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2019 In-service Review:Visual Stimuli

Brett R. Todd, MD, FACEP

Assistant Professor of Emergency Medicine

Oakland University William Beaumont School of Medicine

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1. A CDC laboratory worker presents with malaise, fever, and a painless arm lesion. What is the most appropriate treatment?

A. Doxycycline

B. Cephalexin

C. Penicillin

D. Surgical debridement

E. Dapsone

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A. Doxycycline

Anthrax

• Bacillus anthracis

• Inhalational – initial flu-like, later severe distress, mediastinitis, wide mediastinum on CXR

• Cutaneous – painless vesicle then ulcer with black eschar

• GI

• Bioterrorism agent

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2. A 26 y.o. homeless man presents to the ED complaining of fever, foul breath, and oral pain. What is the diagnosis?

A. Dental caries

B. Acute necrotizing ulcerative gingivitis

C. Ludwig’s angina

D. Periapical abscess

E. Malingering

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• Trench mouth

• Immunosuppressed, HIV, Etoh, Stress

• Fever, pain, bleeding, halitosis

• Grayish pseudomembrane

• Polymicrobial, Fusobacterium, Treponema

• PCN + Flagyl, or Clinda, or Augmentin

• Chlorhexidine rinses

B. Acute Necrotizing Ulcerative Gingivitis

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3. A 24 y.o. man is thrown from his motorcycle at high speed. He is hypertensive on arrival. What is the most appropriate treatment based on the portable chest x-ray shown?

A. Needle thoracostomy

B. Pericardiocentesis

C. ED Thoracotomy

D. Esmolol

E. Tube thoracostomy

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Traumatic rupture of aorta

• Wide mediastinum, enlarged aortic knob, tracheal deviation, apical cap

• Treat like aortic dissection –Beta-blocker, vasodialators

• Goal: HR < 60 - 80, SBP < 120

• Medical management for intimal tear

• Surgery for intramural hematoma, pseudoaneurysm, or free rupture

D. Esmolol

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4. A welder presents with bilateral eye pain after leaving work. His slit lamp exam is shown. Which of the following is true of his condition?

A. Typically resolves spontaneously within 72 hours

B. Symptoms begin within 1 hour of exposure

C. Topical tetracaine should be prescribed for analgesia

D. Opiates should not be prescribed

E. Require topical antibiotics

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Superficial Punctate Keratitis

• Prolonged UV exposure

• Latent period of 6 – 12 hours

• Welders, snow blindness

• Painful – use narcotics, NSAIDs, Cyclopegics

• Spontaneous resolution with corneal healing

A. Typically resolves spontaneously within 72 hours

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5. A 33 y.o. woman has grossly bloody urine after being hit by a car. A retrograde cystogram is shown. All of the following are true about the injury shown except:

A. Usually caused by a pelvic fracture

B. High incidence of injury to other organs

C. Suspect if blood at meatus

D. Gross hematuria usually seen

E. Resolution at 2 weeks with Foley catheter drainage

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Intraperitoneal Bladder Rupture

• Suprapubic pain, blood at meatus, urinary retention

• Most associated with pelvic fracture

• Extraperitoneal –nonoperative with bladder catheter drainage

• Intraperitoneal – operative management

E. Resolution at 2 weeks with Foley catheter drainage

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6. A 13 y.o. boy presents with a limp and 2 weeks of knee pain. What is the diagnosis?

A. Osgood-Schlatter disease

B. Slipped capital femoral epiphysis

C. Patellar dislocation

D. Tibial plateau fracture

E. Legg-Calve-Perthes disease

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• Apophysitis of tibial tubercle

• 10 – 15 yr old males

• Overuse injury, often bilateral

• Pain worse with activity, improves with rest

• Tx: rest, NSAIDs, ice

A. Osgood-Schlatter disease

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7. A 19 y.o. man complains of neck pain and hand paresthesias after diving into a shallow pond. What type of injury is this?

A. Odontoid fracture

B. Jefferson burst fracture

C. Hangman’s fracture

D. Clay shoveler’s fracture

E. SCIWORA

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• C1 burst fracture

• Unstable

• Axial loading force

• C-collar, ortho-spine consult

B. Jefferson burst fracture

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8. A 1 week old boy, born at 30 weeks gestation, is brought in to the ED for emesis. What is the correct diagnosis?

A. Midgut malrotation with volvulus

B. Pyloric stenosis

C. Necrotizing enterocolitis

D. Intussusception

E. Gastroesophageal reflux

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• Usually 1st week of life, usually premies

• Bacterial overgrowth in bowel, invade bowel wall

• Pneumatosis on KUB

• IV Hydration, broad spectrum abtx, surgery consult

C. Necrotizing enterocolitis

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9. A 2 y.o. girl presents to the ED with a fever and rash. What is the diagnosis?

A. Measles

B. Scarlet fever

C. Henoch-Schonlein Purpura

D. Rubella

E. Erythema infectiosum

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• Slapped cheek rash first

• Macular erythema on trunk/limbs

• Fever, headache, sore throat

• Parvovirus B19

• Pregnancy – Hydrops fetalis

• Sickle cell – aplastic crisis

E. Fifth disease/erythema infectiosum/slapped cheek

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10. A 28 y.o. woman presents with 2 days of loss of vision in the right eye. Which of the following is true of the condition shown?

A. Usually painless

B. Pupillary response is normal

C. Visual loss is usually peripheral

D. Affects men more than women

E. Caused by optic nerve demyelination

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Optic neuritis

• Demyelination of optic nv

• 50% develop MS

• Pain with eye movement

• Loss of color worse than visual acuity loss

• Afferent pupillary defect

• Papilledema

• US – elevated disk, ON sheath >5mm

• Tx: IV methyprednisolone

E. Caused by optic nerve demyelination

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11. A 42 y.o. man presents with fever, confusion, and skin lesions after being started on phenytoin. What is the diagnosis?

A. Toxic epidermal necrolysis

B. Erythema multiforme

C. Staphylococcal scalded skin syndrome

D. Toxic shock syndrome

E. Urticaria

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• On spectrum with Stevens-Johnson

• Drugs most common cause• Sulfa, quinolones,

phenytoin,carbamazepine, steroids, immunizations, PCN, ASA, NSAIDs

• Also: malignancy, immunosuppression, infectious, autoimmune, idiopathic

• Macular rash, target, Nikolsysign, mucous membranes

• Tx: IVF, infection control

A. Toxic epidermal necrolysis

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12. A 5 y.o. unvaccinated girl presents to the ED with fever, drooling, and stridor. What is the most common organism based on the film shown?

A. Haemophilus influenza type B

B. Group A streptococcus

C. Staph aureaus

D. Parainfluenza

E. Mixed anaerobes

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• Adults most commonly

• Strep, staph, H. flu

• Thumbprint sign

• Bedside nasopharyngoscopy

• Tx: Emergent ENT consult, IVF, nebulized epi, IV abtx, awake fiberoptic intubation sitting up, cricothyrotomy

A. Haemophilus influenza type B

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13. A 7 month old healthy boy is brought in by his mother who states he is “having trouble breathing after falling off the couch.” What is the next step in management based on the x-ray shown?

A. IV antibiotics

B. Contact child protective services

C. Tube thoracostomy

D. Albuterol

E. Racemic epinephrine

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Child abuse

• Usually parent or guardian

• Mandatory reporting of suspicion

• Concerning fractures:• Rib – esp. posterior

• Corner fracture, bucket handle

• Bruising, oral injuries (frenulum), patterns, stages of healing, burns/scalds, inconsolable

• Skeletal survey, head CT, admit

B. Contact child protective services

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Corner Fracture

Bucket Handle Fracture

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14. A 36 y.o. woman complains of wrist pain after a fall on an outstretched hand. What is the correct diagnosis based on the image shown?

A. Lunate dislocation

B. Scaphoid fracture

C. Perilunate dislocation

D. Scapholunate dislocation

E. Hutchinson fracture

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• Usually result of FOOSH

• Median nerve injury

• Capitate displaced dorsally

• Lunate situated normally on radius

• Ortho consult for reduction

D. Perilunate dislocation

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Perilunate Lunate dislocation

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15. A 20 y.o. man presents with a shoulder dislocation. Which of the following is true regarding the condition shown on his post-reduction film?

A. Results from a posterior shoulder dislocation

B. Requires operative management

C. It is a fracture of the glenoid rim

D. Associated with an increased risk of recurrent shoulder dislocation

E. It is a complication of shoulder reduction

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Complications of anterior shoulder dislocations

• Hill-Sachs deformity• Compression fracture of humeral

head

• Bankart lesion• Fx of inferior glenoid rim

• May need surgery if significant displacement

• Axillary nerve injury

• Axillary artery injury

• Rotator cuff tear

D. Associated with an increased risk of recurrent shoulder dislocation

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16. A 18 y.o. man brings in his pet snake 15 minutes after it bit him on the arm. Each of the following complications may develop if left untreated except:

A. Disseminated intravascular coagulation

B. Immediate pain at bite site

C. Proximal muscle weakness

D. Arm edema

E. Pulmonary edema

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Crotalid/pit viper bite

• Pit = heat sensing organ

• Rattlesnakes and copperheads

• Local tissue injury, compartment syndrome, coagulopathy, thrombocytopenia

• Do not: suck wound, tourniquet

• Tx: antivenom, fasciotomy

C. Proximal muscle weakness

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17. A 21 y.o. woman complains of vaginal itching and a foul-smelling discharge. Which of the following treatments is most appropriate based on the wet mount shown?

A. Ceftriaxone and doxycycline

B. Acyclovir

C. Penicillin G

D. Metronidazole

E. Fluconazole

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Bacterial vaginosis

• Gardnerella vaginalis

• Whitish-gray discharge with odor

• Clue cells – vaginal epithelial cells appear stippled

• Vaginal pH > 4.5

• + whiff test

• Metronidazole

• Do not need to treat partner

D. Metronidazole

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18. A 19 y.o. man presents with a rash. All of the following statements are true about this condition except:

A. Preceded by a herald patch

B. Presumed to be of viral origin

C. Usually asymptomatic

D. Mostly seen in children and young adults

E. Treatment includes oral steroids

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Pityriasis rosea

• Mild exanthem

• 10 - 35 year olds

• Viral, not contagious

• Resolution in 4 – 12 weeks

• Herald patch

• Christmas tree pattern

• Pruritis

• Tx: antihistamine, topical steroids, Calamine for itching

E. Treatment includes oral steroids

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19. A 18 year old male presents after consuming the mushroom shown. What symptoms are likely to develop in the first 24 hours after ingestion?

A. Hallucinations and euphoria

B. Vomiting and diarrhea within 2 hours of ingestion

C. Fulminant liver failure

D. Resolution of symptoms

E. Vomiting and diarrhea 6 hours after ingestion

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Mushroom poisoning

• Early onset poisoning• GI Sx resolve

• Late onset poisoning• After 6 hours

• Amanita Philloides/Death cap

• GI sx after 6 – 24 hours

• Convalescent phase

• Fulmanant hepatotoxicity day 2 – 4

• Tx: NAC

E. Vomiting and diarrhea 6 hours after ingestion

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20. A 43 y.o. man presents with altered mentation 3 hours after an assault with a baseball bat. His head CT is shown. Which of the following statements is true regarding his condition?

A. May present after a lucid interval

B. Caused by tears in the dural bridging veins

C. Common in patients with brain atrophy

D. Most common form of traumatic intracranial hemorrhage

E. Has high mortality even with treatment

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Epidural hematoma

• Tear of middle meningeal artery

• Classically has lucid interval

• Lens shaped hyperdense lesion

• Tx:• Burr hole/neurosurgery

• Elevate head of bed

• Maintain CPP

• Mannitol/hypertonic saline

A. May present after a lucid interval

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21. A 34 y.o. woman complains of cough, fever, and fatigue for 2 weeks. A sputum study is shown. What is the most appropriate treatment?

A. Levofloxacin

B. Isoniazid, rifampin, pyrazinamide, and ethambutol

C. Ceftriaxone and azithromycin

D. Trimethoprim/sulfamethoxazole

E. Isoniazid

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Tuberculosis

• AFB in sputum = “Red Snappers”

• Active TB Treatment:• 4 drug treatment for 8 wks

• Isoniazid, rifampin, pyrazinamide, ethambutol

• 2 drug treatment for 18 wks

• Isoniazid, rifampin

• Latent TB treatment:• Isoniazid for 9 months

B. Isoniazid, rifampin, pyrazinamide, and ethambutol

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22. A 27 y.o. homeless man with HIV presents with fever, headache, and confusion. His brain CT is shown. What is the most likely diagnosis?

A. HIV encephalopathy

B. Neurocysticercosis

C. Toxoplasmosis

D. Cryptococcus neoformans

E. CNS lymphoma

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Ring-enhancing lesions

• HIV: lymphoma or toxoplasmosis

• Migrant worker with seizure: neurocysticercosis

• Others: abscess, syphilis, aspergillosis, MS

C. Toxoplasmosis

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23. A 2 y.o. boy is brought in for a itchy rash on his hands and arms. Which of the following is the most appropriate treatment based on the image shown?

A. Ivermectin

B. Prednisone

C. Mupirocin

D. Permethrin

E. Lindane

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Scabies

• Mite infestation

• Vesiculopustules, papules with linear burrows

• Web spaces, wrists, axillae, groin, periumbilical

• Pruitus, worse at night

• Permethrin for all ages

• Lindane and ivermectin for refractory cases

D. Permethrin

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24. An 18 month old boy is brought in for inconsolable crying episodes and strange appearing stool as shown. What is the most appropriate next step in management?

A. Surgical consultation for laparotomy

B. Technetium scan

C. Abdominal plain film

D. IV hydration and stool culture

E. Air contrast enema

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Intussusception

• 6 – 36 months

• Usually no pathologic lesions

• Possible lesions: Peyer patch, Meckel, tumor, HSP, parasites

• Episodic pain and vomiting

• Lethargy

• Current jelly stool in 50%

• Sausage shaped mass right abd

• Air contrast enema successful in 80%

• Surgical backup

E. Air contrast enema

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25. A 66 y.o. woman presents with right flank pain and vomiting. An abdominal ultrasound is shown. What is the most likely diagnosis?

A. Acute cholecystitis

B. Ureteral stone with hydronephrosis

C. Abdominal aortic aneurysm rupture

D. Liver abscess

E. Acute pancreatitis with pseudocyst

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US findings

• Wall thickening > 3mm

• Pericholecystic fluid

• Sonographic Murphy’s

A. Acute cholecystitis

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26. A 38 y.o. woman presents with right facial paralysis and a painful ear rash as shown. What is the most appropriate next step in management?

A. Ear wick and topical antibiotics

B. Acyclovir + prednisone

C. CT brain

D. Cephalexin + trimethoprim/sulfamethoxazole

E. Ceftriaxone

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Herpes Zoster Oticus

• AKA Ramsey-Hunt Syndrome

• Zoster involving geniculate ganglion – CN VII and VIII

• Tinnitus, hearing loss, facial palsy

• Vesicular rash of canal, auricle, oropharynx

B. Acyclovir + prednisone

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27. A 5 y.o. child presents with confusion and a heart rate of 32 after ingestion of the plant shown. What is the most appropriate treatment?

A. Calcium gluconate

B. Digitalis immune FAB

C. Sodium bicarbonate

D. Activated charcoal

E. Physostigmine

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Digitalis toxicity

• Oleander, foxglove, lily of the valley, milkweed

• Bradycardia, Hyperkalemia, N/V, confusion, visual disturbance, CV collapse

• ECG: dig effect, bidirectional VT

• Dig Immune FAB for dysrhythmias, K > 5.5, Level > 10 acute, Level > 4 chronic or child

• 10 vials in adults

• 20 vials in cardiac arrest

B. Digitalis immune FAB

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Bidirectional Ventricular Tachycardia

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A. Infiltrates are always seen within 6 hours of injury

B. Rarely seen in children

C. CT scan is poorly sensitive

D. Hypoxemia is rare

E. Always occur in the setting of rib fractures

28. A 19 year old man presents with right chest pain and hypoxia after a motorcycle accident. He requires intubation shortly after arrival Which of the following is true regarding the condition shown?

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Pulmonary contusion

• Usually seen immediately on CXR, if after 6 hours – consider ARDS

• Common in pediatrics due to compliant chest wall

• CT most sensitive

• Dyspnea, tachypnea, hypoxia

• +/- Rib fx, flail chest

• Tx – NIV, intubation

A. Infiltrates always seen within 6 hours of injury

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29. A 45 year old man complains of a itchy rash to his arm after a camping trip. Which of the following is true regarding the condition shown?

A. Results from a tick bite

B. 90% of US population is susceptible

C. Treat with cephazolin

D. Topical steroids are the mainstay of treatment

E. Rash appears immediately after exposure

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Poison Ivy, Oak, Sumac dermatitis

• 3 leaf structure

• Vesiculobullous rash

• 10 – 14 days after first exposure

• 1 -2 days later exposures

• 50% non-reactive

• Treat with antihistamines and topical steroids

• Oral steroids for severe cases

D. Topical steroids are the mainstay of treatment

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30. A 55 y.o. man presents with sudden onset of sharp chest pain and dyspnea. What is the most appropriate next step in management based on the chest CT shown?

A. Pericardiocentesis

B. Nitroprusside

C. Heparin

D. tPA

E. Labetalol

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Aortic dissection

• Type A – ascending aorta, surgical management

• Type B – limited to descending aorta, medical management

• Tx:

• Heart rate control with B-Blocker

• Esmolol, Labetalol, Metoprolol

• Diltiazem if B-Blocker contraindication

• Hypertension control

• Nicardipine, nitroprusside, fenoldopam

E. Labetolol

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31. An 18 y.o. college student complains of foul smelling vaginal discharge and dyspareunia. What is the most likely diagnosis based on her speculum exam?

A. Bacterial vaginosis

B. Vaginal candidiasis

C. Trichomonas

D. Genital herpes

E. Gonorrhea

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• Yellow, grey, frothy, foul smelling discharge

• Strawberry cervix

• Wet mount with trichomonads

• Tx: metronidazole

• Treat sexual partner

C. Trichomonas

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32. What is the proper classification of the following tibial fracture?

A. Salter-Harris I

B. Salter-Harris II

C. Salter-Harris III

D. Salter-Harris IV

E. Salter-Harris V

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• S – traight

• A – bove

• be – L – ow

• T – hrough

• R - ecked

B. Salter-Harris II

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33. A scrotal ultrasound is obtained on a 19 y.o. man who complains of 2 days of intermittent testicular pain. What is the most likely diagnosis?

A. Incarcerated inguinal hernia

B. Epididymitis

C. Testicular carcinoma

D. Testicular torsion

E. Cystocele

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• Risk factors - < 1 yr old, puberty, undescended testicle, Bell-Clapper deformity

• Swollen high-riding testicle, transverse lie, absent cremasteric reflex

• US: unilateral absence of flow

• Tx – Manual detorsion, Surgical tx definitive

D. Testicular torsion

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34. A 63 y.o. man presents with right flank pain and vomiting. What is the correct diagnosis based on the ultrasound shown?

A. Ureteral stone with hydronephrosis

B. Acute cholecystitis

C. Cholelithiasis

D. Pancreatitis with pseudocyst

E. Ruptured abdominal aortic aneurysm

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• US preferred over CT• Less radiation

• No difference in missed high-risk dx, adverse events, return visits, hospitalizations

• Dilated collecting system

• Occasionally see stone

A. Ureteral stone with hydronephrosis

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35. A 13 year old boy complains of right eye pain after mowing the lawn. His slit-lamp examination is shown. Which of the following next steps is contraindicated?

A. Ophthalmology consultation in the ED

B. Placement of a protective eye shield

C. Measurement of ocular pressure

D. Orbital CT scan

E. Administer IV ceftriaxone

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Globe rupture

• Can involve sclera or cornea

• Do not apply pressure to eye

• Clinical findings: Tear shaped pupil, Seidel’s sign, shallow anterior chamber, hyphema

• CT orbit

• Ophtho consult, tetanus, antibiotics

C. Measurement of ocular pressure

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36. A 10 year old boy presents to the ED with fever, rash, cough, and conjunctivitis. What is the most likely diagnosis?

A. Hand, foot, and mouth disease

B. Kawasaki’s disease

C. Measles

D. Rubella

E. Varicella

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• Fever, cough, coryza, conjunctivitis

• Koplik spots• Red/white spots on buccal mucosa

• Rash – maculopapular, starts on face, spreads peripheral

C. Measles

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37. A 58 year old woman complains of 4 days of painless visual loss to the right eye. Based one the fundus shown, what is the most likely diagnosis?

A. Central retinal artery occlusion

B. Retinal detachment

C. Vitreous hemorrhage

D. Amaurosis fugax

E. Central retinal vein occlusion

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• Monocular painless vision loss

• Optic disc edema, retinal hemorrhage, dilated veins

• “Blood and thunder”

• Tx – Ophtho consult, antiplatelet, anticoagulation

• Differential • CRAO

• PRES

• Retinal detachment

• Vitreous hemorrhage

• Stroke

• Amaurosis fugax

E. Central retinal vein occlusion

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38. A 10 year old girl presents with a fever, headache, and rash after hiking in North Carolina. What is the most likely diagnosis based on the picture shown?

A. Meningococcemia

B. West Nile encephalitis

C. Rocky Mountain spotted fever

D. Pityriasis rosea

E. Lyme disease

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• Rickettsia rickettsia

• Tick vector

• Summer months

• Oklahoma, Nebraska, Appalachia

• Flu like illness, then arthralgias, peripheral rash spreading centrally

• Vasculitis, myocarditis, encephalitis

• Tx - doxycycline

C. Rocky Mountain Spotted Fever

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39. A 16 year old boy presents with a lesion to the scalp as shown. What is the correct diagnosis?

A. Pyoderma gangrenosum

B. Psoriasis

C. Tinea capitis

D. Ringworm

E. Kerion

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E. Kerion

• Fungal inflammatory infection

• Usually scalp, usually peds

• Trichophyton

• Oral griseofulvin for 6 weeks

• Scaring alopecia risk

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40. A 34 year old man complains of painful swelling to his penis as shown. Which of the following is the most appropriate treatment?

A. Topical nystatin

B. Compression of the glans and manual reduction

C. Hemostatic dilitation

D. Penicillin

E. Acyclovir

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Paraphimosis

• Foreskin unretractable

• Urologic emerencgy – risk of glans necrosis

• Ice, manual reduction, elastic bandage to reduce edema

• Manually reduce

• Dorsal slit if failure

B. Compression of the glans and manual reduction

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