Identifying and Managing Medical Emergencies, Exams of Advanced Education

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Regardingitheidiagnosisiofiacuteiappendicitis,iallitheifollowingiareitrueiE XCEPT: iA.iVitalisignsiareiusuallyiabnormal,ieveniearlyiinitheicourseiofiacuteiapp endicitis. iB.iReboundiisiusuallyielicitedionlyiafteritheiappendixihasirupturedioriinf arcted. iC.iRovsing'sisigniisipainiinitheirightiloweriquadrantiuponipalpationiofithe ileftiloweriquadrant. iD.iTheiobturatorisigniisipainiuponiflexioniandiinternalirotationiofitheihip . iE.iTheipsoasisigniisipainiuponiextensioniofitheihip.i-iCorrectiAnswer- A.iVitalisignsiareiusuallyiabnormal,ieveniearlyiinitheicourseiofiacuteiappe ndicitis. TheiansweriisiA.iTheipresentationiofiacuteiappendicitisivariesitremendo usly.iEarlyiiniitsicourse,ivitalisignsiincludingitemperatureimayibeinormal.i Onceiperforationihasioccurred,itheirateiofilow- gradeifeveri(<38iC)iincreasesitoiabouti40%.iOtherivariationsiinipresentat ioniincludeipainiinitheirightiupperiquadrant,itypicallyifromiairetrocecalio riretroiliaciappendix.

Rosving'sisigniisidescribedias: iA.iTendernessiinitheirightiupperiquadrantithatiisiworseiwithiinspiration. iB.iPelvicipainiuponiflexioniofitheithighiwhileitheipatientiisisupine. iC.iPelvicipainiuponiinternaliandiexternalirotationiofitheithighiwithitheikn eeiflexed. iD.iPainithatiincreasesiwithitheireleaseiofipressureiofipalpation. iE.iPainiinitheirightiloweriquadrantiwhenileftiloweriquadrantiisipalpated.i

• iCorrectiAnswer- E.iPainiinitheirightiloweriquadrantiwhenileftiloweriquadrantiisipalpated. TheiansweriisiE.iRosving'sisigniisipainiinitheirightiloweriquadrantiwhenith eileftiloweriquadrantiisipalpated.iRebounditendernessioccursiwithitheire leaseiofipressure.iTheiiliopsoasisigniisipainiassociatediwithithighiflexion.i Theiobturatorisigniisipainithatioccursiwithithighirotation.iAlliofitheseisig nsiareiassociatediwithiappendicitis.iMurphy'sisigniisicessationiofiinspirat ioniduringipalpationiofitheirightiupperiquadrantiandiisiassociatediwithia cuteicholecystitis. Iniestablishingiaidifferentialidiagnosisiofiabdominalipain,iwhichiofitheifo llowingiisitrue? A.iRadiationiofipainitoitheiscapulaiisisuggestiveiofiacuteihepatitis. iB.iCervicalimotionitendernessiisiaiusefuliphysicalifindingiforidifferentiati ngiwomeniwithioriwithoutiacuteiappendicitis. iC.iInipatientsiwithisickleicellianemiaiwhoipresentiwithiabdominalipainia ndidiarrhea,ishigellosisishouldibeiaitopiconsideration.

iD.iTheionsetiofipainiprioritoitheioccurrenceiofinauseaiandivomitingiisimo reioftenisuggestiveiofiaisurgicalietiology. iE.iDiverticulitisitendsitoicauseipainiinitheirightiupperiquadrant.i- iCorrectiAnswer- D.iTheionsetiofipainiprioritoitheioccurrenceiofinauseaiandivomitingiisimo reioftenisuggestiveiofiaisurgicalietiology. TheiansweriisiD.iPainiprioritoinauseaiandivomitingiisioftenisuggestiveiofi aisurgicalietiologyiofitheipain,isuchiasismalliboweliobstruction.iCervicali motionitendernessihasibeeninotediiniupitoi25%iofiwomeniwithiacuteiap pendicitis.iPatientsiwithisickleicellianemiaiareiproneitoiSalmonellaiinfect ions.iRadiationiofipainitoitheiscapulaiisiclassicallyipresentiiniacuteicholey cystitis.iDiverticulitisipainiisigenerallyilocatediinitheileftiloweriquadrant. Ofitheifollowingipainipatterns,iwhichiisitheileastilikelyiassociatediwithidi agnosisiofipepticiulceridisease? iA.inon-radiating,iburningiepigastricipain iB.ipainithatiawakensiaipatientiinitheimiddleiofitheinight iC.iunrelentingipainioveriaiperiodiofiweeks iD.ireliefiofiabdominalipainiwithiantacids iE.ipainithatiisiworseiprecedingiaimeali-iCorrectiAnswer- C.iunrelentingipainioveriaiperiodiofiweeks TheiansweriisiC.iPainifromipepticiulceridiseaseitypicallyioccursiiniperiodsi ofiexacerbationiandiremission.iUnrelentingipainioveriweeksiorimonthsis houldisuggestianialternativeidiagnosis.iPainiisiclassicallyidescribediasino

n- radiating,iburningiepigastricipain.iSomeipatientsimayialsoicomplainiofic hestioribackipain.iPainiisifrequentlyisevereienoughitoiawakenipatientsifr omisleepiiniearlyimorningihoursibutiisiofteninotipresentiuponiwakingiinit heimorning,iasigastriciacidisecretionipeaksiaroundi 2 ia.m.iandinadirsiupo niawakening. Aimotheribringsiheri 6 iweekioldiboyitoitheiemergencyiroom.iSheistatesith eibabyihasibeenivomitingieverythingishe'sitrieditoifeedihimiforitheipasti 1 2 ihours.iSheistatesithatiheiusuallyieatsireadilyiandicompletesianientireife eding,ibutiheiisiunableitoikeepianythingidown.iTheiemesisiisinon- bloodyiandinon- bilious,ihoweveriitiisiprojectileiininature.iWhatiisitheimostilikelyiconditio niinithisipatient? iA.iviraligastroenteritis iB.iconstipation iC.iappendicitis iD.iintussusception iE.ipyloricistenosisi-iCorrectiAnswer-E.ipyloricistenosis TheiansweriisiE.iHypertrophicipyloricistenosisitypicallyipresentsiinitheise conditoisixthiweekiofilifeiandiisifouritimesimoreicommoniinimalesithanife males.iInfantsiwithihypertrophicipyloricistenosisitypicallyiareivigorousie atersibutishortlyiafterwardiregurgitateitheientireifeedingicontentsiiniaip rojectileifashion.iTheiemesisiisinon- bilious.iTheiclassicifindingioniexamiisiani"olive"ipalpableiinitheiabdomen ,iandidiagnosisiisitypicallyiviaiultrasound.iIntussusceptionitypicallyiprese

ntsibetweenitheiagesiofi 5 iandi 12 imonths.iGastroenteritisiisicharacterize dibyidiarrheaiasiwelliasivomiting.iNeithericonstipationinoriappendicitisit ypicallyipresentiwithiprotractedivomiting,ithoughitheilattericonditionite ndsitoipresentiatypicallyiiniyoungichildreni(andielderlyiadults). Ai 46 iyearioldiwomanipresentsitoitheiemergencyidepartmenticomplainin giofiabruptionsetiofiintermittentisevereipainiinitheileftiflankiandiabdome nithatiwokeiherifromisleep.iSheiisipacingiarounditheistretcheriandiappea rsiextremelyiuncomfortable.iSheihasineveriexperiencedithisitypeiofipaini previouslyiandideniesifeversioriotherisymptoms.iRenalicalculusiisisuspec ted.iWhichiofitheifollowingiisitrueiregardingitheidiagnosisiofirenalicalculii inithisipatient? iA.iUrinalysisidemonstratingihematuriaiconfirmsitheidiagnosis. iB.iKUBidetectsilessithani10%ioficalculi. iC.iHelicaliCTiscanigreaterithani95%isensitiveiandispecificiforirenalicalculi . iD.iUltrasoundiisitheistudyiofichoiceiforidetectingismalliureteralicalculi. iE.iIntravenousipyelogrami(IVP)imayibeiusediinipatientsiwithirenaliinsuff iciency.i-iCorrectiAnswer- C.iHelicaliCTiscanigreaterithani95%isensitiveiandispecificiforirenalicalculi. HelicaliCTiscanihasibeenishownitoibeibothihighlyisensitiveiandispecificiini theidiagnosisiofirenalicalculi.iItiisitheipreferredimodalityiforievaluationii nimanyicenters.iAlthoughiurinalysisitypicallyidemonstratesihematuriaii nipatientsiwithirenalicalculi,ihematuriaiisinotispecificienoughitoiconfirmi theidiagnosis,iandiimagingiisiwarrantediiniallifirst- timeipresenters.iKUBidetectsiapproximatelyi 60 -

70%ioficalculii(thoughistudiesiaddressingithisiissueiareisomewhatimetho dologicallyiflawed).iUltrasoundiisinotireliableiforidetectingismallicalculi,i butiisi 85 - 94%isensitiveiandi100%ispecificiatidemonstratingihydronephrosis.iIVPiis icontraindicatediinipatientsiwithirenaliinsufficiencyidueitoitheidyeiloadin ecessaryitoiperformitheistudy. Ai 50 iyearioldimanipresentsiwithi 1 idayiofigraduallyiworsening,iintermitte nt,ileftiloweriquadrantipainiassociatediwithilooseistools.iHeihasihadinoif eversioribloodyibowelimovements.iSimilarisymptomsiinitheipastiwereis elf- limited.iAllivitalisignsilieiwithininormalilimits.iPhysicaliexaminationisho wsimilditendernessiinitheileftiloweriquadrant,inormaliactiveibowelisoun dsiandineitherimassesinoriperitonealisigns.iHisiprimary- careiphysicianicaniseeihimitomorrowiinihisiclinic.iWhatishouldibeidonein extiinitheiE.D.? iA.iDischargeihomeiafteriaisingleidoseiofiIViantibiotics iB.iDischargeihomeionihigh-fiberidiet,ilaxativesiandistoolisofteners iC.iGastroenterologyiconsultiforiendoscopy iD.iAdmitiforiobservationiandiserialiexaminationsi-iCorrectiAnswer- B.iDischargeihomeionihigh-fiberidiet,ilaxativesiandistoolisofteners Thisipatientihasiclassicidiverticulosisi(saclikeiprotrusionsioficolonicimuc osaithroughitheimuscularis)iwithoutisignsiofiacuteidiverticulitisi(inflam mationiofidiverticula).iUsuallyitheseipatientsicanibeimanagediasioutpati entsiwithiaihigh- fiberidietianditreatmentsitoidecreaseiintestinalispasm.iIfitheipatientidev

elopsifeverioripainiincreasesiheimayineedifurtherievaluationitoiruleioutia bscessiformation.iDiverticulitisiisitreatediwithiantibiotics,ibowelirestian dianalgesics. Youiareitreatingiai 25 iyearioldimaleiwithitheirecentidiagnosisiofiCrohn'sidi seaseiinitheiED.iRegardingiCrohn'sidisease,iyouiknowithat: iA.iLesionsiareitypicallyicontiguous iB.iSmalliboweliinvolvementiisirare iC.iBleedingiisicommonidueitoisuperficialiboweliwalliinflammation iD.iThereiisiaismalliincreasediriskioficolonicanceri-iCorrectiAnswer- D.iThereiisiaismalliincreasediriskioficolonicancer AlthoughiCrohn'sidiseaseimayiinvolveitheientireibowelitract,itheirectumi isirarelyiinvolved.iInvolvediareasiareitypicallyinon- contiguousi(knowniasi"skipilesions")ianditheiinflammationiinvolvesiallio fitheilayersiofitheiboweliwall-- resultingiinimanyiofitheicomplicationsiofiCrohn'sisuchiasiabscessiandifist ulaiformation,iintestinaliobstruction,iandiperforation.iTheiriskioficolonic anceriisionlyislightlyielevatediaboveibaseline.iInicontrast,iUlcerativeicoli tisibeginsiinitheirectumiandimayispreaditoitheiupperipartsiofitheicolonib utineveriinvolvesitheismalliintestine.iTheiulcerationsiareicontiguousiandi involveionlyitheicolonicimucosa.iTheiincidenceioficolonicancerimayibeiin creasediupitoi 30 itimesioveribaseline.

Ai 53 iyearioldiobeseiwomanipresentsitoitheiemergencyidepartment,iacc ompaniedibyithreeiofiherichildren,icomplainingiofisevereiabdominalipai nithatibeganithisiafternooniafterilunch.iPhysicaliexamirevealsimarkediR UQitenderness.iLikelyifindingsionithisipatientiwouldiincludeialliofitheifoll owingiEXCEPT: iA.ipositiveisonographiciMurphy'sisign iB.ipainiinitheirightiscapula iC.ileukocytosisiwithileftishift iD.imarkediinguinalilymphadenopathy iE.iaminotransferasesiandibilirubiniwithininormalilimitsi- iCorrectiAnswer-D.imarkediinguinalilymphadenopathy Thisiwomaniisilikelyisufferingifromiacuteicholecystitis.iPredisposingifact orsiincludeifemaleigender,iobesity,iincreasediageiandiincreasediparity.iI nflammationiofitheigallbladdericausesiRUQipainiandisonographiciMurp hy'sisigni(inspiratoryiarrest,idueitoipain,iwhileitheiultrasoundiprobeiisipo sitionedioveritheigallbladder).iPainimayiradiateitoitheirightiscapula.iLabi studiesiusuallyishowileukocytosisiwithioriwithoutiaileftishift,iandiaminot ransferasesiandibilirubiniareiusuallyiwithininormalilimits. Ai 45 iyearioldiwomanipresentsiwithirightiupperiquadrantipainiandifever.i Theipainiisiworseiafterieating.iOniphysicaliexamisheihasiaiMurphy'sisign.i Theimostilikelyidiagnosisiis: iA.iAppendicitis iB.iDiverticulitis

iC.iCholelithiasis iD.iCholecystitis iE.iMesentericiIschemiai-iCorrectiAnswer-D.iCholecystitis Rightiupperiquadrantipain,ifeveriandiaiMurphy'sisignisuggestsicholecysti tis.iCholelithiasisipresentsiwithisimilaripain,ibutiisinotiassociatediwithife verioriaiMurphy'sisign AlliofitheifollowingifactorsipredisposeitoicecalivolvulusiEXCEPT: iA.ipregnancy iB.iagei 25 - 35 iC.iprioriabdominalisurgery iD.imarathonirunning iE.isevereichroniciconstipationi-iCorrectiAnswer- E.isevereichroniciconstipation Cecalivolvulusioccursiasiairesultiofiabnormalifixationiofitheirighticolonian diincreasedimobilityiofitheicecum.iDependingionitheidegreeiofirotationia rounditheimesentericiaxis,icecalivolvulusicanileaditoitwistingiofitheimes enteryiandiitsibloodivessels.iCecalivolvulusioccursimosticommonlyiinipe oplei 25 - 35 iyearsioldiandishouldibeisuspectediinicasesiofiboweliobstructioniwitho utiknowniriskifactors.iPrioriabdominalisurgeryiandipregnancyipredispos eitoiobstructionioricecalivolvulus;ihowever,ichroniciconstipationiisinotik

nownitoipredisposeitoicecalivolvulus.iInterestingly,imarathonirunnersih aveibeenifounditoihaveiaihigheriincidenceioficecalivolvulus,iperhapsifro mihavingiaithin,iflexibleimesenteryithatimoreieasilyipermitsirotationiofit heicecumiarounditheimesentericipedicle. Whichiofitheifollowingipairingsiofireferredipainiandicausalidiseaseiisileas tilikelyitoibeiencountered? iA.isacralipain — ovarianitorsion iB.iinguinalipain — ureteralicolic iC.iepigastricipain — myocardialiinfarction iD.ishoulderipain — rupturedispleen iE.ithoracicibackipain — pancreatitisi-iCorrectiAnswer-A.isacralipain — ovarianitorsion Ovarianitorsionimayicauseiloweriabdominalipain,ipelvicipain,iadnexalite nderness,iandicervicalimotionitenderness,ibutiitiisinotiknownitoicauseisa cralipain. Ai 72 iyearioldimaniwithiaihistoryiofidiverticulosisipresentsiwithivagueiab dominalipainiforitheipastiday.iHisiphysicaliexamiisinotableiforinormalivit alisigns,ileftiloweriquadrantiabdominalitendernessiwithoutireboundiorig uarding,iandiguaiacipositiveibrownistool.iWork- upiincludingiKUBiandiabdominal/pelviciCTiscanirevealsidiverticulitisiwit houtiperforation.iOfitheifollowingichoices,iwhichiisitheimostiappropriat eimanagementiofithisipatient?

iA.itypeiandicrossitwoiunitsiofipackediredibloodicells iB.iimmediateisurgicaliintervention iC.idischargeionioralipainimedications iD.ibariumienemaitoievaluateiforicarcinomaiofitheicolon iE.iadmissioniforiintravenousiantibioticsiandifluidsi-iCorrectiAnswer- E.iadmissioniforiintravenousiantibioticsiandifluids Forimildiepisodesiofidiverticulitisiiniwhichithereiisinoievidenceiofiperfora tionioriperitonitis,ithereiisinoiindicationiforiimmediateisurgicaliintervent ion.iConservativeimanagementiwithiintravenousifluidsiandiantibioticsia siwelliasibowelirestiisitypicallyifirstiattempted.iAlthoughicolonicarcinom aimayibeiaiprecipitatingifactoriinitheidevelopmentiofidiverticulitis,ibariu mienemaishouldibeiavoidediinitheiacuteiperiodidueitoihighiriskiofiboweli perforation.iAlthoughisomeipatientsiwithimildicasesiofidiverticulitisima yibeidischargedihomeiwithiconservativeitreatment,itheielderlyiareiatihig heririskiofiperforationiandishouldibeiadmitted.iGuaiacipositiveistoolii niseeniiniupitoi50%iofipatientsiwithidiverticulitis.iThereiisinoireasonitoi suspectiacuteibloodilossirequiringitransfusioniinidiverticulitis. Regardingiesophagealiperforation,iwhichiofitheifollowingiisiINCORRECT: iA.iEsophagealiperforationihasibeenireportediasiaicomplicationiofinasog astricitubeiplacement,iendotrachealiintubation,iandiesophagotracheali Combitubeiintubation.

iB.iEsophagealiperforationimayiresultifromiforcefulivomiting,icoughing,i childbirthioriheavyilifting. iC.iOveri80%iofiesophagealiperforationsiareiiatrogenic,iusuallyiasicompli cationsiofiupperiendoscopy,idilation,iorisclerotherapy. iD.iOveri90%iofispontaneousiesophagealiperforationsioccuriinitheiproxi maliesophagus. iE.iIatrogeniciperforationsiofitheiesophagusiusuallyioccuriinitheiproximal iesophagusioriesophagogastricijunction.i-iCorrectiAnswer- D.iOveri90%iofispontaneousiesophagealiperforationsioccuriinitheiproxi maliesophagus. Overi90%iofispontaneousiesophagealiperforationsioccuriinitheidistali esophagus,iwhereasiiatrogeniciperforationsiareifrequentlyiatitheiphary ngoesophagealijunctionioritheiesophagogastricijunction.iForeignibodyio ricausticisubstanceiingestion,isevereibluntiinjuryioripenetratingitrauma,i andicarcinomaiareiothericausesiofiesophagealiperforation. WorkingiinitheiED,iyouihaveiidentifiediaibonyiobjectiwedgediinitheimid- esophagusiofiai 45 iyearioldipatient.iFailureitoipromptlyiremoveiaiforeigni bodyiimpactediinitheiesophagusicouldiresultiin: iA.iEsophagealiperforationiandimediastinitis iB.iEpiglottaliedemaiandiairwayiobstruction iC.iTheirapididevelopmentiofixerostomia iD.iBarrett'siesophagitisi-iCorrectiAnswer- A.iEsophagealiperforationiandimediastinitis

Theicomplicationsiofiesophagealiforeignibodiesiareirareibutiserious.iThe yiincludeiesophagealierosioniandiperforation,imediastinitis,iesophagus- to-tracheaioriesophagus-to- vasculatureifistulaiformation,istrictureiformation,idiverticuliiformation,i anditrachealicompressioni(fromibothitheiesophagealiforeignibodyiandir esultantiedemaioriinfection).iAiritrappingiisiaisigniofiaiforeignibodyiofith eiairway.iRarely,iairwayiforeignibodiesiactiasione- wayivalvesithaticouldicauseihyperinflationiofiailungisegment,iwithiresult antiblebiruptureiandipneumothoraxiformation. Aimotheribringsiheri 35 iyearioldisonitoitheiemergencyidepartmentibecau seiofitremoriandimutismiforitheipastithreeidays.iHisimotherifoundihimiini hisiroomithisimorningilyingistifflyiinihisibed,isoilediwithiurineiandifeces.i Heiappearsiconfusediandiwillinotiresponditoiquestions.iHeiwasidiagnose diwithischizophreniailastiyeariandihasibeenioniseveralimedications.iLasti monthiafterihisimostirecentihospitaliadmissioniforischizophrenia,iheiwa sidischargediwithiaiprescriptioniforihaloperidol.iOniphysicaliexam,iheiisi visiblyidiaphoreticiandihasivitalisignsiasifollows:iTi102.7,iBPi140/98,iPi 11 2,iRi12.iHisineuromusculariexamishowsiextremelyirigidiextremities,iandi hisilaboratoryivaluesiareinotableiforiaiwhiteibloodicellicountiofi15000/m m3iandiabnormallyielevatedicreatineiphosphokinaseilevels.iWhatiisithei mostilikelyiexplanationiforitheseifindings? iA.ineuroleptic-inducediacuteidystonia iB.ineurolepticimalignantisyndrome iC.ischizophreni-iCorrectiAnswer-B.ineurolepticimalignantisyndrome

Neurolepticimalignantisyndromei(NMS)iisianiidiosyncratic,ilife- threateningireactionitoiantipsychoticimedications,iwithihaloperidolibei ngitheimosticommonicause.iItiisicharacterizedibyielevateditemperatures ,i"leadipipe"imuscleirigidity,ialteredimentalistatus,ichoreoathetosis,itre mors,iandiautonomicidysfunctioni(e.g.,idiaphoresis,ilabileibloodipressur e,iincontinence,idysrhythmias).iWhileithisipatient'sitemperatureiisionlyi 102.7,istudentsishouldinoteithatianyipatientsiwithitemperaturesigreater ithani 105 imostilikelyihaveinon- infectiousietiologiesiforitemperatureielevation.iNMSiisithoughtitoibeidu eitoitooimuchiD2iblockadeiinitheisubstantiainigraiandihypothalamus.iTre atmenticonsistsiofistoppingitheicausativeiagentiandiprovidingisupportiv eicare.iMedicationsisuchiasidantrolene,ibromocriptine,iamantadine,ia ndilorazepamiareialsoiofteniused.iTardiveidyskinesiaiisiaichronicimove mentidisorderithatiresultsifromiprolongediuseiofiantipsychoticsiandicani includeiinvoluntaryiandiperiodicimovementsiofitheitongueiorilips,imout hipuckering,ioriflailingimovementsieitheriofitheiextremitiesioriofitheispi ne.iNeuroleptic- inducediacuteidystoniaiisianiacuteispasmiofiaimuscleiorimuscleigroupiass ociatediwithitheiuseiofiantipsychoticiagents.iItipresentsiwithipatientsico mplainingiofineckitwistingi(torticollis),ifixediupperigaze,ifacialimuscleisp asms,ioridysarthriaifromitongueiprotrusions.iIniaisimilarifamilyiwithidyst onia,ineuroleptic- inducediakathisiaiisianiextrapyramidalisyndromeithatiisimanifestibyiagit ationiandirestlessness.iSchizophrenia,icatatonicitype,iaidiagnosisiofiexcl usion,iusuallyidoesinotipresentiwithithisidegreeiofiimpairment. Ai 25 iyearioldimanireturnsitoitheiED,i 24 ihoursiafteribeingireleasedifromit heihospitaliwithiainewidiagnosisiofischizophrenia.iHeihasirecentlyistarte ditoitakeihaloperidaliforihisipsychoticisymptoms.iInitheiEDiheiisinoteditoi haveiinvoluntaryicontractionsiofitheimusclesiofitheiface,iaiprotrudingito

ngue,ideviationiofitheiheaditoioneiside,iandisustainediupwardideviationi ofitheieyes.iVitalisignsiareistable,iandiinitialilabsishowinoielectrolyteiorih ematologicaliabnormalities.iOfitheifollowingichoices,itheipreferredimed icationiforithisiconditioniis: iA.idiphenhydramine iB.ilorazepam iC.iphenobarbital iD.imetoprololi-iCorrectiAnswer-A.idiphenhydramine Acuteidystonia,itheimosticommoniadverseieffectiseeniwithineuroleptici agents,ioccursiiniupitoi5%iofipatients.iDystonicireactions,iwhichicanioccu riatianyipointiduringilong- termitherapyiandiupitoi 48 ihoursiafteriadministrationiofineurolepticsiinit heiemergencyidepartment,iinvolveitheisuddenionsetiofiinvoluntaryicont ractioniofitheimusclesiinitheiface,ineck,ioriback.iTheipatientimayihaveipr otrusioniofitheitonguei(buccolingualicrisis),ideviationiofitheiheaditoionei sidei(acuteitorticollis),isustainediupwardideviationiofitheieyesi(oculogyr icicrisis),iextremeiarchingiofitheibacki(opisthotonos),iorirarelyilaryngosp asm.iTheseisymptomsitenditoifluctuate,idecreasingiwithivoluntaryiactivi tyiandiincreasingiunderiemotionalistress,iwhichioccasionallyimisleadsie mergencyiphysiciansitoibelieveitheyimayibeihystericaliininature.iDystoni cireactionsishouldibeitreatediwithiIMioriIVibenztropinei(Cogentin®),i 1 it oi 2 img,ioridiphenhydraminei(Benadryl®),i 25 itoi 50 img.iIntravenousia dministrationiusuallyiresultsiininear- immediateireversaliofisymptoms.iPatientsishouldireceiveioralitherapyiw ithitheisameimedicationifori 48 itoi 72 ihoursitoipreventirecurrentisympto ms.

Ai 70 iyearioldimaleiwithiacuteideliriumirequiresiadministrationiofihalope ridoliforiagitation.iWhichiofitheifollowingiisiairecognizedisideieffectiofiha loperidol? iA.ifirstidegreeiheartiblock iB.inephrogenicidiabetesiinsipidus iC.iprolongediQTiinterval iD.itransientihepatitisi-iCorrectiAnswer-C.iprolongediQTiinterval Nephrogenicidiabetesiinsipidusimayibeiassociatediwithilithium.iPotenti alisideieffectsiofihaloperidoliincludeiacuteidystonia,iprolongediQTiinterv al,iParkinsonism,iandiakathisia Ai 19 iyearioldiwomaniisibroughtitoitheiemergencyidepartmentibyiherifrie ndsibecauseisheihasibeenisayingithatisheiisiaisuperheroianditryingitoiruni intoitrafficitoiproveithatisheiisiindestructible.iTheifriendsireportithatishei hasibeeniusingidrugsibutitheyidoinotiknowiwhichiones.iWhichiofitheifoll owingipairsiofiocularifindingiandirecreationalidrugiisicommonlyiobserve d? iA.idilatedipupilsi-iheroin iB.iinternucleariophthalmoplegiai-imarijuana iC.ipinpointipupilsi-iamphetamines iD.iverticalinystagmusi-iphencyclidinei-iCorrectiAnswer- D.iverticalinystagmusi-iphencyclidine

Sympathomimeticsi(cocaine,iamphetamines)icauseidilatedipupils.iOpia tesi(heroin)icauseipinpointipupils.iInternucleariophthalmoplegiaiisiasso ciatediwithimultipleisclerosis.iCNiVIipalsyiisinotiassociatediwithianyispeci ficidrugs. Ai 42 iyearioldiformericustodialiworkeripresentsistating,i"Iithinkithatipeop leicaniheariwhatiIiamithinking."iInitheiemergencyidepartment,iheibecom esiextremelyiagitatediandithreatening,iandihisipsychosesibecomeimorei severe.iInichoosingianiantipsychoticimedication,iwhichiofitheifollowingi wouldibeitheimostiappropriateichoice? iA.ihaloperidol iB.ichlorpromazine iC.ithioridazine iD.iketaminei-iCorrectiAnswer-A.ihaloperidol Haloperidoliisitheimostistudiedihighipotencyiantipsychoticiagentiusediini agitatedipatients.iTypicalidosingiisi5- 10 imgiIMieveryi 10 - 30 iminutes.iUnlikeithioridazine,ihaloperidolidoesinoticauseirespirator yidepression,ihasinegligibleianticholinergicisideieffects,iandirarelyica usesihypotension.iAlthoughibenzodiazepinesicanibeiusediinitheiagitated ipatient,irespiratoryidepressionicanioccur,iandicloseimonitoringiisiessen tial. Ai 20 iyearioldicollegeistudentiisibroughtitoitheiemergencyidepartmentiby icampusipoliceiafteriheiwasifoundibyihisiroommateisayingipeopleiinithei

TViwereitryingitoikillihim.iWhichiofitheifollowingicriteriaiisinotianiindicati oniforiadmission? iA.ifirst-timeipsychiatriciepisode iB.idemonstratesiriskiforisuicide iC.iinadequateipsychosocialisupport iD.ilacksicapacityitoicooperateiwithitreatmenti-iCorrectiAnswer-A.ifirst- timeipsychiatriciepisode Forianiacuteipsychiatriciepisode,itheifirstigoaliisimedicallyistabilizingithei patient.iSubsequently,iaipatientiwhoipresentsiwithoutipreviousihistoryi ofiaipsychiatriciepisodeidoesinotinecessarilyineeditoibeiadmitted.iThis,io ficourse,idependsionitheiidentityiandiseverityiofitheicondition,iandiwhet heriiticanibeitreatediinitheiemergencyidepartment. Ai 55 iyear- oldimaleipresentsiwithinewionsetiagitationiandiconfusion.iWhichiofitheif ollowingimedicalihistoriesiwouldisuggestiaipsychiatrici(non- organic)icause? iA.iHistoryiofidiabetesimellitusionly iB.iHistoryiofialcoholiabuseionly iC.iHistoryiofihypothyroidismionly iD.iHistoryiofichroniciobstructiveipulmonaryidiseaseionlyi- iCorrectiAnswer-C.iHistoryiofihypothyroidismionly

Althoughihyperthyroidismimayiresultiinianiagitatedistate,ihypothyroidis miisinotigenerallyiassociatediwithiviolentibehavior.iAlliotherianswersiar eipotentiallyitreatableimedicaliproblemsithaticouldiaccountiforitheipres entationiofianiagitatedioriviolentipatient.iAfteriassuringitheisafetyiofialli partiesiinvolved,itheiemergencyidepartmentiphysicianishouldiruleioutio rganicicausesiofiagitation. Inidealingiwithitheipotentialiviolentipatient,itheiemergencyiphysicianish ould: iA.iApproachitheipatientiiniaicalm,icontrollediandiprofessionalimanner iB.iAssumeithatitheistrengthiofitheidoctor- patientirelationshipiwilliensureisafety iC.iDealiwithitheipatientiiniaiisolatediroomitoiprotectitheipatient'siprivac y iD.iUseiailoudivoiceiandithreatenitoicallisecurityiifitheipatientibecomesiag itatedi-iCorrectiAnswer- A.iApproachitheipatientiiniaicalm,icontrollediandiprofessionalimanner Excessiveieyeicontactimayibeiinterpretediasiaisigniofiaggressioni(answeri A).iEmergencyiphysiciansiareiencourageditoimaintainiintermittentieyeic ontactiwithitheipatientianditoikeepiaiprofessionaliandicalmidemeanor.iA lsoiaiphysicianishouldineveridealiwithianiagitatedioriviolentipatientialon eiinianiisolatediroomi(answeriD).iDoorsishouldialwaysiremainiopeniandi exitsishouldineveribeiblocked.iAmpleisecurityishouldibeicloseiatihandibe foreiinterviewingitheipatienti(answeriE).iFinally,iinvolvedipartiesiareienc ourageditoiremoveianyipersonalieffectsi(e.g.ineckties,inecklaces,iearrin gs,ietc.)ithaticouldibeiusediasiaiweaponibyitheiviolentipatient.

Ai 35 iyear- oldimaleiisiplacedionihisibackionitheigurneyiiniphysicalirestraintsiforiviol entibehavior.iWhichilife-threateningicomplicationicaniarise? iA.icirculatoryiobstruction iB.iMetaboliciacidosis iC.iAsphyxia iD.iRhabdomyolysisi-iCorrectiAnswer-B.iMetaboliciacidosis Bruisesiandiabrasionsiareitheimosticommonicomplicationiofiphysicalires traints.iAfterirestraintiapplication,ipatientsineeditoibeimonitoredifrequ entlyiandipositionsichangeditoipreventineurovascularicomplicationsisuc hiasicirculatoryiobstruction,ipressureisores,iandirhabdomyolysis.iPositio naliasphyxiaicaniariseiwhenipatientsiareiplacediintoitheiproneiorihobble diposition.iProtractedistruggleiagainstirestraintsicanipromoteiaisignifica ntimetaboliciacidosisithatihasibeeniassociatediwithicardiovascularicolla pse.iPatientsiwhoicontinueitoistruggleiwithiphysicalirestraintsishouldibei chemicallyirestrainediasiwell Whichimedicationiisiidealiforitheiagitatedioricombativeipatient? iA.iNitrousioxide iB.iHydromorphone iC.iHaloperidol iD.iPropofoli-iCorrectiAnswer- TheiansweriisiC.iDrugsiwithiairelativelyishortihalf-

lifeiallowiforimoreicarefulimonitoringiofichemicallyirestrainedipatients.i Patientsimayibeigivenimultipleiadministrationsiofitheirestrainingiagenti asineeded.iAntipsychoticsi(suchiasihaloperidol)iandibenzodiazepinesi(su chiasilorazepam)iexhibitimostiofitheseicharacteristicsiandiareicommonly iusediinicombinationiinitheiemergencyidepartment.iTheiuseiofi 5 imgiofiha loperidoliIV/IMiwithi 2 imgiofilorazepamiIV/IM,irepeatedieveryi 30 iminute siasineeded,iisirecommendediforitheicombativeipatientiwhoidoesinotiha veicontraindicationsitoitheseimedications.iHalfidosesishouldibeiusediinit heielderly. 19 iyearioldimaniisibroughtiinitoitheiemergencyidepartmentibyiEMSiafteri beingifoundiobtundediinihisiapartment.iNoiadditionalihistoryiisiavailabl e.iOniarrival,itheipatientiisiminimallyiresponsiveiwithisonorousirespirati onsiandiaipalpableirapidipulse.iTheimostiappropriateiinitialidiagnosticite stiwouldibe iA.iArterialibloodigas iB.iElectrocardiogram iC.iFingerstickiglucose iD.iUrineidrugiscreeni-iCorrectiAnswer-C.iFingerstickiglucose Hypoglycemiaiisiaicommoniandireadilyitreatableicauseiforialterediment alistatus.iAniABGiisiunlikelyitoibeidiagnosticiandimoreilikelyitoireflectisec ondaryiabnormalitiesicausedibyirespiratoryidepression.iWhileiaiurineidr ugiscreenimayishowipositives,iiticannotiquantitateitheiamountiofiaisubst anceioritheitimeiperiodiiniwhichitheiexposureioccurredisoiaipositiveiscre enimayinotireflecticauseiandieffect.iAniEKG,iwhileiaipartiofiaitoxicologyie

valuation,iisinotianiappropriateiinitiateiscreeningitestiforianiunstableipa tientiuntiliairwayiandireadilyireversibleicausesihaveibeeniaddressed. Ai 27 iyearioldiisifoundiunresponsiveiinihisicariinitheihospitaliparkingilotia ndibroughtiinibyisecurity.iDuringiyouriinitialievaluationiyouifindihimitoib eicyanoticiwithipulseioximetryireadingi82%ioniroomiairiwithiairespirator yirateiofi 4 ibreathsiperiminute.iRadialipulsesiareipresentiati 120 ibpm.iPupi lsiarei1mmibilaterally.iYouriteamiisihavingidifficultyifindingiaiveiniforianii ntravenousilineidueitoiextensiveiscarringiofihisiarms.iYouiareisuspiciousi ofianioverdose,iwhichimedicationiwouldiyouiwantitoirapidlyiadministeri asiaipotentialiantidoteiinithisisituation? iA.iGlucose iB.iNaloxone iC.iThiamine iD.iFlumazenili-iCorrectiAnswer-B.iNaloxone Theipatientihasistigmataiofianiopiateioverdoseiwithihypopnea,icyanosis ,iandimioticipupils.iIniaddition,iintravenousidrugiusersiofteniuseiupitheiri veins.iWhileihypoglycemiaicanidefinitelyicauseiaidepressedimentalistat usiandineedsitoibeiassessed,iitishouldinotiresultiinirespiratoryidepressio niorimioticipupils.iThiamineiisiutilizeditoipreventiWernicke'siencephalop athyiparticularlyiinimalnourishedipatientsiwhoipresentiwithihypoglyce miaibutiisinotianiantidoteiperise.iFlumazenilicanibeiuseditoitemporarilyir everseitheirespiratoryidepressionicausedibyibenzodiazepinesibutialsoica rriesiwithiititheiriskiofiprecipitatingiwithdrawaliandiuncontrollableiseizu resiinichronicibenzodiazepineiusers.iAsiairesult,iitiisinotirecommendedifo riroutineiuseiinipatientsiwithialteredimentalistatus.

Ai 53 iyear- oldiknownialcoholicipresentsiwithiagitation,ivomitingiandialterediment alistatus.iHisifingerstickiglucoseiisi148.iHisiserumiethanolileveliisiundetec tableiandihisiheadiCTiisinormal.iAniABGishowsiaipHiofi7.21,ipCO2iofi34,ip O2iofi 98 ioniroomiair.iHisibasicichemistryipaneliincludesiaisodiumiofi136,i potassiumi4.1,ichloridei108,ibicarbonatei14,iBUNi12,icreatininei1.1.iWh atisubstanceiareiyouiconcernedithatiheimayihaveiingested: iA.iEthyleneiglycol iB.iSalicylates iC.iIsopropylialcohol iD.iMethanoleeettei-iCorrectiAnswer-C.iIsopropylialcohol Theipatientiisipresentingiwithiainonianionigapimetaboliciacidosis.iIsopro pylialcoholiisimetabolizediviaialcoholidehydrogenaseitoiacetoneiwhichia ccumulatesiandicausesisignificantiketosisibutinotianianionigap.iOtherito xicialcoholsisuchiasimethanoliandiethyleneiglycoliareiultimatelyimetabo lizeditoiformiciandiglycoliciacidsiwhichicauseitoxicieffectsiandianianionig apimetaboliciacidosis.iSalicylatesiresultiinianianionigapimetaboliciacidos isiwithiaisuperimposedirespiratoryialkalosis.iTheifollowingimnemonicica nibeiuseditoirecallitheicommonicausesiofianiincreasedianionigapimetabo liciacidosis:iCATiMUDPILES; iCi-icyanide iAi-ialcoholiciketoacidosis iTi-itoluene iMi-imethanol iUi-iuremia

iDi-idiabeticiketoacidosis iPi-iparaldehyde iIi-iisoniazid/iron iLi-ilactate iEi-iethyleneiglycol iSi-isalicylates Isopropylialcoholicausesiaiketosisiwithoutianiacidosis. Initreatingihepatitisisecondaryitoialcoholiciliveridisease,ialliofitheifollowi ngiareitrueiEXCEPT: iA.iTreatmentiisiprimarilyisupportiveiincludingifluidsiandielectrolyteicorr ection. iB.iGlucoseishouldibeiadministerediprioritoithiamineitoiavoidiprecipitati ngiacuteiWernicke'siencephalopathy iC.iMagnesiumireplacementishouldibeiinitiatediempiricallyiexceptiinithei settingioficontraindicationsisuchiasirenalifailureiorihypermagnesemia. iD.iCoexistingigastritisishouldibeisoughtioutianditreatediappropriately. iE.iNutritionalistatusishouldibeiassessediwithiattentionitoipossibleiprotei nirestriction.i-iCorrectiAnswer- B.iGlucoseishouldibeiadministerediprioritoithiamineitoiavoidiprecipitati ngiacuteiWernicke'siencephalopathy Alcoholicsioftenihaveilowithiamineilevelsidueitoipoorinutrition,iandilowi glucoseilevelsidueitoitheisuppressioniofigluconeogenesisibyialcohol.iHo wever,ithiamineishouldialwaysibeireplacediprioritoiglucoseitoiavoidithei

potentialicomplicationiofiprecipitatingiWernicke'siencephalopathy.iMa gnesiumilevelsimayiappearinormalionilaboratoryitesting,ibutialcoholicsit ypicallyihaveilowimagnesiumistoresiandishouldibeigivenimagnesiumiem piricallyiunlessicontraindicationsiforimagnesiumiexist.iAlcoholicsishould ialsoibeievaluatediforigastritisiandioverallinutritionalistatusiandishouldib eireferrediappropriately. Ai 45 iyearioldimaniisibroughtitoitheiE.D.,iwithimarkedlyialteredimentalist atusiasireportedibyisomeoneiwhoistaysiwithihimiatiaihomelessishelter.iT heipatientiisiveryiconfusediandiobtunded,iandiunableitoiprovideiaicogen tihistory;itheipersoniwhoibroughtihimitoitheiE.D.inotesitheipatientihasiai "drinkingiproblem."iTheipatient'sivitalisignsiareinormal,iexceptiforiaires piratoryirateiofi22.iAsiheilaysiinitheistretcher,ihisiappearanceiisiasidepict ediinitheiFigure.iOfitheifollowingichoices,iwhichiphysicalifindingiisimostili kelyitoibeipresentioniphysicaliexamination? iA.iHoman'sisign iB.ianteriorichestipainiuponileaningiforward,iwhichiisirelievedibyilyingifla t iC.idendriticirashionitheiposteriorithorax,iwithiaisentinelilesioninotedioni theileftishoulder iD.iuponielevationiofitheiarmsitoi 90 - degreesi(ini 0 - degreesiabduction),iandipronationiofitheihandsiwithifingersispread,iwris tsiandiinterphalangealijointsiareicharacterizedibyijerkyi-iCorrectiAnswer- D.iuponielevationiofitheiarmsitoi 90 - degreesi(ini 0 - degreesiabduction),iandipronationiofitheihandsiwithifingersispread,iwris tsiandiinterphalangealijointsiareicharacterizedibyijerkyialternationsiofie xtensioniandiflexion