quiz&short review for emergency medicine residents

7/29/2019 Quiz&short review for Emergency medicine residents

1/21

QuizMarch 2013


2/21

29 yo male

Fever

Dyspnea

1. positivefinding

2.Proper

management

A


3/21

KEYTEACHING POINTS

1. Acute epiglottitis is a potentially life-threatening condition

resulting from inflammation of the supraglottic structures,

with a current incidence of 1 to 2 cases per 100,000 adults

in the United States.

2. Sore throat is the chief complaint in 7594% of cases ofadult epiglottitis, whereas odynophagia may be present in

as many as 94% of cases.

3. Soft-tissue lateral neck radiography, which may show an

enlarged, misshapen epiglottis (thumbprint sign), has a

sensitivity of 88% in establishing the diagnosis.

4. The definitive diagnosis is made through direct laryngo-

scopic visualization of an enlarged, inflamed epiglottis.

5. Treatment of epiglottitis includes intravenous antibiotics

and close airway monitoring in an ICU setting. Most clini-

cians treat acute cases with intravenous steroids.

Cefotaxime , Ceftriaxone , Ampi-Sulbactam


4/21

89 yo femaleGlaucoma

S/p trabeculectomy

progressive worsenVA drop , eye

pain , photophobia

No contact lens ,denied trauma

VA fingercount

1. positive

finding

2.Proper

management

B


5/21

Findings : Endophthalmitis- red eye with cicumlimbal flush-hypopyonpurulent discharge from lid margin and lashes

Mx : gatifloxacin 0.3% eye dropconsult ophthalmologist for vitrectomy / intravitreal injection of ATB

KEY TEACHING POINTS

1.Endophthalmitis is an ophthalmologic emergency requir-ing a high index of suspicion and prompt consultation with

an ophthalmologist.

2. Initial symptoms of endophthalmitis include pain, redness,

ocular discharge and blurring of vision.

3. Common signs include decreased visual acuity, lid swelling,

conjunctival and corneal edema, anterior chamber cells

and fibrin, hypopyon, vitreous inflammation, retinitis, and

blunting of the red reflex.4. Intravitreal antimicrobial therapy remains the mainstay of

treatment for infectious endophthalmitis; the majority of

patients require intravitreal injections, vitreous tap, sub-

conjunctival steroids or vitrectomy to prevent loss of the

eye.


6/21

13 yo malebicycle collisiontender at Lt side

abdomen

1. positive

finding 2.Grade/Classification by CT?

C


7/21

The American Association for the Surgery of Trauma (AAST)

splenic injury grading system is as follows

grade I

subcapsular haematoma < 10% of surface area

capsular laceration < 1 cm depth

grade II

subcapsular haematoma 10 - 50% of surface area intraparenchymal haematoma < 5 cm in diameter

laceration 1 - 3 cm depth not involving trabecular vessels

grade III

subcapsular haematoma > 50% of surface area or

expanding

intraparenchymal haematoma > 5 cm or expanding

laceration > 3 cm depth or involving trabecular vessels

ruptured subcapsular or parenchymal haematoma

grade IV laceration involving segmental or hilar vessels with major

devascularization (> 25% of spleen) grade V

shattered spleen

hilar vascular injury with devascularised spleen

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Findings : Grade IV splenic laceration.Extensive splenic laceration to hilum

Management : conservative / or Sx


8/21

26 yo malefelt pop in lower neck

while practicing golf.

no weakness

1. positive

finding

2.Proper

management

D


9/21

Findings : Clay-Shovelers Fx of C7spinous process (Oblique fx of base ofspinous process)

Management : conservative / or

KEYTEACHING POINTS

1. A clay-shovelers fracture refers to an oblique fracture of

the base of the spinous process, most commonly occurring

at one of the lower cervical segments.

2. The fracture is believed to occur as a result of forceful

flexion of the cervical spine, or forceful contraction of the

trapezius and rhomboid muscles.3. The injury is most commonly visualized on the lateral

cervical spine radiograph, which should include the entire

cervical spine and the C7-T1 junction.

4. Because the injury involves only the spinous process, this

fracture is considered stable and is not associated with

neurologic impairment.

5. Management involves neurosurgical or orthopedic consul-

tation, pain control and cervical immobilization.


10/21

12 yo boy

1. positive

finding

2.Proper

management

B

E


11/21

B

Findings :fx displace base 1st MTBfx MTB 2-4th

Management :- compartment syndrome

KEYTEACHING POINTS

1. Lisfranc fracture-dislocations of the foot generally result

from high-energy forces, such as crushing trauma to the

foot (often in flexion or rotation).

2. Patients with Lisfranc fracture-dislocations commonly

present with midfoot pain, swelling and decreased ability

to bear weight.

3. The most consistent radiographic finding in Lisfranc joint

dislocations is loss of the usual alignment between the me-

dial borders of the second metatarsal and second cunei-

form.

4. Patients with Lisfranc injuries require urgent consultation

with an orthopedic or podiatric specialist.5. In compartment syndrome of the foot, findings on exami-

nation include increased pain on passive dorsiflexion of the

metatarsophalangeal joints, poor capillary refill and absent

pulses (late findings).

6. Appropriate treatment for suspected compartment syn-

drome of the foot is urgent and complete fasciotomy.


12/21

A B

22 yo m. foot pain during soccer

1. positive

finding

2.Propermanagement

please specify

F


13/21

Findings :fx base of the 5th MTB =Jones fractrure

Management :- compartment syndrome

A B

KEYTEACHINGPOINTS

1. A Jones fracture is a transverse fracture of the proximal

fifth metatarsal at the junction of the diaphysis and meta-physis without extension distal to the intermetatarsal arti-

culation of the fourth and fifth metatarsals.

2. The mechanism of injury in a Jones fracture involves a

large adduction force applied to the forefoot with the ankle

plantar flexed, causing the fifth metatarsal to fracture.

3. Emergent treatment of Jones fractures involves ice, eleva-

tion, splinting of the injured foot and pain control.

4. The definitive treatment of Jones fractures may be non-

operative (bracing or casting and non-weight-bearing forsix weeks) or operative (intramedullary screw fixation or

bone grafting).


14/21

21 yomale. headache / facial flushing / palpitationnot itching

just got back from dinner party at restaurant.T 36.1 P121 BP112/66

1. positive

finding2.Proper

management

3. cause by?

G


15/21

Findings : Scombroid fish poisoningErythematous macular rash on the extremities andtrunk/ Warm.

Management : Anti histamine

KEY TEACHING POINTS

1. Symptoms of scombroid fish poisoning are related to the

ingestion of biogenic amines, especially histamine. The

onset of symptoms of scombroid fish poisoning usually oc-

curs 1030 minutes after ingestion of the implicated fish,

which sometimes has a characteristic peppery and bitter

taste.2. The symptoms of scombroid fish poisoning are nonspe-

cific, and may include flushing, palpitations, headache, nau-

sea, diarrhea, sense of anxiety, prostration or loss of vision

(rare).

3. Findings on physical examination can include a diffuse, mac-

ular, blanching erythematous rash (most common), tachy-

cardia, wheezing (generally only in histamine-sensitive

asthmatics), hypotension or hypertension, and conjuncti-

vitis.4. Treat acute illness with antihistamines as needed; H1-

blockers (e.g., diphenhydramine 2550 mg PO/IV/IM q4

6h) and H2-blockers (e.g., ranitidine 150 mg PO q12h or

50 mg IV q812h, or cimetidine 300 mg PO/IV q68h).

5. Scombroid fish poisoning must be immediately reported to

the local public health department.


16/21

mahimahiamberjack

mackerel-tuna

ScombrotoxismScombroid ichthyotoxicosis

Heat tolerance


17/21

22 yo m. HIVmalaise,fever, dysphagia, generalized mouth pain

cervical lymphadenopathy

1. positive

finding

2.Propermanagement

H


18/21

Acute Necrotizing Ulcerative Gingivostomatitis- HIV-LN positive with generalized mouth pain- hyperemic painful gingiva with erosion of interdental papilla and have light greypseudomembrane over gingival ulceration.

Table 3.5 Clinical Features: Acute Necrotizing Ulcerative Gingivostomatitis

Organisms G Streptococcus mutansG ActinomycesspeciesG Bacteroides fragilisG FusobacteriumG Spirochetes (Treponema vincentiand

Borreliaspecies)

Signs and Symptoms G Fever and cervical lymphadenopathyG Fetid breathG Diffusely erythematous and

edematous gingivaG Necrosis and ulceration of the

interdental gingival papillaG Gray pseudomembrane may overlie

the interdental papilla

Laboratory andRadiographic Tests

G May have an elevated WBC and ESRG Bite-wing radiographs or facial CT

may help delineate the degree ofalveolar bone destruction

CT, computed tomography; ESR, erythrocyte sedimentation rate; WBC, whiteblood (cell) count.

Treatment- Penicillin VK or Erythromycin-mouthwash


19/21

name it .

A

CB

I

li . i li i i lli.


20/21

l i i . l l l li .

A

Blebphitis

Organisms Blepharitis:G Staphylococcus epidermidisG PropionibacteriumacnesG CorynebacteriumspeciesHordeolum:G Most often Staphylococcus aureus, but can be

infected with organisms similar to thosecausing blepharitis

Incubation Period 17 days (up to 12 days)

Signs andSymptoms

Blepharitis:G Usually bilateral and intermittent symptomsG Inflamed eyelid marginsG Eyelid itching, burning, or sorenessG Mild foreign-body sensationG Crusting and debris of eyelid margins,

especially on awakeningG With or without misdirection or loss of

eyelashesG With or without conjunctival injectionG With or without swollen eyelidsG With or without light sensitivityHordeolum:G Usually unilateralG Pointing eruption or pimple-like lesion on

either internal or external side of eyelidG Inflamed eyelid marginG Eyelid itching, burning, or sorenessG Crusting and debris of eyelid margins,

especially on awakeningG With or without conjunctival injection

Laboratory andRadiographicFindings

There are no specific laboratory tests orradiographic findings for these diagnoses. It ispossible to do a microbial culture of the eyelid byswabbing the eyelashes but usually notnecessary in these diagnoses.

Hordeolum


21/21

DacryocystitisTable 29.2 Treatment of Blepharitis and Hordeolum

Patient Category Therapy Recommendations

Adults:PreferredChoices

G Eyelid hygieneG Cleanse eyelids bid with cloth soaked in warm

water for 510 minutesG Wash eyelid margins with diluted baby shampoo,

eyelid cleanser, or a teaspoon of sodiumbicarbonate in cup of boiled water

G Artificial tears (e.g., Hypromellose 0.3%) for thosewith dry eyes

G Topical antibiotics for mild cases of blepharitis andhordeola (e.g., erythromycin ointment1.25 cm to lid margin qid or eye drops such aschloramphenicol (AK-Clor, Chloroptic, 5 mg/mL)q4h)

G Systemic antibiotics (e.g., erythromycin 250 mgPO qid 7 days, azithromycin 500 mg PO day 1,then 250 mg PO daily on days 25) for hordeolum,recurrent staphylococcal blepharitis, severesecondary infection of the meibomian glands, orlocal cellulitis

G External hordeola are often self-limited but can bedrained by lancing the lesion if necessary

Table 29.4 Treatment of Dacryocystitis

Patient Category Therapy Recommendations

Adults:Preferred Choices

Irrigation of the lacrimal sacWarm compressesTopical antibiotics:G Erythromycin ointment 1.25 cm to lid margin qidG Eye drops such as trimethoprim sulfate and

Polymyxin B sulfate ophthalmic solution 1 drop

q3hOral antibiotics:G Pediatric: oral antibiotics: amoxicillin-clavulanate

2040 mg/kg/day divided tid; cefaclor 2040mg/kg/day divided tid

G Adult: cephalexin 500 mg qid or amoxicillin/clavulanate 500 mg bid

G Surgical treatment for dacryoliths, obstruction,or congenital causes

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