Download CRAM SAEM Test 2: Appendicitis, Diverticulitis, and Other Abdominal Pain Conditions and more Exams Medicine in PDF only on Docsity!
CRAM SAEM Test 2 | 100% Correct
Answers | Verified | Latest 2024 Version
what is the obturator sign? what diagnosis is it associated with? - ✔✔a/w appendicitis obturator sign = pain upon flexion and internal rotation of the hip#$/images/upload- flashcards/601487/854522_m.jpg what is Rovsing's sign? what diagnosis is it associated with? - ✔✔a/w appendicitis Rovsing's sign= pain in the RLQ upon palpation of the LLQ#$/images/upload- flashcards/601487/854525_m.jpg Early in the course of acute appendicitis, are vital signs usually abnormal? - ✔✔no - early in its course, vital signs including temperature may be normal. Once perforation has occurred, the rate of low-grade fever (<38 C) increases to about 40%. what is the psoas sign? what diagnosis is it associated with? - ✔✔a/w appendicitis psoas sign = pain upon extension of the hip.#$/images/upload-flashcards/601487/854528_m.jpg explain what rebound in the setting of acute appendicitis means - ✔✔Rebound is usually elicited only after the appendix has ruptured or infarcted. In establishing a differential diagnosis of abdominal pain, the onset of PAIN prior to the occurrence of N/V is more often suggestive of - ✔✔surgical etiology of the pain, such as small bowel obstruction what bug should you think of in patients with sickle cell anemia who present with abdominal pain and diarrhea? - ✔✔salmonella (not shigellosis)
Radiation of pain to the scapula is suggestive of - ✔✔acute choleycystitis (NOT hepatitis) Diverticulitis pain is generally located - ✔✔in the LLQ Describe the pain patterns a/w with peptic ulcer disease (PUD) - ✔✔pain that is worse preceding a meal non-radiating, burning epigastric pain pain that awakens a patient in the middle of the night relief of abdominal pain with antacids note: unrelenting pain over a period of weeks should suggest an alternative diagnosis A 78 year old female presents to the E.D. with a sensation of LLQ abdominal pain, accompanied by some irregular bowel movements and loss of appetite. Her abdominal CT (two images) is shown in the Figure. What is the most likely diagnosis? - ✔✔/images/upload-flashcards/601487/854531_m.jpg#$A patient with this general picture is most likely to have diverticulitis, which is revealed on the CT scan as diverticular disease with inflammation (wall thickening and stranding).#$/images/upload- flashcards/601487/854534_m.jpg A mother brings her 6 week old boy to the emergency room. She states the baby has been vomiting everything she's tried to feed him for the past 12 hours. She states that he usually eats readily and completes an entire feeding, but he is unable to keep anything down. The emesis is non-bloody and non- bilious, however it is projectile in nature. What is the most likely condition in this patient? - ✔✔pyloric stenosis The answer is C. Hypertrophic pyloric stenosis typically presents in the second to sixth week of life and is four times more common in males than females. Infants with hypertrophic pyloric stenosis typically are vigorous eaters but shortly afterward regurgitate the entire feeding contents in a projectile fashion. The emesis is non-bilious. The classic finding on exam is an "olive" palpable in the abdomen, and diagnosis is typically via ultrasound. Intussusception typically presents between the ages of 5 and 12 months. Gastroenteritis is characterized by diarrhea as well as vomiting. Neither constipation nor appendicitis typically present with protracted vomiting, though the latter condition tends to present atypically in young children (and elderly adults).
53yo obese woman presents to ED, accompanied by three of her children, c/o severe abdominal pain that began this afternoon after lunch. PE reveals marked RUQ tenderness. Likely findings on this patient would include: - ✔✔This woman is likely suffering from acute cholecystitis. Predisposing factors include female gender, obesity, increased age and increased parity. Inflammation of the gallbladder causes RUQ pain and sonographic Murphy's sign (inspiratory arrest, due to pain, while the ultrasound probe is positioned over the gallbladder). Pain may radiate to the right scapula. Lab studies usually show leukocytosis with or without a left shift, and aminotransferases and bilirubin are usually within normal limits. 25yo F p/w epigastric pain radiating straight through to the back. Labs are notable only for markedly elevated amylase and lipase. An abdominal X-ray is taken (see Figure). What's the dx? - ✔✔/images/upload-flashcards/601487/924401_m.jpg#$The most likely explanation for her symptoms is gallstone-related pancreatitis The X-ray reveals stones in the gallbladder. These particular stones are not likely the cause of pancreatitis, but the demonstration of gallstone disease raises the likelihood that the patient's pancreatitis is indeed due to gallstones. In the U.S., the most common etiologies of pancreatitis include gallstones (45%) and alcoholism (35%). Alcoholic pancreatitis may occur in young patients as well as in older abusers of alcohol. Many other drugs, infectious agents, and conditions are associated with the development of pancreatitis. A few examples include hypertriglyceridemia, trauma, pregnancy, pancreatic carcinoma, atherosclerotic emboli, and scorpion bites. 45yo F p/w RUQ pain & fever. The pain is worse after eating. On PE she has a (+) Murphy's sign. Most likely dx? - ✔✔Cholecystitis RUQ pain, fever and a Murphy's sign suggests cholecystitis. Cholelithiasis presents with similar pain, but is not associated with fever or a Murphy's sign 47yo M presents, confused, to the ED. He has limited ability to give a history. On PE of the skin, it is noted that there are erythematous changes to both palms. Also, the face and arms are characterized by a number of superficial, tortuous arterioles which fill from the center outwards. The examination of the abdomen reveals violaceous lines radiating from the umbilicus, and there are generally increased venous markings on the abdominal wall (see Figure). What is the most likely diagnosis? - ✔✔liver disease
The patient's palmar erythema, spider angiomata, and caput medusa (due to recanalization of the umbilical vein) are all characteristic of hepatic disease. The figure demonstrates abdominal wall venous engorgement, as well as ascites (another clue to the patient's liver disease). A 57-year-old homeless woman with a history of schizophrenia presents to the emergency department complaining of nausea and severe abdominal pain for 48 hours. The patient is not cooperative with an upright abdominal image, so a flat plate (as shown in the Figure) is obtained. Which of the following is the most likely operative finding in this patient? - ✔✔small bowel obstruction Dilated loops of small bowel with air-fluid levels (which are not well-seen on a flat plate) indicate small bowel obstruction. KUB is not often useful in the diagnosis of appendicitis, ruptured spleen, gallstone disease, or a rectus sheath hematoma (which is an abdominal wall condition most likely seen in anticoagulated patients with trauma or coughing). Despite this woman's history of schizophrenia and possibly diminished ability to relate a clear story of her pain, her complaint of abdominal pain must be taken seriously with a high suspicion for underlying pathology. All of the following factors predispose to cecal volvulus EXCEPT: A. marathon running B. pregnancy C. age 25- 35 D. prior abdominal surgery E. severe chronic constipation - ✔✔constipation DOES not lead to volvulus Cecal volvulus occurs as a result of abnormal fixation of the right colon and increased mobility of the cecum. Depending on the degree of rotation around the mesenteric axis, cecal volvulus can lead to twisting of the mesentery and its blood vessels. Cecal volvulus occurs most commonly in people 25- 35 years old and should be suspected in cases of bowel obstruction without known risk factors. Prior abdominal surgery and pregnancy predispose to obstruction or cecal volvulus; however, chronic constipation is not known to predispose to cecal volvulus. Interestingly, marathon runners have been found to have a higher incidence of cecal volvulus, perhaps from having a thin, flexible mesentery that more easily permits rotation of the cecum around the mesenteric pedicle. A 57 year old ill-appearing man presents with fever, chills, abdominal pain, nausea and vomiting. His abdominal CT is shown in the Figure. Which of the following is LEAST correct regarding this patient's condition? - ✔✔/images/upload-flashcards/601487/924404_m.jpg#$Answer: Emergent percutaneous drainage in the emergency department is indicated
D. Iatrogenic perforations of the esophagus usually occur in the proximal esophagus or esophagogastric junction. E. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting. - ✔✔The answer is A. Over 90% of spontaneous esophageal perforations occur in the distal esophagus, whereas iatrogenic perforations are frequently at the pharyngoesophageal junction or the esophagogastric junction. Foreign body or caustic substance ingestion, severe blunt injury or penetrating trauma, and carcinoma are other causes of esophageal perforation. Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: - ✔✔Esophageal perforation and mediastinitis Working in the ED, you have identified a bony object wedged in the mid-esophagus of a 45 year old patient. Failure to promptly remove a foreign body impacted in the esophagus could result in: A. The rapid development of xerostomia B. Epiglottal edema and airway obstruction C. Esophageal perforation and mediastinitis D. Barrett's esophagitis The answer is C. The complications of esophageal foreign bodies are rare but serious. They include esophageal erosion and perforation, mediastinitis, esophagus-to-trachea or esophagus-to-vasculature fistula formation, stricture formation, diverticuli formation, and tracheal compression (from both the esophageal foreign body and resultant edema or infection). Air trapping is a sign of a foreign body of the airway. Rarely, airway foreign bodies act as one-way valves that could cause hyperinflation of a lung segment, with resultant bleb rupture and pneumothorax formation. A mother brings her 35 year old son to the emergency department because of tremor and mutism for the past three days. His mother found him in his room this morning lying stiffly in his bed, soiled with urine and feces. He appears confused and will not respond to questions. He was diagnosed with schizophrenia last year and has been on several medications. Last month after his most recent hospital admission for schizophrenia, he was discharged with a prescription for haloperidol. On physical exam, he is visibly diaphoretic and has vital signs as follows: T 102.7, BP 140/98, P 112, R 12. His neuromuscular exam shows extremely rigid extremities, and his laboratory values are notable for a white blood cell
count of 15000/mm3 and abnormally elevated creatine phosphokinase levels. What is the most likely explanation for these findings? - ✔✔Neuroleptic malignant syndrome (NMS) is an idiosyncratic, life- threatening reaction to antipsychotic medications, with haloperidol being the most common cause. It is characterized by elevated temperatures, "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and autonomic dysfunction (e.g., diaphoresis, labile blood pressure, incontinence, dysrhythmias). While this patient's temperature is only 102.7, students should note that any patients with temperatures greater than 105 most likely have non-infectious etiologies for temperature elevation. NMS is thought to be due to too much D2 blockade in the substantia nigra and hypothalamus. Treatment consists of stopping the causative agent and providing supportive care. Medications such as dantrolene, bromocriptine, amantadine, and lorazepam are also often used. 25yo M returns to the ED, 24 hours after being released from the hospital with a new diagnosis of schizophrenia. He has recently started to take haloperidal for his psychotic symptoms. In the ED he is noted to have involuntary contractions of the muscles of the face, a protruding tongue, deviation of the head to one side, and sustained upward deviation of the eyes. Vital signs are stable, and initial labs show no electrolyte or hematological abnormalities. Of the following choices, the preferred medication for this condition is: - ✔✔Tx: diphenhydramine Acute dystonia, the most common adverse effect seen with neuroleptic agents, occurs in up to 5% of patients. Dystonic reactions, which can occur at any point during long-term therapy and up to 48 hours after administration of neuroleptics in the emergency department, involve the sudden onset of involuntary contraction of the muscles in the face, neck, or back. The patient may have protrusion of the tongue (buccolingual crisis), deviation of the head to one side (acute torticollis), sustained upward deviation of the eyes (oculogyric crisis), extreme arching of the back (opisthotonos), or rarely laryngospasm. These symptoms tend to fluctuate, decreasing with voluntary activity and increasing under emotional stress, which occasionally misleads emergency physicians to believe they may be hysterical in nature. Dystonic reactions should be treated with IM or IV benztropine (Cogentin®), 1 to 2 mg, or diphenhydramine (Benadryl®), 25 to 50 mg. Intravenous administration usually results in near- immediate reversal of symptoms. Patients should receive oral therapy with the same medication for 48 to 72 hours to prevent recurrent symptoms. A 70yo M with acute delirium requires administration of haloperidol for agitation. Which of the following is a recognized side effect of haloperidol? - ✔✔prolonged QT interval Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia. what's a recognized AE of lithium? - ✔✔Nephrogenic diabetes insipidus
55yo M p/w new onset agitation and confusion. Which of the following PMHx would suggest a psychiatric (non-organic) cause? A. H/o COPD B. H/o DM only C. H/o hypothyroidism only D. H/o alcohol abuse only - ✔✔The answer is C. Although hyperthyroidism may result in an agitated state, hypothyroidism is not generally associated with violent behavior. All other answers are potentially treatable medical problems that could account for the presentation of an agitated or violent patient. After assuring the safety of all parties involved, the emergency department physician should rule out organic causes of agitation. 35yo M is placed on his back on the gurney in physical restraints for violent behavior. Which life- threatening complication can arise? - ✔✔Metabolic Acidosis (not Rhabdo) Bruises and abrasions are the most common complication of physical restraints. After restraint application, patients need to be monitored frequently and positions changed to prevent neurovascular complications such as circulatory obstruction, pressure sores, and rhabdomyolysis. Positional asphyxia can arise when patients are placed into the prone or hobbled position. Protracted struggle against restraints can promote a significant metabolic acidosis that has been associated with cardiovascular collapse. Patients who continue to struggle with physical restraints should be chemically restrained as well. Which medication is ideal for the agitated or combative patient? - ✔✔Haloperidol Drugs with a relatively short half-life allow for more careful monitoring of chemically restrained patients. Patients may be given multiple administrations of the restraining agent as needed. Antipsychotics (such as haloperidol) and benzodiazepines (such as lorazepam) exhibit most of these characteristics and are commonly used in combination in the emergency department. The use of 5 mg of haloperidol IV/IM with 2 mg of lorazepam IV/IM, repeated every 30 minutes as needed, is recommended for the combative patient who does not have contraindications to these medications. Half doses should be used in the elderly. 19yoM is brought in to ED by EMS after being found obtunded in his apt by a friend. No additional history is available. On arrival, the patient is minimally responsive with sonorous respirations and a palpable rapid pulse. The most appropriate initial diagnostic test would be - ✔✔Fingerstick glucose
Hypoglycemia is a common and readily treatable cause for altered mental status. An ABG is unlikely to be diagnostic and more likely to reflect secondary abnormalities caused by respiratory depression. While a urine drug screen may show positives, it cannot quantitate the amount of a substance or the time period in which the exposure occurred so a positive screen may not reflect cause and effect. An EKG, while a part of a toxicology evaluation, is not an appropriate initiate screening test for an unstable patient until airway and readily reversible causes have been addressed. 27yo M is found unresponsive in his car in the hospital parking lot and brought in by security. During your initial evaluation you find him to be cyanotic with pulse ox 82% on room air with a RR of 4 bpm & P120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an IV line due to extensive scarring of his arms. You are suspicious of an overdose, which medication would you want to rapidly administer as a potential antidote in this situation? - ✔✔Naloxone The patient has stigmata of an opiate overdose with hypopnea, cyanosis, and miotic pupils. In addition, intravenous drug users often use up their veins. While hypoglycemia can definitely cause a depressed mental status and needs to be assessed, it should not result in respiratory depression or miotic pupils. Thiamine is utilized to prevent Wernicke's encephalopathy particularly in malnourished patients who present with hypoglycemia but is not an antidote per se. Flumazenil can be used to temporarily reverse the respiratory depression caused by benzodiazepines but also carries with it the risk of precipitating withdrawal and uncontrollable seizures in chronic benzodiazepine users. As a result, it is not recommended for routine use in patients with altered mental status. A 53 year-old known alcoholic presents with agitation, vomiting and altered mental status. His fingerstick glucose is 148. His serum ethanol level is undetectable and his head CT is normal. An ABG shows a pH of 7.21, pCO2 of 34, pO2 of 98 on room air. His basic chemistry panel includes a sodium of 136, potassium 4.1, chloride 108, bicarbonate 14, BUN 12, creatinine 1.1. What substance are you concerned that he may have ingested? A. Methanol B. Ethylene glycol C. Isopropyl alcohol D. Salicylates - ✔✔The answer is C. The patient is presenting with a non anion gap metabolic acidosis. Isopropyl alcohol is metabolized via alcohol dehydrogenase to acetone which accumulates and causes significant ketosis but not an anion gap. Other toxic alcohols such as methanol and ethylene glycol are ultimately metabolized to formic and glycolic acids which cause toxic effects and an anion gap metabolic acidosis. Salicylates result in an anion gap metabolic acidosis with a superimposed respiratory alkalosis. The following mnemonic can be used to recall the common causes of an increased anion gap metabolic acidosis: CAT MUDPILES;
This patient has marked ascites (which may incidentally account for his mild tachypnea due to impairment of respiratory excursion). The most likely explanation given the limited information available is liver disease, and asterixis ("liver flap") as described in choice D is a likely marker of advanced hepatic failure. 60yo M p/w new onset confusion. What finding suggests a functional, as opposed to an organic etiology? - ✔✔auditory hallucinations The other choices (disorientation, abnormal vital signs, acute onset) are all characteristic of organic confusional states. Hallucinations can occur with both organic and functional causes of confusion. Hallucinations associated with organic confusion may be visual, tactile, or auditory. Hallucinations in patients with functional disease tend to be auditory. Delirium is defined as: - ✔✔a global inability to relate to the environment and process sensory input Delusions are defined as - ✔✔false beliefs that are not amenable to arguments or facts to the contrary 75yo F is brought to ED by a family member with a history of progressive forgetfulness and confusion. She has a history of dementia. The most common cause of dementia in the elderly patient is: - ✔✔Alzheimer's disease Most dementia is Alzheimer's type. The second most common cause of dementia is vascular dementia, which accounts for 10 to 20% of all dementias. Primary degenerative dementias include Alzheimer's disease, vascular dementia, subcortical dementias involving the basal ganglia and thalamus (e.g., progressive supranuclear palsy, Huntington's chorea, Parkinson's disease), and Pick's disease, also known as dementia of the frontal lobe type. Smaller percentages are attributable to causes such as anoxic encephalopathy, hepatolenticular degeneration, tumors, and slow virus infections 65yo M is brought to the ED after he was found wandering on the street. He is unkempt and confused. A diagnosis of delirium, rather than dementia, is more likely if which of the following is true? - ✔✔there is a change in the level of consciousness
Patients with delirium have disturbances in consciousness, cognition, and perception. These disturbances tend to occur over a short period of time (hours to days). The delirious patient may be somnolent or agitated. Thought process may be mildly disturbed or grossly disorganized. The clinical presentation may be subdued or explosive, and the course can fluctuate over minutes to hours. The patient's sleep-wake cycle may be altered or reversed; agitation is often present during the night. An acute confusional state can also be one of the protean manifestations of a metabolic or nutritional abnormality, including hepatic encephalopathy, acute renal failure, and diabetic ketoacidosis or hyperosmolarity. 80yo nursing home pt brought to ED with an acute onset of confusion. Which of the following metabolic abnormalities is the most likely explanation? - ✔✔hypernatremia The differential diagnosis of acute confusional states is lengthy. It includes many metabolic/nutritional abnormalities including hypoglycemia, hypo-/hypernatremia, and hypercalcemia. Hypokalemia alone, however, is not a common cause of altered mental status. Which factor is LEAST reliable in differentiating between organic and inorganic causes of confusion? A. Presence of attention deficit B. acute versus chronic onset C. Vital sign abnormalities D. Signs of trauma - ✔✔Presence of attention deficit Presence of an attention deficit is common to all confusional states. All the other options may be used to differentiate organic versus non-organic causes of confusion. Characteristics of organic causes include acute onset, abnormal vital signs, fluctuating level of consciousness, possibly signs of trauma, and/or focal neurologic signs. Inorganic (functional) causes commonly illustrate chronic onset, stable vital signs, absence of trauma or focal neurologic symptoms, and/or delusions and illusions. Facts about hypertensive emergencies: - ✔✔Hypertensive encephalopathy is a true medical emergency, and can cause coma and death over hours; however, encephalopathy due to hypertension is more likely reversible than encephalopathy from other causes. Avoidance of overzealous blood pressure lowering is particularly critical for patients with strokes. Laboratory analysis can be important in cases of hypertension in pediatric patients (for whom renal/renovascular or pheochromocytoma may be identified) and in pregnant patients (for whom laboratory testing can help establish diagnoses such as the HELLP syndrome).
68yo diabetic male, previously living independently, is brought in by his family. He has been acting abnormally for two days. The family reports he is awake all night and sleepy during the day. He is confused about where he is and the time of day, and sometimes doesn't recognize his daughter and son- in-law. At other times he appears and acts almost normally. Which of the following is true regarding his condition? - ✔✔Patients can be agitated and combative, or calm and quiet in this condition. The scenario describes a patient with delirium, a condition in which patients may be agitated and combative, or calm and quiet. The most common cause of delirium in the elderly is medications, accounting for 22-39% of cases. Infection and metabolic abnormalities are other common causes, and delirium may be the first indication that an infection is present. An elderly patient with delirium resulting from an infection may have a normal temperature, a low temperature, or a high temperature. Delirium is characterized by an acute onset of a disturbance in level of consciousness, cognition and attentiveness. It has a fluctuating course, and alterations in sleep-wake cycles are common. Dementia, in contrast, has a slower course, that is gradually progressive over months to years, and consciousness is preserved. In addition to correcting the underlying cause, it is important to minimize stimulation, because the patient with delirium has difficulty processing stimuli. The chest X-ray in the Figure was taken in an intoxicated patient who is conversant, but an unreliable historian. The X-ray findings are best described as indicating: - ✔✔/images/upload- flashcards/601487/966485_m.jpg#$esophageal foreign body The film reveals a classic appearance of a round foreign body (in this case, a pull-top from a beer can) in the esophagus. The foreign body appears to lie outside the tracheal shadow. There is no sign of mediastinal air (which would be expected with penetrating trauma). The X-ray reveals no signs of mediastinitis, but the risk of esophageal perforation and ultimate mediastinitis prompts endoscopic intervention in this patient. 25yo M brought to ED by his family, with a c/o feeling depressed for the past week. In obtaining the history, which of the following statements regarding this patient would support a diagnosis of major depression? - ✔✔The patient has a history of Crohn's disease Depression is more common in patients with history of other medical illnesses, some of which may actually cause depressive symptoms. As compared with major depression, dysthymic disorder is a more chronic, and less severe, form of depressive illness.
42yo M with end stage liver disease due to chronic hepatitis C infection arrives to the ED in stable condition after an unsuccessful suicide attempt by bilateral wrist laceration. He reports no h/o depression or psych disorder. Aside from his liver disease, for which he takes interferon alpha and ribavirin, he reports that he is in good health and takes no other medications. Which of the following factors increased this patient's risk of new-onset suicidal ideation? - ✔✔interferon alfa therapy Interferon alfa, an important cytokine in the early immune response to viral infection, has both antiproliferative and antiviral properties. It is the only therapy approved by the Food and Drug Administration for hepatitis C infection. Interferon alfa has been associated with high rates of central nervous system side effects, including anhedonia, fatigue, anorexia, impaired concentration, sleep disturbance, and suicidal ideation. Clinicians should always look up the side effects of their patients' medications, especially unfamiliar drugs. This can both expedite diagnosis of drug-induced complications and prevent them with appropriate pretreatment. Pretreatment with a selective serotonin reuptake inhibitor appears to be an effective strategy to minimize depression induced by interferon alfa. Chronic hepatitis C infection and end-stage liver disease can both be difficult diseases to live with, however, these conditions are not known to significantly increase a patients' risk for new suicidal ideation. Depression is not a known side effect of ribavirin treatment. Although males have a higher percentage of successful suicide attempt than females, females have a much higher incidence of suicide attempt and ideation than males overall. Which clinical scenario is use of chemical restraint indicated? - ✔✔Patient's behaviors and actions pose an imminent harm to self Which psychiatric disorders is a/w the greatest increased risk of committing suicide? - ✔✔panic disorder (more than depression, schizophrenia, PTSD) Most people who commit suicide suffer from either alcoholism or a diagnosable psychiatric illness. 15- 20% of people with major depression and 10% of people with schizophrenia will commit suicide. Up to 40% of people with panic disorder will attempt suicide at some point in their lives. PTSD also carries an increased risk. When using the "SAD PERSONS" scale to determine suicide risk, which factor conveys the least amount of points? - ✔✔separated, divorced or widowed Being separated, divorced or widowed is an important but less significant factor in determining suicide risk and so is assigned 1 point on the suicide scale. All the others are high-risk factors and are each assigned 2 points on the suicide scale. A score of 6 or more has a sensitivity of 94% and a specificity of
unremarkable. Nasal inspection reveals a swollen, ecchymotic, tender nasal septum. Which of the following is the most appropriate initial step? - ✔✔Incision and drainage of the septal hematoma followed by nasal packing Notes: don't need to consult plastics, can drain hematoma before doing imaging if on PE you don't suspect more serious facial fractures A 24 year old woman is playing racquetball and sustains a direct blow from the ball to the right eye. She presents to the emergency department complaining of eye pain and double vision. On exam, her right eye does not track properly with upward gaze. This finding suggests which of the following injuries? - ✔✔Inferior (NOT superior) orbital wall fracture A 32 year old man is struck several times in the head with a baseball bat. Upon emergency medical service arrival, he is mildly confused, vomits once, and complains of a severe headache. The emergency medical technicians establish two large-bore IVs. Prior to arrival at the emergency department, he loses consciousness and begins to seize. He is actively seizing when he is brought into the trauma bay. What should be the first step in the management of this patient? A. Administration of 2 liters NS bolus B. Administration of phenytoin 1000mg IV C. Rapid sequence intubation using paralytic agent D. Administration of mannitol 50 g IV E. Emergency craniotomy - ✔✔C. Rapid sequence intubation using paralytic agent The airway should be managed as the first priority in this patient. The other maneuvers may be helpful but are secondary to securing an airway and providing oxygenation/ventilation. Airway comes first! A 46 year old man is brought in by EMS after a motor vehicle collision in which he was an unrestrained driver. Although he has no obvious injury to his head or neck, he complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F, BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a tension pneumothorax. Of the following, which is the most appropriate next step in this man's care? A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Placement of a needle decompression device, followed by repeat CXR C. Transfusion of 2 units of O-negative packed red blood cells D. Performance of a chest CT scan to further delineate the pathology - ✔✔Placement of a needle decompression device, followed by repeat CXR This patient needs emergent chest decompression and this is rapidly done by needle thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal chest tube will be placed, but placement may not be rapid enough and he may decompensate in the meantime. Transfusion of blood does nothing to correct the physiology of a tension pneumothorax The most sensitive bedside test for nerve injury in a finger after trauma is: - ✔✔two-point discrimination Light touch is a good screening test, but two-point discrimination is more sensitive and should be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates the nerve is intact. Ottawa ankle rules - ✔✔Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if an ankle X-ray is needed after an injury
- If any of the first 4 answers is present or if there is tenderness over the navicular or base of the 5th metatarsal, an X-ray should be obtained (1) inability to walk 4 steps at the time of the injury (2) inability to walk 4 steps in ED (3,4) tenderness over medial & lateral malleolus what do you need to know about thoracentesis from the anterior approach (needle decompression)? - ✔✔- second intercostal space along the midclavicular line (NOT midaxillary line)
- If a lateral approach is needed, the recommended insertion site is the 4th or 5th intercostal space in the midaxillary line. The lateral approach poses a greater risk of parenchymal injury.
- The needle should always be inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior margin
- After the needle is inserted into the pleural space, a rush of air confirms the presence of a tension pneumothorax.
