#3 -- 2014-09-12 SAEM Tests Practice Questions 2013

Question 1

Which of the following symptoms is not associated with epidural hematomas?
	A. 	Severe headache
	B. 	Sleepiness
	C. 	Nausea
	D. 	Hemotympanum
	E. 	Neurologic deficits

Answer 1

D. Hemotympanum

The answer is D. Although hemotympanum may be found in a patient with an epidural hematoma, it is specifically associated with basilar skull fracture.

Question 2

A 21-year-old woman presents to the emergency department with fevers, headache, neck stiffness, and mild confusion over the past several days. Her temperature is 38.0 C (100.4 F), pulse 106, and blood pressure 116/74. On physical exam she looks ill, and her neck is stiff. Her neurologic exam is normal. A lumbar puncture reveals 105 WBC and 1240 RBC in tube #1 and 126 WBC and 1360 RBC in tube #4; all white cells are lymphocytes. The CSF protein is 68 and the glucose is 78. This patient most likely has which of the following?
	A. 	HSV encephalitis
	B. 	Pneumococcal meningitis
	C. 	Subarachnoid hemorrhage
	D. 	Subdural hematoma

Answer 2

A. HSV encephalitis

Question 3

Which of the following are potential complications of bacterial meningitis?
	A. 	Seizure disorder
	B. 	Focal paralysis or sensory loss
	C. 	Intellectual impairment
	D. 	Sensorineural hearing loss
	E. 	All of the above

Answer 3

E. All of the above

Question 4

All of the following statements about lumbar punctures are true EXCEPT:
A. The subarachnoid space extends to the S2 vertebral level.
B. Patients should be told to keep their neck in maximal flexion throughout the procedure.
C. In locating the puncture site, a line connecting the posterior superior iliac crests will intersect the midline at approximately L4.
D. In the adult and older pediatric population, lumbar punctures may be performed as high as the L2/L3 interspace and as low as the L5/S1 interspace.
E. Patients are positioned in lateral recumbent position with their lower back arched toward the physician.

Answer 4

B. Patients should be told to keep their neck in maximal flexion throughout the procedure.

Question 5

A 65 year old male with a past medical history of poorly controlled hypertension presents with new onset unilateral arm and leg weakness. There is no disturbance of consciousness and there is no evidence of cortical findings (such as aphasia, agnosia, or hemianopsia). What is the most likely location of the vascular obstruction?
	A. 	basilar artery
	B. 	lacunar
	C. 	middle cerebral artery
	D. 	posterior cerebral artery
	E. 	anterior cerebral artery

Answer 5

B. lacunar

The answer is B. Lacunar infarcts occur at the small, terminal branches of the vasculature and more commonly occur in African-Americans and patients with diabetes and hypertension. This patient’s presentation, evidenced by pure loss of motor function without disturbances in other neurological modalities, is consistent with an infarct in the internal capsule. Because terminal branches of the vasculature supply the internal capsule, it is frequently affected in patients with diabetes and hypertension. A vascular obstruction in the MCA would affect not only motor functions, but also produce cortical findings such as aphasia or agnosia.

Question 6

A 19 year old female college student presents to the emergency department with fever, headache, and confusion. Physical exam reveals T103. She is lethargic. The HEENT exam is normal, she has nuchal rigidity, and her lungs are clear. Of the following choices, the next step in her treatment should be:
A. levofloxacin PO or IV
B. head CT
C. head CT, followed by lumbar puncture
D. ceftriaxone IV
E. azithromycin IV

Answer 6

D. ceftriaxone IV

The answer is D. In patients with meningitis, early antibiotics administration is of the utmost importance. Antibiotic administration should not be delayed to await diagnostic work up. Ceftriaxone, administered in some regions with vancomycin depending on the resistance profile of likely etiologic agents, is generally considered an antibiotic of choice in meningitis. Azithromycin and levofloxacin do not have good CNS penetration and therefore are not indicated for meningitis.

Question 7

A 24 year old female without prior medical history presents with a one day history of left sided facial weakness. It was preceded by a headache behind her left ear. On exam she is unable to wrinkle her left forehead or close her left eye. The corner of her mouth droops on the left. The rest of the exam is normal. Which of the following would be inappropriate in the care of this patient?
A. Evaluation of Lyme disease if the patient lives in or has visited a Lyme endemic area.
B. CT of the brain with and without intravenous contrast.
C. Protecting her left eye with moisturizing drops and a patch at bedtime.
D. A short course of prednisone.
E. Acyclovir.

Answer 7

B. CT of the brain with and without intravenous contrast.

The answer is B. Bell’s palsy is an idiopathic palsy of the facial nerve. Although it is the most common cause of a facial nerve palsy, other etiologies must be ruled out. Inability to move the forehead muscle indicates a peripheral lesion, making stroke much less likely. If the remainder of the neurological exam is normal, then imaging is not needed. Lyme disease is a well known cause of facial nerve palsy and patients should be evaluated for this if they live in an endemic region. Half of cases present with retroauricular pain around the time of onset. Most neurologists recommend a short course of prednisone as part of treatment. There is evidence that herpes simplex virus is involved as a causative agent, and acyclovir is recommended. Also extremely important is to protect the involved eye, as it is at risk of drying out because lacrimal gland functioning can be impaired, and the eye is unable to close fully.

Question 8

A 56 year old woman presents to the emergency department with a complaint that “my head is spinning.” For two days she has experienced a spinning sensation periodically, one that she does not associate with any specific position or movement. It subsides after 30 to 45 minutes. It is associated with nausea. She denies visual changes, weakness, or numbness. She feels unsteady on her feet during these episodes. On physical exam, she has horizontal nystagmus; but her neurologic exam is normal, including cranial nerves, motor strength, reflexes, coordination, and gait. Her tympanic membranes are normal; but Rinne and Weber tests reveal decreased hearing on the right with bone conduction that localized to the left ear suggesting right sensorineural hearing loss. Which of the following conditions is associated with these findings?
	A. 	benign positional vertigo
	B. 	multiple sclerosis
	C. 	brainstem stroke
	D. 	vestibular neuronitis
	E. 	labyrinthitis

Answer 8

E. labyrinthitis

The answer is E. Determination of hearing loss is important in the evaluation of vertigo. Central vertigo, such as that which may be associated with multiple sclerosis or stroke, is not accompanied by acute hearing loss because of the distributed nature of the CN VIII nuclei. Acoustic neuroma, a central process, can cause hearing loss because of direct compression of the CN VIII. Even though vestibular neuronitis involves inflammation of CN VIII, it is not associated with hearing loss. Benign positional vertigo is caused by loose particles in the semicircular canals that induce a false sense of motion; however, auditory hearing is unaffected. Labyrinthitis, or inflammation of inner ear structures including semicircular canals and cochlea, can result in sensorineural hearing loss.

Question 9

Which of the following might suggest central rather than peripheral vertigo?
A. Prominent vomiting and diaphoresis
B. Horizontal nystagmus on extreme lateral gaze
C. Transient and episodically related to head movement
D. Diplopia
E. Sudden onset

Answer 9

D. Diplopia

The answer is D. Any cranial nerve deficit should raise the suspicion for a central process as an etiology for vertigo. Some horizontal nystagmus (on extreme lateral gaze) can be a normal finding.

Question 10

A 26 year old woman presents to the emergency department with episodes of spinning associated with nausea, vomiting, and unsteady gait. These occurred three times in the past 12 hours and come on suddenly when she is lying down and turns onto her right side. The spinning is violent and she has vomited several times. Her symptoms resolve spontaneously in 5 to 10 minutes and she feels fine in the interim. She has recently had an upper respiratory infection and has started no new medications. Her neurologic exam is normal. Laying her down quickly over the side of the bed with her head turned to the left reproduces symptoms. Which of the following medications may be effective in preventing further episodes of vertigo?
	A. 	Diphenhydramine
	B. 	Meclizine
	C. 	Diazepam
	D. 	Promethazine
	E. 	Any of the above

Answer 10

E. Any of the above

The answer is E. This patient has symptoms consistent with benign positional vertigo. It is caused by vestibular stimulation, usually from loose debris in the semicircular canals. Benzodiazipines are useful because of their sedative effect on the limbic system, thalamus, and hypothalamus. Vestibular neurons are mediated by acetylcholine; therefore, anticholinergic agents (e.g., meclizine, diphenhydramine, promethazine) are effective to minimize vertigo.

Question 11

The arterial distribution in the Figure which is indicated by the letter "A", and shaded black, is the:
[image]
Figure used with permission from Hamilton et al, Emergency Medicine: An approach to clinical problem-solving
	A. 	basilar artery
	B. 	anterior cerebral artery
	C. 	middle cerebral artery
	D. 	internal carotid artery
	E. 	posterior cerebellar artery

Answer 11

C. middle cerebral artery

Question 12

A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain, progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F). On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is not an acceptable next step?
A. MRI of the spine
B. Analgesia
C. Foley catheter to drain the bladder
D. Hospital admission for neurosurgical consultation in the morning
E. Antibiotics to cover a broad spectrum of organism

Answer 12

D. Hospital admission for neurosurgical consultation in the morning

he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus, chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder decompression for symptomatic relief is important, as is analgesia

Question 13

Which of the following is true about myasthenia gravis?
A. It typically presents as an ascending weakness of the peripheral nervous system.
B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation.
C. Weakness improves as the involved muscles are used repeatedly.
D. The “atropine test” is diagnostic when 0.5 mg of atropine is given intravenously and the patient’s symptoms improve within two minutes.
E. Cooling exacerbates the symptoms, and heat alleviates them.

Answer 13

B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation.

The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon test, where edrophonium is given and the patient’s symptoms are observed to transiently improve. The administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring intubation, frequently for prolonged periods.

Question 14

A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood pressure, which of the following is TRUE?
A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful in this setting
B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action
C. Nitroglycerin decreases BP by decreasing venous return and cardiac output
D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia
E. Esmolol works through both alpha-1 and selective beta-2 blockade

Answer 14

C. Nitroglycerin decreases BP by decreasing venous return and cardiac output

The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term cyclosporine treatment suggests this patient likely has some degree of renal insufficiency.

Question 15

A 14 year-old child presents to the emergency department. His blood pressure is 210/140. He complains of a headache, nausea, and recent blurred vision. Of the following choices, the best goal for lowering his mean arterial blood pressure is to have it drop by:
A. Until symptoms resolve
B. 5% in the first 5-6 hours
C. 25% in the first hour
D. 50% in the first hour
E. To normal for his age in the first hour

Answer 15

C. 25% in the first hour

The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, defines hypertensive urgency. With end-organs symptoms, as above, the presumptive diagnosis is hypertensive emergency. In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the first hour, thereby alleviating symptoms while not compromising cerebral perfusion.

Question 16

A 2 year old male is brought to the ED in status epilepticus. He has not responded to adequate doses of benzodiazepines. Which of the following possible causes of a seizure must be evaluated for in the emergency department?
A. Hypoxia
B. Hypoglycemia
C. Toxic ingestion
D. Head trauma
E. All of the above possible causes must be evaluated for

Answer 16

E. All of the above possible causes must be evaluated for

The answer is E. Seizures have a number of secondary causes, which must be identified and corrected before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse. Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus.

Question 17

Shock is defined as:
	A. 	tachycardia
	B. 	hypotension
	C. 	altered mental status
	D. 	hypovolemia
	E. 	inadequate tissue and organ perfusion

Answer 17

E. inadequate tissue and organ perfusion

The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia, hypotension and altered mental status are all signs and symptoms of shock.

Question 18

The four classic types of shock include all of the following EXCEPT:
	A. 	Distributive
	B. 	Obstructive
	C. 	Hypovolemic
	D. 	Cardiogenic
	E. 	Traumatic

Answer 18

E. Traumatic

The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock states (usually hypovolemic, but also distributive in the case of pericardial tamponade), but there is no “traumatic” shock subtype.

Question 19

An early sign and symptom of shock is:
	A. 	Cyanosis
	B. 	Decreased respiratory rate
	C. 	Tachycardia
	D. 	Hypotension
	E. 	Bradycarda

Answer 19

C. Tachycardia

The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased respiratory rate, which occur as the body attempts to maintain perfusion.

Question 20

All patients with shock should receive as the first priority:
	A. 	Supplemental oxygen
	B. 	Packed red blood cells
	C. 	Trendelenburg positioning
	D. 	Antibiotics
	E. 	Intravenous fluids

Answer 20

A. Supplemental oxygen

The answer is A. The fundamental issue in shock is tissue hypoperfusion and hypoxia. All patients in shock should receive supplemental oxygen initially. Steps to improve oxygenation range from nasal cannula to endotracheal intubation.

Question 21

As compared to adults, children with shock usually:
A. Have more reliable signs and symptoms
B. Have similar epidemiology (i.e. causes for shock states)
C. Are able to maintain their blood pressure better
D. Have different treatment priorities
E. Do not need specialized care

Answer 21

C. Are able to maintain their blood pressure better

The answer is C. While the treatment priorities for pediatric and adult shock are similar, there are some differences; thus, a specialized approach to care is often required. The epidemiology is different, since in children shock tends to be caused by trauma and infections. Children’s signs and symptoms may be more subtle than those of adults in shock, rendering the physical examination less reliable in pediatrics. One of the key differences is a child’s ability to maintain blood pressure despite presence of shock.

Question 22

During hypovolemic shock, hypotension tends to develop after the loss of what percent of blood volume?
	A. 	10%
	B. 	20%
	C. 	30%
	D. 	40%
	E. 	50%

Answer 22

C. 30%

The answer is C. Some texts divide hypovolemic shock into 4 classes based on the percent of volume loss; Class I is loss of up to 15% of circulating blood volume; Class II is 15-30% loss; Class III, 30-40%; and Class 4, over 40%. In general, blood pressure does not drop until approximately 30% of blood volume is lost.

Question 23

All of the following are signs and symptoms of hypovolemic shock EXCEPT:
	A. 	Narrow pulse pressure
	B. 	Cool, clammy skin
	C. 	Warm, moist skin
	D. 	Decreased capillary refill
	E. 	Tachycardia

Answer 23

C. Warm, moist skin

The answer is C. Acute hemorrhage or volume loss is characterized by tachycardia, narrow pulse pressure, poor capillary refill and decreased urine output. Skin tends to be cold and clammy. Late findings include hypotension and altered mental status.

Question 24

The best IV access for volume resuscitation of the hypovolemic patient is:
A. 22g catheter in the dorsum of the hand
B. intraosseous line
C. triple-lumen internal jugular central venous catheter
D. 16g catheter in the antecubital fossa
E. PICC line

Answer 24

D. 16g catheter in the antecubital fossa

The answer is D. A large short catheter is preferred for volume resuscitation. The ideal line is a large caliber introduced in a large or central vein. A 14g or 16g catheter in the antecubital fossa is considered adequate in most settings. Triple lumen and picc line catheters (the PICC is a peripherally introduced indwelling central catheter) are long, very narrow catheters; the length and narrowness increase resistance to fluid flow.

Question 25

All of the following are reasonable fluids for resuscitation of hypovolemia EXCEPT:
	A. 	D5W
	B. 	Blood
	C. 	Albumin
	D. 	Normal saline
	E. 	Lactated Ringer’s

Answer 25

A. D5W

The answer is A. The goal of IV resuscitation is to restore intravascular volume. Fluids that are isotonic are preferred. D5W is hyptonic, and therefore a poor choice for volume resuscitation.

Question 26

As a general rule, when is blood transfusion indicated in the treatment of hypovolemic shock resulting from acute hemorrhage?
	A. 	massive hemorrhage > 30%
	B. 	first line treatment
	C. 	after dopamine
	D. 	minor hemorrhage

Answer 26

A. massive hemorrhage > 30%

The answer is A. Blood transfusion can play a vital role in the treatment of hypovolemic shock from acute hemorrhage. It is generally not the first line treatment. It is indicated in massive blood loss or shock that is not responsive to significant crystalloid infusion (2L or 30 ml/kg). Pressors are not indicated in hypovolemic shock. Elderly patients and those with co-morbid illnesses may require blood products earlier than healthy adults.

Question 27

A 27 year old man is shot in the right leg. He is unconscious. The wound appears to be pulsatile. The medics report he has lost a lot of blood. His heart rate is 160, and his BP is 70/30. He has received 2 liters of IVF normal saline. The next step in management would be:
A. Check a hemoglobin level and hematocrit
B. Administer Type O Rh+ blood
C. Wait for cross-matched blood
D. Give more saline
E. Wait for type-specific blood

Answer 27

B. Administer Type O Rh+ blood

The answer is B. Patients in extremis with acute hemorrhage need aggressive fluid resuscitation. After an initial crystalloid bolus, blood products should be initiated. Type O is the universal donor type, with Rh-negative blood reserved for women of childbearing age. Type-specific blood is another option, but usually takes at least 15-20 minutes to obtain; cross-matching of blood takes even longer.

Question 28

The pathophysiology of cardiogenic shock is:
	A. 	Cardiac pump failure
	B. 	Endotoxins
	C. 	Hypoxia
	D. 	Hypovolemia
	E. 	Vasodilation

Answer 28

A. Cardiac pump failure

Question 29

The treatment of cardiogenic shock may include all of the following EXCEPT:
	A. 	Treatment of ischemia
	B. 	Dopamine
	C. 	Phenylephrine
	D. 	Dobutamine
	E. 	Intra-aortic balloon pump

Answer 29

C. Phenylephrine

The answer is C. The goal of therapy is to improve oxygenation, minimize ischemia, improve pump function, and decrease afterload. Dobutamine is the agent of choice in the setting of heart failure. An intra-aortic balloon pump may be a temporizing measure. Phenylephrine would increase afterload and worsen cardiac output.

Question 30

A 24 year old woman presents with difficulty breathing after eating Chinese food. Her vital signs are: T 97.9, HR 120, BP 80/40, RR 28, SPO2 86%. Her voice is hoarse and her lung auscultation reveals wheezes. She has no JVD. The patient’s most likely diagnosis is:
	A. 	Anaphylactic shock
	B. 	Cardiogenic shock
	C. 	Spinal shock
	D. 	Pulmonary embolism
	E. 	Acute myocardial infarction

Answer 30

A. Anaphylactic shock

The answer is A. The patient’s respiratory symptoms, absence of JVD, and vital signs suggest anaphylaxis (distributive shock). The proximity of symptoms to ingestion of food also suggests an allergic reaction.

Question 31

For a young otherwise healthy patient in anaphylactic shock, the initial best treatment of those listed below is:
	A. 	Dopamine
	B. 	Broad spectrum antibiotics
	C. 	Steroids
	D. 	Epinephrine
	E. 	Diphenhydramine

Answer 31

D. Epinephrine

Question 32

A 15 year old boy dives into a swimming pool, hits his head on the bottom, and subsequently is found to have no sensation or motor function below the nipple line. His vital signs are: T 97.9, HR 76, BP 80/40, RR 12, SPO2 84%. He has no JVD and his lungs are clear. The patient’s diagnosis is:
	A. 	Sepsis
	B. 	Hypovolemic shock
	C. 	Near drowning
	D. 	Neurogenic shock
	E. 	Spinal shock

Answer 32

D. Neurogenic shock

The answer is D. The patient is most likely suffering a spinal cord injury, producing a disruption of the autonomic nervous system leading to vasodilation and hypotension (without the expected tachycardic response). This entity, called neurogenic shock, is a type of distributive shock like anaphylactic shock It is important to rule out other internal injuries in this patient, and then institute therapy with a pressor agent such as phenylephrine.

Question 33

For a patient in neurogenic shock, the correct treatment would likely be all of the following EXCEPT:
	A. 	Spinal immobilization
	B. 	Blood transfusion
	C. 	High dose steroids
	D. 	IV fluid bolus
	E. 	Phenylephrine

Answer 33

B. Blood transfusion

The answer is B. Treatment of a spinal cord injury with neurogenic shock includes high dose steroids, IV fluids, immobilization, and potentially pressors. Blood transfusions are generally not indicated, and care must be taken to avoid fluid overload. – For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 247-248.

Question 34

A 19 year old man is stabbed in the left chest in the 3rd intercostals space just to the left of the sternum. His vital signs are: T 97.9, HR 130, BP 60/48, RR 18, SPO2 84%. He has significant JVD and his lungs are clear. The patient’s diagnosis is:
	A. 	Tension pneumothorax
	B. 	Lung laceration
	C. 	Spinal cord injury
	D. 	Hypovolemic shock
	E. 	Cardiac tamponade

Answer 34

E. Cardiac tamponade

The answer is E. The patient has a stab wound to the left chest near the sternum. His hypotension, clear lungs, and JVD suggest an obstructive shock. He likely has cardiac tamponade and needs emergent decompression either with pericardiocentesis or pericardial window.

Question 35

A 24 year old woman, brought by her sister, enters the emergency department. The 24 year old is writhing in pain, clutching her abdomen and shivering. Her sister states that the patient had a therapeutic abortion performed 3 days ago and has been having worsening abdominal pain ever since. The patient’s vital signs are: T 103.4 F, HR 128, BP 104/72, RR 28, O2 saturation 100% in room air and she has marked lower abdominal pain and voluntary guarding. The most appropriate steps in treatment for this woman’s condition include all of the following EXCEPT:
A. broad-spectrum antibiotics
B. laboratory studies including basic chemistry, complete blood count with differential, coagulations studies, DIC panel, serum pregnancy test, and blood cultures
C. urgent ob/gyn consult to facilitate rapid transport of patient to the operating room
D. intravenous fluids
E. high-dose steroids

Answer 35

E. high-dose steroids

The answer is E. This patient is most likely suffering from a septic abortion in which retained products of conception developed a local infection. This infection has now spread systemically causing the systemic inflammatory response and potentially causing sepsis. Immediate intravenous fluids and broad-spectrum antibiotics are necessary; however, steroids are contraindicated in such a situation and could worsen the infection. The patient needs to be taken to the OR urgently to remove the retained products of conception.

Question 36

A college student who had a mild upper respiratory tract infection last week, presents during the spring. He appears toxic, with fever, headache, and a rash (see figure) which was also noted on the wrists, ankles, flanks, and axilla. Of those listed below, which is the most likely diagnosis?
[image shows purple spotted rash on extremity]
A. angioedema
B. herpes zoster
C. Lyme disease
D. pemphigus vulgaris
E. meningococcemia

Answer 36

E. meningococcemia

The answer is E. This patient’s presentation is consistent with meningococcemia. Lyme disease often presents with a rash (erythema chronicum migrans), but that rash has a different appearance (erythema with central clearing). Pemphgus vulgaris is characterized by intraepidermal blistering, and angioedema is seen more in the mucous membranes. Herpes zoster has an appearance of grouped (painful) vesicles on an erythematous base.

Question 37

Which of the following is a common physiologic finding in septic shock?
A. Decreased urine output
B. Increased pulmonary wedge pressure
C. Increased cardiac index
D. Increased systemic vascular resistance (SVR)
E. Normothermia

Answer 37

A. Decreased urine output

The answer is A. Patients in septic shock have decreased systemic vascular resistance and cardiac index, secondary to endotoxins. They can be hyper- or hypothermic but usually are not normothermic. The pulmonary wedge pressure is often normal or low. Like all shock states, septic shock is generally associated with decreased urine output.

Question 38

All of the following are common causes of septic shock EXCEPT:
A. Pseudomonas aeruginosa
B. Streptococcus pneumoniae
C. Escherichia coli
D. Staphylococcus aureus
E. Group A beta-hemolytic Streptococcus

Answer 38

E. Group A beta-hemolytic Streptococcus

The answer is E. Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pneumoniae are common causes of sepsis. Group A beta-hemolytic Streptococcus is a common agent in pharyngitis but rarely causes sepsis.

Question 39

All of the following are common complications of septic shock EXCEPT:
A. Pulmonary embolus (PE)
B. Acute tubular necrosis (ATN)
C. High-output congestive heart failure (CHF)
D. Disseminated intravascular coagulation (DIC)
E. Adult respiratory distress syndrome (ARDS)

Answer 39

A. Pulmonary embolus (PE)

The answer is A. DIC, ARDS, ATN, and high-output CHF are all complications of shock. While PE is always a concern in critically ill patients, it is not particularly associated with sepsis.

Question 40

While temperatures vary with time of day and method assessed, the generally accepted upper limit of normal temperature is:
	A. 	98.6 F (37 C)
	B. 	99.5 F (37.5 C)
	C. 	100.4 F (38 C)
	D. 	101.3 F (38.5 C)
	E. 	102.2 F (39 C)

Answer 40

C. 100.4 F (38 C)

The answer is C. The hypothalamus regulates body temperature. Fever occurs when the body temperature is raised beyond its normal set point. The upper limit of normal is considered to be 100.4 F or 38 C.

Question 41

A 3-week old presents to the emergency department with a fever of 100.8. The child is otherwise well appearing. After blood culture, the best management of the options below is:
A. Check WBC before further management.
B. UA plus urine culture, LP, antibiotics, and admit
C. Discharge home
D. ampicillin and discharge
E. Admit for observation.

Answer 41

B. UA plus urine culture, LP, antibiotics, and admit

The answer is B. Fever in a child less than 30 days can be a marker for bacteremia, sepsis, and meningitis. Clinical findings are notoriously unreliable in this age group. The work up is fairly straightforward. Blood culture, urine culture and LP are required. After the work up, the child should be started on antibiotics. Ampicillin and gentamycin is the preferred regimen in this age group. In a child 30-90 days old, there is controversy regarding the management algorithm. Some authorities treat all children under 90 days of age the same; others risk-stratify and perform selective work ups.

Question 42

A 23-year-old male presents after a syncopal episode. EKG findings include normal sinus rhythm, a short PR interval (less than 0.12 seconds), QRS duration of 0.11 seconds, and the presence of a “delta wave” (a slurred upstroke to the QRS complex). What condition most likely caused the syncopal episode?
	A. 	Wolff-Parkinson-White syndrome
	B. 	Dextrocardia
	C. 	Vasovagal reaction
	D. 	Brugada syndrome

Answer 42

A. Wolff-Parkinson-White syndrome

The answer is A. T“The classic WPW syndrome consists of tachycardia with the following three features: a short P-R interval (

Question 43

Of the options below, the therapy best for symptomatic 3rd degree heart block is:
	A. 	lidocaine
	B. 	atropine
	C. 	oxygen
	D. 	cardioversion
	E. 	transcutaneous pacer

Answer 43

E. transcutaneous pacer

The answer is E. Complete AV dissociation requires pacing fast enough for adequate perfusion.

Question 44

A 54 year old female presents with palpitations. She is otherwise asymptomatic. EKG shows atrial fibrillation. Vital signs are HR 130-150, BP 148/78, RR 16, T 36.7. What management intervention is most important to accomplish next?
A. Anticoagulation
B. Cardioversion
C. Pharmacologic ventricular rate control
D. Radiofrequency ablation

Answer 44

C. Pharmacologic ventricular rate control

The answer is C. “If the patient is stable, the first priority is to achieve ventricular rate control.”

Question 45

An 8 year old female presents with a regular, narrow-complex SVT. You diagnose AV nodal reentrant tachycardia. Which pharmacologic agent would be most appropriate for initial management?
	A. 	Diltiazem
	B. 	Digoxin
	C. 	Adenosine
	D. 	Lidocaine

Answer 45

C. Adenosine

The answer is C. “Adenosine, a purinergic blocking agent that causes acute and transient AV nodal blockade, is the drug of choice for acute termination of AVNRT. Multiple studies have shown that adenosine is nearly 100 percent effective in terminating AVNRT.”

Question 46

A 65 year old male presents to the emergency department with chest pain. Cardiac monitoring shows a wide complex tachycardia. Past medical history is significant only for hypertension. His BP is 100/66, HR 144, RR 24, and T. 37.5. In addition to ongoing chest pain, he reports dyspnea. His level of consciousness is mildly decreased. Management should proceed on the assumption that he has what abnormal rhythm?
A. Sinus tachycardia with LVH
B. Ventricular tachycardia
C. Supraventricular tachycardia with aberrancy
D. Wolff-Parkinson-White syndrome with retrograde conduction

Answer 46

B. Ventricular tachycardia

The answer is B. “Unstable patients with a wide-complex tachycardia should be treated as if ventricular tachycardia is present. “

Question 47

The best treatment, of the options below, for a patient with second degree AV block Mobitz Type II is:
	A. 	epinephrine
	B. 	aspirin
	C. 	transvenous pacing
	D. 	lidocaine
	E. 	amiodarone

Answer 47

C. transvenous pacingT

he answer is C. Second degree Mobitz Type II heart block easily degrades to complete heart block. Second degree Mobitz Type II is an atrioventricular-block rhythm in which there are intermittently non-conducted atrial beats not preceded by lengthening AV conduction. It is usually due to a block within the His bundle system. The bradycardia often is unresponsive to atropine and patients tend to require pacing.

Question 48

Where are the normally dominant pacemaker cells of the heart found?
	A. 	bundle of His
	B. 	atrioventricular node
	C. 	sinoatrial node
	D. 	accessory pathway of Kent

Answer 48

C. sinoatrial node

Question 49

A 65 year old male presents to the emergency department with palpitations. His heart rate is 250, blood pressure is 140/88, respiratory rate is 24 and oxygen saturation is 95%. The EKG shown in the Figure demonstrates:
[image looks like v tach]
A. a rhythm which requires immediate defibrillation
B. a rhythm requiring verapamil as first line therapy
C. a rhythm that is difficult to identify with certainty
D. ventricular tachycardia

Answer 49

A. a rhythm which requires immediate defibrillation

Question 50

A 22 year old female presents to the emergency department with a “funny feeling” in
her chest. She has had similar episodes but never lasting as long as the current
episode (3-hour duration). Her heart rate is 200, blood pressure is 128/68, respiratory rate is 20 and her pulse oximetry is 96%. Her EKG is shown in the Figure. The best treatment option for this patient is:
[image shows narrow complex tachy]
A. cardioversion
B. lidocaine
C. adenosine
D. verpamil

Answer 50

C. adenosine

The answer is C. The rhythm shown in the EKG is a narrow complex regular
tachycardia. It could also be described as a supraventricular tachycardia (SVT). The
first-line treatments of stable SVT are vagal maneuvers or adenosine. Unstable SVT
(such as that causing hypotension, heart failure, or myocardial ischemia) should be
cardioverted.

Question 51

A 60 year old woman presents to the emergency department with palpitations. Her EKG, shown in the Figure, reveals:
[image]
	A. 	normal sinus rhythm
	B. 	atrial flutter
	C. 	atrial fibrillation
	D. 	ventricular tachycardia

Answer 51

C. atrial fibrillation

Question 52

A 70 year old male presents with lightheadedness. He is noted to be bradycardic. His EKG below reveals:
[image shows progressive PR lengthening then drop]
A. first degree AV block
B. second degree AV block Mobitz Type I
C. second degree AV block Mobitz TypeII
D. complete heart block

Answer 52

B. second degree AV block Mobitz Type I

The answer is B. This is second degree AV block (Mobitz I). Note progressive increase in the PR interval until a blocked P wave occurs. Also note the progressive shortening of the R-R interval before the nonconducted beat. This type rhythm is usually due to abnormal conduction within the AV node. Mobitz I block may occur in normal individuals with heightened vagal tone. It may also occur as a drug effect, especially from digoxin, calcium channel blockers, beta-blockers, or other sympatholytics.

Question 53

A 60 year old female presents with palpitations. Her EKG, shown below, reveals:
[image shows sawtooth p waves]
	A. 	ventricular tachycardia
	B. 	atrial flutter
	C. 	sinus arrhythmia
	D. 	atrial fibrillation

Answer 53

B. Atrial flutter

The answer is B. Atrial flutter has a characteristic saw-tooth pattern. It is generally a regular, narrow complex rhythm. The atrial rate is approximately 300. The rate of conduction can be in a fixed or variable ratio, but 2:1 (atrial:ventricular) is common, resulting in a frequently encountered ventricular rate of about 150. This example has a variable block (2:1 to 4:1).
– For further reading, see Tintinalli, et al., Emergency Medicine: A Comprehensive Study Guide, 5th edition, pages 174-175.

Question 54

What type of rhythm disturbance is seen in the EKG below?
[image: long PR no dropped beats]
A. second degree AV block type I
B. first degree atrioventricular (AV) block
C. second degree AV block type II
D. third degree heart block

Answer 54

B. first degree atrioventricular (AV) block

Question 55

Of the following choices, which diagnosis is most likely in a 35-year old female with intermittent palpitations and the EKG shown in the Figure?
[image shows delta waves]
	A. 	digoxin overdose
	B. 	asthma
	C. 	pericarditis
	D. 	Wolff-Parkinson-White syndrome

Answer 55

D. Wolff-Parkinson-White syndrome

Question 56

Which diagnosis is suggested by the EKG shown in the Figure?
[image shows right sided leads with V1 elevation]
A. right-ventricular ischemia
B. digoxin overdose
C. pericarditis
D. dextrocardia

Answer 56

A. right-ventricular ischemia

Question 57

Of the following choices, which is the most likely diagnosis based on the EKG in the Figure?
[image: prolonged QRS duration, a terminal R wave in V1 and a slurred S wave in leads I and V6]
A. right bundle-branch block
B. left bundle-branch block
C. anteroseptal myocardial infarction
D. Wolff-Parkinson-White syndrome

Answer 57

A. right bundle-branch block

The answer is A. The EKG reveals right bundle-branch block. RBBB are characterized by a prolonged QRS duration, a terminal R wave in V1 and a slurred S wave in leads I and V6. Frequently, an RSR’, or “rabbit ears” pattern can also be seen in the precordial leads.

Question 58

A 40 year old male presents to the emergency department complaining of severe ankle pain after inverting the foot during a soccer game. The triage nurse records the following vital signs: temperature 98.8, pulse 94, respiratory rate 18, BP 188/118. Which of the interventions below is the most appropriate step to take in response to the blood pressure assessment?
A. Administer a sublingual antihypertensive agent since the patient probably only has an ankle sprain and will not need an intravenous line
B. Establish intravenous access in order to optimize the onset of action of parenteral antihypertensive medications
C. Ignore the blood pressure since the patient is asymptomatic other than having ankle pain
D. Order an antihypertensive agent to be given in the emergency department because the patient will be discharged with a prescription for one
E. Take measures to relieve pain and recheck the blood pressure

Answer 58

E. Take measures to relieve pain and recheck the blood pressure

The answer is E. Emergency department therapy should not be instituted based upon a single blood pressure measurement. This is especially true in cases where a patient has a reasonable physiologic explanation (i.e. pain) for elevated blood pressure and other vital signs consistent with pain-mediated sympathetic stimulation. Due to the risk of over-reduction in blood pressure, sublingual agents are rarely appropriate for emergency therapy of hypertension; however, it would be premature to treat the patient with any medication. Asymptomatic patients with elevated blood pressure usually require no cerebral imaging. Additionally, asymptomatic patients usually do not require emergency pharmacologic therapy; even if such therapy is considered the initial abnormal blood pressure should first be rechecked.

Question 59

The blood pressure at which malignant hypertension is defined as present is:
A. an elevated arterial pressure associated with end organ damage
B. an elevated arterial pressure that exceeds the patient’s baseline by 33%
C. diastolic blood pressure of 110 or greater
D. systolic blood pressure of 170 or greater
E. systolic blood pressure of 180 or greater

Answer 59

A. an elevated arterial pressure associated with end organ damage

The answer is A. A hypertensive emergency is defined by the association of elevated blood pressure with end-organ damage, rather than a specific blood pressure reading. Acute end-organ damage associated with a hypertensive emergency (also known as malignant hypertension or hypertensive crisis) can include: hypertensive encephalopathy, intracerebral hemorrhage, hypertensive retinopathy, heart failure and associated pulmonary edema, acute coronary syndrome, acute renal failure, aortic dissection, and eclampsia.

Question 60

Which of the ocular findings below is associated with hypertension?
	A. 	arterio-venous nicking
	B. 	increased cup-to-disk ratio
	C. 	retinal nevus
	D. 	Roth spots
	E. 	cherry red spot

Answer 60

A. arterio-venous nicking

The answer is A. Increased cup-to-disk ratio is seen commonly in patients with glaucoma, but this finding is not associated with acute or chronic hypertension. Systemic hypertension can affect the retinal, choroidal, and optic nerve circulations, with the degree of vascular change depending on the severity and duration of the hypertension. Linear or flame-shaped hemorrhages and cotton-wool patches (caused by infarction of the nerve fiber layer resulting from arteriolar occlusion) are relatively common. Long-standing hypertension can produce sclerotic changes in the vessel walls; this is manifest as a copper or silver discoloration of the arterioles. Lipid (hard) exudates result from abnormal vascular permeability associated with hypertension. Optic disk edema, indicating infarction and hypoxia of the optic disk, is a hallmark of malignant hypertension.

Question 61

With regard to targets for therapy of elevated blood pressure identified during an emergency department visit, which of the following is generally true?
A. Patients with hypertensive emergencies should have blood pressure normalized (for age) within an hour or less
B. The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction
C. Patients with hypertensive emergencies should have mean arterial blood pressure lowered by 50% within 50 minutes
D. Patients with hypertensive urgencies are preferably treated with sublingual
nifedipine, as compared with intravenous agents
E. Patients with hypertensive urgencies should have blood pressure normalized (for age) within an hour

Answer 61

B. The target systolic pressure for patients with acute aortic dissection is an absolute number rather than a percent pressure reduction

The answer is B. Patients with acute aortic dissection who require antihypertensive therapy are usually treated with a combination of a beta-blocker (e.g. propanolol) and a vasodilator (e.g. nitroprusside). Though the specific blood pressure goal varies, most patients should have systolic pressure lowered to at least 120 (some prefer even more dramatic absolute systolic blood pressure goals, as low as 100 or less). Patients with hypertensive emergencies are usually treated with a goal of 20-25% reduction in blood pressure over 30-60 minutes, and patients with hypertensive urgencies should have blood pressure lowered over a longer period (hours to days). Sublingual nifedipine, formerly frequently utilized for mild hypertension, has been more recently identified with potentially dangerous blood pressure reduction “overshoot” (and resultant cerebral hypoperfusion), thus this agent is falling out of favor.

Question 62

A 40 year old female presents to the emergency department complaining of a few days of headaches, excessive sweating, anorexia, heat intolerance and palpitations. She has also been having upper respiratory symptoms over the past week. She is found to have a blood pressure of 170/106 and an EKG, urinalysis, fundoscopic examination, serum creatinine, and neurological evaluation are negative. What is the next step in the evaluation/management?
A. Perform CT scan of the abdomen
B. Avoid sublingual or intravenous therapy in the ED and prescribe an oral beta-blocker
C. Obtain a medication history
D. Schedule a clonidine suppression test to evaluate for pheochromocytoma
E. Administer sublingual nifedipine while the work-up continues

Answer 62

C. Obtain a medication history

The answer is C. Sublingual nifedipine risks overzealous blood pressure reduction, and this patient does not have indication for emergent therapy. Similarly, it would be premature to institute therapy with an oral beta-blocker agent based on a single presentation. Elevated plasma levels of free metanephrine and catecholamines, along with the clinical presentation, could point to pheochromocytoma as a possible etiology. The pheochromocytoma workup may include abdominal CT and/or clonidine suppression testing. However, certain medications (such as viral upper respiratory “cold” medications which this patient may have taken, given her symptoms) can also cause the symptoms of this patient. Therefore, further workup or treatment should occur only after a thorough medication history.

Question 63

Labetalol differs from propanolol in that labetalol is:
A. a mixed alpha-antagonist and beta-agonist
B. selective for the alpha2-adrenergic receptor
C. characterized by an elimination half-life of minutes rather than hours
D. an alpha-and beta antagonist
E. a mixed alpha1-agonist and beta-antagonist

Answer 63

D. an alpha-and beta antagonist

D. Labetalol is a non-selective beta-blocker that also possesses alpha-blocking effects. Metoprolol, atenolol, and esmolol are examples of beta1-selective beta-blockers. Esmolol has an elimination half-life of minutes.

Question 64

A previously healthy 25 year old female arrives at the emergency department with 3 days of headache, nausea, palpitations, and diaphoresis. She initially presented 2 days ago to the hospital's walk-in clinic, where her blood pressure was found to be moderately elevated. At her clinic visit, the initial evaluation for end-organ damage was negative. In the emergency department, assessment of tests sent from the clinic visit is noteworthy for a normal TSH, normal head CT scan, and markedly elevated urine metanephrine levels. If this woman were to require emergency department therapy for hypertension, which of the following agents should be AVOIDED:
	A. 	beta-adrenergic receptor blocker
	B. 	alpha-adrenergic receptor blocker
	C. 	nitroprusside
	D. 	calcium channel blocker
	E. 	ACE-inhibitor

Answer 64

A. beta-adrenergic receptor blocker

The answer is A. Elevated urinary metanephrines in this patient strongly suggest the diagnosis of pheochromocytoma. Initial control of her hypertension should be undertaken with an alpha-adrenergic receptor blockade, or alternatively nitroprusside, calcium channel blocking agents or ACE-inhibitors. Beta-adrenergic blockage should only be given AFTER alpha blockade, to avoid paradoxical increases in blood pressure due to antagonism of skeletal muscle vasodilation. While other agents listed may or may not be optimal for initial blood pressure control, the drug type with the strongest contraindication is the beta-blocker.

Question 65

In a patient with malignant hypertension, the patient’s blood pressure should be reduced to what value in the initial 2 hours of treatment?
A. 120/80 mm Hg
B. 100/70 mm Hg
C. 90/60 mm Hg
D. 75% of the pretreatment mean arterial pressure (MAP)
E. 50% of the pretreatment MAP

Answer 65

D. 75% of the pretreatment mean arterial pressure (MAP)

The answer is D. Malignant hypertension, being defined as hypertension with progressive or severe end-organ damage, usually occurs with a diastolic pressure greater than 130 mmHg. The patient’s MAP should be reduced by approximately 25% in the initial treatment phase, avoiding an excessive drop in pressure which could cause renal or cerebral hypoperfusion. Subsequently, the patient’s blood pressure should be dropped to approximately 160/100 in the first 2 to 6 hours of treatment.

Question 66

You need to treat an adult with no past medical history, who presents with a hypertensive emergency. You have access to all of the following agents. Which of the following is the preferred agent and initial dose?
	A. 	esmolol IV 100-500 mic/kg load
	B. 	hydralazine IM 0.1-0.2 mg/kg
	C. 	labetolol IV 0.2–1.0 mg/kg bolus
	D. 	metoprolol PO 10 mg
	E. 	clonidine PO 0.1 mg

Answer 66

A. esmolol IV 100-500 mic/kg load

The answer is A. Hyptertensive emergencies require treatment with IV agents, primarily for their fast onset of action and ability to be titrated. One would generally not choose an oral agent, such as metoprolol or clonidine, if the other options were available.

Question 67

A 32 year old woman walks into the emergency department two weeks after a fall from a bus. She tripped stepping off the bus and landed with her right hip on the last stair. The fall was only a few feet in distance. She noted very little immediate pain, and there was no pain at all by the next day. However, the next week her right hip began to “burn.” After a day’s burning sensation she developed a rash involving the hip region (see Figure). She denies any chest pain, shortness of breath, nausea or vomiting. Physical examination shows a unilateral, erythematous, maculopapular rash extending from below her umbilicus to her back in a band-like pattern. There are no open lesions or cuts. What is the appropriate management of this patient?
[image]
Figure courtesy of eMedicine.com
A. Discharge home for rest and ice for the next few days for a late-appearing post-traumatic process.
B. Discharge home with analgesics and an antiviral.
C. Obtain an X-ray for fat emboli.
D. Discharge home with a first-generation cephalosporin for a bacterial process.
E. Refer to orthopedics for evaluation of possible right hip fracture.

Answer 67

B. Discharge home with analgesics and an antiviral.

The answer is B. This patient has herpes zoster, commonly known as shingles, which begins as an erythematous rash and after as many as several days becomes vesicular. Shingles can often present after minor trauma, which is thought to reactivate latent varicella-zoster virus. While this patient may relate pain and symptoms to the fall, her ability to ambulate without problems and lack of pain directly after the fall make obtaining an X-ray and referral to orthopedics unnecessary. (Although it may be possible for a patient to ambulate on an impacted hip fracture, the clinical picture points away from orthopedic trauma.) The rash appearance renders a simple ecchymosis or contusion (choice A) unlikely. The characteristic dermatomal distribution of this rash makes a bacterial infection (choice D) much less likely than herpes zoster. Shingles was classically treated with analgesics only, but addition of acyclovir (choice B), if begun within the first several days of the rash, can reduce the incidence of post-herpetic neuralgia.

Question 68

A 58 year old construction worker who has no primary care doctor comes to the emergency department because of a non-pruritic rash above his ankles (see Figure). Physical examination reveals bilateral erythematous and swollen ankles that are mildly warm but non-tender to touch. His overlying skin of both legs show mild scaling and thickened skin. There is no puncture site or visible opening in the skin, although he has prominent varicose veins bilaterally (see Figure). His temperature is 37C (98.6F). He appears to be in no acute distress. What is the most likely diagnosis?
[image]
Figure courtesy of eMedicine.com
	A. 	necrotizing fasciitis
	B. 	stasis dermatitis
	C. 	eczema
	D. 	cellulitis
	E. 	psoriasis

Answer 68

B. stasis dermatitis

The answer is B. This patient’s presentation may be confused with cellulitis but is in fact stasis dermatitis. The facts that his rash is bilateral and associated with varicose veins and lack of fever increase the likelihood of a long-term process such as stasis dermatitis (chronic inflammation of the skin due to venous insufficiency). Microvascular changes hinder the delivery of oxygen to the skin and subcutaneous tissues. A secondary bacterial infection can be superimposed upon stasis dermatitis. Necrotizing fasciitis is more likely characterized by a rapid progression of extreme pain and blister/bullae formation that represents widespread tissue destruction; patients often are visibly toxic. The hallmark of eczema is pruritis, and psoriasis would appear as white or silvery, flaky patches, neither of which are present.

Question 69

A patient with no medical history presents to the emergency department for a second opinion. Nearly a week ago, there was a rapid onset of malaise, headache, backache, and fever. A rash began to appear on the leg a few days after the initial symptoms and the patient presented to a hospital-affiliated walk-in clinic for assessment. The patient had no respiratory symptoms but was noted to have some lesions on the tongue. At the time of his assessment at the walk-in clinic, the fever had resolved and the patient was diagnosed as having a viral syndrome. At the walk-in clinic, a digital photograph of the rash was taken and inserted into his computer records (see top of Figure). It is now 3 days after the initial walk-in clinic visit. You are working in the emergency department where the patient presents complaining of a recurrence of high fevers and a spread of the rash which now involves the face, extremities, and torso (see bottom of Figure). What diagnosis is most consistent with the history and accompanying images?
[image: spots ALL OVER]
Image courtesy of eMedicine.com
	A. 	insect bites with secondary infection
	B. 	erythema multiforme
	C. 	varicella-zoster virus
	D. 	smallpox
	E. 	measles

Answer 69

D. smallpox

The answer is D. The clinical presentation is more consistent with smallpox than any of the other etiologies. Insect bites may have been possible with the initial skin presentation but are much less likely given the spread of the process and the other symptoms. Erythema multiforme is rendered unlikely by the absence of drug ingestion. With chickenpox, fever occurs with the onset of the rash, which is characterized by simultaneous existence of individual lesions at differing stages. Also with chickenpox, the eruption is concentrated over the torso, and given the time course of this example, crusting should have been present if the patient had chickenpox.

Since smallpox has been eradicated worldwide, any cases that do occur (e.g. secondary to terrorist activity) are likely to be misdiagnosed as clinicians are unfamiliar with the disease. After a mean incubation period of 1.5-2 weeks, there is a 2-3 day prodromal phase characterized by abrupt onset of severe headache, backache, and fever. The temperature subsides over 2-3 days. An enanthema over the tongue, mouth, and oropharynx precedes the skin rash by a day. The skin rash begins as small, reddish macules, which become papules with a diameter of 2 to 3 mm over a period of one or two days; after an additional 1-2 days, the papules become vesicles with a diameter of 2 to 5 mm. The lesions occur first on the face and extremities but gradually spread to cover the body. Pustules that are 4 to 6 mm in diameter develop about four to seven days after the onset of the rash and remain for five to eight days, followed by umbilication and crusting. As occurred in this example case, there may be a second, less pronounced temperature spike five to eight days after the onset of the rash, especially if the patient has a secondary bacterial infection. Smallpox lesions have a peripheral or centrifugal distribution and are generally all at the same stage of development. Death from smallpox is ascribed to toxemia, associated with immune complexes, and to hypotension.

Question 70

A patient develops a rash that starts as multiple bilateral target-like macules and papules on the palms and soles. It progresses to widespread sloughing of the skin requiring admission to the burn unit. Which of the following etiologic agents has NOT been implicated in this syndrome?
	A. 	recent immunization
	B. 	barbiturates
	C. 	penicillins
	D. 	sulfa antibiotics
	E. 	corticosteroids

Answer 70

E. corticosteroids

The answer is E. The syndrome described is the spectrum of erythema multiforme/Stevens-Johnson syndrome/toxic epidermal necrolysis. Although the etiology is not always clear, many drugs (including sulfa antibiotics, penicillins, and barbiturates), viral or Mycoplasma infections, and recent immunization have been implicated. Corticosteroids are a controversial adjunct in treatment, but have not been implicated as a cause of the disease.