Carol Rivers'board Review Flashcards
Carol Rivers'board Review Flashcards
Meperidine (Demerol ®)
The diagnosis of malingering may be considered when the patient:
Acute delirium
Which neuroleptic agent reduces agitation, is not very sedation, has
a rapid onset but is associated with extrapyramidal side effects?
Haloperidol (Haldol®)
(Newer neuroleptics, e.g. olanzepine, risperidone, ziprasidone,
have less risk of extrapyramidal side effects)
What are the symptoms of depression?
Sleep disturbance
Change in appetite
Impaired concentration and memory
Reduced level of activity
Dysphoria
Lack of concern for personal appearance
Suicidal thoughts
Feelings of hopelessness/helplessness
Which organic brain syndrome is characterized by progressive impairment of
cognitive function in which recent memory disturbance is the earliest sign?
Dementia
Which drug should never be used for behavior control in the
agitated delirious patient?
Synchronized cardioversion
What is the initial therapy for symptomatic patients with hypertrophic
cardiomyopathy (such symptoms include angina, dyspnea, syncope and
lightheadedness)?
Beta Blockers
What are indications for endocarditis prophylaxis?
Left-sided CHF
Which conditions are most likely to predispose a patient to
subacute bacterial endocarditis?
1. Pre-existing valvular heart disease especially of the mitral
and/or aortic valves. Mitral valve disease is most common
(INCLUDING mitral valve prolapsed).
2. Injecting drug users who present with right-sided disease.
The tricuspid valve (most commonly involved) is usually
normal before onset disease.
Bradydysrhythmias and
AV conduction block
Angina that is a new in onset, occurs at rest or is similar but somewhat
“different” than previous episodes, is severely limiting or lasts longer than a few
minutes, with increased frequency of attacks or resistance to prescribed
medications that previously relieved that symptoms (e.g. NTG, the “blockers”)
demonstrates what?
PVCs
Which drug should be avoided in the therapy of an idioventricular rhythm,
because it may obliterate the patient’s only functioning rhythm?
Lidocaine
What is the treatment of MULTIFOCAL ARTIAL TACHYCARDIA?
Fever Hypoxia
Drugs Anemia
Cardiac ischemia, ACS
Hypovolemia Sepsis
Hypotension Pulmonary embolism
Hyperthyroidism
Cardiac tamponade
Stimulants, illicit drugs
What are the ECG findings in digitalis toxicity?
PVCs* (often bigeminal and multiform)
Junctional tachycardia (common)
SA and AV nodal block
A-Fib with a slow ventricular response
SVT, ESPECIALLY Pat with block
Ventricular tachycardia or fibrillation
Bidirectional V-Tach 9rare but highly suggestive of digitalis toxicity)
Sinus bradycardia/sinus arrest
*MOST COMMON
Substernal chest discomfort greater than 15 minutes’ duration associated with
dyspnea, diaphoresis, lightheadedness, palpitations, nausea and/or vomiting,
with pain likely radiating to the inner aspect of one or both arms, shoulders,
neck or jaw exhibited within a few hours of awakening in the morning
demonstrates what?
Hypertrophic cardiomyopathy
What is the most common complication of thrombolytic therapy in
patients with acute MI?
Reperfusion dysrhythmias
What are the typical ECG findings in an acute inferior wall MI?
Hydralazine
Labetalol
Which diagnosis should be excluded in any patient older than 50
years of ago who presents with abdominal pain, back pain,
weakness or syncope?
Bretylium
Class I antidysrhythmics
(procainamide, isoproterenol)
Propranolol
What electrolyte abnormality is a common cause of dysrhythmias
in AICD patients?
Hypomagnesemia
What is the drug of choice for conversion of a narrow-complex
supraventricular tachycardia?
adenosine (Adenocard®)
Why are alcoholics prone to the development of torsades de
pointes and why is this important therapeutically?
1. Duplex ultrasonography
2. Venogram
Regarding cardiovascular conditions, nausea and vomiting may be
the only presenting sign and symptom of ___ ___ ___.
Inferior wall MI
“Hypertensive emergency” is defined as an extreme elevation of BP
with signs or symptoms of end-organ disease. What is an effective,
reliable and safe drug for a hypertensive emergency in the setting of
myocardial ischemia or CHF?
Sublingual nitroglycerin
The most frequent ECG findings in chronic ischemic heart disease
are ___________
Atrial fibrillation
A middle-aged patient presents to the ED in acute pulmonary edema.
He was seen a week ago for “chest pain” but signed out AMA before
an ECG was done. Current ECG shows an inferior wall infarct.
What is the most likely cause of this patient’s distress at this time?
Significant hyperkalemia
Progressive CHF
What class of drugs are the most effective for the treatment of
chronic CHF associated with dilated cardiomyopathies?
The ACE-inhibitors
Which drug should be avoided in patients with hypertrophic
cardiomyopathy?
Digitalis
(may worsen obstruction)
What is the most frequent complication associated with
implantable cardioverter/defibrillators (ICDs)?
Age 65 years
Congestive heart failure
New ST deviation 0.5 mm in limb and/or precordial leads
New pathologic Q waves
Sustained ventricular tachycardia
Significant elevation of cardiac markers
What is the appropriate treatment for symptomatic
bradydysrhythmias in a patient with a heart transplant?
CBC
INR
aPTT
Creatinine
What are the contraindications to anticoagulant therapy for patients
with DVT?
Absolute contraindications Relative contraindications
Active Bleeding Mild to moderate bleeding
Severe bleeding diathesis or platelet count 20,000/mm3 Brain metastases,
endocarditis
Neurosurgery, ocular surgery Recent major trauma
or intracranial bleeding Major abd. surgery 2 days
within the past 20 days GI or GU bleeding 14 days
Severe hypertension (i.e. Systolic
BP 200 mmHg or diastolicBP 120 mmHg at presentation
SIADH
The acronym is for Syndrome of Inappropriate secretion of
AntiDiuretic Hormone
What are the common precipitating causes of diabetic
ketoacidosis?
Phenothiazines
(They lower the seizure threshold)
The use of high-dose insulin therapy in diabetics is associated with
which emergent complications?
* Hemiparesis
* Hemisensory deficits
* Focal or grand mal seizures
Generalized weakness
Hyporeflexia
Paralysis
In the drug therapy of hyperkalemia, which treatment has the most
rapid onset and the shortest duration of action?
ADMISSION. The long half-lie many of these drugs predisposes the patient to
recurrent episodes until the drug is metabolized.
Chlorpropamide* has a half-life of 36 hours with a duration of effect up to 2-5 days.
Second generation drugs (glipizide, glyburide*, glimepiride) have much shorter
half-lives BUT the duration of action ranges from 10-16 hours (glipizide) up to 24
hours (glyburide).
Hyperthyroidism/thyrotoxicosis
How long after someone stops drinking can symptoms of alcoholic
withdrawal syndrome begins?
1. Hepatic transaminases
* AST ALT suggests alcohol injury
* GGT is the most sensitive indicatory of alcoholic liver damage
2. Increased mean corpuscular volume (MCV) is more specific of alcohol abuse than
any of the transaminases
3. Carbohydrate-deficient transferrin (CDT) is the most specific and sensitive marker
for heavy alcohol consumption; AST ALT (Ratio > 2)
What is the treatment for Wernicke’s encephalopathy?
Glucose-6-Phosphatase Deficiency
Age
Need for bystander or ED CPR
Water characteristics:
1. Clean vs contaminated
2. Temperature
3. Amount aspirated
What is the order of tissue resistance to the flow of electrical
current?
LEAST resistance: nerves, blood vessels, muscles, mucous membranes, moist or wet skin
• HEAD = 18%
• Abdomen = 9%
• Thorax = 9%
• Back = 18%
• Each arm = 9%
• Each leg = 14%
Core temperatures less than ___ are associated with increased myocardial irritability
and case cause nearly any tachydysrhythmia, including conduction delays.
30 C (86 F)
What is the most important cause of morbidity and mortality in
near drowning?
Hypoxia
In patients with this injury, close observation (sometimes in the
hospital) and referral to a plastic or oral surgeon is indicated because
there is the possibility of labial artery hemorrhage as the escher
separates.
Frostbites
A patient presents with an acute abdomen. However, you notice that
there is no tenderness but there is impressive rigidity.
Heat exhaustion. Salt water depletion from sweat loss leads to hypovolemia
and hypoperfusion; neurologic and mental status exams are normal.
The whole body dose of ionizing radiation determines the timing
of the onset of symptoms. The higher the level of exposure, the
_____ symptoms develop.
Earlier
What is the best predictor of survival in patients with radiation
exposure?
Erythema migrans
Doxycycline or tetracycline
Which animals are most likely to harbor the rabies virus? Which
animals are least likely vectors for rabies?
MOST common: skunks, bats, raccoons, cows, dogs, foxes and cats
Household AC current
Lightning strikes
How do you differentiate muscle spasms due to tetanus from those
seen in patients with strychnine poisoning?
Crohn’s Disease
The majority of patients present with abdominal pain, anorexia, diarrhea and weight loss.
The majority of patients have ileum involvement. 30% of patients present with perianal
fissures or fistulas, perirectal abscessed or rectal prolapse.
Ulcerative Colitis
Gradual onset of bloody diarrhea and abdominal pain is the most common presentation
Anorexia and weight loss
What is the clinical presentation of a patient with Boerhaave’s syndrome
and which diagnostic study is likely to be most beneficial?
Severe retching or vomiting followed by lower thorax or epigastric pain is the most common; the
most common tear site is the left posterolateral wall 2-3cm before the stomach. Occasionally pain is
also reported in the restrosternal, left shoulder or upper chest areas.
A standard chest radiograph is almost always abnormal and may show left pleural effusion (most
common), mediastinal or free peritoneal air, widened mediastinum, or left pneumothorax. Diagnosis
may be confirmed by either CT scan or an esophagram using water-soluble contrast (Gastrografin)
since barium may cause additional pleura-mediastinal inflammation if a tear is present.
What is the general management of ingested foreign bodies that are
sharp and pointed?
Initial physical exam and x-ray in ALL children. Labs are usually not necessary.
If symptoms are present, obtain surgical consult. If the ingested item is a sewing needle,
needles in the stomach need endoscopic removal. Needles that have passed into the
intestines require early surgical consult.
If no symptoms are present, follow with serial x-rays.
No progression past the stomach necessitates contrast x-ray to exclude perforation.
Signs of perforation or failure to pass through the GI tract require surgical consultation.
A small child swallow a quarter. Where is it most likely to become
impacted?
The esophagus
Giardia lamblia
Clinical Presentation: A 43-year-old woman presents with epigastric
discomfort after eating dinner. She is tender in both the epigastrium and RUQ.
Ranson’s criteria
On admission: 48 hours later:
* Age > 55 years * Calcium < 8 mg/dL * Glucose > 200 mg/dL pO2 < 60
mmHg
* WBC > 16,000 mm3 * > 10% fall in Hct
* LDH > 350 IU/L * > 5% mg/dL rise in BUN
* AST > 250 Sigma-Frankel* Base deficit > 4 mEq/L
units/L* Sequestration of > 6L of fluid
Name the most common causes of bright red rectal bleeding.
Shigella
Name the most common cause of upper GI bleeding.
Toxic megacolon
What is the drug of choice in patients with severe
pseudomembranous colitis?
Esophageal trauma
What is the chief complaint of patients with Boerhaave’s
syndrome?
Hypocalcemia
Hemorrhagic shock is a potential complication of which
inflammatory GI disorder?
Pancreatitis
What are the historical findings consistent with the diagnosis of
irritable bowel syndrome?
Rome II criteria
Abdominal pain or discomfort > 12 weeks over the past year
accompanied by two of the following
Esophagitis
(secondary to reflux and repeated vomiting)
A patient presents with sudden onset LUQ pain associated with
violent retching (but no vomiting). Upright films of the chest and
abdomen reveal a distended stomach with one or two air0filuid
levels. What is the diagnosis?
Gastric volvulus presents with sudden onset of severe abdominal pain with
retching or vomiting. Upright films of the chest and abdomen may reveal
stomach distension with one or two air fluid levels or a large, gas-filled loop of
bowel in the abdomen or chest.
What is the most common cancer of the small intestine?
Adenocarcinoma
1. RUQ
2. No fever
3. Relatively normal lab studies
What is the most common cause of portal hypertension worldwide?
Schistosomiasis
What is the most common bloodborne viral infection in the United
States?
Varices
Mallory-Weiss tear
UGI bleeding due to a ruptured esophageal varix can be controlled
in 90-95% of cases with what type of treatment
Endoscopic sclerotherapy
Pharmacologic agents (octreotide)
Clinical Presentation: a middle-aged male with cirrhosis who is
confused and unable to hold an assumed position (asterixis).
Contraindications include:
Hiatal hernia (precludes proper tube placement)
Peptic ulcer disease with stricture of the esophagus
Bleeding from esophageal lacerations
Inability of the patient to protect the airway
Endoscopy should precede insertion (if at all possible) so that the diagnosis may be
confirmed
Bloody diarrhea should warrant testing for which bacteria?
Shigella
Salmonella
Campylobactor
Hemorrhagic E. Coli
Protozoal pathogens most frequently associated with diarrhea that
persists for more than 7-10 days are _____ and _____.
Giardia
Cryptosporidium
Patients with refractory cryptosporidiosis, cyclosporiasis or
isosporiasis should be tested for _________.
HIV infection
Head and Neck
What is the distinguishing clinical feature which helps differentiate
croup from epiglottitis?
Mode on onset
Posterior packing
Rebleeding, which occurs 2-5 days after the initial clot loosens, is a
major complication.
Blood staining of the corneal epithelium
Secondary glaucoma
Anterior and posterior synechiae
Optic atrophy from increased IOP associated with hyphema.
What is the most common direct source of posterior nosebleeds?
Retinal detachment
Slit-lamp exam of a painful eye reveals a fluorescein-positive are
with a branching or dendrite pattern.
Treatment:
1. Topical and oral antiviral agents
2. Topical cycloplegic drops
3. Emergent ophthalmologic consultation
Clinical Presentation: A patient complains of weakness of an upper
extremity as well as numbness and tingling of the forearm and middle
finger. When the patient is asked to extend the elbow against resistance,
he is unable to do so and complains of pain in the upper back.
C7
What is the unusual cause of bacterial parotitis?
Staphylococcus aureus
What is the most common presenting symptom of a brain abscess?
Headache
Which abnormal laboratory findings is associated with temporal
arteritis?
• Periorbital/orbital cellulitis
• Brain abscess
What is a complication of sphenoid sinusitis?
1. Admission
2. Parental antibiotics (Adequate coverage from gram negative and
positive organisms usually entails combination therapy, ceftazidime
OR cefepime OR piperacillin-tazobactam PLUS vancomycin.)
3. Immediate ENT consultation regarding surgical drainage and/or
mastoidectomy
A patient complains of a severe sore throat, muffled voice as well
as difficulty swallowing and opening the mouth.
Peritonsillar abscess
What are the two most common supportive complications of group
A beta-hemolytic streptococcal pharyngitis?
Tracheostomy
Cricothyrotomy is usually not feasible because the injury is frequently
below the cricothyroid membrane
Blind nasotracheal intubation attempts mat penetrate the mediastinum
Percutaneous transtracheal insufflation is currently under investigation
What is the most common cause of “pink eye”?
Conjunctivitis
(bacterial and viral)
S. Aureus*
S. pneumoniae
If it occurs on the first 3-5 days → N. gonorrhoeae and/or HSV should be
suspected
Plateau iris
Topical cycloplegics
Anticholinergic agents
Beta-agonists (including inhaled agents)
Sulfa, MAO inhibitors, trycyclics
The most common acute optic neuropathy in patients > 50 years old is _____.
Visual loss is often described as altitudinal (only the upper or lower half of the
visual field is missing); inferior loss is more common.
Optic neuritis
A patient with a corneal ulcer presents with an adherent mucopurulent exudate and a
“ground glass” appearance of the cornea. What is the most likely infecting
organism?
Pseudomonas aeruginosa
Hematology/Oncology
In which area of the body is central cyanosis likely to be detected?
Methemoglobinemia
V/Q mismatches
High altitude
Hemophilia A
What are the potential complications of auto-transfusion?
Air embolus
Dilutional coagulopathy, if volume is > 4000 mL
Sepsis, if contaminated blood is infused
Hemolysis, if the blood has pooled within the pleural cavity for
more than 6 hours
What is the best test for platelet function (aggregation and
adhesion) onto injured vascular surfaces?
Bleeding time
Clinical Presentation: A patient is seen with shortness of breath,
swelling and plethora of the face and upper extremities, and headache.
Sulfa
Pyridium®
Nitrofurantoin
Antimalarials
Dapsone
Methylene blue
Aspirin
NSAIDs
Can thrombocytopenia result from an exchange transfusion?
β-Thalassemia
(Thalassemia major, Cooley’s anemia)
Pseudomonas aeruginosa
What is the most common organism causing life-threatening infection in
patients undergoing bone marrow or solid organ transplants?
Cytomegalovirus
Major Trauma
What is the most appropriate diagnostic study in trauma patients
with blood at the urethral meatus?
Retrograde urethrogram
In the setting of acute trauma, this test should be performed if renal
artery injury is suspected or needs to be excluded.
The 6 Ps
Pain out of proportion to what is expected
Pallor
Piokilothermia
Pulselessness
Parenthesia
Paralysis
What is the role of hyperventilation in the management of elevated
intracranial pressure secondary to trauma?
Relative hypovolemia
Orbital fracture
At what age can surgical cricothyroidotomy be performed on a
child?
“3”
The patient scores 1 point each for eye opening, speech and
best motor response…even when there is none.
What is the leading cause of death in patients sustaining pelvic
fractures?
Hemorrhagic shock
Where are the children (< 11 years old) with cervical spine injuries most
commonly injured?
(e) Mepivacaine
Procaine is the prototype “ester” local anesthetic. All of the anesthetics listed are chemically related to
procaine except mepivacaine is an “amide.”
The amide anthesthetics are associated with far fewer allergic reactions. The other amides are lidocaine,
bupivacaine, etidocaine and prilocaine.
Pelvic fractures are associated with bladder injury. What should
you check for?
Pulmonary contusion occurs within minutes to hours of the injury and is seen on x-
ray as an infiltrate or consolidation that is usually localized to a pulmonary segment
or lobe.
ARDS is associated with delayed onset (12-72 hours after injury) with diffuse
patchy infiltrates seen on chest x-ray (24-72 hours after injury)
Death from drowning is due to _________.
Hypoxia
What are the contraindications for the use of MAST/PASG?
Ureteropelvic disruption
Preterm contractions
What is the most common site of penetrating trauma to the heart?
Blood pressure or
Pulse or
Cardiac rhythm or
Respiratory effect or
Echo cardiac activity or tamponade
Sensory loss on the chest or abdomen is presumptive evidence of
_________.
10%
If one fracture is present, complete radiographic screening of
the entire spine is needed.
In a woman with an orbital fracture, what is the incidence of sexual
assault/domestic violence?
Hypothermia
Barbiturate coma
What should you be looking for on AP and lateral films of the
thoracic and lumbar spine in trauma patients?
Tachycardic
Bradycardic
CT scanning of the thoracic and lumbar spine is particularly useful
for detecting which injuries?
*LLSA reading
Neurology
Clinical Presentation: An elderly woman arrives at the Emergency
Department after an automobile accident. She has neck pain. You saw her
walk in unassisted. Examination reveals a weak handshake but relatively
good proximal arm strength.
What are these syndromes and what are their clinical features?
ANTERIOR CORD SYNDROME (from anterior spinal artery injury or from anterior
cord compression usually from hyperflexion injury) is characterized by paralysis and
pain-temperature loss distal to he lesion with sparing of the posterior columns (position-
vibratory sensation).
What is the most common intracerebral bleed following head
injury?
Subarachnoid hemorrhage
20% of late post-traumatic seizures (those that occur one week to
10 years after head injury) are _________ seizures.
Temporal lobe
What are the early signs of phenytoin toxicity?
Somnolence
Sedation
Slurred speech
Diplopia/blurred vision
Coarse tremor
Nystagmus
A post-viral acute inflammatory demyelinating polyneuropathy with
ascending paralysis and decreased or absent DTRs is the ___- ____ ____.
Guillain-Barré syndrome
Unilateral facial never paralysis that involves the muscles of the
forehead and is differentiated from a stroke by the absence of focal
neurologic deficits is know as _____ _____.
Bell’s palsy. Bell’s palsy affects the forehead, while central CNVII deficits spare the
forehead.
Clinical Presentation: A middle-aged male complains of muscle weakness
after he climbed a flight of stairs. He also complains of double vision. On
examination, there is ptosis.
Myasthenia gravis
What are the most frequent initial symptoms/signs in myasthenia
gravis patients?
Visual sign/symptoms
(ptosis, diplopia, blurred vision)
If a “regular” alcoholic ED patient is confused (or more confused than
usual) _____ _____ must be prominent in the differential diagnosis.
Subdural hematoma
What is the most common cause of focal encephalitis and leading
cause of intracranial mass lesions in AIDS patients?
CNS toxoplasmosis
The clinical picture: fever, headache, focal neurological deficits,
altered mental status or seizures. CT scan with contrast shows
ring enhancing lesions (the signet ring sign).
What early sign in a head injury patient indicates that delayed post-
traumatic epilepsy is a likely sequela?
Cryptococcus neoformans
Concerning patients suspected of cryptococcal meningitis, which
studies should be ordered on the cerebrospinal fluid examination?
S1
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?
Conversion disorder
A young woman presents with papilledema and recurring
headaches. CT reveals slit-like ventricles.
Diagnosis?
Lisfranc’s fracture
Sciatic
What is the most common dislocation of the patella?
The most serious complication is avascular necrosis of the femoral head. The
chance of this problem occurring is in direct proportion to delays in reduction.
A patient with a history of knee injury states that he heard a “popping”
sound at the time of injury. On examination, you find hemarthrosis of
the joint. There is a positive anterior drawer test.
What structure is most likely injured?
The rotator cuff is injured. Partial tears are more common than
complete and the supraspinatus is the most commonly involved
muscle. The supraspinatus is essential for the first 30 degrees of
abduction.
The posterior fat pad sign seen in the lateral radiographic view of
the elbow of an adult is presumptive evidence of which injury?
Calcaneus injuries are most commonly caused by axial load by a fall from a
height.
Why is it important to obtain an early orthopedic referral for
infants with congenital hip dislocation?
Toddler’s fractures are nondisplaced spiral fractures of the distal tibia, and
are usually accidental.
Amputations at the level of the middle phalanx, wrist and distal forearm
have the best chance of a functionally successful reimplantation. The
part(s) should be handled as aseptically as possible. Wrap the part(s) in a
plastic bad and place in iced water in an insulated container. Never
freeze the amputated part.
Fluid analysis of knee joint aspirate reveals the presence of
positive birefringent crystals.
Pseudogout
Streptococcus pneumoniae
Slipped capital femoral epiphysis occurs most frequently in which
group of children?
Note: The slipped epiphysis is best seen on the frog lateral x-ray of
the pelvis.
Which organism causes the majority of cases of occult bacteremia
in children under 24 months of age?
These studies are useful both diagnostically and therapeutically since 90% of
intussusception cases may be corrected if it is performed within the first 12-
24 hours; air insufflation has some advantages over BE and is being used
with greater frequency today.
What are the most common signs/symptoms of hypothermia in
infants?
Lethargy
Decreased feeding
In addition to the rash, what are the characteristic physical findings
if rubella (German measles)?
Osteomyelitis
Septic arthritis
What is the initial fluid therapy for children in shock?
No, unless the child is symptomatic and/or the hernia is not reducible.
Otherwise, these hernias should be repaired on an elective basis.
A child without a spleen is particularly susceptible to which
illness?
Bronchiolitis
This is a viral disease. 70% of cases are caused by the respiratory syncytial virus
(RSV). Less commonly implicated viruses are parainfluenza, adenovirus and
influenza.
Which infection generally occurs from seeding during sepsis or
from spread of a contiguous infection, such as otitis media?
Meningitis
What diagnosis should be considered in children between the ages
of 5 and 12 months who present with abdominal pain?
Intussusception
Why is the funduscopic examination important in the suspected
child abuse victim?
As the disease progresses, the cough becomes the diagnostic and dominant clinical
feature.
Two lessons are to be learned here. First, there are a lot of children less than 1 year old
who are under immunized or not immunized. Be wary of those with respiratory illness
and cough. Second, people immunized more than 12 years ago for pertussis can acquire
the disease if exposed. Note that the current Dtap vaccine reduces the incidence of
pertussis in the United States thereby preventing pertussis epidemics.
What are the Ottawa Knee Rules for ordering knee x-rays in
children > 5 years old with an injury?
A knee x-ray is only required for children > 5 years old if any of these
findings are present on physical exam:
Tuberculosis
What diagnosis is suggested by rust-colored sputum associated with an
infiltrate in the right middle or right lower lobe on chest x-ray?
Mycoplasma pneumoniae
The triad of fever, nonproductive cough, pleuritic chest pain and exertional
dyspnea in a patient who is HIV-positive should suggest what diagnosis?
H. influenzae pneumonia
Which diagnosis should be considered in a patient with who
presents with a cough productive of fetid and bloody sputum?
Lung abscess
You have just intubated a 70kg asthmatic. The pH is 7.0, pO 2 5o
and pCO2 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 hypotension must be instituted. The technique of permissive
hypercapnia (also know as controlled hypoventilation) is common. Oxygenation is
maintained by using a high fraction of inspired oxygen (FiO 2); hypercarbia and
respiratory acidosis (pH maintained at 7.15-7.2 using sodium bicarbonate) and tolerated.
Airway pressure is kept low by providing low tidal volumes (6-8 mL/kg), thus preventing
excessive increases of intrinsic positive end-expiratory pressure, stacking of ventilations
and barotrauma. Low ventilation rates (< 10 breaths/min) and high inspiratory flow rates
provide prolonged time for expiration. Adjunctive therapies (in-line beta2-agonists and
anticholinergics, IV corticosteroids, IV ketamine, and possibly magnesium) to decrease
airway pressure and airway obstruction are delivered simultaneously.
A middle-aged patient presents with sudden onset of cough followed
by shaking chills and shortness of breath. The patients complains of
pleuritic-type chest pain and is noted to be cyanotic. Signs of
pulmonary consolidation are present. What is the most likely etiology?
Klebsiella pneumonia
Which two pathogens are the most common cause of a lobar
infiltrate on chest x-ray?
Staphylococcal pneumonia
What are the most common pathogenic causes of lung abscesses
seen on x-ray?
Q Fever pneumonia
Toxicology
What is the most common initial symptom of botulism in adults?
Visual Difficulties
There are present on more than 90% of cases and result from abducens (VI) nerve palsy.
Severe cases may exhibit fixed dilated pupils from oculomotor (III) never involvement.
In a poisoning patient with an increased anion gap metabolic acidosis, which
etiology is likely with the finding of calcium oxalate crystals in the urine?
Glucagon
Glucagon, which does not depend on beta receptors for its action has both inotropic and chronotropic
effects. It helps to counteract the hypoglycemia induced by beta blocker overdoes. Glucagon is
given as a 5 to 10 mg IV bolus. Because of its short (20 minutes) half life, an infusion of 2-5
mg/hour for adults should be started immediately after the bolus. With cumulative large doses,
glucagon should be diluted in 5% glucose in water for constant infusion. Side effects include nausea
and vomiting in most patients, mild hyperglycemia, hypokalemia and allergic reactions.
Which blood gas measurement is likely to be normal in a patient
with carbon monoxide poisoning?
pO2
For what drug ingestions would alkalinize the urine?
Salicylates
Barbiturates
Withdrawal from which substance produce the distinctive clinical
findings of yawning, lacrimation and piloerection?
Opiates
What are the features of Wernicke encephalopathy?
Alkali
The liquefactive necrosis of alkali ingestion penetrates deeper than the coagulation
necrosis of acid ingestion.
In patients with organophosphate poisoning, large doses of this drug are
frequently needed and may be repeated until tracheobronchial secretions dry
up.
Atropine
The doses are:
Adult – 2 mg IV Q 5-15 minutes prn
Child – 0.05 mg/kg Q 15 minutes prn
Intoxication with this drug of abuse may cause hyperthermia which
may be sudden and lethal.
Cocaine
In patients with hydrofluoric acid burns, effective therapy includes?
Unintentional overdose
(Abuse of barbiturates does not lead to tolerance of its toxic effects. As larger
doses are taken, the greater the likelihood of an unintentional overdose.)
What are the signs of benzodiazepine toxicity?
Central nervous system depression, ranging from mild drowsiness to coma. Significant
respiratory depression is rare, but can be seen with large oral overdoses or during
intravenous conscious sedation, particularly when the benzodiazepine is combined with
an opioid such as fetanyl. Hypotension is uncommon. Other implications include
aspiration pneumonia and pressure necrosis of skin and muscles. Ataxia is the most
common sign of toxicity, occurring in 90% of patients.
Most potentially lethal ODs/poisonings demonstrate clinical manifestations
within several hours of ingestion. Common exceptions to this rule are:
Acetaminophen
Mushrooms (amatoxin, gyromitrin, Cortinarius)
Sulfonylureas
Sustained-release Ca++ channel blockers
Ant metabolites (e.g. methotrexate)
Lomotil
Paresthesias (mouth, face and limbs), ataxia, weakness and an odd
floating sensation are associated with_______.
Phenothiazine
Profound weakness (especially in patients with myasthenia gravis)
is a sign of toxicity of which drug group?
The aminoglycosides
Other important points
Ototoxicity to vestibular and cochlear cells
Nephrotoxicity causing proximal tubular damage and ATN
Peripheral neuropathy in association with constipation suggests
toxicity to what agent?
Vincristine
Urogenital
What is the principle component of renal calculi?
Appendicitis
Gall bladder disease
Pyelonephritis
Pulmonary disease
The lesson here is that appendicitis is a very important consideration since the appendix
is displaced (usually superiorly) as the pregnancy progresses.
What is the most likely diagnosis of a malodorous vaginal
discharge in a 6-year-old girl?
Vulvovaginits
Infections-Garderella vaginalis, Candida, Trichomonas
Irritant and allergic contact
Local response to vaginal foreign body
Testicular torsion is most frequently misdiagnosed as _______.
Epididymitis
What is the treatment for Gardnerella vaginitis?
The standard route of therapy has been oral, but there is also an intravaginal preparation available.
Chlamydia trachomatis
The presentation of this clinical problem may be indistinguishable from a
ruptured ectopic pregnancy.. There is a sudden onset of lower abdominal pain in
a patient with amenorrhea or one in early pregnancy.
Pre-eclampsia
The other important components of this disease are proteinuria (30 mg in 24 hour collection) and
edema.
Hyperreflexia, if present, suggests impending eclampsia 9seizures and/or coma), since 80% of
eclamptic patients have pre-existing hyperreflexia.
Other common presenting symptoms for pre-eclampsia include headache, visual disturbances and
abdominal pain.
What is the usual cause of fetal death following blunt trauma to the
mother?
The examiner’s hand should be used to elevate the presenting fetal part until a
cesarean section can occur.
90% of renal calculi that are up to______ man in diameter will
pass spontaneously.
4-5 mm
Hyperbaric oxygen therapy and IV fluid resuscitation should also be employed if available.
Mortality is about 20%.
What is the emergency treatment of paraphimosis if the foreskin
cannot be reduced manually?
Sulfonamides
Mycobacterium avium
What is the most common cause of cancer in HIV-infected
patients?
Kaposi’s sarcoma
Which is the only opportunistic infection in patients with AIDS that is transmitted
by respiratory route to both immunocomprised and immunocompetent hosts?
Tuberculosis
What is the most common organism causing septic arthritis in patients less
than 50 years-old, particularly teenagers and young adults?
Neisseria gonorrhoeae
Which antibiotics should be avoided throughout pregnancy?
If the patient is still present in the Emergency Department, draw a single line
through the incorrect statement(s), noting the reason for the change, initialing
the correction(s) and time the change.
If the patient left the Department, add a signed, dated and timed addendum to
the chart.
What is the purpose of off-line (indirect) medical control?
Development of protocols
In a disaster situation, a patient with a barely palpable blood
pressure would be categorized as ________.
1- The “gold standard” is not to change shifts at all; work the same
shift all the time and keep the same sleep pattern.
2- Working only one or two night shifts in a row is the next best
strategy because it minimizes circadian disruption.
3- If rotating shifts cannot be avoided it is best to rotate all shifts in
a clockwise direction with a minimum of one month per rotation.
Scalded skin syndrome is usually caused by a _____ in children
(generally less than 6-years-old). Toxic epidermal necrolysis, on
the other hand, is most often caused by a ___ ___ in adults.
Pityriasis rosea
Clinical Presentation: A patient presents with a rash. He was given a thiazide
diuretic recently by the family physician. The rash is scaly or flaking and is
erythematous and warm to the touch.
Exfoliative erythroderma
Clinical Presentation: An elderly male has a history of prostate disease
with urinary tract infections. He presents with fever, a systolic BP < 100
mmHg and a rash. The lesions are erythematous with necrotic centers.
The same presentation could occur in a patient with pneumonia or COPD. In other
words, think about Pseudomonas with a possible gram-negative sepsis and this
particular rash.
Wood’s light examination is helpful in diagnosing which skin
disorders?
Erythrasma
Tinea versicolor
Porphyria cutanea tarda
Some pseudomonal skin infections
The most costly cause of malpractice is?
Failure to diagnose MI
Name the leading cause of septic shock.
Gram-negative bacteremia
Regarding Pseudomonas infections:
1-What is /are the drug(s) of choice?
2-what are alternative choices?
3- Which drug has been associated with multiple treatment failures and is no
longer recommended?
Incision and drainage is the choice, along with an oral cephalosporin and warm
soaks.
If the process extends under the nail, a portion of the nail must be removed.
How does one treat a felon?
1. Osteomyelitis
2. Pseudomonas
How is a skin abscess best treated in the ED?
Prehospital
If a patient has a wound which requires suturing but the patient claims that
he is allergic to lidocaine, what are the available options?
True*