SAEM 241 - 390|2023 LATEST UPDATE|GUARANTEED SUCCESS

A 32 year old male, intravenous heroin abuser, presents with a one-day history of mid-back pain, progressive weakness of his legs, and an inability to urinate. He has a temperature of 38.3° C (100.8° F). On exam, absent patellar deep tendon reflexes are noted, he cannot stand or walk, a distended bladder is palpable, and he has tenderness to palpation over his T10 and T11 vertebrae. Which of the following is not an acceptable next step? A. MRI of the spine B. Analgesia C. Foley catheter to drain the bladder D. Hospital admission for neurosurgical consultation in the morning E. Antibiotics to cover a broad spectrum of organism D. Hospital admission for neurosurgical consultation in the morning he answer is D. A spinal epidural abscess is a neurosurgical emergency, with the outcome being dependent on the speed of diagnosis and surgical decompression. Consequently, urgent neurosurgical evaluation is required. Although an uncommon disease, intravenous drug abuse, diabetes mellitus, chronic renal failure, and immunosuppression are risk factors for its development. Antibiotics to cover Staph. aureus, the most common cause, gram negative bacteria, and anaerobes are needed. Bladder decompression for symptomatic relief is important, as is analgesia Which of the following is true about myasthenia gravis? A. It typically presents as an ascending weakness of the peripheral nervous system. B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation. C. Weakness improves as the involved muscles are used repeatedly. D. The "atropine test" is diagnostic when 0.5 mg of atropine is given intravenously and the patient's symptoms improve within two minutes. E. Cooling exacerbates the symptoms, and heat alleviates them. B. A myasthenic crisis involves an exacerbation of weakness, especially of respiratory muscles, often necessitating intubation. The answer is B. Myasthenia gravis is an autoimmune disease that results from antibodies directed against the acetylcholine receptor (AChR) at the neuromuscular junction. Destruction of the AchR leads to fewer receptors available to bind acetylcholine, with a resulting muscle weakness. Ocular symptoms are usually the first to occur, with diplopia and ptosis being common. The disease typically worsens as the day progresses because of repeated use of the muscles involved. Diagnosis is made with the tensilon test, where edrophonium is given and the patient's symptoms are observed to transiently improve. The administration of atropine is not a diagnostic test. Cooling helps the symptoms and heat exacerbates them. A myasthenic crisis is a feared complication. Patients develop respiratory failure requiring intubation, frequently for prolonged periods. A 36 year old woman on chronic cyclosporine treatment for bilateral lung transplantation visits the emergency department complaining of extreme headache, nausea and vomiting. Her exam is notable for BP 239/165, normal cardiac exam, bibasilar pulmonary rales, and 1+ lower extremity edema. EKG showed asymmetric inverted T-waves in I, aVL, and V4-6. In an effort to acutely control her blood pressure, which of the following is TRUE? A. Hydralazine decreases myocardial oxygen demand by decreasing afterload and would not be useful in this setting B. Nitroprusside would be contraindicated in this patient due to its relatively slow onset of action C. Nitroglycerin decreases BP by decreasing venous return and cardiac output D. Prolonged nitroprusside therapy may potentially cause methemoglobinemia E. Esmolol works through both alpha-1 and selective beta-2 blockade C. Nitroglycerin decreases BP by decreasing venous return and cardiac output The answer is C. Relative to other anti-hypertensive agents, nitroprusside has an extremely rapid onset of action. Although rare, long-term nitroprusside treatment may lead to cyanide toxicity in renal failure patients secondary to the presence of cyanide as an intermediate metabolite. A history of long-term cyclosporine treatment suggests this patient likely has some degree of renal insufficiency. A 14 year-old child presents to the emergency department. His blood pressure is 210/140. He complains of a headache, nausea, and recent blurred vision. Of the following choices, the best goal for lowering his mean arterial blood pressure is to have it drop by: A. Until symptoms resolve B. 5% in the first 5-6 hours C. 25% in the first hour D. 50% in the first hour E. To normal for his age in the first hour C. 25% in the first hour The answer is C. A systolic BP of 210 or more, or a diastolic BP of 140 or greater, defines hypertensive urgency. With end-organs symptoms, as above, the presumptive diagnosis is hypertensive emergency. In hypertensive emergencies, the goal is to decrease mean arterial blood pressure by 10-25% within the first hour, thereby alleviating symptoms while not compromising cerebral perfusion. A 2 year old male is brought to the ED in status epilepticus. He has not responded to adequate doses of benzodiazepines. Which of the following possible causes of a seizure must be evaluated for in the emergency department? A. Hypoxia B. Hypoglycemia C. Toxic ingestion D. Head trauma E. All of the above possible causes must be evaluated for E. All of the above possible causes must be evaluated for The answer is E. Seizures have a number of secondary causes, which must be identified and corrected before the seizure will end. Hypoxemia and hypoglycemia are easily detected by pulse oximetry and bedside measurement of glucose, respectively. Toddlers may ingest many toxins accidentally, such as INH, tricyclic antidepressants, and camphor. Trauma must be considered, too, including child abuse. Sickle cell disease, SLE, and leukemia are some of the medical causes of seizures and status epilepticus. Shock is defined as: A. tachycardia B. hypotension C. altered mental status D. hypovolemia E. inadequate tissue and organ perfusion E. inadequate tissue and organ perfusion The answer is E. Shock is defined as inadequate tissue and organ perfusion. Hypovolemia, tachycardia, hypotension and altered mental status are all signs and symptoms of shock. The four classic types of shock include all of the following EXCEPT: A. Distributive B. Obstructive C. Hypovolemic D. Cardiogenic E. Traumatic E. Traumatic The answer is E. Shock is divided into four mechanistic classifications: hypovolemic (inadequate circulatory volume); cardiogenic (inadequate cardiac pump function); distributive (maldistribution of blood flow); and obstructive (extracardiac obstruction to blood flow). Trauma may lead to various shock states (usually hypovolemic, but also distributive in the case of pericardial tamponade), but there is no "traumatic" shock subtype. An early sign and symptom of shock is: A. Cyanosis B. Decreased respiratory rate C. Tachycardia D. Hypotension E. Bradycarda C. Tachycardia The answer is C. Hypotension is a late finding in shock; narrowing of pulse pressure tends to occur earlier (and is due to increased sympathetic tone). Early signs of shock include tachycardia and increased respiratory rate, which occur as the body attempts to maintain perfusion. All patients with shock should receive as the first priority: A. Supplemental oxygen B. Packed red blood cells C. Trendelenburg positioning D. Antibiotics E. Intravenous fluids A. Supplemental oxygen The answer is A. The fundamental issue in shock is tissue hypoperfusion and hypoxia. All patients in shock should receive supplemental oxygen initially. Steps to improve oxygenation range from nasal cannula to endotracheal intubation. As compared to adults, children with shock usually: A. Have more reliable signs and symptoms B. Have similar epidemiology (i.e. causes for shock states) C. Are able to maintain their blood pressure better D. Have different treatment priorities E. Do not need specialized care C. Are able to maintain their blood pressure better The answer is C. While the treatment priorities for pediatric and adult shock are similar, there are some differences; thus, a specialized approach to care is often required. The epidemiology is different, since in children shock tends to be caused by trauma and infections. Children's signs and symptoms may be more subtle than those of adults in shock, rendering the physical examination less reliable in pediatrics. One of the key differences is a child's ability to maintain blood pressure despite presence of shock. During hypovolemic shock, hypotension tends to develop after the loss of what percent of blood volume? A. 10% B. 20% C. 30% D. 40% E. 50% C. 30% The answer is C. Some texts divide hypovolemic shock into 4 classes based on the percent of volume loss; Class I is loss of up to 15% of circulating blood volume; Class II is 15-30% loss; Class III, 30-40%; and Class 4, over 40%. In general, blood pressure does not drop until approximately 30% of blood volume is lost. All of the following are signs and symptoms of hypovolemic shock EXCEPT: A. Narrow pulse pressure B. Cool, clammy skin C. Warm, moist skin D. Decreased capillary refill E. Tachycardia C. Warm, moist skin The answer is C. Acute hemorrhage or volume loss is characterized by tachycardia, narrow pulse pressure, poor capillary refill and decreased urine output. Skin tends to be cold and clammy. Late findings include hypotension and altered mental status.