ER Q&A IPAP Phase 2

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

Question: What diseases are associated with Streptococcus bovis endocarditis?

Answer: The ulnar (medial) collateral ligament.

Question: What elbow ligament is most commonly injured in pitchers?

Answer: Vertigo resulting from loud sounds, seen in superior canal dehiscence.

Question: What is Tullio's sign?

Answer: A case series.

Question: What is a collection of case reports called?

Answer: Osteomyelitis of the distal phalanx.

Question: What is a potential complication of a felon?

Answer: Oral contraceptive use.

Question: What is a risk factor for mesenteric venous thrombosis in young women?

Answer: Involuntary reflex contraction of the anal sphincter in response to squeezing the glans penis or tugging on the foley catheter. Loss of this reflex is a marker of spinal shock.

Question: What is the bulbocavernosus reflex?

Answer: It is thought to be caused by a persistent CSF leak which results in traction on bridging vessels, dura, and nerves when the patient is upright.

Question: What is the cause of a postdural puncture headache?

Answer: Malassezia furfur.

Question: What is the cause of tinea versicolor?

Answer: Nicardipine or labetalol to a target systolic blood pressure of 160-180 mm Hg.

Question: What is the drug of choice and target systolic blood pressure for patients with a subarachnoid hemorrhage?

Answer: Little leaguer's elbow.

Question: What is the eponym for medial elbow pain affecting adolescents?

Answer: CT scan of the abdomen and pelvis with IV contrast.

Question: What is the imaging study of choice when there is concern for diverticulitis?

Answer: Desmopressin (DDAVP), which causes release of VWF from cells.

Question: What is the initial treatment for prolonged bleeding in patients with von Willebrand disease?

Answer: Cholescintigraphy is the most accurate radiographic test for diagnosing acute cholecystitis.

Question: What is the most accurate radiographic test to diagnose acute cholecystitis?

Answer: Staphylococcus aureus.

Question: What is the most common bacterial cause of septic arthritis in children?

Answer: Hypoxia.

Question: What is the most common cause of secondary polycythemia?

Answer: Hereditary IgA deficiency.

Question: What is the most commonly found hereditary abnormality associated with allergic reaction and anaphylaxis in a patient receiving a blood transfusion?

Answer: Smith fracture.

Question: What is the name of a distal radius fracture with volar displacement and angulation?

Answer: Intravenous metronidazole and ceftriaxone (or cefotaxime) +/- vancomycin.

Question: What is the recommended antibiotic regimen for a brain abscess from an oral or sinus source?

Answer: 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.

Question: What is the relationship between cluster headaches and smoking?Question: What is the relationship between cluster headaches and smoking?

Answer: Cyanotic skin.

Question: What is the skin finding in methemoglobinemia?

Answer: Calcium.

Question: What medication is contraindicated in digitalis toxicity with hyperkalemia?

Answer: Trimethoprim-sulfamethoxazole.

Question: What medication should be prescribed for patients who have a macrolide allergy?

Answer: Type II cytotoxic antibody reaction.

Question: What type of hypersensitivity reaction is responsible for acute hemolytic transfusion reactions?

Answer: Ileoileal intussusception.

Question: What type of intussusception occurs in patients with Henoch-Schönlein Purpura?

Answer: Standard and contact precautions.

Question: What type of precautions are indicated for a patient with C. Difficile colitis?

Answer: Malignancy

Question: What underlying disease is most commonly associated with phlegmasia cerulea dolens?

Answer: Palms, soles and nasolabial folds.

Question: Which anatomical locations merit a specialist evaluation prior to abscess drainage?

Answer: Nitrates.

Question: Which class of medications should be given initially for acute pulmonary edema?

Answer: Hepatitis D (delta).

Question: Which hepatitis is caused by a defective RNA-containing virus?

Answer: Crohn's disease.

Question: Which inflammatory bowel disease is characterized by "skip lesions"?

Correct Answer (D) Middle third of the clavicle Explanation: 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. Fractures of the acromioclavicular joint (A), lateral third (B), and medial third of the clavicle (C) are less common than fractures through the middle third of the clavicle.

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

Correct Answer (B) Brain CT scan with contrast

A 14-year-old treated for sinusitis two weeks ago presents to your ED with worsening headache and fevers over the last week. His mother states that he has been sleeping most of the day and brought him in because he was having trouble walking. He has had no vomiting, vision changes, photophobia, neck pain, or trauma. His vital signs are within normal limits for his age. Your examination shows a pale appearing, somnolent male who wakes and answers questions appropriately. He has a normal cranial nerve exam, negative Kernig's and Brudzinski's signs, but is unable to heel-to-toe walk and has a foot drop on the left. Of the following, what is the next best step to establish the diagnosis? (A) Blood culture (B) Brain CT scan with contrast (C) Electroencephalogram (D) Lumbar puncture

Correct Answer (D) Fever resolution Explanation: /An oral enanthem plus a macular, maculopapular, or vesicular rash on the hands and feet suggests a diagnosis of hand, foot, and mouth disease (HFMD) caused by an enterovirus, most commonly Coxsackievirus A serotypes. This is a clinical diagnosis. Outbreaks are seen in daycare centers, schools, summer camps, hospital wards, and military installations. The most common age group affected are children less than five years of age. The virus is usually transmitted from person to person by the fecal-oral route. However, transmission can occur by contact with oral, respiratory, and vesicular secretions. Patients may present with throat or mouth pain or refusal to eat. Fever is rare and is usually below 38.3°C. Management is largely supportive with hydration and pain control. Infants and children with fever should be excluded from daycare. Once the fever resolves the child can return to daycare. It is also important to practice strict hand hygiene as enteroviruses are spread through stool for several weeks following infection. Hand, foot, and mouth disease is caused by an enterovirus and is not bacteriologic. Therefore, antibiotic therapy (C) is not necessary for management. Fever is rare with this condition. Active skin lesion resolution (B) itself should not be used to determine ability to return to daycare. Because patients may experience pain with eating, proper pain management will improve oral intake. Patients ability to tolerate oral intake (A) may signify that they are improving, but does not necessarily mean that they are no longer contagious.

A 2-year-old girl presents to the Emergency Department with her parents for a rash. She has lesions on her palms and on the soles of her feet, as well as in her oral cavity as shown above. Which of the following indicates that the child can safely return to daycare? (A) Ability to tolerate oral intake (B) Active skin lesion resolution (C) Antibiotic therapy is complete (D) Fever resolution

Correct Answer (D) Viral infection Explanation: 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. Pityriasis rosea is not thought to be autoimmune (A) or bacterial (B) in origin. It can sometimes be confused with tinea corporis, which is a fungal (C) infection.

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

Correct Answer (B) Epidural hematoma, middle meningeal artery Explanation: 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 skull fractures in the temporal bone region resulting in laceration of the middle meningeal artery. Arterial bleeding is the etiology of ⅔ of epidural hematomas and is typically rapid. Epidural hematomas are uncommon in the elderly and in children < 2 years of age due to the close attachment of the skull to the dura. Epidural hematomas account for only 1% of all head-injured patients presenting with coma and are present in 0.5% of all head-injured patients. Signs and symptoms include severe headache, drowsiness, nausea, and vomiting. The classic finding is the lucid interval just prior to rapid deterioration; however, this is present in < 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. These hematomas are sharply defined and do not cross suture lines. Management of epidural hematomas is primarily surgical. Neurosurgery should be consulted immediately for surgical evacuation of the hematoma. Prognosis is good if the epidural hematoma is promptly treated and the patient does not present with coma. Epidural hematoma, bridging veins (A) is an incorrect pairing as the imaging shows an epidural hematoma, however, this is typically caused by injury to the middle meningeal artery and not tearing of the bridging veins. Subdural hematoma, bridging veins (C) is a correct pairing; however, it is an incorrect answer as the imaging shows an epidural hematoma. Subdural hematoma, middle meningeal artery (D) is an incorrect pairing as the imaging shows an epidural hematoma and subdural hematomas are caused by tearing of the bridging veins.

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. Which of the following pairs represents the correct diagnosis and most likely injured vessel? (A) Epidural hematoma, bridging veins (B) Epidural hematoma, middle meningeal artery (C) Subdural hematoma, bridging veins (D) Subdural hematoma, middle meningeal artery

Correct Answer (C) Hypokalemia and metabolic acidosis correlate with a high four-hour acetaminophen concentration Explanation: Acetaminophen overdose results in more than 400 deaths each year in the United States. Following an acute overdose of acetaminophen, the usual pathways of metabolism are saturated resulting in increased production of the toxic metabolite N-acetyl-p-benzoquinoneimine (NAPQI) via the cytochrome P-450 pathway. NAPQI binds to hepatocytes resulting in hepatic necrosis. There are four clinical stages of toxicity. During stage one (the first 24 hours), patients typically present with nausea, vomiting, and malaise. Hypokalemia and metabolic acidosis may be seen during this stage and correlate with a high 4-hour acetaminophen level. Serum transaminases begin to rise 8-24 hours after ingestion. During stage two (days 2-3), there is an improvement in the nausea and vomiting, but the patient may develop RUQ pain and tenderness. Serum transaminases peak in 2-4 days. In stage three (days 3-4), some patients may progress to hepatic failure with recurrence of nausea and vomiting, as well as coagulopathy, renal failure, and encephalopathy. Patients who survive begin to recover over the next two weeks (stage four). Absorption of acetaminophen may not be complete before four hours post-ingestion, making interpretation of levels before that time very difficult. Therefore, treatment decisions are typically made based on the acetaminophen level four hours post-ingestion. An acetaminophen level less than 50 micrograms/mL at two hours post-ingestion rules out acute toxicity (A) is incorrect. Serum transaminases begin to rise 8-24 hours after ingestion. Therefore, serum transaminases are elevated within four hours of acute ingestion (D) is incorrect. Serum transaminases peak in 2-4 days, therefore aspartate transaminase levels peak 24 hours post-ingestion (B) is incorrect.

A 22-year-old woman presents after taking an entire bottle of acetaminophen two hours prior to arrival. Which of the following is true regarding laboratory studies in acute acetaminophen overdose? (A) An acetaminophen level less than 50 micrograms/mL at two hours post-ingestion rules out acute toxicityYour Answer (B) Aspartate transaminase levels peak 24 hours post-ingestion (C) Hypokalemia and metabolic acidosis correlate with a high four-hour acetaminophen concentration (D) Serum transaminases are elevated within four hours of acute ingestion

Correct Answer (A) Anterior cord syndrome Explanation: Injury to the anterior two-thirds of the spinal column results in anterior cord syndrome which is characterized by bilateral loss of motor function and pain and temperature sensation below the level of injury. The dorsal column is usually spared so vibration sense and proprioception are preserved. Anterior cord syndrome occurs in cases of disruption or injury to the anterior spinal artery which can result from the protrusion of bone fragments from a traumatic injury to the vertebrae, disc herniation, or following aortic surgery. It can also result from a flexion/compression injury to the cord. Most improvement in function occurs in the first 24 hours. Anterior cord syndrome carries the worst prognosis of all the incomplete spinal cord syndromes, with less than 20% regaining any degree of muscle function. Brown-Séquard syndrome (A) results from hemisection of the spinal cord, often due to penetrating injuries. Patients present with ipsilateral motor, vibration and proprioception loss, and contralateral pain and temperature loss. Cauda equina syndrome (C) is typically seen in cases of midline disk herniation at the L4-5 level that results in dysfunction of nerve roots, not the spinal cord itself. Patients present with urinary retention with overflow incontinence, fecal incontinence, distal motor weakness, and sensory loss in a saddle distribution. Central cord syndrome (D) is characterized by bilateral motor paresis with the upper extremities affected to a greater degree than the lower extremities. Sensory loss is variable.

A 24-year-old woman presents to the emergency department after a high-speed motor vehicle collision. Her GCS is 14. On neurological examination, she has intact fine touch, but decreased strength and loss of pain and temperature sensation below the T10 level. What is the most likely diagnosis? (A) Anterior cord syndrome (B) Brown-Séquard syndrome (C) Cauda equina syndrome (D) Central cord syndrome

Correct Answer (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 (A) 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 (C) can be used in the treatment of migraine headaches, but has not been found to be effective with cluster headaches. Oral verapamil (D) is first-line treatment for prevention of cluster headaches, but is not effective in the management of acute symptoms.

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 nonfocal 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

Correct Answer (C) Cranial nerve VI Explanation: Idiopathic intracranial hypertension, formerly known as pseudotumor cerebri, is most common in obese women between the ages of 20 and 44 years. The most prominent symptoms include headache, transient diplopia, back pain, and pulsatile tinnitus. Complications of untreated idiopathic intracranial hypertension lead to permanent visual impairment or loss. The increased cranial pressure leads to a cranial nerve VI palsy causing horizontal diplopia. The diagnosis is made by finding evidence of increased intracranial pressure (e.g. papilledema or increased optic nerve sheath diameter) on ultrasound or computed tomography, with a normal neurologic examination and an elevated opening pressure on lumbar puncture (> 25 cm H2O in adults and > 28 cm H2O in children) in the setting of normal cerebrospinal fluid composition and normal neuroimaging. The lumbar puncture should be performed with the patient in the lateral decubitus position and without sedation (both of which may alter the opening pressure). Treatment is initiated with oral acetazolamide to lower the intracranial pressure and decrease the symptoms associated with idiopathic intracranial hypertension. Long-term management may include cerebrospinal fluid shunting and optic nerve sheath fenestration for failing vision. For obese patients, weight loss is recommended. Cranial nerve III palsy (A) causes a "down and out" gaze. When the palsy is caused by a posterior communicating artery aneurysm, the pupil is dilated and nonreactive due to impingement on the parasympathetic fibers that run along the cranial nerve III sheath. When the palsy is due to chronic diabetes mellitus the pupil is spared as only the central nerve fibers of cranial nerve III are affected. The parasympathetic fibers have their own unaffected vascular supply. Cranial nerve IV palsy (B) is relatively rare and causes a vertical diplopia due to a superior and lateral gaze in the affected eye (palsy of the superior oblique ocular muscle). To compensate for the diplopia, patients will tilt their head down and to the opposite side of the palsy. Cranial nerve IV palsies are frequently caused by trauma (e.g. whiplash) that stretches the nerve causing a self limited neuropraxia. Cranial nerve VII palsy (D) is the cause of Bell's palsy, a palsy of the ipsilateral upper and lower facial muscles and also affects the orbicularis muscles, resulting in incomplete closure of the eyelids on the affected side. A distinguishing feature of Bell's palsy is that it is caused by a deficit in the lower motor neurons and involves the forehead. If the lesion was located centrally, it would cause a deficit in the upper motor neurons and the forehead would be spared.

A 34-year-old obese woman presents to the Emergency Department with a complaint of severe headaches for the past two weeks. The headache is worse in the morning and associated with nausea and diplopia. A palsy involving which of the following cranial nerves is most likely responsible for horizontal diplopia? (A) Cranial nerve III (B) Cranial nerve IV (C) Cranial nerve VI (D) Cranial nerve VII

Correct Answer (C) Feelings of hopelessness Explanation: The "SADPERSONS" scale was developed to assess the risk of suicide attempt. According to the scale, two points are given for factors that are considered high risk. These include depression or hopelessness, rational thinking loss, organized or serious attempt, and stated future intent. Lower risk factors are given one point and include male sex, age younger than 19 years or older than 45 years, previous attempts or psychiatric care, excessive alcohol or drug use, separation, divorce or widowed status, and no social supports. Individuals with five points or fewer can questionably seek outpatient treatment. Those with 6 or more points should have emergency psychiatric evaluation and treatment. Those with more than 9 points require psychiatric hospitalization. Divorced status (A), excessive alcohol use (B), and male sex (D) are risk factors, however are worth one point and considered lower risk.

A 28-year-old man presents to the ED with suicidal thoughts. He recently went through a divorce. He reports occasional excessive alcohol and marijuana use. He feels supported by his friends but continues to feel hopeless despite their efforts to encourage him. Which of the following patient factors is most likely to increase his risk of an actual suicidal attempt? (A) Divorced status (B) Excessive alcohol use (C) Feelings of hopelessness (D) Male sex

Correct Answer (B) Incision and drainage followed by oral antibiotics against Staphylococcal and Streptococcal species Explanation: 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. Antibiotics (A) alone are often insufficient to poor penetration of the abscess. Incision and drainage (B) and needle aspiration (D) are not enough in moderate disease or immunocompromised patients.

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

Correct Answer (A) Endometriosis Explanation: Endometriosis is a benign, estrogen-dependent condition that results in endometrial tissue developing in extrauterine sites. The most common site for endometrial implantation is the pelvis, with the ovaries, posterior cul-de-sac, and anterior cul-de-sac affected most frequently. Endometriosis is a disease of women of reproductive age and is rare in postmenopausal women unless they are on estrogen replacement therapy. Dysmenorrhea, pelvic pain, and dyspareunia are the most frequent presenting complaints, but patients may have bowel or bladder symptoms as well. Infertility is found in a quarter of patients. Physical examination is often normal, but depending on the location and size of the implants patients may have localized tenderness on pelvic examination. Pelvic ultrasound is routinely ordered as a first-line test in women with pelvic pain. Although it is unlikely to provide a diagnosis of endometriosis, it can rule out other causes of the patient's symptoms. Definitive diagnosis is made via laparoscopy. Treatment of endometriosis consists of pain management with nonsteroidal anti-inflammatory medications, interruption or cessation of the menstrual cycle via oral contraceptives, and gynecology referral. Surgical management with laparoscopic removal of the implants is another option, especially for those patients wishing to get pregnant. Mittelschmerz (B) is unilateral midcycle pelvic pain related to ovulation. Pelvic inflammatory disease (C) is characterized by fever, pelvic pain, bilateral adnexal pain, cervical motion tenderness, and vaginal discharge. Patients with a ruptured ovarian cyst (D) often present with acute onset of unilateral pelvic pain which may be accompanied by nausea and vomiting.

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

Correct Answer (D) Tricuspid valve vegetations Explanation: Tricuspid valve vegetations are the most likely abnormalities seen on echocardiogram. This patient has endocarditis affecting his tricuspid valve. Risk factors include injection drug use, male sex, age over 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 a multifocal pneumonia (as shown above). Right-sided endocarditis is more common in intravenous drug users. Treatment includes intravenous antibiotic therapy (directed specifically against Staph. aureus) and supportive care. Diffuse myocardial hypokinesis (A) would not be seen in endocarditis unless there was a concomitant myocarditis. Mitral valve vegetations (B) are characteristic of endocarditis, however, embolic events would present in the systemic circulation; not in the lungs. A pericardial effusion (C) would not be expected in an isolated case of endocarditis.

A 32-year-old man presents to the Emergency Department with complaints of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A chest radiograph is obtained and shown above. Which of the following abnormalities is likely to be noted on echocardiogram? (A) Diffuse myocardial hypokinesis (B) Mitral valve vegetations (C) Pericardial effusion (D) Tricuspid valve vegetations

Correct Answer (D) Incision and drainage along the ulnar aspect of the distal phalanx Explanation: A felon is an infection of the pulp of the distal phalanx. It is most frequently caused by penetrating trauma, although can also occur due to spread of an untreated paronychia. Multiple vertical septa divide the pulp space into small compartments which can make drainage after incision more difficult, but also helps prevent the proximal spread of infection. Patients present with erythema, severe throbbing pain, and swelling limited to the distal phalanx. Management consists of early incision and drainage. Following a digital block, a longitudinal incision should be made on the ulnar aspect if the index, middle, or ring fingers are involved, and on the radial aspect if the thumb or pinky are involved. The incision should start 0.5 cm distal to the DIP joint and extend to the distal nail bed. After irrigation, a wick should be left in place for continued drainage. Oral antibiotics against likely pathogens (e.g. S. aureus and streptococci) are typically given if there are signs of associated cellulitis. While antibiotics are usually prescribed in conjunction with incision and drainage, discharge with a 7-day course of oral cephalexin (A) alone is inappropriate treatment. An uncomplicated felon such as this can be managed by an emergency physician. Finger splint and outpatient referral to a hand specialist (B) is unnecessary and delays definitive treatment. Incision along the distal tip of the the distal phalanx (C) is contraindicated as it can lead to instability and loss of sensation of the fingertip.

A 36-year-old woman presents to the Emergency Department with severe pain and swelling of her ring finger. She sustained a small puncture wound to her fingertip on a sewing needle four days ago. Her finger is shown above. What is most appropriate next step in management? (A) Discharge with 7-day course of oral cephalexin (B) Finger splint and outpatient referral to a hand specialist (C) Incision and drainage along the distal tip of the distal phalanx (D) Incision and drainage along the ulnar aspect of the distal phalanx

Correct Answer (C) Malrotation with volvulus Explanation: Malrotation with volvulus is the incomplete rotation of the small intestine around the superior mesenteric artery. When the small bowel twists on itself, creating a volvulus, this causes midgut ischemia and obstructive symptoms (e.g. emesis and abdominal distension). Most cases of malrotation and volvulus present at < 1 year of age. Among infants with malrotation, 75% of those with volvulus present within the first month of life. Symptoms range from mild (with incomplete obstruction) to severe (with complete obstruction, sepsis, and shock). Hematochezia may be late finding secondary to bowel necrosis. Diagnosis is made with imaging. An abdominal X-ray may show the absence of bowel gas in part or all of the abdomen, or the classic "double bubble" sign indicating a distended duodenum and stomach as a result of distal bowel obstruction. An upper gastrointestinal series is the diagnostic test of choice and classically shows a right-sided duodenum (as opposed to midline or left-sided) and a corkscrew appearance of the small bowel due to volvulus. Because the defect occurs distal to the ampulla of Vater (the anatomic structure formed by the union of the common bile duct and the pancreatic duct), the emesis is classically bilious. The mortality rate ranges from 3-15%, therefore early diagnosis and surgical management are paramount to improve survival. Intussusception (A) is not a condition of newborns, but rather occurs most commonly in those ages three months to five years. X-rays are nonspecific and ultrasonography is more sensitive in making the diagnosis. Large bowel obstruction (B) in newborns is likely to result from Hirschsprung's disease, a congenital aganglionosis of the distal colon that makes it difficult for the anus to relax, creating a functional obstruction. Pyloric stenosis (D) creates an obstruction proximal to the ampulla of Vater, so emesis in this setting is non-bilious.

A 4-week-old girl presents to the Emergency Department with lethargy and vomiting for one day. The mother states that the patient's vomit appears greenish. On physical examination, the patient appears toxic with mottled skin and decreased muscle tone. Radiographic studies demonstrate a paucity of bowel gas in the left hemiabdomen. What is the most likely diagnosis? (A) Intussusception (B) Large bowel obstruction (C) Malrotation with volvulus (D) Pyloric stenosis

Correct Answer (C) Aspartate transaminase 250 U/L and alanine transaminase 120 U/L Explanation: Acute hepatitis can be the result of an infectious process (most commonly viral), toxic injury, or alcohol. Alcoholic hepatitis can range from subclinical disease to acute liver failure. Patients present with nausea, vomiting, and RUQ abdominal pain. On examination, they frequently have a tender, enlarged liver, and possibly jaundice. Laboratory studies include a macrocytic anemia and thrombocytopenia. The WBC count is often elevated as is the prothrombin time and bilirubin. Liver transaminases, alanine transaminase (ALT) and aspartate transaminase (AST) are typically elevated 2-10 times normal. Unlike hepatitis due to other causes, AST is predominantly elevated, often with a AST:ALT ratio of 2:1. While patients with alcoholic hepatitis may have elevations of alkaline phosphatase, levels over three to four times normal (alkaline phosphatase 350 U/L) (A) are more typically seen with obstructive etiologies. Serum transaminases over ten times normal (aspartate transaminase 1000 U/L and alanine transaminase 1200 U/L) (B) are unusual in alcoholic hepatitis and would point to a toxic or viral etiology. A mean corpuscular volume of 60 mL (D) would indicate a microcytic anemia. Chronic alcoholics will have a macrocytic anemia.

A 42-year-old man presents to the Emergency Department with nausea, vomiting, and right upper quadrant abdominal pain. He drinks alcohol daily. Which of the following laboratory results would be most consistent with alcoholic hepatitis? (A) Alkaline phosphatase 350 U/L (B) Aspartate transaminase 1000 U/L and alanine transaminase 1200 U/L (C) Aspartate transaminase 250 U/L and alanine transaminase 120 U/L (D) Mean corpuscular volume 60 fL

Correct Answer (C) Resolution of symptoms with the Epley maneuver Explanation: 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 development of horizontal or rotational nystagmus and 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 a greater than 90% success rate. The Dix-Hallpike maneuver elicits rotational or horizontal nystagmus, not vertical nystagmus (D). Low frequency hearing loss (A) is typically seen in Ménière's disease, which is caused by excess fluid in the endolymphatic duct of the inner ear. It is characterized by vertigo that lasts minutes to hours without specific triggers, and is often accompanied by whooshing tinnitus. Treatment includes salt restriction, diuretics, and avoidance of alcohol, tobacco, and caffeine. Reproduction of vertigo with tragal pressure (B), also known as Hennebert's sign, is seen in superior canal dehiscence. Superior canal dehiscence occurs when the bone surrounding the superior semicircular canal erodes, causing communication into the intracranial fossa of the skull. Loud noises or abrupt changes in pressure cause vertigo that lasts minutes to hours. Diagnosis is made via high-resolution temporal bone CT, and treatment is surgical.

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) Low frequency hearing loss (B) Reproduction of vertigo with tragal pressure (C) Resolution of symptoms with the Epley maneuverCorrect Answer (D) Vertical nystagmus with the Dix-Hallpike maneuver

Correct Answer (B) Duodenal ulcer due to H. pylori infection Explanation: The most common cause of upper gastrointestinal (GI) bleeding is an ulcer in the upper GI tract with duodenal ulcers being most common. Sixty to eighty percent of all ulcers are caused by infection with H. pylori. The second most common cause of peptic ulcer formation is the chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin. Other causes include smoking, alcohol use, and steroid use. Classically, gastric ulcers cause pain immediately after meals, whereas food relieves the pain caused by duodenal ulcers. The emergency management of a patient with an upper GI bleed includes airway protection, resuscitation with blood products, and emergent GI consultation for endoscopy. A continuous infusion of a proton pump inhibitor is typically used as it may decrease transfusion requirements. Another complication of peptic ulcer disease is gastric or duodenal perforation. This is a surgical emergency that requires immediate surgical consultation. While duodenal ulcers can be caused by chronic NSAID use (A), most are the consequence of an infection with H. pylori. Gastric ulcers (C, D) are less common than duodenal ulcers and are typically also caused by H. pylori.

A 45-year-old previously healthy man presents to the Emergency Department with a chief complaint of epigastric burning and gnawing pain. While in the waiting room, he has an episode of dark, coffee-ground emesis and continues to vomit while being wheeled to the resuscitation bay. Which of the following is the most likely cause of the patient's symptoms? (A) Duodenal ulcer due to chronic nonsteroidal antiinflammatory drug use (B) Duodenal ulcer due to H. pylori infection (C) Gastric ulcer due to chronic nonsteroidal antiinflammatory drug use (D) Gastric ulcer due to H. pylori infection

Correct Answer (D) Membrane stabilization Explanation: Cardiac membrane stabilization with intravenous calcium gluconate or calcium chloride is the initial management of hyperkalemia (serum potassium > 5.5 mEq/L). This patient has peaked T waves on his ECG, which is seen in patients with clinically significant hyperkalemia. Hyperkalemia may present with a variety of clinical features, including fatigue, generalized weakness, hypotension, or dysrhythmias. Causes include hemolysis from blood draw (most common), prolonged tourniquet use, medications (e.g. NSAIDs, potassium-sparing diuretics, succinylcholine), renal failure, rhabdomyolysis, and tumor lysis syndrome. Hyperkalemia can produce ECG findings such as peaked T waves, shortened QT interval, P wave flattening, prolonged QT interval, and a sinusoidal waveform which may then lead to ventricular fibrillation. Management of hyperkalemia is multi-tiered. Medications include calcium gluconate or calcium chloride, nebulized albuterol, insulin (plus dextrose to prevent hypoglycemia), sodium bicarbonate, loop diuretics (e.g. furosemide), and sodium polystyrene sulfonate. Dialysis may also be needed for elimination of potassium. Direct removal (A) of potassium with dialysis is often needed in severe cases of hyperkalemia, especially in patients with renal failure. However, this takes time to achieve and is not the initial step in management. Gastrointestinal elimination (B) with sodium polystyrene sulfonate can be used to remove potassium from the body. However, the time of onset is up to 30 minutes, so this not the initial step to take in management of hyperkalemia. Intracellular shifting (C) of potassium is achieved with sodium bicarbonate, nebulized albuterol, and insulin (plus dextrose to prevent hypoglycemia). Because cardiac membrane stabilization is crucial and must be done immediately, these other options are considered secondary.

A 48-year-old man with a history of end-stage renal disease on hemodialysis presents with generalized weakness and fatigue. He missed his last dialysis session because he could not arrange transportation. His electrocardiogram is shown above. Which of the following physiologic goals should be accomplished first? (A) Direct removal (B) Gastrointestinal elimination (C) Intracellular shifting (D) Membrane stabilization

Correct Answer (D) Nitroglycerin Explanation: 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. Albuterol (A) is a beta-agonist used in the treatment of bronchospasm and is not used in the setting of acute heart failure. Dobutamine (B) is an inotropic vasopressor used in the management of cardiogenic shock. It alone does not improve hypotension in cases of overt shock. If the systolic blood pressure is < 90 mm Hg, norepinephrine can be added to dobutamine to achieve improvement in hypotension. Furosemide (C) may be given after vasodilators in patients with acute heart failure and severe volume overload. Prior to diuretic use, it is imperative to manage hypertension and cardiac contractility to optimize pulmonary function.

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 100ºF, blood pressure 220/110 mm Hg, heart rate 125 beats/minute, and respiratory rate 30 breaths/minute. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment? (A) Albuterol (B) Dobutamine (C) Furosemide (D) Nitroglycerin

Correct Answer (D) Permethrin 5% cream Explanation: 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 the 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 one 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 as eczema as 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 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 five-month-old girl presents to your ED with a worsening rash. Her regular doctor diagnosed her with eczema three days ago and the parents are trying topical emollients without effect. She is fussy and having difficulty sleeping. She has had no fevers. No one in the family has a history of asthma or atopy, however her five-year-old brother recently developed a similar rash. Your exam shows a well appearing and well nourished infant trying to scratch at the above rash. Of the following, which is the most appropriate topical treatment? (A) Hydrocortisone 1% (B) Mupirocin 2% (C) Nystatin 100,000 units/gram (D) Permethrin 5% cream

Correct Answer (C) Lateral epicondylitis Explanation: The patient has lateral epicondylitis, also known as tennis elbow, an overuse syndrome related to excessive wrist extension. Although named after tennis players, a minority of cases are seen in patients who play tennis. The tendinopathy is associated with activities which require twisting motions, such as driving in screws, use of wrenches, and repetitive assembly line work. It is most commonly seen in patients over age 40. Patients report pain over the lateral epicondyle which is exacerbated by twisting or grasping motions. On examination, patients have point tenderness over the lateral epicondyle at the origin of the extensor carpi radialis brevis tendon. Cozen's test is also suggestive. Cozen's test is performed by having the patient make a clenched fist with the wrist held in extension. The examiner attempts to flex the wrist while the patient resists the motion. A positive result occurs when there is pain over the lateral epicondyle. Radiographs may show tendon calcification or new bone growth at the tip of the epicondyle. The majority of patients improve with supportive therapy, including resting from activities which exacerbate symptoms, ice, compression, use of non-steroidal anti-inflammatory medications, and physical therapy. Carpal tunnel syndrome (A) is also associated with overuse and repetitive movements, but causes wrist pain and paresthesias of the first three digits. De Quervain's tenosynovitis (B) is a painful overuse syndrome affecting the abductor pollicis longus and extensor pollicis brevis tendons on the radial aspect of the wrist. Medial epicondylitis (D), commonly known as golfer's or pitcher's elbow, is a tendinopathy causing pain at the insertion of the flexor carpi radialis on the medial epicondyle of the elbow.

A 52-year-old man presents with elbow pain which has developed over the past few weeks. He has been restoring an old car, using wrenches and other tools which require a twisting movement of the hand. On examination, he is tender at the origin of the extensor carpi radialis brevis tendon on the lateral epicondyle of the humerus. His pain is exacerbated by extending and supinating the wrist. What is the most likely diagnosis? (A) Carpal tunnel syndrome (B) de Quervain's tenosynovitis (C) Lateral epicondylitis (D) Medial epicondylitis

Correct Answer (D) Suprapatellar bursa Explanation: A knee effusion is defined as fluid within the knee joint. Symmetric peripatellar or suprapatellar swelling will be present. In large effusions, excess fluid elevates the patella above the femur and the patella is ballottable against the femur. Effusions can be due to excess synovial fluid from traumatic or atraumatic inflammation, or hemarthrosis following trauma to the knee. Traumatic effusions may result from ligamentous, bony, or meniscal injuries or overuse syndromes. Atraumatic etiologies of knee effusions include osteoarthritis, crystal arthropathies (e.g. gout and pseudogout), and septic arthritis. The knee has several bursa, which are small fluid-filled sacs which serve to decrease friction between moving structures. Some of the bursa communicate with the joint cavity directly and some do not. The suprapatellar bursa, the largest of the bursae, is not a true bursa but rather an extension of the knee joint capsule. When a knee effusion or hemarthrosis is present, fluid can freely flow into and distend the suprapatellar bursa. One technique to increase detection of small effusions is to "milk" the suprapatellar bursa, forcing fluid back into the knee joint. The anserine bursa (A) is located beneath the anserine tendon where the gracilis, sartorius, and semitendinosus muscles insert. It does not communicate with the knee joint. There are two infrapatellar bursae (B), a superficial infrapatellar bursa and a deep infrapatellar bursa, which, in most individuals, do not communicate with the joint space. The prepatellar bursa (C) is located between the patella and the skin, and does not communicate with the joint space.

A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate? (A) Anserine bursa (B) Infrapatellar bursa (C) Prepatellar bursa (D) Suprapatellar bursa

Correct Answer (B) Median nerve injury Explanation: The patient has a Colles' fracture. This is the most common wrist fracture in adults. A Colles' fracture is a transverse fracture through the distal radius, which is dorsally displaced and angulated, causing the characteristic "dinner fork" deformity. In more than half of cases, an associated ulnar styloid fracture is present. The mechanism of injury is typically a fall onto an outstretched hand (FOOSH). Colles' fractures often require reduction to restore radial length and correct the dorsal angulation to the wrist's normal volar tilt. Following reduction, splinting in a sugar tong splint should be performed to maintain fracture alignment. Orthopedics should be consulted for open fractures, associated neurovascular compromise, or if attempts at closed reduction are unsuccessful. Complications of Colles' fractures are more likely in elderly patients and those with inadequate fracture reduction. The median nerve is the most commonly injured nerve, and injuries include contusion, transection, and compression. An acute carpal tunnel syndrome can also result following a Colles' fracture, which mandates an orthopedics consult for immediate surgical decompression. Compartment syndrome (A) can occur after a Colles' fracture, but is rare. Ulnar nerve injury (C) is less common than median nerve injury. Wrist drop (D) results from radial nerve injury and is not common in a Colles' fracture.

A 55-year-old man slips on the ice and braces his fall with his hand. Radiographs of his wrist are shown above. Which of the following is the most common complication of this injury? (A) Compartment syndrome (B) Median nerve injury (C) Ulnar nerve injury (D) Wrist drop

Correct Answer (C) Diverticulitis Explanation: Diverticulitis is a common condition whose prevalence increases with age. Diverticula are small outpouchings of the colon where the vasculature perforates the circular muscular layer of the colon. In the United States, diverticular disease is predominantly in the descending and sigmoid colon. High bowel luminal pressures, obesity, and smoking are all risk factors for the development of diverticula. When diverticula become inflamed, diverticulitis develops. It classically presents with left lower quadrant abdominal pain, fever, and leukocytosis. There may be changes in bowel patterns (constipation or diarrhea), and there may be other GI or even urinary symptoms. In patients with prior episodes of diverticulitis and similar presentations, no further diagnostic imaging is necessary. However, if the prior diagnosis is not confirmed, the presentation is different from prior episodes, or there is concern for perforation, imaging should be pursued. Appendicitis (A) typically presents with right lower quadrant pain, but may also manifest with fever and leukocytosis. Colon cancer (B) does not typically present with fever, but can be an acute onset of pain due to obstruction or bowel perforation. As men get older, urinary tract infection (D) occurs with greater frequency. However, they typically manifest with dysuria, urinary frequency, or urinary urgency.

A 56-year-old man presents to the Emergency Department with lower abdominal pain that began three days ago. Two days ago he developed a fever. He denies nausea or vomiting, but has had some non-bloody diarrhea. "Something like this" happened once before and he was treated with antibiotics, but he cannot recall the actual diagnosis. On exam, he has tenderness in the left lower quadrant. He has an elevated white blood cell count at 15.4 x 109/L. What is the most likely diagnosis? (A) Appendicitis (B) Colon cancer (C) Diverticulitis (D) Urinary tract infection

Correct Answer (B) Complete blood count Explanation: Primary polycythemia vera is a myeloproliferative disorder that affects all cell lines. It occurs primarily in middle-aged or older patients. Symptoms may be mild and nonspecific, such as headache, weakness, dizziness, and pruritus or may be acute and severe manifesting in the thrombotic complications of stroke, myocardial infarction, and deep venous thrombosis. On examination, plethora, engorgement, and splenomegaly are commonly noted. Diagnostic criteria include an increased red cell mass (hemoglobin > 18.5 g/dL in men and > 16.5 g/dL in women), normal oxygen saturation, and splenomegaly on examination. Many patients will also have platelet counts > 400,000/mm3 and white blood cell counts > 12.0 x 109/L. Treatment consists of therapeutic phlebotomy to keep the hematocrit < 55%. A bone marrow biopsy (A) is not required for a diagnosis of primary polycythemia vera. A Coombs test (C) detects antibody or complement on human red blood cell membranes and is used in the diagnosis of hemolytic anemias. A peripheral smear (D) looks for the presence of abnormal or immature cells in the blood. It is also used in the diagnosis of hemolytic anemias and will show schistocytes or spherocytes.

A 56-year-old man presents with intermittent headaches, dizziness, and pruritus over the past two weeks. On examination, heart rate is 87 beats/minute, blood pressure 152/82 mm Hg, and oxygen saturation 97% on room air. He has splenomegaly without associated abdominal tenderness. His neurologic exam is normal. Which of the following studies is most likely to lead to his diagnosis? (A) Bone marrow biopsy (B) Complete blood count (C) Coombs test (D) Peripheral smear

Correct Answer (D) Oral vancomycin Explanation: This patient has severe colitis likely secondary to Clostridium difficile infection. C. difficile is a spore-forming obligate anaerobe that can cause a mild diarrheal illness to severe pseudomembranous colitis requiring surgical intervention. Infection is often antibiotic-induced, and treatment begins with discontinuation of the offending agent. Clindamycin is a common antibiotic associated with C. difficile colitis. Severely ill patients require hospitalization. Moderate to severe infection is seen in patients with a WBC count of > 15,000/mm3 or who have failed initial management with oral metronidazole. Oral vancomycin is the treatment of choice for these patients. The oral preparation is not enterally absorbed and remains intracolonic to exert its efficacy on the bacteria. Emergency colectomy (A) may be indicated in patients with a WBC count of > 20,000/mm3, lactate > 4 mmol/L, age > 75 years, immunosuppression, shock, toxic megacolon, bowel perforation, or multi-organ system failure. Oral metronidazole (C) is the initial treatment for mild C. difficile colitis and those with a WBC < 15,000/mm3. Intravenous vancomycin (B) is not effective in treating C. difficile colitis.

A 62-year-old woman with a past medical history of pseudomembranous colitis presents to the Emergency Department with severe abdominal cramping and diarrhea. Symptoms have been ongoing for four days. She denies fever, emesis, bloody stools, or recent travel. Her abdomen is diffusely tender without peritonitis. Her white blood cell count is 18,000 cells/mm3. Which of the following is the most appropriate next step in management? (A) Emergent colectomy (B) Intravenous vancomycin (C) Oral metronidazole (D) Oral vancomycin

Correct Answer (A) Glucagon Explanation: The patient likely has an esophageal food impaction. Patients at risk include the elderly, those with poor dentition, prisoners, and psychiatric patients. Patients will often given a history of ingestion. Symptoms include substernal pain, foreign body sensation, choking, vomiting, dysphagia, or increased salivation. Meat is the most common food causing esophageal food impaction. The first step in the management of suspected esophageal foreign body or food impaction is to assess airway patency and protection. If there is no imminent airway emergency, assess the status of the food impaction. Food should not be allowed to remain impacted for more than 24 hours. Glucagon 1 to 2 mg IV can be given to help with distal esophageal impaction. If the patient has little to no relief of symptoms after 20 minutes, a second dose may be given. If still unsuccessful, endoscopy should be performed for direct removal of the impacted food bolus. The use of proteolytic enzymes, including meat tenderizers, is not recommended. These products can cause severe mucosal erosion and esophageal perforation. Nimodipine (B) is a dihydropyridine calcium channel blocker that is used primarily to prevent cerebral vasospasm and subsequent ischemia in the setting of spontaneous subarachnoid hemorrhage. Its properties are not therapeutic in the management of esophageal food impaction. Orphenadrine (C) is a tricyclic ethylamine skeletal muscle relaxant. It does not cause smooth muscle relaxation. Somatostatin (D) is a peptide hormone that has many uses in medicine, including the management of GI bleeding and sulfonylurea-induced hypoglycemia.

A 64-year-old man presents with epigastric pain that began while eating chicken. He has been unable to tolerate solids or liquids and reports a foreign body sensation. A chest X-ray is unremarkable for foreign body or acute cardiopulmonary process. Which of the following should be administered? (A) Glucagon (B) Nimodipine (C) Orphenadrine (D) Somatostatin

Correct Answer (A) Acute transfusion reaction Explanation: This patient is suffering from an acute transfusion reaction or hemolytic crisis. This is most commonly caused by ABO incompatibility and may result in activation of the coagulation cascade (DIC). Signs and symptoms include headache, back pain, joint pain, anxiety, fever, tachycardia, hypotension, wheezing, pulmonary edema, and renal failure. Delayed reactions can occur in extravascular spaces, most commonly the spleen, liver, or bone marrow. Hemolytic crisis may also present with pink serum or urine due to severe hemolysis. Management includes discontinuing the transfusion immediately and starting IV fluids to maintain urine output at 30-100 cc/hour. Laboratory analysis should include a repeat type and screen with crossmatching, serum haptoglobin, CBC, and direct Coombs testing to confirm the diagnosis. Febrile transfusion reaction (B) is caused by recipient antibody response to donor leukocytes, leading to release of cytokines. This is generally benign, self-limited, and entirely resolved with slowing or stopping the transfusion. Graft-versus-host reaction (C) occurs when the donor blood attacks the lymphoid tissue of the recipient or host. Symptoms are nonspecific; however, the exam will often reveal hepatomegaly and laboratory testing will assist in the diagnosis as it reveals abnormal liver function tests and pancytopenia. Transfusion-related acute lung injury (D) is non-cardiogenic pulmonary edema leading to bilateral patchy infiltrates within four hours of transfusion. Patients may have rapid progression to ARDS and require ventilatory support with non-invasive positive pressure ventilation or endotracheal intubation.

A 65-year-old woman presents to the ED with generalized weakness. Recent history includes upper GI bleed secondary to peptic ulcer disease. Her hemoglobin was found to be 6.4 g/dL. While receiving a packed red blood cell transfusion, she developed headache, joint pain, fever, wheezing, and hypotension. Which of the following is the most likely cause of these symptoms? (A) Acute transfusion reaction (B) Febrile transfusion reaction (C) Graft-versus-host reaction (D) Transfusion-related acute lung injury

Correct Answer (A) Hypercalcemia Explanation: Hypercalcemia of malignancy occurs in up to 40% of cancer patients and is seen most frequently in patients with breast cancer, lung cancer, and multiple myeloma. It can occur as a result of bone metastases or in patients with tumor-produced substances that affect bone turnover. Symptoms of hypercalcemia can be nonspecific and include nausea, vomiting, constipation, and fatigue. The mnemonic "bones, stones, groans, and psychiatric overtones" is used to remember the symptoms of hypercalcemia. It can also cause an altered mental status ranging from depression, lethargy, and apathy to coma. Electrocardiogram findings include a shortened QT interval and widening and notching of the QRS complex. The normal serum calcium range is 9-10.5 mg/dL. Levels > 12 mg/dL may cause symptoms, especially if acute in onset. Levels > 14 mg/dL are considered a medical emergency. Treatment of severe hypercalcemia consists of correction of dehydration, increasing urinary calcium excretion, and decreasing osteoclastic activity. Patients should be started on saline rehydration to achieve an adequate urinary output. Furosemide can be given to increase the excretion of calcium. Calcitonin inhibits bone resorption as well as increases urinary excretion. Bisphosphonates also play an important role in management by preventing osteoclast attachment to the bone matrix. Corticosteroids can be useful, particularly in long-term management, in patients with breast cancer, myeloma, and lymphoma. Hyperkalemia (B) can cause peaked T waves and a widened QRS. Hypocalcemia (C) will cause a prolonged QT interval on ECG and symptoms of muscle cramping and paresthesias. Hypokalemia (D) can be seen in almost half of patients with hypercalcemia of malignancy. Patients may have nonspecific symptoms of fatigue and generalized weakness. ECG findings include flattened T waves and QT prolongation.

A 66-year-old woman with a history of lung cancer presents with fatigue, generalized weakness, and constipation. Her electrocardiogram is shown above. What is the most likely associated electrolyte abnormality? (A) Hypercalcemia (B) Hyperkalemia (C) Hypocalcemia (D) Hypokalemia

Explanation: This patient presents with acute stroke symptoms, but is ineligible for thrombolytic therapy due to her presentation five hours after the onset of her symptoms. Current recommendations are to treat blood pressure in these situations only when it is > 220/120 mm Hg or if there is evidence of other end-organ damage. This patient has a blood pressure of 200/115 mm Hg and therefore no acute intervention is indicated. If there is an indication to lower the blood pressure, the goal should be a gradual 15% reduction over the first 24 hours of onset as acutely lowering the blood pressure greater than that has been associated with worse outcomes. Labetalol and nicardipine have been shown to maintain adequate cerebral perfusion while lowering blood pressure and are first-line therapies in the setting of stroke. Esmolol infusion (A) can be used for gradual reduction of blood pressure in patients with blood pressures > 220/120 mm Hg although this patient does not meet the criteria. Uncontrolled hypertension is an absolute contraindication to thrombolytic therapy for acute stroke. Patients with blood pressures > 185/110 mm Hg who are otherwise eligible for thrombolytic therapy should receive antihypertensive medications prior to the initiation of thrombolytics. First-line management includes labetalol infusion to a goal blood pressure < 180/110 mm Hg (B). Sodium nitroprusside infusion (D) can cause an increase in intracranial pressure and is therefore not recommended for blood pressure management in the setting of acute stroke unless the pressure is refractory to other medications or the diastolic blood pressure is > 140 mm Hg.

A 68-year-old woman with a history of hypertension presents with right arm weakness, right facial droop, and expressive aphasia that started five hours prior to arrival. Her National Institutes of Health Stroke Scale is nine. There is no evidence of hemorrhage on computed tomography scan of the brain. Her initial blood pressure is 200/115 mm Hg. What is the next best step in management of her blood pressure? (A) Esmolol infusion with target of 15% reduction in systolic blood pressure (B) Labetalol infusion to goal blood pressure < 185/110 mm Hg (C) No acute intervention is indicated (D) Sodium nitroprusside infusion to goal blood pressure < 185/110 mm Hg

Correct Answer (B) Mesenteric ischemia Explanation: Acute mesenteric ischemia is fortunately a rare clinical problem, but has an exceedingly high mortality rate despite treatment. The majority of cases are the result of acute arterial occlusion resulting in embolization from the heart. Risk factors include dysrhythmias (particularly atrial fibrillation), atherosclerosis, valvular heart disease, and recent myocardial infarction. Acute mesenteric ischemia is less frequently secondary to mesenteric arterial thrombosis, which results from progression of atherosclerotic disease or mesenteric venous thrombosis, and occurs in association with a hypercoagulable disorder. The superior mesenteric artery is most frequently affected in acute arterial occlusion. These patients present with sudden onset diffuse abdominal pain, vomiting, and diarrhea. Early on, the pain is out of proportion to physical exam findings. As the ischemia progresses and infarct occurs, pain becomes more localized and peritoneal signs can be present. Elevated serum lactate levels are frequently seen. Abdominal X-rays are nonspecific but may show irregular thickening of the bowel wall, known as "thumbprinting." Late findings include gas in the bowel wall (pneumatosis intestinalis) or portal venous system. CT angiography is the imaging study of choice for diagnosis with a sensitivity and specificity of over 90%. Management includes fluid resuscitation, broad spectrum IV antibiotics, and emergent surgical consultation. Diverticulitis (A) typically presents with fever and localized pain in the left lower quadrant. Patients with a ruptured abdominal aortic aneurysm (C) will likely show signs of shock and have a pulsatile mass on examination. Small bowel obstruction (D) presents with abdominal pain, distension, vomiting, and obstipation.

A 72-year-old man with a history of a cerebrovascular accident, coronary artery disease, and atrial fibrillation presents with acute onset, severe diffuse abdominal pain associated with nausea, vomiting, and diarrhea. Vital signs include blood pressure 152/75 mm Hg, heart rate 95 beats/minute, and temperature of 37.5oC. On examination, he has difficulty lying still on the examining table and is moaning in pain. His abdomen is soft with tenderness in all quadrants with palpation. Which of the following is the most likely diagnosis? (A) Diverticulitis (B) Mesenteric ischemia (C) Ruptured abdominal aortic aneurysm (D) Small bowel obstruction

Correct Answer (A) Arterial thromboembolism Explanation: An arterial thromboembolism is the most likely cause of her symptoms. An arterial thromboembolism occurs when a thrombus embolizes from a proximal source to a distal vessel causing an acute occlusion. Thromboemboli typically originate in the left atrium or left ventricle and most frequently affect the lower extremities. Risk factors include atrial fibrillation, myocardial infarction, and history of large vessel aneurysmal disease. Treatment is aimed at restoring blood flow and preventing propagation of the thrombus. Anticoagulation is recommended as it decreases clot propagation and prevents clotting in the low-flow area distal to the thrombus. Definitive treatment includes catheter-directed thrombolytic therapy or surgical embolectomy. A deep venous thrombosis (B) is caused by a thrombus in the deep venous system. It would not be consistent with sudden onset of cyanosis and pain. Both phlegmasia alba (C) and phlegmasia cerulea dolens (D) are rare complications associated with deep venous thrombi. In phlegmasia albicans, significant swelling is present leading to a pale extremity with reduced arterial flow. Phlegmasia cerulea dolens is the more severe form causing worsening cyanosis of the tissue surrounding the vessel and ultimately venous gangrene of the extremity.

A 75-year-old woman with a history of atrial fibrillation presents to the Emergency Department with forty minutes of sudden onset left leg pain. On physical examination, her leg is dusky and cool to the touch. Which of the following is the most likely diagnosis? (A) Arterial thromboembolism (B) Deep venous thrombosis (C) Phlegmasia alba (D) Phlegmasia cerulea dolens

Correct Answer (B) Increased bleeding time Explanation: The condition described is von Willebrand disease (VWD). It is the most common hereditary bleeding disorder. The most common type, type I, is inherited in an autosomal dominant fashion. Increased tendency to bleed is the result of a qualitative or quantitative defect in von Willebrand factor (VWF), a protein necessary for platelet adhesion function. The resultant platelet type bleeding commonly affects mucosa leading to dental and nasal bleeding as well as menorrhagia and increased bleeding after delivery of a child. Testing for VWD requires examination of the blood for both quantitative and qualitative deficiencies of VWF. VWF antigen assay evaluates quantity of von Willebrand factor. The level of functionality of VWF is tested with one of the following: glycoprotein binding assay, collagen binding assay, ristocetin cofactor activity (RiCof) or a ristocetin-induced platelet agglutination (RIPA) assay. Bleeding time is increased. PTT is normal or may be increased. Platelet counts (A and C) are incorrect since it is the function, not the number, of platelets that is adversely impacted in von Willebrand disease. The platelets have abnormalities in a protein (VWF) required for adhesion function. Partial thromboplastin time (PTT) not prothrombin (PT) (D) is increased because factor VIII is bound to von Willebrand factor. Accordingly, a decrease in VWF will also result in a decrease in factor VIII, which explains the increased PTT. Reduced factor VIII has no corresponding change in prothrombin time (PT).

A five-year-old boy presents to the emergency department with nasal bleeding lasting greater than two hours. In the emergency department, the nurse applied pressure for 20 minutes without successful resolution. The patient appears well and has a normal heart rate and blood pressure. The patient's mother reports that the child's father has a bleeding disorder for which he occasionally uses a nasal spray. The patient has never had testing, and this is his first physician encounter for bleeding. Which lab abnormality would you expect to find for the child's inherited condition? (A) Decreased platelet count (B) Increased bleeding timeCorrect Answer (C) Increased platelet count (D) Increased prothrombin time

Correct Answer (A) Legg-Calvé-Perthes disease

A six-year-old boy presents with left hip pain that started four weeks ago. He denies any history of trauma. He describes the pain as a dull, aching pain that is worse with activity. The pain has gradually worsened, and the mother notes that he now walks with a limp. On examination, his temperature is 37.6oC. He denies pain with palpation of the left leg, but has pain and limited range of motion with internal rotation at the hip. What is the most likely diagnosis? (A) Legg-Calvé-Perthes disease (B) Osgood-Schlatter syndrome (C) Slipped capital femoral epiphysis (D) Transient synovitis

Correct Answer (B) Roseola Explanation: 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. Erythema infectiosum (A), 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. Rubeola (C) is 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. Scarlet fever (D) presents with fever, malaise, and sore throat followed by a fine sandpaper-like rash.

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 as seen in the picture above. What is the likely diagnosis? (A) Erythema infectiosum (B) Roseola (C) Rubeola (D) Scarlet fever

Correct Answer (C) Presence of a third heart sound Explanation: Respiratory distress can result from numerous pathologic states, including obstructive airway disease (e.g. asthma and chronic obstructive pulmonary disease), decompensated heart failure, myocardial infarction, pneumonia, upper airway obstruction, tension pneumothorax, pulmonary embolism, fat embolism, and neuromuscular disease, among others. Emergency physicians must quickly determine the cause of respiratory distress in order to initiate appropriate treatment. Heart failure is a common cause of respiratory distress. A weakened or diseased left ventricle or one facing high systemic pressures cannot adequately pump blood and as a result, blood pools in the lungs, leading to pulmonary edema and clinical symptoms of congestive heart failure. Symptoms include dyspnea on exertion, dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. However, these symptoms are seen in many conditions and cannot be used to distinguish congestive heart failure from other causes of dyspnea. Physical exam findings that suggest congestive heart failure include presence of a third heart sound or S3 gallop (likelihood ratio (LR) 11.0), hepatojugular reflux (LR 6.4), and jugular venous distention (LR 5.1). The combination of an S3 gallop and a chest radiograph showing pulmonary venous congestion or interstitial edema is highly suggestive of congestive heart failure. Jugular venous distention (A) is seen in congestive heart failure, but has a lower likelihood ratio than an S3 gallop. Presence of a fourth heart sound or an S4 (C) is more typical in a patient with diastolic failure and hypertrophic cardiomyopathy. Additionally, S3 is a major criteria for Framingham criteria for heart failure. Wheezing (D) is not predictive of congestive heart failure.

An 81-year-old man presents to the Emergency Department in respiratory distress. He is sitting upright and appears anxious, dyspneic, and diaphoretic. Vital signs show blood pressure of 190/110 mm Hg, heart rate of 130 beats/minute, respiratory rate of 35 breaths/minute, and oxygen saturation of 85% on room air. Which of the following physical examination findings most strongly suggest heart failure as the cause of his respiratory distress? (A) Jugular venous distension (B) Presence of a fourth heart sound (C) Presence of a third heart sound (D) Wheezing

Correct Answer (C) Murphy's sign Explanation: Murphy's sign is positive in patients with acute cholecystitis. During inspiration the lungs expand and the diaphragm moves downward. The downward movement pushes the inflamed gallbladder against the examiner's hand which elicits pain. The gallbladder is found in the right upper quadrant just beneath the liver. Acute cholecystitis occurs when a gallstone blocks the cystic duct which prevents the outflow of bile from the gallbladder. This commonly causes pain after eating since bile is used to emulsify fats ingested from a meal. McBurney's point tenderness (B) is found in the right lower quadrant between the umbilicus and the superior iliac spine. This is the general location of where the appendix is connected to the cecum and helps diagnose acute appendicitis. Deep palpation of this area irritates the inflamed appendix eliciting pain. The psoas sign (D) is positive when a patient experiences increased abdominal pain when the right leg is extended at the hip while the patient lies on the left side. This maneuver is used to help diagnose appendicitis. The Levine sign (A) is positive when a patient is holding a clenched fist over their chest to describe dull, pressing chest pain consistent with the discomfort of angina pectoris.

An obese 37-year-old woman is in the emergency room for right-sided abdominal pain and excessive flatulence. This episode has persisted for several hours. On physical exam you palpate her right upper quadrant while she takes a deep breath. The patient experiences pain and has a transient pause in inspiration. This physical exam finding is associated with which of the following signs? (A) Levine sign (B) McBurney's point tenderness (C) Murphy's sign (D) Psoas sign

Answer: 21 hours when given IV and 72 hours when given PO.

Question: How long does N-acetylcysteine (NAC) administration take?

Answer: Three to eight years after vaccination and 15 years after clinical infection.

Question: How long does immunity last after vaccination or clinical infection?

Answer: 4- 6 minutes.

Question: How long does lidocaine take to be effective following injection via a regional nerve block?

Answer: Until serum acetaminophen levels are undetectable and transaminases are normal or rapidly decreasing.

Question: How long is treatment with N-acetylcysteine continued?

Answer: 5-10%.

Question: How many patients infected with H. pylori will develop an ulcer?

Answer: Pyrazinamide.

Question: In the standard four drug regimen used to treat tuberculosis (rifampin, isoniazid, ethambutol, pyrazinamide), which medication is the most common cause of drug-induced hepatitis?

Answer: Pre-analytic.

Question: In which phase of laboratory testing do most errors occur?

Answer: Parvovirus B19.

Question: Infection with what common childhood virus can cause a transient aplastic crisis in patients with sickle cell disease?

Answer: Congenital short QT syndrome and digoxin effect.

Question: Name two other conditions that cause a shortened QT interval.

Answer: The thorax.

Question: Outside of the pelvis, what is the most frequent location of endometriosis?

Answer: Methemoglobinemia.

Question: Overmedication with nitroglycerin can cause what toxic effect?

1 cm H2O.

Question: Removal of 1 mL of cerebrospinal fluid will decrease the cerebrospinal pressure by how much?

Answer: True.

Question: True or False: Suicide is more common in Caucasians and Native Americans than African Americans, Asians and Hispanics?

Answer: C6 vertebra.

Question: What anatomic landmark corresponds with the narrowest portion of the pediatric airway?

Answer: Battle's sign, raccoon eyes, hemotympanum, and CSF otorrhea and rhinorrhea.

Question: What are the classic physical exam findings that may be seen in basilar skull fracture?

Answer: Premedication with prednisone (50 mg 13 hours, 7 hours and 1 hour prior to the study) and diphenhydramine.

Question: What can be done to minimize recurrent hypersensitivity reactions in patients who need imaging with radiocontrast media?

Correct Answer (B) Measles Explanation: Airborne precautions are necessary to prevent the spread of certain diseases in the healthcare setting. These diseases can be spread by small particle residue (< 5 µm in size) of evaporated droplets that can remain suspended in the air and travel far distances, thereby putting other patients and staff at risk. Airborne spread infectious diseases include rubeola (measles), varicella, and tuberculosis. In addition to standard precautions, patients should be placed in an airborne infection isolation room and healthcare providers should wear a fit-tested N-95 disposable respirator when providing patient care. Influenza (A), Neisseria meningitidis (C), and pertussis (D) are all infectious diseases which are spread by large particle droplets (> 5 µm in size). These droplets are produced by sneezing, coughing, talking, and during procedures, but because of their size do not typically spread further than 3-6 feet from the source. In addition to standard precautions, healthcare workers should use a procedure or surgical mask when caring for these patients.

Healthcare providers should use a fit-tested N-95 mask when caring for a patient with which of the following illnesses? (A) Influenza (B) Measles (C) Neisseria meningitidis (D) Pertussis

Correct Answer (C) Hepatitis Explanation: Isoniazid (INH) is the recommended first-line agent for the treatment of latent tuberculosis (TB). Most individuals take INH daily for six or nine months. Mild, nonspecific hepatic injury occurs in as many as 20 percent of patients taking isoniazid (INH). Usually there are no clinical manifestations and only a mild elevation in serum transaminases (< 100 IU/L). Age plays an important component in the development of hepatotoxicity as adults are more likely to be affected than children. Men and women appear to be equally vulnerable and there is no relationship to race. Other risk factors for hepatitis include alcohol intake, concurrent use of rifampin, liver disease, pregnancy, and intravenous drug abuse. The prognosis for mild cases of isoniazid hepatotoxicity is excellent, with an overall mortality rate of only 0.001 percent. Virtually all cases are self-limited and treatment can be continued with close laboratory testing. Vitamin B6 (pyridoxine) supplementation during INH therapy is necessary in patients to prevent the development of peripheral neuropathy. Isoniazid is metabolized in the liver by acetylation. The average half life is between 1-3 hours. Although the metabolites are excreted in the urine, it has not been known to cause acute kidney injury (A). Arthritis (B) is the most common side effect of pyrazinamide, another medication commonly used to treat tuberculosis. The pain is not usually so severe that a patient needs to stop taking the medication. Optic neuritis (D) is the important side effect of ethambutol. It is usually manifested by a change in visual acuity or by red-green color blindness.

One of your co-residents starts drinking a little too much at journal club, telling you he is "taking it easy" ever since beginning isoniazid for a positive tuberculin skin test. You tell him he should stop because he is in danger of developing which of the following conditions? (A) Acute kidney injury (B) Arthritis (C) Hepatitis (D) Optic neuritis

Correct Answer (A) Extensor carpi radialis brevis Explanation: Lateral epicondylitis, commonly referred to as tennis elbow, is an inflammatory condition involving the lateral epicondyle of the humerus. The lateral epicondyle is the site of origin for the wrist and digit extensors and the forearm supinators. Muscles that originate at the lateral epicondyle include the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris. Lateral epicondylitis is often the result of repetitive supination of the forearm. Patients present with focal tenderness over the lateral epicondyle as well as proximal wrist extensor muscle mass pain with resisted wrist extension with the elbow in full extension, and pain with passive wrist flexion with the elbow in full extension. Treatment includes nonsteroidal anti-inflammatory medications and activity modification. A counterforce brace placed distal to the elbow and physical therapy is recommended as well. The flexor carpi radialis (B) and the pronator teres (C) both originate at the medial epicondyle of the humerus. Medial epicondylitis presents with focal tenderness over the medial epicondyle and proximal wrist flexor muscle mass pain with resisted wrist flexion with the elbow in full extension and pain with passive terminal wrist extension with the elbow in full extension. The triceps (D) tendon inserts on the olecranon. Triceps tendonitis will present with pain and tenderness of the posterior elbow which is worse with extension of the forearm.

Lateral epicondylitis involves inflammation at the attachment of which of the following muscles? (A) Extensor carpi radialis brevis (B) Flexor carpi radialis (C) Pronator teres (D) Triceps

Answer: Prepatellar bursitis.

Question: What condition is caused by prolonged or frequent kneeling?

Answer: Permethrin will not kill unhatched mites so they must apply it twice, one to two weeks apart.

Question: How frequently should a patient with scabies use topical permethrin?

Answer: No.

Question: Do childhood vaccinations protect against Coxsackieviruses?

Answer: Adhesive capsulitis (frozen shoulder).

Question: Early passive shoulder range-of-motion exercises are utilized in clavicle fracture to reduce the risk of what complication?

(D) Meta-analysis Systematic reviews and meta-analyses are the highest order of evidence. Systematic reviews summarize the body of known primary research literature on a topic using a rigorous and predefined search methodology. Meta-analyses combine data from multiple primary randomized control trials. Case reports (B) are the lowest order of evidence as they report on a single patient or event. In a case-control study (A), patients with a particular disease (cases) are matched with patients without the disease (controls) and data is collected retrospectively on both groups to determine an etiology of the disease. A cohort study (C) is stronger than a case-control study and follows a group or groups of people prospectively and monitors how many go on to develop a disease or outcome.

Several randomized control trials have reached conflicting conclusions on the question of whether tamsulosin increases the probability of ureteral stone passage. Which of the following types of research study is thought to be stronger than a randomized control trial? (A) Case - control study (B) Case report (C) Cohort study (D) Meta-analysis

Correct Answer (B) Azithromycin 500 mg orally on day one, followed by 250 mg orally daily on days 2-5 Explanation: Pertussis is a highly contagious respiratory infection caused by Bordetella pertussis. Postexposure prophylaxis should be offered to all close household contacts of a patient diagnosed with pertussis. Those with face-to-face contact within three feet of a symptomatic patient or those with direct contact with nasal, respiratory, or oral secretions are considered close contacts. Given to an asymptomatic person within 21 days of exposure, infection can be prevented. Prophylaxis should also be given to those at high risk for severe infection or those who will have contact with a person at high risk for severe infection including immunocompromised patients, those with significant respiratory disease, infants < 12 months of age, and women who are in their third trimester of pregnancy. Azithromycin 500 mg in a single dose on day one, followed by 250 mg daily for four additional days is the regimen of choice. Azithromycin 1 gram orally x 1 dose (A) is the treatment of choice for Chlamydia cervicitis. Postexposure prophylaxis for meningococcemia is ciprofloxacin 500 mg orally x 1 dose (C). Postexposure prophylaxis is indicated even for close contacts who have already received Tdap vaccination (D) given the high rate of conversion in this group.

What postexposure management is indicated for close adult contacts of a patient diagnosed with pertussis? (A) Azithromycin 1 gram orally x 1 dose (B) Azithromycin 500 mg orally on day one, followed by 250 mg orally daily on days 2-5 (C) Ciprofloxacin 500 mg orally x 1 dose (D) No prophylactic medication is necessary if they have already received Tdap vaccination

Correct Answer (C) Mislabeling a specimen with another patient's information Explanation: Mislabeling a specimen with another patient's information is considered a pre-analytic error. Pre-analytic errors are those that occur during specimen collection and prior to specimen processing. They include errors in technique, timing, and identification (both patient and specimen). Laboratory errors impact patient safety and can lead to adverse events. These errors occur in three phases: pre-analytic, analytic, and post-analytic. Analytic errors are those that occur during specimen processing and can be due to equipment or human failure. An example would be the use of expired testing supplies, such as an expired fecal occult blood card (D). Another example would be failure to input the correct control values into the urine dipstick machine (A). Post-analytic errors occur after specimen results are complete. They are often due to incomplete or incorrect reporting of results, although can be due to incorrect interpretation of results as well. An example would be inputting a negative urine pregnancy test result into the wrong patient's chart (B).

Which of the following could result in a pre-analytic laboratory error? (A) Failure to input the correct control values into the urine dipstick machine (B) Inputting a negative urine pregnancy test result into the wrong patient's chart (C) Mislabeling a specimen with another patient's information (D) Noting that a fecal occult blood card is expired after use

Correct Answer (D) Worsens with coughing or straining Explanation: A postdural puncture headache is the most common complication following a lumbar puncture. Symptoms usually start 24-48 hours after the procedure with a bilateral frontal or occipital throbbing headache that may radiate to the neck and shoulders. The pain is worse when upright and improves or resolves when supine. Pain can also worsen with maneuvers that increase intracranial pressure, such as coughing, sneezing, and straining. Associated symptoms can include nausea, vomiting, photophobia, and blurred vision. Most postdural puncture headaches last only a few days and can be managed with adequate hydration and mild analgesics. For more severe headaches or those lasting longer than 24-48 hours, an epidural blood patch will relieve the symptoms in a majority of patients. It is rare for a post-dural puncture headache to have an onset immediately after the procedure (A). Pain is typically bilateral, not unilateral (B). Symptoms will improve or resolve when supine, not worsen when supine (C).

Which of the following is most consistent with a postdural puncture headache? (A) Onset immediately after the procedure (B) Unilateral pain (C) Worsens when supine (D) Worsens with coughing or straining

Correct Answer (A) Anaphylactoid reaction Explanation: N-acetylcysteine (NAC) is the antidote for acetaminophen ingestions. The most common side effect of IV NAC administration is an anaphylactoid reaction. Most of these reactions consist of skin rash or flushing. Around 1% of patients develop more severe reactions, such as angioedema, bronchospasm, and hypotension. Because the reactions are anaphylactoid (rather than anaphylactic), they are dose, rate, and concentration dependent. Anaphylactoid reactions are mediated by mast cell degranulation, as opposed to anaphylactic reactions, which are IgE mediated. Nausea and vomiting (C) are the most common side effects of oral (PO) administration of NAC. The smell and flavor of NAC is described as that of "rotten eggs." Vomiting of NAC delays antidotal delivery. It is recommended that antiemetics be given prior to PO administration. If there is any vomiting within one hour of administration, the dose should be repeated. Bradycardia (B) is a common side effect of physostigmine administration. Physostigmine is a reversible inhibitor of acetylcholinesterase and is the antidote for anticholinergic delirium. Pulmonary edema (D) is a common side effect of naloxone. The mechanism of this process is unknown. Naloxone can also precipitate withdrawal in patients with opiate dependence.

Which of the following is the most common side effect of intravenous N-acetylcysteine administration? (A) Anaphylactoid reaction (B) Bradycardia (C) Nausea and vomiting (D) Pulmonary edema

Correct Answer (D) Reactions can occur regardless of the dose used Explanation: The risk of a severe life-threatening hypersensitivity reaction to radiocontrast material is very rare, although more mild to moderate reactions occur in up to 3% of cases using nonionic media. Hypersensitivity reactions typically occur within minutes of exposure, are idiosyncratic, and are independent of dose and infusion rate. Risk factors for the development of a reaction include a history of previous hypersensitivity reaction to radiocontrast media, history of atopy or asthma, and possibly certain medications including beta blockers, aspirin, and nonsteroidal anti-inflammatory drugs. Symptoms can include pruritus, flushing, urticaria, edema, bronchospasm, stridor, and hypotension. Treatment consists of stopping the infusion and, depending on the severity of reaction, may include airway management, fluid resuscitation, epinephrine, and antihistamines. Corticosteroids may also be given and may help prevent prolonged or delayed symptoms. The presence of a shellfish allergy (A) is not a risk factor for developing a hypersensitivity reaction to radiocontrast media, despite widespread belief among the general population. Reactions are more commonly seen in patients 20-50 years of age, not in children (B). Reactions cannot be avoided by decreasing the rate of infusion (C) as they are independent of both dose and infusion rate.

Which of the following is true regarding hypersensitivity reactions to radiocontrast media? (A) Presence of a shellfish allergy is a risk factor for developing a hypersensitivity reaction (B) Reactions are more common in children (C) Reactions can be avoided by decreasing the rate of infusion (D) Reactions can occur regardless of the dose used

Explanation: Pertussis (whooping cough) is an acute respiratory illness caused by Bordetella pertussis. Prior to the development of a vaccination, pertussis primarily affected children under the age of 10 years. Since the late 1990s, pertussis has become more prominent in adolescent and adult populations. The clinical course is divided into three stages. The first stage, or known as the catarrhal stage, is often indistinguishable from other respiratory infections. It begins after an incubation period of seven to 10 days and lasts for about a week. Symptoms include rhinorrhea, low-grade fever, malaise, and conjunctival injection. Infectivity is the greatest in the catarrhal stage. Stage two, known as the paroxysmal stage, begins as the fever subsides and the cough develops. Patients have paroxysms of a staccato cough followed by sudden forceful inhalation, producing the characteristic whoop. Only one-third of adult patients develop the whoop, and it is also rare in infants. Infants are at risk of apneic episodes during this stage. The paroxysmal stage lasts two to four weeks. The third, or convalescent stage, lasts several weeks to months and is characterized by a residual cough. Chest X-ray findings include peribronchial thickening and atelectasis. Lobar consolidations (C) are not common and would be concerning for superimposed bacterial infection. Oral amoxicillin (D) is not effective in the treatment of Bordetella pertussis. The antibiotic class of choice includes macrolides. Antibiotic treatment does not significantly reduce the severity or duration of illness but does decrease infectivity. Childhood vaccination and clinical disease do not provide lifelong immunity (A).

Which of the following is true regarding pertussis? (A) Childhood vaccination and clinical disease provide lifelong immunity (B) Infectivity is greatest in the catarrhal stage (C) Lobar consolidations are commonly seen on chest radiography (D) The treatment of choice is oral amoxicillin

Correct Answer (D) Immune complex mediated reaction Explanation: Immune complex mediated reactions (Type III hypersensitivity) occur when IgG or IgM antibodies bind to antigens and form a soluble complex which then causes a local inflammatory reaction. Serum sickness is an example of this type of reaction. Classic serum sickness occurs after administration of a nonhuman protein antigen (e.g. venom antitoxins, rabies antigen). Serum sickness-like symptoms are more commonly seen in children and occur after administration of various medications, such as amoxicillin, cefaclor, and trimethoprim-sulfamethoxazole. Patients present with fever, polyarthralgias, polyarthritis, and a rash usually 1-2 weeks after starting a new medication. Symptoms may start sooner and be more severe in cases where the patient has been exposed to the antigen previously. Treatment consists of supportive care and discontinuation of the offending agent. Resolution of symptoms generally occurs within two weeks. Cell-mediated hypersensitivity (type IV) (A) occurs when sensitized lymphocytes detect an antigen and start an inflammatory reaction, such as in erythema multiforme and Stevens-Johnson syndrome. Cytotoxic antibody reactions (type II) (B) occur when IgM or IgG antibodies bind to membrane-bound antigens resulting in complement activation. IgE-mediated hypersensitivity (type I) (C) is responsible for the majority of anaphylactic reactions.

Which type of hypersensitivity reaction is responsible for serum sickness? (A) Cell-mediated delayed hypersensitivity (B) Cytotoxic antibody reaction (C) Immediate hypersensitivity (D) Immune complex mediated reaction

Correct Answer (C) 7 mg/kg Explanation: The maximum dose of lidocaine with epinephrine that can be injected into the peripheral tissues is 5-7 mg/kg. Lidocaine is the most commonly used anesthesia agent for wound repair because it has a rapid onset following local infiltration (seconds) and short duration of action (maximum of 60 minutes). It can also be used for regional anesthesia. The addition of epinephrine leads to local vasoconstriction, which increases the duration of action (2 to 6 hours). The addition of epinephrine may lead to delayed healing and potentially decrease the resistance to infection. Therefore you should use epinephrine with caution in wounds that are high risk for infection or in which tissue viability is a concern. You should also use caution with epinephrine use on distal areas, such as the fingers, nose, penis, and toes. Although some sources say that with careful screening, epinephrine can be used. The maximum dose of lidocaine without epinephrine is 3-5 mg/kg (B) or a total of 300 mg. A dose of 1 mg/kg (A) is under the maximum dose and a dose of 9.5 mg/kg (D) is over the maximum dose.

You are preparing to close a laceration on a patient's forehead. You decide to use lidocaine with epinephrine for anesthesia under local injection. What is the maximum dose that you can inject into the peripheral tissues? (A) 1 mg/kg (B) 4.5 mg/kg (C) 7 mg/kg (D) 9.5 mg/kg

Correct Answer (C) Oxygen Carbon monoxide (CO) is the most common gas involved in pediatric exposures. Smoke inhalation is responsible for most inadvertent cases. CO is a colorless, odorless gas produced during the combustion of any carbon-containing fuel. Potential sources include wood-burning stoves, old furnaces, and automobiles. Early symptoms are nonspecific, including headache, malaise, nausea, and vomiting. At higher exposure levels, patients can develop mental status changes, confusion, ataxia, syncope, tachycardia, and tachypnea. Severe poisoning is manifested by coma, seizures, myocardial ischemia, acidosis, cardiovascular collapse, and potentially death. On exam, patients may have cherry-red skin. Evaluation should include a carboxyhemoglobin level in all symptomatic patients, arterial blood gas and creatine kinase in severely poisoned patients, and an ECG in any patient with cardiac symptoms. Treatment requires the administration of 100 percent oxygen to enhance elimination of CO. Severely poisoned patients might benefit from hyperbaric oxygen. Amyl nitrite (A) is the treatment for cyanide poisoning. Methylene blue (B) is the treatment for methemoglobinemia. The goal of supportive care (D) is to support the vital functions until the patient can eliminate the toxin from the system. Supportive care in this case is not enough since the patient needs to be treated with 100 percent oxygen.

You evaluate a 10-year-old girl in the ED because of headache. She has been complaining of headache, nausea, and dizziness. She was seen in clinic yesterday and was diagnosed with a viral illness. Her symptoms got worse, and she seems confused. The girl denies rhinorrhea, fever, loss of consciousness, trauma, or burns. Her mother and older brother also complain of headache. You obtain labs that show an elevated carboxyhemoglobin level. Which of the following is the most appropriate therapy? (A) Amyl nitrite (B) Methylene blue (C) Oxygen (D) upportive care