River's Deck #2

Front 1

What drug is contraindicated in patients taking MAOI's because of the occurrence of a severe hyperpyrexic reaction?

Back 1

Meperidine (Demerol)

Front 2

Should the emergency physician ever prescribe antidepressants?

Back 2

No - One common side effect is the development of flagrant psychosis. This usually occurs in a patient who was misdiagnosed as "depression" but actually schizophrenic or has an oranic brain disorder.

Front 3

What are the therapeutic considerations for patients with torsades de pointes?

Back 3

1 - Removal and/or discontinuation of the offending drug or correction of the underlying electrolyte disorder, 2 - Intravenous magnesium (which shortens the QT interval) is the treatment of choice, 3 - Also effective are overdrive pacing and intravenous isoproterenol (Isuprel) which has no effect on the QT interval

Front 4

What is the best initial therapy for the unstable patient with rapid atrial fibrillation?

Back 4

Synchronized cardioversion

Front 5

What is the initial therapy for symptomatic patients with hypertrophic cardiomyapothy (such symptom include angina, dyspnea, syncope and light-headedness)?

Back 5

Beta-blockers

Front 6

What is an absolute indication for endocarditis prophylaxis?

Back 6

Mitral valve insufficiency with regurgitation or thickened leaflets

Front 7

Name the absolute contraindication to the administration of thrombolytic therapy in the acute MI patient?

Back 7

The presence of active GI bleeding

Front 8

What is the classic ECG finding in acute pericarditis?

Back 8

Diffuse nonatomical ST segment elevation with upward concavity is prominent and is seen in all leads except aVR and V1. PR segment depression is often present, most prominent in lead II and often the earliest ECG menifestation of acute pericarditis.

Front 9

Which criterion should be used to distinguish ventricular tachycardia from SVT with aberration?

Back 9

The most reliable criterion is the finding of AV dissociation in ventricular tachycardia.

Front 10

How valuable is the chest x-ray in the diagnosis and management of the patient with CHF?

Back 10

The typical chest x-ray picture does occur prior to the appearance of physical findings. However, the CXR may be deceptive in the resolution phase, since clinical improvement usually occurs earlier than the x-ray suggests.

Front 11

What is the one uncontested indication for digoxin?

Back 11

Uncontrolled atrial fibrillation with concomitant congestive heart failure

Front 12

What is the most common cause of right-sided CHF?

Back 12

Left-sided CHF

Front 13

Which conditions are most likely to predispose a patient to subacute bacterial endocarditis?

Back 13

1 - Pre-existing valvular heart disease especially of the mitral and/or aortic valves. Mitral valve disease is most common (Including mitral valve prolapse), 2 - Injecting drug users who present with right-sided disease. The tricuspid valve (most commonly involved) is usually normal before onset of disease

Front 14

What are the causes of the high mortality rate (>70%) seen in patients with mesenteric vascular occlusion?

Back 14

1 - Difficulty in early diagnosis, 2 - Refractory nature of advanced disease, 3 - Frequent association of other serious diseases

Front 15

What are common conduction disturbances in an acute myocardial infarction?

Back 15

Bradydysrhythmias and AV conduction block

Front 16

What is the most common bacterial organism that causes infective endocarditis? Is this the same organism if the patient is an injecting drug user?

Back 16

Non-viridans streptococci (alpha streptocci). No - the organism is Staphylococcus aureus.

Front 17

What is the adult dose of epinephrine for the patient with anaphylaxis?

Back 17

0.1 - 0.5 mg of a 1:1,000 solution IM q5-15min, max 1mg/dose

Front 18

What is the earliest and most common rhythm disturbance seen with digitalis toxicity?

Back 18

PVC's

Front 19

Which drug should be avoided in the therapy of an idioventricular rhythm, because it may obliterate the patient's only functioning rhythm?

Back 19

Lidocaine

Front 20

What are the electrolyte abnormalities seen in Addison's disease?

Back 20

Hyponatremia (most common), Hyperkalemia (next most common), Hypercalcemia

Front 21

CLINICAL PRESENTATION: A patient complains of sudden onset of SOB while dining out in a restaurant; he was not swallowing food when the sx's began. Physical findings included inspiratory stridor and bilateral expiratory wheezing. What is the most likely diagnosis?

Back 21

Acute anaphylatic reaction

Front 22

Which therapy should NOT be given to the alcoholic who is acutely ill, dehydrated and has the following lab values? Glucose 140, Blood alcohol 0.00, pH 7.18, Serum Ketones elevated

Back 22

Bicarbonate is not indicated. This patient has alcoholic ketoacidosis. The treatment consists of fluid restoration and glucose. Some patients may have even modest hyperglycemia, but "refeeding" usually corrects this.

Front 23

What is the most common (in euvolemic patients) of hyponatremia?

Back 23

SIADH - Syndrome of Inappropriate secretion of AntiDiuretic Hormone

Front 24

What is the most common precipitating cause of diabetic ketoacidosis?

Back 24

Infection

Front 25

In treatment of patients with delirium tremens, which drugs should be avoided?

Back 25

Phenothiazines (They lower the seizure threshold)

Front 26

What are the risks of high-dose insulin therapy in diabetics?

Back 26

Vascular collapse, Acute tubular necrosis, Cerebral edema

Front 27

Core temperatures less than ______ are associated with increased myocardial irritability and can cause nearly any tachydysrhythmia or bradydysrhythmia, including conduction delays.

Back 27

30°C (86°F)

Front 28

What is the most important cause of morbidity and mortality in near-drowing?

Back 28

Hypoxia

Front 29

Inpatients with this injury, close observation (sometime in the hospital) and referral to a plastic or oral surgeon is indicated because there is the possibility of labial artery hemorrhage as the eschar seperates.

Back 29

Electrical burns of the lip

Front 30

Rapid rewarming is the key initial therapy for this environmental emergency

Back 30

Frostbite

Front 31

A patient presents with an acute abdomen. However, you notice that there is no tenderness but there is impressive rigidity. What is the suspected diagnosis?

Back 31

Black widow spider bite (to the lower extremity or genitalia)

Front 32

Arterial occlusion from an air embolus can occur at any site, but the most common presentation is an acute neurologic event (such as confusion). What is the condition called?

Back 32

Barotrauma of ascent

Front 33

A scuba diver develops acute confusion and ataxia after ascent. What is the diagnosis?

Back 33

Cerebral air embolus

Front 34

In patients with carbon monoxide poisoning, oxygen therapy should not be discontinued until the patient is asymptomatic and the COHb level is < ______ %

Back 34

5 - 10 %

Front 35

What is the most common presentation of cholelithiasis?

Back 35

Biliary Colic - No fever, Relatively normal lab studies, Pain relief with meperidine

Front 36

What is the etiology of hepatic abscesses?

Back 36

Pyogenic (usually E. Coli) - 90%; Amebic (Entamoeba histolytica) - 10%

Front 37

What is the most common cause of portal hypertension worldwide?

Back 37

Schistosomiasis

Front 38

What is the most common bloodborne infection in the United States?

Back 38

Hepatitis C Virus

Front 39

What are the two most common causes of esophageal bleeding?

Back 39

Varices (most common) {esophageal and gastric}; Mallory-Weiss tear

Front 40

UGI bleeding due to a ruptured esophageal varix can be controlled in 90 - 95% of cases with ______ and ______.

Back 40

Endoscopy; Pharmacologic agents

Front 41

CLINICAL PRESENTATION: A middle aged male with cirrhosis who is confused and unable to hold an assumed position (asterixis). What is the diagnosis and appropriate management?

Back 41

Hepatic Encephalopathy is the diagnosis. Mgmt includes: Neomycin or lactulose; Decreased protein intake (especially animal protein); Avoid bicarb (alkalosis may precipitate or worsen encephalopathy); Correction of hypokalemia

Front 42

When is the insertion of a Sengstaken-Blakemore tube contraindicated? What procedure should be donne prior to insertion of the tube?

Back 42

Contraindications include: Hiatal hernia (precludes proper tube placement), Peptic ulcer disease with stricture of the esophagus, Bleeding from esophageal lacerations, Inability of the patient to protect the airway. Endoscopy should preceed insertion (if at all possible) so that the diagnosis may be confirmed.

Front 43

Bloody diarrhea should warrant testing for which three bacteria?

Back 43

Shigella, Salmonella, Campylobactor

Front 44

Protozoal pathogens most frequently associated with diarrhea that persists for more than 7 - 10 days are ______ and ______.

Back 44

Giardia - Cryptosporidium

Front 45

Patients with refractory cryptosporidiosis, cyclosporiasis or isosporiasis should be tested for ______.

Back 45

HIV infection

Front 46

Spontaneous hyphemas are associated with ______.

Back 46

Sickle cell disease

Front 47

An acute cranial nerve III palsy with pupillarydilatation is a ______ until proven otherwise.

Back 47

Posterior communicating artery aneurysm

Front 48

You are examing a patient who seems to have Bell's palsy. When you check EOMs, he is unable to abduct the ipsilateral eye. What is the diagnosis?

Back 48

A CVA masquerading as a Bell's palsy

Front 49

Which diagnoses should be considered in a patient with isolated cranial nervepalsy (III, IV or VI) associated with pupil sparing?

Back 49

Diabetic/hypertensive cranial nerve palsy

Front 50

Name the condition in which the iris has an unusual curved shape at the periphery, placing it closer to the cornea and creating a congentially-narrow angle.

Back 50

Plateau iris (predisposes the patient to subsequent development of acute narrow angle glaucoma)

Front 51

What medications have produced sudden attacks of narrow-angle glaucoma?

Back 51

Topical cycloplegics, Anticholinergic agents, Beta-agonists (including inhaled agents)

Front 52

A common precipitator of central retinal artery occlusion is ______.

Back 52

Giant cell arteritis

Front 53

The most common acute optic neuropathy in patients >50 years old is _______. Visual loss is often described as altitudinal (only the upper or lower half of visual field is missing); inferior loss is more common.

Back 53

Nonarteritic anterior ischemic optic neuropathy

Front 54

Which potentiall life-threatening disease should be ruled out in patients in their sixties who c/o dull, aching eye pain that extends to the temple?

Back 54

Ocular ischemic syndrome (Light induced amaurosis should alert the clinician to the possibility of significant carotid occlusion)

Front 55

What is the most common cause of acute visual reduction due to optic nerve dysfunction in patients 20 - 40 years old?

Back 55

Optic neuritis

Front 56

A patient with a corneal ulcer presents with adherent mucopurulent exudate and "ground glass" appearance of the cornea. What is the most likely infecting organism?

Back 56

Pseudomonas aeruginosa

Front 57

What is the most severe form of congenital anemia? (clinical features include bronze skin discoloration and patients are transfusion dependent)

Back 57

β-Thalassemia (Thalassemia major, Cooley's anemia) - This is often misdiagnosed as iron deficiency anemia on blood smear (hypochromic, microcytic red cells)

Front 58

CLINICAL PRESENTATION: A neutrapenic patient develops sepsis associated with nonproductive cough and fever with rales at both bases. He also has an infected sacral decubitus ulcer. What is the likely offending organism?

Back 58

Pseudomonas aeruginosa

Front 59

What is the most common organism causing life-threatening infection in patients undergoing bone marrow or solid organ transplants?

Back 59

Cytomegalovirus

Front 60

What reversible conditions can mimic the appearance of brain death?

Back 60

Hypotherma and Barbiturate coma

Front 61

What should you be looking for on AP and lateral films of the thoracic and lumbar spine in trauma patients?

Back 61

AP: verticle alignment of the pedicles as well as the distance between them (unstable fractures commonly cause widening of the interpedicular distance); Lateral: subluxations, compression fractures and Chance fractures.

Front 62

Patients in hypovolemic shock are usually ______, while those in neurogenic shock are typically ______.

Back 62

Tachycardic - Bradycardic

Front 63

CT scanning of the thoracic and lumbar spine is particularly useful for detecting which injuries?

Back 63

Fractures of the posterior elements (pedicles, laminae, and spinal processes) and the degree of canal compromise caused by burst fractures.

Front 64

True or False: corticosteroids should not be used to treat head injury (whatever the severity)?

Back 64

True … according to a 2006 LLSA article (Lancet, 2004; 364: 1325)

Front 65

A head CT is not indicated in patients who do not have:

Back 65

Headache and/or vomiting, Age < 60 years, Drug/alcohol intoxication, Short-term memory loss, Trauma above the clavicle (per ACEP clinical policy)

Front 66

Important factors for identifying children at low risk for traumatic brain injury after blunt head trauma include the absence of:

Back 66

Abnormal mental status, Clinical signs of skull Fx, Hx of vomiting and/or headache, Scalp hematoma in kids < 20 years old (LLSA Reading)

Front 67

Why is it important to obtain an early orthopedic referral for infants with congenital hip dislocation?

Back 67

Treatment consists of splinting or casting in flexion/abduction to avoid later need for surgery.

Front 68

What is the primary cause of radiculopathy in patients older than 65?

Back 68

Spinal stenosis

Front 69

What is Toddler's Fracture?

Back 69

Toddler's Fracture is a tibial shaft fracture seen in children 9 months - 3 years of age. Nondisplaced spiral fractures of the distal tibia - are usually accidental; Midshaft fractures - occur as a result of nonaccidental trauma.

Front 70

When is angiography with embolization indicated in the treatment of severe hemorrhage secondary to pelvic fracture?

Back 70

angiography with embolization is used to manage hemorrhage when fluid resuscitation has failed and the patient is continuing to hemorrhage. Signs of ongoing bleeding from pelvic fractures include: 1 - >4 units of blood required in < 24 hours or > 6 units were needed in < 48 hours, 2 - There is a large pelvic hematoma on GT, 3 - Hemodynamic instability and a negative DPL, 4 - Large (or expanding) retorperitoneal hemorrhage.

Front 71

What is suggested when there is: Inability to flex the DIP joint of a finger and - There are signs of traumatic tenosynovitis, such as swelling and tenderness in the flexor tendon sheath and a mild flexion deformity?

Back 71

Rupture of the flexor digitorum profundus tendon

Front 72

What is the physical findings of nerve root involvement in patients with lumbar disk compression?

Back 72

L1 - L4 = decreased/absent knee jerk; L5 = decreased/absent dorsiflexion of great toe; S1 = decreased/absent ankle jerk (decreased or absent plantar flexion) plus numbness of the lateral foot

Front 73

What cervical spine injury occurs as the result of axial loading?

Back 73

Jefferson fracture or C1 ring blowout fracture

Front 74

The only indication for an MRI in the ED setting is for the evaluation of ______ ______ ______.

Back 74

Spinal Cord Injuries

Front 75

What psychiatric disorder is most often confused with stroke?

Back 75

Conversion disorder

Front 76

A young woman presents with recurring headaches. CT reveals slit-like ventricles. Diagnosis?

Back 76

Pseudotumor cerebri

Front 77

How does mannitol work in the treatment of cerebral edema?

Back 77

Mannitol directly absorbs the fluid, not just the excess but the normal interstinal fluid as well (which is probably why "rebound" is a problem)

Front 78

What reflex should be checked in patients with a neurogenic bladder?

Back 78

The Bulbocavernosus Reflex - This is a normal cord-mediated reflex elicited by placing a gloved finger in the rectum and squeezing the glans penis (or gently tugging the Foley catheter). Contraction of the anal sphincter is the normal response; absence indicates the presence of spinal shock: a concussive injury to the spinal cord that results in total neurologic dysfunction distal to the site of injury

Front 79

In the early stages of this illness, symptoms are indistinguishable from a nonspecific upper respiratory infection with rhinorrhea, low grade fever, cough, conjunctivitis and anorexia. As the disease progresses, the COUGH becomes the diagnostic and dominant clinical feature. What is the disease?

Back 79

Pertussis or whooping cough. Two lessons are to be learned here. First, there are a lot of children less than 1 year old who are underimmunized or not immunized. Be wary of those with respiratory illness and cough. Second, people immunized more than 12 years ago for pertussis can aquire the disease if exposed. Note that the current DPT vaccine reduces the incidence of pertussis in the US thereby preventing pertussis epidemics.

Front 80

What are the Ottawa Knee Rules for ordering knee x-rays in children > 5 years old with an injury?

Back 80

A knee x-ray is only required for children > 5 years old if any of these findings are present on physical exam: Isolated patellar tenderness, Tenderness at the head of the fibula, Inability to flex knee 90°, Inability to bear weight and walk 4 steps (immediately and in the ED)

Front 81

Do children with post-traumatic seizures following blunt head trauma require admission?

Back 81

In otherwise healthy children with a single post-traumatic seizure, normal neuro exam and head CT, discharge to home with the usual head injury instructions is appropriate.

Front 82

What is the current drug of choice for the treatment of GABHS tonsillopharyngitis in children?

Back 82

Due to increasing rates of PCN failure, a cephalosporing is the DOC for GABHS infection

Front 83

Angled buckle fractures are frequently missed in kids. Which x-ray views are most likely to demonstrate these fractures?

Back 83

AP view elbow - in addition to the proximal radius (which may be fractured), look at the anterior humeral line for a supracondylar fracture; Oblique view - proximal phalanges and metatarsals (especially the base of the first metatarsal - bunk bed fractures); Lateral view - distal femur and distal tibia

Front 84

Which two pathogens are the most common causes of a lobar infiltrate on chest x-ray?

Back 84

Klebsiella (upper lobe) and Strep pneumoniae

Front 85

Which pathogens are the most common causes of a patchy infiltrate on chest x-ray?

Back 85

Group A Strep, Hemophilus influneza (Type B), Stap pneumoniae (early), Pseudomonas, E. coli, Strep pneumoniae (infants/elderly), Legionella

Front 86

What is the most common pathogenic causes of lung abcesses seen on x-ray?

Back 86

Klebsiella, Staph aureus, Pseudomonas, Staph pneumoniae (eventually)

Front 87

What is the classic (as well as most common) x-ray finding of sarcoidosis?

Back 87

Bilateral Mediastinal Lymphadenopathy (an x-ray of this can be seen in Harwood-Nuss 3rd ed. P759, fig 152.1)

Front 88

Most potentially lethal ODs/poisonings demonstrate clinical manifestations within several hours of ingestion. Common exceptions to this rule are:

Back 88

Acetaminophen, Mushrooms (amatoxin, gyromitrin, cortinarius), Sulfonylureas, Sustained release Ca channel blockers, Antimetabolites (methotrexate), Lomotil

Front 89

Paresthesias (mouth, face, and limbs), ataxia, weakness and an odd floating sensation are associated with _______.

Back 89

Paralytic shellfish poisoning

Front 90

Dystonias and buccolingual (or perioral) dyskinesia ("rabbit syndrome") are signs of ______ toxicity

Back 90

Phenothiazine

Front 91

Profound weakness (especially in patients with myasthenia gravis) is a sign of toxicity of which drug group?

Back 91

The aminoglycosides

Front 92

Peripheral neuropathy in association with constipation suggests toxicity to what agent?

Back 92

Vincristine

Front 93

Which infectious complication of AIDS poses the greatest risk of HIV transmission to the general public?

Back 93

Tuberculosis

Front 94

What is the most common organism causing septic arthritis in patients less than 50 years old, particularly teenagers and young adults?

Back 94

Neisseria gonorrhoeae

Front 95

What is the most common opportunistic infection in AIDS patients?

Back 95

Pneumocystis carinii penumonia (PCP)

Front 96

Which antibiotics should be avoided throughout pregnancy?

Back 96

Tetracyclines and quinolones

Front 97

What are the most common causes of vaginal bleeding for premenarchal girls, women in their reproductive years and those after menopause?

Back 97

Premenarch: Trauma, infection, hormonal imbalances; Reproductive years: Pregnancy; Post-menopausal: Neoplasm, medical disorders

Front 98

Regarding puncture wounds of the foot: 1 - What is the major complication that can occur? 2 - What is the usual causative organism if the puncture occurred through a shoe?

Back 98

1 - Osteomyelitis, 2 - Pseudomonas

Front 99

How is a skin abscess best treated in the ED?

Back 99

I&D only (no antibiotics)

Front 100

What are the limitations of pulse oximetry?

Back 100

In comparision to ABGs, a pulse ox provides no info on pH or PaCO2 levels, and only indirectly assesses adequacy of ventilation, the latter of which is important in at least two clinical situations: 1 - During conscious sedation, monitoring ventilation is important to prevent hypoxia; 2 - A decrease in hemoglobin oxygen saturation may result if a patient is hypoventilated or has anemia (Hgb < 5)

Front 101

In a Haz-Mat incident, decontamination is best performed in the ______ setting.

Back 101

Prehospital

Front 102

If a patient has a wound which requires suturing but the patient claims that he is allergic to lidocaine, what are the available options?

Back 102

1 - use an anesthetic from another family, 2 - Give the patient a 0.1 mL dose of lidocaine intradermally from a single dose vial or from a bottle of cardiac lidocaine (multi-dose vials contain methylparaben, a preservative that is the usual culprit of most lidocaine reactions), 3 - Inject diphenhydramine (Benadry) 1%

Front 103

True or False: There is no significant difference in infection rates when using nonsterile gloves rather than sterile gloves in repairing uncomplicated lacerations.

Back 103

True - 2006 LLSA Reading