Quiz&short review for Emergency medicine residents
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Transcript of Quiz&short review for Emergency medicine residents
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7/29/2019 Quiz&short review for Emergency medicine residents
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QuizMarch 2013
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7/29/2019 Quiz&short review for Emergency medicine residents
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29 yo male
Fever
Dyspnea
1. positivefinding
2.Proper
management
A
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KEYTEACHING POINTS
1. Acute epiglottitis is a potentially life-threatening condition
resulting from inflammation of the supraglottic structures,
with a current incidence of 1 to 2 cases per 100,000 adults
in the United States.
2. Sore throat is the chief complaint in 7594% of cases ofadult epiglottitis, whereas odynophagia may be present in
as many as 94% of cases.
3. Soft-tissue lateral neck radiography, which may show an
enlarged, misshapen epiglottis (thumbprint sign), has a
sensitivity of 88% in establishing the diagnosis.
4. The definitive diagnosis is made through direct laryngo-
scopic visualization of an enlarged, inflamed epiglottis.
5. Treatment of epiglottitis includes intravenous antibiotics
and close airway monitoring in an ICU setting. Most clini-
cians treat acute cases with intravenous steroids.
Cefotaxime , Ceftriaxone , Ampi-Sulbactam
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7/29/2019 Quiz&short review for Emergency medicine residents
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89 yo femaleGlaucoma
S/p trabeculectomy
progressive worsenVA drop , eye
pain , photophobia
No contact lens ,denied trauma
VA fingercount
1. positive
finding
2.Proper
management
B
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Findings : Endophthalmitis- red eye with cicumlimbal flush-hypopyonpurulent discharge from lid margin and lashes
Mx : gatifloxacin 0.3% eye dropconsult ophthalmologist for vitrectomy / intravitreal injection of ATB
KEY TEACHING POINTS
1.Endophthalmitis is an ophthalmologic emergency requir-ing a high index of suspicion and prompt consultation with
an ophthalmologist.
2. Initial symptoms of endophthalmitis include pain, redness,
ocular discharge and blurring of vision.
3. Common signs include decreased visual acuity, lid swelling,
conjunctival and corneal edema, anterior chamber cells
and fibrin, hypopyon, vitreous inflammation, retinitis, and
blunting of the red reflex.4. Intravitreal antimicrobial therapy remains the mainstay of
treatment for infectious endophthalmitis; the majority of
patients require intravitreal injections, vitreous tap, sub-
conjunctival steroids or vitrectomy to prevent loss of the
eye.
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13 yo malebicycle collisiontender at Lt side
abdomen
1. positive
finding 2.Grade/Classification by CT?
C
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7/29/2019 Quiz&short review for Emergency medicine residents
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The American Association for the Surgery of Trauma (AAST)
splenic injury grading system is as follows
grade I
subcapsular haematoma < 10% of surface area
capsular laceration < 1 cm depth
grade II
subcapsular haematoma 10 - 50% of surface area intraparenchymal haematoma < 5 cm in diameter
laceration 1 - 3 cm depth not involving trabecular vessels
grade III
subcapsular haematoma > 50% of surface area or
expanding
intraparenchymal haematoma > 5 cm or expanding
laceration > 3 cm depth or involving trabecular vessels
ruptured subcapsular or parenchymal haematoma
grade IV laceration involving segmental or hilar vessels with major
devascularization (> 25% of spleen) grade V
shattered spleen
hilar vascular injury with devascularised spleen
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Findings : Grade IV splenic laceration.Extensive splenic laceration to hilum
Management : conservative / or Sx
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26 yo malefelt pop in lower neck
while practicing golf.
no weakness
1. positive
finding
2.Proper
management
D
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Findings : Clay-Shovelers Fx of C7spinous process (Oblique fx of base ofspinous process)
Management : conservative / or
KEYTEACHING POINTS
1. A clay-shovelers fracture refers to an oblique fracture of
the base of the spinous process, most commonly occurring
at one of the lower cervical segments.
2. The fracture is believed to occur as a result of forceful
flexion of the cervical spine, or forceful contraction of the
trapezius and rhomboid muscles.3. The injury is most commonly visualized on the lateral
cervical spine radiograph, which should include the entire
cervical spine and the C7-T1 junction.
4. Because the injury involves only the spinous process, this
fracture is considered stable and is not associated with
neurologic impairment.
5. Management involves neurosurgical or orthopedic consul-
tation, pain control and cervical immobilization.
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12 yo boy
1. positive
finding
2.Proper
management
B
E
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B
Findings :fx displace base 1st MTBfx MTB 2-4th
Management :- compartment syndrome
KEYTEACHING POINTS
1. Lisfranc fracture-dislocations of the foot generally result
from high-energy forces, such as crushing trauma to the
foot (often in flexion or rotation).
2. Patients with Lisfranc fracture-dislocations commonly
present with midfoot pain, swelling and decreased ability
to bear weight.
3. The most consistent radiographic finding in Lisfranc joint
dislocations is loss of the usual alignment between the me-
dial borders of the second metatarsal and second cunei-
form.
4. Patients with Lisfranc injuries require urgent consultation
with an orthopedic or podiatric specialist.5. In compartment syndrome of the foot, findings on exami-
nation include increased pain on passive dorsiflexion of the
metatarsophalangeal joints, poor capillary refill and absent
pulses (late findings).
6. Appropriate treatment for suspected compartment syn-
drome of the foot is urgent and complete fasciotomy.
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A B
22 yo m. foot pain during soccer
1. positive
finding
2.Propermanagement
please specify
F
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Findings :fx base of the 5th MTB =Jones fractrure
Management :- compartment syndrome
A B
KEYTEACHINGPOINTS
1. A Jones fracture is a transverse fracture of the proximal
fifth metatarsal at the junction of the diaphysis and meta-physis without extension distal to the intermetatarsal arti-
culation of the fourth and fifth metatarsals.
2. The mechanism of injury in a Jones fracture involves a
large adduction force applied to the forefoot with the ankle
plantar flexed, causing the fifth metatarsal to fracture.
3. Emergent treatment of Jones fractures involves ice, eleva-
tion, splinting of the injured foot and pain control.
4. The definitive treatment of Jones fractures may be non-
operative (bracing or casting and non-weight-bearing forsix weeks) or operative (intramedullary screw fixation or
bone grafting).
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21 yomale. headache / facial flushing / palpitationnot itching
just got back from dinner party at restaurant.T 36.1 P121 BP112/66
1. positive
finding2.Proper
management
3. cause by?
G
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Findings : Scombroid fish poisoningErythematous macular rash on the extremities andtrunk/ Warm.
Management : Anti histamine
KEY TEACHING POINTS
1. Symptoms of scombroid fish poisoning are related to the
ingestion of biogenic amines, especially histamine. The
onset of symptoms of scombroid fish poisoning usually oc-
curs 1030 minutes after ingestion of the implicated fish,
which sometimes has a characteristic peppery and bitter
taste.2. The symptoms of scombroid fish poisoning are nonspe-
cific, and may include flushing, palpitations, headache, nau-
sea, diarrhea, sense of anxiety, prostration or loss of vision
(rare).
3. Findings on physical examination can include a diffuse, mac-
ular, blanching erythematous rash (most common), tachy-
cardia, wheezing (generally only in histamine-sensitive
asthmatics), hypotension or hypertension, and conjuncti-
vitis.4. Treat acute illness with antihistamines as needed; H1-
blockers (e.g., diphenhydramine 2550 mg PO/IV/IM q4
6h) and H2-blockers (e.g., ranitidine 150 mg PO q12h or
50 mg IV q812h, or cimetidine 300 mg PO/IV q68h).
5. Scombroid fish poisoning must be immediately reported to
the local public health department.
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7/29/2019 Quiz&short review for Emergency medicine residents
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mahimahiamberjack
mackerel-tuna
ScombrotoxismScombroid ichthyotoxicosis
Heat tolerance
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22 yo m. HIVmalaise,fever, dysphagia, generalized mouth pain
cervical lymphadenopathy
1. positive
finding
2.Propermanagement
H
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Acute Necrotizing Ulcerative Gingivostomatitis- HIV-LN positive with generalized mouth pain- hyperemic painful gingiva with erosion of interdental papilla and have light greypseudomembrane over gingival ulceration.
Table 3.5 Clinical Features: Acute Necrotizing Ulcerative Gingivostomatitis
Organisms G Streptococcus mutansG ActinomycesspeciesG Bacteroides fragilisG FusobacteriumG Spirochetes (Treponema vincentiand
Borreliaspecies)
Signs and Symptoms G Fever and cervical lymphadenopathyG Fetid breathG Diffusely erythematous and
edematous gingivaG Necrosis and ulceration of the
interdental gingival papillaG Gray pseudomembrane may overlie
the interdental papilla
Laboratory andRadiographic Tests
G May have an elevated WBC and ESRG Bite-wing radiographs or facial CT
may help delineate the degree ofalveolar bone destruction
CT, computed tomography; ESR, erythrocyte sedimentation rate; WBC, whiteblood (cell) count.
Treatment- Penicillin VK or Erythromycin-mouthwash
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name it .
A
CB
I
li . i li i i lli.
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l i i . l l l li .
A
Blebphitis
Organisms Blepharitis:G Staphylococcus epidermidisG PropionibacteriumacnesG CorynebacteriumspeciesHordeolum:G Most often Staphylococcus aureus, but can be
infected with organisms similar to thosecausing blepharitis
Incubation Period 17 days (up to 12 days)
Signs andSymptoms
Blepharitis:G Usually bilateral and intermittent symptomsG Inflamed eyelid marginsG Eyelid itching, burning, or sorenessG Mild foreign-body sensationG Crusting and debris of eyelid margins,
especially on awakeningG With or without misdirection or loss of
eyelashesG With or without conjunctival injectionG With or without swollen eyelidsG With or without light sensitivityHordeolum:G Usually unilateralG Pointing eruption or pimple-like lesion on
either internal or external side of eyelidG Inflamed eyelid marginG Eyelid itching, burning, or sorenessG Crusting and debris of eyelid margins,
especially on awakeningG With or without conjunctival injection
Laboratory andRadiographicFindings
There are no specific laboratory tests orradiographic findings for these diagnoses. It ispossible to do a microbial culture of the eyelid byswabbing the eyelashes but usually notnecessary in these diagnoses.
Hordeolum
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DacryocystitisTable 29.2 Treatment of Blepharitis and Hordeolum
Patient Category Therapy Recommendations
Adults:PreferredChoices
G Eyelid hygieneG Cleanse eyelids bid with cloth soaked in warm
water for 510 minutesG Wash eyelid margins with diluted baby shampoo,
eyelid cleanser, or a teaspoon of sodiumbicarbonate in cup of boiled water
G Artificial tears (e.g., Hypromellose 0.3%) for thosewith dry eyes
G Topical antibiotics for mild cases of blepharitis andhordeola (e.g., erythromycin ointment1.25 cm to lid margin qid or eye drops such aschloramphenicol (AK-Clor, Chloroptic, 5 mg/mL)q4h)
G Systemic antibiotics (e.g., erythromycin 250 mgPO qid 7 days, azithromycin 500 mg PO day 1,then 250 mg PO daily on days 25) for hordeolum,recurrent staphylococcal blepharitis, severesecondary infection of the meibomian glands, orlocal cellulitis
G External hordeola are often self-limited but can bedrained by lancing the lesion if necessary
Table 29.4 Treatment of Dacryocystitis
Patient Category Therapy Recommendations
Adults:Preferred Choices
Irrigation of the lacrimal sacWarm compressesTopical antibiotics:G Erythromycin ointment 1.25 cm to lid margin qidG Eye drops such as trimethoprim sulfate and
Polymyxin B sulfate ophthalmic solution 1 drop
q3hOral antibiotics:G Pediatric: oral antibiotics: amoxicillin-clavulanate
2040 mg/kg/day divided tid; cefaclor 2040mg/kg/day divided tid
G Adult: cephalexin 500 mg qid or amoxicillin/clavulanate 500 mg bid
G Surgical treatment for dacryoliths, obstruction,or congenital causes