Emergency Medicine Board Review

EM Board Review by Rosh Review

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50 episodes
Updated Nov 5, 2019

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Nov 5, 2019 · 4 min
What Is the First-Line Treatment for This Patient’s Eye Pain?
Welcome to the next episode of The Reveal where we take you inside the mind of a test-taker to deconstruct and connect the dots of a board-style question so you can become a better student, transform how you learn, and excel not only on high-stakes exams, but also in your general medical knowledge. Let’s get started. Episode 18 is limited to audio only, but video returns for episode 19. A 21-year-old woman presents with pain, tearing, photophobia, and left eye redness. She has been wearing her contact lenses continuously for the last two weeks. A slit lamp examination reveals a white, hazy opacity on the cornea at the 3 o’clock position of the cornea with associated limbal flush. Which of the following is the most appropriate pharmacotherapy? A. Topical acyclovir B. Topical amphotericin B C. Topical ciprofloxacin D. Topical cyclopentolate You can find other episodes of The Rosh Reveal podcast here. Remember to subscribe to the podcast and leave us feedback! Apple podcasts Android Google podcasts For more great Rosh Review content, including thousands of more questions, explanations, and custom teaching images, visit any of the pages below: PA: Didactics, Rotation Exams, PANCE, PANRE Nurse Practitioner: Certification Exam, ENP Certification Exam, AGACNP Certification Exam, AGPCNP Certification Exam, CPNP-PC Certification Exam, PMHNP Certification Exam Nursing: Certified Emergency Nurse (CEN) Certification Exam Emergency Medicine: In-Training Exam, Certification Exam, ConCert Family Medicine: In-Training Exam, Certification Exam Pediatrics: In-Training Exam, Certification Exam OB/GYN: In-Training Exam, Certification Exam Internal Medicine: In-Training Exam, Certification Exam Psychiatry: In-Training Exam, Certification Exam The post What Is the First-Line Treatment for This Patient’s Eye Pain? appeared first on RoshReview.com.
Feb 25, 2019 · 14 min
Ep 52 Roshcast Emergency Board Review
Welcome back to RoshCast for Episode 52! For those of you taking the upcoming in-training exam, an early congratulations! All of your hard work will surely pay off soon. Remember to listen to this episode and old episodes as you get closer to the end for more review. Good luck from us at the RoshCast team! Begin to be now what you will be hereafter. –William James Question 1 A 64-year-old woman presents to the emergency department with a right-sided headache. Past medical history includes hypertension, migraines, and polymyalgia rheumatica. Her symptoms started three days ago and have progressively worsened. She states that this headache is different from her previous migraines. It is frontal and she describes it as an ache without radiation of symptoms. She does describe worsening of symptoms with eating as well as when she brushes her hair. She admits to feeling more tired the last couple of days as well as having partial vision loss in the right eye. She denies any nausea or vomiting. Vital signs demonstrate a temperature of 38°C but otherwise are within normal limits. Physical examination is remarkable for tenderness to palpation over the right temple and visual acuities of 20/40 OS and 20/80 OD. What is the most appropriate next step in this patient’s management? A. Intravenous methylprednisolone B. Obtain erythrocyte sedimentation rate and C-reactive protein to confirm the diagnosis C. Obtain temporal artery biopsy D. Oral prednisone Teaching Image Question 2 A 42-year-old man presents to the emergency department with lower back pain that started acutely while lifting a couch. He complains of pain radiating to the right posterolateral calf. He denies any bowel or bladder incontinence. On examination, he has decreased plantar flexion at the right ankle and numbness of the right lateral foot. Disk herniation at which level is most likely responsible for his findings? A. L2–L3 B. L3–L4 C. L4–L5 D. L5–S1 Teaching Image Question 3 Which of the following is most likely to be seen in hepatorenal syndrome? A. Arteriolar congestion B. Histologically normal kidneys C. Necrosis of the renal tubules D. Segmental sclerosis of the renal glomeruli Teaching Image Question 4 A 27-year-old man presents to the ED with left-hand pain. He was at work as an auto mechanic when he accidentally injected his left index finger with a grease gun. On physical exam, the digit is swollen with a central pinhole wound. The remainder of the hand exam is unremarkable. Which of the following will best determine the amount of tissue damage a substance will cause? A. Chemical properties of the substance B. The pressure of the injection C. The temperature of the substance injected D. The volume of the substance injected Teaching Image Question 5 A 5-year-old girl presents to the ED with a rash that started on her face and spread to her neck, axillae, and groin. Mom states that the patient had an upper respiratory infection one week prior. On examination, the patient’s rash is tender to the touch. Which of the following statements regarding the diagnosis of this patient’s condition is correct? A. Deep layers of the dermis are involved B. It often leaves the patient disfigured from scarring C. Mucous membrane involvement is common D. The disease is caused by an exotoxin producing bacteria Teaching Image Question 6 A 22-year-old man complains of pain, photophobia, and vision loss in his eye. He has a history of sickle cell anemia. His vision is 20/200 in the affected eye. Intraocular pressure is 30 mm Hg in the affected eye. You see the above finding on physical exam. Which of the following medications should be immediately administered to this patient? A. Intravenous ketorolac B. Intravenous mannitol C. Topical acetazolamide D. Topical timolol Teaching Image Vision loss is the most concerning clinical feature in patients with temporal arteritis, whereas jaw claudication is the clinical feature that is most likely associated with a positive temporal artery biopsy. S1 radiculopathy leads to decreased plantar flexion, numbness to the lateral foot, decreased sensation along the posterolateral calf, and decreased Achilles reflex. Hepatorenal syndrome leads to arteriolar constriction and the kidneys here would appear normal histologically. The chemical properties of the substance injected is the primary determinant of damage caused by high-pressure injection injury. While air and clean water have a benign course, paint solvents cause the most severe inflammation. Staph scalded skin syndrome presents in children less than 5 years old and often follows a URI. The rash starts on the face, neck, axillae, and groin, and there will be a positive Nikolsky sign. Patients with a spontaneous hyphema present with decreased visual acuity, elevated intraocular pressure, and an afferent pupillary defect. Immediate treatment is with agents that lower intraocular pressure including topical timolol. That wraps up RoshCast Episode 52! Creating and producing RoshCast has been a ton of fun, but it also takes a ton of time. We are unfortunately halting production for the time being to focus on other projects. We thank you all for your long-time listenership. And don’t forget that there are 51 other episodes. Listen and re-listen on your commute to work, at the gym, or even just at a desk during dedicated study time. A huge thanks also goes out to all of the folks at Rosh Review who have worked diligently to create high-quality clinical questions. If you need to reach us, please e-mail Nachi at nachig@gmail.com. Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images, and tables, as well as bonus teaching points. Jeff, Megha, and Nachi The post Podcast Ep 52: Temporal Arteritis, Disc Herniations, Hepatorenal Syndrome, High Pressure Injection Injury, Pediatric Rash, Hyphema appeared first on RoshReview.com.
Oct 30, 2018 · 13 min
Ep 51 Roshcast Emergency Board Review
A champion is defined not by their wins but by how they can recover when they fall. –Serena Williams Welcome back to RoshCast for Episode 51! For those of you taking the initial certification exam, you’re at the home stretch. Remember to listen to this episode and old episodes as you get closer to the end for more review. Good luck from us at the RoshCast team! We have a great episode for you to get you prepped in your final studies! Question 1 A 46-year-old man presents with a progressive dull headache over the past 3 weeks. It is worse in the morning and with bending over or coughing. He denies any fever or congestion. For the last two days, he has had associated nausea and three episodes of vomiting. Which of the following characteristics seen on neuroimaging would be most consistent with a glioblastoma? A. Heterogenous mass with central necrosis B. Lack of enhancement with administration of contrast C. Presence of calcifications D. Well circumscribed margins Teaching Image Question 2 A 16-year-old African American boy presents with a scalp rash. On examination, it is a 5 x 5 cm boggy and thickened area of the right parietal cap with an overlying scaly and crusty plaque and hair loss. The lesion appears yellowish-green under a Wood’s lamp. What is the treatment of choice for this lesion? A. Clotrimazole ointment B. Ketoconazole shampoo C. Oral amphotericin B D. Oral griseofulvin Teaching Image Question 3 A 22-year-old man recently diagnosed with schizophrenia presents to the ED with altered mental status. His blood pressure is 160/80 mm Hg, pulse 130 beats per minute, and temperature is 39.5°C. He is noted to be confused and diaphoretic. He has muscle rigidity and a tremor in his hands. What is the most likely diagnosis? A. Malignant hyperthermia B. Neuroleptic malignant syndrome C. Serotonin syndrome D. Tyramine reaction Teaching Image Question 4 A 21-year-old woman presents with painful urination. She has no vaginal discharge and is not sexually active. Which of the following is most sensitive for a urinary tract infection on urine dipstick testing? A. Bacteria B. Blood C. Leukocyte esterase D. Nitrites Teaching Image Question 5 Which of the following findings would be consistent with a diagnosis of tetralogy of Fallot? A. Bounding pulses and a continuous machine-like murmur B. Decreased pulses in lower extremities C. Increased pulmonary vascular markings on chest radiography D. Loud, single second heart sound with a harsh systolic murmur Teaching Image Question 6 A 73-year-old man presents with painless vision loss in the right eye. Which of the following on funduscopic examination is most characteristic of central retinal vein occlusion? A. Cherry red fovea B. Pale retina C. Papilledema D. Retinal hemorrhages Teaching Image Teaching Image Teaching Image Glioblastoma is the most common primary malignant brain tumor in adults and presents as a heterogeneous mass with central necrosis. A kerion is a boggy, pus-filled lesion caused by a fungal infection on the scalp. It is treated with a 6 to 8-week course of oral griseofulvin. New antipsychotic medication administration and a presentation of altered mental status, muscle rigidity, hyperthermia, and autonomic instability is classic for the diagnosis of neuroleptic malignant syndrome. On urine dipstick, leukocyte esterase is sensitive while nitrites are specific for a urinary tract infection. Tetralogy of Fallot is the most common cyanotic congenital heart disease and is associated with a harsh systolic murmur that improves with squatting. Central retinal vein occlusion presents with sudden, painless, monocular vision loss with the classic “blood and thunder” appearance and retinal hemorrhages. That wraps up RoshCast Episode 51! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images, and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 51: Glioblastoma, Kerion, Antipsychotics, Urine Dipstick, Tetalogy of Fallot, Central Retinal Vein Occlusion appeared first on RoshReview.com.
Oct 16, 2018 · 17 min
Ep 50 Roshcast Emergency Board Review
A hero is someone who has given his or her life to something bigger than oneself. –Joseph Campbell Welcome back to RoshCast for Episode 50! Wow!! We can’t believe we’re already at Episode 50. It’s been a real journey building this podcast from the original concept two years ago. And in the last year, we have seen some pretty big changes, including Megha joining the team. We are excited to see how RoshCast continues to evolve over the next fifty episodes and two years. None of this would be possible without you, our listeners. Your listenership and feedback is what drives us to keep delivering high-quality content! We value every moment you give your attention to us, and we try our best to design the episode to maximize your learning. We have a pretty involved process for choosing questions to present to you and for how we manipulate and deliver the content before we get it to your ears. With that, let’s kick off a great episode! Question 1 A 70-year-old woman with history of coronary artery disease, hypertension, and diabetes presents to the emergency department with chest pressure and shortness of breath. Her exam is notable for a new holosystolic murmur best heard over the midaxillary line as well as diffuse bilateral rales. Which of the following is most likely to be seen on this patient’s ECG? A. Biventricular tachycardia B. S1Q3T3 pattern C. ST-depressions in I, V6, and aVL without ST-elevations D. ST elevations in II, III, aVF Teaching Image Question 2 A 26-year-old woman with no medical history presents with bleeding gums after brushing her teeth for the last three days. Her complaint was preceded two weeks ago by a URI. Her examination is unremarkable except for oozing from the gums. Labs show a platelet count of 23,000. Which of the following is the most appropriate next step in management? A. IV immunoglobulin B. Platelet transfusion C. Steroids, IV immunoglobulin D. Steroids, IV immunoglobulin, and platelet transfusion Teaching Image Question 3 Which of the following is most suggestive of measles infection? A. A prodrome of fever, lymphadenopathy, and conjunctivitis followed by a maculopapular rash that starts on the face and spreads to the trunk and limbs B. Diffuse maculopapular rash with white spots on the buccal mucosa C. High fever for three days followed by the appearance of a pink maculopapular rash after defervescence D. Presence of shallow ulcers on oral mucosa and vesicular lesions on the palms and soles Teaching Image Question 4 A 23-year-old man who has unprotected, receptive anal intercourse presents to the ED with two weeks of worsening rectal pain and dyschezia. On exam, he has numerous ulcers in the anorectal area and a crop of grouped vesicles containing clear fluid on an erythematous base. The surrounding skin shows no sign of cellulitis or abscess. Which of the following is the most appropriate next step? A. Refer the patient to a surgeon for operative intervention B. Send a serology test C. Send a Tzanck smear D. Treat with acyclovir Question 5 A 5-year-old boy with von Willebrand disease presents with persistent bleeding after he lost a tooth 4 hours ago. Vital signs are unremarkable. Physical exam reveals oozing at the site of the tooth which persists despite pressure. Which of the following is the most appropriate treatment? A. Desmopressin B. Factor VIII concentrate C. Fresh frozen plasma D. Vitamin K Teaching Image Question 6 A 70-year-old man with a history of chronic neck pain presents after a fall. On physical examination, he has a laceration on his chin. Motor strength is 2/5 in his upper extremities and 4/5 in his lower extremities. He has decreased sensation to soft touch in both legs. Which of the following is the most likely diagnosis? A. Anterior cord syndrome B. Brown-Sequard syndrome C. Cauda equina syndrome D. Central cord syndrome Teaching Image A new holosystolic murmur over the midaxillary line, with signs of heart failure, is consistent with acute mitral valve regurgitation. Think of inferior stemi as a possible cause here. Immune thrombocytopenia presents with bleeding that is often preceded by a viral illness. It is treated with steroids and IVIG in most cases. For those with severe or life-threatening bleeding, platelet transfusion should be considered as well. Measles presents with a prodrome of fever and three Cs (coryza, cough, and conjunctivitis) followed by a diffuse maculopapular rash and Koplik spots. A painful vesicular rash on an erythematous base in the anorectal area is consistent with herpes simplex proctitis. Diagnosis is clinical. Treat with antivirals. von Willebrand disease presents with mucosal bleeding, and the first-line treatment is desmopressin. Central cord syndrome is often the result of a hyperextension injury to the cervical spine. It presents with bilateral motor dysfunction that is greater in the upper extremities than the lower extremities. That wraps up RoshCast Episode 50! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 50: Acute Mitral Regurgitation & More appeared first on RoshReview.com.
Oct 2, 2018 · 15 min
Ep 49 Roshcast Emergency Board Review
Life is like riding a bicycle. To keep your balance, you must keep moving. –Albert Einstein Welcome back to RoshCast for Episode 49! We have a lot of exciting material in this episode. Definitely don’t skip this one! For those taking the initial certification exam, it’s just around the corner. Go back and listen to old episodes and review. Question 1 A 14-year-old boy developed an itchy, painful, erythematous rash on his hands, forearms, and face about a day after hiking in nearby woods with some friends. Your exam shows linear erythematous papules over his forearms with similar swelling and erythema around his eyes (including eyelids), cheeks, and forehead. You suspect poison ivy that he reports he has had in the past. Which of the following is most likely to improve the course of his illness? A. Oral diphenhydramine every six hours B. Three-week prednisone taper C. Topical 1% hydrocortisone three times daily D. Topical calamine lotion twice daily Teaching Image Question 2 Which of the following patients will benefit most from receiving tissue plasminogen activator for acute pulmonary embolism detected in the emergency department? A. 55-year-old man with a history of hypertension with vital signs showing HR 100/min, BP 80/40 mm Hg, R 24/min, and oxygen saturation 92% B. 55-year-old man with a history of hypertension with vital signs showing HR 145 bpm, BP 136/86 mm Hg, R 24/min, and oxygen saturation 92% C. 55-year-old woman with a history of hypertension and systemic lupus erythematosus with vital signs showing HR 100 bpm, BP 116/86 mm Hg, R 24/min, and oxygen saturation 85% D. 55-year-old woman with a history of hypertension with vital signs showing HR 110 bpm, BP 122/80 mm Hg, R 24/min, and oxygen saturation 92% with evidence of right ventricular dysfunction on echocardiogram Teaching Image Question 3 A 55-year-old woman presents to the emergency department unresponsive. She and her friend had finished eating 60 minutes earlier when the patient collapsed to the floor while talking. Which of the following foods is most likely the cause? A. Apricot kernels B. Fava beans C. Peanuts D. Poppy seeds Teaching Image Question 4 Which of the following is due to the intense thermal radiation seen in lightning strikes? A. Cataract formation B. Hypertension and tachycardia C. Mydriasis D. Tympanic membrane rupture Teaching Image Question 5 A 32-year-old woman with no past medical history presents to the emergency department with a four-day history of bloody diarrhea and abdominal cramping. She states that her boyfriend is having similar symptoms but did not want to come to the hospital. Their symptoms started two days after they shared a meal at their favorite fried chicken restaurant. The patient’s vital signs are 37.4℃, HR 89/min, BP 112/70 mm Hg, RR 17/min. Physical examination is significant for moist mucus membranes with brisk capillary refill and mild diffuse tenderness to palpation of the abdomen. Which of the following is the most appropriate management of this patient’s illness? A. Admit for IV azithromycin and rehydration B. Admit for IV rehydration and observation for resolution of diarrhea C. Discharge home with ciprofloxacin D. Discharge home with metronidazole Teaching Image Question 6 A 54-year-old man with a history of HIV and recent CD4 count of 85 presents with headache for 3 days. The patient’s sister says that he has been increasingly confused over the last 3 days. While in the emergency department, he has a seizure which resolves spontaneously. Electrolytes are within normal limits. A CT scan is performed and is shown above. Which of the following medication regimens should be given? A. Amphotericin B B. Ganciclovir and foscarnet C. Pyrimethamine, sulfadiazine, and leucovorin D. Trimethoprim-sulfamethoxazole Teaching Image Localized reaction from poison ivy can be treated with topical high-potency corticosteroids. Extensive reactions or reactions involving the face or genitalia need a 2–3-week course of tapering systemic steroids. Persistent hypotension or shock due to acute pulmonary embolism is the only widely accepted indication for systemic thrombolysis. Severe metabolic acidosis is a hallmark feature of cyanide poisoning and treatment is with hydroxycobalamin. Lightning strikes cause injuries via both acute thermal radiation and widespread electrical damage. Intense thermal radiation can cause tympanic membrane perforation. Undercooked poultry is associated with infection from Campylobacter jejuni. This can present with bloody diarrhea, abdominal cramping, and vomiting. Treatment is with fluoroquinolones or azithromycin. Subcortical, ring-enhancing lesions on a CT of the brain in an HIV patient with a CD4 < 100 is indicative of toxoplasmosis and treatment is with pyrimethamine, sulfadiazine, and leucovorin. CNS lymphoma also causes ring-enhancing lesions in patients with AIDS but lesions in this case are usually solitary and located in the periventricular white matter. Symptoms are usually gradually progressive over months rather than days. That wraps up RoshCast Episode 49! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 49: Poison Ivy, tPA, Cyanide Poisoning, & More appeared first on RoshReview.com.
Sep 18, 2018 · 15 min
Ep 48 Roshcast Emergency Board Review
Success is not final, failure is not fatal: it is the courage to continue that counts. –Winston Churchill Welcome back to RoshCast for Episode 48! We’re going to jump right into questions this week. Remember to send us feedback for any changes you would like to see at roshcast@roshreview.com. Question 1 An 8-year-old previously healthy boy presents with back pain and fever for 4 days. He complains of pain in the low back, which is increased with bending or twisting. The pain radiates down into his left leg. He denies trauma. Physical exam is remarkable only for tenderness to palpation over the lumbar spine. What management is indicated A. Ibuprofen and follow up with his pediatrician B. MRI of the lumbar spine C. Plain radiographs of the lumbar spine D. Urinalysis Teaching Image Question 2 A 40-year-old man is brought to the emergency department after being assaulted during a bar fight. He has proptosis of the right eye with a measured intraocular pressure of 50 mm Hg. A lateral canthotomy is started. Once the Kelly clamp is released from the lateral canthus, what is the appropriate next step? A. Clamp the medial canthus B. Cut the inferior crus of the lateral canthal tendon C. Cut the superior crus of the lateral canthal tendon D. Recheck intraocular pressure Teaching Image Question 3 A 25-year-old man presents to the emergency department after sustaining burns to the hands, legs, and chest after falling into a bonfire. On physical examination, there are partial-thickness burns on the upper half of the anterior torso along with the bilateral palms of the hands and bilateral anterior legs. He weighs 70 kg. You begin to initiate fluid resuscitation using the Parkland formula. How much fluid should this patient receive in the first eight hours? A. 10,640 mL B. 4,060 mL C. 5,320 mL D. 8,120 mL Teaching Image Question 4 A 64-year-old man presents to the emergency department with cough and shortness of breath that has progressively been worsening over the last several weeks. He has also been more fatigued and is unable to get around the house anymore. He denies fever and night sweats. He has a past medical history of hypertension and takes lisinopril daily. He is an immigrant from Argentina where he used to work as a miner. He denies tobacco use. What is the most likely diagnosis based on this chest radiograph? A. Histoplasmosis B. Miliary tuberculosis C. Pneumoconiosis D. Sarcoidosis Teaching Image Teaching Image Teaching Image Teaching Image Question 5 A 53-year-old man presents with numbness to his right hand for three to four months. He states that he has numbness with waking up in the morning, which gets better when he shakes his hands. The patient indicates numbness to his first, second, and third digits on the right hand. Which of the following tests is most sensitive for this diagnosis? A. Finkelstein test B. Median nerve compression test C. Phalen test D. Tinel sign Teaching Image Question 6 A young man is involved in a motor vehicle collision and sustains a severe head injury. In the ED, his GCS is 7. His blood pressure is 115/70 mm Hg and heart rate is 85 beats per minute. His pupils are 3 mm and equal and reactive to light. You intubate the patient and place him on a mechanical ventilator. The FAST ultrasound is negative and there are no other obvious injuries. Which of the following is the most important principle to follow in the management of this patient? A. Administer mannitol B. Avoid hypotension C. Hyperventilation D. Initiate induced hypothermia Discitis presents with severe localized radiating pain. The lumbar spine is most commonly involved, and treatment is with IV antibiotics. A lateral canthotomy is performed to relieve intraocular pressure from a retrobulbar hematoma or a postseptal hemorrhage. It is done by cutting the inferior crus of the lateral canthal tendon. The Parkland Formula is used to determine the volume of fluid required for resuscitation of burn patients. It is 4 mL x body weight in kg x % total body surface area of the burn. Half of this fluid is given within the first 8 hours and then other half over the next 16 hours. Pneumoconiosis is a restrictive lung disease that can be caused by inhalation of dust, often in mines. It presents with bilateral ground glass opacities on Chest X-ray. The Median Nerve Compression Test is the most sensitive test for confirming carpal tunnel syndrome. It consists of direct pressure application to the median nerve at the carpal tunnel. Hypotension and hypoxia have both been shown to have a devastating effect on the outcome of patients with traumatic brain injury. That wraps up RoshCast Episode 48! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 48: Pediatric Back Pain, Lateral Canthotomy, & More appeared first on RoshReview.com.
Sep 4, 2018 · 14 min
Ep 47 Roshcast Emergency Board Review
If you fell down yesterday, stand up today. –H. G. Wells Welcome back to RoshCast for Episode 47! Let’s kick off this episode with a review of Neisseria meningitides, an important topic for clinical practice and personal safety. Neisseria meningitides is highly contagious and antibiotic prophylaxis is indicated for close contacts of an infected patient, including those in contact with secretions as well as members of the same household or daycare center. Healthcare workers with close contact with the patient’s secretions should also receive prophylaxis. There are three options for prophylaxis: Rifampin is administered at a dose of 10 mg/kg with a max dose of 600 mg every 12 hours for 4 doses, and this is 100% effective as far as we know. Ceftriaxone 250 mg IM can be given for 1 dose, which is 97–100% effective. The least effective option is Ciprofloxacin 500 mg PO for 1 dose, and that’s 90–95% effective. Even though rifampin is the most effective, be wary of its side effects, which include turning secretions like tears and urine orange. Contact lens wearers should be warned of permanent staining. Teaching Image Now onto this week’s podcast Question 1 A 33-year-old woman presents to the ED with agitation and severe respiratory distress. She has been taking a significant amount of “pain medication” for low back pain, according to her son. The patient is screaming about her “ears ringing.” Vital signs are BP 100/60 mm Hg, HR 140 beats per minute, RR 35 breaths per minute, and T 100.1°F. Which of the following complications is she at risk of developing? A. Hemodynamically significant lower gastrointestinal bleeding B. Increased intracranial pressure C. Noncardiogenic pulmonary edema D. Urinary retention requiring catheterization Teaching Image Question 2 Which of the following is associated with carbon monoxide poisoning? A. Bilateral basal ganglia hypodensities B. Elevated pH C. Low PO2 D. Odor of bitter almonds Teaching Image Question 3 A 62-year-old woman presents to the emergency department with dizziness. She describes the events as a spinning sensation that is worse with position changes. The dizziness is associated with hearing loss as well as tinnitus and vomiting. She notes it started three days ago and that she has had multiple episodes all lasting less than a day since that time. On physical examination, horizontal nystagmus is present as is decreased hearing on the left. The remainder of the ear and neurologic examination is within normal limits. A head CT and brain MRI are performed and are negative. Which of the following is the most likely diagnosis? A. Acoustic neuroma B. Labyrinthitis C. Meniere disease D. Vestibular neuritis Teaching Image Teaching Image Teaching Image Question 4 A 28-year old woman presents with several painful ulcers she has developed in the vaginal area. Examination reveals multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her mouth, her past history is unremarkable. At this time, which of the following is the most likely diagnosis? A. Behcet syndrome B. Herpes simplex C. Reactive arthritis D. Syphilis Teaching Image Question 5 A 65-year-old man on peritoneal dialysis presents because his dialysis effluent is cloudy. You send it for culture and Gram staining, which returns with a preliminary result of gram-positive cocci in clusters. Vital signs are BP 125/70 mm Hg, HR 80 bpm, RR 14/min, and T 98.5°F. Other than abdominal ascites, the physical exam is unremarkable. Which of the following is the most appropriate management for this condition? A. Inpatient management with antibiotics and temporary hemodialysis B. Inpatient management with IV antibiotics C. Outpatient management with intraperitoneal antibiotics D. Outpatient management with oral antibiotics Teaching Image Question 6 Which of the following historical features is most consistent with infantile spasms? A. Occur in clusters lasting a few minutes at a time B. Occur more frequently during sleep C. Onset between 12 and 18 months of age D. Precipitated by loud noises or handling Teaching Image Salicylates, opioids, naloxone, phencyclidine, and meprobamate can cause noncardiogenic pulmonary edema. Patients with acute salicylate toxicity with levels greater than 100 mg/dL and chronic toxicity with levels greater than 60 mg/dL require dialysis. Neurologic sequelae from carbon monoxide poisoning can be identified radiographically within 12 hours of exposure as symmetric hypodense lesions in the basal ganglia. Meniere disease is a set of episodic symptoms including vertigo, hearing loss, tinnitus, and a sense of fullness in the ear. Episodes last anywhere from 20 minutes to 4 hours. Behcet syndrome presents as recurring genital and oral ulcerations and also relapsing uveitis. Peritonitis is the most common complication of peritoneal dialysis, and it can often be treated with intraperitoneal antibiotics as an outpatient. Infantile spasms present before the age of one and EEG shows hypsarrhythmia. This is treated with corticotropin. That wraps up RoshCast Episode 47! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the Submit Feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 47: Salicylate Toxicity, Carbon Monoxide Poisoning, & More appeared first on RoshReview.com.
Aug 21, 2018 · 14 min
Ep 46 Roshcast Emergency Board Review
Only those who dare to fail greatly can ever achieve greatly. –Robert F. Kennedy Welcome back to RoshCast for Episode 46! Let’s kick off this episode with a rapid review of molluscum contagiosum. Molloscum contagiosum is caused by poxvirus. It is seen in children, sexually active adults, and immunocompromised patients like those with HIV. The rash presents as painless, pearly, umbilicate papules, and it is spread by direct skin-to-skin contact. Children present with lesions on the face, trunk, and extremities, whereas sexually active adults can present with lesions in the genital regions, lower abdomen, and thighs. The rash tends to spare the palms and soles. Most patient will not require therapy with spontaneous resolution occurring in months. Those with extensive lesions may benefit from cryotherapy. HIV positive patients with a CD4 count less than 100 are at greater risk for developing molluscum contagiosum. Teaching Image Now onto this week’s podcast Question 1 Which of the following organisms is one of the most commonly implicated in the development of a lung abscess? A. Klebsiella pneumoniae B. Peptostreptococcus C. Staphylococcus aureus D. Streptococcus pneumoniae Teaching Image Question 2 A 26-year-old man presents to the ED after being hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head? A. A collection of blood layering in the basilar cisterns B. A crescent-shaped frontal hematoma crossing suture lines C. A lenticular-shaped hematoma in the temporal region D. An intraparenchymal hemorrhage within the frontal lobe Teaching Image Question 3 A 55-year-old man who is taking several antihypertensive medications presents to the ED with nausea, vomiting, shortness of breath, and a rash after eating a home-cooked Thai meal at a friend’s house about one hour ago. The symptoms began within seconds of the first bite of his meal. Despite the patient being administered 2 doses of intramuscular epinephrine, diphenhydramine, dexamethasone, and crystalloid fluids, his blood pressure remains at 75/38 mm Hg. Which other medication should be considered in this patient? A. Cimetidine B. Glucagon C. Norepinephrine D. Octreotide Question 4 A 36-year-old man presents to the ED after having a seizure. He has a folder full of medical records dating back 15 years. Several of the records are from other cities and states. It is now 11:00 pm on a Friday night. His primary care physician, neurologist, and psychiatrist are “out of town,” and he believes that he needs to be admitted for the duration of the weekend. He has another episode in the ED and immediately following this he returns to his baseline. He is now awake and alert. You immediately draw a serum lactate and it is normal. Which of the following diagnoses should be strongly considered in this patient? A. Conversion disorder B. Hypochondriasis C. Munchausen syndrome D. Somatization Teaching Image Question 5 A 4-year-old boy is brought to the emergency department by his parents after they found him in the backyard shed choking and gagging. Before this event, he was otherwise healthy. His temperature is 101°F, heart rate is 95 bpm, blood pressure is 100/60 mm Hg, and respiratory rate 40/min. On exam, he appears sleepy but continues to cough. Pulmonary findings include moderate retractions and diffuse wheezes. A chest X-ray shows patchy infiltrates. What is the most likely diagnosis? A. Foreign body aspiration B. Hydrocarbon ingestion C. Organophosphate ingestion D. Status asthmaticus Teaching Image Question 6 A 12-year-old boy presents to the ED after his brother bumped into his elbow while he was using a cotton-tipped swab to clean out his ear. He denies dizziness, vertigo, nausea, or hearing loss. On exam, you note a tear of the tympanic membrane and a small amount of blood in the external canal. Which of the following is the most appropriate next step in management? A. Begin antibiotics B. Discharge with instructions to keep the ear canal dry C. Emergency department consultation to ENT D. Pack the ear with gauze Teaching Image Anaerobes like Prevotella, Bacteroides, Fusobacterium, and Peptostreptococcus are the most common organisms found in a lung abscess. On chest radiograph, lung abscesses present as a consolidation with an air fluid level inside a cavitary lesion. An epidural hematoma presents as a hyperdense lenticular-shaped hematoma in the temporal region, and it is caused by a tear in the middle meningeal artery. A lucid interval is often associated with this bleed. Patients taking beta-blockers for hypertension may exhibit persistent hypotension in the setting of anaphylactic shock. They should be treated with glucagon to free up the beta receptor and potentiate the circulating epinephrine to restore vasomotor tone. In Munchausen syndrome, the individual feigns disease in an attempt to gain attention, sympathy, or reassurance. Somatization disorder is characterized by unexplained physical symptoms that lead to significant social and occupational impairment. Conversion disorder is characterized by an unexplained neurologic symptom triggered by a psychological stressor. Hydrocarbon ingestion can cause pneumonitis, and the chest X-ray can show diffuse bilateral infiltrates. Patients with asymptomatic ruptured tympanic membranes can be discharged home with instructions to keep the canal dry. Symptomatic patients require emergent ENT consultation. That wraps up RoshCast Episode 46! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, and bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the Submit Feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 46: Lung Abscesses, Head Injuries, Anaphylaxis & More appeared first on RoshReview.com.
Aug 7, 2018 · 17 min
Ep 45 Roshcast Emergency Board Review
There is only one corner of the universe you can be certain of improving, and that’s your own self. –Aldous Huxley Welcome back to RoshCast for Episode 45! Let’s start out with a review of rabies before getting to core content Q&A. The most common wild reservoirs of rabies are raccoons, skunks, bats, foxes, and coyotes. Domestic animals like cats, dogs, and cattle can also get rabies. Rodents, reptiles, and birds on the other hand are not carriers and cannot transmit rabies. One important factor in deciding if you get rabies postexposure prophylaxis is whether the animal can be found and held for observation. The rabies postexposure prophylaxis has two parts: the immunoglobulin and the vaccine. When giving rabies postexposure prophylaxis, inject the immunoglobulin into the wound and start the rabies vaccine series which the patient will receive on days 1, 3, 7, 14, and 28. Now onto this week’s podcast Question 1 Which of the following is true regarding acute respiratory distress syndrome? A. Define as PaO2:FiO2 > 300 B. Empiric corticosteroids should be given C. Positive end-expiratory pressure should be increased with increases in FiO2 D. Tidal volume should be started at 10 mL/kg in intubated patients Teaching Image Question 2 A 35-year-old man presents to the ED after being assaulted in a bar fight. He has signs of significant facial trauma. On physical exam, you note a tooth fracture through the enamel and dentin but does not involve the pulp. Which of the following is the most appropriate next step in management of his dental injury? A. Calcium hydroxide paste B. Extract the tooth C. Immediate dental consult D. Pencillin VK Teaching Image Question 3 A 62-year-old man presents with acute onset of chest pain with radiation to the shoulders and nausea while walking his dog. On examination, he is diaphoretic with heart rate 94 bpm, respiratory rate 20 bpm, blood pressure 92/59 mm Hg, and oxygen saturation 96% on room air. His ECG reveals 2 mm elevation in aVR. Occlusion of which coronary artery is most likely responsible for this patient’s presentation? A. Left anterior descending artery B. Left circumflex artery C. Left main coronary artery D. Right coronary artery Teaching Image Question 4 A 62-year-old man presents for evaluation of chest pain. Approximately three weeks ago the patient had a myocardial infarction with stent placement. Last evening he developed pleuritic chest pain and fever. He has no cough and does not feel short of breath. His ECG is shown above. Which of the following is the most likely diagnosis? A. Dressler syndrome B. Infarct pericarditis C. Left ventricular aneurysm D. ST segment elevation myocardial infarction Teaching Image Question 5 A 45-year-old man with a history of hypercholesterolemia presents with acute onset of anterior chest pain, nausea, and diaphoresis. His ECG is distinct for upsloping ST elevation in AVR (≥ 1 mm) with ST depressions and tall T waves in the precordial leads. What is the most likely diagnosis? A. Occlusion of the left circumflex artery B. Occlusion of the left main coronary artery C. Occlusion of the proximal left anterior descending artery D. Occlusion of the right coronary artery Teaching Image Question 6 A 25-year-old man presents the emergency department with knee pain. This morning he slipped on the ice and felt a pop in his knee. On physical exam his left knee appears to have a moderate effusion with limited range of motion and medial joint line tenderness. An X-ray of the left knee is performed. A pedunculated, bony exostosis with well-defined margins is seen along the distal lateral femur on the AP view of the knee. What is the most likely diagnosis of the incidental bone lesion? A. Aneurysmal bone cyst B. Osteochondroma C. Osteoid osteoma D. Osteosarcoma Teaching Image Teaching Image Teaching Image Intubated patients with ARDS should be started on low tidal volumes of 6–8 cc/kg of ideal body weight, and the PEEP and FiO2 should be titrated up together. The PaO2 to FiO2 ratio in patients with ARDS is < 300. The lower the ratio, the worse the disease process. There are three classes of dental fractures: Ellis Class I involves injury to the enamel alone and is treated by smoothing any rough edges. Ellis Class II involves injury to the dentin and enamel. This is treated by covering exposed dentin with calcium hydroxide. Ellis Class III involves the pulp along with the dentin and enamel. These usually require antibiotics and immediate dental consult. ST segment elevation in aVR greater than 1 mm or greater than the ST segment elevation in V1 is most concerning for occlusion of the left main coronary artery. Dressler syndrome is pericarditis occuring one week to several months after an MI. A left ventricular aneurysm is a complication of a large anterior wall MI. EKG shows ST segment elevations in the anterior leads. De Winter ECG patterns presents with tall, prominent symmetric T waves in the precordial leads with upsloping ST segment depression greater than 1mm at the J point and ST segment elevation may be seen in aVR De Winter EKG is a STEMI equivalent and represents acute LAD occlusion. Aneurysmal bone cyst, osteochondroma, and osteoid osteoma are benign bone lesions. Osteosarcoma is a malignant bone lesion seen on X-ray as a lytic lesion, a blastic lesion, or a heavily ossified mass. That wraps up RoshCast Episode 45! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast and @RoshReview. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. We’re also launching on Google Play in the near future. Megha and Nachi The post Podcast Ep 45: ARDS, Dental Fractures, STEMIs, Pericarditis, & More appeared first on RoshReview.com.
Jul 24, 2018 · 16 min
Ep 44 Roshcast Emergency Board Review
By failing to prepare, you are preparing to fail. –Benjamin Franklin Welcome back to RoshCast for Episode 44! We are back to an every other week schedule covering core content. Let’s start out with a rapid review of neonatal conjunctivitis. The three dangerous causes of neonatal conjunctivitis that you need to consider in the ED are gonorrhea, chlamydia, and herpes. Gonorrhea is the most aggressive bacteria associated with neonatal conjunctivitis. It presents in the first week of life with purulent drainage and ulcerations, and it can disseminate to cause gonococcal sepsis. Culture the drainage for confirmation, and treat the baby with cefotaxime. Chlamydia neonatal conjunctivitis, which presents in the first month of life, can disseminate into the lungs. Treat with oral erythromycin. The third and least dangerous cause of neonatal conjunctivitis is herpetic. In this case you may see vesicles in the eye. Treat this with IV acyclovir. Now onto this week’s podcast Question 1 A 21-year-old man presents after he was bitten by a spider. He has a picture of the spider on his phone (shown above). Which of the following is a potential complication of a bite by this spider? A. Abdominal rigidity B. Autonomic instability C. Coagulation abnormalities D. Pancreatitis Teaching Image Question 2 A 66-year-old man with hypertension and hyperlipidemia presents after an episode of severe chest pain while walking to work. He is currently asymptomatic. His vitals are T 36.27°C, HR 76/min, BP 143/85 mm Hg, RR 18/min, and oxygen saturation 99%. A 12-lead ECG is performed as seen above. Which of the following is the most appropriate next step in management? A. Give 325 mg of aspirin, and activate the cardiac catheterization lab B. Give 325 mg of aspirin, and admit for serial troponin testing and stress test C. Give 325 mg of aspirin, and discharge home with cardiology follow-up in 24–48 hours D. Send d-dimer, and consider CT pulmonary angiogram if elevated Teaching Image Question 3 A 17-year-old boy from New Jersey presents with a 3-day history of rash and a 1-day history of facial droop. He also complains of a headache. The images above represent the physical examination findings. In addition you note mild nuchal rigidity. A noncontrast head CT is performed and is normal. Which of the following is the next best step for this patient? A. Acyclovir and corticosteroids B. Lumbar puncture C. MRI brain D. Serologic testing for Lyme disease Teaching Image Question 4 A 52-year-old man presents with decreased sensation in the upper extremities and chronic neck pain. He states that the loss of sensation has been progressive for months. On physical examination, he has decreased sensation to pain over the upper back, shoulders, and arms with intact proprioception and light touch. What disorder does this patient exhibit? A. Anterior cord syndrome B. Brown-Sequard syndrome C. Central cord syndrome D. Syringomyelia Teaching Image Question 5 What is the most frequently seen oculomotor sign in patients with Wernicke encephalopathy? A. Lateral nystagmus B. Lateral rectus palsy C. Miosis D. Ptosis Teaching Image Question 6 A patient with metastatic breast cancer presents with weakness and nausea. An ECG is shown above. What electrolyte abnormality is likely in this patient? A. Hypercalcemia B. Hypernatremia C. Hypocalcemia D. Hyponatremia Teaching Image Brown recluse spiders have violin-shaped markings on their back. The toxin here can lead to hematologic abnormalities. There is no antivenin available in the US. Black widow spiders, on the other hand, have a red hourglass shape on their ventral surface and their toxin causes autonomic instability and abdominal wall rigidity. There is an antivenin available, but it’s only used in severe cases. Wellen’s syndrome type A demonstrates biphasic T waves in V1–V3 and type B demonstrates deeply inverted T waves in V1–V3. It is highly specific for a critical stenosis of the LAD. Activate the catheterization lab! There are three stages of Lyme disease: Early Lyme manifests with the classic erythema migrans rash. The second stage is acute disseminated infection which results in neurologic, cardiac, arthritic, and ophthalmic manifestations. The third is late Lyme disease, which presents with worse neurologic manifestations and chronic Lyme arthritis. The most common location of syringomyelia is the cervical spine. Patients present with a cape-like distribution of loss of pain and temperature sensation in the upper extremities with preservation of light touch and proprioception. Anterior cord syndrome is characterized by loss of motor function below the lesion and preservation of position, touch, and vibration sensation. Brown-Sequard syndrome presents with ipsilateral motor function loss and contralateral pain and temperature sensation loss. Central cord syndrome presents with bilateral motor paresis and sensory impairment. The most frequently seen oculomotor sign in Wernicke encephalopathy is lateral nystagmus. Diagnosis of Wernicke encephalopathy requires two out of four of the following criteria: dietary deficiencies, oculomotor dysfunction, cerebellar dysfunction, and altered mental status. Hypercalcemia can cause QT shortening, while hypocalcemia can cause QT prolongation. Malignancy is the most common inpatient cause of hypercalcemia while primary hyperparathyroidism is the most common outpatient cause. That wraps up RoshCast Episode 44! Be sure to also check out the rest of the Rosh Review Blog for questions from prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast and @RoshReview. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. We’re launching on Google Play in the near future also. Megha and Nachi The post Podcast Ep 44: Spider Bites, Biphasic T Waves, Lyme Disease, Syringomyelia, Wernicke Encephalopathy, Electrolyte Abnormalities appeared first on RoshReview.com.
Jul 10, 2018 · 14 min
Ep 43 Roshcast Emergency Board Review
Always do your best. What you plant now, you will harvest later. –Og Mandino Welcome back to RoshCast for Episode 43! After a long pause, we are back with new episodes and a lot of announcements. A lot has happened in the past few months. Jeff had a baby and moved to Pittsburg to start his EMS fellowship. In doing so, he is taking a break from Roshcast to focus on fellowship and his new baby. Megha Rajpal, a fourth-year resident at Mount Sinai, will be taking over as co-host. For epiglottitis, the patient will usually have a rapid-onset fever and dysphagia. On exam, they could be leaning forward, drooling, and even have inspiratory stridor. The typical radiographic finding for epiglottitis is thumbprint sign, which is seen on a lateral neck film. The most common bacteria associated with epiglottitis are H. influenzae and Streptococcus. For management in epiglottitis, airway is the crucial piece. Patients may need to be intubated immediately. Don’t forget to start the patient on antibiotics to treat for the common pathogens. Now onto this week’s podcast Question 1 Which of the following is the most common presenting vital sign abnormality seen in patients presenting with a pulmonary embolism? A. Fever B. Hypoxia C. Tachycardia D. Tachypnea Teaching Image Question 2 A 72-year-old man presents with pain in the right knee. It has increased over the last 24 hours with redness and swelling. Joint aspiration reveals negative birefringent crystals. He reports an allergy to NSAIDs and is a brittle diabetic. Colchicine is prescribed. Which side effect limits its usefulness due to a narrow therapeutic window? A. Headache B. Nausea and vomiting C. Rash D. Sore throat Teaching Image Question 3 A patient presents to the ED after waking up and finding that he was drooling while drinking his coffee. When he looked in the mirror he noticed that the left side of his face was drooping. Which of the following findings is suggestive of a central process? A. Hyperacusis of the left ear B. Inability to close the left eye completely C. Loss of taste sensation D. Preserved ability to raise the eyebrows Teaching Image Question 4 Which of the following is considered a stable cervical spine injury? A. Bilateral facet dislocation B. Clay-shoveler’s fracture C. Hangman fracture D. Teardrop fracture Teaching Image Question 5 A 28-year-old man presents to the emergency department via ambulance after a terrorist set off a large bomb in an airport. On physical exam, he has bilateral tympanic membrane ruptures. Chest X-ray shows bilateral pulmonary contusion. These injuries are most consistent with which category of blast injury? A. Primary B. Quaternary C. Secondary D. Tertiary Teaching Image Question 6 A 19-year-old man presents with eye pain and photophobia in his left eye after being punched there two days ago. He describes blurry vision. On exam, you note consensual photophobia. Which of the following is the most appropriate treatment? A. Homatropine drops B. Timolol C. Topical ketorolac drops D. Topical vasoconstrictor Teaching Image Tachypnea is the most common presenting vital sign abnormality for a pulmonary embolism, while dyspnea at rest or exertion is the most common presenting symptom. Joint aspiration in gout demonstrates negative birefringent monosodium urate crystals. NSAIDs are the first-line treatment. Colchicine can cause severe GI symptoms in more than 10% of patients. When deciding on a central versus peripheral etiology for facial paralysis, preserved ability to raise the ipsilateral eyebrow or close the ipsilateral eye is more concerning for a central lesion than a peripheral lesion. Clay shoveler’s fracture is a stable avulsion fracture of the spinous process of C6–C7. Jefferson burst fracture, bilateral facet dislocation, odontoid type II and type III fractures, any fracture with a dislocation, hangman’s fracture, and teardrop fracture are all unstable cervical spine fractures. Primary blast injury occurs from direct effect from blast shockwaves. Secondary blast injury occurs from the impact of fragments due to exploding devices. Tertiary blast injury occurs when the blast wave propels the body into objects. Quaternary blast injury is due to environmental contamination from the device. In quinary blast injuries, there is bodily absorption of device additives. Traumatic iritis is treated using cycloplegics like homatropine and topical steroids. That wraps up RoshCast Episode 43! Rosh Review is excited to announce the launch of a new podcast called The PA Way hosted by Alison Callahan, PA-C. Definitely worth a listen. Be sure to also check out the RoshCast blog for questions from this episode and prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources there to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast and @RoshReview. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Megha and Nachi The post Podcast Ep 43: Pulmonary Embolism, Colchicine & More appeared first on RoshReview.com.
Feb 22, 2018 · 15 min
Ep 42 Roshcast Emergency Board Review
The secret of change is to focus all of your energy, not on fighting the old, but on building the new. –Socrates Welcome back to RoshCast for Episode 42! With the in-training exam around the corner, go back and power through old episodes during commutes to pick up as many points as possible. Good luck! Patent ductus arteriosus (or PDA) closes, the neonate will present in heart failure and shock. Turner’s syndrome is associated with coarctation. Turner’s is also associated with webbed neck, short stature, and low-set ears. Individuals with Turner’s syndrome are missing an X chromosome as well, making it a 45,XO chromosomal condition. A blood pressure differential between the arms and legs—specifically, the pressure in the arms is higher than the legs. Depending on the specific anatomy, you might even note a difference in the pressures between both arms. Classic EKG and chest X-ray findings associated with coarctation of the aorta include left ventricular hypertrophy and rib notching, respectively. Now onto this week’s podcast Question 1 Which of the following is typically seen in Korsakoff syndrome? A. Cerebellar dysfunction B. Long-term memory impairment C. Ophthalmoplegia D. Recent memory impairment Teaching Image Question 2 Which of the following is the most common physical exam finding in an abdominal aortic aneurysm? A. Abdominal bruit B. Diminished femoral pulses C. Duodenal obstruction D. Pulsatile abdominal mass Teaching Image Question 3 A 24-year-old woman at full term presents with rupture of membranes and contractions. Sterile exam reveals a crowning infant with a visible cord. After elevating the fetal head, what management is indicated? A. Clamp and cut cord and proceed with delivery B. Continue with standard delivery C. Emergent cesarean section D. Intravenous tocolytics Teaching Image Question 4 You suspect a 35-year-old man has epiglottitis with impending airway compromise. Which of the following is the best method for confirming the diagnosis? A. Computed tomography of the neck B. Frontal cervical soft tissue radiograph C. Indirect laryngoscopy D. Lateral cervical soft tissue radiograph Teaching Image Question 5 A 21-year-old man presents with a stab wound to the right chest. His vitals are HR 157/min, BP 81/43 mm Hg, RR 28/min, and oxygen saturation 91%. The patient is intubated, and packed red blood cells are started. Physical examination reveals a bleeding wound to the right chest, a midline trachea, and decreased breath sounds on auscultation of the right hemithorax. Which of the following should be performed next? A. Application of a pelvic binder B. Placement of a right thoracostomy tube C. Right chest thoracotomy D. Transfer to operating room Teaching Image Question 6 A 65-year-old man with a history of hypertension presents with left-sided weakness beginning two hours prior to arrival. Vitals are BP 155/85 mm Hg, HR 102/min, RR 12/min, oxygen saturation 100% on RA. His CT scan is shown above. Which of the following therapies is appropriate? A. Antihypertensives to lower mean arterial pressure by 25% B. Head of bed at 30° C. Neurosurgical evacuation D. Prophylactic antiepileptic drugs Teaching Image Korsakoff syndrome is a chronic neurologic disease caused by thiamine deficiency that typically presents with impairment of recent memory formation. Patients may also exhibit apathy and confabulation. Wernicke’s encephalopathy often presents with ophthalmoplegia, nystagmus, ataxia, and mental status changes. Wernicke’s encephalopathy and Korsakoff syndrome or often seen simultaneously. Treat both Wenicke and Korsakoff syndromes with thiamine and magnesium. The most common physical exam finding in AAA is a pulsatile mass. At a diameter of 5 cm, the risk of rupture increases markedly. Diagnosis is made by ultrasound or CT scan. For umbilical cord prolapse during delivery, plan for an emergent C-section. If C-section is not possible, attempt manual replacement of the cord into the uterus, followed by rapid vaginal delivery. Epiglottitis classically presents with rapid onset of fever and dysphagia, often with drooling, anxiety, stridor, and a muffled voice. The best method for confirming the diagnosis of epiglottitis is via indirect laryngoscopy, which can be done with a nasopharyngoscope. However, be careful as manipulation can lead to laryngospasm and airway obstruction. Make sure a surgical airway kit is available at the bedside. The classic finding on lateral neck X-ray in those with epiglottitis is a thumbprint sign. An ED thoracotomy would be indicated in a patient who loses vitals in route to the hospital or in the ED. For intracranial hemorrages, treatment is first supportive with airway protection and maintenance of adequate perfusion. Elevate the head of the bed to 30 degrees and maintain normothermia, normocarbia, and euglycemia. Current data do not support the use of antiepileptics. That wraps up RoshCast Episode 42! Be sure to also check out RoshCast blog for questions from this episode and prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources there to help prepare you for the boards and the wards. Don’t forget to follow us on twitter @RoshCast and @RoshReview. And you can always email us at RoshCast@RoshReview.com with any feedback, corrections, or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Good luck on the in-training exam next week! Jeff and Nachi The post Podcast Ep 42: Korsakoff Syndrome, AAA, Prolapsed Umbilical Cord appeared first on RoshReview.com.
Feb 5, 2018 · 16 min
Ep 41 Roshcast Emergency Board Review
We are what we repeatedly do. Excellence, then, is not an act, but a habit. –Aristotle Welcome back to RoshCast for Episode 41! As we get closer and closer to the in-training, now would be a great time to go back and listen to old episodes to brush up on some of the core EM knowledge that you may not come across regularly on shift. Let’s get started with a rapid review and our regular mixed content of questions, answers, and high-yield review. Staph aureus is the most common bacterial cause of septic arthritis in adults. In a patient with splenic dysfunction, the strep species are more likely to cause septic arthritis. Septic arthritis classically presents with fever, monoarticular joint pain, and a decreased range of motion. Joint aspirates with a white count > 50,000 with more than 75% PMNs are indicative of septic arthritis. Now onto this week’s podcast Question 1 Which of the following hematological disorders is characterized by intermittent venous and arterial thrombosis, splenomegaly, and abnormal proliferation of all three myeloid cell lines? A. Aplastic anemia B. Chronic myelogenous leukemia C. Disseminated intravascular coagulopathy D. Polycythemia vera Teaching Image Question 2 Which of the following pairs are matched correctly? A. Elevated direct bilirubin – Gilbert’s syndrome B. Elevated indirect bilirubin – Cholestasis C. Elevated transaminases with ALT/AST ratio > 2:1 – Alcoholic hepatitis D. Elevated transaminases with AST and ALT > 10,000 IU/L – Ischemic hepatitis Teaching Image Question 3 Which of the following conditions can result in refractory hypokalemia that is not correctable by the administration of potassium? A. Hypermagnesemia B. Hypernatremia C. Hypomagnesemia D. Hyponatremia Teaching Image Question 4 A 29-year-old man is brought to the ED for a gunshot wound to the right chest. He is diagnosed with a right-sided hemopneumothorax. A tube thoracostomy is subsequently performed with immediate drainage of 250 cc of blood. The nurse connects the chest tube to a commercial suction device, and a chest radiograph is performed that confirms proper placement. You note an absence of respiratory fluctuation of the fluid level in the drainage tube. A repeat chest X-ray shows the right-sided hemothorax remains. Which of the following is true regarding this finding? A. An air leak is present B. The lung is still collapsed C. There is a blockage of the drainage tube D. This is an expected finding Question 5 Which of the following is true regarding Ranson’s criteria? A. A score of 0–3 on admission constitutes a high-risk population B. Glucose > 200 mg/dL on admission is associated with a higher mortality rate C. Hematocrit < 35% at 48 hours is predictive of mortality D. WBC < 10,000 is associated with a higher mortality rate Teaching Image Question 6 The Emergency Medical Treatment and Active Labor Law of 1986, or EMTALA, requires hospitals to provide which of the following? A. Care to all patients B. Interpreters for all patients in a timely manner C. Screening exam, competent ED physicians and appropriate stabilization D. Screening exam, stabilization process, appropriate transfer process Question 7 A 58-year-old man with a history of cirrhosis presents with abdominal pain and fever. His abdomen is tender to palpation with guarding. You are concerned about spontaneous bacterial peritonitis. You perform a paracentesis and send the ascitic fluid for analysis. Which of the following is most consistent with a diagnosis of spontaneous bacterial peritonitis? A. Low ascitic fluid glucose concentration B. Polymorphonuclear neutrophil count < 250 cells/mm3 C. Serum-ascites albumin gradient < 1.1 g/dL D. White blood cell count < 1,000 cells/mm3 Teaching Image Polycythemia vera is a chronic myeloproliferative disorder marked by increased red blood cell production but can involve all three cell lines. Polycythemia vera presents with pruritus, especially after bathing, headaches, bleeding, engorged retinal veins, splenomegaly, and gout. Treatment is with serial phlebotomy or with myelosuppressive agents. Gilbert’s syndrome is associated with an elevated indirect bilirubin. Alcoholic hepatitis is associated with an AST to ALT ratio of roughly 2:1. In ischemic hepatitis, you would expect elevated transaminases over 10,000. Hypomagnesemia can result in refractory hypokalemia not correctable by the administration of potassium. Hypomagnesemia can lead to a prolonged QT, a widened QRS as well as atrial and ventricular dysrhythmias. With respect to chest tubes, an air leak occurs when there is persistent air inside the pleural space. An absence of respiratory fluctuation or a decrease in drainage of a chest tube implies that the system is blocked or the lung is fully expanded. Ranson’s criteria is a scoring system designed to predict mortality from acute pancreatitis. EMTALA, enacted in 1986, is a section of the Consolidated Omnibus Labor Act. It governs how physicians triage, register, examine, workup, treat and/or stabilize, discharge or transfer, utilize resources, and involve medical staff expertise when caring for patients who present to the ED. Spontaneous bacterial peritonitis is diagnosed with an elevated ascitic fluid PMN cell count over 250 and a positive ascitic fluid bacterial culture, all in the absence of a secondary cause of peritonitis like a bowel perforation. SBP is also associated low ascitic glucose concentrations. It’s treated with a third-generation cephalosporin. That wraps up RoshCast Episode 41! Don’t forget to follow us on twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write “Roshcast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast. Until next time, Jeff and Nachi The post Podcast Ep 41: Polycythemia Vera, Ischemic Hepatitis & More appeared first on RoshReview.com.
Jan 19, 2018 · 18 min
Ep 40 Roshcast Emergency Board Review
Dreams and dedication are a powerful combination. -William Longgood Welcome back to Roshcast for Episode 40! After a quick detour last week to talk with Dr. Rosh, we are back at it with our regular routine. But before we get going, if you have any thoughts or feedback on last week’s episode, or even if you have any unanswered questions, make sure you send them our way to RoshCast@RoshReview.com, so that we can get them answered either individually by email or on another special episode. This week, we are going to cover a few pediatric respiratory questions to parallel the EM Clerkship podcast’s most recent episode in addition to some bread and butter emergency medicine. Before we begin, let’s get warmed up with a rapid review covering environmental emergencies, since these are things we see less frequently in our day to do practice but ALWAYS appear on the in-training exam. Pit viper bites cause local swelling and oozing from the wound. Severe envenomations can lead to a DIC like coagulopathy and hemorrhagic bullae. Brown recluse spider bites cause a papule that later blisters and may necrose. Systemic symptoms include renal failure, pulmonary edema, and shock. Black widow spider bites cause a local papule with a halo. Severe systemic symptoms include a peritonitic abdomen, muscle fasciculations, and diaphoresis. Remember that you can identify a black widow spider by the red hourglass on their abdomen. Frostbite should be treated with immersion in a warm water bath set at 37-39 degrees Celsius. Now onto this week’s podcast Question 1 Let’s get right into with a pediatric respiratory question: A 3-year-old girl presents to the ED with 1 hour of a barking cough and inspiratory stridor at rest. On exam, she has mild retractions but is not hypoxic. Which of the following interventions has been shown to reduce hospital length of stay in moderate to severe croup? A. Dexamethasone B. Heliox C. Humidified air D. Racemic epinephrine Teaching Image Question 2 A 33-year-old woman presents with intermittent, intense shooting pain to the left side of the face. She states that the pain begins near her ear and radiates to her chin. The pain is often brought on by chewing and brushing her teeth. Which of the following managements is most likely indicated? A. Carbamazepine B. Dental X-rays C. Mandible CT scan D. Prednisone Teaching Image Question 3 Which of the following cervical spine fractures is considered stable? A. Bilateral facet dislocation B. Flexion teardrop fracture C. Jefferson fracture D. Type I odontoid fracture Teaching Image Question 4 You are working in a busy pediatric ED in December. During your shift, you evaluate and treat four children with moderate croup by administering oral dexamethasone and aerosolized epinephrine. You re-evaluate each child two hours after the initial racemic epinephrine treatment. Which of the following children can most safely be discharged home? A. A 1-year-old boy with persistent stridor at rest B. A 2-year-old uninsured boy with clinical improvement, but no primary care physician C. A 3-month-old girl with a history of tracheomalacia who has clinical improvement D. A 4-year-old girl with retractions that have since resolved Teaching Image Question 5 A 10-year-old boy presents with increased lethargy and vomiting. Mom states the patient has had three days of cough, rhinorrhea, sore throat, and fever. The nanny has been giving the patient an appropriate dose of over-the-counter cold medicine. The physical exam is remarkable for lethargy, mild icterus, and hepatomegaly. Laboratory results are remarkable for markedly elevated AST and ALT. Which medication is most likely responsible for this patient’s presentation? A. Acetaminophen B. Aspirin C. Guaifenesin D. Ibuprofen Teaching Image Question 6 A 52-year-old man with a history of renal failure status post-transplant presents with shortness of breath. He has had a non-productive cough with fevers for the last 3 days. His only medication is mycophenolate mofetil. With ambulation, he desaturates to 85% on room air and his resting saturation is 90%. Physical examination is notable for diffuse bilateral crackles. His chest X-ray is shown above. Which of the following is the most appropriate drug to administer next? A. Anaerobic antibiotic coverage B. Beta-agonist C. Loop diuretic D. Oral corticosteroid Teaching Image Question 7 A 6-month-old girl born at 35 weeks gestation and previously well presents to the ED with wheezing and increased work of breathing. Mom reports that her daughter has had a low-grade fever, rhinorrhea, and cough for the past 3 days. In the ED, the patient’s vital signs are T 38.3ºC, HR 150/min, RR 72/min, and a pulse oximetry of 90% on room air. On exam, she is wheezing, using accessory muscles, and having subcostal retractions. An albuterol nebulizer treatment was given but no improvement was seen. Which of the following is the most appropriate next step in management? A. Administer 1 mg/kg of oral dexamethasone B. Administer another albuterol nebulizer treatment because the patient continues to be wheezing C. Administer high-dose inhaled corticosteroids D. Admit to the hospital and provide supportive care Teaching Image Dexamethasone is the first-line treatment for croup. It reduces hospital length of stay in moderate to severe case of croup. The Westley Croup Severity Score incorporates level of consciousness, cyanosis, stridor, air entry, and retractions to help guide management, which ranges from supportive care, to nebulized epinephrine, to ICU admission and intubation. In children with croup, chest X-ray may show the classic steeple sign. Trigeminal neuralgia presents with paroxysms of lancinating pain, typically in the V2 and V3 dermatomes. Treatment is with carbamazepine. Bilateral facet dislocations, flexion teardrop fractures, Jefferson fractures, and type 2 and type 3 odontoid fractures are all unstable cervical spine fractures. A flexion teardrop fracture is a fracture of the anterior inferior portion of the vertebral body, which disrupts the anterior and posterior ligamentous structures. A Jefferson fracture is a burst fracture. A type 1 odontoid fracture is an avulsion of the tip of the odontoid. A type 2 odontoid fracture, which is the most common, is a fracture at the base of the dens. A type 3 odontoid fracture is a fracture at the junction of the odontoid and the body of C2. Reye syndrome presents with a rapidly progressive, non-inflammatory encephalopathy associated with altered mental status, cerebral edema, and hepatic dysfunction. Patients typically present with respiratory or a GI prodrome followed by an encephalopathic picture. Reye syndrome is caused by salicylate usage in the setting of a viral illness. Influenza and chickenpox are commonly implicated viruses. PJP pneumonia presents with bilateral perihilar infiltrates in a classic batwing appearance. Immunocompromised patients are at risk. PJP pneumonia is ideally treated with trimethoprim-sulfamethoxazole. In sulfa allergic patients, consider primaquine-clindamycin or atovaquone for mild to moderate disease or pentamidine for severe disease. Bronchiolitis should be treated with supportive care. In first-time wheezers, evidence suggests that there is no role for oral steroids or beta-agonists. That wraps up RoshCast Episode 40! Be sure to also check out the blog for questions from this episode and prior episodes, related images and tables, as well as bonus teaching points. There are also tons of other great free resources there to help prepare you for the boards and the wards. Don’t forget to follow us on Twitter @RoshCast and @RoshReview. You can always email us at RoshCast@RoshReview.com with any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. We’ll be back soon with more high quality review. Until next time, Jeff and Nachi The post Podcast Ep 40: Croup, Trigeminal Neuralgia, PJP Pneumonia, & More appeared first on RoshReview.com.
Jan 4, 2018 · 34 min
Ep 39 Roshcast Emergency Board Review
“The person who creates structure the soonest, is the person who is most comfortable in residency the soonest.” -Adam Rosh, MD Welcome back to RoshCast episode number 39! As we mentioned at the end of episode 38, this won’t be a regular old RoshCast. Instead of our regularly scheduled content, we put together an interview with Dr. Adam Rosh – the namesake of the Rosh Review, former program director, and most importantly an emergency physician who has dedicated the last 20 years of his life to education. While this episode will not contain our usual board review content, it will include tactical advice on preparing for and taking your board exam. This episode provides a gold mine of actionable information, tools, strategies, and tactics that you can use not only for your upcoming Shelf exam, In-Training exam, or ABEM Certification exam, but any high stakes endeavor. Some of the topics Dr. Rosh talked about include: The biggest studying challenges going from medical school to residency The best advice Dr. Rosh received when he was an intern A system to 10X your medical knowledge during residency How to implement a study strategy called “layering” to build deep medical knowledge How a “notebook system” made all the difference in the world to building confidence as a resident An opportunity to aggregate Post-it Pearls A system to capture mistakes to improve clinical practice How studying material like the leads of an ECG looking at the heart can lead to improved understanding Using interleaving to improve preparation for the actual exam What do you do if you answered all of the questions in the Qbank? How forgetting leads to improved recall Avoiding the illusion of knowing Choosing the right study material Making sure you prevent people from stealing your time The importance of exercise or simply taking a break to go for a walk to improve recall Upcoming releases within Rosh Review And much more… Items referenced during the interview Flip notebook How to Increase Your Emergency Medicine Board Exam Score by 10 Points An Emergency Medicine Resident’s Clinical Experience That’s wraps up RoshCast Episode 39. Don’t forget to follow us on Twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write “RoshCast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. And let us know if you’d like us to do a Part 2 with Dr. Rosh. Until next time, Jeff and Nachi The post Podcast Ep 39: Special Episode! Listen to an Interview with Dr. Rosh appeared first on RoshReview.com.
Dec 20, 2017 · 16 min
Ep 38 Roshcast Emergency Board Review
Believe you can and you’re halfway there. -Theodore Roosevelt Welcome back to Roshcast episode 38, the last episode of 2018! Before we jump into this week’s episode, we have a few people to recognize. First, congrats to Zain who won the trauma ring tone challenge last episode and will be receiving a Rosh Review subscription. Special mention goes out as well to Clark, David, and Ryker who all responded soon after Zain. We should also recognize Sarah, who won the EM Clerkship-RoshCast crossover challenge and won a free copy of Case Files Emergency Medicine. Stay tuned for more contests to come! Let’s head back to the Rosh Blog and start out with a recent Rapid Review. Central cord usually presents with sensory and motor deficits, with the upper extremities being affected more than the lower extremities. It’s most commonly caused by an extension injury. Anterior cord syndrome presents with complete loss of motor, pain, and temperature below the level of the injury, but you would retain proprioception and vibration sensation. Anterior cord is most often caused by a flexion or vascular injury. Brown Sequard classically occurs after penetrating trauma. It results in ipsilateral loss of motor, vibration, and proprioception with contralateral loss of pain and temperature. Now onto this week’s podcast Question 1 A 3-day-old girl presents with decreased feeding and is found to be limp and minimally responsive. After intubation, at what rate should breaths be delivered? A. 10–16 per minute B. 20–30 per minute C. 40–60 per minute D. 70–80 per minute Teaching Image Question 2 In a malnourished patient, which of the following sources of megaloblastic anemia is expected to develop first? A. Folic acid deficiency B. Hypothyroidism C. Liver disease D. Vitamin B12 deficiency Teaching Image Question 3 What medication should be first-line treatment in moderate musculoskeletal back pain? A. Acetaminophen B. Cyclobenzaprine C. Diazepam D. Oxycodone Question 4 An 18-year-old man presents to the ED with a 4 cm laceration to the right side of his chin. Which of the following nerve blocks is most appropriate? A. A mental nerve block B. A posterior superior alveolar nerve block C. A stellate ganglion block D. An apical nerve block Teaching Image Question 5 A previously healthy 5-year-old girl presents to the ED with left lower extremity pain and an inability to bear weight for 1 day. Mom denies any recent trauma. On exam, the patient has a T 37.9°C, HR 130/min, and RR 28/min. Her left lower extremity is slightly flexed and externally rotated. Lab evaluation reveals a WBC of 8,000, a C-reactive protein of 1 mg/dL, and an erythrocyte sedimentation rate (ESR) of 7 mm/hr. Radiographs are negative for fracture. The patient’s range of motion has improved following administration of ibuprofen. What is the most appropriate course of action in this patient? A. Intravenous antibiotics and admission to the hospital B. MRI to rule out osteomyelitis or septic arthritis C. Orthopedic consultation for arthrocentesis D. Treatment with NSAIDs and discharge with follow-up arranged for the following day Teaching Image Question 6 Which of the following is most likely to present as a ductal-dependent cardiac lesion? A. Atrial septal defect B. Coarctation of the aorta C. Isolated ventricular septal defect D. Mitral valve prolapse Teaching Image For infants, from birth to 1 year old, who require mechanical ventilation, set the rate at 30–60 breaths per minute. For toddlers, ages 1–3 years old, set the rate at 24–40 breaths per minute. For preschoolers, ages 3–6 years old, set the rate at 22–34 breaths per minute. For children 6–12 years old, set the rate at 18–30 breaths per minute. And lastly, for those 12 and older set the rate at 12–16 breaths per minute. To estimate pediatric systolic blood pressure, use the formula 70 plus 2 times the age in years. In the setting of malnutrition, folic acid deficiency and vitamin B12 deficiency can both lead to a megaloblastic anemia. NSAIDs are first-line treatment for musculoskeletal lower back pain. A supraorbital nerve block anesthetizes the ipsilateral forehead and scalp. An infraorbital nerve block anesthetizes the area between the lower eyelid and the upper lip. A posterior superior alveolar nerve block anesthetizes the second and third maxillary molars, as well as part of the first maxillary molar. An inferior alveolar nerve block anesthetizes the ipsilateral mandibular teeth, lower lip, and chin. An apical nerve block anesthetizes a single tooth. The mental nerve block anesthetizes the chin as well as the skin and mucous membranes of the lower lip. Remember that the mental nerve is a branch of the inferior alveolar nerve. Transient synovitis is the most common cause of acute hip pain in children ages three to ten years old. Treatment for transient synovitis is NSAIDs and rest. Ductal dependent cardiac lesions include coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, tricuspid atresia, interrupted aortic arch, and hypoplastic left heart syndrome. To temporarily preserve patency of the ductus arteriosus, treat with prostaglandin E1, or alprostadil, at a dose of 0.05–0.1 mcg/kg/min. Supplemental resources mentioned in the episode: Friedman BW, Irizarry E, Solorzano C, et al. Diazepam is no better than placebo when added to naproxen for acute low back pain.” Ann Emerg Med. 2017;70(2):169–176.. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572–1580. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586–1596. Dental emergencies management strategies that improve outcomes That wraps up RoshCast Episode 38. Don’t forget to follow us on Twitter @RoshCast and @RoshReview. We can also be reached by email at RoshCast@RoshReview.com and are open to any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. To do so, write “RoshCast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. Until next time, Jeff and Nachi The post Podcast Ep 38: Pediatric Intubation, Megaloblastic Anemia, & More appeared first on RoshReview.com.
Dec 8, 2017 · 17 min
Ep 37 Roshcast Emergency Board Review
The most difficult thing is the decision to act, the rest is merely tenacity. The fears are paper tigers. You can do anything you decide to do. You can act to change and control your life; and the procedure, the process is its own reward. -Amelia Earhart Welcome back to Roshcast Episode 37! This week, we’re continuing our collaboration with the EM Clerkship podcast. We’ll cover 3 EKG related questions in addition to 3 randomly generated questions. Maybe we’ll even get to a trauma question… As a reminder, listen closely for the trauma ring tone during this episode and the next episode. And e-mail us at roshcast@roshreview.com or tweet us at Roshcast the exact time of the ring tone to win a subscription. With the in-training exam right around the corner, this will certainly help get you ready for February 28th. Let’s get going with a rapid review from a recent post on the Rosh Review Blog. Supracondylar fracture is the most common type of pediatric elbow fracture. Typically caused by falling on an outstretched hand — or a FOOSH. In a posterolaterally displaced supracondylar humeral fracture, you should be concerned for the median nerve. This can be tested by asking the patient to make an “OK” sign and checking sensation at the volar tip of the index finger For a posteromedially displaced supracondylar fracture you should be concerned about the radial nerve. Have the patient try to make a “thumbs up” sign. And check sensation along the dorsal web space of the hand. Now onto this week’s podcast Question 1 A previously healthy patient who presents with leg pain is found to have a clot within the tibial vein. Which of the following treatments is most likely indicated? A. Aspirin for 6 months B. Heparin and warfarin C. Repeat ultrasound in 2–5 days D. Warfarin alone Question 2 Which of the following is associated with a shortened PR interval? A. Brugada syndrome B. Mobitz 2° AV Block C. Wellens syndrome D. Wolff-Parkinson-White syndrome Teaching Image Question 3 A 29-year-old man presents after a syncopal episode. His ECG reveals an epsilon wave, a small positive deflection buried in the end of the QRS complex. Which of the following tests will likely identify the cause of the patient’s syncope? A. Cardiac catheterization B. Cardiac MRI C. Electrophysiology study D. Stress testing Teaching Image Question 4 A 12-year-old boy is brought to the ED after being struck in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition? A. Asystole B. Supraventricular tachycardia C. Ventricular fibrillation D. Ventricular tachycardia Teaching Image Question 5 A 57-year-old man with hypertension presents complaining of a 6-hour history of a “floater” in the right eye. He states that he has had increasing difficulty reading as the cloudy area blocks his visual field. Additionally, he complains of decreased vision in his right eye. Which of the following represents the appropriate management? A. Administer timolol drops and emergently consult ophthalmology B. Emergent ophthalmology consultation C. Prescribe topical antibiotics and refer to ophthalmology D. Refer patient to ophthalmology for further assessment Teaching Image Question 6 A 27-year-old woman and her 25-year-old sister present with symptoms of facial flushing, headache, abdominal cramping, and diarrhea after eating in a seafood restaurant. They report that the fish they ate had a peppery taste. Which of the following is the most likely cause of their symptoms? A. Anaphylaxis B. Ciguatera C. Scombroid D. Staphalococcus aureus food poisoning Teaching Image Isolated thromboses of the calf veins can be managed by repeating an ultrasound in 2–5 days to determine the need for anticoagulation. Phlegmasia cerulean dolens is caused by extensive iliofemoral occlusion, which leads to vascular congestion and venous ischemia and a painful blue leg. Phlegmasia alba dolens is caused by a massive iliofemoral thrombosis and spasm and leads to a white leg. WPW is a congenital abnormality characterized by an abnormal accessory conduction pathway between the atria and the ventricle known as the bundle of kent. Look out for a delta wave, short PR, and widened QRS interval on EKG. The definitive treatment is ablation. Brugada syndrome is a hereditary condition characterized by a right bundle branch block-like pattern with ST elevation in leads V1 through V3. Wellens syndrome is caused by critical stenosis of the proximal LAD. On EKG you will likely see large inverted T waves or biphasic T waves in leads V2 and V3. Epsilon waves, which are small positive deflections buried in the terminal QRS complex, are characteristic of arrhythmogenic right ventricular cardiomyopathy. It is diagnosed by cardiac MRI. Arrhythmogenic right ventricular cardiomyopathy is treated with antiarrhythmics and an implantable cardiac defibrillator. Commotio cordis occurs when an object strikes the chest over the heart. It can cause sudden death. Commotio cordis is most common in children 5–15 years old, and ventricular fibrillation is the most common underlying rhythm. The commotio cordis risk window is the upstroke of the T wave in the cardiac conduction cycle. Posterior vitreous detachment can cause floaters, decreased vision, and cloudiness. Acute changes warrant emergent ophthalmology consultation. Scombroid poisoning presents with facial flushing, headache, abdominal cramping and diarrhea, palpitations, and rashes. Onset of symptoms can be anywhere from 10 minutes to 24 hours. Treatment is supportive with H1 and H2 blockers. Ciguatera toxicity is associated with muscle weakness, paresthesias, vomiting, diarrhea, and reversal of hot-cold sensation. That wraps up Roshcast Episode 37. Before we officially sign off for this week, we wanted to solicit your help for an upcoming episode. Very soon, we are bringing Adam Rosh, who is the founder of Rosh Review, onto the podcast to discuss everything from study tactics to his favorite pre-test meal. We have a couple of our own questions lined up, but we want to know what questions you have. Send us any questions for Adam to jeff@roshreview.com and we’ll try to squeeze them all in. That’s it for this week. Don’t forget to follow us on Twitter @Roshcast and @RoshReview. And you can always email us at roshcast@roshreview.com with any feedback, corrections or suggestions. You can also help us pick questions by identifying ones you would like us to review. Write “RoshCast” in the submit feedback box as you go through the question bank. Lastly, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about RoshCast. We’ll be back soon with more high-quality review. Until next time, Jeff and Nachi The post Podcast Ep 37: Tibial Vein Clot, PR Interval & More appeared first on RoshReview.com.
Nov 22, 2017 · 17 min
Ep 36 Roshcast Emergency Board Review
Do not go where the pay may lead, go instead where there is no path and leave a trail. -Ralph Waldo Emerson Welcome back to Roshcast Episode 36! This week we continue our collaboration with the EM Clerkship podcast, focusing on pediatrics. Don’t forget that we launched another trauma ring tone contest week, so listen up through Episode 38 to win a subscription to Rosh Review. For this week’s rapid review, we will be covering a few pearls from Yehuda’s most recent posts on the Rosh Review Blog. Let’s get started! Cysticercosis is caused by Taenia solium, a common tapeworm. It’s transmitted via pork. Patients may present with seizures and CNS cysts. Patients with acute angle-closure glaucoma classically present with severe eye pain, blurry vision, photophobia, and a dilated pupil. The intraocular pressure in this case would be elevated. Iritis presents with peri-limbic injection, a constricted pupil, pain, photophobia, and blurry vision. You would expect the intraocular pressure to be normal or even low. Now onto this week’s podcast Question 1 A 4-week-old boy presents with a 2-week history of increasing dyspnea, cough, and poor feeding. On examination you note conjunctivitis, and a chest examination reveals tachypnea and rales. A chest X-ray shows hyperinflation and diffuse interstitial infiltrates. Which of the following is the most likely etiologic agent? A. Chlamydia trachomatis B. Parainfluenza virus C. Respiratory syncytial virus D. Staphylococcus species Teaching Image Question 2 A 6-year-old immigrant boy from Bangladesh presents with fever and rash. The fever started three days ago followed by a rash which started on the head and spread to the rest of the body. Examination reveals a well-appearing child with a maculopapular rash and posterior cervical lymphadenopathy. Which of the following is the most likely causative organism for this disease? A. Measles virus B. Mumps virus C. Parvovirus B19 D. Rubella virus Teaching Image Question 3 A 4-year-old boy presents with respiratory failure. Which of the following represents the correct endotracheal tube for this patient? A. 4.0 cuffed endotracheal tube B. 5.0 uncuffed endotracheal tube C. 5.5 cuffed endotracheal tube D. 6.0 cuffed endotracheal tube Teaching Image Question 4 Which of the following is the most common manifestation of abusive head trauma in infants? A. Epidural hematoma B. Retinal hemorrhage C. Subarachnoid hemorrhage D. Subdural hematoma Teaching Image Question 5 Which of the following should be administered to a symptomatic 3-day-old infant with glucose of 25 mg/dL? A. 1 mL/kg of 50% dextrose (D50) B. 2 mL/kg of 25% dextrose (D25) C. 5 mL/kg of 10% dextrose (D10) D. Glucagon subcutaneously Teaching Image Question 6 A healthy 6-year-old boy presents to the ED with bloody diarrhea. He was in his usual state of health until one week ago when loose, watery stools (up to 10 per day) were noted. He was seen by his pediatrician four days ago but has since developed increasing amounts of blood and pus in his stools along with a low-grade fever. Mom states there is no recent travel, antibiotic use, or known sick contacts. His vitals are heart rate 118 beats per minute, oxygen saturation 100% on room air, and rectal temperature of 38.3°C. Your physical exam reveals a mildly tender abdomen without localization, rebound, guarding, or peritoneal signs. You note grossly bloody stool on rectal exam. A brief discussion with his pediatrician confirms your suspicion of an invasive bacterial diarrhea; a stool culture was positive for Shigella. Which of the following statements is true regarding this condition? A. Antibiotics should be avoided because this is a severe case and the patient is at highest risk of developing hemolytic uremic syndrome B. Antidiarrheal agents (such as diphenoxylate and atropine) are indicated, given the frequency of loose stools C. Extraintestinal manifestations such as hallucinations, confusion, and seizures may occur D. Oral rehydration should be avoided; IV fluids should be initiated Teaching Image Chlaymdial pneumonia is often found in infants 3–16 weeks old. They usually present, non-toxic appearing and afebrile, but with tachypnea and a staccato cough, with or without rales. 50% also have conjunctivitis. Treat with azithromycin. Infants with parainfluenza virus typically present with coryza, a low-grade fever followed by a classic barking cough of croup. Infants with RSV present with lower respiratory tract infections like bronchiolitis. Measles presents with a fever followed by a rash and Koplik spots. Mumps is associated with an infectious parotitis. Infants with parvovirus B19 often present with erythema infectiosum with the classic slapped cheek appearance. Rubella, also called German measles, often presents with a mild febrile illness with a diffuse maculopapular rash, generalized malaise, along with lymphadenopathy. When choosing an endotracheal tube for children use the following formulas. For uncuffed tubes, take the age, divide it by 4, and add 4. For cuffed tubes, take the age, divide it by 4, and add 3.5. Retinal hemorrhages are the most common manifestation of abusive head trauma in infants. Posterior rib fractures without overlying bruises, metaphyseal fractures, sternal fractures, scapular fractures, and skull fractures should raise your suspicion for non-accidental trauma. For hypoglycemic children less than one year of age, use D10 5–10 ml/kg. For hypoglycemic children who are 1 to 8 years old, use D25 2–4 ml/kg. For hypoglycemic children over the age of 8, use D50 1–2 ml/kg. Extraintestinal manifestations of Shigella include confusion, hallucinations, and seizures. For children concerning for shigellosis, treat supportively with PO fluids if tolerated. Antidiarrheal agents should be avoided. Depending on the situation, antibiotics may be needed. That wraps up Episode 36. Don’t forget to follow us on Twitter @Roshcast and @RoshReview. We can also be reached by email at roshcast@roshreview.com and are open to any feedback, corrections, or suggestions. You can help us pick questions by identifying ones you would like us to review. To do so, write “Roshcast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast. Until next time, Jeff and Nachi The post Podcast Ep 36: Pediatrics, Chlamydial Pneumonia, & More appeared first on RoshReview.com.
Nov 9, 2017 · 18 min
Ep 35 Roshcast Emergency Board Review
Reach for it. Push yourself as far as you can. -Christa McAuliffe Welcome back to Roshcast Episode 35! It was great chatting with a bunch of listeners at ACEP last week. We received a lot of excellent feedback. This week, we’ll be doing a couple of diarrhea questions to link up with the last EM Clerkship episode, in addition to a few randomly generated questions. Don’t forget that we are still running a trauma ring tone contest. Listen closely for a ring tone in an upcoming episode and e-mail us at roshcast@roshreview.com or tweet to us at @Roshcast the exact time of the ring tone to win a prize, which will certainly come in handy as we get closer to the in-training exam. Let’s get started with a review from recent posts on the Rosh Review Blog. Pterygium is a fleshy triangular growth from the medial canthus towards the cornea. They are usually slow growing and seen in those with excessive sunlight exposure. They are managed with artificial tears. Pterygium typically doesn’t require surgery but may need excision if it is causing a visual disturbance. Make sure the patient is already following with an ophthalmologist or give them a referral if needed. Retinal detachments present with painless loss of vision, floaters, flashing lights, or as a curtain lowering sensation. On physical, you may see a hazy gray retina with whitish folds. The most common location for an ectopic pregnancy is the fallopian tube. Now onto this week’s podcast Question 1 A 2-year-old girl presents after a witnessed seizure. The parents state that she has not been to daycare in two days, as she has bloody diarrhea and a fever. Her vitals on presentation are T 103.1°F, HR 167/min, BP 73/43 mm Hg, RR 48/min, and oxygen saturation 96%. Currently, the patient has a normal neurologic exam and minimal abdominal tenderness. There are no rashes. Labs show a WBC of 19,000, and urinalysis reveals an elevated specific gravity. Which of the following is the most appropriate next step in management? A. Acetaminophen for fever and follow-up with primary care provider B. Blood and stool cultures, IV antibiotics, and admission C. Neurology consultation and admission D. Oral antibiotics and follow-up with primary care provider Teaching Image Question 2 An 82-year-old nursing-home resident is sent to the emergency department with lower abdominal pain and bloody diarrhea. He has a history of vascular dementia, hypertension, and hyperlipidemia. On examination he is afebrile, and a nasogastric aspirate is negative for evidence of bleeding. Which of the following is the most likely cause of this patient’s bleeding? A. Angiodysplasia B. Diverticular bleeding C. Ischemic colitis D. Peptic ulcer disease Teaching Image Question 3 Which of the following is considered a risk factor for suicide? A. Female sex B. First-trimester pregnancy C. First year of marriage D. Recent incarceration Question 4 Which of the following scenarios is most appropriate to safely discharge home a 2-year-old who has swallowed a coin? A. The child is not drooling B. The child is tolerating oral sips and the parents are reliable C. The coin is in the stomach D. The coin is oriented in the sagittal plane at the level of the clavicular heads Teaching Image Question 5 A 35-year-old-man with a history of occasional bloody diarrhea and abdominal pain presents with acute onset severe abdominal pain. Vital signs are significant for a temperature of 39°C, heart rate 140/min, and blood pressure 82/55 mm Hg. On physical exam, his abdomen is distended and tympanic. Which of the following diagnostic studies is indicated first at this time? A. Abdominal radiograph B. Barium enema C. CT scan of the abdomen pelvis with IV contrast D. Sigmoidoscopy Teaching Image Question 6 A 45-year-old woman complains of two days of fluctuating diplopia and dysphagia. Her exam reveals a left cranial nerve VI palsy, ptosis, and proximal muscle weakness in her extremities. What is the pathophysiology of her disease? A. Antibodies to the acetylcholine receptor at the neuromuscular junction B. Inhibition of acetylcholine release at the synapse C. Mutation of superoxide dismutase causing cell death D. Reduced number of dopamine receptors in the midbrain Teaching Image Patients with Shigella often present with fever, abdominal cramps, and diarrhea with mucus or blood. Infants with Shigella are also at risk for seizures. Shigellosis should be treated supportively. Patients who are immunocompromised, have bacteremia, attend daycare, or live in a nursing home require treatment with antibiotics. Children should be treated with ceftriaxone, 50 mg/kg in a once-daily dose up to a max of 1.5g for 5 days. Ischemic colitis is caused by inadequate blood flow through the mesenteric vessels. It often affects the watershed regions. Ischemic colitis can be treated supportively with bowel rest and IV fluids unless there are signs of peritonitis or infarction. Risk factors for suicide include male sex, age, history of mental illness, personal or family history of a suicide attempt, poor financial situation, unemployment, poor physical health, being Caucasian, and isolation. With respect to suicide, marriage, and first-trimester pregnancy are both protective. Swallowed foreign bodies that do not pass through the esophagus, which occurs 2% of the time, have a risk for esophageal perforation or erosion. Emergent endoscopy is indicated if the swallowed foreign body is a battery, is sharp, or if there are signs of obstruction. Coins in the sagittal plane on X-ray are more likely to be in the trachea than in the esophagus. Toxic megacolon presents with colonic dilatation and systemic toxicity. Patients usually present after having symptoms of colitis for several days. If there is concern for toxic megacolon, an abdominal X-ray should be the first imaging study to look for colonic dilatation, to a diameter greater than 6 cm. Toxic megacolon can be precipitated by IBD, pseudomembranous colitis, CMV colitis, and bacterial colitis. Myasthenia gravis is caused by antibodies to the acetylcholine receptor at the neuromuscular junction. Ptosis and diplopia are the most common first symptoms of a myasthenic crisis. This is followed by proximal muscle weakness, dysphagia, and dyspnea. Respiratory failure can be seen in the later stages. Myasthenia gravis can be diagnosed by the edrophonium or Tensilon test. Myasthenia gravis can be treated with plasma exchange and IVIG. Ice decreases symptoms but is not a permanent solution. That wraps up Episode 35. Don’t forget to follow us on Twitter @Roshcast and @RoshReview. We can also be reached by email at roshcast@roshreview.com and are open to any feedback, corrections, or suggestions. You can help us pick questions by identifying ones you would like us to review. To do so, write “Roshcast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast. Until next time, Jeff and Nachi The post Podcast Ep 35: Shigellosis, Ischemic Colitis, Suicide, & More appeared first on RoshReview.com.
Oct 25, 2017 · 15 min
Ep 34 Roshcast Emergency Board Review
Keep your eyes on the stars and your feet on the ground. -Theodore Roosevelt Welcome back to Roshcast Episode 34! This week we continue our collaboration with the EM Clerkship podcast, focusing on appendicitis. Don’t forget that we launched another trauma ring tone contest last week, so listen up through episode 38 to win the prize. For this week’s rapid review, we reviewed dysbarism in honor of the Rosh Review Core Content Winner’s presentation. If you haven’t seen Dr. Sanders and Dr. Levin’s fantastic presentation, it’s definitely worth checking out. Let’s get started! A diver with an arterial gas embolism would classically presents within 10 minutes with neurologic symptoms that resolve and then recur. Typical symptoms of an arterial gas embolism include unconsciousness, respiratory or cardiac arrest, coma, stupor, confusion, unilateral neurologic changes, visual disturbances, dizziness, or convulsions. Decompression sickness presents in a variety of ways. 68% of patients will present with joint pains, 63% will present with numb patches and paresthesias, and 41% will have constitutional symptoms and fatigue. Other less common symptoms include dizziness, weakness, itching, hearing loss, and tinnitus. On scene, a diver with either an arterial gas embolism or decompression sickness should be treated with the standard IV fluids, supplemental oxygen, and then be placed on a monitor. Definitive treatment is with hyperbaric oxygen. Now onto this week’s podcast Question 1 Which of the following is the average duration of a typical generalized tonic-clonic seizure? A. 1–2 minutes B. 10–15 seconds C. 30–40 seconds D. 4–5 minutes Question 2 A 23-year-old man presents with abdominal pain, vomiting and two loose, nonbloody stools. Physical examination reveals right lower quadrant tenderness to palpation. A CT is performed showing a normal appendix and some inflammation at the ileocecal junction. What pathogen is commonly implicated in this disorder? A. Aeromonas species B. Salmonella enterica C. Vibrio parahaemolyticus D. Yersinia enterocolitica Teaching Image Question 3 A 9-month-old girl presents to the ED with signs of progressive dyspnea. The patient’s mother reports URI symptoms that have been present for two weeks. Over the previous 24 hours, the patient has been increasingly fussy, noted to be sweaty with feeds, and has become increasingly dyspneic. Her vital signs are T 38.3°C, HR 180, RR 38, POx 93%, and BP 60/40. On examination, you note rales at the lung bases. Her heart rhythm is irregular with an S3 gallop, and the liver is palpable 3 cm below the costal margin. Which of the following is the most appropriate therapeutic intervention? A. Dobutamine B. Immediate endotracheal intubation C. Normal saline 20 ml/kg bolus D. Propranolol E. Transcutaneous pacing Teaching Image Question 4 Which of the following statements is true regarding appendicitis? A. An appendicolith is identified in the majority of cases of appendicitis B. Leukocytosis is seen in the majority of cases C. Perforation is rare in patients younger than 2 years D. The presence of an appetite makes the diagnosis unlikely Teaching Image Question 5 Which of the following is most characteristic of phimosis? A. Collection of dilated and tortuous veins surrounding the spermatic cord B. Inability to retract foreskin over glans C. Inability to return retracted foreskin over glans D. Painless cyst filled with sperm Teaching Image Question 6 Which of the following historical features has a high positive likelihood ratio for acute appendicitis? A. Migration of pain from periumbilical area to the right lower quadrant B. Obturator sign C. Presence of pain for more than 48 hours D. Vomiting before onset of pain Teaching Image The average duration of a generalized tonic-clonic seizure is 1–2 minutes. Status epilepticus is defined as any seizure lasting greater than 5 minutes or 2 discrete seizures without a recovery to consciousness. For the treatment of status epilepticus, benzodiazepines are the first-line agents. Second-line agents include phenytoin, fosphenytoin, valproic acid, phenobarbital, and levetiracetam. Pentobarbital and propofol are third-line agents. Yersinia enterocolitica can cause ileocecitis which can mimic appendicitis. Other symptoms include colicky abdominal pain, fever, nausea, vomiting, and diarrhea. Treatment is supportive. Pediatric heart failure is treated with dobutamine if hypotensive or with milrinone if normotensive or hypertensive. Common causes for myocarditis include viruses, bacteria, parasites, cardiotoxins, systemic disorders, radiation, and hypersensitivity. A leukocytosis is seen in up to 70% of patients with appendicitis. Appendicoliths are rarely identified, they are only seen 10% of the time radiographically. 33% of patients diagnosed with appendicitis do NOT report anorexia. Phimosis is the inability to retract the foreskin over the glans. Paraphimosis is the inability to return the retracted foreskin over the glans. Varicocele is a collection of dilated and tortuous veins surrounding the spermatic cord. They usually cause no symptoms. There is a high positive likelihood ratio for acute appendicitis with migration of pain from the periumbilical area to the right lower quadrant. Obturator sign is the elicitation of pain with flexion and internal rotation of the right hip which signifies a pelvic location of the appendix. Rosving sign is palpation of the left lower quadrant causing referred pain to the right lower quadrant. That wraps up Episode 34. We will be at ACEP next week and hope to meet many of you there. Definitely swing by the Rosh Review booth (1442) to say hi and give us some feedback and suggestions! Don’t forget to follow us on Twitter @Roshcast and @Roshreview. We can also be reached by email at roshcast@roshreview.com and are open to any feedback, corrections, or suggestions. You can help us pick questions by identifying ones you would like us to review. To do so, write “Roshcast” in the submit feedback box as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on iTunes to help spread the word about Roshcast. Until next time, Jeff and Nachi The post Podcast Ep 34: Seizures, Yersinia enterocolitica, & More appeared first on RoshReview.com.

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