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Regarding the diagnosis of acute appendicitis, all the following are true EXCEPT:
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
B. Rebound is usually elicited only after the appendix has ruptured or infarcted.
C. Rovsing's sign is pain in the right lower quadrant upon palpation of the left lower quadrant.
D. The obturator sign is pain upon flexion and internal rotation of the hip.
E. The psoas sign is pain upon extension of the hip.
A. Vital signs are usually abnormal, even early in the course of acute appendicitis.
The answer is A. The presentation of acute appendicitis varies tremendously. 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%. Other variations in presentation include pain in the right upper quadrant, typically from a retrocecal or retroiliac appendix.
Rosving's sign is described as:
A. Tenderness in the right upper quadrant that is worse with inspiration.
B. Pelvic pain upon flexion of the thigh while the patient is supine.
C. Pelvic pain upon internal and external rotation of the thigh with the knee flexed.
D. Pain that increases with the release of pressure of palpation.
E. Pain in the right lower quadrant when left lower quadrant is palpated.
E. Pain in the right lower quadrant when left lower quadrant is palpated.
The answer is E. Rosving's sign is pain in the right lower quadrant when the left lower quadrant is palpated. Rebound tenderness occurs with the release of pressure. The iliopsoas sign is pain associated with thigh flexion. The obturator sign is pain that occurs with thigh rotation. All of these signs are associated with appendicitis. Murphy's sign is cessation of inspiration during palpation of the right upper quadrant and is associated with acute cholecystitis.
In establishing a differential diagnosis of abdominal pain, which of the following is true?
A. Radiation of pain to the scapula is suggestive of acute hepatitis.
B. Cervical motion tenderness is a useful physical finding for differentiating women with or without acute appendicitis.
C. In patients with sickle cell anemia who present with abdominal pain and diarrhea, shigellosis should be a top consideration.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.
E. Diverticulitis tends to cause pain in the right upper quadrant.
D. The onset of pain prior to the occurrence of nausea and vomiting is more often suggestive of a surgical etiology.
The answer is D. Pain prior to nausea and vomiting is often suggestive of a surgical etiology of the pain, such as small bowel obstruction. Cervical motion tenderness has been noted in up to 25% of women with acute appendicitis. Patients with sickle cell anemia are prone to Salmonella infections. Radiation of pain to the scapula is classically present in acute choleycystitis. Diverticulitis pain is generally located in the left lower quadrant.
Of the following pain patterns, which is the least likely associated with diagnosis of peptic ulcer disease?
A. non-radiating, burning epigastric pain
B. pain that awakens a patient in the middle of the night
C. unrelenting pain over a period of weeks
D. relief of abdominal pain with antacids
E. pain that is worse preceding a meal
C. unrelenting pain over a period of weeks
previously and denies fevers or other symptoms. Renal calculus is suspected. Which of the following is true regarding the diagnosis of renal calculi in this patient?
A. Urinalysis demonstrating hematuria confirms the diagnosis.
B. KUB detects less than 10% of calculi.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
D. Ultrasound is the study of choice for detecting small ureteral calculi.
E. Intravenous pyelogram (IVP) may be used in patients with renal insufficiency.
C. Helical CT scan greater than 95% sensitive and specific for renal calculi.
Helical CT scan has been shown to be both highly sensitive and specific in the diagnosis of renal calculi. It is the preferred modality for evaluation in many centers. Although urinalysis typically demonstrates hematuria in patients with renal calculi, hematuria is not specific enough to confirm the diagnosis, and imaging is warranted in all first-time presenters. KUB detects approximately 60-70% of calculi (though studies addressing this issue are somewhat methodologically flawed). Ultrasound is not reliable for detecting small calculi, but is 85-94% sensitive and 100% specific at demonstrating hydronephrosis. IVP is contraindicated in patients with renal insufficiency due to the dye load necessary to perform the study.
A 50 year old man presents with 1 day of gradually worsening, intermittent, left lower quadrant pain associated with loose stools. He has had no fevers or bloody bowel movements. Similar symptoms in the past were self-limited. All vital signs lie within normal limits. Physical examination shows mild tenderness in the left lower quadrant, normal active bowel sounds and neither masses nor peritoneal signs. His primary-care physician can see him tomorrow in his clinic. What should be done next in the E.D.?
A. Discharge home after a single dose of IV antibiotics
B. Discharge home on high-fiber diet, laxatives and stool softeners
C. Gastroenterology consult for endoscopy
D. Admit for observation and serial examinations
B. Discharge home on high-fiber diet, laxatives and stool softeners
This patient has classic diverticulosis (saclike protrusions of colonic mucosa through the muscularis) without signs of acute diverticulitis (inflammation of diverticula). Usually these patients can be managed as outpatients with a high-fiber diet and treatments to decrease intestinal spasm. If the patient develops fever or pain increases he may need further evaluation to rule out abscess formation. Diverticulitis is treated with antibiotics, bowel rest and analgesics.
You are treating a 25 year old male with the recent diagnosis of Crohn's disease in the ED. Regarding Crohn's disease, you know that:
A. Lesions are typically contiguous
B. Small bowel involvement is rare
C. Bleeding is common due to superficial bowel wall inflammation
D. There is a small increased risk of colon cancer
D. There is a small increased risk of colon cancer
Although Crohn's disease may involve the entire bowel tract, the rectum is rarely involved. Involved areas are typically non-contiguous (known as "skip lesions") and the inflammation involves all of the layers of the bowel wall--resulting in many of the complications of Crohn's such as abscess and fistula formation, intestinal obstruction, and perforation. The risk of colon cancer is only slightly elevated above baseline. In contrast, Ulcerative colitis begins in the rectum and may spread to the upper parts of the colon but never involves the small intestine. The ulcerations are contiguous and involve only the colonic mucosa. The incidence of colon cancer may be increased up to 30 times over baseline.
A 53 year old obese woman presents to the emergency department, accompanied by three of her children, complaining of severe abdominal pain that began this afternoon after lunch. Physical exam reveals marked RUQ tenderness. Likely findings on this patient would include all of the following EXCEPT:
A. positive sonographic Murphy's sign
B. pain in the right scapula
C. leukocytosis with left shift
B. age 25- 35
C. prior abdominal surgery
D. marathon running
E. severe chronic constipation
E. severe chronic constipation
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.
Which of the following pairings of referred pain and causal disease is least likely to be encountered?
A. sacral pain—ovarian torsion
B. inguinal pain—ureteral colic
C. epigastric pain—myocardial infarction
D. shoulder pain—ruptured spleen
E. thoracic back pain—pancreatitis
A. sacral pain—ovarian torsion
Ovarian torsion may cause lower abdominal pain, pelvic pain, adnexal tenderness, and cervical motion tenderness, but it is not known to cause sacral pain.
A 72 year old man with a history of diverticulosis presents with vague abdominal pain for the past day. His physical exam is notable for normal vital signs, left lower quadrant abdominal tenderness without rebound or guarding, and guaiac positive brown stool. Work-up including KUB and abdominal/pelvic CT scan reveals diverticulitis without perforation. Of the following choices, which is the most appropriate management of this patient?
A. type and cross two units of packed red blood cells
B. immediate surgical intervention
C. discharge on oral pain medications
D. barium enema to evaluate for carcinoma of the colon
E. admission for intravenous antibiotics and fluids
E. admission for intravenous antibiotics and fluids
For mild episodes of diverticulitis in which there is no evidence of perforation or peritonitis, there is no indication for immediate surgical intervention. Conservative management with intravenous fluids and antibiotics as well as bowel rest is typically first attempted. Although colon carcinoma may be a precipitating factor in the development of diverticulitis, barium enema should be avoided in the acute period due to high risk of bowel perforation. Although some patients with mild cases of diverticulitis may be discharged home with conservative treatment, the elderly are at higher risk of perforation and should be admitted. Guaiac positive stool in seen in up to 50% of patients with diverticulitis. There is no reason to suspect acute blood loss requiring transfusion in diverticulitis.
Regarding esophageal perforation, which of the following is INCORRECT:
A. Esophageal perforation has been reported as a complication of nasogastric tube placement, endotracheal intubation, and esophagotracheal Combitube intubation.
B. Esophageal perforation may result from forceful vomiting, coughing, childbirth or heavy lifting.
C. Over 80% of esophageal perforations are iatrogenic, usually as complications of upper endoscopy, dilation, or sclerotherapy.
D. Over 90% of spontaneous esophageal perforations occur in the proximal esophagus.
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?
A. neuroleptic-induced acute dystonia
B. neuroleptic malignant syndrome
C. schizophren
B. neuroleptic malignant syndrome
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. Tardive dyskinesia is a chronic movement disorder that results from prolonged use of antipsychotics and can include involuntary and periodic movements of the tongue or lips, mouth puckering, or flailing movements either of the extremities or of the spine. Neuroleptic-induced acute dystonia is an acute spasm of a muscle or muscle group associated with the use of antipsychotic agents. It presents with patients complaining of neck twisting (torticollis), fixed upper gaze, facial muscle spasms, or dysarthria from tongue protrusions. In a similar family with dystonia, neuroleptic-induced akathisia is an extrapyramidal syndrome that is manifest by agitation and restlessness. Schizophrenia, catatonic type, a diagnosis of exclusion, usually does not present with this degree of impairment.
A 25 year old man 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:
A. diphenhydramine
B. lorazepam
C. phenobarbital
D. metoprolol
A. 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 70 year old male with acute delirium requires administration of haloperidol for agitation. Which of the following is a recognized side effect of haloperidol?
A. first degree heart block
B. nephrogenic diabetes insipidus
C. prolonged QT interval
D. transient hepatitis
C. prolonged QT interval
Nephrogenic diabetes insipidus may be associated with lithium. Potential side effects of haloperidol include acute dystonia, prolonged QT interval, Parkinsonism, and akathisia
Haloperidol is the most studied high potency antipsychotic agent used in agitated patients. Typical dosing is 5-10 mg IM every 10-30 minutes. Unlike thioridazine, haloperidol does not cause respiratory depression, has negligible anticholinergic side effects, and rarely causes hypotension. Although benzodiazepines can be used in the agitated patient, respiratory depression can occur, and close monitoring is essential.
A 20 year old college student is brought to the emergency department by campus police after he was found by his roommate saying people in the TV were trying to kill him. Which of the following criteria is not an indication for admission?
A. first-time psychiatric episode
B. demonstrates risk for suicide
C. inadequate psychosocial support
D. lacks capacity to cooperate with treatment
A. first-time psychiatric episode
For an acute psychiatric episode, the first goal is medically stabilizing the patient. Subsequently, a patient who presents without previous history of a psychiatric episode does not necessarily need to be admitted. This, of course, depends on the identity and severity of the condition, and whether it can be treated in the emergency department.
A 55 year-old male presents with new onset agitation and confusion. Which of the following medical histories would suggest a psychiatric (non-organic) cause?
A. History of diabetes mellitus only
B. History of alcohol abuse only
C. History of hypothyroidism only
D. History of chronic obstructive pulmonary disease only
C. History of hypothyroidism only
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.
In dealing with the potential violent patient, the emergency physician should:
A. Approach the patient in a calm, controlled and professional manner
B. Assume that the strength of the doctor-patient relationship will ensure safety
C. Deal with the patient in a isolated room to protect the patient's privacy
D. Use a loud voice and threaten to call security if the patient becomes agitated
A. Approach the patient in a calm, controlled and professional manner
Excessive eye contact may be interpreted as a sign of aggression (answer A). Emergency physicians are encouraged to maintain intermittent eye contact with the patient and to keep a professional and calm demeanor. Also a physician should never deal with an agitated or violent patient alone in an isolated room (answer D). Doors should always remain open and exits should never be blocked. Ample security should be close at hand before interviewing the patient (answer E). Finally, involved parties are encouraged to remove any personal effects (e.g. neckties, necklaces, earrings, etc.) that could be used as a weapon by the violent patient.
A 35 year-old male is placed on his back on the gurney in physical restraints for violent behavior. Which life-threatening complication can arise?
A. circulatory obstruction
B. Metabolic acidosis
C. Asphyxia
D. Rhabdomyolysis
D. Urine drug screen
C. 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.
A 27 year old 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 oximetry reading 82% on room air with a respiratory rate of 4 breaths per minute. Radial pulses are present at 120 bpm. Pupils are 1mm bilaterally. Your team is having difficulty finding a vein for an intravenous 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?
A. Glucose
B. Naloxone
C. Thiamine
D. Flumazenil
B. 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. Ethylene glycol
B. Salicylates
C. Isopropyl alcohol
D. Methanoleeette
C. Isopropyl alcohol
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;
C - cyanide
A - alcoholic ketoacidosis
T - toluene
M - methanol
U - uremia
D - diabetic ketoacidosis
P - paraldehyde
I - isoniazid/iron
L - lactate
E - ethylene glycol
S - salicylates
Isopropyl alcohol causes a ketosis without an acidosis.
D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky
D. upon elevation of the arms to 90-degrees (in 0-degrees abduction), and pronation of the hands with fingers spread, wrists and interphalangeal joints are characterized by jerky alternations of extension and flexion
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.
A 60 year old male presents with new onset confusion. Which of the following suggests a functional, as opposed to an organic etiology?
A. abnormal vital signs
B. acute onset
C. auditory hallucinations
D. disorientation
C. auditory hallucinations
The other findings 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. a stressed psychological state resulting from extreme emotional stimulus
B. abnormal behavior associated with decreased alertness and decreased psychomotor activity
C. abnormal behavior accompanied by hallucinations, occurring in an oriented patient
D. a global inability to relate to the environment and process sensory input
D. a global inability to relate to the environment and process sensory input
Alterations in mental status resulting from extreme emotional stimulus would usually be functional abnormalities. Patients with delirium manifest increases in alertness and psychomotor activity. Delirium is more than simple alteration of mental status. Delirium is an organic confusional state. Patients with delirium may have hallucinations, but patients who are oriented are more likely to have functional causes for altered mental status.
Which of the following statements regarding psychotic behavior is true?
A. Brief psychotic episodes, often precipitated by events such as death of a loved one, can be characterized by extremely bizarre behavior and speech
B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary
C. Delusional disorder usually results in impairment in daily functioning
D. Schizophreniform disorder is present when a patient meets the diagnostic criteria for schizophrenia but the process has been present for less than one year
B. Delusions are defined as false beliefs that are not amenable to arguments or facts to the contrary
Psychosis can be limited to nonbizarre delusions; patients with this disorder (delusional disorder) rarely have impairment in daily functioning. Fixed, false beliefs that are not held by others with a patient's cultural background are characteristic of delusional thinking.
A 75 year old female is brought the to emergency department 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:
A. Alzheimer's disease
B. Parkinson's disease
