Post Op and Surgical Care Post Op and Surgical Care Case 1 A 60-year-old female presents to your office for severe abdominal pain. She reports that she developed vague left lower quadrant abdominal pain yesterday. This morning she awoke from her sleep with severe, diffuse abdominal pain, anorexia, and vomiting. On examination she is lying very still. Temperature is 38.4° C, pulse 106, respirations 16, blood pressure of 100/62. She has dry mucous membranes. Her abdomen has diminished bowel sounds and is rigid with involuntary guarding and rebound tenderness greatest in the left lower quadrant. On pelvic examination, she is exquisitely tender on the left with a palpable mass. There are no masses on rectal examination, and her stool is negative for occult blood. Laboratory tests include a negative urine pregnancy, WBC 25,500/mm3, HCT 32%, platelets 450,000/mm3, Na 142 meq/L, K 3.2 meq/L, BUN 24 mg/dL, and Cr 1.0 mg/dL. Abdominal x-ray demonstrates free air under the diaphragm. Based on the information available, the most likely diagnosis in this patient is: A) Diverticulitis. B) Pelvic inflammatory disease. C) Appendicitis. D) Ovarian torsion. E) Abdominal aortic aneurysm. Answer: A Discussion The correct answer is A. The most likely cause of this patient’s symptoms is diverticulitis. Answer B, pelvic inflammatory disease (PID), is unlikely in a 60-yearold female. Also, the clinical presentation and pelvic exam findings are more consistent with diverticulitis than PID. Answer C, appendicitis, is unlikely because the pain is present on the left side as opposed to the right side, as one would expect with appendicitis. Answer D, ovarian torsion, is unlikely in a postmenopausal female unless there is a malignancy. Additionally, the pain of ovarian torsion should be colicky rather than constant and there should be no peritoneal signs (at least until the ovary is necrosed). Answer E, abdominal aortic aneurysm, is unlikely because of the exam findings here: there is no pulsatile mass, the patient is normotensive, there is fever, and you can palpate a left lower quadrant mass. However, in older patients presenting with abdominal pain, you must always keep the diagnosis of abdominal aortic aneurysm in mind. Which of the following is true regarding this patient’s underlying disease process? A) The majority of patients with this disease will develop symptoms at some time. B) The condition is associated with a high malignant potential. C) The condition has a peak incidence of occurrence in the sixth, seventh, and eighth decades of life. D) The condition primarily affects the ascending colon. Answer: C Discussion The correct answer is C. Diverticulosis is an acquired disease that peaks in the sixth, seventh, and eighth decades, with about 50% of octogenarians having the condition. Answer A is incorrect. Most are asymptomatic from the disease process with only 10–20% going on to develop symptomatic diverticulitis. Acute diverticulitis has a variety of presentations. Peridiverticular inflammation occurs when a fecalith becomes entrapped in a diverticular wall, resulting in a localized contained microperforation. Pain is typically acute and located in the left lower quadrant. Examination reveals only a mildly tender abdomen without any masses. Peridiverticular abscess and phlegmon result in worsening left lower quadrant abdominal pain, and often a mass is palpable. All of the following physical exam findings indicate peritonitis EXCEPT: A) Murphy’s sign. B) Rovsing’s sign. C) Involuntary guarding. D) Rebound tenderness. Answer: A Discussion The correct answer is A. Peritonitis, as the name implies, is inflammation of the peritoneum. It can be aseptic, bacterial, or viral. Most commonly, peritonitis results from bacterial contamination of the peritoneum after injury to an abdominal viscus. In this patient’s case, generalized peritonitis occurs because either an inflamed section of the colon ruptured or a phlegmon ruptured. Pain due to peritonitis is usually severe and associated with anorexia and emesis. The patient will often have fever, tachycardia, leukocytosis, signs of dehydration, and electrolyte abnormalities. Answer A, Murphy’s sign, is tenderness to palpation of the right subcostal region during deep inspiration and is associated with biliary colic and cholecystitis but does not indicate peritonitis. Answer B, Rovsing’s sign, is pain at the disease site when palpating another site, classically a finding in appendicitis; the area of peritoneal inflammation has increased pain when palpating elsewhere on the abdomen. Answers C and D, involuntary guarding and rebound tenderness, are classic findings in peritonitis. You have identified free air on x-ray, indicating a ruptured viscus. The best film for identifying free air in the abdomen is: A) A flat plate abdomen. B) An upright abdomen. C) A left lateral decubitus film of the abdomen. D) An upright chest radiograph. Answer: D Discussion The correct answer is D. An upright chest radiograph is the one best x-ray film for identifying free air in the abdomen. CT is more sensitive but is not available in all situations and is expensive. While you are waiting for the local surgeon to arrive, which of the following is the LEAST important part of appropriate preoperative management? A) Maintaining the patient in an NPO state. B) Administration of antibiotics to cover gram-negative bacteria. C) Administration of antibiotics to cover gram-positive bacteria. D) Administration of antibiotics to cover obligate anaerobic bacteria. Answer: C Discussion The correct answer is C. The treatment of gram-positive organisms is the least important part of treatment for this patient. Initial treatment of perforated diverticuli should include fluid replacement, electrolyte correction, and, if the patient is vomiting, placement of an NG tube. A urinary catheter can be placed in order to monitor fluid balance if appropriate. Antibiotic therapy should be empirically provided based on the most likely pathogens. Perforations of the appendix, diverticuli, and other parts of the colon account for >80% of the causes of acute bacterial peritonitis. Distal small bowel and colonic perforations should include coverage for gram-negative bacteria, such as E. coli, and obligate anaerobe pathogens, such as B. fragilis. Various antibiotic regimens can be used. Each has benefits and risks that must be tailored to the individual patient. Examples of possible regimens include single-agent treatment with secondgeneration cephalasporin versus an aminoglycoside with metronidazole. Your patient undergoes exploratory laparotomy with removal of a segment of the sigmoid colon and colostomy. On postoperative day 2, the pathologist reports presence of an adenoma in the removed segment. Which of the following is true regarding adenomas and colon cancer? A) Of polyps, tubular adenomas have the highest potential for malignancy. B) Polyps associated with Peutz-Jeghers have a high probability for malignant conversion. C) Most colon cancers occur in the lower right side. D) Colon (as opposed to rectal) cancer is more common in women. Answer: D Discussion The correct answer is D. There are several types of polyps. Inflammatory polyps are common in inflammatory bowel diseases and have no malignant potential. Hamartomas are often associated with Peutz-Jeghers syndrome and have very low malignant potential. Adenomatous polyps include villous, tubulovillous, and tubular. Villous tend to be sessile or flat while the others are more pedunculated. Approximately 7% of tubular, 20% of tubulovillous, and 33% of villous adenomas become malignant. Colon cancer most often occurs on the lower left side where the rectum begins. It peaks in the seventh decade. While rectal cancer is more common in males, colon cancer is more common in females. Following bowel rest for several weeks, your patient undergoes a colonoscopy. Several more polyps are noted during examination, as well as multiple diverticuli extending from the remaining sigmoidal colon to the splenic flexure. Biopsy results show adenocarcinoma. Which of the following tumor markers is elevated in colorectal cancer? A) PSA. B) CEA. C) Beta-HCG. D) CA-125. E) None of the above. Answer: B Discussion The correct answer is B. CEA, carcinoembryonic antigen, may be elevated in colon cancer. It is not useful as a primary screening tool due to low sensitivity and specificity. However, it is helpful in surveillance for recurrence of colon cancer after initial treatment. PSA will be elevated in prostatic cancer, beta-HCG in testicular cancer, and CA- 125 in ovarian cancer. However, CA-125 is not helpful in premenopausal women, in whom it is often found in the blood in low levels. Finally, AFP (alpha fetoprotein) is elevated in liver and testicular cancer. Note that beta-HCG and AFP are generally not elevated in testicular seminomas (although beta-HCG may be mildly elevated in up to 20%). Because of the cancer, hemicolectomy is indicated. Three weeks following your patient’s hemicolectomy, she presents complaining of abdominal pain. The pain is crampy and intermittent. Further history reveals a 24-hour history of vomiting, abdominal bloating, and low-grade fever. She reports her last bowel movement was 2 days ago and denies any flatus over the last 24 hours. On examination, her temperature is 37.1° C, pulse 95, respirations 12, and blood pressure 158/60. Her abdomen is slightly distended, diffusely tender to palpation without rebound or guarding, and has hyperactive bowel sounds. On flat-plate and upright views of the abdomen, there are dilated loops of small bowel and multiple air fluid levels. Which of the following is true regarding this patient’s current disease process? A) She most likely has a closed-loop small bowel obstruction. B) She most likely has an extramural source of obstruction. C) Dilated loops of bowel are defined as bowel loops <5 cm in diameter on plain film. D) Both partial and complete bowel obstructions reveal no colonic gas on plain film. Answer: B Discussion The correct answer is B. This patient most likely has an external source of obstruction. Bowel obstructions are divided into two classes: mechanical and functional (also known as pseudoobstruction, ileus, or neurogenic obstruction). Mechanical obstructions are further classified into both their location and etiology. Possible etiologies include intraluminal bodies (e.g., gallstone ileus or foreign body), intramural lesions (e.g., tumor or intussusception), and extramural lesions (e.g., adhesions). Mechanical obstruction location is divided into proximal obstructions including those at the level of the pylorus, duodenum, and jejunum. Distal obstruction includes the ileum, ileocecal valve, and ascending colon. Finally, low obstruction refers to lesions distal to the ascending colon. Obstructions can further be divided into open- and closed-loop. Open-loop obstructions have an outlet for gas and secretion relief (e.g., vomiting), whereas closed-loop obstructions block both inflow and outflow to an area. Closed- loop obstructions, like bowel torsion or volvulus, cause acute, severe abdominal pain. Bowel obstruction presents with crampy, intermittent abdominal pain, vomiting, distention, and obstipation. History often includes previous abdominal surgery and clinical exam generally includes abdominal distention. Depending on the degree of obstruction and its duration, there may be hyperactive bowel sounds, high-pitched bowel sounds, or decreased or absent bowel sounds. An upright abdominal plain film or lateral recumbent abdominal film confirm diagnosis with findings of dilated loops of small bowel (bowel >3 cm in diameter) on the flat plate and air-fluid levels on the upright or decubitus film. CT scan is more sensitive for obstruction than are plain films and will often reveal the source of the obstruction. However, CT should be reserved for patients in whom the diagnosis is unclear. Patients with a complete small bowel obstruction will lack air in the colon on plain film. However, remember that air can be introduced into the rectum during a rectal exam. Which of the following is NOT a cause of ileus? A) Burns. B) Spinal cord injury. C) Hypokalemia. D) Pneumonia. E) All of the above can cause an ileus. Answer: E Discussion The correct answer is E. All of the above can cause an ileus. Additional causes include: peritonitis, pancreatitis, uremia, narcotics, etc. You diagnose small bowel obstruction, which you believe is most likely related to adhesion formation after hemicolectomy. Which of the following is INCORRECT regarding the management of bowel obstruction? A) Initial treatment orders should include NPO, nasogastric decompression, intravenous fluid resuscitation, and electrolyte replacement as needed. B) This patient should undergo emergent surgical intervention. C) If she has fever or leukocytosis, she should undergo surgical intervention. D) If she requires surgery, broad-spectrum antibiotics to cover anaerobes and gram-negative aerobes should be administered perioperatively. Answer: B Discussion The correct answer is B. Peritoneal adhesions account for more than half of all small bowel obstructions. Approximately 5% of post–abdominal laparotomy patients require adhesion takedown. Up to 80% of episodes of small bowel obstruction caused by adhesions resolve without surgical intervention. Initial treatment for all patients with mechanical bowel obstruction includes restricting oral intake, intravenous fluid resuscitation with Ringer’s lactate or normal saline, and electrolyte correction. Almost all patients require nasogastric decompression to relieve pain and prevent passage of swallowed air. Patients can be safely observed if all of the following conditions are met: no fever, no leukocytosis, no tachycardia, and no localized abdominal pain. Indications for surgery include rapidly progressing abdominal pain or distention, development of peritoneal findings, fever, diminished urine output, leukocytosis, hyperamylasemia, metabolic acidosis, and persistent obstruction. Complete bowel obstruction should always be treated surgically. Also, patients with de novo obstruction (e.g., no history of laparotomy) usually require surgical intervention. If surgery is necessary, broad-spectrum antibiotics that cover anaerobes and gram-negative aerobes should be administered perioperatively to reduce wound infection and abdominal sepsis rates. Which of these patients with a small bowel obstruction can be safely observed? A) A patient with a fever and a partial small bowel obstruction. B) A patient with localized abdominal pain and a partial small bowel obstruction. C) An afebrile patient with a closed loop obstruction. D) All of the above. E) None of the above. Answer: E Discussion The correct answer is E, none of the above. See the answer to the question above for an explanation. Case 2 A 52-year-old female presents to your office as a new patient and requests a “100,000 mile tune-up.” She has not seen a physician in over 10 years and has one complaint today. She has a bulge in her right groin that occurs when she lifts heavy objects and when she coughs. She denies any episodes of severe, persistent pain, redness in the area, fever, or abdominal pain. On physical examination, she is an obese female with normal vital signs. When you ask her to perform a Valsalva maneuver, you can palpate a bulge in the right groin. Which of the following is true regarding this bulge? A) Since she is a female, it most likely represents a femoral hernia. B) Surgery is required in all such cases as soon as possible. C) The larger the bulge, the more likely it is to become incarcerated. D) Hernias are the most common cause of bowel obstruction in someone without prior abdominal surgeries. Answer: D Discussion The correct answer is D. Among patients who have not had abdominal surgery, hernias are the most common cause of bowel obstruction. When patients with a history of abdominal surgery are included, hernias are the second most common cause of bowel obstruction overall. Answer A is incorrect. Hernias in the groin can be direct, indirect, or femoral. In both men and women, the most common type is an indirect hernia, though femoral are more common in women than men. Direct hernias are rare among women. Answer B is incorrect because the surgical repair of hernias is elective. Surgery is absolutely indicated in cases of incarceration, but the incarceration rate is 5% initially and drops to 1% per year after 4–6 months. A risk/benefit analysis is recommended, especially in older patients with comorbid conditions. Answer C is incorrect. Larger hernias are less likely to incarcerate. Incarceration is defined as a loop of bowel slipping into a hernia and becoming entrapped. Strangulation occurs when the incarceration is so severe that it results in a compromised blood supply. To reduce her chances of having recurrent herniation after surgery, you advise her to: A) Be on bed rest before the operation. B) Lose weight before the operation. C) Burst and taper steroids before the operation. D) Pursue an aggressive weight loss program after the operation. Answer: B Discussion The correct answer is B. Obesity is associated with recurrent herniation after hernia repair, so obese patients should be instructed to lose weight before surgery. Other factors associated with hernia recurrence are smoking, steroid use, and infection. Answers A, C, and D are all incorrect because they may increase the risk of hernia recurrence after repair. Your patient mentions that her 6-month-old grandson has a bulge at his navel. Regarding hernias in infants and children, which one of the following statements is most accurate? A) Umbilical hernias in infants require repair if not closed by 1 year of age. B) A scrotal sac that is translucent with a bright light is likely a hydrocele. C) Omphaloceles occur to the right of the umbilicus. D) Caucasian infants have the highest rate of umbilical hernias. Answer: B Discussion The correct answer is B. A scrotal sac that is translucent is generally a hydrocele. A hydrocele is a fluid collection in the tunica vaginalis of the scrotum or processus vaginalis in the inguinal canal. Hydroceles can either be present at birth or develop later. Clinically, a hydrocele illuminates with a bright light. However, it is important to remember that this finding can also be observed with an incarcerated inguinal hernia. Answer A is incorrect. Most umbilical hernias close spontaneously within the first 2–3 years of life. Because of this, operative repair is not recommended before the age of 2 years. Answer C is incorrect. An omphalocele is a defect in the anterior abdominal wall through which intraabdominal contents are extruded. It is seen at the base of the umbilicus (not to the right), and the organs are covered with a membrane. A neonate with a herniation of intraabdominal contents to the right of the umbilicus may have gastroschisis. Needless to say, omphalocele and gastroschisis require surgical repair. Answer D is incorrect. Umbilical hernias occur in 4–9% of Caucasians and 25–50% of black infants. They rarely pose any threat to the infant. Case 3 A 24-year-old male presents to your clinic with a 5- day history of rectal bleeding. For several years, he has had constipating stools but has developed rectal bleeding in the last few days. In addition, he has severe, intermittent, crampy abdominal pain (presumably from constipation). He reports a mild fever. On examination, temperature is 37.9° C, pulse 95, respirations 12, and blood pressure 108/78. His abdomen is nontender. He has no guarding or rebound tenderness. Anoscopy reveals gross blood and 2 internal hemorrhoids. Regarding hemorrhoids in general, which of the following is true? A) Patients with hemorrhoids most commonly complain of perianal burning, itching, swelling, and pain. B) A grade III hemorrhoid can be reduced manually. C) If a patient under the age of 50 with rectal bleeding is found to have hemorrhoids on examination, further studies are not indicated. D) Because they are above the dentate line, strangulated internal hemorrhoids are not painful. Answer: B Discussion The correct answer is B. Grade III hemorrhoids can be reduced manually. Hemorrhoids are normal vascular structures in the anal canal; however, the venules can become engorged and symptoms such as pain, bleeding, and itching may result. Two types of hemorrhoids exist: external hemorrhoids derive from the inferior hemorrhoidal plexus below the dentate line, and internal hemorrhoids derive from the anal cushions above the dentate line. Internal hemorrhoids occur on the left lateral, right anterior, and right posterior anal walls and are classified into Grades I–IV. Grade I hemorrhoids slide below the dentate with straining but not through the anus. Grade II protrude from the anus but spontaneously reduce, whereas Grade III hemorrhoids must be manually reduced. Grade IV internal hemorrhoids cannot be reduced. Answer A is incorrect because most patients with symptomatic hemorrhoids present with painless rectal bleeding. Answer C is incorrect. You should consider further evaluation (e.g., flexible sigmoidoscopy, colonoscopy, etc.) in patients under the age of 50 presenting with rectal bleeding, even if hemorrhoids are present and are the likely source of bleeding. In patients older than 50 with rectal bleeding, a full colonoscopy is routinely recommended to rule out any cancerous process. Answer D is incorrect. Although most internal hemorrhoids do not cause pain, strangulated internal hemorrhoids are very painful and can become necrotic and gangrenous, requiring emergent surgery. Which of the following would you NOT consider as a treatment for this patient’s hemorrhoids? A) Psyllium. B) Dicyclomine. C) Warm sitz baths. D) Short course of topical hydrocortisone. E) Increased water intake. Answer: B Discussion The correct answer is B. Dicyclomine (Bentyl, Antispas) is not indicated. Dicyclomine is an anticholinergic and will contribute to constipation—exactly what you want to avoid in patients with hemorrhoids. Answers A and E are the primary modes of treatment. Psyllium, as well as a diet high in fiber and water, will reduce straining and thus reduce intra-abdominal pressure. Answer C, warm baths or showers, have been shown to reduce anal canal pressures (40° C). Answer D, a short course of topical hydrocortisone (e.g., Anusol HC), may be of benefit. Long-term topical steroids are contraindicated. Finally, good hygiene and analgesia should be prescribed as needed. Which of the following is TRUE about treating hemorrhoids surgically? A) Irritable bowel syndrome is a relative contraindication to hemorrhoid surgery. B) It is best to ligate all hemorrhoids in a single office visit. C) Band ligation results in sloughing of hemorrhoids in about 1–2 weeks. D) Following excision, thrombosed external hemorrhoids should be closed to prevent bleeding. Answer: C Discussion The correct answer is C. Rubber-band ligation generally results in the sloughing of the hemorrhoid in 1–2 weeks. Answer A is incorrect. Inflammatory bowel disease—not irritable bowel syndrome—is a relative contraindication to the surgical treatment of hemorrhoids. Other contraindications to office-based hemorrhoidectomy procedures include bleeding diathesis, pregnancy, postpartum period, anorectal fissures, active anorectal infections, AIDS or other immunodeficient states, portal hypertension, rectal wall prolapse, and anorectal tumors. Complications of hemorrhoidectomy include pain, significant bleeding with sloughing, thrombosis of external hemorrhoids, and very rarely sepsis with pelvic cellulitis. Answer B is incorrect. Although evidence is scarce, standard of care dictates that only 1 hemorrhoid be ligated in a single office visit (due to concerns about excessive tissue necrosis). Answer D is incorrect. Patients who present with external hemorrhoids that are painful, tender, swollen, and with bluish discoloration have thrombosis. If the patient presents within 48 hours of thrombosis, the thrombus should be expressed. It is specifically important not to close the hemorrhoid once the clot is expressed. In fact, a small ellipse of the hemorrhoid should be removed to facilitate continued drainage to and prevent reaccumulation of clot. You prescribe conservative treatment for your patient’s hemorrhoids, and since he does not return for his next scheduled appointment, you assume he is doing well. You see him again 6 months later. He reports that he had indeed healed. Although he still takes psyllium, he began having painful bowel movements with blood-streaked stool 2 days ago. Upon examination of the anus, you find a fissure. All of the following findings would lead you to consider Crohn’s disease EXCEPT: A) Posterior midline fissure. B) Painless fissure. C) Multiple fissures. D) Nonhealing fissure. Answer: A Discussion The correct answer is A. The posterior midline is where solitary fissures, unrelated to inflammatory bowel disease, are typically located. Fissures in any other location should raise suspicion for Crohn’s disease. Answers B, C, and D are also suggestive of Crohn’s. In a patient with an uncomplicated, initial anal fissure, what do you recommend for first-line therapy? A) Lord’s dilation. B) Botulinum toxin injections. C) Topical nitroglycerin. D) Oral psyllium. E) Oral nifedipine. Answer: D Discussion The correct answer is D. All of the options are employed for treating anal fissures. However, in patients with an uncomplicated, initial anal fissure, it seems prudent to initiate conservative therapy (e.g., psyllium, dietary fiber, water, warm soaks, etc.) prior to proceeding to more invasive measures. Most fissures will respond to conservative measures. Generally, healing takes 2–4 weeks. In addition to the treatments listed, topical diltiazem and topical nifedipine are also used, as are various surgical approaches. Lord’s dilation deserves special mention as a relatively arcane procedure for stretching the anal sphincter muscle (under anesthesia, we hope!). You note that this patient’s fissure is deep, ulcerating, and located at the left lateral aspect of the anus. Given this examination, you are concerned about Crohn’s disease. You briefly consider what you know about inflammatory bowel disease (IBD). Which of the following is true of IBD? A) Ulcerative colitis is primarily a diagnosis of young males. B) Crohn’s disease can be isolated to colonic disease. C) Ulcerations with cobblestone appearance are consistent with a diagnosis of ulcerative colitis. D) Crohn’s disease is more common in blacks, while ulcerative colitis is more common in whites. Answer: B Discussion The correct answer is B. Crohn’s disease can be isolated to the colon. Answer A is incorrect because ulcerative colitis is evenly distributed between men and women, with a similar incidence in each. Answer C is incorrect because ulcerations with a “cobblestone” appearance are more consistent with a diagnosis of Crohn’s disease. However, it is difficult to make a diagnosis on visual appearance alone; biopsy is required. Answer D is incorrect. In general, inflammatory bowel disease is more common in whites than nonwhites. Your patient undergoes a colonoscopy with biopsies. The initial results are consistent with Crohn’s disease. Which of the following treatment options should NOT be considered at this time? A) Oral sulfasalazine. B) Oral mesalamine. C) Partial colectomy. D) Oral prednisone. Answer: C Discussion The correct answer is C. Proceeding to surgery is premature. Answer A, oral sulfasalazine, can be used for the treatment of inflammatory bowel disease. Any of the other choices are reasonable as initial therapy in this patient. Other immunosuppressives (e.g., cyclosporine, 6-mercaptopurine) have also been used with success but are considered second-line drugs. For what reason(s) might you refer this patient with Crohn’s disease for surgical intervention? A) Dependence on mesalamine to maintain remission. B) Annoying diarrhea. C) Prophylactic colectomy for extensive small bowel disease. D) Progression of symptoms despite maximal medical therapy. E) All of the above. Answer: D Discussion The correct answer is D. Of the potential indications listed, only disease progression despite maximal medical therapy is an accepted reason for surgical intervention in Crohn’s disease. Answer A is incorrect. Although dependence on steroids is sometimes considered an indication for surgery, dependence on mesalamine (with its more favorable side effect profile) should not be. Answer B is incorrect for obvious reasons. Answer C is incorrect. Although Crohn’s colitis is associated with an increased risk of colon cancer, Crohn’s disease of the small bowel is not. Which of the following is NOT a complication of Crohn’s disease? A) Spondyloarthropathy. B) Pyoderma gangrenosum. C) Uveitis. D) Amyloidosis. E) Hypercalcemia. Answer: E Discussion The correct answer is E. Hypocalcemia may occur as a result of malabsorption and can lead to tetany. All of the other options are complication of Crohn’s disease. Of particular note, amyloidosis can be secondary to chronic inflammation. Amyloid is an acute-phase reactant that is increased in inflammation and deposited in tissues. Case 4 An orthopedic colleague asks you to consult on a 64- year-old male prior to an elective total hip replacement. The surgery is scheduled for 3 months from now. The patient is a smoker with diabetes mellitus type 2 and has recently had a cardiac catheterization that showed significant, but non-bypassable, disease. He is asymptomatic and is able to walk stairs without difficulty. The surgeon would like some preoperative recommendations. You would recommend all of the following EXCEPT: A) The patient should stop smoking 4 weeks before surgery. B) The patient should have preoperative and postoperative beta-blockers if the pulmonary status allows it. C) The patient should have a chest radiograph done. D) The patient should have his hemoglobin/hematocrit drawn. E) The patient should have his creatinine measured. Answer: A Discussion The correct answer is A. Paradoxically, unless patients stop smoking 8 weeks or more before surgery, the risk of adverse pulmonary outcomes is increased. The cause of this phenomenon remains unclear but may occur because the cilia are able to mobilize material in the lungs. Answer B is true. The use of pre-, intra- and postoperative beta- blockers is well supported for patients with coronary artery disease. One of the most serious intraoperative events is a myocardial infarction. Beta-blockers have been shown in multiple studies to reduce this risk and to improve outcomes if the patient has an elevated risk for a myocardial infarction. While answers C, D, and E are true, a lot of other routine preoperative assessment is not supported in the literature, but is recognized as the standard of care. You perform a physical examination on this patient. His vital signs are normal. He is mildly obese. You find a carotid bruit on the right. A carotid duplex examination shows 50% stenosis on the right and minimal stenosis on the left. Of the following, which is TRUE in regard to the treatment for carotid artery disease? A) This patient should undergo carotid endarterectomy immediately. B) Carotid endarterectomy should be used only in patients with symptomatic lesions with stenosis >80%. C) There is a 10% recurrence of lesions in patients who have undergone carotid endarterectomy. D) Morbidity and mortality of carotid endarterectomy approaches 10% for even the best of surgeons. E) Medical management in this patient would start with warfarin. Answer: C Discussion The correct answer is C. Lesions tend to recur in 10% of patients who have undergone endarterectomy. Answer A is incorrect. There is no indication for immediate surgery in this patient. Experienced surgeons have a morbidity and mortality rate of less than 2% with a recurrence rate around 10%. Medical treatments should always be instituted unless contraindicated. The focus is on controlling hypertension, hyperlipidemia, and other vascular risk factors. Medical management typically starts with antiplatelet agents, such as aspirin or clopidogrel, not with anticoagulant agents (e.g., warfarin). You now turn your attention to his diabetes. Regarding preoperative management of diabetic regimens, which of the following statements is FALSE? A) A type 2 diabetic who is diet-controlled should be given no insulin or glucose preoperatively. B) A diabetic patient taking only an oral hypoglycemic agent should be given no insulin or glucose preoperatively. C) Any oral hypoglycemic agents taken by a diabetic patient should be held 1–2 days prior to surgery. D) If a diabetic patient is on insulin, his or her shortacting insulin should be held entirely and twothirds of the NPH dose should be administered. Answer: D Discussion The correct answer is D. Currently, for type 2 diabetics who are controlled by either diet or oral hypoglycemics, no insulin or glucose is recommended before surgery. Instead, if glucose levels are >250 mg/dL, sliding scale short- acting insulin should be administered. Because of the prolonged effects of many oral hypoglycemic agents, they should be held 1–2 days prior to surgery. Type 1 diabetics and insulin-dependent type 2 diabetics should have their short-acting insulin held and one-third to one-half of their long-acting insulin given the morning of surgery. Glucose levels should be drawn every 1–2 hours thereafter, with appropriate sliding scale insulin administered in response. The patient undergoes his hip replacement and his postoperative EKG is normal. Four hours after surgery, he develops mild respiratory distress, a fever, and cough. On chest x-ray, there is a right lower lobe infiltrate. There is no evidence of fluid overload. Which of the following is the most likely cause of this patient’s fever and infiltrate? A) Pneumococcus. B) Gram-negative organisms. C) Atelectasis. D) Aspiration pneumonitis. E) Aspiration pneumonia. Answer: D Discussion The correct answer is D. In the hours after surgery, an aspiration pneumonitis would be the most likely cause of this patient’s current findings. Aspiration pneumonitis occurs when there is aspiration of gastric contents with a pH of <2.5. In order for aspiration pneumonitis to develop, the volume of aspirate needs to be at least 1–4 mL/kg of stomach contents. Aspiration pneumonitis develops over a matter of hours. In contrast, pneumococcal and gram- negative pneumonias generally develop several days after surgery (unless a subclinical pneumonia was present at the time of surgery). Aspiration pneumonia is comprised of anaerobes and mixed flora and develops slowly over days to a week. Atelectasis warrants special mention. Atelectasis does not cause fever. Both atelectasis and fever occur frequently in the postoperative period, but their occurrence together is most likely due to chance. The old adage about atelectasis and fever has been shown to be untrue. Thus, in the postsurgical patient with fever, look for another cause besides atelectasis. Of the following, which generally is NOT a cause of postoperative fever in the first 48 hours? A) Malignant hyperthermia. B) Surgical “trauma” (e.g., cutting through muscle). C) Wound infection. D) Hyperthyroidism. E) Drug fever. Answer: C Discussion The correct answer is C. Wound infections generally are not found in the first 48 hours after surgery. All of the rest can be found either immediately after surgery (malignant hyperthermia, hyperthyroidism, drug fever) or soon thereafter (fever from surgical trauma secondary to the release of cytokines). The patient’s chest radiograph is consistent with aspiration pneumonitis (infiltrate in the right lower lobe). Which of the following is NOT true with regard to aspiration pneumonitis? A) It can progress to ARDS. B) Patients with aspiration pneumonitis present with fever, dyspnea, bronchospasm, and hypoxia. C) It should be treated with antibiotics that cover anaerobes. D) It tends to resolve in about 7 days. Answer: C Discussion The correct answer is C. Aspiration pneumonitis is a chemical process that is unrelated to infection. Thus, aspiration pneumonitis does not need to be treated with antibiotics at all (although it usually is as a practical matter). The rest of the answer choices are true. You treat the patient with fluids and tracheal suction. However, he remains tachycardic and febrile. There is no evidence of dehydration at this point. Which of the following would be the most appropriate first step in the treatment of tachycardia in this postsurgical patient? A) Oral or rectal aspirin. B) Oral or rectal acetaminophen. C) IV beta-blockers. D) IV fluids. Answer: B Discussion The correct answer is B. The initial treatment for this patient is acetaminophen. Reducing the fever and metabolic stress will result in reduction of the heart rate. Answer A is not the best choice since this patient is postsurgical. Giving aspirin (an antiplatelet agent) may result in increased postoperative bleeding. Answer C, IV beta-blockers, can be used and would be appropriate if the patient was having ischemic symptoms and needed an immediate reduction in pulse. Answer D, IV fluid, is incorrect in this patient who is already well hydrated (as stipulated in the question). Note that IV fluids are appropriate in postoperative tachycardia if the patient is dehydrated. You are called to see the patient again. Despite his aspiration pneumonitis, he seemed to be doing well. Then, about 72 hours after surgery, he suddenly developed hypoxia, mental status changes, and a petechial rash. The patient is noted to have thrombocytopenia and fat globules in his urine. The most likely diagnosis is: A) Fat embolism syndrome. B) Thrombotic thrombocytopenic purpura. C) Idiopathic thrombocytopenic purpura. D) Sepsis. Answer: A Discussion The correct answer is A. This is most likely fat embolism syndrome. The triad of hypoxia, mental status changes, and petechial rash should suggest fat embolism. The rash, which is classically confined to the axillae and above (including conjunctivae), is pathognomonic. However, it is only found in 50% of individuals with this syndrome. Answer B is incorrect. Thrombotic thrombocytopenic purpura (TTP) is generally associated with renal failure and fluctuating neurologic symptoms. Additionally, patients with TTP have a microangiopathic anemia. Answer C is incorrect. Idiopathic thrombocytopenic purpura (ITP) is not associated with the neurologic and pulmonary findings occurring with fat embolism syndrome. Answer D is incorrect. Sepsis can present with some similar symptoms but, again, the picture is most consistent with fat embolism. Fat embolism can be caused by which of the following? A) Liposuction. B) Closed treatment of long bone fractures (e.g., external reduction and casting). C) Hip replacement surgery with reaming of the femoral canal. D) Sickle-cell anemia. E) All of the above can cause fat embolism syndrome. Answer: E Discussion The correct answer is E. All of the above can cause fat embolism syndrome. It can also be associated with rapid lipid infusion, fatty liver, panniculitis, bone tumor lysis, etc. Case 5 A 15-year-old male presents to your office with a 3-day history of diarrhea and right lower quadrant pain. He has tenderness in the right lower quadrant with guarding and rebound. He remains afebrile and has been hungry, scarfing down 5 waffles for breakfast. The patient has no other significant history. You decide that this patient might have appendicitis, so you draw some labs. The patient has a normal white blood cell count (7,500/mm3) and a normal urinalysis. Which of the following is true about appendicitis? A) A normal white count effectively rules out the diagnosis of appendicitis. B) The majority of patients with appendicitis present with fever. C) The absence of anorexia effectively rules out appendicitis. D) A fecalith is found on radiograph in the majority of patients with appendicitis. E) None of the above. Answer: E Discussion The correct answer is E. None of the above is true. In order, 10% of patients with appendicitis have a normal white count, a minority of patients with appendicitis present with fever (15% in one study), only 75% of patients with appendicitis complain of anorexia, and a radiographic fecalith is found in only a small minority of patients. Which of the following is specific for appendicitis? A) Obturator sign. B) Psoas sign. C) Rovsing’s sign. D) Tenderness at McBurney’s point. E) None of the above is specific for appendicitis. Answer: E Discussion The correct answer is E. None of the above is specific for appendicitis. An obturator sign is present if there is pain on internal and external rotation of the hip. The obturator sign can be seen with any pelvic abscess that is in contact with the hip area, but is more commonly seen with a retrocecal abscess. The psoas sign is pain on use of the psoas muscle (e.g., lifting the leg at the hip), and it can be seen with any inflammatory process that is in contact with the psoas muscle, including a psoas abscess. Rovsing’s sign occurs when pain increases in an area of peritonitis when the abdomen is palpated elsewhere. For example, in a patient with appendicitis, right lower quadrant pain will be increased with palpation of the left lower quadrant. This is indicative of peritonitis in the area that has increased pain, but it is not specific for appendicitis. Tenderness at McBurney’ s point can be seen in a number of processes, including appendicitis, ileitis, any process in the cecum, urinary tract infection, etc. Which of the following is true about the treatment of pain in the acute abdomen? A) Early treatment with morphine will obscure the proper diagnosis. B) Treatment with pain medication invalidates informed consent. C) Early treatment of pain with morphine is safe except in children. D) Ketorolac is preferred for patients who may undergo a surgical procedure. E) None of the above is true. Answer: E Discussion The correct answer is E. None of the above is true. Early treatment of pain in the acute abdomen actually improves diagnostic accuracy in both children and adults. Ketorolac is not a good choice because of its antiplatelet effects. This will increase the risk of bleeding intraoperatively. Although you have thought a lot about his potential problem, you have not actually done anything more for the 15- year-old with abdominal pain! The test most likely to help you arrive at a diagnosis in this patient is: A) Erythrocyte sedimentation rate (ESR). B) C-reactive protein (CRP). C) Abdominal ultrasound. D) Abdominal CT scan. E) Colonoscopy. Answer: D Discussion The correct answer is D. The test most likely to be helpful in arriving at a diagnosis in this patient is a CT scan of the abdomen looking at the appendix. Answers A and B are incorrect. Both the CRP and the ESR are nonspecific markers of inflammation and are not helpful in the diagnosis of appendicitis. Answer C, an ultrasound, can be used. However, it is not as sensitive as a CT scan. Ultrasound can be useful in the female patient in whom other diagnoses need to be ruled out, such as ovarian cysts or torsion. But when looking specifically at the appendix, CT is preferable. Answer E, colonoscopy, is not particularly useful in the diagnosis of appendicitis but could be used for other purposes, such as looking for inflammatory bowel disease once appendicitis is ruled out by CT. If this patient’s CT scan is positive for appendicitis, the likelihood that he will have a normal appendix removed at appendectomy is: A) 5% B) 10% C) 15% D) 20% Answer: C Discussion The correct answer is C. Unfortunately, the false-positive rate (of taking normal patients to the OR) has not really changed with CT scan. The negative laparotomy rate is still about the same as it was in the pre-CT era. The negative laparotomy rate has gone down in men and in the young but has increased in the elderly and in women. Also, CT may contribute to a delay in therapy and an increased rate of rupture prior to surgery. In general, which of the following is true about appendicitis? A) Pain is in the right upper quadrant in the majority of pregnant women with appendicitis. B) Atypical presentations are more common in the elderly patient than in other groups. C) Patients with a retrocecal appendix generally present with well-localized tenderness and signs of peritoneal irritation. D) None of the above is true. Answer: B Discussion The correct answer is B. Symptoms tend to be atypical in the elderly. In fact, elderly patients may have appendicitis with a normal white count, poorly localized pain, and absence of fever. Answer A is incorrect. Despite classic teaching, patients who are pregnant tend to have “typical” symptoms with right lower quadrant pain. This is especially true in the first half of pregnancy. Certainly the appendix can be displaced cephalad, but the majority will still have right lower quadrant pain. Answer C is incorrect. Patients with retrocecal appendicitis will commonly complain of a dull ache. However, signs of peritoneal irritation may be minimal or absent. Case 6 A 28-year-old white male who was the restrained front passenger of a vehicle traveling in excess of 60 mph is brought to the ED via ambulance. The driver of the vehicle was found dead at the scene. Ambulance personnel report it took 5–10 minutes to extricate the patient. On arrival, he is mumbling incoherently. He is initially able to give his name, but he is slurring his words. He denies any medical problems, medications, or allergies. Vitals signs include temperature of 35.5°C, pulse 148, respirations 35, blood pressure of 65/30, and oxygen saturation of 81% on 100% oxygen by face mask. On exam, he is in severe respiratory distress. Lung sounds are absent on the right and diminished on the left. Heart sounds are muffled. You determine that this patient needs immediate treatment for a pneumothorax. Which of the following is most appropriate at this time? A) Perform needle decompression on the left. B) Perform needle decompression on the right. C) Place a chest tube on the left. D) Place a chest tube on the right. E) Perform a chest radiograph and act on the basis of the results. Answer: B Discussion The correct answer is B. The combination of hypotension, hypoxia, and absent breath sounds suggests a tension pneumothorax. Immediate decompression of the affected hemithorax should be performed by placing a large-bore (14- or 16-gauge) needle through the chest wall to relieve intrathoracic pressure. Traditionally this was accomplished by placing a needle in the second intercostal space at the midclavicular line. However, due to high risk of mediastinal vascular injuries, current practices recommend placing the needle in the traditional location for chest tube—that, is the fifth or sixth intercostal spaces at the midaxillary line. Of particular note is answer E. Tension pneumothorax should never be diagnosed on a chest radiograph. It is a true emergency that requires treatment on the basis of clinical exam. Following needle decompression, your patient’s vital signs are now improved: pulse 122, respirations 28, blood pressure 88/40, and oxygen saturation of 92% on 100% oxygen by face mask. Due to the extent of injuries and continued respiratory difficulties, you intubate the patient. In proceeding with your “ABC” evaluation, you consider the patient’s circulatory status. You estimate that he weighs about 70 kg. Assuming that there is no further fluid loss, what is the APPROPRIATE fluid resuscitation to return his vascular volume to normal? A) 1,500 cc. B) 3,000 cc. C) 4,500 cc. D) 6,000 cc. Answer: C Discussion The correct answer is C. What follows is a way to estimate the patient’s fluid loss—of interest to test-writers but of less interest in the ED. Each 10% of volume lost is equivalent to 500 cc of intravascular volume depletion in a 70 kg male. A 10% volume loss will result in no changes in vital signs. A 20% volume loss results in isolated tachycardia. At 30% volume loss, there is hypotension, tachycardia, possibly altered mentation, and peripheral vasoconstriction resulting in hypothermia. At 50% volume loss, there is marked hypotension, tachycardia, altered mentation, and vasoconstriction. Given this patient’s exam, you can estimate a loss of 30% of his intravascular volume for a total of 1,500 cc of estimated loss (average intravascular volume in 70 kg man = 5,000 cc, thus a 30% volume loss =1,500 cc). Then you must remember that intravascular volume will redistribute to the extravascular space, so fluids should be replaced at a 3:1 ratio. In this case, correct fluid administration for an estimated 30% fluid loss would be 4,500 cc. Use crystalloid solution (normal saline or Ringer’s lactate) via 2 large-bore IV catheters. Note, however, that once a patient has not responded to 2 liters of crystalloid, blood may be necessary. Following improvement in his vital signs, the patient is placed in external fixation device for femur fracture. Operating room fixation is deferred secondary to instability of the patient’s medical status. He is admitted to the intensive care unit on a respirator with Ccollar following negative FAST examination (Focused Assessment with Sonography for Trauma, a sonographic evaluation to rule out fluid in perihepatic, perisplenic, pelvic, and pericardial spaces). Repeat chest x-ray on arrival shows the endotracheal tube and chest tube in appropriate positions. Several rib fractures are noted. There is opacity over the left chest that was not present on the initial trauma chest series. Which of the following is true of this condition? A) It occurs in fewer than 25% of patients with significant blunt trauma to the chest. B) Treatment includes aggressive intravenous steroid and fluid administration. C) The condition starts to resolve in 48–72 hours. D) Treatment includes appropriate antibiotics. Answer: C Discussion The correct answer is C. The condition, pulmonary contusion, begins to resolve in 48–72 hours. However, 2–3 weeks may be required for complete resolution. Answer A is incorrect. Pulmonary contusion occurs in up to 70% of trauma patients with significant blunt chest trauma. It is usually, but not always, associated with fractured ribs. There may also be a flail segment noted. A chest x-ray demonstrates an infiltrative pattern over the affected area, usually about 1 hour posttrauma, but as long as 6–7 hours later. The condition results in a ventilation-perfusion mismatch and is associated with hypoxemia and an increased A-a gradient. If a patient is able to maintain oxygenation and ventilation, intubation may not be required. Answers B and D are incorrect. Treatment currently only involves intubation as necessary, observation, and tincture of time. You elect to proceed with pulmonary artery catheter placement due to the severity of this patient’s condition. Overnight he begins to decompensate. The nurse pages you with his vital signs and Swan-Ganz readings: temperature 37.0, pulse 100, respirations 20 (ventilator set at 14), blood pressure 82/30, PCWP 24 mm Hg (normal 5–15), CI 2.0 L/min/m2 (normal 2.5–3.5), SVR 2,000 dyne-sec/cm2 (normal 1,000–1,500), and oxygen delivery of 700 ml/min (normal 900–1,200). What is the cause of shock at this time? A) Hypovolemic shock. B) Neurogenic shock. C) Cardiogenic shock. D) Septic shock. Answer: C Discussion The correct answer is C. This patient appears to be in cardiogenic shock (elevated pulmonary capillary wedge pressure, decreased cardiac index). Cardiogenic shock may be caused by myocardial failure, valve failure, dysrhythmias, and tamponade. Treatment is directed at the underlying disorder. Shock is classified into hypovolemic; cardiogenic (pump failure); distributive, secondary to inappropriate arterial dilatation (e.g., adrenal insufficiency, anaphylaxis); neurogenic (following cord injury and loss of autonomic function) or noninfectious systemic (inflammatory response system); and obstructive (venous return compromise from cardiac tamponade, tension pneumothorax, etc.). Part of the injuries sustained by this patient include burns to the abdomen and back. Which of the following is FALSE regarding burn wound management in general? A) The Parkland formula for fluid resuscitation calls for 2–4 mL/kg/% body surface area burned, with half of the volume in the first 8 hours and the other half over the next 16 hours. B) Escharotomy should be performed on all partialthickness burns. C) Patients with chemical burns should be treated first with at least half an hour of tap water irrigation. D) Prevention of wound infection via topical antimicrobial agents, such as silver sulfadiazine cream, or via silver- coated dressings is the standard of care. Answer: B Discussion The correct answer is B. Escharotomy is not necessary unless there is a full-thickness wound that is circumferential and is compromising vascular supply. The thinking about this is changing and some suggest escharot omy of all full- thickness burns. Answer A is a correct statement about the Parkland formula. Answer C is also correct with the addendum that any particulate matter should be brushed off prior to irrigation. Water may activate some substances such as sodium hydroxide. Answer D is also a correct statement. Which of the following is true regarding fluid administration in burn and dehydrated patients? A) A peripheral line will deliver fluid more rapidly than a central line of an equivalent gauge. B) Albumin is the fluid of choice in the treatment of burns and should be considered for all patients with significant fluid deficits C) D5 one-half normal saline is the preferred fluid for fluid resuscitation in patients other than burn patients. D) All of the above are true. E) None of the above are true. Answer: A Discussion The correct answer is A. A peripheral line will deliver fluid more rapidly than a central line of an equivalent gauge, according to Poiseuille’s law (flow is directly proportional to tube radius and inversely proportional to tube length). The shorter the catheter, the more quickly fluid is delivered (think of a short traffic jam as opposed to a longer one on the same size road). Answer B is incorrect. Albumin is not considered helpful in most situations and is certainly not the fluid of choice. In fact, albumin may increase adverse outcomes. Answer C is also incorrect. Normal saline—or lactated Ringer’s if you are a surgeon—are the fluids of choice in treating dehydration. Remember that lactated Ringer’s is actually slightly hypotonic and thus may worsen cerebral edema. There is no evidence favoring lactated Ringer’s over normal saline. Emergency Medicine Emergency Medicine Case 1 You get a call from a mother who is panicked because her 4-year-old took some of her theophylline. She thinks it may have been as many as 10 pills but is not clear on the actual number. She is about 35 minutes from the hospital. Your advice to her is: A) Give ipecac to promote stomach emptying and reduce theophylline absorption. B) Do not give ipecac and proceed directly to the hospital. C) Call poison control and then proceed to the hospital. D) None of the above. Answer: B Discussion The correct answer is B. Do not give ipecac but proceed to the hospital. Answer A is incorrect for a couple of reasons. First, giving ipecac is not a particularly effective method of emptying gastric contents. More important, if the patient should start to seize while vomiting as a result of the ipecac, she could aspirate the vomitus, causing an aspiration pneumonitis. Answer C is incorrect because you do not want to delay definitive treatment. You can call poison control while the patient is on the way in. The patient arrives in your ED. She is alert with a tachycardia of 160 beats per minute but with a stable blood pressure. The ingestion occurred about 2.5 hours ago (the child was alone only during that time window). You decide that the next step is GI decontamination. Which of the following statements is true about gastric lavage? A) Except in extraordinary circumstances it should only be done in the first 1.5 hours after an overdose. B) Patients who have had gastric lavage have a higher incidence of pulmonary aspiration than patients who have not. C) The maximum volume that should be used is up to 5 liters. D) It can push pill fragments beyond the pylorus. E) All of the above are true. Answer: E Discussion The correct answer is E. All of the options are true. Generally, the efficacy of gastric lavage is limited. The outcome data do not support the use of gastric lavage after the first 1.5 hours and many experts are now recommending that the time frame be reduced to less than 1 hour. In a particularly severe overdose or in an overdose that is likely to delay gastric emptying (e.g., anticholinergics such as diphenhydramine or tricyclic antidepressants), you might want to try lavage beyond the 1.5 hours, but such circumstances are unusual. Also, patients who have been lavaged do have an increased risk of pulmonary aspiration. It is not a benign procedure. The amount of fluid used for lavage should be limited to a maximum volume of 5 liters. Finally, lavage can push pill fragments beyond the pylorus. The next best step to take with this patient is to: A) Check blood theophylline levels and refer for hemodialysis if markedly elevated. B) Administer 1 gm/kg of charcoal with sorbitol. C) Prophylactically treat this patient for seizures using lorazepam. D) Prophylactically treat this patient for seizures using phenytoin. Answer: B Discussion The correct answer is B. Giving charcoal is indicated in almost all overdose situations. Answer A is incorrect because the patient’s situation could deteriorate by the time blood levels return. Answers C and D are incorrect because seizure prophylaxis is not indicated in this patient. Although seizures are a major manifestation of theophylline toxicity, they are more likely to occur in patients who take theophylline chronically and have toxic blood levels. Acute ingestions are less worrisome. For which of these overdoses is charcoal NOT indicated? A) Acetaminophen. B) Aspirin. C) Iron. D) Digoxin. E) Opiates. Answer: C Discussion The correct answer is C. Charcoal will not bind iron. Thus, it will be of no benefit in iron overdose. Some of you may have answered A. Theoretically, charcoal could interfere with the action of N-acetylcysteine, the antidote for acetaminophen ingestion, by absorbing it. However, this is more of a theoretical concern than an actual one. First, the drugs should be used at different times. Charcoal should be given immediately while N-acetylcysteine is given only after 4-hour levels are available. Second, the doses of N-acetylcysteine recommended are quite high, and you can give a higher dose if you will be using it with charcoal. Answers B, D, and E are all incorrect. While we do have antidotes for digoxin and opiates (Digibind, naloxone), charcoal is still indicated to reduce absorption and should be the first line of treatment for an overdose of digoxin or opiates. Case 2 A 22-year-old female presents to the ED with an overdose. She has a history of depression, and there were empty bottles found at her bedside. The bottles had contained clonazepam (a benzodiazepine) and nortriptyline (a tricyclic). The patient is unconscious with diminished breathing and is unable to protect her own airway. The BEST next step is to: A) Intubate the patient. B) Begin gastric lavage and administer charcoal. C) Administer flumazenil, a benzodiazepine antagonist, to awaken her and improve her respirations. D) Administer bicarbonate. E) None of the above. Answer: A Discussion The correct answer is A. This patient should be intubated. Remember that in any emergency situation, the ABCs (airway, breathing, and circulation) are the priority. Thus, this patient should be intubated in order to protect her airway as well as for ventilation. Answer B is incorrect because, as noted above, patients who are lavaged have a higher incidence of pulmonary aspiration—an even greater concern in the obtunded patient. In fact, airway protection is mandatory before undertaking lavage. Answer C is incorrect. Flumazenil will reverse the benzodiazepine. However, we know from experience that seizures in patients who have had flumazenil are particularly difficult to control. This would be particularly problematic in a patient with a mixed overdose, such as with a tricyclic, where seizures are common. Thus, it is recommended that flumazenil only be used as a reversal agent after procedural sedation in patients who are not on chronic benzodiazepines. You intubate the patient and she is noted to be somewhat hypotensive (70/40) with a pulse of 130. This condition does not respond to a fluid challenge. The pressor of choice in this patient is: A) Dopamine. B) Dobutamine. C) Norepinephrine. D) Epinephrine. E) Vasopressin. Answer: C Discussion The correct answer is C. Norepinephrine is the drug of choice as a pressor agent in tricyclic overdoses. This is because beta agonists may worsen hypotension and norepinephrine is a “pure” alpha agonist. Answer A is incorrect because dopamine may worsen hypotension in this situation. Answer B is also incorrect because dobutamine is a peripheral vasodilator and may actually worsen hypotension. Of course, the hypotensive patient with a tricyclic overdose should also receive an adequate volume of IV fluids. You institute norepinephrine and the patient’s blood pressure returns to an average of 100/60, which is certainly acceptable in this situation. However, you notice that the patient begins to have an abnormal EKG tracing. Which of the following findings would you expect to find in a tricyclic overdose? A) Normal QRS complex. B) 2nd- and 3rd-degree heart block. C) Widened QRS complex. D) Sinus tachycardia. E) All of the above. Answer: E Discussion The correct answer is E. All of the above findings can be seen with a tricyclic overdose. In fact, the most common presenting rhythm is a narrow-complex sinus tachycardia. As toxicity progresses, you can get a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Heart blocks (2nd- and 3rddegree) herald a poor outcome and may be seen late in the course. Asystole is not a primary rhythm in tricyclic overdose and tends to reflect the end-stage of another arrhythmia. Case 3 A patient presents to your office with neck pain after a motor vehicle accident. He was restrained and the airbag deployed. He notes that he had some lateral neck pain at the scene. He continues to have lateral neck pain. Which of the following IS NOT a criterion for clearing the cervical spine clinically? A) Absence of all neck pain. B) Normal mental status including no drugs or alcohol. C) Absence of a distracting injury (such as an ankle fracture). D) Absence of paralysis or another “hard” sign that could be caused by a neck injury. E) All of the above are needed to clear the cervical spine clinically. Answer: A Discussion The correct answer is A. Patients can have lateral neck pain and still have their cervical spines cleared clinically. However, no one will fault you for obtaining radiographs in patients with lateral muscular (e.g., trapezius) neck pain. Patients with central neck pain (e.g., over the spinous processes) DO NEED radiographs to clear their cervical spine. All of the other criteria are required in order to clinically clear the cervical spine. Which of the following is the most common cause of a missed cervical spine fracture on radiograph? A) Poor radiologist reading. B) Failure to do oblique neck radiographs. C) Technically poor-quality films. D) Poor emergency physician or family physician reading. E) Failure to do a routine CT of all cervical spines. Answer: C Discussion The correct answer is C. The most common cause of missed fractures is an inadequate series of radiographs. An adequate series of radiographs for the cervical spine includes an AP film, a lateral film including the top of T-1, and an odontoid film. Answer B is incorrect because oblique neck films do not add much to the reading of cervical spine films for trauma and have been abandoned at most institutions. Answers A and D are incorrect because when a fracture is present on an adequate series, we can usually pick it up. Answer E is incorrect because CT is not yet the standard of care in all patients in whom cervical spine injury is suspected. However, CT is likely to become the standard of care in the near future. The patient’s daughter, who is 4 years of age, was in the same motor vehicle accident and also had her cervical spines cleared by radiograph. However, you get a call from the emergency department 48 hours after the initial accident that she is paralyzed from just above the nipple line down (never a good thing; the lawyers are probably close behind). You review the initial radiographs with the radiologist; they are negative, as is a CT of the cervical spine bones done after the onset of the paralysis. The most likely cause of this patient’s paralysis is: A) Missed transection of the thoracic cord. B) Conversion reaction from the psychological trauma of the accident. C) Subarachnoid hemorrhage. D) Toxin exposure from the accident or at home. E) SCIWORA syndrome. Answer: E Discussion The correct answer is E. This likely represents SCIWORA syndrome (spinal cord injury without radiologic abnormality). This occurs from stretching of the cord secondary to flexion/extension-type of movement in an accident. Patients with SCIWORA syndrome may be paralyzed at the time of initial presentation (in the event of cord transection) or may have a delayed presentation up to 72 hours after the injury. Answer A is incorrect since a cord transection would present with paralysis immediately at the time of injury; B is incorrect because this child is 4 years old, and conversion reaction is unlikely in children. Additionally, conversion reaction is always a diagnosis of exclusion. Answer C is incorrect because this would not generally be the primary presentation of a subarachnoid hemorrhage (headache, stiff neck, perhaps focal neurologic symptoms). Answer D is incorrect for a couple of reasons. First, it is unlikely that a toxin could act overnight. Second, toxins that cause neurologic problems will generally present with a peripheral neuropathy, CNS findings, etc. and not with a cord level injury. The next step to take in this patient is: A) IV methylprednisolone to reduce cord edema. B) Fluid restriction and diuretics to reduce cord edema. C) Mannitol to reduce cord edema. D) Neurosurgical intervention to decompress the cord. E) None of the above. Answer: A Discussion The correct answer is A. Patients with a cord injury should be treated with IV methylprednisolone 30 mg/ kg bolus (3 grams in an adult!) followed by a 5.4 mg/kg drip for 24 hours. The efficacy of this therapy in spinal cord injury in general is limited, and its efficacy in SCIWORA is unknown. However, it is currently considered the standard of care. Neither diuretics nor mannitol will be useful in this situation. Answer D is incorrect since the process of SCIWORA involves stretching of the cord (and subsequent dysfunction) rather than cord compression such as would be seen with a bony injury. SCIWORA represents what percentage of cervical cord injury and paralysis in children? A) 10–20% B) 20–30% C) 30–50% D) 50–75% E) 75–100% Answer: C Discussion The correct answer is C. SCIWORA syndrome is actually a common cause of paralysis after trauma in the pediatric age group. It also occurs in adults, but with much less frequency (0.07% of all adults getting cervical spine radiographs in the ED). The father is, understandably, irate that his child is now paralyzed. You can tell him that the natural history of SCIWORA syndrome in THIS CHILD is likely to be which of the following? A) Continued paralysis with the necessity of longterm, permanent adaptation to the injury. B) Progression of the injury over the next week to include further paralysis in an ascending fashion. C) Resolution of paralysis and sensory symptoms over the next several months. D) Resolution of all symptoms except sensory symptoms over the next several months. E) Large lawsuit payout on the way. Do not pass go, do not collect $200.00 (adjusted for inflation). Answer: C Discussion The correct answer is C. Generally, patients with SCIWORA syndrome regain their strength and sensory abilities over time. However, this depends on when they present with symptoms! Patients who present with paralysis right after the accident may have complete cord transection and thus will not regain function. For this reason, it is important to obtain an MRI on all patients with SCIWORA syndrome (and any trauma-induced paralysis for that matter). Case 4 A hard-core alcoholic presents to the ED after drinking a bottle of automobile winter gas treatment. He is intoxicated, has a headache, and describes “misty” vision, such as might be seen during a snowstorm. He is tachycardic and tachypneic. You start an IV and administer IV saline. You obtain a blood gas, which shows a mild metabolic acidosis. A metabolic acidosis is consistent with all of the following ingestions EXCEPT: A) Ethylene glycol. B) Methanol. C) Ethanol (e.g., vodka, gin, etc.). D) Petroleum distillates (e.g., non-alcohol-containing gasoline products). Answer: D Discussion The correct answer is D. Ethylene glycol, methanol, and ethanol can all cause a metabolic acidosis. Hydrocarbons (e.g., gasoline products) do not cause a metabolic acidosis. The main manifestation of hydrocarbon toxicity is secondary to the inhalation of the hydrocarbon and the resulting pneumonitis. This patient’s electrolytes are as follows: sodium 135 mEq/L, potassium 4.0 mEq/L, bicarbonate 12 mEq/L, chloride 108 mEq/L, BUN 12mg/dl, Cr. 1.0 mg/dl. This patient’s anion gap is: A) 13 B) 15 C) 23 D) Unable to calculate the anion gap with the information provided. Answer: B Discussion The correct answer is B, 15. By convention, the anion gap is calculated without using a major cation, potassium, since it varies by only a few mEq/L and does not appreciably affect the anion gap. Thus, the anion gap is calculated as follows: sodium - (chloride + bicarbonate) In this patient the anion gap is 135 - (108 + 12) = 15 The normal gap is 12 or less. All of the following are causes of an anion gap acidosis EXCEPT: A) Lactic acidosis. B) Diabetic ketoacidosis. C) Renal tubular acidosis. D) Uremia. E) Ingestions such as methanol. Answer: C Discussion The correct answer is C. Which of the following findings IS NOT frequently seen in patients with methanol ingestion? A) Hypopnea. B) Optic disk abnormalities. C) Abdominal pain and vomiting. D) Basal ganglia hemorrhage. E) Meningeal signs, such as nuchal rigidity. Answer: A Discussion The correct answer is A. Hypopnea is not commonly seen in methanol poisoning until the patient is close to death. In fact, the reverse is true. Tachypnea is a frequent finding in methanol overdose. This makes sense. The patient is trying to compensate for a metabolic acidosis by blowing off CO2. Optic disk abnormalities, abdominal pain and vomiting, basal ganglia hemorrhage, and meningeal signs are all seen as part of methanol toxicity. It is thought that many of these signs and symptoms are secondary to CNS hemorrhage. You can test for ethanol at your hospital but do not have a test for methanol on a stat basis and want to be sure that this patient is not just saying he has a methanol ingestion in order to obtain alcohol (a treatment for methanol ingestion). What test is most likely to help you determine if the patient has methanol ingestion? A) CBC. B) BUN/creatinine. C) Liver enzymes. D) Serum osmole gap. E) Amylase and lipase. Answer: D Discussion The correct answer is D, the osmolar gap. What is done here is to subtract the total measured serum osmoles from the osmoles known to be due to ethanol (each 100 mg/dl of ethanol accounts for approximately 22 osmoles). If there is an elevated osmolar gap, it is evidence of a circulating, unmeasured osmole. In this case, it would be methanol. So, for example: Measured serum osmolality = 368 Blood alcohol = 200 mg/dl or about 44 osmoles Calculated osmolality = 2(Na) + BUN/2.8 + glucose/18 = 280 = 6 + 8 = 294 So, osmolar gap = 368 - (294 + 44) = 30 This means that there are 30 unmeasured osmoles, which could, in this case, represent methanol. Thus, we know that the patient is not simply drunk. You decide that there is sufficient evidence that this patient has ingested methanol to institute treatment. Appropriate treatment(s) for this patient include: A) Fomepizole (4-MP). B) Cimetidine. C) Ethanol. D) Medroxyprogesterone. E) A and C. Answer: E Discussion The correct answer is E. Both fomepizole (4-MP) and ethanol are used for methanol ingestion. The idea is to slow down the metabolism of the methanol. The toxicity of methanol is caused by formic acid, which is a byproduct of methanol metabolism. Ethanol is metabolized by alcohol dehydrogenase, the same enzyme that breaks down methanol. Thus, methanol metabolism is competitively inhibited by ethanol. The same holds true for fomepizole, which is a competitive inhibitor of alcohol dehydrogenase. Fomepizole and ethanol can both be used for ethylene glycol ingestion as well. Answer B is incorrect. While cimetidine does reduce alcohol metabolism, the effect is so small as to be negligible. Answer D is incorrect altogether. Medroxyprogesterone has no role (or even potential role) in the treatment of methanol ingestion. Case 5 A family of 4 comes into your ED after being exposed to carbon monoxide (CO). They were in an idling car, running the engine and heater to stay warm. You want to get a carboxyhemoglobin level on the whole family but cannot get a blood gas from the youngest child. What is your response? A) Check an oxygen saturation, and if the oxygen saturation is normal, be reassured. B) Check a venous carboxyhemoglobin level. C) Check a venous carboxyhemoglobin and correct for the difference between venous and arterial samples. D) None of the above. Answer: B Discussion The correct answer is B. A venous carboxyhemoglobin is just as accurate as an arterial carboxyhemoglobin, and it is much less painful to draw. Answer A is incorrect because the pulse oximeter does not reflect hypoxia in carbon monoxide poisoning. Thus, pulse oximetry is useless in determining the carboxyhemoglobin level. Answer C is incorrect because there is no correction needed. When determining which patients need hyperbaric oxygen on the basis of a carboxyhemoglobin level, the level to rely upon is: A) The carboxyhemoglobin level on arrival to the ED. B) The carboxyhemoglobin level at 4 hours after exposure. C) The carboxyhemoglobin level projected to “time zero” (e.g., at the time of exposure). D) None of the above. Answer: C Discussion The correct answer is C. A major consideration regarding the institution of hyperbaric oxygen therapy is the patient’s clinical situation. More severely ill patients with CO poisoning (e.g., severe acidosis, unconscious, unresponsive, etc.) should be considered candidates for hyperbaric oxygen. Also, treatment should be based on the carboxyhemoglobin level projected to time zero. This is the level that gives the most accurate information about the degree of exposure. The father has a headache and a time zero carboxyhemoglobin level of 12%. The mother, who is pregnant, is asymptomatic and has a carboxyhemoglobin level of 16%. One of the children, age 6, has a level of 18%, while another has a level of 23% and was asymptomatic at the scene. The first step in the treatment of these patients is: A) Start an IV and administer saline. B) Start N-acetylcysteine, which is a free radical scavenger. C) Start CPAP to maximize air flow by keeping the airways from collapsing. D) Administer 100% oxygen. E) Intubate the most severe patient, 100% oxygen for the others. Answer: D Discussion The correct answer is D. Because CO competitively binds to hemoglobin in place of oxygen and in fact has greater affinity for hemoglobin than oxygen, highflow 100% oxygen is the cornerstone of treating CO poisoning. Thus, the first step in CO poisoning is to administer 100% oxygen. The rest of the answers are incorrect. If the patient is not ventilating well and requires intubation, this would be appropriate. However, our patients are breathing well and there will be no advantage (and a substantial downside) to intubation. All of the following can be seen with carbon monoxide poisoning EXCEPT: A) Rhabdomyolysis. B) Cardiac ischemia. C) Long-term neurologic sequelae, including dementia. D) Pulmonary edema. E) All of the above can be seen with carbon monoxide toxicity. Answer: E Discussion The correct answer is E. All of the above can be seen with carbon monoxide poisoning. Additional findings include acidosis, cardiac ischemia, seizures, syncope, and headache. Answer C deserves a bit more discussion. Long-term neurologic sequelae can develop days to months after the exposure and can include cognitive deficits, focal neurologic deficits, movement disorders, and personality changes. Such neurologic sequelae do not appear to be related to the level of carboxyhemoglobin but are more likely to occur when a patient has lost consciousness during his or her CO exposure. It appears that using hyperbaric oxygen in the appropriate patient will reduce long-term neurologic sequelae. Your closest diving chamber is about 90 minutes away. You need to make a decision about who to send for hyperbaric oxygen. Which patient will benefit most from hyperbaric oxygen therapy? A) Asymptomatic pregnant mother, time zero carboxyhemoglobin of 16%. B) Asymptomatic 6-year-old, time zero carboxyhemoglobin of 18%. C) Asymptomatic 8-year-old, time zero carboxyhemoglobin of 23%. D) A and C. E) All of the above need hyperbaric oxygen. Answer: A Discussion The correct answer is A. Criteria for hyperbaric oxygen include mental status changes, carboxyhemoglobin level >25%, acidosis, cardiovascular disease, and age >60. Obviously, these are relative criteria. An otherwise normal 60- year-old with a mild exposure need not have HBO. Pregnancy is an indication for HBO therapy because fetal hemoglobin has a high affinity for carbon monoxide and the fetus is highly susceptible to carbon monoxide. All of the following are well-established consequences of hyperbaric oxygen EXCEPT: A) Seizures. B) Psychosis. C) Myopia. D) Ear and pulmonary barotraumas. E) Direct pulmonary oxygen toxicity. Answer: B Discussion The correct answer is B. All of the rest are found as a result of hyperbaric oxygen. Answer C, myopia, is actually found in up to 20% of patients being treated with hyperbaric oxygen. It is due to direct toxicity of oxygen on the lens and usually resolves within weeks to months. Case 6 A 50-year-old immigrant from a country in the developing world is brought to your ED after being bitten by a stray dog. The bite was unprovoked and is on the abdomen. The patient has no other health history of note and has not taken antibiotics for over a year. You irrigate the wound and are deciding about closure. There is a 3-cm laceration on the abdomen. Which of the following is (are) true about dog bites? A) They tend to be primarily crush-type injuries. B) In general, the infection rate is similar to that for a laceration from any other mechanism (e.g., knife cut) except on the hands and feet. C) The primary organism in infected dog bites is Staphylococcus aureus. D) Primary closure of dog bite wounds is an acceptable option (except perhaps on the hands and feet). E) All of the above are correct. Answer: E Discussion The correct answer is E. All of the above are correct. Dog bites (except from very small dogs) tend to be crush injuries (as contrasted with cat bites, which are primarily puncture wounds). The infection rate is about the same as that for other lacerations. Bites on the hands and feet tend to have a higher rate of infection. Most dog bite infections are polymicrobial, with S. aureus playing a large role and Pasteurella playing a smaller, but still significant, role. Other organisms include Streptococcus species and gram-negative species. You are concerned about rabies prophylaxis. Which of the following is (are) viable options? A) Isolating the suspect animal for 3 days. B) Euthanizing the suspect animal and examining its liver. C) Administering rabies immune globulin IM. D) Administering rabies immune globulin IV followed by rabies vaccination series. E) Administering rabies immune globulin by infiltrating it around the wound, followed by rabies vaccination series. Answer: E Discussion The correct answer is E. You should infiltrate rabies immune globulin around the wound and then begin the rabies vaccination series. As much of the immune globulin as possible should be infiltrated around the wound and the rest should be given IM. Answer A is incorrect because animals need to be isolated for 10 days, not 3. Answer B is incorrect. The animal can be euthanized but the brain should be examined and not the liver. Answers C and D are both incorrect methods of administering the vaccine/immune globulin. Which of the following require rabies prophylaxis in all cases? A) Stray rabbit bites. B) Stray rat bites. C) Stray bat bites. D) Stray squirrel bites. E) Stray snake bites. Answer: C Discussion The correct answer is C. All bats should be considered rabid unless available for observation and testing. Also see the CDC Web site for information about rates of infection in wild animals in your area. The question of tetanus prophylaxis is raised. The patient is unsure whether or not he has had a primary tetanus series. The correct course of action is to: A) Begin the patient’s primary series of DPT (diphtheria, pertussis, and tetanus). B) Give the patient tetanus immunoglobulin and begin the primary series of DPT (diphtheria, pertussis, and tetanus). C) Begin the patient’s primary series of DT (diphtheria and tetanus). D) Give the patient tetanus immunoglobulin and begin the patient’s primary series of DT (diphtheria and tetanus). E) Give the patient tetanus immunoglobulin and, since he is an adult, only a single dose of DT (diphtheria and tetanus). Answer: D Discussion The correct answer is D. Since this patient may not have had a primary series of tetanus vaccines, he should have tetanus immunoglobulin and should have a primary tetanus series started. DT is recommended because patients who have poor immunity to tetanus will generally also have poor immunity to diphtheria. Answers A and B are incorrect because adults should not be given the pertussis vaccine. It is not recommended for those <7 years of age. Answer C is incorrect. Since this patient has not had a primary series, he should have tetanus immunoglobulin in addition to starting a primary DT series. Answer E is incorrect because the patient requires a complete primary series, not just a single vaccination. In patients who have completed the primary tetanus vaccine series, the current CDC recommendations for administering a tetanus booster (Td) are: A) Every 10 years unless the patient has sustained a contaminated wound, in which case the booster should be within 5 years. B) Every 10 years regardless. No need to boost at 5 years if the patient has a contaminated wound. C) Every 10 years to the age of 70. D) The primary series of 3 shots and then with each potentially contaminated wound. E) None of the above. Answer: A Discussion The correct answer is A. Patients should receive a tetanus booster (Td) every 10 years or when the patient has a contaminated wound and has not had a booster within the last 5 years. Answer B is incorrect since patients should have a booster when they have a contaminated wound if they have not had one within the last 5 years. Answer C is incorrect because patients should have boosters for life according to the CDC. Answer D is incorrect because patients do not need boosters with every contaminated wound. This offers no additional protection but does increase the risk of side effects. You have irrigated this patient’s wound. Which of the following statements is true about irrigating a wound and wound infections? A) Povidone-iodine as a 50% irrigation solution (e.g., Betadine) in the wound will decrease the infection rate. B) Irrigation with normal saline is the only recommended method of cleaning a wound. C) Irrigation with normal saline and irrigation with tap water are equally effective in reducing wound infection rates. D) Use of epinephrine with lidocaine in a wound increases the rate of infection. E) Irrigation of a wound with either alcohol or hydrogen peroxide will reduce the rate of wound infection. Answer: C Discussion The correct answer is C. Infection rates are the same whether the wound is irrigated with normal saline or tap water. We are not recommending that you start using tap water as an irrigation solution! This is not the standard of care although it is just as effective. Answer A is incorrect. Povidone-iodine is toxic to tissue and polymorphonuclear leukocytes and actually may increase infection rates unless a solution of 1% or less is used. Full-strength povidoneiodine can be used on intact skin as a cleanser but should not be used in a wound. Answer B is incorrect because other solutions (1% povidone-iodine, poloxamer 188, balanced salt solutions, etc.) can be used but are more expensive and do not offer any benefit in reduction of infection rates. Answers D and E are both incorrect. Again, alcohol may be used for cleaning skin but should be kept out of the wound. It is toxic to tissue and acts as a fixative. Hydrogen peroxide is also toxic to tissue and should not be used in open wounds. The patient states that he is “caine” allergic (lidocaine, novocaine, etc.). Which of the following is the most appropriate alternative? A) Diphenhydramine (e.g., Benadryl) 25% solution. B) Phenol. C) Diphenhydramine (e.g., Benadryl) 1% solution. D) There is no true “caine” allergy and lidocaine can be used with impunity. E) All of the above. Answer: C Discussion The correct answer is C. Diphenhydramine in a 1% solution can provide adequate local anesthesia for suturing. Answer A is incorrect because greater than a 1% solution of diphenhydramine can be toxic to tissues. Answer B is incorrect because phenol is toxic to tissues. Answer D is incorrect because, although rare, “caine” allergies do exist. However, most reactions described as allergies are actually local reactions, such as pain of injection, and are not true allergic reactions. This frequently can be determined by a detailed history. What is the BEST choice of suture for closing\ this patient’s skin wound? A) Nylon. B) Silk. C) Gut (“chromic”). D) Dexon. E) Vicryl. Answer: A Discussion The correct answer is A. Nylon is the best choice among those listed for closing a skin wound. Another option would be polypropylene. Both are relatively inert and do not cause much skin reaction. All of the others are either dissolvable (Dexon, Vicryl, gut) or cause significant skin reaction (silk, gut). Additionally, braided suture materials (silk, Dexon, and Vicryl) have higher infection rates than do monofilaments (nylon, polypropylene). How long after a laceration occurs can the wound be closed primarily? A) 6 hours. B) 12 hours. C) 18 hours. D) 24 hours. E) Any of the above can be correct depending on the wound. Answer: E Discussion The correct answer is E. There is no arbitrary time limit to when a wound can be closed. Facial wounds may be closed up to 24 hours after injury for cosmetic reasons, while you may not want to close other, contaminated wounds more than 12 hours after injury. Some wounds you may not want to close at all (e.g., bites to the hand, wounds contaminated with grease, etc.), rather allowing them to close by secondary intention. Case 7 A 38-year-old female with a marked history of depression is seen in your office while you are away on vacation. The patient is currently taking fluoxetine (Prozac). However, the patient remains very depressed and almost vegetative (although not suicidal). She has been on multiple antidepressants in the past but without success. One of your partners decides to start this patient on phenelzine (Nardil), a monamine oxidase inhibitor (MAOI). The patient is instructed to stop the fluoxetine for 2 days. You return from vacation the day the patient starts on phenelzine. You get a call from the ED that the patient has presented with marked muscle stiffness, hypertension, tachycardia, confusion, and fever. The pupils are normal. Which of the following is the most likely cause of this patient’s symptoms? A) Meningitis. B) Fluoxetine overdose. C) Anticholinergic overdose. D) Serotonin syndrome. E) Neuroleptic malignant syndrome. Answer: D Discussion The correct answer is D. This patient has a typical serotonin syndrome, which can be caused by the interaction of an MAOI and a serotonin reuptake inhibitor (SRI). Since fluoxetine (Prozac) has such a long halflife, a two-day washout period is not sufficient before starting an MAOI. Answer A is incorrect because the patient has marked muscle rigidity—not something found in meningitis. Answer B is incorrect because isolated fluoxetine overdoses rarely if ever cause such dramatic symptoms. Answer C is incorrect because the patient has normal pupils. Remember that part of the anticholinergic toxidrome is mydriasis. Answer E is incorrect because this patient is not on any neuroleptics. If this patient were taking neuroleptics, neuroleptic malignant syndrome would be a consideration. The best treatment for this patient with serotonin syndrome is: A) Dantrolene. B) Cyproheptadine. C) Propranolol. D) A and B. E) B and C. Answer: E Discussion The correct answer is E. The best treatments for serotonin syndrome are cyproheptadine and propranolol. Both of these can block some serotonin receptors and reportedly have some benefit. However, there are no controlled trials. Otherwise, treatment is supportive and includes managing the ABCs (airway, breathing, and circulation). Benzodiazepines can be used for seizures and may also help muscle rigidity. Hyperthermia can be treated with ice packs and evaporative cooling. Answer A is incorrect; dantrolene is used for the treatment of MAOI overdose and malignant hyperthermia. It does not work for neuroleptic malignant syndrome or serotonin syndrome. Case 8 A 19-year-old female was drinking in a bar and fell, striking her head. You clear her cervical spine radiographically and are concerned that there may be a basilar skull fracture. All of the following are associated with a basilar skull fracture EXCEPT: A) CSF rhinorrhea. B) Battle’s sign. C) Raccoon eyes. D) Cullen’s sign. E) Hemotympanum. Answer: D Discussion The correct answer is D. Cullen’s sign, a purplish hue around the umbilicus, is associated with hemorrhagic pancreatitis. All of the rest can be associated with a basilar skull fracture. Battle’s sign refers to retroauricular ecchymosis. Raccoon eyes refer to bilateral (or unilateral) periorbital ecchymosis. She indeed has Battle’s sign and raccoon eyes. Your concern for a basilar skull fracture increases. Your next step is to: A) Obtain skull radiographs. B) Order a head CT. C) Consult a neurosurgeon. D) Perform serial neurological examinations. Answer: B Discussion The correct answer is B. CT scan is superior to plain films of the skull, and a skull fracture can exist without brain injury and vice versa. Answer A is incorrect since skull radiographs can miss fractures and have no ability to directly identify brain injuries. Skull radiographs have very limited application in emergency medicine and should not be used routinely for any head trauma. About the only role for skull radiographs in the ED is for the documentation of child abuse. Answers C and D are incorrect because neither will help you diagnose a basilar skull fracture, unless the neurosurgeon can convince you to order the head CT! You follow up your clinical exam with a head CT scan, which shows a basilar skull fracture. She seems to have CSF rhinorrhea. The best course of action at this point is: A) Observe the patient. Do not start prophylactic antibiotics to cover for the CSF leak. B) Neurosurgical consultation as soon as possible for closure of the dura from which CSF is leaking. C) Observe the patient. Start prophylactic antibiotics to cover for the CSF leak. D) Discharge the patient. Start prophylactic antibiotics to cover for the CSF leak. Answer: A Discussion The correct answer is A. Patients with an acute basilar skull fracture should be admitted for observation. However, since most CSF leaks resolve spontaneously, there is no need for neurosurgical consultation to close the dura. Additionally, prophylactic antibiotics are not indicated in the first week following a basilar skull fracture with CSF leak. Case 9 A 17-year-old female fell asleep with her contact lenses in her eyes last evening. This morning she notes quite a bit of eye pain and photophobia. You evert the eyelids and find no evidence of a foreign body. When you stain her eye, you find a corneal ulcer. The treatment for this patient is: A) Debridement with a burr and systemic antibiotics. B) Debridement with a cotton swab and systemic antibiotics. C) Topical antibiotics, cycloplegia, and referral to ophthalmology. D) Copious irrigation, systemic antibiotics, and cycloplegia. Answer: C Discussion The correct answer is C. This is an ophthalmologic emergency that requires topical antibiotics, cycloplegia (for pain control), and referral to an ophthalmologist. These ulcers can become quite deep and result in a ruptured globe. Answers A and B are incorrect because debridement is not a part of management of this condition. Additionally, systemic antibiotics are not indicated. Answer D is incorrect because, again, systemic antibiotics are not needed and irrigation is not going to accomplish much. You consult with your ophthalmologist, who would like you to start a cycloplegic agent on this patient prior to referral. The drug you would choose for a cycloplegic agent is: A) Pilocarpine eyedrops. B) Timolol eyedrops (e.g., Timoptic). C) Tetracaine eyedrops. D) Cyclopentolate eyedrops. Answer: D Discussion The correct answer is D. Cyclopentolate is the only cycloplegic agent listed above. Pilocarpine is a miotic agent. Timolol is a beta-blocker used in the treatment of glaucoma. Tetracaine eyedrops are a topical anesthetic. If your patient just had a simple corneal abrasion, you would not have had to think so hard! Regarding corneal abrasions, you realize that: A) Patching an eye after a corneal abrasion reduces pain and promotes healing. B) If a topical antibiotic is needed after a large corneal abrasion, gentamicin ophthalmic ointment is the drug of choice. C) Tetracaine is a good topical anesthetic and should be considered for home use in patients with a painful corneal abrasion. D) Patients should avoid wearing contact lenses until the eye has healed for at least a week. Answer: D Discussion The correct answer is D. Answer A is incorrect because patching an eye may actually increase pain and decrease healing. Whether or not to use a patch should be a matter of patient comfort only. Answer B is incorrect because gentamicin ophthalmic ointment (as well as other topical aminoglycosides) actually reduces healing of the cornea, and antibiotics are not necessary unless there are signs of infection. Answer C is incorrect because patients should not be sent home with a topical anesthetic. They reduce healing and can lead to further injury if the patient continues a harmful activity such as welding. Case 10 A patient presents to your office after lunch at one of the better restaurants in town. She is complaining of dizziness, flushing, diarrhea, tachycardia, and a severe headache. This started about 30 minutes after she had a grilled tuna fish steak for lunch. A number of other patrons had the fish as well but did not develop symptoms. The fish tasted fine although a bit peppery for her liking. She has never had an allergic reaction to seafood before. The most likely diagnosis is: A) Staphylococcus food poisoning. B) Bacillus cereus food poisoning. C) Ciguatera poisoning. D) Scombroid poisoning. E) Seafood allergy. Answer: D Discussion The correct answer is D. This patient has the classic presentation of scombroid poisoning. Scombroid poisoning occurs when bacteria in a dark-meat fish produce histamine. The fish involved include tuna, mackerel, bluefish, mahimahi, etc. The problem is usually improper handling on the ship and not in the restaurant. The fish may have a metallic or peppery taste. When these fish are eaten, the patient develops a symptom complex suggestive of histamine effects including flushing, diarrhea, dizziness, wheezing, tachycardia, and severe headache. An occasional patient will become hypotensive. The symptoms occur 20–30 minutes after ingesting the suspect fish and are self- limited, generally lasting less than 6 hours. Patients will respond well to antihistamines such as diphenhydramine. The patient is not allergic to the fish and should not be told that she should avoid the fish in the future. Answer A is incorrect because patients with Staphylococcus food poisoning do not develop symptoms quite this quickly and have no flushing, etc. Staphylococcus food poisoning presents with vomiting and, frequently, diarrhea. Answer B is incorrect because Bacillus cereus poisoning occurs after eating rice, especially fried rice, and presents with vomiting and abdominal cramps, with 20–30% having diarrhea. Answer C is incorrect because patients with ciguatera poisoning present with GI symptoms such as cramping, vomiting, and diarrhea followed by nondermatomal neurologic symptoms such as perioral numbness, a feeling that one’s teeth are loose or in the sockets backwards, burning foot pain similar to a neuropathy, ataxia, weakness, and vertigo. The neurologic symptoms can last for up to 1 year. An almost pathognomonic finding for ciguatera poisoning is hot-cold sensory reversal on the face. See Table 1-8. Case 11 A 55-year-old male who is a farmer gets injured by a cow that pins him against a fence. His leg was trapped against the fence for several minutes. Being a typical midwestern farmer, he ignores the injury until later that afternoon, when he presents to your office complaining of severe pain in the calf area. A radiograph is normal, and the patient has normal distal pulses. The calf (his leg, not the cow) is tender with increased pain on passive stretch. His pain seems to be out of proportion to his injury. Which of the following is true? A) Since the patient has excellent pulses, a compartment syndrome is not likely. B) Compartment syndrome is defined as compartment pressures of 30 mm Hg. C) Compartment syndrome is only associated with significant crush injuries or fractures. D) Pain out of proportion to the injury is a red flag for compartment syndrome. E) His calf (the leg, not the cow) likely has mad cow disease. Answer: D Discussion The correct answer is D. Pain out of proportion to the injury is a red flag for compartment syndrome. Answer A is incorrect because pulses can be maintained until there is significant increase in compartment pressures and significant injury to muscle and nerves. Answer B is incorrect because it is difficult to define a specific cutoff for compartment syndrome. Some patients tolerate higher pressures and others cannot tolerate 30mm Hg (normal compartment pressure is zero). However, when the pressure gets above 20–30 mg Hg, strong consideration should be given to the presence of compartment syndrome. Answer C is incorrect. Compartment syndrome can be due to a number of factors including electrical injury, excessive muscle use, tetany, reperfusion after ischemia, etc. You decide that it is likely that this patient has a compartment syndrome. Which of the following labs will be the most helpful in treating this patient? A) CBC. B) UA. C) Glucose. D) Sodium. E) PT/PTT. Answer: B Discussion The correct answer is B. One of the major complications of compartment syndrome is rhabdomyolysis. This will manifest itself as urine that is dipstick-positive for blood but with a negative microscopic exam for red blood cells. The positive dipstick is picking up myoglobin in the urine. This can be confirmed by a serum CPK. CBC, glucose, sodium, and coagulation studies may be appropriate depending on the clinical situation but are not useful in establishing the presence of myoglobinuria. The patient has a positive dipstick for blood with no red blood cells on microscopic exam (presumptive myoglobinuria). A follow-up serum CPK is 32,000. You know that a diagnosis of rhabdomyolysis requiresa CPK >5 times the upper limit of normal, so you make the diagnosis of rhabdomyolysis. You decide to check additional lab tests. Which of the following would be typically found in rhabdomyolysis? A) Elevated calcium, decreased phosphate. B) Decreased potassium, elevated phosphate. C) Elevated phosphate, decreased calcium. D) Any of the above combinations may be seen. Answer: C Discussion The correct answer is C. In addition to an elevated CPK, other laboratory findings in rhabdomyolysis include: hyperphosphatemia, hyperkalemia, hypocalcemia, hyperuricemia, and hypoalbuminemia. Hypocalcemia is the most common laboratory abnormality, being present in approximately 70% of patients. The most common adverse consequence and greatest danger of rhabdomyolysis is: A) DIC. B) Acute renal failure. C) Seizure from hypocalcemia. D) Acute gout from hyperuricemia. E) Cardiac arrhythmia from hyperkalemia. Answer: B Discussion The correct answer is B. Myoglobin precipitates in the renal tubules causing acute renal failure. Answer A, DIC, can occur but is rare. Answer C, seizures from hypocalcemia, have not been reported in this condition, nor has answer D, gout. The potassium elevation from rhabdomyolysis generally does not reach a level sufficient to cause arrhythmias. The primary treatment for rhabdomyolysis is: A) Mannitol infusion. B) Saline infusion. C) Furosemide. D) Dialysis. Answer: B Discussion The correct answer is B. The most important treatment for rhabdomyolysis is saline infusion with alkalinization of the urine. Answer A, mannitol, can be used to increase urine flow, but this is really a treatment that is secondary to good hydration and urine alkalinization. Answer C, furosemide, is not used in rhabdomyolysis. Loop diuretics will actually acidify the urine and are contraindicated. Answer D, dialysis, is what we are trying to avoid by using saline. The patient is able to maintain urine output after you institute saline. What treatment are you going to suggest for the underlying compartment syndrome? A) Fasciotomy. B) Immobilization and traction. C) Hot packs and elevation of the affected limb. D) Ice and elevation of the affected limb. Answer: A Discussion The correct answer is A. The treatment of compartment syndrome is fasciotomy. A rapid surgical or orthopedic consultation is critical in the treatment of compartment syndrome. The patient does well and everyone is happy. Case 12 A 52-year-old truck driver presents to your ED after being out in subzero (Fahrenheit) temperatures for several hours trying to repair his truck. He is hypothermic when you use a rectal thermometer with appropriate calibration. His initial core temperature is noted to be 28° C. He has a pulse of 24, blood pressure of 70/30, and slow mentation. He is awake, however. The appropriate first-line treatment for this patient is: A) Atropine. B) Epinephrine. C) Dopamine. D) Lidocaine. E) None of the above. Answer: E Discussion The correct answer is E. The hypothermic heart is generally resistant to drugs. Thus, the best treatment for this patient is rewarming. If the patient has poor perfusion, rapid rewarming with CPR if indicated is the treatment of choice. All of the following are acceptable methods of rewarming this patient EXCEPT: A) Active external rewarming (e.g., hot packs, etc.). B) Immersion in 40° C water. C) Passive external rewarming (e.g., blankets). D) Heated, humidified oxygen. E) Thoracic lavage with warm fluids. Answer: C Discussion The correct answer is C. Patients with a temperature of below 30° C generally do not have enough endogenous heat production to effectively rewarm themselves. Thus, external or internal active rewarming is indicated. All of the other options are correct methods of rewarming this patient. Extracorporeal blood warming is also effective. Heated lavage fluids (e.g., gastric and rectal) are generally not very effective because of the limited surface area involved. Additionally, this type of lavage can potentially cause electrolyte abnormalities. Rapid rewarming of the extremities is associated with: A) Alkalosis, hypokalemia. B) Acidosis, hypokalemia. C) Acidosis, hyperkalemia. D) Alkalosis, hyperkalemia. E) None of the above. Answer: C Discussion The correct answer is C. Rewarming of the extremities can lead to return of cold blood to the core, leading to a paradoxical drop in body temperature. Additionally, hypothermia causes lactic acidosis with hyperkalemia in the extremities; as the peripheral blood is rewarmed and mobilized, systemic metabolic acidosis with hyperkalemia may result. Which of the following IS NOT associated with an increased risk of hypothermia? A) Diabetes mellitus. B) Obesity. C) Alcohol use. D) Old age. F) Chronic illness. Answer: B Discussion The correct answer is B. Obese patients have a smaller body mass to surface area ratio and do not have an increased risk of hypothermia. Answer C, alcohol use, causes patients to be relatively insensate to cold and also causes peripheral vasodilatation, increasing heat loss. Thermoregulation is impaired as we age. Thus, answer D, old age, is associated with a greater propensity toward hypothermia. Diabetes (answer A) and any chronic illness (answer D) can also predispose to hypothermia. The patient’s mental status clears and he complains that his fingers and toes, which were numb and cold, are now quite painful. You note that there is probably freezing of tissue (frostbite). The BEST method of rewarming the areas with frostbite is: A) Slowly in tepid water. B) Rapidly in the hottest water he can stand (tested by you, of course, to assure that there will be no burns). C) Using a hot air source such as a hair dryer. D) Using moist heat via a heating pad. Answer: B Discussion The correct answer is B. Frostbitten parts should be rewarmed as quickly as possible in hot water, between 37 and 40° C. Water cooler or hotter than this can lead to incomplete thawing and increased tissue loss. The other methods (answers A, C, and D) are not recommended. The patient has a lot of pain after thawing and reperfusion. You control the pain with morphine. Which of the following doses is the appropriate dose of morphine in this 100-kg male? A) 2 mg IV. B) 4 mg IV. C) 6 mg IV. D) 8 mg IV. E) 10 mg IV. Answer: E Discussion The correct answer is E. The correct dose of IV morphine is 0.1 mg/kg or 10 mg in this 100-kg male. Similarly, the correct dose of meperidine (Demerol) is 100 mg (1 mg/kg). It is 2 days later. The patient is noted to have black eschar on multiple fingers and toes. There is no obvious perfusion to these areas. The best course at this point is: A) Debridement of the nonviable tissue. B) Skin grafting over open areas after debridement. C) Observation for a number of weeks despite the black eschar. D) Amputation of the nonviable distal digits. Answer: C Discussion The correct answer is C. It can take weeks for the proper demarcation line for debridement and grafting to become apparent. Thus, aggressive intervention at this point is counterproductive and may lead to additional tissue loss. For this reason answers A and D are incorrect. Skin grafting is also not appropriate at this time because debridement of the eschar is not appropriate. Case 13 A 19-year-old female presents to the ED with complaints of wheezing. She has a history of asthma and you have been following her since her eighth birthday. Generally, she has mild asthma not requiring an inhaled steroid. However, over the past several months things have accelerated so that she now uses her inhaler daily. On exam, she is tachypneic with a respiratory rate of 30 and wheezing in all fields. Her oxygen saturation is 95% and pulse is 110 with a normal blood pressure. Her blood gas is as follows: pH 7.40, CO2 40 mm Hg, O2 92 mm Hg, and HCO3 24 mEq/L (normal blood gas). A normal blood gas in this patient suggests that: A) This is a mild exacerbation and should respond well to therapy. B) She has respiratory acidosis. C) She has respiratory alkalosis. D) This is a severe exacerbation that will require aggressive therapy. E) None of the above. Answer: D Discussion The correct answer is D. A pH of 7.4 with a CO2 of 40 mm Hg in a patient who is asthmatic and tachypneic is a bad sign. The CO2 should be low in a tachypneic patient because she will be blowing off CO2. Thus, normal CO2 and normal pH indicate that the patient is retaining CO2. Answers B and C are both incorrect since the blood gas indicates neither acidosis nor alkalosis. Which of the following tests are indicated in routine evaluation of a patient with an asthma exacerbation? A) Chest x-ray. B) CBC. C) Arterial blood gas. D) A and C. E) None of the above. Answer: E Discussion The correct answer is E. None of the above tests are indicated in the routine evaluation of an asthma exacerbation. A chest x-ray should be reserved for those patients in whom pneumonia or other pulmonary process is suspected (e.g., those with rales, an elevated temperature, etc.). A CBC is not going to change your therapy in the routine asthma exacerbation and is not indicated. Likewise, an ABG is unnecessary in most asthma exacerbations. It can be used to assist in your clinical evaluation to determine whether or not the patient is retaining CO2; however, even in the “crashing patient,” an ABG is not necessary because intubation is a clinical decision and should not be based solely on the blood gas. You decide to initiate therapy for this patient. Of the following options, the initial treatment of this patient is: A) Subcutaneous epinephrine. B) Albuterol MDI (metered-dose inhaler) with spacer. C) Nebulized ipratropium. D) Oral steroids. E) IV steroids. Answer: B Discussion The correct answer is B. The initial treatment for this patient—and any patient presenting with an asthma exacerbation—is a bronchodilator, in this case albuterol. It makes little difference whether this is via nebulizer or MDI, as long as one uses adequate doses. One albuterol nebulization is equal to about 8–10 puffs of an albuterol MDI with a spacer. Answer A is incorrect because subcutaneous epinephrine is the second or third line in the treatment of asthma. Answer C is incorrect. While ipratropium is effective in asthma, it is secondary to albuterol in the treatment of asthma. Answers D and E are incorrect. Steroids are indicated, but bronchodilator therapy is the primary treatment in acute asthma exacerbations. There is no albuterol MDI available to you in your ED, so the patient receives nebulized albuterol. However, she continues to wheeze. How many albuterol treatments can this patient safely be given? A) 1 every other hour. B) 1 an hour. C) 2 an hour. D) 3 an hour. E) Continuous nebulization of albuterol is OK. Answer: E Discussion The correct answer is E. Albuterol can be administered via nebulizer continuously if needed, even in the pediatric age group. Tachycardia, one of the main side affects of albuterol treatment, will often improve with continuous albuterol. This occurs because the patient’s tachycardia is often driven by hypoxia. Once the asthma is adequately treated, oxygenation improves, and the pulse comes down. The patient does not respond well to albuterol alone, so you request the addition of ipratropium. At this point you want to order steroids. Which of the following statements about steroids is true? A) IV steroids are superior to PO steroids in the treatment of asthma. B) Nebulized steroids are just as effective as oral steroids for the treatment of acute asthma exacerbations. C) All patients who are steroid-dependent should have additional steroids even if they have already taken their dose for the day. D) The effective dose range for steroids in asthma is well established. E) Only patients requiring admission should have oral or parenteral steroids. Answer: C Discussion The correct answer is C. All patients who are steroiddependent should get steroids if they present to the ED with an acute exacerbation of asthma. Answer A is incorrect. Intravenous steroids and oral steroids have the same efficacy in acute asthma exacerbations. Thus, the choice of route depends mostly on convenience, cost, and physician preference. Answer D is incorrect. Multiple steroid dosing regimens and ranges of doses have been used in asthma with success. Answer E is incorrect. Discharged patients who have anything more than a minor asthma exacerbation should receive steroids. Which of the following is true about the role of theophylline in the treatment of acute asthma? A) Theophylline/aminophylline should be used in cases unresponsive to 2–3 doses of nebulized albuterol since it has added benefits when used with an inhaled beta-agonist. B) Patients who get theophylline/aminophylline have more side effects than do patients who get continuously nebulized albuterol and get no benefit from the drug. C) If you choose to use theophylline/aminophylline, the therapeutic goal is a serum level of 20 mcg/dl. D) None of the above is correct. Answer: B Discussion The correct answer is B. Patients who are treated with theophylline have more side effects, including tachycardia, nausea, and arrhythmias, than do patients who get continuously nebulized albuterol. Theophylline/ aminophylline have essentially no role in the treatment of acute asthma exacerbations. There is no benefit to theophylline or aminophylline over optimal beta-agonist therapy (e.g., continuous nebulized albuterol if required). Answer C is incorrect because, if used at all, the therapeutic goal for theophylline is a serum level of 15 mcg/dl. The patient responds to nebulizers and steroids. You decide to send her home. Which of the following is true? A) You should discharge the patient on 2 puffs of an albuterol MDI via spacer to be used PRN. B) You should place the patient on a steroid taper. C) You should discharge the patient on 8–10 puffs of an albuterol MDI via spacer to be used every 6 hours around the clock. D) You should start the patient on a steroid inhaler. E) None of the above. Answer: D Discussion The correct answer is D. The patient should be started on a steroid inhaler to prevent recurrent exacerbations. Overlapping this with oral steroids will give the inhaled steroids a chance to work while the patient is being covered with the oral steroids. Answer A is incorrect. The proper dose of albuterol via MDI is 6–10 puffs PRN. Answer B is incorrect because patients do not need a steroid taper if they are not on chronic steroids and will not be taking steroids for more than 10 days. You can simply treat the patient (e.g., with prednisone 40 mg PO QD) and then stop the steroids. No taper is needed. Note that this is not true for patients on chronic steroids who clearly do need a taper. Answer C is incorrect because scheduled albuterol is not as effective as PRN use. Additionally, albuterol can certainly be used more than every 6 hours. Case 14 A 7-year-old presents to the ED with wheezing and hives after being stung by a bee. He was evidently throwing rocks at a yellow jacket nest when he was stung. On exam the patient has hives and wheezing with a normal blood pressure for his age. He is mildly tachycardic. Potentially useful treatments for this patient include all of the following EXCEPT: A) Intravenous diphenhydramine. B) Subcutaneous epinephrine. C) Subcutaneous diphenhydramine. D) Intravenous cimetidine. Answer: C Discussion The correct answer is C. Subcutaneous diphenhydramine can cause skin necrosis and is contraindicated. Either IV or IM diphenhydramine can be used. Of the others, subcutaneous epinephrine should be used in the patient with anaphylaxis who fails to respond to diphenhydramine and cimetidine or who has respiratory distress, hypotension, etc. Intravenous H2 blockers (e.g., cimetidine, ranitidine) are particularly effective in the treatment of anaphylaxis and should be used routinely in these patients. The family is concerned that the stinger may still be in the skin. The proper response is to: A) Remove the stinger with forceps. B) Remove the stinger using a double-edged razor or credit card. C) Leave the stinger embedded in the skin. D) Not worry about even looking for a stinger in this patient. Answer: D Discussion The correct answer is D. The only hymenopterans (bees, wasps, etc.) that leave the stinger in the skin are honeybees. Since this patient was stung by a yellow jacket, there will not be a stinger to find in this child. As for the other answers, either A or B would be appropriate treatment if a stinger was present. The only thing that seems to make a difference in the amount of venom injected is the length of time the stinger is in the skin and not the mechanism by which is removed. So, remove the stinger as quickly as possible by whatever means is available. The patient responds well to the therapy as noted above. You are going to discharge him and want to write his prescriptions. The patient should be discharged with which of the following? A) Diphenhydramine Q6 hours for the next 48 hours. B) Cimetidine for Q12 hours for the next 48 hours. C) An anaphylaxis (“bee sting”) kit. D) All of the above medications. Answer: D Discussion The correct answer is D. Patients can have biphasic reaction mediated by “slow reacting substance of anaphylaxis,” which is now believed to be a neutrophil chemotactic factor. This recurrence may occur up to 48 hours after the initial event. Thus, prescribing medications to prevent the recurrence is prudent. Also, the patient should have a “bee sting” kit available. The parents are concerned about this child who likes to play outside. They worry that he will get stung again. You let them know that: A) Any sting should be treated as an emergency. B) He will continue to be allergic to “bee stings” in the future. C) He should take prophylactic medication before going out to play in the woods or other areas where he might get stung. D) None of the above. Answer: D Discussion The correct answer is D. Here is why. Patients who are allergic to one species of hymenopteran are not necessarily allergic to others. Generally, the allergy is species-specific. Thus, most stings will be benign in an allergic patient unless it is a sting from the offending species. Answer B is incorrect. Many children tend to outgrow “bee sting” allergies. This is in contrast to adults, in whom reactions tend to get worse over time. Answer C is incorrect. Obviously the child should be careful not to irritate yellow jackets, but prophylactic treatment is not routinely indicated. Case 15 A 14-year-old white male presents to the emergency department with acute-onset left testicular pain when running, 1 hour prior to presentation. His past medical history is negative, he is on no medications, and he has no allergies. He denies any trauma to the region. He states that his pain is severe and only on the left. The pain is increased with ambulation and movement. He denies nausea, vomiting, diarrhea, fever, chills, dysuria, hematuria, or penile discharge. His vital signs and physical exam are as follows: temperature 37.0º C, pulse 110, respirations 18, blood pressure 120/85. He is a well-nourished, well-developed white male in distress secondary to pain. Abdomen: Normal bowel sounds, nontender, soft, no masses. Genitourinary: Circumcised male, no penile lesions, no discharge. Left testicle tender to palpation but has a normal lay in the scrotum. The cremasteric reflex is normal bilaterally. What is the significance of the normal lay and cremasteric reflex? A) The cremasteric reflex should be abnormal in epididymitis. B) The presence of a cremasteric reflex effectively rules out testicular torsion. C) The normal lay of the testicle in the scrotum effectively rules out testicular torsion. D) The presence or absence of a cremasteric reflex is not helpful in ruling out testicular torsion. Answer: D Discussion The correct answer is D. The presence or absence of a cremasteric reflex is neither sensitive nor specific enough to confirm or rule out the presence of testicular torsion. Likewise, the lay of the testicle can be normal in patients with testicular torsion. An abnormal testicular lay and absence of the cremasteric reflex may point toward testicular torsion. However, you cannot rely on these findings to rule out testicular torsion. The LEAST likely diagnosis in this patient is: A) Torsion of testis. B) Epididymitis. C) Torsion of appendix testis. D) Torsion of appendix epididymis. E) Testicular tumor. Answer: E Discussion The correct answer is E. Testicular torsion is characterized by acute onset of unilateral testicular pain, often during activity such as running. It has a bimodal age distribution, during the first year of life and again during puberty. The differential diagnosis is dependent on the patient’s age. If the patient is <15 years old, the differential consists of testicular torsion, epididymitis, torsion of appendix testis/appendix epididymis, orchitis, hydrocele, and varicocele. In patients older than 15 years, the differential includes all of these diagnoses (except perhaps orchitis) plus testicular tumor. However, testicular tumors are generally painless. What is the best method for diagnosing testicular torsion? A) Doppler (duplex color). B) Radionuclide scan. C) Surgical exploration. D) Checking the cremasteric reflex. E) MRI. Answer: C Discussion The correct answer is C. Every patient with suspected testicular torsion should have surgical exploration of the scrotum. All of the other studies are adjunctive. For example, radionuclide scan has a false negative rate of about 20%. Surgical exploration is the only definitive diagnostic tool. The window of opportunity for surgery is about 6 hours, after which the testicle may not be salvaged. Orchiopexy should be performed on the involved and uninvolved sides to prevent torsion. Case 16 A 20-year-old female presents to your ED complaining of lower quadrant abdominal pain. She is on “the patch” for contraception and has been faithfully using it. She has had regular menses and has not noticed any change in her pattern of menses. Her pain had a sudden onset but is not associated with any vaginal bleeding. On vaginal exam, you find marked cervical motion tenderness but no palpable adnexal mass. Based on this information, you decide that: A) The absence of an adnexal mass effectively rules out ectopic pregnancy. B) If a patient becomes pregnant, all forms of contraception reduce the risk of ectopic pregnancy. C) The fact that the patient has had normal periods effectively rules out an ectopic pregnancy. D) Cervical motion tenderness effectively clinches the diagnosis of PID. E) None of the above is true. Answer: E Discussion The answer is E, none of the above. Answer A is incorrect because only 10% of patients with an ectopic pregnancy will have a palpable mass in the adnexa. Answer B is incorrect because both the IUD and tubal ligation increase the risk of ectopic pregnancy if the patient becomes pregnant. Answer C is incorrect because 15–20% of patients with ectopic pregnancy have no history of missed menses. Answer D is incorrect because cervical motion tenderness can be present not only in PID but also in other illnesses such as ovarian torsion, ectopic pregnancy, etc. Risk factors for ectopic pregnancy include all of the following EXCEPT: A) Prior ectopic pregnancy. B) History of pelvic inflammatory disease. C) Treatment for infertility. D) Older age. E) All of the above are risk factors for ectopic pregnancy. Answer: E Discussion The correct answer is E. All of the above increase the risk of an ectopic pregnancy. Other risk factors include cigarette smoking, recent elective abortion, IUD use, and tubal ligation. You decide that this patient may have an ectopic pregnancy. A urine HCG test is positive for pregnancy. The significance of a positive pregnancy test is that: A) An ultrasound will be able to detect an ectopic pregnancy if one is present. B) The serum level of HCG is at least 1,000 IU/L. C) Combined with the patient’s abdominal pain and cervical motion tenderness, it effectively rules in an ectopic pregnancy. D) The urine HCG is 98% sensitive for pregnancy 7 days after implantation. E) None of the above is true. Answer: D Discussion The correct answer is D. Answer A is incorrect. The pregnancy test is positive very early and ultrasound may not be positive by an experienced operator until 6 weeks of pregnancy. Answer B is incorrect. The urine may be positive at serum HCG levels of 25–50 IU/L. Patients do not have an HCG level of 1,000 IU/L until 6 weeks of pregnancy. Answer C is incorrect because patients with a normal pregnancy may also have abdominal pain and cervical motion tenderness. The patient’s serum HCG is 440 IU/L. You order an ultrasound and find no evidence of an intrauterine or ectopic pregnancy. Your next step is to: A) Reassure the patient that she does not have an ectopic pregnancy. B) Recheck the HCG in 48 hours. C) Perform a laparoscopy to rule out ectopic pregnancy. D) Recheck the HCG in 1–2 weeks. E) Follow the patient clinically. Answer: B Discussion The correct answer is B. The HCG should double in a normal pregnancy every 1.8–3 days. If the HCG is not doubling in this time frame, it is likely an ectopic pregnancy. Remember, the fact that you did not see an ectopic pregnancy on ultrasound is irrelevant. The HCG is generally at least 1,000 IU/L before anything is seen on ultrasound. By an HCG of 6,000 IU/L, you should certainly be able to see a pregnancy on ultrasound. Answer A is incorrect because of the above. Answer C is incorrect. This is invasive and not needed. Answer D is incorrect because of the time frame; the HCG should be rechecked in 24–48 hours. An ectopic pregnancy may well rupture within 1–2 weeks. Answer E is incorrect. If you follow the patient clinically, you are basically saying that you will wait until the ectopic pregnancy ruptures before addressing the problem. You recheck the HCG in 48 hours and it is now 1,000 IU/L (prior level 440 IU/L). Your interpretation is that: A) This patient does not likely have an ectopic pregnancy. B) This patient has a molar pregnancy. C) This patient has a blighted ovum. D) The patient has fetal demise of an IUP. E) All of the above are possible. Answer: A Discussion The correct answer is A. Since the HCG doubled normally, it is not likely that this is an ectopic pregnancy, a blighted ovum (answer C), or intrauterine fetal demise (answer D). In all of these conditions, the HCG would not double. Answer B is also not likely because in a molar pregnancy, the HCG would rise precipitously. Orthopedic Medicine Orthopedic Medicine Case 1 A 5-year-old boy presents with acute onset of left anterior thigh and hip pain that began 2 days ago with no known prior trauma. He reports that it initially “loosened up” after he had been out of bed for a few hours but has become worse again by afternoon. His pain is exacerbated by weight-bearing and active or passive range of motion (ROM) of the hip. His mother notes that he had a cold 7–10 days ago, but has been asymptomatic until he complained of pain 2 nights ago. She also notes that he has had a low-grade fever. He has no other significant constitutional symptoms and appears to be in some pain, but otherwise appears well. Based on the information obtained thus far, which of the following is the most likely diagnosis? A) Osteomyelitis. B) Rheumatic fever. C) Slipped capital femoral epiphysis (SCFE). D) Legg-Calvé-Perthes disease. E) Transient (toxic) synovitis. Answer: E Discussion The correct answer is E, transient (toxic) synovitis. This presentation is classic for transient synovitis, a condition most commonly presenting in the 2- to 6-year age range, more commonly in boys (male to female ratio of 2–3 to 1). It is often preceded by a viral respiratory infection, although numerous studies have failed to demonstrate a specific viral or bacterial agent. Physical exam reveals a limp or refusal to walk and complaint of pain over the groin and/or proximal thigh. There is pain with ROM testing, especially during abduction. Most children will be afebrile; a temperature of <38° C is consistent with this condition. Appropriate diagnostic workup might include which of the following? A) Joint aspiration. B) Plain film radiographs. C) ESR. D) CBC with differential. E) All of the above. Answer: E Discussion The correct answer is E. All of the above may be appropriate, as transient synovitis is a diagnosis of exclusion. Patients with mild symptoms may be observed without further investigation. However, if the pain is significant, if ROM is significantly impaired, or if the temperature is >37.5° C, further diagnostic workup is indicated. Laboratory findings consistent with transient synovitis include: clear joint fluid aspirate, normal CBC, mildly increased ESR, effusion seen on ultrasound, or a widened joint space on plain films. Blood cultures, ASO titer, bone scan, and MRI may also be of benefit to rule out other possibilities (e.g., septic arthritis, rheumatic fever, SCFE, etc.). It is of extreme importance to differentiate transient synovitis from septic arthritis. radiographic procedures can be used to reliably discriminate between transient synovitis and septic hip arthritis? A) CBC. B) Sedimentation rate. C) Ultrasound demonstrating fluid. D) ASO titer. E) None of the above. Answer: E Discussion The correct answer is E. No laboratory study can reliably differentiate a septic hip from transient tenosynovitis. A WBC count of >18,000 cells/mm3 is suggestive of septic hip but does not prove the diagnosis is septic hip. Likewise, a normal WBC count does not rule out septic hip. Seventy-one percent of patients with transient synovitis will have an effusion present, so the presence or absence of an effusion on ultrasound is not a good differentiator. You must have a high clinical suspicion for septic arthritis and consider the diagnosis in the appropriate patient. What is the most appropriate treatment for this patient with transient synovitis? A) Open fixation. B) Immobilization. C) Antibiotics. D) Surgical decompression. E) None of the above. Answer: E Discussion The correct answer is E. Conservative treatment is warranted: the appropriate initial treatment is rest and observation. Also, transient synovitis generally responds well to oral NSAIDs (e.g., ibuprofen). Home care is acceptable; however, admission is indicated if the diagnosis is equivocal or if significant pain management is required. For septic arthritis, prompt administration of an intravenous antibiotic—directed at the most likely infecting pathogen and altered as necessary based on culture results—is indicated. When septic hip is detected early, joint decompression by aspiration along with antibiotics may be sufficient. However, surgical decompression is often indicated to minimize the risk of osteonecrosis, and therefore prompt early orthopedic consultation is needed. Case 2 Concept Review Legg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip. In the vast majority of instances, the disorder is unilateral. Both hips are involved in less than 10% of cases, and the joints are involved successively, not simultaneously. Legg-Calvé-Perthes disease usually occurs in children aged 4-10 years, with a mean age of 7 years. It occurs more commonly in boys than in girls, with a male-to-female ratio of 4:1. The condition is rare, occurring in approximately 4 of 100,000 children. The cause is not known, but children with Legg-Calvé-Perthes disease (LCPD) have delayed bone age, disproportionate growth, and a mildly shortened stature. LCPD may be idiopathic, or it may result from a slipped capital femoral epiphysis, trauma, steroid use, sickle-cell crisis, toxic synovitis, or congenital dislocation of the hip. Rapid growth occurs in relation to development of the blood supply of the secondary ossification centers in the epiphyses, creating an interruption of adequate blood flow and making these areas prone to avascular necrosis. Interruption of the blood supply to the bone results in necrosis, removal of the necrotic tissue, and its replacement with new bone. Bone replacement may be so complete and perfect that completely normal bone may result. The adequacy of bone replacement depends on the age of the patient, the presence of associated infection, congruity of the involved joint, and other mechanical and physiologic factors. Necrosis may occur after trauma or infection, but idiopathic lesions can develop during periods of rapid growth of the epiphyses. The earliest sign of Legg-Calvé-Perthes disease (LCPD) is an intermittent limp (abductor lurch), especially after exertion, with mild or intermittent pain in the anterior part of the thigh. LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and the classic presentation has been described as a painless limp. The patient may present with limited range of motion of the affected extremity. The most common symptom is persistent pain. Hip pain may develop and is a result of necrosis of the involved bone. This pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture. The patient may have an antalgic gait with limited hip motion. Pain may be present with passive range of motion and limited hip movement, especially internal rotation and abduction. Children with LCPD can have a Trendelenburg gait resulting from pain in the gluteus medius muscle. Laboratory studies and radiography may supplement medical history taking and physical examination in the assessment of a child with a limp. Case 2 A 6-year-old white male is brought in by his parents because he is complaining of pain in his hip and anterior thigh. He is walking much less than usual since the pain began about 4 weeks ago. You order a plain radiograph, which shows mild sclerosis with some increased density of the femoral head. An MRI is ordered, which the radiologist interprets as “demonstrating osteonecrosis of the femoral head.” What is the most likely diagnosis in this patient? A) Osteomyelitis. B) Septic arthritis. C) Slipped capital femoral epiphysis (SCFE). D) Legg-Calvé-Perthes disease (LCPD). E) Sickle-cell anemia. Answer: D Discussion The correct answer is D. LCPD is idiopathic osteonecrosis of the femoral head. It is unilateral in 90% of cases, and the typical age range is 4–8 years, but 2- to 12-year-olds may present with the disease as well. Answer A is a possibility, although there should be evidence of osteomyelitis on MRI. Answer B is discussed in the previous case. Answer C, slipped capital femoral epiphysis, generally occurs in obese children (usually male) who are in early adolescence. Answer E, sicklecell anemia, can cause osteonecrosis of the femoral head also, but the disease is rare in white populations. Legg-Calvé-Perthes disease is actually less common in blacks. Which of the following factors MOST affects the outcome in patients with Legg-Calvé- Perthes disease? A) Age at onset of illness. B) Findings of subchondral fractures or fragmentation. C) Early appropriate treatment. D) Severity of pain and ability to bear weight. E) Bilateral involvement. Answer: A Discussion The correct answer is A. Compared to older children, younger children generally have a longer time for remodeling to occur via molding of the femoral head within the acetabulum; and therefore, younger children have less flattening of the femoral head. Which of the following is the best initial treatment for this patient? A) Joint replacement. B) Osteotomy. C) Rest and traction. D) None of the above. Answer: C Discussion The correct answer is C. The initial treatment for a patient with Legg-Calvé-Perthes disease typically includes rest, traction, and the use of an abduction brace. The objectives are to increase ROM in the hip and to reduce the risk of significant deformity. In general, patients should be seen by a specialist. This is especially true for older children (>6 years) and those with very limited ROM (abduction <40°). Answer A is incorrect because joint replacement is not an option. Answer B is incorrect. While osteotomy may be used, it is typically reserved for older children and patients who are not progressing well with conservative therapy. LCPD is difficult to treat, largely because of the long duration of treatment and activity restrictions required. Periods of rest with traction, casting, or bracing, and surgical intervention, may be indicated over 1–2 years of treatment and observation. Even with the best of care, prognosis is fair, with need for total hip replacement reaching approximately 50% by middle age due to severe degenerative arthritis. Case 3 A 15-year-old female cross-country runner presents to your clinic with the chief complaint of knee pain. She describes a gradual increase in her symptoms during the first 3 weeks of the season. She wants to run varsity this year and has done extra running and hill training after practice each day. She describes anterior knee pain in the patellar region with little or no swelling, but complains of crepitus and pain exacerbated by stair climbing and running. The most likely diagnosis for the condition described is: A) Osteochondritis dissecans (OCD). B) Osgood-Schlatter disease. C) Chondromalacia patellae. D) Patellofemoral pain syndrome. E) Femoral stress fracture. Answer: D Discussion The correct answer is D. Patellofemoral pain syndrome is a common overuse syndrome seen more frequently in runners and female athletes. Higher incidence in females is thought to be due to the mechanical disadvantage of an increased Q-angle. The Q-angle is formed by the intersection of a line drawn from the anterior-superior iliac spine through the center of the patella and a second line drawn from the tibial tubercle through the center of the patella. This angle should be <22° in females and <18° in males. Patellofemoral syndrome may involve lateral subluxation or mal-tracking within the femoral groove due to vastus medialis weakness. Maltracking may be observed clinically and subluxation may be seen on plain films using a Merchant view. Answer B, Osgood-Schlatter disease, is also related to overuse but is 2–3 times more common in males, particularly in athletes engaging in repetitive jumping. Pain is generally well localized to the tibial tubercle. Radiographic evidence of fragmentation of the epiphysis or heterotropic ossification anterior to the tubercle may be seen, but is not necessary for diagnosis. Answer C, chondromalacia patellae, is softening of the articular cartilage of the patella as seen on arthroscopy and may be a result of long-term patellofemoral dysfunction. This is a surgical diagnosis and the term should be avoided clinically. Answer A, osteochondritis disiccans (OCD), is osteonecrosis of subchondral bone most commonly occurring on the lateral side of the medial femoral condyle, but is also seen elsewhere in the knee, elbow, hip, and ankle. It is thought that repetitive micro-trauma or occasionally an acute injury occurs to the blood supply of subchondral bone. The covering articular cartilage is supplied by synovial fluid and may protect the affected segment from detaching and allow nonsurgical healing in the skeletally immature. A significant acute injury or continued micro-trauma may lead to partial or complete (loose body) separation of the necrotic segment. Surgical intervention is warranted in these cases or in the skeletally mature. These lesions are typically visible on plain film radiographs; however, MRI may be helpful in assessing the integrity of the overlying articular surface. What is the preferred treatment for this female runner? A) Arthroscopic debridement. B) Decreased activity level and quadriceps strengthening. C) Evaluation for “female athlete triad.” D) Casting or immobilization. E) Corticosteroid injection. Answer: B Discussion The correct answer is B. Quadriceps strengthening is usually initiated by resisted straight leg raises to minimize patellofemoral compressive forces. NSAIDs and cross-training may also be of benefit. Also, consider physical therapy referral for exercise instruction and trials of therapeutic modalities such as orthotics. Recalcitrant cases and patients with recurrent dislocation/ subluxation should be referred to orthopedics for consideration of surgical intervention. Case 4 A 13-year-old male presents to the clinic with his mother for difficulty walking. He is unsure of when the problem first began, but has noticed it getting worse over the last week. It has forced him to stop playing sports. He reports a dull pain in the left hip but denies trauma. On examination, you find an obese male in no distress. There is loss of internal rotation at the left hip joint. When his hip is flexed to 90°, this loss of ROM is more pronounced. What is the most likely diagnosis in this case? A) Developmental dysplasia of the hip. B) Septic arthritis. C) Slipped capital femoral epiphysis (SCFE). D) Legg-Calvé-Perthes disease (LCPD). E) Transient (toxic) synovitis. Answer: C Discussion The correct answer is C. SCFE occurs most commonly in active, overweight, adolescent males. Shear forces across the relatively weak physis cause displacement. Slippage is generally gradual, but may occur acutely. Mean age at presentation is 12 for females (range 10–14) and 13 for males (range 11–16). Endocrinopathies should be considered in those presenting atypically or outside the typical age range. Watch for development of a similar process in the contralateral hip over time. Which of the following studies do you obtain to confirm the diagnosis? A) AP and frog-lateral radiographs. B) CT scan. C) MRI. D) ESR. E) No diagnostic studies are warranted. Answer: A Discussion The correct answer is A. Radiographs of the hip should demonstrate displacement of the femoral head, which can then be classified as mild, moderate, or severe. Answers B and C are incorrect because the radiograph is diagnostic in most cases. Answer D is incorrect since SCFE is not an inflammatory condition. Answer E is incorrect. Imaging should be obtained in order to confirm the diagnosis and rate the severity. The treatment of choice for this patient is: A) Surgical fixation. B) Immobilization. C) Antibiotics. D) Surgical decompression. E) Physical therapy. Answer: A Discussion The correct answer is A. The goals of treatment of SCFE are to prevent further slippage, promote closure of the physis, and minimize the risk of osteonecrosis or chondrolysis. These aims are best accomplished through referral to an orthopedic surgeon and, ultimately, surgical fixation. Answers B and E are incorrect because referral might be delayed. Answers C and D are incorrect because SCFE is not an infectious process. Case 5 A 2-year-old child presents to your office with his mother. He hasn’t been using his right arm. According to the mother, the child was unwilling to leave the sandbox and a tug-of-war ensued, with the mother eventually picking the child up by his forearm. The LEAST likely cause of elbow pain in this age group is: A) Radial head subluxation. B) Infection. C) Occult fracture. D) Medial epicondylitis. Answer: D Discussion The correct answer is D. Medial epicondylitis—actually a degenerative, overuse condition—is rare in young children. Medial epicondylitis, which presents with pain over the medial epicondyle of the elbow and pain with resisted flexion of the wrist, is common in pitchers in Little League, golfers, and some tennis players. Treatment consists of rest and NSAIDs. All of the other options are possible causes of elbow pain in 2- year-old children. Which of the following statements about pediatric orthopedic injuries is correct? A) Bone is generally stronger than ligaments in the 2-year-old child. B) Children’s bones are particularly brittle and susceptible to breaking when compared to patients in the teenage years. C) Osteogenesis imperfecta is associated with multiple fractures and blue sclera. D) Epiphyseal injuries are described using the Katherine-Harris scale. Answer: C Discussion The correct answer is C. Osteogenesis imperfecta, which is a defect in bone formation, is associated with multiple fractures as a child and throughout life. There are several subtypes of varying severity. There is also variable penetrance, with members of the same family having differing degrees of bone weakness. In the worst case, the child dies in infancy. Answer A is incorrect. Ligaments are frequently stronger than bone in the child. Thus, any injury (e.g., refusal to move an arm) should be assumed to be of bony origin unless proven otherwise. Answer B is also incorrect. Answer D is incorrect. Injuries are described using the Salter-Harris scale (seen below), not the Katherine-Harris scale. Salter-Harris Classification What abnormality are you likely to see on a radiograph of this 2-year-old child? A) Dislocation at the wrist between the radius and ulna and the carpal bones. B) Dislocation of the shoulder. C) Fracture in the midshaft of the radius and ulna. D) Dislocation at the elbow of the olecranon. E) No abnormality will likely be seen on radiograph. Answer: E Discussion The correct answer is E. This case is typical of “nursemaid’s elbow,” which is a subluxation of the radial head. The radiograph is generally normal. All of the other answer choices are incorrect. The appropriate treatment for subluxation of the radial head is: A) Surgical. B) Closed reduction using finger traps and weights. C) Closed reduction using the Stimson technique. D) Supination of the forearm and then flexing the arm at the elbow. E) None of the above. Answer: D Discussion The correct answer is D. There are a number of techniques for reducing a subluxed radial head, and many different movements may accomplish your goal. Some physicians rapidly flex the elbow. The most accepted technique is supinating the forearm followed by flexing the elbow. You should feel the reduction take place with a “click” at the elbow. Case 6 A 28-year-old male presents to your clinic for evaluation of lower back pain (LBP). Yesterday morning he first noticed the discomfort, manifesting as stiffness and soreness in the lower back. The day before had been spent running a floor polisher while working as a custodian at the local elementary school. He describes his pain as sharp in nature and 8/10 in intensity. He denies radiation of the pain, sensory changes, and constitutional symptoms. He is concerned this may be an injury to a disk and that he may be permanently disabled due to his extreme pain. This patient will benefit most from treatment by what type of provider? A) Family physician. B) Orthopedist. C) Chiropractor. D) Any of the above. Answer: D Discussion The correct answer is D. There is no difference in outcome when patients with acute back pain are treated by a family physician, a chiropractor, or an orthopedic surgeon. However, therapy by a family physician is the most cost- effective (and deep in your heart, you know it’s the best). Which of the following signs or symptoms would be “red flags” indicating the need for early imaging and/or referral? A) Pain radiating down one or both legs into the posterior thigh. B) Severe pain, prompting the patient to request narcotics. C) Pain greater with active lumbar extension than with forward flexion. D) New-onset erectile dysfunction with back pain. E) None of the above. Answer: D Discussion The correct answer is D. The onset of erectile dysfunction is suggestive of neurologic involvement and warrants further investigation. None of the other options is suggestive of significant disease requiring immediate intervention. (Answer A certainly could represent a disk. However, this does not require immediate intervention.) Early imaging should be obtained in all of the following situations EXCEPT: A) Neurologic symptoms such as bowel or bladder dysfunction and impotence. B) History of fever, night sweats, or weight loss. C) History of cancer. D) Trauma. E) Age < 50. Answer: E Discussion The correct answer is E. Patients over the age of 50 should have early imaging. Which of the following should be performed as part of this patient’s initial evaluation today? A) History and physical exam. B) Plain film radiographs. C) Laboratory tests (e.g., CBC, ESR, CRP). D) MRI or CT. E) All of the above. Discussion The correct answer is A. Answers B and D are incorrect because radiologic studies are not necessary in most patients and should only be obtained on the first visit if a red flag is present. Such red flags can include bowel or bladder dysfunction, onset of impotence, fevers or nightsweats, night pain, history of cancer, saddle anesthesia, history of recent trauma, age >50 or <18, use of steroids, pain for >6 weeks, or any infection or suspicion of neoplasia. Answer C is incorrect because lab tests are not helpful in most typical cases of LBP. However, if signs or symptoms suggesting an inflammatory or infectious condition are present, you should consider lab tests and imaging. Which of the following is the most common cause of low back pain? A) Mechanical (lumbosacral sprain/strain). B) Systemic (neoplasm/infectious). C) Neurologic (neuropathy, including mononeuropathy and inflammatory demyelinating diseases). D) Referred pain (nephrolithiasis, AAA, inflammatory bowel, dysmenorrhea). E) Metabolic. Answer: A Discussion The correct answer is A. Mechanical causes account for up to 98% of cases of back pain. This is the reason you do not need all those lab tests and x-rays when a patient initially presents with LBP. Upon physical examination, you note the vital signs are normal. Straight leg raise (SLR) testing on the right leg at 55° reproduces the patient’s pain in the lower back and a painful “tightness” in the posterior thigh. He complains of the same discomfort on the left at 30°. Based on this finding, which of the following statements is true? A) This is a positive SLR test bilaterally and is specific for disk herniation. B) This is a positive SLR test on the left and is specific for disk herniation. C) This is a positive SLR test on the right and is specific for disk herniation. D) This is a negative SLR test bilaterally for disk herniation. Answer: D Discussion The correct answer is D. The SLR test can be performed in several ways, which are listed here: _ Seated active: With the patient seated on the exam table, ask that he dorsiflex the foot and extend the knee. _ Seated passive: With the patient seated on the exam table, the examiner passively extends the knee, and radicular symptoms will be exacerbated with passive ankle dorsiflexion. _ Lying passive: With the patient in a supine position, the examiner holds the knee in full extension and passively flexes the hip, and radicular symptoms will be exacerbated with passive ankle dorsiflexion. In all cases, the test is positive when radicular symptoms occur (e.g., pain, paresthesias down the leg below the level of the knee—not back pain or thigh pain from muscle stretching) between 25° and 75° of hip flexion while lying or with knee extension while seated. The symptoms will be exacerbated with active or passive ankle dorsiflexion. However, straight leg raising is not highly sensitive nor specific for disk disease. “Crossover” pain with radicular symptoms in the leg not lifted is very specific for disk disease. Even though straight leg raising is negative, you continue your neurologic exam. On further examination, you note symmetric patellar reflexes, diminished Achilles reflex on the right, and symmetric strength in the legs except for decreased strength with ankle eversion on the right. You also note decrease in gross sensation to light touch over the lateral malleolus on the right. Which of the following nerve roots is most likely compromised? A) L3. B) L4. C) L5. D) S1. E) S2-3-4. Answer: D Discussion The correct answer is D. Appropriate initial treatment for this patient’s acute back pain should include which of the following? A) Strict bed rest. B) NSAIDs. C) Corset or lumbar belt. D) Referral for epidural steroid injection or endoscopic disk resection. Answer: B Discussion The correct answer is B. In acute mechanical back pain (no longer than 6 weeks), regardless of the method of treatment, 40% are better within 1 week, 60–85% in 3 weeks, and 90% in 2 months. Negative prognostic factors include more than 3 episodes of back pain, gradual onset of symptoms, and prolonged absence from work. Bed rest does not contribute to a return of function and may worsen outcomes. Early mobilization of the patient is best for allowing him to continue activities as tolerated. You prescribe your NSAID of choice and recommend rehabilitation exercises. Which of the following has been shown to be effective at reducing the recurrence of back injury in the workplace? A) Back support belts. B) “Back School,” which teaches proper lifting techniques, etc. C) Increasing physical fitness and muscle tone. D) A and C. E) B and C. Answer: C Discussion The correct answer is C. The only thing that has been unequivocally shown to reduce further back injuries is improving the overall fitness of the patient and his muscle tone. Of special note, back support belts, long worn in industry, have been demonstrated to be worthless. “Back School” also does not seem to help. Case 7 A patient presents to your office after a baseball collision (yeah, sure, they were in a bar . . .). During the game, another man’s face accidentally hit his fist, and he suffered a laceration over the dorsum of the left fifth MCP joint. Exam reveals a painful erythematous and edematous fifth MCP joint with ROM limited secondary to pain. The patient states, “You should see the other guy. I knocked out 2 of his teeth and broke 2 others.” He brightens at this memory, confirming your suspicion that he was not playing baseball. Which of the following are concerns about this injury? A) A septic joint. B) Fracture. C) Extensor tendon injury. D) Foreign body. E) All of the above. Answer: E Discussion The correct answer is E. This injury is likely secondary to an indirect “bite injury” when the patient’s hand struck the opponent in the mouth, and is at high risk for infection. Even a small laceration may produce a devastating infection involving the deep palmar space, osteomyelitis, and joint sepsis. A boxer’s fracture (a fracture of the neck of the fifth metacarpal), tendon laceration, and foreign body (tooth fragments) are common with this mechanism of injury. Appropriate treatment for the laceration described above would include all of the following EXCEPT: A) Tetanus prophylaxis, antibiotics, and admission if clinical evidence of infection is already present. B) Radiographs to rule out fracture and radiopaque foreign body. C) Anesthetize wound edges followed by wound exploration, debridement, and irrigation. D) Primary closure of deep and superficial layers after exploration, debridement, and irrigation. Answer: D Discussion The correct answer is D. Primary closure may lead to a significant infection. All wounds suspected of being caused by human bites should be allowed to close by secondary intention. Most can be treated on an outpatient basis if the joint has not been penetrated, there is no tendon or bony injury, and medical care is received in the first 8 hours following the injury. The wound edges should be anesthetized and the wound explored for foreign body, debridement of necrotic tissue, and assessment for damage to tendons or joint capsule. Remember to evaluate the tendons with the fingers flexed, as the injured area of the tendon may retract with extension; these injuries most often occur with the fist closed. Irrigation with at least 1,000 ml of normal saline followed by application of a sterile dressing is indicated. Referral is appropriate if there is tendon, bone, nerve, or joint capsule damage, or if deep infection is suspected. Radiographs demonstrate a fifth metacarpal fracture with some angulation. What is the maximal acceptable angulation and rotation for a boxer’s fracture, fourth or fifth metacarpal, to maintain full hand function? A) 10° of dorsal angulation and 5° of rotation. B) 30° of dorsal angulation and 5° of rotation. C) 40° of dorsal angulation and 5° of rotation D) 60° of dorsal angulation and 0° of rotation. E) None of the above. Answer: E Discussion The correct answer is E. If there is an extensor lag, any degree of rotation, or >40° of dorsal angulation, significant functional deficits may result. Reduction should be attempted if angulation is >10°. Patients should be advised that with angulations >10–15° there will likely be a loss of MCP prominence, although there should be no loss of function. If this is unacceptable to the patient, referral is recommended. Case 8 A 65-year-old male presents with left shoulder pain and weakness that started after he put a new roof on his house. The pain came on gradually and is made worse with abduction and flexion of the shoulder joint. He describes himself as active and healthy, and he only takes acetaminophen when needed for shoulder pain. You suspect that he may have a rotator cuff injury. If this is the case, what do you expect to find on exam? A) Tenderness to palpation of the greater tuberosity of the humerus. B) Limited active range of motion. C) Normal passive range of motion. D) Shoulder shrug with attempted abduction. E) Any of the above. Answer: E Discussion The correct answer is E. Okay, so this might fit under the category of “trick question,” but the shoulder exam can be normal in a patient with rotator cuff tear, or it can include any of the elements listed in A through D. Which of the following muscles is not a part of the rotator cuff? A) Supraspinatus. B) Infraspinatus. C) Subscapularis. D) Teres major. E) Teres minor. Answer: D Discussion The correct answer is D. The rotator cuff consists of the other four muscles listed, and functions to rotate the arm and stabilize the humeral head. Which of the following muscles is the most commonly torn in the rotator cuff? A) Supraspinatus. B) Infraspinatus. C) Subscapularis. D) Teres minor. Answer: A Discussion The correct answer is A. The supraspinatus is generally the point of origin for most tears. Based on your history and physical exam, you diagnose a rotator cuff injury. Appropriate initial management of this 65-yearold male should be: A) NSAIDs and physical therapy. B) Oral corticosteroids and physical therapy. C) Subacromial injection with corticosteroid and physical therapy. D) Surgical repair and physical therapy. E) None of the above. Answer: A Discussion The correct answer is A. For initial management in an individual >60 years of age, NSAIDs and physical therapy for 6 weeks are the best answer. If they have no improvement or inadequate response, a corticosteroid injection may be used judiciously. Injection will likely cause at least short-term pain relief but is thought to weaken the tendon and may accelerate extension of the tear. Oral steroid dosing may provide relief, but it is associated with a higher incidence of systemic side effects. Patients with significant symptoms or failed therapy should be considered for MRI, orthopedic referral, and surgical management. Patients under the age of 60 with acute traumatic tears should be considered for surgery, with best results within 6 weeks of injury. Your patient is successful in rehabilitating his left shoulder, but then he returns 2 years later with right shoulder problems. The right shoulder has become progressively stiff and painful, and his ROM is now significantly limited in all directions. Your examination is consistent with “frozen shoulder” or adhesive capsulitis. Adhesive capsulitis is most commonly associated with which of the following? A) Diabetes mellitus type 1. B) Hyperthyroidism. C) Spondyloarthitis. D) Nondominant arm. E) Male gender. Answer: A Discussion The correct answer is A. Adhesive capsulitis has no clear predilection as to gender, race, arm dominance, or occupation. It is characterized by loss of ROM of the shoulder in all directions, with loss of both passive and active motion. It has a high incidence in patients with type 1 diabetes and tends to be more recalcitrant in those patients, of whom up to 50% will have bilateral involvement—although not necessarily concomitantly. Adhesive capsulitis is not typically related to trauma, but it can be associated with disuse due to pain, osteoarthritis, sling use, etc. Other conditions that are associated with adhesive capsulitis include hypothyroidism, cervical disc disease, and Parkinson’s disease. What initial treatment do you recommend for this patient? A) Arthroscopic debridement. B) Oral corticosteroids. C) NSAIDs and a sling for comfort. D) Extended progressive physical therapy. E) Mobilization under anesthesia. Answer: D Discussion The correct answer is D. A progressive stretching program with heat and NSAIDs to improve comfort is the most appropriate early treatment. A corticosteroid injection may be beneficial, but should be used cautiously in diabetic patients. Oral steroids have no greater benefit than NSAIDs. Answer C is incorrect because a sling will contribute to further immobilization and worsening of the problem. Mobilization under anesthesia may be a last resort in true adhesive capsulitis, but is more commonly used for posttraumatic or postoperative joint stiffness or adhesions that do not respond to conservative treatment. Case 9 A 24-year-old female presents to the clinic 24 hours after slipping on a patch of ice outside her home. She reports feeling a “pop” and immediate pain on the lateral aspect of the ankle. She reports significant swelling in the first few hours, with pain and inability to bear weight initially, but now she is able to walk with a significant limp. She reports no significant past injuries to the foot or ankle. On exam, you note edema/ effusion over the lateral ankle, some ecchymosis, tenderness, but no laxity on anterior drawer and inversion stress. There is no bony tenderness on palpation of the foot and ankle, but there is tenderness anterolaterally in the soft tissue. The most likely injury this patient has suffered is: A) Fracture of the distal tibia. B) Fracture of the distal fibula. C) Sprain of the lateral ligament complex. D) Sprain of the medial ligament complex. E) Syndesmosis sprain. Answer: C Discussion The correct answer is C. A sprain is most likely because there is no bony tenderness. And, since she is tender laterally, the lateral ligament complex is most likely sprained. In this case, the most likely structure injured would be the: A) Anterior talofibular ligament. B) Distal fibula. C) Distal tibia. D) Deltoid ligament. E) Achilles tendon. Answer: A Discussion The correct answer is A. This is a sprain of the anterior talofibular ligament. This is the first ligament injured with an inversion ankle sprain. It is followed by the calcaneofibular ligament if enough force is involved. Answer E, Achilles tendon injury (specifically rupture), is of special note. First, this injury presents as pain in the Achilles tendon area. With a complete Achilles tendon tear, the patient will have marked weakness of plantar flexion. A diagnostic test (Thompson test) is to squeeze the posterior calf. In response, the foot should plantar flex. If this does not occur, consider Achilles rupture. Operative and nonoperative treatments have been used. Operative treatment carries a lower risk of re-rupture. Which of the following is the most appropriate management of this patient’s injury? A) Cast for 4 weeks followed by physical therapy. B) Crutches, non-weight-bearing for 2 weeks, and then progressive physical therapy. C) Rest, ice, elevation, and early mobilization using external support, crutches or cane if needed. Progress to activity as tolerated. D) Refer for orthopedic consultation. E) Immobilization, heat for comfort, analgesics or NSAIDs, and progress to activities as tolerated. Answer: C Discussion The correct answer is C. Treatment for most grade I and II sprains includes external support, such as an air or gel splint, ice application, and elevation; early mobilization is critical and will hasten recovery. NSAIDs or acetaminophen should be used for pain control. The patient should be allowed partial weight bearing as tolerated with crutches or a cane. Patients with recurrent problems of instability or an acute grade III sprain should be referred to an orthopedist for evaluation. Ottawa Ankle Rules Case 10 A 45-year-old female hospital clerk presents with bilateral aching pain in the forearms and thenar eminences. The pain is made worse with driving and typing. She also has intermittent numbness over the same areas. She tried to ignore the symptoms, but today she dropped her coffee mug on her computer keyboard and became alarmed at her loss of strength. She has hypothyroidism and is obese, but she reports that her health is otherwise good. Based on the history alone, which of the following is the most likely diagnosis? A) Carpal tunnel syndrome. B) Osteoathritis. C) Ulnar neuropathy. D) Diabetic neuropathy. Answer: A Discussion The correct answer is A. Carpal tunnel syndrome is due to median nerve entrapment in the carpal tunnel of the wrist. Typical symptoms include numbness, paresthesias, and pain at the palmar/radial aspect of the hand, quintessentially the thenar eminence. In more severe or long-lasting cases, you may see atrophy of the thenar eminence. Patients may also develop weakness of thumb opposition. Ostoearthritis of the wrists does not usually give the neurological symptoms of numbness and weakness; however, osteoarthritis of the cervical spine can cause spondylosis and nerve root impingement. Ulnar neuropathy involves the ulnar aspect of the arm, rather than the radial aspect, which is involved with carpal tunnel syndrome. Diabetic neuropathy typically presents in the feet, since they are innervated by the longest nerves in the body. On exam, Tinel’s sign is positive (tapping over the median nerve at the wrist produces tingling in the first 3 digits and the radial half of the ring finger). Also, Phalen’s sign is positive (placing the wrists in a flexed position causes aching and numbness in the median nerve distribution). What is the best next step in the continuing evaluation and management of this patient? A) Nerve conduction studies. B) Radiograph of the wrist. C) MRI of the cervical spine. D) Orthopedic referral. E) Initiation of treatment. Answer: E Discussion The correct answer is E. In a clear-cut case of carpal tunnel syndrome, there is no need for further studies. If the diagnosis is in doubt, EMG/nerve conduction studies may be of benefit. If the ROM in the wrist is limited, x-rays may be helpful. At this point in time, MRI and orthopedic referral are not likely to add much. Which of the following is NOT associated with carpal tunnel syndrome? A) Hypothyroidism. B) Diabetes mellitus. C) Amyloid. D) Polycythemia vera. E) Rheumatoid arthritis. Answer: D Discussion The correct answer is D. All of the above are associated with carpal tunnel syndrome except for polycythemia vera. Polycythemia vera can cause a painful condition of the hands called erythromelalgia, which is a burning pain of the hands and feet associated with erythema, pallor, or cyanosis. It responds to aspirin. The point here is that patients with carpal tunnel syndrome should have a systemic cause ruled out either clinically or with labs. What is the most appropriate initial treatment? A) Thumb spica splint. B) Steroid injection. C) NSAIDs and neutral position wrist splints. D) Short arm casts. Answer: C Discussion The correct answer is C. Conservative therapy should be initiated first, unless there is some compelling reason for more aggressive therapy (e.g., severe weakness of the hands and loss of function). Most patients respond well to NSAIDs and the use of neutral position splints. The traditional cock-up splints are not as effective as neutral position splints. The splints should be worn at night. The patient may wear the splints during the day, too, but she should take them off for several hours per day to avoid disuse muscle atrophy. Answer A is incorrect; a thumb spica is not needed. Answer B, steroid injection, might be tried if initial conservative measures fail. If you choose to perform a steroid injection, avoid injecting steroids directly into the median nerve. Answer D is just wrong—don’t cast patients with carpal tunnel syndrome!