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2019 In-Service Review: Visual Stimuli

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2019 In-Service Review: Visual Stimuli 1/11/2019 1. A CDC laboratory worker presents with malaise, fever, and a painless arm lesion. What is the most appropriate treatment? 2019 In-service Review: A. Doxycycline Visual Stimuli B. Cephalexin C. Penicillin Brett R. Todd, MD, FACEP D. Surgical debridement Assistant Professor of Emergency Medicine E. Dapsone Oakland University William Beaumont School of Medicine 1 2 1 2 A. Doxycycline Anthrax • Bacillus anthracis • Inhalational – initial flu-like, later severe distress, mediastinitis, wide mediastinum on CXR • Cutaneous – painless vesicle then ulcer with black eschar • GI • Bioterrorism agent 3 4 3 4 2. A 26 y.o. homeless man presents to the ED complaining of fever, foul breath, and oral pain. What is the diagnosis? A. Dental caries B. Acute necrotizing ulcerative gingivitis C. Ludwig’s angina D. Periapical abscess E. Malingering 5 6 5 6 1 1/11/2019 3. A 24 y.o. man is thrown from his B. Acute Necrotizing Ulcerative Gingivitis motorcycle at high speed. He is hypertensive • Trench mouth on arrival. What is the most appropriate • Immunosuppressed, HIV, treatment based on the portable chest x-ray Etoh, Stress • Fever, pain, bleeding, halitosis shown? • Grayish pseudomembrane • Polymicrobial, Fusobacterium, A. Needle thoracostomy Treponema B. Pericardiocentesis • PCN + Flagyl, or Clinda, or C. ED Thoracotomy Augmentin • Chlorhexidine rinses D. Esmolol E. Tube thoracostomy 7 8 7 8 D. Esmolol Traumatic rupture of aorta • Wide mediastinum, enlarged aortic knob, tracheal deviation, apical cap • Treat like aortic dissection – Beta-blocker, vasodialators • Goal: HR < 60 - 80, SBP < 120 • Medical management for intimal tear • Surgery for intramural hematoma, pseudoaneurysm, or free rupture 9 10 9 10 4. A welder presents with bilateral eye pain after leaving work. His slit lamp exam is shown. Which of the following is true of his condition? A. Typically resolves spontaneously within 72 hours B. Symptoms begin within 1 hour of exposure C. Topical tetracaine should be prescribed for analgesia D. Opiates should not be prescribed E. Require topical antibiotics 11 12 11 12 2 1/11/2019 A. Typically resolves spontaneously within 72 hours 5. A 33 y.o. woman has grossly bloody urine Superficial Punctate Keratitis after being hit by a car. A retrograde • Prolonged UV exposure cystogram is shown. All of the following are • Latent period of 6 – 12 hours true about the injury shown except: • Welders, snow blindness • Painful – use narcotics, A. Usually caused by a pelvic fracture NSAIDs, Cyclopegics B. High incidence of injury to other organs • Spontaneous resolution with corneal healing C. Suspect if blood at meatus D. Gross hematuria usually seen E. Resolution at 2 weeks with Foley catheter drainage 13 14 13 14 E. Resolution at 2 weeks with Foley catheter drainage Intraperitoneal Bladder Rupture • Suprapubic pain, blood at meatus, urinary retention • Most associated with pelvic fracture • Extraperitoneal – nonoperative with bladder catheter drainage • Intraperitoneal – operative management 15 16 15 16 6. A 13 y.o. boy presents with a limp and 2 weeks of knee pain. What is the diagnosis? A. Osgood-Schlatter disease B. Slipped capital femoral epiphysis C. Patellar dislocation D. Tibial plateau fracture E. Legg-Calve-Perthes disease 17 18 17 18 3 1/11/2019 A. Osgood-Schlatter disease 7. A 19 y.o. man complains of neck pain and • Apophysitis of tibial tubercle hand paresthesias after diving into a shallow • 10 – 15 yr old males pond. What type of injury is this? • Overuse injury, often bilateral • Pain worse with activity, A. Odontoid fracture improves with rest B. Jefferson burst fracture • Tx: rest, NSAIDs, ice C. Hangman’s fracture D. Clay shoveler’s fracture E. SCIWORA 19 20 19 20 B. Jefferson burst fracture • C1 burst fracture • Unstable • Axial loading force • C-collar, ortho-spine consult 21 22 21 22 8. A 1 week old boy, born at 30 weeks gestation, is brought in to the ED for emesis. What is the correct diagnosis? A. Midgut malrotation with volvulus B. Pyloric stenosis C. Necrotizing enterocolitis D. Intussusception E. Gastroesophageal reflux 23 24 23 24 4 1/11/2019 C. Necrotizing enterocolitis 9. A 2 y.o. girl presents to the ED with a • Usually 1st week of life, fever and rash. What is the diagnosis? usually premies • Bacterial overgrowth in bowel, invade bowel wall A. Measles • Pneumatosis on KUB B. Scarlet fever • IV Hydration, broad spectrum C. Henoch-Schonlein Purpura abtx, surgery consult D. Rubella E. Erythema infectiosum 25 26 25 26 E. Fifth disease/erythema infectiosum/slapped cheek • Slapped cheek rash first • Macular erythema on trunk/limbs • Fever, headache, sore throat • Parvovirus B19 • Pregnancy – Hydrops fetalis • Sickle cell – aplastic crisis 27 28 27 28 10. A 28 y.o. woman presents with 2 days of loss of vision in the right eye. Which of the following is true of the condition shown? A. Usually painless B. Pupillary response is normal C. Visual loss is usually peripheral D. Affects men more than women E. Caused by optic nerve demyelination 29 30 29 30 5 1/11/2019 E. Caused by optic nerve demyelination 11. A 42 y.o. man presents with fever, Optic neuritis confusion, and skin lesions after being • Demyelination of optic nv started on phenytoin. What is the diagnosis? • 50% develop MS • Pain with eye movement A. Toxic epidermal necrolysis • Loss of color worse than visual acuity loss B. Erythema multiforme • Afferent pupillary defect C. Staphylococcal scalded skin syndrome • Papilledema D. Toxic shock syndrome • US – elevated disk, ON sheath E. Urticaria >5mm • Tx: IV methyprednisolone 31 32 31 32 A. Toxic epidermal necrolysis • On spectrum with Stevens- Johnson • Drugs most common cause • Sulfa, quinolones, phenytoin,carbamazepine, steroids, immunizations, PCN, ASA, NSAIDs • Also: malignancy, immunosuppression, infectious, autoimmune, idiopathic • Macular rash, target, Nikolsy sign, mucous membranes • Tx: IVF, infection control 33 34 33 34 12. A 5 y.o. unvaccinated girl presents to the ED with fever, drooling, and stridor. What is the most common organism based on the film shown? A. Haemophilus influenza type B B. Group A streptococcus C. Staph aureaus D. Parainfluenza E. Mixed anaerobes 35 36 35 36 6 1/11/2019 A. Haemophilus influenza type B 13. A 7 month old healthy boy is brought in by his mother who states he is “having • Adults most commonly trouble breathing after falling off the • Strep, staph, H. flu • Thumbprint sign couch.” What is the next step in • Bedside nasopharyngoscopy management based on the x-ray shown? • Tx: Emergent ENT consult, IVF, nebulized epi, IV abtx, awake A. IV antibiotics fiberoptic intubation sitting B. Contact child protective services up, cricothyrotomy C. Tube thoracostomy D. Albuterol E. Racemic epinephrine 37 38 37 38 B. Contact child protective services Child abuse • Usually parent or guardian • Mandatory reporting of suspicion • Concerning fractures: • Rib – esp. posterior • Corner fracture, bucket handle • Bruising, oral injuries (frenulum), patterns, stages of healing, burns/scalds, inconsolable • Skeletal survey, head CT, 39 40 admit 39 40 14. A 36 y.o. woman complains of wrist pain Bucket Handle Fracture after a fall on an outstretched hand. What is the correct diagnosis based on the image Corner Fracture shown? A. Lunate dislocation B. Scaphoid fracture C. Perilunate dislocation D. Scapholunate dislocation E. Hutchinson fracture 41 42 41 42 7 1/11/2019 D. Perilunate dislocation • Usually result of FOOSH • Median nerve injury • Capitate displaced dorsally • Lunate situated normally on radius • Ortho consult for reduction 43 44 43 44 15. A 20 y.o. man presents with a shoulder Perilunate Lunate dislocation dislocation. Which of the following is true regarding the condition shown on his post- reduction film? A. Results from a posterior shoulder dislocation B. Requires operative management C. It is a fracture of the glenoid rim D. Associated with an increased risk of recurrent shoulder dislocation E. It is a complication of shoulder reduction 45 46 45 46 D. Associated with an increased risk of recurrent shoulder dislocation Complications of anterior shoulder dislocations • Hill-Sachs deformity • Compression fracture of humeral head • Bankart lesion • Fx of inferior glenoid rim • May need surgery if significant displacement • Axillary nerve injury • Axillary artery injury • Rotator cuff tear 47 48 47 48 8 1/11/2019 16. A 18 y.o. man brings in his pet snake 15 minutes after it bit him on the arm. Each of the following complications may develop if left untreated except: A. Disseminated intravascular coagulation B. Immediate pain at bite site C. Proximal muscle weakness D. Arm edema E. Pulmonary edema 49 50 49 50 C. Proximal muscle weakness Crotalid/pit viper bite • Pit = heat sensing organ • Rattlesnakes and copperheads • Local tissue injury, compartment syndrome, coagulopathy, thrombocytopenia • Do not: suck wound, tourniquet • Tx: antivenom, fasciotomy 51 52 51 52 17. A 21 y.o. woman complains of vaginal itching and a foul-smelling discharge. Which of the following treatments is most appropriate based on the wet mount shown? A. Ceftriaxone and doxycycline B. Acyclovir C. Penicillin G D. Metronidazole E. Fluconazole 53 54 53 54 9 1/11/2019 D. Metronidazole 18. A 19 y.o. man presents with a rash. All of the following statements are true about this Bacterial vaginosis condition except: • Gardnerella vaginalis • Whitish-gray discharge with A. Preceded by a herald patch odor • Clue cells – vaginal epithelial B. Presumed to be of viral origin cells appear stippled C. Usually asymptomatic • Vaginal pH > 4.5 D. Mostly seen in children and young adults • + whiff test E. Treatment includes oral steroids • Metronidazole • Do not need to treat partner 55 56 55 56 E. Treatment includes oral steroids Pityriasis rosea • Mild exanthem • 10 - 35 year olds • Viral, not contagious • Resolution in 4 – 12 weeks • Herald patch • Christmas tree pattern • Pruritis • Tx: antihistamine, topical steroids, Calamine for itching 57 58 57 58 19.
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