Emergency Medicine Q & A, 2009, Pg

Emergency Medicine Q & A, 2009, Pg


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weakness, diarrhea, and an itchy rash. The most likely cause of his symptoms is:
a. Scombroidosis.
b. Sul\ufb01tes in the salad.
c. Ciguatera \ufb01sh poisoning.
d. Monosodium glutamate.
e. Iodine allergy.
The answer is b. Sul\ufb01tes are used as preservatives in food, wines, and some medications. Ten percent of asthmatics
may be sensitive to sul\ufb01tes and exposure may cause life-threatening bronchospasm and hypotension. Monosodium
glutamate (MSG) has been associated with reactions ranging from \ufb02ushing and wheezing to nausea and vomiting.
MSG reactions are not felt to be immune mediated. Scombroid poisoning is caused by ingesting a histamine-like
compound found in certain spoiled \ufb01sh (tuna, mackerel). Facial \ufb02ushing, diarrhea, and urticaria are common
manifestations. Ciguatera \ufb01sh poisoning produces nausea, vomiting, diarrhea, and neurologic symptoms (myalgias,
painful sensory paresthesias).
The toxin is found in \ufb01sh (grouper, snapper) that have fed on a particular marine dino\ufb02agellate.
4. A 63-year-old man presents with a history of several weeks of intermittent fevers, muscle weakness,
arthralgias, and headaches. He also notes recent pain and tenderness on the side of his scalp when he puts on
his glasses. On examination, his temperature is 38.3\u25e6C (101\u25e6F). He has mild proximal muscle weakness.
There is marked tenderness to palpation over the right temporal area. A CPK is normal, CBC shows a mild
normochromic normocytic anemia, and WBC is 10,000. The ESR is 110 mm/h. You know that:
a. Temporal artery biopsy may con\ufb01rm the diagnosis.
b. Treatment of choice is a third- or fourth-generation \ufb02uoroquinolone.
c. This is a migraine headache.
d. The underlying pathophysiology is a virus.
e. Prognosis is poor despite treatment.
The answer is a. Giant cell arteritis, of which temporal arteritis is the most common presentation, is a systemic
vasculitis involving medium and large arteries. It often presents with fever, a markedly elevated ESR, anemia,
myalgias, cephalgia, and temporal artery tenderness. The serum CPK levels are usually normal. Blindness may
occur from involvement of the ophthalmic artery. The disease responds rapidly to systemic steroids and the
prognosis is good if treated early. A positive biopsy of the temporal artery con\ufb01rms the clinical diagnosis.
5. Angioedema:
a. Appears as indurated patches of the periorbital and perioral tissue, hands, feet, and scrotum.
b. Causes intensely pruritic lesions.
c. When hereditary is caused by overproduction of C1 esterase, and may result in life-threatening laryngeal edema
or intestinal colic.
d. When hereditary almost always improves with epinephrine and steroids.
e. Involves the super\ufb01cial dermis, as opposed to urticaria.
The answer is a. Alterations of vascular permeability cause urticaria and angioedema. Acute urticaria is IgE
mediated and more common in adolescents. Chronic urticaria (>6 weeks duration) is nonallergic and more
common in adults. Lung or colon cancer, pregnancy, hypothyroidism, viral infections (hepatitis), and drugs (oral
contraceptives, ASA) have been associated with urticaria. Angioedema involves the deep dermis and subcutaneous
tissues. Urticaria lesions are pruritic. Treatment for hereditary angioedema may include steroids and androgens to
increase C1 esterase production. The treatment of acute urticaria may include removal of the offending agent and
administering H1 and H2 antagonists, epinephrine, and corticosteroids.
... CHAPTER 9 Immunologic Emergencies 125
6. Of conditions listed, the one most frequently implicated in lower extremity pain is:
a. Reactive arthritis.
b. Calci\ufb01c tendonitis.
c. Adhesive capsulitis.
d. Rotator cuff injury.
e. Pancoast tumor.
The answer is a. Reactive arthritis (formerly Reiter\u2019s syndrome) generally involves the joints of the lower
extremities. Calci\ufb01c tendonitis or rupture of the rotator cuff are common causes of shoulder pain. Loss of
abduction is not a speci\ufb01c \ufb01nding for these and occurs in other disorders. Shoulder arthrography or MRI is
necessary to diagnose rotator cuff tears. NSAIDs are the treatment of choice for tendonitis, but select cases may
bene\ufb01t from local steroid injection. Aseptic necrosis is more commonly seen in the hip, but can occur in the
humeral head. Causes of aseptic necrosis include systemic corticosteroid therapy, repeated intra-articular steroid
injections, sickle cell disease, alcoholism, and dysbaric injury. Adhesive capsulitis may occur following trauma and is
characterized by pain and severe limitation of movement. The apex of the lung should always be inspected on
shoulder \ufb01lms as a Pancoast tumor may produce shoulder pain.
7. A common EKG \ufb01nding in a patient with rheumatoid arthritis is:
a. Atrial bigeminy.
b. Left anterior hemiblock.
c. Prolonged PR interval.
d. Right atrial hypertrophy.
e. Shortened QT interval.
The answer is c. ECG is indicated for patients with arthritis who have a history of chest pain or complaints that
might be related to the heart, or physical examination \ufb01ndings of a new or changing heart murmur, evidence of
congestive heart failure, or cardiomegaly. In carditis, prolongation of the P-R interval is the most common \ufb01nding,
and if pericarditis is present, acute diffuse ST segment elevations may be noted.
8. The triad of fever, joint pain, and rash in a woman of childbearing age should suggest the diagnosis of
systemic lupus. You also know that:
a. The most common cardiac manifestation is left bundle-branch block is, reported in 30% of patients.
b. Exudative pleural effusions are relatively common.
c. Persistent hematuria is seen in approximately 50% of patients.
d. Neurologic presentations, such as seizures, stroke, psychosis, migraines, and peripheral neuropathies, are
frequently the \ufb01rst signs of disease.
e. Unlike rheumatoid arthritis, the in\ufb02ammation of the hands is asymmetric.
The answer is b. Pleural effusions, seen in 12% of SLE patients, are usually exudative in nature. Like rheumatoid
arthritis, the in\ufb02ammation of the hands, speci\ufb01cally the proximal interphalangeal and the metacarpophalangeal
joints, is symmetric. Clinical nephritis, de\ufb01ned as persistent proteinuria, is seen in approximately 50% of patients.
Nervous system manifestations are varied and include seizures, stroke, psychosis, migraines, and peripheral
neuropathies, but are rarely the initial sign. Pericarditis is the most common cardiac manifestation of SLE, reported
in 30% of patients.
126 Emergency Medicine Q & A: Pearls of Wisdom ...
9. The most common \ufb01nding in patients with Behc¸et syndrome is recurrent, painful genital aphthous ulcers.
However the hallmark \ufb01nding for this disease is:
a. Green sclera.
b. Hypopyon uveitis.
c. Bullous conjunctivitis.
d. Optic neuritis and a \u201cblueberry\u201d spot on the retina.
e. Recurrent, painful corneal ulcers.
The answer is b. Recurrent, painful aphthous ulcers that involve the oral mucosa and genitals are clinically
predominant, but the hallmark of Behc¸et\u2019s, a hypopyon uveitis, is seen rarely. Other eye involvement includes iritis,
uveitis, and optic neuritis, all of which can lead to blindness. CNS vasculitis, resulting in meningoencephalitis,
intracranial hypertension, or a multiple sclerosis-like syndrome, can also occur.
10. You are evaluating a 35-year-old woman who complains of precordial chest pain. She has a long history of
systemic lupus. You know that:
a. Libman-Sachs vegetations are infectious excrescences on the aortic valve, representing bacterial endocarditis.
b. Lupus pericarditis requires high-dose steroid therapy.
c. Pericardial effusions are found in more than half of lupus patients.
d. Pericarditis is the most common cardiac manifestation of SLE.
e. SLE patients have no increased risk of coronary artery disease.
The answer is d. Pericarditis is the most common cardiac manifestation of SLE, reported in 30% of patients. Signs
and symptoms include fever, tachycardia,