Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


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cell disease or hemolytic anemias, can lead to
gallstone formation, these are pigment gallstones, not cholesterol stones.
17. A 45-year-old man with a history of alcoholism complains of 12 hours of severe, painful hemorrhoids. Past
medical history is signi\ufb01cant for upper gastrointestinal bleeding due to alcoholic gastritis. He has not
consumed alcohol for 2 years. He has a nontender, protuberant abdomen with shifting dullness. Rectal
examination reveals a severe prolapsed internal hemorrhoid with a thrombosis and a large thrombosed
external hemorrhoid. The best treatment plan is to:
a. Discharge home on stool softeners, sitz baths, and opioid pain relief.
b. Incise the hemorrhoid, evacuate the clot, discharge home on stool softener, sitz bath, and pain medicine.
c. Consult and admit to surgical service.
d. Do a coagulation pro\ufb01le; if normal, evacuate the clot of the external hemorrhoid; and discharge home on stool
softener, sitz bath, and pain medicine.
e. Do a coagulation pro\ufb01le; if normal, then only evacuate the clot of the internal hemorrhoid; and discharge home
on stool softener, sitz bath, and pain medicine.
The answer is c. Portal hypertension may cause severe hemorrhoids. Bleeding from this site can be dif\ufb01cult to
control. This particular patient requires a surgeon\u2019s expertise and his management is beyond the scope of customary
treatment in an emergency department.
32 Emergency Medicine Q & A: Pearls of Wisdom ...
18. A 63-year-old woman complains of severe abdominal pain and diarrhea. She has a history of congestive heart
failure (CHF) and atrial \ufb01brillation. She is allergic to shrimp. Medications include furosemide and digitalis.
Physical examination reveals a soft abdomen with mild tenderness and guarding; bowel sounds are
hypoactive; and the remainder of her examination is unremarkable. Vital signs are: temperature, 36.2\u25e6C
(97.2\u25e6F); heart rate, 100/min; respiratory rate, 30/min. Laboratory studies show: WBC, 19,500/mm3;
potassium, 3.0 mEq/dL; arterial pH, 7.27; arterial PCO2, 27. Abdominal radiographs show an adynamic
ileus, but no free air. She has no acute EKG \ufb01ndings. Your next step is to order:
a. Emergent angiography.
b. Four-hour intravenous potassium replacement.
c. Admission to an observation unit.
d. Ultrasound of gallbladder to rule out atypical cholecystitis.
e. Digitalis FAB fragments.
The answer is a. The diagnosis of exclusion is mesenteric ischemia; clues include abdominal pain out of proportion
to physical \ufb01ndings, a history of cardiac disease, digitalis use, and acidosis. Atypical cholecystitis in the elderly
population does not present this way. Physical \ufb01ndings are vague because the visceral pain \ufb01bers of the ischemic
bowel do not result in stimulating muscle spasm, as in peritonitis. Mesenteric ischemia requires angiography. An
allergy to shrimp is not an absolute contraindication to emergency angiography. The administration of FAB
fragment is not indicated in this particular patient.
19. Choose the correct statement about laboratory studies available to test hepatic function:
a. AST is more speci\ufb01c than ALT as a marker of hepatocyte injury.
b. Prothrombin time and albumin re\ufb02ect hepatocyte synthetic function.
c. Elevated alkaline phosphatase (AP) re\ufb02ects catabolic function of the liver.
d. Lactate dehydrogenase (LDH) elevation is highly speci\ufb01c for hepatocyte damage.
e. Elevated serum ammonia levels reliably correlate with acute worsening of hepatic function.
The answer is b. Laboratory tests for hepatobiliary disease can be divided into three general categories: (1) markers
of acute hepatocyte injury and death, including aspartate aminotransferase (AST or SGPT), alanine
aminotransferase (ALT or SGOT), and alkaline phosphatase; (2) measures of hepatocyte synthetic function,
including prothrombin time and albumin; and (3) indicators of hepatocyte catabolic activity, including direct and
indirect bilirubin, and ammonia. AST is nonspeci\ufb01c as it also found in heart, smooth muscle, kidney, and brain
tissues; ALT is a more speci\ufb01c marker of hepatocyte injury. Moderate elevations of LDH are seen in all
hepatocellular disorders and cirrhosis, but may also become signi\ufb01cantly elevated as a result of hemolysis. Ammonia
levels do not correlate accurately to clinical status.
20. In diagnosing a patient with peptic ulcer disease or gastritis, the most helpful symptom is:
a. Pain at night.
b. Food intolerance.
c. Pain made worse by food.
d. Belching.
e. Nausea.
The answer is a. Although no symptoms allow complete discrimination, peptic ulceration is more likely than
nonulcer dyspepsia or cholelithiasis in the presence of night pain; pain relieved by food, milk, or antacids; and a
shorter duration of pain. Postprandial pain, food intolerance, nausea, retrosternal pain, and belching are not related
to peptic ulcer disease.
... CHAPTER 2 Abdominal and Gastrointestinal Emergencies 33
21. Melena:
a. Is present in 95% of patients with upper gastrointestinal bleedings (UGIB).
b. Is from blood that has been in the GI tract for at least 24 hours.
c. Is present in approximately one-third of lower gastrointestinal bleedings (LGIB).
d. May occur from as little as 10 mL of blood in the GI tract.
e. Will remain black and tarry for no more than 24 hours after bleeding stops.
The answer is c. Melena (from the Greek melaina, meaning \u201cblack\u201d) or black tarry stools occurs from
approximately 150\u2013200 mL of blood in the GI tract. Melena is present in approximately 70% of patients with
upper GI bleed and 33% of patients with lower GI bleed. Black nontarry stool may result from as little as 60 mL of
blood. Blood from the jejunum or duodenum must remain in the GI tract for at least 8 hours before it turns black.
Stool may remain black and tarry for several days after bleeding has stopped.
22. A 58-year-old man complains of dif\ufb01culty swallowing. He has a peculiar habit of making two or three
attempts to swallow his saliva as he speaks. He appears nervous. The most likely site of esophageal
dysfunction in this patient is at the:
a. Gastroesophageal junction.
b. Level of the left mainstem bronchus.
c. Level of the frontal cortex.
d. Level of the third cranial nerve brainstem nucleus.
e. Level of the cricopharyngeus.
The answer is e. Dysphagia is the awareness that something is wrong with swallowing. Globus hystericus is the
sensation of a lump in the throat from emotional causes (c). This patient\u2019s symptoms are characteristic of transfer
dysphagia, or the inability to initiate swallowing, and may be caused by mechanical or neuromuscular disorders.
Causes of transfer dysphagia include pharyngitis, tonsillar abscesses, monilial or herpetic infection, foreign bodies,
epiglottitis, and carcinoma of the base of the tongue or pharynx. Neuromuscular causes may be associated with
nasopharyngeal regurgitation and aspiration; stroke, polymyositis, and bulbar palsies (d) are among the causes.
Esophageal body dysphagia (a and b) is associated with retrosternal pain and regurgitation. In this patient, without
other evidence of disease, choice e is the best answer. Zenker\u2019s diverticulum should also be suspected.
23. The majority of esophageal perforations are:
a. Spontaneous.
b. Iatrogenic.
c. Traumatic.
d. Caused by caustic ingestion.
e. Idiopathic.
The answer is b. Spontaneous esophageal perforation accounts for only 15% of cases, with iatrogenic injuries
accounting for most of the remainder. These usually occur as a complication of upper endoscopy, dilation,
sclerotherapy, or other GI procedures.
34 Emergency Medicine Q & A: Pearls of Wisdom ...
24. Ciguatera \ufb01sh poisoning classically causes:
a. Perioral, hand, and foot paresthesias.
b. Painless hematuria.
c. Wheezing and cyanosis.
d. Chest pain and palpitations.
e. A generalized maculopapular rash.
The answer is a. Vomiting and diarrhea occur 2\u201330 hours after ingestion of contaminated grouper, snapper,