ROSH REVIEW Emergency Medicine Latest 2023 Already Graded A

ROSH REVIEW Emergency Medicine Latest 2023 Already Graded A A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from summer camp 1 week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae surrounding scattered, erythematous papules. Which of the following is the most appropriate treatment? Ketoconazole Lindane Permethrin Prednisone Correct Answer ( C ) Explanation: This patient has scabies; a pruritic dermatitis caused by cutaneous infection with the mite Sarcoptes scabei, var hominis. Scabies is spread by skin-to-skin contact and should be considered in patients with generalized pruritus, especially when exposure to others with similar symptoms is reported. The rash of scabies involves papules, which are often excoriated. Burrows are pathognomonic but not uniformly present. Unless previously infected, pruritus generally takes 3-6 weeks to develop because symptoms are due to delayed (Type IV) sensitivity reaction. The pruritus is classically worse at night and affects the web spaces of the fingers, flexor aspect of the wrists, axillae, groin, nipples, and the periumbilical region. Except in cases involving an immunocompromised host, the scalp and face are generally spared. Diagnosis is clinical but can be confirmed by placing scrapings collected with a #15 blade scalpel in mineral oil for microscopic examination. The treatment of choice for primary scabies infection is the application of topical scabicidal agents, with repeat application in 7 days. The treatment of choice is permethrin 5% lotion. Individuals affected by scabies should avoid skin-to-skin contact with others. Patients with typical scabies may return to school or work 24 hours after the first treatment. Should family members of an infected individual also be treated for scabies? Yes, family members and sexual contacts. Scabies Sarcoptes scabiei Pruritic rash worse at night Linear burrows Interdigital spaces of hands/feet, penis, breasts Permethrin (first line) Ivermectin **head and back are sparred (head involved in children) An 18-month-old boy presents to the emergency department with worsening shortness of breath. The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms? Bordetella pertussis Haemophilus influenzae Parainfluenza virus Respiratory syncytial virus Correct Answer ( D ) Explanation: The patient has bronchiolitis, which is the most common lower respiratory tract infection in patients less than two years of age. It remains the leading cause for hospitalization in infants under one year of age. Bronchiolitis is most commonly caused by respiratory syncytial virus (RSV), but may be caused by other viral agents. Bronchiolitis is inflammation of the lower respiratory tract, which involves edema, epithelial cell necrosis, bronchospasm, and increased mucus production. The resultant lower airway obstruction causes increased work of breathing and wheezing. Bronchiolitis is a clinical diagnosis based on age under two years old, rhinorrhea, tachypnea, and wheezing. Unlike asthma or reactive airway disease, there is often no significant improvement with albuterol. There is often a history of several days of upper respiratory symptoms, such as rhinorrhea, mild cough, and mild fever. Rapid antigen tests, blood work, and radiographs are not usually needed. Radiographs may demonstrate hyperinflation and atelectasis, but do not show any focal infiltrates like with pneumonia. Bronchiolitis is usually self-limited, with respiratory status typically improving over 2-5 days. Management involves supportive care. Bronchiolitis What months of the year contain the peak incidence of RSV in North America? November to March. A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test? Bedside echocardiography Chest radiograph Computed tomography angiogram of the chest Electrocardiogram Correct Answer ( A ) Explanation: This patient presents with a clinical picture consistent with obstructive shock. His distended neck veins, full right upper quadrant, muffled heart sounds, and hypotension are all consistent with pericardial tamponade. A pericardial sac slowly accumulating fluid can stretch without obstructing cardiac function. Tamponade occurs when rapid fluid accumulation results in elevated pressures that inhibit venous return. This is a dynamic process over the course of the cardiac cycle, therefore bedside echocardiography is the diagnostic test of choice. Fluid around the heart with evidence of right atrial compression and right ventricular diastolic collapse are diagnostic of pericardial tamponade. Pericardial Effusion What is the emergent treatment of pericardial tamponade? Pericardiocentesis. An 8-year-old African-American girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right sided facial droop and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management? Alteplase Exchange transfusion MRI brain Tranexamic acid Correct Answer ( B ) Explanation: Cerebrovascular events are a potential complication of sickle cell disease. This patient developed symptoms concerning for acute ischemic stroke. For pediatric patients with acute ischemic stroke in the setting of sickle cell disease, exchange transfusion is the treatment of choice. Transfusion goals include decreasing hemoglobin S levels to less than 30% and obtaining a total hemoglobin level of 10 g/dL. For adults with acute ischemic stroke in the setting of sickle cell disease, consider tissue plasminogen activator (tPA). tPA is not indicated or approved for use in pediatric patients Tranexamic acid (D) is an antifibrinolytic agent used in the management of hemorrhage. Indications include acute traumatic hemorrhage, intraoperative blood loss, and obstetric hemorrhage. Tranexamic acid is not used for ischemic events Manage Sickle Cell What is the most common bacterial cause of acute chest syndrome