critical q’s & as sixth edition. behavioral what are the factors associated with an increased...

Critical Qs & As Sixth Edition

Behavioral

What are the factors associated with an increased likelihood of suicide? Elderly (or adolescent) and male Unmarried (single, divorced, widowed) Recent loss of loved one (usually within 6 months) Family History of suicide Past suicide attempts or a suicide plan Unemployment or severe financial difficulties Severe family stress Recent major depression, bipolar disorder, schizophrenia, alcoholism, drug abuse or loss of a parent in early childhood or adolescence

What drug is contraindicated in patients taking MAO inhibitors because of the occurrence of a severe hyperpyrexic reaction? Meperidine (Demerol )

The diagnosis of malingering may be considered when the patient: Has history of antisocial personality disorder Feigns mental illness or amnesia Fails to cooperate with a history, physical exam and diagnostic evaluation

The _______ is often inappropriately calm in the setting of devastating chief complaint, such as acute blindness or paralysis. Patient suffering from a conversion disorder

A patient presents with severely agitated, violent behavior. What is the most appropriate management? Physical restraint/seclusion followed by administration of Haloperidol (Haldol) 5 mg IM, Ziprasidone (Geodon) or Lorazepam (Ativan).

A patient who has an acute disturbance of consciousness cognition and perception has what type of illness? Acute delirium

Which neuroleptic agent reduces agitation, is not very sedation, has a rapid onset but is associated with extrapyramidal side effects? Haloperidol (Haldol) (Newer neuroleptics, e.g. olanzepine, risperidone, ziprasidone, have less risk of extrapyramidal side effects)

What are the symptoms of depression? Sleep disturbance Change in appetite Impaired concentration and memory Reduced level of activity Dysphoria Lack of concern for personal appearance Suicidal thoughts Feelings of hopelessness/helplessness

Which organic brain syndrome is characterized by progressive impairment of cognitive function in which recent memory disturbance is the earliest sign? Dementia

Which drug should never be used for behavior control in the agitated delirious patient? The opioids, morphine and meperidine, can exacerbate acute brain failure.

Monoamine oxidase inhibitors (MAOIs) have serious food and drug interactions. What are they? 1. MAOIs + food containing tyramine (aged cheese, chianti wine) or sympathomimetic drugs (pressors, OTC stimulants/decongestants) ACUTE 2. MAOIs + meperidine (Demerol) COMA 3. MAOIs + SSRIs confusion, diaphoresis, shivering and myoclonus ( SEROTONIN SYNDROM )

Patients who present with vague symptoms such as weakness, fatigue, headache or pain may have ______ _____. Masked or hidden depression

Cardiovascular

Which dysrhythmia occurs primarily with severe hypoxia secondary to acute exacerbation of chronic obstructive pulmonary disease? Multifocal atrial tachycardia

What is the initial ECG abnormality in patients with torsades de pointes (a vibrant of polymorphic ventricular tachycardia)? Prolongation of the QT interval. A QT interval 500 msec clearly increases risk of torsades

What are the common precipitating factors of torsades de pointes? Most cases are ACQUIRED, as opposed to the less common congenital causes. Acquired causes are: Drug induces (type IA and IC antidysrhythmics, cyclic antidepressants, phenothiazines, organophosphates, droperidol and antihistamines) Drug combinations: astemizole or terfenadine with azole antifungals (fluconazole, ketoconazole) or with macrolide antibiotics (erythromycin, clarithromycin) Electrolyte abnormalities, especially hypomagnesemia and hypokalemia

What are the therapeutic consideration for patients with torsades de pointes? 1. Removal and / or discontinuation of the offending drug or correction of the underlying electrolyte disorder; 2. Intravenous magnesium (which shortens the QT interval) is the TREATMENT OF CHOICE ; 3. Also effective are overdrive pacing and intravenous isoproterenol (Isuprel) which has no effect on the QT interval.

What is the best initial therapy for the unstable patient with rapid atrial fibrillation? Synchronized cardioversion

What is the initial therapy for symptomatic patients with hypertrophic cardiomyopathy (such symptoms include angina, dyspnea, syncope and lightheadedness)? Beta Blockers

What are indications for endocarditis prophylaxis? High risk conditions for endocarditis include prosthetic heart valves and valve repair material; history of previous infective endocarditis; unrepaired cyanotic congenital heart disease; repaired congenital heart defect with prosthetic material, or repaired congenital heart disease with residual defects, and cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve.

What is usually seen in young, otherwise healthy patients as a result of either accidental or intentional overdose is commonly associated with hyperkalemia, high digoxin levels and bradydysrhythmias as well as AV block; toxicity in these patients most closely correlates with the degree of hyperkalemia (not the serum digoxin level)? Acute digitalis toxicity

What is the classic ECG finding in acute pericarditis? Diffuse nonanatomical ST segment elevation with upward concavity is prominent and is seen in all leads except a VR and V 1. PR segment depression is often present, most prominent in lead II and often the earliest ECG manifestation of acute pericarditis.

Which criterion should be used to distinguish ventricular tachycardia from SVT with aberration? Fusion and capture beats indicate AV dissociation and are practically diagnostic of ventricular tachycardia.

A 65-year old woman with a PMH of CAD, CHF and renal insufficiency is brought in by ambulance for evaluation. Her mediations include furosemide, digitalis, sublingual nitroglycerin and baby aspirin. According to family members, she has become progressively more confused and week over the past few days and has not been eating well. The ECG shows a regular wide complex tachycardia with alternating QRS polarity (bi-directional ventricular tachycardia) and laboratory evaluation reveals a digoxin level of 3.5 and a potassium of 3.0. What is the most likely diagnosis? Chronic intoxication with digoxin

Transient, episodic chest discomfort that is predictable and reproducible, i.e. familiar symptoms occur from a characteristic stimulus that improves with rest or sublingual nitroglycerin within a few minutes, demonstrates what? Stable angina. These patients are usually sent home or observed briefly in the ED.

What is the most common cause of right-sided CHF? Left-sided CHF

Which conditions are most likely to predispose a patient to subacute bacterial endocarditis? 1. Pre-existing valvular heart disease especially of the mitral and/or aortic valves. Mitral valve disease is most common ( INCLUDING mitral valve prolapsed). 2. Injecting drug users who present with right-sided disease. The tricuspid valve (most commonly involved) is usually normal before onset disease. NOTE: Murmurs are frequently ABSENT

What are the reasons for the high mortality rate (>70%) seen in patients with mesenteric vascular occlusion? 1. Difficulty in early diagnosis 2. Refractory mature of advanced disease 3. Frequent association of other serious diseases 4. Age at which disease occurs has high frequency of comorbid disease 5. Small bowel warm ischemia time is 2-3 hours

What is the most common bacterial organism that causes infective endocarditis? Is this the same organism if the patient is an injecting drug user? Non-viridans streptococci (alpha streptococci) No. the organism is Staphylococcus aureus.

What are the common conduction disturbance in an acute myocardial infarction? Bradydysrhythmias and AV conduction block

Angina that is a new in onset, occurs at rest or is similar but somewhat different than previous episodes, is severely limiting or lasts longer than a few minutes, with increased frequency of attacks or resistance to prescribed medications that previously relieved that symptoms (e.g. NTG, the blockers) demonstrates what? Unstable angina. Patients are admitted for observation or coronary care.

What is the earliest and most common rhythm disturbance seen with digitalis toxicity? PVCs

Which drug should be avoided in the therapy of an idioventricular rhythm, because it may obliterate the patients only functioning rhythm? Lidocaine

What is the treatment of MULTIFOCAL ARTIAL TACHYCARDIA? The MOST IMPORTANT consideration in this dysrhythmia is aggressive treatment of the underlying cause(s) (hypoxia, CHF, sepsis, theophylline toxicity).

What are the most common causes of sinus tachycardia? Condition in which catecholamine release is physiologically enhanced (flight, fright, anger, stress, pain) Fever Hypoxia Drugs Anemia Cardiac ischemia, ACS Hypovolemia Sepsis Hypotension Pulmonary embolism Hyperthyroidism Cardiac tamponade Stimulants, illicit drugs

What are the ECG findings in digitalis toxicity? PVCs* (often bigeminal and multiform) Junctional tachycardia (common) SA and AV nodal block A-Fib with a slow ventricular response SVT, ESPECIALLY Pat with block Ventricular tachycardia or fibrillation Bidirectional V-Tach 9rare but highly suggestive of digitalis toxicity) Sinus bradycardia/sinus arrest *MOST COMMON

Substernal chest discomfort greater than 15 minutes duration associated with dyspnea, diaphoresis, lightheadedness, palpitations, nausea and/or vomiting, with pain likely radiating to the inner aspect of one or both arms, shoulders, neck or jaw exhibited within a few hours of awakening in the morning demonstrates what? Acute myocardial infarction. An AMI is classified as a non-ST- segment elevation MI (NSTEMI) or an ST-segment elevation MI (STEMI). These patients are admitted to CCU after appropriate treatment.

A patient with the chief complaint of syncope has a systolic ejection- type murmur heard maximally either as the lower left sternal border or at the apex that increases with Valsalva maneuver. The ECG shows left ventricular hypertrophy. What is the suspected diagnosis? Hypertrophic cardiomyopathy

What is the most common complication of thrombolytic therapy in patients with acute MI? Reperfusion dysrhythmias

What are the typical ECG findings in an acute inferior wall MI? Acutely, ST segment elevation occurs in leads II, III and a VF. Reciprocal ST segment depression may occur in leads I, a VL and I V 1 V 6. REMEMBER: Q waves may take hours to develop or they may be absent (non-Q wave infarctions).

Which drugs may be used for hypertensive emergencies in eclampsia prior to delivery? Hydralazine Labetalol

Which diagnosis should be excluded in any patient older than 50 years of ago who presents with abdominal pain, back pain, weakness or syncope? Abdominal aortic aneurysm REMEMBER that the absence of a palpable abdominal mass and/or the presence of a palpable femoral pulse DOES NOT exclude this diagnosis

Who is more likely to have atypical presentation for acute coronary syndrome? Elderly patients, diabetic patients and women

What is a therapeutic contraindication to the administration of IV verapamil? Recent IV administration of propranolol

Which drugs are contraindicated in the treatment of ventricular tachydysrhythmias caused by digitalis toxicity? Bretylium Class I antidysrhythmics (procainamide, isoproterenol) Propranolol

What electrolyte abnormality is a common cause of dysrhythmias in AICD patients? Hypomagnesemia

What is the drug of choice for conversion of a narrow-complex supraventricular tachycardia? adenosine (Adenocard)

Why are alcoholics prone to the development of torsades de pointes and why is this important therapeutically? Chronic alcoholism is associated with hypomagnesmia which can lead to prolongation of the QT interval, a common cause of torsades. Treatment with magnesium is essential because this rhythm may degenerate into V-fibrillation.. Furthermore, if lidocaine or procainamide are given, they may aggravate the dysrhythmia.

Which type of angina is classically associated with ST segment elevation (rather than depression) and pain that is usually relieved promptly by nitrates? Prinzmentals (variant) angina. The other point here is that this type of angina usually occurs AT REST.

What is consideration the THERAPY OF CHOICE in the setting of an acute aortic dissection associated with hypertension? Intravenous beta blocker (propranolol, esmolol or labetalol) in combination with nitroprusside. NOTE: The goal of therapy is reduction of aortic wall stress both by lowering blood pressure and by decreasing cardiac output.

CLINICAL PRESENTATION : Pain and swelling in the calf and tenderness on AP compression. 1. What is the INITIAL diagnostic study of choice? 2. What diagnostic study is the most SENSITIVE 1. Duplex ultrasonography 2. Venogram

Regarding cardiovascular conditions, nausea and vomiting may be the only presenting sign and symptom of ___ ___ ___. Inferior wall MI

Hypertensive emergency is defined as an extreme elevation of BP with signs or symptoms of end-organ disease. What is an effective, reliable and safe drug for a hypertensive emergency in the setting of myocardial ischemia or CHF? Sublingual nitroglycerin

The most frequent ECG findings in chronic ischemic heart disease are ___________ Nonspecific ST and T waves changes (ST segment elevation/depression

What lab tests are helpful in the diagnosis of alcoholism? 1. Hepatic transaminases * AST ALT suggests alcohol injury * GGT is the most sensitive indicatory of alcoholic liver damage 2. Increased mean corpuscular volume (MCV) is more specific of alcohol abuse than any of the transaminases 3. Carbohydrate-deficient transferrin (CDT) is the most specific and sensitive marker for heavy alcohol consumption; AST ALT (Ratio > 2)

What is the treatment for Wernickes encephalopathy? 1. Thiamine 100 mg. Administration of glucose prior to thaimine may precipitate Wernickes encephalopathy in patients with severe thiamine deficiency. 2. Resistance to thiamine may occur secondary to hypomagnesemia (magnesium is a cofactor for thiamine transketolase)

Infants who present at 3-4 months of age with hepatomegaly and hypoglycemia are likely to have _______. What retinal changes are seen in about half of these cases? Glucose-6-Phosphatase Deficiency symmetric, yellowish paramacular lesions

Which factors are important in predicting the outcome for a near drowning victim? Age Need for bystander or ED CPR Water characteristics: 1. Clean vs contaminated 2. Temperature 3. Amount aspirated

What is the order of tissue resistance to the flow of electrical current? LEAST resistance: nerves, blood vessels, muscles, mucous membranes, moist or wet skin INTERMEDIATE resistance: dry skin GREATEST resistance: bone, tendon, fat

Which organ system is LEAST sensitive to an acute radiation exposure? Central nervous system

What is the clinical feature that distinguishes heat stroke from heat exhaustion? Central nervous system dysfuntion (In heat exhaustion, mentation is not impaired.)

Which injury is most likely to be present in a survivor of a lighting strike? Rupture of the tympanic membranes

At what temperature does the hypothermic patient lose the ability to generate heat by shivering? Below 32 C (90 F)

A patient complains of severe muscle cramping involving the calves, thighs and shoulders. Questioning reveals that the cramps began after a bout of intensive physical activity and profuse sweating, during which he had been replacing fluid losses with a hypotonic solution. His body temperature is normal. What is the most likely diagnosis? Heat cramps. Inadequate replacement of salt from loss through sweating leads to hyponatremia and muscle cramps.

What is the MODIFIED rule of nines which may be used in CHILDREN ? HEAD = 18% Abdomen = 9% Thorax = 9% Back = 18% Each arm = 9% Each leg = 14%

Core temperatures less than ___ are associated with increased myocardial irritability and case cause nearly any tachydysrhythmia, including conduction delays. 30 C (86 F)

What is the most important cause of morbidity and mortality in near drowning? Hypoxia

In patients with this injury, close observation (sometimes in the hospital) and referral to a plastic or oral surgeon is indicated because there is the possibility of labial artery hemorrhage as the escher separates. Electrical burns of the lip/mouth

Rapid rewarming is the key initial therapy for this environmental emergency. Frostbites

A patient presents with an acute abdomen. However, you notice that there is no tenderness but there is impressive rigidity. What is the suspected diagnosis? Black widow spider bit (to the lower extremity or genitalia)

What is the most common presentation of arterial gas embolization after driving? Air embolus or decompression sickness

A scuba diver develops acute confusion and ataxia after an ascent. What is the diagnosis? Cerebral air embolus or decompression sickness (from an ascent that was too rapid)

A patient presents with extreme fatigue and profuse sweating on a very hot day. He complains of lightheadedness, nausea, vomiting and a dull headache. He is tachypneic, tachycardic and hypotensive. Body temperature is normal. What is the most likely diagnosis? Heat exhaustion. Salt water depletion from sweat loss leads to hypovolemia and hypoperfusion; neurologic and mental status exams are normal.

The whole body dose of ionizing radiation determines the timing of the onset of symptoms. The higher the level of exposure, the _____ symptoms develop. Earlier

What is the best predictor of survival in patients with radiation exposure? The absolute lymphocyte count, 48 hours after exposure.

What is the treatment of puncture wounds (stings) from sea urchins, stingrays or lionfish? 1. Remove spine (if possible) 2. Wash with sea water or fresh water 3. Submerge wound in hot water for 30-90 minutes

Concerning the initial management of patients with radioactive skin contamination, is it preferable only to was or to was AND scrub the skin? Washing with water and mild or nonionic soap is done in conjunction with GENTLE scrubbing. Harsh scrubbing may damage the skin with introduction of radioactive material into the underlying tissues.

Does successful recovery from tetanus confer immunity to the disease? No! The patient needs full primary immunization plus boosters through the years as indicated.

Which tick-bone illness is characterized by severe retro-orbital headache and photophobia and requires only supportive therapy? Colorado tick fever

CLINICAL PRESENTATION : a patient presents ill with fever and a rash. The rash began as discrete red maculopapular lesions on the wrists and ankles. It then spread to the trunk. Early on, the lesions were blanched but later became petechial. What disease characteristically does this? Rocky Mountain spotted fever (RMSF)

Circular skin lesions with a bright-red to blue-red border and a pale center are characteristic of ___ ___, which is the hallmark of early___ ____. Erythema migrans Lyme disease (stage I)

Antibiotic therapy for adults (nonpregnant and nonlactating) and children older than 8 years for Lyme disease stage I is_________. Doxycycline or tetracycline

Which animals are most likely to harbor the rabies virus? Which animals are least likely vectors for rabies? MOST common: skunks, bats, raccoons, cows, dogs, foxes and cats LEAST common: rodents (squirrels, chipmunks, rats and mice) and lagomorphs (as in Bugs Bunny and the March Hare) NOTE: Rabies can affect all mammals.

What is the management of primate (ape) bite? Careful handwashing for 20 minutes after a bite is the best treatment for prevention of infection with herpes virus simiae (70% fatality rate). Acyclovir should be started at the first sign of infection.

There are two types of heat stroke. What are they? Classic heatstroke is envirmentally0induced 9hot, humid weather) and occurs most commonly in those who live in homes without air- conditioning (especially the elderly) and those with inadequate fluid intake (e.g. the debilitated). Lab abnormalities are mild. Exertional heat stroke is exercised-induced 9athletes, military recruits) and is associated with significant lab abnormalities: hypoglycemia, hypocalcemia, hyperuricemia, lactic acidosis and rhabdomyolysis. Acute renal failure and coagulopathy (often to a marked) may also occur.

Sudden cardiac arrest from electrocution occurs with exposure to ____ or ____. Household AC current Lightning strikes

How do you differentiate muscle spasms due to tetanus from those seen in patients with strychnine poisoning? Tetanic muscle contractions are continuous, whereas, muscle spasms associated with strychnin poisoning usually have periods of relaxation between contractions. Also, lockjaw is characteristic of tetanus, not strychnine.

An elderly patient who lives a sedentary lifestyle and is taking medication for chronic illnesses presents with sweating, then develops hot, dry skin. The patient lives in an unairconditioned apartment and temperatures have been in the 90s. Lab findings include respiratory alkalosis and mild metabolic acidosis, coagulopathy and CPK elevation; glucose and calcium levels are normal. What is the most likely diagnosis? Heat stroke. This is true medical emergency, characterized by an altered LOC, any neurologic findings and an elevated temperature.

You are examining a patient who has a rash that looks like chicken pox. How do you know that it isnt smallpox? In patients with smallpox (Variola major) all lesions are in the same stage of eruption, unlike chicken pox (Varicella)

A young, healthy patient is engaged in strenuous exercise on a warm day in August. The patient is diaphoretic on presentation. The following findings are obtained: respiratory alkalosis and marked lactic acidosis, DIC and rhabdomyolysis (machine oil urine), increased BUN/creatinine, hypoglycemia and hypocalcemia. What is the diagnosis? Exertional heat stroke

What are the differentiating clinical features that distinguish Crohns disease from ulcerative coltis? Crohns Disease The majority of patients present with abdominal pain, anorexia, diarrhea and weight loss. The majority of patients have ileum involvement. 30% of patients present with perianal fissures or fistulas, perirectal abscessed or rectal prolapse. Ulcerative Colitis Gradual onset of bloody diarrhea and abdominal pain is the most common presentation Anorexia and weight loss

What is the clinical presentation of a patient with Boerhaaves syndrome and which diagnostic study is likely to be most beneficial? Severe retching or vomiting followed by lower thorax or epigastric pain is the most common; the most common tear site is the left posterolateral wall 2-3cm before the stomach. Occasionally pain is also reported in the restrosternal, left shoulder or upper chest areas. A standard chest radiograph is almost always abnormal and may show left pleural effusion (most common), mediastinal or free peritoneal air, widened mediastinum, or left pneumothorax. Diagnosis may be confirmed by either CT scan or an esophagram using water-soluble contrast (Gastrografin) since barium may cause additional pleura-mediastinal inflammation if a tear is present.

What is the general management of ingested foreign bodies that are sharp and pointed? Sharp or pointed objects, as well as objects longer than 5cm and wider than 2cm or oddly shaped foreign bodies such as opened safety pins, MUST BE REMOVED ENDOSCOPICALLY. They should be removed BEFORE passing through the pylorus because 15-35% will cause perforation, usually in the region of the ileocecal valve.

What is the management of ingested foreign bodies that are sharp or pointed IN CHILDREN ? Initial physical exam and x-ray in ALL children. Labs are usually not necessary. If symptoms are present, obtain surgical consult. If the ingested item is a sewing needle, needles in the stomach need endoscopic removal. Needles that have passed into the intestines require early surgical consult. If no symptoms are present, follow with serial x-rays. No progression past the stomach necessitates contrast x-ray to exclude perforation. Signs of perforation or failure to pass through the GI tract require surgical consultation.

A small child swallow a quarter. Where is it most likely to become impacted? The esophagus The three most common site for impaction are: 1. The cricopharyngeus muscle (C 6 ) = 70% 2. Adjacent to the aortic arch and carina (T 4 ) = 15% 3. Lower esophageal sphincter/diaphragmatic hiatus (T 10-11 ) = 15%

Which types of hepatitis produce neither a chronic infection nor a carrier state? Hepatitis A and Hepatitis E

What pharmacologic agents may be used in the management of esophageal food impaction and how do they work? Sublingual Nitroglycerin relaxes smooth muscle. Sublingual Nifedipine reduces lower esophageal tone. Glucagon relaxes smooth muscle and is most effective at the distal esophageal sphincter. Tartaric Acid and sodium Bicarbonate produce CO 2 (which may help advance the food bolus into the stomach.)

The clinical presentation of an esophageal foreign body in children may be dysphagia. What else is possible? Respiratory distress due to compression of the pliable trachea, including cough or stridor. Food refusal, weight loss, drooling, gagging, emesis/hematemesis, chest pain or sore throat.

What is the appropriate therapy for a patient with a cecal volvulus? Is the treatment the same for a sigmoid volvulus? Cecal volvulus requires surgery as soon as possible. No, acute management of sigmoid volvulus in stable patients is detorsion and decompression with a rectal tube via either a sigmoidoscopy or colonoscopy (90% success rate). Unstable patients with signs of peritonitis, ischemic bowel or failure of endoscopic decompression requires emergent surgery.

Name the most common causes (s) of: 1. All types of intestinal obstruction 2. Small bowel obstruction 3. Large bowel obstruction 1. Adynamic ileus 2. Adhesions, external hernias 3. Carcinoma, sigmoid diverticulitis and volvulus Adhesions are the most common cause of MECHANICAL small bowel obstruction, whereas carcinoma is the most common cause of MECHANICAL colon obstruction.

Clinical Presentation: A 45-year-old presents with substernal chest pain following forceful vomiting. Boerhaaves syndrome (spontaneous esophageal rupture) occurs mainly in MALES between the ages of 40-60 and usually involves the LEFT SIDE of the esophagus.

Both Mallory-Weiss syndrome and Boerhaaves syndrome involve tears of the esophagus. How do these tears differ anatomically? Mallory-Weiss syndrome involves a partial thickness tear of the MUCOSAL layer. Typically, upper GI bleeding is the presentation. Boerhaaves syndrome involves a complete rupture with ALL LAYERS of the esophagus involved, typically presenting as left-sided chest pain.

A patient has recently returned from a back-packing trip in Colorado and presents with abdominal pain, bloating and gas. He also complains of postprandial abdominal cramping, an urgency to defecate and has diarrhea that is frothy and foul-smelling. A stool specimen sent to the lab is negative for ova and parasites. What is the most likely etiology. Giardia lamblia

Clinical Presentation: A 43-year-old woman presents with epigastric discomfort after eating dinner. She is tender in both the epigastrium and RUQ. Which radiographic study is the gold standard in establishing the diagnosis? Diagnostic confirmation of cholecystits requires nuclear scintigraphy (HIDA), which demonstrates 95% senisitvity and specificity for acute cholecystits, while ultrasound or CT scanning can assess anatomy and secondary signs, which may guide therapy, but the HIDA scan can relay information of the biliary tree.

What are poor prognostic signs in patients with pancreatitis? Ransons criteria On admission:48 hours later: * Age > 55 years* Calcium 200 mg/dL pO 2 < 60 mmHg * WBC > 16,000 mm 3 * > 10% fall in Hct * LDH > 350 IU/L* > 5% mg/dL rise in BUN * AST > 250 Sigma-Frankel* Base deficit > 4 mEq/L units/L* Sequestration of > 6L of fluid

Name the most common causes of bright red rectal bleeding. Anal lesions, particularly fissures and hemorrhoids

Name the most common cause of bloody diarrhea. Shigella

Name the most common cause of upper GI bleeding. Peptic ulcer disease (duodenal ulcer is most common)

A patient with diagnosed ulcerative colitis demonstrates a traverse colon measuring > 8 cm on an abdominal film. What is the significant of this finding? Toxic megacolon

What is the drug of choice in patients with severe pseudomembranous colitis? Oral metronidazole or vancomycin. If critically ill, intravenous metronidazole and oral vancomycin.

What is the most common complication of upper GI endoscopy? Esophageal trauma

What is the chief complaint of patients with Boerhaaves syndrome? Chest pain, which is usually severe and lancinating. Patient history may include vomiting or other Valsalva maneuver, including cough or heavy lifting.

Clinical Presentation: A patient with a recent history of CAD, MI or peripheral vascular disease develops sudden onset of abdominal pain. There is also diarrhea that is positive for occult blood. What is the suspected diagnosis? Mesenteric vascular occlusion

A young woman presents with recurrent episodes of altered bowel function (diarrhea or constipation). The episodes are usually precipitated by stress and the pain is described as crampy or achy and is confined to the lower abdomen. In association with constipation, it is relieved by defecation or gas passage. Extracolonic symptoms (bloating, belching, reflux) are common. The patients denies anorexia, fever and weight loss. Nonspecific exam findings may include vague lower abdominal tenderness and a palpable stool-filled sigmoid colon. Labs are unremarkable. What is the likely diagnosis? Irritable bowel syndrome (IBS)

Which abnormal electrolyte finding is seen in patients with acute pancreatitis? Hypocalcemia

Hemorrhagic shock is a potential complication of which inflammatory GI disorder? Pancreatitis

What are the historical findings consistent with the diagnosis of irritable bowel syndrome? Rome II criteria Abdominal pain or discomfort > 12 weeks over the past year accompanied by two of the following * Relief of discomfort with defecation * Association of discomfort with altered stool frequency * Association of discomfort with altered stool form

What are the most likely causes of lower GI bleeding in children? Meckels diverticulum is the most common cause of significant lower GI bleeding in children. Anal fissure is the most likely cause of minor lower GI bleeding in a healthy infant beyond the neonatal period without previous GI history.

What is the most common cause of upper GI bleeding in pregnancy Esophagitis (secondary to reflux and repeated vomiting)

A patient presents with sudden onset LUQ pain associated with violent retching (but no vomiting). Upright films of the chest and abdomen reveal a distended stomach with one or two air0filuid levels. What is the diagnosis? Gastric volvulus presents with sudden onset of severe abdominal pain with retching or vomiting. Upright films of the chest and abdomen may reveal stomach distension with one or two air fluid levels or a large, gas-filled loop of bowel in the abdomen or chest.

What is the most common cancer of the small intestine? Adenocarcinoma Usually occurs in the proximal small bowel Higher incidence in patients with long-standing Crohns disease

What is the most frequent site for aortoenteric and ileoenteric fistulae? The distal duodenum (Consider this diagnosis in patients with GI bleeding and a history of aneurysms)

What is the carcinoid syndrome? Carcinoid tumor cells (usually in the distal small bowel) secrete 5- hydroxytryptophan wheezing/shortness of breath, intermittent flushing, abdominal pain, diarrhea, signs and symptoms of right-sided valvular heart disease. Diagnosis is confirmed by obtaining a urine level of 5- hydroxyindoleacetic acid (5-HIAA).

What is the etiology of hepatic abscesses? Pyogenic ( usually E. Coli) 90% Amebic (Entamoeba histolytica) 10%

What is the most common presentation of cholelithiasis? 1. RUQ 2. No fever 3. Relatively normal lab studies

What is the most common cause of portal hypertension worldwide? Schistosomiasis

What is the most common bloodborne viral infection in the United States? Hepatitis C Virus (HCV)

What are the two most common causes of esophageal bleeding? Varices Mallory-Weiss tear

UGI bleeding due to a ruptured esophageal varix can be controlled in 90-95% of cases with what type of treatment Endoscopic sclerotherapy Pharmacologic agents (octreotide)

Clinical Presentation: a middle-aged male with cirrhosis who is confused and unable to hold an assumed position (asterixis). What is the diagnosis and appropriate management? Hepatic encephalopathy is the diagnosis. Management includes: Lactulose Decreased protein intake (especially animal protein) Avoidance of all sedatives and tranquilizers Avoid bicarbonate (alkalosis may precipitate or worsen encephalopathy) Correction of hypokalemia Rifaximin

When is the insertion of a Sengstaken-Blakemore tube for esophageal varix hemorrhage contraindicated? What procedure should be done prior to insertion of the tube? Contraindications include: Hiatal hernia (precludes proper tube placement) Peptic ulcer disease with stricture of the esophagus Bleeding from esophageal lacerations Inability of the patient to protect the airway Endoscopy should precede insertion (if at all possible) so that the diagnosis may be confirmed

Bloody diarrhea should warrant testing for which bacteria? Shigella Salmonella Campylobactor Hemorrhagic E. Coli

Protozoal pathogens most frequently associated with diarrhea that persists for more than 7-10 days are _____ and _____. Giardia Cryptosporidium

Patients with refractory cryptosporidiosis, cyclosporiasis or isosporiasis should be tested for _________. HIV infection

Head and Neck

What is the distinguishing clinical feature which helps differentiate croup from epiglottitis? Mode on onset Symptoms of croup start gradually, whereas symptoms of epiglottitis tend to begin abruptly, particularly in children.

What is the appropriate initial study in a patient with headache, lethargy, nuchal rigidity and papilledema? Computed tomography (CT) of the head should be done initially to exclude the presence of mass lesions prior to lumbar puncture. The important consideration here is subarachnoid hemorrhage, secondary to a ruptured aneurysm. If meningitis is a possibility, administration of antibiotics should be delayed.

A teardrop-shaped pupil in a patient with a history of trauma to the eye suggests what injuries? Corneoscleral perforation or laceration Rupture of the globe

What is the most common precipitating factor in the development of Ludwigs angina (cellulitis of the floor of the mouth)? Dental disease (infections, extractions, trauma)

Clinical Presentation: An adult male was struck in the eye by a fist 3 days ago. Over the past 24 hours, he has developed redness, pain and photophobia. 1. How would you confirm the diagnosis? 2. How is this treated? The diagnosis is traumatic iritis. This is conformed by a slit lamp examination which demonstrates cells and flare in the anterior chamber. treatment consists of long-acting topical mydriatic-cycloplegic drops (dilate the constricted pupil, relax ciliary spasm) and topical corticosteroids (reduce inflammation).

Of all patients with epistaxis, the ones who must be admitted are those treated with _____. Posterior packing The feared complications are: Hypoxia and hypercarbia Sudden death due to dislodgement of the pack Dysrhythmias and coronary ischemia

List the complications of a hyphema. Rebleeding, which occurs 2-5 days after the initial clot loosens, is a major complication. Blood staining of the corneal epithelium Secondary glaucoma Anterior and posterior synechiae Optic atrophy from increased IOP associated with hyphema.

What is the most common direct source of posterior nosebleeds? Posterior branches of the sphenopalatine artery

A patient presents within 3 days of a tooth extraction complaining of severe pain and of foul breath odor. What is the diagnosis? Acute alveolar osteitis (dry socket)

What is the diagnosis in patients who complain of flashing lights in front of the eyes, especially at night and in the peripheral visual field? Retinal detachment

Slit-lamp exam of a painful eye reveals a fluorescein-positive are with a branching or dendrite pattern. What is the diagnosis and treatment of this disease? Herpes simplex keratitis Treatment: 1. Topical and oral antiviral agents 2. Topical cycloplegic drops 3. Emergent ophthalmologic consultation

Clinical Presentation: A patient complains of weakness of an upper extremity as well as numbness and tingling of the forearm and middle finger. When the patient is asked to extend the elbow against resistance, he is unable to do so and complains of pain in the upper back. Where is the lesion located? C7C7

What is the unusual cause of bacterial parotitis? Staphylococcus aureus

What is the most common presenting symptom of a brain abscess? Headache

Which abnormal laboratory findings is associated with temporal arteritis? Markedly elevated sedimentation rate (usually over 50mm/hour). Maximum normal sedimentation rate can be calculated as age (10+ if female)/2.

Compressive dressing applied to an external ear injury may cause _____. Necrosis of the ear cartilage

What are the complications of ethmoid sinusitis? Periorbital/orbital cellulitis Brain abscess

What is a complication of sphenoid sinusitis? Cavernous sinus thrombosis

Mastoiditis is usually a complication of which disorder? Untreated or inadequately treated acute otitis media

What is the treatment of mastoiditis? 1. Admission 2. Parental antibiotics (Adequate coverage from gram negative and positive organisms usually entails combination therapy, ceftazidime OR cefepime OR piperacillin-tazobactam PLUS vancomycin.) 3. Immediate ENT consultation regarding surgical drainage and/or mastoidectomy

A patient complains of a severe sore throat, muffled voice as well as difficulty swallowing and opening the mouth. What is the suggested diagnosis? Peritonsillar abscess

What are the two most common supportive complications of group A beta-hemolytic streptococcal pharyngitis? Acute otitis media Acute sinusitis They are caused by spread of organisms via the eustachian tube (otitis media) and direct spread to sinuses (sinusitis)

A patient with a history of blunt trauma to the face has enophthalmos (recognizable as slight ptosis) on physical examination. Which diagnosis should be considered? Blowout fracture of the orbit

What is the currently recommended emergency treatment for complete laryngeal obstruction due to trauma? Tracheostomy Cricothyrotomy is usually not feasible because the injury is frequently below the cricothyroid membrane Blind nasotracheal intubation attempts mat penetrate the mediastinum Percutaneous transtracheal insufflation is currently under investigation

What is the most common cause of pink eye? Conjunctivitis (bacterial and viral) Bacterial causes include N. gonorrhoeae in the newborn as the most vision-threatening, but C. trachomatis is the most common in newborn. In adults, the most common bacteria is S. aureus. The most common virus is adenovirus.

Acute bacterial conjunctivitis in adults is most commonly doe to ____ and ____. S. Aureus* S. pneumoniae * The most common cause of mucopurulent conjunctivitis

What are the characteristic fluorescein uptake patterns in keratitis due to exposure, acanthamoeba and herpes simplex? Exposure keratitis horizontal band Acanthamoeba keratitis ring shape Herpes simplex keratitis branching dendritic pattern

How do you differentiate between central retinal artery occlusion and central retinal vein occlusion on funduscopic exam? Patients with central retinal artery occlusion have a cherry-red spot in the center of the fovea; those with central retinal venous occlusion have a blood and thunder fundus.

What causes acute thermal epiglottitis? A direct thermal insult from ingestion of hot food or liquid (or from smoking cocaine) may precipitate thermal epiglottitis.

Neonatal conjunctivitis (ophthalmia neonatorum) occurs in the first 3-15 days of life. Which organisms are likely to be responsible? If it occurs on the first 3-5 days N. gonorrhoeae and/or HSV should be suspected If it occurs between 5-15 days Chlamydia trachomatis, *HV, H. influenzae, S. pneumoniae, S. aureus or Staphylococcus should be suspected. *Concomitant pneumonia may be present

Spontaneous hyphemas are associated with __________. Sickle cell disease Diabetes and neoplasms should also be considered

An acute cranial nerve III palsy with pupillary dilation is a ____ until proven otherwise. Posterior communicating artery aneurysm

You are examining a patient who seems to have a Bells palsy. When you check EOMs, he is unable to abduct the ipsilateral eye. What is the diagnosis? A CVA masquerading as a Bells palsy

Which diagnosis should be considered in a patient with an isolated cranial nerve palsy (III, IV or VI) associated with pupil sparing? Diabetic/hypertensive cranial nerve palsy

Name the condition in which the iris has an unusual curved shaped at the periphery, placing it closer to the cornea and creating a congenitally narrow angle. Plateau iris (predisposes the patient to the subsequent development of acute, narrow- angle glaucoma)

What medications have produced sudden attacks of narrow-angle glaucoma? Topical cycloplegics Anticholinergic agents Beta-agonists (including inhaled agents) Sulfa, MAO inhibitors, trycyclics

The most common acute optic neuropathy in patients > 50 years old is _____. Visual loss is often described as altitudinal (only the upper or lower half of the visual field is missing); inferior loss is more common. Nonarteritic anterior ischemic optic neuropathy

Which potentially life-threatening disease should be excluded in patients in their sixties who complain of dull, aching eye pain that extends to the temple? Ocular ischemic syndrome (Light-induced amaurosis should alert the clinician to possibility of significant carotid occlusion)

What is the most common cause of acute visual reduction due to optic nerve dysfunction in patients w20-40 years old? Optic neuritis

A patient with a corneal ulcer presents with an adherent mucopurulent exudate and a ground glass appearance of the cornea. What is the most likely infecting organism? Pseudomonas aeruginosa

Hematology/Oncology

In which area of the body is central cyanosis likely to be detected? The tongue and oral mucous membranes

In which clinical entity is there severe tissue hypoxia but no peripheral cyanosis? Carbon monoxide poisoning

What are the causes of central cyanosis? Methemoglobinemia V/Q mismatches High altitude NOTE: Cold exposure causes peripheral cyanosis.

With which blood disorder would one associate the common appearance of aseptic necrosis of the femoral head? Sickle cell disease

Why are O-negative packed cells preferable to O-negative whole blood prior to cross-match? O-negative packed cells are less concentrated with anti-A and anti-B antibodies.

What is the most common cause of a prolonged PTT with a normal PT? Hemophilia A

What are the potential complications of auto-transfusion? Air embolus Dilutional coagulopathy, if volume is > 4000 mL Sepsis, if contaminated blood is infused Hemolysis, if the blood has pooled within the pleural cavity for more than 6 hours

What is the best test for platelet function (aggregation and adhesion) onto injured vascular surfaces? Bleeding time

Clinical Presentation: A patient is seen with shortness of breath, swelling and plethora of the face and upper extremities, and headache. What is the diagnosis? Superior vena cava syndrome

Which drug should you avoid in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency? Sulfa Pyridium Nitrofurantoin Antimalarials Dapsone Methylene blue Aspirin NSAIDs

Can thrombocytopenia result from an exchange transfusion? Dilutional thrombocytopenia occurs in cases of massive transfusion, exchange transfusion or extracorporeal circulation.

You are seeing a child who took some of Grandpas coumadin. There is no evidence of bleeding and the PT is normal. Do you administer vitamin K or just observe him? Observe. Vitamin K is indicated for serious bleeding since the result of overdose is a functional deficiency of vitamin K.

What is the most severe from of congenital anemia? (clinical features include bronze skin discoloration and patients are transfusion-dependent). -Thalassemia (Thalassemia major, Cooleys anemia) This is often misdiagnosed as iron deficiency anemia on blood smear (hypochromic, microcytic red cells).

Clinical Presentation: A neutropenic patient develops sepsis associated with nonproductive cough and fever with rales at both bases. He also has an infected sacral decubitus ulcer. What is the likely offending organism? Pseudomonas aeruginosa

What is the most common organism causing life-threatening infection in patients undergoing bone marrow or solid organ transplants? Cytomegalovirus

Major Trauma

What is the most appropriate diagnostic study in trauma patients with blood at the urethral meatus? Retrograde urethrogram

In the setting of acute trauma, this test should be performed if renal artery injury is suspected or needs to be excluded. CT scanning with 3-D reconstruction and IV contrast

In a trauma patient with signs of intramural duodenal hematoma (gastric outlet obstruction), which is the most sensitive diagnostic study? Upper GI air-contrast study

What are the classic signs of compartment syndrome? The 6 Ps Pain out of proportion to what is expected Pallor Piokilothermia Pulselessness Parenthesia Paralysis

What is the role of hyperventilation in the management of elevated intracranial pressure secondary to trauma? The role is very limited (which is a change from previous practice). Hyperventilation should only be considered for herniation or clinical deterioration despite adequate resuscitation and mannitol; if used, the pCO 2 should be maintained between 25-30 Torr.

What is the immediate cause of death from an untreated tension pneumothorax? Relative hypovolemia The tension severely impedes venous return which results in a fatal reduction in cardiac output.

In a patient presenting with a periorbital hematoma or a hyphema, what diagnosis should be excluded? Orbital fracture

At what age can surgical cricothyroidotomy be performed on a child? When the cricothyroid membrane is palpable, around age 12.

When viewing cervical spine films in a child with possible injury, what are normal variants? Wedging of the anterior cervical bodies, (especially C 3 which is seen up to age 12) Anterior pseudosubluxation of C 2 over C 3 or C 3 on C 4

A patient with a head injury is unresponsive both to verbal and painful stimuli. There is no eye opening whatsoever. What is the Glasgow coma score? 3 The patient scores 1 point each for eye opening, speech and best motor responseeven when there is none.

What is the leading cause of death in patients sustaining pelvic fractures? Hemorrhagic shock

Where are the children (< 11 years old) with cervical spine injuries most commonly injured? The upper C-spine

What is the most common cause of sudden death following a MVC or fall from a great height? A traumatic aortic rupture

Clinical Presentation: A patient has a facial laceration that requires suturing. He claims an allergy to procaine. Which of the following is the safest choice for local anesthesia? (a) Benoxinate HCI (b) Benzocaine (c) Cocaine (d) Tetracaine (e) Mepivacaine (e) Mepivacaine Procaine is the prototype ester local anesthetic. All of the anesthetics listed are chemically related to procaine except mepivacaine is an amide. The amide anthesthetics are associated with far fewer allergic reactions. The other amides are lidocaine, bupivacaine, etidocaine and prilocaine.

Pelvic fractures are associated with bladder injury. What should you check for? Hematuria; do a urethrogram/cystogram if appropriate.

How does one differentiate pulmonary contusion from adult respiratory distress syndrome (ARDS) on chest x-ray? Pulmonary contusion occurs within minutes to hours of the injury and is seen on x-ray as an infiltrate or consolidation that is usually localized to a pulmonary segment or lobe. ARDS is associated with delayed onset (12-72 hours after injury) with diffuse patchy infiltrates seen on chest x-ray (24-72 hours after injury)

Death from drowning is due to _________. Hypoxia

What are the contraindications for the use of MAST/PASG? Pulmonary edema is an absolute contraindication to use of the MAST garment. Relative contraindications for MAST use are pregnancy, impaled objects, evisceration of the abdominal contents, and thoracic and diaphragmatic injuries.

What is the most common cause of fetal death following blunt trauma? Second only maternal death, abruptio placentae is the most common cause of fetal death.

What are the NEXUS criteria? No posterior midline cervical tenderness No evidence of intoxication Normal level of alertness No focal neurologic deficit No distracting painful injuries

What is the most common ureteral injury in the setting of blunt trauma? Ureteropelvic disruption Should be suspected with fractures of the lumbar spine: urinalysis may be normal)

What is the best radiographic modality for the evaluation of renal trauma? Contrast-enhanced CT has become the study of choice because it provides more information than the IVP. (Current literature recommends that adults with microscopic hematuria < 100 RBCs/HPF do not require emergent CT unless it is accompanied by hypotensionincluding in the field)

What are the most common sequela following blunt abdominal trauma during pregnancy? Preterm contractions

What is the most common site of penetrating trauma to the heart? The right ventricle

A multiple-injured patient without a head injury and multiple long-bone fractures undergoes a dramatic worsening of his neurological status? What diagnosis should be considered in this scenario? Fat Embolism syndrome (The classic triad of symptoms is: acute respiratory failure, global neurologic dysfunction and a petechial rash)

When assessing indications for thoracotomy in trauma arrest patients, signs of life in the field or on arrival in the ED include: Blood pressure or Pulse or Cardiac rhythm or Respiratory effect or Echo cardiac activity or tamponade

Sensory loss on the chest or abdomen is presumptive evidence of _________. Spinal cord injury/involvement

What percent of patients with a C-spine fractures have a second, noncontiguous vertebral fracture? 10% If one fracture is present, complete radiographic screening of the entire spine is needed.

In a woman with an orbital fracture, what is the incidence of sexual assault/domestic violence? Greater than 30%

Which reversible conditions can mimic the appearance of brain death? Hypothermia Barbiturate coma

What should you be looking for on AP and lateral films of the thoracic and lumbar spine in trauma patients? AP: vertical alignment of the pedicles as well as the distance between them (unstable fractures commonly cause widening of the interpedicular distance) Lateral: subluxations, compression fractures and Chance fractures.

Patients in hypovolemic shock are usually ______, while those in neurogenic shock are typically ________. Tachycardic Bradycardic

CT scanning of the thoracic and lumbar spine is particularly useful for detecting which injuries? Fractures of the posterior elements (pedicles, laminae + spinal processes) and the degree of canal compromise causes by burst fractures.

True or false: corticosteroids should not be used to treat head injury (whatever the severity)? Trueaccording to a 2006 LLSA article* *Lancet, 2004; 364: 1325

In mild traumatic brain injury and no loss of consciousness, a head CT is indicated for: Focal neurologic deficit Severe headache or vomiting Age > 65 years Physical signs of basilar skull fracture GCS less than 15 Coagulopathy Dangerous mechanism of injury *ACEP Clinical Policy

Important factors for identifying children at low risk for traumatic brain injury after blunt head trauma include the absence of: Abnormal mental status Clinical signs if skull fracture History of vomiting and/or headache Scalp hematoma in children < 2 years old *LLSA reading

Neurology

Clinical Presentation: An elderly woman arrives at the Emergency Department after an automobile accident. She has neck pain. You saw her walk in unassisted. Examination reveals a weak handshake but relatively good proximal arm strength. What is the diagnosis? Central cord syndrome

What is the most common spinal cord syndrome and what are its clinical features? Central cord syndrome usually occurs in patients with pre-existing cervical stenosis from degenerative arthritis or cervical canal narrowing from protrusion or tumor. Weakness is greater in arms than in legs and distal muscles are affected more tham proximal.

In addition to the central cord syndrome, there are two other incomplete spinal cord injury syndromes. What are these syndromes and what are their clinical features? BROWN-SQUARDS SYNDROME is a unilateral cord problem (usually from penetrating trauma) with ipsilateral paralysis and loss of position- vibratory sensation with contralateral pain and temperature loss. ANTERIOR CORD SYNDROME (from anterior spinal artery injury or from anterior cord compression usually from hyperflexion injury) is characterized by paralysis and pain-temperature loss distal to he lesion with sparing of the posterior columns (position-vibratory sensation).

What is the most common intracerebral bleed following head injury? Subarachnoid hemorrhage

20% of late post-traumatic seizures (those that occur one week to 10 years after head injury) are _________ seizures. Temporal lobe

What are the early signs of phenytoin toxicity? Somnolence Sedation Slurred speech Diplopia/blurred vision Coarse tremor Nystagmus

A post-viral acute inflammatory demyelinating polyneuropathy with ascending paralysis and decreased or absent DTRs is the ___- ____ ____. Guillain-Barr syndrome

Unilateral facial never paralysis that involves the muscles of the forehead and is differentiated from a stroke by the absence of focal neurologic deficits is know as _____ _____. Bells palsy. Bells palsy affects the forehead, while central CNVII deficits spare the forehead.

Clinical Presentation: A middle-aged male complains of muscle weakness after he climbed a flight of stairs. He also complains of double vision. On examination, there is ptosis. What is the diagnosis? Myasthenia gravis

What are the most frequent initial symptoms/signs in myasthenia gravis patients? Visual sign/symptoms (ptosis, diplopia, blurred vision)

If a regular alcoholic ED patient is confused (or more confused than usual) _____ _____ must be prominent in the differential diagnosis. Subdural hematoma

What is the most common cause of focal encephalitis and leading cause of intracranial mass lesions in AIDS patients? CNS toxoplasmosis The clinical picture: fever, headache, focal neurological deficits, altered mental status or seizures. CT scan with contrast shows ring enhancing lesions (the signet ring sign).

What early sign in a head injury patient indicates that delayed post- traumatic epilepsy is a likely sequela? Acute intracerebral hematoma or a depressed skull fracture

What must be considered if a patient presents with vertigo associated with neurologic complaints? Occlusion of posterior inferior cerebellar artery (Wallenbergs syndrome)

A patient with subtle meningeal sign has the following CSF findings: *Protein = elevated *Glucose = low *Cell count = lymphocytes (about 80%) Which type of meningitis is this? CSF findings of increased protein, decreased glucose and a lymphocytic predominance of WBCs suggest chronic or subacute meningitis either from tuberculosis or fungal infection. In addition to TB and fungal cultures, acid-fast smear, India ink preparation and cryptococcal antigen should also be ordered.

What is the most likely bacterial organism causing meningitis in an 8-year-old girl? Streptococcus pneumoniae predominates from the ages of 3 months up to 10-12 years of age. Neisseria meningitides is more common up to the age 19. Hemophilus influenzae meningitis has declined significantly since the advent of routine immunization.

What is the most common presenting neurologic manifestation of diphtheria? Paralysis of the palatal muscles

What is the primary consideration for the etiology of meningitis in an AIDS patient? Cryptococcus neoformans

Concerning patients suspected of cryptococcal meningitis, which studies should be ordered on the cerebrospinal fluid examination? Cryptococcal antigen and An India ink preparation

Where does the spinal cord originate and terminate? The spinal cord begins at the medulla oblongata (approximately at the atlanto-occipital junction) and ends between T 12 and L 3.

What is the main cause of radioculopathy in patients > 65 years old? Spinal stenosis is an unusual narrowing of the spinal canal that impinges on the cauda equina and nerve roots. This results in pain in one or both extremities brought on by walking, relieved by rest and exacerbated by back extension.

An elderly woman who was rear-ended in a motor vehicle collision sustains a cervical injury. She complains of neck pain. You find upper extremity weakness that does not localize to any particular spinal level. What is the diagnosis? Central cord syndrome

An absent deep tendon reflex at the ankle suggests a lesion of which nerve root? S1S1

What is suggested when there is: * Inability to flex the DIP joint of a finger and * There are signs of traumatic tenosynovitis, such as swelling and tenderness in the flexor tendon sheath and a mild flexion deformity? Rupture of the flexor digitorum profundus tendon

What are the physical findings of nerve root involvement in patients with lumbar disk compression? L 3 L 4 = decreased/absent knee jerk L 5 = decreased/absent dorsiflexion of great toe S 1 = decreased/absent Achilles reflex (decreased or absent plantar flexion) plus numbness of the lateral foot

What cervical spine injury occurs as the result of axial loading? Jefferson fracture or C 1 ring blowout fracture

What is the most common cause of focal intracranial mass lesions in patients with HIV? Toxoplasma gondii. Common signs and symptoms include headache, fever, altered mental status and seizures

What psychiatric disorder is most often confused with stroke? Conversion disorder

A young woman presents with papilledema and recurring headaches. CT reveals slit-like ventricles. Diagnosis? Idiopathic intracranial hypertension. This is seen primarily in young, obese women of childbearing age. Risk factors include oral contraceptive use, anabolic tetracyclines and Vitamin A use. CSF pressures are > 200 mm H 2 O if not obese and > 250 mm H 2 O if obese.

How does mannitol work in treatment if cerebral edema? Mannitol causes an osmotic diuresis, increasing GFR so that volume is rapidly excreted decreasing hydrostatic pressure.

What reflex should be checked in patients with a neurogenic bladder? The Bulbocavernosus Reflex This is a normal cord-mediated reflex elicited by placing a gloved finger in the rectum and squeezing the glans penis (or gently tugging the Foley catheter). Contraction of the anal sphincter is the normal response; absence indicates the presence of spinal shock: concussive injury to the spinal cord that results in total neurologic dysfunction distal to the site of injury.

Orthopedics

What is the mechanism whereby infectious tenosynovitis occurs in the flexor tendon of a finger? Penetrating trauma, particularly a puncture wound, along the volar aspect of the finger or in the palm of the hand.

Clinical Presentation: A young athlete complains of lower leg pain with no history of trauma. The lower leg is firm and tender lateral to the tibia, but it is of equal girth when measured against the opposite leg. What diagnosis must be excluded? Acute compartment syndrome Remember the 6 Ps Note that all need not be present. Pain out of proportion to what is expected Pallor Piokilothermia Pulselessness Paresthesia Paralysis If untreated, ischemia of the nerves + muscles lead to the end stage known as Volkmanns Ischemic Contracture.

Which nerve injury is most commonly associated with anterior glenohumeral dislocations? Axillary (C 5 C 6 ) 5-54% incidence of axillary nerve damage and is more frequent when age > 50. test lateral shoulder sensation.

Fractures of the clavicle are most likely to occur on which region of the bone? Middle third (80%)

A fracture at the base of the second metatarsal is pathognomonic for what type of injury? Lisfrancs fracture This is a fracture of the base of the second metatarsal with separation of the first and second metatarsals.

What is the most immediate concern in patients with fractures of the tibia and fibula? The development of a compartment syndrome

Calcaneus fractures may be associated with what other fracture or injury? Lumbar spine fracture (10%) Bilateral calcaneal fracture (10%) Calcaneus injuries are most commonly caused by axial load by a fall from a height.

Damage to which nerve is frequently associated with acetabular fractures? Sciatic

What is the most common dislocation of the patella? Lateral usually occurring from a twisting injury on an extended knee.

Answer the following concerning hip dislocation: 1. What is the most common type of hip dislocation? 2. What are the expected physical findings? 3. What is the most serious complication? Posterior dislocation occurs in 90% of cases The leg is shortened, adducted and internally rotated. The most serious complication is avascular necrosis of the femoral head. The chance of this problem occurring is in direct proportion to delays in reduction.

A patient with a history of knee injury states that he heard a popping sound at the time of injury. On examination, you find hemarthrosis of the joint. There is a positive anterior drawer test. What structure is most likely injured? Anterior cruciate ligament (70%)

Where are the tendinous insertions of the muscles comprising the rotator cuff The subscapularis inserts on the lesser tubercle of the humerus. The supraspinatus, infraspinatus and teres minor all insert on the greater tubercle. All four originate from the scapula.

Clinical Presentation: A patient complains of a painful shoulder after a fall. There is no fracture. On examination, there is weak and painful abduction with tenderness over the greater tuberosity. What is the diagnosis? The rotator cuff is injured. Partial tears are more common than complete and the supraspinatus is the most commonly involved muscle. The supraspinatus is essential for the first 30 degrees of abduction.

The posterior fat pad sign seen in the lateral radiographic view of the elbow of an adult is presumptive evidence of which injury? Fracture of the radial head

What are the signs of flexor tenosynovitis? The following are known as Kanavels four signs of flexor tenosynovitis: The finger is held in slight flexion Symmetric swelling of the finger Tenderness along the flexor tendon sheath Pain with passive extension of the finger

Fracture of the lateral tibial plateau may be associated with injury of the ________? Anterior cruciate and medical collateral ligament

In patients with calcaneus fractures, what other injuries are commonly used? Lumbar spine fracture (10%) Bilateral calcaneal fracture (10%) Calcaneus injuries are most commonly caused by axial load by a fall from a height.

Why is it important to obtain an early orthopedic referral for infants with congenital hip dislocation? Treatment should consist of splinting or casting in flexion/abduction to avoid later instability, chronic dislocations and need for surgery.

What is the most common midfoot fracture? The most common fracture is a navicular bone fracture.

What is a Toddlers fracture? Toddlers fractures are nondisplaced spiral fractures of the distal tibia, and are usually accidental. Note: mid-shaft fractures in children who are nonambulatory generally occur as a result of nonaccidental trauma.

When is angiography with embolization indicated in the treatment t of severe hemorrhage secondary to pelvic fracture? Angiography with embolization is used to manage hemorrhage when fluid resuscitation has failed and the patient is continuing to hemorrhage. Signs of ongoing bleeding from pelvic fractures include: (1) > 4 units of blood are required in 6 units were needed in < 48 hours (2) Persistent hemodynamic instability with a negative evaluation for other sources of hemorrhage or a pelvic hematoma on CT (3) Large (or expanding) retroperitoneal hemorrhage

Name the tests used to assess the stability of the anterior and posterior cruciate ligaments of the knee. ACLS Tests PCL Tests Anterior drawer sign Posterior drawer sign Lachman test Posterior sat test Pivot shift

Consider the following questions regarding amputations involving the hand: 1- Which amputations have the best prognosis for reimplantation? 2- How should the amputated part(s) be preserved? Amputations at the level of the middle phalanx, wrist and distal forearm have the best chance of a functionally successful reimplantation. The part(s) should be handled as aseptically as possible. Wrap the part(s) in a plastic bad and place in iced water in an insulated container. Never freeze the amputated part.

Fluid analysis of knee joint aspirate reveals the presence of positive birefringent crystals. What is the diagnosis? Pseudogout Uric acid crystals are negatively birefringent

Pediatrics

What is the best screening test for the diagnosis of Reyes syndrome? Serum ammonia level

Clinical Presentation : A young boy (3 to 9 years of age) presents with a limp. There is no history of trauma. There is no recent or current febrile illness. On examination, the hip is noted to be slightly flexed, externally rotated, and abducted. What is mot likely the diagnosis? What other diagnosis must be considered? Transient synovitis is the most common cause of a nontraumatic limp. If the condition is chronic, exclude Legg- Calv-Perthes disease (avascular necrosis of the femoral head)

What are the most common pathogens causing pneumonia in children after the newborn period? Viruses (age < 5 years) Mycoplasma pneumonias (ages 5-15 years)

What is the most common cause of bacterial pneumonia in children after the newborn period? Streptococcus pneumoniae

Slipped capital femoral epiphysis occurs most frequently in which group of children? Obese males, ages 10-16 or slender, rapidly-growing adolescents (usually male) Note: The slipped epiphysis is best seen on the frog lateral x-ray of the pelvis.

Which organism causes the majority of cases of occult bacteremia in children under 24 months of age? Group B streptococcus (0-2 months) Streptococcus pneumoniae (3-36 months)

What is the most primary dysrhythmia in children? Paroxysmal supraventricular tachycardia (PSVT)

What is the most common pre-arrest rhythm disturbance seen in the setting of pediatric arrest? Bradyarrhythmias, especially sinus bradycardia; asystole is the most common arrest rhythm. Note: Epinephrine is the drug of choice (after oxygenation and ventilation) for treating bradycardia in the pediatric population.

In which age group are radial head subluxations most commonly seen? Children less than 6 years of age; peaks between 2-3 years

Which fractures are most commonly seen in children who fall on an outstretched arm? Distal radial fracture (epiphyseal fractures and/or torus fractures)

Clinical Presentation: A 1-year-old presents with intermittent abdominal discomfort and a palpable sausage-shaped mass in the right mid- abdomen. What is the most appropriate therapeutic course of action? Air insufflation or barium enema (BE) These studies are useful both diagnostically and therapeutically since 90% of intussusception cases may be corrected if it is performed within the first 12-24 hours; air insufflation has some advantages over BE and is being used with greater frequency today.

What are the most common signs/symptoms of hypothermia in infants? Lethargy Decreased feeding

In addition to the rash, what are the characteristic physical findings if rubella (German measles)? Lymphadenopathy involving the postauricular, posterior cervical and suboccipital nodes. Early findings include a 1-5 day prodome of fever, malaise, headache and sore throat.

Clinical Presentation : A child known to have a ventricular septal defect develops sudden onset of agitation and cyanosis. What is the most likely explanation? Reversal of the shunt has occurred This is the Eisenmenger complex. Congenital heart lesions causing shunts are best corrected before this point, since pulmonary hypertension may not reverse after surgery.

Because of the unique nature of the blood supply to the skeletal system, ______ and _____ ______ frequently occur together in infants. Osteomyelitis Septic arthritis

What is the initial fluid therapy for children in shock? Rapid infusion of crystalloids, 20mL/kg

In the setting of an acute upper respiratory infection occurring in unimmunized children less than four years old, what is an important disease to include in the differential diagnosis? Pertussis (whopping cough)

What is the most common complication of pertussis (whooping cough)? Secondary bacterial pneumonia

Is the discovery of an inguinal hernia in an infant a surgical emergency? No, unless the child is symptomatic and/or the hernia is not reducible. Otherwise, these hernias should be repaired on an elective basis.

A child without a spleen is particularly susceptible to which illness? Bacteremia or sepsis from gram-positive encapsulated organisms Streptococcus pneumoniae (pneumococcus) heads the list.

Which respiratory tract infection is most commonly confused with asthma? Bronchiolitis This is a viral disease. 70% of cases are caused by the respiratory syncytial virus (RSV). Less commonly implicated viruses are parainfluenza, adenovirus and influenza.

Which infection generally occurs from seeding during sepsis or from spread of a contiguous infection, such as otitis media? Meningitis

What diagnosis should be considered in children between the ages of 5 and 12 months who present with abdominal pain? Intussusception

Why is the funduscopic examination important in the suspected child abuse victim? Retinal hemorrhages may be seen in the shaken baby syndrome

Prior to vaccinations, in the early stages if this illness, symptoms are indistinguishable form a nonspecific upper respiratory infection with rhinorrhea, low grade fever, cough, conjunctivitis and anorexia. As the disease progresses, the cough becomes the diagnostic and dominant clinical feature. What is the disease? Pertussis or whooping cough Two lessons are to be learned here. First, there are a lot of children less than 1 year old who are under immunized or not immunized. Be wary of those with respiratory illness and cough. Second, people immunized more than 12 years ago for pertussis can acquire the disease if exposed. Note that the current Dtap vaccine reduces the incidence of pertussis in the United States thereby preventing pertussis epidemics.

What are the Ottawa Knee Rules for ordering knee x-rays in children > 5 years old with an injury? A knee x-ray is only required for children > 5 years old if any of these findings are present on physical exam: Isolated patellar tenderness Tenderness at the head of the fibula Inability to flex knee 90 Inability to bear weight and walk up 4 steps (immediately and in the ED)

What is the current drug of choice for the treatment of GABHS tonsillopharyngitis in children? Penicillin remains the drug of choice for GABHS infection. If treatment failure or penicillin allergy, consider a cephalosporin.

Do children with pos-traumatic seizures following blunt head trauma require admission? In otherwise healthy children with a single post-traumatic seizure, normal neurologic exam and head CT, discharge to home with the usual head injury instructions is appropriate.

What type of fracture occurs because the bone at the metaphyseal- diaphyseal junction fails to compress? Torres fracture is a fracture without cortical disruption

Pulmonary

You are viewing the chest x-ray of a patient who is a traveler from overseas that reveals a diffuse pneumonia associated with a moderate pleural effusion and lymphadenopathy. What is your diagnosis? Tuberculosis

What diagnosis is suggested by rust-colored sputum associated with an infiltrate in the right middle or right lower lobe on chest x-ray? S. pneumoniae (pneumococcal) pneumonia This is the most common cause of community-acquired bacterial pneumonia in normal hosts, which peak incidence in winter and early spring.

A pulse oximetry reading would not be helpful in a patient with __________. carbon monoxide poisoning or methemoglobinemia

Clinical Presentation: An ill-looking child is brought in because if earache. Examination reveals bullous myringitis, as well as rales and rhonchi on the chest exam. What is the causative organism? Mycoplasma pneumoniae

The triad of fever, nonproductive cough, pleuritic chest pain and exertional dyspnea in a patient who is HIV-positive should suggest what diagnosis? Pneumocystis jirovecii pneumonia It is the most common etiology, but bacterial pathogens and tuberculosis must be considered. Although patients with PCP may present with typical features of subacute onset of nonproductive cough, fever, shortness of breath, diffuse interstitial infiltrates on chest radiography and arterial hypoxemias, 10-20% of patients subsequently proven to have PCP lack these findings. PCP usually has a subacute presentation characterized by nonproductive cough, exertional dyspnea and weight loss. Tachypnea and tachycardia are usually present.

What is the initial drug of choice for patients with Pneumocystis jirovecii pneumonia? TMP-SMX is treatment of choice; the usual regiment is 20mg/kg of TMP and 100mg/kg of SMX daily in four divided doses, to be continued for 21 days. For most adult patients, a regimen of three ampoules (80mg of TMP and 400mg of SMX per ampule) every 6 hours is appropriate. For patients allergic to sulfa, pentamidine can be given, 4mg/kg over 1 hour.

An elderly, debilitated patient with a history of diabetes, alcoholism and COPD presents in early spring with a cough and sputum production that has been getting worse. He complains of fever, shortness of breath and pleuritic-type chest pain. There are rules but no signs of consolidation with breath sounds. What is the most likely etiology? H. influenzae pneumonia

Which diagnosis should be considered in a patient with who presents with a cough productive of fetid and bloody sputum? Lung abscess

You have just intubated a 70kg asthmatic. The pH is 7.0, pO 2 5o and pCO 2 100. What are your initial ventilator settings? The vent setting should allow for permissive hypercapnia. A ventilator strategy providing adequate oxygenation and ventilation while minimizing high airway pressure, barotrauma and systemic

critical q’s & as sixth edition. behavioral what are the factors associated with an increased...

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