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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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B. Jefferson burst fracture

• C1 burst fracture • Unstable • Axial loading force • C-collar, ortho-spine consult

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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

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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

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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

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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

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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

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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

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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

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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

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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,

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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

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D. Perilunate dislocation

• Usually result of FOOSH • Median nerve injury • Capitate displaced dorsally • Lunate situated normally on radius • Ortho consult for reduction

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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

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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

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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

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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

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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

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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

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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

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19. A 18 year old male presents after consuming the mushroom shown. What symptoms are likely to develop in the first 24 hours after ingestion? A. Hallucinations and euphoria B. Vomiting and diarrhea within 2 hours of ingestion C. Fulminant liver failure D. Resolution of symptoms E. Vomiting and diarrhea 6 hours after ingestion

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20. A 43 y.o. man presents with altered E. Vomiting and diarrhea 6 hours after ingestion mentation 3 hours after an assault with a

Mushroom poisoning baseball bat. His head CT is shown. Which of • Early onset poisoning the following statements is true regarding • GI Sx resolve his condition? • Late onset poisoning • After 6 hours A. May present after a lucid interval • Amanita Philloides/Death cap • GI sx after 6 – 24 hours B. Caused by tears in the dural bridging veins • Convalescent phase C. Common in patients with brain atrophy • Fulmanant hepatotoxicity day 2 – 4 • Tx: NAC D. Most common form of traumatic intracranial hemorrhage E. Has high mortality even with treatment

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A. May present after a lucid interval

Epidural hematoma • Tear of middle meningeal artery • Classically has lucid interval • Lens shaped hyperdense lesion • Tx: • Burr hole/neurosurgery • Elevate head of bed • Maintain CPP • Mannitol/hypertonic saline

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21. A 34 y.o. woman complains of cough, fever, and fatigue for 2 weeks. A sputum study is shown. What is the most appropriate treatment?

A. Levofloxacin B. Isoniazid, rifampin, pyrazinamide, and ethambutol C. Ceftriaxone and azithromycin D. Trimethoprim/sulfamethoxazole E. Isoniazid

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B. Isoniazid, rifampin, pyrazinamide, and ethambutol 22. A 27 y.o. homeless man with HIV presents with fever, headache, and confusion. His brain Tuberculosis CT is shown. What is the most likely diagnosis? • AFB in sputum = “Red Snappers” • Active TB Treatment: A. HIV encephalopathy • 4 drug treatment for 8 wks • Isoniazid, rifampin, pyrazinamide, B. Neurocysticercosis ethambutol C. Toxoplasmosis • 2 drug treatment for 18 wks • Isoniazid, rifampin D. Cryptococcus neoformans • Latent TB treatment: E. CNS lymphoma • Isoniazid for 9 months

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C. Toxoplasmosis

Ring-enhancing lesions • HIV: lymphoma or toxoplasmosis • Migrant worker with seizure: neurocysticercosis • Others: abscess, syphilis, aspergillosis, MS

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23. A 2 y.o. boy is brought in for a itchy rash on his hands and arms. Which of the following is the most appropriate treatment based on the image shown?

A. Ivermectin B. Prednisone C. Mupirocin D. Permethrin E. Lindane

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D. Permethrin 24. An 18 month old boy is brought in for inconsolable crying episodes and strange Scabies appearing stool as shown. What is the most • Mite infestation • Vesiculopustules, papules appropriate next step in management? with linear burrows • Web spaces, wrists, axillae, A. Surgical consultation for laparotomy groin, periumbilical B. Technetium scan • Pruitus, worse at night C. Abdominal plain film • Permethrin for all ages • Lindane and ivermectin for D. IV hydration and stool culture refractory cases E. Air contrast enema

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E. Air contrast enema Intussusception • 6 – 36 months • Usually no pathologic lesions • Possible lesions: Peyer patch, Meckel, tumor, HSP, parasites • Episodic pain and vomiting • Lethargy • Current jelly stool in 50% • Sausage shaped mass right abd • Air contrast enema successful in 80% • Surgical backup 75 76

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25. A 66 y.o. woman presents with right flank pain and vomiting. An abdominal ultrasound is shown. What is the most likely diagnosis?

A. Acute cholecystitis B. Ureteral stone with hydronephrosis C. Abdominal aortic aneurysm rupture D. Liver abscess E. Acute pancreatitis with pseudocyst

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26. A 38 y.o. woman presents with right A. Acute cholecystitis facial paralysis and a painful ear rash as US findings shown. What is the most appropriate next • Wall thickening > 3mm step in management? • Pericholecystic fluid • Sonographic Murphy’s A. Ear wick and topical antibiotics B. Acyclovir + prednisone C. CT brain D. Cephalexin + trimethoprim/sulfamethoxazole E. Ceftriaxone

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B. Acyclovir + prednisone

Herpes Zoster Oticus • AKA Ramsey-Hunt Syndrome • Zoster involving geniculate ganglion – CN VII and VIII • Tinnitus, hearing loss, facial palsy • Vesicular rash of canal, auricle, oropharynx

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27. A 5 y.o. child presents with confusion and a heart rate of 32 after ingestion of the plant shown. What is the most appropriate treatment?

A. Calcium gluconate B. Digitalis immune FAB C. Sodium bicarbonate D. Activated charcoal E. Physostigmine

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B. Digitalis immune FAB Bidirectional Ventricular Tachycardia Digitalis toxicity • Oleander, foxglove, lily of the valley, milkweed • Bradycardia, Hyperkalemia, N/V, confusion, visual disturbance, CV collapse • ECG: dig effect, bidirectional VT • Dig Immune FAB for dysrhythmias, K > 5.5, Level > 10 acute, Level > 4 chronic or child • 10 vials in adults • 20 vials in cardiac arrest

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28. A 19 year old man presents with right chest pain and hypoxia after a motorcycle accident. He requires intubation shortly after arrival Which of the following is true regarding the condition shown?

A. Infiltrates are always seen within 6 hours of injury B. Rarely seen in children C. CT scan is poorly sensitive D. Hypoxemia is rare E. Always occur in the setting of rib fractures

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29. A 45 year old man complains of a itchy A. Infiltrates always seen within 6 hours of injury rash to his arm after a camping trip. Which Pulmonary contusion of the following is true regarding the • Usually seen immediately on condition shown? CXR, if after 6 hours – consider ARDS A. Results from a tick bite • Common in pediatrics due to B. 90% of US population is susceptible compliant chest wall • CT most sensitive C. Treat with cephazolin • Dyspnea, tachypnea, hypoxia D. Topical steroids are the mainstay of treatment • +/- Rib fx, flail chest E. Rash appears immediately after exposure • Tx – NIV, intubation

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D. Topical steroids are the mainstay of treatment

Poison Ivy, Oak, Sumac dermatitis • 3 leaf structure • Vesiculobullous rash • 10 – 14 days after first exposure • 1 -2 days later exposures • 50% non-reactive • Treat with antihistamines and topical steroids • Oral steroids for severe cases

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30. A 55 y.o. man presents with sudden onset of sharp chest pain and dyspnea. What is the most appropriate next step in management based on the chest CT shown?

A. Pericardiocentesis B. Nitroprusside C. Heparin D. tPA E. Labetalol

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31. An 18 y.o. college student complains of E. Labetolol foul smelling vaginal discharge and Aortic dissection dyspareunia. What is the most likely • Type A – ascending aorta, diagnosis based on her speculum exam? surgical management • Type B – limited to descending A. Bacterial vaginosis aorta, medical management • Tx: B. Vaginal candidiasis • Heart rate control with B-Blocker C. Trichomonas • Esmolol, Labetalol, Metoprolol D. Genital herpes • Diltiazem if B-Blocker contraindication • Hypertension control E. Gonorrhea • Nicardipine, nitroprusside, fenoldopam

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C. Trichomonas

• Yellow, grey, frothy, foul smelling discharge • Strawberry cervix • Wet mount with trichomonads • Tx: metronidazole • Treat sexual partner

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32. What is the proper classification of the following tibial fracture?

A. Salter-Harris I B. Salter-Harris II C. Salter-Harris III D. Salter-Harris IV E. Salter-Harris V

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33. A scrotal ultrasound is obtained on a 19 B. Salter-Harris II y.o. man who complains of 2 days of • S – traight intermittent testicular pain. What is the • A – bove most likely diagnosis? • be – L – ow • T – hrough A. Incarcerated inguinal hernia • R - ecked B. Epididymitis C. Testicular carcinoma D. Testicular torsion E. Cystocele

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D. Testicular torsion

• Risk factors - < 1 yr old, puberty, undescended testicle, Bell-Clapper deformity • Swollen high-riding testicle, transverse lie, absent cremasteric reflex • US: unilateral absence of flow • Tx – Manual detorsion, Surgical tx definitive

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34. A 63 y.o. man presents with right flank pain and vomiting. What is the correct diagnosis based on the ultrasound shown?

A. Ureteral stone with hydronephrosis B. Acute cholecystitis C. Cholelithiasis D. Pancreatitis with pseudocyst E. Ruptured abdominal aortic aneurysm

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35. A 13 year old boy complains of right eye pain A. Ureteral stone with hydronephrosis after mowing the lawn. His slit-lamp examination • US preferred over CT is shown. Which of the following next steps is • Less radiation contraindicated? • No difference in missed high-risk dx, adverse events, return visits, hospitalizations A. Ophthalmology consultation in the ED • Dilated collecting system B. Placement of a protective eye shield • Occasionally see stone C. Measurement of ocular pressure D. Orbital CT scan E. Administer IV ceftriaxone

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C. Measurement of ocular pressure

Globe rupture • Can involve sclera or cornea • Do not apply pressure to eye • Clinical findings: Tear shaped pupil, Seidel’s sign, shallow anterior chamber, hyphema • CT orbit • Ophtho consult, tetanus, antibiotics

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36. A 10 year old boy presents to the ED with fever, rash, cough, and conjunctivitis. What is the most likely diagnosis?

A. Hand, foot, and mouth disease B. Kawasaki’s disease C. Measles D. Rubella E. Varicella

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37. A 58 year old woman complains of 4 days of C. Measles painless visual loss to the right eye. Based one the • Fever, cough, coryza, fundus shown, what is the most likely diagnosis? conjunctivitis • Koplik spots A. Central retinal artery occlusion • Red/white spots on buccal mucosa • Rash – maculopapular, starts B. Retinal detachment on face, spreads peripheral C. Vitreous hemorrhage D. Amaurosis fugax E. Central retinal vein occlusion

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E. Central retinal vein occlusion

• Monocular painless vision loss • Optic disc edema, retinal hemorrhage, dilated veins • “Blood and thunder” • Tx – Ophtho consult, antiplatelet, anticoagulation • Differential • CRAO • PRES • Retinal detachment • Vitreous hemorrhage • Stroke • 11 11 Amaurosis fugax 5 6

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38. A 10 year old girl presents with a fever, headache, and rash after hiking in North Carolina. What is the most likely diagnosis based on the picture shown?

A. Meningococcemia B. West Nile encephalitis C. Rocky Mountain spotted fever D. Pityriasis rosea E. Lyme disease

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39. A 16 year old boy presents with a lesion to the C. Rocky Mountain Spotted Fever scalp as shown. What is the correct diagnosis? • Rickettsia rickettsia • Tick vector • Summer months A. Pyoderma gangrenosum • Oklahoma, Nebraska, B. Psoriasis Appalachia • Flu like illness, then C. Tinea capitis arthralgias, peripheral rash D. Ringworm spreading centrally • Vasculitis, myocarditis, E. Kerion encephalitis • Tx - doxycycline

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E. Kerion

• Fungal inflammatory infection • Usually scalp, usually peds • Trichophyton • Oral griseofulvin for 6 weeks • Scaring alopecia risk

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40. A 34 year old man complains of painful swelling to his penis as shown. Which of the following is the most appropriate treatment?

A. Topical nystatin B. Compression of the glans and manual reduction C. Hemostatic dilitation D. Penicillin E. Acyclovir

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B. Compression of the glans and manual reduction

Paraphimosis • Foreskin unretractable • Urologic emerencgy – risk of glans necrosis • Ice, manual reduction, elastic bandage to reduce edema • Manually reduce • Dorsal slit if failure

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