Rosh Review Q1.3

A 32-year-old woman who is at 20 weeks gestational age presents to the ED after a seizure. Her vital signs are BP 115/70, HR 105, RR 16, T 98.7°F, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/microliter. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition?

A. Delivery of fetus

B. Magnesium sulfate

C. Plasmapharesis

D. Platelet transfusion

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Questions are taken from RoshReview.com

Tracings 4.1

A 62 year-old man was conveyed to the  ED in Police Department custody complaining of pressure-like chest pain. The patient relates that his chest pain came on coincidentally with the stress brought on by his arrest approximately 24 hours prior. It has been “off and on” since then. The police had taken the patient to an outside hospital on the day prior to this ED visit for chest pain. The patient reports that he was told that he had “some type of heart block” and that they wanted to do a cardiac catheterization but he refused and left AMA.

The patient relates a history of chest pain dating back several years but he has never had a heart attack. The pain occurs twice a week, is precipitated by stress or exercise, does not radiate, is accompanied by “a little” shortness of breath and generally resolves after 20 minutes.  He relates that he “miserably failed” a stress test one year prior, but did not want to undergo a cardiac catheterization at the time.

PMH: Type 2 diabetes, hyperlipidemia.  Medications are glipizide 10 mg twice a day, nitroglycerin sublingually when necessary, simvastatin 20 mg daily, aspirin 81 mg daily. He denies alcohol, tobacco, and illicit drug use.

On exam, BP is 122/76, R 18, P 78 and irregular, T 36.0. there are no other significant findings.

This ECG is obtained. What is your interpretation?

The ECG reflects normal sinus rhythm at a rate of 75 bpm (P waves identified with arrows). Some of the P waves that fall on T waves look slightly more peaked than the others but this is an interaction with the T wave, not a second atrial focus. This fact is confirmed by the observation that the P waves all march out.

The long PRs and widely varying PR intervals might make one tempted initially to interpret the tracing as 3rd degree AV block.

However, a basic ECG principle is: be suspicious of complete HB as a diagnosis when the QRS rhythm is irregular. Why? Because you should expect an escape AV nodal or ventricular rhythm to be regular. And this rhythm is pretty irregular.

So….another look reveals that there are repeating PR intervals of differing durations, each identified on the tracing above as “A”, “B”, and “C”. This rules out A-V dissociation…and eliminates complete heart block as a diagnosis.

The cycles of increasing P-R intervals with some blocked  P waves (marked with “X”) are diagnostic of Mobitz Type I (Wenckebach) second degree heart block. One of the blocked beats (marked with a question mark) falls on a QRS complex and is therefore not visible.

There is generally 3:2 conduction present, that is, for each 3 P waves, 2 are conducted to the ventricles and produce QRS complexes. (Or you could also say 3:1 block; for each 3 P waves, 1 is blocked.) The exception is the third complete group of beats, for which there is only an “A” PR interval before a P wave is blocked, reflecting 2:1 conduction (or, if you prefer, block).

When second degree heart block presents with consistent 2:1 conduction, it is impossible to tell whether there is Type I or Type II second degree block. However, when there is 2:1 block with concurrent evidence of Wenckebach conduction, as we have here, we can assume that Wenckebach conduction  prevails.

Finally, there is also first degree heart block, as the shortest P-R interval measures 0.44 sec. Indeed, if this were not present, the diagnosis of Mobitz I would be considerably less problematic.

Case follow up: the patient ruled out for acute MI with 2 negative troponins. He was offered cardiac catheterization and/or further cardiology consultation but signed out against medical advice.

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics are derived from the EM Model for Resident Education. Cases are prepard by Dr. William Berk.

Rosh Review A1.2

Q. A 39-year-old woman presents to the ED complaining of pain and swelling to her distal index finger. On exam, you note her finger as seen in the below image. There is mild tenderness and full range of motion at the distal interphalangeal joint. Which of the following is the most likely diagnosis?

A. Eponychia

B. Felon

C. Herpetic whitlow

D. Paronychia

The lesion seen above is a herpetic whitlow, secondary to herpes simplex infection. This is the most common viral infection of the hand. It is usually caused by direct inoculation of the virus into an open wound or broken skin. It is often reported in adult women who also have genital herpes, children with coexistent herpetic gingivostomatitis, and healthcare workers who are exposed to orotracheal secretions. The infection usually involves a single finger and begins with localized pain, pruritus, and swelling, followed by the appearance of clear vesicles. Systemic symptoms are usually absent. But, secondary bacterial infection of the vesicles can occur. Over two weeks, the vesicles coalesce to form an ulcer, at which time the lesion may be difficult to distinguish from other common finger infections, such as a felon or paronychia. The lesions will resolve spontaneously over 3 to 4 weeks. The lesions should be kept covered. The role of oral acyclovir is not clear in immunocompetent individuals, but should be administered in the immunocompromised and those with recurring infections.

An eponychia (A) is a localized soft tissue infection, similar to a paronychia (D), but occurs under the eponychium aspect of the nail. Both present with a swelling, erythema, and tenderness at the respective nail fold. A felon (B) is an infection of the fingertip pulp. The main difference between this finger infection and others is the fingertip is separated into small closed spaces by vertical septae. Infection can easily spread along these compartments.

All Questions are taken from RoshReview.com

Rosh Review Q1.2

Q. A 39-year-old woman presents to the ED complaining of pain and swelling to her distal index finger. On exam, you note her finger as seen in the below image. There is mild tenderness and full range of motion at the distal interphalangeal joint. Which of the following is the most likely diagnosis?

A. Eponychia

B. Felon

C. Herpetic whitlow

D. Paronychia

Answer will post on Thursday

All Questions are taken from RoshReview.com

Rosh Review A1.1

Image

Q. Which of the following is classically seen in flexor tenosynovitis?

A. Extended position of the involved digit

B. Fusiform swelling of the digit

C. Tenderness over the extensor sheath

D. Vesicular eruption over the flexor surface

The flexor tendons of the fingers are covered by a double layer of synovium to promote gliding of the tendon underneath. Infections in the synovial spaces in the hand tend to spread along the course of the flexor tendon sheaths and may extend proximally to the hand. Infections are usually due to penetrating trauma involving the sheath, but occasionally from hematogenous spread. There are four cardinal signs of acute flexor tenosynovitis that are usually present to help distinguish tenosynovitis from other hand infections. These criteria are referred to as the Kanavel signs.

Kanaval Criteria for Flexor Tenosynovitis
Tenderness along the course of the flexor tendon
Fusiform or symmetrical swelling of the finger
Pain with passive range of motion
A flexed posture of the finger

Flexor tenosynovitis is a surgical emergency. Consultation with a hand surgeon is warranted along with intravenous antibiotics.

The affected digit is held in a flexed (A), not extended posture. The tenderness is over the flexor (C) sheath, not extensor. Vesicles (D) are not commonly associated with flexor tenosynovitis. A localized herpes simplex infection may cause vesicles to form on a digit.

Ref: Lyn ET, Mailhot T: Hand, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch)47:p 521-522.

All Questions are taken from RoshReview.com

Rosh Review Q1.1

Image

QWhich of the following is classically seen in flexor tenosynovitis?

A. Extended position of the involved digit

B. Fusiform swelling of the digit

C. Tenderness over the extensor sheath

D. Vesicular eruption over the flexor surface

Answer will post on Thursday

All Questions are taken from RoshReview.com