies. Hereditary angioedema is caused by deficiency or dysfunction of C1-esterase inhibitor and is usually precipitated by stress or trauma. Acquired angioedema is also secondary to deficiency or dysfunction of C1-esterase inhibitor, but is not due to a genetic cause, rather, it appears later in life. The exact etiology is unknown, but the condition is exceedingly rare. The most common cause of drug-induced angioedema is due to an adverse reaction from angiotensin-converting enzyme (ACE) inhibitors. When ACE is inhibited by medications, angiotensin I is not converted to angiotensin II, and bradykinin is not metabolized. It is thought that the increased level of bradykinin is responsible for angioedema induced by ACE inhibitors. Angioedema can result in severe airway compromise or, less commonly, compromise in the GI tract that is associated with abdominal pain. Evaluation should focus on ruling out laryngeal edema and airway compromise. Although direct visualization is best, asking the patient to phonate a high-pitched "E" is one quick way of assessing for laryngeal edema. If the patient is able to do so, then the presence of laryngeal edema is unlikely. Treatment is mainly supportive, with special attention to airway protection. Angioedema caused by deficiency or dysfunction of C1-esterase inhibitor can be treated by replacing C1-esterase inhibitor with fresh frozen plasma or other recombinant agents. Angiotensin is a peptide hormone that causes vasoconstriction and a subsequent increase in blood pressure. It is part of the renin-angiotensin system, which is a major target for drugs (ACE inhibitors) that lower blood pressure. An elevated level of angiotensin is not responsible for angioedema. C1-esterase inhibitor (C) serves as the main regulator of the kallikrein-kinin system. As a result of decreased amounts of functional C1-esterase inhibitor, when the kallikrein-kinin system becomes activated, it is not kept in check. This leads to increased formation of bradykinin and the resultant increased vascular permeability and edema formation. This is the pathophysiology of hereditary angioedema, not ACE-inhibitor-induced angioedema. Histamine (D) has many roles in the body, but its primary role is within the immune system. Mast cells release histamine through a process known as degranulation when they have been sensitized with IgE antibodies and then come in contact with an appropriate antigen leading to the development of urticaria and pruritus

A 27-year-old man presents to the ED with sudden onset abdominal pain, facial and lip swelling (as shown above), and shortness of breath. The patient reports several sporadic episodes of lip swelling since his teens but has never sought medical treatment. His family history is unknown because he is adopted. On exam, you note significant tongue and facial swelling. You prepare for the possibility of a definitive airway. Which of the following treatments will have the most benefit for this condition? A Angiotensin-converting enzyme inhibitor B C1 esterase inhibitor C Diphenhydramine, epinephrine, and methylprednisolone D Epinephrine, nebulized beta-2 agonist, and methylprednisolone

B C1 esterase inhibitor The patient is most likely suffering from hereditary angioedema, which is typically caused by a genetic lack or deficiency of C1 esterase inhibitor. It usually presents first in adolescence. The lack of C1 esterase inhibitor allows for unregulated activity of vasoactive mediators, resulting in recurrent episodes of angioedema. C1 esterase inhibitor concentrate is the treatment of choice for hereditary angioedema. An alternative treatment is fresh frozen plasma, which contains C1 esterase inhibitor, among other components of plasma.

A 34-year-old man presents with fever, chest pain radiating to the neck, and neck swelling two days after swallowing a razor blade. Physical examination shows an ill-appearing patient with neck swelling and crepitus. A chest X-ray reveals a small right-sided pleural effusion and subcutaneous emphysema. Which of the following diagnostic tests should be considered first? A Bronchoscopy B CT scan of the chest and neck C Esophagram D Soft tissue X-ray of the neck

B CT scan of the chest and neck The patient presents with signs and symptoms concerning for mediastinitis; a diagnosis that should be confirmed with CT scan of the chest and neck. A CT is indicated when a suspected esophageal perforation is difficult to locate or diagnose on contrast esophagram, when contrast esophagram cannot be performed (eg, uncooperative or unstable patient), and in patients with free peritoneal air. Mediastinitis is inflammation of the mediastinum typically produced by bacterial infection. It is most commonly caused by esophageal rupture or perforation. Other causes include tracheal rupture or descending spread of head and neck infections. Patients will be toxic appearing on presentation and will complain of fever, dyspnea, pleuritic chest pain, neck pain, and swelling. Physical examination often reveals crepitus around the neck and chest. Chest X-ray is the typical first imaging modality and often reveals subcutaneous emphysema, widening of the mediastinum, and pleural effusions. Necrotizing infections may result in pneumomediastinum evident on CXR. CT scan of the chest and neck is the best diagnostic modality. Patients should be treated with broad-spectrum antibiotics and have subspecialty consultation with cardiothoracic surgery, ENT, and gastroenterology. Rupture of the esophagus carries a high mortality

A 34-year-old man presents with "heartburn." His evaluation leads the provider to believe that gastroesophageal reflux disease is the etiology of his symptoms. Which of the following increases symptoms of reflux? A Beta-blockers B Caffeine C Spearmint D Testosterone supplements

B Caffeine There are multiple dietary factors which contribute to relaxation of the lower esophageal sphincter. When this occurs, symptoms of GERD, most notably heartburn increase. Caffeine, along with other things like chocolate, ethanol, peppermint, fatty foods and nicotine all relax the lower esophageal sphincter Evidence-based positional modification to decrease reflux symptoms ==> Elevation of the head of the bed.

A 65-year-old man with a history of CHF and an AICD presents with palpitations and lightheadedness. His vitals are T 98.7°F, HR 140 bpm, BP 75/43 mm Hg, RR 32/min, and oxygen saturation 94%. His rhythm strip is seen above. What management is indicated? A Administer amiodarone 150 mg intravenously B Cardiovert the patient C Defibrillate the patient D Wait for AICD to deliver shock

B Cardiovert the patient The patient presents with unstable ventricular tachycardia, requiring immediate electrical cardioversion. Patients with advanced heart failure often have AICDs placed due to their increased risk of lethal dysrhythmias. The role of the AICD is to shock the patient without delay if they develop one of these dysrhythmias. However, AICDs do fail to deliver appropriate shocks for a number of reasons, including but not limited to battery failure, lead fracture, and inappropriate programmed shock parameters. AICDs typically have a short delay from dysrhythmia onset to delivery of shock, but this delay should not last more than 2-3 seconds. When a patient with an AICD presents with an unstable dysrhythmia, they should be treated like any patient with an unstable dysrhythmia. Transthoracic defibrillation and cardioversion can be performed in the usual manner, with the sternal pad placed 10 cm from the AICD subcutaneous site. If the patient arrests, chest compressions should be initiated. It is possible that the AICD will fire during chest compressions, but there have been no reports of harm to providers in this situation. The AICD may be inactivated prior to beginning resuscitation or after resuscitation by placing a magnet over the AICD site.

A 23-year-old, sexually active woman presents with abdominal pain. Vital signs are normal. Pregnancy test is negative. Pelvic examination reveals cervical motion tenderness and bilateral adnexal tenderness. Which of the following treatments is most likely indicated? A Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once + metronidazole for 7 days B Ceftriaxone 500 mg IM once + doxycycline 100 mg PO BID for 14 days + metronidazole for 14 days C Clindamycin 300 mg PO BID for 7 days +metronidazole 500 mg for 14 days D Metronidazole 500 mg PO BID for 7 days

B Ceftriaxone 500 mg IM once + doxycycline 100 mg PO BID for 14 days + metronidazole for 14 days This patient presents with signs and symptoms consistent with pelvic inflammatory disease (PID) and should be treated with ceftriaxone 500 mg IM, 2 weeks of doxycycline and metronidazole. PID is an ascending infection beginning in the cervix and vagina and ascending to the upper genital tract. Neisseria gonorrhoeae and Chlamydia trachomatis are most commonly implicated. It can present with a myriad of symptoms although lower abdominal pain is the most common. Other symptoms include fever, cervical or vaginal discharge, and dyspareunia. Pelvic examination reveals cervical motion tenderness (CMT), adnexal tenderness, and vaginal or cervical discharge. Inadequately treated PID can lead to tubo-ovarian abscess, chronic dyspareunia, and infertility. Due to the variable presentation and serious sequelae, the CDC recommends empiric treatment of all sexually active women who present with pelvic or abdominal pain and have any one of the following: 1) cervical motion tenderness, 2) adnexal tenderness or 3) uterine tenderness. Treatment should cover the most common organisms and typically consists of a third generation cephalosporin (ceftriaxone) and a prolonged course of doxycycline. Patients with systemic manifestations or difficulty tolerating PO should be admitted for management.

A 22-year-old man presents to the ED with fever and a rash. He was backpacking in Tennessee recently and has been having malaise, fever, and bilateral calf tenderness for two days. The rash began today. Which of the following is characteristic of the rash associated with Rocky Mountain spotted fever? A Centrifugal B Centripetal C Mucosal D Targetoid

B Centripetal Rocky Mountain spotted fever (RMSF) is a human rickettsial tick-borne disease in the United States. Similar diseases exist and are named based on geographic location (e.g., Mediterranean spotted fever, Queensland tick typhus). The disease is most commonly detected in June and July. The reported cases occur in most commonly in North Carolina, Tennessee, Oklahoma, Missouri, and Arkansas. The obligate intracellular organism Rickettsia rickettsiae is carried by the American dog tick Dermacentor. Hosts of the tick include cattle, deer, cats, dogs, horses, and rodents. Fever, headache, malaise, and myalgias are early clinical features. Rash occurs two to four days after fever, and up to half of patients do not recall a tick bite. The rash is maculopapular and characteristically begins on the hands, feet, ankles, and wrists and then spreads in a centripetal fashion toward the trunk. The rash itself is not specific for the disease and may occur in other illnesses. Ocular findings = Nonexudative conjunctivitis and periorbital edema RMSF can also cause gastrocnemius tenderness, meningismus, lymphadenopathy, abdominal pain, vomiting, renal failure, and myocarditis. Treatment for RMSF is with doxycycline 100 mg orally twice daily for seven days. Weight-based dosing for children is recommended given the small chance of tooth staining with a single course of treatment. Chloramphenicol is an alternative in pregnant women.

An 82-year-old man with a history of benign prostatic hyperplasia and hypertension presents with lower abdominal pain and difficulty urinating. On examination, he is afebrile with a palpable suprapubic mass. An indwelling catheter is placed with initial drainage of 800 mL of clear urine. Over the next two hours, his urine output is 750 mL. Urinalysis shows negative for leukocyte esterase and nitrites. Microscopic examination reveals 10 RBC/hpf, 3 WBC/hpf, and no bacteria. Which of the following is the next best step in management? A Admit for intravenous antibiotic administration B Check serum electrolytes and admit for volume replacement C Discharge home to follow up with urology in 3 days D Discontinue the urinary catheter and attempt a voiding trial

B Check serum electrolytes and admit for volume replacement Urinary retention is the inability to pass urine voluntarily. The incidence increases with age and men are more commonly affected than women. The most frequent cause in men is benign prostatic hyperplasia resulting in bladder outlet obstruction. Urinary retention also occurs in 70% of patients with prostate cancer, although this diagnosis is not always known at the time of presentation. Other causes of urinary retention in men include urethral stricture, severe prostatitis, and medications (e.g. anticholinergics, antihistamines, TCAs). The most frequent causes of urinary retention in women include pelvic masses, prolapse of the pelvic organs, and infections. Neurogenic causes (e.g. multiple sclerosis, cauda equina, spinal cord lesions) and postoperative retention can also be seen in both sexes. Patients with acute urinary retention present with suprapubic discomfort and a distended bladder that is tender to palpation. Urinary retention may also develop slowly or be due to chronic obstructions. These patients are typically older with multiple medical problems. They frequently have overflow incontinence and may present with little to no pain. Management of urinary retention includes placement of an indwelling catheter for decompression of the bladder. A urinalysis should also be obtained to rule out infection or significant hematuria. Patients with long-standing obstruction are at risk for post-obstructive diuresis. Urinary output of > 200 ml/hr for 2-4 hours after initial drainage is concerning and should prompt admission for volume replacement, as well as electrolyte monitoring and repletion.

Which of the following is the most common surgical emergency in the elderly? A Appendicitis B Cholecystitis C Diverticulitis D Pancreatitis

B Cholecystitis Acute cholecystitis is the most common surgical emergency in patients older than 65 years of age. Vascular disasters such as aortic aneurysm, aortic dissection, mesenteric ischemia, and myocardial infarction, always need to be considered in patients with abdominal pain, however, the prevalence of biliary tract disease is more common. Typically, upper abdominal pain, especially RUQ pain is present along with nausea, vomiting, and anorexia. Elderly patients are less likely to present with fever, leukocytosis, or significant tenderness. Ultrasound is the initial imaging choice, looking for gallstones, gall bladder wall thickening, and pericholecystic fluid. HIDA scans are used if ultrasound is non-diagnostic for admitted patients with high suspicion for acute cholecystitis. Fluid resuscitation, early antibiotic administration, and cholecystectomy reduce mortality and morbidity in the elderly.

A 48-year-old man presents with bilateral swollen lower extremities. Which of the following may lead to a false-negative result for proteinuria on a urine dipstick? A Alkaline urine B Dilute urine C Hematuria D Prolonged dipstick immersion in urine

B Dilute urine Urine dipstick tests are often performed to evaluate for the presence of proteinuria as a sign of impaired renal function. This occurs through a color change of tetrabromophenol blue. There is an approximate relationship between the protein concentration and color intensity, however, reliably positive results occur only at concentrations above 30 mg/dL. Thus, dilute urine can generate false-negative results for proteinuria.

A 12-year-old boy presents to the ED with headache, vomiting, and lethargy for 2 days. He had a ventriculoperitoneal shunt placed for hydrocephalus 1 year ago. What is the most likely cause of his shunt malfunction? A Abdominal pseudocyst formation B Choroid plexus obstruction C Loculation D Mechanical failure E Slit ventricle syndrome

B Choroid plexus obstruction The most common cause of ventriculoperitoneal shunt malfunction is proximal tubing obstruction by the choroid plexus or increased protein within the cerebrospinal fluid (CSF). Symptoms are consistent with increased intracranial pressure leading to vomiting and irritability with a bulging fontanelle in infants and headache, nausea, vomiting, lethargy, ataxia, and cranial nerve palsies in older children and adults. Treatment requires neurosurgical consultation with tapping of the shunt and measurement of the opening pressure. This will help ascertain whether the obstruction is proximal or distal and direct the ultimate intervention needed to fix the problem Abdominal pseudocysts form around the peritoneal catheter. They are generally asymptomatic until they become large enough to cause abdominal pain. Though far less common, the development of ventricular loculations can lead to noncommunicating, nondraining CSF accumulations. When present in the fourth ventricle, such loculations may obstruct the Sylvian aqueduct, leading to increased intracranial pressure (ICP) and symptoms of brainstem compression. Mechanical failure results from fracture disconnection, migration, or misplacement of a shunt. Fracture is usually a delayed complication that develops from the degradation of tubing and growth of the patient. Disconnection, on the other hand, occurs shortly after surgery. Though all will present with signs and symptoms of increased ICP, they are less common than obstructive causes of shunt malfunction. Slit ventricle syndrome is seen in 5-10% of all patients with shunts. The ventricles are over-drained, resulting in occlusion of the proximal shunt orifice, which limits drainage and causes ICP to rise. As fluid reaccumulates in the ventricle, the occlusion is relieved, allowing drainage to resume. This presents as cyclical, episodic symptoms of raised ICP.

Which of the following statements regarding copperhead envenomation is true? A Antivenom reverses local soft-tissue findings B Coagulopathy is halted by antivenom but may have delayed reoccurrence C Compartment syndrome is common after copperhead envenomation D Tourniquet application is indicated in the prehospital setting

B Coagulopathy is halted by antivenom but may have delayed reoccurrence Copperhead envenomation can cause significant thrombocytopenia and coagulopathy, which can be halted by antivenom (Crotalidae polyvalent immune Fab). Platelet counts may be very low, yet significant bleeding is rare. As such, antivenom is the preferred initial treatment for patients with coagulopathy and thrombocytopenia. Blood products should be reserved when hemorrhagic complications develop despite adequate antivenom administration. A delayed recurrence (lag period of approximately three days) of thrombocytopenia and coagulopathy may be seen, which is relatively resistant to antivenom. Coagulopathy and thrombocytopenia may last up to three weeks post-envenomation, during which time patients should be monitored and advised not to undergo elective procedures or participate in contact sports. Antivenom should be administered to patients with moderate to severe envenomation until local control of swelling has been obtained. Then maintenance doses may be considered. Despite the tendency to cause significant soft-tissue swelling, compartment syndrome is rare This is because copperhead fangs are relatively short and do not penetrate deeply enough to enter the fascial compartment. In the rare instance when compartment syndrome does occur, antivenom, not fasciotomy, is the first-line treatment. This is because excising tissue likely will not significantly halt the envenomation process. Following crotaline envenomation, successful treatment of documented elevated compartment pressure with antivenom and mannitol alone is reported. Tourniquet application has been used in the past as field treatment for snake envenomation. It was thought that occluding blood flow would prevent venom from entering systemic circulation. Copperhead venom has little systemic toxicity, so tourniquet application can cause local tissue necrosis and limb ischemia. Immobilization with supportive care and rapid transport for medical evaluation should be the priority in prehospital settings, not tourniquet application.

A 75-year-old man with dementia presents to the ED with severe vomiting and diarrhea. He is admitted to the hospital for renal failure and dehydration. An infectious workup is initiated because he has a leukocytosis. The following day, he develops pancytopenia, renal failure, and acute respiratory distress syndrome. He is transferred to the intensive care unit where he has a cardiac arrest and expires. When the family arrives, they report the patient was in his usual state of health until three days ago, when he suffered a gout flare and began to take excessive amounts of a new medication to control the pain. Ingestion of what medication could account for this patient's presentation and clinical course? A Acetaminophen B Colchicine C Indomethacin D Oxycodone E Prednisone

B Colchicine This patient's presentation is consistent with colchicine poisoning. Colchicine is a microtubule inhibitor used for gout and other inflammatory conditions. Colchicine toxicity is initially manifested by severe gastrointestinal distress, dehydration, and leukocytosis. This is followed by pancytopenia, multisystem organ failure, and sudden cardiac death over the next one to seven days. Patients who survive may go on to experience alopecia, myopathy, and neuropathy. Colchicine is metabolized by the liver and excreted by the kidney, therefore, renal or hepatic failure may potentiate toxicity, even at therapeutic doses. Treatment involves gastrointestinal decontamination, fluid resuscitation, and aggressive supportive care (such as granulocyte colony-stimulating factors). Acetaminophen (A) initially does not cause significant symptoms; if present, symptoms may be nonspecific. When taken in excess, acetaminophen is metabolized by the CYP450 to a toxic metabolite NAPQI that causes delayed hepatic toxicity. Multisystem organ failure and death usually occur secondary to hepatic failure. Indomethacin (C) is a nonsteroidal anti-inflammatory medication (NSAID). Toxicity includes abdominal distress, gastrointestinal bleeding, and renal failure. As with the other agents, pancytopenia and sudden cardiac death rarely occur in the setting of NSAID ingestion. Oxycodone (D) is an opioid pain reliever. Overdose is characterized by depressed mental status, respiratory depression, and pinpoint pupils. Abdominal discomfort may occur, but it is not of the same magnitude that occurs with colchicine. Pancytopenia does not occur with opioids. Prednisone (E) is often used as an alternative to colchicine in the setting of acute gout. Adverse effects from prednisone include gastrointestinal upset, leukocytosis, hyperglycemia, and mental status changes. Multisystem organ failure, pancytopenia, and sudden cardiac death generally do not occur with glucocorticoids, even in the setting of overdose

Which of the following lesion characteristics is most concerning for melanoma? A 5 mm in size B Color variation C Smooth borders D Symmetry in shape

B Color variation Melanoma accounts for < 1% of total skin cancers, but is responsible for the majority of deaths attributed to skin cancer. Basal cell cancer and squamous cell cancer are the two most common types of skin cancer. Melanoma is the result of malignant transformation of melanocytes and is caused primarily by ultraviolet exposure from the sun. The characteristics of melanoma include asymmetry, border irregularity, color variation (especially red, white, or blue tones in a black or brown lesion), diameter > 6 mm and a lesion that is evolving in appearance over time. Referral for excisional biopsy is indicated if any suspicious characteristics are present. Early recognition and treatment is key. Five year survival for stage 0 melanoma is 97%, but decreases to less than 20% in stage IV disease.

A 21-year-old woman presents to the ED with a diffuse, pruritic rash. She also complains of abdominal cramping and shortness of breath. The patient took a bite of a peanut butter cookie 30 minutes prior to arrival. In the ED, her vital signs are BP 110/66, HR 98, RR 22, and oxygen saturation 95% on room air. She appears flushed and is continuously scratching her body. Although she does not appear in significant respiratory distress, auscultation of her lungs reveals wheezes bilaterally. In addition to oxygen and copious IV fluids, which of the following medications is most appropriate to administer? A Corticosteroids and H1 blocker B Corticosteroids, H1 blocker, H2 blocker, intramuscular epinephrine, and albuterol C Corticosteroids, H1 blocker, intramuscular epinephrine, and albuterol D Corticosteroids, H2 blocker, intramuscular epinephrine, and albuterol

B Corticosteroids, H1 blocker, H2 blocker, intramuscular epinephrine, and albuterol This patient experienced an anaphylactic reaction to the peanuts contained in the peanut butter cookie. Anaphylaxis, an IgE mediated response, is characterized by any or all of the following: dyspnea, cardiovascular compromise, abdominal cramping, and a pruritic urticarial rash. In the ED, initial management includes stabilization of the respiratory and cardiovascular systems, removal of any trigger, oxygen, and copious IV fluids. Oftentimes, intubation is necessary in those with severe dyspnea, hypoxia, or impending respiratory failure. Several medications are necessary for anaphylaxis. First, epinephrine is most important. In those with impending respiratory or cardiovascular collapse, epinephrine can be given intravenously. However, in those who are more stable, intramuscular epinephrine can be used. Antihistamines are given to diminish the histaminergic reaction. Although H1 blockers are classically considered, both H1 and H2 blockers should be utilized. Systemic corticosteroids should also be administered. The onset of action of corticosteroids is approximately 4-6 hours, which is thought to prevent rebound anaphylaxis (though the data is suspect). Aerosolized albuterol can also be given in those with anaphylaxis to help treat bronchospasm.

Pertussis (whooping cough)

Classic unremitting paroxysmal cough followed by a whoop that is characteristic of pertussis. There may be as many as 40 episodes per day and symptoms can last up to four weeks. The characteristic whoop may be absent in adults and in infants less than 6-months-old Treatment: Macrolide antibiotics (e.g., erythromycin, clarithromycin, azithromycin); trimethoprim-sulfamethoxazole is an acceptable alternative. Prevention is achieved through administration of the pertussis vaccine DTaP in children < 7-years-old, Tdap in children > 7 years, and adults.

A 52-year-old woman in good health presents with 2 days of fever, chills, and productive cough. Vital signs show a temperature of 38.1°C, pulse of 80, and blood pressure of 135/81. Respiratory rate and room air oxygenation is normal. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most appropriate management? A Clindamycin prescription and discharge B Doxycycline prescription and discharge C Intravenous ceftriaxone and azithromycin and hospital admission D Intravenous piperacillin/tazobactam and vancomycin and hospital admission

B Doxycycline prescription and discharge The patient has community-acquired pneumonia (CAP). Common causes of CAP include Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis, and atypical agents like Mycoplasma pneumonia and Chlamydia pneumoniae. Treatment options include doxycycline, azithromycin (if local resistance is < 25%), or high-dose amoxicillin. Other than fever, her vital signs are normal and outpatient treatment is appropriate.

A 17-year-old boy presents to the ED from a correctional facility reporting general malaise with nausea and vomiting 1 day after a weightlifting competition. Vital signs are a T of 37.2°C, BP of 100/65 mm Hg, HR of 125 bpm, and RR of 22/min. Physical exam reveals an uncomfortable, fatigued patient who has diffuse muscle soreness. Urinalysis shows 3+ blood on dipstick evaluation. What is the most important next test to direct acute management? A Creatine kinase assay B ECG C Microscopic urinalysis D Serum creatinine

B ECG This patient presents with exercise-induced rhabdomyolysis. Although the causes of rhabdomyolysis are manifold, potential complications are independent of etiology. Of all the complications, hyperkalemia is the most concerning and can lead to sudden cardiac death if undiagnosed. ECG changes indicative of hyperkalemia are thus critical to identify early in the course of management. Hyperkalemia results from impaired calcium transport with increased intracellular calcium accumulation, cellular necrosis, and expulsion of intracellular contents (including potassium) into the bloodstream. Rhabdomyolysis can also lead to acute tubular necrosis and kidney failure, which will exacerbate developing hyperkalemia by decreasing renal potassium clearance. Hyperkalemia is an immediate life-threatening condition that develops shortly after muscle injury. Absent point-of-care electrolyte analyzers, the most rapid way to screen for hyperkalemia, is through an ECG. Rhabdomyolysis is not defined by a specific creatine kinase (CK) (A) level. But in general, a serum CK five or more times the upper limit of normal (a threshold that may differ by lab) is considered indicative of rhabdomyolysis. In the absence of cerebral or myocardial infarction, a CK five or more times the upper limit of normal is diagnostic for serious muscle injury. Urinalysis (C) typically shows brownish discoloration with "large" blood on dipstick but few, if any, red blood cells on microscopic evaluation. This occurs because most dipstick tests cannot distinguish myoglobinuria from hematuria or hemoglobinuria. Protein, brown casts, and renal tubular epithelial cells may also be present. Measures of kidney function (D) and an electrolyte panel should be obtained in all patients with suspected rhabdomyolysis. But as mentioned, waiting for results may lead to a delay in the identification of life-threatening complications. In addition to hyperkalemia, hyperphosphatemia and hypocalcemia may also be seen. Additional (though less worrisome) laboratory abnormalities include elevated uric acid and low albumin.

A 14-year-old girl presents to the emergency department with complaints of fever, headache, and myalgias. Symptoms started abruptly yesterday. She recently returned from a month-long summer camp in the Ozarks of Arkansas. On physical examination, her vital signs are temperature 101.4°F, heart rate 112 bpm, blood pressure 100/70 mm Hg, respirations 18 breaths/minute, and oxygen saturation 99% on room air. She has no nuchal rigidity and no rash is present. Laboratory analysis reveals leukopenia, thrombocytopenia, and slightly elevated liver transaminases. Which of the following is the most likely diagnosis? A Colorado tick fever B Ehrlichiosis C Lyme disease D Rocky mountain spotted fever

B Ehrlichiosis Ehrlichiosis is a bacterial infection caused by a gram-negative, obligate intracellular rickettsia-like coccobacilli transmitted by Amblyomma americanum (lone star tick). It is endemic to the south central and south Atlantic regions of the United States with a peak incidence in the summer months of June through August. The onset of symptoms is approximately nine days following a tick bite. Patients will present with an abrupt onset of fever, headache, myalgias, and rigors. Other associated symptoms include nausea, vomiting, diarrhea, and abdominal pain. Rash is seen in one-third of patients. Patients with severe cases may develop complications such as optic neuritis, acute respiratory distress syndrome, meningitis, pericarditis, renal failure, or disseminated intravascular coagulation. Initial diagnosis is based largely on clinical presentation, as confirmatory testing is not available immediately. Diagnostic serologic testing is available through the Centers for Disease Control and Prevention. Initial laboratory testing may reveal leukopenia, thrombocytopenia, and elevated liver function tests. A hallmark in the diagnosis is the detection of morulae, or intracellular mulberry-like clusters, on peripheral smear. Treatment is with doxycycline or tetracycline for seven to 14 days. Rifampin may be used in those allergic to tetracyclines.

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? A Computed tomography scan of the maxillofacial region B Electrocardiogram C Erythrocyte sedimentation rate D Panorex X-rays

B Electrocardiogram The patient has jaw pain that began during exertion. This presentation is concerning for acute coronary syndrome (ACS) and the patient should have an immediate electrocardiogram (ECG) performed. Acute coronary syndrome is a constellation of signs and symptoms that occurs when there is an imbalance between myocardial oxygen demand and supply. The most common cause of acute coronary syndrome is disruption of an atherosclerotic plaque, which results in platelet aggregation or thrombus formation at the site of the plaque, blocking or reducing coronary blood flow through the affected vessel. Coronary arterial spasm and factors extrinsic to the coronary arteries (e.g. hypotension, increased myocardial demand from tachycardia or thyrotoxicosis) can also cause acute coronary syndrome. The most common symptoms of acute coronary syndrome are chest pain, often described as discomfort, pressure, tightness, or heaviness. Associated symptoms are common, including diaphoresis, nausea, vomiting, dyspnea, lightheadedness, and syncope. Symptoms triggered by exercise or exertion, stress, and a cold environment are also concerning for acute coronary syndrome. 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. Providers should have a low threshold to evaluate for ACS in these patients with atypical symptoms.

Which of the following is an absolute contraindication to Tdap vaccine administration? A Anaphylaxis to egg products B Encephalopathy after prior Tdap vaccination C Family history of sudden unexplained infant death D Fever at time of administration

B Encephalopathy after prior Tdap vaccination Vaccination against Clostridium tetani is frequently given in the emergency department. Knowing the absolute contraindications helps to avoid inappropriate vaccine administration. Absolute contraindications to specific vaccines include an anaphylactic reaction to a prior dose of the vaccine and severe immunodeficiency. Depending on the vaccination, pregnancy may also be an absolute contraindication. Specifically for the tetanus, diphtheria, and pertussis (Tdap) vaccine, encephalopathy after prior Tdap vaccination not attributable to another identifiable cause within 7 days of the previous dose is an absolute contraindication. This contraindication is specific for the pertussis components and does not apply to the tetanus and diphtheria (Td) vaccine At what ages should DTaP be used instead of Td or Tdap?

A 20-year-old woman presents with an acute onset of dizziness. The patient describes the sensation that the room is spinning when she turns her head to the left, and it is accompanied by nausea and vomiting. The symptoms resolve with turning her head away from that side. Examination reveals left-sided nystagmus elicited by movement and no other neurologic findings. What management is indicated? A Brain MRI B Epley maneuver C Non-contrast head CT D Oral steroids

B Epley maneuver This patient presents with peripheral vertigo most consistent with benign paroxysmal peripheral vertigo (BPPV) and should be treated with an Epley maneuver. Vertigo is defined as the sensation of disorientation in space combined with a sensation of motion. Patients typically describe a room-spinning sensation or the feeling of seasickness. Vertigo can be divided into two types: central and peripheral. Central vertigo are those disorders arising from the central nervous system and include ischemic stroke, vertebrobasilar insufficiency and infectious causes (meningitis, mastoiditis, syphilis). Central vertigo is characterized by a longer duration of symptoms, minimal change with position, gradual onset, and multidirectional nystagmus. Peripheral vertigo includes BPPV, Meniere disease, labyrinthitis, and vestibular neuritis. Peripheral vertigo may have intermittent symptoms (BPPV) or continuous symptoms but should not be associated with other neurologic deficits or changes and should have unidirectional nystagmus. The symptoms in BPPV are elicited by specific movements of the head and relieved by returning the head to a neutral position. The symptoms should be acute in onset and of short duration. In BPPV, the symptoms are caused by the presence of an otolith in one of the semicircular canals. Although pharmacologic intervention may be necessary in the acute setting with meclizine or benzodiazepines, the best treatment for BPPV is the Epley maneuver. The Epley maneuver is a series of positions that the clinician takes the patient through that leads to expulsion of the otolith from the semicircular canal and thus the relief of symptoms.

Which of the following is an indication for plain radiographs of the lumbosacral spine in the setting of low back pain? A Age 45 years B History of prostate cancer C Pain present for three weeks D Pain with radiation to the lateral foot

B History of prostate cancer Low back pain is a frequent presenting complaint in the emergency department and the majority of these patients have uncomplicated musculoskeletal pain. Plain radiographs contribute little to the workup and management of these patients in the absence of findings that would be concerning for possible fracture, malignancy, infection, or cauda equina syndrome (the so-called "red flag" diagnoses). Indications for imaging include age < 18 years and > 50 years, history of fever, weight loss, malignancy (e.g. history of prostate cancer), injection drug use, immunocompromised state, trauma, progressive neurologic deficits, and symptoms lasting > 4-6 weeks.

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? A Chlamydia trachomatis B Escherichia coli C Klebsiella D Pseudomonas

B Escherichia coli Eighty percent of the cases of acute bacterial prostatitis are secondary to infection with Escherichia coli. Acute bacterial prostatitis is characterized by fever, low back, and perineal pain. Constitutional symptoms include malaise, fatigue, myalgias, and arthralgias. Patients may also experience increased urinary frequency, urgency, and dysuria, as well as urinary retention. Prostate exam reveals a tender, swollen, and boggy prostate. Acute cystitis often accompanies acute prostatitis and therefore urine culture generally gives the causative pathogen. Chlamydia trachomatis and Neisseria gonorrhea should be considered in patients less than 35 years of age and those with multiple sexual partners.

A 34-year-old woman presents with neck pain, swelling, and difficulty swallowing for 2 days. She is febrile to 102.3°F. Examination reveals an ill-appearing woman, sitting upright in bed, with elevation of the tongue, trismus, and drooling. The patient is unable to fully open her mouth. What management is indicated? A CT scan of the neck with contrast B Fiber-optic intubation and broad-spectrum antibiotics C Intravenous antibiotics and admission to a floor bed D Rapid sequence intubation

B Fiber-optic intubation and broad-spectrum antibiotics The patient presents with signs and symptoms concerning for Ludwig angina and should have early airway protection and admission for broad-spectrum antibiotics. Ludwig angina is a rapidly progressive cellulitis that begins in the submandibular space and spreads to the mouth and neck. The most common source of infection is from dental disease. Edema of the mouth occurs with infection of the sublingual and submandibular spaces and can progress to airway obstruction. Patients often present complaining of dysphagia, odynophagia, neck pain, and swelling. The patient may also have tongue swelling and protrusion, trismus, and a "hot potato" voice. Examination may reveal an inability to fully open the mouth, tongue swelling, and a "woody" consistency of the floor of the mouth. A "bull neck" describes patients who have brawny edema of the neck and hyoid. Because the patient may rapidly deteriorate, it is important to consider early prophylactic intubation. In the awake patient who is maintaining their airway and oxygenation, it is preferable to perform fiber-optic or awake intubation. After securing the airway, advanced imaging may be pursued for the diagnosis and broad-spectrum antibiotics should be started. Most common complications of Ludwig angina = Internal jugular thrombosis, intracranial extension, and mediastinitis

A 45-year-old man with diabetes presents with a blood sugar of 600 mg/dL and a serum sodium of 125 mEq/dl. What treatment should be initiated to correct the serum sodium? A 3% hypertonic saline B Fluid resuscitation with normal saline C Sodium bicarbonate D Sodium chloride tablets

B Fluid resuscitation with normal saline This patient presents with hyponatremia secondary to an elevated serum glucose (pseudohyponatremia). The patient's serum sodium will correct as the glucose is treated. Increasing serum glucose concentrations increase plasma osmolarity. This creates an osmotic gradient and draws water from the intracellular space into the serum. This osmotic shift decreases the effective concentration of other substances including sodium. However, the total body content of sodium has not changed. In general, for every serum glucose increase of 100 mg/dL over normal (100 mg/dL) the serum sodium will decrease by 1.6 mEq. Therefore, in the above patient, the increased glucose concentration leads to a decrease in the sodium concentration of 8 mEq: [600 mg/dl (actual) - 100 mg/dl (normal)] X 1.6 mEq/100 mg/dl = 8 mEq This brings the patient's serum sodium to 133 mEq/dl which is within the normal range. Treatment of the patient's hyperglycemia will lead to a shift in the osmotic gradient and water will move back into the intracellular space thus reversing the change in sodium.

A 26-year-old woman fell through the ice while ice skating on a frozen lake. She is rescued by a friend after being immersed in the water up to her mid-chest for 25 minutes and is rushed to the emergency department, where you find her to be awake but somnolent. She has very poor fine motor control and is not shivering. After removing her wet clothing and wrapping her in warm blankets, what is the next best step to manage her hypothermia? A Bilateral chest tubes for pleural irrigation with warmed fluids B Forced air warming of the thorax C Submersion in a warm bath D Warmed peripheral IV fluids

B Forced air warming of the thorax Cold water immersion is defined as immersion into water below 77℉, and causes a significant risk of hypothermia and death. There are four phases of physiologic responses to cold water immersion without submersion of the head. During the first two minutes of immersion, the cold shock response consists of gasping and hypoventilation, which can lead to drowning from inhalation of water. In the second phase, five to 15 minutes after immersion, cold incapacitation sets in, in which cooling of skin and peripheral muscle and nerve fibers causes finger stiffness and poor coordination, leading to the inability to swim or grasp rescue devices and, ultimately, death. Hypothermia is the third phase of cold water immersion and does not typically set in until more than 30 minutes of immersion. The final phase of cold water immersion is peri-rescue collapse, which can be secondary to sudden vasodilation with loss of hydrostatic pressure on removal from water or "after drop," in which the core temperature continues to decrease after rescue, causing cardiac arrest. The degree of hypothermia can be classified by a patient's level of consciousness, movement, shivering, and alertness. Patients with mild hypothermia (33-35℃) are awake, alert, and shivering, but have impaired motor function. Treatment includes insulation and active external rewarming of the trunk. Moderately hypothermic patients (29-32℃) are awake but have decreased alertness, have stopped shivering, and have significantly impaired motor function. Treatment includes active external rewarming (radiant heat lamps, forced air warming of the thorax) followed by active internal rewarming (pleural irrigation with warmed fluids) if there is no improvement in temperature. Those with severe hypothermia (≤ 28℃) are often unconscious and are at a very high risk for ventricular fibrillation and death. Cold and unconscious patients should be checked for a pulse and respirations carefully for 60 seconds, and cardiopulmonary resuscitation should be initiated if there is no pulse. Otherwise, treatment is similar as for moderate hypothermia, however, if hypothermia does not respond to warmed IV fluids, more invasive warming methods are indicated, including irrigation of the bladder, peritoneum, and pleural cavities with warm fluids or even extracorporeal blood rewarming.

A 24-year-old healthy woman presents to the ED reporting that she cannot move her legs. The symptoms occurred suddenly after she was told that her fiancé died in a motorcycle accident. She does not report associated symptoms, including pain. The sensation and deep tendon reflexes in her lower extremities are normal. She has normal muscle tone. What is the most likely diagnosis? A Body dysmorphic disorder B Functional neurological symptom disorder C Illness anxiety disorder D Somatic symptom disorder

B Functional neurological symptom disorder The patient likely has functional neurological symptom disorder. This disorder is characterized by abnormalities or deficits of motor or sensory function that are not medically explained, such as blindness, seizure, paresis, paralysis, tremors, aphonia, or anesthesia. Classically, symptoms occur suddenly following a psychosocial stressor and are nonpainful. MC in Young women with low socioeconomic status and a low level of education. DSM-5 criteria ≥ 1 symptom(s) of altered sensory function or altered voluntary motor function Not consistent with recognized neurological or medical conditions Patient's symptoms are not better explained by another medical condition Symptoms cause Significant distress, Impairment in functioning OR Need for medical evaluation Treatment includes patient education and developing a therapeutic alliance (first-line), physical therapy for motor Sxs, cognitive behavioral therapy (CBT) for other somatic symptoms

A 17-year-old boy presents to the ED with a painless mass on the left side of his neck, which he first noticed 3 months ago. It is now increasing in size. The patient also reports a 10-pound weight loss and night sweats. On exam, you note a 5 cm rubbery, firm, and mobile mass located in the anterior cervical triangle. The overlying skin is intact, with no redness, streaking, or drainage. What is the most likely diagnosis? A Burkitt lymphoma B Hodgkin lymphoma C Non-Hodgkin lymphoma D T-cell lymphoma

B Hodgkin lymphoma This patient most likely has Hodgkin lymphoma. Lymphoma is the most common malignancy of the head and neck in children. Hodgkin lymphoma typically occurs in teenagers, with a neck mass serving as the presenting complaint 80% of the time. The mass is most often supraclavicular or in the anterior cervical triangle. It is often accompanied by constitutional symptoms such as weight loss, fevers, and night sweats (B symptoms). + Reed-Sternberg Cells Localized, single group of nodes; contiguous spread Bimodal age distribution: 15-35 and > 55 B symptoms (fevers, night sweats, weight loss) Reed-Sternberg cells Associated with EBV

A 4-year-old girl presents with an ear ache. Examination reveals a red, bulging, tender tympanic membrane. Air-bubbles in a thick, yellow fluid are visible behind the eardrum. Which of the following bacteria is the most likely cause of these signs and symptoms? A Clostridium perfringens B Haemophilus influenzae C Klebsiella pneumoniae D Methicillin-resistant Staphylococcus aureus

B Haemophilus influenzae The common ear infection or earache usually refers to otitis media (OM), the most common infection for which antibiotics are prescribed for children in the US. Although its peak prevalence is between 6 and 24 months of age, nearly 80% of all children under 3 years of age have had at least one episode. The most common causative bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, with Haemophilus influenzae (non-typeable) being most common. Typical symptoms include otalgia, fever, irritability, cough, anorexia, headache, diarrhea, and pulling on the ears. Fever and tympanic membrane abnormalities (erythema, bulging, cloudiness, tenderness, fluid, air-bubbles, pus, hemorrhage, or perforation) are key to this diagnosis. Antibiotics are recommended for all children younger than 6 months of age, children between 6 months and 24 months if the diagnosis is unclear, and in those with signs of severe infection. First-line therapy is amoxicillin 80 to 90 mg/kg per day

An adult patient presents to your ED with a report of a sudden-onset, severe headache that began 2 hours previously and peaked within minutes. The patient has no focal neurological findings, fever, or altered mental status, and there is no recent history of head trauma. Based on the characteristics of the patient's symptoms, you feel strongly that you must rule out a subarachnoid hemorrhage. The CT scanner at your facility is a modern generation scanner. Which of the following is the most appropriate diagnostic approach for this patient? A Head CT with IV contrast B Head CT without contrast C Head CT without contrast followed by lumbar puncture if CT is normal D Lumbar puncture followed by head CT without contrast

B Head CT without contrast Head CT without contrast is correct. In the past, approximately 5% of subarachnoid hemorrhages were missed on noncontrast head CT scans. Subsequently, patients with negative scans usually underwent lumbar puncture in an attempt to identify any remaining subarachnoid bleeds via cerebrospinal fluid red blood cell counts or the presence of xanthochromia. However, newer generation CT scanner sensitivity has improved to the point of identifying subarachnoid hemorrhage with nearly 100% accuracy when performed within 6 hours of the onset of symptoms. A lumbar puncture can be difficult to perform, may be refused by the patient, is uncomfortable for the patient, and may be complicated by post-procedure headaches related to cerebrospinal fluid leaks and infection. It can also be difficult to interpret fluid study results due to traumatic taps and ill-defined definitions of xanthochromia. Therefore, in patients who present within 6 hours of symptom onset, lumbar puncture is no longer considered mandatory and may be considered more risky than beneficial.

Which of the following is the most common cause of a bilateral pleural effusion in resource-rich countries? A Bacterial pneumonia B Heart failure C Malignancy D Tuberculosis

B Heart failure Pleural effusions occur when fluid accumulates between the parietal and visceral pleurae. In a healthy patient, fluid is continually produced by the parietal pleura, which reduces friction allowing for smooth lung expansion. If there is overproduction or decreased reabsorption, fluid can accumulate in the potential space. Depending on the volume present, pleural effusions can be clinically silent or cause symptoms, such as dyspnea or chest pain. On physical exam, there will be decreased breath sounds and dullness to percussion. Pleural effusions can be seen on upright chest X-ray when there is more than 150-200 cc of fluid present. Smaller effusions may only be seen on left lateral decubitus films or CT scan. Pleural effusions can be classified as transudates or exudates based on Light criteria. Fluid is an exudate if one or more of the following are present: (1) pleural fluid/serum protein ratio > 0.5, (2) pleural fluid/serum lactate dehydrogenase (LDH) > 0.6, or (3) pleural fluid LDH > 2/3 of the upper limit for serum LDH. Common causes of transudates include congestive heart failure, cirrhosis, and nephrotic syndrome. Common causes of exudates include malignancy, infection, and pulmonary embolism. Overall, the most common cause of a pleural effusion in resource-rich areas is heart failure.

A 60-year-old woman presents with two days of right upper quadrant abdominal pain that is constant in nature and associated with subjective fever, nausea, and vomiting. Vital signs are significant for a temperature of 38.1°C, heart rate 87 bpm, blood pressure 140/80 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation of 99% on room air. On physical examination, her abdomen is soft with right upper quadrant tenderness and a positive Murphy sign. Which of the following tests is most sensitive and specific in diagnosing this patient's most likely condition? A Computed tomography scan with intravenous contrast B Hepatobiliary iminodiacetic acid (HIDA) scan C MRI with gadolinium D Ultrasound

B Hepatobiliary iminodiacetic acid (HIDA) scan This patient has suspected acute cholecystitis and requires an imaging study for confirmation. Although an ultrasound of the gallbladder is the usual initial diagnostic imaging study for clinically suspected acute cholecystitis, hepatobiliary iminodiacetic acid (HIDA) scanning is considered the most sensitive and specific test for diagnosing acute cholecystitis. IDA is administered intravenously, taken up by hepatocytes, and excreted into the bile canaliculi. Failure to obtain an outline of the gallbladder within one hour proves cystic duct obstruction and, in the appropriate clinical setting, confirms the diagnosis of acute cholecystitis. Visualization of the gallbladder and common duct within one hour has a high negative predictive value. A HIDA scan is usually obtained when the ultrasound study is equivocal.

A 42-year-old man presents with low back pain and a normal neurologic examination. Which of the following would prompt emergent imaging of the lumbosacral spine? A History of heavy lifting B History of intravenous drug use C Positive straight leg raise D Radicular pain

B History of intravenous drug use The evaluation of acute low back pain must eliminate the presence of red flags suggesting serious etiologies requiring urgent evaluation. Multiple causes of low back pain exist including vascular, visceral, musculoskeletal, infectious, mechanical, and rheumatologic. Pain may originate from the vertebral column, spinal cord, nerve roots, musculature, or abdominal and thoracic organs. A history of intravenous drug use should raise the index of suspicion for an infectious etiology (e.g. epidural abscess, osteomyelitis, discitis) and imaging with MRI to evaluate the lower back is indicated. Many patients expect imaging during their evaluation and higher patient satisfaction is linked with performance of the ancillary testing. However, most patients do not require emergent diagnostic imaging studies.

A woman in her third trimester of pregnancy is involved in a motor vehicle collision. She presents to the ED with new-onset vaginal bleeding and pelvic pain. Which of the following laboratory abnormalities is consistent with the most likely diagnosis? A Decreased prothrombin time B Hypofibrinogenemia C Proteinuria D Thrombocytosis

B Hypofibrinogenemia Abruptio placentae is a condition of premature separation of the placenta from the uterus. This patient exemplifies the presentation of placental abruption. Abnormal placenta-uterus separation may lead to significant fetal and maternal stress. One of the most common maternal complications is a consumptive coagulopathy. Placental separation results in intravascular and retroplacental coagulation. This excessive coagulation depletes platelets, fibrinogen, and other clotting factors, leading to thrombocytopenia and hypofibrinogenemia, as well as an increase in the international normalized ratio and the activated partial thromboplastin time. If placental abruption is a suspected cause of third-trimester bleeding, laboratory evaluation of the above values should be obtained early in the management plan. If abnormalities are found, component therapy should be initiated via transfusions of platelets and fresh frozen plasma

A 55-year-old man is sent to the ED from his family doctor's office for evaluation of a mass. He is an inventory manager at a local warehouse and is in charge of loading and unloading daily deliveries of boxes. He describes intermittent left lower abdominal pain and fullness that improves with lying down. On examination, you observe a left indirect inguinal hernia. Which of the following structures serves as the medial border of this type of hernia? A Femoral nerve B Inferior epigastric vessels C Linea alba D Rectus sheath

B Inferior epigastric vessels Inguinal hernias may be direct or indirect, depending on the location of bowel extrusion through the abdominal wall defect. Direct inguinal hernias occur through a weakened transversalis fascia and are bordered laterally by the inferior epigastric vessels, medially by the rectus sheath, and inferiorly by the inguinal ligament. These structures compose the Hesselbach triangle. Indirect inguinal hernias pass from the internal to the external inguinal ring through a patent processus vaginalis. The medial border of this tract is the inferior epigastric vessels. Indirect inguinal hernias often travel into the scrotum, and patients may present with scrotal swelling or a complaint of a "mass." Reducible hernias do not require emergent surgical consultation. Hernias that are irreducible (incarcerated) or show signs of ischemia (strangulated) require acute operative intervention to prevent bowel necrosis and systemic illness. 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 typeProtrudes 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 49-year-old man presents to the ED with right shoulder pain after falling from his bicycle while riding at a high speed. His exam is unremarkable except that his right arm is locked in abduction over his head. Which of the following is the likely diagnosis? A Anterior shoulder dislocation B Inferior shoulder dislocation C Posterior shoulder dislocation D Sternoclavicular joint dislocation E Superior shoulder dislocation

B Inferior shoulder dislocation Inferior shoulder dislocations are uncommon but can be quite serious. This dislocation is also referred to as luxatio erecta, meaning to place upward, which refers to the characteristic presentation of the arm in this image. This injury is unlikely to be missed on clinical exam because the patient holds the arm elevated at 180° and cannot adduct it. It looks similar to a person asking a question. The humeral head can be palpated along the lateral chest wall. Inferior shoulder dislocations are always accompanied by detachment of the rotator cuff. The axillary artery and brachial plexus are often injured, as well, because the humeral head tears through the inferior capsule. Inferior shoulder dislocations are generally managed by traction-countertraction reduction under procedural sedation.

What is the most common type of hernia found in women? A Femoral hernia B Inguinal hernia C Obturator hernia D Umbilical hernia

B Inguinal hernia Nearly three-quarters of all hernias found are inguinal hernias. While inguinal hernias are more common in men than women, they are still the most common type of hernia found in women as well. Inguinal hernias can either be direct or indirect. Indirect hernias are the more common of the two and are the result of a hernia sac protruding through the patent processus vaginalis. Direct hernias are due to a defect of the transversalis fascia in Hesselbach triangle. Unlike men, groin hernias in women do not often present with a visible bulge. They often complain of a heaviness or dull discomfort in the groin or pelvic discomfort which is exacerbated by heavy lifting, straining or prolonged standing. As physical exam findings are typically lacking in women with inguinal hernias, diagnosis depends on a high clinical suspicion and ultrasonography or computed tomography.

A 64-year-old man with a history of diabetes and hypertension presents with chest pain and dyspnea. He appears pale and diaphoretic. ECG shows ST-elevation in the precordial leads and reciprocal ST-segment depression in leads II, III, and aVF. He is at a rural hospital without a cardiac catheterization lab. Which of the following is an absolute contraindication to fibrinolysis? A Blood pressure of 170/100 mm Hg B Intracerebral arteriovenous malformation C Peptic ulcer D Previous ischemic stroke 6 months ago

B Intracerebral arteriovenous malformation This patient has an anterior ST-elevation myocardial infarction. The primary goal of treatment for STEMI is rapid reperfusion to salvage ischemic myocardium, either with the use of fibrinolytic therapy or via percutaneous coronary intervention (PCI). Absolute contraindications to fibrinolysis are those conditions which predispose to life-threatening bleeding complications. This includes previous history of intracranial hemorrhage, known malignant intracranial neoplasm or other cerebrovascular lesion (such as arteriovenous malformation), suspected aortic dissection, known bleeding diasthesis, active bleeding other than menses, significant head or facial trauma within the previous three months, or ischemic stroke within the previous three months. Relative contraindications include uncontrolled hypertension (>180/110 mm Hg), current use of anticoagulants, internal bleeding within the previous 2-4 weeks, ischemic stroke more than three months previous, active peptic ulcer, non compressible vascular punctures, and pregnancy. Several fibrinolytic agents are available, including tissue plasminogen activator (t-PA), streptokinase, reteplase, and tenecteplase. Current reperfusion guidelines call for a "door to needle" time of 30 minutes for thrombolytics, and a "door to balloon" time of 90 minutes for PCI

A 9-year-old girl with a known history of diabetes is transferred to your ED with the diagnosis of diabetic ketoacidosis. Her initial lab results reveal a glucose of 675 mg/dL, sodium of 129 mEq/L, potassium of 5.9 mEq/L, bicarbonate of 5 mEq/L, and a venous blood gas with a pH of 7.01. At the first hospital, the patient received two boluses of normal saline and a bolus of insulin. She is now on an insulin infusion, and her glucose level is 301 mg/dL. The patient reports a headache. On exam, she seems confused and agitated. Which of the following is the most appropriate next step in management? A Dextrose infusion B Intravenous mannitol C Intravenous steroids D Stop the insulin infusion

B Intravenous mannitol The patient has severe diabetic ketoacidosis (DKA). A life-threatening complication of DKA is the development of cerebral edema. It generally occurs 6 to 10 hours after the initiation of therapy without warning and is associated with a mortality rate of up to 90%. The exact mechanism for the development of cerebral edema is still unclear, however, it has a greater propensity to develop in the pediatric population than in the adult population. At the first signs of altered mental status in children being treated for DKA, mannitol should be administered to help reduce intracerebral pressure. Dextrose infusion (A) with D5 0.45% NS should be initiated when serum glucose levels reach 250-300 mg/dL. Steroids (C) are ineffective treatment for cerebral edema secondary to DKA and may worsen hyperglycemia. Stopping the insulin infusion (D) will not alter the development of cerebral edema.

A 14-year-old girl presents with right thigh pain that has been going on for the last month. She recalls being kicked in the leg during soccer practice before her symptoms started. She was last seen in the ED 2 weeks ago and was diagnosed with a muscle contusion. On exam, there is a mass palpable over the anterior distal thigh. X-ray of the femur shows a distal femoral diaphyseal lesion with cortical destruction and periosteal reaction in a sunburst pattern. Which of the following is true regarding the most likely diagnosis? A Blunt trauma is associated with the pathogenesis B Ionizing radiation for childhood cancer is a risk factor C It most often involves the axial skeleton followed by the long bones D Pathologic fracture is a common presenting sign

B Ionizing radiation for childhood cancer is a risk factor Osteosarcoma is the most common primary malignancy of the bone. It presents in a bimodal age distribution, with peaks in early adolescence and in adults over the age of 65. The most common presenting symptoms are pain and swelling in the affected area. Plain radiographs typically show a mixed radiodense and lytic lesion arising from the metaphyseal bone described as a sunburst pattern. Codman triangle or elevation of the periosteum of the bone at the periphery of the tumor is a classic but nonspecific feature. The use of ionizing radiation for treatment of childhood solid cancers is well implicated in the development of secondary cancers, with osteosarcoma most often presenting within two decades following treatment. Other risk factors include Paget disease in the adult population and genetic diseases predisposing to a variety of malignancies, for example, retinoblastoma.

A 7-year-old boy presents to the emergency department with a scaly scalp lesion. On physical exam there is patchy alopecia present with a central area that is tender and boggy. What best describes the lesion seen in the image above? A Impetigo B Kerion C Lipoma D Psoriasis

B Kerion He has a kerion that is caused by a severe tinea capitis infection. This is a fungal infection of the scalp that presents with a pruritic area of scaling hair loss. It is most commonly caused by Trichophyton and Microsporum dermatophytes. A kerion is a severe inflammatory response with a suppurative lesion. Initial treatment is with an oral antifungal (e.g. griseofulvin, terbinafine, fluconazole). Oral steroids may also be considered in the setting of severe inflammation, however, it is unknown if they improve outcomes.

A 60-year-old woman presents to the ED with a fever of 38.3°C for one day. She has end-stage renal disease and is dialyzed through a tunneled catheter in her right internal jugular vein. What is the appropriate management of this patient? A Leave the catheter in place, obtain peripheral and catheter blood cultures, and await sensitivities B Leave the catheter in place, obtain peripheral and catheter blood cultures, and start IV antibiotics C Remove the catheter, obtain peripheral and catheter blood cultures, and await sensitivities D Remove the catheter, obtain peripheral and catheter blood cultures, and start IV antibiotics

B Leave the catheter in place, obtain peripheral and catheter blood cultures, and start IV antibiotics Although most foreign bodies are removed when a nidus of infection is assumed, dialysis catheters are left in place and a trial of antibiotics is started. This is due to the difficulty of obtaining vascular access in patients with end-stage renal disease. Approximately half of patients with tunneled catheters will develop bacteremia within the first six months of dialysis, 5-10% of whom will manifest serious complications such as osteomyelitis, endocarditis, and death. Blood cultures must be drawn both peripherally and from the catheter so that colony counts can be compared in order to narrow down the catheter as the source of infection. Vancomycin is the drug of choice because of its action against methicillin-resistant skin flora (the likely origin of infection). Ceftazidime should also be given for additional coverage.

A patient suffers a large anteroseptal myocardial infarction. Which of the following vessels is most likely to be occluded? A Circumflex artery B Left anterior descending artery C Right coronary artery D Right marginal artery

B Left anterior descending artery Occlusion of the circumflex artery (A) causes lateral myocardial infarction. Occlusion of the right coronary artery (C) causes inferior myocardial infarction. The right marginal artery (D) is a branch of the right coronary artery and is associated with inferior myocardial infarction and right ventricular infarction.

Which of the following statements is most correct regarding appendicitis? A An appendicolith is identified in the majority of cases B Leukocytosis is seen in the majority of cases C Perforation is rare in patients younger than 2 years of age D The presence of an appetite makes the diagnosis unlikely

B Leukocytosis is seen in the majority of cases Appendicitis is the most common surgical cause of abdominal pain. The highest incidence occurs in patients 10 to 30 years of age, and the highest misdiagnosis rate is in infants and the elderly due to atypical presentations. Leukocytosis (> 10,000/mcL) occurs in up to 80% of patients diagnosed with appendicitis, however a normal white blood cell count should not be used to rule out the diagnosis. The primary inciting event is obstruction of the appendiceal lumen, commonly from an appendicolith, lymphoid hyperplasia, or tumor. Obstruction leads to increased intraluminal pressure and distention of the appendix (visceral pain/periumbilical pain). Increased distention leads to vascular compromise of the appendiceal wall and bacterial invasion causing localized peritoneal inflammation (somatic pain/RLQ pain).

A 25-year-old woman presents to the emergency department with two weeks of fevers and chills. She has been staying in nearby shelters and is unsure of her vaccination history. Many of the people she has stayed with have had a cough recently. She appears thin and her vital signs are within normal limits. Which of the following is the most common manifestation of extrapulmonary tuberculosis? A Keratoconjunctivitis B Lymphadenitis C Restrictive pericarditis D Vertebral body involvement

B Lymphadenitis Infection with Mycobacterium tuberculosis has the potential to affect nearly every organ system. Homelessness, an immunocompromised state (e.g., cancer, HIV, diabetes mellitus), close contacts with affected individuals, intravenous drug users, immigrants, the elderly and those living in long-term care facilities (e.g., shelters, prison, nursing homes) are at increased risk for contracting tuberculosis. Painless lymphadenitis (scrofula) is the most common extrapulmonary manifestation of tuberculosis (TB). It is typically characterized by enlarged, painless, erythematous, firm nodes that do not need to be incised and drained. The most common central nervous system manifestation of extrapulmonary TB is meningitis due to subependymal tubercle rupture into the subarachnoid space. The syndrome of inappropriate antidiuretic hormone (SIADH) is also a central nervous system complication. The spine and joints may be affected as well (e.g. Pott's disease). Pleural effusions are common. The pulmonary vasculature may be affected leading to mild to massive hemoptysis. Acute dissemination may occur and is more common in elderly patients and those with HIV. Tuberculosis can affect the bilateral adrenal glands and lead to adrenal insufficiency.

A 57-year-old man presents to the Emergency Department complaining of a pruritic rash. He reports the rash has been present "my whole life" with intermittent flares. Physical examination of the rash is shown above. Treatment of this condition is aimed at which of the following organisms? A Candida albicans B Malassezia C Poxvirus D Rickettsia rickettsii

B Malassezia Malassezia (formerly known as Pityrosporum ovale) is a generally harmless lipophilic yeast responsible for seborrheic dermatitis. It is found in the hair follicles and sebum and has a predilection for oily skin and intertriginous areas. Seborrheic dermatitis is a chronic inflammatory disease characterized by a scaling rash on an erythematous base. Areas most affected include the eyebrows, nasolabial creases, scalp, ears, axillae, inframammary folds, umbilicus, groin, and gluteal crease. It may present with severe pruritus and have a waxing and waning course. Those at increased risk for severe disease include patients with HIV and Parkinson's disease. Treatment consists of shampoos or topical agents with selenium sulfide or zinc pyrithione. Topical antifungals such as ketoconazole and topical corticosteroids for glabrous skin may also be used.

A young woman presents with a concern about stained underwear. She reports that, for the last 3 days, she has noticed a malodorous greenish discharge. You take a thorough history and perform a pelvic examination. Which of the following is the best next step in evaluating this concern? A Bacterial culture B Microscopic examination of discharge C Pelvic ultrasonography D Serum complete blood count and chemistries

B Microscopic examination of discharge Infective vaginitis is very likely, given the above clinical description. In the initial evaluation of these symptoms, it is important to determine the causative agent. A potassium hydroxide whiff test can be performed to detect the amine-like fishy odor of bacterial vaginosis or Trichomonas vaginitis. However, direct microscopic examination of the discharge suspended in saline (termed wet preparation) will reliably establish the diagnosis and subsequently direct proper therapy

A 72-year-old woman presents to the ED after a fall off of her porch. On physical exam, you note a large parietal scalp hematoma. Which of the following is an indication for emergent surgery? A Intracranial pressure of 23 mm Hg B Midline shift of greater than 5 mm C Placement of an external ventricular drain D Sinus bradycardia to 42 beats per minute

B Midline shift of greater than 5 mm This patient's imaging and physical examination are consistent with a traumatic acute subdural hematoma. A subdural hematoma is a collection of blood between the dura and the arachnoid mater. Management of subdural hematomas includes neurosurgical consultation for possible surgical evacuation; however, small subdural hematomas may be closely observed with serial non-contrast CTs of the head. Indications for emergent surgery in a patient with a subdural hematoma include neurologic deterioration or midline shift > 5 mm on CT. Subdural hematomas occur most commonly in individuals with brain atrophy, such as patients who abuse alcohol and elderly patients. Subdural hematomas occur when there is rupture of the bridging veins from movement of the brain relative to the skull. This results in blood filling the potential space between the dura and arachnoid. Acute subdural hematomas are characteristically seen after a traumatic head injury. Patients typically present with a headache, mental status changes, seizures, or focal deficits. Subdural hematoma is diagnosed on non-contrast CT of the head and appears as a crescent-shaped hematoma that may cross suture lines.

Which of the following statements regarding drug rash with eosinophilia and systemic symptoms related to anticonvulsant use is true? A Cross-reactivity between anticonvulsants is rare B Mucous membranes are spared early in the disease C Onset usually occurs after longstanding therapy D Rash is the most common initial symptom

B Mucous membranes are spared early in the disease DRESS (aka drug rash with eosinophilia and systemic symptoms) is a potentially fatal complication of anticonvulsant therapy. The rash occurs after one to two weeks of nonspecific symptoms. It is erythematous and initially spares the mucous membranes. The classic triad is fever, rash, and internal organ involvement. Within one to two weeks, multi-organ system failure and death can occur. Treatment is with intravenous steroids and immunoglobulin. The offending drug should be discontinued. Mortality rates can be as high as 10%. DRESS related to anticonvulsant use is caused by medications that have an aromatic ring such as phenytoin, carbamazepine, phenobarbital, primidone, and oxcarbazepine. While DRESS mostly occurs with anticonvulsant medications, other drugs such as sulfonamides, dapsone, minocycline, vancomycin, raltegravir, trimethoprim-sulfamethoxazole, and kinase inhibitors can also cause DRESS.

A 12-year-old boy presents with high fever, muscle and joint aches, and headache for two days. He states he just got back from a camping trip in North Carolina. His exam is unremarkable. Labs are normal except for platelets of 95,000/µL and a serum sodium of 128 mEq/L. Which of the following is the most appropriate next step in management? A Obtain a Babesia microti DNA PCR and administer atovaquone and azithromycin B Obtain a Rickettsia rickettsii immunofluorescence assay and administer doxycycline C Send Lyme disease titers and administer amoxicillin D Supportive care

B Obtain a Rickettsia rickettsii immunofluorescence assay and administer doxycycline This patient is suffering from early Rocky Mountain spotted fever (RMSF) from an infection with the organism Rickettsia rickettsii. RMSF is a tick-borne illness that is endemic to North, South, and Central America. Although RMSF cases have been reported throughout most of the contiguous United States, five states (North Carolina, Oklahoma, Arkansas, Tennessee, and Missouri) account for over 60% of all cases. Clinically, RMSF is characterized by high fevers, arthralgias, myalgias, and a petechial rash, which begins on the ankles and wrists and spreads centrally. Early in the disease, there is often no rash, and some patients with confirmed RMSF never go on to develop a rash. Thus, the early presentation of RMSF is similar to that of a non-specific viral illness. The clinician may be steered towards the diagnosis of RMSF by the presence of thrombocytopenia and hyponatremia. R. rickettsii is an obligate intracellular bacteria transmitted to humans by the American dog tick (Dermacentor variabilis) and the Rocky Mountain wood tick (Dermacentor andersoni). RMSF can progress to involve the cardiopulmonary system (myocarditis, AV blocks, dysrhythmias, interstitial pneumonitis, pulmonary edema, etc.), nervous system (encephalomyelitis, meningitis, cerebral thrombovasculitis, etc.), and can also have cutaneous manifestations (vasculitis, ecchymosis, and ulcerations). Rickettsial antibodies can be obtained, but indirect immunofluorescence assay is the standard test for diagnosis as it has a high sensitivity (95%). Treatment is most effective when started early in the course of disease. Doxycycline 100 mg twice a day for 7-10 days is the most common regimen, but chloramphenicol can be substituted in those with a history of severe reaction to tetracycline antibiotics.

Your emergency department has been overwhelmed by a chemical warfare attack in your city. Most patients are arriving with varying degrees of ocular and dermal burns. Those closest to the point of attack have arrived intubated with blood-filled endotracheal tubes. Which chemical warfare agent was most likely used in this attack? A Cyanide B Mustard C Phosgene D Sarin

B Mustard Quick recognition of chemical warfare agent exposure is imperative to minimize potential spread within the community and healthcare providers. Each answer falls into one of the four groups of chemical warfare agents: cyanide-related toxins, vesicants (mustard), choking agents (phosgene), and nerve agents (sarin). The patient's symptoms above correlate most with a mustard gas exposure. Mustard gas is a vesicant that acts as an alkylating agent, damaging anything it touches. It is the only vesicant agent that does not cause pain immediately upon exposure, allowing it to spread further within the victim population before attempts at decontamination. Symptoms commonly present as a triad of ocular, dermal, and pulmonary injuries, as these organ systems are where the gas can easily come into contact. As with all chemical warfare agents, the mainstay of treatment is immediate removal from the source of the gas, decontamination, and supportive care.

A 22-year-old man recently diagnosed with schizophrenia presents to the ED with altered mental status. His blood pressure is 160/80 mm Hg, pulse is 130 bpm, and temperature is 39.5°C. He is noted to be confused and diaphoretic. He has muscle rigidity and a tremor in his hands. What is the most likely diagnosis? A Malignant hyperthermia B Neuroleptic malignant syndrome C Serotonin syndrome D Tyramine reaction

B Neuroleptic malignant syndrome Neuroleptic malignant syndrome (NMS) is a life-threatening condition characterized by muscle rigidity, autonomic instability, altered mental status, and hyperthermia that occurs soon after initiation or dose adjustment of a dopaminergic or antipsychotic drug. .This patient was likely started on an antipsychotic medication when he was diagnosed with schizophrenia. Other risk factors for the development of NMS include high dosage, high-potency antipsychotic medications, parenteral formulation, dehydration, preceding psychomotor agitation, and previous episodes of NMS. The diagnosis is made when a patient develops severe muscle rigidity and hyperthermia while taking a neuroleptic or antipsychotic medication and develops two or more of the following symptoms: diaphoresis, dysphagia, tremor, incontinence, altered mental status, tachycardia, mutism, hypertension or labile blood pressure, rhabdomyolysis, leukocytosis, and symptoms that are not caused by another substance, neurologic, medical, or psychological disorder

A 21-year-old woman presents with urinary frequency and dysuria for 2 days. Vital signs are within normal limits. Examination reveals mild suprapubic tenderness with no costovertebral angle tenderness. What is appropriate management of this patient? A Ceftriaxone B Nitrofurantoin C Noncontrast CT scan of the abdomen and pelvis D Phenazopyridine

B Nitrofurantoin This patient presents with an uncomplicated acute cystitis and can be treated with nitrofurantoin. Urinary tract infection (UTI) is an inflammatory response to microorganisms in the urinary tract. Patients will present with dysuria, frequency, urgency, hematuria, and suprapubic pain when infection is in the bladder. Cystitis represents infection of the lower urinary tract (pyelonephritis is infection of the upper urinary tract) and is common in women of all age groups but relatively uncommon among young men. Uncomplicated cystitis is defined as inflammation of the bladder in patients in the absence of pregnancy, medical comorbidities, and toxic appearance. The most common causative organisms are Escherichia coli and Staphylococcus saprophyticus. First-line antibiotic agents for uncomplicated cystitis include nitrofurantoin and trimethoprim-sulfamethoxazole (TMP-SMX). Ciprofloxacin is a common first-line drug in regions where resistance to TMP-SMX is greater than 10-20%. Pregnancy should be ruled out in all women of child-bearing age prior to choosing an antibiotic

A 52-year-old man presents from his primary care clinician's office for evaluation of an abnormal electrocardiogram. His ECG is seen above. He has no symptoms. What is the appropriate management? A Measurement of cardiac enzymes B No intervention C Telemetry observation D Transcutaneous pacer pad placement

B No intervention This ECG demonstrates an example of second-degree, type I atrioventricular (AV) block. AV block results from impaired conduction through some portion of the electrical circuit impairing communication between the atria and ventricles. In first and second degree AV block, there is a partial disruption of the electrical circuitry as opposed to third degree heart block when there is no electrical communication between the atria and ventricles (AV dissociation). In second-degree heart block, some sinus impulses do not reach the ventricles at all. In second-degree, type I AV block, there is lengthening of the PR interval until ultimately a beat is dropped. This is also known as Wenckebach or Mobitz I. In many cases, second-degree, type I heart block is a normal variant. Other times, the etiology is likely related to increased vagal tone and in most cases, requires no treatment. It can also occur in a myocardial infarction and usually resolves after the infarct period. Second-degree, type II heart block is characterized by a dropped beat without any prolongation of the PR interval. Type II is never considered a normal variant. What infectious etiology is associated with complete heart block? Lyme disease.

A 45-year-old woman with a history of breast cancer presents to the emergency department with weakness, confusion and constipation. She is found to have a serum calcium concentration of 15 mg/dL. What is the most appropriate initial treatment? A Furosemide B Normal saline C Pamidronate D Prednisone

B Normal saline Hypercalcemia is usually mild (< 12 mg/dL), asymptomatic and typically does not require emergent treatment. Hypercalcemic crisis, however, occurs in a subset of patients where the serum calcium concentration is usually greater than 14 mg/dL and requires emergent treatment. Hypercalcemic crisis occurs most often in patients with primary hyperparathyroidism, malignant disease or secondary to medications (e.g. thiazide diuretics, lithium, estrogens). The clinical manifestations are nonspecific, vary widely, and can include neurologic (fatigue, lethargy) cardiovascular (shortening of the QT interval on ECG, bradycardia), renal (dehydration, nephrolithiasis) and gastrointestinal (nausea, vomiting, constipation) findings. Goals of therapy include a stepwise process of volume repletion, renal calcium elimination, osteoclast inhibition and treatment of the primary disorder. Initial treatment is the administration of normal saline to increase intravascular volume. ECG: shortened QT interval Most common causes: Malignancy (most common inpatient cause), Primary hyperparathyroidism (most common outpatient cause)

A 19-year-old woman presents to the emergency room for ear pain. She had her tragus pierced a few days ago. Shortly after, she began having increased pain at her piercing site. Her physical exam reveals a tender tragus with erythema covering both the tragus and surrounding auricle. She complains of pain when moving her auricle in any direction. What is the most appropriate treatment for this patient's condition? A Oral cephalexin and removal of the piercing B Oral ciprofloxacin and removal of the piercing C Topical hydrocortisone cream and removal of the piercing D Warm compresses and salt water soaks around the piercing

B Oral ciprofloxacin and removal of the piercing This patient has acute perichondritis, an infection of the connective tissue surrounding the cartilaginous tissue of the ear. Pseudomonas aeruginosa is the most common microbe responsible for this infection. Risk factors include any trauma or skin breakdown over the helix or tragus, especially with indwelling material like ear piercings. Diagnosis is clinical, but if an abscess is present, wound cultures should be taken after incision and drainage to ensure appropriate sensitivities. Given the poor blood supply to cartilage, prolonged courses of antibiotics may be required. Despite treatment, auricle necrosis, auricle deformity, and permanent cartilage damage may occur. Treatment is with immediate removal of any foreign bodies (e.g., earrings), antipseudomonal antibiotics (e.g., ciprofloxacin), and close follow-up to ensure adequate improvement.

A 42-year-old woman with a history of hypertension and diabetes presents to the emergency department with redness, swelling, and mild pain around her left eye for 2 days. She reports no vision changes or fever. She remembers rubbing and scratching around her eye a few days ago but does not recall any trauma. On exam, she has erythema with edema of the lateral upper eyelid and under her left eye. Her conjunctivae are clear, and no foreign bodies are found. Extraocular movements are intact, and her vision is 20/30 in both eyes. What is the most appropriate pharmacological treatment for this illness? A Oral cefdinir B Oral clindamycin and amoxicillin-clavulanate C Topical ciprofloxacin drops D Topical erythromycin ointment

B Oral clindamycin and amoxicillin-clavulanate This patient is presenting with signs of preseptal cellulitis, an infection of the anterior portion of the eyelid that does not involve the orbit or other orbital structures. It is generally a mild condition that has few complications when treated appropriately. Symptoms can be similar to orbital cellulitis, a more severe infection involving the orbit. However, in contrast to orbital cellulitis, preseptal cellulitis does not present with ophthalmoplegia, pain with eye movements, and proptosis. Preseptal cellulitis generally arises from external bacterial sources with the most common etiologies being Streptococcus pneumoniae, Staphylococcus aureus, and other streptococcal species. Blood cultures are rarely positive and site cultures are difficult to obtain. Treatment is done empirically and should cover sinus and skin flora. However, the choice of treatment has been made more difficult with the emergence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA). Empiric antibiotic therapy that has good coverage for methicillin-resistant Staphylococcus aureus and coverage for streptococcal species is clindamycin with amoxicillin-clavulanate. Trimethoprim-sulfamethoxazole can substitute for clindamycin. Most patients can be treated with oral antibiotics on an outpatient basis. What imaging study can help a clinician differentiate orbital cellulitis from preseptal cellulitis? CT Orbits with contrast

A 75-year-old man on chemotherapy for metastatic prostate cancer presents with a fever. His white blood cell count is 1,200 cells/microL with 22% neutrophils, 44% lymphocytes, 8% monocytes, and 9% bands. Which of the following mandates antibiotic treatment? A Oral temperature of 100.4°F measured once B Oral temperature of 101°F measured once C Rectal temperature of 100°F for one hour D Rectal temperature of 99.6°F measured for one hour

B Oral temperature of 101°F measured once In patients on chemotherapy, the development of neutropenia is a known complication due to suppression of bone marrow production of all cell lines. When evaluating these patients, it is critical to calculate the absolute neutrophil count (total white blood cell count x % neutrophils). Neutropenia is defined as an absolute neutrophil count of < 1500 cells/microL or an ANC that is expected to decrease to this level within 48 hours. If the patient is neutropenic, guidelines have been established to define what constitutes a fever. The Infectious Disease Society of America defines neutropenic fever as a single oral temperature measurement of 101°F (38.3°C). Additionally, two oral temperature measurements measured at least one hour apart of 100.4°F (38°C) is also considered a fever. It is important to recognize that the measurement of a rectal temperature and the performance of a digital rectal examination are not recommended in neutropenic patients. In theory, this maneuver may increase bacterial translocation through mucosa that is inflamed as a result of chemotherapy.

A 29-year old man presents with complaints of deformed and discolored toenails. On exam, you note the findings seen above. A KOH scraping from the subungual debris is positive for hyphae. Which of the following is the most appropriate first-line treatment for this patient? A Oral ketoconazole 200 mg daily for 6 weeks B Oral terbinafine daily for 12 weeks C Oral trimethoprim/sulfamethoxazole daily for 12 weeks D Topical ketoconazole daily for 6 weeks

B Oral terbinafine daily for 12 weeks Onychomycosis describes nail infections caused by any fungus, including dermatophytes, yeasts, and nondermatophyte molds. Onychomycosis may involve the nail plate and other parts of the nail unit including the nail matrix. The majority of distal and proximal subungual onychomycosis results from Trichophyton rubrum. Yeast onychomycosis is most common in the fingers and is most often caused by Candida albicans. The diagnosis is usually clinical but can be confirmed by KOH and culture. Clippings of the nail plate and scrapings of the subungual keratosis can be examined with KOH and microscopy. Nail clippings can also be sent to pathology in formalin to be examined with periodic acid-Schiff (PAS) stain for fungal elements. The first-line treatment is terbinafine, a synthetic antifungal that inhibits ergosterol synthesis. The most concerning side effect of terbinafine is liver failure. Therefore, patients should undergo monitoring of LFTs. A second-line agent is itraconazole. What are some topical prescription medications available in the United States for the treatment of onychomycosis?Efinaconazole 10% and Ciclopirox 8% solution.

Acute pericarditis

Classically characterized by ECG changes including diffuse ST segment elevation and PR depression. Cause of acute pericarditis are manifold and include viral infections, malignancy, drug-induced, uremia, radiation exposure, and post-myocardial infarction. It is characterized by sharp chest pain radiating to the left trapezius, worse with inspiration or lying supine and improved with sitting up or leaning forward. A friction rub on auscultation is highly suggestive.

A 19-year-old man presents with a painless ulcer on the shaft of his penis present for the last three days. Examination is also notable for bilateral non-tender inguinal adenopathy. He reports he is sexually active with men. What is the most appropriate course of action? A Ceftriaxone IM B Penicillin IM C Rapid plasma reagen test D Viral culture

B Penicillin IM Syphilis is caused by the spirochete Treponema pallidum. Transmission occurs during exposure of moist skin to an infected area as the organism does not survive on dry surfaces. Syphilis progresses through three stages of illness. Primary syphilis is characterized by the chancre shown in the picture above. The lesion occurs at the site of exposure and begins as an erythematous papule that ultimately ulcerates. The ulcer has raised edges, sharply demarcated borders, and a clean base. Left untreated, the chancre resolves after 2-6 weeks. Bilateral painless inguinal adenopathy is sometimes present. Secondary syphilis develops 5-8 weeks after resolution of the chancre. Most commonly, this stage involves a diffuse total body rash beginning on the trunk and spreading distally, often involving the palms and soles. During this stage, condylomata lata may develop (broad-based papules in the perineal area). Syphilis then enters a latent period, which can last for years in immunocompetent patients and then manifest most commonly affecting the cardiac or nervous systems. The treatment of primary syphilis is penicillin G benzathine 2.4 million units IM. What is the treatment of a pregnant patient with syphilis and a penicillin allergy? Admission for penicillin desensitization as only penicillin is effective in these patients. Primary: painless chancre Secondary: lymphadenopathy, condyloma lata, rash on palms and soles Tertiary: gummas VDRL and RPR positive 1-4 weeks after infection Primary or secondary: IM benzathine penicillin G, 1 dose Tertiary: IM benzathine penicillin G qwk for 3 weeks

A 27-year-old man with a history of leukemia presents with penile pain that occurred gradually over 1 hour. On physical examination, he has an erect penis and appears uncomfortable due to pain. Intracavernosal administration of which of the following is indicated at this time? A Lidocaine B Phenylephrine C Prostaglandin D Terbutaline

B Phenylephrine Priapism is an erectile emergency caused by persistent engorgement of the corpora cavernosa of the penis. Priapism is categorized as either low-flow or high-flow. Low-flow priapism is more common, painful, and results from decreased venous outflow. Low-flow: venous, painful, emergency Rx: aspiration, intracavernous phenylephrine High-flow: arterial, semierect, painless Rx: observation, arterial embolization. Aspiration performed at 2 or 10 o'clock position High-flow priapism is painless and is most often due to trauma resulting in penile artery laceration leading to excessive arterial blood flow and corporal engorgement. Patients at risk for priapism include those with sickle cell disease, leukemia, lymphoma, and those taking anticoagulant medications. Intracavernosal drug injection can also result in priapism. Diagnosis is primarily with history and physical examination. Management includes hydration, supplemental oxygen administration (in cases of sickle cell disease), analgesia, and occasionally intracavernosal aspiration and irrigation. Phenylephrine is a vasoactive agent that may be injected into the corpora cavernosa, and urologic consultation is recommended prior to administration. Complications of priapism include impotence, penile fibrosis, and urinary retention.

A 24-year-old woman presents to the ED with concerns about vaginal discharge and pelvic discomfort for 3 days. The pelvic exam reveals a thin, white discharge; a friable cervix, diffusely tender; and mild adnexal tenderness. Which of the following additional findings should prompt you to admit the patient to the hospital? A Allergy to doxycycline B Positive urine beta-human chorionic gonadotropin C Recent intrauterine device removal D Temperature of 38.3°C

B Positive urine beta-human chorionic gonadotropin Pelvic inflammatory disease (PID) is an ascending infection of the upper portions of the genital tract, most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Women with PID can have markedly divergent clinical symptoms ranging from mild discomfort to frank peritonitis. Because of this variability, the Centers for Disease Control and Prevention (CDC) recommend empiric treatment for PID in all sexually active women who have uterine or adnexal tenderness and cervical motion tenderness. The CDC has also developed several criteria for admission of patients with PID. A patient with a positive urine pregnancy test should be admitted to the hospital for further care What impact does pelvic inflammatory disease have on future pregnancies? It increases the risk of ectopic pregnancy and infertility

A 23-year-old woman presents to the emergency department for bilateral eye pain. She was sitting by a fire for a few hours after a full day of skiing when she noticed gradually worsening bilateral eye pain, tearing, and photophobia. What is this patient's most likely diagnosis? A Herpes keratitis B Radiation burn C Smoke irritation D Thermal burn

B Radiation burn Radiation burn, or ultraviolet keratitis, is characterized by diffuse corneal injury due to the direct effects of ultraviolet radiation. The classic fluorescein exam finding is diffuse punctate uptake due to the ultraviolet light causing corneal epithelial damage. Risk factors include snow sports, welding, and tanning bed use in patients who do not use or improperly use eye protection. Diagnosis is made with fluorescein exam. Patients commonly have a delayed onset, of up to 10 hours, of symptoms from initial injury. Symptoms include bilateral eye pain, photophobia, and tearing. Physical exam may reveal conjunctival injection and decreased visual acuity. Treatment is with ophthalmic antibiotics and cycloplegics. Patients should have ophthalmology follow-up within 24 hours if their symptoms have not resolved.

Which of the following findings reliably rules out pericarditis and makes myocardial infarction more likely in a patient with chest pain? A PR segment depression B Reciprocal precordial ST depressions C ST segment elevation D Tachycardia

B Reciprocal precordial ST depressions Patients with pericarditis should never have reciprocal ST depressions (excluding occasional depressions in aVR and V1). Patients with pericarditis typically present with chest pain that is sharp and pleuritic in nature. The pain is often improved with sitting forward and worse with lying flat. Physical examination may reveal a pericardial friction rub although this sign can be intermittent. ECG is the most reliable diagnostic tool. The ECG findings evolve with time. Early on, diffuse ST elevation is seen with PR segment depression. In later stages, ST and PR segments normalize and T waves flatten and can become inverted. Early findings of pericarditis can be difficult to distinguish from ST elevation myocardial infarction (STEMI). In STEMI, ST elevations are typically accompanied by ST segment depressions.

A 17-year-old boy presents with altered mental status. He is confused and speaking incoherently. His vital signs are T of 38.3°C, HR of 130 bpm, BP of 90/55 mm Hg, RR of 30/min, and SaO2 of 99%. His finger-stick blood glucose is > 450 mg/dL. IV fluids are started. His blood gas is pH of 7.13, pCO2 of 20 mm Hg, bicarbonate < 5 mEq/L, and potassium of 2.9 mEq/L. Which of the following is the most appropriate next step? A Give an insulin bolus of 0.1 units/kg followed by a drip at 0.1 units/kg/hr B Replenish potassium and hold insulin until potassium > 3.3 mEq/L C Replenish potassium and start an insulin drip at 0.1 units/kg/hr D Start an insulin drip at 0.1 units/kg/hr

B Replenish potassium and hold insulin until potassium > 3.3 mEq/L This patient is experiencing severe diabetic ketoacidosis (DKA). The treatment of DKA should focus on initial resuscitation in hemodynamically unstable patients: IV fluids, electrolyte repletion, cessation of ketogenesis with an insulin infusion, and identification of the underlying cause of DKA. In DKA, there is either an absolute lack of insulin or a relative lack of insulin (to metabolic demands), leading to increased serum glucose. The increase in serum glucose leads to an osmotic diuresis, leaving the patient both dehydrated (causing hemodynamic instability) and depleted of electrolytes. Simultaneously, cells produce ketones from fatty acid and protein metabolism as uptake of glucose is inhibited by the lack of insulin. The osmotic diuresis can lead to dangerously low potassium levels, and 10% of patients will present with a serum potassium < 3.3 mEq/L. The initiation of insulin therapy can further drop potassium levels by 0.5-1.0 mEq within minutes due to intracellular shifts. As a result, serum potassium levels can reach dangerously low arrhythmogenic levels. The American Diabetes Association (ADA) recommends obtaining a serum potassium level prior to initiating insulin therapy. Additionally, the ADA recommends holding insulin if the initial serum potassium is < 3.3 mEq/L (class II recommendation) Although insulin (A) is a vital component of treatment of DKA and the ADA recommends starting insulin as a bolus followed by a continuous infusion, potassium repletion should take precedence. Regardless of the initial serum potassium, all DKA patients are total-body potassium depleted. Thus, the ADA recommends starting an insulin infusion along with potassium repletion (C) when the initial potassium is between 3.3 and 5.5 mEq/L. Recent data suggest that starting an insulin infusion alone (D) may be appropriate, but this is not currently endorsed by the ADA.

Which of the following best describes the finding seen in the ECG? A Left bundle branch block B Right bundle branch block C Third-degree AV block D Type I second degree AV block

B Right bundle branch block Bundle branch blocks are abnormal conduction abnormalities (not rhythm disturbances) in which the ventricles depolarize in sequence, rather than simultaneously, thus producing a wide QRS complex (> 120 msec) and a ST segment with a slope opposite that of the terminal half of the QRS complex. A right bundle branch block (RBBB) is a unifascicular block in which ventricular activation is by way of the left bundle branch. The impulse travels down the left bundle, thus activating the septum from the left side (as it normally does in the absence of RBBB). This is followed by activation of the free wall of the left ventricle and finally the free wall of the right ventricle. Because of the two changes in direction, there is a tendency toward triphasic complexes in a RBBB (RSR'). The ECG in a RBBB will show a wide S wave in lead I and a RSR' pattern in lead V1. In left bundle branch block (A), lead I has a large R wave and in lead V1 there is a negative QS or rS complex. Third-degree AV block (C) presents with complete P and QRS dissociation. Type I second-degree AV block (D) has progressively prolonging PR intervals with dropped QRS complexes.

An 18-month-old girl presents to the emergency department with a rash. Mom reports that she has had a high fever for the last three days. Today, the fever broke, but she developed a maculopapular rash on her trunk. What is the likely diagnosis? A Erythema infectiosum B Roseola C Rubeola D Scarlet fever

B Roseola Roseola infantum is caused by human herpesvirus 6 and the vast majority of cases are seen in children under two years old. The disease is characterized by a high fever (often as high as 41 oC) for 3-5 days, which ends abruptly and is followed by the onset of a diffuse fine maculopapular rash on the trunk which may spread to the face and extremities. There is no mucous membrane involvement. Children affected are typically not ill appearing. The illness is self-limited, with the rash lasting only a few days. Treatment consists of fever control as needed

A 65-year old man with a history of hypertension and tobacco use presents to the ED after a syncopal episode. He is currently complaining of severe back pain that radiates to his groin. Vitals are BP 80/40 mm Hg and HR 110 bpm. On physical exam he is noted to have a scrotal hematoma. Which of the following is the most likely diagnosis? A Hemorrhagic pancreatitis B Ruptured abdominal aortic aneurysm C Testicular rupture D Testicular torsion

B Ruptured abdominal aortic aneurysm A ruptured abdominal aortic aneurysm, or AAA, should be suspected in a patient with a history of smoking and hypertension presenting with syncope. Most patients with abdominal aortic aneurysms are men over the age of 60. Classically a ruptured AAA presents with flank pain, hypotension, and a pulsatile mass. However, this only occurs in a small percentage of patients. The most common presenting symptoms are back or abdominal pain, but syncope can be a presenting sign in about 10% of patients. A retroperitoneal rupture may present with periumbilical ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign). Retroperitoneal blood may dissect into the perineum and groin leading to scrotal or vulvar hematomas. Risk factors for AAA including hypertension, advanced age, smoking, and hyperlipidemia. Bedside ultrasound can be used in unstable patients who present with syncope, hypotension, and abdominal or flank pain to confirm free fluid in the abdomen. Emergent surgical consultation for operative management is warranted

An 8-year-old boy is brought to the ED with right wrist pain after a fall in the playground. He has tenderness over the distal radius. After receiving ibuprofen, he is sent to radiology for plain films of the wrist. In anticipation of the results, which of the following is true regarding distal radius fractures in children? A Reduction is not required in greenstick fractures with < 30 degrees of angulation B Salter-Harris type IV fracture requires surgical management C The diagnosis of a Salter-Harris type I fracture is made radiographically D There is a high risk of vascular compromise with torus fractures

B Salter-Harris type IV fracture requires surgical management The fracture line of Salter-Harris type IV fracture begins at the articular surface, crosses the epiphysis and growth plate, and extends into the metaphysis, splitting off a metaphyseal fragment. Operative management is required to ensure anatomic reduction, avoid angular deformity, and prevent loss of joint function. This type of fracture is associated with growth disturbances.

A 29-year-old man with a history of HIV presents with shortness of breath and fever. He has a productive cough but denies hemoptysis. You obtain the chest radiograph seen above. Which of the following is true regarding the patient's diagnosis? A Elevated LDH is common B Spread is by the hematogenous route C Steroids should be administered prior to antibiotics if the PaO2 is < 80 D Trimethoprim-sulfamethoxazole is the treatment

B Spread is by the hematogenous route The chest radiograph demonstrates miliary tuberculosis (TB), or acute disseminated tuberculosis. The term miliary was first used to describe the pathologic lesions seen on radiographs that appeared as small millet seeds. Miliary TB occurs when the host is unable to contain a recently acquired or a dormant TB infection. The condition was mostly seen in young children after primary infection, but now is more common in the elderly and in persons infected with HIV. Spread of the mycobacteria occurs through the hematogenous route, which leads to the multisystem nature of miliary TB. Clinically, patients develop many signs and symptoms similar to those of active pulmonary TB—fever, weight loss, anorexia, and weakness. Hemoptysis is uncommon. The classic miliary pattern seen in the radiograph is present in approximately 50% of cases. Hyponatremia is sometimes seen from development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The mortality rate is higher than for other forms of TB, which is likely due to a delay in treatment.

A 21-year-old man presents for evaluation of a sore throat. The patient reports a fever and sore throat for two days. On examination, his oropharynx is erythematous with enlarged tonsils and bilateral exudates. In addition to nonsteroidal anti-inflammatory drugs, which of the following has been shown to produce the greatest reduction in pain? A Acetaminophen B Dexamethasone C Intravenous hydration D Penicillin

B. Dexamethasone Dexamethasone administered in a single dose of 0.6 mg/kg up to a maximum of 10 mg is associated with a reduction of pain and duration of pain in patients with moderate to severe pharyngitis. The medication is available orally or parenterally and has the same effectiveness in either form. The mainstay of therapy for patients with pharyngitis is treatment with non-steroidal anti-inflammatory agents.

What finding on lumbar puncture increases the suspicion of cryptococcal meningitis?

Clear CSF with a high opening pressure.

A woman presents with right breast pain, fever, and malaise for three days. She has been breastfeeding her newborn child for the last three weeks. On exam, there is an area of focal erythema and tenderness. No mass or fluctuance is noted. What is the most likely pathogen responsible for causing her condition? A Escherichia coli B Staphylococcus aureus C Streptococcus agalactiae D Streptococcus pyogenes

B Staphylococcus aureus Mastitis is a localized and painful inflammation of the mammary gland that can be associated with fever and malaise. Lactational mastitis primarily occurs within the first few months of breastfeeding, when the skin of the breast is prone to damage due to frequent feedings. It may also occur much later, when the infant develops teeth and can cause local trauma to the area during feeding. The most common pathogen is Staphylococcus aureus, which accounts for 40% of the cases. It is important to distinguish mastitis (cellulitis) from an abscess (requires surgical drainage) and inflammatory breast cancer (rare but deadly). In addition to antibiotics such as dicloxacillin or cephalexin, which cover for Staphylococcus aureus, the patient should be encouraged to apply cool compresses and continue breastfeeding. If the patient does not respond to antibiotics within 72 hours, the patient should be evaluated again for the possibility of breast abscess. What is a galactocele? A cystic collection of fluid caused by an obstructed milk duct.

A 44-year-old woman presents to the ED with right upper quadrant pain, nausea, and occasional vomiting that began one week after eating raw oysters. On examination, she has mild right upper quadrant tenderness. Her laboratory values are notable for elevated aspartate aminotransferase and alanine aminotransferase (ALT). A bedside right upper quadrant ultrasound is negative for any evidence of cholelithiasis or cholecystitis. Which of the following is true regarding her diagnosis? A Superinfection with hepatitis D can result in fulminant hepatic failure B The disease is self-limiting C The risk of chronic infection is > 75% D Transmission is primarily through intimate contact via blood, semen, or saliva

B The disease is self-limiting. The patient ate raw oysters and contracted hepatitis A virus. Transmission of hepatitis A is spread by the fecal-oral route either directly via person-to-person contact or indirectly through ingestion of contaminated water or food, particularly undercooked shellfish. Hepatitis A virus (HAV) has an incubation period of 15-30 days when patients are asymptomatic. This is followed by a prodromal phase of nausea, vomiting, and malaise. One week into the illness, they may develop dark-colored urine (bilirubinuria) and several days later, clay-colored stools and jaundice. HAV does not have a carrier state, and death from hepatic failure is rare. Treatment is supportive, and the disease is usually self-limiting. What is the most common type of viral hepatitis in the United States? Hep C

Which of the following regarding the rule of nines is correct regarding infants? A The body is disproportionally larger in infants than in adults B The head is disproportionally larger in infants than in adults C The legs are disproportionally larger in infants than in adults D The rule of nines is not reliable in infants, so another scale should be used

B The head is disproportionally larger in infants than in adults The rule of nines is frequently used to help determine burn size in acutely burned patients. Infants and children have a relatively larger portion of the body surface area in the head and neck, which makes up for the relatively smaller surface area of the lower extremities. Infants have 21% of the total body surface area in the head and neck (18% of head alone, compared to 9% in adults) and 14% in each leg, which incrementally approaches the adult proportions with increasing age

A 45-year-old man presents with an irritated, tearing right eye. He works in construction and thinks he must have gotten something in his eye earlier in the day. He has no medical problems and does not wear contact lenses. Physical exam using the Wood light is significant for a small area of fluorescein uptake on the cornea. No foreign body is present. Which of the following is the most appropriate treatment? A Immediate irrigation using Morgan lens B Topical antibiotics C Topical beta-blockers D Topical steroids

B Topical antibiotics Corneal abrasions commonly result from eye trauma, foreign bodies, or contact lens use that lead to a defect in the corneal surface epithelium. Patients may present with pain, tearing, foreign body sensation, and photophobia. Examination using a cobalt blue light source (slit lamp or Wood light) and fluorescein staining should be performed. Most patients will require the use of a topical anesthetic agent such as proparacaine to facilitate this examination. Thorough examination, including upper lid eversion, must be performed to evaluate for ocular foreign bodies. Treatment includes topical antibiotics to prevent secondary infection. Most patients may be treated with erythromycin ointment; however, contact lens wearers should be treated with antipseudomonal topical antibiotics such as ciprofloxacin or tobramycin. Topical cycloplegic agents may be prescribed to help reduce pain; oral analgesia may also be necessary. Topical anesthetics should not be prescribed because repeated use can delay healing. Corneal abrasions generally heal within 24 to 72 hours.

A 48-year-old man who does not have housing is brought in by EMS. He has been walking outside in the snow for many hours wearing only tennis shoes. He reports that he is unable to feel his feet. On examination, his feet are cold to the touch, whitish in color, and swollen. He has delayed capillary refill and multiple clear, fluid-filled bullae on his toes. Which of the following is the most appropriate thawing technique? A Water immersion at temperatures between 35-36°C B Water immersion at temperatures between 37-39°C C Water immersion at temperatures between 40-42°C D Water immersion at temperatures between 43-45°C

B Water immersion at temperatures between 37-39°C Frostbite is best treated with warm water immersion in a circulating bath with water temperatures kept between 37-39°C. Rewarming generally takes 15 to 30 minutes and should continue until the tissues feel pliable and distal erythema returns. Rewarming is often associated with significant throbbing and burning pain, which can be treated with parenteral analgesic administration. Frostbite occurs when a cold stress results in peripheral vasoconstriction of the acral (fingers, toes, ears, and nose) areas in an attempt to minimize heat loss and further cold exposure leads to crystal formation and cell destruction. Signs and symptoms of first-degree frostbite include numbness and pain. Second-degree frostbite is characterized by edema, vesicle formation, and erythema. Third-degree is characterized by hemorrhagic vesicles and fourth-degree frostbite extends into the deeper osseous and muscle layers. Water immersion at temperatures less than 37°C (A) is not sufficient to rewarm the tissues. Previous recommendations were to rewarm affected areas in a water bath of 40-42°C. However, it has been found that temperatures greater than 40°C (C and D) do not warm the tissue faster and can cause the process to be more painful. Temperatures above 42°C can cause tissue damage.

post partum hemorrhage

Blood loss of ≥ 1,000 mL or bleeding associated with signs and symptoms of hypovolemia within 24 hours of birth regardless of route of delivery Most commonly caused by uterine atony PE will show an enlarged boggy uterus Management Empty bladder Bimanual exam and uterine massage Oxytocin and additional uterotonics (e.g., prostaglandins) Tamponade (balloon or surgery)

A 24-year-old man presents to the emergency department for evaluation of abdominal pain. Yesterday, he had diffuse abdominal pain, which is now localized in the right lower quadrant. He is nauseated with a fever. He has focal tenderness in the abdomen 2 cm from the right anterior superior iliac spine. Which of the following is true regarding this condition? A A computed tomography scan of the abdomen and pelvis is necessary B A non-compressible 7 mm tubular structure on ultrasound confirms the diagnosis C A white blood cell count of 7,000 cells/mm3 rules out the suspected diagnosis D Narcotic pain medication will alter physical examination findings

B. A non-compressible 7 mm tubular structure on ultrasound confirms the diagnosis McBurney's point is located 2 cm from the anterior superior iliac spine and is the location of the appendix in most individuals. Focal tenderness in this region with a history suggestive of acute appendicitis is highly predictive of the diagnosis. Patients classically describe generalized or periumbilical pain that migrates to the right lower quadrant, often associated with fever, nausea, and anorexia. Physical examination findings include tenderness over McBurney's point, a positive psoas sign (an increase in pain when the right hip is extended while the patient is lying on the left side), a positive obturator sign (pain when the right hip is flexed and internally rotated while the patient is supine), and a positive Rovsing's sign (pain in the right lower quadrant when the left lower quadrant is palpated). The diagnosis can be made on ultrasound when a non-compressible tubular structure measuring at least 6-7 mm is identified in the area of pain. In most cases, the diagnosis is made by CT scan of the abdomen and pelvis using contrast although there is a growing body of data suggesting contrast is not necessary

An 86-year-old woman with a history of hypertension presents to the emergency department with syncope. She was going for a walk with her dog when she became short of breath, had chest pain, and then passed out. Bystanders do not report any seizure-like activity and the patient returned to her baseline mental status in the ambulance. Vital signs are BP 142/113, HR 90, RR 12, T 37.0°C. Examination shows an elderly woman with a laceration to the back of her scalp without active bleeding. Lung examination shows mild rhonchi and crackles and heart examination shows a murmur. What is the most likely diagnosis causing syncope in this patient? A Aortic dissection B Aortic stenosis C Hypertrophic cardiomyopathy D Myocardial infarction

B. Aortic stenosis Aortic stenosis, a structural abnormality of the aortic valve that prevents left ventricular outflow, is the most common cardiac valve lesion in the United States and is most commonly caused by degenerative calcification associated with increasing age, hypertension, smoking, elevated cholesterol, and diabetes. Bicuspid aortic valves and congenital heart disease are causes as well, but generally in younger patients. The classic presentation of aortic stenosis includes the triad of dyspnea, chest pain, and syncope. Often, a long asymptomatic period is followed by stepwise onset of symptoms starting with dyspnea followed by chest pain, syncope, and finally signs of heart failure. Classic physical examination findings are a late peaking systolic murmur and a narrowed pulse pressure. The patient in this question most appropriately fits the presentation of aortic stenosis due to her age, complaints of chest pain, dyspnea, and exertional syncope and a physical examination with a heart murmur and narrowed pulse pressure.

A 74-year-old woman presents to the ED with difficulty breathing for two days. She has a history of hypertension and emphysema. She has a 50 pack-year smoking history. In the ED, her vital signs are BP 128/78, HR 90, RR 20, oxygen saturation 94% on room air, and temperature 98.8°F. She is thin and using accessory muscles of respiration. A chest X-ray demonstrates an increased anterior-posterior diameter and decreased airspace markings but no acute cardiopulmonary process. An ECG shows no ST-segment or T-wave changes. Which of the following is the most appropriate treatment for this patient? A Antibiotics B Beta-agonists, anticholinergics, and corticosteroids C Positive pressure ventilation D Smoking cessation and observation

B. Beta-agonists, anticholinergics, and corticosteroids This patient has a chronic obstructive pulmonary disease (COPD) exacerbation. COPD consists of chronic bronchitis and emphysema, and this patient has previously been diagnosed with emphysema. Emphysema is an airspace disease with destruction of the alveolar septa. The loss of these septa leads to decreased support within the bronchial walls, causing airway collapse during expiration. Therefore, emphysema is classified as an obstructive airway disease. Patients with emphysema typically have exertional dyspnea, a prolonged expiratory phase, pursed lips upon expiration, are thin, and use accessory muscles of respiration. Patients with emphysema are often called "pink puffers." COPD exacerbations can have various triggers, such as infection or environmental pollutants. Treatment of this patient's acute COPD exacerbation includes oxygen, nebulized or inhaled beta-agonists, and anticholinergics as well as systemic corticosteroids.

A 35-year-old woman presents with severe throbbing, pain, and swelling to the distal aspect of her ring finger, as seen above. On exam, you note symmetric swelling of the distal finger. Which of the following is the most appropriate treatment? A Advance a #11 scalpel blade parallel to the nail and under the eponychium B Complete incision through septa on the ulnar aspect of distal finger C Oral acyclovir D Warm soaks, elevation, and anti-staphylococcal antibiotics

B. Complete incision through septa on the ulnar aspect of distal finger Most commonly caused by Staphylococcus aureus Treatment is incision and drainage The patient has a felon, an infection of the pulp of the distal finger or thumb. This is a distinct entity from other subcutaneous abscesses because of the presence of multiple vertical septa that divide the pulp into small fascial compartments. A felon usually begins as an area of cellulitis and progresses rapidly to severe throbbing, pain, swelling, and increased pressure in the distal pulp space. Management invariably involves an incision and drainage through the septa to provide adequate drainage and to relieve pressure in septal compartments. This is best achieved by placing a single lateral incision made along the ulnar aspect of digits 2-4 and the radial aspects of digits 1 and 5 to avoid the pincher surfaces. The incision must be made dorsal enough to avoid the neurovascular bundle. The wound should then be irrigated and loosely packed with gauze and splinted.

What pathogen should be suspected in a patient with a persistent paroxysmal cough that lasts for weeks?

Bordetella pertussis, the causative agent of pertussis

A 53-year-old man with intravenous drug use presents with shortness of breath. For the last week, he has had increasing shortness of breath with cough and fevers. Vital signs are T 101.8 F; BP 130/78; HR 106; RR 14; and 93% room air. His chest X-ray is shown above. What is the likely etiology of these findings? A Deep venous thrombosis B Endocarditis C Fungal infection D Pneumocystis jiroveci pneumonia

B. Endocarditis Septic emboli result from infections in one place of the body, particularly, heart valves in endocarditis, traveling to a distant location causing infections in another site. Intravenous drug users are at particular risk for infective endocarditis. In general, most patients who develop infective endocarditis have an underlying valvular abnormality. In intravenous drug use, the non-sterile techniques of injection cause frequent episodes of bacteremia, one of which may cause an infection of the heart valve. Injection drug users are at particular risk of developing endocarditis of the tricuspid valve. When this occurs, pieces of the vegetation break off and can travel into the pulmonary circulation as septic emboli to the lungs. Many patients with infective endocarditis will develop septic emboli. Injection drug users may also develop thrombophlebitis in the peripheral veins at the site of their injections. Septic emboli can also originate at these sites and travel back to the right side of the heart passing into the lung. Once in the lung, septic emboli cause infiltrates, cavities, abscesses, infarcts, and even gangrene. In addition to causing infections, septic emboli can occlude any vascular structure and cause other non-infectious problems including stroke, blindness, extremity edema, renal infarct, splenic infarct, pulmonary embolism, or myocardial infarction. The affected organ system depends on the site of the original lesion and whether it travels into the pulmonary or systemic circulation.

A 16-year-old girl presents to your ED with a rash that has worsened over the last 4 days. She has had no fevers, cough, or other ill symptoms and seems to not be bothered by the rash. The rash is fixed and has not changed locations. Her vital signs are within normal limits for her age. You note the above lesions symmetrically along her distal arms and palms on your exam. She has a few similar lesions along the vermillion border and buccal mucosa, but none in her nose. She has no vaginal or anal lesions. Which of the following is the most likely diagnosis? A Acute onset urticaria B Erythema multiforme C Hand, foot, and mouth disease D Stevens-Johnson syndrome

B. Erythema multiforme Erythema multiforme is a well-described but poorly understood disease that typically affects young adults. The most common factors that are linked to erythema multiforme are herpes simplex virus 1 and 2 or Mycoplasma pneumoniae, but it has also been linked to other infections, medications, autoimmune processes, immunization, and menstruation. Its lesions are fixed and generally symmetric and typically worsen over 3-5 days with new crops lasting for 1-3 weeks. Lesions have a characteristic appearance involving three specific zones giving it a targetoid appearance. Lesions generally appear in the distal extremities and can involve the palms and soles. Lesions are frequently seen along the vermillion border and intraorally. Intraoral lesions alone are uncommon but reported. It is a self-limiting illness and is usually mild but can have a severe or recurrent presentation. Patients with frequent recurrence tend to improve with oral acyclovir or systemic corticosteroids. There is a high association with Mycoplasma pneumoniae in children and appropriate antibiotic treatment should be considered in patients with concurrent respiratory symptoms.

A 20-year-old woman presents with right-sided facial swelling and photophobia. She has right periorbital erythema that is tender to touch, as well as moderate proptosis and pain with extraocular movements. Direct spread from which sinus is the most common cause of this condition? A Cavernous B Ethmoid C Frontal D Sphenoid

B. Ethmoid Orbital cellulitis is an infection of the structures behind the anatomic orbital septum. The most common etiology is direct spread from the paranasal sinuses. The most commonly implicated sinus is the ethmoid sinus. This is likely due to a perforated lamina papyracea. Other causes include trauma, periorbital skin infections, ocular foreign body, recent ocular surgery, or hematogenous spread from systemic bacteremia. This is polymicrobial infection with the most common organisms being S. aureus, S. pneumoniae and anaerobes. Diabetics and immunocompromised patients are susceptible to mucormycosis. Clinical features include facial pressure, fever, limited and painful extraocular movements, proptosis, abnormal pupillary response, and decreased visual acuity. Diagnosis is made with computed tomography of the orbits, but high clinical suspicion may prompt therapeutic intervention prior to definitive diagnosis. Management includes early ophthalmology consultation, parenteral antibiotics and often surgical debridement if an ocular abscess exists. A lateral canthotomy may be indicated if intraocular pressure is elevated causing acute optic neuropathy. Complications from orbital cellulitis include osteomyelitis, brain abscess, cavernous sinus thrombosis, meningitis, epidural abscess, and subdural empyema

A 27-year-old man is diagnosed with a spontaneous pneumothorax. After performance of a tube thoracostomy, what is the easiest way to check for an air leak? A Connect to suction and look for an absence of respiratory fluctuation B Have the patient cough and look for bubbles in the water seal chamber C Have the patient hold his breath and look for a change in water level D Monitor the water level for respiratory variation

B. Have the patient cough and look for bubbles in the water seal chamber In the case of a spontaneous pneumothorax, an injury to the patient's bronchial tree causes air to leak into the pleural space causing collapse of the lung. After insertion of the chest tube (tube thoracostomy), the lung should re-inflate. When placed on suction, this negative pressure allows continuous expansion until the injury heals itself. An air leak in the system indicates the presence of continuous bronchial injury or possibly a problem with the mechanics of the chest tube system. If an air leak exists and the patient coughs, this generates positive flow through the bronchial system and will cause air bubbles to form in the water seal chamber. This actually confirms patency of the system but does also suggest that there is a persistent air leak with air escaping into the pleural space and then into the tube system When a chest tube drainage system is functioning correctly, the fluid level in the drainage tube fluctuates with inspiration and expiration. The absence of respiratory fluctuation suggests either a block in the system or full lung expansion. After a period of time, suction is removed and the tube system is left on water seal alone. When a patient holds his breath, there should be no change in the water level. If there is change, it may imply a problem with the overall system and its integrity should be assessed. Monitoring the water level for respiratory variation shows that the system is functioning properly as there is some minimal change in level because of the respiratory cycle. The negative intrathoracic pressure is not significant enough to pull water back into the thorax when the tube system is kept below the level of the patient.

What syndrome is possible with a person who is abusing MDMA and dextromethorphan?

Both increase serotonin levels, which can lead to serotonin syndrome. Sympathomimetic and serotonergic effects Hypertension, hyperthermia, dehydration, bruxism Hyponatremia Complications: serotonin syndrome, seizures

What are the most common sites of metastatic disease with melanoma?

Brain, liver, and bone.

What is the name for the variant of otitis media where vesicles are present on the tympanic membrane?

Bullous myringitis.

A 29-year-old previously healthy man presents with chest pain. He suffered from a "cold" recently. He awoke this morning with pain in the middle of his chest that radiated into his back. The pain is pleuritic and he feels short of breath. He denies recent trauma and travel. His vital signs are heart rate 74 beats per minute, blood pressure 128/74 mm Hg, respiratory rate 14 breaths per minute, oxygen saturation of 98% on room air, and temperature of 98.6°F. His electrocardiogram shows diffuse nonspecific ST elevations and PR depressions. Bedside cardiac ultrasound does not show an effusion. Which of the following is the most appropriate therapy? A Heparin B Ibuprofen C Prednisone D Warfarin

B. Ibuprofen Acute pericarditis, acute inflammation of the pericardium, is commonly preceded by or occurs concomitantly with a viral illness. It manifests with sharp, positional chest pain. Electrocardiogram (ECG) classically reveals diffuse ST elevations and PR depressions early in disease. The two most concerning complications are pericardial effusion and myocarditis. With uncomplicated pericarditis in an otherwise healthy individual, hospitalization tends to be unnecessary. Further evaluation is unnecessary unless symptoms persist or change. Treatment for uncomplicated acute pericarditis is with nonsteroidal anti-inflammatory drugs, most commonly ibuprofen, in association with colchicine. Generally a 1-3 week course will resolve the episode. One quarter of patients will have recurrence.

A 28-year-old woman with a history of diabetes mellitus and intravenous drug use presents with a swollen, painful, tender nodule in her left antecubital fossa. She denies a fever. There is overlying erythema spreading half way up her arm and down to her mid-forearm. An ultrasound of nodule reveals cobblestoning and a fluid collection. What is the best treatment for this patient? A Incision and drainage B Incision and drainage followed by oral antibiotics against Staphylococcal and Streptococcal species C Needle aspiration D Oral antibiotics against Staphylococcal and Streptococcal species

B. Incision and drainage followed by oral antibiotics against Staphylococcal and Streptococcal species Cellulitis is a skin infection involving the dermis and subcutaneous tissues of the skin. An abscess is a pocket of pus from a purulent cellulitis. Risk factors for abscess development include injury to skin (commonly from IV drug injection, abrasion, or insect bite), diabetes mellitus, and immunologic abnormalities. The most common bacteria involved in cellulitis or abscess formation are Staphylococcus aureus (both methicillin sensitive and methicillin resistant) and Streptococcus species. An uncomplicated abscess in an immunocompetent patient without significant cellulitis requires only incision and drainage. However, in an immunocompromised patient (e.g. diabetic) or an extensive cellulitis beyond the abscess should get an abscess incision and drainage followed by antibiotics. Risk factors, such as IV drug use, alcoholism, diabetes, and a poor social situation may warrant admission. The specific antibiotic choice should be based on local sensitivities.

Which of the following can be used to differentiate patients who are drug seeking from those who are experiencing pain? A Lack of pain medication prescriptions from your hospital B No reliable way to differentiate these two situations C Pain scale of 10 out of 10 D Vital signs are normal

B. No reliable way to differentiate these two situations Pain is a subjective experience and there is no reliable way to differentiate between a patient with true physical pain and one who is "drug seeking." Drug seeking behavior is thought of as actions taken by an individual to obtain medications that are not necessary for the treatment of a medical condition. This often involves pain medications (particularly opiates) and sedative hypnotic agents (e.g. benzodiazepines). The goal of the behavior may be for personal use or for illegal sale or redistribution. Over the last decade, opiates have been prescribed at increasing rates and morbidity and mortality related to prescription opiates have increased to a marked degree. In spite of this, patient's pain must be addressed in the emergency department making the job of clinicians difficult in differentiating true pain from secondary gain. Techniques: lost prescription, multiple drug allergies, self-mutilation Management: refuse drug, drug counseling referral

A 14-year-old boy developed an itchy, painful, erythematous rash on his hands, forearms, and face about a day after hiking in nearby woods with some friends. Your exam shows linear erythematous papules over his forearms with similar swelling and erythema around his eyes (including eyelids), cheeks, and forehead. The patient reports he has had this in the past. Which of the following is most likely to improve the course of his illness? A Oral diphenhydramine every six hours B Three week prednisone taper C Topical 1% hydrocortisone three times daily D Topical calamine lotion twice daily

B. Three week prednisone taper Allergic contact dermatitis (i.e. Rhus dermatitis), in this case caused by oleoresin in the sap of certain plants such as poison ivy, is a delayed type IV hypersensitivity reaction and may not present for as long as seven to ten days after exposure. With repeated exposures the reaction can develop within 12 hours as with our patient. It typically presents as itching and redness followed by papules, vesicles, and sometimes bullae often in a linear arrangement. Treatment for localized reactions involving small areas is with topical high-potency corticosteroids. Reactions that are extensive or involve the face or genitals respond well to a two to three week course of tapering systemic corticosteroids such as prednisone. The rash is known to rebound with shorter courses of oral corticosteroids so a longer duration of treatment is recommended.

Testicular Torsion Summary

Bimodal distribution: infants and young men Sx: intense scrotal pain PE: exquisite tenderness of the testicle, hard testes, high-riding testes, absent cremasteric reflex Diagnosis is made by ultrasound with Doppler Treatment: urgent surgery, manual detorsion if surgery delayed

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

Inguinal Hernias Summary

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 typeProtrudes through internal ring, lateral to IEA Mnemonic: MDs don't lie​Medial to IEA: directLateral to IEA: indirect Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation

Achalasia

Bird-beak esophagus seen on barium swallow that represents dilation of the upper esophagus with narrowing of the lower esophagus Sx: dysphagia to solids and liquids PE: absent peristalsis in the lower esophagus Diagnosis is made by esophageal manometry: increased LES pressure

Which of the following patients mandates reporting to health authorities in all 50 states or to federal officials? A A 33-year-old man who was involved in a motor vehicle collision and is found to have a blood alcohol level of 300 g/dL B A 45-year-old man who sustained a gunshot wound to his leg C A 79-year-old man with tuberculosis D An 8-year-old girl who was bitten on her face by the neighbor's dog

C A 79-year-old man with tuberculosis All states require hospitals to report certain events or illnesses to local public health authorities. The intent is to prevent the spread of communicable diseases, protect citizens from disease and violence, and prosecute criminal acts. In each instance, the state statute overrides patients' rights of confidentiality. The statutes typically also provide physicians with immunity from civil liability or criminal prosecution if the reporting is done in good faith. Typical communicable diseases that must be reported to the federal government include those of epidemiological concern such as sexually transmitted infections and highly communicable illnesses like tuberculosis, hepatitis, pertussis, and recently methicillin-resistant Staphylococcus aureus. Some, but not all, states require that physicians report drivers in motor vehicle collisions while intoxicated (A). Most, but not all, states mandate the reporting of injuries from a deadly weapon (B)—stab or gunshot wounds. Most, but not all, states require reporting of animal bites (D), particularly dog and cat bites.

A 17-year-old girl is brought into the emergency department by a friend after being found lethargic with an empty pill bottle at her bedside. An initial arterial blood gas shows a pH of 7.28, pCO2 of 55 mm Hg, and a serum HCO3 of 24 mEq/L. Which one of the following acid-base disturbances is present? A Acute (compensated) primary metabolic alkalosis B Acute (uncompensated) primary metabolic acidosis C Acute (uncompensated) primary respiratory acidosis D Uncompensated mixed metabolic/respiratory acidosis

C Acute (uncompensated) primary respiratory acidosis This patient's arterial blood gas (ABG) shows an abnormally low pH (acidosis) with an elevated pCO2 and a normal bicarbonate level, consistent with an uncompensated primary respiratory acidosis. Normal values are pH 7.36-7.44, pCO2 36-44 mm Hg, and HCO3 22-26 mEq/L. The primary disturbance will either be respiratory (change in pCO2) or metabolic (change in HCO3). The body will attempt to compensate by retaining or exhaling CO2 (if metabolic) or HCO3 (if respiratory). For example, in the above case, the patient's kidneys will increase levels of HCO3 to counteract the elevated CO2 in the blood. Since this is not seen (HCO3 is normal), it can be assumed that this disturbance is acute and uncompensated. Acute (compensated) primary metabolic alkalosis (A) is characterized by a normal pH, high pCO2, and elevated HCO3. Acute (uncompensated) primary metabolic acidosis (B) is characterized by a low pH, normal (or low if starting to compensate) pCO2, and low HCO3. An uncompensated mixed metabolic/respiratory acidosis (D) is characterized by a low pH, high pCO2, and low HCO3

An 83-year-old woman is brought to the ED by her husband, who reports a two-day history of increasing lethargy, generalized weakness, and occasional confusion. Her past medical history is significant for coronary artery disease, hypertension, hypothyroidism, and diabetes. Her temperature is 92.3°F (33.5°C), heart rate is 60 beats per minute, blood pressure is 80/55 mm Hg, and respiratory rate is 12 breaths per minute. She is somnolent but arousable and occasionally inaccurate when responding to questions. Physical examination reveals pretibial nonpitting edema with otherwise unremarkable extremities. Her complete blood count and basic metabolic panel are normal. Chest X-ray reveals an increased cardiac silhouette. What is the definitive treatment for this patient? A Active and passive rewarming measures B Administration of hydrocortisone C Administration of intravenous levothyroxine D Intravenous bolus of normal saline followed by vasopressor

C Administration of intravenous levothyroxine This patient has myxedema coma, a serious complication of hypothyroidism. It is characterized by hypothermia and altered mental status. It develops primarily in patients with a longstanding history of hypothyroidism following a precipitating event such as infection, trauma, discontinuation of thyroid replacement medications, or environmental exposure. Additional exam findings may include bradycardia, hypotension, and seizure. Despite the name, nonpitting edema and coma are rare. The most important initial treatment is thyroid hormone replacement, usually as an intravenous dose of levothyroxine. Such treatment is empiric and does not require confirmatory laboratory studies prior to administration. Dose IV levothyroxine at 0.3 to 0.5 mg but decrease to 0.1 mg in patients with heart disease. Give stress dose steroids as appropriate. Hemodynamic support and treatment of the precipitating event are also important in management. Active and passive rewarming measures (A) may be necessary in the severely hypothermic patient but should be considered adjuncts to definitive treatment with levothyroxine. Adrenal crisis can appear clinically similar to myxedema coma, therefore, until that possibility has been excluded, patients should be treated with stress dose hydrocortisone (B) as well. However, this patient has evidence of myxedema on exam, making myxedema coma the more likely diagnosis. Intravenous bolus of normal saline and vasopressor (D) may precipitate fluid overload and heart failure, therefore, it should be used judiciously as supportive care. Which patients are at greatest risk of developing myxedema coma? Elderly female patients.

An 83-year-old woman is brought to the ED by her husband, who reports a two-day history of increasing lethargy, generalized weakness, and occasional confusion. Her past medical history is significant for coronary artery disease, hypertension, hypothyroidism, and diabetes. Her temperature is 92.3°F (33.5°C), heart rate is 60 beats per minute, blood pressure is 80/55 mm Hg, and respiratory rate is 12 breaths per minute. She is somnolent but arousable and occasionally inaccurate when responding to questions. Physical examination reveals pretibial nonpitting edema with otherwise unremarkable extremities. Her complete blood count and basic metabolic panel are normal. Chest X-ray reveals an increased cardiac silhouette. What is the definitive treatment for this patient? A Active and passive rewarming measures B Administration of hydrocortisone C Administration of intravenous levothyroxine D Intravenous bolus of normal saline followed by vasopressor

C Administration of intravenous levothyroxine This patient has myxedema coma, a serious complication of hypothyroidism. It is characterized by hypothermia and altered mental status. It develops primarily in patients with a longstanding history of hypothyroidism following a precipitating event such as infection, trauma, discontinuation of thyroid replacement medications, or environmental exposure. Additional exam findings may include bradycardia, hypotension, and seizure. Despite the name, nonpitting edema and coma are rare. The most important initial treatment is thyroid hormone replacement, usually as an intravenous dose of levothyroxine. Such treatment is empiric and does not require confirmatory laboratory studies prior to administration. Dose IV levothyroxine at 0.3 to 0.5 mg but decrease to 0.1 mg in patients with heart disease. Give stress dose steroids as appropriate. Hemodynamic support and treatment of the precipitating event are also important in management.

A 32-year-old woman presents with vomiting and abdominal pain. She reports taking 40 acetaminophen tablets (500 mg each) in a suicide attempt 24 hours prior to arrival. Which of the following sets of laboratory results would be most consistent with hepatotoxicity secondary to acetaminophen overdose in this patient? A Alkaline phosphatase 550 U/L, gamma-glutamyltransferase 250 U/L, total bilirubin 4.7 mg/dL B Aspartate aminotransferase 280 U/L, alanine aminotransferase 130 U/L C Aspartate aminotransferase 4,600 U/L, alanine aminotransferase 3,200 U/L, alkaline phosphatase 140 U/L D Aspartate aminotransferase 5,800 U/L, alanine aminotransferase 6,300 U/L, total bilirubin 4.0 mg/dL

C Aspartate aminotransferase 4,600 U/L, alanine aminotransferase 3,200 U/L, alkaline phosphatase 140 U/L Acetaminophen is one of the most widely available medications and a leading cause of fatalities from oral poisonings in the United States. Acetaminophen is metabolized by conjugation with glutathione and sulfate into nontoxic metabolites. When glutathione supplies are overwhelmed in cases of overdose, a larger proportion of acetaminophen is oxidized by cytochrome p450 to a highly toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI). NAPQI binds to cell proteins in the liver, initiating a process that results in hepatic cell death. Liver transaminases begin to rise within 8-12 hours in severe poisonings, with a peak in transaminase levels 72-96 hours after ingestion. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) can be markedly elevated in cases of severe toxicity, up to 25-50 times normal, and at times exceeding 10,000 U/L. However, in the early stages of hepatotoxicity (24-36 hours), AST abnormalities precede other evidence of hepatic dysfunction. AST elevations are the most sensitive for developing hepatotoxicity in acetaminophen overdose. Later, as hepatotoxicity worsens, in addition to elevated transaminases, patients will have elevated prothrombin time and total bilirubin, as well as metabolic acidosis. Of the above choices, AST 4,600 U/L, ALT 3,200 U/L, and alkaline phosphatase 140 U/L is most consistent with drug-induced hepatotoxicity from acetaminophen. Ideally, treatment of acetaminophen overdose is with N-acetylcysteine (NAC) within 8 hours of ingestion. In those patients with a delayed presentation (> 24 hours post-ingestion), NAC is still indicated if there is a detectable acetaminophen level or any evidence of liver injury on laboratory investigation. Sx: abdominal pain, nausea, vomiting, and jaundice PE: RUQ tenderness Labs: elevated AST and ALT Treatment is N-acetylcysteine (restores glutathione) Rumack-Matthew nomogram: stratifies the risk of liver failure Above Rumack-Matthew nomogram line: treat Below Rumack-Matthew nomogram line: no treatment necessary Determine if overdose was accidental or intentional What dose of acetaminophen is typically required to ca

A 35-year-old woman presents to the ED with fever and RUQ abdominal pain. Vital signs are BP 100/65 mm Hg, HR 110 bpm, and T 38.3°C. A focused ultrasound assessment is performed, as seen in the video. What is the most likely diagnosis? A Ascending cholangitis B Biliary colic C Cholecystitis D Choledocholithiasis

C Cholecystitis The ultrasound demonstrates multiple findings of acute cholecystitis, including thickening of the gallbladder wall and the presence of gallstones and pericholecystic fluid. There was likely a sonographic Murphy sign during the ultrasound study. The sonographic Murphy sign differs from that found on physical examination (arrest of inspiration on deep palpation of the right upper quadrant) and is positive when the point of maximal tenderness is identified in the right upper quadrant, when the gallbladder is identified on the ultrasound screen. In this way, one can be certain the gallbladder is the tender structure as it is being directly visualized. Ultrasound: Cholecystitis Gallbladder wall thickening (> 3 mm) Pericholecystic fluid Sonographic Murphy sign Cholelithiasis

A 21-year-old woman with a history of cystic fibrosis presents with a fever, increasing cough, and sputum production. Her X-ray shows a right lower lobe infiltrate. She has not been hospitalized in the last six months. Which of the following medications should be included in her treatment regimen? A Amphotericin B Cefazolin C Ciprofloxacin D Erythromycin

C Ciprofloxacin Cystic fibrosis is an autosomal recessive disease causing a mutation in the chloride transport system on the surface of exocrine glands. In the pulmonary organ system, patients develop a large amount of thick secretions. These thick secretions impair the normal function of the respiratory system, particularly, in the ability to expectorate mucous. Patients suffer acute pulmonary exacerbations when they develop a bacterial infection causing additional inflammation within the lung. The chest X-ray is often of limited utility in the diagnosis of pneumonia because of its baseline irregularities in patients with longstanding disease. When cystic fibrosis patients develop pneumonia, broad-spectrum antibiotics are required to cover Staphylococcus aureus, Haemophilus influenzae, and also Pseudomonas aeruginosa. By the time patients reach 18 years of age, there is an 80% prevalence of Pseudomonas in pulmonary infections and antibiotics like ciprofloxacin with activity against this organism must be administered. These patients should receive double-coverage for Pseudomonas (e.g. piperacillin-tazobactam plus ciprofloxacin or an aminoglycoside). Patients also require aggressive chest physical therapy during the course of an acute pulmonary illness.

A 49-year-old woman presents to the Emergency Department after being assaulted by her boyfriend with a knife. She was stabbed multiple times in the back, groin, and abdomen. She is awake and irritable. Her vital signs include a temperature of 99.1°F, HR 131 beats/minute, RR 34 breaths/minute, BP 98/57 mm Hg, and oxygen saturation 96% on room air. This patient is in which of the following classes of hemorrhagic shock? A Class I B Class II C Class III D Class IV

C Class III Hemorrhagic shock can be described as one of four classes based on a number of factors, including blood volume lost, vital sign changes, mental status, urine output, and type of resuscitative fluid needed. Class I shock is characterized by blood loss < 750 mL (< 15% volume loss), HR < 100 beats/minute, normal blood pressure, normal to increased pulse pressure, RR < 20 breaths/minute, and normal mental status to slight anxiety. Class II shock (B) is characterized by blood loss 750-1500 mL (15-30% volume loss), tachycardia (HR > 100 beats/minute), normal blood pressure, decreased pulse pressure, RR 20-30 breaths/minute, and the patient may be irritable or slightly confused. Class III shock is characterized by blood loss 1500-2000 mL (30-40% volume loss), HR > 120 but < 140 beats/minute, hypotension, decreased pulse pressure, RR 30-40 breaths/minute, and an irritable or lethargic mental status. Class IV shock (D) is characterized by blood loss > 2000 mL (> 40% volume loss), HR > 140 beats/minute, decreased blood pressure, decreased pulse pressure, RR > 40 breaths/minute and lethargy Patients in class III or IV hemorrhagic shock require blood and crystalloid fluid replacement therapy.

A 28-year-old woman presents to the ED complaining of mild abdominal pain. Abdominal exam is unremarkable. Pelvic exam reveals scant blood in the vaginal vault and a closed os. Urinalysis is normal. The patient is Rh-positive. Her LMP was six weeks ago. A bedside transabdominal ultrasound is performed. What is the most appropriate next step in the management plan? A Administer Rh(D) immune globulin B Arrange for dilation and curettage C Discharge home with instructions for vaginal rest D Obstetrical consultation for ectopic pregnancy

C Discharge home with instructions for vaginal rest To confirm an intrauterine pregnancy on ultrasound, you must identify a gestational sac and yolk sac within the uterus. Such findings can be visualized on transvaginal ultrasound as early as 6 weeks gestational age. This patient's presentation is consistent with a threatened abortion as evidenced by a confirmed intrauterine pregnancy on ultrasound, a closed os, and vaginal bleeding. She can be discharged home with vaginal rest, bleeding precautions, and outpatient follow-up with her obstetrician.

A 24-year-old man who is sexually active presents with reports of the "flu" for the past 3 weeks. Specifically, he reports generalized weakness, malaise, myalgias, a low-grade fever, and anorexia. He reports no upper respiratory infection symptoms or a cough. He has intercourse with men and does not always use condoms. He is concerned that he may have contracted HIV. His vital signs are significant for a blood pressure of 128/62 mm Hg, a heart rate of 82 beats per minute, an oxygen saturation of 99% on room air, and a temperature of 101.3°F (38.5°C). The physical exam reveals a well-appearing man who is in no acute distress with no thrush or abnormal findings. Laboratory values reveal WBC of 6.2 × 109/L with 3% bands, hemoglobin of 15.6 g/dL, and platelets of 120/microL. Chest radiograph and urinalysis are normal. You suspect acute HIV syndrome and obtain a rapid antigen/antibody combination assay. Which of the following statements best describes the next step in management? A Admit the patient for confirmatory studies if positive B Discharge and reassure the patient if negative C Discharge with confirmatory blood tests if positive D Make the diagnosis of HIV if positive

C Discharge with confirmatory blood tests if positive Acute HIV syndrome (also known as acute seroconversion syndrome) may follow primary exposure by 2 to 4 weeks and cause nonspecific symptoms, including fever, chills, malaise, myalgias, pharyngitis, diarrhea, or other neurologic or immunologic symptoms. These symptoms are generally mild with spontaneous resolution and are often mistaken for a benign viral illness. As a result, many patients do not seek medical care during this phase. When testing for HIV, positive oral swab results should be considered preliminary pending confirmation (required) with serum testing via HIV-1/HIV-2 differentiation immunoassay or western blot. Oral swab testing has the advantage of being highly sensitive, relatively inexpensive, rapid, and noninvasive, and can detect antibodies for both HIV-1 and HIV-2. However, oral testing has a lower positive predictive value in low-prevalence populations than blood testing and may have a higher false-positive rate. Therefore, positive results (D) should be confirmed with HIV-1/HIV-2 differentiation immunoassay or western blot prior to diagnosis. Admission is not required (A) for a new diagnosis of HIV in the asymptomatic or nontoxic patient when proper outpatient follow-up can be arranged. Patients will generally develop detectable antibodies between 2 and 8 weeks following initial infection. Therefore, during this period, antibody-based testing may yield falsely negative (B) results. Patients should be instructed to repeat the test in 2 to 3 months.

A 17-year-old girl presents with the above rash a week after hiking in the woods. She does not report a tick bite. She otherwise has no symptoms. What management is indicated? A Ceftriaxone 2 g for 14 days B Chloramphenicol 1 g for 21 days C Doxycycline 100 mg twice a day for 3 weeks D No treatment while awaiting diagnostic testing

C Doxycycline 100 mg twice a day for 3 weeks This patient presents with erythema migrans, the typical rash seen in early Lyme disease, and requires 3 weeks of treatment with oral doxycycline. Lyme disease is an illness caused by transmission of Borrelia burgdorferi bacteria from a tick. The common vector is Ixodes scapularis. Transmission from tick to person requires attachment and feeding for more than 48 hours. Thus, early removal of ticks can prevent transmission. Typically, erythema migrans presents 7-10 days after infection and is proceeded by nonspecific constitutional symptoms (fever, malaise, fatigue). Approximately 90% of patients report the presence of the rash. The rash begins as a small papule at the site of infection and gradually expands (1-2 cm/day). Typically, the rash will have central clearing, but this is not universal. Further hematogenous spread of B. burgdorferi can cause numerous symptoms, including arthralgias, neurologic manifestations, and heart block. The diagnosis of Lyme disease is based primarily on clinical features, but serologic or ELISA testing can be used to confirm the diagnosis. Prompt treatment of early manifestations can both shorten symptom duration and prevent progression to later disease stages. Early Lyme disease should be treated with oral doxycycline 100 mg twice a day for 21 days. Amoxicillin and cefuroxime are alternatives to doxycycline. A negative pregnancy test should be obtained in all women of child-bearing age before starting on doxycycline

Penicillamine (Cuprimine)

Chelation of metal ions: Copper, gold, lead, mercury, zinc, arsenic Chelating agent for Wilson's disease.

A 25-year-old man is brought into the ED after he was bitten by a spider. He brings the dead black widow spider with him to show you. Which of the following statements is correct regarding this type of spider bite? A A bite causes local necrotic wound toxicity B An antivenom is not available in the United States C Envenomation causes the release of acetylcholine and norepinephrine at nerve terminals D The spider's venom contains a variety of cytotoxic enzymes

C Envenomation causes the release of acetylcholine and norepinephrine at nerve terminals A black widow spider has a yellow-red hourglass shape on its abdomen classically identifies it. Black widow spider venom is a neurotoxin. Envenomation causes the release of acetylcholine and norepinephrine at nerve terminals, leading to severe muscle cramping, typically involving the abdominal wall, back, and legs. There are also systemic effects that lead to CNS and peripheral nerve hyperactivity. Patients may demonstrate dizziness, restlessness, profuse sweating, difficulty speaking, ptosis, hypertension, and tachycardia. Treatment is mainly supportive with opioids and benzodiazepines. The effects of the bite, independent of the toxin, are self-limited. There is an equine-derived antivenin available, but it is reserved for patients with severe symptoms or significant comorbidities because the antivenin itself can lead to fatal complications The brown recluse spider contains a variety of cytotoxic enzymes that can lead to local tissue necrosis. There is no antivenin available in the United States for brown recluse spider bites. A brown recluse bite leaves behind a localized red lesion that often (but not always) heals on its own.

A 6-year-old boy complains of a one day history of severe otalgia and drainage from his ear. On examination, there is purulent fluid in the external canal. The tympanic membrane is inflamed and deeply erythematous and a small tear is noted in the tympanic membrane. In addition to treatment with antibiotics, which of the following is the most appropriate management? A Emergent otolaryngology referral for surgical repair B Evaluation for non-accidental trauma C Expectant management D Outpatient otolaryngology referral

C Expectant management The patient has acute otitis media complicated by a tympanic membrane perforation. The classic presentation of otitis media is the rather sudden development of otalgia following a prodrome of an upper respiratory infection. Complications of acute otitis media can be temporal or intracranial. Intratemporal complications include tympanic membrane perforation, mastoiditis, and facial nerve paralysis. Intracranial complications, although rare in the post-antibiotic era, include meningitis, brain abscess, and lateral venous sinus thrombosis. Tympanic membrane perforation is the most common complication of acute otitis media. Tympanic membrane perforation occurs when increased middle ear secretions results in pressure build-up in the normally air-filled middle ear cavity. Perforations in the tympanic membrane most commonly occur at the pars tensa. Perforation is usually preceded by severe pain. Otalgia may be improved after the perforation owing to a reduction in pressure. Tympanic membrane perforations usually heal spontaneously and expectant management is appropriate for perforations caused by otitis media. If the perforation does not heal and becomes chronic, otolaryngology follow-up is appropriate.

A healthy 6-year-old boy presents to the ED with bloody diarrhea. He was in his usual state of health until one week ago when loose, watery stools (up to 10 per day) were noted. He was seen by his pediatrician four days ago but has since developed increasing amounts of blood and pus in his stools along with a low-grade fever. Mom states there is no recent travel, antibiotic use, or known sick contacts. His vitals are a heart rate 118 beats per minute, oxygen saturation 100% on room air, and rectal temperature of 100.94°F (38.3°C). Your physical exam reveals a mildly tender abdomen without localization, rebound, guarding, or peritoneal signs. You note grossly bloody stool on rectal exam. A brief discussion with his pediatrician confirms your suspicion of an invasive bacterial diarrhea; a stool culture was positive for Shigella. Which of the following statements is true regarding this condition? A Antibiotics should be avoided because this is a severe case and the patient is at highest risk of developing hemolytic uremic syndrome B Antidiarrheal agents (such as diphenoxylate and atropine) are indicated, given the frequency of loose stools C Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur D Oral rehydration should be avoided; IV fluids should be initiated

C Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur Shigella species cause an invasive diarrhea that rarely infects infants younger than 3-months-old and is most common between 2 and 3 years of age. Infection is typically transmitted by person-to-person (fecal-oral) contact or through ingestion of contaminated material. Clinical illness varies from mild to severe, with some patients exhibiting abdominal cramps and tenderness. Dysentery (diarrhea with significant blood, pus, and mucus) occurs in approximately 33% of patients. Some patients may also develop extraintestinal manifestations such as reactive arthritis, seizures, and hallucinations. OREGON TRAIL! The general management of diarrhea from a bacterial source is oral rehydration and avoidance of anti-diarrheal agents. Antibiotics should not be given to young, healthy individuals and should be reserved for immunocompromised, bacteremic, or hospitalized patients. Although antibiotics (A) are generally not indicated for the treatment of mild illness, they should be considered in more severe cases. Hemolytic uremic syndrome (HUS) is a potentially fatal complication that may develop when antibiotics are administered to children (but not adults) with enterohemorrhagic E. coli (O157.H7). HUS results from the release of Shigella-like toxin by dying E. coli (and less commonly by infection with S. dysenteriae 1). Antidiarrheal agents (B) are not recommended because they can worsen bacterial invasion of the bowel wall and prolong the infection and carrier state. If dehydration is a concern, oral rehydration (D) should be attempted prior to initiating IV fluids because the patient is not vomiting and is able to tolerate oral intake. Oral rehydration protects the integrity of the colon barrier.

A 45-year-old man presents with melena and is found to have a hemoglobin of 6.5 g/dL. Approximately one hour after a transfusion of packed red blood cells is started, he develops fever and chills and complains of subjective dyspnea. Other than low-grade fever, his vital signs are normal. Laboratory workup shows a normal LDH and haptoglobin and a chest radiograph is unremarkable. Which of the following is the most likely diagnosis? A Acute hemolytic reaction B Bacterial infection C Febrile non-hemolytic transfusion reaction D Transfusion-related acute lung injury

C Febrile non-hemolytic transfusion reaction This patient has a febrile non-hemolytic transfusion reaction. This mechanism is thought to be a result of antibodies in the recipient's blood reacting with white cell antigens in the donor blood or due to cytokines which accumulate in the donor blood during storage. Symptoms include fever, chills, headache, myalgias, and dyspnea. The workup of a patient with a febrile reaction includes stopping the transfusion until an acute hemolytic reaction is ruled out. Febrile non-hemolytic transfusion reactions are clinically benign and usually self-limited. They can be treated with antipyretics. The risk of febrile reactions can be reduced by using leukocyte reduced red cells

A 7-year-old boy with a history of asthma is brought to the ED with an acute onset of stridor and urticaria extending throughout his entire body. Which of the following is a risk factor for fatal anaphylaxis? A Age less than 10 years B Early epinephrine administration C History of asthma D Predominance of cutaneous symptoms

C History of asthma Anaphylaxis is characterized by a constellation of findings ranging from mild to severe. Patients may become hypotensive secondary to profound vasodilation and increased vascular permeability. It may be accompanied by acute angioedema of the upper airway, bronchoconstriction, pulmonary edema, or urticaria. The risk of death from anaphylaxis in the pediatric ED is < 1%. A history of asthma has consistently been cited as a risk factor for fatal food-related anaphylaxis Preexisting IgE antibodies → mast cell degranulation → shock, airway compromise Leading cause of fatal anaphylaxis: penicillin Epinephrine Adults: 0.3 to 0.5 mL 1:1,000 (1 mg/mL) solution IM q5-15 minutes Children: 0.01 mg/kg 1:1,000 (1 mg/mL) solution IM q5-15 minutes ​Refractory hypotension in a patient on beta-blockers: glucagon Adjunctive medicines include: histamine H1 and H2 antagonists, corticosteroids, beta-2 agonists, and glucagon

Methylene blue Antidote

Chemical producing severe methemoglobinemia. Ifosamide-induced encephalopathy. Reduces methemoglobin to hemoglobin.

A 36-year old woman presents complaining of 10/10 low back pain. She dramatically describes how she injured herself during sexual intercourse with a younger man. Despite her pain, she is resting comfortably on the stretcher and talking loudly on her cell phone. Her hair and makeup are well done and she is dressed in provocative clothing. She demands to be evaluated by a male doctor. She makes a point to undress in front of the physician and is wearing lingerie. Which of the following personality disorders does this patient most likely have? A Antisocial B Borderline C Histrionic D Narcissistic

C Histrionic Individuals with histrionic personality disorder tend to be excessively emotional and overall demonstrate attention-seeking behavior. They want to be the center of attention. They often exaggerate (e.g. complaining of 10/10 pain although resting comfortably and talking on the phone), can be very flirtatious, overly dramatic and may be sexually seductive (e.g. flirting with the doctor, wearing lingerie, and talking about her sexual escapades). They rely on this manipulative behavior to meet their needs. This disorder is more common in women and affects approximately 3% of the general population.

A 26-year-old man presents with one day of muscle aches, dark urine, and fatigue after intense exercise yesterday. Which of the following would be expected on laboratory analysis? A 51-100 rbc/hpf on urinalysis B Elevated bicarbonate C Hyperkalemia D Hypouricemia

C Hyperkalemia Rhabdomyolysis is a potentially life threatening condition caused by the breakdown of skeletal muscle and the release of intracellular contents into the bloodstream. This causes a cascade of metabolic abnormalities which include increased creatine kinase, increased serum and urine myoglobin, and hyperkalemia. The increase in potassium can lead to life threatening dysrhythmias and death. The elevated myoglobin can overwhelm the glomerulus and cause an acute kidney injury. The myoglobin forms casts in the glomeruli which is worsened by volume depletion and the subsequent renal vasoconstriction, thus causing tubule obstruction. Complications of rhabdomyolysis can be viewed as early or late findings. Compartment syndrome, acidosis and electrolyte disorders, hypovolemia, and hepatic dysfunciton are all early findings. The late complication of myoglobin-induced acute kidney injury is the main focus of managing a patient with rhabdomyolysis. Aggressive fluid administration and urine alkalinization is necessary to maintain filtration at the glomerular level.

A patient is found to be hyponatremic. Laboratory evaluation reveals low serum osmolality, urine sodium concentration > 20 mmol/L, and a fractional excretion of sodium (FENa) > 1%. He appears to be fluid overloaded. Which of the following is the most likely cause of this hyponatremia? A Cirrhosis B Heart failure C Hypertensive nephropathy D Syndrome of inappropriate ADH release (SIADH)

C Hypertensive nephropathy Hyponatremia is defined as sodium less than 135 mEq/L. Hyponatremia can occur in a hypovolemic, euvolemic, or hypervolemic state. Hypervolemic hypo-osmolar hyponatremia is associated with fluid overload. The etiology is usually from a perceived low intravascular volume by the kidneys and active water reabsorption in excess to sodium retention. If urine sodium is low (<20) causes include liver failure, cirrhosis, hepatorenal syndrome, nephrotic syndrome, and heart failure. If urine sodium is high (>20) causes include acute or chronic renal failure, such as that caused by hypertensive nephropathy. Treatment of hypervolemic hypo-osmolar hyponatremia is dialysis. Cirrhosis (A) and heart failure (B) is often the cause of hypervolemic hypo-osmolar hyponatremia when the urine sodium is low (<20). SIADH (D) results in euvolemic hyponatremia with urine osmolality greater than serum osmolality. The excess ADH causes total body water to increase thereby diluting total body sodium. Despite the increased total body water, these patients typically do not show evidence of edema or heart failure as the increased water is intracellular not intravascular. What causes hypovolemic hyponatremia with elevated urine sodium >20? Renal sodium loss from thiazide diuretics, osmotic diuresis, nephropathy, or mineralocorticoid deficiency.

A 55-year-old woman presents to the ED with crampy abdominal pain that has been progressing over the past 3 days. She notes nonbloody emesis, vomiting, and diarrhea alternating with constipation. She has previously undergone a hernia repair, cholecystectomy, and hysterectomy. On exam, her abdomen is soft and diffusely tender, with quiet bowel sounds. A plain radiograph is obtained and reveals air-fluid levels and a lack of air in the rectum. What is the most common electrolyte imbalance associated with this condition? A Hypercalcemia B Hypocalcemia C Hypokalemia D Hyponatremia

C Hypokalemia The patient has a small bowel obstruction (SBO), most likely due to adhesions that have developed from her multiple abdominal surgeries. The common presentation of SBO includes crampy and poorly localized abdominal pain, vomiting, and abdominal distension. Bowel sounds can be hyperactive initially but become quiet or absent once complete obstruction occurs. Abdominal plain-film findings include air-fluid levels, dilated loops of small bowel above the point of obstruction, and lack of air in the rectum. Dehydration and associated hypokalemia are common. Treatment measures include IV hydration, potassium repletion, nasogastric tube placement, and surgical consultation.

A 32-year-old woman climbing a mountain develops a dry cough, dyspnea on exertion, and decreased exercise tolerance which progresses to a productive cough and marked dyspnea at rest. What is the most likely underlying pathophysiology? A Bacterial infection involving the alveoli B Decreased oncotic pressure leading to capillary leak C Hypoxic vasoconstriction of pulmonary vessels leading to endothelial damage D Left ventricular failure and elevated pulmonary capillary wedge pressure

C Hypoxic vasoconstriction of pulmonary vessels leading to endothelial damage High altitude pulmonary edema (HAPE) is caused by hypoxic vasoconstriction of pulmonary vessels, leading to elevated pulmonary pressures and resultant endothelial damage and pulmonary edema. Symptoms start with cough and decreased exercise tolerance and can progress to severe dyspnea at rest, productive cough, and low grade fever. Rales and rhonchi may be noted on auscultation. HAPE is a life-threatening condition that requires immediate descent. If descent is not possible, a portable hyperbaric chamber should be used until descent is possible. Additional treatments include supplemental oxygen and calcium channel blockers like nifedipine.

What antibiotic is best known for causing aplastic anemia?

Chloramphenicol.

What are the three types of gallstones?

Cholesterol stones and black (calcium bilirubinate) and brown (associated with infection) pigmented stones. Bilary Colic RUQ pain or tenderness Worsened by fatty foods US: Wall echo shadow (WES) sign: gallbladder wall, gallstone echoes, gallstone shadowing Elective cholecystectomy

A 69-year-old man with a history of atrial fibrillation had a syncopal episode while on vacation in India and struck his head on the stairs. He was transported to the local clinic to be evaluated. His wife accompanied him and she informs the provider that her husband is on a "blood thinner" but she is not sure which one. The patient is alert but is not oriented to time or place. You suspect a subdural hematoma but there is no access to a CT scanner at this time. His vital signs are within normal limits. While awaiting transportation to a facility with a CT scan, which of the following labs should be ordered? A Alcohol level B Basic metabolic profile C INR, PT, aPTT, and platelet count D Vitamin K level

C INR, PT, aPTT, and platelet count Subdural Hematoma Risk factors: traumatic head injury, advancing age, anticoagulant use, coagulopathy, thrombocytopenia Caused by tearing of the bridging veins between arachnoid and dura Sx: acute or subacute neuro sx, headache, mental status changes, seizures, or focal deficits Dx: crescent-shaped hematoma on noncontrast CT Management includes neurosurgical consultation, blood pressure control, reversal of anticoagulation Elderly patients on anticoagulation therapy are at high risk of subdural hematomas when they fall. In general, elderly patients are at risk of falls because they tend to have balance difficulties and decreased vision in older age. A non-contrast CT of the head is the gold diagnostic standard for diagnosing a subdural hematoma. A subdural hematoma usually appears as a hyper dense, crescent-shape-mass between the skull and the brain. A coagulation panel is necessary in the workup of a suspected subdural hematoma because individuals on anticoagulants or who are alcoholics may have an associated coagulopathy placing them at higher risk for a subdural hematoma. In addition, if INR levels are found to be elevated, reversal agents (e.g. vitamin K and fresh frozen plasma can be administered). Therefore, all patients with a head injury should have at least a basic coagulation panel (INR, PT, aPTT, and platelet count). Fresh frozen plasma or platelets should be given as needed.

A 35-year old man believes he has colon cancer. He reports that his "peristalsis is louder than usual" and he has "excessive flatulence." He shows you a logbook that he has been keeping of his bowel habits for the last 6 months. He reports no weight loss, fatigue, night sweats, blood in his stool, or family history of colon cancer. He is having difficulty sleeping. What is the most likely diagnosis? A Body dysmorphic disorder B Functional neurological symptom disorder C Illness anxiety disorder D Somatic symptom disorder

C Illness anxiety disorder The patient has illness anxiety disorder. This was a new diagnosis that was introduced with the DSM-5, and it replaced reactive hypochondriasis. Ex: Care-seeking type and care-avoidant type Patients that were previously diagnosed with reactive hypochondriasis are now classified as somatic symptom disorder or illness anxiety disorder. Most patients fall under the somatic symptom disorder diagnosis. If the patient reports predominantly physical symptoms, the patient has somatic symptom disorder. Patients with minimal physical symptoms and a greater focus on a possible disease have illness anxiety disorder. The patient will have excessive worry about having or acquiring a serious undiagnosed general medical disease. If there are physical symptoms present, it is typically due to an exaggeration of normal body functions. It is typically chronic in nature.

An 84-year-old woman presents to the emergency department with altered mental status. Family reports she has had poor oral intake over the past week. She has a history of heart failure. Her blood pressure is 80/50 mm Hg. Her heart rate is 45 beats per minute. Her serum digoxin level is 10 ng/mL, potassium is 6.1 mEq/L, and creatinine is 3.5 mg/dL. Which of the following is the most appropriate initial therapy for this patient? A Administer procainamide for ventricular dysrhythmias B Calcium chloride should be administered for hyperkalemia C Immediate administration of digoxin-specific antibody fragments D The patient should receive immediate hemodialysis E Transvenous pacing should be performed for symptomatic bradycardia

C Immediate administration of digoxin-specific antibody fragments This patient is presenting with digoxin toxicity as manifested by bradycardia, hypotension, and elevated potassium levels. In this patient, digoxin toxicity is most likely chronic secondary to dehydration and renal failure as the kidney eliminates digoxin. Hyperkalemia, which develops in part from digoxin-mediated inhibition of the Na/K ATPase pump, is the most important predictor of outcome in the setting of digoxin toxicity, with a mortality rate in untreated patients of nearly 100% when potassium levels exceed 5.5 mEq/L. The treatment of choice for digoxin toxicity is digoxin-specific antibody fragment (Fab) that also improves hyperkalemia. Digoxin has a large volume of distribution and is significantly protein-bound, therefore, it is poorly removed by hemodialysis (D). Additionally, the hyperkalemia associated with digoxin toxicity often resolves with the administration of digoxin-specific antibody fragment. The patient in this scenario has renal failure and may ultimately require hemodialysis, but it is not indicated to treat digoxin toxicity. Calcium (B) administration is often indicated to stabilize the myocardial membrane in the setting of hyperkalemia. In the digoxin-poisoned patient where there is increased intracellular calcium, the administration of calcium may precipitate cardiac standstill, or the "stone heart" phenomenon, and should be avoided. Treatment with digoxin-specific antibody fragment is often sufficient to treat digoxin-induced hyperkalemia. Overaggressive management may lead to hypokalemia, which can also worsen digoxin toxicity. There are anecdotal reports of successful transcutaneous pacing (E) in digoxin toxicity, however, transvenous pacing has been associated with ventricular dysrhythmias and should be avoided. Digoxin toxicity may cause ventricular dysrhythmias. Treatment with class IA antidysrhythmics such as procainamide (A) may precipitate ventricular dysrhythmias in the setting of digoxin poisoning and should be avoided. Class IC agents such as flecainide and class III agents such as amiodarone may have similar effects and should also be avoided. Lidocaine is the preferred antidysrhythmic if treatment with digoxin-specific antibody fragment fails

A 16-year-old boy presents to the ED with a foreign body sensation and buzzing in his right ear that began early this morning and woke him up. Physical exam reveals a moving insect in the external auditory canal. Which of the following is the most appropriate next step in management of this condition? A Discharge with otolaryngology follow-up B Foreign body removal with alligator forceps C Instillation of lidocaine solution in the ear canal D Irrigation of the ear canal with saline

C Instillation of lidocaine solution in the ear canal The patient presents with a live insect foreign body in his ear canal. Insects are one of the most common otic foreign bodies in both adults and children. Patients with live insect foreign bodies in the ear canal often require immediate attention because of the extent of their discomfort and agitation. The first step in management is instillation of lidocaine solution in the ear canal to drown the insect. This step is crucial as it will increase patient comfort, prevent further trauma to ear structures caused by the insect, and make removal of the insect easier. It may also have an irritant effect on the insect, causing it to exit the ear on its own, as well as provide anesthesia for subsequent foreign body removal. Other liquids can be used to drown the insect, but these may not have an irritant effect and will not provide anesthesia. Once the insect is dead, attempts to remove it can follow Many techniques and tools for otic foreign body removal exist, including indirect foreign body removal via irrigation of the ear canal with saline (D) or water as well as direct foreign body removal with alligator forceps (B), suction, right-angle hooks, balloon-tipped catheters, or glue-tipped swabs. Irrigation is contraindicated if the tympanic membrane is perforated or if the foreign body is vegetable matter, as this can swell in the presence of moisture and become more difficult to remove. Once the foreign body is removed, it is important to reinspect the ear canal for remaining foreign bodies and evidence of trauma or infection. Although discharge with ENT follow-up (A) may be necessary if complications arise or foreign body removal is unsuccessful, it is not an appropriate first step in management of this condition since the emergency physician can successfully remove most otic foreign bodies.

An obese 23-year-old woman presents to the ED complaining of a constant, gradual-onset headache and transient blurry vision. Her vital signs are within normal limits for her age. She denies fever, neck stiffness, head trauma, radicular pain, or rash. She has no room-spinning sensation. Her serum beta-HCG is negative. Her serum acetaminophen level is 0 mcg/mL and her serum salicylate level is 7 mg/dL. The additional history of pulsatile tinnitus makes which of the following diagnoses most likely? A Chronic salicylism B Endolymphatic hydrops C Intracranial hypertension D Viral labyrinthitis

C Intracranial hypertension Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is most commonly seen in overweight women between the ages of 18 and 45 years. The typical symptoms include headaches, transient vision changes (e.g., diplopia, blurring, vision loss), back pain, and pulsatile tinnitus. In fact, approximately half of patients with IIH report pulsatile tinnitus. Risk factors include oral contraceptive pill use, polycystic ovarian syndrome, anemia, polycythemia, synthetic growth hormone use, prothrombotic disorders, and medications such as lithium, vitamin A, and tetracycline. If the diagnosis is not made and treated in a timely manner, permanent visual impairment may result. Emergency department assessment includes a complete neurologic examination, an evaluation for papilledema, computed tomography imaging to rule out other causes of increased intracranial pressure (ICP), and a lumbar puncture (LP) in the lateral decubitus position to measure the opening pressure and to evaluate the cerebrospinal fluid (CSF). The diagnosis is made when there is a normal neurologic examination, normal neuroimaging, an elevated opening pressure (> 25 cm H2O), and normal CSF studies. LP can be both diagnostic and therapeutic for IIH because removing CSF can improve symptoms. Temporary symptom resolution is not sensitive or specific for IIH and is not included in the diagnostic criteria. CSF is removed until the pressure reaches 15 to 20 cm H2O. Post-LP headache is a common complication of which patients should be made aware. Treatment is aimed at preserving vision and preventing vision loss. Acetazolamide, a carbonic anhydrase inhibitor, is effective for managing IIH on an outpatient basis. Patients should be counseled about weight loss. Recalcitrant cases may require optic nerve sheath fenestration or CSF shunting if conservative therapies are ineffective and vision is worsening

A 19-year-old woman presents with pain in her mouth. She underwent an extraction of an impacted molar 3 days prior to the onset of her pain. Her pain had been improving, however, the pain began worsening acutely today. Which of the following is the most appropriate treatment? A Dilute hydrogen peroxide rinsesYour Answer B Incision and drainage C Iodoform gauze packing moistened with oil of clove D Root canal

C Iodoform gauze packing moistened with oil of clove This patient is suffering from dry socket, also known as acute alveolar osteitis. Patients undergo dental extraction and after the procedure, a hemostatic blood clot forms in the socket. Pain is common for 24 hours post-procedure and then improves. When the healing blood clot is lost from the socket, the patient develops acute, severe pain. Most commonly, it occurs 3-4 days after the extraction and is associated with a foul odor. Pain is related to inflammation and a localized infection of the bone. PEx: Exposed bone and no clot in the extraction site Treatment includes: packing the open socket with iodoform gauze. The gauze is saturated with either a medicated dental paste or eugenol (oil of cloves). Patients will require analgesia and may benefit from a nerve block.

A 22-year-old woman presents to the emergency department with eye pain. She was cleaning the bathroom at a local restaurant when bleach splashed into her eye. What is the next best step? A Complete a slit lamp exam B Instill fluorescein and look for a corneal defect C Irrigate the eye with normal saline D Obtain a visual acuity

C Irrigate the eye with normal saline With any ocular chemical exposure, the most important step is to flush the eye with copious saline. This removes any residual chemical from the eye and prevents further damage due to the offending agent. This is accomplished by inserting a Morgan lens and irrigating with 1-2 liters of normal saline. Pain relief can be provided by instilling a topical anesthetic (e.g. proparacaine or tetracaine) into the eye just prior to initiating the saline flush. After copious irrigation, the pH of the eye should be checked. If the pH is still not neutral, irrigation should be continued until a neutral pH is achieved. Acid burns tend to lead to a coagulative necrosis of the eye that results in an eschar that prevents further burning. Alkali burns, on the other hand, result in a liquefactive necrosis that continues to penetrate into the tissue. Irrigation can stop the progression of ocular damage, so it should be the top priority on patient arrival.

An 18-year-old woman presents with a laceration to her face from a dog bite that occurred 10 hours ago. The patient owns the dog. Examination reveals a 4 cm laceration to the left cheek with no signs of infection. What is the most likely management that is indicated? A Irrigation and antibiotics B Irrigation and primary wound closure C Irrigation, primary wound closure, and antibiotics D Primary wound closure and antibiotics

C Irrigation, primary wound closure, and antibiotics Mammal bites to any part of the body should be copiously irrigated and explored, followed by an assessment for primary closure. In this patient, primary closure is recommended as the laceration is on the face. Canine bites often involve laceration as well as crush injury to tissue depending on the size of the dog. The presence of a crush injury may make primary wound repair difficult. Additionally, devascularization of the tissue may make primary closure contraindicated as the risk of infection increases. Classically, it was taught that lacerations sustained from dog bites should be irrigated, given antibiotics, and not primarily repaired because of these risks. However, more recent literature has shown that the risk of infection was no different for primary closure versus healing by secondary intention. Additionally, if the laceration is to a cosmetic area like the face, primary repair should be attempted. As with any laceration, tetanus status should be updated. Copious irrigation and wound exploration is central to good wound care. Exploration should pay particular attention to the presence of foreign bodies, especially teeth, which may break off during the bite. Antibiotics are indicated for deep puncture wounds, moderate to severe crush wounds, wounds requiring closure, wounds on the hands, genitalia, or joints, and in patients who are immunocompromised.

A 40-year-old woman presents to the ED complaining of abdominal pain. Her vital signs are T 97.88°F (36.6°C), HR 88 bpm, BP 125/70 mm Hg, and RR 14/min. Her laboratory results are as follows: WBC 9,000/L, hemoglobin 12 mg/dL, platelets 250,000/L, AST 45 U/L, ALT 40 U/L, alkaline phosphatase 75 U/L, and total bilirubin 0.9 mg/dL. The ultrasound is obtained and shown above. Which of the following statements is correct regarding these findings? A CT scan has the greatest sensitivity in diagnosing this condition B Diagnosis is confirmed by elevated AST, ALT, alkaline phosphatase, and total bilirubin C It is the most frequent cause of acute pancreatitis D The most common clinical manifestation is acute cholecystitis

C It is the most frequent cause of acute pancreatitis The ultrasound shows multiple gallstones collected in the dependent portion of the gallbladder. The large anechoic structure is the gallbladder. The echogenic stones cast an acoustic shadow as seen in the image below. Gallstones are responsible for causing acute pancreatitis in up to 45% of cases, making it the most common etiology of acute pancreatitis. Ethanol consumption is the second most common cause of acute pancreatitis, but the most common cause of chronic pancreatitis.

Which of the following is true regarding active tuberculosis? A A cavitary lesion on CT of the chest is pathognomonic B Isoniazid treatment for six months is adequate therapy C It may have varied appearance on chest X-ray D Patients with active tuberculosis need droplet precautions

C It may have varied appearance on chest X-ray Most patients evaluated for tuberculosis present with reactivation of an old infection. When an immunocompetent person is exposed to tuberculosis, the immune system effectively gains control over the infection in the lung. It remains quiet and often never re-activates during a person's lifetime. Most patients are asymptomatic during primary infection and only develop symptoms during a re-activation. Approximately 8-10% of persons who do not take chemoprophylaxis after a primary infection (typically identified through a positive skin PPD test) will develop active tuberculosis. Cough is the most common symptom of pulmonary tuberculosis. Additionally, patients may develop fever (more common in the afternoon or evening), night sweats, and hemoptysis. Due to the effects of cytokines (particularly tumor necrosis factor alpha), patient often lose weight. The classic X-ray finding on chest radiograph is a cavitary lesion in the upper lobe of the lung. However, tuberculosis can cause varied abnormalities on X-ray including infiltrate in any portion of the lung. Lymphadenopathy is commonly seen in the hilum on X-ray. A cavitary lesion on CT of the chest (A) is not pathognomonic for tuberculosis. There are multiple other infectious causes of cavitary lesions in the chest including Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and fungal lesions. Isoniazid treatment for six months (B) is the recommended treatment for someone with evidence of a latent infection identified through a PPD test. For active tuberculosis, patients receive multiple anti-tuberculosis agents to which the organism is susceptible. Worldwide, increasing rates of drug resistant tuberculosis has been seen. The most common drug regimen is remembered by the mnemonic RIPE standing for rifampin, isoniazid, pyrazinamide, and ethambutol. Patients with active tuberculosis need airborne precautions, not droplet precautions (D). The size of the droplets is quite small necessitating airborne precautions in a negative pressure room with recirculating air.

A 17-year-old boy presents to the ED with altered mental status. He consumed an unknown substance while in the woods with his friends. Upon arrival, his vital signs are a T of 38.2°C, HR of 120 bpm, BP of 150/90 mm Hg, RR of 20/min, and SpO2 of 98% on room air. On exam, he is agitated with dilated pupils and warm, dry skin. The rest of the exam is unremarkable. Which of the following substances was the most likely to have been ingested? A Amanita phalloides B Foxglove C Jimsonweed D Morning glory E Pokeweed

C Jimsonweed The patient has anticholinergic symptoms as demonstrated by dry skin, hyperthermia, tachycardia, dilated pupils, and altered mental status. Other potential findings include decreased bowel motility and urinary retention. Jimsonweed is a plant that contains belladonna alkaloids, which have potent antimuscarinic effects, as described previously. Depending on the amount of plant ingested, anticholinergic symptoms can last for days. Treatment includes decontamination with activated charcoal (for early presenters with a secure airway), benzodiazepines for agitation, and physostigmine for severe refractory anticholinergic symptoms. Ingestion of jimsonweed can be intentional for hallucinogenic effects or unintentional.

A 7-year-old girl presents to the emergency department with right eye swelling. She is a previously healthy, fully immunized girl on no medications and without any known allergies. Her father states the symptoms started 2 days ago with mild periorbital erythema and edema. The patient has been battling an upper respiratory infection with nasal congestion and discharge, which recently changed in color and became thick. Vital signs are remarkable for temperature of 38.9°C, HR of 130 bpm, and RR of 18/min. Physical examination is remarkable for significant right periorbital erythema and edema, tachycardia, and equally responsive pupils. Examination is negative for proptosis and pain with extraocular muscle testing. Which clinical feature helps rule out the more emergent process when diagnosing this patient? A Afferent pupillary defect B Erythema C Lack of pain with extraocular movements D Proptosis

C Lack of pain with extraocular movements Preseptal cellulitis is an infection of the anterior portion of the eyelid and periorbital tissues. Postseptal, or orbital, cellulitis is an infection that involves the content of the orbit (adipose tissue and muscles). Differentiating the two is crucial, as management is significantly different and the outcomes, if postseptal cellulitis is missed, can be catastrophic. The clinical features of both pre- and postseptal cellulitis are nearly identical, with both demonstrating erythema, warmth, and tenderness to palpation. Visual acuities and pupillary responses are both normal with preseptal cellulitis, and there is a lack of pain with extraocular movements, no proptosis, and no diplopia. If any of these clinical features are present or if the clinician has a high enough suspicion for postseptal cellulitis, then a CT scan of the orbit should be obtained to evaluate and rule out postseptal cellulitis. Patients with preseptal cellulitis that appear nontoxic can be treated as an outpatient with amoxicillin-clavulanic acid and 24-hour ophthalmology follow-up. Patients < 5 years of age or those with significant comorbidities with preseptal cellulitis should be admitted for intravenous antibiotic therapies that include cefuroxime, ceftriaxone, or ampicillin-sulbactam. All patients with postseptal cellulitis require admission with emergent ophthalmology consultation and intravenous antibiotics. Vancomycin is added if methicillin-resistant Staphylococcus aureus (MRSA) is suspected Afferent pupillary defect (A) and proptosis (D) are both clinical features concerning for postseptal cellulitis. If either of these are present, further evaluation with a CT scan of the orbits would be warranted to evaluate and rule out postseptal cellulitis. If present, the patient would require admission with emergent ophthalmology consultation as well as intravenous antibiotics that include cefuroxime, ceftriaxone, or ampicillin-sulbactam. Vancomycin is added if MRSA is suspected. Erythema (B) can be present in both preseptal and postseptal infections and is not a clinical feature that can help differentiate between the two disease processes

A 21-year-old woman presents with painful urination. She has no vaginal discharge and is not sexually active. Which of the following is most sensitive for a urinary tract infection on urine dipstick testing? A Bacteria B Blood C Leukocyte esterase D Nitrites

C Leukocyte esterase Urinary tract infections are a common complaint of patients. Many women experience a urinary tract infection during their life because of the proximity of the urethral opening to the vaginal and perirectal areas. Infections are much less common in men unless they have had cystoscopy or a urinary catheter. UTIs do increase in frequency in older men. Leukocyte esterase is an enzyme found in neutrophils which are not normally present in urine unless an infection is present. It has a sensitivity of 75-96% in detecting pyuria associated with a urinary tract infection.

A 48-year-old man presents with fever and an acutely painful scrotum. He has significant pain during testicular palpation. A cremasteric reflex is present and Doppler ultrasonography shows an enlarged, thickened epididymis with increased blood flow to the left testicle. There is no discharge from the urinary meatus. Which of the following is the most appropriate antibiotic for this condition? A Ceftriaxone plus doxycycline B Doxycycline C Levofloxacin D Penicillin

C Levofloxacin Epididymitis occurs most commonly in men between the ages of 14 and 35 years. However, it can occur in any age group. It occurs from an ascending infection from the urethra, prostate, or bladder, and occasionally by hematogenous spread. Epididymitis is characterized by gradually increasing dull, unilateral scrotal pain, fever, and dysuria. Examination usually reveals localized epidydimal edema and tenderness (posterior aspect of scrotum), possible testicular tenderness, and a normal cremasteric reflex. Pain may be relieved with testicular elevation (positive Prehn sign). Scrotal pain should be initially evaluated with a color Doppler ultrasound test, and in the case of epididymitis, the typical findings are an enlarged, thickened epididymis with increased blood flow. The most common organisms responsible for epididymitis in those 14 to 35 years-of-age are Neisseria gonorrhoeae and Chlamydia trachomatis. In older individuals (traditionally >35 years of age) and nonsexually active individuals, the Gram-negative rod bacteria (Escherichia, Klebsiella, Enterobacter, and Citrobacter species) are most common. Trimethoprim-sulfamethoxazole or a fluoroquinolone such as levofloxacin or ciprofloxacin is the recommended treatment in this age group. Ceftriaxone plus doxycycline (A) is the treatment of choice for suspected orchitis or epididymitis in men between the ages of 14 and 35 years. Doxycycline (B) is not recommend as the sole antibiotic for orchitis in any age group. Penicillin (D) is more appropriate for streptococcal or staphylococcal infections, both of which are not common etiologies of orchitis or epididymitis.

An 80-year-old man who does not have housing is found in his riverside tent with confusion and fever in July. On physical examination, the patient is disoriented with T 38.2°C, HR 122 bpm, BP 106/84 mm Hg, and oxygen saturation 99% on room air. You note splenomegaly, flaccid paralysis, and multiple mosquito bites. Which lab abnormality would lead you to suspect West Nile encephalitis in this patient? A Decreased cerebrospinal fluid glucose level B Leukocytosis C Lymphopenia D Markedly increased serum ALT and AST

C Lymphopenia Patients with West Nile encephalitis will have leukopenia with a pronounced and prolonged lymphopenia, which can aid in distinguishing it from other causes of encephalitis. West Nile encephalitis is an arthropod-borne virus (arbovirus) endemic to the Middle East and now found throughout the United States. It is transmitted by the Culex mosquito, with birds serving as the intermediate host. Most people with West Nile encephalitis will remain asymptomatic or have a mild viral syndrome. Patients with symptomatic encephalitis will present with new psychiatric symptoms, cognitive deficits, seizures, flaccid paralysis, and tremors. Most will have a headache and low-grade fever. In patients with meningoencephalitis, a lumbar puncture will show a pleocytosis with mostly lymphocytes, normal to elevated glucose, and increased protein.

A 24-year-old woman presents to the emergency department after vomiting and then collapsing at a dance party. Upon arrival, she is arousable but confused. Her vital signs are T 39.4°C, HR 112 bpm, BP 150/88 mm Hg, and RR 18/min. Her laboratory values are notable for creatinine of 1.4 mg/dL, sodium of 128 mEq/dL, and creatine phosphokinase of 12,000 IU/L. Her pupils are equal and reactive, and she has mild lower extremity clonus. Which of the following substances is the most likely etiology of this patient's presentation? A Cocaine B LSD C MDMA D Methamphetamine E PCP

C MDMA The patient in this scenario has MDMA (ecstasy) intoxication. MDMA is a popular club drug that has both sympathomimetic and serotonergic effects. Toxicity is manifested by euphoria, agitation, hyperthermia, dehydration, rhabdomyolysis, and elevated creatinine. MDMA works by stimulating the release and inhibiting the reuptake of the following neurotransmitters: norepinephrine, dopamine, and serotonin. Hyperthermia is caused by multiple factors, including vigorous activity, dehydration, and serotonergic effects. Serotonin syndrome can occur in conjunction with hepatotoxicity, renal failure, and disseminated intravascular coagulation. Another associated clinical feature is hyponatremia, which occurs because of gastrointestinal losses and alterations in antidiuretic hormone secretion. Rarely, seizures, coma, and death have been reported. Care for MDMA intoxication is largely supportive and includes rehydration, electrolyte repletion, intravenous crystalloids for rhabdomyolysis, cooling measures for hyperthermia, benzodiazepines for seizures, and ensuring a safe environment for the patient.

What is the most common hematologic abnormality seen in a patient who chronically drinks large amounts of alcohol? A Leukocytosis B Leukopenia C Macrocytosis D Thrombocytosis

C Macrocytosis The most common hematologic manifestation in the chronic alcoholic is macrocytosis. The direct effects of ethanol and its metabolites, as well as the secondary nutritional deficiency, and chronic liver disease lead to many hematologic abnormalities. Macrocytosis occurs secondary to folate deficiency, reticulocytosis, liver disease, and vitamin B12 deficiency.

A 42-year-old woman presents with right upper quadrant pain and jaundice. She has no fever. One week ago, she had a laparoscopic cholecystectomy. Laboratory analysis reveals a total bilirubin of 4.2 mg/dL and direct bilirubin of 3.7 mg/dL. What is the appropriate plan? A Exploratory laparoscopy B Hepatobiliary Iminodiacetic Acid (HIDA) scan C Magnetic resonance cholangiopancreatography (MRCP) D Right upper quadrant ultrasound

C Magnetic resonance cholangiopancreatography (MRCP) Patients typically undergo cholecystectomy for cholecystitis or symptomatic biliary colic. At the time of the operation, may patients have an intraoperative cholangiogram to evaluate for the presence of a bile duct stone. In some cases, the stone is not identified or the cholangiogram is not performed. This patient presents with right upper quadrant pain, jaundice and laboratory values that are suggestive of biliary obstruction, possibly from a retained bile duct stone. An MRCP (magnetic resonance cholangiopancreatography) is a non-invasive test that will allow visualization of the biliary system and the retained stone. A CT scan may also visualize a retained stone although is limited in its ability to visualize the distal duct in some cases. Endoscopic retrograde cholangiopancreatography may also be performed and has the advantage of being diagnostic and therapeutic allowing for stent placement or the removal of a stone

A 5-year-old boy presents to the ED with pain from his penis, and physical exam is as shown above. Which of the following statements is true regarding this condition? A Gentle retraction of the foreskin typically treats the problem B It is associated with bulging of the foreskin with urination C Manual reduction with firm pressure for 5-10 minutes is the initial treatment D Urinary retention often occurs

C Manual reduction with firm pressure for 5-10 minutes is the initial treatment This patient exhibits paraphimosis. This condition occurs when the proximal foreskin cannot be reduced distally over the glans penis, resulting in distal vascular congestion. This is a true urologic emergency. Physical exam reveals a flaccid proximal penis with erythema and engorgement distal to the obstruction. Initial treatment involves sliding the foreskin distally and manual reduction with firm pressure to the glans for 5-10 minutes to reduce edema. If this is unsuccessful and there is no urologist immediately available, a dorsal slit procedure should be performed by injecting local anesthesia and making a vertical incision of the constricting band

A 35-year-old man presents, complaining of right ankle pain for two days. He reports associated fever and an inability to bear weight. On exam, his vitals are T 38.6°C, HR 89 bpm, BP 110/80 mm Hg, and RR 20/min. His right ankle is swollen, erythematous, and diffusely tender with limited range of motion. You decide to perform an ankle arthrocentesis to evaluate for a septic joint. Which of the following is the most widely accepted approach for ankle arthrocentesis? A Lateral to the extensor hallucis longus tendon, directed toward the joint space B Medial to the extensor hallucis longus tendon, directed toward the joint space C Medial to the tibialis anterior tendon, directed toward the anterior edge of the medial malleolus D Posterior to the tip of the lateral malleolus, directed superiorly and laterally E Posterior to the tip of the medial malleolus, directed superiorly and laterally

C Medial to the tibialis anterior tendon, directed toward the anterior edge of the medial malleolus In general, arthrocentesis of the tibiotalar (ankle) joint involves entering the joint space from the medial aspect. The first step is to identify the medial malleolar sulcus, which is bordered medially by the medial malleolus and laterally by the tibialis anterior tendon. This tendon can be easily identified by having the patient dorsiflex the foot. The needle should be inserted just medial to the tibialis anterior tendon and directed toward the anterior edge of the medial malleolus. An alternative is the lateral approach, which is performed by inserting the needle between the base of the lateral malleolus and the lateral border of the extensor digitorum longus, advancing the needle perpendicular to the fibular shaft.

An 18-year-old college student with a history of HIV (CD4+ 250/µL) presents to the ED with a headache, fever, and stiff neck for 2 days. He thought he had a cold and has been taking acetaminophen without relief of his headache. Vital signs are T 102.38°F (39.1°C), BP 100/50 mm Hg, HR 140 bpm, and RR 30/min. He is sleepy but arousable. On exam, you place the patient's right hip and knee into a flexed position and then proceed to extend the knee. The patient winces when the knee is just beyond 90 degrees of flexion. You also note petechiae on his trunk and extremities, with one small area on his right forearm that looks like a purple patch with a gray necrotic center. Which of the following is the most likely diagnosis? A Cryptococcal meningitis B Herpes encephalitis C Meningococcemia D Pneumococcal meningitis E Toxoplasmosis

C Meningococcemia This patient has meningococcemia, a disease caused by Neisseria meningitidis. The clinical presentation ranges from a mild febrile illness to fulminant disease progressing to death within hours. Patients with meningococcal meningitis may present similarly to patients with meningitis of other origins with headache, photophobia, vomiting, fever, and signs of meningeal inflammation. Petechiae generally appear on the extremities and may progress to involve almost any body surface. Macular lesions may progress to purpura and ecchymoses in fulminant meningococcemia (purpura fulminans). The patient in this scenario exhibits a positive Kernig sign, representing meningeal irritation, and has a purpuric lesion on his right forearm characterized by a gray necrotic center surrounded by a purple ring. Morbidity and mortality are high in meningococcemia but reduced with prompt recognition and immediate initiation of antibiotic therapy. Ceftriaxone and vancomycin are acceptable first-line agents.

A 30-year-old man presents to the ED with 3 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 1 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? A Ciprofloxacin 500 mg daily for 7 days B Clindamycin 300 mg qid for 7 days C Metronidazole 250 mg tid for 7 days D Rifaximin 200 mg tid for 7 days

C Metronidazole 250 mg tid for 7 days This patient is presenting with signs and symptoms consistent with giardiasis, the most common cause of parasitic diarrheal infection in the United States. Fecal-oral transmission of Giardia lamblia occurs with the ingestion of cysts in contaminated water, either municipal water supplies or outdoor water sources (streams and rivers). It is rarely transmitted through food. Giardiasis is noninvasive, and infection remains confined to the lumen of the small intestine. Classic symptoms include explosive diarrhea, colicky abdominal pain, and pale, loose, foul-smelling stools. The incubation period is 1-3 weeks, followed by an abrupt onset. Treatment is empiric. The appropriate regimen is metronidazole 250 mg three times a day for 7 days.

A 6-year-old girl presents with 4 days of intermittent abdominal pain, nausea, and arthralgias. Today, she developed a palpable, erythematous rash on her buttocks and lower extremities as shown above. Which of the following laboratory results is consistent with the most likely diagnosis? A Elevated alanine aminotransferase and aspartate aminotransferase B Elevated prothrombin time C Microscopic hematuria D Thrombocytopenia

C Microscopic hematuria Henoch-Schonlein purpura (HSP) is a systemic vasculitis caused by immune complex deposition with immunoglobulin A which affects arterioles and capillaries. Children ages 4-11 years are most commonly affected although it can be seen in adults. Episodes are often preceded by an upper respiratory infection or streptococcal infection. The clinical presentation is characterized by nonpruritic, palpable purpura on the buttocks and lower extremities and occurs in nearly all patients. Gastrointestinal symptoms of nausea, vomiting, diarrhea, and colicky abdominal pain are often present. Polyarthralgias and edema are typically present and often localized to the the lower extremities. Renal involvement is also common with evidence of hematuria and proteinuria on urinalysis. Elevated creatinine is less frequently seen and indicates a worse renal prognosis. Treatment is supportive with symptoms typically resolving over 3-4 weeks. About one third of patients will have recurrence of symptoms, although they are generally milder than the initial presentation. Progression to renal failure occurs in only a very small percentage of patients.

A 34-year-old pregnant woman at 10 weeks gestation presents to the emergency department for vaginal bleeding and abdominal pain. On examination, the patient's cervical os is closed. A transvaginal ultrasound confirms an intrauterine pregnancy but is unable to detect cardiac activity. What classification of spontaneous abortion does the patient have? A Incomplete abortion B Inevitable abortion C Missed abortion D Threatened abortion

C Missed abortion The patient is presenting with a missed abortion, a type of spontaneous abortion. A spontaneous abortion is defined clinically as a pregnancy loss before 20 weeks of gestation. Although spontaneous abortions can occur unprovoked, common risk factors include maternal age, previous history of miscarriage, inherited thrombophilias, obesity, and other concurrent medical conductions such as diabetes and thyroid disease. A missed abortion refers to intrauterine fetal death prior to 20 weeks gestation in a patient with a closed cervical os and retention of the pregnancy. The patient may or may not have symptoms such as vaginal bleeding or pelvic pain. Management of missed abortions often depends on patient preference and condition but can be managed with surgical uterine aspiration, medical uterine evacuation, or expectant management. An incomplete abortion (A) refers to cases where a patient presents with vaginal bleeding and has a dilated cervical os with incomplete passage of products of conception. An inevitable abortion (B) refers to cases where there is an impending miscarriage. Patients present with vaginal bleeding with a dilated cervical os on cervical exam but no passage of fetal tissue. A threatened abortion (D) is the most common cause of vaginal bleeding in pregnancy and refers to cases where patients may or may not progress to an inevitable, incomplete, or complete abortion. Patients may also progress to have a normal pregnancy. These patients present with vaginal bleeding with a closed cervical os on exam.

A 20-year-old man presents to the emergency department after being stung by a scorpion while gathering wood for a camp fire. His friend captured an image of the scorpion which appears to be a bark scorpion. Which of the following findings is most likely to be observed on physical examination? A Bidirectional nystagmus and ataxia B Localized erythema and abdominal rigidity C Motor restlessness and hypersalivation D Symmetric ascending flaccid paralysis

C Motor restlessness and hypersalivation Scorpions are found in the warmer United States climates. The bark scorpion, Centruroides sculpturatus, is found in Texas, Arizona, California and New Mexico. It possesses venom that can cause systemic toxicity, while most other scorpion species in the United States only cause localized pain at the sting site. Toxic side effects are due to opening of neuronal sodium channels which leads to prolonged depolarization of somatic and autonomic nerve fibers. Clinical manifestations include uncontrollable extremity jerking that resembles seizures, oculomotor dysfunction, pharyngeal dysfunction, respiratory compromise, tongue fasciculations, motor restlessness and hypersalivation. Treatment includes opioids for pain control and benzodiazepines for sedation as needed. Hypertension leading to pulmonary edema can be abated by the alpha-blocker prazosin. An equine-derived antivenom exists but should be reserved for patients with severe systemic toxicity

A 27-year-old pet shop owner presents to the ED with a lesion on the back of her right hand. She describes a red, raised bump that has grown larger into a purple bump over the course of several weeks. On exam, you note the multiple purple nodules along a lymphatic route. What is the most likely cause of her skin lesion? A Mycobacterium avium complex B Mycobacterium kansasii C Mycobacterium marinum D Mycobacterium ulcerans

C Mycobacterium marinum This patient most likely has "fish tank granuloma," a persistent granulomatous infection caused by the handling of tropical fish tanks or other activities involving contact with fish. Mycobacterium marinum is the infectious agent. Exposure is usually through an abrasion or break in the skin. It is characteristically associated with a skin lesion that develops three weeks after exposure. The lesion begins as a red plaque that progresses into a nodule or cluster of nodules along lymphatics. Lymphadenopathy is uncommon. Treatment can be difficult and may require several months of antibiotic therapy. Atypical Mycobacteria Mycobacterium avium complex: CD4 < 50 cells/mm3, TB-like disease M. kansasii: TB-like disease M. marinum: fish contact, skin lesion, lymphadenopathy uncommon M. ulcerans: ulcerative skin lesion, rural tropical environment

A 17-year-old boy presents with 2 days of nasal congestion and headache. Examination reveals a well-appearing boy with tenderness to palpation over the left maxillary sinus and nasal congestion and discharge. The patient is afebrile. Which of the following managements is most likely indicated? A Amoxicillin for 7 days B CT scan of the sinuses C Nasal decongestants and follow-up D Plain radiographs of the face

C Nasal decongestants and follow-up The patient presents with symptoms consistent with acute rhinosinusitis and should have a topical or systemic decongestant prescribed and follow-up arranged. Approximately 1-2% of viral upper respiratory tract infections are complicated by rhinosinusitis. Symptoms often depend on the sinus affected. Sphenoid sinusitis may cause headache alone. Maxillary sinusitis causes pain in the area of the zygoma as well as maxillary dental pain. Ethmoid sinusitis can cause ocular or periorbital pain, and frontal sinusitis can cause severe headaches around the orbits and forehead. The classic symptoms of rhinosinusitis are mucopurulent nasal discharge, facial pain, fullness over the sinus, nasal congestion, and a pressure-like feeling. Acute rhinosinusitis usually builds in intensity over 7-10 days. The majority of acute rhinosinusitis cases are caused by viruses and will spontaneously resolve with supportive therapy alone Bacterial causes are suggested when the patient has not improved after 10 days of conservative therapy. Some patients will also experience "double-sickening" or an initial improvement followed by worsening symptoms. Supportive treatment should consist of analgesics, antipyretics, and decongestants.

A 24-year-old man who emigrated from Mexico 5 years ago presents to the ED via EMS after he had a seizure at home. His spouse noticed tonic-clonic activity that lasted about one minute. The patient has no past medical history. Vital signs are BP 138/89, HR 105, T 37.7°C, RR 18, and pulse oximetry 100% on room air. He is somnolent but responds to verbal command and is moving all four extremities purposefully. A CT scan is obtained and seen above. Which of the following is the most likely diagnosis? A Herpes encephalitis B Meningioma C Neurocysticercosis D Toxoplasmosis

C Neurocysticercosis Cysticercosis is caused by the larval form of the tapeworm Taenia Solium, a common CNS pathogen found in many tropical areas. It is acquired by humans who swallow eggs found in the feces of a person who has intestinal tapeworm. The adult worm matures in the small intestine. The larval form may penetrate through the gut wall and end up any where in the body. The most common sites include the CNS, muscle, and soft tissue. In the brain, the larvae form an expanding cyst that induces an intense immunologic reaction from the host. Neurologic symptoms begin when the involved neural tissue cannot accommodate the enlarging cyst. Seizure activity often is the first indication of cysticercosis, which should be considered in any adult patient with undiagnosed seizures, especially immigrants. CT scan with contrast or MRI may reveal a ring-enhancing lesion. These lesions may mimic a CNS abscess, metastasis, or primary tumor. Benzodiazepines are used to treat an actively seizing patient. Albendazole is the treatment of choice for Taenia Solium. Corticosteroids may be necessary if there is edema due to CNS cysts. Neurologic consultation is recommended for neurocysticercosis because obstructive hydrocephalus is a complication.

A 45-year-old woman presents with low back pain. She states that she has had back pain for years, but it is worse today. She reports the pain is in the lower part of her back and radiates to her left foot. Physical examination reveals no midline tenderness to palpation of the lower back and a positive straight leg raise. She exhibits no weakness, and has a normal sensory exam. What diagnostic testing is indicated in the ED? A CT scan of the lumbar spine B MRI of the lumbar spine C No immediate imaging D X-ray of the lumbar spine

C No immediate imaging This patient presents with signs and symptoms of sciatica, which may be due to a herniated disk and does not require emergent imaging. Sciatica describes a lumbar radiculopathy that is commonly seen in individuals. Patients typically complain of sharp, burning, or shooting pain beginning in the back and radiating down the leg past the knee. There may be associated numbness or weakness or both on the affected side. The pain is often exacerbated with bending, straining, or sitting and relieved with lying supine. Physical examination often reveals tenderness in the sciatic notch and a positive straight leg raise. To perform a straight leg raise, start with the patient lying supine. The symptomatic leg is then passively raised with the knee fully extended. Eliciting back pain that radiates down the leg into the knee at 30-70 degrees of leg elevation is suggestive of an L5-S1 radiculopathy. The straight leg raise has good sensitivity (91%) but poor specificity (26%). Sciatica symptoms are typically caused by lumbar disk herniation (sensitivity of 95%). Weakness of ankle dorsiflexion, toe extension, ankle plantar flexion, and knee extension are common findings in disk herniation. Immediate imaging is not indicated in patients with symptoms consistent with disk herniation. The majority of patients with disk herniation and sciatica will improve with conservative management alone.

A 15-year-old boy presents with decreased hearing and otorrhea. On examination of the ear, you see the image above. Which of the following is safe? A Antipyrine-benzocaine drops B Gentamicin drops C Ofloxacin otic suspension D Swimming

C Ofloxacin otic suspension Tympanic membrane perforations occur most commonly from infections as pressure builds up behind the membrane causing it to rupture. Perforation may also result from trauma, including direct ear trauma, explosions, severe pressure (diving), and direct injury from ear cleaning or other instrumentation. In the setting of infection, copious purulent drainage in the external canal is often present. Most perforated membranes heal spontaneously without intervention. Antibiotics may be considered in the presence of an active infection. Typically, the suspension form is used rather than a solution due to increased viscosity and less likelihood of entering the inner ear. This may be given in combination with antibiotic drops, although prophylactic antibiotics for an isolated perforation are not required. Rarely, otolaryngology physicians may place a patch over the eardrum if healing is prolonged or ultimately repair the perforation surgically. In children with a perforated tympanic membrane after otitis media, systemic oral therapy is preferred over topical agents. The quinolones (e.g., ciprofloxacin or ofloxacin) are not toxic and can be administered to patients with perforated tympanic membranes. Tympanic Membrane Perforation Foreign body, infection, blast, ↑ barometric pressure Pars tensa most commonly perforated Pain, ↓ hearing, bleeding ​Keep ear dry, analgesics, topical antibiotics for contaminated injuries 90% heal in a few months What environmental accident is associated with tympanic membrane perforation? Lightning strike.

A 45-year-old man presents to the emergency room after tripping over a curb. He is unable to put any weight on his right foot. On physical exam, there is bruising over the medial plantar surface and tenderness over the tarsometatarsal joint. Radiographs reveal an avulsion fracture of the second metatarsal and widening of the space between the medial cuneiform and base of the second metatarsal. Which of the following is the most appropriate treatment? A Midfoot arthrodesis B Non-weight bearing cast immobilization for 8 weeks C Open reduction and internal fixation D Walking boot for four weeks

C Open reduction and internal fixation Open reduction and internal fixation is indicated for Lisfranc injuries with any evidence of instability or bony fracture. A Lisfranc injury is characterized by a disruption of the tarsometatarsal joints, which connect the forefoot to the midfoot. The injury can range from a mild sprain to severe dislocations with fracture. Lisfranc injuries are more common in males and in the third decade of life. The injury usually results from excessive indirect rotational forces and axial loading through a hyper-plantar flexed foot. Common causes of Lisfranc injuries include motor vehicle accidents, falls, or sports. Patients usually present with severe foot pain and an inability to bear weight. Physical exam may reveal midfoot bruising of the plantar surface, generalized swelling, and tenderness of the tarsometatarsal joint. Anteroposterior, lateral, and oblique radiographs are first line imaging. Stress radiographs may be necessary if non-weight bearing radiographs are unremarkable and there is high suspicion. Radiographic findings may include disruption of second metatarsal, avulsion fragments, or malalignment of the fourth metatarsal and the cuboid bone. Nonoperative management is indicated in patients with no displacement on stress radiographs and no evidence of bony injury. Operative management is indicated in patients with any evidence of instability or fracture. Posttraumatic arthritis is the most common complication of Lisfranc injuries. Which ligament connects the medial aspect of the cuneiform to the second metatarsal base? Lisfranc ligament.

Which of the following causes acute painful loss of vision? A Central retinal artery occlusion B Central retinal vein occlusion C Optic neuritis D Retinal detachment

C Optic neuritis Optic neuritis, an inflammatory, demyelinating disease of the optic nerve, presents as an acute monocular loss of vision. It is more frequently seen in young women. Although often idiopathic, approximately 30% of patients will develop multiple sclerosis (MS) within five years. Vision loss, most commonly a loss of central vision, and loss of color perception, develop over a period of hours and peaks in about one week. Eye pain, typically worse with eye movements, occurs in about 90% of patients. On examination, an afferent pupillary defect is usually present as is a swollen disk. Diagnosis is made based on history and physical exam findings. Magnetic resonance imaging of the brain and orbits with gadolinium will confirm the diagnosis and is helpful in determining those patients at risk for developing multiple sclerosis. After peak vision loss at one to two weeks, symptoms will gradually improve. Intravenous corticosteroids have been shown to increase the rate of recovery, as well as delay the onset of multiple sclerosis, although long-term visual outcome and rate of developing MS at five years are not affected by this treatment.

Which of the following can be used to distinguish a seizure from a syncopal episode? A Loss of consciousness B Loss of urinary continence C Post-ictal period D Tongue biting

C Post-ictal period Syncope and seizure are often confused and difficult to differentiate. However, patients with syncope should not experience a post-ictal period or prolonged state of confusion. Syncope is defined as a sudden, transient loss of consciousness along with a loss of postural tone. The majority of cases are benign but determining which cases are potentially life-threatening or are harbingers of bad outcomes is difficult. All syncopal episodes result from the same pathophysiology; dysfunction of both cerebral hemispheres or dysfunction of the reticular activating system in the brainstem. After a syncopal episode, patients may have brief (seconds) episodes of confusion but will not experience a true post-ictal period.

A 65-year-old man with hypertension and diabetes presents with chest pain for 2 days. He states the pain is sharp, burning, and severe. You note the findings on the image above. What management is indicated? A Admission for serial troponins B Intravenous acyclovir for 7 days C Oral acyclovir for 7 days D Prednisone for 5 days

C Oral acyclovir for 7 days This patient presents with herpes zoster, more commonly referred to as shingles. Zoster results from reactivation of latent varicella-zoster virus (VZV) in cranial nerve or dorsal root ganglia with spread along the sensory nerve to the dermatome. The major risk factor for herpes zoster is increasing age, as there is a decline in T-cell immunity. Although herpes zoster can progress to a systemic infection, particularly in those with immunocompromised states, the major complication is postherpetic neuralgia. Postherpetic neuralgia can be severe and debilitating. Antiviral therapy (usually with acyclovir or valacyclovir) is recommended in all immunocompromised patients and selected groups of non-immunocompromised patients. Antiviral agents hasten the resolution of lesions, reduce the formation of new lesions, reduce viral shedding, and decrease the severity of acute pain. Therapy should be started as soon as possible, and efficacy decreases after 72 hours of symptoms. Once the herpes zoster lesions are crusted over no longer considered infectious

A 43-year-old man with asthma presents to his primary care physician with wheezing. He reports that he was recently visiting a friend who had pets in the home. He describes his symptoms as feeling breathless and having chest tightness. An asthma exacerbation is diagnosed. After 6 inhaled albuterol treatments he feels better and his lungs are clear. Which of the following is true regarding further management? A Intravenous corticosteroid is indicated B Intravenous magnesium sulfate is indicated C Oral corticosteroid is indicated D Oral respiratory antibiotic is indicated

C Oral corticosteroid is indicated The patient presents with a moderate asthma exacerbation that has resolved with beta-agonists and should have oral corticosteroids added to his treatment. Corticosteroids inhibit the release of inflammatory mediators and cytokines and decrease recruitment of inflammatory cells in asthma. This results in decreased airway inflammation and secondarily limits induced bronchoconstriction. The effect of steroids begins within hours in an acute asthma exacerbation and reduces both the rate of relapse and rate of admission in severe attacks. In general, patients with moderate to severe reactions should have short-course corticosteroids added to their treatment regimens. Oral prednisone or prednisolone are appropriate interventions. Short-term relapse (within 3 days) is fairly common at around 11%

A 30-year-old woman misses work and presents to the emergency department with pelvic pain rated at 6/10. She states it began yesterday with the onset of menstruation. She has regular cycles with a normal amount of blood flow but has not had this pain before. She denies spinal, urologic, and rectal symptoms. Vital signs are normal, and her physical examination and pelvic ultrasound are unremarkable. Serum beta-hCG is negative. Other than referral to a gynecologist for further evaluation, which of the following is the most appropriate initial treatment? A Intravenous ketoral B Intravenous morphine C Oral ibuprofen D Oral pregabalin

C Oral ibuprofen This patient's working diagnosis is most concordant with primary dysmenorrhea, in which there is significant pain associated with the first few days of menses, which alters normal activity or requires pain medication to control. Although secondary causes, such as endometriosis and pelvic inflammatory disease, are the most common misdiagnoses of primary dysmenorrhea, her stable presentation and normal initial diagnostic testing favor symptomatic control and follow-up evaluation. To treat dysmenorrhea, nonsteroidal anti-inflammatory medications (NSAIDs) and acetaminophen are usually helpful to decrease prostaglandin levels which counters the underlying pathophysiology. in addition, the addition of oral contraceptives may help further.

A 13-year-old boy presents with his mother to the emergency department with symptoms of headache, vomiting, and a decreased level of consciousness. The patient's symptoms gradually increased over several minutes after having an argument with his mother. The mother endorses a history significant for recurrent nosebleeds and states the patient's father died from long-standing congestive heart failure. Physical examination reveals an obtunded patient. The patient's pulse is 120, BP is 170/95 mm Hg, temperature is 99.3℉, and RR is 16. CT scan of the brain without contrast reveals an intraparenchymal hemorrhage. Examination of the patient's oral mucosa is reveals telangiectasias. Which of the following is the most likely diagnosis? A Angiofibroma B Autosomal dominant polycystic kidney disease C Osler-Weber-Rendu syndrome D Peutz-Jeghers syndrome

C Osler-Weber-Rendu syndrome = Also known as hereditary hemorrhagic telangiectasia (HHT) The patient's symptoms of headache, vomiting, and a decreased level of consciousness are concerning for intracranial pathology. The mother describes a history significant for recurrent nosebleeds as well as congestive heart failure in the patient's father. CT scan of the brain reveals an intraparenchymal hemorrhage and the image depicted illustrates characteristic telangiectasias of the oral mucosa. Together, these features are consistent with Osler-Weber-Rendu syndrome, or hereditary hemorrhagic telangiectasias. The disease is inherited in autosomal dominant fashion and presents with arteriovenous malformations in multiple organs including brain, liver, and lung. Ruptured intracranial AVM's are a common presentation in young patients with the disease and comprise a significant portion of the morbidity and mortality. Patients often note a history of recurrent nosebleeds due to arteriovenous malformations of the sinus tract. The patient's father likely experienced high-output cardiac failure due to arteriovenous malformations. Osler-weber rendu syndrome is a an autosomal dominant disease characterized by arteriovenous malformations of the brain, liver, and lung that can lead to sudden intraparenchymal hemorrhage and high output congestive heart failure. Pt is at elevated risk of venous thromboembolisms. Autosomal dominant Telangiectasia of oral mucosa and finger tips Epistaxis, Gl bleeding, AVMs Labs show anemia

As you are irrigating the external ear canal of a 20-year-old man to treat cerumen impaction, the patient experiences sudden hearing loss and otalgia. You stop irrigating and attempt to visualize the tympanic membrane but cannot visualize it. Which of the following is the most appropriate next step in management? A Continue to irrigate with warm water B Emergent otolaryngology consultation C Otolaryngology referral in 1-2 weeks D Prescribe oral antibiotics and otolaryngology referral in 1-2 weeks

C Otolaryngology referral in 1-2 weeks Treating cerumen impaction involves gentle irrigation at the superior portion of the external auditory canal. This technique directs the pressure of the irrigant stream toward the wall of the canal and not the tympanic membrane. The most common complication of irrigation is traumatic tympanic perforation. When this occurs, patients usually experience sudden hearing loss, severe otalgia, or vertigo. Visualizing the tympanic membrane in this scenario is sometimes difficult. Perforation of the tympanic membrane is a clinical diagnosis. In cases of suspected perforation following irrigation, follow-up with otolaryngology is necessary. Foreign body, infection, blast, ↑ barometric pressure Pars tensa most commonly perforated Pain, ↓ hearing, bleeding ​Keep ear dry, analgesics, topical antibiotics for contaminated injuries 90% heal in a few months

A 44-year-old woman presents with a three day history of pleuritic chest pain radiating to the back. It is worsened by lying supine. On examination, a friction rub is appreciated when she leans forward. Which of the following would you expect to see on her ECG? A Peaked T waves in V1-V6 B PR depression in aVR C PR depression in II, aVF, and V4-V6 D ST segment elevation in the anterior leads with reciprocal changes inferiorly

C PR depression in II, aVF, and V4-V6 Pericarditis is a syndrome characterized by inflammation of the pericardium. There are many possible causes including infectious, infiltrative, uremic, and post-MI, but most cases are idiopathic. Patients present with chest pain that is typically described as sharp and pleuritic and may radiate to the shoulder. It is worse with lying supine and improved with sitting forward. On exam, the friction between the inflamed visceral and parietal pericardium results in a rub which is best heard over the left sternal border and may be intermittent. It can be accentuated by having the patient lean forward in full expiration. The ECG is the most reliable diagnostic tool. Diffuse ST elevations and PR depressions in V2-V6, I, II, III, aVL and aVF are seen in the first hours to days of illness with reciprocal ST depression and PR elevation in aVR. In contrast to changes seen in acute myocardial infarction, the ST segments are concave, diffuse and not associated with T wave inversions initially. Over the course of one to three weeks, the ST segments will normalize and the T waves flattened. The flattened T waves can later become inverted followed by a return to a normal appearing ECG after many weeks.

A 2-year-old girl presents to the emergency department with lethargy, vomiting, and fever. The mother reports that her daughter experienced several episodes of abdominal pain at home, during which she would draw up her legs to her chest and scream. She was well previously, other than a mild upper respiratory infection about one week ago. Vital signs are HR 115, RR 22, and T 101°F. Which of the following would confirm your suspected diagnosis? A Empty rectal vault on digital rectal examination B Involuntary flexion of the hips and knees following flexion of the neck C Palpation of a sausage-shaped mass in the right upper quadrant D Palpation of an olive-shaped mass in the upper abdomen

C Palpation of a sausage-shaped mass in the right upper quadrant Intussusception occurs when one segment of the intestine telescopes into another, usually the ileum into the colon. It is the most common cause of intestinal obstruction in children younger than 2 years of age. Intussusception is rare before the age of 2 months, but may occur in any age group. The mortality rate for untreated intussusception is high. The classic triad of clinical findings consists of intermittent abdominal pain, vomiting and bloody ("currant jelly") stools, however, all three findings are present in less than one third of patients. Another presentation is a child with unexplained lethargy, which may divert the provider to an evaluation for altered mental status. Patients may have a fever, usually low-grade. Children often have had a recent viral illness. The physical examination between attacks may be normal, although palpation of a sausage-shaped mass in the right upper quadrant (representing the actual intussuscepted intestine) and an empty space in the right lower quadrant (representing the movement of the cecum out of its normal position) is possible. This combination is called Dance's sign and is considered pathognomonic for intussusception. A presentation consistent with the intermittent symptoms of intussusception should prompt further evaluation even if the patient is asymptomatic at the time. Ultrasound is usually the imaging modality of choice. Contrast or air enemas may be both diagnostic and therapeutic. Either type of enema requires readily available back up by a pediatric surgeon in the event of failure of the bowel to reduce or perforation. Children presenting with peritonitis, with free air on plain films, or who are in shock require emergent surgical reduction.

What is the most common cause of croup? A Adenovirus B Haemophilus influenzae type b C Parainfluenza virus D Streptococcus spp.

C Parainfluenza virus Parainfluenza virus is the most common cause of croup. Croup is classically associated with a barking, seal-like cough and inspiratory stridor. Radiographs may show subglottic narrowing ("steeple sign") caused by edema. AKA: Laryngotracheobronchitis The typical age group is 6 months to 3 years, but the condition can be seen in children up to 5 years of age. The infection and inflammation are usually self-limiting, and conservative management is recommended. Evidence supports the routine use of corticosteroids in most children with croup. Intervention at an earlier phase of the illness reduces the severity of symptoms and the rates of return to a health care practitioner for additional medical attention, ED visits, and hospital admissions. Many children respond to a single, oral dose of dexamethasone. For those who do not tolerate the oral preparation, nebulized budesonide or intramuscular dexamethasone are reasonable alternatives. Mild disease can be treated with humidified oxygen. Moderate to severe disease should be treated with steroids and nebulized racemic epinephrine. SUMMARY: 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

What is the most frequently involved site of pediatric linear skull fractures? A Frontal bone B Occipital bone C Parietal bone D Temporal bone

C Parietal bone Skull fractures can be classified as linear, depressed, basilar or open. Linear fractures, accounting for 75% of all pediatric skull fractures, are single fractures that extends through the entire thickness of the skull. They do not typically cross the suture lines. The most common mechanisms of injury include falls, motor vehicle accidents, and recreational activities. Linear fractures occur most frequently in the parietal bone. While most do not result in intracranial injury, those that cross the middle meningeal groove or major venous dural sinuses can disrupt vascular structures and result in epidural hematomas. Patients often present with a history of injury and localized pain and swelling. Signs of an associated intracranial injury include severe headache, altered mental status, repetitive vomiting, and focal neurologic findings on physical examination. Noncontrast CT of the head is the diagnostic modality of choice.

A 28-year-old man presents with right knee pain after he fell playing soccer. On exam, his patella is superiorly displaced. He is tender inferior to the patella and is unable to extend his leg at the knee. Which of the following is the most likely diagnosis? A Osgood-Schlatter disease B Patella fracture C Patellar tendon rupture D Quadriceps tendon rupture

C Patellar tendon rupture The patient is suffering from a patellar tendon rupture. There are three ways to damage the extensor mechanism of the knee: patella fracture, patellar tendon rupture, and quadriceps tendon rupture. The classic findings of patellar tendon rupture include the inability to extend the knee, superior patellar displacement, and tenderness inferior to the patella. Patella tendon rupture is more common in otherwise healthy young athletes, such as this patient described above. "Pop" during injury, fall directly on knee Unable to extend knee Knee pain or swelling Patella alta on X-ray Referral to orthopedics

A 56-year-old dentist presents with worsening right wrist pain over the past month. The patient denies any trauma and locates the pain over the radial wrist with radiation into the forearm. You suspect de Quervain tendinopathy. Which physical exam test will confirm this diagnosis? A Assess for tenderness over the anatomic snuff box B Instruct the patient to hold the dorsal surfaces of their hands together in flexion for 30-60 seconds to reproduce symptoms C Patient grasps thumb in fist and deviates wrist ulnarly to reproduce pain D Tapping on the volar aspect of the wrist which elicits paresthesias distally

C Patient grasps thumb in fist and deviates wrist ulnarly to reproduce pain The patient is experiencing de Quervain tendinopathy which involves the extensor pollicis brevis and abductor pollicis longus tendons. It is usually due to overuse and is common in those who work with their hands. The discomfort is located over the radial styloid process with radiation of the pain proximally into the forearm and occasionally distally to the thumb. Pain tends to be constant but worse with grasping, abduction of the thumb, or ulnar deviation of the wrist. The Finkelstein test is diagnostic and pathognomonic. The patient grasps his or her affected thumb in their palm, making a fist and then deviates the wrist in the ulnar direction. Pain with this maneuver is considered a positive test. Treatment for de Quervain tendinopathy is NSAIDs and a thumb spica splint.

Emergency physicians are sometimes asked to make recommendations regarding travel options for patients with specific conditions, including recent illnesses, recent surgery, recent trauma, and indwelling medical devices. Which of the conditions listed below poses the greatest risk of barotrauma of ascent during flight? A Patients who smoke B Patients with a myocardial infarct within the past week C Patients with air-cuffed endotracheal or tracheostomy tube D Patients with congestive heart failure

C Patients with air-cuffed endotracheal or tracheostomy tube Patients with air-cuffed endotracheal or tracheostomy tubes is correct. Risks of ascent include both barotrauma related to expanding gases and difficulties related to hypoxia. This question focuses on risks related to barotrauma rather than hypoxia. In general, decreasing pressure related to ascent during air travel poses risk involving gas-filled organs or cavities within the body. These affected areas can include the middle ear (barotitis), the sinuses (aerosinusitis), the gastrointestinal tract, and any other body system where gas has accumulated, including the lungs and cranium. Barotrauma of ascent risk is also found in recent surgery patients, those with in-dwelling medical devices that normally contain air (such as endotracheal or tracheostomy tube cuffs), and patients with recent trauma with related swelling. Pneumatic splints can cause lack of blood flow due to expanding volume within the air-filled chambers. Non-bivalved, circumferential plaster, metal, or plastic casts can obstruct blood flow when traumatized underlying tissues swell against the increasingly constrictive cast. Air-cuffed endotracheal and tracheostomy tubes also pose a risk due to increasing cuff volume. Some recommend replacing the cuff air with water, while others recommend decreasing the amount of air within the cuff to allow for gas expansion. Patients with acute otitis media or acute upper respiratory infections can suffer from ear or sinus barotrauma when the eustachian tube or other gas-venting chambers and openings occlude due to swelling and infectious drainage. Patients with a myocardial infarct within the past week (B) is incorrect. Patients with this history can experience problems due to altitude-related hypoxia rather than barotrauma. Patients with congestive heart failure (D) is incorrect. Patients with congestive heart failure may suffer from hypoxia related to ascent, but are not more vulnerable to barotrauma. Patients who smoke (A) is incorrect. Smokers do not experience higher risk of barotrauma of ascent as an independent factor. Cabin pressure is required to be sufficient to maintain altitude equivalents of between 1500 and 2500 meters (4000 and 8000 feet).

Which of the following is true regarding sudden unexpected infant death (SUID)? A Most cases occur in infants younger than 1-month-old B Normal-term infants have a higher incidence of sudden unexplained infant death (SUID) than preterm infants C Peak incidence is between 2 and 4 months of age D The diagnosis is usually made in the emergency department

C Peak incidence is between 2 and 4 months of age Some 95% of sudden unexpected infant death (SUID) infants die before 6 to 8 months of age, with a peak occurring between 2 and 4 months of age. SUID may occur at any time during the first two years of life, but it is rare in children younger than 1 month of age and in those older than 1 year of age. Risk factors: maternal smoking or drug use, prone sleeping position. Male babies and multiple births are also risk factors Recommendations: supine sleeping, pacifiers, breastfeeding Most cases occur in infants younger than 6 to 8 months, with a peak occurring between 2 and 4 months. Approximately 20% of all SUID cases occur in the preterm (B) population. The diagnosis of SUID is made at autopsy after postmortem evaluation fails to reveal another cause of death. Autopsies of SUID victims demonstrate the effects of chronic hypoxemia, but no specific findings are pathognomonic of SUID. Fewer than 5% of cases related to child abuse

Which of the following complications can be prevented by simultaneously administering pyridoxine and isoniazid in a patient with tuberculosis exposure? A Color blindness B Hepatitis C Peripheral neuropathy D Renal failure

C Peripheral neuropathy Isoniazid (INH) inhibits the enzyme responsible for the conversion of pyridoxine (vitamin B6) to one of its active metabolites, pyridoxal phosphate (PLP). This depletion of vitamin B6 may lead to complications such as peripheral neuropathy and seizures. Therefore, vitamin B6 should be administered concomitantly to patients taking isoniazid. PLP is also a coenzyme required for the synthesis of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter. Decreased GABA formation in the setting of vitamin B6 deficiency may also contribute to seizures

A 52-year-old man with a recent diagnosis of hypertension complains of intense itching after taking hot showers. He also reports increasing fatigue over the prior four months. Past medical history is significant for hypertension, for which he takes propranolol. His review of systems is otherwise normal. What physical exam finding is most consistent with his diagnosis? A Pallor B Petechiae C Plethora D Purpura

C Plethora This patient is most likely suffering from primary polycythemia vera, a condition in which the unregulated production of red blood cells leads to erythrocytosis (Hct > 60%). Clinically, its onset is usually slow and progressive, marked by complications of sludging, thrombosis, or infarction in the peripheral circulation. Early signs of polycythemia vera include hypertension, plethora (a ruddy complexion), and itching after hot showers due to histamine release from increased basophil and mast cell production. Splenomegaly and hepatomegaly are also commonly found on physical exam. Late findings include headache, fatigue, vertigo, chest pain, claudication, and vision changes What is the immediate ED management of a patient with polycythemia vera and altered mental status? Phlebotomy of at least 500 mL of blood. Polycythemia Vera Patient presents with headache, dizziness, pruritus after showering PE will show hypertension, splenomegaly Labs will show increased RBC mass, overproduction of all cell lines, increased Hgb Most commonly caused by mutation of the Janus kinase 2 gene (JAK2) Treatment is phlebotomy, hydroxyurea, aspirin

A 55-year-old man with a history of lung cancer presents with dyspnea that developed gradually over the last three days. He denies chest pain, fever or cough. Vital signs are notable for blood pressure of 130/75 mm Hg, heart rate of 105 beats/minute, respiratory rate of 26 breaths/minute, temperature of 37.1°C, and oxygen saturation of 90% on room air. Dullness to percussion and decreased breath sounds are noted from the base of the left lung halfway up the lung fields. Which of the following is most likely to be seen on chest radiograph? A Consolidation of the left lower lobe B Hampton hump C Pleural effusion D Pneumothorax

C Pleural effusion The patient has a pleural effusion. A pleural effusion is collection of fluid within the pleural space. Pleural effusions are associated with many conditions, including congestive heart failure, bacterial pneumonia, malignancy, cirrhosis, nephrotic syndrome, and inflammatory conditions (e.g. rheumatoid arthritis and systemic lupus erythematosus). In this case, the patient has an effusion related to his lung cancer, known as a malignant pleural effusion. Physical examination findings of pleural effusion include decreased breath sounds and dullness to percussion at the base of the lung. Asymmetric chest wall expansion, with diminished or delayed expansion on the affected side, may also be present. Pleural effusions are categorized on the basis of fluid characteristics as either transudative or exudative. Light criteria are used to distinguish transudative from exudative effusions. Criteria for an exudative effusion are as follows: (1) pleural fluid to serum protein ratio > 0.5, (2) pleural fluid and serum lactate dehydrogenase (LDH) ratio > 0.6, (3) pleural fluid LDH > 200 IU/mL. Common causes of transudative effusions include congestive heart failure, cirrhosis with ascites, and nephrotic syndrome. Common causes of exudative effusion include malignancy, pulmonary infections (e.g. bacterial pneumonia, empyema, abscess, pulmonary tuberculosis), and inflammatory conditions (e.g. rheumatoid arthritis, lupus, pancreatitis).

A woman suffers from an acute attack of vertigo, nausea, and vomiting. You suspect viral labyrinthitis. Which of the following medications is the best choice in treating the vertigo? A Acyclovir B Phentermine C Prednisolone D Prochlorperazine

C Prednisolone Commonly a complication of otitis media, upper respiratory infection, or meningitis, labyrinthitis is an abnormality of the inner ear vestibular system, which consists of three semicircular canals, vestibule, utricle, and sacule. When the vestibular system is damaged, injured, or inflamed, balance deficits and vertigo arise. However, since an anatomic connection between the vestibular system and cochlea exist, tinnitus and hearing impairment also occur. The classic clinical picture of labyrinthitis is acute, profound, incapacitating vertigo, with nausea, vomiting, and nystagmus. Tinnitus and hearing impairment usually accompany the onset of vertigo. These symptoms resemble those of Meniere's disease, however, in Meniere's disease, symptoms are intermittent and possibly less severe. Furthermore, the pathology is different between the two conditions. Labyrinthitis is mainly due to inflammation, while an excess of inner ear fluid causes Meniere's disease. Treatment of suspected viral labyrinthitis includes bed rest, hydration, antiemetics, and vestibular depressants. Treatment with corticosteroids during the acute period of vertigo has been shown to improve the recovery of peripheral vestibular function in patients with acute labyrinthitis. Benzodiazepines are also effective.

A 20-year-old woman with a history of asthma presents to the emergency department with a recurrent pruritic rash as shown above. She has tried multiple topical medications including over-the-counter hydrocortisone cream and prescription triamcinolone ointment. She feels no improvement in her symptoms, which are intermittent and recurrent. Which of the following is the next best step in management? A Discontinue all topical steroids B Order Lyme titers C Prescribe betamethasone ointment D Prescribe permethrin

C Prescribe betamethasone ointment Topical corticosteroids in ointment formulations are the cornerstone of management for atopic dermatitis, or eczema. Atopic dermatitis is seen in patients with with other associated allergic disorders, such as asthma and allergic rhinitis. Its course is marked by remissions and exacerbations. The hallmark of the dermatitis is intense pruritus, often unrelieved by routine treatments, such general skin care and over-the-counter topical medications. It is best to prescribe betamethasone ointment, a fluorinated corticosteroid ointment that is recommended when symptoms are severe. These ointments should not be used on the face as they can cause severe tissue atrophy.

A 20-year-old woman with a history of asthma presents to the emergency department with a recurrent pruritic rash as shown above. She has tried multiple topical medications including over-the-counter hydrocortisone cream and prescription triamcinolone ointment. She feels no improvement in her symptoms, which are intermittent and recurrent. Which of the following is the next best step in management? A Discontinue all topical steroids B Order Lyme titers C Prescribe betamethasone ointment D Prescribe permethrin

C Prescribe betamethasone ointment Topical corticosteroids in ointment formulations are the cornerstone of management for atopic dermatitis, or eczema. Atopic dermatitis is seen in patients with with other associated allergic disorders, such as asthma and allergic rhinitis. Its course is marked by remissions and exacerbations. The hallmark of the dermatitis is intense pruritus, often unrelieved by routine treatments, such general skin care and over-the-counter topical medications. It is best to prescribe betamethasone ointment, a fluorinated corticosteroid ointment that is recommended when symptoms are severe. These ointments should not be used on the face as they can cause severe tissue atrophy. Risk factors: history of asthma or hay fever Sx: Itchy, scaly rash on arms, often worse in the winter PE: thick, leathery, hyperpigmented areas on flexor surfaces Tx: topical corticosteroids, lubricating ointments

Which of the following is the greatest risk factor for an ectopic pregnancy? A Multiple sexual partners B Previous abdominal surgery C Previous ectopic pregnancy D Previous pelvic inflammatory disease

C Previous ectopic pregnancy

Which of the following ECG findings is associated with sudden cardiac death? A First-degree AV block B Premature ventricular contractions C Prolonged QT interval D Right bundle branch block

C Prolonged QT interval A prolonged QT interval, defined as a QTc greater than 440 milliseconds in men and 460 milliseconds in women, is commonly found in patients who have died from sudden cardiac death. . Long QT syndrome should be suspected in patients with recurrent syncope during exertion and those patients with family history of sudden cardiac death. However, some patients have no symptoms or family history and they may present with sudden cardiac death. ECGs obtained during a sudden cardiac death event will show a polymorphic ventricular tachydysrhythmia called torsades de pointes, which can lead to ventricular fibrillation and death Long QT syndrome can be congenital, acquired, or drug-induced. Southeast Asian and Pacific Rim countries have the highest populations of people with congenital long QT syndrome. Structural or coronary heart disease can lead lead to long QT syndrome. Medications that lead to alterations in magnesium or potassium can cause long QT syndrome as well. If found, treatment can include beta blockers, potassium supplementation, or implantable defibrillators.

A 19-year-old man presents to the ED after jamming his finger while playing basketball. On exam, he has swelling and tenderness to the proximal interphalangeal joint and pain with proximal interphalangeal joint extension. An X-ray is negative for fracture. What type of splint should be placed to prevent the deformity seen in the above image from developing? A Distal interphalangeal joint in extension, proximal interphalangeal joint and metacarpal phalangeal joint with full range of motion B Distal interphalangeal joint, proximal interphalangeal joint, and metacarpal phalangeal joint in extension C Proximal interphalangeal joint in extension, distal interphalangeal joint and metacarpal phalangeal joint with full range of motion D Proximal interphalangeal joint in flexion, distal interphalangeal joint in extension, and metacarpal phalangeal joint with full range of motion

C Proximal interphalangeal joint in extension, distal interphalangeal joint and metacarpal phalangeal joint with full range of motion This is a Boutonnière deformity. The area over the proximal interphalangeal (PIP) joint is a common site of injury. The central slip, which inserts into the base of the middle phalanx, and the lateral bands, which insert in the distal phalanx, all aid in finger extension. When the central slip is disrupted, the lateral bands slip volarly over the PIP joint (giving the appearance of a button popping up through a buttonhole, hence the term boutonnière) and will hold the PIP in flexion and the distal interphalangeal (DIP) joint in extension. This deformity usually develops 10-21 days after injury, so a high level of suspicion must be maintained at the time of injury to prevent it. If a central slip injury is suspected, the PIP should be splinted in extension. The DIP and metacarpal phalangeal (MCP) joint should have full range of motion. These patients should be referred for close follow-up with a hand surgeon. If a fracture is present at the site of central slip attachment, surgical internal fixation may be required.

A full-term neonate is brought to the ED for constant crying for the last three hours. In the ED, he sleeps quietly in his mother's arms. He cries when you examine him but is immediately consoled when he is swaddled and held. His exam is normal. What is the most appropriate next step in his management? A CT scan of the head to rule out intracranial hemorrhage B Lumbar puncture to rule out serious bacterial infection C Reassurance D Skeletal survey for abuse

C Reassurance Neonates cry in varying patterns throughout the day. Although crying is typically a sign of hunger or normal uncomfortable states (wet diaper, gas), it may also signal pain or underlying disease. An easily consoled infant without a source of crying after a thorough history and physical exam can be discharged with parental reassurance. A thorough exam for crying includes completely exposing the infant; palpating the fontanels; fluorescein staining of the eyes for corneal abrasions; examining the fingers, toes, and penis for hair tourniquets; and checking for hernias. It is also important to look for retinal hemorrhages and palpate the extremities for accidental or deliberate trauma.

What other evaluation should a febrile infant with first urinary tract infection be referred to undergo? A Intravenous pyelogram B Nuclear scanning with technetium-labeled dimercaptosuccinic acid C Renal and bladder ultrasonography D Voiding cystourethrography

C Renal and bladder ultrasonography The 2011 American Academy of Pediatrics UTI Clinical Practice Guideline, Action Statement 5, states that febrile infants with first UTI should undergo renal and bladder ultrasonography (RBUS) to detect anatomic abnormalities that may require further evaluation and intervention. The RBUS should be done during the first two days of treatment to identify serious complications such as renal or perirenal abscesses or pyelonephrosis if the patient's clinical illness is unusually severe or is not clinically improving. However, if the patient demonstrates significant improvement, then the RBUS should be performed after resolution of the acute illness Intravenous pyelogram (A) can identify the patient's anatomy and some information on the functioning of the renal system. However, the study unnecessarily exposes the infant to intravenous contrast and radiation. Renal and bladder ultrasonography is a safer alternative. Technetium-labeled dimercaptosuccinic acid scan (B) has greater sensitivity for detection of acute pyelonephritis than RBUS or voiding cystourethrogram (VCUG), but is not recommended as routine evaluation in infants with first febrile UTI because of the radiation dose that may increase with follow-up studies and reduced renal function. VCUG (D) should not be performed routinely after first febrile UTI due to its cost and radiation exposure. Also, the benefit of identifying high-grade vesicoureteral reflux is unclear, given that the treatment with antimicrobial prophylaxis seems to be ineffective in preventing recurrence of febrile UTIs.

An 18-year-old hurdler gets tripped up and falls, contacting the running track through his hyperextended left wrist. He presents to the ED with dorsolateral wrist pain, erythema, edema, and anatomic snuffbox tenderness. Initial anteroposterior, lateral, and oblique radiographs are negative for fracture. He is splinted and discharged. His discharge paperwork should contain directions to obtain which of the following? A MRI in 4 weeks if pain persists B Primary care medical clearance examination for upcoming orthopedic surgery C Repeat radiographs in 2 weeks D Rheumatological consultation for wrist inflammation

C Repeat radiographs in 2 weeks Falling on an outstretched hand (FOOSH injury; "outstretched" refers to wrist hyperextension) is a common cause of scaphoid fracture, which represents the most common fractured carpal bone. The most common fracture site on the scaphoid is the waist. Since the blood supply to the scaphoid enters distally, any > 1 mm fracture or displacement is worrisome for complications of osteonecrosis and nonunion. A scaphoid fracture should be suspected any time there is snuffbox tenderness. Wrist and scaphoid X-rays may be negative in the setting of acute fracture. Therefore, patients with snuffbox tenderness or suspicion of scaphoid fracture should be placed in a thumb spica splint with repeat radiographs or MRI in 10-14 days. The more proximal the fracture, the greater the likelihood of osteonecrosis

A 14-year-old boy presents to the Emergency Department for a rash. He reports the abrupt onset of fever, headache, and myalgias three days ago. This morning, he developed a blanching, red, macular rash on his wrists and palms that now involves his extremities and trunk. What is the most likely cause of his symptoms? A Measles virus B Neisseria meningitidis C Rickettsia rickettsii D Staphylococcus aureus

C Rickettsia rickettsii Rocky Mountain spotted fever (RMSF) is a febrile, tick-borne illness caused by Rickettsia rickettsii. Patients present with abrupt onset of fever, headache, myalgias, and nausea followed three to five days later with a blanching, macular rash that initially is found on the wrists and ankles before spreading centripetally. The rash later becomes petechial. Despite its name, RMSF is relatively rare in the Rocky Mountain states and is found primarily in the southeastern United States. Carried mostly by the American dog tick (Dermacentor variabilis) and the Mountain wood tick (Dermacentor andersoni), R. rickettsii is an obligate intracellular bacteria that damages endothelial cells. This in turn starts a cascade of reactions that result in widespread vascular lesions that manifest as the clinical features of the disease. Without treatment, mortality is near 25%. Management includes supportive care and doxycycline

An 18-year-old college student presents with altered mental status and fever. The patient's roommate reports that the patient complained of headache earlier in the day. The patient is started on antibiotics and sent for a CT scan which is normal. A lumbar puncture is performed and the gram stain demonstrates gram negative diplococci. Which of the following should be administered to the patient's close contacts? A Amoxicillin B Doxycycline C Rifampin D Trimethoprim-sulfamethoxazole

C Rifampin The patient described has meningitis caused by Neisseria meningitides identified on the gram stain (Gram negative diplococci). Antibiotics for the patient should not be delayed and should include ceftriaxone and vancomycin. Neisseria meningitides is highly contagious and may be responsible for outbreaks in close quarters including college dorms and army barracks. Given its contagious nature, antibiotic prophylaxis is indicated for close contacts of the patient including those in contact with secretions as well as members of the same household, daycare center, or nursery school. Healthcare workers with close contact with the patient's secretions should also receive prophylaxis. Rifampin may be administered at a dose of 10 mg/kg to a maximum of 600 mg every 12 hours for four doses. Other alternatives include intramuscular ceftriaxone and ciprofloxacin. Antibiotic prophylaxis is also indicated for meningitis caused by Hemophilus influenzae. Neisseria meningitidis Meningitis Young Outbreaks in close quarters Septicemia, meningitis Tx: third-generation cephalosporin PPX: rifampin

A 45-year-old woman with a history of dialysis-dependent kidney failure presents to the emergency department with shortness of breath. Her vital signs are 95/60 mm Hg, HR 105 bpm, RR 24/min, and SpO2 97% on room air. A bedside cardiac ultrasound is performed, as seen above. What is the earliest sonographic finding of this patient's diagnosis? A Interventricular septal flattening B Left atrial collapse C Right atrial collapse D Right ventricular collapse

C Right atrial collapse The earliest sonographic finding of cardiac tamponade is a large pericardial effusion with evidence of right atrial collapse. This occurs during the period of end-diastole to early systole when the right atrial pressure is minimal. With a continued increase in pericardial pressure, a relative collapse of the right ventricle (D) during diastole will appear. This is followed by an equalization of ventricular pressures, resulting in a visible flattening or deviation of the interventricular septum (A) toward the left ventricular cavity on ultrasound. Collapse of the left atrium (B) will occur only when there is isolated left-sided tamponade, a rare situation that can arise when severe underlying pulmonary hypertension is present.

A 22-year-old man presents after encountering a Portuguese man-of-war in the ocean. He reports significant stinging to his leg with some paresthesias. Which of the following has been shown to be most effective to neutralize additional nematocysts? A Cold fresh water B Hydrogen peroxide C Salt water D Vinegar

C Salt water In the United States, the Portuguese man-of-war is found in water along the southern US coast, West coast, and Hawaii. Worldwide, it is found in tropical and subtropical oceans. Envenomation occurs through nematocysts and is typically limited to local pain, paresthesias, and dermatitis. In more severe envenomations, patients develop nausea, headache, chills and rarely cardiopulmonary collapse. After discharge, nematocysts can still function after the animal dies or the tentacles are separated from the animal. Additionally, they may not all discharge at the time of initial attack, but may release the venom during attempted rescue and treatment. The first attempt at treatment is to remove the nematocysts without causing them to discharge. Hot water and topical lidocaine have been shown to be more universally beneficial in improving pain symptoms and are preferentially recommended. However, these treatments are less available at beaches. Therefore, removing the nematocysts and washing the area with saltwater is considered first line. Urine is NOT effective at preventing nematocyst discharge

An 18-year-old girl presents to the ED with left ankle pain. Earlier in the day she was playing softball and slid into second base and "twisted her ankle." On exam, you note moderate swelling, tenderness, and pain with passive range of motion of the ankle. You note some abnormal motion when stressing the joint. Which of the following is the most likely diagnosis? A First-degree sprain B First-degree strain C Second-degree sprain D Second-degree strain

C Second-degree sprain Sprains are classified as ligamentous injuries resulting from an abnormal motion of a joint. In such cases, there is injury to the ligamentous fibers of a supporting joint. Sprains are graded according to the severity of pathologic findings, however, clinically the grades are often indistinct. A second-degree sprain is a partial tear of a ligament (more than first-degree). Clinically, there will be moderate hemorrhage and swelling, tenderness, painful motion, abnormal motion, and loss of function. Although there may be some laxity with stressing of the joint, an absence of end points will be seen only with complete ligament rupture (i.e., third-degree sprains).

A 32-year-old woman is brought to the ED by her husband because she "has been acting strangely." She has a past medical history of depression that is well controlled with fluoxetine. He also reports she has been suffering from a cold and took over-the-counter cough medication a few hours prior to the onset of her symptoms. She is agitated and confused. Her blood pressure is 160/80 mm Hg, pulse is 140 beats per minute, and temperature is 39°C. She is flushed and her pupils are dilated. She has clonus and hyperreflexia in her lower extremities, as well as a tremor in her hands. What is the most likely diagnosis? A Malignant hyperthermia B Neuroleptic malignant syndrome C Serotonin syndrome D Tyramine reaction

C Serotonin syndrome The patient is suffering from serotonin syndrome likely due to an interaction between her antidepressant medication, fluoxetine and dextromethorphan, a cough suppressant found in many over-the-counter cough and cold medications. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Serotonin syndrome results from excessive serotonin accumulation in the synaptic cleft and manifests as a triad of altered mental status, autonomic instability, and neuromuscular abnormality. Serotonin syndrome often occurs as the result of a drug-drug interaction between medications that increase the amount of serotonin in the synaptic cleft or following an overdose with an SSRI Treatment is BZDs, cyproheptadine, removing the offending agent(s)

A 3-year-old girl presents to the ED with her parent and grandparent for evaluation of vaginal spotting. The child has no other concerns and specifically does not report sexual abuse or trauma when questioned without family. After watching a news special on sexual abuse, the parent is concerned that her daughter may have been sexually assaulted, despite no specific reports. The child is acting appropriately, and there are no external lesions or signs of trauma. The internal pelvic exam is difficult due to the patient's age. Which of the following statements applies to this patient? A Obtain a pelvic X-ray prior to attempting a physical exam B She is the victim of abuse, so do no further evaluation without a trained nurse present and contacting authorities C She may have a vaginal foreign body D Vaginitis is an unusual diagnosis in this age group

C She may have a vaginal foreign body Children often fear parental disapproval of a vaginal foreign body placement. This often leads to a delay in diagnosis until secondary signs (such as vaginal bleeding, foul-smelling discharge, or purulent drainage) are noted by parents. The physical exam is often quite difficult, owing to patient anxiety, small anatomic size, and parental concerns about sexual or physical abuse. However, a thorough vaginal exam is indicated in patients with vaginal bleeding or discharge. Use of a nasal speculum with procedural sedation or trained assistant (such as a child life specialist) may facilitate this exam

Neostigmine (Prostigmin)

Cholinesterase inhibitor/Anticholinesterase which causes accumulation of acetylcholine at cholinergic receptor sites. Prevent cholinesterase from inactivating acetylcholine, resulting in improved transmission of nerve impulses. Used for myasthenia gravis. Precautions/interactions: do not administer if systolic BP is less than 90 mm Hg. Side effects: slow HR, chest pain, weak pulse, increased sweating and dizziness, feeling like need to pass out, weak or shallow breathing, urinating more than usual, seizures, and trouble swallowing. Wear medic alert bracelet. Monitor for cholinergic crisis.

A 77-year-old man presents with chronic low back pain with a radicular pattern of burning paresthesias equally down both legs. The paresthesias worsen after walking for 5 minutes and improve after a few hours of sitting down. Which of the following is the most likely diagnosis? A Ankylosing spondylitis B Peripheral neuropathy C Spinal stenosis D Zygapophyseal joint osteoarthritis

C Spinal stenosis This patient describes a classic example of intermittent neurogenic claudication, the hallmark of spinal stenosis. The spine's central and foraminal canals narrow when the spine is in extension, as with walking, and open up when in flexion, as in sitting. Up to 30% of adults > 60 years of age have lumbar stenosis anatomically, but many are asymptomatic. In general, paresthesias are found in neurogenic claudication but not in vascular claudication. Also, leg pain due to vascular claudication resolves when the patient stops walking, whereas neurogenic claudication does not immediately subside.

A 44-year-old man is transferred from a nursing facility for thrombocytopenia. He was transferred to a nursing facility 6 days ago for pulmonary embolism and is on low-molecular-weight heparin. His platelets have decreased from 352 to 100 x 109/L. There is no active bleeding at this time. Which of the following is the most likely management indicated? A Continue current therapy B Order heparin-induced platelet aggregation studies and continue therapy while awaiting results C Stop low-molecular-weight heparin and start fondaparinux D Transfuse platelets

C Stop low-molecular-weight heparin and start fondaparinux This patient presents with heparin-induced thrombocytopenia (HIT) requiring immediate cessation of heparin. HIT is an immune-mediated side effect of heparin. It occurs in 0.5-2.6% of patients receiving unfractionated heparin and is less common in patients receiving low-molecular-weight heparins (< 1%). It usually occurs within 5-7 days of initiation of therapy. Thrombotic complications are serious and can lead to limb loss in 20% and death in 30%. Diagnosis is made by a drop in platelets of 50% after heparin is started. Serotonin release assays and heparin-induced platelet aggregation assays can confirm the diagnosis. Management focuses on stopping the offending agent (unfractionated or low-molecular-weight heparin) and starting an unrelated anticoagulant if continued therapy is indicated. Typically, direct thrombin inhibitors (lepirudin, argatroban), factor Xa inhibitors (fondaparinux), or heparinoids (danaparoid) are indicated for continued treatment. What is the transfusion trigger for patients with thrombocytopenia in the absence of acute bleeding or required surgery? A platelet level < 10,000/µL should prompt transfusion, as these patients are at increased risk of spontaneous hemorrhage.

A 25-year-old woman makes a rapid unplanned ascent while scuba diving at a depth of 50 feet. One minute after surfacing, she suffers a loss of consciousness. She is towed to shore and two minutes later goes into cardiac arrest. What position should the first responders use during her resuscitation? A Left lateral decubitus B Right lateral decubitus C Supine D Trendelenburg

C Supine This patient has an arterial gas embolism, the most common cause for loss of consciousness and cardiovascular collapse in a diver during the first few minutes after ascent. It is caused by expanding gas that ruptures pulmonary alveoli, introducing air into the pulmonary venous circulation. From there, the air embolism can travel to the brain and heart, causing sudden neurologic deficit and cardiovascular collapse. Immediate intervention includes placement of the patient in a supine position, administration of 100% oxygen by face mask, and intravenous fluids to increase perfusion. Definitive treatment involves rapid recompression using hyperbaric therapy The left (A) and right lateral decubitus (B) position is recommended if the patient is vomiting and thus becomes at risk for aspiration. Previously it was thought that placing patients in the Trendelenburg position (D) would "trap" air in the left ventricle. However, research has shown that air distribution occurs quickly, and rather than being helpful, the Trendelenburg position merely increases intracranial pressure, decreases cerebral perfusion, and interferes with other resuscitative measures.

A 75-year-old man with a history of insulin-dependent diabetes presents to the ED complaining of right eye pain. The patient was watching his grandson play baseball and all of a sudden experienced retroocular and supraorbital pain associated with diplopia. The patient mentions that just last month, he went for his annual medical exam and everything was "normal". His hemoglobin A1c at the time, however, was 8%. On exam, you note right-sided ptosis and the inability of the patient to move his right eye superiorly and medially. Fundoscopic exam is normal, and the pupillary light reflex is present. You obtain an MRI and it is normal. Which of the following statements is correct regarding this diagnosis? A A lateral canthotomy should be performed emergently to reduce ischemia of the optic nerve B Restriction of eye movements occurs from a fracture of the inferior orbital floor leading to entrapment of a rectus muscle C Symptoms are caused by occlusion of an intraneural nutrient artery serving the oculomotor nerve D The retina will exhibit dilated congested veins giving the characteristic "blood and thunder" appearance E Vision loss is secondary to atherosclerotic plaque embolization

C Symptoms are caused by occlusion of an intraneural nutrient artery serving the oculomotor nerve This patient has a cranial mononeuropathy. Though uncommon, this is strongly associated with diabetes and most often affects the extraocular muscles. The oculomotor nerve is most frequently involved, followed by the trochlear (CN IV) and abducens (CN VI) nerves. The basis of this mononeuropathy appears to be ischemia of the cranial nerve caused by occlusion of an intraneural nutrient artery. This results in injury primarily in the center of the nerve because the core fibers are more dependent on the blood supply from nutrient arteries; peripheral fibers are less affected because they also get supply from collateral vessels. The preservation of the circumferentially located parasympathetic fibers results in sparing of the pupillary light reflex. The sparing of the pupillary light reflex helps to differentiate this mononeuropathy from one caused by a tumor or aneurysm.

A 12-year-old boy is brought to the ED after being struck in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition? A Asystole B Supraventricular tachycardia C Ventricular fibrillation D Ventricular tachycardia

C Ventricular fibrillation Commotio cordis occurs when an object such as a baseball strikes the chest and produces sudden death. It most commonly occurs in children between 5 and 15 years of age with no known predisposing cardiac conditions. Of the few cases where a documented cardiac rhythm post-blunt trauma to the chest has been captured, the most common identified rhythm is ventricular fibrillation. The majority of patients do not survive. What sports does commotio cordis occur most often in? Baseball, although cases have occurred in ice hockey, lacrosse, softball, and fist fights.

A 21-year-old track-and-field athlete trips during her race resulting in severe foot pain. She presents with erythema and edema. During examination, stabilization of the calcaneus and rotation of the forefoot results in a clicking sensation and severe dorsal foot discomfort. Toe flexion and extension is maintained in a normal, nonpainful range. You most likely suspect a dislocation of which of the following joints? A Fibulotalar B Metatarsophalangeal C Tarsometatarsal D Tibiotalar

C Tarsometatarsal Fracture-dislocation of the tarsometatarsal joints is commonly called a Lisfranc injury. These joints exist between the three cuneiforms and the cuboid proximally and the five metatarsals distally, with the key joint being the "locking" interaction between the middle cuneiform and the second metatarsal base. Common mechanisms of injury include trauma and tripping. Pain is located on the dorsum of the midfoot, as compared to perimalleolar ligamentous pain. As such, Lisfranc injuries are easily misdiagnosed as ankle sprains. A key exam finding is pain with forefoot rotation against a stabilized hindfoot (calcaneus). This maneuver is not painful in ankle sprains or ankle mortise injury, but severely painful with Lisfranc injuries. Diagnosis can be upheld when an AP radiograph reveals lateral shift of the second metatarsal off the middle cuneiform. Nondisplaced injuries are treated with non-weight bearing and casting, however, any displacement necessitates surgical intervention

A 53-year-old man is brought into the ED by EMS after he was found lying on the sidewalk next to a homeless shelter. On exam, the patient appears disheveled and is cold to touch. His eyes are closed. He does not answer your questions. His blood pressure is 90/40 mm Hg, heart rate is 40 beats per minute, respiratory rate is 14 breaths per minute, temperature is 84.2°F (29.0°C). An ECG is obtained. Which of the following statements is correct regarding this diagnosis? A Defibrillation is an effective treatment in patients with this condition who develop a dysrhythmia B Definitive treatment is with cardiac catheterization and stent placement C The characteristic ECG findings can also be seen in other conditions such as local cardiac ischemia, sepsis, and CNS lesions D Thrombolytics should be administered if there are no contraindications and the cardiac catheterization lab is unavailable

C The characteristic ECG findings can also be seen in other conditions such as local cardiac ischemia, sepsis, and CNS lesions The electrocardiographic features of hypothermia are very recognizable. The Osborn, or J, wave is seen at the junction of the QRS complex and ST segment. J waves are potentially diagnostic but not prognostic. They may appear at any temperature less than 31.0°C (87.8°F). The amplitude of the J wave corresponds to the degree of hypothermia. The J deflection may be a result of hypothermic ionic alterations. These alterations may also be seen with cardiac ischemia, with sepsis or CNS lesions, and occasionally in young normothermic patients. Defibrillation (A) and many medications may be ineffective until the core temperature is above 86°F (30.0°C). If defibrillation is warranted but unsuccessful, active rewarming should be initiated while CPR is continued. As hypothermia progresses, the patient's rhythm slows, proceeding from sinus bradycardia to atrial fibrillation with slow response, and may proceed to other dysrhythmias, including ventricular fibrillation and asystole. Some J waveform abnormalities can simulate myocardial injury. This patient requires rewarming

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

C The patient has pyelonephritis; start parenteral ceftriaxone and admit In general, symptoms associated with lower UTIs are limited to the genitourinary system and include dysuria, urgency, frequency, hematuria, and suprapubic abdominal pain. In addition to lower urinary symptoms, patients with upper UTIs (pyelonephritis) also develop constitutional symptoms such as fever, vomiting, and malaise and may also have back and flank pain. Therefore, clinical symptoms are often used to differentiate the location of infection. Unfortunately, the correlation between clinical symptoms and the presence and location of the UTI is not exact, and symptoms alone cannot be reliably used to predict the location of infection. Young children and elderly patients, in particular, may have atypical presentations of GU infections. There are multiple treatment options for uncomplicated lower UTI, including single-dose and short-course (three to five days) therapy; local resistance patterns should be consulted when determining a specific antibiotic course. Complicated lower UTI should be treated for seven to ten days. Upper tract UTI should be treated with 10 to 14 days of antimicrobial therapy. Nontoxic patients may be treated as an outpatient. Toxic or pregnant patients and those with urologic abnormalities, immunocompromised, or inability to tolerate oral intake should be placed on parenteral antibiotics. Ceftriaxone has excellent coverage of E. coli and is generally considered the first line for parenteral treatment of uncomplicated pyelonephritis, but local resistance patterns should be considered when selecting specific agents. Fluoroquinolones are another option.

A 16-year-old girl presents with right thumb pain after a fall while skiing. Physical examination reveals pain and swelling of the right thumb. X-ray of the thumb is negative. Valgus stress at the metacarpophalangeal joint results in increased pain and deviation of 40 degrees. What treatment is indicated? A CT scan of the thumb B Sugar tong splint and urgent referral for surgical management C Thumb spica splint and urgent referral for surgical management D Thumb spica splint for 4 weeks and primary care follow-up

C Thumb spica splint and urgent referral for surgical management The patient presents with rupture of the ulnar collateral ligament (UCL) and requires immobilization and urgent surgical management. Injury to the UCL was initially described in Scottish gamekeepers (hence gamekeeper's thumb). The injury was developed through the repetitive motion of twisting the necks of rabbits. Today, the injury is most commonly seen in skiers, who receive the injury during a fall while holding a ski pole. The mechanism of injury is forced abduction of the thumb, resulting in a tear of the UCL near its insertion at the proximal phalanx. Physical examination reveals swelling and tenderness along the ulnar surface of the thumb and difficulty with making a pinching motion. Valgus stress of the UCL can differentiate a partial tear from a complete rupture of the ligament. Stress should be applied to the metacarpophalangeal joint in full extension and at 30 degrees of flexion. If there is more than 35 degrees of joint laxity or 15 degrees of laxity beyond the unaffected thumb, a complete UCL rupture should be suspected. Both partial tears and complete ruptures should be placed in a thumb spica splint. Partial tears typically will recover completely with immobilization, whereas complete ruptures invariably need surgical repair. A thumb spica splint and follow-up with primary care is appropriate for a partial tear but not for a complete rupture

A 38-year-old man presents to the ED after he was assaulted. The patient reports he was punched and kicked across his thorax. The area of most pain is in his left lateral chest. On arrival in the ED, his blood pressure is 130/95 mm Hg, heart rate is 100 beats per minute, temperature is 98.24°F (36.8°C), respiratory rate is 20 breaths per minute, and oxygen saturation is 100% on room air. Physical exam reveals tenderness to palpation along the left lateral costal margin and left upper quadrant of the abdomen. There are no peritoneal signs and no crepitus noted along the chest wall. A supine portable chest X-ray shows no acute intrathoracic process. A bedside FAST exam is performed which shows shows an anechoic collection in the subphrenic space . Repeat blood pressure is 140/90 mm Hg with a heart rate of 95 bpm. Which of the following is the most appropriate next step in the management of this patient? A Admission to a monitored hospital bed for serial abdominal exams B Observe the patient for six hours and discharge home if he is pain free C Transport for computed tomography of the abdomen and pelvis with intravenous contrast D Transport to the operating room for emergent exploratory laparotomy

C Transport for computed tomography of the abdomen and pelvis with intravenous contrast In the setting of trauma, free fluid collections are presumed to be hemoperitoneum. Free fluid in the left upper quadrant most often collects in the subphrenic space. A patient with blunt abdominal trauma who has stable vital signs and hemoperitoneum on FAST exam requires a CT of the abdomen and pelvis with IV contrast to determine the source of bleeding as well as extent of injury. The most likely source of hemoperitoneum is solid-organ injury (spleen in this case).

Deficits of cranial nerves III, IV, and VI on one side suggest which diagnosis?

Cavernous sinus thrombosis.

What is the classic slit lamp appearance of the eye in patients with traumatic iritis?

Cells and flare in the anterior chamber.

A man who presents with syncope is placed on the cardiac monitor. On the monitor, you note a repeating trend of six P waves, five of which are followed by a narrow QRS complex and one of which is not followed by a QRS complex. The PR interval during this trend progressively increases. Which of the following is the most likely diagnosis? A First-degree atrioventricular block B Third-degree atrioventricular block C Type I second-degree atrioventricular block D Type II second-degree atrioventricular block

C Type I second-degree atrioventricular block A key distinction between first-degree and second-degree heart block is that in first-degree block, the P wave is always followed by a QRS complex. In other words, the ratio of P waves to QRS complexes is 1:1 (the electrical signal from the atria always passes to the ventricles). In second-degree atrioventricular (A) block, the electrical impulse sometimes conducts to the ventricles. There are two main types of second-degree AV block. In Mobitz type I (or Wenckebach) second-degree block, there is a progressive beat-to-beat lengthening of the PR interval until a P wave does not conduct through the AV node. The absent conduction and resultant "missing" QRS complex is called a "dropped" QRS, which represents an absent beat of ventricular contraction. First-degree AV block (A) has a 1:1 ratio of P waves to QRS complexes with a prolonged PR interval. Mobitz type II second-degree heart block (D) is characterized by a nonconducted P wave that is not preceded by progressive PR interval prolongation. AV dissociation, or third-degree AV block (B), occurs when none of the P waves conduct through the AV node. This complete AV block occurs with separate atrial and ventricular rates. There is no discrete correlation or trend between P waves and QRS complexes.

A 50-year-old woman presents to the ED with minor chest pain. She lifted some heavy groceries from the car yesterday. She has a history of hypertension that is controlled with metoprolol. In the ED, her vital signs are BP 120/80, HR 68, RR 14, and oxygen saturation 99% on room air. Her rhythm strip is seen above. Which of the following is the represented rhythm? A First-degree heart block B Third-degree heart block C Type I second-degree heart block D Type II second-degree heart block

C Type I second-degree heart block The ECG displays type I second-degree heart block. Second-degree heart block is defined by one or more impulses not reaching the ventricles and is classified as type I or type II. Type I second-degree block, also known as Wenckebach or Mobitz I block, generally involves the AV node. It can be caused by medications such as beta-blockers, digoxin, calcium channel blockers, and adenosine, all of which slow the AV node. It may also be seen secondary to an inferior wall myocardial infarction or increased vagal tone. ECG findings depict progressive PR interval lengthening until a QRS complex is skipped, representing a dropped beat. Type I second-degree heart block is usually asymptomatic. Unless there is symptomatic bradycardia, this heart block does not necessitate treatment. If symptomatic bradycardia occurs, the inciting agent should be stopped or a pacemaker should be placed.

Which of the following statements is most accurate regarding the history or physical exam in patients with acute ischemic heart disease? A Elderly patients present more often with typical chest pain than atypical symptoms B Reproducible chest wall tenderness excludes ischemia as a cause of chest pain C Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation D Women rarely present with atypical features of acute coronary syndrome

C Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation A typical feature of acute coronary syndrome (ACS) is crushing retrosternal chest pain or pressure. Often this is lacking, and patients present with atypical features of the pain or the presence of angina-equivalent symptoms (e.g., dyspnea, nausea, vomiting, dizziness). Many patients with a diagnosis of ACS have pain that is pleuritic, positional, or reproduced by palpation. One large study showed up to 33% of patients diagnosed with acute myocardial infarction did not have chest pain on presentation. Atypical complaints include dyspnea, nausea, diaphoresis, syncope, and pain in the arms, epigastrium, shoulder, or neck. Atypical features of ACS are present with increasing frequency in older populations. In patients older than 85 years (A), atypical symptoms are more common than typical chest pain, with dyspnea being the most common. Isolated physical exam findings are rarely diagnostic of the origin of chest pain. Palpation of the chest wall (B) may reveal localized tenderness, but 5-10% of patients with ACS have chest pain and associated palpable chest wall tenderness. Being a woman (D) is a risk factor for an atypical presentation of ACS

Which of the following statements is most accurate regarding the history or physical exam in patients with acute ischemic heart disease? A Elderly patients present more often with typical chest pain than atypical symptoms B Reproducible chest wall tenderness excludes ischemia as a cause of chest pain C Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation D Women rarely present with atypical features of acute coronary syndrome

C Up to 33% of patients diagnosed with acute myocardial infarction do not have chest pain on presentation A typical feature of acute coronary syndrome (ACS) is crushing retrosternal chest pain or pressure. Often this is lacking, and patients present with atypical features of the pain or the presence of angina-equivalent symptoms (e.g., dyspnea, nausea, vomiting, dizziness). Many patients with a diagnosis of ACS have pain that is pleuritic, positional, or reproduced by palpation. One large study showed up to 33% of patients diagnosed with acute myocardial infarction did not have chest pain on presentation. Atypical complaints include dyspnea, nausea, diaphoresis, syncope, and pain in the arms, epigastrium, shoulder, or neck. Central chest discomfort is the most common presenting symptom in patients with acute ischemic heart disease

An older man is brought from the nursing home for evaluation of altered mental status. On laboratory testing he is found to have acute kidney failure with a BUN of 75 mg/dL and creatinine of 5.0 mg/dL. Which of the following is most likely to be elicited on history or physical examination? A Cystitis B Diuretic use C Urinary retention D Vomiting

C Urinary retention The patient has markedly elevated BUN and creatinine values at a ratio of 15:1. When evaluating acute renal failure, the ratio of BUN/Creatinine is helpful for the identification of the underlying cause. Ratios of <10:1 are suggestive of an intrinsic renal problem (tubular, interstitial, or glomerular injuries) whereas post-renal pathology due to obstruction of flow (neurogenic bladder, mass, stricture, prostate enlargement) will result in a ratio of 10-20:1. Prerenal causes of renal failure will often lead to the BUN/Creatinine ratio of > 20.In this case, acute urinary retention suggests an outflow obstruction either mechanically or due to medication side effects. Additionally, the calculation of the fractional excretion of sodium (FENa) is helpful in identifying a prerenal causes where the valuate is <1%. FENa = UNaPCr/UCrPNa.

A 33-year-old woman with a history of frequent urinary tract infections presents to the Emergency Department with right flank pain and dysuria that started acutely today. The pain is associated with a low grade fever, nausea, and vomiting. Urinalysis is positive for leukocyte esterase and nitrites. Microscopic examination reveals 26 WBC/hpf and 2+ bacteria. A noncontrast abdominal computed tomography scan shows a staghorn calculus in the right kidney. Which of the following is the likely composition of the staghorn calculus? A Calcium oxalate B Cystine C Magnesium, ammonium, and phosphate D Uric acid

C, Magnesium, ammonium, and phosphate Urologic stone formation is the result of supersaturation of dissolved salts in the urine which then condense into a solid. Struvite (magnesium-ammonium-phosphate) stones account for about 10-15% of all stones. They occur almost exclusively in patients with urinary tract infections caused by urea-splitting bacteria such as Proteus, Klebsiella, Providencia, Pseudomonas, and Staphylococcus species. They are also the most common cause of staghorn calculi (large stones that cause a cast of the renal pelvis). Treatment of staghorn calculi is difficult as antibiotic penetration of the stone is poor and the risk for urosepsis exists as long as the stone remains.

A 62-year-old man presents with a productive cough and shortness of breath. He cannot recall how long he has been coughing for but he says that the mucus appears white. Which of the following is consistent with the diagnosis of chronic bronchitis? A A cough 1 day a month for 3 consecutive months that resolves B A cough most days of the month for 1 month each year for at least 2 consecutive years C A cough most days of the month for 3 months each year for at least 2 consecutive years D A cough most days of the month for 6 months that resolves

C. A cough most days of the month for 3 months each year for at least 2 consecutive years A person with chronic bronchitis has a mucus-producing cough most days of the month, three months of a year, for two years in a row without other underlying disease to explain the cough. After a long period of irritation, the individual will experience excess mucus production, the lining of their airways becomes thickened, an irritating cough develops, air flow may be hampered, and the lungs become scarred. Chronic bronchitis is a subcategory of chronic obstructive pulmonary disease (COPD). Patients with chronic bronchitis generally have a history of smoking, are overweight, and demonstrate cyanosis on exam. They are often referred to as "blue bloaters." Since COPD is an obstructive process, pulmonary function tests show an increased residual volume, increased total lung capacity, and a decreased FEV1/FVC.

Following several hours of forceful vomiting, a 65-year-old man develops severe pleuritic chest pain that radiates to his back. In the emergency department, a chest X-ray reveals small bilateral pleural effusions with left larger than the right. Which of the following is the next most appropriate diagnostic study? A Barium esophagram B Computed tomography angiogram of the chest C Diatrizoate meglumine and diatrizoate sodium solution esophagram D Upper endoscopy

C. Diatrizoate meglumine and diatrizoate sodium solution esophagram This patient presents with signs and symptoms consistent with Boerhaave syndrome, or esophageal rupture. Diagnosis includes an initial chest X-ray, which may show subcutaneous emphysema, pneumomediastinum, pleural effusion (left > right), or simply a widened mediastinum. The most appropriate subsequent study would be a diatrizoate meglumine and diatrizoate sodium solution esophagram as it uses water-soluble contrast. Boerhaave syndrome characteristically occurs after repeated forceful emesis or retching. It is most commonly seen in men 50-70 years of age. Rupture of the esophagus is full-thickness and typically occurs at the weakest point, which is the distal posterolateral esophagus. Patients typically present with chest pain that may be pleuritic but may also present with back pain, dysphagia, or subcutaneous emphysema. The classic finding on physical exam is auscultation of the sound of crunching air within the mediastinum while attempting to auscultate the heart. This is known as the Hamman crunch. Management includes surgical consultation immediately upon suspicion of the diagnosis and broad-spectrum antibiotics that include gram-negative and anaerobic coverage due to exposure to oral and GI flora. Even with prompt treatment, mortality remains high at 35%. A barium esophagram is relatively contraindicated in a patient with esophageal rupture due to the potentially corrosive nature of barium contrast to mediastinal structures. An upper endoscopy is contraindicated in esophageal rupture due to the potential to make the condition worse.

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? A Arrhythmogenic right ventricular dysplasia B Dilated cardiomyopathy C Hypertrophic cardiomyopathy D Long QT syndrome

C. Hypertrophic cardiomyopathy Cardiomyopathies are a heterogeneous group of disorders in which there is abnormal cardiac structure, impaired myocardial function, or altered myocardial electrical activity. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in competitive athletes. The prevalence in the general population is estimated to be 1 in 500. In hypertrophic cardiomyopathy, patients have asymmetric hypertrophy that primarily involves the intraventricular septum. This results in reduced compliance of the hypertrophied ventricle, impaired diastolic relaxation, and restricted left ventricular filling. Although many patients are asymptomatic, the most frequent complaint is dyspnea on exertion. Additional symptoms include chest pain, decreased exercise tolerance, and syncope. There may be a family history of sudden cardiac death. On physical examination, patients may have a systolic ejection murmur, heard at the lower left sternal border or at the apex, and a fourth heart sound is often present. Characteristic ECG findings include findings of left ventricular hypertrophy and left atrial enlargement. Chest radiographs are usually nonspecific. Diagnosis is confirmed by echocardiography.

A 41-year-old man presents to the emergency department in respiratory distress. He has a history of asthma but recently ran out of his medications. He appears in moderate distress. Little air movement is heard on bilateral chest auscultation. He is given albuterol and ipratropium bromide. What is the mechanism of action of albuterol? A Activation of gene transcription B Blockade of calcium channels C Increase of cyclic adenosine monophosphate D Reduction of smooth muscle cyclic guanosine monophosphate

C. Increase of cyclic adenosine monophosphate Systemic corticosteroids such as intravenous methylprednisolone, bind intracytoplasmic receptors, activate gene transcription and initiate new protein synthesis. Magnesium sulfate is used in acute asthma exacerbations because it blocks calcium channels and also plays a role in mast cell stabilization and cholinergic neuromuscular transmission. Inhaled ipratropium bromide reduces smooth muscle cyclic guanosine monophosphate (c-GMP) in addition to acting as a postsynaptic competitive antagonist for acetylcholine.

This is a treatment option for aspiration pneumonia in patients with a penicillin allergy.

Clindamycin. Aspiration pneumonia occurs when oral flora are aspirated into the lungs and lead to infection, and is seen in patients prone to aspiration, such as those with altered level of consciousness, use of alcohol or other sedative drugs, swallowing dysfunction, or neurologic disease.

A 52-year-old man presents with painful swelling of the right wrist. On examination, the joint is warm and swollen. Which of the following is consistent with a diagnosis of gout on joint fluid analysis? A Calcium pyrophosphate crystals B Elevated uric acid level C Negative birefringent crystals D WBC count of 125,000/µL

C. Negative birefringent crystals Gout is caused by the deposition of monosodium urate monohydrate crystals in joints throughout the body. Gout and pseudogout are the two most common crystal-induced arthropathies. The initial joint involved in gout in most cases is the first metatarsal phalangeal joint of the foot. Ultimately, 90% of patients with gout experience a flare of arthritis in this location at some point in their lifetime. Gout is caused by a problem with the metabolism of urate or uric acid causing increased accumulation in the blood and tissues. With supersaturating concentrations of urate in the tissues, crystals precipitate. These crystals cause a marked inflammatory reaction in the joint leading to painful swelling of the affected joint. Although most of the time monoarticular, gout may be polyarticular as well. When examined under a microscope, the crystals exhibit a needle-like shape. Under polarizing microscopy, they exhibit negative birefringence. Certain risk factors increase the chance of gout development including: hypertension, diabetes, obesity, dietary excess, alcohol consumption, and thiazide/loop diuretics

A 21-year-old man presents to the emergency department with a headache and neck stiffness. The patient just finished basic training with the Army. He is febrile, has nuchal rigidity, and petechia on his bilateral lower extremities. A lumbar puncture is performed and the Gram stain shows a gram-negative diplococci. Which of the following organisms will most likely be isolated from his cerebrospinal fluid? A Haemophilus influenzae B Listeria monocytogenes C Neisseria meningitidis D Streptococcus pneumoniae

C. Neisseria meningitidis His symptoms include fever and nuchal rigidity that are classically associated with meningitis. The Gram stain shows a gram-negative diplococci which is consistent with Neisseria meningitidis. For adults, this is the second most common cause of acute bacterial meningitis in the United States. If left untreated, it has a high mortality rate even in previously healthy young adults. Vaccination and herd immunity have reduced the incidence in the United States, however, epidemics remain common in South America, Africa, and parts of Asia. Currently, the most widely used meningococcal vaccination does not include coverage for the serogroup B infection, which is now the most common type seen in the United States. Neisseria meningitidis Meningitis Young Outbreaks in close quarters PPX: rifampin Streptococcus pneumoniae is a gram-positive diplococci and is the most common cause of bacterial meningitis in immunocompetent adults. Listeria monocytogenes meningitis is typically seen in infants, elderly, or immunocompromised adults. On Gram stain appears as a gram-positive rods and coccobacilli.

A 36-year-old woman presents to the emergency department with progressive lower back pain. She denies history of fever or trauma, but the pain worsened acutely when she bent over to pick up a box earlier today. Which of the following features is most concerning for cauda equina syndrome? A Decreased patellar reflex on the right B Decreased sensation of the lateral foot C Pain radiating down both legs D Positive straight leg raise

C. Pain radiating down both legs Cauda equina syndrome is a neurosurgical emergency that results from sudden compression of multiple lumbar and sacral nerve roots. Often the result of massive central disk herniation, it can also be caused by trauma, malignancy, and epidural abscess or hematoma. Patients present with acute onset of lower back pain with pain, weakness, and numbness affecting multiple levels and both legs. Urinary retention is the most consistent examination finding and has a positive predictive value of 99%. Patients may complain of overflow urinary incontinence. Other findings include saddle anesthesia, decreased rectal tone, and fecal incontinence. Emergent neurosurgical consultation is indicated for operative decompression.

A 58-year-old woman who works on an assembly line complains of bilateral wrist pain for the last several months. She describes pain, numbness, and paresthesias in her thumb, index, and long fingers. Which of the following tests is most likely to be positive? A Adson's test B Finkelstein's test C Phalen's test D Tinel's sign

C. Phalen's test The patient has carpal tunnel syndrome. Symptoms of carpal tunnel syndrome include gradual onset of numbness, paresthesias, and pain in the thumb, index, and long fingers. Symptoms are often worse at night and after strenuous activity. Carpal tunnel syndrome is commonly caused by repetitive strain. It can also be seen after distal radius and carpal bone fractures and dislocations, or as a result of systemic conditions (e.g rheumatoid arthritis, hypothyroidism, pregnancy, and diabetes). Phalen's test has a sensitivity of 76% and specificity of 80% for carpal tunnel syndrome. The test is performed by having the patient fully flex the wrists and push them together with the hands facing downward. A positive test is elicited if the patient develops paresthesias or numbness in the median nerve distribution within 60 seconds. Tinel's sign is less sensitive that Phalen's sign for carpal tunnel syndrome. A positive test is demonstration of pain or paresthesias in the median nerve distribution when the median nerve is tapped on at the wrist. Cervical radiculopathy and thoracic outlet syndrome should also be considered as symptoms can mimic carpal tunnel syndrome. Nerve conduction studies are used to confirm the diagnosis of carpal tunnel syndrome, with reported sensitivity of 85 to 90%. Nonoperative management for carpal tunnel syndrome includes splinting the wrist in a neutral position, antiinflammatory medications, and cortisone injections into the carpal tunnel. For persistent or severe symptoms, surgical release of the flexor retinaculum is performed.

Which of the following is true regarding acute respiratory distress syndrome? A Defined as a PaO2:FiO2 > 300 B Empiric corticosteroids should be given C Positive end expiratory pressure should be increased with increases in FiO2 D Tidal volume should be started at 10 mL/kg in intubated patients

C. Positive end expiratory pressure should be increased with increases in FiO2 In ​acute respiratory distress syndrome (ARDS), positive end expiratory pressure (PEEP) and FiO2 should be simultaneously titrated up in order to treat hypoxia. ARDS is defined as inflammation of the lung parenchyma leading to impaired gas exchange. It is characterized by an acute onset of lung injury with bilateral opacities on chest X-ray (not explained by other pulmonary pathology), respiratory failure, and a decreased PaO2:FiO2 ratio. Patients with ARDS are difficult to oxygenate and ventilate and have a high mortality. The ARDSnet trial showed that these patients should be started on low tidal volumes and that PEEP and FiO2 should be titrated up together in order to achieve oxygenation goals. PaO2:FiO2 < 300 is consistent with ARDS. Corticosteroids have been shown to improve outcomes in certain scenarios, but are only recommended for early moderate to severe cases of ARDS. Tidal volume should initially be set at 6-8 ml/kg of ideal body weight.

A 72-year-old man presents with the rash seen above. He first noticed a pruritic patchy erythematous rash 2 weeks ago which has progressed to tense bullae. Lesions can be found on his trunk, upper arms, axillae, and inner thighs. Which of the following is the most appropriate treatment of this condition? A Acyclovir B Cephalexin C Prednisone D Trimethoprim-sulfamethoxazole

C. Prednisone Bullous pemphigoid is a disease that primarily affects patients between 60-80 years old. It is an autoimmune disorder that involves autoantibody-mediated damage to the epithelial basement membrane zone. Patients present with a prodrome of a pruritic erythematous urticarial or papular rash followed weeks later by the development of tense bullae atop normal or erythematous skin. The bullae can rupture leaving moist, erythematous erosions and crusting. Nikolsky sign, slipping of the epidermis away from the underlying dermis when gentle lateral pressure is applied, is negative. The lesions can be numerous and widespread, but do not typically affect the mucous membranes. Treatment includes topical steroid ointment for localized disease. Oral prednisone is indicated in widespread disease. Lesions heal without scarring. Patients often suffer from a chronic, relapsing course

An otherwise healthy 4-year-old boy presents with his parents for vomiting and diarrhea. Several kids at his school have had similar symptoms. He began to have nonbloody, nonbilious vomiting yesterday and this morning began to have nonbloody diarrhea. He felt warm at home, but he is currently afebrile. He is well-appearing and playful. He is able to drink water without difficulty. Which of the following is the next best step? A Administer intravenous fluids B Admit for observation C Provide reassurance and discharge home D Send stool cultures

C. Provide reassurance and discharge home Viral gastroenteritis is a common illness in children. Globally, it is one of leading causes of pediatric deaths due to dehydration. Transmission is via the fecal-oral route. Once infected, patients will often have non-bloody, non-bilious vomiting and then develop watery diarrhea. The patient may have fever, and may have some abdominal pain. The duration of illness is typically less than 7 days. Dehydration is the biggest concern. Children who can successfully take oral liquids and appear well are safe for discharge home. The parents should be provided with reassurance, given instructions for oral hydration and red flag symptoms. Some children require pharmacologic control of their nausea. Oral ondansetron is the first line anti-emetic for gastroenteritis.

A 71-year-old woman presents to the emergency department with right ear otalgia and otorrhea. These symptoms began three days ago and have been getting progressively worse. The pain is exacerbated with chewing. On physical exam, she has pain when traction is applied to the pinna. The external auditory canal appears edematous with discharge. Point of care glucose is 381 mg/dL. Which of the following is the most likely causative organism? A Haemophilus influenzae B Moraxella catarrhalis C Pseudomonas aeruginosa D Streptococcus pneumoniae

C. Pseudomonas aeruginosa Pseudomonas aeruginosa is the most common cause of malignant (necrotizing) external otitis. This condition involves an infection of the external auditory canal that can extend into the skull base. Risk factors include advanced age, uncontrolled diabetes, and human immunodeficiency virus (HIV). Initial symptoms include pain and discharge from the affected ear. On physical exam the patient may have exquisite tenderness when traction is applied to the pinna. The external auditory canal often appears edematous with discharge. As the infection extends into the skull base cranial nerve palsies are common. Extension into the temporomandibular joint can cause pain with chewing. The mainstay of treatment is an antipseudomonal antibiotic regimen, which typically includes a course of a fluoroquinolone. The most severe complications include meningitis and brain abscesses.

Which bone is fractured in all types of Le Fort facial fractures? A Ethmoid bone B Nasal bone C Pterygoid plates D Zygoma

C. Pterygoid plates The Le Fort classification system attempts to differentiate midfacial fractures, which account for up to 20% of all facial fractures. In 1901, René Le Fort described three predominant midfacial injury patterns. Each type involves separation of a portion of the midface from the skull base. The pterygoid plates, of the sphenoid bone, must be fractured to diagnose any type of Le Fort fracture. The Le Fort I fracture is a horizontal maxillary fracture with the fracture line passing from the nasal septum to the pterygoid plate, leading to a free-floating palate. The Le Fort II fracture is a pyramidal fracture from the nasal bridge crossing the orbital rim through the maxilla to the pterygoid plates, resulting in a free-floating maxilla (and nose). The Le Fort III fracture is a transverse fracture from the nasal bridge across the orbit and zygomatic arch/frontozygomatic suture to the pterygoid plates and the base of the sphenoid, leading to a free-floating face and thus also termed craniofacial disjunction. A high-resolution computed tomography (CT) scan of the face with axial and coronal slices, and if possible, with 3D reconstruction, is ideal to define these complex fractures. Due to the reality of present-day high-speed, high-impact mechanisms in trauma from motor vehicle crashes, sports injuries, and other causes, most fractures will be a combination of more than one Le Fort type. Patients with Le Fort fractures often present dramatically and with significant hemorrhage. Therefore, aggressive protection of the airway is of primary concern. In the field and prehospital setting, it is generally safer to allow a conscious, talking patient to sit up leaning forward to protect their own airway instead of making an attempt to secure a difficult airway with limited resources and backup. Once in the emergency department, the practitioner can determine whether to proceed with intubation or whether a primary cricothyrotomy may be necessary. Le Fort fractures require admission and usually surgical repair.

A 19-year-old man presents to the Emergency Department with an avulsed tooth. He struck his mouth on the back of another player's head while playing basketball. He arrives thirty minutes after the injury with his right maxillary central incisor in a bag of cold milk. Which of the following is the most appropriate management? A Discharge home with next day dental follow up B Fill the alveolar socket with eugenol oil C Reimplant the avulsed tooth D Scrub the tooth with normal saline

C. Reimplant the avulsed tooth Reimplant the avulsed tooth (B) is the most appropriate next step. Avulsed permanent teeth should be reimplanted as soon as possible, ideally within 30 minutes of the injury. For every minute that the tooth is out of its socket, there is a 1% chance of reimplantation failure. If the tooth is not able to be reimplanted immediately, it should be stored in an appropriate medium. Cold milk is preferable to sterile water or saliva as it has magnesium and calcium. Hank's solution, a neutral cell culture medium, is ideal. Once the tooth is reimplanted, the tooth should be stabilized until dental follow up is arranged. Avulsed primary teeth should not be reimplanted.

What is the most common presenting symptom in patients with acute ischemic heart disease?

Central chest discomfort. Ischemic Heart Disease Angina: exercise-induced discomfort, relieved by rest or nitroglycerin Unstable angina: symptoms at rest or a change in usual symptom pattern Atypical presentations occur in up to one-third of patients Older population, women, history of diabetes, stroke, or heart failure: increased risk for atypical presentation Initial ECG changes: T wave prolongation and magnitude Up to 50% of ECGs are normal or nonspecific Cardiac biomarkers useful in diagnosis Aspirin, nitrates, clopidogrel, heparin, and beta-blockers (within 24 hours) Preferred treatment for AMI: angioplasty or stenting

An uncomfortable-appearing 3-year-old boy presents to your emergency department with a rash that began earlier today. He has had 3 days of illness with fevers and a refusal to be touched. He has a temperature of 39.7°C, heart rate of 150 bpm, blood pressure of 105/70 mm Hg, respiratory rate of 22/min, and oxygen saturation of 97% on room air. He has bright circumoral erythema with crusting and fissuring around his mouth, eyes, and nose. His oral and nasal mucosa are not involved. He has generalized skin peeling as shown above. Which of the following is the most likely diagnosis? A Bullous impetigo B Ecthyma C Staphylococcal scalded skin syndrome D Toxic epidermal necrolysis

C. Staphylococcal scalded skin syndrome Staphylococcal scalded skin syndrome is a severe skin infection caused by two toxins (A and B) produced by Staphylococcus that target and cleave desmoglein 1 (DSG1). It typically affects children under the age of five, causing localized or diffuse sloughing of the skin and can be compared to a severe sunburn. Patients usually seem relatively comfortable but in more severe cases can present in septic shock and have fluid or electrolyte imbalances. The organism is most commonly isolated from the nasopharynx. The bullae are sterile but should be cultured to differentiate lesions from bullous impetigo that are typically positive. Circumoral erythema without mucosal involvement is common and differentiates it from Stevens-Johnson syndrome as desmoglein 3 (DSG3), not desmoglein 1 (DSG1), is predominant in mucosa. Treatment depends on severity but includes intravenous penicillinase-resistant penicillins such as oxacillin or nafcillin. Vancomycin can be used if methicillin resistant Staphylococcus aureus is suspected. These patients warrant close monitoring for fluid and electrolyte changes.

A 38-year-old woman presents with a pruritic rash that has developed over the past several weeks. Physical exam reveals well-demarcated, erythematous plaques with a silver scale located on both elbows. Which of the following is the most appropriate therapy? A Oral cephalexin B Topical diphenhydramine C Topical hydrocortisone D Topical mupirocin

C. Topical hydrocortisone The patient in question is presenting with psoriasis, a chronic inflammatory skin disease that can develop at any age. Its rash appears as well-demarcated, erythematous plaques with a silver scale, and is usually symmetrically distributed. The most common sites of involvement include the scalp, extensor elbows, knees, and gluteal cleft; however, the hands, feet, trunk, or nails may also be involved. Rash may be localized or diffuse. Diagnosis is often suspected based on clinical presentation but may be confirmed by skin biopsy. Localized disease may be treated with topical hydrocortisone or other high-potency topical corticosteroids. Alternative treatments include vitamin D analogs, tar, and topical retinoids. More severe disease may be treated with phototherapy, systemic retinoids, methotrexate, or biologic immune modifying agents. This patient has limited, localized psoriasis so topical corticosteroids is a reasonable treatment option.

Which of the following medications is used in treating acute angle closure glaucoma? A Topical cyclopentolate B Topical homatropine C Topical timolol D Topical trifluridine

C. Topical timolol Acute angle closure glaucoma occurs in older patients with anatomically shallow anterior chambers. This results in the lens resting too close to the iris which increases resistance to aqueous outflow from the posterior to the anterior chamber. Acute attacks are precipitated by pupillary dilation, such as by entering a dimly lit room, emotional upset, or various anticholinergic and sympathomimetic medications. When the pupil dilates, the degree of pupillary blockage increases, resulting in an accumulation of aqueous humor in the posterior chamber, bowing of the iris forward, and obliteration of part, or all, of the angle. The subsequent rapid rise in intraocular pressure results in symptoms of severe eye pain, headache, nausea, vomiting, and decreased vision. Signs include a firm and tender globe, a hazy cornea, a mid-dilated poorly reactive pupil, and an elevated intraocular pressure (> 20 mm Hg). Acute angle closure glaucoma is an ophthalmologic emergency and treatment should be initiated immediately. Topical beta-blockers (e.g. timolol) and alpha-agonists (e.g. apraclonidine) as well as oral or intravenous carbonic anhydrase inhibitors (e.g. acetazolamide) decrease the secretion of aqueous humor from the ciliary body. Topical steroids are given to reduce inflammation. Mannitol reduces the volume of aqueous humor, but should be used with caution in patients with renal or cardiovascular disease.

A 72-year-old man presents with painful swelling in his right groin. On physical examination, there is a tender fullness in the right groin without any overlying skin changes. Which of the following will help facilitate reduction? A Flexion of the hip B Insertion of a finger into the inguinal canal C Trendelenburg positioning D Warm compresses

C. Trendelenburg positioning This patient has an inguinal hernia requiring reduction. First attempts are with direct pressure. If this is unsuccessful, placing the patient in the Trendelenburg position with an overlying ice pack may facilitate reduction. Administration of pain medication also increases successful reduction.

What ophthalmologic emergency results in a "blood and thunder" appearance on fundoscopic examination?

Central retinal vein occlusion.

A 17-year-old boy presents to the emergency department after being struck in the arm by a baseball. On physical examination, he has ecchymosis and swelling over the right medial epicondyle. He is most likely to have decreased sensation of which of the following dermatomes? A C7 B C8 C T1 D T2

C8 Examination of the upper extremity is critical in patients with traumatic injuries in order to determine underlying pathology. Understanding the upper extremity dermatomes helps facilitate accurate diagnosis, management, and response to therapy. Sensation of the fifth (or little) finger and medial half of the fourth (or ring) finger assesses the C8 dermatome. Imaging may be needed to rule out an underlying fracture. Isolated medial epicondyle fractures usually occur in children and adolescents and often result from posterior elbow dislocations, repeated stress (e.g., throwing a baseball), or a direct blow. Examination findings include pain and swelling over the medial epicondyle and painful elbow flexion or forearm supination. Nondisplaced or minimally displaced medial epicondyle fractures are managed nonoperatively with early range of motion. Complications include ulnar nerve palsy and avascular necrosis. Sensation of the tip of the third (or long) finger assesses the C7 (A) dermatome. This also grossly assesses the sensory function of the median nerve. The skin overlying the medial epicondyle is innervated by the T1 (or first thoracic) dermatome (C) and is part of the ulnar nerve but is not typically altered by injury at the medial epicondyle. The T2 (D) dermatomal distribution includes the medial upper arm from the anterior midline to the posterior midline, excluding the skin overlying the deltoid and axilla.

What is the classic triad of an opiate toxidrome?

CNS depression, respiratory depression, and pinpoint pupils (CPR) PE: decreased respiratory rate, sedation, miosis, hyporeflexia, bradycardia, hypotension, hypothermia Labs: glucose to rule out hypoglycemia EKG - prolonged QTc interval may be seen with methadone Tx: respiratory support, opioid antagonist - naloxone Prolonged observation after naloxone if overdose with long-acting opioid Initiating opioid agonist therapy and/or take home naloxone reduce overdose mortality

A 33-year-old man presents with 5 days of gradual onset nonproductive cough, fatigue, and fever. He also notes a 15-pound weight loss over the last month. He is tachypneic with a heart rate of 105 beats/minute, a temperature of 38.2°C, and an oxygen saturation of 89% on room air. On examination, white plaques are noted on his tongue, and his lungs are clear on auscultation. His chest X-ray is shown above. Which of the following is the most likely causative agent? AInfluenza A BKlebsiella pneumoniae CPneumocystis jiroveci DStreptococcus pneumoniae

CPneumocystis jiroveci Pneumocystis jiroveci (formerly carinii) pneumonia (PCP) is an opportunistic fungal pathogen that primarily affects immunocompromised patients, including those with HIV/AIDS, as well as cancer and organ transplant patients on immunosuppressants. PCP is one of the most common AIDS-defining opportunistic infections. Patients present with gradual onset of nonproductive cough, fever, dyspnea, and decreased exercise tolerance. Patients with previously undiagnosed HIV/AIDS may also present with symptoms, such as weight loss and oral candidiasis. Lung auscultation is often normal, although rales or rhonchi may be present. Chest X-ray shows bilateral diffuse interstitial perihilar infiltrates that extend in a bat-wing pattern, although atypical findings, such as a normal chest X-ray or apical infiltrates, can be seen. Spontaneous pneumothorax is also seen in about 10% of patients. Arterial blood gases are often abnormal with decreased pO2 and respiratory alkalosis. Lactate dehydrogenase is increased, with the degree of elevation used as a marker for a worse prognosis. In HIV patients, CD4 counts are typically < 200 cells/mm3. Intravenous trimethoprim-sulfamethoxazole is the antibiotic of choice. Steroids are indicated in patients with moderate to severe disease as indicated by pO2 < 70 mm Hg. They have been found to decrease mortality and accelerate recovery.

What bacteria species is most commonly associated with the development of Guillain-Barré syndrome?

Campylobacter jejuni is the most common bacteria species 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

Hyponatremia

Can present in a variety of ways, depending on the etiology. The patient can appear dehydrated (hypovolemic hyponatremic) or edematous (hypervolemic hyponatremic), or the fluid status can be normal (syndrome of inappropriate ADH release, psychogenic water drinking, drugs, hypothyroidism).

Which Tinea infections require PO antifungals?

Capitis or unguium

What is a severe side effect with chronic ipecac use?

Cardiac toxicity from accumulation of emetine, a component of ipecac

Aortic dissection Summary

Cause: HTN and atherosclerosis of vaso vasorum Presents with tearing chest pain to back Type A: ascending and urgent B: descending and B-blockers Complications: pericaridal tamponade or renal failure

Tuberculosis (TB)

Caused by Mycobacterium tuberculosis Risk factors: HIV, immigration from an endemic area, immunosuppression, malnutrition Primary TBUsually asymptomatic and progresses to latent TB with no interventionCXR: often normal, hilar adenopathy, Ghon focus Latent TBAsymptomaticScreening: tuberculin skin test (TST) or interferon-gamma release assay (IGRA)Tx: rifampin for 4 months, INH-rifampin daily for 3 months, or INH-rifapentine weekly for 3 months. Alternative is INH for 9 months or 6 months. Reactivation TBSx: fever, night sweats, weight loss, productive cough, hemoptysis CXR: upper lobe infiltrates, apical cavitary lesions Dx: sputum smears for acid-fast bacilli (AFB) x3, sputum or tissue culture for AFB (gold standard) Tx: rifampin, INH, pyrazinamide, ethambutol (RIPE) for 6 months Monitor LFTs, add vitamin B6 (prevent peripheral neuropathy due to INH) Comment: Positive TST determined by mm of induration and risk factors 15 mm: people with no known risk factors10 mm: immigration from high-prevalence countries < 5 years ago, injection drug use, residents/employees of high risk settings (homeless shelter, correctional facilities, hospitals, nursing homes), children < 4 years old or exposed to adults in high risk categories 5 mm: HIV infection, recent TB contact, CXR consistent with prior TB, organ transplant, TNF-α inhibitors or chronic steroids

Cardiac tamponade

Caused by accumulation (often rapid) of fluid in the pericardial sac that exceeds the elastic qualities of the pericardium and creates increased intrapericardial pressure. When the distensibility of the pericardial fibers is overwhelmed, intraventricular filling becomes impaired, resulting in decreased end-diastolic filling pressure and ultimately decreased cardiac output. Pericardial fluid can be seen on ultrasound within the pericardial space. Tamponade physiology is clinically diagnosis with Beck's triad: jugular venous distention, muffled heart sounds, and hypotension. ECG findings include electrical alternans (QRS amplitude varies from tall to short) which is a result of the heart "swinging" within the pericardial fluid toward and away from the ECG leads

Pneumocystis Pneumonia (PCP)

Caused by the fungus Pneumocystis jirovecii Risk factors: HIV, immunocompromised host, or immunosuppression Sx: gradual onset of dyspnea, nonproductive cough, fever Labs: ABG, CD4 < 200/mm3, increased LDH CXR: diffuse bilateral ground-glass opacities (batwing pattern), if CXR is nondiagnostic obtain CT Dx: confirm with staining or PCR of respiratory specimens (induced sputum or BAL) Tx: TMP-SMX, add corticosteroids for moderate to severe disease (air PO2 <70 mm Hg or A-a gradient ≥35 mm Hg) Comments: can present with pneumothorax

Mediastinitis Summary

Causes: esophageal rupture or perforation > surgery, head or neck infections CP radiating to neck or intrascapular region, Neck or chest crepitus CT to Dx Rx: Broad-spectrum Abx, ENT or cardiothoracic surgery consultation

HIV

Clinical course: exposure → acute HIV syndrome → seroconversion → asymptomatic period → symptomatic period Dx: 4th generation HIV-1/2 combination antigen and antibody immunoassay followed by HIV-1/HIV-2 differentiation immunoassay Dx tests become positive during seroconversion (3-12 weeks after exposure) Chronic watery diarrhea: Cryptosporidium White cottage-cheese lesions: Candida Irremovable white lesions on lateral tongue: hairy leukoplakia (EBV) Pneumonia, CD4 < 200/mm3: PCP TB: CD4 < 200/mm3, may have negative CXR or PPD Ring-enhancing intracranial lesions + focal neurologic deficits: Toxoplasma gondii Ring-enhancing intracranial lesions + AMS: primary CNS lymphoma Meningitis, CD4 < 100/mm3: Cryptococcus Focal neurologic deficits, nonenhancing white matter lesions, CD4 < 200/mm3: PML (JC virus) Retinitis, cotton-wool spots: CMV Dark purple skin or mouth nodules: Kaposi sarcoma Cutaneous: HSV, zoster reactivation What two malignancies affect the bowel of HIV patients? Kaposi sarcoma and lymphoma

What is the microscopic finding in a patient with bacterial vaginosis?

Clue Cells

Snake anti-venin

Cobra bite Neutralizes venom by binding with circulating venom components and with locally deposited venom by accumulating at the bite site.

What therapy, when used in the acute phase, may be effective in preventing recurrent symptoms of pericarditis?

Colchicine. Pericarditis Sx: pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE: tachycardia and pericardial friction rub, distant heart sounds ECG: PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Most common causes: idiopathic then viral (coxsackie) Tx: NSAIDs, colchicine

Why is warm water recommended when irrigating the external auditory canal?

Cold water can induce severe vertigo.

What colony count is considered diagnostic for infection when urine is collected by catheterization?

Colony count > 50,000 cfu/mL. Pediatric Urinary Tract Infection Boys ≤ 1 year, girls < 2 years MCC: E. coli High-risk patients: US for vesicoureteral reflux (VUR) VUR → kidney damage

Mandated Reporting Requirements

Communicable diseases Child abuse Elder abuse Domestic violence: victim can refuse reporting in most states Most states: GSWs Failure to report may → penalties or civil liability

Disseminated Intravascular Coagulation (DIC)

Complex, acquired disorder in which clotting and hemorrhage simultaneously occur widespread activation of the coagulation and fibrinolytic cascade, leading to a life-threatening bleeding disorder. It is associated with a prolonged aPTT/PT, low platelet count, low fibrinogen level, elevated fibrin degradation products, elevated D-dimer, increased thrombin time, and decreased antithrombin III levels. Microangiopathic hemolytic anemia is invariably present and, accordingly, schistocytes are commonly seen on peripheral blood smear.

Tonsillolithiasis

Condition caused by chronic inflammation of the tonsils in which small concretions develop within one or both of the tonsils. Symptoms of this condition may include halitosis, foreign body sensation, dysphagia, odynophagia, otalgia, and neck pain (though many patients are asymptomatic). Definitive treatment is surgical removal (though not required if symptoms are not bothersome).

What is the name given to wart-like genital lesions associated with secondary syphilis?

Condyloma lata.

What is the most common cause of aortic stenosis in people < 65 years old?

Congenital bicuspid valve

What is Dance sign?

Considered pathognomonic for intussusception, it is a sausage-like mass in the RUQ representing the actual intussusceptum and an empty space in the RLQ representing the movement of the cecum out of its normal position. Intussusception (Telescoping Bowel) Patient will be a child 6 months to 3 years old Colicky abdominal pain, vomiting, and bloody stools (currant jelly) Diagnosis is made by ultrasound (target sign) Most common cause is idiopathicAlthough less common, it is important to be vigilant for pathologic lead points in children of any age Treatment is air or hydrostatic (contrast or saline) enema

Ultrasound: Intrauterine Pregnancy (IUP)

Criteria for Dx: yolk sac (YS) within a gestational sac (GS), intrauterine fetal pole, or intrauterine fetal heart activity IUP seen on transvaginal ultrasound > 38 days after LMP or beta-hCG > 1,500 mIU/mL IUP seen on abdominal ultrasound > 45 days after LMP or beta-hCG > 6,000 mIU/mL YS: present at 5-6 weeks with beta-hCG > 2,000 mIU/mL, first definitive sign of IUP Double decidual sac sign helps distinguish between IUP and a pseudogestational sac

Pericarditis vs STEMI

Criteria that favor STEMI: - Reciprocal ST depression in any leads (except aVR & V1) - STE in lead III > the STE in lead II ​​​​​​​​ - Horizontal or Convex upwards ST-segment morphology - Checkmark sign (R-T sign) - Q-waves that you know are new​​ (be cautious if they are old) - Rarely cause tachycardia (unless cardiogenic shock) Criteria that favor Pericarditis: ==> Look for these only after looking for STEMI -Pronounced PR-segment depression in multiple leads (only reliably seen in viral acute pericarditis, may be transient) - Pericardial friction rub - Spodick's sign - down sloping of T-P line (may be suggestive of pericarditis if no signs of STEMI found) - Can produce new atrial tachyarrhythmias - Tachycardia favors pericarditis (unless in cardiogenic shock)

Which pathogen commonly causes chronic diarrhea in patients with AIDS?

Cryptosporidium

Which of the following patients needs further workup in the emergency department for first-time seizure, assuming that all of them have returned to baseline and have normal glucose levels? A 10-month-old with a 1-day temperature of 38.3°C whose seizure lasted for 5 minutes B 15-month-old with a 1-day temperature of 38.1°C whose seizure lasted for 10 minutes C 3-year-old with a 1-day temperature of 40.2°C whose seizure lasted for 3 minutes D 8-year-old with a 2-day temperature of 38.8°C whose seizure lasted for 5 minutes

D 8-year-old with a 2-day temperature of 38.8°C whose seizure lasted for 5 minutes For a child to be diagnosed with a febrile seizure, certain criteria should be met. Generally accepted criteria include a seizure occurring in a child between the ages of 6 months to 5 years associated with a temperature > 38°C. Additional criteria include the lack of central nervous system infection or inflammation or any metabolic condition that may result in seizure activity. The child must also not have a prior history of afebrile seizures. Simple febrile seizures last less than 15 minutes, have no focal features, and do not recur in a 24-hour period. Complex febrile seizures last longer than 15 minutes, have focal features, or occur more than once in a 24-hour period. An 8-year-old with a 2-day temperature of 38.8°C does not meet the age requirement of a febrile seizure and, therefore, requires further workup, including CBC, blood cultures, urine analysis, urine culture, and cerebrospinal fluid analysis with culture

You need to prescribe antibiotics to a patient with a history of penicillin allergy. He reports that he developed a diffuse body rash when he took amoxicillin but no airway involvement. Which of the following medications is most likely to cause a reaction? A Cefepime B Cefotetan C Ceftriaxone D Cephalexin

D Cephalexin Traditionally, rates of cross reactivity between penicillin allergic patients and cephalosporins is quoted at 10%. However, on further investigation, it appears that this depends on the specific agent and is not the same for all generations of cephalosporins. Recent data suggests that the cross reaction is closer to 1%, and it is associated almost exclusively with first generation cephalosporins (e.g., cephalexin). The other generations are likely negligible. Ultimately the amount of reaction relates to the similarity of the R1 side chain on the cephalosporin molecule to penicillin. These side chains are only shared in 1st and 2nd generation cephalosporins and therefore care must be taken in these patients. The risk is also increased if patients had a true anaphylaxis to penicillin rather than an isolated rash. Which class of cephalosporins has activity against Pseudomonas? Fourth.

Which of the following is an appropriate therapy for a patient with severe acute pancreatitis? A Antibiotics B Anticholinergic agents C Calcium chloride D Crystalloid infusion

D Crystalloid infusion The management of pancreatitis is primarily supportive. All patients with pancreatitis require fluid resuscitation, as volume depletion is common secondary to inadequate oral intake, vomiting, and third-space losses. Fluids should be replaced with lactated Ringer's solution or normal saline; several liters may be required. There is emerging evidence that resuscitation with lactated Ringer's may reduce the incidence of systemic inflammatory response syndrome (SIRS) as compared to normal saline. Vital signs and urine output should be used to judge the adequacy of volume replacement. No indication for NG Tube typically

A 53-year-old man with a history of coronary artery disease, hypertension, and hyperlipidemia presents with chest pain, lightheadedness, and palpitations. His vital signs are T 36.8°C, HR 140 bpm, BP 88/50 mm Hg, RR 18/min, and SpO2 99%. A 12-lead ECG is performed. Which of the following represents the appropriate management? A Adenosine 6 mg IV B Amiodarone 150 mg IV C Diltiazem 10-20 mg IV D Electrical cardioversion

D Electrical cardioversion This patient has a wide complex tachycardia. Given his age and hemodynamic instability, this rhythm should be treated as ventricular tachycardia. The ECG shows a regular wide complex tachycardia at 150 bpm. No discernible P waves exist, and the QRS duration is > 200 ms. Additionally, the patient is hemodynamically unstable, so immediate synchronized electrical cardioversion is indicated Adenosine (A) is used in the treatment of atrioventricular nodal reentrant tachycardia (AVNRT) but is not useful in ventricular dysrhythmias because the site of action is the atrioventricular (AV) node and ventricular dysrhythmias originate below the AV node. Amiodarone (B) can be used for chemical cardioversion in hemodynamically stable patients without ischemic symptoms. Diltiazem (C) is also an AV-nodal blocker that can be used in the treatment of atrial dysrhythmias, including AVNRT and atrial fibrillation or flutter, not ventricular tachycardia.

A 17-year-old boy presents to the ED 30 minutes after intentionally ingesting an unknown amount of drain cleaner. The active ingredient is sodium hydroxide; the pH of the product is 13. Upon arrival, the patient is afebrile, HR is 120 bpm, BP is 130/70 mm Hg, RR is 22/min, and oxygen saturation is 97% on room air. He appears uncomfortable and reports chest discomfort. There are superficial burns of the oral mucosa and inflammation in the posterior oropharynx, but he is not in respiratory distress. Which of the following is true regarding this patient's care? A Activated charcoal should be administered because the patient presented within an hour of ingestion B Dilution with milk or water may be performed C Gastric lavage should be performed to prevent systemic toxicity D He should be kept NPO in preparation for endoscopy E Induction of vomiting with ipecac may be attempted

D He should be kept NPO in preparation for endoscopy Alkaline ingestions may cause severe corrosive damage with liquefactive necrosis. This patient has clear evidence of oropharyngeal injury and should be kept NPO in preparation for endoscopy. Endoscopy will help determine the extent of injury and help guide management, disposition, and follow-up decisions. For caustic ingestions, endoscopy should be performed early, within 12-24 hours of ingestion. Endoscopy should be avoided after the first 2 days post ingestion and for at least 2 weeks thereafter because wound strength is at its weakest during this time, increasing the risk of esophageal perforation during the procedure Induction of vomiting with ipecac (E) is contraindicated because vomiting can cause further esophageal damage. This issue aside, use of ipecac has not been shown to improve outcomes in any circumstance and may increase complications. Therefore, its routine use is no longer recommended. Activated charcoal (A) is contraindicated when an alkaline corrosive has been ingested because there is an increased risk of perforation and leakage of charcoal into the mediastinum, which is a complication associated with significant morbidity and mortality. Alkaline corrosives generally cause local injury and not systemic toxicity (unless significant tissue necrosis or perforation occurs), limiting the benefit of activated charcoal. Additionally, the administration of charcoal can obscure endoscopic visualization. Severe esophageal injury may occur from alkaline ingestions. Insertion of a nasogastric tube with gastric lavage (C) may cause perforation and should be avoided. Early dilution (B) (within a few minutes) may be attempted in patients with mild or no symptoms. Dilution should be avoided in patients who are significantly symptomatic and have potential for airway compromise. The patient in this case presented 30 minutes after ingestion and has evidence of mucosal injury, thus dilution would be potentially harmful.

An otherwise healthy 16-year-old boy sustains a splenic injury after being struck in the abdomen by the handlebars of his bicycle during a collision with a parked car. Which of the following findings warrants surgical intervention? A Grade I splenic injury and no availability of angiography for embolization B Grade IV splenic laceration C Hematocrit of 33% D Hemodynamic instability E Presence of splenic blush on CT scan

D Hemodynamic instability The spleen is one of the most commonly injured organs in the abdomen. Splenic injuries are important because they are fairly common and can be deadly. The vast majority of splenic injuries, however, can be managed nonoperatively. Of paramount importance in the determination of the appropriateness of nonoperative management is the hemodynamic stability of the patient. Pediatric patients are usually excellent candidates for nonoperative management. However, any patient, regardless of age, who is hemodynamically unstable, particularly those with persistent hypotension despite fluid resuscitation, will require operative intervention. Children have a thicker splenic capsule and firmer parenchyma ==> success rate of nonoperative management for splenic injury higher in children

A 40-year-old woman presents with weakness, fatigue, nausea, and diarrhea. Physical exam reveals orthostatic hypotension and axillary fold hyperpigmentation. Which of the following laboratory abnormalities would you expect to find in this patient? A Hypercalcemia B Hypermagnesemia C Hypokalemia D Hyponatremia

D Hyponatremia Primary adrenal insufficiency (Addison disease), or hypocortisolism, is most commonly caused by autoimmune destruction of the adrenal cortex. Nonspecific symptoms of hypocortisolism include weakness, fatigue, weight loss, anorexia, orthostasis, and listlessness. The most specific sign of primary adrenal insufficiency is hyperpigmentation, typically of the mucous membranes, axillary folds, and nipples. Another specific symptom of primary adrenal insufficiency is salt craving. Because the adrenal cortex is damaged, aldosterone levels are also affected. A decrease in aldosterone will lead to less renal sodium reabsorption and less renal potassium excretion, with subsequent hyponatremia and hyperkalemia. A net loss of sodium to the urine may lead to polyuria and hypovolemia. Hyponatremia associated with adrenal insufficiency may cause seizures, delirium, coma, or death.

A 24-year-old woman presents to the emergency department with complaints of epigastric discomfort and bloating. On physical exam, she has erosion of dental enamel and calluses on the dorsum of her dominant hand. What electrolyte abnormality is most likely present? A Hyperchloremia B Hyperkalemia C Hypermagnesemia D Hypophosphatemia

D Hypophosphatemia Hypophosphatemia is associated with bulimia nervosa. This is a disorder characterized by episodes of binge eating followed by behaviors to prevent weight gain (e.g. laxative misuse, excessive exercise, and self-induced vomiting). Common symptoms include dehydration, dental erosion, abdominal pain, and bloating. Calluses on the dorsum of the hand form due to the pressure of the teeth while stimulating the gag reflex. Chronic vomiting, laxative abuse, and diuretic abuse can cause hypokalemia, hypochloremia, hypomagnesemia, and a metabolic alkalosis.

A 63-year-old man with prostate cancer and bony metastasis presents with nausea, decreased oral intake, constipation, generalized fatigue, and mild confusion. His vitals are T 37.1°C, HR 102 bpm, BP 95/57 mm Hg, RR 20/min, oxygen saturation 96%, and finger stick blood glucose 102 mg/dL. On examination, he has slow mentation, normal pupil size, dry mucous membranes, and decreased bowel sounds. A chemistry panel shows the following: Sodium: 133 mEq/L Potassium: 3.3 mEq/L Chloride: 97 mEq/L Bicarbonate: 23 mEq/L Blood urea nitrogen: 27 mg/dL Creatinine: 2.2 mg/dL Calcium: 13.1 mg/dL Magnesium: 2.1 mg/dL Which of the following treatments should be initiated immediately? A Bisphosphonates B Calcitonin C Intravenous furosemide D IV normal saline

D IV normal saline This patient's multiple symptoms are caused by hypercalcemia secondary to osteolytic bone metastasis from his prostate cancer. Hypercalcemia often presents with nonspecific symptoms, including fatigue, weakness, confusion, hypertension, bradycardia, polyuria, polydipsia, dehydration, nausea, vomiting, constipation, ataxia, and coma. Any symptomatic hypercalcemia or asymptomatic hypercalcemia with a serum level > 14 mg/dL should be aggressively treated. Treatment should start with repletion of intravascular volume with isotonic saline. Restoring glomerular filtration rate (GFR) will lead to renal calcium clearance. Bisphosphonates (A) and calcitonin (B) are osteoclast inhibitors and reduce calcium mobilization from bone. These agents take many hours to work and do not have a role in emergent treatment of hypercalcemia. Furosemide (C) is a loop diuretic that inhibits resorption of calcium but must be preceded by volume expansion because it will exacerbate dehydration and diminished GFR.

A 32-year-old woman presents with abdominal pain, nausea, vomiting, and change in skin color for 6 days. She states that she had unprotected intercourse 4 weeks ago. Which one of the following tests indicates acute infection with hepatitis B as the cause of the patient's symptoms? A Antibody to hepatitis B e antigen (Anti-HBe) B Antibody to hepatitis B surface antigen (Anti-HBs) C IgG antibody to B core antigen (Anti-HBc-IgG) D IgM antibody to B core antigen (Anti-HBc-IgM)

D IgM antibody to B core antigen (Anti-HBc-IgM) This patient presents with symptoms consistent with acute Hepatitis B virus (HBV) infection. HBV is primarily transmitted through parenteral exposure (needle stick, intravenous drug use) or through unprotected intercourse. Transmission through blood transfusion is rare due to advances in screening techniques. Acute viral hepatitis presents with malaise, fever, anorexia, nausea, vomiting, abdominal discomfort, and diarrhea. Often, jaundice leads patients to consult a physician. Fulminant hepatitis is characterized by the acute onset of hepatic failure and encephalopathy over a short period of time (usually days). Measurement of hepatic enzymes can demonstrate 10- to 100-fold elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. ALT is usually elevated to a greater degree than AST in viral hepatitis (the reverse is usually true in alcoholic hepatitis). Hyperbilirubinemia can be moderate (5-10 mg/dL) or severe (15-25 mg/dL) and usually presents days to weeks after the onset of symptoms. Both direct and indirect bilirubin will be elevated in viral hepatitis. Serum testing can also be used to diagnose the type of viral hepatitis. Acute hepatitis B is characterized by the presence of IgM antibody to B core antigen (Anti-HBc-IgM) Anti-HBs (B) cannot be used to diagnose acute HBV infection as it does not differentiate between active infection, past exposure, or immunization to Hepatitis B. IgG antibody to B core antigen (Anti-HBc-IgG) (C) is produced in response to core antigen later in the infection course and persists for life. The presence of antibody to HBV e antigen (Anti-HBe) (A) indicates resolving infection and low infectivity.

A 23-year-old man presents with testicular pain for 3 hours. He does not report any trauma. The pain is constant, sharp, and severe and is accompanied by nausea and vomiting. His vital signs are normal, except for a heart rate of 110 bpm. On examination, there is no swelling, but the left testicle is extremely tender to palpation. The cremasteric reflex is absent. What management is indicated? A Ceftriaxone 500 mg IM once and doxycycline 100 mg PO BID for 7 days B CT scan of the abdomen and pelvis without contrast C Immediate scrotal ultrasound followed by urology consultation D Immediate urology consultation followed by scrotal ultrasound

D Immediate urology consultation followed by scrotal ultrasound This patient has signs and symptoms concerning for testicular torsion, one of the few true urologic emergencies. Torsion of the testes results from an extravaginal or intravaginal defect leading to twisting of the spermatic cord and resultant ischemia of the testicle. Although the majority of torsion occurs in the absence of trauma, motor vehicle collisions and straddle injuries have been associated with this disorder. Initially, twisting causes decreased venous return, but eventually, arterial obstruction occurs. Physical exam often reveals a tender swollen testicle with a transverse lie that may be higher than the unaffected testicle due to shortening of the spermatic cord with twisting. An absent cremasteric reflex (elevation of the testicle caused by stroking of the inner thigh) is nearly universal (100% in patients > 30 months of age). The duration of vascular obstruction affects the testicular salvage rate. Torsion recognized within 6 hours of symptom onset is associated with a salvage rate of 80-100%, while a delay of 24 hours or longer is almost always associated with a loss of the testicle. Because of the time-sensitive nature of the disorder, urologic consultation must be immediately obtained as the only definitive way to diagnose and treat testicular torsion is with exploration and detorsion in the operating room. Manual detorsion can be attempted in the emergency department if there is a delay in the consultation

A 13-year-old girl is stung on the thigh by a stingray while swimming. She presents to the ED approximately 30 minutes later, reporting severe pain at the site of the sting. On exam, you note a 1.5 cm laceration with an erythematous border on her right anterior thigh. Which of the following is the best next step? A Immerse in 10% povidone-iodine solution B Immerse in 5% acetic acid C Immerse in saltwater at 25°C (77°F) D Immerse in tap water at 45°C (113°F)

D Immerse in tap water at 45°C (113°F) Stingrays use their tail stinger to cause injury through puncture of the skin and local injection of poison. Patients usually present with severe pain at the sting site. Systemic effects are rare. ED management is focused on wound care with removal of any foreign bodies (the stinger can break off in the wound), careful cleaning, tetanus prophylaxis, and pain management. Additional treatment involves mitigation of the poison by immersion of the affected body part in hot water (45°C) for 30-90 minutes or until pain subsides. This immersion is believed to break down the poison, reversing its adverse effects

While performing a laceration repair on a healthy 20-year-old man, a large volume of bupivacaine solution is inadvertently injected intravascularly. Shortly after, the patient complains of mouth tingling and a metallic taste before becoming bradycardic, hypotensive, unresponsive, and finally pulseless. After securing the patient's airway and initiating CPR, which of the following is the next best step in the definitive management of this patient? A Atropine IV B Calcium IV C Hemodialysis D Lipid emulsion IV

D Lipid emulsion IV This patient is showing signs of local anesthetic systemic toxicity (LAST) after direct injection of bupivacaine to his vasculature. Although rare, local anesthetic systemic toxicity has potential to be quickly fatal without appropriate treatment due to extensive cardiac and CNS toxicity. Local anesthetic systemic toxicity can be caused by any local anesthetic, but bupivacaine has a higher propensity due to its increased potency. Neurologic signs of local anesthetic systemic toxicity include perioral sensations, metallic taste, change in mental status, and in severe cases, seizures. Cardiac signs are diverse including bradycardia or tachycardia, hypotension, ventricular dysrhythmias, and asystole. Treatment includes management of ABCs, symptomatic treatment if seizures present, ACLS if indicated, and ultimately lipid emulsion. Lipid emulsion is thought to work by removing anesthetic from cardiac tissue and transporting it to organs for metabolism.

Which of the following is a common cause of hypomagnesemia? A Antacid use B Hypoparathyroidism C Hypothyroidism D Malnutrition

D Malnutrition Chronic malnourishment, such as seen in chronic alcohol use, children with severely restricted diets, or older patients, is a common cause of hypomagnesemia. Other risk factors are eating disorders and patients with cancer. In addition to poor nutrition, hypomagnesemia can be seen in patients on diuretic agents, as well as a number of other medications (e.g., aminoglycosides and proton pump inhibitors). Patients commonly have concurrent hypokalemia, and presenting symptoms and signs are likely due to both of these abnormalities. Common symptoms include muscle cramping and diffuse weakness. More serious complications include vertigo, ataxia, seizures, increased deep tendon reflexes, and cardiac conduction abnormalities. Dysrhythmias include atrial fibrillation, PVC, ventricular tachycardia, and torsades de pointes. QTc prolongation is common prior to the development of ventricular dysrhythmias. In patients with normal renal function, a dose of 1-2 grams of magnesium over 10-60 minutes can be given. The dose and rapidity of administration depend on the severity of the presentation (i.e., should be pushed for torsades de pointes).

A 4-day-old infant diagnosed with cystic fibrosis via amniocentesis presents with abdominal distension and vomiting. Which of the following is the most likely cause of his symptoms given his diagnosis of cystic fibrosis? A Duodenal atresia B Intussusception C Malrotation with midgut volvulus D Meconium ileus

D Meconium ileus Cystic fibrosis is an autosomal recessive disorder caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This mutation results in defects in chloride transport which leads to thick, viscous secretions in the lungs, pancreas, liver, intestines and reproductive tract. While pulmonary symptoms often predominate, cystic fibrosis is a multisystem disease that results in a median predicted survival rate of less than 40 years. Meconium ileus is the earliest clinical manifestation of cystic fibrosis, affecting 10-20% of those diagnosed. Conversely, up to 90% of infants found to have meconium ileus will ultimately be diagnosed with cystic fibrosis. Meconium ileus typically presents in the first few days of life with abdominal distention, vomiting and failure to pass meconium. Abdominal radiographs will show dilated loops of bowel. Diagnosis is confirmed with hyperosmolar contrast enema which can also be therapeutic. All infants diagnosed with meconium ileus who are not known to have cystic fibrosis should have a sweat test. By LATE ADOLESCENCE a majority of patients with cystic fibrosis colonized with Pseudomonas aeruginosa

A 35-year-old man presents to the emergency department with several hours of abdominal pain. The patient notes that he was suicidal earlier in the day and took two bottles of acetaminophen. Examination reveals diffuse abdominal pain that localizes to the epigastrium. Which of the following is the active metabolite seen in acetaminophen toxicity? A N-acetyl cysteine B N-acetyl glucosamine C N-acetyl-p-aminophenol D N-acetyl-p-benzoquinoneimine

D N-acetyl-p-benzoquinoneimine Acetaminophen toxicity is one of the most common causes for hospital admissions, antidote usage and fatalities following ingestion in the United States. Acetaminophen is rapidly absorbed into the bloodstream and at therapeutic levels is broken down into harmless metabolites that are excreted in the urine. Following a large ingestion or repeated supratherapeutic ingestions, the amount of N-acetyl-p-benzoquinoneimine (NAPQI) produced overwhelms the body's natural glutathione stores and causes hepatocellular death. Decision to treat is based upon the Rumack-Matthew nomogram. Once the decision to treat has been made, patients should be treated with N-acetyl cysteine because it acts as a glutathione precursor and enhances acetaminophen conjugation to a non-toxic metabolite. N-acetyl-p-aminophenol (APAP) is the scientific name for acetaminophen and N-acetyl cysteine (NAC) is the treatment for an acetaminophen overdose. N-acetyl glucosamine is a monosaccharide that is derived from glucose and has been used in the treatment of autoimmune disorders such as inflammatory bowel disease.

Syncope

Differentiate between syncope and seizure ECG for all San Francisco Syncope Rule (high-risk criteria): CHESS​CHFHematocrit < 30%ECG abnormalSOBSystolic BP < 90 mm Hg Adolescent athlete + syncope: HOCM (hypertrophic cardiomyopathy) Young woman + abdominal pain + syncope: ectopic pregnancy Older man + abdominal or flank pain + syncope: AAA Sudden-onset severe HA + syncope: SAH Woman + prodrome of nausea, sweating, warmth + syncope: vasovagal Malignancy + sudden-onset SOB + syncope: PE Vasovagal syncope is usually associated with a prodrome of nausea, warmth, pallor, lightheadedness, and/or diaphoresis.

A patient presents with chest pain and the ECG with inferior ST elevation myocardial infarction (STEMI). Which of the following medications is contraindicated in this patient's management? A Aspirin B Clopidogrel C Heparin D Nitroglycerin

D Nitroglycerin the use of nitroglycerin is relatively contraindicated in management. In patients with myocardial ischemia or infarction, nitrates are used to decrease myocardial oxygen demand. They increase venous capacitance leading to decreased preload and are direct coronary artery vasodilators. Coronary artery vasodilation leads to increased blood flow to ischemic myocardium. The beneficial effects of nitrates are profound leading to their recommendation for most patients with a systolic blood pressure > 90 mm Hg. An inferior STEMI is one of these contraindications. Patients with an inferior STEMI may also have right ventricular infarct and be preload dependent. In a patient with an inferior STEMI, right ventricular infarct is suggested by the presence of ST elevation in lead III larger than that in lead II. A right ventricular infarct can be discovered by performing a right-sided ECG and looking for ST elevation in lead "RV4." In these patients, a preload reducing medication like nitroglycerin can lead to a precipitous drop in blood pressure.

A 37-year-old woman presents to the emergency department with a headache and associated nausea and dizziness that started last night (14 hours ago) while she was jogging. She indicates this is the worst headache she has ever had, and it has not improved after taking acetaminophen and ibuprofen. She has a history of migraines and a previous ectopic pregnancy. Her medications include acetaminophen, ibuprofen, and sumatriptan for her headaches. Her examination is normal. What is the most appropriate diagnostic evaluation for this patient? A Computed tomography angiography of the head B Magnetic resonance imaging of the brain C Noncontrast computed tomography of the head D Noncontrast computed tomography of the head followed by lumbar puncture if CT negative

D Non-contrast computed tomography of the head followed by lumbar puncture if CT negative This patient presents with a headache that could be consistent with spontaneous subarachnoid hemorrhage (SAH). Her headache is different than previous headaches she has had, is the worst headache she has ever had and is associated with symptoms of nausea and dizziness that can be found in patients with SAH. Additionally, patients with SAH frequently develop symptoms while engaged in activities that cause increased blood pressure, such as exercise. The imaging modality of choice when SAH is suspected is a noncontrast CT of the head. The sensitivity of CT in diagnosing SAH is highest shortly after symptoms begin and is estimated to be 98-100% within 6 hours of the onset of symptoms. Sensitivity decreases to about 91% at 24 hours and continues to decline rapidly thereafter, reaching 50% at 1 week. For suspected SAH, a negative head CT is typically followed by a lumbar puncture (LP) or CT angiography. Given the life-threatening nature of this disease and the fact that head CT is not 100% sensitive for SAH after several hours (>14hrs), lumbar puncture is still recommended CT angiography can help diagnose SAH in a patient suspected of the diagnosis who presents for evaluation > 6 hours after symptom onset. However, this test would only be performed after negative non-contrast head CT imaging.

Which of the following is the most common form of liver disease in the United States? A Hepatitis A B Hepatitis B C Hepatitis C D Nonalcoholic fatty liver disease

D Nonalcoholic fatty liver disease Nonalcoholic fatty liver disease (NAFLD) is, more or less, a benign condition that has become increasingly common in the United States and Western Europe as weight gain and obesity have become more common. It is now the most common cause of liver disorder in the United States and other industrialized countries. In fatty liver, the liver functions normally and looks normal under the microscope, except for accumulations of fat within cells. NAFLD is often detected when imaging tests of the abdomen are obtained for other reasons (e.g., an ultrasound to look for gallstones). Liver function blood tests are either normal or slightly increased. The diagnosis may be confirmed with a right upper quadrant ultrasound examination. If the liver function tests are significantly elevated or if there are other signs of liver disease (e.g., jaundice), then a liver biopsy may be recommended to look for other problems such as nonalcoholic steatohepatitis (NASH). Aside from losing weight, there is no other treatment, though people with liver disease should be vaccinated against hepatitis A and B if they are not already immune.

Which of the following is the hallmark characteristic of mumps? A Cough, coryza, and conjunctivitis B Epididymo-orchitis C Maculopapular rash D Non-suppurative parotid swelling

D Nons-uppurative parotid swelling Mumps is a viral illness characterized by fever, swelling, and tenderness of the salivary glands, with the parotid gland most commonly affected. The disease is seen most commonly in the winter and spring months and is communicable 7-10 days after the onset of parotitis. Nonsuppurative parotid swelling is the hallmark of mumps. The swelling can be unilateral or bilateral and is sometimes associated with trismus. Less commonly, patients experience epididymo-orchitis, which also can be unilateral or bilateral, and meningitis. The cerebrospinal fluid in these cases usually demonstrates a lymphocytic pleocytosis and mildly decreased glucose. Rare complications include transverse myelitis, Guillain-Barré syndrome, pancreatitis, myocarditis, and deafness. Treatment is supportive Patient will be an unvaccinated child between 2 and 9 years of age History of fever, headache, vomiting, and malaise PE will show fever, parotid swelling, and tenderness Labs will show leukopenia, lymphocytosis, and an elevated serum amylase Most commonly caused by Paramyxoviridae Most common complication in adult men is orchitis During which trimester of pregnancy is mumps most devastating? Congenital infection is rare, but there is an increased likelihood of fetal loss if it occurs in the first trimester.

Which of the following is true of foreign body aspiration? A Children younger than one year have a delayed presentation B Cough is always seen with aspiration C Most aspirated foreign bodies are radiopaque D Obstructive emphysema is the most common abnormal radiologic finding

D Obstructive emphysema is the most common abnormal radiologic finding Unilateral obstructive emphysema is the most common finding indicating airway obstruction. The aspirated foreign body creates a one-way valve effect. This allows inflow of inspired air but prevents complete exhalation. The result is hyperexpansion of the affected lung and, on radiograph, relative hyperlucency with decreased lung markings on the affected side. Additional findings include atelectasis and postobstructive pneumonia. It is important to note that a normal chest radiograph does not rule out the presence of a foreign body and can be seen in about 30% of cases. Infants younger than one year (A) tend to present more acutely than older children due to the relatively small caliber of their airways. Generally, children between the ages of 1 and 3 years are at the highest risk for foreign body aspiration. Although cough may be present (B), wheezing and choking are more commonly seen. Depending on where the foreign body is lodged, an intermittent, position-dependent cough may be noted. Physical exam often reveals decreased breath sounds on the side of the obstruction. Most aspirated foreign bodies are radiolucent (C) because they are often of vegetable origin. However, absent visualization of a foreign body or an abnormal chest radiograph (especially one with signs of unilateral bronchial obstruction) is sufficient to prompt further investigation by CT or bronchoscopy.

Which of the following therapies for COPD is associated with a reduction in mortality? A Anticholinergics B Inhaled corticosteroids C Long-acting inhaled beta-2 agonists D Oxygen

D Oxygen Long-term oxygen therapy reduces COPD mortality. The primary goal of long-term therapy is to increase the baseline PaO2 to > 60 mm Hg or the arterial oxygen saturation to > 90% at rest. Smoking cessation is also key and lowers mortality. Pharmacotherapy does not alter disease progression, but it does provide symptomatic relief, control of exacerbations, and improved quality of life. Anticholinergics (A) such as ipratropium bromide and long-acting inhaled beta-2 agonists (C) such as salmeterol act as bronchodilators and, in combination, improve bronchodilation more than either drug alone. Inhaled corticosteroids (B) are used in select patients with predicted and recurrent exacerbations. Hypoxemic patients should be given supplemental oxygen with SpO2 goal of 88-92% Management options include bronchodilators, anticholinergics, steroids, supplemental oxygen, noninvasive ventilation, smoking cessation, vaccinations, and antibiotics for severe disease, infection present, or those requiring ventilation

An 18-year-old boy presents to the ED after a submersion injury at a local lake. On arrival, he is awake, alert, and cooperative. However, you note he is visibly dyspneic and can speak only in short phrases. Vital signs are BP 145/90 mm Hg, HR 98 bpm, RR 32/min, T 36.2°C, and SpO2 91% on high-flow oxygen. Pulmonary exam reveals diffuse bilateral rales. Which of the following is the most appropriate treatment? A Correct electrolyte imbalance B Intravenous antibiotics C Intravenous corticosteroids D Oxygen by positive pressure ventilation

D Oxygen by positive pressure ventilation The patient demonstrates signs of impending respiratory failure (dyspnea, speaking in short phrases, bilateral rales, hypoxia) and requires tracheal intubation with mechanical ventilation. The decision to intubate a submersion victim is based on clinical impression and objective determination of the adequacy of oxygenation and ventilation. A PaCO2 > 50 mm Hg, an oxygen saturation < 90%, or PaO2 < 60 mm Hg on high-flow oxygen mandates intubation to increase functional residual capacity, decrease intrapulmonary shunting, and reduce ventilation-perfusion mismatch

A 19-year-old man presents to the clinic with the painless penile ulcer. He reports unprotected intercourse with several partners. What is the recommended first line treatment? A Ceftriaxone 500 mg IM x 1 B Doxycycline 100 mg PO BID x 7days C Levofloxacin 500 mg PO x 7 days D Penicillin 2.4 million units IM x1

D Penicillin 2.4 million units IM x1 Doxycycline (B) is an alternative agent for the treatment of syphilis and can be used in those patients who are penicillin allergic. Ceftriaxone 500 mg IM x1 (A) is the drug of choice in the treatment of gonorrhea (Neisseria gonorrhoeae). Gonorrhea typically presents with purulent urethral discharge but can be asymptomatic. Sx: painless ulcer that forms 3 weeks post sexual activity and disappears in 3-6 weeks PE: vaginal, anal, or oral chancre - painless, punched-out lesion with a raised margin, lymphadenopathy Dx: darkfield microscopy, RPR/VDRL confirmed by FTA-ABS Caused by spirochete Treponema pallidum Tx: single IM injection of benzathine penicillin Mnemonic: syphilis is painless ulcer

An 18-year-old man's right leg is trapped beneath his overturned vehicle for nearly three hours before he is extricated and brought to the ED. On arrival, his right lower extremity is cool, mottled, insensate, and motionless. Despite normal vital signs, pulses cannot be palpated below the femoral artery. The compartments of the lower extremity are firm. Which of the following is most likely to improve the chances of limb salvage? A Administering anticoagulant drugs B Administering thrombolytic therapy C Immediately transferring to a trauma center D Performing a right lower extremity fasciotomy

D Performing a right lower extremity fasciotomy The patient has a crush injury to his right lower extremity with advanced compartment syndrome. The only intervention to improve the chances of limb salvage is to perform a right lower extremity fasciotomy. Normal tissue pressure ranges are between 0-10 mm Hg. Capillary blood flow within the compartment may be compromised at pressures > 20 mm Hg. Muscle and nerve fibers are at risk for ischemic necrosis at pressures > 30-40 mm Hg. These pressures may still be tolerated depending on the perfusion pressure, therefore, there is a recent trend toward using delta pressures. Delta pressure = [diastolic blood pressure (DBP) - intracompartment pressure]. A delta pressure ≤ 30 mm Hg is suggestive of compartment syndrome

A 5-month-old girl presents to your ED with a worsening rash. Her regular doctor diagnosed her with eczema 3 days ago, and the parents have been applying topical emollients without effect. She is fussy and is having difficulty sleeping. She has had no fevers. No one in the family has a history of asthma or atopy. However, her 5-year-old brother recently developed a similar pruritic rash. Your exam shows a well-appearing and well-nourished infant trying to scratch at the above rash. Which of the following is the most appropriate topical treatment? A Hydrocortisone 1% B Mupirocin 2% C Nystatin 100,000 units/gram D Permethrin 5% cream

D Permethrin 5% cream Scabies is a highly contagious infestation of the mite Sarcoptes scabiei causing a common polymorphic intensely pruritic rash in children. The classic presentation is that of linear burrows in the webs of fingers and toes, but this is rarely seen. The lesions can be subtle, small erythematous nondescript papules, vesicles, or nodules that are often excoriated and may be tipped by a hemorrhagic crust. The distribution of the lesions varies depending on the patient's age, likely representing the different areas with which the mite has contact. In adults, the lesions are often seen in the axillae, nipples, wrists, elbows, waist, and groin. In infants and toddlers, the distribution includes the head, neck, trunk, axillae, palms, soles, and ankles. Treatment is with permethrin 5% cream. The entire family and everyone who comes in contact with the infant should be treated simultaneously. Bed linens and other fomites should be cleaned or placed in a plastic bag for 1 week to interrupt the life cycle of the parasite. Permethrin dries the skin, so the use of emollients is recommended after treatment. Scabies is often mistaken for eczema since the lesions can appear diffuse and eczematous. However, hydrocortisone 1% (A) will only worsen the illness. Consider scabies in infants with recent widespread dermatosis without a history of atopy. Impetigo can be treated with mupirocin 2% (B). However, this infection typically has golden crusting not seen in our patient. Scabies can be confused with a fungal skin infection as it can have what appears to be satellite lesions. However, the location is very unusual. Nystatin 100,000 units/gram (C) will not treat scabies.

A 6-month-old previously healthy boy presents to the emergency department with a cough and vomiting. His symptoms began with a mild cough 10 days ago. Over the past 48 hours, he has developed coughing spells followed by increased inspiratory effort, as well as post-tussive vomiting. On physical exam, his lungs are clear to auscultation. He has bilateral subconjunctival hemorrhages. Which of the following is the most likely explanation for these findings? A Croup B Epiglottitis C Foreign body aspiration D Pertussis

D Pertussis Pertussis is the most likely cause of his symptoms. Pertussis (whooping cough) is caused by the Bordetella pertussis bacteria. It is commonly transmitted by aerosolized respiratory droplets. Although vaccination for pertussis is widespread, the incidence has been increasing over the past 20 years. Classically, patients will develop evolving symptoms over three distinct stages. The first stage or the catarrhal stage begins with a mild cough and coryza. This worsens over the course of 1-2 weeks and transitions into the paroxysmal stage. This is characterized by severe coughing attacks followed by a forced inspiratory effort with a characteristic whooping sound. Post-tussive vomiting can occur in nearly half of affected patients, especially patients < 1 year old. These severe coughing episodes frequently cause subconjunctival hemorrhages. During the final stage or the convalescent stage the cough slowly resolves over weeks to months. Pertussis is treated with a macrolide antibiotic

Acute Respiratory Distress Syndrome (ARDS) SUMMARY

Diffuse alveolar damage → ↑ alveolar capillary permeability → acute respiratory distress syndrome Causes: sepsis > gastric aspiration, shock Hypoxemia refractory to O2 PA wedge pressure < 18 mm Hg PaO2: FiO2 < 300 mm Hg ↑ A-a gradient CXR: bilateral infiltrates Rx: PEEP, low TVs (6 mL/kg)

A 19-year-old man presents with agitation. EMS states that his friends called 911 after the patient became agitated after smoking drugs. Vital signs are HR 133 bpm, BP 163/93 mm Hg, RR 24/min, SpO2 97%, and finger stick glucose 110 mg/dL. Physical examination reveals an agitated, combative man who is sweating and grunting. Eye exam reveals rotatory nystagmus. What is the most likely etiologic agent? A Cocaine B Heroin C Marijuana D Phencyclidine

D Phencyclidine The patient presents with altered mental status, hypertension, tachycardia, and nystagmus consistent with the use of phencyclidine (PCP). PCP is a dissociative agent originally used as a general anesthetic. It was recalled due to the high rate of emergence reactions associated with the drug. It is structurally related to ketamine. PCP acts as a glutamate receptor (NMDA) antagonist and acts at the dopamine-norepinephrine-serotonin reuptake pump. There are a number of delivery routes for the drug including oral, nasal, rectal, insufflation, or smoking. It can also be delivered by the parenteral route (IV, IM, or SQ). Patients experience a wide spectrum of findings that are similar to other sympathomimetic agents including autonomic changes (tachycardia, tachypnea, hypertension, hyperthermia). Additionally, patients can exhibit agitation, confusion, and violent behavior. A classic finding in PCP intoxication is vertical, horizontal, or rotatory nystagmus. Ataxia, muscle rigidity, and seizures have also been described. Treatment of PCP intoxication focuses on supportive care with benzodiazepines for sedation, cooling as needed, and protection of the patient from self-harm. Phencyclidine (PCP) Intoxication HTN, tachycardia, hyperthermia Vertical, horizontal, or rotatory nystagmus Variable pupil size Combative behavior Complications: rhabdomyolysis, seizures BZDs, cooling, IVF, charcoal

Which of the following drugs would be expected to precipitate acute rejection in a lung transplant patient taking cyclosporine? A Cimetidine B Erythromycin C Nifedipine D Phenytoin

D Phenytoin The current mainstay agent of transplant immunosuppression is cyclosporine. Cyclosporine inhibits both cellular and humoral immunity. It is a potent inhibitor of helper-inducer T cells without affecting the suppressor T cell subset. It has significant risks of toxicity, including dose-related nephrotoxicity. Due to its metabolism by cytochrome P450 enzymes, many common post-transplant drugs alter cyclosporine levels. Those drugs that induce cytochrome P450 enzymes decrease the half-life of cyclosporine and reduce its immunosuppressant effect, precipitating acute rejection. Phenytoin induces cytochrome P450 enzymes. Other common drugs that induce P450 enzymes include nafcillin, phenobarbital, and rifampin. NSAIDs contraindicated ==> NSAIDs exacerbate cyclosporine-induced renal insufficiency by further reducing glomerular filtration. Cyclosporine decreases renal blood flow and has a direct toxic effect on renal tubules.

An 18-year-old woman presents with altered mental status after an unknown ingestion. Her vitals are BP 155/90, HR 122, T 100.7°F, RR 28. Physical examination reveals warm, dry skin, mydriasis, and bladder distension. ECG is seen above. What medication is both diagnostic and therapeutic in this overdose? A Bicarbonate B Lorazepam C Naloxone D Physostigmine

D Physostigmine This patient presents with signs and symptoms of an anticholinergic toxidrome and physostigmine can rapidly reverse symptoms giving a definitive diagnosis as well as clinical improvement. Anticholinergic agents may block a number of different anticholinergic receptors but in terms of patients presenting with an anticholinergic overdose, this typically results from blockade of muscarinic receptors, which is often used interchangeably with anticholinergic. Anticholinergic poisoning results in pupillary dilation, dry mucous membranes, flushed skin, hyperthermia, tachycardia, hypertension, urinary retention, decreased bowel sounds, and dry skin. Additionally, patients exhibit altered mental status ranging from agitation to visual hallucinations to incoherent speech. CNS stimulation can also cause seizures. In massive ingestion, patients can exhibit coma and cardiovascular collapse. Wide-complex tachycardia secondary to sodium channel poisoning is rarely seen. Similar symptoms can be seen in tricyclic antidepressant overdose and a screening ECG should be evaluated for QRS prolongation or the presence of a terminal R wave in aVR. In the absence of these findings, physostigmine can be administered. Physostigmine is an acetycholinesterase inhibitor that blocks the degradation of acetylcholine and overcomes the effects of acetylcholine receptor blockade. It reverses delirium in 87% of patients and agitation in 97% of patients. Physostigmine response is also diagnostic in this toxidrome, as it does not reverse the action of other toxins. However, it should be avoided in patients with tricyclic antidepressant overdose.

A 29-year-old man is brought to the ED with shortness of breath after sustaining a stab wound to the right chest. You do a bedside pulmonary ultrasound which shows no lung sliding. Vital signs are BP 125/70 mm Hg, HR 101 bpm, RR 22/min, and pulse oximetry 92% on room air. What is your next step in management? A Begin a chest thoracotomy B Continue observation while the patient breathes 100% oxygen C Obtain a chest CT scan D Place a chest tube

D Place a chest tube Ultrasound diagnosis of a pneumothorax is based on the absence of two findings normally seen along the pleural surface: lung sliding and comet tail artifacts. When using the ultrasound's M-mode, the lack of lung sliding and comet tail artifact (indicative of a pneumothorax) is described as the "stratosphere or barcode sign." To identify the stratosphere sign, you must first be able to identify the normal appearance of lung sliding often described as the "seashore sign" on ultrasound M-mode. Superficial soft tissue does not move much during respiration and appears as flat lines on M-mode. Normal lung sliding creates a grainy M-mode appearance and is referred to as "waves on a beach," where the smooth soft tissue lines meet the rough lung lines at the bright white pleural line. With pneumothorax, lung sliding is absent and flat lines will be seen above and below the pleura, described as the stratosphere sign. Given that this was detected in the setting of penetrating trauma, the patient is most likely going to require placement of a chest tube for the diagnosis of pneumothorax.

Which of the following symptoms is a hallmark of acute bronchitis? A Dyspnea B Frank hemoptysis C Pleuritic chest pain D Productive cough

D Productive cough Acute bronchitis is caused by inflammation of the large airways of the lung. The hallmark is productive cough. It is usually caused by respiratory viruses and is self-limited within three weeks. Although many clinicians prescribe antibiotics for acute bronchitis, a bacterial source is identified in less than 10% of cases. These cases are most often seen in settings of community outbreaks among college campuses and military personnel. Patients rarely experience dyspnea (A). If dyspnea is present, pneumonia should be suspected. Patients with bronchitis often have blood-streaked sputum not frank hemoptysis (B). If hemoptysis is present, the clinician should be concerned about tuberculosis. Pleuritic chest pain (C) is more associated with pneumonia than bronchitis. Acute Bronchitis Patient presents with a productive cough for > 5 days Most commonly caused by viruses Treatment is symptomatic management Most common cause of minor hemoptysis Routine Abx therapy not indicated

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? A Discharge home with ibuprofen for pain relief B Order a computed tomography scan of the chest C Perform a chest tube thoracostomy D Place patient on 100% oxygen and repeat chest radiograph in six hours

D Place patient on 100% oxygen and repeat chest radiograph in six hours This patient has a spontaneous simple pneumothorax. A pneumothorax is a collection of air in the pleural space. A simple pneumothorax has no communication with the atmosphere and does not show any signs of a tension. Simple pneumothoraces can be any size and may be spontaneous or the result of trauma. A communicating pneumothorax results from a defect in the chest wall (e.g. from a stabbing or gunshot wound). A tension pneumothorax occurs when progressive accumulation of air results in compression and shift of the mediastinal structures. This can lead to rapid onset of cardiovascular and respiratory distress. The incidence of spontaneous pneumothorax is greatest in young, healthy men and the majority are smokers. Patients present with pleuritic chest pain and dyspnea. Examination findings include decreased breath sounds and hyperresonance to percussion. Tracheal deviation, hypotension, and JVD would be signs concerning for a tension pneumothorax. Diagnosis is made by chest X-ray. An end expiratory view increases the sensitivity of the chest X-ray in cases of a small pneumothorax. Ultrasound can also be used with absence of normal lung sliding being diagnostic of a pneumothorax. A small spontaneous pneumothorax in a healthy, minimally symptomatic patient can be treated with 100% oxygen, observation, and repeat radiography in six hours. If there is no progression on repeat chest X-ray, the patient can be discharged home with close follow up. Spontaneous pneumothoraces have a 20-50% chance of recurrence.

A 29-year-old man presents to the ED with a gunshot wound to his right chest. His blood pressure is 110/80 mm Hg, HR 101 bpm, RR 16/min, and pulse oxygenation 95% on room air. You suspect an open pneumothorax. Which of the following is the most important immediate step in the management of this patient? A Endotracheal intubation B Packing the wound C Placing a chest tube through the chest wound D Placing an occlusive dressing over the wound with tape on three sides

D Placing an occlusive dressing over the wound with tape on three sides An open pneumothorax, also referred to as a communicating pneumothorax, is associated with a defect in the chest wall. It is more common in combat injuries, but is also seen with civilian gunshot wounds. Air can sometimes be heard flowing loudly in and out of the defect, prompting the term "sucking chest wound." The loss of chest wall integrity causes the involved lung to paradoxically collapse on inspiration and expand slightly on expiration, forcing air in and out of the wound. Immediate treatment involves placing an occlusive dressing over the wound, which helps convert the injury to a closed pneumothorax. One side of the dressing should be left untaped to prevent conversion of the injury to a tension pneumothorax. Endotracheal intubation (A) may be necessary, but the chest wall injury should be addressed first. Without repair, air will continue to leak out of the chest, even with positive pressure ventilation. Packing the wound (B) should be avoided because the negative pressure during inspiration can suck the packing into the chest cavity. A chest tube (C) will be required but should occur at the fourth or fifth intercostal space at the anterior axillary line. If the chest wall wound is at this position, the chest tube can be placed just outside the site of injury, and an occlusive dressing can be placed over the wound.

A 42-year-old HIV and HCV positive woman presents with shortness of breath, nonproductive cough, and generalized weakness. She states she was diagnosed with HIV 18 years ago and has been intermittently compliant with medications during this time. She smokes one pack of cigarettes daily and has a remote history of IV drug use. Blood pressure is 108/58 mm Hg, respiratory rate 24/min, heart rate 102 bpm, and temperature 100.9°F (38.3°C). An arterial blood gas reveals a partial pressure of oxygen of 75 mm Hg and calculated A-a gradient of 25 mm Hg. Physical exam reveals a thin woman in mild respiratory distress. You note diffuse oropharyngeal thrush. Breath sounds are coarse bilaterally with a prolonged expiratory phase and occasional wheezing. Chest radiograph shows no infiltrate. Which of the following is the most likely diagnosis and most appropriate management? A Community-acquired pneumonia; obtain basic blood work, serum lactate, blood cultures; and initiate treatment with parenteral ceftriaxone and doxycycline B Community-acquired pneumonia; obtain basic blood work, serum lactate, blood cultures; and initiate treatment with parenteral vancomycin and piperacillin/tazobactam C Pneumocystis pneumonia; obtain basic blood work, a serum lactate dehydrogenase; and initiate treatment with albuterol via nebulizer and oral prednisone D Pneumocystis pneumonia; obtain basic blood work, a serum lactate dehydrogenase; and initiate treatment with trimethoprim-sulfamethoxazole and albuterol via nebulizer

D Pneumocystis pneumonia; obtain basic blood work, a serum lactate dehydrogenase; and initiate treatment with trimethoprim-sulfamethoxazole and albuterol via nebulizer Pneumocystis pneumonia (PCP) is one of the most common opportunistic infection among AIDS patients, although its incidence has decreased since the development of highly active antiretroviral therapy (HAART). It is caused by Pneumocystis jiroveci, a fungal organism that was formerly known as Pneumocystis carinii. Approximately 70% of HIV-infected patients acquire PCP at some time during their illness. PCP is often the initial opportunistic infection that establishes the diagnosis of AIDS and occurs when the CD4 count is < 200. Patients with PCP are often more hypoxic relative to their chest X-ray findings and degree of respiratory distress. The classic presenting symptoms of PCP are fever, cough (nonproductive), and shortness of breath that begins with exertion and progresses over time to occur at rest. The chest X-ray may show diffuse interstitial infiltrates, but it may also be normal in up to 20% of cases. The diagnosis is further suggested by an elevated serum lactate dehydrogenase (LDH), although LDH elevation has a low specificity for PCP. A definitive diagnosis is not necessary to initiate treatment with oral or parenteral trimethoprim-sulfamethoxazole. Community-acquired pneumonia (A and B) is the most common type of pneumonia in HIV-infected patients. Chest X-ray findings will often show an opacification lobar infiltrate, whereas chest radiographs in PCP may be normal or show diffuse interstitial infiltrates. The evidence of opportunistic infection in the current patient in conjunction with normal chest X-ray makes PCP more likely. PCP should be treated with trimethoprim-sulfamethoxazole. An alternative agent is pentamidine. Steroids (C) should be administered to patients with a partial pressure of arterial oxygen of < 70 mm Hg or an alveolar-arterial gradient of > 35 mm Hg

A 42-year-old man presents with foot complaints. Last night, he was awakened with severe pain in his right great toe. He denies a history of recent injury. Examination reveals significant edema and erythema of the first metatarsophalangeal joint. The overlying skin is intact but warm. Range of motion, both passive and active, are limited. Which of the following is the most likely diagnosis? A Pediculosis B Pellagra C Pes planus D Podagra

D Podagra Arthritis has several causes other than degeneration (OA) and autoimmune dysfunction (RA). Deposition of crystals into the synovium is one of those causes. Gout involves deposition of monosodium urate crystals into the joint. Acute, nighttime onset of intense monoarticular edema and pain is typical of gouty arthritis. Many cases occur in the great toe's metatarsophalangeal joint, which is termed podagra, while other cases commonly occur in the knee and tarsal joints. Joint aspiration and fluid analysis is recommended. Radiographs may be normal, or may only show soft tissue edema. Serum uric acid levels may be normal during an acute attack of gout, however, interval asymptomatic hyperuricemia commonly exists between, and prior to, the onset of acute attacks. Acute cases are treated with colchicine, indomethacin, intraarticular corticosteroids, and decompressive-aspiration.

Which of the following nerve blocks would be most appropriate to alleviate dental pain involving tooth #15 (left second maxillary molar)? A Buccal nerve block B Inferior alveolar nerve block C Mental nerve block D Posterior superior alveolar nerve block

D Posterior superior alveolar nerve block The commonly used adult tooth numbering system starts with #1 at the right third maxillary molar and ends with #32 at the right third mandibular molar. Primary tooth numbering in children is similar using letters A through T. Dental pain is an increasingly common emergency department chief complaint. Dental anesthesia for procedures or patient comfort can be achieved using either a supra-periosteal local infiltration around the individual tooth apex or using a nerve block. The posterior superior alveolar nerve block anesthetizes the second and third maxillary molars (#15 and #16 on the left) and occasionally the first molar. After application of a topical anesthetic to the gauze-dried mucosa for 60 to 90 seconds, about 1-3 mL of local anesthetic is injected using a 25- to 27-gauge needle to a depth of 20-25 mm distal to the distal buccal root of the upper second molar toward the maxillary tuberosity, i.e., upward, backward, and inward. Frequent aspiration during injection is crucial to avoid the risk of hematoma from puncturing the pterygoid plexus. Bupivacaine with epinephrine is theoretically one of the best choices for dental anesthesia due to its longer duration of action and due to the rich vascularity of the oral cavity. However, care must be taken not to inject epinephrine directly into the vasculature.

A 55-year-old woman with a past medical history of hypertension, type 2 diabetes mellitus, severe chronic obstructive pulmonary disease and migraines presents with left hip pain for 2 weeks. She states that the pain is worse with weightbearing and ambulation. She denies any recent trauma. Vital signs are temp 98.5°F, HR 85 beats/minute, RR 14 breaths/minute, BP 150/85 mm Hg, oxygen saturation 95% on room air. On physical examination, she has tenderness to palpation of the left hip and full range of motion. Distal sensation, motor strength and pulses are intact. X-ray of the left hip is concerning for avascular necrosis of the femoral head. Which of the following is most likely responsible for this finding? A Carvedilol B Dihydroergotamine C Metformin D Prednisone

D Prednisone Patients with multiple chronic medical problems as the one described in this question often take multiple medications for their comorbidities. This patient likely takes systemic steroids (e.g. prednisone) for her chronic obstructive pulmonary disease, which may have contributed to her current condition. Long-term systemic corticosteroids have been shown to cause a variety of adverse effects. These include weight gain, poor wound healing, cataracts, hyperglycemia, psychosis, and avascular necrosis. Avascular necrosis (AVN) is also referred to as osteonecrosis or aseptic necrosis. Acute trauma can disrupt blood flow to bone and can cause AVN over time. Corticosteroid-induced AVN most commonly affects the femoral head. Proposed mechanisms of AVN include fat hypertrophy, fat embolization and intravascular coagulation leading to reduced blood flow.

A 40-year-old woman presents to the ED after having an aggressive outburst at work. Her coworkers felt threatened and called 911. They describe her as a gentle, kind, and dependable person. However, over the last few days, she has become withdrawn and noted to be talking to herself frequently. Her blood pressure is 128/68 mmHg, heart rate is 78 bpm, respiratory rate is of 15/min, temperature is 37.2°C, and her oxygen saturation is 99% on room air. She does not report previous psychiatric history but tells you that she was recently prescribed a new medication. Which of the following medications is most likely responsible for this behavior? A Amlodipine B Metoprolol C Naproxen D Prednisone

D Prednisone Steroid-induced psychosis is a constellation of signs and symptoms that can develop within the first 5 days of treatment with a corticosteroid. Signs and symptoms commonly include emotional lability, anxiety, distractibility, pressured speech, sensory flooding, insomnia, depression, agitation, auditory and visual hallucinations, intermittent memory impairment, mutism, disturbances of body image, delusions and hypomania. The amount necessary to produce this effect is thought to be greater than 40 mg of prednisone daily (or an equivalent dose of another corticosteroid). It is important to note that previous history of psychological disease does not predict the development of steroid psychosis. Symptoms can be quite severe. Patients should be warned when they are prescribed this type of medication as up to 3% of patients with steroid psychosis will commit suicide. Nonpsychiatric causes of acute psychosis should be considered in patients who present with acute psychotic symptoms, are > 35 years of age, and have no previous psychiatric history.

A 45-year-old woman presents with an abrupt onset of headache that began while running on a treadmill 6 hours before arrival. The headache did not resolve with NSAIDs. You obtain the CT scan seen above. On return from the CT scanner, her vital signs are a T of 38°C, HR 113 bpm, BP 163/95 mm Hg, RR 18/min, and oxygen saturation of 91% on room air. The patient is drowsy and confused. What is the most appropriate next step in management? A Administer ceftriaxone and vancomycin B Administer nimodipine C Perform a lumbar puncture D Prepare for intubation

D Prepare for intubation The CT scan is diagnostic of a subarachnoid hemorrhage. The most common cause of a nontraumatic subarachnoid hemorrhage is a ruptured berry aneurysm (up to 80%). Other causes include arteriovenous malformations, cavernous angiomas, mycotic aneurysms, and neoplasms. The headache is classically described as sudden in onset and sometimes associated with physical exertion. Associated symptoms include nausea and vomiting (75%), neck stiffness (25%), and seizures (17%). Patients with altered mental status are at risk for respiratory depression and hypercapnia, which can lead to worsening elevated intracranial pressure (ICP). The patient in the clinical scenario, who is drowsy and confused, should have a definitive airway placed.

A 72-year-old man is brought to the ED from a nursing home for evaluation of oliguria. He is found to have an acutely elevated blood urea nitrogen and plasma creatinine from baseline. A Foley catheter is placed. His urine sodium is < 20 mEq/L and fractional excretion of sodium is < 1%. Which of the following is most consistent with these findings? A Acute tubular necrosis B Loop diuretic medication C Osmotic diuresis D Prerenal azotemia

D Prerenal azotemia This patient's oliguria with acutely elevated blood urea nitrogen (BUN) and plasma creatinine suggests he has acute kidney injury (AKI). His urine sodium of < 20 mEq/L and fractional excretion of sodium of < 1% indicate he has intact reabsorptive function and is able to conserve sodium. This is consistent with prerenal azotemia as the cause of his acute kidney injury. Other findings suggestive of a prerenal etiology of acute kidney injury is a BUN to creatinine ratio > 20:1. What kind of casts would be expected on a urinalysis in a patient with prerenal azotemia? Hyaline casts or no casts at all. Prerenal Acute Kidney Injury ↓ RBF → ↓ GFR BUN to Cr > 20 Urine Na < 20 mEq/L FENa < 1%

A 64-year-old woman with breast cancer and bony metastases presents with nausea, vomiting, and generalized weakness. She is found to have an elevated calcium level. Which of the following is an indication for emergent hemodialysis? A Calcium level of 15 mg/dL B Inability to tolerate oral fluids C Multiple myeloma as the underlying malignancy D Presence of heart failure with reduced ejection fraction

D Presence of heart failure with reduced ejection fraction The mainstay of treatment for symptomatic hypercalcemia is IV fluids, followed by adjunctive treatments like loop diuretics, calcitonin, and bisphosphonates. Emergent hemodialysis is indicated for patients with calcium > 18 mg/dL, neurologic symptoms, or those in whom patients which giving large volumes of fluid is problematic, such as individuals with heart failure with reduced ejection fraction or renal failure. Calcium > 15 mg/dL (A) is incorrect because a calcium > 18 mg/dL is the trigger for hemodialysis. Inability to tolerate oral fluids (B) is not an indication for hemodialysis. Such a patient would still be able to receive IV fluids. Multiple myeloma (C) is one of the malignancies commonly associated with hypercalcemia, but it alone is not an indication for hemodialysis. Other malignancies which commonly result in hypercalcemia include cancers of the lung, breast, head and neck, and leukemias. Hypercalcemia is the most common electrolyte disorder associated with cancer, and occurs in many cancer patients. Multiple etiologies are responsible, including local bone breakdown from metastatic bone disease and secretion of parathyroid-hormone-related protein (PTHrP) by tumor leading to increased calcium resorption from bone

Which of the following cerebral spinal fluid results is most consistent with a diagnosis of bacterial meningitis? A Glucose 60 mg/dL B Glucose 90 mg/dL C Protein 30 mg/dL D Protein 90 mg/dL

D Protein 90 mg/dL An elevated CSF protein of 90 mg/dL is consistent with a diagnosis of bacterial meningitis. Normal adult CSF protein levels are between 15 and 45 mg/dL. An elevated CSF protein is indicative of meningitis (from all causes), encephalitis, subarachnoid hemorrhage, vasculitis, demyelinating disease, and malignancy. There are several types of meningitis including bacterial, viral, fungal, and parasitic. Bacterial meningitis is caused by multiple pathogens including S. pneumoniae, N. meningitides, and Listeria monocytogenes. The likelihood of each pathogen varies based on the patient's age and comorbid state. Signs and symptoms associated with bacterial meningitis include fever, vomiting, meningismus, headache, photophobia, malaise, lethargy, altered mental status, and seizures. Significant morbidity and mortality are associated with bacterial meningitis. Bacterial meningitis is diagnosed via lumbar puncture with cerebral spinal fluid analysis. Specific CSF characteristics are noted, and laboratory tests are sent in order to diagnose meningitis. The initial measurement is an opening pressure, which should be measured in the lateral decubitus position. Next, the turbidity of the fluid should be noted as it is obtained. Cell count and differential are often abnormal in bacterial meningitis. Normal CSF contains no more than 5 WBCs/HPF and no more than one PMN/HPF. WBC counts of greater than 500 with > 90% PMNs are suggestive of bacterial meningitis. Gram stain yields the causative organism up to 80% of the time. CSF glucose is generally low in bacterial meningitis. The CSF-to-serum glucose ratio is 0.4 in normal individuals. Generally, CSF glucose levels of 50-100 mg/dL are considered normal (A and B). Normal adult CSF protein levels are between 15 and 45 mg/dL (C). In the case of bacterial meningitis, CSF protein levels are elevated and CSF glucose levels are low. In the setting of a suspected traumatic lumbar puncture, what is the accepted ratio of WBCs to RBCs? 1 WBC per 700 RBCs

Which of the following is most closely associated with the development of acute cor pulmonale? A Acute bronchitis B Hospital-acquired pneumonia C Left-sided heart failure D Pulmonary embolism

D Pulmonary embolism Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Pulmonary hypertension is the common link between lung dysfunction and the heart in cor pulmonale. Cor pulmonale is usually a chronic condition, but acute pulmonary embolism (more common) and acute respiratory distress syndrome are associated with acute cor pulmonale. The underlying pathophysiology in massive pulmonary embolism causing cor pulmonale is the sudden increase in pulmonary resistance. In chronic cor pulmonale, right ventricular hypertrophy generally predominates. In acute cor pulmonale, right ventricular dilation mainly occurs.

A 71-year-old woman with a past medical history of atrial fibrillation and multiple myeloma presents with palpitations and shortness of breath that began 1 hour ago. She denies fever, cough, hemoptysis or chest pain. Her vital signs include a temperature of 99.5°F, BP 84/58 mm Hg, RR 22 breaths/minute, HR 119 beats/minute, oxygen saturation 92% on 4 liters nasal cannula. Her left leg appears swollen. Her bedside echocardiogram demonstrates poor right ventricular systolic function with no pericardial free fluid. Her chest X-ray shows bibasilar opacities. Which of the following most likely explains her condition? A Acute pericarditis B Cardiac tamponade C Inferior myocardial infarction D Pulmonary embolism

D Pulmonary embolism Pulmonary emboli are classified as massive, submassive or less severe based on the severity of cardiopulmonary stress. Massive pulmonary emboli are defined as clots that cause systolic blood pressure < 90 mm Hg for > 15 minutes, a systolic blood pressure of < 100 mm Hg with a history of hypertension, or a > 40% reduction in baseline systolic blood pressure. They are caused by a large clot burden which increases pulmonary arterial pressure. This creates acute right heart strain because of the right ventricular outflow obstruction. The most common ECG finding in the setting of pulmonary embolus is sinus tachycardia. Ultrasonography of the heart may demonstrate right ventricular hypokinesis, dilation or low ejection fraction. Massive pulmonary emboli can therefore lead to obstructive shock and death if not managed emergently. Risk factors for developing a pulmonary embolus include recent surgery, trauma, prolonged immobility, infection, cancer, estrogen use, age >50 years, and any condition that impedes venous flow. The greatest risk for venous thromboembolism is acute immobility of the hip or knee with non-weightbearing. High-risk surgeries that promote the formation of pulmonary emboli include joint replacements, central nervous system surgeries, and abdominal surgeries to remove cancer. High risk cancers include pancreatic, ovarian, stomach, renal cell carcinoma, glioblastoma, multiple myeloma and metastatic melanoma. Patients with a pulmonary embolism and respiratory distress, hypotension, hypoxia (oxygen saturation <90%) despite supplemental oxygenation, right heart strain on echocardiography or elevated troponins are candidates for thrombolytic therapy with alteplase (tissue plasminogen activator).

A 2-month-old child presents with projectile vomiting. The child initially remains hungry following the episodes of vomiting but, in time, loses interest in feeding and presents to the emergency department appearing wasted and severely dehydrated. On physical exam, the patient appears dehydrated, and a small olive-like structure can be palpated in the right upper quadrant. What is the most likely diagnosis? A Formula intolerance B Gastroesophageal reflux disease C Hirschsprung disease D Pyloric stenosis

D Pyloric stenosis Infants with infantile hypertrophic pyloric stenosis are typically asymptomatic until 3 to 4 weeks of age, although a small number may present as early as the first week of life. Initially, infants present with mild spitting, which progresses to nonbilious projectile vomiting following feedings. Vomiting may be so forceful that it exits through the nostrils as well as the mouth. Emesis may contain "coffee ground" material or small amounts of frank blood but is not bilious. Early in the course, the infant remains hungry following vomiting episodes but, with time, loses interest in feeding and may present wasted and severely dehydrated. Infantile hypertrophic pyloric stenosis is a form of gastric outlet obstruction caused by hypertrophy of circular muscle surrounding the pyloric channel. Correction of infantile hypertrophic pyloric stenosis is the most common abdominal operative procedure during the first 6 months of life. It is arguably not a true congenital defect because the muscular hypertrophy and obstruction tend to be an evolving process during the postnatal period. On physical examination, the infant with infantile hypertrophic pyloric stenosis may appear wasted and dehydrated, but the extent is variable and related to severity and duration of symptoms. Diagnostic Test is US or UGI series (string sign) The classic physical signs are a palpable pyloric mass and visible peristaltic waves. The palpable "olive" is most easily felt in a wasted patient, immediately following emesis or aspiration of the stomach. Boys outnumber girls by a ratio of 4-5:1. The initial therapy is fluid and electrolyte replacement to correct dehydration and hypochloremic metabolic alkalosis. Depending on severity, fluid and electrolyte repletion can usually be accomplished within 24 hours. Definitive therapy is the Ramstedt pyloromyotomy, which entails a longitudinal incision through the hypertrophied pyloric muscle down to the submucosa on the anterior surface of the pylorus.

A 28-year-old woman presents to the emergency department for a lump on her back. She denies fever, chills, weight loss, trauma, dysuria, hematuria, or abdominal pain. Her vital signs are within normal limit for her age. She has a 2 cm soft, mobile, nontender subcutaneous mass without surrounding erythema. Which of the following is the most appropriate next step in management? A Incision and drainage B Oral antibiotics and discharge C Outpatient oncology follow-up D Reassurance and discharge

D Reassurance and discharge A lipoma is a benign, slow-growing fatty tumor that is very common, occurring in approximately 1% of the population. The majority are subcutaneous, but intramuscular, retroperitoneal, or gastrointestinal (e.g., esophagus, stomach, small bowel) lipomas have been described. They are usually asymptomatic. They may be confused with a sebaceous cyst or abscess, so the mass should be evaluated for surrounding erythema, induration, and warmth. Subcutaneous lipomas are usually not affixed to underlying fascia and the surrounding and overlying skin are normal appearing without induration or erythema. Ultrasonography has approximately 95% sensitivity and 94% specificity for detecting subcutaneous lipomas. They mainly cause cosmetic concerns and are removed for this reason rather than for pain or infection. The fibrous capsule must be removed to prevent recurrence. Other reasons for removal include symptomatic lesions, size > 5 cm, and histologic evaluation. Prognosis is great, and recurrence is dependent on complete resection.

Blunt Abdominal Trauma SUMMARY

Diaphragmatic injuries: SOB, Kehr sign, CXR: NGT curled in chest, abdominal organ herniation, thoracic aorta rupture Solid organ injuries: spleen most commonly injured, HD instability Retroperitoneal injuries: hematuria, Grey Turner sign, Cullen sign Hollow viscus injuries: seatbelt sign, peritoneal signs, free air on CXR, Chance fracture Bicycle handlebar injury: pancreatic injury or duodenal hematoma FAST CT: low sensitivity for diaphragmatic, pancreatic, and hollow viscus injuries DPL positive if > 10 mL gross blood or > 100,000 RBC/mL Laparotomy if HD unstable, peritonitis, free air on CXR

Which of the following is considered a risk factor for suicide? A Female sex B First trimester pregnancy C First year of marriage D Recent release from incarceration

D Recent release from incarceration Suicide is the fourth leading cause of death in the United States for individuals between the ages of 18 and 65. Therefore, it is important for emergency physicians to have an understanding of the risk factors associated with suicide. Individuals who were incarcerated and recently released are at high risk of attempting suicide. During the first 2 weeks of release, the suicide risk is up to 12 times that of the general population and approaches that of individuals who have been recently released from an inpatient psychiatric facility. Other important risk factors include male sex, history of psychiatric illness, history of previous suicide attempts, unemployment, drug and alcohol use disorder, chronic illness and pain, recent sexual or physical abuse, lack of housing, veterans, divorce or marital separation, firearms in the home, and lack of religious affiliation. men are more likely to die of suicide

Which of the following indices reported in a standard complete blood count panel is most helpful to differentiate between iron deficiency anemia and thalassemia? A Mean corpuscular hemoglobin B Mean corpuscular hemoglobin concentration C Mean corpuscular volume D Red blood cell distribution width

D Red blood cell distribution width Red blood cell distribution width (RDW) is a measure of the deviation in volume of the RBCs. It is calculated by dividing the standard deviation of the MCV by the mean MCV and multiplying by 100. RDW = (SD MCV / mean MCV) x 100 It is useful in differentiating thalassemia from iron deficiency anemia. The RDW is usually increased in iron deficiency and normal in thalassemia.

A 13-year-old boy with no significant medical history presents to urgent care with a headache 3 days after a closed head injury. The patient states that he stood up from a kneeling position and hit the top of his head on a wood cabinet. There was no loss of consciousness or evidence of seizure activity. In addition to the headache, he reports difficulty concentrating at school and dizziness. His physical examination is unremarkable. What management is indicated? A CT scan of the head with contrast B CT scan of the head without contrast C MRI of the brain D Referral to primary care clinician

D Referral to primary care clinician The patient presents with minor head trauma and concerns consistent with a concussion and should have follow-up arranged with their primary care clinician or concussion specialist. A concussion is a minor traumatic brain injury (TBI) that is often seen in motor vehicle collisions and collision sports (e.g., football, hockey). It is typically caused by a rotational or acceleration-deceleration injury. Patients will present with a number of nonspecific symptoms, including headaches, dizziness, confusion, amnesia, difficulty concentrating, and blurry vision but do not have focal neurologic findings. Despite the absence of severe intracranial injury, patients can have chronic and debilitating symptoms from concussions. Neurology referral is recommended, as patients should have functional testing and tracking of their symptoms to resolution. It is vital to counsel patients to avoid contact sports or activities that increase the risk of recurrent injury as these patients are at risk for more severe injury with a second impact.

A 44-year-old woman presents complaining of dizziness. She states that the room spins to the right every time she turns her head quickly. These episodes last three to five seconds and resolve on their own. Which of the following additional findings is most likely to be present in this patient? A Horizontal nystagmus with the Dix-Hallpike maneuver B Low frequency hearing loss C Reproduction of vertigo with tragal pressure D Resolution of symptoms with the Epley maneuver

D Resolution of symptoms with the Epley maneuver Benign paroxysmal positional vertigo (BPPV) occurs when otoliths that reside in the utricle of the inner ear are displaced into the posterior semicircular canal. When the head is turned rapidly, these otoliths move within the canal, and the patient feels the illusion of rotational motion. The otoliths typically settle within three to five seconds, leading to resolution of symptoms. To diagnose BPPV, the Dix-Hallpike maneuver is performed. The patient is placed in a sitting position on a bed or examination table. The patient's head is turned 45º and is laid supine quickly with his or her head hanging off the table. A positive test occurs with the nystagmus beats upward and torsionally with a reproduction of vertigo. This is repeated for both sides, with each repetition of the maneuver having decreased intensity and duration. A positive Dix-Hallpike maneuver indicates pathology in the posterior canal ipsilateral to the direction of the patient's head. To treat BPPV, the Epley maneuver is performed. For example, if the patient has a positive Dix-Hallpike maneuver on the right, his or her head is rotated 45º to the right, and is laid supine quickly with his or her head hanging off the table. This is identical to the Dix-Hallpike test, except this position is held for one to two minutes. The patient's head is then rotated 90º to the left, and is again held for one to two minutes. The patient is then instructed to lie on his or her left side, and the head is rotated to the left 90º. The patient will be looking at the floor at a 45º angle. After being held for one to two more minutes, the patient is moved back to the seated position. When performed correctly, the Epley maneuver has an 85% success rate.

Which of the following states a correct order of electrical current through the heart during one cycle of normal cardiac depolarization? A Atrioventricular node → sinoatrial node B Bundle of His → atrioventricular node C Left bundle branch → right bundle branch D Right bundle branch → Purkinje fibers

D Right bundle branch → Purkinje fibers A normal cycle of cardiac depolarization begins in the right atrium in the sinoatrial node and passes through the internodal tracts in the right atrium to activate the atrioventricular node. The AV node then sends the electrical impulse to the Bundle of His, which then passes current through the left and right bundle branches to the ventricular Purkinje fibers. Atrioventricular (AV) block is characterized as a delay in processing the electrical impulse within the atrioventricular node. This ultimately results in a delay in ventricular depolarization and contraction. There are three main types: first, second, and third degree AV block. First-degree AV block is characterized as a prolonged PR interval > 0.2 sec, beginning at the start of the P wave and ending at the start of the QRS complex. Common causes of this type of block include electrolyte abnormalities, enhanced vagal tone (as in athletes), myocarditis, infarction, and medications. Common medications which slow cardiac conduction through the AV node and produce a prolonged PR interval include beta and calcium-channel blockers, anticholinesterases, and digitalis.

A 23-year-old man who has unprotected, receptive anal intercourse presents to the ED with two weeks of worsening rectal pain and dyschezia. On exam, he has numerous ulcers in the anorectal area and a crop of grouped vesicles containing clear fluid on an erythematous base. The surrounding skin shows no sign of cellulitis or abscess. Which of the following is the most appropriate next step? A Refer the patient to a surgeon for operative intervention B Send a serology test C Send a Tzanck smear D Treat with acyclovir

D Treat with acyclovir This patient is suffering from herpes simplex proctitis, a sexually transmitted infection. The diagnosis is clinical. Patients present with a painful vesicular rash on an erythematous base. Constitutional symptoms and lymphadenopathy are common. Treatment with antivirals shortens the duration of illness, decreases viral shedding, and improves constitutional symptoms. Commonly used antivirals include acyclovir, valacyclovir, and famciclovir.

A 72-year-old man presents with chest heaviness associated with diaphoresis and shortness of breath. Acute occlusion of which of the following coronary arteries is most likely to cause transient complete heart block with a narrow QRS complex? A Left anterior descending B Left circumflex C Left coronary D Right coronary

D Right coronary A branch off of the right coronary artery (RCA) is responsible for the blood supply of the AV node in 70%-80% of the population. This is often referred to as being "right dominant." In the remaining portion of the population, the left coronary artery provides flow to the AV node. In complete heart block, there is no communication between the atrium and ventricle because of interruption of electrical flow through the AV node in the setting of acute ischemia to the node. Occlusion of the RCA (causing an inferior infarct) can cause complete heart block as it supplies the AV node. This block is usually transient and asymptomatic with a narrow QRS complex, and does not often require pacing. From which coronary artery does the SA node receive its blood flow? The right coronary artery in 55% of patients and left coronary artery in 45% of patients.

A 72-year-old woman presents to the ED after a syncopal episode. Prior to the episode, she had been experiencing shortness of breath and chest pain while walking. On exam, you auscultate a murmur. What is the most likely location and quality of this murmur? A Apical; harsh systolic murmur B Apical; mid-systolic click with a crescendo murmur C Lower left sternal border; holosystolic, blowing murmur D Right, second intercostal space; harsh systolic murmur

D Right, second intercostal space; harsh systolic murmur The patient has aortic stenosis. It commonly presents with the triad of chest pain, dyspnea, and syncope. Due to its anatomical location, the murmur with aortic stenosis is best heard over the right, second intercostal space. It is a harsh midsystolic ejection murmur that has a crescendo-decrescendo shape and radiates to the right carotid artery. Other findings in aortic stenosis include a diminished pulse, narrow pulse pressure, and left ventricular hypertrophy. An apical harsh systolic murmur (A) is heard with mitral incompetence. An apical midsystolic click with crescendo murmur (B) is heard with mitral valve prolapse. A lower left sternal border holosystolic blowing murmur (C) is heard with tricuspid regurgitation.

A 17-year-old girl presents with a fever, myalgias, and headache. She noted a rash that began 4 days after she noted her fever. The macular rash began on her wrists and ankles and spread toward her chest. She recently returned from hiking the Appalachian Trail in North Carolina about 1 week ago and is concerned about her symptoms. Which of the following is the most likely diagnosis? A Babesiosis B Colorado tick fever C Lyme disease D Rocky Mountain spotted fever

D Rocky Mountain spotted fever Rocky Mountain spotted fever (RMSF) is a life-threatening infection caused by Rickettsia rickettsii transmitted by dog ticks. Its name derives from its original description in Montana and Idaho in the late 19th century and from the typical petechial rash occurring initially on the wrists and ankles and spreading centripetally (toward the center). It may also involve the palms and soles. Despite its name, most cases are reported from the southeastern and south-central United States. A little more than 50% of the cases present with the classic triad of rash, fever, and tick exposure, although the rash is rarely present during the first 3 days of the illness and usually appears on day 4. Abrupt onset of fever, severe headache, and myalgias are the most common presenting symptoms 5-7 days after the tick bite.

Which of the following statements regarding drug exposure and overdose in pregnancy is true? A Gastric decontamination with charcoal or whole-bowel irrigation should be avoided in pregnancy B Iron crosses the placenta and causes direct fetal toxicity C Most antidotes should not be given in pregnancy due to the risk of fetal harm D Salicylate overdose is associated with poor fetal outcomes E The threshold to treat carbon monoxide poisoning is the same in pregnant and nonpregnant women

D Salicylate overdose is associated with poor fetal outcomes Salicylate toxicity is associated with significant fetal morbidity and mortality for several reasons. Unionized salicylate crosses the placenta, and because the pH of the fetus is slightly higher, the salicylate becomes ionized and accumulates in the fetus. The fetus is also unable to hyperventilate, a common compensatory mechanism for the acid-base abnormalities that occur in the setting of salicylate poisoning. The fetus has fewer metabolic buffers and less ability to excrete salicylate. Salicylate can also displace bilirubin from protein-binding sites, enabling it to cross the blood-brain barrier, which can result in kernicterus. Finally, by inhibiting prostaglandin synthesis, salicylates can lead to premature closure of the ductus arteriosus, which can cause fetal distress. The treatment of salicylate poisoning in the pregnant patient is similar to that of the nonpregnant patient and includes decontamination, urinary alkalization, and, in severe overdose, hemodialysis. Gastric decontamination with activated charcoal and whole bowel irrigation (A) are considered safe in pregnancy. Additionally, gastric lavage can also be performed if indicated. Induction of vomiting with syrup of ipecac may increase intra-abdominal pressure and has not been shown to improve outcomes and is contraindicated. In pregnancy the fetus doesn't appear to be susceptible to high maternal serum Iron (B) levels, but it does cause severe maternal metabolic derangements and shock, which are associated with adverse fetal outcomes. The antidote for iron poisoning, deferoxamine, is pregnancy category C. Although there is a paucity of randomized controlled data, most antidotes (C) should not be withheld in the setting of pregnancy. Maternal toxicity and instability is the most important contributor for fetal morbidity and mortality. Most antidotes have not demonstrated fetal harm and, therefore, should not be withheld. Carbon monoxide (E) exposure is a leading cause of poisoning fatalities in the United States. The fetus is at greater risk for toxicity because there is decreased oxygen delivery to the placenta, the presence of carboxyhemoglobin in the fetal circulation, and impaired ability to remove CO by ventilation. As such, the carboxyhemoglobin concentrations are higher, and the half-life of CO in the fetus is almost five times that of the mother. Because of this, treatment with supplemental oxygen should be five times longer in the pregnant patient. Additionally, the threshold for treating with hyperbaric oxygen is lower in the pregnant patient (> 25% in base population or > 15% in pregnancy or fetal distress).

A 48-year-old man presents to the ED with severe cellulitis on his right foot. His older mother accompanies him and tells you that she has been encouraging him to seek treatment for several weeks. The man lives alone in a remote area and only comes to town once a month for supplies. Several of his toes are gangrenous, and he does not seem upset when you tell him he may need an amputation. Which of the following personality disorders best fits with this patient's behavior? A Antisocial B Borderline C Paranoid D Schizoid

D Schizoid People with schizoid personality disorder are socially withdrawn and isolated. They prefer to live alone and lead solitary lifestyles (e.g., live in a remote area). They are classically described as "loners" and have very few close interpersonal relationships. Because they do not openly display their emotions, they tend to be perceived as emotionally cold, aloof, and apathetic (i.e., do not become upset at the thought of amputation) MC in men

A 20-year-old college student presents four hours after she was struck in the face by a volleyball. She complains of decreased vision, pain, and watering of the affected eye, which is accompanied by the abnormality seen in the image above. What additional test should be performed first while waiting for the ophthalmologist to arrive? A Applanation tonometry B CT scan of the brain C Fundoscopy D Seidel test

D Seidel test This patient is presenting with a traumatic hyphema. This injury is most commonly caused by rupture of an iris root vessel resulting in accumulation of blood or clot in the anterior chamber of the eye. Given the finding of decreased visual acuity in the setting of a hyphema, the patient should be evaluated for increased intraocular pressure via applanation tonometry. However, prior to performing tonometry, a globe rupture must be ruled out. The Seidel test is a simple procedure to evaluate for potential globe rupture. Performance of this test involves staining of the eye with fluorescein and evaluating for aqueous humor leakage using a cobalt blue light source. When positive, lime-green fluid can be seen streaming from the injured globe. Sickle Cell Anemia - associated with spontaneous hyphema development

An obese 20-year-old man presents with a two-day history of pain and swelling to the gluteal crease. He denies fever or any other associated symptoms. Physical exam reveals a tender, swollen, fluctuant mass to the superior gluteal cleft. Which of the following is the most likely diagnosis? A Bartholin gland abscess B Hidradenitis suppurativa C Perianal abscess D Pilonidal abscess

D. Pilonidal abscess This patient has a pilonidal abscess. More common in men than women, pilonidal abscess occurs in the midline at the superior gluteal fold. Pilonidal cysts usually occur due to an ingrown hair becoming embedded in the skin. They can become infected, forming a painful abscess. Incision and drainage should be performed followed by surgical referral for definitive treatment. Antibiotics are generally unnecessary unless the patient is immunocompromised or has an associated cellulitis. Tx: - I&D - Consider antibiotics - Refer to surgery

A 22-year-old woman presents complaining of vaginal bleeding. She reports having cramps and passing a large "blood clot" earlier this morning. She took a home pregnancy test earlier in the month and it was positive. Urine pregnancy test in the ED is positive. Her cervical os is closed and she has minimal bleeding. Ultrasound confirms a complete abortion. Hemoglobin is 12.5 g/dL. Which of the following is the most appropriate next step? A Administer intramuscular methotrexate B Consult OB/GYN for emergent dilation and curettage C Discharge home with outpatient OB/GYN follow up in 24 hours D Send blood for a type and screen

D Send blood for a type and screen The patient had a complete abortion, however, she is at risk for Rh isoimmunization and therefore a type and screen should be sent to assess her Rh status. Rh isoimmunization occurs when an Rh-negative mother is exposed to Rh-positive fetal blood and develops anti-Rh-antibodies. Subsequent Rh-positive pregnancies are at risk of developing hemolysis and hydrops fetalis. RhoGAM (anti-Rh immunoglobulin) is given to Rh-negative mothers to prevent this from occurring. It is given routinely at 28-weeks of pregnancy, however, it must also be given in threatened and complete abortions, ectopic pregnancies, amniocentesis, and following abdominal trauma

A 42-year-old woman complains of two days of pain and swelling in the right submandibular area. She complains of dry mouth and worsening of the swelling and pain during mealtime. Vital signs are unremarkable. Which of the following is the first-line treatment for this condition? A Antihistamines B Dilation and incision C Oral antibiotics D Sialogogues

D Sialogogues This patient has symptomatic sialolithiasis, which results in outflow obstruction by a stone or calculus in the salivary gland or duct. The submandibular location is most commonly involved because it has more viscous secretions and runs an uphill course. Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone. Palpable stones may also be "milked" from the duct, if they are distal enough, by gentle stroking in a posterior to anterior direction.

A 36-year-old woman presents to the ED with multiple concerns. She reports having headaches, joint pain, back pain, and muscle aches for the last 10 years. She also reports chronic diarrhea since the age of 18. In addition, she has numbness and tingling in her toes. She is estranged from her husband because she can no longer have sexual intercourse due to pain. She has visited multiple primary care physicians and frequented many local emergency departments. A neurologist, rheumatologist, gastroenterologist, gynecologist, and cardiologist have evaluated her. She has undergone cardiac catheterization, colonoscopy, MRI of her brain and spine, multiple X-rays of her joints, and diagnostic laparoscopy, all of which were unremarkable. She lost her job since she attends frequent doctor appointments and because she spends much of her time on the internet researching her symptoms. Which of the following diagnoses should be considered? A Factitious disorder B Functional neurologic symptom disorder C Illness anxiety disorder D Somatic symptom disorder

D Somatic symptom disorder Somatic symptom disorder is a polysymptomatic disorder that begins before the age of 30 years and extends over many years. The symptoms are not intentionally feigned, are misinterpreted or exaggerated, and not medically attributable to a single condition. They ultimately lead to social and occupational stress, often resulting in loss of relationships and employment. The diagnostic criteria include required parts with some qualifiers as listed below. This is very difficult to diagnose. Patients are likely to be harmed by frequent diagnostic studies.

A 57-year-old woman with a history of alcoholic liver cirrhosis presents complaining of vomiting bright red blood once this morning, but she has no active vomiting. Vitals are T 98.7°F, HR 113 bpm, BP 103/66 mm Hg, RR 22/min, and oxygen saturation 97%. Examination reveals a woman in moderate distress, scleral icterus, and black stools on rectal examination. The patient is placed on a monitor and has two large-bore IVs placed. A unit of packed red cells is started, and the gastroenterologist is called. What therapy should be initiated at this time? A Place a Sengstaken-Blakemore tube B Placement of a nasogastric tube for lavage C Start a proton pump inhibitor drip D Start octreotide drip and antibiotics

D Start octreotide drip and antibiotics This patient presents with an upper gastrointestinal bleeding (UGIB), likely secondary to varices. When patients present with an UGIB, it is important to clinically determine the most likely site of bleeding, as this will guide management and determine prognosis. Overall, bleeding from peptic ulcer disease is much more common than bleeding from esophageal or gastric varices. However, in patients with known liver cirrhosis or stigmata of liver cirrhosis (scleral icterus, caput medusa), varices are more common. Bleeding varices are a common presentation of an UGIB in patients with liver cirrhosis or failure. Approximately 60-70% of patients with decompensated cirrhosis will have varices at the time of diagnosis, and 30% of these patients will experience variceal bleeding within the first year. Variceal hemorrhage is potentially life-threatening, and aggressive therapy is necessary to reduce morbidity and mortality. Management should start with good supportive care, including supplemental oxygen and two large-bore IVs. In patients with significant hemorrhage, it is reasonable to start packed red blood cell (PRBC) transfusion without a hematocrit. Additionally, the first hematocrit may not be reflective of the patient's status, as it takes hours for the hematocrit number to calibrate after bleeding. After supportive care, the next intervention should be to involve a gastroenterologist to perform esophagogastroduodenoscopy (EGD). EGD can be both diagnostic and therapeutic in UGIB. Emergency department pharmacotherapy in variceal hemorrhage involves octreotide and antibiotics. Octreotide is a somatostatin analog that causes shunting of blood from the splanchnic circulation, leading to decreased blood flow to the esophageal varices. Although the use of octreotide has not been shown to decrease mortality, it does reduce the need for transfusion. The administration of prophylactic antibiotics to patients at high risk for variceal bleeding reduces the risk of recurrent bleeding and overall infectious complications during hospitalization and may reduce mortality. Ceftriaxone 1 g per day or ciprofloxacin 400 mg twice a day is recommended for this indication, with ceftriaxone showing mild superiority.

Which of the following supports the diagnosis of biliary colic? A An ultrasound that shows an empty gallbladder and duct B Pain that is relieved by eating food C Radiation of abdominal pain to the lumbar region D Steady abdominal pain localized in the right upper quadrant

D Steady abdominal pain localized in the right upper quadrant The term colic is misleading in the diagnosis of biliary colic. Most patients with biliary colic have steady pain, not colicky, in the right upper quadrant or epigastrium. The pain of biliary colic is thought to be caused by contraction of the gallbladder, with transient obstruction of the cystic duct or common bile duct by the stone. With continued obstruction, inflammation of the gallbladder wall leads to cholecystitis. Physical exam in biliary colic usually reveals mild tenderness to palpation in the right upper quadrant. Lab tests are usually normal. The diagnosis is made clinically and by demonstrating stones in the gallbladder on ultrasound. Plain films have a limited role in detecting gallstones because less than 10% of gallstones contain calcium. Management is usually supportive.

A 29-year-old man presents to the emergency department with acute altered mental status, headache, and neck stiffness. Intravenous corticosteroids, ceftriaxone, and vancomycin are given. A noncontrast head CT scan shows no evidence of mass effect. Subsequently a lumbar puncture is performed and a cerebrospinal fluid sample is obtained. It has a cloudy appearance, opening pressure of 27 cm H₂O, white blood cell count of 3,013 cells/µL with a predominance of polymorphonucleocytes, glucose level of 30 mg/dL, and protein level of 62 mg/dL. A point of care blood glucose is 110 mg/dL. Which of the following is the most likely causative organism? A Cryptococcus neoformans B Herpes simplex virus C Mycobacterium tuberculosis D Streptococcus pneumoniae

D Streptococcus pneumoniae The cerebrospinal fluid (CSF) results are most consistent with bacterial meningitis, therefore Streptococcus pneumoniae is the most likely causative organism. This typically presents with the classic triad of fever, confusion, and neck stiffness. In adults, it is commonly due to Streptococcus pneumoniae and Neisseria meningitidis. Often the fluid will appear cloudy or purulent. The CSF glucose in bacterial meningitis is < 40% of the serum glucose. The white blood cell count will typically be > 1,000 cells/µL with a predominance of polymorphonucleocytes (PMNs). Other findings typical of bacterial meningitis include an elevated opening pressure and increased protein level.

A 3-year-old boy presents with his parent for fever and right ear tugging for 2 days. He has also had 1 week of rhinorrhea on review of systems. His vaccines are up to date. His physical exam is remarkable only for a temperature of 38.8°C (101.8°F) and a bulging and erythematous right tympanic membrane. What is the most likely pathogen? A Haemophilus influenzae type b B Moraxella catarrhalis C Staphylococcus aureus D Streptococcus pneumoniae

D Streptococcus pneumoniae This patient presents with signs and symptoms of otitis media. Otitis media is diagnosed by the presence of a middle ear effusion evidenced by absent or limited mobility of the tympanic membrane (TM) or the presence of a bulging TM or an air-fluid level behind the TM. Additionally, the middle ear should have inflammation presenting as erythema or pain. Otitis media may be caused by a number of different bacteria. Streptococcus pneumoniae accounts for 15-25% of the cases of otitis media in children. Other common causative organisms are Haemophilus influenzae and Moraxella catarrhalis. In the past, all otitis media was treated immediately with antibiotics. However, more recent recommendations recognize that many middle ear infections have viral causes and do not require antibiotics. The American Academy of Pediatrics currently endorses either antibiotic therapy or observation for children ≥ 2 years who are immunocompetent with mild signs and symptoms and no otorrhea. Severe acute otitis media is defined as moderate to severe otalgia, otalgia for at least 48 hours, or fever > 39°C (102.2°F). If the decision is made to start antibiotics, first-line therapy should be with high-dose amoxicillin 80-90 mg/kg/day divided into two doses.

A 29-year-old man with sickle cell anemia presents to the ED for fever and purpuric rash on his legs. He is ill-appearing. Vital signs are T 102.2°F, HR 118 beats/minute, BP 101/78 mm Hg, RR 12 breaths/minute, and oxygen saturation 96% on room air. Which of the following organisms is most likely responsible for these findings? A Clostridium perfringens B Listeria monocytogenes C Staphylococcus aureus D Streptococcus pneumoniae

D Streptococcus pneumoniae This patient's clinical picture is suggestive of pneumococcal sepsis. He is at risk due to functional asplenia from autoinfarction from sickle cell disease, and his purpuric rash is the result of coagulopathy associated with asplenia. The spleen functions to filter and phagocytose certain bacteria and parasitized blood cells. Patients with anatomic asplenia (e.g., postsplenectomy) or functional asplenia (e.g., splenic autoinfarction from sickle cell anemia) are at risk for sepsis from encapsulated organisms, including Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Salmonella, and Capnocytophaga. Patients with sickle cell disease should be counselled on staying current on their pneumococcal immunization. Ceftriaxone or other third-generation cephalosporins are the treatment of choice.

A 21-year-old man presents with a headache. What feature should raise the concern for a subarachnoid hemorrhage? A Age < 40 B Fever C History of intravenous drug use D Sudden onset of headache

D Sudden onset of headache A sudden onset of headache should raise concern for subarachnoid hemorrhage (SAH). SAH is a life-threatening disorder that involves extravasation of blood into the subarachnoid space. SAH can either be traumatic or spontaneous. Spontaneous SAH is associated with intracranial aneurysms about 80% of the time. Patients typically present with a sudden onset of severe headache that is classically described as "the worst headache of their life." The headache of SAH is often associated with nausea and vomiting (75%) and may have concomitant neck stiffness (25%) and seizures (17%). Meningismsus is present in half of patients. The workup of a patient with a suspicion of a subarachnoid hemorrhage typically involves a noncontrast head CT. The sensitivity of CT imaging in detecting SAH declines over time. Therefore, in patients presenting with signs and symptoms of SAH > 6 hours in duration, a negative non-contrast CT should be followed by a lumbar puncture or CT angiography.

A 56-year-old man with a history of COPD presents to the ED after developing right-sided chest pain and difficulty breathing. His vital signs are blood pressure of 130/80 mm Hg, heart rate of 92 bpm, respiratory rate of 24/min, temperature of 36.7°C, and oxygen saturation of 93% on room air. A chest radiograph is obtained and shows a right-sided pneumothorax involving approximately 40% of the hemithorax without other findings. What is the appropriate definitive intervention for this patient? A 100% oxygen therapy via nonrebreather mask B Placement of a 7 F catheter with a Heimlich valve using Seldinger technique C Posteriorly directed placement of a 32 F chest tube D Superiorly directed placement of a pigtail catheter

D Superiorly directed placement of a pigtail catheter This patient has a spontaneous pneumothorax secondary to his chronic illness of COPD. The incidence of secondary pneumothorax is three times higher in men than women, and it is most commonly associated with COPD (up to 70% of cases). Malignancy may also be causative and, when present, suggests lung metastases. Other etiologies include tuberculosis and lung abscess. A 20 F chest tube directed superiorly or cephalad (towards the head) or catheter thoracostomy (a pigtail catheter) is most appropriate for the management of this type of pneumothorax. Posterior placement of a 32 F chest tube (C) is used when there is a hemothorax, hemopneumothorax, or large effusion with or without a pneumothorax or when mechanical ventilation is anticipated when a pneumothorax is present. When these are not present, a smaller caliber tube is preferred because it is less invasive. A 7 F catheter with Heimlich valve (B) is placed in smaller, primary (not secondary) spontaneous pneumothoraces where aspiration is likely to be most successful. Very small spontaneous pneumothoraces can also be managed with 100% oxygen nonrebreather mask (A) and observation

A 44-year-old man presents to the ED with 2 weeks of rectal pressure and throbbing rectal pain that worsens with defecation. His vital signs are blood pressure 112/82 mm Hg, heart rate 102 bpm, respiratory rate 16/min, and temperature 101.12°F (38.4°C). Rectal examination reveals a fluctuant, tender mass in the rectal lumen with purulent drainage. Which of the following is the most effective management of this patient's condition? A Emergency department incision and drainage B Intravenous antibiotics C Sitz baths, viscous lidocaine, stool softener, and a high-fiber diet D Surgical consultation

D Surgical consultation The patient has an intersphincteric abscess, a type of perirectal abscess characterized by continued rectal pressure, with worsened throbbing pain on defecation. Often, nothing is noted on external examination of the anus, but internal rectal examination will reveal a tender, fluctuant mass. The patient needs to have the abscess drained in the operating room so that the entire abscess and fistulae network can be evaluated and treated.

A 33-year-old man presents with a rash which has developed over the past two days. He has no significant past medical history and is fully vaccinated. Which of the following exam findings best supports a diagnosis of erythema multiforme? A Honey-crusted lesions around the nose and mouth B Salmon-colored oval patches in a Christmas tree pattern on the trunk C Sharply demarcated erythematous plaques with a silver scale located on extensor surfaces D Target lesions located on bilateral upper extremities

D Target lesions located on bilateral upper extremities Erythema multiforme is an acute, immune-mediated skin condition. It most commonly affects adults between 20 and 40 years of age and is more prevalent in men than women. The most common precipitating factor is infection; other causes include drugs, malignancy, and autoimmune disease. The characteristic physical exam finding in erythema multiforme is the target lesion, which is composed of an erythematous plaque with a dusky center surrounded by a pale ring with a bright-red border. The target lesion resembles a bull's eye and usually measures less than 3 cm. Distribution is symmetric, most commonly involving the upper extremities and face, but may also involve the trunk, lower extremities, palms, and soles. Lesions are usually asymptomatic, but some patients experience pruritus or burning. The rash generally develops over three days and resolves within two weeks. Diagnosis is made clinically, based on history and physical exam findings. Erythema multiforme is self-limited and may be treated symptomatically with topical corticosteroids and oral antihistamines.

A 17-year-old girl presents to the ED with mouth pain. She smokes cigarettes and has poor dental hygiene. Her pain has progressively worsened over the previous 2 weeks. She now describes dysphagia and odynophagia. On examination, you note trismus, upper midline neck swelling, and associated edema of the floor of the mouth that is causing tongue elevation. Her vital signs are T 38.4°C, BP 120/80 mm Hg, HR 110 bpm, and RR 22/min. Which of the following is true regarding her condition? A A lateral soft tissue neck radiograph demonstrating a thumbprint sign is the most common radiographic finding B Haemophilus influenzae type B is the most common causative organism C Orotracheal intubation is the best method of airway control D The most common cause is from an odontogenic abscess that breaks through cortical bone of the mandible E Treatment includes incision and drainage, oral antibiotics, and discharge home

D The most common cause is from an odontogenic abscess that breaks through cortical bone of the mandible This patient has Ludwig angina, which is defined by cellulitis of the submandibular and sublingual spaces with associated tongue elevation. The most common cause is a dental abscess that spreads into the soft tissue submental, sublingual, and submandibular spaces, causing elevation and posterior displacement of the tongue Aggressive, rapidly spreading cellulitis of bilateral submandibular, sublingual, and submental spaces Dental infections (molars) or immunodeficiency PE: tongue elevation, brawny edema, dysphagia, dysphonia, drooling Dx: clinical, CT Tx: fiberoptic or awake intubation, antibiotics, ENT consultation

Which of the following is true regarding hyperventilation in the head-injured patient? A It improves oxygenation, which helps to reduce secondary brain injury B It induces cerebral vasodilation, which helps to reduce intracranial pressure C Target PaCO2 is 20-25 mm Hg D The onset of effect is within 30 seconds

D The onset of effect is within 30 seconds Acute hyperventilation in a severe head trauma patient can be a life-saving intervention. The goal is to prevent or delay herniation until a more definitive procedure can be performed. The onset of effect is within 30 seconds. Hyperventilation is thought to cause vasoconstriction of the cerebral vasculature leading to a reduction of intracranial pressure. However, prolonged hyperventilation is not recommended because it may lead to profound vasoconstriction and ischemia resulting in poorer outcomes. Hyperventilation should be employed only when a patient experiences an acute neurologic decline or demonstrates signs consistent with herniation.

Which of the following statements regarding allergic drug reactions is true? A Celecoxib often causes a reaction in patients with an antibiotic sulfonamide allergy B Cross-reactivity between penicillins and first-generation cephalosporins is 50% C Patients with a history of anaphylaxis to penicillin can never be given penicillin D The onset of serum sickness generally occurs within one to two weeks

D The onset of serum sickness generally occurs within one to two weeks Serum sickness is an immune-complex mediated reaction characterized by malaise, joint pain, urticaria, fever, adenopathy, and hepatosplenomegaly. Symptoms usually begin one to two weeks after drug exposure and may take several weeks to resolve. Treatment is generally supportive, with corticosteroids administered for more severe cases Celecoxib contains a sulfonamide moiety (A), but recent data shows that the cross-reactivity between antibiotic sulfonamides and non-antibiotic sulfonamides may not occur at all or, at the very least, this potential is extremely low. Specifically, the mechanisms of cross-reactivity causing anaphylaxis are very unlikely to occur when using a non-antibiotic sulfonamide. The true cross-reactivity rate is unclear. The rate of cross-reactivity of penicillins and first-generation cephalosporins is approximately 1%-7%, not 50% (B). Third- and fourth-generation cephalosporins have a much lower cross-reactivity than first-generation, closer to 1%. Many patients with a penicillin allergy can tolerate second- and third-generation cephalosporins without issue. However, patients with a history of life-threatening reactions to penicillin should not receive cephalosporins in the ED unless absolutely necessary. Patients with a history of anaphylaxis with penicillin should not be given penicillin or cephalosporins, however, there are a few selected indications where desensitization should be performed (C). ==>An example of this would be the pregnant patient with syphilis and a penicillin allergy. Careful desensitization should be undertaken in the ICU with increasing doses of the medication.

A 2-year-old previously healthy girl presents to the ED with complaints of 3 days of low-grade fever and congestion followed by noisy breathing and cough. Upon examination, you note a frequent barking cough, audible stridor at rest, and retractions. The child does not appear to be in any distress. Which of the following is the most appropriate next step in management? A The patient has mild croup and can be discharged after a single dose of oral steroids B The patient has mild croup and can be discharged after a single dose of steroid and 5 mg albuterol nebulizer C The patient has moderate croup and should receive oral steroids and be discharged after racemic epinephrine nebulizer with next-day follow-up D The patient has moderate croup and should receive oral steroids and racemic epinephrine nebulizer and be observed in the ED for 3 hours and discharged if symptoms abate

D The patient has moderate croup and should receive oral steroids and racemic epinephrine nebulizer and be observed in the ED for 3 hours and discharged if symptoms abate Croup (laryngotracheitis) is the most common cause of infectious acute upper airway obstruction (stridor). The etiology is viral (parainfluenza, influenza, and respiratory syncytial virus) with erythema and swelling of the trachea just below the vocal cords. Patients classically present with a barky or seal-like cough. The mean age of affected patients is 18 months. There is a seasonal increase in autumn and early winter. Because the lungs are not directly affected, oxygen saturation can be maintained even in severe illness. Aerosolized epinephrine (R or L) decreases airway obstruction. It is indicated for children with stridor at rest or marked work of breathing (tachypnea, retractions, accessory muscle use). Maximal effect is seen within 30 minutes, with potential rebound to baseline within 3 hours. Patients without resting stridor after 3 hours can be safely discharged home. A single dose of oral dexamethasone decreases the need for hospitalization and return ED visits. The patient's croup is moderate not mild (A and D), therefore, she should receive aerosolized epinephrine to treat the airway obstruction and then be observed in the emergency room, not sent home and followed up the next day. Albuterol should not be used for croup because stimulation of vascular beta-receptors in the airway may cause vasodilation and worsen airway edema. Mild croup is managed with a single-dose steroid, and the patient can usually be safely discharged home. It is prudent to observe patients for at least 3 hours if they receive aerosolized epinephrine (B) because symptoms may recur within this period. Some studies have found that rebound occurred in over 30% of cases after the second hour. If symptoms reoccur, another aerosolized epinephrine treatment is indicated and the patient should be admitted.

Which of the following is correct when estimating an adult burn patient's percent of total body surface area affected? A Each arm is approximately 18% B The area covered by the patient's palm is approximately 5% C The entire head is approximately 18% D The perineum is approximately 1%

D The perineum is approximately 1% 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. In adults, the head is estimated to be 9% (C), the anterior and posterior torso are each 18%, the arms are 9% each (A), and the legs are 18% each. The area covered by the individual's palm and fingers is approximately 1% (B). Adjustments to the "Rule of Nines" are made for pediatric patients to account for their relatively larger head and smaller legs. In pediatric patients, the head is estimated to be 18%, the anterior and posterior torso are each 18%, the arms are 9% each, and the legs are 14% each

A 3-year-old boy presents to the ED after one episode of generalized convulsions. Parents note that he was confused afterward but has since returned to his baseline. Neurologic exam is nonfocal. His temperature in the ED is 101.9°F. Which of the following best describes the prognosis for this disease process? A Antipyretics have been shown to prevent seizure recurrence in children with future fever episodes B Children generally outgrow this condition between the age of 8 to 12 years C The prevalence of epilepsy is the same as the general population D The risk of recurrent febrile seizure at later date is 30%

D The risk of recurrent febrile seizure at later date is 30% This child is presenting with signs and symptoms consistent with a simple febrile seizure. Febrile seizures are defined as seizures associated with fever in children age 6 months to 5 years. Febrile seizures are a diagnosis of exclusion. They occur in 3-4% of the population and do have a familial predisposition. The peak occurrence of febrile seizures is at age 14 to 18 months. There is also a strong association with the disease process of roseola. Antipyretics have not been shown to decrease frequency or prevent recurrence of febrile seizures. Children who have a febrile seizure have a 30% chance of having another febrile seizure at some point in the future. Risk factors for recurrence include age < 1 year, seizure occurred with low fever, or the child had a complex febrile seizure. Simple febrile seizures represent 85% of all febrile seizures. A simple febrile seizure is characterized by the following criteria: (1) generalized tonic-clonic seizure, (2) occurring in the appropriate age group of age 6 months to 5 years, (3) seizure is less than 15 minutes in duration, (4) the child has a nonfocal neurologic exam, and (5) there is no recurrence of seizures within 24 hours. Management of simple febrile seizures is supportive. More recent studies suggest that antipyretics may have the potential to prevent febrile seizure recurrence during the same fever episode.

Which of the following is a risk factor for ectopic pregnancy? A Alcohol use B Cocaine use C Heroin use D Tobacco use

D Tobacco use Ectopic pregnancy is the third leading cause of maternal death and now accounts for up to 2% of all pregnancies. There are multiple risk factors for ectopic pregnancy, including prior ectopic pregnancy or tubal surgery, pelvic inflammatory disease (PID), tobacco use, advanced maternal age, prior spontaneous or medically induced abortion, a history of infertility treatment, and a current intrauterine device (IUD). The classic presentation is the sudden onset of severe unilateral pelvic pain and vaginal bleeding in a patient with a known or suspected pregnancy. Unfortunately, these findings are nonspecific. Up to 25% of patients with an ectopic pregnancy will lack some or all of them. Physical exam findings are also quite variable, and a normal exam does not eliminate the possibility of the diagnosis. Alcohol (A) is considered a teratogen, and its abuse during pregnancy has been associated with a characteristic syndrome of neurological and structural abnormalities known as fetal alcohol syndrome. Cocaine (B) is a potent vasoactive substance associated with spontaneous abortion and placental abruption, as well as preterm and low-birth-weight babies. The abuse of heroin (C) and other opiates leads to fetal physical dependence and can result in neonatal withdrawal.

A 9-month-old boy presents to the ED after falling a short distance from the couch to the floor. Other than waving his right wrist, he has no other injuries or complaints. Which of the following is the most likely diagnosis? A Greenstick fracture B Salter-Harris type I fracture C Salter-Harris type II fracture D Torus fracture

D Torus fracture Bones of children are softer and more resilient than in adults. This leads to more incomplete fractures. A torus, or buckle fracture, is an incomplete fracture characterized by wrinkling or buckling of the cortex. These fractures often occur at the end of long bones. A deformity should not occur in a torus fracture because the periosteum and cortex are intact on the side of the bone opposite to the fracture. Radiographically, these are subtle fractures, and care must be taken to avoid misdiagnosis.

Which of the following is commonly seen in patients during the initial period of infection with yellow fever? A Hypoglycemia B Renal failure C Seizures D Transaminitis

D Transaminitis Yellow fever is difficult to distinguish from other possibly severe illnesses such as malaria, viral hepatitis, typhoid fever, leptospirosis, rickettsial infections, and Filoviridae (e.g., Ebola). It is a mosquito-borne illness that should be considered in patients returning from South America and Africa with sudden onset of nonspecific symptoms like fever, headache, and vomiting. While not specific for yellow fever, transaminitis is common. Other laboratory abnormalities are leukopenia, thrombocytopenia, prolonged clotting times, azotemia, and albuminuria. Cases that continue after the remission stage can present with severe gastrointestinal hemorrhage and multiorgan dysfunction. Prevention is key as vaccination is available; however, patients with confirmed yellow fever should be kept in mosquito-free areas to prevent transmission. Appropriate precautions are required as laboratory samples are also infectious. Coma, delirium, hypoglycemia (A), hypotension, renal failure (B), seizures (C), and gastrointestinal and other hemorrhages are generally only seen in yellow fever in cases that have progressed past the remission stage. Most cases are self-limited, and all are treated with supportive care

A 24-year-old woman with no medical history presents with left wrist pain after a fall. The left extremity is grossly deformed, and the patient reports severe pain. The patient has a blood pressure of 183/100 mm Hg. What management is indicated for the patient's elevated blood pressure while awaiting X-rays? A Arrange admission for blood pressure control B Start an oral beta-blocker and monitor for response C Start intravenous beta-blocker and admit to the intensive care unit D Treat the patient's pain and reassess the blood pressure

D Treat the patient's pain and reassess the blood pressure Patients with elevated blood pressure and an absence of end-organ damage (e.g., acute coronary syndrome, aortic dissection, encephalopathy, change in renal function) do not require admission for management. A primary care physician in the outpatient setting best cares for these patients. Asymptomatic Hypertension Most common causes of BP elevation: pain, anxiety No workup usually indicated, ED may consider checking Cr Outpatient follow-up

A 26-year-old woman with a known history of AIDS presents to the ED for strange behavior, according to her boyfriend. Reportedly, she complained of a headache for a few days prior and then began acting bizarrely. In the ED, she has a temperature of 38.5°C. Neurological examination is remarkable for word-finding difficulties accompanied by episodes of clanging and echolalia, along with decreased attention span, recall, and consolidation. A contrast CT scan of the brain reveals multiple ring-enhancing lesions without evidence of midline shift. Which of the following is the most appropriate next step in management? A Consult neurosurgery for a brain biopsy B Obtain an MRI C Treat with dexamethasone D Treat with pyrimethamine and sulfadiazine E Treat with trimethoprim-sulfamethoxazole

D Treat with pyrimethamine and sulfadiazine This patient with AIDS and altered mental status most likely has cerebral toxoplasmosis, the most common cause of focal encephalitis in patients with AIDS. It is often accompanied by fever, headache, altered mentation, focal neurological deficits, and seizures. It is caused by the protozoa Toxoplasma gondii. The initial diagnosis is based on history, physical, and head CT scan. The appearance of multiple ring-enhancing lesions on contrast-enhanced head CT scan is pathognomonic. Treatment should be initiated with pyrimethamine and sulfadiazine. Some regimens also include folinic acid

A 15-year-old boy presents with an itchy rash to the groin. The rash is scaly and has a reddish-brown color. It does not fluoresce under a Wood lamp. What is the pathogen responsible for this condition? A Candida B Corynebacterium minutissimum C Sporothrix schenckii D Trichophyton rubrum

D Trichophyton rubrum This patient suffers from tinea cruris, otherwise known as "jock itch." It is caused by a dermatophyte, most commonly Trichophyton rubrum. Infection occurs at the epidermal layer and results in inflammation and hyperplasia of the skin that produces areas of scaly skin with dermatitis. Tinea cruris does not fluoresce under Wood's lamp. Microscopic examination of a potassium hydroxide wet mount will reveal segmented hyphae consistent with Trichophyton rubrum. Treatment involves topical antifungal agents for two weeks Candida (A) produces a superficial irritation rash that will fluoresce under Wood's lamp and may produce satellite lesions. Corynebacterium minutissimum (B) is a bacterium that causes a dermal infection, most often in the genitocrural areas, that fluoresces a deep red under Wood's lamp. Sporothrix schenckii (C) causes a granulomatous infection from direct inoculation of the skin by spores; the most often source is soil and plants.

A man is sent home with a prescription for an antibiotic after being diagnosed with a urinary tract infection. He returns because his eyes are yellow 2 days later. Which of the following antibiotics was most likely initially prescribed? A Amoxicillin B Cephalexin C Doxycycline D Trimethoprim-sulfamethoxazole

D Trimethoprim-sulfamethoxazole Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive hereditary disease that results in characteristically low levels of G6PD. Individuals with this deficiency may exhibit nonimmune hemolytic anemia in response to a variety of oxidant stressors such as exposure to particular medications or, more commonly, infection. Trimethoprim-sulfamethoxazole can cause oxidative stress that leads to hemolytic anemia.

A 10-year-old boy presents to the emergency department with a rash. He was diagnosed with streptococcal pharyngitis over 1 week ago and was prescribed amoxicillin. He has been taking the medication as directed and is currently on day 9 of therapy. He does not report other medical problems and does not take any other medications. His skin does not itch. He does not report other symptoms, including fever, vomiting, throat swelling, and trouble breathing. On examination, he is well-appearing with normal vital signs. A light macular rash is noted on his forearms, torso, and back. What type of hypersensitivity reaction is this patient experiencing? A Type I B Type II C Type III D Type IV

D Type IV Drug hypersensitivity reactions are the unwanted result of immune or inflammatory cell stimulation by the offending drug. These reactions are divided into subgroups based on the timing of the appearance of symptoms, the clinical presentation, and the immunologic mechanism causing the symptoms. The patient in this question is presenting with a delayed reaction since the rash developed several days after the onset of medication use. The true definition of a delayed reaction is after 6 hours of drug ingestion, but most delayed reactions occur several days after starting treatment. This patient is presenting with a maculopapular rash, and he does not have other systemic symptoms. A delayed hypersensitivity reaction in a patient without other systemic symptoms most fits with a Type IV hypersensitivity reaction. Type IV reactions are not mediated by antibodies. Instead, they involve the activation of T cells, which takes time, leading to a delayed response. Penicillin-based medications are the ones in which allergy is most commonly reported, and delayed maculopapular eruptions to amoxicillin classically begin after 7-10 days of treatment. These delayed maculopapular cutaneous eruptions are the most common type of rash reported in patients with penicillin allergy. Although the majority of patients with a Type IV hypersensitivity reaction, especially to amoxicillin, will have a benign rash, more serious delayed reactions can occur such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug rash with eosinophilia and systemic symptoms. Treatment of Type IV hypersensitivity reactions is to stop using the offending agent. Can a patient with a Type IV hypersensitivity reaction to penicillins use the drug in the future? YES, if the reaction was delayed, not associated with systemic symptoms, and did not involve a blistering rash.

Which of the following is associated with an increased likelihood of testicular torsion? A Age greater than 50 years B Epididymitis C Fixed testis D Undescended testis

D Undescended testis Testicular torsion can occur at any age, but it has bimodal peaks: the first year of life and at puberty (ages 12 to 18). Up to 50% of all cases are reported to occur during sleep Torsion results from a maldevelopment of fixation between the enveloping tunica vaginalis and the posterior scrotal wall, as seen with an undescended testicle (cryptorchidism). Characteristically, the involved testis is aligned along a horizontal rather than a vertical axis. Frequently, there is a history of an athletic event, strenuous physical activity, or trauma just before the onset of scrotal pain. The pain usually occurs suddenly, is severe, and is usually felt in the lower abdominal quadrant, the inguinal canal, or the testis. On physical exam, there is loss of the cremasteric reflex in nearly 100% of patients with torsion. The cremasteric reflex is a superficial reflex observed in men. This reflex is elicited by lightly stroking the superior and medial part of the thigh. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis on the side stroked. In the setting of testicular torsion, this reflex is absent. The testicle is usually tender and firm, and the scrotum is swollen and tender. In cases with a high suspicion for torsion, the patient should be taken to the OR immediately by a urologist. If the diagnosis is equivocal, ultrasound with color Doppler is the best diagnostic modality.

A 5-year-old boy is brought to the emergency department by his mother, who believes that he put a button battery in his ear. Physical exam reveals what appears to be a button battery in the right external auditory canal. Which of the following is the best next step in management? A Attempt to remove the foreign body using alligator forceps B Attempt to remove the foreign body using irrigation C Discharge patient for next day otolaryngology follow-up D Urgent consultation with otolaryngology

D Urgent consultation with otolaryngology Foreign bodies of the external auditory canal are most commonly found in young children and most often include beads, pebbles, tissue paper, small toys, popcorn kernels, and insects. Patients with external auditory canal foreign bodies are often asymptomatic but may present with decreased hearing or ear pain. The diagnosis is confirmed by visualizing the foreign body in the external auditory canal on otoscopy. Button batteries in the external auditory canal can cause destruction due to strong electrical currents and pressure necrosis. Otolaryngology should be consulted urgently, before any removal attempts for button batteries, potentially penetrating foreign bodies, or foreign body with evidence of injury to the external auditory canal, tympanic membrane, or middle ear. For other foreign bodies, removal using irrigation or direct visualization and forceps may be attempted.

Which of the following treatments is contraindicated in the treatment of a 5-month-old with supraventricular tachycardia? A Adenosine B Ice bag to face C Propranolol D Verapamil

D Verapamil Due to poor calcium reserves in the sarcoplasmic reticulum in infants, verapamil (calcium channel blocker) use in infants can cause profound hypotension and cardiovascular collapse. Therefore, it should be avoided in patients younger than 12 months of age. Adenosine (A) is the first-line agent to treat supraventricular tachycardia. Applying ice to the face (B) or other vagal maneuvers can be attempted before administration of adenosine. Propranolol (C) is a nonselective beta-blocker used in supraventricular tachycardia, but it is less effective than adenosine

A 16-year-old girl presents to the ED reporting that she cannot walk up steps. She has been well recently except for an episode of gastroenteritis 2 weeks ago. On exam, she has decreased strength in her bilateral lower extremities with absent patellar and ankle jerk reflexes. What is the most important next test to perform? A Electromyography B Lumbar puncture C MRI lumbar spine D Vital capacity

D Vital capacity This patient has Guillain-Barré syndrome (GBS), an immune-mediated peripheral neuropathy caused by myelin sheath destruction. It is often preceded by a viral illness, infection with Campylobacter jejuni, or vaccination. In the classic presentation of GBS, a viral illness is followed by an ascending symmetric weakness or paralysis with decreased or absent deep tendon reflexes. The most serious complication of GBS is respiratory failure from diaphragmatic weakness. Measuring the vital capacity (<20 mL/kg or reduction >30 percent from prior measurement) or negative inspiratory force (NIF, <-30 cm H20) is critical to assessing respiratory effort. These easily repeated tests predict developing diaphragmatic weakness and the need for prophylactic intubation. GBS is treated with supportive care, IV immune globulin, and possibly plasmapheresis. All patients with suspected GBS should be admitted to an intensive care unit. Miller Fisher variant of GBS associated with descending paralysis

A 37-year-old woman on oral contraceptives presents with pleuritic chest pain and shortness of breath. Which of the following findings is most specific for pulmonary embolism? A Atelectasis B Hamman sign C Normal radiograph D Westermark sign

D Westermark sign Pulmonary emboli most commonly result from deep venous thrombi in the legs that move and pass through the right ventricle into the pulmonary vasculature. The emboli can lodge anywhere across the pulmonary circulation including the main pulmonary arteries or at the smallest subsegmental levels. Traditional chest radiography rarely provides information helpful in identifying pulmonary embolism as the definitive cause of a patient's symptoms but may suggest alternative causes. Westermark sign is a rare but highly specific finding on chest X-ray representing oligemia of the pulmonary vasculature visualized distal to the site of embolism.

What diagnostic test should be used in a low risk patient by Wells criteria in the workup of pulmonary embolism?

D-dimer

What is the treatment for bleeding in mild von Willebrand disease?

Desmopressin (DDAVP), which stimulates the release of von Willebrand factor (and Factor VIII) stored in vascular endothelial cells. von Willebrand Disease Most common inherited bleeding disorder due to reduced, dysfunctional, or absent von Willebrand factor Sx: increased mucocutaneous bleeding, heavy menses, excessive postpartum bleeding Labs: aPTT may be prolonged, VWF antigen, platelet-dependent VWF activity (ristocetin cofactor assay), factor VIII activity Tx options: desmopressin (DDAVP), von Willebrand factor concentrate Most cases autosomal dominant, consider genetic counseling and testing of 1st degree relatives

Kleihauer-Betke test

Determined amount of fetal blood in maternal circulation if large fetomaternal transfusion is suspected

A 29-year-old man presents to the emergency department with neck pain after an assault. He has a history of intravenous drug use and is currently incarcerated. His vital signs include T 99.5°F, RR 12 breaths/minute, BP 140/80 mm Hg, HR 95 beats/minute, and oxygen saturation 100% on room air. On physical examination, he has midline cervical tenderness and diminished grip strength bilaterally. Rectal tone is intact. Vibration and proprioception are normal. Which of the following is the most likely diagnosis? A Anterior cord syndrome B Brown-Séquard syndrome C Cauda equina syndrome D Central cord syndrome

D. Central cord syndrome Central cord syndrome is an incomplete spinal cord syndrome due to neck hyperextension. It is the most common spinal cord syndrome. Signs and symptoms include upper extremity weakness greater than lower extremity weakness. Upper extremity sensory loss is also more notable than the lower extremities. The centrally located spinothalamic and corticospinal tracts are most affected, and fibers affecting the upper extremity are more medial to the central canal of the spinal cord than are fibers affecting the thorax, lower extremities or sacrum. Bowel and bladder functions are usually maintained, and posterior column functions (e.g., proprioception) are intact.

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? A Acute kidney injury B Dilated common bile duct C Elevated lipase D Hypotension

D. Hypotension Cholangitis is caused by obstruction of the common bile duct and subsequent ascending infection. Most commonly, a stone is the source of obstruction. The diagnosis was first described by Charcot in 1877 with the clinical triad of fever, right upper quadrant pain, and jaundice. It is important to recognize that both cholecystitis and acute hepatitis can cause similar symptoms. The most common organisms responsible for cholangitis are the typical pathogens of the biliary tract: E. coli, Klebsiella, Enterococcus, and Bacteroides. Without relief of the obstruction and treatment with antibiotics, patients do poorly and go on to develop sepsis. The presence of Charcot's triad and sepsis - defined as hypotension and altered mental status - is called Reynold's pentad.

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 (37.7°C), blood pressure 220/110 mm Hg, heart rate 125 bpm, and respiratory rate 30/min. 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? A Albuterol B Dobutamine C Furosemide D Nitroglycerin

D. Nitroglycerin Acute hypertensive heart failure can result in pulmonary edema that must be managed with aggressive preload and afterload reduction. Nitroglycerin can be administered sublingually and intravenously to achieve rapid and titratable improvement in hypertension via vasodilation with a reduction in preload and afterload. Initial management involves sublingual administration until IV access is established and a titratable infusion can be initiated. In addition to addressing hypertension, acute heart failure exacerbations are managed with supplemental oxygen, non-invasive positive pressure ventilation, loop diuretics (e.g., furosemide) in cases of severe volume overload, and assessment of an underlying cause (e.g., acute myocardial infarction, pericardial tamponade). Patients may require intubation when hypoxic or hypercarbic respiratory failure ensues. Patients who present with hypotension in the setting of acute heart failure (i.e. cardiogenic shock) should not receive nitroglycerin and may require vasopressors to maintain hemodynamic stability.

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 demonstrates free air under the diaphragm. What is the most likely diagnosis? A Cholecystitis B Gallstone pancreatitis C Gastritis D Perforated gastric ulcer

D. Perforated gastric ulcer Dyspepsia is a common complaint. There is no definitive association with age, sex, socioeconomic status, smoking, or alcohol abuse. Peptic ulcer disease is marked by ulcerations of the gastric mucosa, often due to nonsteroidal anti-inflammatory drug use or H. pylori infection. When the ulcer erodes through the entire bowel, the result is a perforated gastric ulcer. The patient often experiences an abrupt onset of severe epigastric pain as gastrointestinal contents leak into the peritoneal cavity. Plain films of the chest or abdomen may demonstrate free air under the diaphragm, although this is not a universal finding. They initially develop a chemical and ultimately a bacterial peritonitis, and may become septic if left untreated. This is a surgical emergency. Emergent consultation with a general surgeon combined with broad-spectrum antibiotic administration and aggressive resuscitation is merited

A 45-year-old man arrives in the ED after a motor vehicle collision. On exam, the patient is in acute respiratory distress. Auscultation reveals no breath sounds over the right chest and the trachea is deviated to the left. Which of the following is the most appropriate next step in management? A Insert a large-bore chest tube into the right anterior axillary line at the 5th intercostal space B Obtain a STAT portable chest X-ray C Perform endotracheal intubation D Perform needle decompression in the mid-clavicular line, 2nd intercostal space on the right

D. Perform needle decompression in the mid-clavicular line, 2nd intercostal space on the right A tension pneumothorax occurs when an injury to the chest wall or lung or both causes a functional one-way valve, allowing air to enter the pleural space with inspiration but trapping it during expiration. This leads to increasing pressure in the pleural space, which can eventually cause tracheal deviation to the contralateral side, decreased venous return, and a precipitous drop in cardiac output. Findings on clinical exam for a tension pneumothorax include tracheal deviation pointing away from the affected lung, jugular venous distension, and hypotension. The diagnosis is clinical and chest X-ray should not be obtained prior to intervention. Management includes immediate needle decompression (18-gauge or larger) in the second or third midclavicular intercostal space (above the rib) followed by tube thoracostomy Following needle decompression, tube thoracostomy should be performed to prevent re-accumulation of intrapleural air. Endotracheal intubation should not be performed first, as it delays treatment of the tension pneumothorax. The need for endotracheal intubation should be re-assessed once the pneumothorax is treated.

Which of the following risk factors is the strongest predictor of suicide? A Access to firearms B History of depression C Male sex D Prior history of suicide attempts

D. Prior history of suicide attempts In the United States, there are approximately 10-40 suicide attempts for every completed suicide. Evaluation of risk factors is critical when determining if a patient is at high risk for suicide Patients with a previous suicide attempt are 5-6 times more likely to attempt suicide again, and 50% of individuals who complete suicide have a prior history of at least one suicide attempt. Providers who suspect that a patient may be suicidal should evaluate for suicidal ideation, plan, and intent. There is no data to suggest that asking a patient about suicide will initiate a suicidal plan or attempt. Patients deemed high risk for suicide due to risk factors, suicidal ideation, plan, or intent should be connected with emergency psychiatric services immediately and monitored for safety. History of depression, schizophrenia, and bipolar disorder are the second most common risk factors for suicide after a prior history of attempts. Other risk factors for suicide include substance abuse, hopelessness, impulsivity, single marital status, unskilled occupation, physical illness, family history of suicide, and identification as gay, lesbian, bisexual, or transgender. F>M to attempt

A 23-year-old woman presents with an asthma exacerbation. Which of the following is associated with an increased mortality? A History of hospitalization at age 18 B Hypoxemia C Peak flow < 50% predicted D Prior intubation

D. Prior intubation Rates of asthma mortality have decreased over time. Mortality rates are higher in women and Black patients. Assessing risk factors related to increased rates of mortality are important to identify in the evaluation of a patient with an acute exacerbation. A history of prior intubations is associated with increased mortality in patients with an acute asthma exacerbation. Other factors include history of ICU admission, two or more hospitalizations for asthma in the past year, three or more ED visits for asthma in the past year, hospitalization or an ED visit for asthma in the past month, use of more than two metered-dose inhalers (MDI) canisters per month, and current or recent use of corticosteroids.

A 32-year-old woman with a history of depression presents to the Emergency Department with thirty minutes of continued tonic clonic seizure activity. A few months ago, she started a medication after a positive purified protein derivative tuberculin skin test. In addition to lorazepam, which of the following medications is likely to stop her seizure activity? A Fosphenytoin B Hypertonic saline C Magnesium sulfate D Pyridoxine

D. Pyridoxine Lorazepam and pyridoxine is the best initial treatment for status epilepticus from a isoniazid overdose. Isoniazid is a commonly used medication in the treatment of latent tuberculosis. Acute isoniazid overdoses typically present with altered mental status and seizure activity that begins within 30 to 60 minutes of the ingestion. Seizure management is focused on restoring GABA levels, the inhibitory neurotransmitter. Both intravenous pyridoxine and lorazepam should be initially administered. Both of these medications have a quick onset and can terminate seizure activity within minutes. Severe isoniazid overdose cases are at high risk of aspiration and often require endotracheal intubation.

A 45-year-old man with a history of chronic NSAID use reports he vomited blood at home. He had one episode and has not had any in the ED. His vital signs are BP 120/68, HR 108, RR 18, saturation 100% on room air. The on call gastroenterologist asks you to perform nasogastric aspiration and lavage. Which of the following is true regarding this procedure? A A negative aspirate rules out upper GI bleeding B If the aspirate clears after a flush it is considered negative for active bleeding C Nasogatric tube insertion is contraindicated in variceal bleeding patients D Red blood aspiration with red blood stool is associated with increased mortality

D. Red blood aspiration with red blood stool is associated with increased mortality Performance of nasogastric aspiration and lavage in the setting of upper GI bleeding is controversial because the procedure has never demonstrated benefit in terms of the patients clinical outcome. Additionally, its sensitivity relies on the location of bleeding proximal to the pylorus. The presence of blood products does confirm an upper GI source of bleeding. Furthermore, if the test is performed in the context of hematochezia and the nasogastric aspirate is positive for red blood, this patient has a higher mortality. The presence of bright red blood in the upper GI tract along with the lower GI tract implies brisk upper GI bleeding. Red blood aspiration with red blood stool is associated with increased mortality.

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? A Dopamine receptor antagonism B Inhibition of the reabsorption of sodium from the distal convoluted tubules C Positive allosteric modulators of GABA type A receptors D Relocation of free floating otoconia

D. Relocation of free floating otoconia When evaluating a patient with vertigo, it is important to differentiate between central and peripheral causes. The history and physical exam findings that suggest a peripheral cause include rapid onset, increase in intensity with head movement, quality defined as intense spinning, change in sensation of hearing, vertical and rotary nystagmus that does not change direction, normal neurologic exam, positive and fatigable Dix-Hallpike test, positive horizontal head impulse test, and negative test of skew. A central cause is more likely if the onset is insidious, quality is ill-defined, head positional changes do not affect the severity of the vertigo, symptoms are not proportional to stimulus, nystagmus is horizontal and changes direction, positive neurologic findings are present, negative horizontal head impulse test, and positive test of skew. One of the most common causes of peripheral vertigo is benign paroxysmal positional vertigo (BPPV) which is a mechanical disorder of the inner ear causing transient vertigo and associated nystagmus precipitated by certain head movements. BPPV is caused by inappropriate activation of a semicircular canal by free-floating otoconia (stones in the semicircular canals) that have become displaced from the utricular sac by aging, head trauma, or labyrinthine disease. It is most common after the age of 50 years. The Dix-Hallpike test can aid in the diagnosis of BPPV, but it should not be attempted in patients with a carotid bruit. To perform the test, start with the patient seated upright, rotate the head 30-45 degrees to one side. Keeping the head in this position, rapidly bring the patient supine until the head is 20 degrees below the level of the examining table. Rotatory nystagmus following a latency of < 30 seconds is considered a positive test; the nystagmus exhibits rapid eye torsions toward the affected ear and fatigues after 10-40 seconds. The side exhibiting the positive test is the side of the lesion. The most definitive treatment for BPPV is the Epley maneuver which uses gravity to relocate free floating otoconia along the semicircular canals and into the utricle, where they are unlikely to cause vertigo.

A 20-year-old woman presents to the emergency department by ambulance unable to ambulate. She is confused and agitated. Her sister states that the patient started taking sertraline two days ago. The pill bottle has 60 tablets missing. Physical exam reveals tachycardia, hyperreflexia, and ataxia. What is the most likely diagnosis? A Anticholinergic syndrome B Carcinoid syndrome C Reye syndrome D Serotonin syndrome

D. Serotonin syndrome Serotonin syndrome presents with central nervous system dysfunction, autonomic instability, and neuromuscular hyperactivity resulting from overstimulation of serotonin receptors. It can occur from an overdose of antidepressants or by taking two or more serotonergic agents such as selective serotonergic receptor inhibitors (SSRIs), tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs). The syndrome can present with fever, altered mentation, agitation, diaphoresis, clonus, tremor, hyperreflexia, seizures, and coma. Diagnosis is largely based on history and clinical findings. Treatment includes intubation as needed, benzodiazepines for seizures or agitation, along with supportive measures. Specific treatment includes cyproheptadine if the patient fails to improve with benzodiazepines and supportive measures.

A 3-year-old fully immunized girl presents after a seizure. She had a febrile seizure approximately 6 months ago. Today she experienced a 35 second generalized tonic-clonic seizure. She had a postictal period of 20 minutes and is now at her neurologic baseline. Emergency Medical Services were called and she had a blood glucose level of 84 mg/dL. The parents report that she has had a cough and runny nose for the past day. Shortly before the seizure, she developed a fever to 39.3°C. On exam, she is a well appearing girl with a supple neck, no rashes, normal tympanic membranes, normal pharynx, clear lungs, and a soft abdomen. She is still febrile at 39.0℃. What is the most likely diagnosis? A Complex febrile seizure B Epilepsy C Meningoencephalitis D Simple febrile seizure

D. Simple febrile seizure Febrile seizures occur in 2-5% of the general pediatric population. Simple febrile seizures are defined as a generalized tonic-clonic seizure lasting < 15 minutes, associated with a fever, in a child 6 months to 5 years of age, and occurring only once in a 24 hour period. Differentiating between simple febrile seizures and complex febrile seizures is important for downstream evaluation, but does not change the recommended evaluation in the emergency department. The American Academy of Pediatrics states that no diagnostic studies are needed specific to a febrile seizure, and the goal of evaluation should be identifying the source of the fever. Once the source of the fever is determined, appropriate therapy should be initiated for the fever source, but no specific interventions are needed for the febrile seizure.

A 56-year-old man with a history of COPD presents to the ED after developing right-sided chest pain and difficulty breathing. His vital signs are blood pressure of 130/80 mm Hg, pulse of 92 beats per minute, respiratory rate of 24 breaths per minute, temperature of 36.7°C, and pulse oximetry of 93% on room air. A chest radiograph is obtained and shows a right-sided pneumothorax involving approximately 40% of the hemithorax. What is the appropriate definitive intervention for this patient? A 100% oxygen therapy via nonrebreather mask B Placement of a 7F catheter with a Heimlich valve using Seldinger technique C Posteriorly directed placement of a 32F chest tube D Superiorly directed placement of a pigtail catheter

D. Superiorly directed placement of a pigtail catheter This patient has a spontaneous pneumothorax secondary to his chronic illness of COPD. The incidence of secondary pneumothorax is three times higher in men than women, and it is most commonly associated with COPD (up to 70% of cases). Malignancy may also be causative and, when present, suggests lung metastases. Other etiologies include tuberculosis and lung abscess. A 20F chest tube directed superiorly or cephalad (towards the head) or catheter thoracostomy (a pigtail catheter) is most appropriate for management of this type of pneumothorax. Posterior placement of a 32F chest tube (C) is used when there is a hemothorax, hemopneumothorax, or large effusion or when mechanical ventilation is anticipated. When these are not present, a smaller caliber tube is preferred because it is less invasive. A 7F catheter with Heimlich valve (B) is placed in smaller, primary (not secondary) spontaneous pneumothoraces where aspiration is likely to be most successful. Very small spontaneous pneumothoraces can also be managed with 100% oxygen nonrebreather mask (A) and observation.

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? A Bony tenderness in the malleolar zone B Bony tenderness in the midfoot zone C Inability to bear weight on the ankle D Swelling over the lateral malleoli

D. Swelling over the lateral malleoli The most common type of ankle injury is an ankle sprain to the lateral ankle. Typically, these are minor and are due to an inversion injury. Sprains are categorized into three grades. Grade I involves no tearing of the ligaments with minimal functional loss, pain, swelling, and ecchymosis. Weight-bearing is tolerable. Grade II sprains occur with a partial tear and some loss of functional ability. They tend to be more painful, with swelling, ecchymosis, and difficulty bearing weight. Grade III sprains result from a complete tear, with significant functional loss, pain, swelling, and bruising, and an inability to bear weight. The Ottawa Ankle Rules are frequently used by physicians and nurses to determine the likelihood of a fracture versus a sprain and the need for imaging. Swelling over the lateral malleoli is a common finding in ankle sprains. This finding, particularly without other bony tenderness in a patient who is able to bear weight, is more indicative of an ankle sprain and would not make a physician more suspicious for an ankle fracture. In patients with a lateral sprain and the ability to bear weight, treatment consists of analgesics, an elastic bandage or ankle brace, and no sport involvement with follow up in a week if no improvement.

A 22-year-old man presents to the ED after being struck in the head with a baseball bat. The patient was initially alert and talking to you, but is becoming progressively more somnolent. A non-contrast computed tomography scan of his head is shown above. In which of the following locations are you most likely to palpate a fracture? A Frontal bone B Occipital bone C Parietal bone D Temporal bone

D. Temporal bone This patient's imaging and physical examination are consistent with a traumatic acute epidural hematoma. An epidural hematoma is a collection of blood between the skull and the dura. Epidural hematomas are usually associated with a skull fracture of the temporal bone resulting in laceration of the middle meningeal artery. The classic finding is a lucid interval just prior to rapid deterioration; however, this is present in less than 30% of epidural bleeds. Diagnosis is via 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. Neurosurgery should be consulted immediately for surgical evacuation of the hematoma.

Conduct Disorder vs. Antisocial Personality Disorder

Diagnosis Conduct disorder: Dx at any age, specified as to whether Sxs present prior to 10 years (childhood-onset), which has a worse prognosis Antisocial personality disorder: must be 18 for formal Dx but have demonstrated Sxs of conduct disorder prior to 15 Both associated with increased risk of development if experienced childhood abuse or adversity and have low activity variant of the monoamine oxidase-A gene Treatment Conduct disorder: multisystemic therapy with parent, teacher, legal, etc. Antisocial personality disorder: difficult to treat due to absence of motivation, tendency to manipulate therapeutic relationship Prevention and early intervention best option (e.g., promotion of positive parenting, reducing adversities)

A previously healthy 37-year-old man presents with right ear pain which has been present for the past 3 days. On examination, the external canal is erythematous and edematous. A crusted exudate is present. The external canal is so swollen that it will not allow passage of an otoscope to visualize the tympanic membrane. Which of the following is the most appropriate treatment? A Oral amoxicillin-clavulanate B Oral fluconazole C Topical acetic acid 2% solution with ear wick placement D Topical ciprofloxacin 0.3% and dexamethasone 0.1% drops with ear wick placement

D. Topical ciprofloxacin 0.3% and dexamethasone 0.1% drops with ear wick placement The patient has otitis externa, which refers to infection and inflammation of the external auditory canal. Factors that predispose to otitis externa include local trauma (often from scratching or attempted cerumen removal) and elevation of the local pH (frequent contact with water from swimming in pools or freshwater lakes). The clinical presentation of otitis externa includes erythema and edema of the external canal. Clear or purulent otorrhea and crusting exudate may be present. The inflammation may spread to the tragus and auricle and, in severe cases, to the periauricular soft tissues. The treatment for bacterial otitis externa should be aimed at treating the most common organisms that cause otitis externa: Pseudomonas aeruginosa, Staphylococcus aureus, Enterobacteriaceae, and Proteus species. Topical treatment is standard, with oral medications reserved for febrile patients or those with involvement of the periauricular soft tissues. If the tympanic membrane is ruptured or external canal inflammation precludes visualization of the tympanic membrane such that perforation cannot be ruled out, nonototoxic topical medications should be used to avoid causing damage to the inner ear. In this case, the best choice is topical ciprofloxacin 0.3% and dexamethasone 0.1% drops. To maintain patency given the significant edema, an ear wick may be placed.

A 32-year-old man presents to the emergency department with a report 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 an echocardiogram? A Diffuse myocardial hypokinesis B Mitral valve vegetations C Pericardial effusion D Tricuspid valve vegetations

D. Tricuspid valve vegetations Tricuspid valve vegetations are the most likely abnormalities seen on an echocardiogram. This patient has endocarditis affecting his tricuspid valve. Risk factors include injection drug use, male sex, > 65 years old, and underlying structural heart disease. Diagnostic workup includes blood cultures and a transesophageal echocardiogram. A transesophageal echocardiogram has a higher sensitivity to detect vegetations than a transthoracic echocardiogram. Complications include sepsis and embolic events. In this case, the vegetations are on the right side of the heart and have embolized to the lungs causing multifocal pneumonia (as shown above). Right-sided endocarditis is more common in intravenous drug users. Treatment includes intravenous antibiotic therapy (directed specifically against Staphylococcus aureus) and supportive care.

A 35-year-old man presents with acute onset epigastric abdominal pain. He has marked tenderness on exam and is tachycardic. You suspect a perforated viscus. Which of the following is the first line imaging modality? A Computed tomography scan of the abdomen and pelvis B Lateral decubitus abdominal X-ray C Ultrasound of the abdomen D Upright chest X-ray

D. Upright chest X-ray The evaluation of a patient with acute abdominal pain in whom a perforated viscus is suspected begins with an upright chest X-ray. With the patient in an upright position, air gets trapped under the diaphragm and is visualized. However, in up to 30% of cases, free air is not visible. CT scan of the abdomen and pelvis is the most sensitive test for the identification of a perforation. However, it takes time to perform and will potentially delay diagnosis. A lateral decubitus abdominal X-ray may identify a perforation if the appropriate side of the patient is up. Ultrasound of the abdomen is becoming more commonly used for the evaluation of free air, however remains a skill that is user and experience dependent.

A 65-year-old man presents with 3 days of fever, fatigue, and malaise. He also complains of increased urinary frequency and perineal pain. His prostate is swollen and boggy. Which of the following is true regarding this condition? A Antibiotics are ineffective in treating this condition B Prostatic massage is therapeutic C The most common pathogen is Pseudomonas D Urine culture will often reveal the causative pathogen

D. Urine culture will often reveal the causative pathogen Acute cystitis often accompanies acute bacterial prostatitis and therefore urine culture generally reveals the causative pathogen. The patient is suffering from acute bacterial prostatitis, which is characterized by fever, lower back pain, and perineal pain. Constitutional symptoms may include malaise, fatigue, myalgias, and arthralgias. Patients may also experience increased urinary frequency, urgency, and dysuria, as well as urinary retention. Prostate exam reveals a tender, swollen, and boggy prostate. Nontoxic patients can be discharged on a 4-6 week course of oral ciprofloxacin or trimethoprim-sulfamethoxazole. Patient with signs of systemic toxicity should be admitted and started on intravenous ciprofloxacin or ceftriaxone with or without gentamicin. Patients should be evaluated by a urologist. Antibiotic therapy should be started immediately and often requires 4-6 weeks of therapy. Prostatic massage should be limited as palpation may lead to bacteremia and sepsis. The most common cause of acute bacterial prostatitis is Escherichia coli. The other less common causes include Klebsiella, Pseudomonas, Enterobacter and Proteus. 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

An obese 40-year-old woman presents with heartburn. She reports that she experiences heartburn once a week after meals, and reports that it is worse if she lays down shortly after eating. Which of the following lifestyle and dietary modifications are most likely to result in an improvement in this patient's symptoms? A Alcohol cessation B Tobacco cessation C Weight loss and drinking milk with each meal D Weight loss and elevation of the head of the bed

D. Weight loss and elevation of the head of the bed This patient is presenting with classic symptoms of gastroesophageal reflux disease (GERD). GERD classically presents as heartburn and regurgitation. Symptoms often occur after meals and are associated with postural changes and relief with antacids. Other symptoms include chest discomfort, dysphagia, nausea, chronic cough, and wheezing. The diagnosis can often be made clinically based on the patient's symptoms. Some lifestyle and dietary modifications, including weight loss and elevation of the head of the bed, are recommended for all patients with GERD. Patients who are overweight or have had recent weight gain should be advised to lose weight. Elevation of the head of the bed is recommended for patients with nocturnal symptoms. Patients with mild symptoms (less than two episodes per week) are treated with histamine-2 receptor antagonists such as ranitidine. If symptoms persist, the treatment should be changed to a proton pump inhibitor. Treatment should be continued for at least eight weeks after symptoms become controlled. Patients with frequent symptoms (two or more episodes per week) should be immediately started on proton pump inhibitors. Patients who do not respond to proton pump inhibitor therapy should be referred for upper endoscopy.

What is an alternative test that may be performed by a skilled technician in evaluation of ischemic versus nonischemic priapism?

Doppler ultrasonography. Priapism Low-flow: venous, painful, emergencyRx: aspiration, intracavernous phenylephrine High-flow: arterial, semierect, painlessRx: observation, arterial embolization Aspiration performed at 2 or 10 o'clock position

What chemotherapeutic agent is associated with dilated cardiomyopathy?

Doxorubicin.

Which chemotherapeutic agent is most commonly implicated in causing myocarditis?

Doxorubicin.

A 14-month-old girl is brought to the ED with fever and rash. Mom states that the fever has been present for one week. She was seen twice by her pediatrician, who diagnosed her with an acute viral febrile illness with cervical adenitis and conjunctivitis. He placed her on a three-day course of antibiotics, which she has completed. On exam, her vital signs are T 38.9°C, HR 165, and RR 28. She is noted to be very irritable and has a diffuse erythematous blanching rash. She has dry oral mucous membranes and dry, cracked lips. Which of the following is true regarding this patient's condition? A A chest radiograph will likely reveal the diagnosis B An ECG will demonstrate diffuse ST segment elevation and P wave depression C Cardiology should be consulted for a STAT echocardiogram D Corticosteroids should be administered early in the course of treatment E Early treatment can significantly reduce the complication rate

E Early treatment can significantly reduce the complication rate This patient has Kawasaki disease. Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an inflammatory vasculitis of unknown etiology. Peak incidence occurs in children 18-24 months old with almost all in patients < 4 years old. Although there is no definitive test for Kawasaki disease, one must meet certain criteria to establish the diagnosis. A patient must have a minimum of five consecutive days of fever and then at least four out of the following five criteria: (1) cervical adenopathy of at least 1.5 cm, (2) peripheral extremity changes, (3) a polymorphous rash, (4) nonpurulent conjunctivitis, and (5) oral involvement, which may include strawberry tongue, pharyngitis, or dry and cracked lips. Not all patients with Kawasaki disease actually meet the criteria. Kawasaki disease should be considered in all children who have a prolonged, unexplained fever that does not respond to antibiotics. Once the diagnosis is established or highly suspected, treatment is aimed at decreasing the inflammation of the myocardium and coronary arteries to avoid the most feared complication of Kawasaki disease, coronary artery aneurysms. The two major components of treatment include intravenous immunoglobulin (IVIG) infusion and high-dose aspirin therapy. This combination of IVIG and high-dose aspirin, when initiated within ten days from the onset of the illness, can substantially decrease the progression to coronary artery dilation and aneurysm formation compared to aspirin therapy alone. However, despite prompt treatment, 2% to 4% of the children still develop coronary artery abnormalities.

A 55-year-old woman without significant medical history presents with right-sided facial weakness that began acutely 1 hour prior to arrival. She woke up from sleep this morning with a dry right eye and is now unable to move the right side of her mouth. You ask the patient to smile and raise her eyebrows, and you note a right-sided facial droop and no forehead wrinkling on the right side. Her neurological exam and vital signs are otherwise normal. Which of the following is the most appropriate next step in management? A Administer a small dose of edrophonium, followed by a full dose, and observe the patient for improvement of her symptoms B Administer intravenous prochlorperazine C Obtain a blood glucose level, basic laboratory work, and CT scan of the head D Obtain a National Institutes of Health Stroke Scale, bring the patient to the CT scanner, and consult a neurologist E Provide prescriptions for corticosteroids, antivirals, artificial tears, and an eye patch and have the patient follow up with her physician

E Provide prescriptions for corticosteroids, antivirals, artificial tears, and an eye patch and have the patient follow up with her physician This patient has Bell palsy, partial or complete paralysis of the facial nerve (cranial nerve VII). Typical symptoms include sudden onset of unilateral facial paralysis, including the forehead, decreased tearing, hyperacusis, and loss of taste sensation on the anterior two-thirds of the tongue that can progress over 1 to 7 days. Many patients describe a viral prodrome. The physical exam is key in the diagnosis to establish the presence of a peripheral rather than a central seventh nerve palsy. Upper and lower facial weakness is present in the peripheral nerve palsy. In central seventh nerve palsy, common in stroke syndromes, only the lower facial weakness is present. The forehead is spared because of bilateral hemispheric innervations to the forehead muscles. Treatment includes corticosteroids, antivirals (for patients with severe to complete paralysis), artificial tears, and eye protection.

A 23-year-old man presents to the ED with a chief complaint of difficulty breathing. He has a history of asthma and is poorly compliant with his maintenance medications. Immediately upon arrival, an albuterol and ipratropium continuous nebulized breathing treatment is initiated by respiratory therapy. On evaluation, you find the patient to be somnolent with his eyes closed but arousable with sternal rub. On lung examination, he has minimal air movement with faint, prolonged wheezing and clear evidence of subcostal retractions. Vital signs are a blood pressure of 120/65 mm Hg, heart rate of 110 bpm, respiratory rate of 32/min, temperature of 98.6°F (37°C), and oxygen saturation of 90% on nebulized treatment. What is the most appropriate next step in the management of this patient? A Administer intravenous magnesium sulfate B Administer intravenous terbutaline C Administration of heliox D Begin bilevel positive airway pressure E Rapid sequence intubation

E Rapid sequence intubation This patient has a severe asthma exacerbation. Intensive therapy with inhaled bronchodilators and systemic corticosteroids is usually sufficient to reduce airflow obstruction and alleviate symptoms. However, a small percentage of patients will show signs of worsening ventilation. The decision to intubate is based on clinical examination and should not be delayed once deemed necessary. This patient has altered mental status with evidence of hypoxemia and is showing signs of respiratory exhaustion (somnolence, eyes closed, subcostal retractions). Definitive airway management is the best treatment for this patient. Heliox (C) and bilevel positive airway pressure (D) are noninvasive airway management options for asthmatics not responding to pharmacologic interventions. Heliox is administered via a nonrebreather mask. It is a mixture of helium and oxygen. It is less dense than air and, therefore, results in decreased work of breathing. Bilevel positive airway pressure provides positive pressure on inhalation and, to a lesser degree, exhalation. It reduces respiratory muscle fatigue by increasing functional residual capacity and helping to inflate alveoli during inspiration. Bilevel positive airway pressure and heliox are best administered to patients with intact mental status who can be compliant with the treatments. Magnesium sulfate (A) and terbutaline (B) are treatment options for patients with asthma who have not responded sufficiently to nebulized bronchodilators and corticosteroids but do not yet require definitive airway management. Magnesium sulfate acts by dilating bronchial smooth muscle. Terbutaline is a long-acting beta-agonist that produces bronchodilation. It can be given subcutaneously to patients having difficulty with inhaled beta 2-agonists but otherwise are protecting their airway.

A 15-year-old girl presents to the ED four hours after an intentional ingestion of an unknown amount of acetaminophen. Her caseworker witnessed the ingestion and confirms the time. Her initial symptoms include nausea and vomiting. Her physical examination is unremarkable. The four-hour serum acetaminophen concentration is 102 mcg/mL. You plot this on the Rumack-Matthew nomogram to assess the risk for hepatotoxicity. All other laboratory tests are within normal limits. Which of the following is the most appropriate course of management? A Administer a dose of syrup of ipecac to induce vomiting of the acetaminophen pills because the ingestion was within four hours B Administer multidose charcoal until the acetaminophen level is zero C Oral N-acetylcysteine 140 mg/kg, and then 70 mg/kg every four hours for 17 doses D Perform orogastric lavage to prevent further absorption of the acetaminophen E The patient does not require treatment with N-acetylcysteine; she should be referred for psychiatric evaluation

E The patient does not require treatment with N-acetylcysteine; she should be referred for psychiatric evaluation An acute (vs. chronic) overdose of acetaminophen begins within four hours of a single ingestion. The lowest dose capable of causing acute toxicity is 7.5 grams in an adult and 150 mg/kg in children. Dose history, however, should be used only for risk assessment. Confirmed diagnosis of acute toxicity requires use of the Rumack-Matthew nomogram. Any level taken at four hours post-ingestion that falls below the treatment line (150 mcg/mL), even if only slightly so, does not require further evaluation or treatment for acute acetaminophen toxicity. Although many animal and human studies have shown a reduction in drug concentration with induced emesis (A) (e.g., syrup of ipecac), no clinical benefit for this technique has been proven. In addition, the use of ipecac may delay the administration of more critical oral treatments. Multidose activated charcoal (B) is typically reserved for ingestions involving a life-threatening amount of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. It is also indicated in any ingestion of a significant amount of any slowly released medications, a xenobiotic known to form concretions or bezoars, or medications with known enterohepatic circulation. Oral N-acetylcysteine 140 mg/kg, and then 70 mg/kg every four hours for 17 doses ==> This is the standard dosing regimen of oral N-acetylcysteine (C) used in potentially hepatotoxic ingestions of acetaminophen. This patient's four-hour acetaminophen level places her below the treatment line, so such therapy is not needed. Orogastric lavage (D) is associated with many complications but does have utility in certain drug ingestions. This patient does not require any form of GI decontamination, given that her acetaminophen concentration is below the treatment line and her time of ingestion was more than two hours prior to ED arrival.

A 38-year-old man is brought to the emergency department after being found unresponsive in a parking lot. He is apneic and has pinpoint pupils. He responds to naloxone, yet his urine toxicology screen is negative, despite high suspicion for opioid overdose. Which of the following statements regarding toxicology screening assays for opioids is true? A Clonidine overdose can mimic opioid toxicity and will be detected on opioid screens B Heroin itself is routinely detected on urine opioid screening assays C Synthetic opioids such as fentanyl and buprenorphine are frequently detected on routine urine toxicology screens D The duration of a positive screening test does not depend on the drug or dose involved E There is great variability in the ability to detect oxycodone exposure, depending on the assay used

E There is great variability in the ability to detect oxycodone exposure, depending on the assay used The patient is exhibiting signs of opioid intoxication (apnea, pinpoint pupils, and response to naloxone), yet the opioid toxicology screen is negative. The patient in this scenario was ultimately found to have ingested oxycodone. Oxycodone will cross-react with opioid urine screens only 5% to 30% of the time, depending on assay used, leading to false-negative results Clonidine overdose (A) can present with apnea and pinpoint pupils and may respond to naloxone, but clonidine is not an opioid and does not cross-react with the assay. The majority of urine opioid screens test for morphine, codeine, and their metabolites. Heroin (B) rarely cross-reacts with available assays, but its specific metabolite, 6-monoacetylmorphine (6-MAM) can be detected. Much like heroin, however, 6-MAM has a short half-life (30-40 min), making rapid detection difficult. Consequently, heroin use is most often inferred from identification of its end product, morphine. Synthetic opioids (C) such as meperidine, buprenorphine, propoxyphene, methadone, fentanyl, and tramadol are structurally different and do not cross-react with standard opioid screens and will yield false-negative results. The duration of a positive screening test (D) depends on the half-life of the parent drug and its metabolites, as well as the magnitude of the exposure. The longer the half-life of the parent compound and its metabolites, or the greater the amount of exposure, the longer the patient will test positive

Which of the following conditions is associated with a normal platelet count? A Disseminated intravascular coagulation B Hemolytic uremic syndrome C Systemic lupus erythematosus D Thrombotic thrombocytopenic purpura E Von Willebrand disease

E Von Willebrand disease Von Willebrand disease (vWD) is the most common hereditary bleeding disorder and is present in 1% of the population. It is caused by abnormal von Willebrand factor (vWF), which serves two key roles in normal hemostasis. It is a cofactor for platelet adhesion, as well as the carrier protein for factor VIII. Skin and mucosal bleeding symptoms are common in people with vWD, particularly in children and adolescents. This includes recurrent epistaxis, gingival bleeding, bruising, GI bleeding, and menorrhagia in young women. Hemarthosis is not typical unless severe disease is present. VWD is associated with a normal platelet count, normal aPTT/PT, and prolonged bleeding time.

Which of the following conditions is associated with a normal platelet count? A Disseminated intravascular coagulation B Hemolytic uremic syndrome C Systemic lupus erythematosus D Thrombotic thrombocytopenic purpura E Von Willebrand disease

E Von Willebrand disease Von Willebrand disease (vWD) is the most common hereditary bleeding disorder and is present in 1% of the population. It is caused by abnormal von Willebrand factor (vWF), which serves two key roles in normal hemostasis. It is a cofactor for platelet adhesion, as well as the carrier protein for factor VIII. Skin and mucosal bleeding symptoms are common in people with vWD, particularly in children and adolescents. This includes recurrent epistaxis, gingival bleeding, bruising, GI bleeding, and menorrhagia in young women. Hemarthosis is not typical unless severe disease is present. VWD is associated with a normal platelet count, normal aPTT/PT, and prolonged bleeding time

Torsades de pointes Summary

ECG will show rhythm > 180 bpm and frequent variation in the QRS axis and morphology Most commonly caused by acquired or congenital long QT interval syndrome Treatment Unstable: defibrillation Stable: intravenous magnesium sulfate and stopping the offending drug Intravenous isoproterenol and overdrive pacing are second-line therapies for torsade after magnesium.

A 32-year-old woman presents to the ED for vaginal discharge. Her vital signs are within normal limits for her age, and her last menstrual period was two weeks ago. Speculum examination reveals a retained vaginal tampon with malodorous discharge but no cervical lesions or bleeding. Review of her medical record reveals multiple prior visits describing similar events. Upon attempt to discharge the patient, she adamantly refuses and demands admission. Which of the following is the most likely diagnosis? A Factitious disorder imposed on self B Illness anxiety disorder C Narcissistic personality disorder D Pelvic congestion syndrome

Factitious disorder imposed on self is a type of disorder in which patients feign signs or symptoms with the goal of playing the role of the sick patient without any evidence of external incentives. Formerly "Munchausen" The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for factitious disorder imposed on self is 1) falsification of signs or symptoms (physical or psychological), or induction of injury or disease associated with deception, 2) presents to others as injured, ill, or impaired, 3) deceptive behavior is apparent in the absence of external incentives, and 4) behavior is not explained by another mental disorder. There must be objective evidence of deceptions and illness falsification behavior without inference about intent or motivation of the presenting behavior. Their "medical imposture" usually begins before age 20, and they are diagnosed in their 30s. Patients often wander from hospital to hospital ("doctor shopping"), demand hospital admission, refuse discharge, and exhibit extensive medical knowledge. Their strong desire for hospitalization often sends them to various cities, states, and even countries seeking medical attention. They often view themselves as important. The patient in this case is likely intentionally leaving vaginal foreign bodies in place and presenting to multiple health care settings as a means to seek repeated medical attention. MC in women

What is the most common inherited hypercoagulable state?

Factor V Leiden mutation.

True or false: a noncollapsible IVC indicates a patient completely volume resuscitated.

False. IVC diameter is also dependent on pulmonary vascular resistance and right-heart function. Patients with increased right-heart pressure may have a non-collapsible IVC despite being volume depleted. Ultrasound: IVC and Shock IVC collapse with inspiration > 50%: hypovolemia

What are the risks to an Rh-positive fetus after an Rh-negative mother has been exposed to Rh-positive fetal blood?

Fetal anemia, hydrops fetalis, and death

What additional symptoms are often present in tuberculous pericarditis?

Fever, night sweats, and weight loss Pericarditis Summary Sx: pleuritic chest pain radiating to the back that is worse when lying back and improved when leaning forward PE: tachycardia and pericardial friction rub, distant heart sounds ECG: PR depression, PR elevation (aVR), diffuse ST segment elevation (concave) Most common causes: idiopathic then viral (coxsackie) Tx: NSAIDs, colchicine

Thermal Burn Summary

Fire: obtain CO levels Industrial fire: suspect CN toxicity Superficial: similar to sunburn Superficial partial: red, painful, blisters Deep partial: white, leathery, painless Full-thickness: charred, insensate = ABCs and consider intubating early Rule of 9s Parkland formula: 4 mL × weight (kg) × % total BSA burned50% given in first 8 hours, remainder over 16 hours Target urine output: 0.5-1 mL/kg/h in adults, 1-2 mL/kg/h in children Consider escharotomy for circumferential and full-thickness burns

Thermal Burn

Fire: obtain CO levels Industrial fire: suspect CN toxicity Superficial: similar to sunburn Superficial partial: red, painful, blisters Deep partial: white, leathery, painless Full-thickness: charred, insensate ABCs and consider intubating early Rule of 9s Parkland formula: 4 mL × weight (kg) × % total BSA burned50% given in first 8 hours, remainder over 16 hours Target urine output: 0.5-1 mL/kg/h in adults, 1-2 mL/kg/h in children Consider escharotomy for circumferential and full-thickness burns

What is a potential complication of anorectal abscesses?

Fistula formation. Perform careful rectal exam Dull achy pain in rectum Complication: fistula Operative drainage required

For what condition is aerosolized racemic epinephrine commonly used?

Laryngotracheobronchitis (Croup).

A bubbling wound in neck trauma is indicative of injury to what structure?

Larynx or trachea Laryngotracheal Injuries Most commonly affected area: cervical trachea Hoarseness Dysphonia, SQ emphysema Intubation may yield false lumen and airway loss

Complex febrile seizures

Last > 15 minutes, recur within a 24-hour period Focal Occur in children < 6 months or > 5 years of age without any signs of serious infection Consider LP, Neuroimaging, Neuro consult If lasting > 5 min, a dose of diazepam gel, nasal, buccal, or suppository can be used

Ottowa Ankle Rules

Lateral most common, medial and high ankle sprains more severe History of ankle inversion for lateral sprain PE will show pain and swelling Ottawa Ankle Rules to determine imaging Imaging will show partial or complete tearing of ligaments Most commonly injured anterior talofibular ligament (ATFL) Treatment is RICE therapy (lacking formal studies), functional bracing, functional rehabilitation Emerging treatment MEAT (movement, exercise, analgesia, treatment) or MORE (movement, options, vary, ease)

Which two components of the cardiac cycle are impaired in heart failure with preserved ejection fraction?

Left ventricular filling and relaxation. Low-Output Heart Failure Systolic dysfunction More common than high-output heart failure Causes: ischemic heart disease (most common), hypertension, cardiomyopathy, valvular heart disease Decreased CO, increased LVEDP, and increased systemic oxygen extraction ratio Rx: oxygen, BPAP, nitrates, furosemide

What is the most common cause of right-sided heart failure?

Left-sided heart failure. Acute Decompensated Heart Failure Patient presents with exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea PE will show pitting edema, S3 heart sound Labs will show ↑ BNP Chest X-ray will show cardiomegaly, cephalization, Kerley B lines, effusions Diagnosis is made by echo (most useful study) Treatment BPAP: ↑ oxygenation, ↓ work of breathing, ↓ preload, afterload Nitroglycerin: ↓ preload, afterload Furosemide: diuresis Hypotension without signs of shock: dobutamine (may worsen hypotension) Severe hypotension with signs of shock: norepinephrine (↑ systemic vascular resistance, ↑ HR, ↑ BP, ↑ myocardial O2 demand)

What pediatric condition is characterized by avascular necrosis of the femoral head?

Legg-Calvés-Perthes disease.

What mycobacterial infection is suggested by skin lesions and neuropathy?

Leprosy

What is the common constellation of symptoms associated with dextromethorphan use?

Lethargy, agitation, ataxia, diaphoresis, hypertension, and nystagmus.

What liquids have been shown to be effective in drowning otic live insect foreign bodies?

Lidocaine (spray, gel, and solution), oil (olive and mineral), and alcohol.

What treatment options are available to patients with de Quervain tendinopathy who do not respond to NSAIDs and splinting?

Local glucocorticoid injection and surgery.

What is the name for a pleural effusion that is confined to a fixed pocket in the pleural space?

Loculated pleural effusion.

Heat Stroke

Loss of thermoregulatory mechanisms Dry skin in older patients, moist when due to physical activity Altered mental status Abnormal LFTs Rapid cooling to 39°C: evaporative or cold water immersion Avoid antipyretics

Priapism Summary

Low-flow: venous, painful, emergency Rx: aspiration, intracavernous phenylephrine High-flow: arterial, semierect, painless Rx: observation, arterial embolization Aspiration performed at 2 or 10 o'clock position

What is the noninfectious complication of diverticular disease?

Lower GI bleeding.

What is the most commonly involved site of cellulitis?

Lower extremity.

What is the most common cause of bilateral Bell palsy?

Lyme disease.

Hypertrophic Cardiomyopathy Summary

May present as sudden death in a young athlete Sx: dyspnea on exertion (most common), syncope, orthopnea, chest pain, palpitations PE: harsh crescendo-decrescendo systolic murmur that increases in intensity with Valsalva maneuver and decreases with squatting Dx: repolarization changes on ECG, echocardiography (LVH with septal hypertrophy) Most commonly caused by an autosomal dominant genetic mutation - clinical evaluation of 1st degree relatives recommended Management includes refraining from vigorous physical activity, ICD for high risk patients Rx options for symptomatic patients: beta-blockers or calcium channel blockers

What is the most common complication of Boerhaave syndrome?

Mediastinitis Sx: severe chest pain PE: Hamman crunch (mediastinal crackling with each heartbeat) Chest X-ray: pneumomediastinum Diagnosis is made by esophagram with water-soluble oral contrast Caused by a full-thickness esophageal rupture due to iatrogenic > forceful vomiting Most common location is left posterolateral distal esophagus Treatment is emergent surgical consult and broad-spectrum antibiotics

acute hemolytic reaction

Medical emergency and occurs from the rapid hemolysis of donor red blood cells from host antibodies. Symptoms occur within minutes of onset of the transfusion and include fever, chills, and back pain. Uncontrolled hemolysis can lead to acute renal failure and DIC. The majority of acute hemolytic reactions occur because of transfusion of ABO incompatible blood (i.e. type A red cells transfused to a type O individual), usually due to human error. The transfusion should be stopped immediately if an acute hemolytic reaction is suspected. Treatment is supportive.

What is the most concerning differential diagnosis for a febrile seizure?

Meningitis. Patients at greatest risk for meningitis are those under 18 months, those with a focal or prolonged seizure, those who had a seizure in the ED, or those who have seen a physician within the previous 48 hours Febrile Seizure Age: 6 months to 5 years SimpleNumber of seizures: 1 Duration: < 15 minsType: generalized ComplexNumber of seizures: > 1 in 24 hrsDuration: > 15 minsType: focal or generalized Simple: no further workup, reassurance Complex: further workup depending on age and clinical picture

Overmedication with nitroglycerin can cause what toxic effect?

Methemoglobinemia.

What antibiotic can cause a disulfiram effect?

Metronidazole

What blood vessel is most commonly injured in patients with an epidural hematoma?

Middle meningeal artery.

Legionella pneumophila

Most common causative organism of Legionnaires disease. Legionella is a gram-negative bacillus that lives in the water supply. Transmission occurs through inhalation of contaminated aerosolized droplets emanating from equipment such as cooling towers, evaporative condensers, and shower heads. Legionnaires disease tends to occur in clusters, with common exposure to the same contaminated source. Spread does not occur from person to person. Infection is associated with hyponatremia, elevated liver enzymes, GI symptoms (watery diarrhea, nausea, vomiting, and abdominal pain), and neurologic signs (seizures, altered mental status, and gait disturbances). Approximately half of patients with Legionnaires disease will have relative bradycardia.

Dilated Cardiomyopathy Summary

Most common cause: 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 alcohol Rx 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

Central Cord Syndrome Summary

Most common incomplete spinal cord syndrome Hyperextension injury Bilateral motor and sensory deficits Upper extremity > lower extremity

A 13-year-old boy falls while skateboarding and sustains a clavicle fracture. Which region of the clavicle is most commonly fractured? A Acromioclavicular joint B Lateral third of the clavicle C Medial third of the clavicle D Middle third of the clavicle

Middle third of the clavicle The clavicle is the most commonly fractured bone in children. The middle third is the most commonly fractured part of the clavicle, representing 80% of all injuries. Fractures of the medial third are rare (5%), and usually result from a direct blow to the chest. Fractures of the lateral third are also uncommon (15%), and result from a direct blow to the top of the shoulder. Fractures of the lateral third may involve injury to the acromioclavicular joint. Patients with clavicle fractures typically present with pain over the fracture site and hold the affected arm close to the body. Ecchymosis, crepitus, and swelling may be seen over the fracture. The skin should be carefully inspected. Tenting of the skin is concerning because it can result in pressure necrosis and progression to an open fracture. A careful neurovascular assessment should be performed since the subclavian vessels and brachial plexus run in close proximity to the clavicle and can be injured as a result of the fracture. Radiographs with a dedicated clavicle view are confirmatory. Initial management of clavicle fractures involves pain control, brief immobilization, and appropriate follow-up care for early mobilization. Options for immobilization include a simple sling, sling and swathe, or figure-of-eight splint. Most patients can be discharged with outpatient follow-up. Immediate orthopedic consultation is indicated if there is neuromuscular injury, tenting of the skin, or interposition of soft tissues. Injuries involving the acromioclavicular joint require urgent orthopedic follow-up because they have a higher risk of nonunion and surgical intervention may be necessary.

What antibiotic is used for the treatment of skin lesions in scleroderma?

Minocycline. Patient presents with fatigue, stiff joints, pain PE will show thickening and hardening of the skin Limited cutaneous scleroderma causes CREST syndrome - Calcinosis of the skin, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia Labs Anti-topoisomerase I (anti-Scl-70) antibody (specific for diffuse disease)anticentromere antibody (specific for limited disease) Most commonly caused by an autoimmune disease

Gout Summary

Mono or oligo-articular arthritis caused by uric acid crystals Risk factors: male sex, age > 30 Sx: podagra (acute onset of pain in the first MTP) PE: hot, red, tender joint, tophi Labs: needle-shaped crystal with negative birefringence, uric acid can be low, normal or elevated Treatment: Acute: NSAIDs, steroids, colchicine Chronic: allopurinol (first line), febuxostat, probenecid *Can be triggered by loop and thiazide diuretics

Ventricular Tachycardia

More than three consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Wide complexes Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia

Ventricular tachycardia (V-tach)

More than three consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Wide complexes Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia

What other blood product is commonly transfused in a woman with abruptio placentae?

Packed red blood cells, to treat the volume-depleting and oxygen-carrying insult which stems from abruption. Risk factors: hypertension, trauma, or cocaine use Painful vaginal bleeding Most often during the third trimester Labs will show hypofibrinogenemia Tx: fetal monitoring, hemodynamic stabilization, delivery

What is the common side effect of rifampin?

Orange discoloration of body fluids. Tuberculosis (TB) Caused by Mycobacterium tuberculosis Risk factors: HIV, immigration from an endemic area, immunosuppression, malnutrition Primary TB Usually asymptomatic and progresses to latent TB with no intervention CXR: often normal, hilar adenopathy, Ghon focus Latent TB Asymptomatic Screening: tuberculin skin test (TST) or interferon-gamma release assay (IGRA) Tx: rifampin for 4 months, INH-rifampin daily for 3 months, or INH-rifapentine weekly for 3 months. Alternative is INH for 9 months or 6 months. Reactivation TB Sx: fever, night sweats, weight loss, productive cough, hemoptysis CXR: upper lobe infiltrates, apical cavitary lesions Dx: sputum smears for acid-fast bacilli (AFB) x3, sputum or tissue culture for AFB (gold standard) Tx: rifampin, INH, pyrazinamide, ethambutol (RIPE) for 6 months Monitor LFTs, add vitamin B6 (prevent peripheral neuropathy due to INH) Comment: Positive TST determined by mm of induration and risk factors 15 mm: people with no known risk factors 10 mm: immigration from high-prevalence countries < 5 years ago, IV drug use, residents/employees of high risk settings (homeless shelter, correctional facilities, hospitals, nursing homes), children < 4 years old or exposed to adults in high risk categories 5 mm: HIV infection, recent TB contact, CXR consistent with prior TB, organ transplant, TNF-α inhibitors or chronic steroids

What are two complications of an untreated felon?

Osteomyelitis and skin necrosis.

Postrenal Acute Kidney Injury

Outflow obstruction BUN to Cr 10-20:1 Ultrasound

Acute Coronary Syndrome: Management - Medical Therapy

Oxygen - indicated for O2 sat < 90%, dyspnea, heart failure Nitroglycerin - relieves ongoing chest pain, lowers BP Morphine - relieves pain, reduces work of breathing in setting of pulmonary edemaonly used if nitroglycerin fails to relieve the paincan be associated with negative outcome Beta Blockers - prevent recurrent ischemia and dysrhythmia Antiplatelet agents - reduce recurrent coronary artery thrombosis, stent thrombosis, and death Aspirin - given before PCI and continued indefinitelyP2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) - continue for 1 year if stent placedGPIIb/IIIa antagonists for patients undergoing PCI Anticoagulation - if LV thrombus or Afib present and all patients receiving thrombolytic therapy ACE Inhibitors - reduce cardiovascular events, prevent LV remodeling High dose statin - lipid lowering, lowers risk of death, recurrent MI, and stroke

Acute Coronary Syndrome: Management - Reperfusion

PCI - increased survival, decreased ICH and recurrent MIPCI center: < 90 minutes "door to device" time Non-PCI center: transfer for PCI if "door to device" time can be <120 minutes Thrombolysis - if PCI is not available or "door to device" time > 120 minutes Administer within 30 minutes, can be given up to 12 hours of symptom onset Contraindications: ICH, intracranial malignancy, stroke within 3 months, aortic dissection

How is Rocky Mountain spotted fever diagnosed?

PCR can be used initially, and serial serologic examinations by indirect fluorescent antibody confirm the diagnosis, retrospectively. Rocky Mountain Spotted Fever (RMSF) History of recently being in the woods, hiking, or camping Abrupt onset of severe headache, photophobia, vomiting, diarrhea, and myalgia PE will show maculopapular eruption on palms and soles Most commonly caused by Rickettsia rickettsii Empiric treatment based on clinical presentation Diagnosis confirmed by serologic testing Treatment is ALWAYS doxycycline, even in children

Supraventricular Tachycardia (SVT) or Paroxysmal Supraventricular Tachycardia (PSVT) Summary

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

Anterior Shoulder Dislocation Summary

PE will show arm abducted, externally rotated, apprehension test positive X-ray will show humeral head displaced inferiorly and medially Diagnosis is made by anteroposterior (AP) and axillary shoulder X-ray Most commonly caused by trauma from a fall or forceful throwing motion Complications: axillary nerve damage, Bankart lesion, Hill-Sachs deformity

Pleural Effusion Summary

PE will show ↓ breath sounds + dull percussion + ↓ tactile fremitus CXR will show blunting of the costophrenic angle Can also use CT or US to diagnose Most common causes = Transudate: heart failure Exudate: infection > malignancy, PE Management includes treating underlying cause, therapeutic thoracentesis, tube thoracostomy Light criteria are used to differentiate between transudative and exudative effusions

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 TreatmentFirst-line: benzodiazepines (e.g., lorazepam)Second-line: phenytoin or fosphenytoin, valproic acid, levetiracetamThird-line: pentobarbital, propofol, phenobarbital

Compartment Syndrome Summary

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

primary dysmenorrhea

Pain starts 1 or 2 days before menses Pain is only related to menstrual cycle ↑ PGF2alpha → ↑ uterine contractions Pain management: NSAIDs (first line) or acetaminophen Hormonal therapy: estrogen-progestin contraceptives

What signs and symptoms are consistent with a L5 radiculopathy?

Pain that radiates down the lateral aspect of the leg into the foot, weakness with foot dorsiflexion, and decreased sensation between the first and second toes.

Which anatomical locations merit a specialist evaluation prior to abscess drainage?

Palms, soles and nasolabial folds.

What is the most common serious complication of ERCP?

Pancreatitis occurs in 1% of patients.

What is the most common cause of viral parotitis?

Paramyxovirus.

A dorsal slit procedure may be performed for what urologic emergency?

Paraphimosis.

Infection with what common childhood virus can cause a transient aplastic crisis in patients with sickle cell disease?

Parvovirus B19

What factors should be considered in prostate cancer screening?

Patient age, prostate volume, digital rectal examination findings, family history, and patient race.

Primary Adrenal Insufficiency (Addison Disease)

Patient presents with abdominal pain, nausea, vomiting, diarrhea, fever, and confusion PE will show hyperpigmentation of skin and mucus membranes and hypotension Labs will show hyponatremia and hyperkalemia Most commonly caused by autoimmune destruction of the adrenal cortex Treatment is hydrocortisone or other glucocorticoid

Subarachnoid Hemorrhage (SAH)

Patient presents with abrupt onset of "worst headache of life" or thunderclap headache Diagnosis is made by non-contrast CT scan, blood will appear white on the CT If CT negative and performed within 6 hours of symptom onset, subarachnoid hemorrhage effectively ruled out If CT negative and suspicion high, lumbar puncture or CT angiography Most commonly caused by a ruptured aneurysm Hunt & Hess classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm)

Optic Neuritis Summary

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

Erythema Multiforme (EM) Summary

Patient presents with acute onset of symmetric target lesions on palms and soles, face and trunk may also be involved PE will show target-like rash with a central dark papule surrounded by a pale area and a halo of erythema Most commonly caused by herpes simplex virus (HSV) Treatment is usually self-limiting, supportive Common drugs that cause EM: sulfa, oral hypoglycemics, anticonvulsants, penicillin, NSAIDs (SOAPS) Erythema multiforme minor: localized eruption of the skin with minimal or no mucosal involvement Erythema multiforme major: one or more mucous membranes are involved

BPPV (benign paroxysmal positional vertigo)

Patient presents with sudden onset of sensation of room spinning in connection with positional changes of the head, lasting seconds to minutes Common cause of recurrent peripheral vertigo resulting in dislodged otolith that leads to disturbances in semicircular canals (95% horizontal, 5% horizontal). Presents with transient vertigo (lasting <1min) and mixed upbeat-torsional nystagmus triggered by changes in head position. N/V uncommon due to short lived. Dx: by Dix-Hallpike maneuver. Tx: Epley maneuver. subsides in wks to months, but 30% recur w/in a yr. antivertigo meds CI. -Prochlorperazine is a dopamine receptor antagonist - It may assist in controlling nausea associated with BPPV, but will not directly treat the vertigo. - Diazepam works by positive allosteric modulators of the GABA type A receptors. It acts centrally to suppress vestibular response and does help reduce the symptoms of vertigo. However, it only suppresses the symptoms and does not treat the underlying cause of BPPV.

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

Atypical Pneumonia Summary

Patient presents with the gradual onset of dry cough, dyspnea, and extrapulmonary symptoms such as headache, myalgias, fatigue, and GI disturbance PE: rales with auscultation of lung fields Chest X-ray: interstitial infiltrate Most commonly caused by: Mycoplasma pneumoniae: youngLegionella: smokers, aerosolized water, air travel, GI symptoms, hyponatremia Chlamydophila pneumoniae: close quarters outbreaks, young, follows pharyngitis Coxiella burnetii: livestock exposure, include LFTs Chlamydophila psittaci: bird exposure, hyperpyrexia, severe HA Treatment: either empiric therapy (covering typical and atypical PNA) or directed therapy (azithromycin for C. pneumoniae)

Pyloric Stenosis Summary

Patient will be 2-8 weeks of age Nonbilious projectile vomiting after feeding and early satiety PE will show RUQ olive-like mass (hypertrophied pylorus) Labs will show hypochloremic hypokalemic metabolic alkalosis Diagnosis is made by ultrasound or UGI series (string sign) Treatment is surgical

Bullous pemphigoid Summary

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

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

Roseola (Exanthema Subitum)

Patient will be a child 6 months to 3 years of age History of high fever lasting 3-4 days Rash that started after the fever went away PE will show blanching macular or maculopapular rash with a distribution that begins at the neck and trunk region and spreads to the face and extremities

Intussusception (Telescoping Bowel) Summary

Patient will be a child 6 months to 3 years old Colicky abdominal pain, vomiting, and bloody stools (currant jelly) Diagnosis is made by ultrasound (target sign) Most common cause is idiopathic - Although less common, it is important to be vigilant for pathologic lead points in children of any age Treatment is air or hydrostatic (contrast or saline) enema

Staphylococcal Scalded Skin Syndrome (SSSS) Summary

Patient will be a child < 6 years old Presents with a rash and "peeling skin" PE will show widespread painful erythema and large, flaccid bullae (Nikolsky positive) and desquamation Most commonly caused by exotoxins and epidermolytic toxins of Staphylococcus aureus Treatment is beta-lactamase- and penicillinase-resistant PCN (i.e. oxacillin, nafcillin), vancomycin, first-generation cephalosporins

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

Retropharyngeal Abscess Summary

Patient will be a toxic-appearing child, 3-5 years old History of trauma or URI Fever, sore throat, dysphagia PE will show trismus, stridor, nuchal rigidity, muffled voice, cri du canard (duck quack) Neck X-ray will show widened retropharyngeal space twice the size of the vertebral body Diagnosis is made by CT Most commonly caused by S. aureus, group A Streptococcus, anaerobes, foreign body Treatment is intravenous antibiotics, I&D

Who should be considered for emergent ventriculostomy placement?

Patients with a GCS 8, those with transtentorial herniation, or those with significant intraventricular hemorrhage or hydrocephalus Intracerebral Hemorrhage Patient will be > 50 years of age History of hypertension and atherosclerotic risk factors Neurological deficits (indistinguishable from ischemic) PEPontine lesion: pinpoint pupils, coma, decerebrate posturingCerebellar: vomiting, dizziness, CN VI palsy Most commonly caused by spontaneous bleeding from arterioles Treatment is blood pressure control (nicardipine), ICP control, reverse all coagulopathies

The ECG in left ventricular hypertrophy (LVH)

Patients with hypertension and various other valvular disorders (i.e., aortic stenosis) may develop left ventricular hypertrophy which can cause ECG abnormalities that mimic cardiac ischemia LVH leads to prolonged depolarization (increased R wave peak time) and delayed repolarization (ST & T wave abnormalities) in the lateral leads There are numerous ECG voltage criteria that are specific for the diagnosis of LVH, however they are insensitive (~50%) and some patients with LVH may have relatively normal ECGs Voltage criteria alone are not diagnostic of LVH and must be accompanied by non-voltage criteria In young patients specifically, voltage criteria may be normal variants termed "high left ventricular voltage" Gold standard diagnostic tests for LVH include: echocardiography and cardiac MRI

Nephrolithiasis (Kidney Stones)

Patients with suspected renal stone require imaging ==> First episode of renal colic, unclear diagnosis, concomitant UTI, the elderly. Sx: flank pain radiating to groin PE: patient won't lie still, hematuria Diagnosis: non-contrast helical CT, most common location is the ureterovesical junction (UVJ) Most commonly caused by calcium oxalate Struvite: staghorn calculi, urease-producing bacteria Uric acid: radiolucent on X-ray, gout Cystine: children with metabolic diseases Treatment < 5 mm: likely to pass spontaneously > 5 mm: medical expulsive therapy (tamsulosin), urology consultation in certain cases > 10 mm: urology consultation, shock wave lithotripsy, ureteroscopy

ECG findings in Hyperkalemia

Peaked T-waves (even when inverted) Widening of the QRS (often marked) Prolonged PR-interval Flattening and eventual loss of P-waves Bizarre tachydysrhythmias, pseudo ventricular tachycardia ("slow V. Tach") Bizarre brady dysrhythmia, advanced AV Blocks and sinus pauses Axis changes (especially RAD) Fascicular & Bundle Branch Blocks Pseudo ACS with ST-segment changes (can mimic STEMI) Pseudo Brugada syndrome pattern Sine wave morphology Hypocalcemia is also present with Hyperkalemia and this is what causes long Q-T

The majority of blunt bladder injuries are associated with what fracture?

Pelvic fracture Intraperitoneal: nonemergent surgical repair Extraperitoneal: nonsurgical Evaluate with urethrogram, cystogram, or CT cystogram

Ultrasound: Cardiac Tamponade

Pericardial effusion Diastolic right ventricular collapse (high specificity) Systolic right atrial collapse (earliest finding) Plethoric IVC = dilated and non-collapsible with respiration

What are predisposing factors to developing a peritonsillar abscess?

Periodontal disease, smoking, chronic tonsillitis, and previous peritonsillar abscesses.

What common neurologic symptom is associated with isoniazid?

Peripheral neuropathy.

What is a common complication of increased doses of vitamin B6 (pyridoxine)?

Peripheral neuropathy. Isoniazid (INH) Toxicity ↓ B6 (pyridoxine) → ↓ GABA → refractory seizures with anion gap metabolic acidosis Antidote: B6

How frequently should a patient with scabies use topical permethrin?

Permethrin will not kill unhatched mites so they must apply it twice, one to two weeks apart. 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% or oral ivermectin (ivermectin not first-line in pregnancy or pediatrics < 2 months old)

What is the most common sign of immune thrombocytopenia?

Petechiae.

What physical exam finding of an extremity suggests a massive clot burden and threatens limb loss?

Phlegmasia cerulea (or alba) dolens.

What is the treatment of spinal stenosis?

Physical therapy that focuses on flexion exercises and abdominal or core strengthening.

What snakes are responsible for most of the snakebites in the United States?

Pit vipers, also known as crotaline snakes (rattlesnake, cottonmouth, copperhead) Snakes Viperidae Depression between eyes Significant local reaction → systemic toxicity Compartment syndrome Thrombocytopenia **Antivenom** Elapidae Red on yellow kill a fellow, red on black venom lack Minimal local reaction → neurotoxicity -Respiratory paralysis -Due to scarcity of antivenom in US, give for symptomatic eastern coral snake bites, otherwise supportive treatment

A 40-year-old woman presents with weakness, fatigue, nausea, and diarrhea. Physical exam reveals orthostatic hypotension and axillary fold hyperpigmentation. Which of the following laboratory abnormalities would you expect to find in this patient? A Hypercalcemia B Hypermagnesemia C Hypokalemia D Hyponatremia

Primary adrenal insufficiency (Addison disease), or hypocortisolism, is most commonly caused by autoimmune destruction of the adrenal cortex. Nonspecific symptoms of hypocortisolism include weakness, fatigue, weight loss, anorexia, orthostasis, and listlessness. The most specific sign of primary adrenal insufficiency is hyperpigmentation, typically of the mucous membranes, axillary folds, and nipples. Another specific symptom of primary adrenal insufficiency is salt craving. Because the adrenal cortex is damaged, aldosterone levels are also affected. A decrease in aldosterone will lead to less renal sodium reabsorption and less renal potassium excretion, with subsequent hyponatremia and hyperkalemia. A net loss of sodium to the urine may lead to polyuria and hypovolemia. Hyponatremia associated with adrenal insufficiency may cause seizures, delirium, coma, or death Parathyroid hormone, not cortisol, is responsible for maintaining calcium homeostasis (A). Cortisol has no effect on magnesium (B) levels. Hyperkalemia not hypokalemia (C) is seen in primary adrenal insufficiency.

suicide risk factors

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 Social supports lacking Organized plan No spouse Sickness (psychiatric or general medical illness) Most completed suicides involve firearms

What two structures are involved in a Monteggia fracture-dislocation?

Proximal ulna fracture and radial head dislocation.

What pathogens most commonly cause otitis externa?

Pseudomonas aeruginosa, Enterobacteriaceae and Proteus species, Staphylococcus aureus Necrotizing Otitis Externa - Potentially life-threatening disease in elderly patients with diabetes and immunocompromised patients. Caused by Pseudomonas

What is the name for systolic blood pressure changes > 10 mm Hg with inspiration?

Pulsus paradoxus.

Right Bundle Branch Block (RBBB)

QRS interval > 0.12 sec Notable features = Predominantly positive QRS in V1rSR or rsR in lead V1Wide S in lead I and V6

Inferior ST-Elevation Myocardial Infarction

RCA occlusion ST elevations: II,III, aVF RV infarctionST elevations: V4R and V5RJVD, hypotensionRx: IVF NTG contraindicated

Hemorrhagic pancreatitis

Rapid progression of acute pancreatitis with the rupture of pancreatic vessels and subsequent hemorrhage Can lead to hypotension and symptoms similar to that of a ruptured AAA. Retroperitoneal blood from hemorrhagic pancreatitis can lead to periumbilical, flank, or scrotal ecchymosis, but in a patient with risk factors for AAA and no history of alcohol use, a ruptured abdominal aortic aneurysm is more likely.

What is the most common cause of acute adrenal insufficiency in the United States?

Rapid withdrawal of exogenous steroids in patients on long-term therapy Corticoadrenal Insufficiency 1°: Addison disease Weakness, fatigue, anorexia, weight loss Hyperpigmentation (1° disease) Hyponatremia and hyperkalemia (1° disease) ↑ ACTH = 1° disease ↓ ACTH = 2° disease Hydrocortisone Fludrocortisone (1° disease)

What is second impact syndrome?

Rapid-onset cerebral edema following a second mild traumatic brain injury before recovery from the first

PVCs (Premature Ventricular Contractions)

Rate: Regular underlying rate (usually) P wave: Absent (or abnormal) in PVC QRS: PVC: wide > 0.12 seconds; shape is bizarre; T wave inversion Conduction: Normal before & after PVC Rhythm: Irregular; may occur in singles, couplets or triplets

Benign Prostatic Hyperplasia (BPH) Summary

Risk factors: advancing age Sx: hesitancy, intermittence or incontinence, frequency or fullness, urgency, nocturia (HI FUN) PE: smooth, firm, mobile prostate without any nodules or indurations Dx: digital rectal exam, UA to rule out alternate causes Caused by stromal and epithelial cell growth in the transitional zone of the prostate Tx: alpha-blockers, 5-reductase inhibitors, surgery (TURP)

Aortic Stenosis

Risk factors: advancing age, diabetes, hypertension Sx: dyspnea, chest pain, syncope PE: crescendo-decrescendo systolic murmur that radiates to the carotids, paradoxically split S2, S4 gallop. Murmur decreases with Valsalva Most commonly caused by degenerative calcification Treatment: aortic valve replacement

Aortic Dissection

Risk factors: advancing age, male sex, HTN, Marfan syndrome Sx: acute onset of "ripping" or "tearing" chest pain or back pain PE: asymmetric pulses or SBP difference of > 20 mmHg CXR: widened mediastinum Dx: CT angiography or transesophageal echocardiogram (TEE) Treatment: reduce BP and HR (beta-blockers), pain control, emergency surgery (Type A dissection) Type A: involves ascending aorta Type B: involves only descending aorta

Cholelithiasis Summary

Risk factors: female sex, age 40-50 years old, pregnancy, obesity, rapid weight loss Sx: slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Gallstones most commonly made of cholesterol Treatment is observation or cholecystectomy

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

Risk factors: female sex, obesity, meds (tetracycline, OCPs, vitamin A, steroids) Sx: diffuse headache and visual blurring, peripheral vision loss PE: bilateral papilledema, CN VI palsy Elevated opening pressure on LP Treatment is acetazolamide, serial LPs, weight loss

Bacterial Endocarditis

Risk factors: injection drug use, valvular heart disease Sx: fever, rash, cough, and myalgias PE: fever, Roth spots, Osler nodes, murmur, Janeway lesions, anemia, nailbed hemorrhages, emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by: IVDA: Staphylococcus aureus, tricuspid Native valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral Tx: antibiotics GI malignancy: Streptococcus bovis Dental prophylaxis in some cases

Bacterial Endocarditis Summary

Risk factors: injection drug use, valvular heart disease Sx: fever, rash, cough, and myalgias PE: fever, Roth spots, Osler nodes, murmur, Janeway lesions, anemia, nailbed hemorrhages, emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by:IVDA: Staphylococcus aureus, tricuspidNative valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral Tx: antibiotics GI malignancy: Streptococcus bovis Dental prophylaxis in some cases

anorectal fistula

abnormal communication between the anorectum and the cutaneous surface. It occurs most commonly in patients with anorectal abscesses, Crohn's disease, trauma, foreign bodies, tuberculosis, and cancer

Digoxin works by inhibiting which pump?

The sodium/potassium ATPase pump on the cardiac cell membrane, which leads to increased intracellular calcium and extracellular potassium. Digoxin Toxicity Sx: nausea, vomiting, vision changes (yellow halos) ECG: PVCs, atrial tachycardia with AV block, bidirectional ventricular tachycardia Labs: digoxin level, renal function, hyperkalemia is associated with a poor prognosis Treatment is digoxin-specific antibody fragment Hypokalemia increases risk of digoxin toxicity

bacterial endocarditis Summary

Risk factors: injection drug use, valvular heart disease Sx: fever, rash, cough, and myalgias PE: fever, Roth spots, Osler nodes, murmur, Janeway lesions, anemia, nailbed hemorrhages, emboli (FROM JANE) Diagnosis is made by echocardiography and Duke criteria Most commonly caused by: IVDA: Staphylococcus aureus, tricuspid Native valve: Staphylococcus aureus, viridans streptococci (most common in previously diseased), mitral Tx: antibiotics GI malignancy: Streptococcus bovis Dental prophylaxis in some cases

What is the most common cause of dysentery in the United States?

Shigella sonnei. Although there are four Shigella species, S. sonnei is the most common and has only one known subtype. Other species include S. dysenteriae, S. flexneri, and S. boydii. Each has multiple subtypes Shigellosis Patient presents with fever, bloody and mucoid diarrhea, and seizures (more common in children) Labs will show fecal RBCs and WBCs Treatment is based on resistance patterns but commonly azithromycin or ciprofloxacin Complications: HUS, reactive arthritis

Acute Bacterial Prostatitis Summary

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

Community-Acquired Pneumonia (CAP) Summary

Sx: fever, productive cough, dyspnea, fatigue PE: rales, rhonchi, dullness to percussion Dx: CXR - interstitial infiltrates and lobar opacity Labs: Sputum gram stain/cultures and blood cultures recommended only in hospitalized patients with severe CAP or empirically treated for MRSA or P. aeruginosa PSI preferred over CURB-65 to stratify risk, inpatient vs outpatient management Most commonly caused by Streptococcus pneumoniae Tx: depends on severity and risk factors for MRSA and P. aeruginosa (see 2019 IDSA guidelines)

Ankylosing Spondylitis (Radiographic Axial Spondyloarthritis)

Risk factors: male sex, age < 40 Sx: low back pain that's most severe at night and morning stiffness that improves with exercise PE: limited spinal mobility, decreased lumbar lordosis X-ray: squared vertebral bodies, multiple vertebral fusions (bamboo spine) Labs: increased ESR, positive HLA-B27 Treatment options include NSAIDs, physical therapy, TNF-alpha blockers Associated with: uveitis, aortitis, IBD, psoriasis, apical pulmonary fibrosis Diseases associated with HLA-B27: "PAIR" Psoriatic arthritis Ankylosing spondylitis Inflammatory bowel disease Reactive arthritis

Ankylosing Spondylitis (Radiographic Axial Spondyloarthritis) SUMMARY

Risk factors: male sex, age < 40 Sx: low back pain that's most severe at night and morning stiffness that improves with exercise PE: limited spinal mobility, decreased lumbar lordosis X-ray: squared vertebral bodies, multiple vertebral fusions (bamboo spine) Labs: increased ESR, positive HLA-B27 Treatment options include NSAIDs, physical therapy, TNF-alpha blockers Associated with: uveitis, aortitis, IBD, psoriasis, apical pulmonary fibrosis Diseases associated with HLA-B27: PAIRPsoriatic arthritisAnkylosing spondylitisInflammatory bowel diseaseReactive arthritis

Acute Coronary Syndrome: Management

Reperfusion PCI - increased survival, decreased ICH and recurrent MIPCI center: < 90 minutes "door to device" time Non-PCI center: transfer for PCI if "door to device" time can be <120 minutes Thrombolysis - if PCI is not available or "door to device" time > 120 minutes Administer within 30 minutes, can be given up to 12 hours of symptom onset Contraindications: ICH, intracranial malignancy, stroke within 3 months, aortic dissection Medical Therapy Oxygen - indicated for O2 sat < 90%, dyspnea, heart failure Nitroglycerin - relieves ongoing chest pain, lowers BP Morphine - relieves pain, reduces work of breathing in setting of pulmonary edemaonly used if nitroglycerin fails to relieve the paincan be associated with negative outcome Beta Blockers - prevent recurrent ischemia and dysrhythmia Antiplatelet agents - reduce recurrent coronary artery thrombosis, stent thrombosis, and death Aspirin - given before PCI and continued indefinitely P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) - continue for 1 year if stent placed GPIIb/IIIa antagonists - for patients undergoing PCI Anticoagulation - if LV thrombus or Afib present and all patients receiving thrombolytic therapy ACE Inhibitors - reduce cardiovascular events, prevent LV remodeling High dose statin - lipid lowering, lowers risk of death, recurrent MI, and stroke

What acid base disturbance is expected in salicylate toxicity?

Respiratory alkalosis with elevated anion gap metabolic acidosis Salicylate Toxicity Aspirin, wintergreen, bismuth subsalicylate Respiratory alkalosis + anion gap metabolic acidosis Hypoglycemia Tinnitus Rx: activated charcoal (if < 2 hour from ingestion), urine alkalinization, K+ Hemodialysis indications: Level > 100 mg/dL, Coma, Rising levels despite alkalization, Kidney failure, Pulmonary edema, Altered mental status, Clinical deterioration

What is the most common cause for the development of a boutonnière deformity?

Rheumatoid arthritis due to prolonged inflammation leading to central slip rupture

What type of mid-body fracture is commonly seen in child abuse?

Rib fractures

Right Bundle Branch Block (RBBB)

Right ventricular depolarization is delayed Criteria: - Wide QRS, QRS interval > 0.12 sec - RSR' in V1, V2 ("bunny ears") with ST depression and T wave inversion - Late S waves in I, aVL, V5, V6 (reciprocal changes) - Notable features: Predominantly positive QRS in V1rSR or rsR in lead V1, Wide S in lead I and V6

Cerebral toxoplasmosis

Ring-enhancing lesion in basal ganglia, seizures, headaches protozoan infection by Toxoplasmosis gondii. This typically leads to focal encephalitis in AIDS patients most commonly with a CD4 count below 100 cells/mL. Contrast enhancing CT typically shows ring-enhancing lesions with toxoplasmosis as well. Tx: trimethoprim-sulfamethoxazole PPX, sulfadiazine+pyrimethamine

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, IVIG, or plasmapheresis

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 ultrasoundDefinitive dx: gestational sac with a yolk sac or embryo outside of the uterine cavityFree fluid with debris is suggestive to ruptured ectopic Most commonly located in a fallopian tube Treatment is methotrexate or surgery

SJS/TEN

SJS is the formal diagnosis when the lesions involve < 10% total body surface area while TEN involves > 30% Signs and symptoms of SJS and TEN include fever, recent upper respiratory tract infection, purulent sputum, and the classic rash. The rash begins as atypical target-like lesions and progresses to painful bullae on an erythematous base. There is a positive Nikolsky sign as the epidermis separates with slight lateral pressure. There is universal mucous membrane involvement and frequent eye erythema, pain, and discharge. Diagnosis is classically clinical; however, if there is diagnostic uncertainty, a skin biopsy may be required. Management is supportive with hydration as though these lesions were a large burn. Patients should be admitted to a burn center for management of this disease process. Ophthalmology should be consulted if there is any indication of ocular involvement. Steroids are not indicated for this disease process. Mortality depends upon the degree of total body surface area involvement as a larger area leads to increased risk of infection.

LVH with strain pattern & cardiac ischemia

ST segment changes may lack sensitivity and specificity for coronary occlusion, and diagnostic uncertainty is especially exacerbated in patients with underlying LVH Nothing has been adequately validated to help differentiate the two with certainty If voltage criteria for LVH are not present, it is best to assume ischemia LVH has asymmetric T wave inversions while ischemic T wave inversions tend to be symmetrical Horizontal ST segment depression favors ischemia Horizontal ST segment elevation (checkmark sign) favors ischemia When in doubt, get serial ECGs and compare to old ECGs to look for evolving changes

What is the most common significant dysrhythmia in pediatrics?

SVT/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

What organism is the leading cause of osteomyelitis in pediatric sickle cell patients?

Salmonella, followed by S. aureus.

Salter-Harris classification of fractures:

Salter-Harris Classification of Fractures This classification is for the purpose of prognosis of the fracture. Type I offers the best prognosis and Type V the worst. 1. Type I - fracture extends to the epiphyseal plate resulting in displacement of the epiphysis. 2. Type II - fracture is through the epiphyseal plate and extends into the metaphysis. 3. Type III - fracture involved the epiphyseal plate and the epiphysis. 4. Type IV - fracture involves the epiphyseal plate, epiphysis, and metaphysis. 5. Type V - a crushing type of injury applied to the epiphysis in which the epiphyseal plate is injured Salter-Harris Fractures SALTER mnemonic I: slipped epiphysis II: fracture above physis, most common III: fracture below physis IV: fracture through physis V: erasure of the growth plate Management I-II: nonoperative IV-V: surgery required Negative radiographs do not rule out a Salter I fracture

What is the most common site of origin for Ludwig angina?

Second Mandibular molar

What side effect is common with rifampin?

Secretions (tears, urine) will turn orange. Contact lens wearers should be warned of permanent staining.

Histrionic Personality Disorder

Seeking attention, want to be center of attention Dramatic Flamboyant Seductive behavior Sexually inappropriate Treatment: psychotherapy

Hemolytic Uremic Syndrome (HUS)

Serious, Microangiopathic hemolytic anemia with renal failure is the hallmark of HUS, often with accompanying platelet destruction. usually preceded by infectious diarrhea and is strongly associated with the O157:H7 strain of enterohemorrhagic E. coli.

What are the diagnostic criteria for diabetic ketoacidosis?

Serum glucose > 250 mg/dL, acidosis (pH < 7.30), bicarbonate < 15 mEq/L, and the presence of urine or serum ketones. 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 Management Treat precipitating cause Correct volume depletion with NS, add dextrose to fluids once glucose is < 200 mg/dL Replete K+ deficit (usually falsely elevated), do not start insulin if K+ < 3.3 mEq/L IV 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

Which of the following is a risk factor for sudden unexpected death in infancy? A Maternal age over 35 years old B Maternal smoking C Sleeping in separate beds D Supine sleeping

Sudden unexpected infant death (SUID) is the most common cause of death in the United States for children between 1 month and 1 year of age. The term has largely replaced sudden infant death syndrome (SIDS). The cause is unknown. Maternal smoking, particularly during pregnancy, is the strongest maternal risk factor. Mothers under 20 years of age, not mothers of advanced maternal age (A), are at increased risk for SUID. Environmental risk factors include sleeping on a soft surface, sharing a bed (C), and prone sleeping, which inspired the Back to Sleep campaign against SUID to promote supine sleeping (D). There has been a 50% reduction of SUID since the start of the campaign. Sudden Unexpected Infant Death (SUID) Peak incidence: 2 and 4 months (median age 11 weeks) Risk factors: maternal smoking or drug use, prone sleeping position Recommendations: supine sleeping, pacifiers, breastfeeding

What medication classes are most commonly implicated in causing erythema multiforme?

Sulfa, oral hypoglycemics, anticonvulsants, penicillin, and NSAIDs.

Which medications are most commonly associated with erythema multiforme?

Sulfonamides, antiepileptic medications, and antibiotics. These should be stopped, if possible, in patients presenting with erythema multiforme.

What is the treatment of tender breast engorgement in a non-breastfeeding postpartum woman?

Supportive bra, cold compresses, and avoidance of breast stimulation.

What are some symptoms seen in early ethanol withdrawal?

Sweating, flushing, sleep disturbances, hallucinations, seizures, and mild mental status changes Alcohol Use Disorder Mild: Two to three symptoms Moderate: Four to five symptoms Severe: Six or more symptoms Symptoms Recurrent drinking leading to inability to fulfill major role obligations Recurrent drinking in hazardous situations Continued drinking despite alcohol-related social or interpersonal problems Evidence of tolerance or alcohol withdrawal Use of alcohol for relief or avoidance of withdrawal Drinking in larger amounts or over longer periods than intended Persistent desire or unsuccessful attempts to stop or reduce drinking Great deal of time spent obtaining, using, or recovering from alcohol Important activities given up or reduced because of drinking Continued drinking despite knowledge of physical or psychological problems caused by alcohol Craving or having a persistent urge to drink alcohol

Mumps

Swelling and pain on both sides of face Sore throat Fever Aches and pains Very contagious for up to 7 days before symptoms show and 10 days after symptoms start Symptoms may last 10 days typically affects the salivary glands with swelling and pain. Other areas that may be infected with mumps include the testes, pancreas, and meninges

Diverticulitis Summary

Sx: abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE: localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT with IV contrast: thickened bowel wall, "fat stranding," may show complications - bowel perforation, abscess, fistula, obstruction Consider treatment with supportive care and/or antibiotics based on risk factors and presentation. Antibiotics to cover gram-negative and anaerobic bacteria, bowel rest, and surgery (in severe cases) High-fiber diet can help in prevention

Acetaminophen Toxicity

Sx: abdominal pain, nausea, vomiting, and jaundice PE: RUQ tenderness Labs: elevated AST and ALT Treatment is N-acetylcysteine (restores glutathione) Rumack-Matthew nomogram: stratifies the risk of liver failureAbove Rumack-Matthew nomogram line: treatBelow Rumack-Matthew nomogram line: no treatment necessary Determine if overdose was accidental or intentional

Acute Angle-Closure Glaucoma Summary

Sx: acute unilateral pain and vision loss, headache, vomiting, and seeing halos around lights PE: cloudy cornea and fixed mid-dilated pupil Dx: increased IOP Tx: emergent ophthalmology evaluation, topical beta-blockers (timolol), topical alpha-agonists (apraclonidine), miotics (pilocarpine), carbonic anhydrase inhibitors (acetazolamide), iridotomy

Ulcerative Colitis Summary

Sx: bloody diarrhea, crampy abdominal pain, tenesmus PE: continuous mucosal inflammation, always involving the rectum, absence of perianal involvement (prevalent in Crohn) Extra-intestinal findings: uveitis, erythema nodosum, peripheral arthritis, sacroiliitis, ankylosing spondylitis Tx: options depend on severity and location of disease Mild-moderate: mesalamine, topical or oral steroids, 5-ASA Severe: IV steroids +/- topical steroids initially, then anti-TNF or anti-integrin, colectomy for refractory cases (curative) Complications: toxic megacolon, ↑ colon cancer risk

Cholecystitis Summary

Sx: colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE: Murphy sign, Boas sign (hyperaesthesia, increased or altered sensitivity, below the right scapula) Diagnosis - Initial: U/S; Gold standard: HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy

Pulmonary Embolism Summary

Sx: dyspnea, pleuritic chest pain, cough, syncope PE: tachypnea, tachycardia, possible signs of DVT (calf pain or swelling) ECG: sinus tachycardia, nonspecific ST segment and T wave changes, RV strain, S1Q3T3 (classic finding) CXR: nonspecific abnormalities, Hampton hump (pleural-based wedge infarct), Westermark sign (vascular cutoff sign) Dx: CT pulmonary angiography most preferred, VQ scan alternative Tx:Anticoagulation: heparin, LMWH, warfarin, novel oral anticoagulants (NOAC)Thrombolytics, embolectomy in hemodynamically unstable patients Comment: in low clinical suspicion: negative D-dimer excludes PE

Acute Pancreatitis Summary

Sx: epigastric pain radiating to the back, worse when lying down and better when leaning forward, nausea, and vomiting PE: flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs: 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) Caused by gallstones > alcohol, hypertriglyceridemia, drugs Treatment is IV fluids, analgesics Complications: necrotizing pancreatitis, pancreatic pseudocyst

Acute Pancreatitis Summary

Sx: epigastric pain radiating to the back, worse when lying down and better when leaning forward, nausea, and vomiting PE: flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs: 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) Caused by gallstones > alcohol, hypertriglyceridemia, drugs Treatment is IV fluids, analgesics Complications: necrotizing pancreatitis, pancreatic pseudocyst

Ultrasound: Focused Assessment with Sonography in Trauma (FAST)

The FAST exam is highly sensitive and specific for the detection of free intraperitoneal fluid. It has poor sensitivity for solid-organ injury, hollow viscous injury, and retroperitoneal injury. Views: hepatorenal, splenorenal, pelvis, pericardium Stable patient + positive FAST → CT Unstable patient + negative FAST → repeat FAST or DPL Unstable patient + positive FAST → laparotomy

Salter Harris Classification System

The Salter-Harris classification is used to describe pediatric injuries involving the physis, the cartilaginous epiphyseal growth plate at the end of long bones. There are five types of fractures in this classification, and management depends on the type and severity of the fracture. SALTER mnemonic: I slipped epiphysis II: fracture above physis, most common III: fracture below physis IV: fracture through physis V: erasure of the growth plate Management I-II: nonoperative IV-V: surgery required Negative radiographs do not rule out a Salter I fracture - MC missed on X-Ray

At what acetaminophen level would treatment with N-acetyl cysteine (NAC) be warranted at four hours?

Treatment should be initiated at an acetaminophen level of 150 μg/mL Acetaminophen Toxicity Sx: abdominal pain, nausea, vomiting, and jaundice PE: RUQ tenderness Labs: elevated AST and ALT Treatment is N-acetylcysteine (restores glutathione) Rumack-Matthew nomogram: stratifies the risk of liver failure Above Rumack-Matthew nomogram line: treat Below Rumack-Matthew nomogram line: no treatment necessary

Central retinal artery occlusion

acute and painless monocular vision loss-- the entire visual field is gone. Fundoscopic findings include pale retina (ischemia) and a cherry-red macula. Most common causes are embolisms through the internal carotid to opthalmic artery to central retinal. Risk factors: a-fib and carotid artery stenosis. It could also be causes by temporal arteritis

Gastritis

acute or chronic inflammation of the gastric mucosa. It presents with a gnawing or burning pain that may improve with ingestion of milk, food, or antacids due to a buffering effect on stomach acid. Abrupt onset of worsening pain indicates the gastritis has developed a complication, like an ulcer perforation. Postprandial abdominal pain is common with cholelithiasis and patients with cholecystitis may present with sudden worsening of their pain, fever, nausea, and vomiting. They may also have RUQ abdominal pain.

Croup (laryngotracheobronchitis)

acute respiratory syndrome in children and infants, acute obstruction of larynx caused by an allergen, foreign body, infection - certain viruses, bark like cough (strider) viral infection that has a characteristic barking cough that sounds like a seal. Patients may also exhibit inspiratory stridor in more severe illness.

Intussusception

occurs infrequently in patients with cystic fibrosis and is the result of inspissated bowel contents serving as a lead point. Patients will present with colicky abdominal pain, vomiting, a palpable mass and bloody stool.

What are the management implications of a type A dissection?

Type A dissections are any dissection involving the ascending aorta and should all be considered for surgical repair because of the increased mortality rate seen with medical management.

Hypersensitivity Reaction

Type I: anaphylactic, IgE mediated Type II: cytotoxic, IgG and IgM antibodies, complement activation Type III: immune complex mediated, complement activation Type IV: cell mediated, T cells

Malignant hyperthermia

occurs with the use of certain anesthetic agents (halothane and succinylcholine) and manifests as severe muscle rigidity and hyperthermia

Heparin-Induced Thrombocytopenia (HIT)

Type II HIT: autoantibodies to platelet factor 4 upon exposure to heparin, venous or arterial thromboses Labs: thrombocytopenia 5-10 days after heparin exposure Dx:4T score determines pretest probabilityPF4 antibody assay (sensitive)Serotonin release assay (specific) Tx: stop heparin immediately, use direct thrombin inhibitor Type I HIT: not clinically significant, mild thrombocytopenia that usually reverses without heparin cessation

Umbilical hernias

Typically acquired in adults, resulting from conditions that increase intra-abdominal pressure such as ascites, obesity and pregnancy. Incarceration is unusual with umbilical hernias. The majority of umbilical hernias in infants and young children, which result from incomplete closure of the umbilical ring, close spontaneously.

What is Auspitz sign?

The appearance of small bleeding spots when psoriasis plaques are removed.

How is the rash of pemphigus vulgaris different than that seen in bullous pemphigoid?

The bullae in pemphigus vulgaris are flaccid and Nikolsky sign is positive. Mucous membrane involvement is typical.

What compound is responsible for the toxicity in acetaminophen poisoning?

The compound N-acetyl-p-benzoquinoneimine (NAPQI), a metabolite of acetaminophen. Sx: abdominal pain, nausea, vomiting, and jaundice PE: RUQ tenderness Labs: elevated AST and ALT Treatment is N-acetylcysteine (restores glutathione) Rumack-Matthew nomogram: stratifies the risk of liver failure Above Rumack-Matthew nomogram line: treat Below Rumack-Matthew nomogram line: no treatment necessary

What is the most important factor that determines morbidity from septic arthritis?

The degree of articular cartilage destruction. 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 common cause overall: S. aureus Infants < 3 mo: Group B Streptococcus (Streptococcus agalactiae) N. gonorrhoeae is a common cause in young, sexually active individuals Tx: IV Abx, joint drainage, surgical washout

How is Finkelstein's test performed?

The examining physician grasps the patient's thumb and ulnar deviates the hand sharply.

Deep venous thrombosis

The formation of a blood clot within the larger veins of an extremity, typically following a period of prolonged immobilization. Common cause of pulmonary embolism. Pulmonary emboli will cause shortness of breath, tachycardia, and hypoxia. In some cases, a low- grade fever may be present. Pulmonary infarcts occur at the periphery of the lung due to the occlusion in the arterial circulation from the embolism. It is uncommon to have multiple and central lesions on CXR

horizontal head impulse test

The horizontal head impulse test is useful in differentiating between a peripheral and central cause by assessing the vestibulo-ocular reflex. ==> To perform the head impulse test, have the patient fixate on a visual target. Then rapidly rotate the patient's head from the center position to approximately 40 degrees to the right and then back to the center. An intact vestibulo-ocular reflex compensates by rapidly and smoothly moving the eyes in the opposite direction of the head rotation. If the vestibulo-ocular reflex is impaired, the patient will not be able to maintain their gaze on the visual target and instead will exhibit a rapid simultaneous movement of both eyes (corrective saccade) to reacquire fixation upon the visual target. The test should then be repeated on the left side. Patients with acute vestibular syndrome and an abnormal horizontal head impulse test are likely to be suffering from a peripheral vestibular lesion. If there is no corrective saccade, this is highly suspicious for a central lesion (e.g. stroke).

What is obstipation?

The inability to pass either stool or flatus for more than eight hours despite a perceived need. It is highly suggestive of intestinal obstruction.

What organism is the most common cause of pneumonia in HIV-positive patients?

The most common organism is Streptococcus pneumoniae

What is the recommended compression to ventilation ratio in a newborn child?

The optimal ratio is 3 compressions to 1 ventilation for a total of 90 compressions per minute and 30 breaths per minute

A 38-year-old man presents to the emergency department with complaints of left shoulder pain that started three months ago. He works as a painter and denies any known injury. Pain is worse with overhead movement. ECG was completed upon arrival and demonstrates a normal sinus rhythm with no acute changes. Upon examination of the shoulder, there is no deformity. He is tender over the deltoid and trapezius regions. His range of motion includes limited abduction and forward flexion to only 90 degrees with full external rotation. Special testing reveals a positive Hawkins test and a negative empty can test. A shoulder X-ray is negative for any acute fracture. Which of the following is the most likely diagnosis? A Acromioclavicular separation B Adhesive capsulitis C Full-thickness supraspinatus tear D Subacromial bursitis

The subacromial space is an area between the coracoacromial arch and the greater tuberosity of the humerus. It contains the long head of the biceps tendon, the supraspinatus tendon, and the subacromial bursa. Subacromial bursitis is most often an overuse injury due to chronic impingement. Patients who participate in frequent overhead activity are most at risk. The most common complaints are pain with overhead movement and difficulty finding a comfortable position at night due to pain. On physical examination, they likely will have a positive Neer impingement sign (pain with arm in 180 degrees forward flexion, followed by internal rotation) and Hawkins impingement sign (pain with arm in 90 degrees abduction, elbow flexed at 90 degrees, followed by internal rotation). Initial treatment is conservative with rest, nonsteroidal anti-inflammatory drugs and activity modification. Some patients may need additional physical therapy or a subacromial bursa steroid injection. Those with continued pain may proceed to further imaging with ultrasound or MRI and consideration of decompression surgery with orthopedics. What are the four muscles that make up the rotator cuff? Supraspinatus, infraspinatus, subscapularis, teres minor.

Intracranial Hemorrhage on ECG

There are many nonspecific ECG changes seen in patients with intracranial hemorrhage including ST changes, QT prolongation, and T-wave inversions. Occasionally these changes can mimic acute coronary syndromes including STEMI and can lead to misdiagnosis, unnecessary thrombolytics, or PCI ECG changes in supra tentorial intracerebral hemorrhage are very common and consist in QT-c prolongation, ST segment abnormalities and brady/tachycardia.

What is the recommended antibiotic regimen to treat Klebsiella pneumonia?

Third-generation cephalosporin and aminoglycoside

Abortion Classifications

Threatened abortion: vaginal bleeding with closed internal os Inevitable: vaginal bleeding with open os Incomplete: partial passage of products of conception (POC) Complete: complete passage of POC Missed: fetal death < 20 weeks without POC passage Missed abortion complications: infection, coagulopathy Rh-negative women → Rho(D) immune globulin

Lyme disease

Tick-borne disease caused by the spirochete Borrelia burgdorferi.

Which Tinea infection in children always requires systemic antifungal therapy?

Tinea capitis

Besides Tinea capitis, which other tinea infection should be treated with systemic antifungal medication?

Tinea unguium (onychomycosis).

A 28-year-old woman presents to the ED complaining of mild abdominal pain. Abdominal exam is unremarkable. Pelvic exam reveals scant blood in the vaginal vault and a closed os. Urinalysis is normal. The patient is Rh-positive. Her LMP was six weeks ago. A bedside transabdominal ultrasound is performed. What is the most appropriate next step in the management plan?

To confirm an intrauterine pregnancy on ultrasound, you must identify a gestational sac and yolk sac within the uterus. Such findings can be visualized on transvaginal ultrasound as early as 6 weeks gestational age. This patient's presentation is consistent with a threatened abortion as evidenced by a confirmed intrauterine pregnancy on ultrasound, a closed os, and vaginal bleeding. She can be discharged home with vaginal rest, bleeding precautions, and outpatient follow-up with her obstetrician. Ultrasound: Intrauterine Pregnancy (IUP) Criteria for Dx: yolk sac (YS) within a gestational sac (GS), intrauterine fetal pole, or intrauterine fetal heart activity IUP seen on transvaginal ultrasound > 38 days after LMP or beta-hCG > 1,500 mIU/mL IUP seen on abdominal ultrasound > 45 days after LMP or beta-hCG > 6,000 mIU/mL YS: present at 5-6 weeks with beta-hCG > 2,000 mIU/mL, first definitive sign of IUP Double decidual sac sign helps distinguish between IUP and a pseudogestational sac

What does a tombstone ECG mean?

Tombstoning ST-segment elevation is a type of ST-segment elevation with a specific morphology which is observed in the early period of acute myocardial infarction. This ECG appearance is a notion beyond morphological difference and is associated with more serious clinical results.

What medications are used to decrease production of aqueous humor in patients with acute angle closure glaucoma?

Topical beta-blockers, carbonic anhydrase inhibitors (e.g., acetazolamide), and systemic osmotic agents (e.g., mannitol).

Mental nerve block

Used for buccal soft tissues from midline to the second mandibular premolar and is often used for lower lip lacerations in order to avoid potential distortion of anatomy from local infiltration that could impair optimal repair.

Seidel test

Used to determine ruptured globe (positive test = leaking of aqueous through fluroscein stain - fluroscein in tear drop pattern) 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

Light's Criteria

Used to determine whether a pleural effusion is exudative or transudative. Satisfying any ONE criterium means it is exudative: Pleural Total Protein/Serum Total Protein ratio > 0.5. Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6

What is the treatment of non-severe C. difficile colitis?

Vancomycin (PO) or fidaxomicin (PO). Risk factors: history of recent antibiotic use (clinda most common), hospitalization, age > 65 Sx: loose stools (≥3 over 24h), abdominal pain Diagnosis made with two-step testing to distinguish from colonization: sensitive test initially (NAAT or GDH), followed by specific test: toxin EIA Treatment in adults: Non-severe or severe: oral vancomycin or oral fidaxomicin Fulminant: oral vancomycin with parenteral metronidazole Treatment in children: Mild: discontinuation of any nonvital antibiotic therapy and administration of fluid and electrolyte replacement Non-severe: oral vancomycin or oral metronidazole Severe or fulminant: oral vancomycin Patients with at least two Clostridioides difficile infection recurrences treated with appropriate antibiotic therapy: guidelines recommend use of fecal microbiota transplantation

What conditions will have a positive Tzanck test?

Varicella, herpes zoster, and herpes simplex, pemphigus vulgaris

What effect does hypoventilation have on intracranial pressure?

Vasodilation of cerebral vasculature and increased intracranial pressure.

What factor contributes most to the kinetic energy of a body in motion?

Velocity

A 55-year-old man with a history of acute coronary syndrome and a coronary artery bypass graft five years prior presents with dyspnea and diaphoresis. An ECG is completed in triage and is shown above. His blood pressure is 120/70 mm Hg, and he is alert and oriented, speaking in full sentences, with a respiratory rate of 22 breaths/minute and oxygen saturation of 99% on room air. Which of the following pharmacologic agents should be administered? A Amiodarone B Digoxin C Diltiazem D Metoprolol

Ventricular tachycardia is a type of wide-complex tachycardia with a ventricular rate greater than 100 bpm and QRS duration greater than 0.12 seconds. It originates within or below the Bundle of His. On ECG, a minimum of three consecutive wide QRS complex beats is necessary to diagnose ventricular tachycardia. Supraventricular tachycardia with abnormal conduction or aberrancy appears much like monomorphic ventricular tachycardia, making it difficult to distinguish between the two. The clinical history can aid in the differential. Ventricular tachycardia is more often seen in patients greater than 50 years of age with a history of ischemic heart disease, congestive heart failure, or prior history of ventricular tachycardia. ECG findings of AV dissociation, fusion beats or QRS greater than 0.14 seconds is more consistent with ventricular tachycardia. Patients presenting with a wide complex tachycardia carry a high risk of developing ventricular fibrillation, especially if the RR interval is less than 0.2 seconds. AV nodal blocking agents are contraindicated in the treatment of wide complex tachycardia as they will leave an unopposed accessory pathway, which will, in turn, lead to a faster ventricular response and possibly to ventricular fibrillation. Amiodarone is a class I, II, III and IV antidysrhythmic agent that works on sodium channels, beta-adrenergic receptors, and potassium and calcium channels. It is administered as a loading dose of 150 mg IV over 10 minutes followed by a continuous infusion. Procainamide, a class Ia antidysrhythmic, may also be considered. Ventricular Tachycardia More than three consecutive ectopic ventricular beats Monomorphic, polymorphic Bidirectional: digoxin toxicity Wide complexes Pulseless: immediate defibrillation Unstable: synchronized cardioversion Stable: procainamide, amiodarone, synchronized cardioversion (refractory) If unsure, manage all wide complex tachycardias as ventricular tachycardia

What is the classic triad in Meniere disease?

Vertigo, tinnitus, and hearing loss

WPW Syndrome with Atrial Fibrillation

Very rapid irregularly irregular tachycardia (rates may approach 250-300 beats/min) with wide QRS complexes that vary in morphology Often misdiagnosed as SVT, VT, or atrial fibrillation with BBB Misdiagnosis and treatment with AVN blockers can be deadly! Treat with procainamide, or preferably electrical cardioversion Key Point: Avoid all AV Nodal blockers Adenosine Beta-blockers Calcium channel blockers Digoxin Amiodarone

What maneuver can be performed by the delivering provider while awaiting medication administration for uterine atony?

Vigorous bimanual uterine massage.

What vitamin deficiencies do patients with cystic fibrosis develop?

Vitamin A, D, E, and K deficiencies from gastrointestinal malabsorption.

Ultrasound: Biliary Colic

Wall-echo-shadow sign (WES) Gallbladder wall, gallstone echoes, gallstone shadowing

What is a positive Brudzinski sign?

When the patient's neck is bent towards the chest, the patient reflexively flexes the hips and knees to relieve pressure

Do angiotensin II receptor blockers cause angioedema?

Yes, although the incidence is less than for angiotensin-converting enzyme inhibitors Angioedema Sx: swelling of the tongue, face, larynx, bowels Mast cell-mediated: associated with urticaria, bronchospasm, hypotensionallergic reactions (type I hypersensitivity), ASA, NSAIDS, idiopathicDx: tryptase level may confirm episode was mast cell-mediated Bradykinin-mediated: not associated with urticariaACEi, hereditary or acquired C1 inhibitor deficiency Dx: ↓C4 in C1 inhibitor deficiency, C1-INH protein level and function Tx: Laryngeal angioedema - airway management, intubation Anaphylaxis - epinephrine, IVF Non-anaphylaxis mast cell-mediated - antihistamines, steroids ACEi - discontinue culprit medication Hereditary: C1 esterase inhibitor concentrate, kallikrein inhibitor, bradykinin-B2-receptor antagonist, FFP

Methemoglobinemia

a blood disorder in which an abnormal amount of methemoglobin, a form of hemoglobin, is produced Signs and symptoms of methemoglobinemia (methemoglobin level above 10%) include shortness of breath, cyanosis, mental status changes, headache, fatigue, exercise intolerance, dizziness, and loss of consciousness. People with severe methemoglobinemia (methemoglobin level above 50%) may exhibit seizures, coma, and death (level above 70%). Healthy people may not have many symptoms with methemoglobin levels below 15%. However, people with co-morbidities such as anemia, cardiovascular disease, lung disease, sepsis, or who have abnormal hemoglobin species (e.g. carboxyhemoglobin, sulfhemoglobinemia or sickle hemoglobin) may experience moderate to severe symptoms at much lower levels (as low as 5-8%) Symptoms may include headache, dizziness, shortness of breath, nausea, poor muscle coordination, and blue-colored skin (cyanosis). Complications may include seizures and heart arrhythmias. Methemoglobinemia can be due to certain medications, chemicals, or food or it can be inherited. - Substances involved may include: benzocaine, nitrates, or dapsone. The diagnosis is often suspected based on symptoms and a low blood oxygen that does not improve with oxygen therapy. Diagnosis is confirmed by a blood gas. -Treatment : generally with oxygen therapy and methylene blue. Other treatments may include vitamin C, exchange transfusion, and hyperbaric oxygen therapy. Methemoglobinemia is relatively uncommon, with most cases being acquired rather than genetic.

LSD (lysergic acid diethylamide) intoxication

a hallucinogenic drug derived from ergot alkaloids Patients generally present with heightened awareness with auditory and visual hallucinations. Other clinical effects include gastrointestinal distress and sympathomimetic signs, such as hypertension and tachycardia. Coma, seizures, hyperthermia, and rhabdomyolysis have also been reported in the setting of LSD intoxication, but rarely hyponatremia.

Korsakoff's syndrome

a neurological disorder caused by a lack of thiamine (vitamin B1) which causes anterograde amnesia, retrograde amnesia, and severe memory loss. The memory loss leaves gaps in patient memories resulting in confabulation or invented memories that the patient believes are true. Treatment is with thiamine repletion, which should occur prior to any glucose administration due to the risk of further neuronal damage.

schizoid personality disorder

a personality disorder characterized by persistent avoidance of social relationships and little expression of emotion individuals are socially withdrawn, isolated, and tend to be emotionally apathetic

Factitious disorder

a psychiatric disorder in which the individual feigns disease in an attempt to gain attention, sympathy, or reassurance. There is often a longstanding history of doctor and hospital shopping, frequent hospitalizations, and extensive medical records. They are generally well-spoken, intelligent, and able to communicate in medical jargon. Even though this case does raise the index of suspicion for considering this diagnosis, it did not describe deceptive actions by the patient to have been demonstrated, which is needed for making the diagnosis. Remember that these actions are not done for obvious external rewards (e.g., monetary benefits).

Atrial Fibrillation (A-Fib)

an irregular and often very fast heart rate originating from abnormal conduction in the atria If the patient is hemodynamically stable, the approach to management (rate versus rhythm control) depends on the time of dysrhythmia onset. If the onset is unknown or > 48 hours, then cardioversion should be delayed until the patient can be adequately anticoagulated with enoxaparin followed by warfarin. In the interim, rate control would be accomplished with either esmolol a short-acting beta-blocker, or diltiazem , a calcium channel blocker. For patients with stable paroxysmal atrial fibrillation and a duration of onset < 48 hours, chemical cardioversion using procainamide can be attempted. In hemodynamically unstable patients, synchronized electrical cardioversion is recommended regardless of the dysrhythmia duration. Alternatives to procainamide include amiodarone, ibutilide, and, to a lesser degree, flecainide.

Pyridoxine deficiency

anemia, impaired immune function, weakness, dermatitis, neurological disorders (vitamin B6) is a pediatric disease that usually becomes noticeable within the first 12 months of life in infants with a lack of pyridoxine, a coenzyme responsible for numerous essential metabolic reactions. The disease presents with several key symptoms, including seizures, irritability, cheilitis (inflammation of the lips), conjunctivitis, and neurologic symptoms. In patients receiving isoniazid, pyridoxine deficiency can lead to a sideroblastic anemia because it is required as a cofactor in heme synthesis Pyridoxine deficiency is a cause of microcytic anemia

Tinea pedis

athletes foot, typically involves the skin between the toes, but can spread to the sole, sides, and dorsum of the involved foot .The acute form presents with erythema and maceration between the toes, sometimes accompanied by painful vesicles

systemic lupus erythematosus (SLE)

autoimmune disease with widespread organ involvement. It is not associated with scleroderma. Patients with lupus are at particularly high risk for renal failure, early cardiovascular disease, and thromboembolic disease (especially if antiphospholipid syndrome is present).

Kienböck disease

avascular necrosis of the lunate

pelvic inflammatory disease (PID)

inflammation and infection of organs in the pelvic region; salpingitis, oophoritis, endometritis, endocervicitis an ascending infection resulting in a spectrum of disorders of the upper female genital tract, including any combination of endometritis, salpingitis, peritonitis, and tubo-ovarian abscess. Physical exam most often reveals lower abdominal tenderness to palpation, vaginal discharge, cervical motion tenderness, and adnexal tenderness.

Osgood-Schlatter disease

inflammation of the patellar ligament at the tibial tuberosity that is most commonly seen in adolescent males. It manifests as a painful lump inferior to the knee.

What is the Jarisch-Herxheimer reaction?

inflammatory reaction that occurs after treatment for syphilis or other spirochetes; fever, chills, malaise, HA, myalgia, rash, pharyngitis A febrile reaction to antigens that are liberated when spirochetal bacteria (classically syphilis) are destroyed by antibiotic therapy.

tertiary blast injuries

injuries due to impact with another object - Fracture - Traumatic Amputation

Sarin gas

is an organophosphate nerve gas that leads to an cholinergic toxidrome. Treatment is with atropine and pralidoxime.

HSV encephalitis

is associated with fever, headache, and focal neurologic signs, often localized to the temporal lobe. The patient may complain of a bad odor not perceived by anyone else (temporal lobe hallucination). Treatment includes acyclovir

Anterior Shoulder dislocation

most common shoulder dislocation and one of the most common joint dislocations seen by an emergency clinician. The patients usually have their arm to the side, holding it in slight abduction and external rotation. There is usually a deformity seen at the glenohumeral joint, and a sulcus sign (a visible gap along the lateral edge of the acromion process) is often noted

Hypercalcemia

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency Can occur with malignancy, hyperparathyroidism, drugs (Lithium and thiazide diuretics), immobilization, Paget disease, or excessive intake (vitamin D toxicity, milk-alkali syndrome). Major clinical findings can be remembered with the phrase "stones, bones, groans, and psychiatric overtones" (nephrolithiasis, weakness, abdominal pain or constipation, confusion or depression). Hypercalcemia shortens the QT interval.

Which arbovirus is treatable with existing antiviral medications?

none West Nile Virus Mosquitos Summer and fall Flulike Sx, URI Sx, rash Complication: meningoencephalitis

Femoral Hernia

occur when the hernia sac protrudes through the femoral canal, resulting in the bulge or mass below the inguinal ligament. They are much more commonly seen in women than men (although still less common than inguinal hernias overall) and are more likely to result in incarceration or strangulation.

Psoriatic Arthritis (PsA)

occurs in up to 20% of patients with psoriasis. Other than psoriasis, patients exhibit asymmetrical oligoarthropathy or symmetrical polyarthropathy, spondylitis, and arthritis mutilans.

Wolf-Parkinson-White Syndrome

∙An accessory conduction pathway from atria to ventricles through the bundle of Kent, *causing premature ventricular excitation because it lacks the delay seen in the AV node.* ∙Treatment is *radiofrequency ablation.* ∙Want to avoid AV nodal blocking agents. ∙Look for delta wave. Ventricular pre-excitation caused by the presence of a congenital accessory pathway in patients with symptomatic arrhythmias Classic ECG triad: Short PR interval (< 120 ms), widened QRS interval (> 120 ms), delta wave (slurring and slow rise of the initial upstroke of the QRS) Delta waves may be very subtle or absent in some leads Short PR interval is your major clue...always check intervals and look in all 12 leads! Modified conduction through the accessory pathway will cause abnormal ventricular depolarization and result in secondary ST segment and T wave abnormalities WPW pattern can be subtle, transient, or intermittent!