Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


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king\ufb01sh from tropical and subtropical waters. Subsequently, the patient develops neurologic manifestations such as
myalgias, weakness, paresthesias of the perioral region and distal extremities, and severe burning sensations of the
hands and feet. Treatment is supportive care. The disease usually lasts for several days, but symptoms may persist
for months.
25. The most common cause of acute diarrheal disease is:
a. Food intolerance.
b. Toxic contaminants.
c. Bacterial disease.
d. Parasitic contaminants.
e. Viral illness.
The answer is e. Most cases of acute diarrheal illness are caused by viral infections (Norwalk virus, rotavirus,
enteroviruses, and adenoviruses). Other etiologies of diarrhea include antibiotic-induced colitis, in\ufb02ammatory
bowel disease, lactose intolerance, obstruction (paradoxical diarrhea from impaction), bacterial toxins, food toxins
(mushrooms, ciguatera), individual sensitivity to food, and systemic illnesses (malabsorption and malignancy).
26. In differentiating a patient with cholangitis from one with simple cholecystitis, the most helpful \ufb01nding is:
a. Fever.
b. Hyperlipasemia.
c. Jaundice.
d. Murphy\u2019s sign.
e. Elevated serum aminotransferases.
The answer is c. Although patients with cholangitis, in general, will have a higher fever and appear more ill than
those with cholecystitis, there can be considerable variability and overlap. The presence of jaundice is the clinical
sign most helpful in differentiating these two disorders. An elevated bilirubin is characteristic of cholangitis and
uncommon in cholecystitis. Elevated serum aminotransferases may be found in both conditions.
27. The most frequent cause of acute pancreatitis in patients older than 50 years presenting to community
hospitals is:
a. Gallstones.
b. Alcohol.
c. Carcinoma of the pancreas.
d. Viral infection.
e. Trauma.
... CHAPTER 2 Abdominal and Gastrointestinal Emergencies 35
The answer is a. Biliary pancreatitis is the most common cause of acute pancreatitis in patients older than 50 years
in the community hospital setting. Alcohol is a more common cause in patients younger than 50 years in urban
areas. Trauma, viral infection, and pancreatic carcinoma are less common causes of acute pancreatitis.
28. The most common indication for surgery secondary to acute diverticulitis is:
a. Abscess.
b. Hemorrhage.
c. Perforation.
d. Fistula formation.
e. Obstruction.
The answer is a. While all of these complications are reported with diverticular disease, the most common
indication for surgery is abscess formation, accounting for up to 50% of complications. Obstruction accounts for
another 10\u201330%, while free perforation can occur in 10\u201315% of complicated cases of diverticulitis. Fistula
formation is uncommon, and bleeding almost always occurs in the absence of in\ufb02ammation.
29. Radiation proctocolitis is a common side effect of radiation therapy. Choose the correct statement about this
troublesome condition:
a. Acute radiation proctocolitis requires aggressive therapy with high-dose steroids.
b. More than half of patients with pelvic radiation develop chronic radiation proctocolitis.
c. Chronic radiation proctocolitis can begin anytime up to 2 years after the end of radiation therapy.
d. Symptoms of chronic radiation proctocolitis are easily distinguished from infectious or ischemic colitis.
e. Massive rectal bleeding requiring transfusion and surgery is common with both presentations.
The answer is c. Radiation proctocolitis occurs in 50\u201375% of patients receiving radiation to the pelvis. Acute
radiation proctocolitis begins during or shortly after a course of radiation therapy, usually is easily diagnosed, and is
self-limited. Chronic radiation proctocolitis typically begins anytime up to 2 years after the end of radiation
therapy, although 10% of cases have onset delayed beyond 2 years. Approximately 5\u201310% of patients with pelvic
radiation develop chronic radiation proctocolitis. Bleeding can occur but is usually not hemodynamically
signi\ufb01cant. Symptoms of chronic radiation proctocolitis generally are clinically indistinguishable from other causes
of bowel in\ufb02ammation including IBD, infectious colitis, and ischemic colitis.
30. Formation of a pilonidal sinus is best characterized as:
a. An acquired problem that has a high rate of recurrence despite surgical treatment.
b. An acquired problem that rarely recurs after surgical excision.
c. A congenital problem that commonly recurs after surgical excision.
d. A congenital problem that rarely recurs after surgical excision.
e. A congenital problem that is best treated with antibiotics.
The answer is a. Once considered a congenital problem, the formation of a pilonidal sinus is now considered to be
an acquired problem. Incision and drainage with packing is adequate initial therapy; clumps of hair and detritus
should be removed. Antibiotics are not necessary unless cellulitis is present or the patient is immunocompromised.
The condition has a relatively high recurrence rate.
36 Emergency Medicine Q & A: Pearls of Wisdom ...
31. A 48-year-old woman complains of epigastric and right upper quadrant pain and jaundice. She has a fever of
39.5\u25e6C (103.1\u25e6F) with chills. She probably has:
a. Viral hepatitis.
b. Alcoholic hepatitis.
c. Pancreatitis.
d. Ascending cholangitis.
e. Acute cholecystitis.
The answer is d. Charcot triad consists of fever with chills, right upper quadrant pain, and jaundice. A purulent
infection extends into the liver. Ascending cholangitis is a surgical emergency and carries a high mortality.
32. Acute mesenteric ischemia is most commonly caused by:
a. Arterial thrombosis.
b. Arterial embolus.
c. Venous occlusion.
d. Hypercoagulable state.
e. Nonocclusive vascular disease.
The answer is b. Although all of the above can cause acute mesenteric ischemia, the most common cause is an
arterial embolus.
33. In predicting severity of illness for a patient with acute pancreatitis, useful \ufb01ndings in the emergency
department include:
a. Lactate dehydrogenase level.
b. Serum calcium level.
c. Serum lipase level.
d. Hematocrit.
e. Serum amylase level.
The answer is a. Ranson\u2019s criteria are used to predict in-hospital mortality. Useful presentation criteria include the
patient\u2019s age, WBC, AST (SGOT), amylase, and LDH levels at the time of admission. After 48 hours, the criteria
include a falling hematocrit, rising BUN and low calcium. Serum lipase is a more speci\ufb01c indicator of acute
pancreatitis than serum amylase, but it is not included in Ranson\u2019s criteria.
34. Choose the correct statement about foreign bodies of the esophagus:
a. Button battery ingestion in a child always mandates endoscopic removal.
b. Proteolytic enzymes are the initial treatment of choice in a patient with esophageal food impaction from a piece
of chicken meat with bone.
c. Refusal to eat in an otherwise healthy child suggests an esophageal foreign body.
d. Smooth muscle relaxers, such as tolteridine (Detrol), have proven useful.
e. Radiographs generally show a stuck coin to be sideways on the AP view.
... CHAPTER 2 Abdominal and Gastrointestinal Emergencies 37
The answer is c. Esophageal perforation is a known complication of using papain to dissolve an esophageal meat
bolus. Furthermore, if aspirated, papain may result in hemorrhagic pulmonary edema. Glucagon can be used to try
and relieve a food impaction by acting to relax the esophagus. Children may only present with the inability to
swallow (drooling) in cases of ingestion of a foreign body. Ingested button batteries must be removed from the
esophagus only if they do not spontaneously pass into the stomach. The mnemonic to remember coin orientation
on radiographs: Is it SAFE? Sideways\u2013Airway; Face\u2013Esophagus.
35. Cecal volvulus:
a. Is common in infants.
b. Is the most common cause of bowel obstruction in pregnancy.
c. Occurs more frequently