E3 ER Exam

D. Theophylline Theophylline has a very narrow therapeutic index, with toxic effects of tachycardia, nausea, vomiting, and seizures.

A 16-year-old adolescent girl is brought to the ED after taking a number of pills from her parents' medicine cabinet. The parents have brought in all the medication bottles. Which of the following is most concerning for toxicity? A. Ampicillin B. Diphenhydramine C. Fluoxetine D. Theophylline

B. Call anesthesia and prepare for RSI. This patient displays signs of impending airway obstruction. His worsening airway edema, despite appropriate medical therapy, dictates intubation before complete airway occlusion and a cricothyroidotomy is required. There is no wheezing to suggest bronchoconstriction that could be treated with a bronchodilator such as albuterol. Stridor is a worrisome sign of upper airway obstruction. Normal respiratory rate and oxygen saturation should not delay intubation as falling oxygen saturation is a late sign of respiratory failure. Cricothyroidotomy is only indicated after all other measures have failed.

A 20-year-old man presents to the emergency department after being stung by a bee. His skin is red and covered with welts. He has obvious swelling of his lips and tongue, but no wheezes. After treatment with appropriate medications, he complains of throat swelling and his voice is hoarse. He has stridorous inspirations but a normal respiratory rate and oxygen saturation. What is the most appropriate management of this patient airway? A. Continued observation as long as oxygen saturation remains normal B. Call anesthesia and prepare for RSI. C. Begin high-dose nebulized albuterol and continue to observe. D. Prepare for cricothyroidotomy.

B. Call anesthesia and prepare for RSI. This patient displays signs of impending airway obstruction. His worsening airway edema, despite appropriate medical therapy, dictates intubation before complete airway occlusion and a cricothyroidotomy is required. There is no wheezing to suggest bronchoconstriction that could be treated with a bronchodilator such as albuterol. Stridor is a worrisome sign of upper airway obstruction. Normal respiratory rate and oxygen saturation should not delay intubation as falling oxygen saturation is a late sign of respiratory failure. Cricothyroidotomy is only indicated after all other measures have failed.

A 20-year-old man presents to the emergency department after being stung by a bee. His skin is red and covered with welts. He has obvious swelling of his lips and tongue, but no wheezes. After treatment with appropriate medications, he complains of throat swelling and his voice is hoarse. He has stridorous inspirations but a normal respiratory rate and oxygen saturation. What is the most appropriate management of this patient airway? A. Continued observation as long as oxygen saturation remains normal B. Call anesthesia and prepare for RSI. C. Begin high-dose nebulized albuterol and continue to observe. D. Prepare for cricothyroidotomy.

Ovarian torsion The intermittent crampy abdominal pain is classic for ovarian torsion. Although this patient's pain moves from the umbilicus to the lower quadrant area, it has lasted longer than 24 hours, without fever.

A 21-year-old woman experiences crampy abdominal pain that begins near the umbilicus and moves to the lower right quadrant. The pain has progressed over days, and is intermittent and crampy. The patient is afebrile and complains of some nausea.

Calcium gluconate This patient is likely receiving magnesium sulfate for seizure prophylaxis, and the antidote for hypermagnesemia is calcium gluconate

A 22-year-old pregnant woman with preeclampsia receiving intravenous medication to prevent seizures develops weakness and difficulty breathing.

Crohn disease Inflammatory bowel disease (Crohn disease or ulcerative colitis) often affects individuals in their teens or twenties, with abdominal pain, diarrhea (often bloody), and extraintestinal manifestations such as joint pain or eye findings.

A 22-year-old woman complains of intermittent severe abdominal pain with diarrhea. She also has some joint pain.

C. Cervical motion tenderness on physical examination Although cervical motional tenderness is not specific for acute salpingitis, and can be seen with other acute inflammatory conditions of the lower abdomen such as diverticulitis and appendicitis, it is a classic finding of pelvic inflammatory disease.

A 22-year-old woman is noted to have lower abdominal pain associated with some dysuria and abnormal menses. Her appetite has decreased recently. The pregnancy test is negative. Which of the following findings would most likely suggest pelvic inflammatory disease? A. Endometrial biopsy showing atypical cells B. Vaginal wet mount demonstrating clue cells C. Cervical motion tenderness on physical examination D. Pain on rectal examination

Naloxone Naloxone is the treatment of choice for opiate overdose. This individual likely is a heroin abuser.

A 24-year-old man is brought into the ED with somnolence, pinpoint pupils, and track marks on his arm

E. Prescribe the patient nitrofurantoin for 5 to 7 days and have her follow-up with her obstetrician. The patient is pregnant and has evidence of a urinary tract infection on the urinalysis. Pregnant patients are at high risk for preterm labor and perinatal mortality if a urinary infection goes untreated. Therefore, this patient should receive a 5 to 7 days course of nitrofurantoin or a penicillin-based antibiotic and follow-up with her obstetrician. The patient does not need to be admitted to the hospital for intravenous antibiotics. This would likely be the case if she were diagnosed with pyelonephritis. The patient should not wait for culture results and delay receiving her antibiotics. It is important to eradicate the bacteriuria as quickly as possible. This patient does not report the symptoms of gonorrhea or Chlamydia (eg, vaginal discharge) at this time, and does not require further evaluation for these conditions. Fluoroquinolones (eg, ciprofloxacin) are contraindicated in pregnant patients due to the risk of fetal abnormalities (eg, tendon mal-development).

A 24-year-old woman presents to the ED for painful urination over the last 2 days that is associated with urinary urgency. She states that she is pregnant and the fetus is at 12-week gestational age as measured by ultrasound. On examination, she is well appearing, and sitting comfortably in bed. Her blood pressure is 115/70 mm Hg, heart rate is 81 beats per minute, respiratory rate is 16 breaths per minute, and temperature is 37.2°C (98.9°F). A urinalysis reveals 5 WBC/ mm3, 1+ leukocyte esterase, and 1+ bacteria. The urine is negative for nitrite and blood. As you return to the patient bed to tell her the results, she states that her pain has resolved, she is urinating without difficulty, and wants to go home. Which of the following is the most appropriate course of management? A. Admit the patient for intravenous antibiotics. B. Discharge the patient with a prescription for antibiotics and tell her to fill the prescription only if the culture results are positive. C. Ask the patient to undergo another examination to evaluate for gonorrhea and Chlamydia. D. Administer a dose of ciprofloxacin in the ED and have the patient call the hospital to find out her culture results. E. Prescribe the patient nitrofurantoin for 5 to 7 days and have her follow-up with her obstetrician.

C. At 4 hours postingestion A serum APAP should be drawn 4 hours postingestion; the nomogram has relevance between 4 hours and 24 hours postingestion.

A 25-year-old man is brought into the ED 1 hour after a witnessed overdose of 20 to 25 pills of acetaminophen tablets. At what time would be the best time to draw the APAP level? A. As soon as the patient arrives in the ED B. At 2 hours postingestion C. At 4 hours postingestion D. At 8 hours postingestion

D. Phencyclidine intoxication Phencyclidine intoxication often presents with agitation, superhuman strength, and rotatory or vertical nystagmus.

A 25-year-old man is brought to the emergency room by police because of suspected cocaine intoxication. He is noted to be very agitated (fighting against five burly policemen) and wild eyed. On examination, his blood pressure is 180/100 mm Hg and heart rate 110 beats per minute. He is noted to have rotatory nystagmus. The neurologic examination reveals no focal abnormalities. Which of the following is the most likely diagnosis? A. Amphetamine intoxication B. Cocaine intoxication C. Opiate intoxication D. Phencyclidine intoxication

C. 6 days Clonazepam is a long-acting benzodiazepine. Abrupt discontinuance of short-acting benzodiazepines may be symptomatic after 2 to 3 days while withdrawal from long-acting agents may present up to 7 days after cessation. Treatment of benozodiazepine withdrawal involves reinstitution of a benzodiazepine followed by a gradual taper.

A 25-year-old woman has been taking clonazepam every day for 3 years for generalized anxiety disorder. She is in town on vacation but forgot her medication at home. When is she most likely to start showing symptoms of withdrawal? A. 12 hours B. 2 days C. 6 days D. 10 days

D. Lorazepam intravenously Benzodiazepines should be used as the first-line agent for nearly all cocaine toxicities. The hypertension is caused by sympathetic stimulation. β-Blockers are contraindicated because they can result in unopposed α-adrenergic stimulation and exacerbation of the chest pain and hypertension. Hypertension not responsive to benzodiazepines may require intravenous phentolamine, an α-adrenergic antagonist.

A 28-year-old man is noted to have extremely elevated blood pressure (210/130 mm Hg) associated with chest pain and dyspnea. His urine drug screen is positive for cocaine metabolites. Which of the following is the best next step? A. Albuterol intravenously B. Ephedrine intravenously C. Labetalol intravenously D. Lorazepam intravenously

A. Obtain CBC, amylase, liver function tests, and ultrasound of the gallbladder. Discuss with surgical consultants regarding admission to the hospital.

A 30-year-old woman presents with epigastric pain that developed following dinner. The patient describes having similar pain prior to the current episode, but previous episodes were less severe. The patient was diagnosed as having gastroesophageal refl ux disease by her primary care physician and prescribed a proton pump inhibitor, which has been ineffective in resolving her pain. The current pain episode has been severe and persistent for 3 hours. The patient has a temperature of 38°C (100.4°F), heart rate of 100 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 130/90 mm Hg. The abdominal examination reveals no abdominal tenderness. The administration of 30 mL of antacids and 4 mg of morphine sulfate resulted in some relief of pain. Which of the following is the most appropriate next step? A. Obtain CBC, amylase, liver function tests, and ultrasound of the gallbladder. Discuss with surgical consultants regarding admission to the hospital. B. Follow up with her primary care physician in 2 weeks. C. Admit the patient to the hospital for upper GI endoscopy. D. Prescribe antacids and discharge the patient from the ED, with follow-up by her primary care physician. E. Obtain an ultrasound of the gallbladder, prescribe oral antibiotics, analgesics, and arrange for an outpatient follow-up with her primary care physician.

E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists This patient has severe anaphylaxis, and it would be appropriate to move straight to intravenous epinephrine. If intravenous dosing is not immediately available, then intramuscular epinephrine should be given. Attention should then be turned to managing the airway. Because of the significant laryngeal edema, endotracheal intubation will be nearly impossible; hence, cricothyroidotomy may be required. After securing the airway, steroids, beta agonists, H1 and H2 antagonists should be administered.

A 32-year-old man collapses in the emergency room after being brought in by paramedics. He was stung by a bee and known to be highly allergic. He appears cyanotic and had extreme stridor in the ambulance. Severe laryngeal edema is notable. Which of the following is the best treatment? A. Nebulized albuterol, H1 and H2 antagonists, corticosteroids, and crystalloids B. Subcutaneous epinephrine, H1 and H2 antagonists, and corticosteroids C. Rapid sequence intubation, subcutaneous epinephrine, and corticosteroids D. Intramuscular epinephrine, rapid sequence intubation, and corticosteroids E. Intravenous epinephrine, rapid sequence intubation with preparation for a surgical airway, corticosteroids, nebulized albuterol, and H1 and H2 antagonists

D. Ultrasound of the pelvis Imaging is the best way to assess for TOA. Tubo-ovarian abscess is often subtle in its presentation and may not be associated with fever or elevated WBC. Most TOAs can be treated medically with antibiotics rather than requiring surgical therapy.

A 32-year-old woman is noted to have a 2-day history of low-grade fever and lower abdominal tenderness. The examination reveals cervical motion tenderness and adnexal tenderness. Which of the following is best in assessing for possible tubo-ovarian abscess? A. Degree of temperature B. Elevation of leukocyte count C. Pelvic examination revealing adnexal mass D. Ultrasound of the pelvis E. Rebound tenderness of the abdominal examination

A. Ultrasonography Because the patient is pregnant during the first trimester, the initial imaging test should be sonography to avoid the radiation-related teratogenic/ mutagenic effects on the fetus.

A 33-year-old woman is pregnant at 12 weeks' gestation and presents with right flank pain and gross hematuria. She is afebrile. Which of the following imaging tests is most appropriate for this patient? A. Ultrasonography B. KUB C. IVP D. Retrograde pyelography E. Helical CT without contrast

A. Initiate NAC due to potentially toxic exposure At 24 hours postingestion, NAC therapy may still be useful. Due to the historically toxic exposure, NAC should be started while a serum APAP level and liver enzymes are checked. If the APAP level is undetectable and the liver enzymes are normal, subsequent doses of NAC can be discontinued. The Rumack-Matthew nomogram is not applicable for ingestions more than 24 hours prior to evaluation.

A 34-year-old man admits taking "the whole bottle" of acetaminophen over the course of 36 hours because of a severe headache. Which of the following is the best guide to determine whether to initiate NAC therapy? A. Initiate NAC due to potentially toxic exposure B. Serum APAP level and liver enzymes C. Plotting the serum APAP level on the nomogram D. If over 24 hours have elapsed, NAC therapy is not efficacious

B. Escherichia coli E coli is the infecting organism in more than 80% of all UTIs. All of the other choices cause urinary tract infections, but are less common. S saprophyticus is a common organism in young, sexually active women. In hospitalized or nursing home patients, Pseudomonas spp and Staphylococcus spp are frequent pathogens. Lactobacilli are normal urethral flora and are not considered a causative organism. Complicated UTIs are more likely to be caused by other organisms.

A 34-year-old woman complains of mild crampy suprapubic abdominal pain, dysuria, and urinary frequency for the last 3 days. She has no fever. Her blood pressure is 125/70 mm Hg, heart rate is 88 beats per minute, respiratory rate is 16 breaths per minute, and temperature is 36.8°C (98.3°F). She has no significant past medical history and is able to drink oral fluids with difficulty. She has a clean-catch urinalysis that reveals 2+ leukocyte esterase, 1+ nitrite, 1+ blood, and 2+ bacteria. Her β-hCG is negative. Which of the following organisms is most likely responsible for her presentation? A. Klebsiella spp B. Escherichia coli C. Pseudomonas aeruginosa D. Proteus mirabilis E. Enterobacter spp

Pancreatitis Pancreatitis usually presents with mid-epigastric pain that penetrates straight to the back, is constant in nature, and is associated with nausea and vomiting. Common etiologies include alcohol abuse and gall stones.

A 35-year-old man complains of epigastric abdominal pain which seems to "bore straight to the back." He has nausea and vomiting

D. Naloxone This patient likely has an opiate intoxication (drowsiness and pinpoint pupils). Cocaine intoxication usually causes agitation and dilated pupils. Naloxone counteracts the effect of opioids.

A 35-year-old man is brought to the ED with altered level of consciousness, drowsiness, and pinpoint pupils. Which of the following is the most appropriate initial therapy for this patient? A. Activated charcoal B. Bicarbonate C. Lorazepam D. Naloxone

D. Give the entire course of NAC and no further APAP levels are necessary Once it is determined by the nomogram that the APAP dose is potentially toxic, the entire NAC regimen is given. No further APAP levels need to be drawn.

A 38-year-old school teacher took a "large number of Tylenol tablets" and is found to have an APAP level of 200 μg/mL. The estimated time postingestion is 8 hours. The first dose of NAC is given. Which of the following is the next step to guide therapy? A. Check APAP level 4 hours after the first NAC dose and if below the toxicity line, no further NAC needed. B. Check the APAP level 12 hours after the first NAC dose and if below the toxicity line, no further NAC needed. C. Check the APAP level and liver function tests at the 8 hour after the first NAC dose and if in the normal/nontoxic range, then no further NAC needed. D. Give the entire course of NAC and no further APAP levels are necessary

A. Renal pelvis Constant pain is most likely to be located in the kidney. Colicky pain is most likely to be located in the ureter and is caused by the stretching caused by the stone and inflammatory processes in the lumen of the ureter. Most stones in the renal pelvis or bladder are asymptomatic.

A 39-year-old man complains of the sudden onset of severe left flank pain after running a marathon. He describes the pain as constant with radiation to his left groin area. A urinalysis shows microscopic hematuria and the presence of cysteine crystals. Where is the stone most likely to be located? A. Renal pelvis B. Proximal ureter C. Distal ureter D. Uretero-vesicular junction E. Bladder

Cholelithiasis The right upper quadrant abdominal pain following meals (especially fatty meals) is very typical of cholelithiasis. The pain often radiates to the right scapula. If she had fever, cholecystitis would be suspected.

A 41-year-old woman complains of pain in the upper abdomen especially after eating. The pain seems to travel to her right shoulder. She has bloating at times.

B. Place IV, NG tube, and Foley catheter, initiate broad-spectrum antibiotics, and prepare patient for operation. This patient presents with signs and symptoms of high-grade small-bowel obstruction. The physical examination is highly suspicious for presence of intra-abdominal complications associated with the obstruction; therefore, CT scan is unlikely to contribute further in the diagnosis, and nonoperative therapy is inappropriate for a patient who is already exhibiting signs and symptoms of complicated small-bowel obstruction.

A 44-year-old woman with a past history of appendicitis that was treated by appendectomy 2 years ago presents with abdominal pain of 4-day duration. Her temperature is 38.5°C (101.3°F), pulse rate is 120 beats per minute, and blood pressure is 100/84 mm Hg. Her abdomen is distended and diffusely tender, with guarding. An occasional, high-pitched bowel sound is present. A kidneys, ureters, bladder (KUB) x-ray reveals a markedly dilated small bowel without air or stool in the colon. Which of the following is the most appropriate course of management? A. Place IV, NG tube, and Foley catheter, initiate broad-spectrum antibiotics, and obtain CT of abdomen. B. Place IV, NG tube, and Foley catheter, initiate broad-spectrum antibiotics, and prepare patient for operation. C. Place IV, NG tube, and Foley catheter, initiate broad-spectrum antibiotics, and attempt nonoperative treatment. D. Place IV, NG tube, and Foley catheter, initiate broad-spectrum antibiotics, obtain CT scan of abdomen, and prepare patient for an operation. E. Place IV, NG tube, and Foley catheter. Admit the patient to the ICU for monitoring.

Glucagon Glucagon is effective in treating calcium-channel blocker or β-blocker overdose.

A 45-year-old man takes too many of his antihypertensive pills and is noted to have a heart rate of 40 beats per minute

D. Disrobe the patient, place on a monitor, and obtain vital signs. In all patients the ABCs take priority. The patient should be assessed and the physical examination performed before administering any medications. In this patient with altered mental status of unknown etiology, the "coma cocktail" will likely be administered, but should be guided by the physical examination and history.

A 45-year-old man who runs his own business has been struggling with his finances since undergoing three surgeries to fix his right shoulder. He has been visiting multiple doctors to help control his pain. EMS was called to his office after an employee found the patient on his office floor with a bottle of vodka and a prescription medication bottle lying next to him. Which of the following should be the first course of action in the ED? A. Administer naloxone as he likely overdosed on pain medications. B. Give thiamine to prevent Wernicke-Korsakoff syndrome. C. Obtain a capillary blood glucose check. D. Disrobe the patient, place on a monitor, and obtain vital signs.

A. Alcohol The agitation, tremor, and autonomic hyperactivity point towards alcohol withdrawal. All patients admitted to the hospital for medical or traumatic conditions should be asked about drug and alcohol use. After admission, they may not have access to the drugs and/or alcohol they regularly use and may present with withdrawal syndromes.

A 50-year-old man is admitted for a femur fracture following a motor vehicle collision. Two days after admission, he becomes very agitated, tremulous, diaphoretic, tachycardic, and hypertensive. From what substance might he be withdrawing? A. Alcohol B. Cocaine C. Marijuana D. Oxycodone

B. Lorazepam This patient is exhibiting a sympathomimetic toxidrome. Her presentation is very similar to the patient in question 3. However, the key difference is that this patient has wet skin, while the patient in question 3 has dry skin. The patient should receive as much lorazepam as is needed to stop the seizure and allow the temperature to fall. Physostigmine is a treatment for anti-muscarinic toxicity and would not be helpful in this patient. Labetalol is a β-blocker. This patient has signs of active sympathomimetic excess. Treatment with a a-blocker may lead to unopposed `-1 agonism and potentially may worsen a patient tissue perfusion. While this patient is wet, she has none of the other signs of a cholinergic toxicity. Therefore, atropine and pralidoxime are not recommended. Phytonadione is vitamin K and is the treatment for warfarin toxicity. This patient recently used crack cocaine.

A 55-year-old homeless woman presents to the ED brought by ambulance. The police found her seizing in the street. Her vital signs are BP 220/150, HR 140, T 101°F, RR 16, pulse ox 100% on room air. On examination she has 6 mm pupils, very wet skin, decreased bowel sounds and is having uncontrollable limb movements. A check of her blood sugar is normal. What medication should this patient be administered? A. Physostigmine B. Lorazepam C. Labetalol D. Atropine then pralidoxime E. Phytonadione

C. Nausea and vomiting despite antiemetics Hospitalization is required if the patient is unable to tolerate anything by mouth. Gross hematuria and flank pain are expected with nephrolithiasis. Appropriate analgesics should be prescribed for patients if they will not be hospitalized. Stones 6 mm or less will generally pass spontaneously without interventions.

A 55-year-old man presents to the emergency department complaining of right flank pain for the past 2 weeks. He has noted some gross hematuria and has been unable to eat anything secondary to nausea and vomiting. Which of the following is an indication for hospitalization? A. Gross hematuria B. Right flank pain C. Nausea and vomiting despite antiemetics D. Age greater than 50 years E. Presence of a 6-mm stone

Vitamin K This patient likely has warfarin overdose, which is treated by vitamin K.

A 56-year-old woman taking tablets to "thin her blood" is noted to be bleeding from her gums and has multiple bruises on her arms and legs. Life-threatening bleeding can be addressed with transfusion with clotting factors

D. Epinephrine 0.15 mg intramuscular Intramuscular epinephrine should be administered immediately. If there is significant respiratory or airway compromise, then the patient should be controlled.

A 6-year-old girl with a known peanut allergy is brought to the ED by ambulance after accidentally eating a cookie made with peanut butter at a school party. She is wheezing with hives. Which of the following should be the fi rst intervention? A. Endotracheal intubation B. Normal saline 20 cc/kg IV C. Examination of the skin D. Epinephrine 0.15 mg intramuscular E. Nebulized albuterol

C. Lorazepam 2 mg IV While all are appropriate treatments for alcohol withdrawal, benzodiazepine dosing is tapered to the patient agitation. It may be redosed at 10 to 30 minute intervals for patients in severe withdrawal. Very high doses may be required especially if the patient has DTs.

A 60-year-old homeless man presents to the ED with acute alcohol withdrawal. He has been given 2 mg of lorazepam IV, but still appears very agitated and anxious. What is the most appropriate next step? A. Clonidine 0.2 mg PO B. Haloperidol 5 mg IV C. Lorazepam 2 mg IV D. Propanolol 100 mg PO

D. Establish IV access and place the patient on a cardiac monitor. This woman may indeed have a urinary tract infection; however, her vital signs are unstable. The mainstay of treatment in emergency medicine is to first address the patient airway, breathing, and circulation (ABCs). This patient is hypotensive (eg, BP 83/38 mm Hg). The first step in her management is placing an IV line and administering fluids. She should also be placed on a cardiac monitor to monitor her blood pressure, heart rate, and rhythm. Once her ABCs are addressed, laboratory studies should be obtained, including a urinalysis and culture. She should also receive broad-spectrum antibiotics and an antipyretic. This patient may need a lumbar puncture, but not until her ABCs are addressed. This patient requires admission to the hospital.

A 64-year-old woman is brought to the ED by her family for mental status changes. She has multiple sclerosis and self-catheterizes for urine. The family reports that over the past several days she has not been feeling well. They state that the patient vomited that day and was behaving bizarrely. Her vital signs are blood pressure of 83/38 mm Hg, heart rate of 135 beats per minute, respirations of 26 breaths per minute, and rectal temperature 38.8°C (101.9°F). After a history and physical examination, which of the following is the most appropriate next step in management? A. Obtain a urinalysis and culture. B. Start broad-spectrum antibiotics. C. Perform a lumbar puncture. D. Establish IV access and place the patient on a cardiac monitor. E. Discharge the patient after close follow-up is arranged

D. Ciprofloxacin 500 mg bid for 14 days Men with urinary tract infections automatically fit into the "complicated" variety of UTIs. Therefore, the most appropriate therapy is ciprofloxacin for 14 days. With the exception of amoxicillin as monotherapy, all of the above choices are appropriate for treatment of certain types of UTIs. Complicated UTIs mandate 14 days of therapy with an appropriate antibiotic. The emergency physician should also consider sending urine cultures on this patient and provide good follow-up. Patients with benign prostatic hypertrophy or other lower urinary tract obstructions may be discharged with a Foley catheter if they have good follow-up, understand how to manage their catheter, and have to significant medical comorbidities.

A 65-year-old man with hypertension and benign prostatic hyperplasia (BPH) presents to the ED with urinary retention and a UTI on a catheterized urine analysis. He was evaluated by the urologist and is being discharged home with an in-dwelling Foley catheter and follow-up in the urology clinic in 1 week. Which of the following is the most appropriate antibiotic for this patient? A. TMP-SMX bid for 3 days B. Nitrofurantoin 100 mg for 14 days C. Amoxicillin 100 mg tid for 14 days D. Ciprofloxacin 500 mg bid for 14 days E. Levofloxacin 250 mg qd for 3 days

C. Physostigmine This patient is exhibiting an antimuscarinic toxidrome. This is characterized by tachycardia, fever, hallucinosis, dilated pupils, hypoactive bowel sounds, and dry axilla. The mnemonic is: mad as a hatter (hallucinations), dry as a bone (anhydrosis), red as a beet (increased agitation and fever), and blind as a bat (mydriasis). Treatment should be either decreasing the agitation and temperature through benzodiazepines or increasing acetylcholine by preventing its metabolism (physostigmine, an acetylcholinesterase inhibitor). Atropine is an anti-muscarinic drug and would worsen this patient toxidrome. Pralidoxime is a drug which makes acetylcholinesterase work again after exposure to an organophosphate. This patient does not have signs of cholinergic excess, therefore, pralidoxime would not be helpful. Flumazenil should not be given to adult patients because, as acting benzodiazepine antagonist, it may precipitate seizures that are not responsive to benzodiazepines. Fomepizole is an inhibitor of alcohol dehydrogenase and is helpful in the treatment of patients poisoned with ethylene glycol, methanol or other toxic alcohols. This patient had an accidental overdose of her diphenhydramine for her seasonal allergies.

A college student with a history rhinorrhea comes in after being found by her roommate with an altered mental status. Her vitals are BP 160/90, HR 120, RR 18, T 100.5°F, pulse ox 100%. On examination she is picking at the air, has decreased bowel sounds, 6-mm pupils and no moisture in her axilla. Her blood sugar is normal. Which medication should they give her? A. Atropine B. Pralidoxime C. Physostigmine D. Flumazenil E. Fomepizole

D. Pralidoxime This patient is exhibiting a cholinergic toxidrome. The mnemonic for this is DUMBBELLS (Defecation, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Lethargy, and Salivation). The treatment is to prevent the patient from drowning in his or her own saliva by administering atropine 1 mg at a time until the secretions dry up. In addition, pralidoxime (2-PAM) is administered to increase acetylcholinesterase availability and reduce acetylcholine. Benzodiazepines would not help with this patient. Physostigmine is a treatment for anti-muscarinic toxicity and would worsen this patient condition. Pyridoxine is vitamin B6 and can be useful in treating seizures if they are caused by isoniazid (INH). Naloxone is an opiate antagonist and while this presentation has some overlap with the opiate toxidrome, this patient is tachypneic and has excessive secretions that are not seen in the opiate toxidrome. His exposure was from the pesticides on the farm.

A farmer presents to the ED with difficulty in breathing. His vitals are BP 85/55, HR 50, T 97.8°F, RR 28, and pulse ox 91% room air. His examination reveals wheezing; excessive perspiration, vomiting, and tearing, and 1 mm pupils. Which is the best treatment for this patient toxicity? A. Benzodiazepines B. Physostigmine C. Pyridoxine D. Pralidoxime E. Naloxone

Identify the species, clean and immobilize the site, and administer antivenin. This is a high-risk snakebite. The authorities should immediately be notified to search for the snake. Although some percent of venomous snakebites fail to inject venom, this bite is clearly envenomed. The rapid swelling, pain, and discoloration demands immediate attention. First responders should immobilize the site and place constriction bands that do not obstruct arterial flow. The swelling is not a compartment syndrome unless elevated pressures are measured. Avoid incisions and fasciotomies or packing in ice. Immediate antivenin injection in and around the site should be a priority. Remember that species-specific antivenin is important and that administration time is critical. Best results are obtained within 4 hours. Mark the swelling every 15 minutes, evaluate coagulation profiles, electrocardiogram (ECG), renal function, and liver function, and consider ICU admission to ensure adequate perfusion and to avoid disseminated intravascular coagulation (DIC). An index of antivenin can be obtained from the American Zoo and Aquarium Association (301-562-0777) as well as your local poison control center (800-222-1222).

A scoutmaster brings a boy scout to the ED with a snakebite to his left foot. He says he heard the snake's rattle just before it bit him. His entire foot is purple, swollen to his mid-calf, and very painful to the touch.

B. Naloxone This patient is exhibiting an opiate toxidrome. He has miotic pupils and decreased respirations, GI motility and mental status. The treatment for this is patient should include a trial of naloxone; enough to increase his oxygenation. This patient likely stole opiate medication from his grandmother. Charcoal would not help this patient as he is already severely symptomatic. Additionally, charcoal would be contraindicated in this patient because of the risk of aspiration. Flumazenil is a benzodiazepine antagonist. Lorazepam is a benzodiazepine. Atropine is a strong anti-muscarinic drug and would not be helpful in treating this patient.

A teenager comes home after visiting his grandmother who is sick with cancer. His parents call 911 because he is minimally responsive. They find him with a BP 90/60, HR 65, T 98.5°F, RR 6, pulse ox 89% on room air. His examination includes 2 mm pupils, decreased bowel sounds, hyporeflexia, and responsiveness only to noxious stimuli. The paramedics check his blood sugar, which is normal, and administer which of the following? A. Charcoal B. Naloxone C. Flumazenil D. Lorazepam E. Atropine

E. CT scan is helpful in differentiating between the two pathological conditions in this patient. History and physical examination is often inadequate in differentiating mechanical large-bowel obstruction from functional large-bowel obstruction, and this would be especially true in a patient with Alzheimer disease and possible cause for functional large-bowel obstruction. CT scan of the abdomen, barium enema and/or 4-view radiographs of the abdomen are some of the imaging tests used in this setting.

A third-year medical student has been given an assignment to assess the relative value of methods to differentiate between functional intestinal obstruction and mechanical obstruction. The patient scenario is that of a 90-year-old woman with Alzheimer disease, urinary tract infection, and abdominal distension. Which of the following statements is most accurate for this clinical learning issue? A. The history and physical examination is the most important test in differentiating between the two disorders. B. The history and physical examination while often unhelpful is better than imaging tests in differentiating between the two disorders. C. The history and physical examination is typically unhelpful in differentiating between the two disorders. D. Imaging tests are rarely helpful, may exacerbate the condition and worsen the prognosis. E. CT scan is helpful in differentiating between the two pathological conditions in this patient.

Clean bite site and treat with prophylactic antibiotics. Human bites have high rates of infectivity. This wound does not appear to be infected. Nonetheless, the wound should be cleaned and 3- to 5-day course of prophylactic antibiotics should be initiated. Human bites rarely lead to retained teeth so a radiograph is not indicated. If this bite occurred on the hand or across a joint space, a radiograph should be performed. Tetanus toxoid should be given if indicated. TDaP has now been approved for use in patients over 65 years old.

A woman arrives in your ED with a human bite to her breast that occurred earlier in the day. There is a small puncture wound and no signs of cellulitis.

A. Proteus This woman has a magnesium ammonium phosphate stone, which are common in women and are associated with urease-producing organisms. Proteus, Pseudomonas, and Klebsiella are all urease-producing organisms.

After passing a kidney stone, a 38-year-old woman is told by her primary care physician that she had passed a magnesium ammonium phosphate stone. She is most likely to have had a urinary infection caused by which of the following organisms? A. Proteus B. Escherichia coli C. Enterococcus species D. Group B Streptococcus E. Staphylococcus aureus

C. Blood pressure of 80/40 mm Hg Hypotension indicates a systemic reaction and cardiovascular compromise, thereby classifying this allergic reaction as anaphylaxis. The other option may all be part of an anaphylactic response, but may also just be simple allergic reactions.

An 18-year-old woman is brought to the ED with suspected anaphylaxis. Which of the following most suggests anaphylaxis rather than a simple allergic reaction? A. Itching B. Watery eyes C. Blood pressure of 80/40 mm Hg D. Hives E. Anxiety

D. A 70-year-old man with abdominal pain and distension, a 10-cm pulsatile mass in the epigastrium, and blood pressure of 70/50 mm Hg The patient in "D" is hemodynamically unstable and possesses signs and symptoms suggestive of ruptured abdominal aneurysm. A CT scan would likely delay his care and is contraindicated in this situation. The patient described in choice A likely has diverticulitis, where CT may be appropriate for severity staging. The patient described in choice B likely has acute pancreatitis, where CT is helpful for the stratification of disease severity. The patient described in choice C may have complicated appendicitis or some other complicated GI or gynecological process, where CT can be useful for differentiation. The patient described in choice E has an incarcerated umbilical hernia with signs and symptoms of intestinal obstruction related to this finding. Surgical intervention is indicated based on his presentation alone.

For which of the following patients is CT of the abdomen contraindicated? A. A 60-year-old man with persistent left lower quadrant pain, fever, and a tender mass B. A 45-year-old alcoholic man with diffuse abdominal pain, WBC 18,000 cells/mm3, and serum amylase of 2000 C. A nonpregnant 18-year-old woman with suprapubic and right lower quadrant pain, fever, right lower quadrant mass, and WBC of 15,000 cells/mm3 D. A 70-year-old man with abdominal pain and distension, a 10-cm pulsatile mass in the epigastrium, and blood pressure of 70/50 mm Hg E. A 24-year-old man with a new finding of painful, irreducible umbilical hernia who presents with 12-hour history of abdominal distension and vomiting

D. Watching the ETT pass through the vocal cords Watching the ETT pass through the vocal cords is the best way to assure proper placement. CXR has no role in differentiating between endotracheal and esophageal intubation. The other choices are helpful but not failsafe.

The best way to confirm endotracheal tube placement is A. Chest x-ray B. End tidal CO2 C. Breath sounds heard in both lung fields D. Watching the ETT pass through the vocal cords

D. Watching the ETT pass through the vocal cords is the best way to assure proper placement. CXR has no role in differentiating between endotracheal and esophageal intubation. The other choices are helpful but not failsafe.

The best way to confirm endotracheal tube placement is A. Chest x-ray B. End tidal CO2 C. Breath sounds heard in both lung fields D. Watching the ETT pass through the vocal cords

B. Sharp, persistent, and well-localized pain in the left lower quadrant Somatic pain is generally associated with irritation of the parietal peritoneum, resulting in localized, persistent, and sharp pain. This type of pain is aggravated by movement and can produce spasm in the overlying abdominal wall musculature, which is manifested as involuntary guarding.

Which of the following features best characterizes somatic pain? A. Midline location B. Sharp, persistent, and well-localized pain in the left lower quadrant C. Intermittent pain D. Pain is improved with body movement

B. Acute renal failure Succinylcholine transiently increases serum potassium levels. It is presumptively contraindicated in renal failure patients who often have elevated potassium levels. Acute burns are not a contraindication. Beginning 2 to 3 days after a burn, acetylcholine receptor upregulation can lead to hyperkalemia. Neither coronary artery disease nor sepsis is a contraindication to the use of succinylcholine

Which of the following is a contraindication to succinylcholine? A. Acute burns B. Acute renal failure C. History of coronary artery disease D. Sepsis

B. Succinylcholine transiently increases serum potassium levels. It is presumptively contraindicated in renal failure patients who often have elevated potassium levels. Acute burns are not a contraindication. Beginning 2 to 3 days after a burn, acetylcholine receptor upregulation can lead to hyperkalemia. Neither coronary artery disease nor sepsis is a contraindication to the use of succinylcholine.

Which of the following is a contraindication to succinylcholine? A. Acute burns B. Acute renal failure C. History of coronary artery disease D. Sepsis

B. Hernia Statistically speaking, a hernia would be the most likely cause of small bowel obstruction in a patient without previous abdominal operations or other causes of adhesions.

Which of the following is the most likely cause of small-bowel obstruction in 25-year-old woman with no previous abdominal operations? A. Adhesions B. Hernia C. Crohn disease D. Adenocarcinoma of the small bowel E. Endometriosis

D. Early administration of epinephrine Again, early recognition of anaphylaxis and immediate dosing of epinephrine is most important.

Which of the following management options is the greatest determinant of patient outcome in anaphylaxis? A. Timely administration of steroids B. Administration of diphenhydramine C. Early identification of the allergen D. Early administration of epinephrine E. Aggressive resuscitation with intravenous fluids

D. A 67-year-old woman with 3+ bacteria, a sulfa allergy, and a history of lupus. Despite a chronic medical condition, this patient may be safely discharged home. Because this patient has a sulfa allergy, TMP-SMX should not be administered. Other treatment options include quinolones, amoxicillin/ clavulanate, and nitrofurantoin. All of the other patients should be admitted for treatment. All pregnant patients with pyelonephritis require admission. The 13-year-old and 88-year-old are not tolerating their diet and require intravenous hydration. The 44-year-old has a urinary obstruction with a UTI, which makes it a complicated UTI. These patients are at high risk for developing sepsis. For most admitted patients, urine cultures should be sent to guide antibiotic therapy.

Which of the following patients with pyelonephritis can be safely discharged home with close follow-up? A. A 23-year-old woman in her second trimester of pregnancy. B. A 13-year-old woman who cannot tolerate her diet despite anti-emetics. C. An 88-year-old man with urinary retention and dehydration. D. A 67-year-old woman with 3+ bacteria, a sulfa allergy, and a history of lupus. E. A 44-year-old woman with a kidney stone and hydroureter on CT scan.

Clean the site and begin rabies prophylaxis with active and passive immunization. This injury is at high risk for rabies transmission. Dusk is the usual time for bat activity, and although this man did not feel a bite, he discovered bite marks under his injury site. Bats carry high rates of rabies and this man was bitten on the face. Because the animal cannot be examined, immediate passive and active immunization should be initiated and tetanus administered, if indicated. As always, watch for secondary bacterial infection and update his tetanus status if it has been more than 5 years since his last immunization.

While raking leaves under his fruit tree at dusk, a man says a bird flew into his face. When he checked his face in the mirror he saw a bite mark under blood streaks.

C. Attempt to remove any foreign body from the mouth and reposition the airway with chin lift or jaw thrust. The most common cause of airway obstruction is the tongue and/or soft tissues of the upper airway. No other adjuncts may be necessary for initial management except relieving the obstruction with airway repositioning. This should certainly be the first step, and there is no need to wait for the code cart before performing this maneuver. There is no indication for chest compressions in a patient with palpable pulses. The patient will require BVM ventilation after airway repositioning and placement of an oral airway. If the patient is easy to ventilate, reversible causes of respiratory depression, such as a narcotic overdose, should be investigated and may eliminate the need for RSI.

You are the first person on scene to a code blue in your hospital. You arrive to find an elderly woman who is unconscious, has a weak pulse and does not appear to be breathing. Your first steps are A. Wait for the code cart to arrive and then intubate the patient. B. Begin chest compressions and mouth-to-mouth resuscitation. C. Attempt to remove any foreign body from the mouth and reposition the airway with chin lift or jaw thrust. D. Begin bagging the patient immediately.

C. Attempt to remove any foreign body from the mouth and reposition the airway with chin lift or jaw thrust. The most common cause of airway obstruction is the tongue and/or soft tissues of the upper airway. No other adjuncts may be necessary for initial management except relieving the obstruction with airway repositioning. This should certainly be the first step, and there is no need to wait for the code cart before performing this maneuver. There is no indication for chest compressions in a patient with palpable pulses. The patient will require BVM ventilation after airway repositioning and placement of an oral airway. If the patient is easy to ventilate, reversible causes of respiratory depression, such as a narcotic overdose, should be investigated and may eliminate the need for RSI.

You are the first person on scene to a code blue in your hospital. You arrive to find an elderly woman who is unconscious, has a weak pulse and does not appear to be breathing. Your first steps are A. Wait for the code cart to arrive and then intubate the patient. B. Begin chest compressions and mouth-to-mouth resuscitation. C. Attempt to remove any foreign body from the mouth and reposition the airway with chin lift or jaw thrust. D. Begin bagging the patient immediately

Clean site, observe animal, and watch for signs of secondary infection. This is a low-risk bite. The dog is your housedog with a low risk of ever contracting rabies. You have it immunized every year and can observe it for 10 days. As always, clean the bite thoroughly and consider radiographs to be sure no broken teeth are in the wound or that the bone has been penetrated. Administer tetanus if indicated and watch for secondary bacterial infection. Prophylactic antibiotics are indicated.

Your dog, who was immunized against rabies within the last year, bites your neighbor.