Exam (elaborations)
Rosh Review Emergency Medicine With Complete Solutions Latest Update
- Course
- ROSH
- Institution
- University Of Pennsylvania
Rosh Review Emergency Medicine With Complete Solutions Latest Update
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lOMoARcPSD|22014731Rosh Review Emergency Medicine A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from summer camp 1 week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae surrounding scattered, erythematous papules. Which of the following is the most appropriate treatment?
Ketoconazole
Lindane
Permethrin
Prednisone - correct answers Correct Answer ( C )
Explanation:
This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus, especially when exposure to others with similar symptoms is reported. The rash of scabies involves papules, which are often excoriated. Burrows are pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes 3-6 weeks to develop because symptoms are due to delayed (Type IV) sensitivity reaction. The pruritus is classically worse at night and
affects the web spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice for primary scabies infection is the application of topical scabicidal agents, with repeat application in 7 days. The treatment of choice is permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may return to school or work 24 hours after the first treatment.
Should family members of an infected individual also be treated for scabies? - correct answers Yes, family members and sexual contacts.
Scabies - correct answers Sarcoptes scabiei
Pruritic rash worse at night
Linear burrows
Interdigital spaces of hands/feet, penis, breasts
Permethrin (first line)
Ivermectin
**head and back are sparred (head involved in children)
An 18-month-old boy presents to the emergency department with worsening shortness of breath. The parents report he has
had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms? Bordetella pertussis
Haemophilus influenzae
Parainfluenza virus
Respiratory syncytial virus - correct answers Correct Answer ( D )
Explanation:
The patient has bronchiolitis, which is the most common lower respiratory tract infection in patients less than two years of
age. It remains the leading cause for hospitalization in infants under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus (RSV), but may be caused by other viral agents. Bronchiolitis is inflammation of the lower respiratory tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased mucus production. The resultant lower airway obstruction causes increased work of breathing and wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old, rhinorrhea, tachypnea, and wheezing. Unlike asthma or reactive airway lOMoARcPSD|22014731
disease, there is often no significant improvement with albuterol. There is often a history of several days of upper respiratory symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests, blood work, and radiographs are not usually needed. Radiographs may demonstrate hyperinflation and atelectasis, but do not show any focal infiltrates like with pneumonia. Bronchiolitis is usually self-limited, with respiratory status typically improving over 2-5 days. Management involves supportive care.
Bronchiolitis - correct answers What months of the year contain the peak incidence of RSV in North America? - correct answers November to March.
A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test? Bedside echocardiography
Chest radiograph
Computed tomography angiogram of the chest
Electrocardiogram - correct answers Correct Answer ( A )
Explanation:
This patient presents with a clinical picture consistent with obstructive shock. His distended neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without obstructing cardiac function. Tamponade occurs when rapid fluid accumulation results in elevated pressures that inhibit venous return. This is a dynamic process over the course of the cardiac cycle, therefore bedside echocardiography is the diagnostic test of choice. Fluid around the heart with evidence of right atrial compression and right ventricular diastolic collapse are diagnostic of pericardial tamponade.
Pericardial Effusion - correct answers What is the emergent treatment of pericardial tamponade? - correct answers Pericardiocentesis.
An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right sided facial droop and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management? Alteplase
Exchange transfusion
MRI brain
Tranexamic acid - correct answers Correct Answer ( B )
Explanation:
Cerebrovascular events are a potential complication of sickle cell disease. This patient developed symptoms concerning for acute ischemic stroke. For pediatric patients with acute ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of choice. Transfusion goals include decreasing hemoglobin S levels to less than 30% and obtaining a total hemoglobin level of 10 g/dL. For adults with acute ischemic stroke in the setting of sickle cell disease, consider tissue plasminogen activator (tPA). tPA is not indicated or approved for use in pediatric patients
Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage. Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric hemorrhage. Tranexamic acid is not used for ischemic events
Manage Sickle Cell - correct answers What is the most common bacterial cause of acute chest syndrome in adults with sickle cell disease? - correct answers Atypical bacteria such as Chlamydia pneumoniae, Mycoplasma pneumoniae, Mycoplasma hominis. lOMoARcPSD|22014731
Correct Answer ( B )
Explanation:
The patient has atrial fibrillation with rapid ventricular response. Atrial fibrillation results when multiple areas of the atrial
myocardium simultaneously depolarize and contract. As a result, the atrial walls do not contract in a coordinated fashion, but rather "quiver" or "fibrillate." The electrocardiographic hallmarks of atrial fibrillation are a narrow, complex, irregularly irregular rhythm and no discernible P waves. The rate may be slow, normal, or fast. Atrial fibrillation is usually
associated with ischemic or valvular heart disease, and can also be seen in cardiomyopathies, myocarditis, and thyrotoxicosis. Patients with atrial fibrillation may be asymptomatic, or may complain of palpitations, dizziness, lightheadedness, chest pain, or dyspnea. Patients in whom atrial fibrillation results in a rapid ventricular rate may develop clinical heart failure due to inadequate ven - correct answers A 52-year-old man with a history of diabetes mellitus and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 135 beats/minute, blood pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation
of 97% on room air. His electrocardiogram is shown above. Which of the following is the most appropriate initial management? Administer intravenous adenosine
Administer intravenous diltiazem
Sedate the patient and perform synchronized cardioversion with 100 joules
Transport the patient to the cardiac catheterization suite
Afib Image - correct answers What are options for outpatient anticoagulation for atrial fibrillation? - correct answers Warfarin or new oral anticoagulant
drugs (e.g., dabigatran, rivaroxaban, apixaban).
A 65-year-old man with a past medical history of hypertension presents to the Emergency Department with "tearing" chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first? Aspirin
Esmolol
Heparin
Nitroprusside - correct answers Correct Answer ( B )
Explanation:
Esmolol is the first line treatment for a hypertensive patient with an aortic dissection. Rate-controlling medication (e.g. esmolol) should be given before vasodilators to prevent reflex tachycardia and subsequent increase in aortic shearing forces. An aortic dissection occurs when the intima tears allowing blood to cause a false channel and intramural hematoma. If this extends to the heart it can precipitate myocardial infarction, severe aortic regurgitation, or pericardial tamponade leading to death. Risk factors include a history of hypertension, collagen vascular disease or aortic aneurysm, as well as current pregnancy and cocaine use. Based on the Stanford classification, a dissection is classified as type A if it involves the ascending aorta while a type B dissection is limited to the descending aorta. Treatment of a type A dissection requires surgical management while type B dissections are typically managed medically
Nitroprusside (D) reduces blood pressure through vasodilation and can be given after a rate controlling agent, such as esmolol, has been initiated
Aortic Dissection Management - correct answers Question: What toxicity is associated with use of nitroprusside? - correct answers Cyanide poisoning.
Correct Answer ( C )
Explanation:
This patient is exhibiting signs and symptoms consistent with myxedema coma. Myxedema coma is defined as severe lOMoARcPSD|22014731
hypothyroidism resulting in a decompensated metabolic state and mental status change. It is classically characterized by thickened, non-pitting edema of the skin diffusely associated with severe chronic hypothyroidism. Precipitating factors of myxedema coma include infection, cold exposure, stroke, or medications such as amiodarone or lithium. Mortality in myxedema coma is proportional to the severity of the patient's hypothermia. Other signs and symptoms of myxedema coma include hypoventilation, bradycardia, poor cardiac contractility, decreased cardiac output, pericardial effusion, and altered mental status. The diagnosis of myxedema coma is a clinical diagnosis based upon history and physical examination findings and exclusion of other causes of coma. As with other caus - correct answers A 74-year-old woman with a history of hypothyroidism presents to the ED with confusion, rigors, and lightheadedness. Vital signs are BP 110/64 mm Hg, HR 48 beats per minute, RR 12 breaths per minute, and T 95.2°F. Her electrocardiogram is shown above. Which of the following is the most likely diagnosis? Digoxin toxicity
Hyperosmolar nonketotic coma
Myxedema coma
Nephrogenic diabetes insipidus
What medication is classically implicated in causing nephrogenic diabetes insipidus? - correct answers Lithium.
A 5-year-old boy presents to the emergency department complaining of right hip pain. He is febrile and refuses to bear weight on the right foot. There is no history of trauma. X-rays are obtained and are unremarkable. Which of the following diagnostic tests would best confirm or exclude a diagnosis of osteomyelitis?
Blood culture
Complete blood count with differential
Erythrocyte sedimentation rate
Serum glucose - correct answers Correct Answer ( C )
Explanation:
Pediatric patients with underlying osteomyelitis almost universally have an elevated erythrocyte sedimentation rate (ESR).
An elevated ESR and C-reactive protein have a 98% sensitivity for osteomyelitis in children. The two most common symptoms of osteomyelitis in children are fever and joint pain. Other symptoms include malaise, fatigue, sudden refusal to bear weight on the affected joint and limp. The affected site may be warm, swollen, and painful to the touch. The gold standard in diagnosis is a bone biopsy and culture. Otherwise there is no one single laboratory test that confirms the diagnosis of osteomyelitis. A complete blood cell count may (B) be helpful if the white blood cell count and/or platelets are abnormal. However an elevated white blood cell count is not specific for osteomyelitis and may also be normal despite an underlying infection. Platelets are acute phase reactants and a thrombocytosis may indicate an underlying inflammatory process, however this is also non-specific. An elevated serum glucose (D) may be seen in individuals with a history of diabetes as osteomyelitis can precipitate diabetic ketoacidosis. However, in the general population serum glucose would not be helpful in diagnosing osteomyelitis. Blood culture (A) may be positive for the causative agent, however the result will not be available in a time frame that is useful to the EM physician. X-rays are often unremarkable early in the disease course. CT scan, bone scan, and MRI are often used in the acute phase to reliably diagnose osteomyelitis.
Osteomyelitis Review - correct answers Adults: contiguous spread
Children: hematogenous spread
Most common: S. aureus
Sickle cell: Salmonella
Cat/dog bites: Pasteurella multocida
Plain films: periosteal elevation or bony erosions
Bone scan, MRI
Long term ABX
Name 3 risk factors associated with the development of osteomyelitis? - correct answers Sickle cell anemia, recent surgery, immunocompromise, diabetes, peripheral vascular disease, hemodialysis, IV drug abuse.
A 38-year-old man presents to the emergency department with low back pain that began this morning when he rolled over
in bed. Throughout the day, he tried ibuprofen and acetaminophen without relief, which prompted him to come to the
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