08/07

A 33-year-old man presents to the emergency department with difficulty swallowing, which is preventing him from eating. He states that he has had progressive pain with swallowing for the past week. The patient has a medical history of human immunodeficiency virus, and his most recent CD4 count was 90 cells/mm³. Physical exam reveals a normal oropharynx with no signs of trauma. Which of the following is the most likely diagnosis?

• Candida esophagitis

• Cytomegalovirus esophagitis

• Eosinophilic esophagitis

• Herpes esophagitis

Answer explanation

This patient is presenting with dysphagia and odynophagia in the setting of human immunodeficiency virus, suggesting a diagnosis of Candida esophagitis. Esophageal candidiasis typically presents in patients with human immunodeficiency virus with or without concomitant oropharyngeal candidiasis. The most common presenting symptom is odynophagia with retrosternal pain, and the patient will commonly have a CD4 count < 100 cells/mm³. The diagnosis is typically suspected clinically. However, endoscopy can confirm the diagnosis and will demonstrate esophageal plaques with yeast and pseudohyphae on biopsy. In a patient with human immunodeficiency virus and odynophagia, it is appropriate to empirically treat with oral fluconazole without performing an endoscopy, given the high frequency of this diagnosis. If the patient’s symptoms are refractory to this treatment, endoscopy can be performed to confirm the diagnosis, and the appropriate treatment can be started.

A 14-year-old boy is brought to the ED with chest pain 10 hours after a motorcycle collision. He was wearing a helmet and sustained no head, face, or neck trauma. His oxygen saturation is 89% on a nonrebreather face mask. He has bilateral chest wall ecchymosis and tenderness to palpation. His chest X-ray is shown above. What is the most appropriate therapy at this time?

• Bilateral tube thoracostomies

• Extracorporeal oxygenation

• Intravenous furosemide

• Orotracheal intubation

Answer explanation

The patient’s X-ray illustrates pulmonary contusions as a result of blunt chest wall trauma. Pulmonary contusions represent edema and bleeding into the lung parenchyma as a result of direct chest trauma. It occurs in approximately 20% of patients admitted for trauma and is the most common chest injury seen in the pediatric population. Signs and symptoms may not be present initially, as they develop over a period of up to 24 hours. Patients experience chest pain, dyspnea, tachycardia, tachypnea, hypoxia, and potentially hypotension. Pulmonary contusions occur in the absence and presence of rib fractures. Chest X-rays can detect large contusions, but initial films may underestimate the severity of the tissue injury until later in the clinical course. Radiographic findings are typically absent for 12–24 hours after the initial injury. X-rays will demonstrate patchy areas of radiopacity with a blushed appearance in a segmental distribution that can mimic pneumonia. Sensitivity improves with computed tomography (CT), and even small, clinically insignificant contusions may be identified. Management of pulmonary contusions is mainly supportive with supplemental oxygen. This may require orotracheal intubation if hemorrhages are large or bilateral or if there are problems with oxygenation and ventilation. Patients with unilateral contusions should be positioned with the unaffected lung down to optimize oxygenation. This is in contrast to patients with pulmonary hemorrhage who are positioned with the bad lung down to prevent hemorrhage from affecting the good lung.

 

Which of the following conditions are Reed-Sternberg cells seen in?

• Acute promyelocytic leukemia

• Burkitt lymphoma

• Hodgkin lymphoma

• Non-Hodgkin lymphoma

Answer explanation

Reed-Sternberg cells are characteristic of Hodgkin lymphoma. These cells have a characteristic owl-eye appearance and lay within a mixture of inflammatory cells consisting of granulocytes, macrophages, plasma cells, and lymphocytes. Hodgkin lymphoma is the abnormal growth of lymphocytes and presents as a progressive enlargement of lymph nodes. It is the most common malignancy in ages 15–19 but has a bimodal distribution and presents in older age as well. Risk factors include HIV and Epstein-Barr virus (EBV). On exam, the enlarged lymph nodes are typically firm, rubbery, and painless. Superficial skin changes are usually absent. About 50% of patients experience B symptoms (fevers, night sweats, and weight loss). Complications include airway compromise and superior vena cava syndrome from progressive lymph node enlargement. Treatment is with chemotherapy and radiation, and the prognosis is good.

In patients with a presumed tripod fracture, which imaging study is the mainstay of emergent evaluation?

• CT Ankle

• CT Hip

• CT Face

• CT Mandible

Answer explanation

A tripod fracture is a triple fracture pattern made up of fractures of the three main processes of the zygoma: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital rim. This leads to free movement of the zygoma. All forms of zygomatic fractures are most commonly due to direct and forceful trauma. Diagnosis is confirmed with computed tomography of the face. Tripod fractures are associated with vision loss and poor cosmetic outcomes without timely operative repair. Patients commonly present with cheek swelling, ecchymosis, and severe tenderness to palpation. Crepitus and mobility of the cheek may be present. Epistaxis may indicate concomitant sinus fractures. Those with isolated zygomatic arch fractures can be discharged with pain control and close plastic surgery follow-up. Zygomatic fractures involving the sinuses should receive antibiotics. Tripod fractures with significant malar eminence flattening or vision changes should be given intravenous antibiotics (e.g., ampicillin-sulbactam) and admitted after emergent plastic or oral maxillofacial surgery consultation.

A 7-month-old boy presents to the emergency department because of nonbilious vomiting after meals for the past day. The baby draws his legs up every 10–20 minutes and is inconsolable. The patient has normal vital signs. On physical exam, there is some mucoid blood in the diaper. An ultrasound is performed and negative for any acute pathology. What is the best next step in the evaluation of this patient?

• Contrast enema

• Discharge with reassurance

• Single view abdominal X-ray

• Surgical consultation for operative treatment

Answer explanation

This patient has intussusception with the characteristic triad of colicky abdominal pain, red-currant jelly stools, and vomiting. It is a common cause of small bowel obstruction in children. There is telescoping or prolapse of one portion of the bowel into an immediately adjacent segment, most commonly due to hyperplastic tissue causing weakness in the intestinal wall. Ultrasound is a good screening tool to look for intussusception. If ultrasound is nondiagnostic in a high-risk patient, a contrast enema will need to be performed by a radiologist. Contrast enema is the gold standard and is both diagnostic and therapeutic. Intussusception most commonly occurs at the ileocolic junction. The ensuing swelling of the bowel wall and compression quickly lead to obstruction. Venous engorgement and ischemia of the intestinal mucosa cause bleeding and mucous discharge, which results in the classic description of red-currant jelly stool. The male-to-female ratio is approximately 3:1. A vertically oriented mass may be palpable in the right upper quadrant. Fever is a late finding and is suggestive of enteric sepsis

A 57-year-old woman with multiple myeloma presents with myalgias, abdominal pain, generalized weakness, and confusion. Laboratory testing demonstrates a calcium of 15.5 mg/dL. Aggressive hydration with normal saline is initiated. Which of the following medications is also indicated?

• Bisphosphonate

• Hydrochlorothiazide

• Insulin

• Methylprednisolone

Answer explanation

Hypercalcemia is generally a product of another underlying disorder and not a primary process in itself. Causes are grouped into four categories: malignancy (primary hematologic, metastases to the bone, or parathyroid hormone-producing tumors), hyperparathyroidism, increased intake (milk-alkali syndrome, vitamin D or A toxicity), and increased bone breakdown (immobilization).

Clinically, patients experience lethargy, weakness, myalgias, constipation, and anorexia. The clinical presentation is often remembered by the mnemonic bones, stones, groans, and psychiatric overtones. The first step in treatment is aggressive hydration. The addition of intravenous bisphosphonates (e.g., zoledronic acid) inhibits calcium release from bone. It is usually reserved for hypercalcemia associated with malignancy.

A 52-year-old man presents with abdominal pain. A CT scan is performed showing intussusception. What is the appropriate management?

• Barium enema

• Exploratory laparotomy

• Flexible sigmoidoscopy

• Observation

Answer explanation

Intussusception can be seen at all ages, although it is much more common in children under the age of 2. In children between 6 months and 3 years of age, it is the most common cause of intestinal obstruction. In children, the cause is often idiopathic and speculated to result from enlargement of the lymphatic tissue from a recent infection. Intussusception is the cause of only 1–5% of small bowel obstructions outside of childhood. In adults, a mechanical cause is found in approximately 90% of cases. In approximately two-thirds of cases, a tumor is found on exploration. Patients with immunocompromise, particularly advanced HIV, are at increased risk secondary to lymphatic tissue growth, as seen in lymphoma and some opportunistic infections. Unlike cases in children, intussusception in adults is treated surgically unless there has been definitive testing before to ensure a benign cause of the obstruction.

A 16-year-old boy presents to the emergency department with a head injury after a fall from a moving vehicle. He seems unaware of his surroundings and does not localize to pain or voice, yet is agitated and intermittently struggling with the resuscitation team. There are no other obvious injuries, but he appears cyanotic. An intravenous line and vital signs are obtained, showing a heart rate of 140 beats per minute, blood pressure of 150/95 mm Hg, and an oxygen saturation of 64% with a good waveform. Bag-mask ventilation is ineffective in improving his oxygen saturation due to his agitation. Which of the following medications is the best choice to improve preoxygenation and the success of this patient's intubation?

• Haloperidol

• Ketamine

• Lorazepam

• Succinylcholine

Answer explanation

Patients who are hypoxic at the beginning of an intubation attempt are already on the steep part of the oxygen-hemoglobin dissociation curve and are expected to become profoundly hypoxic when they become apneic. Patients who become profoundly hypoxic are at risk of dysrhythmia, hypoxic brain injury, and cardiac arrest. The chances of a successful first-pass intubation are also significantly lower in hypoxic patients. Usually, maneuvers such as repositioning, a jaw thrust, and two-person positive pressure ventilation are sufficient to improve oxygen saturation unless there is lung pathology such as a pulmonary contusion or pneumothorax. When agitated patients are persistently hypoxic or expected to have a sudden drop in oxygen saturation (e.g., a young infant with a traumatic pneumothorax), a pause between administration of the induction agent and neuromuscular blocking agent (NMBA) gives the resuscitation team time to optimize preoxygenation. Of the choices above, ketamine is the best choice to improve the chance of successful intubation. Administration of ketamine to facilitate preoxygenation has been termed delayed sequence intubation (i.e., it is procedural sedation to facilitate oxygenation by dissociating a combative or agitated patient enough to accept positive pressure ventilation). Once oxygenation is optimized, the resuscitation team administers the NMBA and the intubation is completed.

A 40-year-old man presents with rectal pain and fever. Physical examination reveals an indurated left buttock with fluctuance tracking towards the anus. Digital examination reveals tenderness and fluctuance. What is the best next step in management?

• CT scan and surgical consultation

• Incision and drainage in the emergency department

• Intravenous antibiotics

• Oral antibiotics and outpatient follow-up

Answer explanation

This patient presents with signs and symptoms concerning for a deep anorectal abscess and requires a CT scan for diagnosis and surgical consultation for operative management. Some anorectal abscesses can be treated with simple incision and drainage in the emergency department (perianal). However, the deeper abscesses cannot be adequately drained without anesthesia. Ischiorectal, intersphincteric, supralevator, and postanal abscesses typically require more invasive management. These abscesses often present with rectal pain and may have associated fever. An external examination may not reveal the full extent of the abscess, but patients often have severe tenderness on the rectal examination. In intersphinchteric and supralevator abscesses, a rectal examination may reveal fluctuance or a tender mass. CT scan of the pelvis can delineate the extent of the disease and aid in guiding management.

A 50-year-old woman presents to the ED after being assaulted by her grandchild. She is awake, alert, and following commands. She reports a severe headache. She has a 2 cm occipital scalp laceration with pulsatile bleeding. Her vital signs are T 98.5°F (36.9ºC), BP 92/66 mm Hg, HR 112 beats/minute, RR 14/minute, and SpO₂ 100% on room air. The remainder of her primary and secondary surveys are unremarkable. Which of the following is the best next step in care?

• Computed tomography of the head

• Orotracheal intubation

• Primary repair of the laceration

• Sonography of Morrison pouch

Answer explanation

The resuscitation of trauma patients always begins with identifying and treating immediately life-threatening injuries beginning with the ABCs: airway, breathing, and circulation. If the airway (“A”) is patent and maintainable with no immediate need for emergent intervention, an assessment of breathing (“B”) is performed next. This is most commonly achieved by auscultating for the presence of bilateral breath sounds and inspection of penetrating trauma to determine if acute intervention (e.g., tube thoracostomy, needle decompression) is indicated. Once “A” and “B” are considered stable, the next element that is assessed is circulation (“C”). This includes both hemorrhage control and blood pressure management. If active bleeding is present, especially if this bleeding is resulting in hypotension, it should be addressed immediately. Hemorrhage control begins with applying direct pressure at the site of bleeding. If direct pressure is insufficient or manual pressure is not able to be held while the remainder of the patient’s assessment is completed, other measures may be taken to control hemorrhage. This may include the application of a pressure dressing, tourniquet application, or primary closure. Bleeding scalp wounds can often achieve hemostasis with primary repair of the laceration or avulsion with staples or sutures. These measures are concomitantly performed while large-bore intravenous access is obtained and blood and blood products are given when needed. Once circulation is stabilized, the remainder of the primary survey (disability and exposure) can be completed. After the primary survey, a secondary survey is performed, during which a complete head-to-toe examination is completed, identifying any abnormal findings. Trauma resuscitations, including the primary and secondary surveys, should ideally be performed the same way, in the same order, on every patient, every day