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
Slide 4
What drug is contraindicated in patients taking MAO inhibitors
because of the occurrence of a severe hyperpyrexic reaction?
Meperidine (Demerol )
Slide 5
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
Slide 6
The _______ is often inappropriately calm in the setting of
devastating chief complaint, such as acute blindness or paralysis.
Patient suffering from a conversion disorder
Slide 7
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).
Slide 8
A patient who has an acute disturbance of consciousness
cognition and perception has what type of illness? Acute
delirium
Slide 9
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)
Slide 10
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
Slide 11
Which organic brain syndrome is characterized by progressive
impairment of cognitive function in which recent memory disturbance
is the earliest sign? Dementia
Slide 12
Which drug should never be used for behavior control in the
agitated delirious patient? The opioids, morphine and meperidine,
can exacerbate acute brain failure.
Slide 13
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 )
Slide 14
Patients who present with vague symptoms such as weakness,
fatigue, headache or pain may have ______ _____. Masked or hidden
depression
Slide 15
Cardiovascular
Slide 16
Which dysrhythmia occurs primarily with severe hypoxia
secondary to acute exacerbation of chronic obstructive pulmonary
disease? Multifocal atrial tachycardia
Slide 17
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
Slide 18
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
Slide 19
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.
Slide 20
What is the best initial therapy for the unstable patient with
rapid atrial fibrillation? Synchronized cardioversion
Slide 21
What is the initial therapy for symptomatic patients with
hypertrophic cardiomyopathy (such symptoms include angina, dyspnea,
syncope and lightheadedness)? Beta Blockers
Slide 22
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.
Slide 23
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
Slide 24
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.
Slide 25
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.
Slide 26
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
Slide 27
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.
Slide 28
What is the most common cause of right-sided CHF? Left-sided
CHF
Slide 29
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
Slide 30
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
Slide 31
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.
Slide 32
What are the common conduction disturbance in an acute
myocardial infarction? Bradydysrhythmias and AV conduction
block
Slide 33
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.
Slide 34
What is the earliest and most common rhythm disturbance seen
with digitalis toxicity? PVCs
Slide 35
Which drug should be avoided in the therapy of an
idioventricular rhythm, because it may obliterate the patients only
functioning rhythm? Lidocaine
Slide 36
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).
Slide 37
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
Slide 38
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
Slide 39
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.
Slide 40
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
Slide 41
What is the most common complication of thrombolytic therapy in
patients with acute MI? Reperfusion dysrhythmias
Slide 42
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).
Slide 43
Which drugs may be used for hypertensive emergencies in
eclampsia prior to delivery? Hydralazine Labetalol
Slide 44
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
Slide 45
Who is more likely to have atypical presentation for acute
coronary syndrome? Elderly patients, diabetic patients and
women
Slide 46
What is a therapeutic contraindication to the administration of
IV verapamil? Recent IV administration of propranolol
Slide 47
Which drugs are contraindicated in the treatment of ventricular
tachydysrhythmias caused by digitalis toxicity? Bretylium Class I
antidysrhythmics (procainamide, isoproterenol) Propranolol
Slide 48
What electrolyte abnormality is a common cause of dysrhythmias
in AICD patients? Hypomagnesemia
Slide 49
What is the drug of choice for conversion of a narrow-complex
supraventricular tachycardia? adenosine (Adenocard)
Slide 50
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.
Slide 51
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.
Slide 52
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.
Slide 53
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
Slide 54
Regarding cardiovascular conditions, nausea and vomiting may be
the only presenting sign and symptom of ___ ___ ___. Inferior wall
MI
Slide 55
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
Slide 56
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)
Slide 90
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)
Slide 91
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
Slide 92
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
Slide 93
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
Slide 94
Which organ system is LEAST sensitive to an acute radiation
exposure? Central nervous system
Slide 95
What is the clinical feature that distinguishes heat stroke
from heat exhaustion? Central nervous system dysfuntion (In heat
exhaustion, mentation is not impaired.)
Slide 96
Which injury is most likely to be present in a survivor of a
lighting strike? Rupture of the tympanic membranes
Slide 97
At what temperature does the hypothermic patient lose the
ability to generate heat by shivering? Below 32 C (90 F)
Slide 98
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.
Slide 99
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%
Slide 100
Core temperatures less than ___ are associated with increased
myocardial irritability and case cause nearly any tachydysrhythmia,
including conduction delays. 30 C (86 F)
Slide 101
What is the most important cause of morbidity and mortality in
near drowning? Hypoxia
Slide 102
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
Slide 103
Rapid rewarming is the key initial therapy for this
environmental emergency. Frostbites
Slide 104
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)
Slide 105
What is the most common presentation of arterial gas
embolization after driving? Air embolus or decompression
sickness
Slide 106
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)
Slide 107
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.
Slide 108
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
Slide 109
What is the best predictor of survival in patients with
radiation exposure? The absolute lymphocyte count, 48 hours after
exposure.
Slide 110
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
Slide 111
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.
Slide 112
Does successful recovery from tetanus confer immunity to the
disease? No! The patient needs full primary immunization plus
boosters through the years as indicated.
Slide 113
Which tick-bone illness is characterized by severe
retro-orbital headache and photophobia and requires only supportive
therapy? Colorado tick fever
Slide 114
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)
Slide 115
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)
Slide 116
Antibiotic therapy for adults (nonpregnant and nonlactating)
and children older than 8 years for Lyme disease stage I
is_________. Doxycycline or tetracycline
Slide 117
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.
Slide 118
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.
Slide 119
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.
Slide 120
Sudden cardiac arrest from electrocution occurs with exposure
to ____ or ____. Household AC current Lightning strikes
Slide 121
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.
Slide 122
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.
Slide 123
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)
Slide 124
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
Slide 125
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
Slide 126
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.
Slide 127
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.
Slide 128
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.
Slide 129
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%
Slide 130
Which types of hepatitis produce neither a chronic infection
nor a carrier state? Hepatitis A and Hepatitis E
Slide 131
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.)
Slide 132
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.
Slide 133
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.
Slide 134
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.
Slide 135
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.
Slide 136
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.
Slide 137
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
Slide 138
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.
Slide 139
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
Slide 140
Name the most common causes of bright red rectal bleeding. Anal
lesions, particularly fissures and hemorrhoids
Slide 141
Name the most common cause of bloody diarrhea. Shigella
Slide 142
Name the most common cause of upper GI bleeding. Peptic ulcer
disease (duodenal ulcer is most common)
Slide 143
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
Slide 144
What is the drug of choice in patients with severe
pseudomembranous colitis? Oral metronidazole or vancomycin. If
critically ill, intravenous metronidazole and oral vancomycin.
Slide 145
What is the most common complication of upper GI endoscopy?
Esophageal trauma
Slide 146
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.
Slide 147
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
Slide 148
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)
Slide 149
Which abnormal electrolyte finding is seen in patients with
acute pancreatitis? Hypocalcemia
Slide 150
Hemorrhagic shock is a potential complication of which
inflammatory GI disorder? Pancreatitis
Slide 151
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
Slide 152
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.
Slide 153
What is the most common cause of upper GI bleeding in pregnancy
Esophagitis (secondary to reflux and repeated vomiting)
Slide 154
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.
Slide 155
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
Slide 156
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)
Slide 157
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).
Slide 158
What is the etiology of hepatic abscesses? Pyogenic ( usually
E. Coli) 90% Amebic (Entamoeba histolytica) 10%
Slide 159
What is the most common presentation of cholelithiasis? 1. RUQ
2. No fever 3. Relatively normal lab studies
Slide 160
What is the most common cause of portal hypertension worldwide?
Schistosomiasis
Slide 161
What is the most common bloodborne viral infection in the
United States? Hepatitis C Virus (HCV)
Slide 162
What are the two most common causes of esophageal bleeding?
Varices Mallory-Weiss tear
Slide 163
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)
Slide 164
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
Slide 165
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
Slide 166
Bloody diarrhea should warrant testing for which bacteria?
Shigella Salmonella Campylobactor Hemorrhagic E. Coli
Slide 167
Protozoal pathogens most frequently associated with diarrhea
that persists for more than 7-10 days are _____ and _____. Giardia
Cryptosporidium
Slide 168
Patients with refractory cryptosporidiosis, cyclosporiasis or
isosporiasis should be tested for _________. HIV infection
Slide 169
Head and Neck
Slide 170
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.
Slide 171
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.
Slide 172
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
Slide 173
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)
Slide 174
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).
Slide 175
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
Slide 176
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.
Slide 177
What is the most common direct source of posterior nosebleeds?
Posterior branches of the sphenopalatine artery
Slide 178
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)
Slide 179
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
Slide 180
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
Slide 181
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
Slide 182
What is the unusual cause of bacterial parotitis?
Staphylococcus aureus
Slide 183
What is the most common presenting symptom of a brain abscess?
Headache
Slide 184
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.
Slide 185
Compressive dressing applied to an external ear injury may
cause _____. Necrosis of the ear cartilage
Slide 186
What are the complications of ethmoid sinusitis?
Periorbital/orbital cellulitis Brain abscess
Slide 187
What is a complication of sphenoid sinusitis? Cavernous sinus
thrombosis
Slide 188
Mastoiditis is usually a complication of which disorder?
Untreated or inadequately treated acute otitis media
Slide 189
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
Slide 190
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
Slide 191
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)
Slide 192
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
Slide 193
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
Slide 194
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.
Slide 195
Acute bacterial conjunctivitis in adults is most commonly doe
to ____ and ____. S. Aureus* S. pneumoniae * The most common cause
of mucopurulent conjunctivitis
Slide 196
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
Slide 197
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.
Slide 198
What causes acute thermal epiglottitis? A direct thermal insult
from ingestion of hot food or liquid (or from smoking cocaine) may
precipitate thermal epiglottitis.
Slide 199
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
Slide 200
Spontaneous hyphemas are associated with __________. Sickle
cell disease Diabetes and neoplasms should also be considered
Slide 201
An acute cranial nerve III palsy with pupillary dilation is a
____ until proven otherwise. Posterior communicating artery
aneurysm
Slide 202
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
Slide 203
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
Slide 204
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)
Slide 205
What medications have produced sudden attacks of narrow-angle
glaucoma? Topical cycloplegics Anticholinergic agents Beta-agonists
(including inhaled agents) Sulfa, MAO inhibitors, trycyclics
Slide 206
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
Slide 207
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)
Slide 208
What is the most common cause of acute visual reduction due to
optic nerve dysfunction in patients w20-40 years old? Optic
neuritis
Slide 209
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
Slide 210
Hematology/Oncology
Slide 211
In which area of the body is central cyanosis likely to be
detected? The tongue and oral mucous membranes
Slide 212
In which clinical entity is there severe tissue hypoxia but no
peripheral cyanosis? Carbon monoxide poisoning
Slide 213
What are the causes of central cyanosis? Methemoglobinemia V/Q
mismatches High altitude NOTE: Cold exposure causes peripheral
cyanosis.
Slide 214
With which blood disorder would one associate the common
appearance of aseptic necrosis of the femoral head? Sickle cell
disease
Slide 215
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.
Slide 216
What is the most common cause of a prolonged PTT with a normal
PT? Hemophilia A
Slide 217
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
Slide 218
What is the best test for platelet function (aggregation and
adhesion) onto injured vascular surfaces? Bleeding time
Slide 219
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
Slide 220
Which drug should you avoid in patients with
glucose-6-phosphate dehydrogenase (G6PD) deficiency? Sulfa Pyridium
Nitrofurantoin Antimalarials Dapsone Methylene blue Aspirin
NSAIDs
Slide 221
Can thrombocytopenia result from an exchange transfusion?
Dilutional thrombocytopenia occurs in cases of massive transfusion,
exchange transfusion or extracorporeal circulation.
Slide 222
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.
Slide 223
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).
Slide 224
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
Slide 225
What is the most common organism causing life-threatening
infection in patients undergoing bone marrow or solid organ
transplants? Cytomegalovirus
Slide 226
Major Trauma
Slide 227
What is the most appropriate diagnostic study in trauma
patients with blood at the urethral meatus? Retrograde
urethrogram
Slide 228
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
Slide 229
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
Slide 230
What are the classic signs of compartment syndrome? The 6 Ps
Pain out of proportion to what is expected Pallor Piokilothermia
Pulselessness Parenthesia Paralysis
Slide 231
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.
Slide 232
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.
Slide 233
In a patient presenting with a periorbital hematoma or a
hyphema, what diagnosis should be excluded? Orbital fracture
Slide 234
At what age can surgical cricothyroidotomy be performed on a
child? When the cricothyroid membrane is palpable, around age
12.
Slide 235
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
Slide 236
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.
Slide 237
What is the leading cause of death in patients sustaining
pelvic fractures? Hemorrhagic shock
Slide 238
Where are the children (< 11 years old) with cervical spine
injuries most commonly injured? The upper C-spine
Slide 239
What is the most common cause of sudden death following a MVC
or fall from a great height? A traumatic aortic rupture
Slide 240
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.
Slide 241
Pelvic fractures are associated with bladder injury. What
should you check for? Hematuria; do a urethrogram/cystogram if
appropriate.
Slide 242
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)
Slide 243
Death from drowning is due to _________. Hypoxia
Slide 244
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.
Slide 245
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.
Slide 246
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
Slide 247
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)
Slide 248
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)
Slide 249
What are the most common sequela following blunt abdominal
trauma during pregnancy? Preterm contractions
Slide 250
What is the most common site of penetrating trauma to the
heart? The right ventricle
Slide 251
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)
Slide 252
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
Slide 253
Sensory loss on the chest or abdomen is presumptive evidence of
_________. Spinal cord injury/involvement
Slide 254
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.
Slide 255
In a woman with an orbital fracture, what is the incidence of
sexual assault/domestic violence? Greater than 30%
Slide 256
Which reversible conditions can mimic the appearance of brain
death? Hypothermia Barbiturate coma
Slide 257
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.
Slide 258
Patients in hypovolemic shock are usually ______, while those
in neurogenic shock are typically ________. Tachycardic
Bradycardic
Slide 259
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.
Slide 260
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
Slide 261
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
Slide 262
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
Slide 263
Neurology
Slide 264
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
Slide 265
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.
Slide 266
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).
Slide 267
What is the most common intracerebral bleed following head
injury? Subarachnoid hemorrhage
Slide 268
20% of late post-traumatic seizures (those that occur one week
to 10 years after head injury) are _________ seizures. Temporal
lobe
Slide 269
What are the early signs of phenytoin toxicity? Somnolence
Sedation Slurred speech Diplopia/blurred vision Coarse tremor
Nystagmus
Slide 270
A post-viral acute inflammatory demyelinating polyneuropathy
with ascending paralysis and decreased or absent DTRs is the ___-
____ ____. Guillain-Barr syndrome
Slide 271
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.
Slide 272
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
Slide 273
What are the most frequent initial symptoms/signs in myasthenia
gravis patients? Visual sign/symptoms (ptosis, diplopia, blurred
vision)
Slide 274
If a regular alcoholic ED patient is confused (or more confused
than usual) _____ _____ must be prominent in the differential
diagnosis. Subdural hematoma
Slide 275
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).
Slide 276
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
Slide 277
What must be considered if a patient presents with vertigo
associated with neurologic complaints? Occlusion of posterior
inferior cerebellar artery (Wallenbergs syndrome)
Slide 278
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.
Slide 279
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.
Slide 280
What is the most common presenting neurologic manifestation of
diphtheria? Paralysis of the palatal muscles
Slide 281
What is the primary consideration for the etiology of
meningitis in an AIDS patient? Cryptococcus neoformans
Slide 282
Concerning patients suspected of cryptococcal meningitis, which
studies should be ordered on the cerebrospinal fluid examination?
Cryptococcal antigen and An India ink preparation
Slide 283
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.
Slide 284
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.
Slide 285
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
Slide 286
An absent deep tendon reflex at the ankle suggests a lesion of
which nerve root? S1S1
Slide 287
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
Slide 288
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
Slide 289
What cervical spine injury occurs as the result of axial
loading? Jefferson fracture or C 1 ring blowout fracture
Slide 290
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
Slide 291
What psychiatric disorder is most often confused with stroke?
Conversion disorder
Slide 292
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.
Slide 293
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.
Slide 294
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.
Slide 295
Orthopedics
Slide 296
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.
Slide 297
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.
Slide 298
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.
Slide 299
Fractures of the clavicle are most likely to occur on which
region of the bone? Middle third (80%)
Slide 300
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.
Slide 301
What is the most immediate concern in patients with fractures
of the tibia and fibula? The development of a compartment
syndrome
Slide 302
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.
Slide 303
Damage to which nerve is frequently associated with acetabular
fractures? Sciatic
Slide 304
What is the most common dislocation of the patella? Lateral
usually occurring from a twisting injury on an extended knee.
Slide 305
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.
Slide 306
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%)
Slide 307
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.
Slide 308
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.
Slide 309
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
Slide 310
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
Slide 311
Fracture of the lateral tibial plateau may be associated with
injury of the ________? Anterior cruciate and medical collateral
ligament
Slide 312
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.
Slide 313
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.
Slide 314
What is the most common midfoot fracture? The most common
fracture is a navicular bone fracture.
Slide 315
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.
Slide 316
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
Slide 317
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
Slide 318
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.
Slide 319
Fluid analysis of knee joint aspirate reveals the presence of
positive birefringent crystals. What is the diagnosis? Pseudogout
Uric acid crystals are negatively birefringent
Slide 320
Pediatrics
Slide 321
What is the best screening test for the diagnosis of Reyes
syndrome? Serum ammonia level
Slide 322
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)
Slide 323
What are the most common pathogens causing pneumonia in
children after the newborn period? Viruses (age < 5 years)
Mycoplasma pneumonias (ages 5-15 years)
Slide 324
What is the most common cause of bacterial pneumonia in
children after the newborn period? Streptococcus pneumoniae
Slide 325
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.
Slide 326
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)
Slide 327
What is the most primary dysrhythmia in children? Paroxysmal
supraventricular tachycardia (PSVT)
Slide 328
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.
Slide 329
In which age group are radial head subluxations most commonly
seen? Children less than 6 years of age; peaks between 2-3
years
Slide 330
Which fractures are most commonly seen in children who fall on
an outstretched arm? Distal radial fracture (epiphyseal fractures
and/or torus fractures)
Slide 331
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.
Slide 332
What are the most common signs/symptoms of hypothermia in
infants? Lethargy Decreased feeding
Slide 333
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.
Slide 334
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.
Slide 335
Because of the unique nature of the blood supply to the
skeletal system, ______ and _____ ______ frequently occur together
in infants. Osteomyelitis Septic arthritis
Slide 336
What is the initial fluid therapy for children in shock? Rapid
infusion of crystalloids, 20mL/kg
Slide 337
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)
Slide 338
What is the most common complication of pertussis (whooping
cough)? Secondary bacterial pneumonia
Slide 339
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.
Slide 340
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.
Slide 341
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.
Slide 342
Which infection generally occurs from seeding during sepsis or
from spread of a contiguous infection, such as otitis media?
Meningitis
Slide 343
What diagnosis should be considered in children between the
ages of 5 and 12 months who present with abdominal pain?
Intussusception
Slide 344
Why is the funduscopic examination important in the suspected
child abuse victim? Retinal hemorrhages may be seen in the shaken
baby syndrome
Slide 345
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.
Slide 346
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)
Slide 347
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.
Slide 348
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.
Slide 349
What type of fracture occurs because the bone at the
metaphyseal- diaphyseal junction fails to compress? Torres fracture
is a fracture without cortical disruption
Slide 350
Pulmonary
Slide 351
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
Slide 352
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.
Slide 353
A pulse oximetry reading would not be helpful in a patient with
__________. carbon monoxide poisoning or methemoglobinemia
Slide 354
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
Slide 355
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.
Slide 356
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.
Slide 357
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
Slide 358
Which diagnosis should be considered in a patient with who
presents with a cough productive of fetid and bloody sputum? Lung
abscess
Slide 359
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