Rosh Review A1.4

A 22-year-old man presents to the ED with clonus of his neck to the right.  Which of the following drugs is he most likely to be taking?

A. Benztropine

B. Cocaine

C. Haloperidol

D. Ziprasidone

This man is having a dystonic reaction, which is a common side effect of haloperidol and other typical antipsychotic drugs.  Haloperidol is a high potency antipsychotic that blocks dopamine-2 receptors at the basal ganglia which can lead to acute dystonia shortly after drug initiation (50% occur within 48 hours, 90% within 5 days) and sustained movement disorders (parkinsonism and tardive dyskinesia) with prolonged use. Symptoms of acute dystonia include intermittent, involuntary and uncoordinated hyperkinetic movements most often affecting the tongue, face, neck, trunk or extremities.  Treatment is with IM or IV benztropine or diphenhydramine and recovery is rapid after medication administration.

Benztropine (A) has both anticholinergic and antihistamine activity and is commonly used for the treatment of movement disorders. Although cocaine (B) does not typically cause dystonia, it can increase the risk for dystonic reactions and is associated with choreoathetoid movements that are referred to as crack-dancing.  Ziprasidone (D) is an atypical antipsychotic drug that is much less likely to cause dystonia and other extrapyramidal symptoms.

Rosh Review Q1.4

A 22-year-old man presents to the ED with clonus of his neck to the right.  Which of the following drugs is he most likely to be taking?

A. Benztropine

B. Cocaine

C. Haloperidol

D. Ziprasidone

Answer will post on Thursday morning

Rosh Review A1.3

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

The patient has thrombotic thrombocytopenic purpura (TTP). The classic pentad of TTP includes CNS abnormalities, renal pathologyfevermicroangiopathic hemolytic anemia, and thrombocytopenia. However, diagnostic criteria have recently been simplified to include all adults with microangiopathic or microvascular hemolytic anemia and thrombocytopenia with no other explanation for these findings. TTP shares many clinical and laboratory features as HELLP syndrome. HELLP syndrome is less common before 24 weeks gestation and the derangements in hemoglobin and platelet levels are more severe in TTP. The treatment mainstay of treatment for TTP is plasmapheresis (plasma exchange), which can achieve remission of disease in 80% of patients. If plasmapheresis cannot be immediately performed, fresh frozen plasma (FFP) should be administered, until pheresis can be performed.

The patient’s fetus is nonviable at 20 weeks gestation (A) and cannot be delivered. If the fetus is viable, delivery is an option. However, the patient is at high risk for bleeding complications and medical therapy and plasmapheresis is the first line of treatment. Magnesium sulfate (B) is used in the treatment of eclampsia. Although this patient had a seizure, her blood pressure is normal and her lab results are more consistent with TTP than eclampsia. While platelet levels are low in TTP,platelet transfusion (D) is reserved only for patients with life-threatening bleeding. Any administration of platelets will result in destruction from platelet aggregation in the microvascular circulation.

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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

Click on the comment link below to submit your answer. The correct answer will post on Thursday.

Questions are taken from RoshReview.com

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.

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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

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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.

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